Every finding on record at Golden Pavilion Healthcare

Based on interviews and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 3) when Resident 3 exited the facility with Resident 4 without the facility's knowledge or supervision.This failure placed Resident 1 at risk of injury or harm.Resident 3 was admitted on [DATE] with diagnoses including abnormal posture and abnormalities of gait and mobility (changes in walking or movement, such as limping, shuffling, or losing balance). Resident 3 was discharged on 6/29/26.Review of Resident 3's minimum data set assessment (MDS, a federally mandated resident assessment tool), dated 6/5/26, indicated moderate cognitive impairment (noticeable changes or decline in memory or thinking) and use of a walker or cane for ambulation.Review of Resident 3's Elopement Risk Evaluation, dated 6/3/26, indicated no elopement risk due to no wandering issues reported.Resident 4 was admitted on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (partial weakness) following cerebral infarction (blood clot or blocked vessel stopping blood flow to part of the brain) affecting the left non-dominant side.Review of Resident 4's MDS assessment, dated 4/10/26, indicated cognitive intactness (mental and thinking abilities functioning normally) and use of a motorized wheelchair for mobility.During an interview on 7/22/26 at 10:41 AM, Resident 4 stated, I go out to the store sometimes. I have to tell them (facility staff) and sign out each time. Resident 4 further stated that Resident 3 wanted to know which one I go to. I said, 'I can show you,' so we went down the block together. When asked if they were accompanied by facility staff, Resident 4 replied, No.During an interview on 7/22/26 at 10:50 AM, Certified Nursing Assistant (CNA) 1 confirmed assignment to Resident 3 during the incident. CNA 1 stated, She is pretty alert but can be a little confused about things. I remembered seeing her walking by herself with a cane. When asked if she was aware that Resident 3 exited the facility during her shift, CNA 1 replied, I was unaware of the whole thing. It was never brought up to me.During an interview on 7/22/26 at 4:05 PM, Licensed Vocational Nurse (LVN) 1 was asked if Resident 1 could make decisions for herself. LVN 1 stated, In that moment, someone else was making decisions for her; a family member. LVN 1 recalled seeing Resident 3 and Resident 4 together on the evening of 6/9/26, (Resident 3) was holding a Panda Express. (Resident 4) in her wheelchair, walking together. They were going back to their room. LVN 1 stated she learned of the incident when Family called, I answered the phone. They were upset, asking how come she (Resident 3) was allowed to go outside without us knowing about it. (Resident 3) called them (family member). LVN 1 added, She (Resident 3) could get run over, we would never know she is outside the building. It's our responsibility to know where they are, who they are going with . because they are under our care.During an interview on 7/23/26 at 9:46 AM, Resident 3's family member (FM) 1 stated that on the evening of 6/29/26, Resident 3 spoke with another FM by phone and told them that she went to the store with another resident to buy food. FM 1 said, We called them (facility). I spoke with her nurse and the supervisor. They did not even know she left with a stranger until we told them. FM 1 added, She could have lost her balance and fallen. She could have gotten into an accident, and they would not even know. They're supposed to keep her safe.During an interview on 7/23/26 at 11:06 AM, the Director of Nursing (DON) stated, No when asked if residents are allowed to leave the facility without staff knowledge. The DON stated, That's a safety risk. Residents with cognitive impairment need to leave with staff or their representative. Another resident is not adequate to supervise a resident.Review of facility policy, titled Elopement/Wandering, dated 2/2025, indicated: Definitions: Elopement: The resident/patient exits the Center without staff knowledge OR the resident/patient enters an unsafe area without staff knowledge or presence. Examples of elopement.2. A resident exits the front door without staff knowledge or presence. This is elopement.This finding represents past non-compliance with this regulatory requirement. There was sufficient evidence that the facility corrected the non-compliance as of 7/7/26 and there were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction.

Based on interview and record review, the facility failed to report a resident-to-resident abuse allegation to California Department of Public Health (CDPH, state survey agency) and the Ombudsman's Office (an advocacy organization who protect the rights, health, and welfare of residents in long-term care facilities) within two hours, as required.This failure had the potential to leave residents in the facility vulnerable to further abuse.Review of the document titled Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 6/10/26, submitted by the facility to CDPH on 6/10/26 at 3:26 PM, indicated that Resident 1 reported that on the night of 6/9/26, Resident 2 requested assistance, and when Resident 1 was unable to understand the request, Resident 2 struck Resident 1.Review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included Guillain-Barre syndrome (is a rare neurological disorder in which the body's immune system mistakenly attacks the peripheral nerves).Review of Resident 2's admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included drug rash with eosinophilia and systemic symptoms syndrome (DRESS, a rare, severe allergic reaction to certain medications).During a concurrent interview and record review on 7/21/26 at 1:22 PM with Social Services Staff (SSS) 1, Resident 2's Social Services Note, dated 6/10/26 at 9:59 AM was reviewed. The note indicated that SSS 1 followed up with Resident 2 regarding the alleged abuse incident on 6/9/26 involving Resident 1. SSS 1 stated that she was notified by nursing staff about the abuse allegation on 6/10/26 around 9 AM during stand-up meeting (a brief meeting during which facility staff review the previous 24 hours, share updates, and plan resident care).During a concurrent interview and record review on 7/22/26 at 10:09 AM, Registered Nurse (RN) 1 reviewed the facility's fax confirmation reports (documents generated after a fax is sent that proves whether the delivery was successful or failed) for CDPH and the Ombudsman's Office. The reports indicated that Form SOC 341was faxed to CDPH at 3:26 PM and to the Ombudsman's office at 3:28 PM on 6/10/26 which was more than 2 hours after the facility learned about the allegation. RN 1 stated, It's reportable. It (reporting) needs to be done within two to four hours.During an interview on 7/23/26 at 10:22 AM, the Administrator stated that reporting timeframes for allegations of abuse are Two hours if there is serious bodily injury.Review of the facility's policy titled, Abuse Reporting and Response, dated 10/2025 indicated Policy Statement: The Center immediately reports all suspected and/or allegations of abuse.in accordance with state and federal law. 1. Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.4. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follows: a. Immediately but not later than 2 hours - all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury.This finding represents past non-compliance with this regulatory requirement. There was sufficient evidence that the facility corrected the non-compliance as of 7/7/26 and there were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction.

Based on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 1) when Resident 1 fell off the bed to the floor.This failure resulted in Resident 1's fall with fractures to the left humerus (the long bone in the upper arm that goes from the shoulder to the elbow) and left distal femur (lower part of thigh bone found behind the kneecap [bone located at the front of the knee]).Review of Resident 1's admission Record indicated, Resident 1 was readmitted on [DATE], with diagnoses including unspecified injury of left and right thigh, type 2 diabetes (a disease that occurs when your blood sugar is too high), muscle weakness, and history of transient ischemic attack (TIA, a mini-stroke caused by temporary blockage of blood flow to the brain).During an observation on 7/20/26 at 9:29 AM in Resident 1's room, Resident 1 was asleep with bed in low position and upper grab bar (a safety device attached to the side of a bed to help people get in and out, change positions, and prevent accidental falls) on each side in the upright and locked position.During an interview on 7/20/26 at 9:41 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was alert, oriented, and dependent on some of her activities of daily living (ADL, referring to basic self-care tasks like bathing, toileting) requiring one-person assistance. CNA 1 stated she was one of the staff who helped transfer Resident 1 back to bed when she fell on 8/12/25. CNA 1 stated Resident 1 was lying face down on the floor on the right side of the bed crying in pain. According to CNA 1, Resident 1 was screaming help me, help me.During a concurrent observation and interview on 7/20/26 at 10:07 AM with CNA 1 in Resident 1's room, CNA 1 stated Resident 1's bed was not in the lowest position when she fell 0n 8/12/25. CNA 1 stated, We had to lower the bed when we transferred her [Resident 1] from the floor. It [bed] was higher because she [CNA 2] was changing her [Resident 1]. CNA 1 stated Resident 1's bed was in a higher position so as not to hurt your back during ADL care.During a concurrent observation and interview on 7/20/26 at 11:13 AM with Resident 1 in her room, Resident 1 was lying in bed, alert, oriented, coherent, pleasant, and well-kempt. Resident 1 stated on the day that she fell [8/12/25], CNA 2 came to clean and change her brief, standing on her [Resident 1] left side, height of bed was higher than it is now.about three feet [from the floor] .like on her [CNA 2] waist. Resident 1 demonstrated how she fell and stated she held on to the right upper grab bar with her right hand and I turned on my right side by myself [from lying position] .miscalculated how far I was from the edge of the bed [right side] . I fell face down on the floor. [CNA 2] didn't know what happened.how I fell. Resident 1 stated, Bar was functioning well. Furthermore Resident 1 stated that when she fell I was definitely in pain on my left side, shoulder and leg. I broke my left shoulder and kneecap.During a telephone interview conducted on 7/20/26 at 11:41 AM with CNA 2, CNA 2 stated Resident 1 was alert and oriented, dependent on her toileting needs with one-person assistance, and able to roll on her left or right side from lying position with grab bar as assistive device (any tools, equipment, or software products used to increase, maintain, or improve the functional capabilities of people with disabilities or limitations). CNA 2 stated she was situated on the left side of the bed, bed was by waist level [to prevent hurting back], upper grab bars on both sides secured upright, and no fall mat used when Resident 1 fell on 8/12/25. CNA 2 further stated Resident 1 was holding on the upper right grab bar with her [Resident 1] right hand and had resident roll toward her [Resident 1] right side [face turned in the opposite direction from CNA 2]. CNA 2 stated while providing perineal care (or peri care, the gentle cleaning of the female genital and anal areas) on 8/12/25, Resident 1 kept moving and scratching her back, lost her balance and fell off the bed.During an interview on 7/22/26 at 3:00 PM with CNA 2, CNA 2 described Resident 1's placement in bed before the fall on 8/12/25 as near the edge of the bed. When asked what she could have done to prevent Resident 1's fall, CNA 2 stated, Make sure to position [resident] properly.place her in the middle of the bed.not on the edge.before rolling to side. Furthermore, CNA 2 stated, I learned my lesson.During an interview on 7/21/26 at 7:55 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was alert and oriented with some confusion at times, had lower extremity (consisting of the hip, thigh, knee, leg, ankle, and foot) weakness, no upper extremity (consisting of the shoulder, arm, forearm, and hand) limitations, able to roll on either side from lying position while holding on to the grab bar, and was dependent on her toileting needs with one-person assistance. LVN 1 stated that on 8/12/25, she went to Resident 1's room when CNA 2 called for help. Resident 1 was on the floor on the right side of the bed face down on her stomach screaming get me off the floor. According to LVN 1 during peri care, Resident 1 said she slipped far too over while turning to her side. LVN 1 stated Resident 1 complained of pain on the left side of her body.During an interview on 7/22/26 at 1:34 PM with Director of Nursing (DON), DON stated Resident 1 had capacity (mental ability to make decisions), weakness in lower extremities, and able to help turn herself with the use of grab bars. At time of fall on 8/12/25, per DON, Resident 1 was one-person assist with bed mobility (an individual's physical ability to change positions while in bed), no fall mat, and bed was in high position while CNA 2 was providing care. Additionally, prior to the incident Resident 1 had moderate fall risk (indicating an increased chance of falling; to prevent injury, healthcare providers typically implement fall precautions). When asked what could have been done to prevent the fall, DON stated, CNA education on patient alignment and proper positioning prior to turning.During a concurrent interview and record review on 7/22/26 at 1:58 PM with the DON, Resident 1's care plans, initiated on 7/22/25, were reviewed. DON acknowledged that the care plans were effective prior to the fall and stated, Yes, everything was active. DON confirmed there was no care plan to address Resident 1's risk for falls and stated, She doesn't have one. I don't see any care plan. When asked if Resident 1 had a care plan for the use of grab bar, DON stated, I don't see it. It should have a care plan. Furthermore, DON stated the importance of resident care plan was it directs staff on what care residents require.Review of Resident 1's Nursing Progress Note dated 8/12/25 at 8:22 AM indicated, .Writer [LVN 1] found resident on the floor of right side of bed laying [sic] on her stomach face down.Resident screaming in pain.Resident stated pain 10/10 (the worst pain possible often causing shock, crying out, or immobility) on entire left side. Resident left arm unable to lift.Review of Resident 1's Nursing Progress Note dated 8/12/25 at 4:02 PM indicated, At 3 PM - [name] RN from [name of hospital] called that resident will be admitted for fracture of left knee and left shoulder, but will be sent out to another hospital due to inability to manage the care/surgery trauma fracture.Review of Resident 1's Nursing Progress Note dated 8/14/25 at 10:44 PM indicated, Patient re-admitted from [name of hospital] at approximately 5:30 PM with diagnosis of femoral fracture (break in the thigh bone) .Review of Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool) dated 7/25/25, indicated, BIMS (Brief Interview for Mental Status, evaluates the ability to remember and think clearly) score of 14, indicating resident was cognitively intact. The MDS indicated Resident 1had lower extremity impairment on both sides and was dependent (helper does all the effort, resident does none of the effort to complete the activity) with toileting hygiene (ability to maintain perineal hygiene). The MDS likewise indicated substantial/maximal assistance (helper does more than half the effort; resident able to assist) with bed mobility (roll left and right; the ability to roll from lying on back to left and right side and return to lying on back on the bed).Review of Resident 1's Morse Fall Scale (simple method of assessing a patient's likelihood of falling), dated 7/21/25, indicated, Moderate risk of falling with a score of 40.Fall Scoring: Moderate Risk 25-44.Review of Resident 1's ED (Emergency Department) Provider Notes from the General Acute Care Hospital (GACH), dated 8/12/25 at 4:39 PM, indicated, .HPI (History of Present Illness) Resident 1 presents as trauma from [name of hospital] s/p (status post) fall from bed. Now with c/o (complaint of) left upper extremity pain and left lower extremity pain.ED Course & Medical Decision Making: S/p fall with extremity trauma. Injuries identified at outside hospital include left humerus fx (fracture) and left distal femur fracture.During an interview on 7/22/26 at 2:33 PM with the Administrator (ADM), the ADM stated they did not have policies to address accidents/falls, comprehensive care planning, and activities of daily living at the time of Resident 1's fall incident on 8/12/25.

Based on interview and record review, the facility failed to include one of one sampled resident (Resident 1) and her representative in developing Resident 1's comprehensive care plan when there were no interdisciplinary team (IDT, a group of health experts including doctor, nurse, therapist, social worker, dietitian and activity staff) meetings conducted after completion of Resident 1's assessments for quarterly review and significant change of condition due to fall with injuries.This failure violated Resident 1's right to participate in planning for her care.Review of Resident 1's admission Record indicated, Resident 1 was readmitted on [DATE] with diagnoses including unspecified injury of left and right thigh, type 2 diabetes mellitus (a lifelong condition where high blood sugar occurs because the body cannot make enough insulin [hormone that regulates blood sugar] or use it the right way), muscle weakness, and history of transient ischemic attack (TIA, a mini-stroke caused by temporary blockage of blood flow to the brain).Review of Resident 1's ED (Emergency Department) Provider Notes from the General Acute Care Hospital (GACH), dated 8/12/25 at 4:39 PM, indicated, .HPI (History of Present Illness) Resident 1 presents as trauma from [name of hospital] s/p (status post) fall from bed. Now with c/o (complaint of) left upper extremity pain and left lower extremity pain.ED Course & Medical Decision Making: S/p fall with extremity trauma. Injuries identified at outside hospital include left humerus (the long bone in the upper arm that goes from the shoulder to the elbow) fx (fracture) and left distal femur (lower part of thigh bone found behind the kneecap [bone located at the front of the knee]) fracture.Review of Resident 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool) indicated five MDS were completed in 2025: 1. Annual Assessment with Assessment Reference Date (ARD, refers to the specific endpoint for the observation [or look-back] periods in the MDS assessment process) 1/24/25; 2. Quarterly Review Assessment with ARD 4/25/25; 3. Quarterly Review Assessment with ARD 7/25/25; 4. Significant change in status with ARD 8/18/25 and 5. Quarterly Review Assessment with ARD 11/10/25.During an interview on 7/20/26 at 11:13 AM with Resident 1, Resident 1 stated she is primarily responsible for her healthcare decisions, with her daughter and mother involved in some ways. When asked if she and her mother were invited to attend IDT meetings, Resident 1 stated, We don't go.I didn't even know they existed.I don't think she [mother] knows either.During an interview on 7/20/26 at 2:54 PM with Nurse Case Manager (NCM), NCM stated scheduled IDT meetings were done for new admissions, quarterly, and annually after MDS is completed. Additionally, NCM stated impromptu IDT meetings were conducted for a resident's change of condition (e.g. placed on hospice care [ type of care, a program, or a place that focuses on the comfort, dignity, and quality of life for people who are terminally ill and expected to live six months or less]) and when requested by resident's family.During a concurrent interview and record review on 7/20/26 at 3:06 PM with NCM, Resident 1's IDT meeting notes were reviewed. NCM acknowledged there were two quarterly IDT meetings held in 2025; on 1/24 25 attended in person by the resident and resident representative and on 4/23/25, where Resident 1's daughter participated in the meeting via teleconference (a live meeting where two or more people in different places talk to each other using audio or video technology). NCM stated, No IDT meetings in July and November [quarterly assessment] .none after change of condition [2025].During an interview on 7/20/26 at 3:35 PM with Social Services Assistant (SSA), SSA stated care conferences/IDT meetings were held before or on the day of MDS assessment to determine if resident needed ancillary services (dental, vision, podiatry [care and treatments focused on the feet, ankles, and lower legs]) or if family wanted the services for the resident. SSA stated the process to engage the resident in the care conference was if the resident is alert and oriented.go to them first.ask if they can participate in the IDT meeting.up to the resident if she/he wants to invite family members. Furthermore, SSA stated Resident 1's mother was an emergency contact and was not notified of the appointment date and time for the care conference, just ask [Resident1] what she wants.ask [Resident 1] if she wants her mom to be in the care conference.During a concurrent interview and record review on 7/20/26 at 3:48 PM with Social Services Director (SSD), Resident 1's IDT meeting notes were reviewed. Per SSD, there were two IDT meetings held in 2025, one on 1/24/25 and the next was on 4/23/25. SSD stated a part-time SSA was responsible for calling/inviting the resident's family to join the care conference. SSD acknowledged there was no documentation that Resident 1's family was notified for a care conference in July and November 2025. According to SSD, part of her responsibility was make sure care conferences were done in a timely manner.every quarter and annually.four every year [IDT meeting]. SSD stated the main purpose of the care conference was to address any concerns, any changes in resident's condition. When asked why there were no IDT meetings held in July and November 2025, SSD had no reply.During an interview on 7/21/26 at 1:35 PM with Assistant Director of Nursing, the ADON stated a care conference was conducted for new admission, resident change of condition, annually, and quarterly [based on MDS assessment], or when requested by family; attended by IDT members [nursing, dietary, social services, activities]. ADON stated, It's important for care conferences to be held for the resident and family to be aware of any development/decline in resident's condition. ADON acknowledged that there were no IDT meetings held in July and November [quarterly assessment] and change of condition in 2025 for Resident 1 and stated, I don't see any. None.During an interview on 7/22/26 at 2:09 PM with Director of Nursing, the DON acknowledged the IDT meetings held in 2025 were on 1/24/25 and 4/23/25. When asked when the next IDT meeting was conducted, DON stated, Not until 1/20/26. I don't know how it was missed.During an interview on 7/22/26 at 2:33 PM with the Administrator (ADM), the ADM stated they did not have policies to address comprehensive care planning at the time care conferences were not conducted for Resident 1 in 2025.

Based on interview and record review, the facility failed to ensure five of 35 sampled residents (Residents 27, 50, 223, 175, and 32) received necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, residents' choices, and the facility's policies and procedures when the facility failed to: 1a. Implement Resident 27's ordered bowel protocol, as evidenced by no PRN ( pro re nata - as needed) constipation medications being administered during a seven day period without a bowel movement (BM).1b. Notify the physician when Resident 27 refused scheduled constipation medications, including Senna oral tablets (a stimulant laxative typically producing a BM in 6 to 12 hours) and MiraLAX oral powder (Polyethylene Glycol, an over-the-counter osmotic laxative - draw water into the intestine, softening the stool and increasing bowel movements - typically producing a BM within 1 to 3 days).1c. Develop a care plan addressing Resident 27's risk for constipation while receiving opioid therapy (a class of potent drugs that act on the nervous system to relieve pain with a side effect of constipation), and for the episodes of refusing ordered constipation medications. These failures resulted in Resident 27 experiencing severe pain, requiring transfer to the emergency room (ER) for treatment of fecal impaction (a result of constant constipation when a large lump of dry, hard stool stuck inside the rectum). And had the potential to result in decreased skin integrity, muscle strength, and range of motion (the extent of movement possible at a joint) for Resident 50's upper and lower extremities.2. The Restorative Nursing Program (a nursing care service designed to help individuals maintain or improve their physical, mental, and psychosocial independence) was not followed for Resident 50.3. Collaborate with the Hospice agency in the development of a Hospice care plan for Resident 223. 4. Identify and provide resident specific care needs to one of 35 sampled residents (Resident 175) who verbalized wanting to die to the psychiatrist during the psychiatrist consultation visit. This failure had the potential to result in harm to Resident 175. 5. Follow the physician order for the administration of pain medication for one of 35 sampled residents (Resident 32). This failure resulted in Resident 32 experiencing unrelieved back pain. 1. During a review of Resident 27's admission record indicated, the resident was readmitted to the facility on [DATE] with the following diagnoses: Ulcerative (chronic) proctitis with other complications (a limited form of ulcerative colitis which causes inflammation and ulcers within the lining of the rectum). Bladder-neck obstruction (a blockage at the neck of the bladder). Hemiplegia (total paralysis of one side of the body) and hemiparesis (partial weakness or reduced control affecting one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Unilateral (one-sided) primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right knee. Presence of right artificial knee joint. Chronic pain syndrome (a condition where persistent pain lasts beyond the expected healing time). During a review of Resident 27's Minimum Data Set (MDS – a federally mandated resident assessment tool) quarterly assessment, Assessment Reference Date (ARD - refers to the specific endpoint for the observation look-back periods in the MDS assessment process) of 4/13/26, indicated no cognitive impairment (any difficulty with mental processes, including memory, learning, concentration, and decision-making), was receiving PRN pain medications including opioid medications. During a review of Resident 27's admission History and Physical (H&P), dated 5/18/26, indicated, a chief complaint of rectal pain for one week and no stool for numerous days. CT (a computerized tomography scan - a type of imaging that uses X-ray techniques to create detailed images of the body) imaging indicated significant constipation with associated proctitis. The plan included aggressive disimpaction (a procedure used to relieve severe fecal impaction) with enemas and senna. During a concurrent interview and record review on 6/3/26 at 10:34 AM with Licensed Vocational Nurse (LVN) 1, Resident 27's hospital transfer form was reviewed. The hospital transfer form dated 5/14/26 indicated Resident 27 was transferred to the emergency room for severe abdominal and perineal pain (discomfort or aching in the pelvic floor) rated 10/10 (the absolute worst level of pain imaginable). PRN oxycodone ( powerful, prescription-only painkiller used to treat severe pain) 5 milligrams (mg) was administered prior to transfer. Upon return on 5/16/26, diagnoses included fecal impaction and proctitis. During a review of Resident 27's nursing progress note dated 5/14/26 indicated, Resident 27 experienced uncontrolled anorectal (discomfort in the anal or rectal area) pain rated 10/10, received PRN oxycodone, and subsequently requested transfer to the ER after pain worsened. During a review of Resident 27's B&B (bowel and bladder) – Bowel Monitor report, dated 5/1/26 through 5/14/26, for all shifts (day, evening, and night), indicated, No Bowel Movement on the following dates: 5/2/26, 5/3/26, 5/4/26, and 5/6/26, 5/7/26, 5/8/26, 5/9/26, 5/10/26, 5/11/26, and 5/12/26. During an interview on 6/8/26 at 9:33 AM, Registered Nurse Supervisor (RNS) 1 confirmed Resident 27 had three consecutive days without a BM (5/2/26 – 5/4/26) and seven consecutive days (5/6/26 – 5/12/26). RNS 1 stated that PRN medications should have been administered per the bowel protocol. During a review of Resident 27's Order Summary Report for May 2026, indicated the following medication active orders: 3/27/26: Polyethylene Glycol 3350 Oral Powder 17 gram by mouth one time a day for Constipation/hold for loose stool. Dissolve powder with 8 ounces of water prior to administration. 4/1/26: Senna Oral Tablet 8.6 mg (Sennosides). Give 2 tablets by mouth two times a day for laxative. 3/27/26: Dulcolax Oral Tablet Delayed Release 5 mg (Biscodyl). Give 3 tablets by mouth every 24 hours as needed for no BM x 24 hours. Repeat every 6 hours if no results. 4/1/26: Dulcolax Rectal Suppository ( a solid but readily meltable cone or cylinder of usually medicated material for insertion into a bodily passage or cavity) 10 mg (Bisacodyl). Insert 1 suppository rectally every 24 hours as needed for Constipation. 4/1/26: Oxycodone Hydrochloride (HCl) oral Tablet 5 mg (oxycodone HCl). Give 1 tablet by mouth every 4 hours as needed for pain. During a concurrent interview and record review on 6/8/26 at 9:40 AM with RNS 1, Resident 27's Medication Administration Record (MAR) from 5/1/26 to 5/14/26 was reviewed. RNS 1 confirmed and stated there was no documentation that any PRN constipation medication was administered during this period. The MAR indicated Resident 27 occasionally refused Senna, typically the morning dose; however, there was no documentation that the physician was notified of refusals. During a concurrent interview and record review on 6/8/26 at 9:46 AM with RNS 1, Resident 27's nursing progress notes for May 2026 were reviewed. RNS 1 found no evidence that the physician was notified of Resident 27's refusal of constipation medications and seven days without a bowel movement. RNS 1 stated that refusals must be reported so alternative treatment can be ordered, and that three days without a bowel movement requires immediate physician notification. During an interview on 6/8/26 at 9:48 AM, LVN 1 stated they did not notify the physician of Senna refusals and had not recognized the seven day absence of bowel movements. During a review of Resident 27's hospital Discharge Summary, dated 5/16/26, indicated the following diagnoses: fecal impaction with proctitis and urinary retention (the inability to completely or partially empty the bladder) most likely secondary to constipation. The Discharge Summary indicated, CT imaging on 5/14/26 confirmed rectal fecal impaction and proctitis. During a concurrent interview and record review on 6/8/26 at 9:50 AM with RNS 1, Resident 27's plan of care was reviewed. RNS 1 confirmed and stated there was no care plan addressing Resident 27's risk for constipation associated with opioid use, new diagnosis of fecal impaction with proctitis, and episodes of medication refusal. During an interview on 6/8/26 at 3:48 PM, the Director of Nursing (DON) stated the facility does not have a policy for medication refusals or comprehensive care planning and stated staff use clinical judgment. During a review of the facility's policy and procedure titled, Bowel Protocol, updated May 2025, indicated, Policy Statement: Residents are treated for constipation. Procedure: 1. The licensed nurse reviews the bowel monitor daily. 2. If a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program. 3. If the facility has no specific bowel program the nurse administers medication as ordered as follows: - administer milk of magnesia (an osmotic laxative used to relieve occasional constipation and as an antacid to treat heartburn and indigestion) per physician order on day four. If milk of magnesia offers no results, administer a stimulant laxative suppository or oral tablet (Bisacodyl, Senna, etc.) per physician order on the next shift, during waking hours only. If resident continues to have no results from suppository, administer an enema on the next shift, during waking hours only. If no results from enema, notify physician. 2. DEFINITION: Highest practicable physical, mental, and psychosocial well-being is defined as the highest possible level of functioning and well-being, limited by the individual's recognized pathology and normal aging process. During a review of Resident 50's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 50 was initially admitted to the facility on [DATE] with multiple diagnosis with an onset of 1/27/26 including: Functional quadriplegia (the partial or total paralysis of all four limbs as well as the torso), abnormal posture (any deviated body alignment that pulls the spine or joints out of their neutral position), and other abnormalities of gait (a person's pattern of walking) and mobility. A review of Resident 50's Minimum Data Set (MDS: a standardized resident assessment tool), dated 5/5/2026, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 50 scored 6 out of 15, this indicated Resident 50 had severe impairment in memory/reasoning. Resident 50's MDS also indicated limitations in range of motion that included impairments on both sides of her upper extremities (shoulder, elbow, wrist, hand), impairments on both sides of her lower extremities (hip, knee, ankle, foot), and was on the Restorative Nursing Program for passive range of motion (the movement of a joint entirely by an external force) and splint (a supportive device used to immobilize and protect an injured body part) or brace assistance. During a review of the facility's policy and procedure titled, Restorative Program, last revised on 3/2019, the policy indicated, .The Restorative Program focuses on achieving and maintaining optimal physical, mental, and psychological functioning of the resident to attain/maintain each resident's highest practicable functioning. During a concurrent observation and interview on 6/1/26 at 12:33 PM with a Certified Nursing Assistant (CNA 2) at Resident 50's bedside, Resident 50 was lying in bed on her right side with bilateral (both) upper and lower extremity contractures (the permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff and restricts normal movement). A pillow was placed between Resident 50's legs, but no towel or pressure relieving device was in place under Resident 50's left elbow. CNA 2 stated, Resident 50 could not move her arms or legs independently and staff place pillows in between Resident 50's legs to reduce pressure. When asked if pillows or towels were placed under Resident 50's elbows, CNA 2 stated, No. During a review of Documentation Survey Report V2, dated May-26 and June-26, the Survey report indicated no documentation for RNA 5x/wk FOR BOTH UPPER/LOWER EXTREMITY PROM and RNA PROGRAM #1: RNA program splinting program for Right elbow comfy splint for 5x/wk ongoing.(pls check skin, put towel on left elbow at all times per rehab) was noted on the following dates; 5/20/26, 5/27/26, 5/29/26, and 6/2/26. During an observation on 6/3/26 at 10:46 AM in Resident 50's room, Resident 50 was lying in bed on her back with no pillow or pressure relieving device in between legs, or towel under her left elbow. During an observation on 6/3/26 at 3:10 PM in Resident 50's room, Resident 50 was lying in bed on her right side with no pillow or pressure relieving device in between legs, or towel under her left elbow. During an interview on 6/8/26 at 1:32 PM with the Assistant Nursing Director (ADON 2), ADON 2 stated, no documentation on the medical record indicates the task was not completed. A review of Resident 50's Care Plan Report initiated on 4/6/2026 was reviewed. The Care Plan Report indicated Resident 50 was at risk for impaired skin integrity (the overall health and condition of the skin) related to: weakness, reduced mobility, and advanced age. Interventions implemented included Nursing Rehab/Restorative: Passive ROM Program: RNA 5x/wk FOR BOTH UPPER/LOWER EXTREMITY PROM and Nursing Rehab/Restorative: Splint/Brace Program. 3. During a review of Resident 223's admission record, dated 6/5/26, the admission Record indicated admitted on [DATE] with diagnoses including: Encounter for Palliative Care, Hemiplegia (weakness of one side of body) Fracture of second Cervical vertebra (break in the neck part), Vascular Dementia (memory decline that reduce blood flow to the brain). During a review of Resident 223's Order Summary Report, dated 6/1/26, the Order Summary Report indicated, Admit to ABL Hospice with terminal diagnosis of: Cerebrovascular Accident (a medical condition when there is a loss of blood flow to a part of the brain). During a review of Care Plan Report, dated 6/1/26, indicated, The resident has terminal diagnosis r/t Cerebrovascular Disease and is receiving hospice through ABL Hospice. There is no evidence of ongoing communication with the facility and the hospice agency. During a concurrent interview and record review on 6/3/26 at 2:30 PM with RN/MDS, resident 223's Care Plan Report was reviewed, dated 6/1/26. The Care Plan Report indicated, on Hospice, RN/MDS stated, Hospice care plan should indicate name and phone number of hospice agency, who the contact person to call for changes of condition. Per MDS, she starts care plan but unable to edit the template. MDS confirmed hopsice care plan for Resident 223 is not complete. During an interview on 6/5/26 at 3 PM with Assistant Director of Nursing (ADON1), ADON1 stated, the Hospice staff comes and each Hospice agency has a binder where the Hospice staff writes their visit documentation. They come to the nurse on duty and give some updates of the patient's condition. During a review of ABL Hospice binder, on 6/8/26 at 3 PM, binder has one documentation by RN staff on 6/1/25, indicated, admitted to ABL Hospice. No further documentation. During an interview on 6/8/26 at 3 PM with ADON1, ADON1 stated, there should be documented coordination of plan of care for patients on Hospice. Reviewed the binder, ADON1 confirmed, There is no schedule of hospice staff visits found. There is no coordination of care between us and the hospice agency. During an interview on 6/8/26 at 3:30PM, with Registered Nurse Supervisor (RNS4), RNS4 stated, the hospice nurse was here today and talked about the resident trying to take off neck brace, per hospice nurse it is okay. ADON1 did not find hospice nurse documentation as well as facility nurse documentation about the neck brace. During a review of facility's policy and procedure titled, Hospice- Provision of Care by Outside Providers, dated 8/2013, the Hospice policy indicated, centers collaborate with outside providers to coordinate the provision of hospice care as directed by each resident's physician. Procedure: 2. A POC (Plan of Care) is established in collaboration with the resident/resident's authorized representative to the extent possible and with the hospice. Hospice establishes the POC related to the terminal illness, related conditions, directive for management of pain and other uncomfortable symptoms. 3. The center maintains a POC that is consistent with the hospice POC. Plan is reviewed and updated as needed but no less often then quarterly. 6. The RCM or designee for the resident coordinates services with hospice. 4. During a review of the face sheet (a document created during admission which contains resident identification) Resident 175 was admitted with diagnoses including dementia (decline in memory or decision making ability), schizophrenia ( a severe mental illness that affects how a person think, feels, and behave), depression (persistent feeling of hopelessness or loneliness) and anxiety disorder (persistent feeling of fear or worrying). During a review of the minimum Data Set (MDS, a standard assessment tool) dated 2/6/26, Bried Interview of Mental Status (BIMS, a brief memory check to help determine cognitive functioning that includes thinking, learning, remembering, and problem-solving ability) score of 6 indicated severe cognitive impairment. During the initial rounding on 6/1/26, Resident 175 refused to meet with NS. Resident 175 preferred her door to always closed so no one knows her location. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 7 on 6/2/26, at 11:32 AM, Resident 175 was sitting on edge of bed, able to keep position, verbally responsive to Licensed Vocational Nurse (LVN) 7. Resident 175 declined to be interviewed and slammed the door closed. LVN 7 stated Resident 175 had aggressive behavior as manifested by screaming, cursing, and throwing things. During a review of the physician order for 6/2026, it indicated antipsychotic medication orders for Resident 175 as follows: Olanzapine 20 mg. Give one tablet by mouth at bedtime (HS). Olanzapine 5 mg. Give one tablet by mouth at HS. (Give a total dose of 25 mg at HS. 20 mg tab + 5 mg tab = 25 mg). During a concurrent interview and record review on 6/4/26, at 9:25 AM with LVN 7, Resident 175's Medication Administration Record (MAR) for 5/26 was reviewed. The MAR indicated, on 5/1/26, 5/2, 5/4, 5/5, 5/7 to 5/19/26, 5/22 to 5/25/26, 5/27 to 5/3126 (a total 26 times of 31 days) for the 2100 (9 PM) administration time, Resident 175 refused taking the olanzapine (an anti-psychotic, used to treat severe mental illness). During a review of facility document Behavior Monitoring and Interventions Report for 5/2026, it indicated Resident 175 manifesting behaviors as follows: making disruptive sounds, express anger at others, throwing things/food, throwing things at others, refusing shower/care, refusing medication, restlessness, withdrawal/isolation, screaming at others, wandering, cursing at others, not sleeping, sadness/tearful, threatening others, disrobing in public. Resident 175 had manifested other behavior such as entering other residents' room, being physically aggressive towards others, being accusatory, pacing, calling 911, and verbalizing persistent beliefs that are not true. During a recurrent interview and record review on 6/4/26, at 10:51 AM, with the Director of Nursing (DON), the psychiatrist consultation visit note dated 3/10/26 was reviewed. The Psychiatry visit notes dated 3/10/26, indicated, .History of present illness: Fell a few days ago. Once again refusing almost all medications. Past behavior of crying yelling, calling 911 (for pain, after refusing pain medication), responding to hallucinations, aggression towards staff, residents, and family members. Hit TV, threw water on the floor. In community she tends to function at a low level, prone to noncompliance (especially with diabetic medications); does better when she stays on her medications. Came to this facility after hospitalization when she was found at home. Was taking Olanzapine, Trazodone, and Mirtazapine at home. Last inpatient hospitalization in May of 2023, stabilized on Mirtazapine and Zyprexa at that time. Endorses past psychiatric hospitalizations and seeing a psychiatrist at SFGH but denies schizophrenia or any other psychiatric diagnosis. In facility since 7-11-24. Sources of information: patient, staff, medical record.MEDICAL HISTORY: schizophrenia, diabetes mellitus, hypertension, hyperlipidemia, GERO, history of falls. atelectasis, constipation CURRENT PSYCHIATRIC MEDICATION: Olanzapine 25 mg po qhs (increased 12-24-25) tor schizophrenia M/B responding to auditory hallucinations . SUBJECTIVE: I want to die. That is the only thing she says today. IMPRESSION: Schizophrenia, insomnia .No more aggressive behavior but she is refusing medications again and generally functions at a very low level. Will continue to monitor. PLAN: No changes at this time. The DON stated that the psychiatric visit notes were sent by the provider to the facility medical records (MR) department the same day of visit or the day after. MR department then sent an email to the DON to notify them that the visit notes were received. DON stated, I can't review all of them. We don't read all of doctor's documentation. DON further stated that she has not interviewed Resident 175. The DON acknowledged the SI/verbalization of wanting to die was not identified, resident specific behavior monitoring was not initiated, and there was care plan with intervention created to address SI / verbalization of wanting to die. The DON further stated the need to discuss the incident with the psychiatrist. During an interview on 6/8/26, at 10:16 AM, the Administrator stated that the facility has no policy and procedures to address the following: Care of Resident with Suicidal Ideation, Resident Safety, and Behavior Management. 5. During a review of the face sheet (a document created during admission which contains resident identification) Resident 32 was admitted with diagnoses with diagnoses including laminectomy (a spinal surgery to relieve pressure on the spinal cord or nerves) due to spinal stenosis (narrowing of spaces within the spine) and mood disorder (a mental health condition that affects the persons emotional state). During observation on 6/1/26, AT 11:13 AM, Resident 32 was alert, verbally responsive. Resident 32 was aware of the medical condition for admission to the facility. Resident 32 stated to not being able to sleep well at night due to the pain medication does not help relieve back pain. During a concurrent interview and record review on 6/3/26, at 10:32 AM, with the Registered Nurse (RN) 6, the physician orders dated 5/2026 and 6/2026 were reviewed. RN6 stated that the physician order indicated pain medication ordered for Resident 32 as follows: Oxycodone Hcl (used to relieve pain) 5 milligrams (mg, a unit of measurement). To give one tablet by mouth every six hours as needed for mild to moderate pain. Oxycodone Hcl 5 mg. give two tablets by mouth every six hours as needed for severe pain. Oxycodone Hcl 5 mg. Give two tablets by mouth in the morning one hour prior to physical therapy. RN 6 stated that the facility uses the numeric pain assessment/ [NAME] faces. (0 - no hurt, a happy smiling face. The person feels no pain. 2 – hurts a little bit. A mild smile. The pain is slight. 4 – hurts a little more. A straight mouth. The pain is noticeable but manageable. 6 – hurts even more: A slightly downturned mouth. The pain is increasing. 8- Hurts whole lot: A frowning mouth. The pain is intense.10 – Hurts worst. A crying distraught face. The pain is severe and unimaginable as possible). During a review of the MAR for 5/2026 and 6/2026, it indicated: 5/5/26 = pain 3/10 - pain medication for mild to moderate pain was not administered. 5/26/26 = pain 7/10- pain medication for mild to moderate pain was not administered. 5/29/26 – pain 6/10 - pain medication for mild to moderate pain was not administered. 5/30/26 = 10/10 - pain medication for severe pain was not administered. 6/3/26 – 3/10 - pain medication for mild to moderate pain was not administered. During a review of the facility Policy and Procedure titled, Pain Management dated 5/2026, indicated, .It is the policy of this center that residents receive care and maintain the highest quality of care and life.The resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the plan of care and or physician order. Data for the evaluation of pain management is collected from the medication administration record (MAR), nursing progress notes and through the daily clinical meeting/review process.An appropriate pain scale is selected for us based upon resident ability and needs. Examples may include but not limits to: Numeric 1-10. Verbal descriptor Scale, [NAME] Faces, and the PAINAD (Pain Assessment in Advanced Dementia). For residents using PRN pain medications, a 0-10 pain scale is used to document levels of pain both before and after receiving pain medication. If it is determined that pain is not controlled to the resident's satisfaction, the medical provider is consulted.A resident may state that non-pharmacological interventions are ineffective and request only pharmacological intervention be implemented and their request is honored.

Based on interview and record review, the facility failed to ensure the governing body provided effective oversight of the Quality Assurance and Performance Improvement (QAPI) program-a data driven, proactive approach used to monitor and improve the quality of services. The facility did not implement, sustain, or evaluate corrective actions developed in response to identified deficiencies.This lack of governing body oversight resulted in recurrent noncompliance and had the potential to negatively impact the quality of care and services provided to residents, including their quality of life.(Cross reference: F554, F584, F609, F656, F677, F755, F761)Review of the facility's QAPI Meeting Minutes from June 2026 to July 2026 showed no documented evidence of oversight regarding the implementation of the action plans meant to address identified deficiencies. During an interview on 7/30/26 at 4:00 PM, Nursing Home Administrator (NHA) stated each department was responsible for implementing corrections, Department Managers or designees address issues during rounds and audits, reporting results in QAPI meetings. Review of the QAPI Meeting minutes dated 6/29/26 indicated, .4. Each Department will report on the following, Minutes to include summary, compliance %, comparison when appropriate, and action/recommendations . Review of the facility's policy and procedure titled, QAPI Plan, revised March 2024, indicated, Policy Statement: The Center develops Quality Assurance Performance Improvement (QAPI) Plan to identify and correct quality deficiencies when they occur throughout the Center, as well as to identify opportunities for improvement . The Quality Assurance (QAA) Committee oversees the Center QAPI program. They are tasked with identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine and validate changes are effective and sustained . Governance and Leadership: 1. The Executive Director is responsible and accountable to the corporation to ensure QAPI is effectively implemented and integrated throughout the center .5. Executive Director validates that the QAPI plan is reviewed at least annually in the QAA Committee. Revisions occur as needed to reflect any changes in practices or services. Revisions are reviewed by the QAA committee as well as our governing body .

Based on interview and record review, the facility failed to ensure a qualified social worker was employed on a full-time basis. This failure had the potential to result in residents not receiving appropriate coordination of medically related social services to meet their needs. (Cross Reference to F578, F628, F644, F605, F677, F685, and F745)Review of the personnel file for the Director of Social Services (DSS), identified by the facility as the Social Services Director, showed no documentation of required one year of supervised social work experience to meet the regulatory qualifications for a social worker in a skilled nursing facility.During an interview on 6/3/26 at 4:25 PM, the DSS stated the facility had three social workers, including the DSS. When asked about their qualifications, the DSS stated: The DSS holds a bachelor's degree in psychology. One social worker has a Social Service Designee in Long Term Care certificate. The third social worker did not have a certificate.The DSS further stated this was their first job in a healthcare setting and that they did not have prior social work experience.During an interview on 6/3/26 at 4:43 PM, the Nursing Home Administrator (NHA) stated that the Executive Assistant to the Administrator was recently promoted to Social Services Director. The NHA stated the posting for a Licensed Social Worker position was removed because the current DSS had a bachelor's degree in psychology.Review of the job description for Social Services Director, updated March 2025, indicated, .Education, Licensure, and Experience - 1. A minimum of a bachelor's degree from an accredited program of social work or gerontology preferred or as per state law requirements. 2. Prefer a minimum of two years of work-related experience in long term care or other related programs. 3. If applicable (per State requirement) maintain current license. 4. Maintain on going education to understand and initiate changes in social service program that are current with regulatory requirements and Community's standards .

Based on interview and record review, the facility failed to ensure a qualified social worker was employed to provide required medically related social services. This failure resulted in Residents #68, #5, #32, #175, #223, #221, and #__ not receiving medically related social services; and had the potential to negatively impact other residents' ability to receive timely medically related social services, including psychosocial support, discharge and transition assistance, and advocacy regarding resident rights. (Cross Reference to F578, F628, F644, F605, F677, F685, and F745)Review of the facility's license to operate, it indicated the facility had a bed capacity of 239, with an effective date of 11/19/2025 and expires on 11/18/2026.The facility census on 6/1/26 was 214 residents. Review of the personnel file for the Director of Social Services (DSS), identified by the facility as the Social Services Director, showed no documentation of required one year of supervised social work experience to meet the regulatory qualifications for a social worker in a skilled nursing facility.During an interview on 6/3/26 at 4:25 PM, the DSS stated the facility had three social workers, including the DSS. When asked about their qualifications, the DSS stated: The DSS holds a bachelor's degree in psychology. One social worker has a Social Service Designee in Long Term Care certificate. The third social worker did not have a certificate.The DSS further stated this was their first job in a healthcare setting and that they did not have prior social work experience.During an interview on 6/3/26 at 4:43 PM, the Nursing Home Administrator (NHA) stated that the Executive Assistant to the Administrator was recently promoted to Social Services Director. The NHA stated the posting for a Licensed Social Worker position was removed because the current DSS had a bachelor's degree in psychology.Review of resident records for Residents #68, #5, #32, #175, #223, #221, and #__ showed: Missing or incomplete psychosocial assessments Delayed updates to care plans and care conference meetings Lack of follow up on ancillary services (dental, podiatry, vision) Lack of follow up regarding documented mood or adjustment concerns Incomplete or missing advance directives and discharge planningReview of the job description for Social Services Director, updated March 2025, indicated, .Education, Licensure, and Experience - 1. A minimum of a bachelor's degree from an accredited program of social work or gerontology preferred or as per state law requirements. 2. Prefer a minimum of two years of work-related experience in long term care or other related programs. 3. If applicable (per State requirement) maintain current license. 4. Maintain on going education to understand and initiate changes in social service program that are current with regulatory requirements and Community's standards .

Based on interview, record review, and policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI - refers to the coordinated application of two mutually reinforcing aspects of a quality management system) Program that ensured the development and implementation of policies and procedures governing resident care, treatment, services, and physical environment.This systemic failure resulted in multiple deficient practices that impacted the quality of care, quality of life, and resident safety. (Cross Reference to F578, F628, F644, F655, F656, FF658, F677, F684, F685, F689, F745, F755, F756, F757, F761, and F850)During an interview on 6/9/26 at 3:17 PM, the Nursing Home Administrator (NHA) acknowledged that multiple facility policies and procedures governing resident care and services were missing. The NHA stated that the corporate office had removed a large number of policies, and the facility had not replaced or updated them.Review of facility documents confirmed that there were no policies or procedures in place for the following areas:Restorative Nursing Assistant (RNA) job descriptionRestorative nursing programPhysical and occupational therapy servicesActivities of Daily Living (ADLs)Comprehensive care planningAccident preventionCare of residents with suicidal ideationMedication refusal procedures Behavior ManagementCare of Resident with Suicidal IdeationResident SafetyComprehensive Care PlanningCare ConferenceInterdisciplinary TeamChange In ConditionAccident PreventionPhysician's OrderReview of the facility's QAPI Plan, updated March 2024, indicated, Policy Statement: The Center develops a Quality Assurance Performance Improvement (QAPI) Plan to identify and correct quality deficiencies when they occur throughout the Center, as well as to identify opportunities for improvement . The Quality Assurance (QAA} Committee oversees the Center QAPI program. They are tasked with identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine and validate changes are effective and sustained . Review of the Facility Assessment, revised January 2026 indicated, .The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require . Our mission is to deliver compassionate, high-quality healthcare services in the state in which we serve. We are dedicated to enhancing the well-being and dignity of every individual we serve through innovative care practices and personalized attention .

Based on observation, interview, and record review, the facility failed to actively assist to discharge on e of 35 sampled residents (Resident 32) when Resident 32 expressed the desire to be discharged and to transfer to another facility. The facility failure resulted in Resident 32 experiencing emotional distress during her stay in the facility. During a review of the face sheet (a document created during admission which contains resident identification) Resident 32 was admitted with diagnoses with diagnoses including laminectomy (a spinal surgery to relieve pressure on the spinal cord or nerves) due to spinal stenosis (narrowing of spaces within the spine) and mood disorder (a mental health condition that affects the persons emotional state). During a review of the Social Services (SS) notes dated 5/28/26, the SS notes indicated Resident 32 transitioning to long term care (LTC) starting 5/28/26. During observation on 6/1/26, AT 11:13 AM, Resident 32 was alert, verbally responsive. Resident 32 was aware of the medical condition for admission to the facility. Resident 32 had a flat affect (absence of emotional expression). Resident 32 stated to not being able to sleep well at night due to back pain and that the pain medication does not help relieve the pain. During an interview on 6/3/26, at 9:47AM, Certified Nurse Assistant (CNA, caregiver) 10 stated being the sitter assigned only to Resident 32. CNA 6 stated that she served her meals, assisted in getting dressed and wrote down what the Resident 32 were doing. During a concurrent interview and record review on 6/3/26, at 10:22 AM, Registered Nurse Supervisor (RNS) 1 stated Resident 32 was on one-on-one monitoring due to suicidal ideation (thoughts of ending one's life). RNS 1 stated that on 5/29/26, Resident 32 attempted to stab herself on the head with a fork. RNS 1 stated Resident 32 reached out to the previous medical provider, who then called 911 for crisis intervention for Resident 32. RNS 1 further stated that Resident 32 agreed to go to the emergency department on 5150 hold (a California legal code that allows the police officers and mental health professionals to involuntary detain a person experiencing a mental health crisis [an immediate risk of self-harm or harm to others] for psychiatric evaluation of up to 72 hours). RNS 1 stated that Resident 32 returned to the facility the same day after the ED informed the facility that Resident was cleared. RNS 1 reviewed the ED After Visit notes Summary dated 5/29/26, that indicated Resident 32's diagnosis included suicidal ideation, chronic pain syndrome, acute pain of left knee mood disorder. The ED after visit summary indicated that psychiatry and social services consultations were completed. RNS 1 further reviewed Resident 32's health record and did not find the complete psychiatric and social services consultations in ED. RNS 1 stated the facility will request a copy.During a review of the nurses' notes dated 5/29/26, it indicated that the facility received a call from Primary Care Physician's (PCP) nurse at around 4:12 PM, informing the facility that residents had called them three times (3x) since 10:30 AM. The nurses' notes indicated that Resident 32 reported that she felt uncomfortable and not safe in the facility. Resident 32 was advised to call 911 if they felt like hurting herself. The nurses' notes further indicated that on Resident 32's latest call to the PCP's office, Resident 32 verbalized that her life is in danger and that she might hurt herself .During a review of Change in Condition notes dated 5/29/26, indicated that the police officers/crisis intervention came to the facility and addressed concerns that Resident 32 was feeling desperate and didn't want to stay in the facility. Resident attempted to stab herself on the head with a fork. During an interview on 6/4/26, Medical Records Staff 1 stated the facility had obtained the copy of the psychiatric evaluation completed in ED when Resident 32 went on 5150 hold. During a review of the psychiatry note from ED dated 5/29/26, indicated Resident 32, . reported Two recent falls: one where she hit her back on a table and one in a shower with a Certified Nurse Assistant (CNA, caregiver) present, resulting in significant pain, (resident 32) Described feeling unsupported at the facility, perceiving that staff were against her, and expressed frustration and exhaustion with her current situation. (Resident 32) Stated desire to return to her previous rehabilitation facility (name of rehab) for continued therapy as she still requires assistance with ambulation and activities of daily living . expressing distress bout her treatment in the facility, stating that such situations could lead people to consider suicide . Collateral information from the chart and facility indicated concern for possible paranoia and adjustment disorder with mixed anxiety and depression . (Resident 32) expressed a strong desire to transfer to another rehabilitation facility .Her statements regarding the facility were interpreted as distress .Active Problem list included recurrent mood disorder and recurrent major depression .Mental status examination indicated .Mood: tired, frustrated .thought content: preoccupied with facility issues .judgement: impaired . The psychiatry notes from ED dated 5/292/6, further indicated (Resident 32's) mental status revealed impaired insight and judgment . There is evidence of adjustment disorder with mixed anxiety and depression, likely related to her medical condition, recent falls, and perceived mistreatment in the facility . Continued monitoring for delirium and adjustment disorder is warranted, and transfer to a more supportive rehabilitation environment may be critical . Recommendation .medical social work consult to place resident (patient) at (name of rehab facility) . During a review on the care plan intervention for Resident 32 dated 5/29/26, the care plan did not address the emotional distress Resident 32 was experiencing in the facility. During a review of the Interdisciplinary (IDT) Meeting Notes dated 6/1/26, it indicated for the social services to follow up. The IDT meeting notes did not address Resident 32 wanting to be discharge and transferred to another facility resulting to Resident 32 experiencing emotional distress in the facility. During a review of the social services notes dated 5/28/26, 6/1/26, and 6/2/36, did not address the Resident 32 wanting to be discharged and transferred to another facility resulting to Resident 32 experiencing emotional distress in the facility. During an interview with the Director of Nursing on 6/4/26, at 10:51 AM, the DON stated that the social services follow up resident referrals.During a review of the Policy and Procedure titled, Transfer and discharge date d 5/2025, indicated, .The facility validates transfer and discharges occur in a manner that maintains or improves the resident's physical, mental, and psychosocial well-being .Transfer and discharges may occur for any of these reasons: The resident's welfare and the resident's needs cannot be met in the facility. The residnet's health has improved sufficiently so they no longer need services provided by the facility, The safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. The health of individuals in the facility would otherwise be endangered .Social services/Designee coordinates transfers or discharges to assist in the resident's adjustment.

Based on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services that included accurate and safe administration of medications, availability of medications, and accurate accountability and record of controlled substance (CS; medications that can be easily abused and are under strict government control) when:1. A nursing staff did not correctly prime an insulin pen as per manufacturer's instructions during the medication administration for one of one resident (Resident 133). This had the potential for too much or too little insulin being administered.2. Three out of five inspected emergency kits (e-kits, box containing medications for immediate use during a medical emergency) were not replaced within 72 hours, as required. This had the potential for medication unavailability during a medical emergency.3. A routine twice-daily breathing medication, Advair Diskus, for a non-sampled resident (Resident 122) was being used past the discard date and not accurately administered. Within a period of 1 month and 23 days, only 18 doses were administered from the inhaler. This had the potential for untreated medical condition or treatment failure for the resident.4. CS disposition (destruction) records were not readily available for review. This resulted in a lack of system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications.5. CS medications were signed out of the Controlled Drug Record (CDR, an inventory sheet) but not documented on the Medication Administration Record (MAR) for 3 out of 4 residents (Resident 12, 18, and 68). This had the potential for loss/abuse of CS medications. 1. During the medication administration observation on 6/1/26 at 12:14 PM, with Licensed Vocational Nurse Supervisor (LVNS), she was observed preparing an insulin dose for Resident 133. She stated the resident needed 1 unit of insulin. She removed the Insulin Lispro Kwikpen (a pre-filled pen containing lispro, a short-acting insulin to lower blood sugar) from the medication cart, turned the dose dial to 2 units, pointed the pen downward into a cup, and pressed on the injection button to prime the pen. Then LVNS dialed the dose to 1 unit. On 6/1/26 at 12:17 PM, LVNS injected the insulin into the resident's abdomen. On 6/01/26 at 12:21 PM, a review of the manufacturer's online instructions with LVNS regarding the priming of the Insulin Lispro Kwikpen indicated to hold the pen upright to remove air, and observing for the insulin drop or stream coming out of the needle while pressing on the injection button. This way the user can make sure the needle works before dialing to the ordered unit. LVNS acknowledged she did not hold the pen upright while priming the insulin needle. A review of the INSTRUCTIONS FOR USE Insulin Lispro KwikPen from the manufacturer, revised July 2023, indicated in part: Step 6 To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle.- If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times.- If you still do not see insulin, change the Needle and repeat priming steps 6 to 8 .Step 9: Turn the Dose Knob to select the number of units you need to inject. 2. During an inspection of the 1East Medication Room on 6/1/26 at 2:47 PM with LVN 7, two ekits were observed being sealed with yellow seals, indicating they were previously opened. LVN 7 opened these 2 ekits for inspection. The log in the injectable medication ekit indicated it was opened for resident use on 5/23/26 (9 days before survey date); and the log in the oral medication ekit indicated it was opened for resident use on 5/27/26 (5 days before survey date). LVN 7 verified these findings and stated she did not know how soon to replace the ekits after opening but we call the pharmacy as soon as opened. During an inspection of the 2West Medication Room with LVN 8 on 6/1/26 at 3:51 PM, an inspection of the oral medication ekit indicated it was sealed with yellow seals, indicating it was previously opened. LVN 8 opened the ekit for inspection. The log in the oral ekit indicated it was first opened for resident use on 5/22/26 (10 days before survey date). During an interview with the Director of Nursing (DON) on 6/2/26 at 10:41 AM, she stated opened ekits are to be replaced within 24 hours but will check what the policy says. During a telephone interview with the Consultant Pharmacist (CP) on 6/4/26 at 9:37 AM, he stated opened ekits are to be replaced within 72 hours. A review of the facility's policy and procedure (P&P) titled EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS, dated 8/2014, indicated, If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. 3. On 6/1/26 at 2:11 PM, inspection of the 1West Team 2 Medication Cart with the LVN Supervisor (LVNS) identified a Fluticasone-Salmeterol (Advair) Diskus (inhaler with medications for breathing problems such as asthma and chronic obstructive lung disease) for Resident 122, which had the open date of 4/8/26. The manufacturer's instructions on the carton indicated to discard 1 month after opening. LVNS verified Resident 122's Advair Diskus was being used past the discard date, which would have been on 5/8/26 (24 days before survey day). On 6/1/26 at 2:45 PM, a review of the Advair Diskus for Resident 122 with LVNS indicated: it came with 60 doses; was dispensed by the pharmacy on 3/18/26; was opened on 4/8/26; and the dose indicator showed it had 42 doses remaining. This indicated that only 18 doses (60 - 42 = 18) had been administered. The LVNS acknowledged this finding and stated she could not explain it. Further review of the medication cart contents revealed there were 2 additional Advair Diskus inhalers for Resident 122. One had the dispense date of 4/13/26, and the other 5/27/26. Both were still intact (unopened). A review of Patient 122's clinical record indicated she was admitted to the hospital with diagnoses including acute respiratory (breathing) failure with hypoxia (low levels of oxygen in your body tissues), pleural effusion (abnormal buildup of excess fluid in the pleural space, the thin area between your lungs and chest wall), and kidney dialysis (treatment that removes wastes and excess fluid from your blood). A review of Resident 122's Minimum Data Set (MDS, a care area assessment and screening tool), dated 1/27/26, indicated he had a BIMS (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15) score of 11, which indicated her cognitive condition was moderately impaired. A review of Resident 122's physician's orders indicated she had an order for Advair Diskus Inhalation Aerosol Powder (Fluticasone-Salmeterol) 250-50 micrograms per actuation, 1 inhalation orally two times a day for shortness of breath (SOB) since 3/18/26. A review of Resident's 122's April and May 2026 MARs indicated the nursing staff has been documenting, except for 12 occasions where the staff held the dose for various reasons, they administered the Advair Diskus twice daily to the resident 95 times since 4/8/26 (open date): 38 times in April and 57 times in May. In other words, in a period of 1 month and 23 days from 4/8 to 5/31/26, the staff documented they administered 95 times while only 18 doses of the Advair Diskus were used. During an interview with Resident 122, on 6/2/26 at 1:10 PM, Resident 122 stated she has been in the facility for a long time and did not come with her own inhalers and the facility provided medications for her. She stated she sometimes could not breathe well and has SOB due to water in her lungs. When asked whether she was administered the Advair inhaler routinely, she stated she did not like the purple (Advair) inhaler, only the red one which she used to have. She stated she refused each time the purple one was offered because she did not like the taste it leaves in her mouth. During an interview with the LVNS on 6/2/26 at 1:18 PM, she stated Resident 122 used be on the red inhaler called Symbicort (a combination of breathing medications) but it was discontinued and changed to Advair. She stated the resident sometimes refused her Advair inhaler and prefers the Symbicort. When asked if the nursing staff communicated with the doctor about the resident's preference for Symbicort or refusal of Advair, the LVNS reviewed the nursing progress notes and stated, No. During a concurrent interview and record review with the DON, Nurse Consultant (NC) 1, and NC 2, on 6/2/2026 at 1:58 PM, the DON stated her team did an investigation about Resident 122's Advair administration, and what they identified was inaccurate documentation from the nursing staff. She explained that there were situations when the staff documented they administered the medication while the resident was not in the facility (such as being hospitalized ). The DON and the NCs explained they looked into the 42 doses left from the opened Advair Diskus. There were 12 occasions where the dose was held due to various reasons such as refusal or hospitalization, this left 30 times (42 - 12 = 30) where it was documented on the MAR but not actually administered. The DON stated the nursing staff should have communicated with the physician about the resident's refusal and about her preference for Symbicort. On 6/3/26, the DON provided the pharmacy's dispensing record for Resident 122. Its review indicated one Advair Diskus was delivered on 3/18/26; one on 4/14/26, and one on 5/28/26. Both the 4/14 and 5/28/26 Advair Diskus inhalers were unopened (not used). During another interview with the DON on 6/3/26 at 1:13 PM, she verified the pharmacy dispensed 3 Advair Diskus inhalers since 3/18/26; only 1 was used, and only 18 doses from that opened inhaler were administered although the staff documented they administered twice daily since 3/18/26 except for the 12 held occasions. When asked what she thought might have happened, the DON stated, I don't know what happened. She verified the medication was not given as ordered for Resident 122. During an interview on 6/4/26 at 12:19 PM, the DON stated the facility uses the pharmacy policy related medication administration. Its review indicated it did not delineate the process for following the physician's orders. She stated it is expected that the nursing staff follow the physician's orders as it is within the nursing scope of practice. A review of review of the facility's P&P titled PROCEDURES FOR ALL MEDICATIONS, dated 4/2008, indicated, the facility to administer medications in a safe and effective manner. It further indicated, If resident refuses medication, document refusal on (MAR or TAR [treatment administration record]). 4. On 6/2/26 at 10:49 AM in the presence of the DON, a large, locked cabinet was observed inside the DON's office. The DON opened the cabinet for inspection, which showed it was full of controlled substance (CS) medications. The DON stated these were discontinued or discharged CS medications waiting to be destroyed with the Consultant Pharmacist (CP). The DON stated she did not keep a log of the medications inside this cabinet. She explained whenever the staff nurse gives them to her, she verifies the amount with the controlled drug record (CDR, an inventory sheet), then she would put the medication along with the CDR inside the cabinet until it is destroyed with the CP. During destruction, they both would verify the amount and sign the CDR. The DON stated they last did the destruction of CS medications on 4/7/26, and the previous time was about a month before that. The DON stated the disposition records were given to the Medical Records Office to file. She was requested to provide the CS disposition records for the last two destruction conducted with the CP. On 6/2/26 at 11:19 AM, the Medical Records Staff (MRS) stated the CDRs for destroyed medications are given to her, and they are filed in the individual resident's overflow chart. However, she did not keep copies of the CDRs or a log of the medications that were destroyed. The only way to access them is to identify the residents' names whose medications were destroyed during the last 2 times, so she could pull the charts. During an interview on 6/2/26 at 11:38 AM, the DON stated she did not know the MRS would just scan the CDRs into the individual resident's chart and not keep copies. She stated she could not provide disposition records for the last 2 times as requested. She acknowledged it was difficult to readily identify what was destroyed, such as resident names, drug names, drug strength, quantities, etc., the last few times including those conducted on 4/7/26. A review of the California Code of Regulations Title 22, section 72369(b)-(c) indicated, (b) Separate records of use shall be maintained on all Schedule II drugs. Such records shall be maintained accurately and shall include the name of the patient, the prescription number, the drug name, strength and dose administered, the date and time of administration and the signature of the person administering the drug . Drug records shall be maintained for drugs listed in Schedules III and IV of the above Act [Federal Comprehensive Drug Abuse Prevention and Control Act of 1970] in such a way that the receipt and disposition of each dose of any such drug may be readily traced. A review of facility's P&P titled CONTROLLED MEDICATIONS, dated 4/2008, indicated: Facility should record destruction of controlled substances on medication/destruction form, narcotic count form, or medication disposition log book. 5. On 6/3/26 at 3:36 PM, a concurrent interview and record review was conducted with the DON. She stated whenever a PRN (as-needed) controlled medication was requested from the resident, the nursing staff would assess the resident's pain, review the medication order, make sure the order matches the indication, administer the medication, and document the administration on the MAR. a. A review of Resident 12's physician's orders indicated an order for Hydrocodone-Acetaminophen (Norco, a CS medication for pain) 5-325 mg, 1 tablet every 6 hours as needed for severe pain, dated 5/4/26. On 6/3/26 at 3:40 PM, a review of Resident 12's CDR for Norco 5-325 mg and the May 2026 MAR with the DON indicated the nursing staff signed 1 tablet out of the CDR but did not document the administration on the MAR on 3 occasions: on 5/5 at 0630; 5/6 at 0630, and 5/13/26 at [illegible time]. During the review, the DON verified the missing documentation and stated, I don't find them but they should be documented on the MAR. b. A review of Resident 68's physician's orders indicated an order for Oxycodone (a potent narcotic for pain) 5 mg, 1 tablet every 6 hours as needed for breakthrough pain, dated 11/15/25. On 6/3/26 at 3:44 PM, a review of Resident 68's CDR for Oxycodone and the May 2026 MAR with the DON indicated the nursing staff signed 1 tablet out of the CDR on 5/31/26 at 10:00 but did not sign the name; and another tablet on 5/31/26 at 2000 but did not document the administration on the MAR. The DON reviewed both the MAR and the corresponding nursing progress notes and stated she could not find the administration on 5/31/26 at 2000. c. A review of Resident 18's physician's orders indicated an order for Hydrocodone-Acetaminophen (Norco) 5-325 mg, 1 tablet every 6 hours as needed for severe pain, dated 4/25/26. On 6/3/26 at 3:48 PM, a review of Resident 18's CDR for Norco 5-325 mg and the December 2025 MAR indicated the nursing staff signed out 1 tablet from the CDR but did not document the administration on the MAR on 5 occasions: on 12/8 at [illegible time], 12/8 at 2200, 12/13 at 2100, 12/21 at 1946, and 12/23/26 at 0030. After reviewing the MAR and the nursing progress notes, the DON stated she could not find evidence they were administered. On 6/3/26 at 3:54 PM, the DON acknowledged CS were not fully accounted for Residents 12, 18, and 68. A review of facility's P&P titled CONTROLLED MEDICATIONS, dated 4/2008, indicated:Whenever a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4) Initials of the nurse administering the dose on the MAR after the medication is administered.

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for 2 out of 35 sampled residents (Residents 11 and 88). Resident 11 has been receiving an antibiotic for longer than 6 months without a stop date and an evaluation for long term use, resulting in unnecessary medication use which is longer than needed for the resident. Resident 88 had no CP's monthly MRRs from January 2026 to June 2026, which had the potential for unidentified medication irregularities. Also, the CP failed to identify undated/expired inhalers during the monthly medication inspection resulting inhalers for 10 residents (18, 28, 43, 44, 48, 65, 56, 122, 139, and 157) identified without a labeled open date or being used past the discard date per manufacturer's instructions in 4 out of 4 inspected medication carts. This had the potential for untreated/ineffective treatment and negative health outcomes for the residents. 1. During the medication administration observation on 6/2/26 at 9:17 AM, Licensed Vocational Nurse 2 (LVN 2) was observed administering the Polytrim (polymyxin B-trimethoprim- a combination of antibiotics to treat eye infections) eye solution into Resident 11's eyes. A review of Resident 11's physician's orders indicated an order for Polytrim Ophthalmic Solution (Polymyxin B-Trimethoprim), instill 1 drop in right eye two times a day for bacterial eye infections, dated 11/27/25 (more than 6 months ago). The order did not have a stop date. During a concurrent interview and record review with LVN 2 on 6/2/26 at 12:14 PM, when asked why Resident 11 has been receiving the Polytrim eye drops for over 6 months, LVN 2 stated he did not know. He reviewed Resident 11's clinical record and stated, I don't see any diagnoses of active eye infection. During an interview with the Director of Nursing (DON) on 6/2/26 at 2:03 PM, she stated she could not find the reason why Resident 11 being on the Polytrim eye drops this long. During a telephone interview with the CP on 6/04/26 at 10:18 AM, he stated it's not ideal for Resident 11 to be receiving the Polytrim eye drop this long. When asked whether he had made a recommendation regarding the long-term use, the CP stated, Unfortunately I did not do an MRR [recommendation]. He stated he missed it for many months during the monthly MRR for Resident 11. During a review of Resident 88's admission Record, dated 6/3/26, the admission Record indicated admitted on [DATE] with diagnoses including, Fracture of left Femur( a break in the thigh bone), Chronic Obstructive Pulmonary Disease( COPD ) (a long term lung condition that makes it hard to breathe due to lack of oxygen exchange in the lungs), Schizophrenia(a chronic severe brain disorder that affects how a person thinks, feels and act). During a review of Order Summary Report dated 6/8/26, the Order Summary Report indicated, Abilify Oral Tablet 30 mg one tablet by mouth in the morning for Schizophrenia m/b paranoia and isolation, pacing, Clonazepam Oral tablet 1 mg by mouth two times a day for anticonvulsant, Lithium Carbonate ER Oral tablet ER 300 mg one tablet by mouth in the morning/ two tablets at bedtime for Schizophrenia m/b paranoia. During a concurrent interview and record review on 6/5/26 at 2PM, with DON, Resident 88's Medication Regimen Review (MRR) in a binder was reviewed. The MRR list included Resident 88, last pharmacy consultant medication review was 12/31/25. There has been no medication review from January 2026 to June 2026. DON has confirmed no pharmacist review on file for 2026. During a review of facility document, Long Term Care Psychiatry, dated 4/14/26. The Long-Term Psychiatry note indicated, Reason for Visit: Management of Schizophrenia. Current psychiatric medications: Abilify 30mg, Venlafaxine ER 150 mg, Lithium 300 mg in am and 600 mg at HS, Lithium level 0.9 as of 4/8/06, stable. Impression: Schizoaffective disorder, manageable. Labs show no adverse effects of medications; Lithium level is stable. During a review of Care Plan Report, dated revised on 2/26/26, the Care Plan Report indicated behavior monitoring: delusions, insomnia, pacing, withdrawal/isolation. Psychotropic/ Anticonvulsant Monitor: Side Effects: blurred vision, sedation, dry mouth, drowsy, constipation, restless, mood decline. During a review of Consultant Pharmacist's Recommendation to Interdisciplinary Team (IDT) includes the following classifications: MRR, dated 12/31/25, the MRR indicated Resident 88 has schizophrenia managed by abilify 30mg, lithium 300 mg, venlafaxine 150mg. Venlafaxine was decreased on 9/26/25 and Trazadone was discontinued on 10/31/25. IDT suggests no change due to recent reductions. No other MRR note found for 2026. During a review of Policy and Procedure, Consultant Pharmacist Reports, dated 6/21, the report indicated, Policy: The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. B. The consultant pharmacist reviews the medication regimen (MRR) of each resident at least monthly either on site or remotely. 2. During the medication cart inspections for 4 out 4 medication carts, inhalers for 10 residents were identified without open date or being used past the discard date per manufacturer's instructions, as follows: A. On 6/1/26 at 10:06 AM, inspection of the 2East Team 2 Medication Cart with LVN 6 identified the following: - An opened Anoro (a combination of breathing medications to treat breathing problems) oral inhaler for Resident 48 had no open date. A review of the manufacturer's instructions on the carton box indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray . - An Advair Diskus (oral inhaler to treat breathing problems) for Resident 65 was opened but had no open date; - An Advair Diskus for Resident 48 was opened but had not open date. - An Advair Diskus for Resident 18 had an open date of 4/26/26. During the inspection, 6/1/26 at 10:33 AM, a review of the manufacturer's instructions on the box for Advair Diskus with LVN 6 indicated: Discard ADVAIR DISKUS 1 month after opening the foil pouch . LVN 6 verified the above findings and that the Advair Diskus for Resident 18 would have expired on 5/26/26 (6 days before survey date). B. On 6/1/26 at 10:41 AM, inspection of the 2West Team 2 Medication Cart identified and were verified with Registered Nurse (RN) 2: - An opened fluticasone/salmeterol (Advair) Diskus for Resident 157 had no open date - An Anoro oral inhaler for Resident 44 had no open date - An opened Trelegy Ellipta (a combination of 3 medications for breathing problems) for Resident 43 had no open date. The manufacturer's instructions on the carton box indicated to discard the inhaler 6 weeks after opening the moisture-protective foil tray . - Three opened Trelegy Ellipta inhalers for Resident 28 had no opened date. During the inspection, 6/1/26 at 11 AM, RN 2 verified the above findings and that the Advair was good for 1 month after opening; and the Anoro and Trelegy Ellipta were good for only 6 weeks after opening. She confirmed the inhalers should have been dated. C. On 6/1/26 at 11:22 AM, inspection of the 1East Team 1 Medication Cart with LVN 7 identified the following: - An opened Breyna (a combination of breathing medications, to treat breathing problems) Inhaler for Resident 139 had no open date. A review of the manufacturer's instructions on the carton with LVN 7 indicated: Discard the inhaler when the labeled number of inhalations have been used or within 3 months of opening the foil pouch. - An Incruse Ellipta (a long-acting medication to treat breathing problems) for Resident 56 had an open date of 3/28/26. A review of the manufacturer's instructions on the carton with LVN 7 indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray LVN 7 verified the inhaler was being used past the discard date, which would have been 5/9/26 (23 days before survey date). D. On 6/1/26 at 2:11 PM, inspection of the 1West Team 2 Medication Cart with the LVN Supervisor (LVNS) identified the Fluticasone-Salmeterol (Advair) Diskus for Resident 122, which had the open date of 4/8/26. The manufacturer's instructions on the carton indicated to discard 1 month after opening. LVNS verified Resident 122's Advair Diskus was being used past the discard date, which would have been on 5/8/26 (24 days before survey date). On 6/1/26 at 2:45 PM, a review of the Advair Diskus for Resident 122 with LVNS indicated: it came with 60 doses; was dispensed by the pharmacy on 3/18/26; was opened on 4/8/26; and the dose indicator showed it had 42 doses remaining. This indicated that only 18 doses (60 - 42) had been administered since 4/8/26 (1 month and 23 days ago) while the resident was supposed to be receiving 1 dose twice daily. During a telephone interview with the CP on 6/4/26 at 9:37 AM, he stated he made monthly visits to the facility during which he would inspect two out of eight medication carts each month as part of his responsibilities. The CP stated the most recent monthly visits were conducted on 4/7/26 and 5/19/26. When asked whether he identified undated opened inhalers during his medication cart inspection, the CP stated, I don't check every med cart. It is very difficult for me to catch those as he only did random check of the medications inside the cart. The CP stated he inspected the 1West Team 1 and Team 2 medication carts during the 5/19/26 visit but did not find any expired or unlabeled inhalers. The CP was advised that Resident 122's expired Advair Diskus was identified in the 1West Team 2 Medication Cart during the survey. A review of the PHARMACIST CONSULTANT SUMMARY REPORT for April 2026 indicated the following under Drug Storage and Labeling, 1 east med cart audits, No expired meds found on cart, A review of the PHARMACIST CONSULTANT SUMMARY REPORT for May 2026 indicated there was no indication the CP identified unlabeled or expired inhalers. A review of the facility's P&P titled CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS, dated 10/2017, indicated: Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to . A resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when use in . ii. Excessive duration . 3) Checking the medication storage areas, and the medication carts, for proper storage and labeling of medications, cleanliness, and removal of expired medications .

Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications in 4 out of 4 inspected medication carts when inhalers for 10 residents (Residents 18, 28, 43, 44, 48, 65, 56, 122, 139, and 157) were not dated after opening, and 3 inhalers for 3 residents (Residents 18, 56, and 122) were being used past the discard date per manufacturer's specifications. These failures resulted in residents receiving outdated and/or ineffective medications which could result in ineffective treatment and negative health outcomes for the residents such as the medical condition not being treated as intended. 1. On [DATE] at 10:06 AM, inspection of the 2East Team 2 Medication Cart with Licensed Vocational Nurse (LVN) 6 identified the following: a. An opened Anoro (a combination of breathing medications to treat breathing problems) oral inhaler for Resident 48 had no open date. A review of the manufacturer's instructions on the carton box indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray .b. An Advair Diskus (oral inhaler to treat breathing problems) for Resident 65 was opened but had no open date;c. An Advair Diskus for Resident 48 was opened but had not open date. d. An Advair Diskus for Resident 18 had an open date of [DATE]. During the inspection, [DATE] at 10:33 AM, a review of the manufacturer's instructions on the box for Advair Diskus with LVN 6 indicated: Discard ADVAIR DISKUS 1 month after opening the foil pouch . LVN 6 verified the above findings and that the Advair Diskus for Resident 18 would have expired on [DATE] (6 days before survey date). 2. On [DATE] at 10:41 AM, inspection of the 2West Team 2 Medication Cart identified and were verified with Registered Nurse (RN) 2: a. An opened fluticasone/salmeterol (Advair) Diskus for Resident 157 had no open dateb. An Anoro oral inhaler for Resident 44 had no open datec. An opened Trelegy Ellipta (a combination of 3 medications for breathing problems) for Resident 43 had no open date. The manufacturer's instructions on the carton box indicated to discard the inhaler 6 weeks after opening the moisture-protective foil tray .d. Three opened Trelegy Ellipta inhalers for Resident 28 had no opened date. During the inspection, [DATE] at 11 AM, RN 2 verified the above findings and that the Advair was good for 1 month after opening; and the Anoro and Trelegy Ellipta were good for only 6 weeks after opening. She confirmed the inhalers should have been dated with open date. 3. On [DATE] at 11:22 AM, inspection of the 1East Team 1 Medication Cart with LVN 7 identified the following: a. An opened Breyna (a combination of breathing medications, to treat breathing problems) Inhaler for Resident 139 had no open date. A review of the manufacturer's instructions on the carton with LVN 7 indicated: Discard the inhaler when the labeled number of inhalations have been used or within 3 months of opening the foil pouch. b. An Incruse Ellipta (a long-acting medication to treat breathing problems) for Resident 56 had an open date of [DATE]. A review of the manufacturer's instructions on the carton with LVN 7 indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray LVN 7 verified the inhaler was being used past the discard date, which would have been [DATE] (23 days before survey date). 4. On [DATE] at 2:11 PM, inspection of the 1West Team 2 Medication Cart with the LVN Supervisor (LVNS) identified the fluticasone/salmeterol (Advair) Diskus for Resident 122, which had the open date of [DATE]. The manufacturer's instructions on the carton indicated to discard 1 month after opening. LVNS verified Resident 122's Advair Diskus was being used past the discard date, which have been on [DATE] (24 days before survey date). A review of the facility's STORAGE OF MEDICATIONS, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . and Outdated . medications .are immediately removed from stock .

Based on observation, interview, and record review, the facility failed to ensure the nursing practices that met the professional standards for 1 of 35 sampled residents (Resident 224) and two non-sampled residents (Resident 75 and 122) when: 1. The nursing staff did not accurately document the medication administration for Resident 122. Within a period of 1 month and 23 days, the nursing staff documented they administered the medication on the Medication Administration Record (MAR) 95 times but only 18 doses from an inhaler were used. This resulted in inaccurate documentation and resident not receiving the medication as intended for her medical condition. 2. A nursing staff failed to accurately document a refusal of a medication for Resident 75. 3. The facility failed to ensure the informed consent for Resident 224's Sertraline (medication to treat depression) was obtained from the physician prior to administration and failed to account for the discrepancy in the medication count. This failure had the potential for the resident/resident representative not being informed in advance of the risks and benefits of the medication, the treatment alternatives, or other options before making the decision for treatment. 1. On 6/1/26 at 2:11 PM, inspection of the 1West Team 2 Medication Cart with the LVN Supervisor (LVNS) identified a Fluticasone-Salmeterol (Advair) Diskus (inhaler with medications for breathing problems such as asthma and chronic obstructive lung disease) for Resident 122, which had the open date of 4/8/26. The manufacturer's instructions on the carton indicated to discard 1 month after opening. LVNS verified Resident 122's Advair Diskus was being used past the discard date, which would have been on 5/8/26 (24 days before survey day). On 6/1/26 at 2:45 PM, a review of the Advair Diskus for Resident 122 with LVNS indicated: it came with 60 doses; was dispensed by the pharmacy on 3/18/26; was opened on 4/8/26; and the dose indicator showed it had 42 doses remaining. This indicated that only 18 doses (60 - 42 = 18) had been administered. The LVNS acknowledged this finding and stated she could not explain it. Further review of the medication cart contents revealed there were 2 additional Advair Diskus inhalers for Resident 122. One had the dispense date of 4/13/26, and the other 5/27/26. Both were still intact (unopened). A review of Patient 122's clinical record indicated she was admitted to the hospital with diagnoses including acute respiratory (breathing) failure with hypoxia (low levels of oxygen in your body tissues), pleural effusion (abnormal buildup of excess fluid in the pleural space, the thin area between your lungs and chest wall), and kidney dialysis (treatment that removes wastes and excess fluid from your blood). A review of Resident 122's Minimum Data Set (MDS, a care area assessment and screening tool), dated 1/27/26, indicated he had a BIMS (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15) score of 11, which indicated her cognitive condition was moderately impaired. A review of Resident 122's physician's orders indicated she had an order for Advair Diskus Inhalation Aerosol Powder (Fluticasone-Salmeterol) 250-50 micrograms per actuation, 1 inhalation orally two times a day for shortness of breath (SOB) since 3/18/26. A review of Resident's 122's April and May 2026 MARs indicated the nursing staff, RNs and LVNs, have been documenting, except for 12 occasions where the staff held the dose for various reasons, they administered the Advair Diskus twice daily to the resident 95 times since 4/8/26 (open date): 38 times in April and 57 times in May. In other words, in a period of 1 month and 23 days from 4/8 to 5/31/26, the staff documented they administered 95 times while only 18 doses of the Advair Diskus were used. During an interview with Resident 122, on 6/2/26 at 1:10 PM, Resident 122 stated she has been in the facility for a long time and did not come with her own inhalers and the facility provided medications for her. She stated she sometimes could not breathe well and has SOB due to water in her lungs. When asked whether she was administered the Advair inhaler routinely, she stated she did not like the purple (Advair) inhaler, only the red one which she used to have. She stated she refused each time the purple one was offered because she did not like the taste it leaves in her mouth. During an interview with the LVNS on 6/2/26 at 1:18 PM, she stated Resident 122 used be on the red inhaler called Symbicort (a combination of breathing medications) but it was discontinued and changed to Advair. She stated the resident sometimes refused her Advair inhaler and prefers the Symbicort. When asked if the nursing staff communicated with the doctor about the resident's preference for Symbicort or refusal of Advair, the LVNS reviewed the nursing progress notes and stated, No. During a concurrent interview and record review with the DON, Nurse Consultant (NC) 1, and NC 2, on 6/2/2026 at 1:58 PM, the DON stated her team did an investigation about Resident 122's Advair administration, and what they identified was inaccurate documentation from the nursing staff. She explained that there were situations when the staff documented they administered the medication while the resident was not in the facility (such as being hospitalized ). The DON and the NCs explained they looked into the 42 doses left from the opened Advair Diskus. There were 12 occasions where the dose was held due to various reasons such as refusal or hospitalization, this left 30 times (42 - 12 = 30) where it was documented on the MAR but not actually administered. The DON stated the nursing staff should have communicated with the physician about the resident's refusal and about her preference for Symbicort. On 6/3/26, the DON provided the pharmacy's dispensing record for Resident 122. Its review indicated one Advair Diskus was delivered on 3/18/26; one on 4/14/26, and one on 5/28/26. Both the 4/14 and 5/28/26 Advair Diskus inhalers were unopened (not used). During another interview with the DON on 6/3/26 at 1:13 PM, she verified the pharmacy dispensed 3 Advair Diskus inhalers since 3/18/26; only 1 was used, and only 18 doses from that opened inhaler were administered although the staff documented they administered twice daily since 3/18/26 except for the 12 held occasions. When asked what she thought might have happened, the DON stated, I don't know what happened. She verified the medication was not given as ordered for Resident 122. 2. During the medication administration observation on 6/3/26 at 9:39 AM, LVN 5 was observed preparing 7 medications for Resident 75 including an Anoro Ellipta oral Inhaler (a combination of medications for breathing problems) 62.5-25 micrograms per actuation. On 6/3/26 at 9:46 AM, at Resident 75's bedside, Resident 75 stated she did not want to take her medications now. A review of Resident 75's physician's orders indicated an order for Anoro 62.5-25 micrograms per actuation, inhale 1 puff orally in the morning for SOB, dated 8/22/25. During a concurrent interview and record review on 6/3/26 at 11:48 AM, LVN 5 stated Resident 75 refused to take her Anoro inhaler today; she also refused it yesterday. A review of Resident 75's June 2026 MAR with LVN 5 indicated Anoro was documented as administered, not as refused, on 6/2/26 at 0800. LVN 5 stated she should have documented as refused but did not. A review of review of the facility's P&P titled PROCEDURES FOR ALL MEDICATIONS, dated 4/2008, indicated, the facility to administer medications in a safe and effective manner. It further indicated, If resident refuses medication, document refusal on (MAR or TAR [treatment administration record]). The policy did not address the following of the physisician's orders. During an interview with the Director of Nursing (DON) on 6/4/26 at 12:19 PM, she stated nurses are expected to follow the physician's orders which is within the nursing scope of practice. A review of the job description for Registered Nurses, updated March 2025, indicated the essential functions for RNs included, Obtains and administers prescribed medications and treatment in accordance with nursing techniques. Documents same according to Community policy and standards of practice. A review of the job description for LVNs, revised March 2025, indicated the LVN maintains standards of professional nursing practice . Administers specified medications . and notes time and amount on resident charts (as allowed by state law). 3. Review of Resident 224's admission record indicated, was admitted to the facility on [DATE] with diagnoses including stroke affecting left non-dominant side; cardiac arrest due to underlying cardiac condition (condition in which the heart suddenly and unexpectedly stops beating); ventricular tachycardia (an abnormal heart rhythm that's too fast ); follicular lymphoma grade 1 (stage 1 cancer of the lymph nodes); paroxysmal atrial fibrillation (a type of irregular, chaotic heart rhythm); and depression. Review of Resident 224's Minimum Data Set (MDS – a federally mandated resident assessment tool) assessment, dated 5/31/26 indicated, no cognitive (thought process) impairment. Section N: Medications of the MDS indicated Resident 224 was taking an antidepressant (prescription medications used to treat depression, anxiety disorders, chronic pain, and other mood conditions) during the last seven days or since admission. Review of Resident 224's Order Summary Report for June 2026 indicated the following orders: 5/30/26: Sertraline Hydrochloride (HCl) oral tablet 25 milligrams (mg). Give 25 mg by mouth one time a day for Depression for four (4) weeks. Start Date: 5/31/26 5/30/26: Sertraline HCl oral tablet 25 mg. Give 50 mg by mouth one time a day for Depression. Start Date: 6/28/26 5/30/26: Trazodone HCl oral tablet 50 mg. give 1 tablet by mouth at bedtime for Depression w/b Insomnia. Start Date: 5/31/26 During a concurrent interview and record review on 6/3/26 at 10:48 AM, Registered Nurse Supervisor (RNS) 1, reviewed the resident's medication orders and stated that Sertraline was not administered until 5/30/26 because the consent had not yet been signed by the physician. Review of Resident 224's Psychoactive Drug Consent, dated 5/28/26, indicated the physician signed consent for Sertraline 25 mg on 5/30/26. Review of Resident 224's Medication Administration Record (MAR) for May 2026 indicated, Sertraline HCl 25 mg PO daily. Start Date 5/29/26. Hold Dated 05/28/26 to 05/30/26. During a concurrent interview and record review on 6/3/26 at 12:28 PM, Licensed Vocational Nurse (LVN) 1 reviewed the MAR and the Sertraline supply. The MAR indicated Sertraline was placed on hold 5/28/26–5/29/26 and administered on 5/30/26. The bubble pack from pharmacy, dispensed 5/28/26, contained 14 tablets originally and 8 tablets remained at the time of review. LVN 1 stated that 10 tablets should have remained since the medication was on hold for two days, and the nurse was unable to explain why only eight tablets remained.

Based on interview and record review, the facility did not ensure that one of three residents ( Resident 223), was free of medication that is not clinically indicated and necessary to treat specific condition, when Seroquel (a medication to treat mental health disorders) was ordered for Dementia. This failure has potential for resident to develop unnecessary side effects from medication. During a review of Resident 223's admission record, dated 6/5/26, the admission Record indicated admitted on [DATE] with diagnoses including: Encounter for Palliative Care, Hemiplegia (weakness of one side of body) Fracture of second Cervical vertebra ( break in the neck part), Vascular Dementia( memory decline that reduce blood flow to the brain).During a review of Resident 223's Order Summary Report, dated 6/1/26, the Order Summary Report did not indicate order for Seroquel. No physician's order for Seroquel in the clinical document.During a review of Medication Administration Record (MAR), dated June 2026, indicated, Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) give 50 mg by mouth at bedtime for insomnia. MAR indicated given 6/3 and 6/4. During a review of Care Plan Report, dated 6/1/26, indicated, Impaired psychosocial well-being as evidenced by behaviors requiring intervention and psychotropic drug utilization related to a diagnosis of: Anxiety, Dementia.During an interview on 6/1/26 at 10 AM with Resident 223's daughter, daughter stated, her dad is admitted for Hospice Care. The other facility does not take long term care patients, so my dad cannot be Hospice in their facility, so we came here.we are happy we were able to find this place. Per daughter, her dad fell and broke his spine at home and that changed everything. Now he needs to be in Hospice for management of pain.During a concurrent interview and record review on 6/5/26 at 1 PM, with Director of Nursing (DON). The Order Summary Report was reviewed. Per DON, The Order Summary Report indicated, Seroquel 50 mg for Dementia. DON stated, we do not give Seroquel for Dementia. Even if he is on Hospice. That is not an appropriate diagnosis per DON. Per DON, will review the chart.During an interview on 6/5/26 at 2PM with Director Social Services (DSS), DSS stated, resident was admitted on [DATE] for skilled services from another facility. Resident is in Hospice Care with ABL Hospice. His Brief Interview for Mental Status ( BIMS) score is 3. He lived with his daughter and used a cane or walker before his fall at home.During a review of Psychoactive Drug Consent, dated 5/29/26, the Consent indicated Medication name: Lorazepam 0.5mg. Consent obtained by Registered Nurse (RN) from physician. Resident's Representative, daughter ([NAME] Gross) gave consent accepted use of medication on 5/29/26. No consent obtained for Seroquel.

Based on interview and record review, the facility failed to conduct complete and accurate assessment for six of 35 sampled residents (Resident 225, 226, 227, 228, 229, and 230) when: Coding in Section GG (Functional Abilities and Goals) of the Minimum Data Set (MDS) did not reflect Resident 225's actual mobility and locomotion abilities.Brief Interview for Mental Status (BIMS) assessments for five residents were completed by a staff member who did not possess the required skills and qualifications to conduct the assessment. This deficient practice placed residents at risk for inaccurate assessments, leading to inappropriate care planning, misidentification of needs, and failure to provide services in accordance with residents' functional and cognitive status. 1. Review of Resident 225's admission record indicated, was admitted to the facility on [DATE] with diagnoses including multiple fractures of left ribs; contusion of lung (a bruise to the lung tissue caused by blunt or penetrating trauma, which causes blood and fluid to leak into the lungs); stroke; cognitive communication deficit (difficulty with communication skills due to an underlying disruption in thinking processes, such as memory, attention, or executive function); abnormalities in gait and mobility (irregular, unsteady, or inefficient walking patterns and difficulties moving around freely); other psychoactive substance dependence (a clinical diagnosis for a moderate or severe substance use disorder). Review of Resident 225's MDS assessment dated [DATE], indicated Resident 225 has severe cognitive impairment. Section GG of the MDS indicated, Resident 225 has impairment on one side of the upper extremity (shoulder, elbow, wrist, hand); required set up or clean up assistance with eating; partial/moderate assistance with oral hygiene, personal hygiene, and mobility; substantial/maximal assistance with toileting, bathing, and dressing; and dependent on propelling a manual wheelchair. Review of Resident 225's admission Nursing Evaluation dated 1/23/26, indicated, Resident 225 required two person assist with bed mobility and did not use an assistive device. The evaluation did not include assessment of walking or transfer abilities. During a concurrent interview and record review on 6/9/26 at 12:15 PM with Registered Nurse Supervisor (RNS), Resident 225's admission Nursing Progress Note dated 1/23/26 was reviewed. The admission Nursing Progress Note indicated, Resident 225 arrived via wheelchair on 1/23/26. The RNS confirmed the Resident 225 was able to self propel with supervision, however, needed some help due to complaints of rib pain. Review of Resident 225's Elopement Risk Evaluation dated 1/23/26 indicated the Resident 225 has no cognitive impairment and was able to ambulate independently with an assistive device and could wheel himself, which conflicted with both the MDS coding and the admission Nursing Evaluation. These inconsistencies demonstrated that the MDS Section C (cognitive assessment) and Section GG assessment did not accurately reflect Resident 225's actual cognitive, functional, and mobility status as required. 2. During an interview on 06/09/2026 at 10:25 AM with the Admissions Assistant (AA), the AA stated that the Nursing Home Administrator (NHA) instructed them to complete the Brief Interview for Mental Status (BIMS) assessments for five residents (Residents 226, 227, 228, 229, and 230). The AA reported that they are not a licensed nurse, had never completed BIMS assessments before being asked to do so, and had not received any training on how to perform the assessments. During a review of BIMS Evaluation for Resident 226, dated 12/31/2024 at 1:10 PM, the BIMS Evaluation indicated it was completed by the AA and Resident 226 received a BIMS Summary Score of 12. During a review of BIMS Evaluation for Resident 227, dated 01/14/2025 at 2:11 PM, the BIMS Evaluation indicated it was completed by the AA and Resident 227 received a BIMS Summary Score of 15. During a review of BIMS Evaluation for Resident 228, dated 12/18/2024 1:23 PM, the BIMS Evaluation indicated it was completed by the AA and Resident 228 received a BIMS Summary Score of 15. During a review of BIMS Evaluation for Resident 229, dated 12/19/2024 9:54 AM, the BIMS Evaluation indicated it was completed by the AA and Resident 229 received a BIMS Summary Score of 11. During a review of BIMS Evaluation for Resident 230, dated 12/11/2024 1:28 PM, the BIMS Evaluation indicated it was completed by the AA and Resident 230 received a BIMS Summary Score of 15. During a concurrent interview and record review on 06/09/2026 at 11:14 AM with the Director of Staff Development (DSD), the DSD confirmed that AA's last job descriptin is for Activities During a concurrent interview and record review on 06/09/2026 at 11:14 AM with the Director of Staff Development (DSD), the AA's last signed Job Description dated 04/26/2017 was reviewed. The Job Description indicated AA was assigned to Activities, and not to nursing. During a concurrent interview and record review on 06/09/2026 at 11:14 AM with the DSD, the AA's Employment File was reviewed. The Employment File indicated AA did not have a nursing license. The AA completed BIMS assessments for five residents, even though the AA was not a licensed nurse.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP- a detailed approach to care customized to an individual resident's needs) for six of 35 sampled residents (Residents 1, 8, 27, 68, 166, 231) when:1. The facility did not develop and implement a comprehensive person-centered care plan for Resident 1's Infection control practices (Cross-reference F880).2. The facility did not develop and implement a comprehensive person-centered care plan for Resident 8's new pressure ulcer.3. The facility did not develop and implement a comprehensive person-centered care plan for Resident 68's Cataract diagnosis and risk for visual decline (Cross-reference F685).These failures had the likelihood of residents not receiving individualized care. 1. During a review of Resident 1's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and re-admitted with multiple diagnosis with an onset of 5/1/26 including: Type 2 Diabetes Mellitus with other skin ulcer (a slow-healing open wound on the caused by complications from type 2 diabetes), Non-pressure chronic Ulcer (an open sore or wound on the skin that fails to heal properly within several weeks) of unspecified Part or Right lower leg with unspecified severity, Local infection of the skin and subcutaneous (the deepest layer of your skin) tissue, Other acute osteomyelitis (a sudden, short-term bone infection usually caused by bacteria), Right Tibia and fibula, Cellulitis of Right lower limb (a serious bacterial infection of the deep layers of the skin and underlying tissues), Streptococcus Group A (a common bacteria that lives on the skin), Acquired absence of left leg below the knee (amputation; the removal of a body part). During an observation on 6/1/26 at 11:27 AM, in 1 west hallway, No Enhanced Barrier Precaution (EBP) signage was posted for Resident 1 on his door or entry to room. During a concurrent interview and record review on 6/3/26 at 10:11 AM with an LVN Supervisor (LVNS), Resident 1's Care Plan (undated) was reviewed. The care plan indicated that there was no current care plan for infection control interventions and/or prevention measures as well as no implementation of EBP during high contact care to minimize the spread of infection due to Resident 1's chronic wound. LVNS stated Resident 1 should have been placed on EBP when Resident 1's wound initially developed. When asked what criteria are utilized to determine implementation of EBP, LVNS stated EBP is implemented for all residents that have wounds or are prone to infections. During a concurrent interview and record review on 6/3/26 at 10:32 AM with the Infection Preventionist (IP), Resident 1's Care Plan (undated) was reviewed. The IP verified there was no current care plan for infection control interventions and/or prevention measures as well as no implementation of EBP during high contact care. IP stated facility staff is made aware of EBP implementation with EBP signage/notifications posted outside of the residents' door or entryway to residents' room, as well as staff training. When asked to provide records of training for EBP implementation for Resident 1, IP was unable to obtain any supporting documentation. 2. During an observation on 6/1/26 at 2 PM, in Resident 8's room, Resident 8 was in bed, awake, smiling, had a doll next to her, and a display of family picture by her bedside. Resident was not verbally responsive and was connected to tube feeding. During an interview on 6/1/26 at 2:15PM, with CNA (Certified Nursing Assistant) 5, CNA5 stated, Resident 8 had been her patient for long time, she is just happy. She has family that visits and take her around the building. She has no skin breakdown. She is total care with ADLs. During a review of admission Record for Resident 8, dated 6/3/26, admission Record indicated admitted on [DATE] with diagnoses including: Cerebral Infarction (death of brain tissue caused by prolonged lack of blood) affecting left dominant side, Gastrostomy status( a medical device inserted through the abdomen directly to the stomach), Dementia( loss of memory and thinking skills) . During a review of Order Listing Report, dated 6/1/26, the Order Listing Report indicated, tx: Stage 1 PI (pressure injury - localized damage to the skin and tissue from prolonged pressure) on sacrum: clean and dry with NS and gauze, apply medihoney, cover with foam dressing every shift. Review of Care Plan Report, under skin impairment, with last initiated date 12/6/25. The care plan report did not indicate stage 1 PI on sacrum as stated in the Order Listing Report. During a interview on 6/4/26 at 9:30 AM, with RNS 2, RNS 2 stated, resident 8 has a stage 1 wound on sacrum on 6/2/25 was assessed to be stage 2 by treatment nurse and with same treatment order. RNS 2 stated she has updated the care plan now. 3. During a review of Resident 68's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 68 was initially admitted to the facility on [DATE] with multiple diagnosis including: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (nerve damage throughout the body caused by long-term high blood sugar [glucose] levels), Essential (Primary) Hypertension (high blood pressure), and Hyperlipemia (too much fat in your blood). A review of Resident 68's Minimum Data Set (MDS: a standardized resident assessment tool), dated 3/19/2026, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 68 scored 15 out of 15, this indicated Resident 68 had intact memory/reasoning. During an interview on 6/1/26 at 11:32 AM with Resident 68, Resident 68 stated, she has not received assistance from the social worker department regarding a bill and coordination on obtaining a pair of prescription glasses to assist with her current vision concerns. Resident 68 stated she did not have a vision examination for several years, and on the most recent facility visit by an Optometrist she was told she needed eyeglasses. Resident 68 reported she has not received any follow-up information or assistance to coordinate obtaining her eyeglasses. During a concurrent interview and record review on 6/3/26 at 2:40 PM with an LVN Supervisor (LVNS), Resident 68's Care Plan Report (undated), was reviewed. The Care plan indicated, there was no current care plan for Resident 68's Cataract diagnosis or risk for/actual altered vision. LVNS stated, she was not aware of Resident 68 having a diagnosis of Cataracts or vision impairments. LVNS verified Resident 68 has an active diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy which increases risk for vision loss and/or impairments.

Based on observation, interview, and record review, the facility failed to ensure for three out of 35 sampled residents (Residents 5, 50, 197), who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene when; Resident 5's fingernails were outgrown and required cutting.Resident 50 had moderate amount of white scattered hair on her chin.Resident 197 had a moderate amount of grey and white scattered hair on her chin. These failures had the potential to impact the health and well-being of the residents.Findings:1.During a review of Resident 5's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 5 was initially admitted to the facility on [DATE] and re admitted on [DATE] with multiple diagnosis including: Parkinson's Disease (a progressive brain disorder that mainly affects how you move), abnormal gait (any walking pattern that deviates from the body's natural sequence of balance), and mobility, muscle weakness, lack of coordination, need for assistance with personal care, and Ataxia (lack of coordination).A review of Resident 5's Minimum Data Set (MDS: a standardized resident assessment tool), dated 4/20/2026, the Minimum Data Set indicated Resident 5's limitations in range of motion that included impairments on one side of her upper extremities (shoulder, elbow, wrist, hand), impairments on both sides of her lower extremities (hip, knee, ankle, foot) and required substantial/maximal assistance (Helper does MORE THAN HALF the effort) for Personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands). During a concurrent observation and interview on 6/2/26 at 10:59 AM with Resident 5's assigned Certified Nursing Assistant (CNA 3) at the resident's bedside, Resident 5's fingernails on both of her hands were approximately one inch long with noted jagged edges. CNA 3 stated, he only provides assistance with activities of daily living (ADL- the basic, routine self-care tasks required to manage one's own physical needs) if the residents requests assistance. CNA 3 verified Resident 5's fingernails were long and stated he can cut them with a nail clipper provided by the facility. Resident 5 stated she would like her nails to be trimmed due to fear of them breaking and experiencing pain as a result. Upon further observation, Resident 5's bilateral toenails were outgrown and slightly under turned. Resident 5 stated she had not been seen by a podiatrist since her admission to the facility and was told only diabetic residents can be seen by podiatry. CNA 3 verified Resident 5's toenails were outgrown and stated, he does not trim toenails and would have to get the social worker to assist.During a review of Resident 5's Care Plan Report last revised on 4/19/26, the care plan indicated Resident 5 had a .performance deficit r/t (related to) gait and mobility problems.Interventions/Tasks.PERSONAL HYGIENE: The resident needs one person assistance with personal hygiene. 2. During a review of Resident 50's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 50 was initially admitted to the facility on [DATE] with multiple diagnosis with an onset of 1/27/26 including: Functional quadriplegia (the partial or total paralysis of all four limbs as well as the torso), abnormal posture (any deviated body alignment that pulls the spine or joints out of their neutral position), and other abnormalities of gait (a person's pattern of walking) and mobility.A review of Resident 50's Minimum Data Set (MDS: a standardized resident assessment tool), dated 5/5/2026, the Minimum Data Set indicated, Resident 50 had limitations in range of motion that included impairments on both sides of her upper extremities (shoulder, elbow, wrist, hand), impairments on both sides of her lower extremities (hip, knee, ankle, foot) and required substantial/maximal assistance (Helper does MORE THAN HALF the effort) for Personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands). During a concurrent observation and interview on 6/1/26 at 12: 33 PM with Resident 50's assigned Certified Nursing Assistant (CNA 2) at the resident's bedside, Resident 50 had moderate amount of white scattered hairs on her chin. When asked what personal hygiene care is provided to Resident 50, CNA 2 stated she provides total (no assistance from the resident) care which includes brushing Resident 50's teeth, giving her showers, and keeping her clean. When asked if she provides any shaving assistance for facial hair, CNA 2 stated, No. When asked if she would like her facial hair removed, Resident 50 stated, Yes. 3. During a review of Resident 197s admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 197 was admitted to the facility on [DATE] with multiple diagnosis including: Type 2 Diabetes Mellitus without complications (a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels), Gout- unspecified (extremely painful form of arthritis), Non- Alzheimer's Dementia, abnormalities of gait and mobility, muscle weakness, need for assistance with personal care.A review of Resident 197's Minimum Data Set (MDS: a standardized resident assessment tool), dated 5/5/2026, the Minimum Data Set indicated, Resident 197 required Partial/moderate assistance (Helper does LESS THAN HALF the effort) for Personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands).During a concurrent observation and interview on 6/1/26 at 11:02 AM with Resident 197's assigned Certified Nursing Assistant (CNA 1) at the resident's bedside, Resident 197 had a moderate amount of grey and white scattered hair on her chin. CNA 1 stated, he provides Resident 197 with assistance in showering, brushing her teeth, washing her face, and shaving. CNA 1 stated he shaved Resident 197 last week. CNA 1 verified Resident 197 had multiple white and grey hair on her chin and under her nose. When asked if she would like to be shaved, Resident 197 stated, Yes, I would like to be shaved. CNA 1 stated he would shave Resident 197 after gathering supplies.During a review of Certified Nursing Assistant Job description last revised on October 2020, the job description, indicated, .Duties and Responsibilities .Assist residents with personal grooming .Assist non-diabetic residents with nail care including clipping, trimming, cleaning the fingers, fingernails and toenails. When asked for a facility policy and procedure for ADL care, personal hygiene, and/or grooming the Nursing Home Administrator (NHA) stated, We do not have this as a policy.

Based on observation, interview, and record review, the facility failed to maintain a safe and homelike environment when; 1. The Communal Shower Room on 1 [NAME] had several areas of black and pink residue and build up along the tiled flooring and corners of the shower stall and material was found hanging from the ceiling with exposed material underneath. 2. Resident 191's window blind is splattered with yellow colored dirt, the wall underneath the window was cracked and scraped. This failure had the potential to result in injuries to the resident's and staff health. Findings: 1. During an observation 6/1/26 at 2:37 PM in the communal Shower room on 1 West, several areas of black and pink residue and build up along the tiled flooring and corners of the shower stall were noted. An area on the ceiling above the shower stall observed to have material hanging from ceiling with exposed material underneath. Cracked and chipping paint on the perimeter of the area was hanging from the ceiling. brown, grey, pink, and black discolorations seen throughout the linings and corners of the shower stall. During a review of Job Description- Housekeeping Supervisor, dated 2/2024, the job description indicated, .ESSENTIAL FUNCTIONS.Assigns team members their duties and inspects work for conformance (acting in agreement or harmony with a set of rules, standards, or specifications) to prescribed standards of cleanliness. During a concurrent observation and interview on 6/1/26 at 2:46 PM with the Housekeeping and Laundry Director (HLU) and Housekeeping Aide (HSK 1), in the 1 west communal shower room, multiple areas of black and pink residue build up on corners and flooring of white tile in the shower stall and material hanging from ceiling with exposed material underneath was observed. HLU stated, the black and pink residue was present throughout the shower stall and was from the grout and tiles on the flooring. A white paper towel was placed on the residue and wiped in multiple sites in the presence of the HLU and HSK. After wiping the sites, the paper towel had black and pink residue noted on the towel. The HLU stated, The grout (A dense, paste-like material used to fill the gaps between tiles) needs to be replaced. HLU measured the area on the ceiling, which measured 14inches by 13inches. HLU verified site needed to be repaired. During a review of Job Description- Housekeeper, dated 3/2025, the job description indicated, JOB SUMMARY.A housekeeper provides daily housekeeping services to maintain the Community's safety, sanitation, and attractive condition.ESSENTIAL FUNCTIONS.2. Maintains clean and sanitary conditions in assigned areas as directed, according to established standards, observing proper cleaning and disinfecting techniques. During a concurrent interview and record review on 6/1/26 at 2:50PM with HSK 1, the Shower Room Cleaning Log, dated 5/27/26- 5/31/26 was reviewed. The cleaning log indicated, HSK 1 cleaned the 1 west shower room on the above dates with a corresponding signature. HSK 1 stated, he cleaned the shower room on the days signed, and the black and pink residue had been present for at least 2 months. HSK 1 stated he cleans around the residue, and there are times when there is poopoo left in the drain as well. HSK 1 said he did not report to maintenance for repairs or to the housekeeping Supervisor. When asked if HLU conducts facility inspections on communal spaces such as the shower rooms, HLU stated he did not. HLU and HSK 1 both stated 1 west communal shower room was not clean. During a review of the facility's policy and procedure titled, Routine Community Inspections, undated, the policy indicated, 1. Routine community inspections are conducted to guarantee and maintain a livable, efficient, and safe environment. During a concurrent observation and interview on 6/1/26 with the Maintenance Director (MD) and a Maintenance Assistant (MA) in the 1 west communal shower room, the above-mentioned observations of the areas of black and pink residue on the shower stall floor as well as the material hanging from ceiling with exposed material underneath. MD stated he was not aware of the black and pink residue on the shower stall floor as well as the material hanging from ceiling. When asked if facility equipment and communal spaces (ie: Shower rooms, guest bathrooms, etc.) were inspected routinely? MD stated, No. MD stated they are provided with tasks each week to complete, and the maintenance staff are currently working on other areas in the facility. When asked if the maintenance staff was aware of the material hanging from the ceiling, MA stated, he was not aware of the areas noted and had not inspected the communal shower room within the past several months. During a review of Daily log for Plant Operations, dated 4/05/26, the Daily log for Plant Operations indicated 1 [NAME] Shower room facets and shower fixtures, grab bars, and floor tiles were inspected with no leaks found. Additional notes indicated, Patched ceiling at 1 [NAME] shower completed and signed by MA. During a review of Daily log for Plant Operations, dated 5/27/26, the Daily log for Plant Operations indicated 1 [NAME] Shower room facets and shower fixtures, grab bars, toilet seat covers, and floor tiles were inspected with no leaks found. Additional notes indicated, .There damage in ceiling- Will fix next week completed and singed by MD. During a review of Job Description- Maintenance Supervisor, last revised on 3/2025, the job description indicated, .KNOWEDGE, SKILLS, AND ABILITIES.7. Ability to assess physical plant problems and respond to physical plant problems 24 hours a day, seven days a week. 2. During a review of admission Record , dated, 6/3/26, the admission Record indicated , Resident 191 was admitted on [DATE] with diagnoses including: Bullous Pemphigoid( is an autoimmune disorder that attacks the skin and causes blistering), Paranoid Schizophrenia ( a severe brain disorder that's affects how a person thinks ,feels and acts), Obsessive Compulsive Disorder(a mental health condition characterized by a cycle of uncontrollable, chronic thoughts and repetitive behaviors that severely interfere with daily functioning). During an observation on 6/1/26 at 11 AM, in resident 191 room, the window blind is splattered with yellowish dirt or grime, wall under the window is scraped and cracked, yellowish splattered dirt. Resident did not say anything when asked about it. Resident has a Brief Interview for Mental Status(BIMS) score of NA, severely impaired. During an interview on 6/2/26 at 3PM, with Maintenance Director (MD), MD stated he is aware of the room condition for Resident 191, the window blind needs to be changed and the wall needs to be fixed. Per MD he has a schedule of painting to do in the building, just started two months ago as MD. During an interview on 6/3/26 at 2PM, with CNA 5, CNA 5 stated, the window blind has been that dirty, we notified maintenance of that and the walls dirty and we tried to clean it ourselves. The resident might get upset if someone comes in her side to clean but it needs to be cleaned.

Based on observation, interview and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices: 1. The facility failed to implement their smoking policy and procedures (P&P) when it allowed one (1) of 11 residents (Resident 88) who smoked in the facility to keep in possession of their own lighters and cigarettes inside the resident care area. 2a. The facility failed to provide adequate supervision to prevent accidents when Resident 225 was left unsupervised while smoking, and was later found at a nearby facility. This deficient practice placed the resident at risk for injury and unsafe wandering/elopement.2b. The facility failed to provide adequate supervision to Resident 225 when he eloped from the facility and was not located for 19 hours. These failures had potential for Residents 88 and 225 to experience significant harm and/or death. 1. During a review of Resident 88's admission Record, dated 6/3/26, the admission Record indicated admitted on [DATE] with diagnoses including, Fracture of left Femur( a break in the thigh bone), Chronic Obstructive Pulmonary Disease( COPD ) (a long term lung condition that makes it hard to breathe due to lack of oxygen exchange in the lungs). During an observation on 6/1/26 at 10 AM, resident 88's room, there were two cigarette lighters and a small red bottle with fluid and other mini collectibles cars, a mug and umbrella on the windowsill. Resident 88 was not in the room. During an interview on 6/2/26 at 11 AM with Registered Nurse Supervisor (RNS2), RNS 2 stated, Resident 88 is an independent smoker, he is ambulatory and goes out to the smoking area. Showed RNS 2 the lighters and bottle on the windowsill, RNS2 stated, resident is not supposed to have his smoking materials with him. During an observation and interview on 6/2/26 at 11:30 AM in Resident 88's room. Resident 88 sitting in bed, greeted and introduced myself. Asked him where his collections are, since it is not on the windowsill anymore. Resident opened his bedside drawer and showed me all of his lighters and small cars. Confirmed the red bottle is a vape. Resident stated, he vapes, and he has collections of these vapes, you want to see it?. During a review of Smoking Safety Evaluation, dated 4/29/26, indicated IDT Decision : Resident BIMS is 14. Can smoke independently. Resident educated on always keeping items in safe and locked location. During a review of Resident 88s Care Plan Report, dated 6/2/26, the Care Plan Report indicated, Resident Independent with smoking. Resident was vaping in his room on 6/2/26. Interventions: The resident can smoke unsupervised. The resident's smoking supplies are stored in the Smoking supply cabinet. During a review of facility's Resident Smoking Safety Independent and Unsupervised Policy, dated 11/2005, the Policy indicated, 1. a. Resident who are safe to smoke independently must store their materials in a locked box in their room or a lockable mailbox container outside. 2a. Review of Resident 225's admission record indicated, was admitted to the facility on [DATE] with diagnoses including multiple fractures of left ribs; contusion of lung (a bruise to the lung tissue caused by blunt or penetrating trauma, which causes blood and fluid to leak into the lungs); stroke; cognitive communication deficit (difficulty with communication skills due to an underlying disruption in thinking processes, such as memory, attention, or executive function); abnormalities in gait and mobility (irregular, unsteady, or inefficient walking patterns and difficulties moving around freely); other psychoactive substance dependence (a clinical diagnosis for a moderate or severe substance use disorder). Review of Resident 225's MDS assessment dated [DATE], indicated Resident 225 has severe cognitive impairment. Section GG of the MDS indicated, Resident 225 has impairment on one side of the upper extremity (shoulder, elbow, wrist, hand); required set up or clean up assistance with eating; partial/moderate assistance with oral hygiene, personal hygiene, and mobility; substantial/maximal assistance with toileting, bathing, and dressing; and dependent on propelling a manual wheelchair. During a concurrent interview and record review on 6/9/26 at 12:15 PM with Registered Nurse Supervisor (RNS) 2, Resident 225's change in condition (CIC) progress note was reviewed. The CIC indicated that on 1/30/26, staff from [Name of facility] called to inform the facility that Resident 225 was in their building and appeared confused. RNS 2 stated that Resident 225 had gone outside to smoke and became lost attempting to return to the facility. Review of Resident 225's Elopement Risk Evaluation dated 1/23/26 indicated the resident was documented as having no cognitive impairment, being able to walk independently with an assistive device, able to self propel, and not an elopement risk. Review of Resident 225's admission Nursing Evaluation dated 1/23/26 indicated Resident 225 was not a smoker. Review of the Smoking Safety Evaluation dated 1/26/26 indicated the resident was safe to smoke with supervision. During a concurrent interview and record review on 6/9/26 at 12:20 PM with RNS 2, Resident 225's smoking care plan was reviewed. The care plan, initiated 1/31/26, indicated The resident is a supervised smoker. RNS 2 stated that Resident 225 required supervision when smoking as indicated in the Smoking Safety Evaluation completed on 1/26/26. RNS 2 further stated that the smoking care plan should have been initiated immediately after the Smoking Safety Evaluation was completed. Review of the facility's policy and procedures titled, Resident Smoking Safety Independent and Unsupervised, updated January 2025, indicated, .Residents who wish to smoke are evaluated for their ability to smoke safely. An established set of criteria is used to evaluate safety risks. Residents who do not meet the established criteria to smoke independently are aided/supervised during smoking activities . Review of the facility's policy and procedures titled, Elopement/Wandering, updated February 2025, indicated, .1. A resident is found in the parking lot of the Center by a staff or visitor without staff knowledge or presence. This is elopement . Procedure: .2. Residents with a diagnosed substance use disorder (SUD) or that have a history of substance use are counseled on the risks of leaving the premises without adequate supervision or assistance and the risks of drug use without medical supervision and counseled on the center leave process. 2b. During a record review of Discharge Summary, dated 1/23/26, the discharge summary indicated, Resident 225's chronic problems included .Polysubstance Use Disorder/ Methadone- Utox (urine toxicology test; a laboratory test that detects the presence of specific legal drugs, illicit substances in a person's urine) positive for cocaine, fentanyl, methadone. During a review of Resident 225's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 225 was initially admitted to the facility on [DATE] and re-admitted with multiple diagnosis with an onset of 3/18/6 including, but not limited to: Adjustment Disorder with Depressed mood, Cognitive Communication Deficit, Other Psychoactive Substance Dependence, uncomplicated. A review of Resident 225's Minimum Data Set (MDS: a standardized resident assessment tool), dated 1/26/26, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 225 scored 3 out of 15, this indicated Resident 225 had severe impairment in memory/reasoning. During an interview on 6/8/26 at 1:29 PM with Director of Social Services (DSS), when asked what was the facility protocol for residents admitted with a history of Substance Use Disorder (SUD; recurrent use of alcohol or drugs, causing clinically significant impairment), the DSS stated the resident is placed on behavior monitoring and the facility develops and implements a personalized comprehensive care plan regarding the substance use history are triggers. If a resident is demonstrating behaviors that may be related and/or caused by SUD the Social Services department will add a care plan (such as Impaired Psychosocial Wellbeing). The DSS stated there are no current care plans identifying risks or potential behaviors for residents with a history of SUD. The DSS later added, she was not currently aware of any referrals to mental health services/evaluations in place for residents within the facility with hx of SUD. During a review of Elopement Risk Evaluation- V 2 dated 1/30/26, the elopement evaluation indicated, Resident 225 had a history of wandering which placed him in significant risk of getting to an unsafe situation, had a substance use disorder, had wandered in the past month, and was an elopement risk. During a concurrent interview and record review on 6/8/26 at 1:35 PM with the Assistant Director of Nursing (ADON 2), Resident 225's Progress Notes dated 3/14/26 was reviewed. The progress note indicated, Resident 225 was .last seen around 1300 (1pm).Resident was not seen in the tv room and supervisor was notified resident has (not) been seen since 1300. ADON 2 stated resident 225 was last seen in the facility on 3/14/26 at 1pm and was not located until 3/15/26 at 8:37 AM. ADON 2 added, the resident was wearing a wander [NAME] (monitoring device), although no documentation was noted of device alarming staff when Resident 225 exited the facility. During a concurrent interview and record on 6/8/26 at 1:42 PM with ADON 2, Resident 225's Progress Notes dated 3/15/26, was reviewed. The progress note indicated, Resident 225 was in a local hospital emergency room for evaluation and was brought to the emergency room on 3/14/26 at 11:54 PM. ADON 2 stated, prior to the incident Resident 225 was monitored with frequent visual checks. When asked how frequent the visual checks were completed for Resident 225, ADON 2 stated It's just when we do our rounds referring to the certified nursing assistant and Licensed Nurse staff. ADON 2 was unable to provide documentation for referenced visual checks. During a concurrent interview and record on 6/8/26 at 1:51 PM with ADON 2, Resident 225's ED Provider Notes dated 3/16/26, was reviewed. The provider notes indicated, Resident 225 was assessed in the emergency room for Clinical Impressions that included Pneumonia and Rib fracture. ADON 2 stated, no documentation was found in Resident 225's medical record regarding Nurse to Nurse Report or condition of resident upon his arrival to the emergency room following his elopement. During a review of the facility's policy and procedure titled Elopement/Wandering, last revised on 2/2025, the P&P indicated, .Examples of Elopement.5. A resident with a substance use disorder, leaves the premises without signing out or doesn't let staff know they are leaving. This is a (SUD) elopement.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received tube feeding (a method of delivering liquid nutrition, fluids, and medication directly into the digestive system through a feeding tube when a person cannot eat or drink enough by mouth) in accordance with physician order, the comprehensive person-centered care plan, and the resident's goals when Resident 1's tube feeding rate was increased from 60 to 200 mL/hr (milliliters per hour, which is a unit of measurement for a flow or infusion rate). This failure resulted in Resident 1 transferring to a local acute care hospital and eventually passing away due to aspiration pneumonia (a lung infection. It happens when food, liquid, or vomit is breathed into the airways or lungs instead of being swallowed, leading to inflammation and a potential bacterial infection. Symptoms include cough, fever, shortness of breath, and chest pain).Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system (routine postoperative check-ups, wound care, suture removal, and other follow-up care related to digestive system surgery), pneumonitis due to inhalation of food and vomit (known as aspiration pneumonia), dysphagia (difficulty swallowing), and sepsis (a life-threatening blood infection). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/30/25 indicated, Resident 1 was cognitively intact and on feeding tube. Review of Resident 1's Discharge Summary from the hospital upon admission to the facility, dated 10/27/25, the Discharge Summary indicated, . Date of admission: [DATE] Date of discharge: [DATE] . Titrate (the process of gradually adjusting a medication or feeding dosage to achieve the optimal therapeutic effect with minimal side effects) tube feeds as needed . Condition on discharge: stable . Review of Resident 1's comprehensive care plan regarding tube feeding initiated on 10/28/25, the care plan indicated, . Goal . The resident will be free of aspiration . Review of Resident 1's Order Summary Report, active orders as of 11/12/25, the Order Summary Report indicated, Formula: Jevity 1.5 (a high-calorie, fiber-fortified liquid nutrition formula for people who cannot get enough nutrients from oral intake) via PEG(Percutaneous Endoscopic Gastrostomy) tube (a feeding tube inserted through the abdominal wall directly into the stomach) @ (at) 60 mL/hour x (times) 20 hours . (Start 1700 (5 PM), Stop 1300 (1 PM)). Fluid water flush 200 mL Q6H (every 6 hours) . Start Date 10/31/2025 . Review of Resident 1's nursing progress notes titled, Daily Skilled dated 11/10/25 at 12:23 PM, the progress notes indicated, . jevity 1.5 @ 60 ml x 20 hrs, tolerating feedings . no nausea . abdomen soft . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 7:27 AM entered by Registered Nurse (RN) 1, the Nursing Progress Notes indicated, . Writer started medication pass at 715am (7:15 AM on 11/12/25). Upon checking resident's BP (blood pressure), resident was spitting up saliva (the clear, watery fluid in the mouth made by the salivary glands) and complained of severe nausea . Writer checked resident's Kangaroo pump (a brand of medical device used for enteral feeding, delivering liquid nutrition, hydration, or medication directly into a resident's gastrointestinal tract via a feeding tube) and noticed that her feed was running at 200ml/hr rather than 60ml/hr as ordered. Writer stopped the feed and assessed the resident . Lung sounds (the noises made by the lungs during breathing) were clear . Resident was tachycardic (experiencing a fast heartbeat, defined as a resting heart rate greater than 100 beats per minute in adults) with pulse of 104 . Resident did not complain of any pain but was only experiencing nausea. Notified Medical Doctor (MD) of the situation . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 2:36 PM, the Nursing Progress Notes indicated, . Resident requested cough medicine and Tylenol (a brand of medication) for her coughing. Upon assessing resident, resident seemed to sound more congested. Noted crackles (a sound like bubbling or popping which means abnormal lung sounds) bilaterally upon listening to lung sounds. Notified MD . MD assessed resident . MD ordered for resident to be sent out to ED for chest X-ray to rule out aspiration pneumonia . Transportation came to pick up resident and left around 1230pm (12:30 PM) . Review of Resident 1's Nursing Progress Note dated 11/12/25 at 3:06 PM, the nursing progress note indicated, . XXX (the hospital name) called to update that the resident was admitted . Dx (diagnosis): Aspiration PNA (pneumonia) and Sepsis (a life-threatening blood infection). During a concurrent record review and interview on 11/26/25 at 11:55 AM with Director of Nursing (DON), Resident 1's MEDICATION ADMINISTRATION RECORD (MAR) dated from 11/1/25 to 11/30/25 was reviewed. The MAR indicated, Resident 1 was on formula named Jevity 1.5 via PEG tube at 60 mL/hr for 20 hrs (Start at 5 PM and stop at 1 PM) with fluid water flush 200 mL every 6 hours. The MAR indicated, Licensed Vocational Nurse (LVN) 1 signed for Jevity in the evening on 11/11/25 from 3 PM to 10:59 PM and LVN 2 signed for Jevity at night from 11 PM on 11/11/25 to 6:59 AM on 11/12/25. DON stated, When a nurse signs the MAR, they are supposed to verify that the rate is accurate, when asked what signing the MAR meant. DON further stated, for this incident, when RN 1 checked the tube feeding pump at 7:15 AM on 11/12/25, RN 1 found out that the tube feeding pump was set to 200 mL/hr instead of the ordered rate of 60 mL/hr. During an interview on 11/26/25 at 3:09 PM with LVN 1 via phone, LVN 1 stated, he had hung a new bottle of Jevity for Resident 1 around 5:30 or 5:45 PM on 11/11/25. LVN 1 stated, he had not checked the feeding rate on the pump during his PM shift after hanging up the bottle around 5:30 or 5:45 PM, when asked when he had last checked the feeding rate. LVN 1 stated, he did not check the pump settings with LVN 2 during the shift change around 11 PM. LVN 1 acknowledged, he was not sure Resident 1 was receiving the correct amount of tube feeding during his shift because he did not check the pump's feeding rate during his PM shift. LVN 1 stated, No, when asked if Resident 1 had experienced any symptoms of nausea or vomiting prior to this incident. LVN 1 acknowledged, there was a possibility that the wrong amount of tube feeding might be given to Resident 1 during his shift. LVN 1 stated, At least 30 minutes or 1 hour, when asked how often he should monitor the pump's feed rate. During an interview on 11/26/25 at 3:31 PM with RN 1, RN 1 stated, when making rounds on 11/12/25 at about 7:15 AM, Resident 1 had nausea and he realized the Jevity feeding rate on the pump was at 200 mL/hr which was different from what the doctor had ordered, so he stopped the pump immediately. RN 1 stated, Resident 1 told him that she felt nausea on the night of 11/11/25 but did not report it to LVN 2 (the night shift out going nurse) because Resident 1 thought it would go away. RN 1 stated, The nausea may have been caused from the (feeding) rate being too high which is a potential complication . RN 1 further stated, he did not check the tube feeding pump setting with LVN 2 during the shift change. During an interview on 11/26/25 at 4:13 PM with LVN 2 via phone, LVN 2 stated, No, ma'am, when asked if LVN 2 noticed that Resident 1 had been feeling nauseous on the night of 11/11/25. LVN 2 stated, she checked the tube feeding pump settings around 2 AM on 11/12/25 to replace the previous Jevity bottle with a new one as it was already empty when asked when she had last checked the feeding rate on the pump. LVN 2 stated, Maybe, I mis looked, when asked if she had checked the tube feeding rate on the pump for Resident 1 when she started working around 11 PM. LVN 2 stated, she overlooked at that time. LVN 2 stated, she was not sure what the pump's tube feeding settings were at that time. LVN 2 stated, I did not set it up. Honestly, I mis looked. LVN 2 stated, she just hung the new Jevity bottle without changing the setting of the pump around 2 AM on 11/12/25. LVN 2 stated, she should check feeding pump settings, stoma site, and residuals when asked what she should check when making rounds for residents receiving tube feedings. LVN 2 acknowledged that she missed checking the feeding pump settings for Resident 1. LVN 2 stated, I did not when asked if she checked the tube feeding rate on the pump after hanging the new Jevity bottle after 2 AM. LVN 2 further stated, At least 2 hours, when asked how often she should monitor the pump's feed rate. She stated, Honestly, I did not when asked if she checked it every 2 hours. During an interview on 11/26/25 at 4:50 PM with LVN 1 via phone, LVN 1 stated, I started to hang the new bottle at 5:30 PM or 5:45 PM, when asked again when he hung the new bottle on 11/11/25. LVN 1 stated, he was not one hundred percents sure if he had set the feeding rate of Jevity to 60 mL/hr at that time. During a concurrent interview and record review on 12/3/25 at 2:08 PM with LVN 3, the facility's policy and procedure (P&P) titled, Enteral Feeding Tube updated in May 2025 was reviewed. The P&P indicated, . 1) Upon admission or initiation, the licensed nurse obtains a specific provider order including the following: a) Type/Name of formula b) Amount to be administered . d) Flow rate . f) Water flushes . LVN 3 verified that initiation meant starting a new tube feeding orders, hanging up a new bottle, or checking in between shifts when asked. LVN 3 stated, while the P&P did not specify explicably about monitoring tube feeding pump settings during shifts, initiation included everything, including monitoring, when asked. During an interview on 12/4/25 at 10:53 AM with DON via phone, DON stated, It (the tube feeding pump) wasn't properly set. The rate was adjusted, when asked about the root cause of the incident. DON stated, the Jevity feeding was set as at 200 mL/hr and the water flushing was set to 60 mL. DON further stated, the Volume to be infused (total volume) on the tube feeding pump was not set, and that if it had been, the error could have been detected sooner. DON also stated, LVN 2 should have questioned to herself why she was hanging up the new bottle of Jevity at 2 AM on 11/12/25. Review of Resident 1's hospital notes from Hospital A titled, ED Provider Notes dated 11/12/25 indicated, . Arrival Time: 12:50 PM . pt (patient) sent from SNF (Skilled Nursing Facility, a healthcare facility that provides continuous skilled nursing and supportive care to residents who require a level of medical supervision on an extended basis) for eval of possible aspiration . with increased shortness of breath (difficulty catching breath). Per the patient the tube feeds were mistakenly increased from 60cc (measure of volume in the metric system, same as milliliter (mL)) qhr (every hour) to 200cc qhr for 12 hours and when morning nurse noticed . they found the error in rate. they worried she may have aspirated . with cough and hypoxia (a deficiency of oxygen reaching the body's tissues or organs, preventing them from functioning properly, often leading to serious damage or death, especially in the brain) . Review of Resident 1's hospital notes from Hospital A titled, Discharge Summary dated 11/20/25 indicated, . Death Summary Date of admission: [DATE] date of death : 11 /19/25 Reason for Hospital admission (Admitting Diagnosis): acute hypoxemic respiratory failure (critical condition where the lungs fail to oxygenate the blood adequately) . Etiology (the cause) likely aspiration pna (pneumonia) (TF rate was accidentally increased from 60 - > 200 cc / hr) . Patient passed peacefully on 11/19/25 .

Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for four of eight sampled residents (Resident 1, 3, 4, and 6) when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated and reassessed Residents 1,3, 4, and 6's nutritional status to recommend nutritional interventions, after unplanned severe and continuous weight loss. a. Resident 1 experienced progressive weight loss from ,d+[DATE] to ,d+[DATE], with a total weight loss of 39.6 pounds (lbs.- a unit of measurement) (20 percent of body weight) with no implemented interventions to address the unplanned weight loss during this period. b. Resident 3 experienced a continuous and progressive weight decline from ,d+[DATE] to ,d+[DATE], with a total loss of 44 lbs. (21 percent of body weight). There was a delay of care coordination with the RD, nursing, and physician to ensure weight loss was recognized and interventions were implemented during this period. c. Resident 4 experienced a 6.2 lbs. (six percent) weight loss within 3 months' time (,d+[DATE] to ,d+[DATE]). There was no nutrition assessment and there was no plan of care during weight loss period. d. Resident 6 had continuous weight decline from ,d+[DATE] to ,d+[DATE], with a total loss of 26.8 lbs. or 10.9 %. There was no nutritional assessment and plan of care to address weight loss and prevent further weight loss. As a result, the facility's system was not effective at ensuring the Registered Dietitian (RD) and the Interdisciplinary team (IDT- a group of health professionals from the diverse fields who work in coordinated fashion toward a common goal for the resident) evaluated unplanned weight loss. The facility failed to ensure that nutrition interventions to address identified nutritional concerns were implemented. These failures resulted in weight loss for Residents 1, 3, 4 and 6. Findings: Resident 1 During a review of Resident 1's History and Physical (H&P) dated [DATE], indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (also known as stroke- refers to damage to tissues in the brain due to loss of oxygen to the area), hypertension (high blood pressure), diabetes mellitus type II (a chronic condition that affects the way the body processes blood sugar in the body) Heart Failure (is a condition that occurs when the heart can't pump as well as it should) and dysphagia (difficulty swallowing). Resident 1's admission diet order was CCHO (consistent carbohydrate diet), SB6 (soft bite diet, level 6) texture and nectar thick fluids. Resident 1's medical record, indicated he weighed 200 pounds on his first admission on [DATE]. Resident 1 had multiple admissions including recent Covid - 19 diagnosis which resulted in poor appetite. Resident 1 was sent out and admitted to the hospital due to chest discomfort on [DATE] and re admitted back to the facility on [DATE]. Resident 1 was sent out and admitted to the hospital for altered level of consciousness on [DATE] and readmitted to the facility on [DATE]. On [DATE], Resident 1 expired. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) assessment, dated [DATE] indicated Resident 1 weighed 160 pounds (lbs.) and had a Weight loss of 5 % or more in the last month or loss of 10% in the last 6 months and was not on physician prescribed weight -loss regimen [ a program that is supervised by a medical professional that specializes primarily in weight loss for individual that have a hard time losing weight despite their efforts] Resident 1's cognitive skills for daily decision making was cognitively intact. During a review of Resident 1's Weight Summary indicated the following weights: [DATE]- 200.0 lbs. [DATE]- 160.4 lbs. [DATE]- 160.4 lbs. [DATE]- 149.0 lbs. [DATE]- 134.4 lbs. Resident admission weight on [DATE] was 200 lbs. There was no weight done by the staff in the month of ,d+[DATE]. On [DATE] Resident 1's weight recorded was 160.4 lbs., a 19.8 percent loss in 3 months. On [DATE] Resident 1's weight went down to 149.0 lbs. (comparison weight [DATE], 160.4 lbs. 7 %- 11.4 lbs.). And on [DATE], weight was documented as 131.4 lbs. (comparison weight [DATE], 160 lbs.- 18.1%- 29 lbs.) (Total weight loss from [DATE] to [DATE] was approximately 34.3 % equivalent to 68.6 lbs. During a review of Resident 1's Nutrition Comprehensive assessment dated [DATE], Registered Dietitian 1 (RD 1) documented Resident 1's weight was 200 lbs. (Weight was taken from Resident 1's admission weight record on [DATE]). The RD 1 documented Inadequate intake r/t reduced appetite secondary to covid+ aeb [as evidence by] eating ,d+[DATE]% of meals along w/ meal refusals. The nutritional intervention included was to order Glucerna every day between meals. Under Monitoring & Evaluation section, indicated to Monitor PO, wt [weight] trends, honor food preference as able and obtain wt. per facility protocol, and to follow up as needed. During a review of Resident 1's Order Recap Report (ORR) dated [DATE] to [DATE], it indicated Glucerna was ordered on [DATE] (a month and a half after it was recommended by the RD 1 on [DATE]). It also indicated an order on [DATE], [DATE], and on [DATE] for weekly weights for 4 weeks, then reevaluate one time a day every Wednesday for four weeks. During a review of Resident 1's Nutrition Comprehensive assessment dated [DATE], The Registered Dietitian 2 (RD 2) documented Resident 1's readmission weight 160.4 lbs. on [DATE] and had Weight loss 18 kg (20 % UBW [ Usual Body Weight) from [DATE] to ,d+[DATE], it also indicated that it was unclear if its due to weight variances from previous admission. During a review of Resident 1's weight loss care plan, initiated on [DATE] and revised on [DATE] indicated the goal was to maintain weight, > 50 % of meals, nourishments and supplements and will be free from signs and symptoms of dehydration. Interventions listed included obtain weight as ordered, monitor for signs and symptoms of dehydration, and encourage fluids while awake in addition with meals. There was no indication the care plan was implemented as interventions such as weekly weight monitoring. During a review of the physician's Progress Notes dated [DATE] to [DATE], there was no documentation the physician was aware and or addressed Resident 1's severe weight loss until [DATE]. The physician progress notes dated [DATE] indicated under the Chief Complaint/ Nature of Presenting Problem was, weight loss, poor appetite and covid follow up. It also indicated; Resident 1 had been losing weight with over 10 lbs. in less than 2 weeks. Under the Plan for weight loss and poor appetite was RD consult, encourage to eat and to continue Remeron (for depression manifested by poor oral intake). During a concurrent interview and record review on [DATE] at 11:15 AM with the Restorative Nursing Assistant 1 (RNA 1) (2 East unit) and RNA 2 (2 West unit), Resident 1's electronic weight record (EWR) summary and 2 East and 2 West unit's weight binders were reviewed. Resident 1's EWR summary indicated on [DATE] Resident 1's weight was 200 lbs. (Admission weight). There was no recorded weight for the month of [DATE]. The following weight recorded was on [DATE], Resident 1's weight documented was 160.4 lbs. (Re admission weight). 2 West unit weight binder indicated Resident 1's weight was 200 lbs. taken on ,d+[DATE]. RNA 2 stated that was the only weight record of Resident 1 in 2 West unit before Resident 1 transferred to 2 East unit. There was no documented weight of Resident 1 in 2 East unit record binder. RNA 1 stated, Resident 1 was transferred from 2 West to 2 East unit on the first week of ,d+[DATE]. RNA 1 stated Resident 1's weight was never taken while he was in 2 East unit. During a concurrent interview and record review on [DATE] at 10 AM with the Director of Nursing (DON), Resident 1's medical electronic record was reviewed. In the nutrition comprehensive assessment dated [DATE], the RD 1 did not document the actual re -admission weight (re-admission [DATE]) but rather documented the previous weight of Resident 1 taken on [DATE] (Initial admission.) The nutrition intervention recommendation of Glucerna every day in between meals and to obtain weight per facility protocol, and to follow up as needed were not implemented. There was no nutrition and weight loss care plan to address the nutritional status of Resident 1 on time. (Weight loss care plan was initiated on [DATE]). There was no documentation of the license nurses informing the RD and or the physician about Resident 1's severe weight loss. There was no documentation of the physician was aware and addressed the severe weight loss during the period when Resident 1 lost his appetite and had poor intake. The DON verified and acknowledged the findings. The DON stated the facility missed taking Resident 1's weights as ordered and as per facility's policy. The DON reviewed the RD1's comprehensive assessment dated [DATE], and stated, Resident 1's weight should have been taken when he was re - admitted to the facility on [DATE]. The DON further stated that the RD 1 could have documented the actual weight of Resident 1 when he was readmitted on [DATE], and it could have addressed and monitored the progressive weight loss on time. The DON stated when a Resident had a weight loss, the information was given to the nurses and the nurse was responsible for notifying the physician and the RD. The DON stated physician notification should have been documented in Resident 1's clinical record. The DON confirmed physician notification was not documented in the electronic medical record. The DON stated there was a gap in communication with the previous RD (RD 1), she stated her expectation from the RD was to attend every weight meeting in the facility, provide recommendations and interventions regarding nutrition issues and to talk to the management directly regarding the weight and nutrition issues. The DON stated the RD 1 transitioned from full time to part time and to on call during the period of ,d+[DATE] through ,d+[DATE]. The DON added, the RD 1 is no longer working in the facility. During a concurrent interview and record review on [DATE], at 11:40 AM, with RD 2, Resident 1's weight summary, nutrition assessment and nutrition notes from ,d+[DATE] through ,d+[DATE] were reviewed. The RD 2 stated she started to work at the facility on the last week of ,d+[DATE] as a part time basis and sometimes remotely. The RD 2 stated her job duties included completing nutritional evaluations on all new admissions and focusing on the residents with weight loss issues. The RD 2 also indicated she was not sure how the facility conducts their IDT meeting for weight loss issues. The RD 2 stated she communicated with the Dietary manager (DM), if there was a new admission in the facility or if there were weight loss issues. She stated Resident 1 was re admitted to the facility on [DATE], and that was the reason why she did Resident 1's nutrition comprehensive assessment on [DATE]. It indicated Resident 1's weight was 160.4 lbs. and had Significant weight change of 5 lbs. % or more in the last month or weigh change 10 % or more in the last 6 months. The RD 2 documented that there was a Wt. loss 18 kg (20 % UBW [Usual Body Weight] from [DATE] to [DATE], unclear if d/t [due to] wt. scale from previous admit The RD 2 stated the previous RD (RD1) did not specify if it was a planned weight loss, and if it was planned, it should have been coordinated with the resident and the physician such as what was the expectations and what was the weight to achieve. During an interview on [DATE] at 11:25 AM, with Registered Nurse 1 (RN 1), RN 1 stated License nurses were responsible in documenting a resident's weight in their medical electronic record. RN 1 stated she obtains resident weight list from the Restorative Nurse Assistant (RNA). If a resident triggered an alert for significant weight change, she would notify the physician and would document the physician notification in the electronic medical record, under progress notes and update the care plan. Resident 3 During a review of Resident 3's Resident Dashboard indicated Resident 3's initial admission was on [DATE] with diagnoses including acute embolism (a block in an artery caused by blood clots or other substances) and thrombosis (is the formation of a blood clot inside of blood vessels) of deep veins or right upper extremity, type 2 diabetes mellitus (characterized by high level of sugar in the blood), rheumatoid arthritis (causes joint inflammation and pain) and effusion (an abnormal collection of fluid in hollow spaces or between tissues of the body). Admission Diet was Consistent Carb diet, Regular texture. Thin liquid consistency. During a review of Resident 3's Weights and Vitals Summary indicated as follows: Resident 3's admission weight was 208 lbs.; Resident 3 experienced a continuous and progressive weight decline from [DATE] to [DATE]. Monthly weights taken as follows: [DATE] - 208 lbs. (Admission weight) [DATE] - 210 lbs. ,d+[DATE]//22 - 198 lbs. [DATE] - 200 lbs. [DATE]- 200 lbs. [DATE] -202.2 lbs. [DATE]- 181.4 lbs. [DATE]- 166 lbs. [DATE]- 166 lbs. In the months of ,d+[DATE] to ,d+[DATE], Resident 3 lost 12 lbs. (5.7 % weight loss). In the months of ,d+[DATE] to ,d+[DATE] Resident 3 lost 20.8 lbs. (10%) in a month, In the months of ,d+[DATE] to [DATE], Resident 3 loss additional 15.4 lbs. (8%). Resident 3 experienced a total weight loss 44 lbs. or 21% of her body weight over 6 months, which was considered severe. During a review of Resident 3's Nutrition Comprehensive assessment dated [DATE], it indicated RD 1 documented Resident 3's admission weight was 202.2 lbs. and that there was no significant weight change of 5 lbs./5% or more in the last month or weight change of 10% or more in the last 6 months. RD 1 indicated in the summary notes that Resident 3's weight had been stable for 180 days. RD 1 indicated the nutritional goal for Resident 3 included no significant weight changes, intake 50 % or more of most meals and maintain skin integrity. There was no follow up Nutrition Comprehensive Assessment after [DATE]. During a review of Resident 3's Nutrition Quarterly Review dated [DATE], indicated Resident weight 30 days (one month) ago was 200 lbs. and 208 lbs. 180 days (six months) ago. The RD 1 indicated that Resident 3 had a significant weight loss (Considered significant loss-5 % weight loss in a month, 7.5 % in 3 months and 10 % weight loss in six month) of 34 lbs. rather than severe weight loss (Considered severe weight loss- greater than 5% in one month, greater than 7.5% in 3 months and greater than 10 % in six months) During a review of NSG [nursing]: Skilled Charting progress notes from [DATE] to [DATE] indicated Resident 3 was stable, no significant change, and to continue current plan of care. There was no documentation of resident 3's weight loss was reported to the RD and physician. During a review of Resident 3's physician's Visit dated [DATE] through [DATE], under Nursing Home Progress Note indicated History Comments 2: Patient is awake, alert, good mood, no reports of shortness of breath, chest pain abdominal pain, headaches, TIA's [ Transient Ischemic Attack- a temporary blockage of blood flow to the brain] or decrease oral intake There was no indication of Resident 3's weight loss was recognized by the physician. During a review of Resident 3's Unspecified: Dietary care plan dated [DATE] indicated Resident 3 was at risk for altered status, one of the interventions was to Assess and report to MD ARNP [Advance Registered Nurse Practitioner]: any significant weight loss or gain. There was no care plan to address the severe weight loss for Resident 3. During a concurrent interview and record review on [DATE] at 11:20 AM with the RD 2 and the Dietary Manager (DM), Resident 3's weight record summary and nutrition assessments were reviewed. The RD 2 stated she was not familiar with Resident 3's weight and nutrition issues, and it was being handled by the other RD consultant in the facility that had just started recently as a part time consultant. The DM stated she was not aware of Resident 3's nutrition and weight issues before because during that time, it was The RD 1 was the one involved in taking care of weight and nutrition issues. During a concurrent interview and record review on [DATE] at 11:40 AM with the DON, Resident 3's medical electronic record was reviewed. The DON was asked why the severe weight loss of Resident 3 was not identified or interventions provided on time. The DON acknowledged that there was a gap in communication with the RD 1, and the nursing staff. The DON stated the facility was a big facility and there was only one RD during that time. Resident 4 During a review of Resident 4's face sheet (document containing personal and medical information) dated [DATE], indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including, Traumatic subdural hemorrhage (Buildup of blood on the surface of the brain) without loss of consciousness and Dementia (loss of cognitive functioning, remembering). On [DATE], Resident 4's documented weight was 109.0 lbs. Resident 4's diet was Regular diet with minced and moist texture and nectar thick liquids. During a review of Resident 4's Weight Summary indicated as follows: [DATE]- 109 lbs. [DATE]- 109 lbs. [DATE]- 115.8 lbs. [DATE]- 116 lbs. [DATE]- 120 lbs. [DATE]- 119 lbs. [DATE]- 120 lbs. [DATE]- 123 lbs. [DATE]- 122 lbs. [DATE]- 122 lbs. [DATE]- 118 lbs. [DATE]- 113 lbs. [DATE]-115.8 lbs. [DATE]- 115 lbs. Resident 4 weights was from 109 lbs. to 123 lbs. within seven months. The weight was stable for two months and began declining from ,d+[DATE] through ,d+[DATE], Resident 4 lost 6.2 lbs. in three months' time (6 % weight loss). There was no Nutrition Assessment done during the weight loss period. During a review of Resident 4's Care Plan There was no care plan /intervention documentation to address the weight loss. During a concurrent observation and interview on [DATE] at 12:20 PM with Resident 4 in his room. Resident 4 was observed sitting on his bed with his meal tray on top of his bedside table. Resident 4 stated he was done eating his lunch. Resident 4's meal tray was observed with untouched pudding, thicken fruit juice, thicken milk, and untouched mashed potatoes still on his plate. Resident 4 stated, I don't like this food, that is the reason probably why I'm losing weight During a review of Resident 4's Amount Eaten with Meals dated [DATE] indicated the amount Resident 4's had eaten for lunch was documented as 3 equivalent of 50 to 75 %. During a concurrent interview and record review on [DATE] at 1 PM with Certified Nurse Assistant 1 (CNA1), Resident 4's Amount Eaten with Meals documentation was reviewed. CNA1 stated he document the meal intake percentages based on his own calculation only. During a concurrent interview and record review on [DATE] at 10:50 AM with the DM, Resident 4's latest History and Food Preferences dated [DATE] was reviewed. It indicated special request for lunch was puree fruit and pudding. The DM stated there was no updated food preference for Resident 4, and Resident 4 was on her to do list. Resident 6 During a review of Resident 6's face sheet (Document containing personal and medical information) dated [DATE] indicated Resident 1 admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, hypertension, gout (a form of arthritis- joint inflammation) and acute cystitis (bladder infection). Resident 6's admission weight was documented as 215.6 lbs. During a review of Resident 6's Weight Summary indicated as follows: [DATE]- 215.6 lbs. [DATE]- 212.3 lbs. [DATE] 191.2 lbs. [DATE]- 192.0 lbs. [DATE]- 188.8 lbs. The weight summary indicated, Resident 6's admission weight on [DATE] was 215.6 lbs. There was no weight documented on the month of ,d+[DATE]-,d+[DATE]. On [DATE], Resident 6's weight recorded was 212.3 lbs., and on [DATE] resident weight declined to 191.2 lbs. (9.7%) loss in one month. [DATE], resident weight continued to decline to 188.8 lbs. (Total weight loss from [DATE] to [DATE] was 26.8 lbs. (12% loss in six months). There was no nutritional assessment and care plan documentation during the weight loss period. During a review of Nursing progress note dated ,d+[DATE] through ,d+[DATE], there was no documentation that Resident 6's weight loss was reported to the RD and MD. During a concurrent interview and record review on [DATE], at 2:22 PM with the DON, Resident 6's weight summary, nutritional assessment and nursing progress notes were reviewed. The DON acknowledged that there was no documentation the nursing staff reported the weight loss to the RD and to the primary physician. The DON stated that there should be a nutritional assessment and care plan done to address Resident 6's weight issue. The DON stated, there was a communication gap with the previous RD (RD1). During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, revised ,d+[DATE], the P& P indicated Weight Assessment 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends overtime. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change have been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 1 month 5% weight loss is significant; greater than 5 % is severe. 3 months- 7.5 % weight loss is significant; greater than 7.5 is severe. 6 months- 10 % weight loss is significant; greater than 10 % is severe. 7. If the weight change is desirable, this will be documented and no change in the care plan will be necessary . Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plan shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .Interventions for undesirable weight loss shall be based on careful consideration of the following .Interventions for undesirable weight loss shall be based on careful consideration of the following . Nutrition and hydration needs of the resident . During a review of the facility's P&P titled Nutritional Assessment, revised ,d+[DATE], the P& P indicated, .As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition .Individualized care plans shall address , to the extent possible: .goals and benchmarks for improvement; and d. timeframes and parameters for monitoring and reassessment . During a review of the facility P&P titled, Nutrition (impaired) Unplanned Weight loss- Clinical Protocol revised ,d+[DATE], indicated Assessment and Recognition .The nursing staff will monitor and document the weight and dietary intake of residents in format which permits comparison overtime . The staff will report to the physician's significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake . The facility document titled Dietitian undated, indicated .Duties and Responsibilities . Care plan and Assessment Functions . Develop a written dietary plan of care (preliminary and comprehensive) that identifies the dietary problems/needs of the resident and the goals to be accomplished for each dietary problem/need identified .Review nurses notes to determine if the care plan is being followed. Discuss problem areas with the director of Nursing Services . Review and revise the care plans and assessments as necessary, but at least quarterly .

Based on interview and record review, the facility failed to address suicidal ideation (thinking about wanting to end one's own life) when the facility did not re-assess Resident 2's verbalization I no longer wish to be here on 9/8/22, and the facility did not create and implement a care plan for suicidal ideation for one of three residents reviewed. This failure resulted in Resident 2's suicide attempt on 9/21/22, by using scissors to cut his neck. Findings: 1. During review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including generalized anxiety (persistent worry and fear) disorder, depression (elevation or lowering of a person's mood), and paraplegia (paralysis of the lower body), and previous suicide attempt. Review of Resident 2's minimum data set (MDS, resident assessment tool) dated 8/26/22, indicated Resident 2 was cognitively intact and required extensive assistance to perform activities of daily living (ADLs, things like bathing, eating, and toileting). Resident 2 had mood symptoms present of feeling down or depressed and was moving more slowly or was increasingly fidgety. Review of Resident 2' pre-admission screening and resident review (PASRR, is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 5/13/22, indicated positive for Level 1 screening which prompted a PASSR Level II (A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) evaluation. However, PASSR II evaluation was not completed. During an interview with Administrator (ADM)and Director of Nursing (DON) on 9/30/22 at 1:30 PM, both of them stated PASRR II evaluation was never completed for Resident 2. Review of Resident 2's physician order dated 9/2022, indicated Escitalopram oxalate 5 milligram (mg, measurement unit of mass) 1 tablet a day for depression; Diazepam 5 mg. Give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness . During review of the physician's note dated 9/8/22 indicated that Resident 2 stated I no longer wish to be here and agreed to speak to the psychiatry team. During an interview with the DON on 10/28/22 at 10:40 AM, DON stated that no documentation was present in Resident 2's clinical record between care providers (doctors, NP, nurses, staff, etc.) regarding the assessment or lack of assessment of suicidal ideation in Resident 2. DON also stated that the referral on 9/8/22 from the doctor to Psych NP was the only referral/ communication between staff regarding Resident 2's suicidal ideation. Review of the psychiatry nurse practitioner's (NP) note dated 9/9/22 indicated that Resident 2 has had suicidal thoughts, but the NP was unable to evaluate the resident . Will visit again next time I am in the building. Plan: no changes currently . During an interview with the ADM on 10/20/22 at 11:55 AM, ADM stated that Resident 2 had verbalized to the physician on 9/08/22 that he did not wish to be here. The ADM viewed the sentence was in the context of the heatwave at the time, as Resident 2 was sitting in front of the fan. The ADM stated that if they knew Resident 2 had any suicidal ideation then they would have searched Resident 2 for hazardous objects, provided safe cutlery, and performed safety checks on Resident 2 every 15 minutes. During an interview with the Director of Nursing (DON) on 10/28/22 at 10:40 AM, the DON stated the NP did not come back to the facility to re-evaluate Resident 2. DON acknowledged the NP should have re-evaluated Resident 2 to assess his suicidal thoughts. Review of Resident 2's care plan titled at risk for psychosocial well-being due to adjustment to skilled nursing facility created and initiated on 5/21/22, indicates the facility will refer to mental health team as needed and contact social services for follow up if exhibiting behaviors of depression, anxiety, anger, delusions, or adjustment concerns . Interview with the Social Worker (SW) and Case Manager (CM) on 9/30/22 at 3:20 PM, the SW and CM stated no referral was made or visit/s made by the SW or CM to address suicide. Review of facility's policy and procedure titled, Behavior Assessment, Intervention and Monitoring revised March 2019, states that the Facility will provide, and residents will receive behavioral-health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment . The policy also stated the Resident will have minimal complication associated with the management of altered or impaired behavior. Per this policy, the facility will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors . Under the section of Monitoring , the policy states that If the resident is being treated for altered behavior or mood, the interdisciplinary team (team treating the Resident that consist of the Physician, Nurses, social worker, and administration) will seek and document any improvement or worsening in the individual's behavior, mood, and function . 2. Review of Resident 2's clinical record, indicated there was no care plan to address his suicidal ideation. During an interview with the DON on 10/28/22 at 3:56 PM, she stated that there was no care plan for addressing Resident 2's suicidal ideation, because the facility staff did not re-assess Resident 2 when he stated he no longer wish to be here. During an interview on 10/04/22 at 11:34 AM with Licensed Vocational Nurse (LVN 2) for Resident 2 on the night of 9/21/22, LVN 2 stated that they did not do safety checks on Resident 2 at the time of the incident because she was unaware of Resident 2's suicide ideations. LVN 2 also stated that had she known about Resident 2's suicidal thoughts, LVN 2 would have done periodic safety check on him. During an interview with the Certified Nurse Assistant (CNA 1) on 10/10/22 at 2:33 PM, CNA 1 stated she did not do a safety check for Resident 2 prior to the incident because she too was unaware Resident 2 had suicidal ideations. During an interview with the social worker (SW) on 10/27/22 at 11:11 AM, SW stated that her department was never notified that Resident 2 had suicidal thoughts. The SW stated if the department was made aware, then they would have formulated a plan with the care team to keep Resident 2 safe. Review of Resident 2's progress notes dated 9/21/22 indicated At 12:36 a.m., while charting at the nursing station, writer heard resident yell out, I'm going to slit my neck. This writer immediately ran into resident's room and saw resident with small amount of blood flowing down his neck. Applied pressure to wound, initiated code blue (Emergency Code for immediate medical attention) and dialed 911 for suicide attempt. Asked resident what item he used; resident stated scissors. Asked resident where the scissors are, resident refused to give information .Resident turned to his side table and pulled out green pair of scissors. Nurse standing on right side of resident able to confiscate scissors out of resident's hands safely. Resident refused to state where he obtained the scissors from. Review of Resident 2's history of present illness (HPI) from acute hospital dated 9/21/22, indicated At SNF (skilled nursing facility) where he resides, Resident 2 attempted suicide by using trauma shears to neck. He reports 2 other suicide attempts. He says he does not see life worth due to his paraplegia and chronic pain and wants a cocktail (mixture of medications) to die but says he cannot find a doctor to give him anything. He emphasizes he does not want to return to that hell (SNF) .Resident 2 confirmed attempting suicide two other times in addition to the one he was admitted for , while at the skilled nursing facility. Resident 2 stated that he does not see life worth of living due to his paraplegia, and wants a cocktail to die, but can't find a doctor to help him. Resident 2 stated that he feels likes he can no longer be mobile with his wheelchair and his activity has declined during his skilled nursing stay . Resident 2 verified causing an open wound to the throat was an attempt to suicide, and his intent to die is 100% and that he will try any means possible . Review of the policy titled suicide threats revised December 2007 indicated All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in residents' behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present .

Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure injury for Resident 277, one of three sampled residents with pressure injuries. The facility assessed Resident 277 as high risk for developing pressure injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence. A pressure injury may present as intact skin and may be painful). However, the facility failed to implement interventions to off load pressure to Resident 277's heels. As a result of this failure, Resident 277 developed a pressure injury to her left heel on 6/24/21. Findings: A review of Resident 277's admission record dated 6/17/21 indicated, she had [CONDITION(S)] ([CONDITION(S)], when the kidney failed to function normally), dementia (decline in memory or cognition), and diabetes (abnormally high sugar level in the blood). During initial tour and concurrent interview with Certified Nurse Assistant (CNA) 3, on 6/22/21, at 10:15 AM, Resident 277 was lying on her back, head of bed elevated, and both her heels were touching the mattress. There were no devices implemented to elevate her heels or to off load pressure to her heels. CNA 3 stated, She (Resident 277) cannot do anything for herself. She is totally dependent and has a pressure ulcer (pressure injury) on the buttock. During an observation and concurrent interview with the CNA 3, on 6/23/21, at 9 AM, Resident 277 was lying on her back with head of bed elevated, both her heels were touching the mattress. There were no devices implemented to elevate her heels or to off load pressure to her heels. CNA 3 stated she was waiting for help to clean the resident. During wound care observation and concurrent interview with the Treatment Nurse (TN), on 6/24/21, at 9 AM, TN explained that she will do wound treatment to the left buttock. Resident 277 moaned and stated, My left foot hurts. Resident 277's heel was observed to have a dark purple patch. The TN stated, I just learned about it (left foot pressure injury) this morning. It measures 3.5 centimeters by 4 centimeters. The pressure injury is new. A review of Resident Data Collection dated 6/17/21, indicated Resident 277 has no pressure injury on the left heel on the day of admission. A review of Resident 277's care plan dated 6/19/21, indicated the following: .Focus: High risk for pressure injury related to (RT) diagnosis (DX): [CONDITION(S)] ([CONDITION(S)]), Peripheral vascular disease (PVD) [CONDITION(S)] . Goal: Will not have pressure injury through review date .target date: 9/16/21. Interventions/Tasks: Assist and turning and repositioning every (q) shift; Pressure relieving device in bed and wheelchair; Provide good nutrition and hydration; Assist with meals; Offer fluids as ordered; Provide good skin care after incontinent episode; Assess for skin breakdown Q shift and notify MD (doctor)/Responsible Person (RP) . A review of Nursing Notes dated 6/18/21, 6/19/21, 6/20/21, 6/21/21, 6/22/21, and 6/24/21 did not indicate that Resident 277 has left foot pressure injury. A review of the facility policy and procedure titled, Pressure Injury Risk assessment dated ,d+[DATE], identified [CONDITION(S)], diabetes and cognitive impairment as risk factors for the development of pressure injuries. The policy indicated . General guidelines .2. Risks factors that increases a resident's susceptibility to develop .pressure injury (PI) .b. impaired/decreased mobility . h.circulation deficits . i.[CONDITION(S)] .diabetes .m cognitive impairment . A review of the facility policy and procedure titled, Prevention of Pressure Injuries dated 4/2020, indicated .Skin assessment 3. Inspect the skin .when performing or assisting with personal care or activity of daily living (ADLs) . The cause of pressure injuries is prolonged pressure to a bony area of the body. Uninterrupted pressure is the main cause of pressure injuries, impaired mobility is probably the most common reason residents are exposed to unrelieved pressure. Immobility if prolonged, leads to muscle and soft tissue atrophy (decrease in size), decreasing the bulk over which bony prominence's are supported, further increasing the risk of developing pressure ulcer. The Journal of Legal Nurse Consulting, Spring 2012, recommends that care givers off load bony areas of the body to prevent pressure injuries. The Journal of Legal Nursing Consulting stated Pressure can be lessened by establishing a patient turning schedule that is documented. The standard of care for turning and repositioning is every 2 hours in the recumbent individual and every 15 minutes in a seated person .Off load the heels with a pillow, heel protection device, or wedge .

Based on observation, interview, and record review the facility failed to ensure nutritional assessment was done for one of four residents (Resident 86) when the Registered Dietitian (RD) did not assess the nutritional status after the staff notified him of the development of a Stage 2 Pressure Ulcer (PU) on the right buttocks. This deficient practice resulted in the Stage 2 Pressure Ulcer's progression or worsening to a Stage 3, then to a Stage 4, and placed the resident's health and well-being at risk. Definitions: According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure Injury Stages is defined as follows: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis (the lower or inner layer of the two main layers of cells that make up the skin). Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum (protein rich liquid that separates out when blood jell) filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (to have a layer of skin come off) and eschar (a piece of dead tissue that is cast off from the surface of the skin) are not present. Stage 3 Pressure Injury: Full thickness skin loss Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Stage 4 Pressure Injury: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia (sheet of connective tissue beneath the skin that can be felt), muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Findings: During a review of the Record of Admission on 11/26/18, it indicated Resident 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 10/2/18 showed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was oriented to date, time, and place. During an observation on 11/26/18 at 9:45 AM, Resident 86 was in bed and awake. There was a bed trapeze (a versatile accessory that provides a patient with something secure to grasp when they're trying to change position while in bed or to help facilitate the process of getting out of bed and onto a wheelchair or other mobility device) attached to the bed. Restorative Nurse Assistant (RNA) 1 was at the bedside providing passive exercises to the resident. The RNA 1 stated the resident had a pressure ulcer in the back and was using a pressure relieving mattress. During a review of Resident 86's clinical record and concurrent interview with the Charge Nurse (CN) 1 on 11/26/18 at 9:46 AM, the (MONTH) (YEAR) Weekly Pressure Sore Log indicated Resident 86 developed a Stage 2 Pressure Ulcer (PU) on the right upper buttocks on 11/14/18, and it progressed to a Stage 3 on 11/21/18. The CN 1 stated the PU is now a Stage 4 and it was a facility acquired pressure ulcer. During a review of the facility's undated Wound/Skin Healing Record on 11/26/18, it indicated the date of onset for the PU was 11/13/18, Stage 3 was marked, and Dietary was notified on 11/13/18. The Episodic Care Plan indicated a Problem for PU with the date of 11/13/18 and written, Stage 3 right upper buttock. During an observation and concurrent interview on 11/26/18 at 11:04 AM, Resident 86 was in bed. The Licensed Vocational Nurse (LVN) 7 stated the PU was Stage 3. When the LVN 7 removed the dressing, there was a foul smell and the LVN 7 stated the PU had a drainage, and, there was an eschar (sometimes called a black wound because the wound is covered with thick, dry, black necrotic tissue. Eschar may be allowed to slough off naturally, or it may require surgical removal (debridement) to prevent infection). Resident 86 stated the foul smell started a week ago and the physician did not come to see him. The CN 1 stated there was a conflict of schedule when the physician arrived and the resident was attending an activity. The CN 1 stated the resident would be sent to the hospital today for debridement (surgical removal of lacerated (torn), devitalized (weakened), or contaminated tissue). During a review of the Dietary Progress Notes (DPN) for Resident 86 and concurrent interview with the Director of Nursing (DON) on 11/29/18 at 10:15 AM, it indicated the Nutritional Assessment (NA) by the Registered Dietitian (RD) was done on 6/1/18 (quarterly NA) and on 9/7/18 (annual NA). There was no evidence a nutritional assessment was done when the PU was detected on 11/13/18. The most recent NA by the RD was on 11/26/18 when Resident 86 was sent to the hospital for debridement procedure. The DON stated the resident had prior history of PU when he was initially admitted and it healed. The DON further stated the RD was notified by the staff of the development of Stage 2 PU on 11/13/18 and after reviewing the entire medical record, the DON verified there was no nutritional assessment completed when the staff notified the RD of the Stage 2 PU. During an interview on 11/29/18 at 10:53 AM, the RD verified he was notified by the staff on 11/13/18 but did not evaluate the resident. When asked, the RD stated he knew the resident well, he was moderately obese, had frequently seen him in the hallway, seating in his wheelchair, and had asked him about his food preferences and his weight. The RD stated if a resident was having poor nutritional intake or was malnourished, in his perspective, the resident should be seen right away but Resident 86 was eating well, he was not malnourished. The RD further stated the facility protocol was to evaluate resident with pressure ulcer when notified and then monthly. During a review of the undated facility policy titled, Pressure Ulcers, it indicated, Medical nutritional therapy will be provided . for those at risk or have a diagnosed pressure ulcer. The goal will be to promote healing . and restore the resident to optimal nutritional status . Procedure: Nutritional protocols for Residents at High Risk of Pressure Ulcer . 1. The dietetics professional will review the medical record as well as the pressure ulcer report when assessing /reassessing nutritional status. 4. Nutrition interventions will be implemented. 5. A note will be written . indicating the plan of action and . will be reviewed again within 1 - 4 weeks based on individual need. 6. The dietetics professional will review effectiveness of interventions . If the skin has worsened, it is wise to repeat the food intake study and re evaluate needs . During a review of the undated facility policy under Pressure Ulcer Management Program, it indicated, It is the policy . to have a system of evaluation, assessment and monitoring of resident's for pressure sore . Procedure: 1. 5. Dietary contact will be made for nutritional assessment.

Based on observation, interview and record review, the facility failed to prevent development of pressure sores for one of 35 sampled residents (Resident 11). For Resident 11, who was admitted with intact skin but identified as high risk for pressure sore, the facility failed to provide care and services to prevent development of a Stage III pressure sore (a tissue loss to the level of under-the-skin fat). The deficient practice resulted in Resident 11's development of a Stage III pressure sore on 8/13/13 after two weeks in the facility. Findings: Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Braden Scale (an assessment tool for pressure sore risks), dated 7/28/13, indicated a score of 11 which meant the resident was at high risk of developing pressure sore. Review of the 8/2/13 MDS (Minimum Data Sheet - an assessment tool) indicated Resident 11 had no pressure sore on admission; incontinent of bowel and the resident needed extensive assistance of staff for performance of all of his of ADLs (activities of daily living), including bed mobility, transfers from a bed to a chair, walking, eating, drinking, personal hygiene and toilet use. It also indicated he demonstrated no problem with behaviors, including no rejection of care. Review of the care plan, dated 7/28/13, indicated Resident 11 was at "Risk of development of skin breakdown." The care plan's interventions included to monitor skin condition every shift, to report any changes, to assist with ADLs, mobility and transfers, and to provide good incontinent care. There was no documented evidence of implementation of the care plan's interventions until after development of a Stage III pressure sore on 8/13/13 (16 days later). The care plan did not address interventions on how to prevent development of pressure sore like turning every two hours to relieve pressure on prone areas (back, buttocks and tailbone area), increase frequency of incontinent care according to resident needs and applying barrier cream to skin. Review of the 8/5/13 Pressure Sore CAA (Care Area Assessment) indicated, "Extrinsic risk factors - Confined to bed or chair all or most of the time. Need special mattress or seat cushion to reduce or relieve pressure." An air mattress and 'Roho' cushion (mattress used to treat and prevent sores by repositioning the body so that the weight is redistributed as uniformly as possible) was provided on 9/16/13 (50 days later from admission on 7/28/13) after Resident 11 developed a Stage III pressure sore on 8/13/13. Review of the Wound/skin Healing Record indicated on 8/13/13 the resident had Stage III pressure sore measuring 1.5 cm x 0.5 cm with 90% slough and pink color on surrounding skin. On 8/13/13, wound is still Stage III and was 1.3 cm x 0.5 cm. with 30% slough and pink color on surrounding skin. On 9/13/13 the wound was still Stage III and was 0.5 cm x 0.5 cm. Review of the Nurse's Notes from 7/28/13 to 8/12/13 indicated no documentation that the licensed nurses assessed the resident's skin condition every shift as indicated on the 7/28/13 care plan's intervention. On 8/10/13, the licensed nurse documented, "Kept clean, dry and comfortable". On 8/11/13, licensed nurse documented, "Kept clean, dry and comfortable." On 8/12/13 AM and PM shift, the licensed nurse had no documentation about Resident 11's skin condition. Review of the Nurse's Notes, 8/13/13 at 2:00 AM, a licensed nurse (LN) indicated, "Resident was noted c (with) Stage III pressure sore on coccyx (tailbone). Size 1.5 cm (centimeter) x 0.5 cm. 90% slough. Surrounding area also noted c redness. Small amount of serous drainage (clear and watery drainage from the wound) present. No foul odor present. Wound edges are light pinkish in color. No c/o (complain of) pain or discomfort. Will call MD (medical doctor) and RP (responsible party) in AM." There was no documentation of nursing assessment of a skin break before 8/13/13. The 7/28/13 pressure ulcer care plan, the Nurse's Notes on 8/10/13, 8/11/13 and 8/12/13, and Resident 11's medical record as verified by the DON (Director of Nursing), had no documentation that Resident 11's skin condition was "monitored every shift" according to the 7/28/13 care plan. There was no documentation that Resident 11's skin on the tailbone area was assessed and monitored by licensed nurses for any changes at least in the last 24 hours until on 8/13/13 at 2:00 AM when the licensed nurse noted a Stage III pressure sore. The National Pressure Ulcer Prevention Panel (NPUAP) website, indicated Pressure Ulcer Prevention Points included: RISK ASSESSMENT: Long-term care - assess on admission, weekly for four weeks, then quarterly and whenever the resident's condition changes. SKIN CARE: perform a head to toe skin assessment at least daily, especially checking pressure points such as sacrum (tailbone area), hips, heels, elbows, and the back of the head; cleanse skin at time of soiling, and use a topical barrier to protect the skin; MECHANICAL LOADING AND SUPPORT SURFACES: reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care; use a written repositioning schedule and place at-risk persons on pressure-redistributing mattress and chair cushion surfaces. There was no documentation of following this professional standard on skin care for Resident 11. In an observation on 9/16/13 at 2:55 PM, Resident 11 was lying on his back watching television. During a concurrent interview, when the resident was asked if he got out of bed that day, he responded, "Yes." When he was also asked if he had pain or discomfort on his back and buttocks, he stated, "Sometimes." When asked if he was aware that he had wound on his buttocks, he stared on the television and was not able to answer further questions. In an interview on 9/16/13 at 3:00 PM, CNA (Certified Nurse Aide) 4 stated Resident 11 did get out of bed but was put back to bed because the charge nurse told him Resident 11 could not sit for a long time on the wheelchair because of the wound in the coccyx (tailbone). He also stated the resident could walk with assistance and had no problem eating or drinking. When asked what measures he did to prevent pressure sore, he stated turning the resident every two hours and to report skin changes or skin breakdown. When asked if he documented any of the measures like the turning every two hours, he stated there was no instruction from the licensed nurses to document it. In an interview on 9/19/13 at 11:00 AM, LN 8 (RN Supervisor AM shift on 8/11/13) stated when LVN (Licensed Vocational Nurse) and CNA noted redness or open skin and he was made aware of it, he would do a skin assessment. When asked how often skin assessment was done for resident at high risk for pressure sore, he stated, "If there was no report of skin changes, I will assess weekly." It was discussed with LN 8 that Resident 11's care plan indicated to monitor skin every shift and there was no documentation that this was done; LN 5 stated he would talk to staff about it. In an interview on 9/19/13 at 11:45 AM, LN 5 (RN (Registered Nurse) Supervisor AM shift on 8/12/13) stated that she hardly go with LVN to check on resident's skin condition. She stated when LVN and CNA reported to her any skin breakdown, she would do a skin assessment. She stated that for resident who were at high risk of developing pressure sore, skin assessments were done weekly while no changes on the skin condition. It was discussed with LN 5 that Resident 11's care plan indicated to monitor skin every shift and there was no documentation that this was done; LN 5 did not comment about it. In an interview on 9/19/13 at 11:50 AM, DON stated the resident was incontinent of bowel and bladder, impaired mobility and behavior problem of wanting to sit in the wheelchair for a long time. There was no documented evidence of assessment, monitoring, evaluation, and care planning for the risk of sitting in a wheelchair for a long time for Resident 11. During an interview on 9/19/13 at 11:55 AM, when discussed with the DON that there was no documentation of skin assessment from 7/28/13 to 8/12/13 (16 days) and then on 8/13/13 at 2:00 AM, the nurse documented that Resident 11 had a Stage III pressure sore, she stated, "Isn't that a sign of good care that we do for residents when a nurse did skin assessment even at 2:00 AM?" When she was told that the medical record did not identify behavior issues as risk factors for development of pressure sore, she stated the resident wanted to sit in the wheelchair for a long time and she would check if there was any care plan developed. There was no documentation provided regarding Resident 11's behavior. Furthermore, on 9/19/13 at 11:55 AM, when asked what preventive measures were done to prevent the development of Stage III pressure sore, DON stated the staff was turning the resident every two hours and the resident was provided an air mattress and 'Roho' cushion on 9/16/13. When she was told that those measures were done after the resident developed Stage III pressure sore, she stated, "We know our residents and we do the best we could for them." In an interview on 9/19/13 at 3:45 PM, when LN (Licensed Nurse) 7 was asked if she did a skin assessment on 8/12/13 on the PM shift, she stated she assessed Resident 11's skin with a charge nurse/supervisor but could not remember if there was a change of skin condition. She verified in the Nurse's Notes that all she documented on 8/12/13 at 3-11 shift was "8 PM, MD X (a physician) seen and examined resident, no new order." LN 7 also acknowledged there was no documentation of skin condition on 8/12/13. When asked how she assessed the resident's skin, she stated, the RN supervisor went with her and looked at the resident's skin. Review of the facility's Skin and Wound Assessment policy and procedure (P&P), dated 10/28/08, indicated, "Goal: To provide accurate documentation, skin integrity will be assessed on all patient/residents to identify problems and provide treatment in a timely manner. Policy: The licensed nurse will perform a skin assessment upon admission, weekly and as needed." There was no documented evidence of following this P&P to provide needed skin assessment and to prevent skin break.

Based on interview and record review, the facility failed to ensure sufficient fluid intake to maintain proper hydration for one of 35 sampled residents (Resident 20) when the Resident 20's fluid intake was not monitored and provided interventions to prevent dehydration in a timely manner. This failure resulted in the resident required admission to acute care hospital for an acute kidney injury secondary to dehydration. Findings: Resident 20 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE] following a three day hospitalization for dehydration and kidney injury. Her [DIAGNOSES REDACTED]. Review of the 8/16/13 MDS (Minimum Data Sheet - an assessment tool) indicated severe impairment of mental status but she had the ability to understand others and to make her own needs known. It also indicated the resident required extensive assistance in eating and drinking. Resident 20 demonstrated no problem with behaviors, including no rejection of care. Review of the care plan, dated 2/19/13, indicated Resident 20 was on a mechanical textured (soft food) diet and she was at moderate risk for dehydration due to multiple [DIAGNOSES REDACTED]. The interventions included to urge 75% (percent) intake and to offer substitute if less than 50% and observe for dehydration. Review of the Dietary Nutritional Assessment, dated 2/21/13, did not indicate how much fluids the resident needed and/or any fluid restriction. When the resident was readmitted , the Nutritional Evaluation, dated 8/14/13, indicated the resident needed 1,380 milliliter (ml.) of fluids. Review of the CNA (Certified Nursing Assistant) notes of meal percentage intake from 8/3/13 to 8/6/13 (a total of four days), the resident refused to eat on two occasions and her average intake was 25% at each meal. The ADL (Activities of Daily Living including transfer from a bed to a chair, eating, bathing, dressing, and toilet use) sheet documentation did not indicate if the resident took fluids included on each meal tray like water, milk and juice. Additionally, there was no documentation of how much fluids the resident consumed at each meal and/or at every shift. Review of the Nurse's Notes indicated the following: 8/3/13 at 10:00 AM, the resident had cough with no mucus and had "no appetite." At 1:40 PM the nurse documented that he spoke to the doctor regarding Resident 20's condition and the doctor ordered to continue cough medications and "monitor for any changes." At 3:00 PM, the licensed nurse documented, "Encouraged fluid as tolerated..." On 8/4/13, still with occasional cough. On 8/5/13 at 12:00 AM, "Skin dry and warm to touch." At 6:00 AM, "Fluids encouraged." At 6:30 PM, licensed nurse documented that she called and spoke to the doctor regarding resident cough and chest X-ray and laboratory tests were ordered by the doctor. At 11:00 PM, "Fluids encouraged." On 8/6/13 at 12:00 AM, "Skin dry and warm to touch...fluids given, tolerated 60 ml. At 2:30 PM, "Encouraged fluid intake as tolerated." At 10:45 PM, the physician visited the resident and ordered to transfer the resident to an acute care hospital. There was no documentation Resident 20 was reassessed for "high risk of dehydration" (2/19/13 moderate dehydration risk) when her food intake declined in the last four days (8/3/13 to 8/6/13). Additionally, the nursing care plan, dated 2/19/13, was not revised for interventions to be implemented in a timely manner to prevent dehydration until she came back from the hospital on [DATE]. The Dietary Nutritional Assessment, CNA meal percentage intake sheet and Nurse's Notes had no evidence or documentation that sufficient fluids was provided to Resident 20 according to her calculated needs of 1,380 ml. Review of the Doctor's Progress Notes of Dr. Y, dated 8/6/13 at 10:45 PM, indicated, "Had cough... dry lips and oral mucosa...Dehydration... Transfer for direct admission." Review of the 8/6/13 laboratory results indicated abnormal test results for dehydration, for examples: Urea Nitrogen was 42 (normal value: 5-26); Creatinine was 1.75 (normal value: 0.44 - 1.10). Review of the hospital Transfer Summary from the acute care hospital, dated 8/10/13, indicated, "I (physician Dr. Y) saw the patient in the nursing home. The patient appeared to be lethargic and dehydrated. Therefore, the decision was made to admit the patient directly for further workup and treatment. ... The patient's clinical condition is much improved with good oral hygiene now and patient is more oriented ...and she appeared well hydrated. BUN (blood urea nitrogen) and creatinine returned to almost normal of 26 and 0.89 on the day prior to discharge." The discharge [DIAGNOSES REDACTED]. In an interview on 9/20/13 at 2:10 PM, CNA 3 stated that Resident 20 usually stays in front of the nursing station. She stated that the resident never refused a drink when offered like juice, milk, coffee and water. She added that the resident could hold a glass but the resident needed to be offered a drink because she has dementia. In an interview on 9/20/13 at 2:30 PM, RD (Registered Dietitian) stated that Resident 20 had no fluid restriction even with a [DIAGNOSES REDACTED]. When asked why there was no calculation of resident's fluid needs on the Nutritional Assessment, he stated that the fluid needs were standard for all patients with no fluid restriction between 1,300 to 2,000 ml. He stated that he was aware of the decline in food intake but staff were monitoring the resident. When asked if he was aware that the resident was transferred to the hospital for dehydration, he stated, "I was not aware of the dehydration." In an interview on 9/20/13 at 3:10 PM, LN (Licensed Nurse) 6 stated the resident had not been eating well for a few days before the resident was transferred to hospital. LN 6 verified the CNA meal intake percentage that Resident 20 was eating less than usual. When asked what LN 6 did when Resident 20's food intake declined, she stated that she kept monitoring the resident, encourage resident to eat and drink, give snacks and reported the resident's condition to the supervisor. When asked if she knew how much fluids Resident 20 needed, LN 6 stated, "I don't know." When asked if she assessed Resident 20 for signs of dehydration, LN 6 stated that she did but did not document it on the nursing notes. In an interview on 9/20/13 at 3:15 PM, LN 5 (Registered Nurse Supervisor) stated there was no intake and output (I&0) monitoring until Resident 20 came back from the hospital on [DATE]. When asked how did the staff knew how much fluids Resident 20 took in 24 hours if there was no I&O monitoring, she stated the staff monitor the resident for signs and symptoms of dehydration. In an interview on 9/20/13 at 4:05 PM, DON (Director of Nurses) stated that if resident's food intake significantly declined, the licensed nurse should do an assessment and change of condition and should also do intake and output (I&O) as appropriate. The DON was told by the surveyor that Resident 20's food intake significantly declined for four (4) days and had coughing for a few days before she was transferred to the hospital, and there was no documentation in the medical record of nursing assessment for signs and symptoms of dehydration. She stated that resident was taking 100% of snacks in between meals. It was discussed with her that it was only at AM snacks that Resident 20 took 100% but PM and at night she "refused." DON was told by the surveyor that there was no calculation of individualized estimated fluid needs for the resident and there was no revision of care plan for at risk of dehydration until the resident was readmitted from the hospital and had a [DIAGNOSES REDACTED]. Review of the facility's policy and procedure (P&P), entitled, Intake and Output with a revision date of 6/2009, indicated, "It is the policy of this facility to assess residents and initiate fluid intake and output monitoring as appropriate. ... Upon admission, an evaluation by the licensed nurse will consist of determining the amount of fluid consumed and excreted for a 72-hour period. Sufficiency of these amounts will be based on the individual needs of the resident." There was no documented evidence that the facility implemented this P&P for Resident 20 to assess I&0 to prevent dehydration.