Every finding on record at Holiday Manor Care Center

Based on interview and record review, the facility failed to ensure the resident representative/conservator (a court appointed individual who has the legal authority to make healthcare and medical decisions for a person who is unable to make those choices themselves) was involved in and notified of the transfer and discharge (the movement or release of a resident from a facility's care) for one of three sampled residents (Resident 1), who is under conservatorship.This failure had the potential to result in an inappropriate and unsafe discharge, as Resident 1 was transferred to an assisted living facility (a residential housing option that provides personal care support and meals for adults who need help with daily activities but do not require round-the-clock nursing care) without the confirmed consent or involvement of the legally authorized decision maker, and without ensuring the discharge was necessary and appropriate to meet Resident 1's needs.During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was initially admitted to the facility on [DATE], readmitted on [DATE], and discharged to an assisted living facility on 8/14/2026. The admission Record indicated that Resident 1's medical diagnoses included metabolic encephalopathy (a general brain malfunction caused by chemical imbalances or toxins in the blood), polyneuropathy (dysfunction or damage of many nerves outside the brain and spine, causing numbness, tingling, pain, or weakness, often starting in the hands and feet), and osteoarthritis (when the protective cartilage that cushions the ends of your bones wears down over time, often causing pain).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/18/2026, the MDS indicated that Resident 1 had adequate hearing and vision ability, was usually able to understand and be understood by others, did not have significant issues with memory recall or orientation to time, and required supervision or minimal assistance with toileting, getting into a shower, bathing, and putting on shoes.During a record review of Resident 1's Telephone Order(TO) dated 8/13/2026, the TO indicated Resident 1 may discharge to the assisted living.During a record review of Resident's 1 Notice of Transfer and Discharge form dated 8/14/2026, the Notice of Transfer and Discharge form indicated under signature of Resident/Resident representative was Resident 1's name.During a record review of the email conversations between facility and the conservator dated 8/14/2026, the email indicated Resident 1 was moved to the assisted living.During an interview on 8/25/2026 at 12:50 p.m. with the Social Services Designee (SSD), the SSD stated that if a resident has a conservator, the conservator must be involved in the discharge planning and decision making process.During a concurrent interview and record review on 8/25/2026 at 1:30 p.m. with the Director of Nursing (DON), Resident 1's Interdisciplinary Team (IDT, healthcare and support professionals from different fields who meet to review, plan, and evaluate coordinated care for a patient) Conference Record dated 08/13/2026 was reviewed. The IDT Conference Record indicated the SSD had informed the IDT that Resident 1 and the conservator were aware and in agreement with the planned discharge. The DON stated that this record was the only documentation they could find that indicated that Resident 1's conservator was aware of the plan prior to discharge.During an interview on 8/25/2026 at 3:40 p.m. with the SSD, the SSD stated that after reviewing her notes, she had not started in the position until after Resident 1 had been discharged . The SSD stated that Resident 1 was discharged during the gap between when the previous SSD left the position and when she began. The SSD stated that she was unable to find any documentation that indicated Resident 1's conservator was aware of the discharge decision prior to the discharge.During an interview on 8/26/2026 at 10:55 a.m. with the Discharge Planner (DCP), the DCP stated that she did not contact Resident 1's conservator prior to discharge. The DCP stated that she had the impression from the previous SSD that Resident 1's conservator was aware of discharge plan and had agreed but did not contact the conservator to confirm. The DCP stated that she was unable to find any documentation confirming consent from Resident 1's conservator. The DCP stated that she should have made contact with Resident 1's conservator to confirm consent for discharge prior to discharging Resident 1.During an interview on 8/26/2026 at 11:40 a.m. with the DON, the DON stated that all staff involved in Resident 1's discharge planning should have confirmed that Resident 1's conservator consented to the discharge prior to the actual discharge.During a review of the facility's policy and procedure (P&P) titled Discharging the Resident, last revised on 12/2016, the P&P indicated if the Resident is being discharged home, ensure that resident and/ or responsible party receive teaching and discharge instructions.

Based on interview and record review the facility failed to ensure to reduce one of eight sampled resident's (Resident 1) risks of falls by failing to:Monitor orthostatic blood pressures (a series of blood pressure measurements taken while a patient lies down, sits, and stands to check for low blood pressure) as ordered by the physician.Complete Resident 1' post fall evaluation following the resident's fall on 6/19/2026.These failures had the potential to place Resident 1 at increased risk for injury related to falls.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/2/2021 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- chronic lung disease causing difficulty in breathing), displaced intertrochanteric fracture of the left femur (a broken, left hip), epilepsy (a long-term brain condition that causes repeated seizures [a sudden, uncontrolled burst of electrical activity in the brain that temporarily disrupts how the body and mind function]), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2026, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. The MDS indicated that Resident 1 was independent with eating, oral hygiene, upper body dressing, and bed mobility (movement), and required setup or clean-up assistance from staff with lower body dressing and personal hygiene, and supervision for toileting and showering. The MDS indicated Resident 1 could walk 10 feet once standing with staff's supervision or touching assistance and used a wheelchair. 1. During a review of Resident 1's physician order summary report, the physician order summary report indicated an order dated 5/23/2025 to check Resident 1's orthostatic blood pressures every Saturday during evening shift with the resident lying down, sitting and standing. During a review of Resident 1's physician order summary report, the physician order summary report indicated an order dated 11/3/2025 to administer haloperidol (an antipsychotic [a type of prescription medication primarily used to manage how the brain processes information, helping to clear up severe confusion, severe distortions of reality, or overwhelming mood swings] medication) five (5) milligrams (mg - metric unit of measurement, used for medication dosage and/or amount), three times a day for schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Medication Administration Record (MAR- a record that indicates medications given and activities completed for the resident) for 6/2026, 7/2026, and 8/2026, the MAR indicated an entry of NA for standing orthostatic blood pressure for the following dates on the evening shift: 6/13/2026, 6/20/2026, 6/27/2026, 7/4/2026, 7/18/2026, 7/25/2026 and 8/1/2026. The MAR's Chart Code (a legend used to define all abbreviated terms) did not have NA listed as a possible code. During a concurrent interview and record review on 8/21/2026 at 9:24 a.m., with Registered Nurse 2 (RN 2), RN 2 reviewed the physician's orders for orthostatic blood pressures and the MAR for 6/2026, 7/2026, and 8/2026. RN 2 stated NA meant Not Applicable. RN 2 stated NA might indicate that the resident refused to stand but the documentation was unclear. RN 2 stated all documentation should be clear to ensure proper communication among staff. During a concurrent interview and record review on 8/21/2026 at 11:34 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed the physician's orders for orthostatic blood pressures and the MAR for 7/2026 and 8/2026. LVN 1 stated that 'NA' might mean not applicable, but it was not listed as one of the codes for documentation and further stated he did not know why licensed nurses documented NA. LVN 1 stated that licensed nurses did not obtain Resident 1's orthostatic blood pressure while standing; therefore, the physician's order was not followed. LVN 1 stated it was important to follow the physician's order so the physician could review the trends and have sufficient information to evaluate the resident's condition. During a concurrent interview and record review on 8/21/2026 at 1:21 p.m., with the Director of Nursing (DON), the DON reviewed the physician's orders for orthostatic blood pressures and the MAR for 6/2026, 7/2026, and 8/2026. The DON stated that NA meant Not Applicable and the resident refused care. The DON further stated if Resident 1 refused care, licensed nurses should have informed the physician and documented the refusal. The DON stated Resident 1's refusal to have orthostatic blood pressures taken was not documented and reported to the physician. The DON stated that the resident's refusal should have been documented and reported to the physician because the physician order is part of the resident's plan of care. 2. During a record review of Resident 1's Post Fall Evaluation, dated 6/19/2026, the Post Fall Evaluation indicated that the pre fall or post fall risk scores were not completed. During a concurrent interview and record review on 8/20/2026 at 12:46 p.m., with RN 1, RN 1 reviewed Resident 1's Post Fall Evaluation dated 6/19/2026 and stated that the pre and post fall risk scores were not filled out. RN 1 stated if the required post fall evaluation was not completed, it could result in placing at resident at increased risk for additional falls and injuries.During a concurrent interview and record review on 8/21/2026 at 1:21 p.m., with the DON, the DON stated that the RN Supervisors were responsible for documenting the Post Fall Evaluations. The DON stated that the scores should have been completed to evaluate Resident 1 risk for falling, and to inform other staff that the resident was at high risk for falls. During a review of the facility policy and procedure (P&P) titled Falls and Fall Risk, Managing last reviewed on 1/28/2026, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors. 2. Resident conditions that may contribute to the risk of falls include. g. medication side effects, h. orthostatic hypotension,During a review of the facility's P&P, titled Fall Risk Assessment, last reviewed on 1/28/2026, the P&P indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (AOL) capabilities, activity tolerance, continence, and cognition. During a review of the facility's P&P, titled Antipsychotic Medication Use, last reviewed on 1/28/2026, the P&P indicated, nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. such as orthostatic hypotension.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 19 (Resident 12, 1, and 79) sampled residents when the facility failed to: a. Develop and implement a care plan addressing Resident 12's visual impairment. b. Develop and implement a care plan for Resident 1 to address the risks associated with the use of Seroquel (a medication used to treat certain mental/mood disorders) which carries a Black Box Warning (is the most stringent safety warning the FDA can require from a drug manufacturer. As the name implies, a box warning is a bold, black-bordered notice at the top of a drug's label or informational package insert. This prominent warning is designed to alert health care providers and patients to serious, life-threatening, or permanently disabling risks associated with the drug's use, should an adverse reaction occur). c. Develop and implement a care plan addressing Resident 79's hyperglycemia (occurs when a resident has too much sugar [glucose] in their blood, often because their body has too little insulin or cannot use it properly) which can lead to diabetes complications, such as nerve damage, eye disease and kidney damage. These deficient practices had the potential to negatively affect the provision of care and services provided to Resident 12, Resident 1, and Resident 79. Findings: a. During review of Resident 12's admission Record (AR), the AR indicated that the facility admitted the resident on 4/14/2026 with diagnoses that included essential hypertension (high blood pressure) and blindness right eye category 3 and left eye category 3 (Category 3 blindness is a World Health Organization (WHO) classification for moderate-to-severe visual impairment). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2026, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and the resident was totally dependent (helper does all the effort) on staff with eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear. The resident`s MDS Section V (Section V of the Minimum Data Set (MDS) is the Care Area Assessment (CAA) Summary. It translates clinical data into actionable care planning by summarizing triggers, identifying resident problems, and documenting the interdisciplinary team's decisions on whether to proceed with further assessment) indicated that care planning for visual impairment is triggered. During a concurrent interview on 05/20/2026 at 9:41 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 12`s MDS Section V and care plans. RN 2 stated that care planning for visual impairment was triggered in the CAA, however there was no care plan developed as it was missed by the MDS nurse. RN 2 stated that due to Resident 12`s impaired vision and diminished functional ability, there should have been a care plan with individualized interventions to promote safety and address the resident's needs During a review of the facility's policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/28/2026, the PP indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.the interdisciplinary team (a group of health care professionals such as nursing, physician, and social services who meet to collaborate on the best plan of care for the resident) reviews and updates the care plan: at least quarterly, in conjunction with the required quarterly MDS assessment. b. During review of Resident 1's admission Record (AR), the AR indicated that the facility originally admitted the resident on 1/21/2024 and readmitted on [DATE] with diagnoses that included unspecified psychosis not due to a substance or known physiological condition (mental disorder, not otherwise specified) and Alzheimer`s disease (a progressive, irreversible brain disorder that slowly destroys memory and cognitive skills). During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and the resident required supervision or touching assistance (helper provides visual cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear. During a concurrent interview and record review on 5/20/2026 at 10:17 a.m., with Registered Nurse 2 (RN 2) reviewed Resident 12`s care plan and Seroquel's Black Box Warning details from the electronic health record (EHR). RN 2 stated that there was no care plan addressing the black box warning for Seroquel. RN 2 stated that medications with Black Box Warning should have a specific monitoring of the potential adverse effects of the medication (Seroquel) including suicidal ideation to ensure proper interventions are in place to promote resident safety. During a review of the facility provided Black Box Warning Details (printed from facility electronic health record on 5/20/2026 at 10:47 a.m.), which indicated that in patients of all ages who are started on antidepressant therapy, monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors. During a review of the facility's policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/28/2026, the P&P indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.the interdisciplinary team (a group of health care professionals such as nursing, physician, and social services who meet to collaborate on the best plan of care for the resident) reviews and updates the care plan: at least quarterly, in conjunction with the required quarterly MDS assessment. c. During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted Resident 79 on 3/29/2026 with diagnoses including type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with DM neuropathy(nerve damage caused by high blood sugar),and unspecified atrial fibrillation (A-fib -irregular and often rapid heartbeat). During a review of Resident 79's MDS, the MDS indicated Resident 79's was severely impaired. During a review of Resident 79's Order Summary Report active as of 5/1/2026, the Order Summary Report indicated the following order dated 3/26/2026: -Accuchecks (blood glucose [simple sugar] monitoring tests to measure blood sugar levels) BID (two times a day) for diabetes and to call the medical doctor if greater than (>) 200 milligrams per deciliter ([mg]/dL, a metric unit of measure for blood sugars). During a record review of Resident 79's electronic Medication Administration Record (eMAR) for 5/2026, the eMAR indicated that on 5/9/2026 the resident's blood glucose level was 302 mg/dL. During a concurrent interview and record review on 5/21/2026 at 9:26 a.m. with the Director of Nursing (DON), Resident 79's care plans were reviewed. The DON stated Resident 79 did not have a care plan that addressed hyperglycemia and included appropriate interventions. The DON stated a care plan should have been developed to ensure the resident received appropriate care, as uncontrolled hyperglycemia can lead to complications such as vomiting confusion, nausea, and dizziness. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed on 1/28/2026, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The comprehensive, person-centered care plan: includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen's ice machine was free from a black particle on the inside of the ice machine which had the potential to affect 87 of 88 residents receiving ice from the kitchen's ice machines. 2. Ensure three cutting boards were free from cracks and scratches. 3. Ensure two oven mitts did not have black spots on them. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins).Findings: During a kitchen observation and interview with Dietary Supervisor (DS), on 5/18/2026 at 9 a.m., observed the kitchen ice machine with black particles on the napkin that was used to wipe the interior sides and metal portion in the middle interior of the ice machine. The DS stated the black particles should not be there but be clean so that bacteria will not be present and had the potential for residents to get an infection. The DS stated she was not sure why they were there. The DS stated the ice machine is cleaned once a month by the Maintenance Director (MD). Observed the ice machine scoop with dark spots. The DS stated this should be discarded and replaced. Observed two green and one brown cutting board that had cracks and scratches with the DS. The DS stated those cutting boards should be discarded and replaced with new ones. Observed a pair of oven mitts that had dark spots on them. [NAME] 1 stated when the mitts are too much dirty, she discards them. The DS stated she was going to replace them. During an interview with the MD and DS upon return to the kitchen on 5/18/2026 at 10:02 a.m., the DS stated the ice machine is used for placing ice in bins to keep milk and juice cold for the residents. The MD and DS stated the ice machine was used that morning for that reason. The DS stated some residents ask for ice at times, but no one asked for ice this morning. The MD stated the ice machine was last cleaned approximately two weeks ago, displaying the Ice Machine Monthly Cleaning Log which indicated the MD cleaned the ice machine on 4/29/2026. The MD stated the dark spots may be from the breakdown of the coating on the ice machine scoop because staff hit the metal sides and middle metal part with the scoop. The MD displayed the ice scooper which was silver with dark spots. The MD stated the dark spots are from tarnish in which the coating that was on the ice scoop has come off. The MD stated it is important to clean the ice machine because it reduces possible contamination of ice to residents, prevents biofilm (a complex community of microorganisms, like bacteria, fungi, or algae that irreversibly stick to a surface) buildup, like sludge (another word for biofilm) buildup. The MD stated that biofilm is bacteria, that if not cleaned, had the potential to spread to residents. During a review of the facility's policy and procedure titled, Ice Machine Cleaning Procedures, last reviewed 1/28/2026, the policy indicated the ice machine needs to be cleaned and sanitized monthly. The policy indicated the internal components are to be cleaned monthly or per manufacturer's recommendations. During a review of the facility's policy and procedure titled, Safety and Infection Control, last reviewed 1/28/2026, the policy indicated the kitchen will be equipped with safe equipment, which is to be maintained in good working order.

Based on interview and record review, the facility failed to notify the physician for two of 19 sampled residents (Resident 79 and Resident 41) when:1. Resident 79's blood sugar was greater than 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars, normal reference range 80 - 130 mg/dL) as indicated in the physician's order. This deficient practice placed Resident 79 at risk of becoming hyperglycemic (occurs when a resident has too much sugar [glucose] in their blood, often because their body has too little insulin or cannot use it properly) which can lead to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) complications, such as nerve damage, eye disease and kidney damage. 2. Resident 41 refused Metformin (blood sugar lowering medication), Divalproex Sodium (medication to control seizure [sudden, uncontrolled burst of electrical activity in the brain, causing temporary changes in behavior, awareness, movements, or sensation]), and Clopidogrel Bisulfate (medication to prevent stroke]).This failure in lack of timely notification had the potential to result in improper medication timing and increased risk for adverse drug effects. Findings: 1. During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted Resident 79 on 3/29/2026 with diagnoses including type II diabetes mellitus with DM neuropathy (nerve damage caused by high blood sugar), and unspecified atrial fibrillation (A-fib -irregular and often rapid heartbeat). During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 79 cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) is severely impaired. During a review of Resident 79's Order Summary Report active as of 5/1/2026, the Order Summary Report indicated the following order dated 3/26/2026: -Accu-Checks (blood glucose [simple sugar] monitoring tests to measure blood sugar levels) BID (two times a day) for diabetes and to call the medical doctor if greater than (>) 200 milligrams per deciliter ([mg]/dL, a metric unit of measure for blood sugars). During a record review of Resident 79's electronic Medication Administration Record (eMAR) for 5/2026, the eMAR indicated that on 5/9/2026 the resident's blood glucose level was 302 mg/dL. During a concurrent interview and record review on 5/20/2026 at 3:03 p.m. with Registered Nurse 1 (RN 1), Resident 79's physician orders and Medication Administration Record (MAR) for May 2026 were reviewed. RN 1 stated Resident 79's blood sugar was 302 mg/dL on 5/9/2026. RN 1 stated that based on the physician's order, the licensed nurse should have notified the physician when Resident 79's blood sugar exceeded 200 mg/dL. RN 1 stated it was important to follow the physician's orders to reduce Resident 79's risk of complications related to elevated blood sugar. RN 1 stated the high blood sugar result from 5/9/2026 should have been reported to the physician. RN 1 stated that failure to follow the physician's order could have resulted in Resident 79 experiencing increased thirst, headaches, blurred vision, and diabetic ketoacidosis (DKA). During a concurrent interview and record review on 5/21/2026 at 9:31 a.m. with the Director of Nursing (DON), Resident 79's physician orders and Medication Administration Record (MAR) for May 2026 were reviewed. The DON stated that the physician's order for accucheks required licensed nurses to notify the physician if the resident's blood sugar was greater than 200 mg/dL. The DON stated there were no progress notes or documentation indicating the physician had been notified regarding the elevated blood sugar result of 302 mg/dL on 5/9/2026. The DON stated that the failure to report the high blood sugar level to the physician placed Resident 79 at increased risk for complications associated with uncontrolled hyperglycemia, which could lead to conditions such as blurred vision, vomiting, confusion, nausea, and dizziness During a review of the facility's policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, reviewed on 1/28/2026, the P&P indicated, Blood glucose monitoring: Follow the provider orders for blood glucose monitoring. Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugar above target levels). Signs and symptoms of hyperglycemia may include the following: a. Increased thirst; b.Frequent urination; c.Sugar in the urine; d.Fatigue; e.Headache; and f.Blurred vision. Hyperglycemia and vascular damage can lead to: a.cardiovascular and cerebrovascular disease, including heart disease and stroke; b.cognitive impairment; c.kidney disease; d. glaucoma, cataracts, retinopathy, blindness; e.nerve damage (diabetic neuropathy); f.foot complications- neuropathy, dry skin, calluses, poor circulation, ulcers; g.skin problems - fungal/bacterial infections, itching, diabetic dermopathy; and/or h.gastroparesis (delayed stomach emptying). 2. During a review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 8/15/2022 and readmitted on [DATE] with diagnoses including epilepsy (brain disorder characterized by recurrent seizures [sudden, uncontrolled burst of electrical activity in the brain, causing temporary changes in behavior, awareness, movements, or sensation]), type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with DM polyneuropathy(nerve damage caused by high blood sugar),and hypertension (HTN, high blood pressure). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognition was intact. During a review of Resident 41's Physician Order Summary Report, the report indicated the following orders: 1. Metformin (blood sugar lowering medication) tablet 1000 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) give 1000 mg orally two times a day for DM, dated 7/30/2024. 2. Divalproex Sodium (medication to control seizure) table 500 mg give 1 tablet by mouth two times a day for seizure, dated 7/30/2024. 3. Clopidogrel Bisulfate (medication to prevent [NAME]) 75 mg give 1 tablet by mouth one time a day for cerebrovascular accident (CVA-commonly called a stroke) prophylaxis (PP-preventive care), dated 5/5/2026. During a review of Resident 41's Electronic Medication Administration Record (EMAR), the EMAR indicated that LVN 3 documented administration of the following medications as indicated by checkmarks and LVN 3's initials: 1. Metformin 1000 mg twice daily for Type 2 Diabetes Mellitus with diabetic polyneuropathy, scheduled for administration at 8 a.m. on 5/18/2026. 2. Divalproex Sodium 500 mg twice daily for seizure, scheduled for administration at 9 a.m. on 5/18/2026. 3. Clopidogrel 75 mg once daily for CVA PP, scheduled for administration at 9 a.m. on 5/18/2026. During a concurrent observation and interview on 5/18/2026 at 12:46 p.m. with LVN 3, at nursing station 1, observed inside Medication Cart 1 first drawer, a medication cup containing three medications (an orange tablet, a white tablet, and a blue tablet). LVN 3 stated the three tablets in the medication cup belonged to Resident 41. LVN 3 identified 3 medications as Metformin 500 mg for the 8 a.m. dose, Clopidogrel 75 mg for the 9 a.m. dose, and Divalproex Sodium 500 mg for the 9 a.m., dose. LVN 3 stated Resident 41 was sleepy and refused all three medications, so she saved them (medications) in a medication cup to administer them later. During an interview on 5/18/2026 at 1:02 p.m., with LVN 3, LVN 3 stated medications must be administered within the one hour window (8 a.m. dose by 9 a.m.; 9 a.m. dose by 10 a.m.). LVN 3 stated she signed Resident 41 eMAR indicating the medications were given even though she did not administer them (Metformin for 8 a.m., Clopidogrel for 9 a.m., Divalproex Sodium for 9 a.m.). LVN 3 stated she did not document that Resident 41 refused the medications and did not notify the physician of the medication refusal. LVN 3 stated she placed the medications in a cup inside the cart to give later. LVN 3 stated she was aware that these medications are clinically significant and that not administering them as ordered could put the resident at risk for seizures (Divalproex Sodium), stroke (Clopidogrel), and elevated blood sugar (Metformin). LVN 3 further stated that she did not know why she signed the medication as given when it had not been administered. During an interview on 5/18/2026 at 1:12 p.m., with Director of Nursing (DON), the DON stated that LVN 3 did not document Resident 41's medication refusal and could not provide any documentation showing the physician had been notified, even 3-4 hours after the refusal occurred. The DON stated medications must be administered within one hour of their prescribed time; therefore, the 8 a.m. dose should have been given no later than 9 a.m., and the 9 a.m. dose no later than 10 a.m. The DON stated that when a resident refuses medication, the nurse must immediately discard the medication, document the refusal and the reason, and notify the physician. The DON stated that missing the Clopidogrel dose increases the resident's risk for a stroke, missing the Divalproex Sodium dose increases the resident's risk for seizures, and missing the Metformin may result in elevated blood sugar.During a review of the facility's Policy and Procedure titled, Medication Administration, reviewed on 1/28/2026, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed. During a review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, reviewed on 1/28/2026, the P&P indicated documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: the resident's response and stated reason(s) for request, discontinuation or refusal; the resident's condition and any adverse effects due to the request; the date and time the practitioner was notified as well as the practitioner's response.

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of four sampled residents (Resident 2), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated Resident 2's right to privacy and confidentiality of medical records. Findings: During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 2/23/2024 with diagnoses including dysphagia (difficulty swallowing) and essential hypertension (a condition in which blood pressure is higher than normal). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/29/2026, the MDS indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 2 was totally dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a concurrent medication pass observation and interview on 5/20/2026 at 7:44 a.m., observed Licensed Vocational Nurse 1 (LVN 1) stepped away from the medication cart located in the hallway and left the laptop computer screen open on top of the medication cart. The computer screen displayed Resident 2's medication information and was visible while unattended. During the interview, LVN 1 stated that he should have ensured that Resident 2`s electronic health record was not accessible and open while he stepped away from the medication cart. LVN 1 stated that it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) to have the resident's health information visible to unauthorized persons. During a review of The Health Insurance Portability and Accountability Act (HIPAA) of 1996, it indicated the HIPAA Security Rule protects specific information cover the Privacy Rule law applies fully to nursing homes, requiring them to protect the privacy of residents' health information (PHI) by implementing appropriate safeguards, including technical, administrative, and physical measures to prevent unauthorized access, use, or disclosure of this information, particularly electronic protected health information (ePHI). During a review of the facility's policy and procedure (P&P), titled, Confidentiality of Information and Personal Privacy, last reviewed on 1/28/2026, the policy indicated that the facility will safeguard resident the personal privacy and confidentiality of all resident personal and medical records.

Based on interview, and record review, the facility failed to update and revise a resident`s care plan by failing to: a. Update and revise a care plan after a resident's physician discontinued the resident's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment for one of one resident (Resident 83) reviewed under the dialysis care area. This deficient practice had the potential to result in Resident 83's inadequate care and monitoring due to the care plan not reflecting the resident's current dialysis treatment and related care needs. b. Update and revise a resident`s Activities of Daily Living (the fundamental self-care tasks required to manage one's physical well-being and live independently) care plan after the target date of 4/10/2026 for one of five residents (Resident 19) reviewed under the dementia care area. This deficient practice had the potential to result in care interventions that may not have reflected the resident's current needs and goals.Findings: a. During a review of Resident 83's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission record indicated the facility admitted the resident to the facility on 9/15/2025 with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 83' s Quarterly (assessed every three months, includes the assessment period 12/16/2025 to 3/16/2026) Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2026, the MDS indicated Resident 83 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 83 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. The MDS indicated Resident 16 received dialysis treatments. During a review of Resident 83's Physician's Orders, the orders indicated the following: Dialysis Appointment, Tuesday chair time (the time the resident is at the dialysis center receiving dialysis) 12 p.m. to 3:30 pm, in the afternoon every Tuesday for ESRD, dated 9/15/2026. Dialysis Site –Perma catheter (a specialized, durable tube inserted under the skin and into a large central vein to provide long-term access to the bloodstream) on right upper chest every shift for ESRD, dated 9/15/2026. Not anymore dialysis as per Resident 83's dialysis center, dated 1/27/2026. During a review of Resident 83's active Care Plan for Permacath, initiated 9/16/2025, the care plan indicated resident will not experience an infection at catheter site. During a review of Resident 83's active care plan for Dialysis, initiated 12/17/2025, the care plan indicated a goal that the resident will have no signs or symptoms of complications that could arise daily by the next three months. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 5/21/2026 at 9:52 a.m., reviewed Resident 83's Physician's Orders. RN 2 stated Resident 83's dialysis was discontinued on 1/27/2026 per physician order. Reviewed care plans for Permacath and Dialysis with RN 2. RN 2 stated that these care plans should have been discontinued immediately because the resident is no longer receiving dialysis treatments. RN 2 stated this is important to ensure Resident 83 is receiving the appropriate care. During a concurrent interview and record review with the Director of Nursing (DON) on 5/21/2026 at 12:43 p.m., the DON reviewed Resident 83's Physician's Orders and care plans for Permacath and Dialysis. The DON stated Resident 83's dialysis treatments were discontinued on 1/27/2026. The DON stated the dialysis care plans should have been discontinued immediately because the resident no longer receives dialysis treatments and there was a positive change of condition for Resident 83 after 1/27/2026. The DON stated this is to ensure Resident 83's data is accurate and to provide the appropriate care for the Resident 83. During a review of the facility's policy and procedure (PP) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/28/2026, indicated the following: -Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team (a group of health care professionals such as nursing, physician, and social services who meet to collaborate on the best plan of care for the resident) reviews and updates the care plan: (but not limited to) when there is a significant change in the resident's condition. b. During a review of Resident 19's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities) and chronic obstructive pulmonary disease (COPD, a progressive, irreversible lung disease that restricts airflow and makes breathing difficult). During a review of Resident 19' s Quarterly MDS, dated [DATE], the MDS indicated Resident 19 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 19 required supervision or touching assistance (helper provides visual cues) with eating oral hygiene, toileting hygiene, lower body dressing, and putting on/and taking off footwear. During a concurrent record review and interview on 5/19/2026 at 2:45 p.m., reviewed with Registered Nurse 2 (RN 2) Resident 19`s Care Plan for ADL deficit related to anxiety, depression, schizophrenia (a mental health disorder that affects how a person thinks, feels, and behaves), dementia and COPD. The review indicated that the CP for ADL deficit was initiated on 1/09/2026 with a goal /target date of 4/10/2026. The review of the CP for ADL deficit was not revised or renewed after the 4/10/2026 target date. RN 2 stated the care plans are evaluated quarterly to determine whether the goals have been met and whether the interventions remain effective to ensure continuity of care. RN 2 stated that without an updated care plan, staff may be unable to determine whether the resident is progressing toward goals or experiencing decline in condition, and necessary services may not be provided. During a review of the facility's PP titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/28/2026, the PP indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.the interdisciplinary team reviews and updates the care plan: at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review, the facility failed to provide books of interest to a resident to support the resident's activity preferences as identified in the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/7/2025, for one of three residents (Resident 82) investigated under the care area of Activities. This deficient practice had the potential to result in the resident's activity preferences not being honored, leading to reduced quality of life.Findings: During a review of Resident 82's admission Record, the admission Record indicated that the facility admitted the resident to the facility on 9/03/2025 and re-admitted on [DATE], with diagnoses that included but not limited to depression and schizophrenia (a chronic and severe brain disorder that affects how a person interprets reality). During a review of Resident 82`s admission Minimum Data Set (MDS - a resident assessment tool), dated 9/07/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS Interview for Activity Preferences indicated that it was very important to the resident to have books, newspapers, and magazines to read. During a concurrent observation and interview with Resident 82 on 5/18/2026 at 10:24 a.m., observed resident in his room. The resident stated he spends most of his time in his room reading books. The resident stated that he had already read the book at his bedside twice and did not have any other books available. The resident further stated that he would be glad if staff could provide or lend him additional books and National Geographic magazines to read. During a follow up observation and interview with Resident 82 in his room on 5/19/2026 at 4:05 p.m., in the presence of the Activity Director (AD), observed Resident 82 watching television. Resident 82 stated that he only has one book which he had already read twice. Resident 82 stated that he would love to have additional books and National Geographic magazines to read. During an interview on 5/19/2026 at 4:10 p.m. with the AD, the AD stated residents who do not attend activities should still be provided with activities of their preference. The AD stated that if a resident prefers reading, the facility should provide reading materials consistent with the resident's interests. The AD further stated that it would be frustrating for the residents if they did not have access to books of if their activity preferences are not supported. During a review of the facility`s policy and procedure (P&P) titled Group Programs and Activities Calendar, last reviewed on 1/28/2026, the P&P indicated that the activity director/coordinator periodically reviews the current types of activity programs in terms of the current facility population and changes are made based on this analysis with input from the resident council and the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents during review of one of two medication carts (Med Cart 1) affecting Resident 41 by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN) 3 administer medications within the required one hour timeframe. 2. Ensure LVN 3 did not document medications in the electronic Medication Administration Record (eMAR) as administered when medications have not been given. 3. Ensure LVN 3 document medication refusal in the eMAR and notify the physician of the refusal. 4. Ensure LVN 3 store medications in the medication cart in accordance with the facility policy. These failures placed the resident at risk for avoidable harm and significant clinical complications due to improper medication administration, documentation, and storage practices. Findings: During a review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 8/15/2022 and readmitted on [DATE] with diagnoses including epilepsy (brain disorder characterized by recurrent seizures(sudden, uncontrolled burst of electrical activity in the brain, causing temporary changes in behavior, awareness, movements, or sensation), type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with DM polyneuropathy(nerve damage caused by high blood sugar),and hypertension (HTN, high blood pressure). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 4/29/2026, the MDS indicated Resident 41's cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During a review of Resident 41's Physician Order Summary Report, the report indicated the following orders: 1. Metformin (blood sugar lowering medication) tablet 1000 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) give 1000 mg orally two times a day for DM, dated 7/30/2024. 2. Divalproex Sodium (medication to control seizure) table 500 mg give 1 tablet by mouth two times a day for seizure, dated 7/30/2024. 3. Clopidogrel Bisulfate (medication to prevent [NAME]) 75 mg give 1 tablet by mouth one time a day for cerebrovascular accident (CVA-commonly called a stroke Prophylaxis (PP), dated 5/5/2026. During a review of Resident 41's Electronic Medication Administration Record (EMAR), the EMAR indicated that LVN 3 documented administration of the following medications as indicated by checkmarks and LVN 3's initials: 1. Metformin 1000 mg twice daily for Type 2 Diabetes Mellitus with diabetic polyneuropathy, scheduled for administration at 8 a.m. on 5/18/2026. 2. Divalproex Sodium 500 mg twice daily for seizure, scheduled for administration at 9 a.m. on 5/18/2026. 3. Clopidogrel 75 mg once daily for CVA PP, scheduled for administration at 9 a.m. on 5/18/2026. During a concurrent observation and interview on 5/18/2026 at 12:46 p.m. with LVN 3, at nursing station 1, observed inside Medication Cart 1 first drawer, a medication cup containing three medications (an orange tablet, a white tablet, and a blue tablet). LVN 3 stated the three tablets in the medication cup belonged to Resident 41. LVN 3 identified 3 medications as Metformin 500 mg for the 8 a.m. dose, Clopidogrel 75 mg for the 9 a.m. dose, and Divalproex Sodium 500 mg for the 9 a.m., dose. LVN 3 stated Resident 41 was sleepy and refused all three medications, so she saved them (medications) in a medication cup to administer them later. During a concurrent interview and record review on 5/18/2026 at 12:58 p.m. with LVN 3, reviewed Resident 41's eMAR from 5/1/2026 to 5/30/2026. LVN 3 stated the eMAR indicated the following medications had been administered on 5/18/2026: 1. Metformin 1000 mg twice daily for Type 2 Diabetes Mellitus with diabetic polyneuropathy for the 8 a.m. dose 2. Divalproex Sodium 500 mg twice daily for seizure for the 9 a.m. dose.3. Clopidogrel 75 mg once daily for CVA PP for the 9 a.m. dose.During an interview on 5/18/2026 at 1:02 p.m., with LVN 3, LVN 3 stated medications must be administered within the one hour window (8 a.m. dose by 9 a.m.; 9 a.m. dose by 10 a.m.). LVN 3 stated she signed Resident 41 eMAR indicating the medications were given even though she did not administer them (Metformin for 8 a.m., Clopidogrel for 9 a.m., Divalproex Sodium for 9 a.m.). LVN 3 stated she did not document that Resident 41 refused the medications and did not notify the physician of the medication refusal. LVN 3 stated she placed the medications in a cup inside the cart to give later. LVN 3 stated she was aware that these medications are clinically significant and that not administering them as ordered could put the resident at risk for seizures (Divalproex Sodium), stroke (Clopidogrel), and elevated blood sugar (Metformin). LVN 3 further stated that she did not know why she signed the medication as given when it had not been administered. During an interview on 5/18/2026 at 1:12 p.m., with Director of Nursing (DON), the DON stated that LVN 3 did not document Resident 41's medication refusal and could not provide any documentation showing the physician had been notified, even 3-4 hours after the refusal occurred. The DON stated medications must be administered within one hour of their prescribed time; therefore, the 8 a.m. dose should have been given no later than 9 a.m., and the 9 a.m. dose no later than 10 a.m. The DON stated that when a resident refuses medication, the nurse must immediately discard the medication, document the refusal and the reason, and notify the physician. The DON stated that missing the Clopidogrel dose increases the resident's risk for a stroke, missing the Divalproex Sodium dose increases the resident's risk for seizures, and missing the Metformin may result in elevated blood sugar. The DON stated that licensed nurses must never save refused medications in the cart, since they may be forgotten or mistakenly administered later, and stated that all three medications were clinically significant and that failure to administer them as ordered constituted a significant medication error. During an interview on 5/21/2026 at 1:28 p.m., with DON, the DON stated that medications should be initialed and checked mark only after each medication is administered. The DON stated if a resident refused the staff should document refusals by entering 2 in the eMAR and record the refusal in the progress notes at the time it occurs, not 3-4 hours later. During a review of the facility's Policy and Procedure titled, Medication Administration, reviewed on 1/28/2026, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed. During a review of the facility's P&P titled, Medication Labeling and Storage, reviewed on 1/28/2026, the P&P indicated Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. Medications may not be transferred between containers. During a review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, reviewed on 1/28/2026, the P&P indicated documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: the resident's response and stated reason(s) for request, discontinuation or refusal; the resident's condition and any adverse effects due to the request; the date and time the practitioner was notified as well as the practitioner's response. During a review of the facility's P&P titled, Documentation, reviewed on 1/28/2026, the P&P indicated, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation .in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled, Adverse Consequences and Medication Errors, reviewed on 1/28/2026, the P&P indicated, medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include omission - a drug is ordered but not administered and, wrong time.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one of one of resident (Resident 30) reviewed under the care area of insulin by failing to clarify and carry out the physician's order to change Resident 30's insulin administration regimen from twice daily to once daily, resulting in the resident not receiving prescribed insulin from 4/3/2026 through 5/20/2026. This deficient practice had the potential to result in uncontrolled blood glucose levels, including hyperglycemia and its associated complications such as nerve damage, kidney damage and diabetic ketoacidosis (DKA-life threatening medical emergency when people with diabetes do not have insulin. Without insulin, the body cannot use energy, so it breaks down fat too fast, creating a toxic amount of acid) due to the failure to administer prescribed insulin therapy.Findings: During a review of Resident 30 's admission Record, the admission Record indicated that the facility admitted Resident 30 on 3/30/2026 with diagnoses including essential hypertension (a condition in which blood pressure is higher than normal) and type 2 diabetes mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 4/03/2026, the MDS indicated that the resident had the ability to make self-understood and had the ability to understand others). The MDS further indicated that Resident 30 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent record review and interview on 5/21/2026 at 8:27 a.m., reviewed Resident 30`s physician`s telephone orders dated 4/3/2026 and Medication Administration Record (MAR) from 4/3/2026 to 5/20/2026, with the Director of Nursing (DON). The DON stated the order indicated to discontinue Lantus Insulin ( a long-acting man-made-insulin used to control high blood sugar in adults and children with diabetes mellitus) twice a day and to only give Lantus Insulin in the morning, Accu-Chek (painless finger-pricking to draw blood samples for testing) twice a day and call physician if the blood sugar is greater than 200 milligram per deciliter (mg/dl- for individuals without diabetes, normal blood sugar levels generally range from 70 to 99 mg/dL when fasting, and stay below [140 mg/dL] two hours after a meal). The DON stated that the change in the physician's order was missed by the licensed nurses, resulting in the resident not receiving Lantus insulin from 4/3/2026 through 5/20/2026. The DON stated that because the order was not carried out, the medication was not reflected on the MAR. During a review of the MARs from 4/2026 through 05/2026, the DON confirmed there was no documented administration of Lantus insulin during that period. The DON stated that not receiving Lantus Insulin could have resulted in Resident 30 experiencing hyperglycemia with symptoms such as nausea, vomiting and dizziness. The DON stated that untreated hyperglycemia could have resulted in complications and hospitalization. During a review of the facility`s policy and procedure (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus,) last reviewed on 1/28/2026, the PP indicated that Complications associated with diabetes can be attributed to: uncontrolled hyperglycemia and subsequent damage to vasculature.hyperglycemia and vascular damage can lead to kidney disease, glaucoma, nerve damage. During a review of the facility's P&P titled, Adverse Consequences and Medication Errors, dated 1/28/2026, the P&P indicated, A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include omission - a drug is ordered but not administered and, wrong time.

Based on observation, interview and record review, the facility failed to ensure an expired Lantus Insulin (a long-acting man-made-insulin used to control high blood sugar in people with diabetes mellitus [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing]) pen for Resident 30 was removed from one of two medication carts (Med Cart 2) inspected during inspection of medication carts. This deficient practice had the potential for the Lantus Insulin to be used beyond the use by date which could affect the efficacy and render the insulin non-effective in the management of Resident 30's diabetes. Findings: During a concurrent medication cart inspection of Med Cart 2 and interview on [DATE] at 11:27 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed stored inside Med Cart 2 a Lantus Insulin pen prescribed for Resident 30, with an open date of [DATE]. LVN 2 stated that the Lantus insulin pen should only be used for 28 days after opening. LVN 2 stated that if it used beyond 28 days, the medication may lose its effectiveness, which could result in uncontrolled blood sugar levels for the resident. During a review of Resident 30 's admission Record, the admission Record indicated that the facility admitted Resident 30 on [DATE] with diagnoses essential hypertension (a condition in which blood pressure is higher than normal) and type 2 diabetes mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated that the resident had the ability to make self-understood and had the ability to understand others). The MDS further indicated that Resident 30 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene. During an interview on [DATE] at 3:19 p.m., interviewed Registered Nurse 1 (RN 1). RN 1 stated that expired medication should not be kept in the medication cart to prevent its potential use and if used it will no longer be effective which can result to Resident 30 experiencing hyperglycemia and its complications such as blurred vision and kidney disease. During a review of the facility`s policy and procedure (PP) titled Medication Storage and Labeling, the PP indicated that multi-dose vials that have been opened or accessed are (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review the facility failed to maintain complete and accurate clinical records for two of 19 sampled residents (Resident 23 and Resident 41) by: a. Failing to accurately document insulin (a natural hormone [are chemicals which circulate in the blood stream] that turns food into energy and manages your blood sugar level) injection site administrations. The deficit practice resulted in incomplete and inaccurate clinical records that did not reflect the resident's actual treatment and failed to meet accepted documentation standards. b. Failing to ensure Licensed Vocational Nurse 3 (LVN 3) did not document medications in the electronic Medication Administration Record (eMAR) as administered when medications have not been given. The deficit practice resulted in inaccurate and incomplete medication documentation that did not reflect the resident's actual medication status. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated the facility admitted Resident 23 on 2/13/2024 and readmitted on [DATE] with diagnoses including type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) , hypertension (HTN, high blood pressure), and bipolar disorder (a mental health condition characterized by significant and often severe mood swings that affect a person's energy, activity levels, and behavior). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/04/2026, the MDS indicated Resident 23's cognition ((the mental process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 23's Electronic Medication Administration Record (eMAR) for the period 5/01/2026-5/31/2026, the eMAR indicated an order for Insulin Glargine (long-acting insulin to lower blood glucose level) 100 units/ml (units of a drug are present per milliliter), inject 38 units subcutaneously (under skin) at bedtime. The area designated for documenting the insulin injection site contained numerical entries instead of anatomical locations. The following entries were recorded: 5/07/2026 - 142 5/13/2026 - 212 5/14/2026 - 156 5/18/2026 - 189 5/19/2026 - 303 During a concurrent interview and record review on 5/20/2026 at 4:37 pm with Director of Nursing (DON), Resident 23's eMAR for the period of 5/01/2026 to 5/31/2026 was reviewed. The DON stated the eMAR indicated an active order for Insulin Glargine 100 units/mL, 38 units subcutaneously at bedtime. The DON stated that the area designated for documenting the insulin injection site is required to contain a specific anatomical location, such as right abdomen, left abdomen, right thigh, or left thigh. The DON confirmed that the entries documented on the following dates-142 (5/07/2026), 212 (5/13/2026), 156 (5/14/2026), 189 (5/18/2026), and 303 (5/19/2026)-were incorrect and not acceptable documentation. The DON stated these numbers do not correspond to any approved facility code, and nursing staff should not be documenting numerical values in place of anatomical locations. The DON acknowledged that the entries were inaccurate, did not reflect proper documentation standards, and were not consistent with facility policy for insulin administration recording. The DON stated that the purpose of documenting the injection site is to ensure proper rotation of sites. 2. During a review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 8/15/2022 and readmitted on [DATE] with diagnoses including epilepsy (brain disorder characterized by recurrent seizures (sudden, uncontrolled burst of electrical activity in the brain, causing temporary changes in behavior, awareness, movements, or sensation), type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with DM polyneuropathy(nerve damage caused by high blood sugar), and hypertension (HTN, high blood pressure). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognition was intact.During a review of Resident 41's Electronic Medication Administration Record (EMAR), the EMAR indicated that LVN 3 documented administration of the following medications as indicated by checkmarks and LVN 3's initials: 1. Metformin 1000 mg twice daily for Type 2 Diabetes Mellitus with diabetic polyneuropathy, scheduled for administration at 8 a.m. on 5/18/2026. 2. Divalproex Sodium 500 mg twice daily for seizure, scheduled for administration at 9 a.m. on 5/18/2026. 3. Clopidogrel 75 mg once daily for cerebrovascular accident (CVA-commonly called a stroke) prophylaxis (PP- preventive care), scheduled for administration at 9 a.m. on 5/18/2026. During a concurrent observation and interview on 5/18/2026 at 12:46 p.m. with LVN 3, at nursing station 1, observed inside Medication Cart 1 first drawer, a medication cup containing three medications (an orange tablet, a white tablet, and a blue tablet). LVN 3 stated the three tablets in the medication cup belonged to Resident 41. LVN 3 identified 3 medications as Metformin 500 mg for the 8 a.m. dose, Clopidogrel 75 mg for the 9 a.m. dose, and Divalproex Sodium 500 mg for the 9 a.m., dose. LVN 3 stated Resident 41 was sleepy and refused all three medications, so she saved them (medications) in a medication cup to administer them later. During a concurrent interview and record review on 5/18/2026 at 12:58 p.m. with LVN 3, reviewed Resident 41's eMAR from 5/1/2026 to 5/30/2026. LVN 3 stated the eMAR indicated the following medications had been administered on 5/18/2026: 1. Metformin 1000 mg twice daily for Type 2 Diabetes Mellitus with diabetic polyneuropathy for the 8 a.m. dose 2. Divalproex Sodium 500 mg twice daily for seizure for the 9 a.m. dose.3. Clopidogrel 75 mg once daily for CVA PP for the 9 a.m. dose.During an interview on 5/18/2026 at 1:02 p.m., with LVN 3, LVN 3 stated medications must be administered within the one hour window (8 a.m. dose by 9 a.m.; 9 a.m. dose by 10 a.m.). LVN 3 stated she signed Resident 41 eMAR indicating the medications were given even though she did not administer them (Metformin for 8 a.m., Clopidogrel for 9 a.m., Divalproex Sodium for 9 a.m.). LVN 3 further stated that she did not know why she signed the medication as given when it had not been administered. During an interview on 5/21/2026 at 1:28 p.m., with DON, the DON stated that medications should be initialed and checked mark only after each medication is administered.The DON stated if a resident refused the licensed nurse should document refusals by entering 2 in the eMAR and record the refusal in the progress notes at the time it occurred, not 3-4 hours later. During a review of the facility's Policy and Procedure titled, Medication Administration, reviewed on 1/28/2026, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed.During a review of the facility's P&P titled, Documentation, dated 1/28/2026, the P&P indicated, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation .in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) by failing to conduct infection surveillance for a resident who was prescribed a long-term (being prescribed for more than seven to ten days) antibiotic for one (Residents 4) of three residents sampled for antibiotic usage. This deficient practice had the potential for Resident 4 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a review of Resident 4's admission Record (face sheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 1/29/2021and re-admitted on [DATE] with diagnoses that included liver cirrhosis (condition where healthy liver tissue is permanently replaced by scar tissue due to chronic, long-term liver damage). During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/27/2026, indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 4 was dependent (helper does all the effort; resident does not of the effort to complete the activity) on staff for showering, dressing, and personal hygiene. The MDS indicated Resident 4 is taking an antibiotic medication. During a review of Resident 4's Physician's Orders, dated 3/27/2026, the Physician's Orders indicated an order for Neomycin Sulfate Oral Tablet 500 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth three times a day for cirrhosis. During a review of Resident 4's Care Plan for Liver Cirrhosis, initiated 2/28/2026, the care plan indicated Resident 4 is at risk for discomfort, shortness of breath, fluid retention and exacerbation (a sudden worsening of a disease) secondary to liver cirrhosis. The care plan indicated a goal that Resident 4 will have no signs or symptoms of exacerbation manifested by shortness of breath and discomfort daily for 90 days. The care plan indicated an intervention to give Neomycin Sulfate 500 mg tablet by mouth three times a day as ordered. During a concurrent interview and record review with the Infection Preventionist (IP) on 5/20/2026 at 9:13 a.m., the IP reviewed Resident 4's Liver Cirrhosis Care Plan. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) should be created to ensure the McGeer's (a criteria of signs and symptoms that must be met to qualify an infection as being a true infection) criteria and Loeb's criteria (to determine whether starting antibiotics is necessary for a suspected infection, thereby reducing antibiotic overuse) are met. The IP stated she documents on the infection surveillance form for new antibiotics within 48 hours admission to the facility and checks to see if a resident's signs and symptoms (s/s) follow McGeer's and Loeb's criteria and to communicate with the doctor if the s/s do not meet McGeer's or Loeb's criteria to see if he wants to continue the antibiotic. The IP stated Resident 4 is on the antibiotic, Neomycin, long term (longer than seven to ten days) to prevent bacterial growth and prevent accumulation of ammonia. When asked why this information was not included on Resident 4's care plan, the IP stated another licensed nurse wrote the care plan and may not have been as knowledgeable regarding Resident 4's condition. When asked why there was no infection surveillance form for Resident 4's Neomycin use, the IP stated Resident 4 was on the antibiotic long term. When asked if there should be some documentation such as a physician's note that indicates the rationale for the long-term use of Neomycin, the IP stated, upon further consideration, there should be some documentation somewhere regarding this. The IP stated the pharmacy is obtaining the rationale. The IP stated she would speak with Resident 4's physician to obtain documentation for his rationale for continued use of the Neomycin. The IP stated infection surveillance is important for Resident 4's well-being, to monitor blood laboratory values such as ammonia, to have no adverse effects of the medication, and to ensure the physician and licensed nurses are on the same page regarding Resident 4's condition. During an interview with the Director of Nurses (DON) on 5/21/2026 at 12:50 p.m., the DON stated every resident prescribed an antibiotic should have a surveillance assessment. The DON stated this is important to monitor the usage of the antibiotic, monitor the effectiveness. The DON stated it is important to know why a resident is being treated and to ensure a resident is not at risk for more infection. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, last reviewed 1/28/2026, the P&P indicated the following: -The IP will be responsible for infection surveillance and multi-drug-resistant organism (MDRO, refers to bacteria that have mutated and are no longer killed by the antibiotics typically used to treat them) tracking. -The IP will collect and review data such as: i. Type of antibiotic ordered, route of administration, antibiotic costs ii. Whether the order was made by phone, if order was given by attending physician iii. Whether appropriate tests such as cultures were obtained before ordering antibiotic iv. Whether the antibiotic was changed during the course of treatment During a review of the facility's P&P titled, Antibiotic Time-Out, last reviewed 1/28/2026, the P&P indicated the following: -An antibiotic time-out is meant to prompt the physician to revisit the need for the antibiotic 48-72 hours after starting the antibiotic. -The facility licensed nurse (IP, DON, or charge nurse) will contact the prescribing physician 48-72 hours after initiation of antibiotics to answer these questions: a. Does the resident have an infection that will respond to antibiotics? b. If so, is the resident on the right antibiotic (s) dose, and route of administration? c. Can a more targeted antibiotic be used to treat the infection? d. How long should the resident receive the antibiotic?

Based on interview and record review, the facility failed to notify a physician for one of three sampled residents (Resident 1) regarding the following:1. Resident 1's elevated blood sugar (BS) levels greater than 200 milligrams per deciliter (mg/dl - unit of measurement) per the physician orders.2. Resident 1's refusal to undergo a complete blood count (CBC - an essential blood test that measures the cells circulating in the blood, including the red blood cells [oxygen transport], white blood cells [infection fighting], and platelets [clotting], used to evaluate overall health and diagnose medical conditions) for anemia (a condition in which the body lacks sufficient healthy red blood cells) on 4/6/2026.These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and a decline in the resident's overall health status. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated that Resident 1 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, bed mobility (movement), and transfers for chair/bed-to-chair and toilet. The MDS further indicated that Resident 1 was independent with eating.1. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated a Physician Order dated 4/1/2026 (to start on 4/2/2026) for BS check two times a day for diabetes mellitus (DM - a disorder characterized by difficulty in BS control and poor wound healing) before breakfast and before dinner, with instructions to notify the physician when BS levels exceeded 200 mg/dl. During a review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional at a facility) for 4/2026, the MAR indicated that licensed nurses documented BS checks at 6:30 a.m. and 4:30 p.m. The MAR indicated multiple instances in which Resident 1's BS levels exceeded 200 mg/dl, as follows: 4/2/26 at 4:30 p.m. BS was 239. 4/3/26 at 4:30 p.m. BS was 498. 4/4/26 at 4:30 p.m. BS was 205. 4/5/26 at 6:30 a.m. BS was 226, and at 4:30 p.m. BS was 389.During a concurrent interview and record review on 4/10/2026 at 1:30 p.m., with Registered Nurse 4 (RN 4), Resident 1's Physician Order dated 4/1/2026 (to start on 4/2/2026) and MAR for 4/2026 were reviewed. RN 4 reviewed Resident 1's progress notes from 4/2/2026 to 4/5/2026 and stated that RN 4 was unable to locate documentation indicating that licensed nurses notified the physician regarding elevated BS readings greater than 200 mg/dl obtained before meals. RN 4 further stated that it is important to notify the physician of elevated BS results, as the physician may adjust the treatment plan, including modifications to insulin (a hormone that helps regulate blood sugar levels) dosages. During a concurrent interview and record review on 4/10/2026 at 3:30 p.m., with RN 3, Resident 1's Physician Order dated 4/1/2026 (to start on 4/2/2026) and MAR for 4/2026 were reviewed. RN 3 stated that RN 3 documented Resident 1's BS as 239 on 4/2/2026 at 4:30 p.m. and 498 on 4/3/2026 at 4:30 p.m. RN 3 stated that the physician was not notified regarding BS levels greater than 200 mg/dl and stated that RN 3 was unable to locate documentation indicating that other licensed nurses had notified the physician either. During a concurrent interview and record review on 4/10/2026 at 4:23 p.m., with the Director of Nursing (DON), Resident 1's Physician Order dated 4/1/2026, MAR for 4/2026, and BS summaries since the original admission on [DATE] were reviewed. The DON stated that licensed nurses should notify the physician of elevated BS levels greater than 200 mg/dl regardless of whether the BS checks are completed before or after meals. The DON further stated that licensed nurses are responsible for reporting elevated BS levels along with the resident's current anti-hyperglycemic medications (used to treat DM by lowering BS levels) so the physician can determine whether changes to the plan of care are necessary to control the resident's BS.2. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated a Physician Order dated 4/1/2026 (to start on 4/6/2026) for CBC to be completed every Monday day shift for anemia. During a concurrent interview and record review on 4/10/2026 at 2:19 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Physician Order to check CBC every Monday for anemia and Resident 1's test request form dated 4/6/2026 were reviewed. LVN 1 reviewed Resident 1's progress notes from 4/1/2026 to 4/10/2026 and stated that LVN 1 did not notify the physician on 4/6/2026 regarding Resident 1's refusal to check the CBC and that the physician was not notified until 4/8/2026. LVN 1 reviewed General Acute Care Hospital 1 (GACH 1) History and Physical (H&P) Report dated 3/27/2026 and stated that GACH 1's H&P Report indicated Resident 1 had a history of bleeding with low hemoglobin (an iron-rich protein found in red blood cells that transport oxygen from the lungs to the body's tissues and returns carbon dioxide from tissues back to the lungs) when transferred to the hospital on 3/26/2026. LVN 1 stated that LVN 1 should have notified the physician immediately on 4/6/2026 regarding Resident 1's refusal to complete the CBC, as this was the responsibility of licensed nursing staff. During a concurrent interview and record review on 4/10/2026 at 3:57 p.m., with the Director of Nursing (DON), Resident 1's Physician Order to check CBC every Monday for anemia was reviewed. The DON stated that the licensed nurse should have notified the physician immediately when Resident 1 refused the CBC on 4/6/2026 and should not have delayed notification until 4/8/2026.During a review of the facility's policy and procedures (P&P) titled Change in a Resident's Condition or Status last reviewed on 1/28/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . The nurse will notify the resident's attending physician or physician on call when there has been a(an). Refusal of treatment or medications two (2) or more consecutive times. specific instruction to notify the physician of changes in the resident's condition. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Diabetes - Clinical Protocol last reviewed on 1/28/2026, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into Medication Administration Record and care plan.

Based on interview and record review, the facility licensed nurses failed to accurately assess and complete fall risk evaluations for two of three sampled residents (Resident 1 and Resident 2).These deficient practices had the potential to place the residents at increased risk for injury related to falls.a. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated that Resident 1 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, bed mobility (movement), and transfers for chair/bed-to-chair and toilet. The MDS further indicated that Resident 1 was independent with eating.During a review of Resident 1's Fall Risk Evaluation dated 2/20/2026, the Fall Risk Evaluation indicated the following:1. History, Current Status, Predisposing Conditions Section. This section indicated to conduct assessment upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. However, systolic blood pressure (the top [higher] number in a blood pressure reading, measuring the maximum pressure in your arteries when the heart contracts and pumps blood) was not marked, and several items were left blank. 2. Gait (a person's particular manner, style, or pattern of walking or running) and Balance Section. This section requires observation of the resident's gait and balance, including having the resident stand on both feet without holding onto anything, if safe to do so. If assistive devices are required, provide the device and then proceed. Walk straight forward; walk through a doorway; and make a turn. No items were marked that best describes the resident abilities, including the option not able to perform function. 3. Medications Section. This section requires documentation of medications associated with fall risk or selection of none if applicable. No items were marked, including none of these medications taken currently or within the last seven (7) days.During a review of Resident 1's Fall Risk Evaluation dated 2/20/2026, the Fall Risk Evaluation indicated that the evaluation was in progress with a total fall score of eight (indicating the resident was not considered at high risk for potential falls).During a concurrent interview and record review on 4/9/2026 at 1:52 p.m., with Medical Records Assistant 1 (MRA 1), Resident 1's Fall Risk Evaluation dated 2/20/2026 was reviewed. MRA 1 stated that Resident 1's Fall Risk Evaluation dated 2/20/2026 was incomplete, which is why it remained marked as in progress.During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication form dated 3/25/2026, timed at 3:08 p.m., the SBAR indicated that Resident 1 fell in the bathroom, as reported by Resident 1's family. The SBAR indicated that two staff members assisted Resident 1 back to bed following the incident.During a review of Resident 1's Fall Risk Evaluation dated 3/25/2026, the Fall Risk Evaluation indicated the following:1. History, Current Status, and Predisposing Conditions Section. History of falls (past three [3] months) was marked as no falls in the past three (3) months despite SBAR (dated 3/25/2026) documentation of a fall on the same date. Vision status was not marked, with items left blank. Predisposing disease was marked for none present.During a review of Resident 1's Fall Risk Evaluation dated 3/25/2026, the Fall Risk Evaluation indicated a fall score of five (indicating the resident was not considered at high risk for potential falls).During a concurrent interview and record review on 4/9/2026 at 1:42 p.m., with Registered Nurse 1 (RN 1), Resident 1's Fall Risk Evaluation dated 3/25/2026 was reviewed. RN 1 stated that RN 1 performed Resident 1's Fall Risk Evaluation after the fall incident occurred on 3/25/2026. However, RN 1 did not include the actual fall incident that occurred on 3/25/2026 when responding to the question regarding history of falls in the past three (3) months. RN 1 stated that she (RN 1) left the vision status section blank and marked none present for predisposing disease because RN 1 did not see the diagnosis of cerebrovascular accident (CVA - known as stroke, loss of blood flow to a part of the brain). RN 1 further stated that the Fall Risk Evaluation for Resident 1 was incomplete.During a further interview and record review on 4/9/2026 at 2:41 p.m., with RN 1, when RN 1 was asked why the Fall Risk Evaluations should be completed correctly, RN1 stated that accurate completion is necessary to identify residents at high risk for falls and to ensure appropriate interventions are implemented to reduce fall risk based on the evaluation results. b. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted Resident 2 on 1/21/2024 and readmitted on [DATE] with diagnoses that included pneumonitis (swelling and irritation of the lung tissue), DM, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2's cognition was severely impaired, and Resident 2 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, and toilet transfer. The MDS further indicated Resident 2 required supervision or touching assistance for bed mobility (movement), and transfers between bed and chair.During a review of Resident 2's Fall Risk Evaluation dated 2/21/2026, the Fall Risk Evaluation indicated the following:1. Medications Section. No items were marked, including the option none of these medications taken currently or within the last seven (7) days.During a review of Resident 2's Fall Risk Evaluation dated 2/21/2026, the Fall Risk Evaluation indicated a fall score of 12.During a review of Resident 2's Fall Risk Evaluation dated 3/29/2026, the Fall Risk Evaluation indicated the following:2. Gait and Balance Section. No items were marked, including the option not able to perform function. 3. Medication Section. No items were marked, including the option none of these medications taken currently or within last seven (7) days.During a review of Resident 2's Fall Risk Evaluation dated 3/29/2026, the Fall Risk Evaluation indicated a fall score of 10 (indicating the resident was not considered at high risk for potential falls).During a concurrent interview and record review on 4/9/2026 at 4:40 p.m., with RN 2, Resident 2's Fall Risk Evaluations dated 2/21/2026 and 3/29/2026 were reviewed. RN 2 stated that the Fall Risk Evaluations were not completed accurately. RN 2 stated that it was very important to complete the Fall Risk Evaluations with correct and complete information to be able to implement appropriate interventions aimed at preventing or reducing fall risks.During an interview on 4/10/2026 at 3:49 p.m., with the Director of Nursing (DON), the DON stated that licensed nurses should complete the Fall Risk Evaluations accurately and thoroughly to properly assess the resident's risk for falls. The DON further stated that appropriate interventions and implementations should be developed and implemented based on the results of a correctly completed evaluation for each resident.During a review of the facility's policy and procedures (P&P) titled, Fall Risk Assessment last reviewed on 1/28/2026, the P&P indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition.

Based on interview and record review, the facility's licensed nurses failed to follow physician orders for one of three sampled residents (Resident 1) to check blood sugar (BS) two times a day for diabetes mellitus (DM - a disorder characterized by difficulty in BS control and poor wound healing) before breakfast and before dinner, and to notify the physician when BS levels exceed 200 milligrams per deciliter (mg/dl - unit of measurement). These deficient practices had the potential to result in medication errors and negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated that Resident 1 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, bed mobility (movement), and transfers for chair/bed-to-chair and toilet. The MDS further indicated that Resident 1 was independent with eating.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated that there was a Physician Order dated 2/20/2026 to check BS two times a day for DM before breakfast and before dinner, and to notify the physician when BS levels were greater than 200 (mg/dl). During a review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional at a facility) for 3/2026, the MAR indicated that licensed nurses documented BS checks at 9 a.m. and 6 p.m. The MAR further indicated multiple instances in which Resident 1's BS levels exceeded 200 mg/dl, as follows: On 3/1/2026 at 9 a.m. BS was 256, and at 6 p.m. BS was 298. On 3/2/2026 at 6 p.m. BS was 366. On 3/3/2026 at 9 a.m. BS was 254, and at 6 p.m. BS was 314. On 3/4/2026 at 9 a.m. BS was 278, and at 6 p.m. BS was 307. On 3/5/2026 at 9 a.m. BS was 253, and at 6 p.m. BS was 356. On 3/6/2026 at 9 a.m. BS was 241, and at 6 p.m. BS was 388. On 3/7/2026 at 9 a.m. BS was 370, and at 6 p.m. BS was 361. On 3/8/2026 at 9 a.m. BS was 247. On 3/9/2026 at 6 p.m. BS was 350. On 3/10/2026 at 6 p.m. BS was 457. On 3/11/2026 at 9 a.m. BS was 243, and at 6 p.m. BS was 440. On 3/12/2026 at 6 p.m. BS was 419. On 3/13/2026 at 6 p.m. BS was 352. On 3/14/2026 at 9 a.m. BS was 368, and at 6 p.m. BS was 350. On 3/15/2026 at 9 a.m. BS was 382, and at 6 p.m. BS was 260. On 3/16/2026 at 6 p.m. BS was 211. On 3/17/2026 at 9 a.m. BS was 234, and at 6 p.m. BS was 418. On 3/18/2026 at 6 p.m. BS was 313. On 3/20/2026 at 6 p.m. BS was 258. On 3/21/2026 at 9 a.m. BS was 224. On 3/23/2026 at 6 p.m. BS was 291. On 3/25/2026 at 6 p.m. BS was 232. On 3/26/2026 at 9 a.m. BS was 241, and at 6 p.m. BS was not checked due to hospitalization.During a concurrent interview and record review on 4/10/2026 at 1:07 p.m., with Registered Nurse 1 (RN 1), Resident 1's Physician Order dated 2/20/2026 and MAR for 3/2026 were reviewed. RN 1 stated that RN 1 documented Resident 1's BS as 457 on 3/10/2026 at 6 p.m., 440 on 3/11/2026 at 6 p.m., and 419 on 3/12/2026 at 6 p.m. RN 1 further stated that Resident 1's BS was checked after meals rather than before meals, as ordered. RN 1 further stated that the physician was not notified regarding the elevated BS levels exceeding 200 mg/dl. During a concurrent interview and record review on 4/10/2026 at 1:20 p.m., with RN 1 and Licensed Vocational Nurse 1 (LVN 1), Resident 1's Physician Order dated 2/20/2026 and MAR for 3/2026 were reviewed. LVN 1 stated that LVN 1 was the charge nurse for the morning shift for Resident 1 and overlooked the prescribed BS checking times. LVN 1 stated that the physician's order was to check BS before meals, however, the MAR was incorrectly transcribed to indicate 9 a.m. and 6 p.m. after meals, and LVN 1 followed the incorrect times. When LVN 1 was asked whether the physician was notified regarding BS levels greater than 200 mg/dl per the physician order, LVN 1 stated that the physician was probably called once or twice but LVN 1 could not recall the specific dates or times. RN 1 reviewed Resident 1's Progress Notes from 3/1/2026 to 3/26/2026 and stated that there was no documentation found indicating that licensed nurses notified the physician regarding Resident 1's elevated BS levels greater than 200 mg/dl. During a concurrent interview and record review on 4/10/2026 at 3:18 p.m., with Registered Nurse 3 (RN 3), Resident 1's Physician Order dated 2/20/2026 and MAR for 3/2026 were reviewed. RN 3 reviewed all BS values documented by RN 3 at 6 p.m. on the following dates: 3/2/2026, 3/3/2026, 3/5/2026, 3/6/2026, 3/9/2026, 3/13/2026, 3/16/2026, 3/17/2026, 3/18/2026, 3/20/2026, 3/23/2026, and 3/25/2026. RN 3 stated that the Physician's Order to check BS before meals and to notify the physician for BS levels greater than 200 mg/dl was missed. RN 3 stated that Resident 1's BS was checked after meals instead of before meals and that the physician was not notified consistently for elevated BS readings. RN 3 further stated that the physician may have been contacted a couple of times regarding elevated BS levels, however, were not documented. RN 3 further stated that licensed nurses should notify the physician of elevated BS levels, as such elevations may be related to insulin (a hormone that helps regulate blood sugar levels) and may require adjustments to the plan of care, including changes to anti-hyperglycemic medications (used to treat DM by lowering high blood sugar levels) to control BS level. During a concurrent interview and record review on 4/10/2026 at 4:23 p.m., with the Director of Nursing (DON), Resident 1's Physician Order dated 2/20/2026, MAR for 3/2026 and BS summaries since the original admission on [DATE] were reviewed. The DON stated that the licensed nurses should notify the physician of elevated BS greater than 200 mg/dl, regardless of whether the BS readings were obtained before or after meals. The DON further stated that it is the responsibility of the licensed nurses to report elevated BS levels along with the resident's current anti-hyperglycemic medications so the physician can determine whether changes to the plans of care are necessary to achieve better BS control. The DON stated that licensed nurses should monitor and document symptoms associated with high blood sugar such as excessive thirst, frequent urination, fatigue, blurry vision, and headaches. During a review of the facility's policy and procedures (P&P) titled, Diabetes - Clinical Protocol last reviewed on 1/28/2026, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into Medication Administration Record and care plan.During a review of the facility's P&P titled, Administering Medications last reviewed on 1/28/2026, the P&P indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of three sampled residents (Resident 1).This deficient practice had the potential to delay staff response and result in unmet resident needs. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated that Resident 1 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, bed mobility (movement), and transfers for chair/bed-to-chair and toilet. The MDS further indicated that Resident 1 was independent with eating.During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication form dated 3/25/2026, timed at 3:08 p.m., the SBAR indicated that Resident 1 fell in the bathroom, as reported by Resident 1's family. The SBAR indicated that two staff members assisted Resident 1 back to bed following the incident.During a review of Resident 1's untitled care plan report initiated on 4/1/2026, the care plan report indicated Resident 1 had activities of daily living (ADLs- activities such as bathing, dressing and toileting performed daily) deficits. The care plan report indicated an intervention to ensure the call light was within reach and that staff responded promptly to resident calls/requests. During a concurrent observation and interview on 4/9/2026 at 1:09 p.m., with Resident 1 and Certified Nursing Assistant 1 (CNA 1), in Resident 1's room, it was observed that Resident 1 was sitting on the resident bed, and Resident 1's call light cord and button were hanging over the bulletin board located under Resident 1's overhead wall-mounted lamp. Resident 1 stated that the call light should be within reach; however, Resident 1 was unable to access Resident 1's call light and could not see where it was. Resident 1 further stated that staff assistance could not be obtained if needed at that time. CNA 1 stated that if Resident 1 is unable to reach the call light when needed, Resident 1 may attempt to move without assistance, which could result in a potential fall incident. CNA 1 further stated that the resident's call light should be kept within reach at all times. During an interview on 4/10/2026 at 4:23 p.m., with the Director of Nursing (DON), the DON stated that Resident 1 had one documented fall incident since the initial admission. The DON further stated that the call light should be kept within the resident's reach at all times, as failure to do so may result in Resident 1 attempting to move without assistance, increasing the risk for falls. During a review of the facility's policy and procedures (P&P) titled, Answering the Call Light last reviewed on 1/28/2026, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to ensure that the Physician Progress Notes (records documenting the physician's assessment, evaluation, and management of resident care) were maintained as required for one of three sampled residents (Resident 1).This deficient practice had the potential to result in inconsistent care coordination due to incomplete documentation and placed Resident 1 at risk for poor continuity of care and unmet care needs.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 2/20/2026 and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was intact. The MDS indicated that Resident 1 required moderate assistance from staff with oral care, toileting, personal hygiene, showering, lower body dressing, bed mobility (movement), and transfers for chair/bed-to-chair and toilet. The MDS further indicated that Resident 1 was independent with eating.During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication form dated 3/16/2026, timed at 6:50 p.m., the SBAR indicated that Resident 1 verbalized statements expressing a belief Resident 1 was going to die and reported feelings of hopelessness, as reported by Resident 1's family.During a review of Resident 1's Physician's Order dated 3/16/2026, timed at 7 p.m., the Physician's Order indicated an order for a psychiatry (the branch of medicine focused on diagnosing, treating, and preventing mental, emotional, and behavioral disorders) evaluation to be conducted by a psychiatrist (a medical doctor specializing in mental health).During a concurrent interview and record review on 4/9/2026 at 4:22 p.m., with Registered Nurse 2 (RN 2), no Physician Progress Notes were found in Resident 1's clinical record related to Resident 1's psychiatry evaluation since 3/16/2026. RN 2 stated that the psychiatry consultation note could not be located. RN 2 stated that follow-up for Resident 1's mood changes, including statements of wanting to die and feelings of hopelessness, should have occurred on the same day or, at minimum, the following day.During an interview on 4/10/2026 at 1:15 p.m., with the Director of Nursing (DON), the DON stated that the facility received Resident 1's Psychiatry Progress Notes dated 3/16/2026 from Psychiatrist 1 during a quality assurance meeting held on 3/25/2026. During a follow-up interview on 4/10/2026 at 4:03 p.m., with the DON, the DON stated that Psychiatrist 1 provided Resident 1's Psychiatry Progress Notes dated 3/16/2026 in person several weeks after examining the resident. The DON stated that the facility needed to address this issue with the physicians, as some do not consistently provide their documentation on the same day services are rendered. When the DON was asked about the importance of maintaining physician progress notes in the resident's clinical record, the DON stated that such documentation reflects the resident's care needs and the services provided to the residents. The DON further stated that physician notes should be received within seven (7) days of the date of service.During a review of the facility's policy and procedures (P&P) titled, Physician Services last reviewed on 1/28/2026, the P&P indicated, Physician orders and progress notes are maintained in accordance with current OBRA (stands for Omnibus Budget Reconciliation Act, also known as the Nursing Home Reform Act of 1987, setting federal standards of how care should be provided to residents) regulations and facility policy.During a review of the facility's P&P titled, Physician Progress Notes last reviewed on 1/28/2026, the P&P indicated, Physician progress notes must be maintained for each resident. Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc.

Based on interview and record review, the facility failed to: 1. Ensure a copy of the resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was readily available in the resident's medical record for one (Resident 49) out of six sampled residents investigated for Advance Directives. 2. Ensure two of six sampled residents (Resident 20 and Resident 291) were provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive upon admission. These deficient practices had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care. Findings: 1. During a review of Resident 49's Admission Record, the Admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from a chemical imbalance in the blood, often caused by underlying systemic illnesses or organ dysfunction, rather than a primary brain injury). During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 3/11/2025 at 1:36 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 49's Advance Directive Acknowledgement form, dated 1/31/2025. RN 1 confirmed that the Advance Directive Acknowledgement form indicated that the resident had an Advance Directive. RN 1 stated he could not find a copy of the resident's Advance Directive in the resident's medical record. During an interview on 3/11/2025 at 1:44 p.m., with Resident 49, in the presence of RN 1, Resident 49 confirmed she did have an Advance Directive. During a concurrent interview and record review on 3/11/2025 at 1:47 p.m., with the Social Services Designee (SSD), reviewed Resident 49's Social Services progress notes. The SSD stated she did not have any documentation indicating that she followed up with either the resident or the resident's family regarding obtaining a copy of the Advance Directive. During an interview on 3/12/2025 at 10:54 a.m., the SSD stated that the purpose of an Advance Directive was so that the resident can communicate their needs and wishes regarding their healthcare. The SSD stated it was important to have a copy of the resident's Advance Directive readily available in the medical record so that the facility was aware of and could carry out the resident's healthcare wishes. The SSD stated if they did not have a copy of the resident's Advance Directive, and an emergency came up, there was a potential that the facility will not know how to carry out the resident's wishes for their healthcare and may potentially do something that goes against their wishes. The SSD stated she should have followed up with the resident or the resident's family member immediately to obtain a copy of the resident's Advance Directive. During a review of the facility's policy and procedure titled, Advance Directives, last reviewed on 2/26/2025, the policy and procedure indicated that Advance Directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social service director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The residents wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 44309 2.a. During a review of Resident 20's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 2/3/2025, and readmitted on [DATE], with diagnoses including sepsis (a life-threatening blood infection), type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 20's Minimum Data Set (MDS-a resident assessment tool) dated 3/1/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 20 was dependent to staff (helper does all the effort) for oral hygiene, toileting hygiene, personal hygiene, showering, and bathing, and upper and lower body dressing. During a review of Resident 20's Advance Directive Acknowledgement Form (ADA-a document provided by the facility that indicates whether a resident has an AD, would like information regarding creation of an AD, or refusal to create an AD), the form in the resident`s chart was blank with no entries on it. During a concurrent interview and record review on 3/11/2025 at 11:25 a.m., with Registered Nurse 2 (RN2), Resident 20's ADA form was reviewed. RN 2 stated that Resident 20 was readmitted to the facility on [DATE] and he has a conservator (a person appointed by the court to make decisions about personal matters for the resident, including decisions about medical care, food, clothing, where the person will live). However, the resident`s ADA form was not completed. RN 2 stated there is no evidence that Resident 20 or his responsible party was provided with written information concerning the right to refuse or formulate an advance directive. During a concurrent interview and record review on 3/11/2025 at 11:36 a.m., with the facility`s Medical Record Director (MRD), Resident 20`s ADA form was reviewed. The MRD stated that Resident 20`s ADA form was not completed upon his admission to the facility, and it is blank. The MRD stated that the ADA form is required to be completed upon resident`s admission to the facility. MRD stated that the ADA form contains information regarding the resident`s right to be informed and to receive information on how to formulate an AD. MRD stated that the potential outcome of not completing ADA form is that the resident`s wishes may not be honored. During review of the facility's Policy and Procedure (P&P) titled, Advance Directives, last reviewed on 2/26/2025, the P&P indicated that the resident has the right to formulate an AD, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives. The resident pr representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an AD if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an AD, the information may be provided to the resident`s legal representative. Nursing staff will document in the medical record the offer to assist and the resident`s decision to accept or decline assistance. 47883 2.b. During a review of Resident 291's Admission Record, the Admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). During a review of Resident 291's History and Physical (H&P- a comprehensive assessment of a patient's health, performed by a doctor during an initial visit), dated 1/25/2014, the H&P indicated that Resident 291 had the capacity to understand and make decisions. During a review of Resident 291's Scheduled Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/23/2025, indicated that Resident 291 had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS also indicated that the resident needed supervision with eating, moderate assistance with oral and personal hygiene and was dependent on 2 or more helpers with bed mobility, shower transfer, dressing, and toileting. During a concurrent interview and record review on 3/11/2025 at 11:48 A.M. with the Social Services Director (SSD) reviewed Resident 291's physical chart. The SSD stated that the advance directive acknowledgement form was completely blank, and she does not have any evidence that the resident was provided with written information concerning the right to refuse or formulate an advance directive if he chooses to do so. The SSD also stated that the advance directive acknowledgement form should have been signed by Resident 291 on admission. During an interview on 3/13/2025 at 3:47 P.M., with the Director of Nursing (DON), the DON stated that it is important to have the advance directive acknowledgement form in Resident 291's clinical record because it contains information about the resident's right to accept or refuse medical treatment and the right to formulate an advanced directive. The DON stated that the facility should provide written information regarding Advanced Directives to the resident or the resident's representative at the time of admission. During a review of the facility's policies and procedures titled Advance Directives, revised 2/26/2025, the policy indicated: Prior to or upon admission of a resident, the social services director or designee inquires of the resident , his/her family member and or his or her legal representative , about the existence of any written advance directive. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) by failing to: 1. Develop a care plan addressing a resident's diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) for one of one sampled resident (Resident 49) investigated for trauma-informed care. 2. Develop a care plan addressing a resident's restorative nursing assistant (RNA - an ongoing program that focuses on helping individuals, especially those in long-term care, maintain and improve their functional abilities and independence, often following rehabilitation) therapy for one of two sampled residents (Resident 47) investigated under the care area of position and mobility. 3. Resident 85's refusal of vaccination for Covid-19 (disease cause by the SARS-CoV-2 virus, that spreads throiugh respiratory droplets. Most people infected with the virus will experience mild to moderate respiratory illness) and influenza (viral infection of the nose, throat and lungs). 4. Resident 63' activities preferences. 5. Resident 21's use of oxygen. These deficient practices had the potential to result in failure to deliver the necessary care and services. Findings: 1. During a review of Resident 49's Admission Record, the Admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including PTSD. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2025, the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated the resident has a diagnosis of PTSD. During a concurrent interview and record review on 3/11/2025 at 1:56 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 49's care plans dated 1/31/2025 to 3/11/2025. RN 1 stated that Resident 49 had a diagnosis of PTSD. RN 1 stated he could not find a care plan addressing Resident 49's diagnosis of PTSD. During an interview on 3/12/2025 at 11:18 a.m., with the Director of Nursing (DON), the DON stated it was important for the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) to determine the specific care Resident 49 would need for her PTSD. The DON stated it was important to note what triggered Resident 49 so that facility staff could avoid those triggers. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Services provided for or arranged by the facility and outlined in the comprehensive care plan are provided by qualified persons; culturally competent; and trauma-informed. During a review of the facility's policy and procedure titled, Trauma Informed Care and Culturally Competent Care, last reviewed on 2/26/2025, the policy and procedure indicated to develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. 2. During a review of Resident 47's Admission Record, the Admission Record indicated the facility originally admitted the resident on 7/31/2023 and readmitted the resident on 9/10/2024 with diagnoses including difficulty in walking and muscle wasting and atrophy (the thinning or loss of muscle tissue, leading to a decrease in muscle mass and strength). During a review of Resident 47's MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making and required maximal assistance from staff for most ADLs. During a concurrent interview and record review on 3/12/2025 at 9:54 a.m., with RN 1, reviewed Resident 47's physician's orders and Resident 47's care plans dated 9/10/2024 to 3/12/2025. RN 1 stated Resident 47 had a physician's order for RNA passive range of motion (PROM - moving a joint through its full range of motion without the resident's active muscle contraction) exercises on the bilateral upper extremities (BUE) every day five times a week or as tolerated, ordered on 12/18/2024. RN 1 stated Resident 47 also had a physician's order for RNA for ambulation (walking) with a front wheel walker (FWW) as tolerated every day for five times a week with two-person assistance for safety, ordered on 12/18/2024. RN 1 stated he could not find any care plans addressing Resident 47's RNA treatments. During an interview on 3/12/2025 at 11:21 a.m., with the DON, the DON stated that Resident 47 should have had a care plan addressing his RNA treatments. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. 47883 3. During a review of Resident 85's Admission Record, the Admission Record indicated the facility admitted the resident on 12/11/2024 and readmitted her on 1/17/2025 with diagnoses including chronic obstructive pulmonary disease (COPD- long -term disease that makes it hard to breath), essential hypertension (high blood pressure), and major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 85's History and Physical (H&P - a comprehensive assessment that involves a healthcare provider obtaining a thorough medical history from the patient and performing a physical examination to understand their current health status and any presenting problems), dated 12/12/2024, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, an assessment and care screening tool) dated 3/8/2025, the MDS indicated that the resident had an intact cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 85 required supervision (helper sets up or cleans up; resident completes activity) with eating and moderate assistance with oral hygiene, upper body dressing and toileting hygiene, shower and lower body dressing. During a review of Resident 85's Vaccine consent dated 12/28/2024, it indicated that Resident 85 refused Covid 19 and Influenza (viral infection of the nose, throat and lungs) vaccination. During a concurrent interview and record review on 3/12/2025 at 10:58 p.m., the Infection Preventionist (IP) reviewed Resident 85 care plans and stated that there was no care plan created addressing Resident 85 refusal of Covid 19 and Influenza vaccination. The IP stated it was important to create care plan to address and monitor Resident 85 for possible complications secondary to vaccination refusal. During an interview on 3/13/2025 at 3:47 p.m., the Director of Nursing (DON) stated that Resident 85 should had a care plan addressing his refusal of vaccination. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. 4.During a review of Resident 63's Admission Record, the Admission Record indicated the facility admitted the resident on 1/3/2025 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and cellulitis (a bacterial skin infection) of left lower limb. During a review of Resident 63's History and Physical (H&P - a comprehensive assessment that involves a healthcare provider obtaining a thorough medical history from the patient and performing a physical examination to understand their current health status and any presenting problems), dated 1/31/2025, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS, an assessment and care screening tool) dated 2/7/2025, the MDS indicated that the resident was mildly impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated that Resident 63 required supervision (helper sets up or cleans up; resident completes activity) with shower and personal hygiene. During a concurrent observation and interview on 3/10/2025 at 10:00 a.m., with Restorative Nursing Assistant 1 (RNA 1), Resident 63 was observed in wheelchair in the dining room, where the television (TV) was turned off. Resident 63 stated that he would like to watch television, and he does not like that the television was turned off at that time. RNA 1 stated that the activity department was playing movies at designated times throughout the of the day while at other times the residents were encouraged residents to be involve in other activities. During a concurrent interview and record review on 3/12/2025 at 10:58 p.m., the Activity Director (AD) reviewed Resident 63's activities initial review dated 02/01/2025 and care plans. The AD stated that according to past activities interests the resident liked to participate in watching TV. The AD stated that there was no care plan created to address Resident 63 activity preferences. The AD stated it was important to create care plan to address and monitor Resident 63 for his activity's preferences. During an interview on 3/13/2025 at 3:47 p.m., the Director of Nursing (DON) stated that Resident 63 should had a care plan addressing his activities preferences and needs. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. 44309 5. During a review of Resident 21's Admission Record (face sheet), the admission record indicated that the facility admitted the resident on 1/7/2025, with diagnoses including acute (rapid onset and relatively short duration) respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), difficulty in walking, dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 1/11/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 21 required staff partial/moderate assistance (helper does less than half the effort) for oral hygiene, showering and bathing, and personal hygiene. The MDS further indicated that Resident 21 received continuous oxygen therapy on admission and within the last 14 days. During a review of Resident 21`s Physician Order Summary Report dated 1/7/2025, the order summary report indicated to administer oxygen at two (2) liters per minute via nasal canula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed (PRN) for Shortness of Breath (SOB). During a review of Resident 21's care plans, the care plans did not indicate an evidence of a comprehensive care plan addressing Resident 21`s oxygen use. During a concurrent interview and record review on 3/13/2025 at 11:45 a.m., with Assistant Director of Nursing (ADON), Resident 21`s physician orders and care plans were reviewed. ADON stated that Resident 21 is using oxygen as needed. However, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s oxygen use. ADON stated it is required to develop a person-centered care plan with goal and interventions to monitor Resident 21`s oxygen use. ADON stated the potential outcome of not developing a care plan for a resident who uses oxygen is the lack of care and the inability to implement the specific services and monitoring that resident requires. During an interview on 3/13/2025 at 2:36 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 21`s oxygen use. The DON stated that the potential outcome is providing inadequate care to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/26/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents` conditions change.

Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1), when the facility discharged Resident 1, who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to SNF 2, a non-locked facility (a facility that does not have secured or locked units) on [DATE] without providing safe and orderly discharge services by: 1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE]. 2. Failing to ensure that the facility staff at SNF 1 provided SNF 2 with the discharge summary and recapitulation of stay (a summary of a resident course of treatment and stay at a facility) for Resident 1 when Resident 1 was discharged to SNF 2 on [DATE]. SNF 2 was only provided the Order Summary Report (a list of the physician orders for a resident, while the resident was admitted to a facility). 3. Failing to ensure facility staff from SNF 1 conducted a hand off communication (the transfer of resident medical information from the licensed nurse of the discharging facility to the licensed nurse of the receiving facility for continuity of care) to SNF 2 in preparation of receiving and admitting Resident 1 on [DATE]. 4. Failing to ensure facility staff established or specified the specific care that Resident 1 needed that SNF 1, a locked unit was unable to provide, that required Resident 1 to be discharged to SNF 2, an unlocked and less secure unit. 5. Failing to ensure the facility staff at SNF 1 utilized medical transport when discharging Resident 1 to SNF 2 on [DATE], after the facility identified that Resident 1 was a danger to self and to others. These deficient practices resulted in Resident 1 being discharged from SNF 1 to SNF 2 on [DATE] using a non-medical transport after Resident 1 was identified as being a danger to himself (Resident 1) and to others; and placed Resident 1 at increased risk for injury, medication errors, and worsening of unresolved medical conditions. On [DATE] at approximately 3:30 a.m., Resident 1 expired at SNF 2, less than nine hours after arriving at SNF 2. On [DATE] at 5:16 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON) and Social Service Director (SSD) due to the facility ' s failure to ensure Resident 1 was free from neglect when the facility discharged Resident 1 to SNF 2 without providing safe and orderly discharge. On [DATE] at 3:45 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1). 2. On [DATE], the DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician. 3. On [DATE], the DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation. 4. On [DATE], the DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2. 5. On [DATE], Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, and all other Department Heads regarding ensuring all residents are free of neglect related to discharge services to ensure resident ' s safety and promote their (resident) highest well-being from the time residents enter the facility to the time residents leave the facility. 6. On [DATE], the DON continued providing in-services to admissions office staff, nursing staff, and social services staff regarding the facility ' s current policies and procedures for the prevention of Neglect related to Discharge/Transfer services. On [DATE] at 4:00 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ Removal Plan, the SSA removed the IJ situation in the presence of the ADM, DON, and Minimum Data Set Nurse (MDSN). Findings: 1. During a review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease that causes breathing problems by restricting airflow), type two (2) diabetes mellitus (a long-term medical condition in which the body has trouble controlling blood sugar and using it for energy), schizoaffective (a mental illness that can affect a person ' s thoughts, mood and behavior) disorder and psychosis (a severe mental condition in which thought and emotions are affected that contact is lost with external reality). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated that Resident 1 had memory problems and difficulty in making decisions regarding tasks of daily life. During a review of Resident 1 ' s Admission Summary dated [DATE] timed at 4:00 p.m. indicated Resident 1 was incontinent (unable to voluntarily control the excretion of urine or the contents of the bowels) of bladder (a sac- shaped muscular organ that stores urine) and bowel (a long, tube-shaped organ in the abdomen that is part of the digestive system) function, had unsteady gait (pattern of walking), was confused (refers to the inability to think clearly or quickly), and agitated (a condition in which a person is unable to relax and be still) towards others. The Admission Summary further indicated that Resident 1 had a preference of sitting and crawling on the floor requiring one to one (1:1- where a staff member is assigned to monitor the resident at all times) supervision. During a review of Resident 1 ' s Physician Discharge Summary dated [DATE] indicated Resident 1 ' s discharge was necessary for the health and safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical (medical) or behavioral status. During a review of Resident 1 ' s Notice of Transfer/Discharge, with a notification date of [DATE] and effective date of [DATE], indicated that the notice was to inform Resident1 that the discharge to SNF 2 was necessary for the safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical or behavioral status. During a review of Resident 1`s Physician`s Order dated [DATE], timed at 2:20 p.m., indicated that MD 1 provided a verbal order to discharge Resident 1 to SNF 2. The Physician ' s Order was documented by RN 2 and signed by MD 1. During a review of Resident 1 ' s Recapitulation of Stay dated [DATE], timed at 5:00 p.m. indicated Resident 1 ' s reason for discharge to SNF 2 was because of behavior (not specified). Resident 1 ' s Recapitulation of Stay indicated Resident 1 needed skilled care and nursing services and required assistance with physical functioning such as bathing, bed mobility, dressing, toilet use, locomotion (ability to move from one place to another) and walking. During a review of Resident 1 ' s Health Status Note dated [DATE] timed at 5:10 p.m. indicated Resident 1 was discharged to SNF 2 via a non-medical transport. During a review of Resident 1 ' s SNF 2 Record of Death, dated [DATE], the Record of Death indicated that Resident 1 expired in SNF 2 on [DATE] at 3:30 a.m. During a concurrent interview and record review on [DATE] at 11:30 a.m. with RN 2, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. RN 2 stated that on [DATE], RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone before inputting the order to discharge Resident 1 to SNF 2. RN 2 stated that RN 2 entered the physician order to discharged Resident 1 to SNF 2 on [DATE] and indicated that the order was received verbally by MD 1 because RN 2 was told by SSD that Resident 1 needed a physician order for discharge. RN 2 stated that when the SSD informs the licensed nurses of the facility that a resident is to be discharged , a licensed nurse will enter a verbal order for discharged into the resident ' s physician order record on behalf of the physician. During a concurrent interview and record review on [DATE] at 11:50 a.m. with MD 1, MD 1 reviewed Resident 1 ' s Physician ' s Order dated [DATE] to discharge Resident 1 to SNF 2. MD 1 stated that MD 1 was not in the facility on [DATE]. When MD 1 was asked how come MD 1 signed the physician order to discharge Resident 1 to SNF 2 on [DATE] when RN 2 had stated that RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone, MD 1 stated that this is what is normally done in the facility. MD 1 further stated that Resident 1 ' s physician order to discharge to SNF 2 dated [DATE] did not include the reason for the discharge. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that only physicians, nurse practitioners and physician assistant can give an order to discharge a resident. RN 2 stated that on [DATE], RN 2 should have, but did not communicate with MD 1 concerning Resident 1 ' s discharge. RN 2 stated that by entering the order to discharge Resident 1 to SNF 2 on [DATE], RN 2 deprived Resident 1 of a safe discharge to SNF 2, which is required for a safe and orderly discharge. During a concurrent interview and record review on [DATE] at 4:07 p.m. with the DON, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. The DON stated that RN 2 ' s actions of entering the order to discharge Resident 1 to SNF 2 on [DATE] without communicating to MD 1 was neglectful and the RN 2 should have acted based on her scope of practice. 2. During an interview with Registered Nurse 4 (RN 4) on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE] at approximately 6:40 p.m. Resident 1 arrived at SNF 2 with only a summary of Resident 1 ' s Physician Orders dated [DATE] from SNF 1. RN 4 stated that RN 4 attempted to call SNF 1 several times to attempt to speak with a licensed nurse from SNF 1 and obtain additional discharge information. RN 4 stated SNF 1 did not answer the phone. RN 4 stated that RN 4 had no prior knowledge that Resident 1 would be arriving to be admitted into SNF 2. During an interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 4:15 p.m., LVN 3 stated that LVN 3 works at SNF 2. LVN 3 stated that on [DATE], Resident 1 had suddenly arrived at SNF 2. LVN 3 stated that LVN 3 had no prior knowledge that Resident 1 was arriving to SNF 2 for admission. LVN 3 stated that Resident 1 arrived with no Discharge Summary, and Recapitulation of Stay from SNF 1. LVN 3 stated that Resident 1 arrived with only Resident 1 ' s Physician Order Summary Report (totaling to four pages) from SNF 1. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that on [DATE], the only discharge paperwork that RN 2 completed for Resident 1 was writing Resident 1 ' s physician order for discharge. RN 2 stated that RN 2 endorsed Resident 1 ' s discharge to the oncoming shift nurse, Registered Nurse 3 (RN 3). RN 2 stated that RN 3 was to finish Resident 1 ' s discharge on [DATE]. During a concurrent interview and record review on [DATE] at 4:21 p.m. with Medical Records Director 1 (MRD 1), Resident 1 ' s discharge forms, clinical and discharge documentations from [DATE] to [DATE] were reviewed. MRD 1 stated that there was no documented evidence found that a Discharge Care Plan, and a Medication Reconciliation (process of identifying the most accurate list of all medications that the resident is taking) form was completed, and copies of the Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2. During an interview with the DON on [DATE] at 4:24 p.m., the DON stated that there was no documented evidence found that copies of Resident 1 ' s Discharge Summary and Recapitulation of Stay from SNF 1 were sent with Resident 1 to SNF 2. The DON stated that this was a neglectful deficient practice because the Discharge Summary and Recapitulation of Stay for Resident 1 should have been provided to Resident 1 as part of the safe and orderly discharge services. During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that on [DATE] RN 3 completed Resident 1 ' s discharge packet which included Resident 1 ' s Discharge Summary and Recapitulation of Stay. RN 3 stated that RN 3 did not fax the discharge packet of Resident 1 to SNF 2. During a follow-up interview with MRD 1 on [DATE] at 5:58 p.m., MRD 1 stated that the nursing staff involved in Resident 1 ' s discharge on [DATE], that included RN 3, should have but did not send Resident 1 ' s discharge documentation including a Discharge Summary, a Recapitulation of Stay to SNF 2. 3. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that RN 2 did not, by phone, in person, or in writing, communicate with any staff from SNF 2 of Resident 1 ' s discharge on [DATE]. During an interview with the DON on [DATE] at 4:17 p.m., the DON stated that to the DON ' s best knowledge, no nursing staff from SNF 1 gave a hand off communication report to a licensed nurse at SNF 2 as part of safe and orderly discharge services. The DON stated that this was a neglectful deficient practice because the nursing staff from SNF 1 should have conducted a hand off communication report to the licensed nurses at SNF 2. The DON stated that SNF 2 should be informed of the most current and pertinent nursing and medical information concerning Resident 1 in order to provide the necessary care and services to Resident 1. During an interview with the DON on [DATE] at 4:00 p.m., the DON stated that licensed nurses of SNF 1 did not follow the facility ' s policy and procedure for a safe and orderly discharge, when on [DATE], the facility staff of SNF 1 did not provide a hand off communication regarding Resident 1 ' s pertinent nursing and medical information to SNF 2. During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that RN 3 did not give a hand off communication report to any staff at SNF 2. During an interview with MRD 1 on [DATE] at 5:38 p.m., MRD 1 stated that no nursing staff from SNF 1 documented in Resident 1 ' s medical record that a hand off communication was conducted with SNF 2 regarding Resident 1 ' s discharge on [DATE]. 4. A review of the facility ' s Facility Assessment Data Collection Tool, dated ,d+[DATE] through ,d+[DATE], indicated that the facility had admitted and treated other residents with psychosis and other mental disorders, impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life). The facility ' s Facility Assessment Data Collection Tool further indicated that the facility had admitted and treated residents in need of behavioral support, behavioral healthcare needs dementia care .and other mental disorders. During a concurrent interview and record review on [DATE] at 3:20 p.m. with the DON, the facility ' s Facility Assessment Data Collection Tool dated ,d+[DATE] through ,d+[DATE] was reviewed. The DON stated that the facility was capable of and had been providing care for residents with same diagnoses and behavior that Resident 1 had. The DON stated she was not aware of any services that Resident 1 needed that the facility could not provide that SNF 2 could provide other than that SNF 2 was not a locked facility. During a review of Resident 1 ' s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Conference Notes, dated [DATE], indicated the facility ' s IDT met to discuss Resident 1 ' s condition as of [DATE], two days after the facility admitted Resident 1 from General Acute Care Hospital 2 (GACH 2) on [DATE]. The document indicated the IDT specifically discussed Resident 1 ' s fall incidents, Resident 1 ' s nutritional status and weight, Resident 1 ' s need for reminders to participate in group activities and a one to one staff assignment to ensure resident is safe. The document also indicated, Unable to determine discharge plan at this time. During a review of Resident 1 ' s Health Status Note, dated [DATE], 2:43 p.m., the health status note indicated that Resident 1 was unsteady on his feet and needed a one-to-one supervision (a nurse or health care support worker who provides care to a single resident for a period of time) to ensure his (Resident 1) safety related to falls prevention. During a review of Resident 1 ' s care plan dated [DATE] indicated that Resident 1 was at risk for wandering (a resident ' s aimless, repetitive movement from one area to another that puts them at risk of harm). During an interview with MTR 1 on [DATE] at 11:32 a.m., MTR 1 stated that MTR 1 did not know the specific reason why the facility wanted to discharge Resident 1 to SNF 2 or what services Resident 1 needed that SNF 1 could not provide but SNF 2 could. During an interview with the DON on [DATE] at 3:29 p.m., the DON stated that Resident 1 had medical conditions and needs such that Resident 1 required the level of care that a locked unit can provide. The DON stated specifically, Resident 1 needed one-to-one supervision to prevent falls. The DON further stated that Resident 1 was at risk for elopement (to leave a skilled nursing facility without notice or permission), from the facility related to Resident 1 ' s wandering behavior. The DON stated that there was nothing required in Resident 1 ' s plan of care that SNF 1 could not provide. During a concurrent interview and record review on [DATE] at 3:35 p.m. with the DON, reviewed Resident 1 ' s IDT Conference Note dated [DATE]. The DON stated that on [DATE], the IDT Team was unable to determine discharge plans for Resident 1. The DON stated that Resident 1 required one-to-one supervision to ensure Resident 1 ' s safety. The DON stated that Resident 1 had episodes of aggressive behaviors towards staff however the IDT Conference Note dated [DATE] did not indicate what specific behaviors were observed, what specific interventions could have been implemented to address the aggressive behaviors or other behaviors related to Resident 1 ' s mental illness. The DON stated there was no documentation found of the facility ' s attempts to meet the resident ' s needs or what services the new receiving facility (SNF 2) had in order to meet the resident ' s needs. During an interview with the ADM on [DATE], 3:59 p.m., ADM stated that ADM was not aware of any specific services that Resident 1 needed that SNF 1 could not provide but that SNF 2 could provide. 5. During an interview with RN 4 on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE], at approximately 6:40 p.m. the driver (Driver 1) of a private non-medical vehicle arrived at SNF 2 and informed RN 4 that he (Driver 1) was instructed to drop off Resident 1. RN 4 stated that Driver 1 helped bring Resident 1 inside SNF 2. During an interview with the DON on [DATE] at 4:26 p.m., the DON stated that the facility did not ensure that Resident 1 was provided with a safe and appropriate (medical) form of transportation when the facility utilized a ride share company (a company that uses independent contractors with no training regarding medical safety, to transport people between various places) to discharge Resident 1 to SNF 2. The DON stated that SNF 1 had knowledge of Resident 1 ' s medical condition and history of aggressive behavior. The DON stated that Resident 1 ' s medical conditions included mental illness, and therefore the facility should have provided Resident 1 with professional medical transportation services to ensure Resident 1 ' s safety as part of safe and orderly discharge services. The DON stated that utilizing a non-medical transportation to transport Resident 1 from SNF 1 to SNF 2 was neglectful because the facility should have provided Resident 1 with professional medical transportation services as part of safe and orderly discharge services but did not do so. During a concurrent interview and record review on [DATE] at 3:40 p.m., with the DON, the facility ' s policy titled, Resident Rights, last reviewed by the facility on [DATE], was reviewed. The policy indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to . to be free from . neglect . The DON stated that Resident 1 had a right to safe and orderly discharge services as defined by federal regulations and the facilities policies regarding discharge services. The DON stated that the facility did not follow its policy regarding resident ' s right to be free of neglect when the facility failed to provide Resident 1 with safe and orderly discharge services on [DATE].

Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1), who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to Skilled Nursing Facility 2 (SNF 2), a non-locked facility (a facility that does not have secured or locked units) on [DATE] by: 1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE]. 2. Failing to ensure that the facility staff at SNF 1 provided SNF 2 with the discharge summary and recapitulation of stay (a summary of a resident course of treatment and stay at a facility) for Resident 1 when Resident 1 was discharged to SNF 2 on [DATE]. SNF 2 was only provided the Order Summary Report (a list of the physician orders for a resident, while the resident was admitted to a facility). 3. Failing to ensure facility staff from SNF 1 conducted a hand off communication (the transfer of resident medical information from the licensed nurse of the discharging facility to the licensed nurse of the receiving facility for continuity of care) to SNF 2 in preparation of receiving and admitting Resident 1 on [DATE]. 4. Failing to ensure facility staff established or specified the specific care that Resident 1 needed that SNF 1, a locked unit was unable to provide, that required Resident 1 to be discharged to SNF 2, an unlocked and less secure unit. 5. Failing to ensure the facility staff at SNF 1 utilized medical transport when discharging Resident 1 to SNF 2 on [DATE], after the facility identified that Resident 1 was a danger to self and to others. These deficient practices resulted in Resident 1 being discharged from SNF 1 to SNF 2 on [DATE] using a non-medical transport after Resident 1 was identified as being a danger to himself (Resident 1) and to others; and placed Resident 1 at increased risk for injury, medication errors, and worsening of unresolved medical conditions. On [DATE] at approximately 3:30 a.m., Resident 1 expired at SNF 2, less than nine hours after arriving at SNF 2. On [DATE] at 5:16 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON) and Social Service Director (SSD) due to the facility ' s failure to ensure Resident 1 was provided a safe and orderly discharge when the facility discharged Resident 1 to SNF 2 using a non-medical transport, and without conducting a hand off communication to ensure continuity of care in order to minimize the risk of medical errors, and ensure all necessary medical information of Resident 1 from SNF 1 was given to SNF 2 in order to allow for a seamless transition of care upon discharge. On [DATE] at 3:45 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: 1. On [DATE], Resident 1 was discharged to SNF 2 and is no longer a resident of the facility (SNF 1). 2. On [DATE], the DON in-serviced RN 2 to enter physician orders for discharge only after speaking to the physician. 3. On [DATE], the DON in-serviced the facility Marketer 1 (MTR 1) to no longer arrange resident transportation. 4. On [DATE], the DON in-serviced RN 2 regarding giving report to the nurse at the receiving facility of SNF 2. 5. On [DATE], Medical Director Medical Doctor 1 (MDMD 1) in-serviced the ADM, DON, Assistant Director of Nursing (ADON), SSD, regarding ensuring all residents receive all discharge services (providing and completed needed discharge documentations and conducting hand off report to receiving facility) needed to ensure the resident ' s safety and promote the resident ' s highest well being from the time of discharge. On [DATE] at 4:00 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ Removal Plan, the SSA removed the IJ situation in the presence of the ADM, DON, and Minimum Data Set Nurse (MDSN). Findings: 1. During a review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a common lung disease that causes breathing problems by restricting airflow), type two (2) diabetes mellitus (a long-term medical condition in which the body has trouble controlling blood sugar and using it for energy), schizoaffective (a mental illness that can affect a person ' s thoughts, mood and behavior) disorder and psychosis (a severe mental condition in which thought and emotions are affected that contact is lost with external reality). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated that Resident 1 had memory problems and difficulty in making decisions regarding tasks of daily life. During a review of Resident 1 ' s Admission Summary dated [DATE] timed at 4:00 p.m. indicated Resident 1 was incontinent (unable to voluntarily control the excretion of urine or the contents of the bowels) of bladder and bowel function, had unsteady gait (pattern of walking), has confusion (refers to the inability to think clearly or quickly), and agitated (a condition in which a person is unable to relax and be still) towards others. The Admission Summary further indicated that Resident 1 has a preference of sitting and crawling on the floor requiring one to one (1:1- where a staff member is assigned to monitor the resident at all times) supervision. During a review of Resident 1 ' s Physician Discharge Summary dated [DATE] indicated Resident 1 ' s discharge was necessary for the health and safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical (medical) or behavioral status. During a review of Resident 1 ' s Notice of Transfer/Discharge, with a notification date of [DATE] and effective date of [DATE], indicated that the notice was to inform Resident1 that the discharge to SNF 2 was necessary for the safety of individuals in the facility that would be endangered due to Resident 1 ' s clinical or behavioral status. During a review of Resident 1`s Physician`s Orders dated [DATE], timed at 2:20 p.m., indicated that MD 1 provided a verbal order to discharge Resident 1 to SNF 2. The order was documented by RN 2 and signed by MD 1. During a review of Resident 1 ' s Recapitulation of Stay dated [DATE], timed at 5:00 p.m. indicated Resident 1 ' s reason for discharge to SNF 2 was because of behavior (not specified). Resident 1 ' s Recapitulation of Stay indicated Resident 1 needed skilled care and nursing services and required assistance with physical functioning such as bathing, bed mobility, dressing, toilet use, locomotion (ability to move from one place to another) and walking. During a review of Resident 1 ' s Health Status Note dated [DATE] timed at 5:10 p.m. indicated Resident 1 was discharged to SNF 2 via a non-medical transport. During a review of Resident 1 ' s SNF 2 Record of Death, dated [DATE], the Record of Death indicated that Resident 1 expired in SNF 2 on [DATE] at 3:30 a.m. During a concurrent interview and record review on [DATE] at 11:30 a.m. with RN 2, Resident 1 ' s Physician ' s Order dated [DATE], timed at 2:20 p.m. that indicated that MD 1 gave a verbal order to discharge Resident 1 to SNF 2 and was documented by RN 2 was reviewed. RN 2 stated that on [DATE], RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone before inputting the order to discharge Resident 1 to SNF 2. RN 2 stated that RN 2 entered the physician order to discharged Resident 1 to SNF 2 on [DATE] and indicated that the order was received verbally by MD 1 because RN 2 was told by SSD that Resident 1 needed a physician order for discharge. RN 2 stated that when the SSD informs the licensed nurses of the facility that a resident is to be discharged , a licensed nurse will enter a verbal order for discharged into the resident ' s physician order record on behalf of the physician. During a concurrent interview and record review on [DATE] at 11:50 a.m. with MD 1, MD 1 reviewed Resident 1 ' s Physician ' s Order dated [DATE] to discharge Resident 1 to SNF 2. MD 1 stated that MD 1 was not in the facility on [DATE]. When MD 1 was asked how come MD 1 signed the physician order to discharge Resident 1 to SNF 2 on [DATE] when RN 2 had stated that RN 2 had not spoken with MD 1 to obtain the verbal order for Resident 1 ' s discharge, either in person or by phone, MD 1 stated that this is what is normally done in the facility. MD 1 further stated that Resident 1 ' s physician order to discharge to SNF 2 dated [DATE] did not include the reason for the discharge. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that only physicians, nurse practitioners and physician assistant can give an order to discharge a resident. RN 2 stated that on [DATE], RN 2 should have, but did not communicate with MD 1 concerning Resident 1 ' s discharge. RN 2 stated that by entering the order to discharge Resident 1 to SNF 2 on [DATE], RN 2 deprived Resident 1 of a safe discharge to SNF 2, which is required for a safe and orderly discharge. 2. During an interview with Registered Nurse 4 (RN 4) on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE] at approximately 6:40 p.m. Resident 1 arrived at SNF 2 with only a summary of Resident 1 ' s Physician Orders dated [DATE] from SNF 1. RN 4 stated that RN 4 attempted to call SNF 1 several times to attempt to speak with a licensed nurse from SNF 1 and obtain additional discharge information. RN 4 stated SNF 1 did not answer the phone. RN 4 stated that RN 4 had no prior knowledge that Resident 1 would be arriving to be admitted into SNF 2. During an interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 4:15 p.m., LVN 3 stated that LVN 3 works at SNF 2. LVN 3 stated that on [DATE], Resident 1 had suddenly arrived at SNF 2. LVN 3 stated that LVN 3 had no prior knowledge that Resident 1 was arriving to SNF 2 for admission. LVN 3 stated that Resident 1 arrived with no discharge summary, and recapitulation of stay from SNF 1. LVN 3 stated that Resident 1 arrived with only Resident 1 ' s Physician Order Summary Report (totaling to four pages) from SNF 1. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that on [DATE], the only discharge paperwork that RN 2 completed for Resident 1 was writing Resident 1 ' s physician order for discharge. RN 2 stated that RN 2 endorsed Resident 1 ' s discharge to the oncoming shift nurse, Registered Nurse 3 (RN 3). RN 2 stated that RN 3 was to finish Resident 1 ' s discharge on [DATE]. During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that on [DATE] RN 3 completed Resident 1 ' s discharge packet which included Resident 1 ' s Discharge Summary and Recapitulation of Stay. RN 3 stated that RN 3 did not fax the discharge packet of Resident 1 to SNF 2. During an interview with Medical Records Director 1 (MRD 1) on [DATE] at 5:58 p.m., MRD 1 stated that the nursing staff involved in Resident 1 ' s discharge on [DATE], that included RN 3, should have but did not send Resident 1 ' s discharge documentation including a Discharge Summary, a Recapitulation of Stay to SNF 2. 3. During an interview with RN 2 on [DATE] at 4:02 p.m., RN 2 stated that RN 2 did not, by phone, in person, or in writing, communicate with any staff from SNF 2 of Resident 1 ' s discharge on [DATE]. During an interview with the DON on [DATE] at 4:17 p.m., the DON stated that to the DON ' s best knowledge, no nursing staff from SNF 1 gave a hand off communication report to a licensed nurse at SNF 2 as part of safe and orderly discharge services. DON stated that since the nursing staff from SNF 1 did not give a hand off communication report to the licensed nurses at SNF 2, SNF 2 would not know the most current and pertinent nursing and medical information concerning Resident 1. During an interview with the DON on [DATE] at 4:00 p.m., the DON stated that licensed nurses of SNF 1 did not follow the facility ' s policy and procedure for a safe and orderly discharge, when on [DATE], the facility staff of SNF 1 did not provide a hand off communication regarding Resident 1 ' s pertinent nursing and medical information to SNF 2. During an interview with RN 3 on [DATE] at 5:03 p.m., RN 3 stated that RN 3 did not give a hand off communication report to any staff at SNF 2. During an interview with MRD 1 on [DATE] at 5:38 p.m., MRD 1 stated that no nursing staff from SNF 1 documented in Resident 1 ' s medical record that a hand off communication was conducted with SNF 2 regarding Resident 1 ' s discharge on [DATE]. 4. During a review of Resident 1 ' s Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Conference Notes, dated [DATE], indicated the facility ' s IDT met to discuss Resident 1 ' s condition as of [DATE], two days after the facility admitted Resident 1 from General Acute Care Hospital 2 (GACH 2) on [DATE]. The document indicated the IDT specifically discussed Resident 1 ' s fall incidents, Resident 1 ' s nutritional status and weight, Resident 1 ' s need for reminders to participate in group activities and a one to one staff assignment to ensure resident is safe. The document also indicated, Unable to determine discharge plan at this time. During a review of Resident 1 ' s Health Status Note, dated [DATE], 2:43 p.m., the health status note indicated that Resident 1 was unsteady on his feet and needed a one-to-one supervision (a nurse or health care support worker who provides care to a single resident for a period of time) to ensure his (Resident 1) safety related to falls prevention. During a review of Resident 1 ' s care plan dated [DATE] indicated that Resident 1 was at risk for wandering (a resident ' s aimless, repetitive movement from one area to another that puts them at risk of harm). During an interview with MTR 1 on [DATE] at 11:32 a.m., MTR 1 stated that MTR 1 did not know the specific reason why the facility wanted to discharge Resident 1 to SNF 2 or what services Resident 1 needed that SNF 1 could not provide but SNF 2 could. During an interview with the DON on [DATE] at 3:29 p.m., the DON stated that Resident 1 had medical conditions and needs such that Resident 1 required the level of care that a locked unit can provide. The DON stated specifically, Resident 1 needed one-to-one supervision to prevent falls. The DON further stated that Resident 1 was at risk for elopement (to leave a skilled nursing facility without notice or permission), from the facility related to Resident 1 ' s wandering behavior. The DON stated that there was nothing required in Resident 1 ' s plan of care that SNF 1 could not provide. During a concurrent interview and record review on [DATE] at 3:35 p.m. with the DON, reviewed Resident 1 ' s IDT Conference Note dated [DATE]. The DON stated that on [DATE], the IDT Team was unable to determine discharge plans for Resident 1. The DON stated that Resident 1 required one-to-one supervision to ensure Resident 1 ' s safety. The DON stated that Resident 1 had episodes of aggressive behaviors towards staff however the IDT Conference Note dated [DATE] did not indicate what specific behaviors were observed, what specific interventions could have been implemented to address the aggressive behaviors or other behaviors related to Resident 1 ' s mental illness. The DON stated there was no documentation found of the facility ' s attempts to meet the resident ' s needs or what services the new receiving facility (SNF 2) had in order to meet the resident ' s needs. During an interview with the ADM on [DATE], 3:59 p.m., ADM stated that ADM 1 was not aware of any specific services that Resident 1 needed that SNF 1 could not provide but that SNF 2 could provide. 5. During an interview with RN 4 on [DATE] at 3:12 p.m., RN 4 stated RN 4 worked at SNF 2. RN 4 stated that on [DATE], at approximately 6:40 p.m. the driver (Driver 1) of a private non-medical vehicle arrived at SNF 2 and informed RN 4 that he (Driver 1) was instructed to drop off Resident 1. RN 4 stated that Driver 1 helped bring Resident 1 inside SNF 2. During an interview with the DON on [DATE] at 4:26 p.m., the DON stated that the facility did not ensure that Resident 1 was provided with a safe and appropriate form of transportation when the facility utilized a ride share company (a company that uses independent contractors with no training regarding medical safety, to transport people between various places) to discharge Resident 1 to SNF 2. The DON stated that SNF 1 had knowledge of Resident 1 ' s medical condition and history of aggressive behavior. The DON stated that Resident 1 ' s medical conditions included mental illness, and therefore the facility should have provided Resident 1 with professional medical transportation services to ensure Resident 1 ' s safety as part of safe and orderly discharge services. During a review of the facility ' s policy and procedure titled Discharging the Resident, last reviewed [DATE], indicated that if a resident is being discharged to another facility, the facility is to ensure a transfer summary is completed and telephone report is called to the receiving facility. During a review of the facility ' s policy and procedure titled Transfer of Discharge Documentation, last reviewed on [DATE], indicated that documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum a. The reason(s) for the transfer or discharge f. A summary of the resident's overall medical, physical, and mental condition h. Disposition of medications . Should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or . Should the resident be transferred or discharged because health of individuals in the facility would otherwise be endangered, the basis for the transfer or discharge must be documented in the resident's clinical record by a physician.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by: 1. Resident 2 for one of five sampled residents (Resident 1), when on 11/1/2023, Resident 2 punched Resident 1 in the stomach. 2. Resident 4 for one of five sampled residents (Resident 3), when on 11/11/2023, Resident 4 punched Resident 3 in the face. These deficient practices resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility, and Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility. Resident 3 sustained a bloody nose (bleeding from inside the nostrils caused by the physical impact of being hit on the nose). Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's severely impaired cognition (ability to think and make decisions) and Resident 3's moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: 1. A review of Resident 1's Admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/15/2023, indicated Resident 1 had the ability to sometimes make self understood (limited ability to making requests) and had the ability to sometimes understand others (responds adequately to simple, direct communication only). A review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident 's condition) dated 11/1/2023, and timed at 11:32 a.m., indicated that on 11/1/2023 at around 10:45 a.m., Certified Nurse Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) immediately separated Resident 1 and Resident 2, and that Resident 1 had stated that Resident 2 had hit Resident 1 in the stomach. A review of Resident 2's Admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included schizoaffective disorder, (mental illness that can affect your thoughts, mood and behavior) bipolar type (symptoms of a mental disorder including mania [condition of abnormally heightened and extreme changes in mood or emotions and energy level], depression [mental disorder including persistent sadness or lack of interest], and psychosis [collection of symptoms that affect the mind]) and borderline personality disorder (mental illness that severely impacts a person's ability to manage their emotions) A review of Resident 2's MDS dated [DATE], indicated Resident 2 had the ability to sometimes make self understood and had the ability to sometimes understand others. A review of Resident 2's SBAR Communication Form dated 11/1/2023 timed at 10:45 a.m. indicated that on 11/1/2023 at around 10:45 a.m., Resident 2 hit Resident 1 with a closed fist using her right hand in the abdominal (stomach) area. The SBAR further indicated that Resident 2 stated she hit Resident 1 because Resident 1 was standing next to Resident 2. During an interview on 11/15/2023 at 9:45 a.m. with Resident 1, Resident 1 stated that she was unable to recall the incident between Resident 2 that had occurred on 11/1/2023. During an interview on 11/15/2023 at 11:50 a.m. with CNA 1, CNA 1 stated that on 11/1/2023 at close to lunch time (approximately 10:45 a.m.), CNA 1 saw Resident 2 sitting in her wheelchair near the nursing station. CNA 1 stated that Resident 1 walked over and stood next to Resident 2. CNA 1 stated she saw Resident 2 appear to be irritated and that Resident 2 suddenly reached out with her right hand in a closed fist and hit Resident 1 in stomach area with the backside of Resident 2's fist. When asked how CNA 1 knew that Resident 2 was irritated, CNA 1 stated that she heard Resident 2 state move, you're too close to me as she hit Resident 1. CNA 1 stated that the incident was not an accident and that Resident 2 looked irritated as she hit Resident 1. CNA 1 stated that she then saw Resident 1 holding her stomach with both hands immediately after being hit by Resident 2. During an interview on 11/15/2023 at 2:50 p.m. with LVN 1, LVN 1 stated that on 11/1/2023 he was in the nursing station charting (documenting in medical records) when CNA 1 reported that Resident 2 had hit Resident 1. LVN 1 stated that according to Resident 2, Resident 2 hit Resident 1 because Resident 1 was next to Resident 2. During an interview on 11/15/2023 at 5:55 p.m. with the Administrator (ADM), ADM stated that as the facility's abuse coordinator (person designated to investigate abuse allegations) she investigated the incident that occurred on 11/1/2023 at approximately 10:45 a.m. between Resident 1 and Resident 2. ADM stated that Resident 1 was found to have been hit in the stomach by Resident 2 with a closed fist. When asked if Resident 1 was free from abuse while under the care of the facility, ADM stated no. 2. A review of Resident 3's Admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had the ability to usually make self understood and ability to usually understand others. A review of Resident 3's SBAR Communication Form, dated 11/1/2023 timed at 7:15 p.m., indicated on 11/11/2023 at around 7:45 p.m. Resident 3 was found by Certified Nursing Assistant 3 (CNA 3) having a fist fight (a fight in which people hit each other using their tightly closed hands) with Resident 4. The SBAR Communication Form further indicated that as a result of the fist fight, Resident 3 sustained a bloody nose and torn shirt. A review of Resident 4's Admission Record, indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 4's MDS dated [DATE], indicated Resident 4 had the ability to make self understood and ability to understand others. A review of Resident 4's SBAR Communication Form dated 11/11/2023 timed at 8:49 p.m., indicated that on 11/11/2023 at around 7:15 p.m. Resident 4 was found by CNA 3 having a fist fight with Resident 3. The form indicated that Local Law Enforcement (LLE) were notified to investigate the incident. The form indicated that Resident 4 was then transferred to the General Acute Care Hospital (GACH) on 11/11/2023 at 11:00 p.m. for further evaluation. During an interview on 11/15/2023 at 10:10 a.m. with Resident 3, Resident 3 stated that he was unable to recall the incident with Resident 4 that had occurred on 11/11/2023. During an interview on 11/15/2023 at 2:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 11/11/2023 at around 7:30 p.m., he saw Resident 3 and Resident 4 hitting each other. CNA 2 stated that he saw the two residents were both seated in their own wheelchairs and were both hitting each other with closed fists. CNA 2 stated that he saw Resident 3 with blood on the resident's face at the time he separated Resident 3 and Resident 4. During an interview on 11/15/2023 at 2:29 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that on 11/11/2023 around 7:00 p.m., CNA 3 observed Resident 3 and Resident 4 sitting in their own wheelchairs close by each other. CNA 3 stated that Resident 3 and Resident 4 were seen talking to each other at first, then both residents started to scream at one another. CNA 3 stated that as she tried to separate the two residents, Resident 3 and Resident 4 held onto each other's wheelchairs. CNA 3 stated that she then saw Resident 4 hit Resident 3 first in the face. CNA 3 stated she was unable to recall if Resident 3 had hit Resident 4. CNA 3 stated that she saw Resident 3 bleeding from his nose. During an interview on 11/15/2023 at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 11/11/2023, LVN 2 was notified by CNA 3 of a fist fight between Resident 3 and Resident 4. LVN 2 stated that when she went and saw Resident 3, Resident 3 had blood dripping from both nostrils that covered the resident's upper lip. LVN 2 stated that Resident 3 was observed with his shirt ripped apart on the right chest and shoulder area. During an interview on 11/15/2023 at 5:55 p.m. with the ADM, ADM stated that as the facility's abuse coordinator she investigated the incident between Resident 3 and Resident 4. ADM stated that Resident 3 and Resident 4 were in a physical altercation which resulted in Resident 3 having a bloody nose. When asked if Resident 3 was free from abuse while under the care of the facility, ADM stated no. A review of the facility's Policies and Procedures titled, Abuse Prevention, undated, indicated the facility does not condone any form of resident abuse. Physical Abuse is defined as hitting, slapping, pinching, and/or kicking. The P&P further indicated that the facility would promote an environment free from abuse and mistreatment.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 1) on 9/23/2023 when Resident 2 hit and scratched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin tear (a wound that happens when the layers of skin separate or peel back) on the left cheek of his face and redness (red discoloration to the skin) on right cheek of his face, left cheek of his face, and left lower jaw. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of chronic kidney disease (the gradual loss of kidney function). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/16/2023, indicated Resident 1 had severely impaired cognition and required total assistance from staff with activities of daily living such as bed mobility, transfers, eating, toilet use, personal hygiene, and bathing. A review of Resident 1's Situation - Background - Assessment - Recommendation (SBAR) Communication Form (a form used to facilitate prompt communication regarding a change in a resident's health condition), dated 9/23/2023 timed at 9:50 a.m., indicated on 9/23/2023 at around 7:25 a.m. Certified Nurse Assistant 1 (CNA 1) found Resident 1 being hit and scratched by Resident 2. The SBAR further indicated that Resident 1 was noted with open skin and active bleeding on the face requiring pressure to be applied to the open skin to stop the bleeding. A review of Resident 1's Wound Assessment Report dated 9/23/2023, indicated Resident 1 sustained a skin tear on the left cheek with a length of 1.0 centimeters (cm- a unit of measurement) and a width of 1.0 cm, edges are not well approximated (not a clear cut edge on the skin) with presence of torn skin flaps (skin removed from area of the face), and redness on the left cheek measuring 2.0 cm by 3.0 cm. Further review of the Wound Assessment Report dated 9/23/2023, indicated that upon assessment of Resident 1's right cheek, the resident sustained redness measuring 2.5 cm by 3.5 cm and redness measuring 0.5 cm by 0.2 cm to the left lower jaw. A review of Resident 1's Physician Order dated 9/23/2023 indicated to apply steri-strips (thin adhesive bandages or strips of tape applied across a cut to keep the edges of the wound together as it heals) on the left cheek until it falls off and to monitor for any signs and symptoms of infection. Further review of Resident 1's Physician Order dated 9/23/2023 indicated to monitor Resident 1's right cheek, left cheek and left lower jaw for discoloration (change in natural skin color) and for adverse reaction such as pain, discomfort, or further skin breakdown daily for 30 days. A review of Resident 2's Admission Record, indicated Resident 2 was originally admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included hydrocephalus (a brain disorder with too much fluid built up inside the brain that causes pressure on the brain's tissues), generalized anxiety (feeling of worry, nervousness, or unease) disorder and mood disorder. A review of Resident 2's MDS dated [DATE], indicated Resident 2 had moderately impaired cognition. A review of Resident 2's SBAR Communication Form dated 9/23/2023 timed at 8:09 a.m. indicated on 9/23/2023 at around 7:25 a.m. Resident 2 went inside Resident 1's room and started hitting and scratching Resident 1. The SBAR Communication Form further indicated Resident 2 was observed with disruptive behavior (any behavior or conduct that interferes with safe resident care) by hitting, grabbing, scratching, and threatening Resident 1. A review of Resident 3's Admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] then readmitted on [DATE] with a diagnosis of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking). A review of Resident 3's MDS dated [DATE], indicated Resident 3 had intact cognition. During an interview on 10/12/2023 at 2:20 p.m. with Resident 3, Resident 3 stated that on 9/23/2023, unable to recall the time, Resident 3 witnessed the physical altercation (a dispute between two residents in which one sustain bodily injury as a result) between Resident 1 and Resident 2. Resident 3 stated that he shares a room with Resident 1. Resident 3 stated he was in his bed when he saw Resident 2 standing on the right side of Resident 1 as Resident 1 was lying in bed. Resident 3 stated that he saw Resident 2 then hit Resident 1 with what appeared to be a rolled-up towel. Resident 3 stated that he then saw Resident 2 with both hands clenched into a fist. Resident 3 stated he witnessed Resident 2 repeatedly hit Resident 1's face. Resident 3 stated that he then saw Resident 1 bleeding from the face. Resident 3 stated it appeared as if Resident 1 was unable to defend himself as he was being attacked by Resident 2. During an interview on 10/12/2023 at 3:15 p.m. with Resident 2, Resident 2 was unable to recall the incident with Resident 1 on 9/23/2023. During an interview on 10/12/2023 at 6:30 p.m. with CNA 1, CNA 1 stated that on 9/23/2023 at around 7:25 a.m., CNA 1 heard Resident 3 calling CNA 1's name to his room stating that someone was fighting in the room (referring to Resident 1 and Resident 3's room). CNA 1 stated she ran in to the room to find Resident 2 standing on the right side of Resident 1. CNA 1 stated she saw Resident 2 had his left hand on Resident 1's bed for support while using his (Resident 2) right hand in a closed fist to hit Resident 1 on the face. CNA 1 stated she told Resident 2 to stop and had to hold him back. CNA 1 stated she saw Resident 1 bleeding from the face. During an interview on 10/13/2023 at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 9/23/2023 at around 7:25 a.m., LVN 2 heard CNA 1 screamed from Resident 1's room. LVN 2 stated that she ran over and saw CNA 1 redirecting Resident 2 away from Resident 1's room. LVN 2 stated that Resident 1's left cheek had open skin and was bleeding from the face. LVN 2 stated that after tending to the residents she reported the incident immediately to the Director of Nursing (DON) that Resident 2 was found physically abusing Resident 1. LVN 2 further stated Resident 1 was later transferred to a General Acute Care Hospital 1 (GACH 1) not related to the incident with Resident 2. During an interview on 10/13/2023 at 5:10 p.m. with the Administrator (ADM), the ADM stated that she is the abuse coordinator (the person that investigates allegations of abuse in the facility). ADM stated she was notified by the DON regarding the incident between Resident 1 and Resident 2 that occurred on 9/23/2023. ADM stated that her investigation of the incident between Resident 1 and Resident 2 was physical abuse, with Resident 1 having sustained physical injuries. A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 2/2023, indicated that it is the right of the resident to be free from abuse. A review of the facility's P&P titled, Abuse Prevention, undated, indicated the facility does not condone any form of resident abuse. Physical Abuse is defined as hitting, slapping, pinching, and/or kicking. The P&P further indicated that the facility would promote an environment free from abuse and mistreatment.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe and sanitary condition when did not ensure food was stored, prepared and served in accordance with professional standards of food service safety by: 1. Having cockroaches (small insects that carry and spread infectious diseases) in the kitchen and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed). 2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice. The above deficient practices placed all 75 of 75 residents residing in the facility and who consumed food including iced water, prepared in the kitchen at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death. On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Administrator and Director of Nursing (DON). On 5/20/2021 at 3:19 p.m., IJ situation was abated (removed) in the presence of the Administrator, DON, and the Administrator Designee, after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following: a. MS inspected structural problems to repair and clean. b. Pest control service was provided immediately c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately. e. The ice machine and ice storage containers including hard to reach areas was drained, sanitized, and deep cleaned (disassembling the ice machine and bin, removing mineral deposits from areas or surfaces that are in direct contact with water, cleaning the exterior panels and around the ice machine) per manufacturers instruction. f. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours. g. Staff were provided with training in kitchen sanitation and infection control. Cross Reference F880 and F925 Findings: 1. On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall. On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings. On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place. The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition. The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe). A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches). On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired. On 5/18/2021 at 9:33 a.m., Kitchen Staff 1 (KS 1) stated she had observed a cockroach or two recently (did not recall dates) and would kill them and had reported to DS. On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches. A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services. A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects. A review of the facility's undated policy and procedure titled, Sanitation Audit, indicated the RD and/or DS will conduct audit a minimum of once per month or more often if deemed necessary. A form would be competed as specific as possible with comments then review findings with staff and administrator as appropriate. Develop a plan of correction for any problems and follow up within one to two weeks. 2. On 5/17/2021 at 8:43 a.m., during an observation of the ice machine and concurrent interview with DS, there was dark substance underneath the running water and the collection bin had buildup matter of light-yellow color. Upon interview, DS stated maintenance staff cleaned the ice machine monthly. DS stated kitchen staff did not have the manufacturer's guidelines for cleaning and disinfecting the ice machine and they did not open the upper compartment to clean the inner components or the lower bin. DS stated the ice machine was used to provide ice to the residents in the water pitcher at bedside and iced water or drinks with or between meals. DS was not sure who was responsible to ensure the ice machine was in sanitary condition to prevent contamination of the ice and subsequent risk for the resident to develop water-borne illness. On 5/17/2021 at 10:15 a.m., during an interview, Maintenance Supervisor (MS) stated the contracted pest control technician came monthly and last month the technician recommended to come twice a month to treat the cockroach infestation, but this was not implemented. MS also stated he cleaned the ice machine once a month with the last cleaning on 4/22/2021. MS stated he saw a video from the manufacturer on how to clean the ice machine and the process included emptying all the ice from the machine, using a cleaning product, then a disinfectant to run through in the machine's cleaning load, and remove the front panel to put it in the dishwasher. MS stated he did not follow the manufacturer's cleaning and sanitizing recommendations. On 5/17/2021 at 2:56 p.m., during an observation and concurrent interview, MS opened the ice machine upper compartment and removed the stainless-steel cover. There was thick and dark substance buildup on the inner cover (water curtain), lower and upper plastic where ice was produced, and on the water trough. There was black, brown, and pink residue buildup, heavy black substance buildup inside the crevices of the lower section towards the back. MS stated he had never gone that far back into the machine because he could not reach that far and did not know it had to be done. MS stated monthly cleaning was not enough and he could not be sure if it was 100% clean after running the machine with cleaner and sanitizer because he could not see the back section. MS stated he thought it was normal to have buildup and did not know there were professional cleaning services for ice machines. MS stated he had not followed the manufacturer's recommendations for cleaning and disinfecting. On 5/18/2021 at 9:18 a.m., a concurrent interview with RD consultant and a review of a kitchen report dated 9/8/2020 and 4/2/2021 indicated the ice machine was clean. The RD consultant stated the report did not specify an inspection of the ice machine internal components was conducted to ensure cleanliness. The RD Monthly Kitchen Rounds Checklist forms dated 2/17/2021, 3/10/2021, and 4/23/2021, were reviewed with RD consultant. RD consultant verified the checklist form did not include an inspection of the ice machine condition. RD consultant stated she was responsible to ensure staff followed the ice machine manufacturer's cleaning and sanitizing guidelines to prevent ice contamination. A review of the ice machine manufacturer's manual titled Maintenance, indicated cleaning and sanitizing of ice machine procedure must be performed a minimum of once every six months . machine and bin must be disassembled, cleaned, and sanitized. The procedure states to clean all components in the water flow path. All ice produced must be discarded and mineral deposits should be removed from areas or surfaces that are in direct contact with water. Removing the ice machine top cover may allow easier access. Use a soft bristle nylon brush, sponge, or cloth to carefully clean the parts, soak for 5 minutes, then rinse with clean water. While components soaking, use nylon brush or cloth to thoroughly clean the following ice machine areas including side walls, base (area above water trough), evaporator plastic parts(top, bottom, and sides), bin or dispenser and rinse all thoroughly with clean water. Spray a mix of sanitizer and water on all the components and areas without rinsing after. After waiting 20 minutes, the ice machine could be used again.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a safe and sanitary environment by: 1. Having cockroaches (small insects that carry and spread infectious diseases) in the kitchen and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed). 2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice. The above deficient practices placed all 75 of 75 residents residing in the facility and who consumed food including iced water, prepared in the kitchen at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death. On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declare in the presence of the facility's Administrator and Director of Nursing (DON) of the findings. On 5/20/2021 at 3:19 p.m., the SA removed the IJ in the presence of the Administrator, DON, and the Administrator Designee after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following: a. MS inspected structural problems to repair and clean. b. Pest control service was provided immediately c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately. e. The ice machine and ice storage containers including hard to reach areas was drained, sanitized, and deep cleaned (disassembling the ice machine and bin, removing mineral deposits from areas or surfaces that are in direct contact with water, cleaning the exterior panels and around the ice machine) per manufacturers instruction. f. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours. g. Staff were provided with training in kitchen sanitation and infection control. In addition, the facility failed to ensure infection control prevention practices were implemented by: 3. One Certified Nursing Assistant (CNA 6) out of 117 staff and visitors listed on 5/19/2021, not completing the screening questionnaire for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious infection transmitted from person to person and affects the respiratory track) before starting the shift. If CNA 6 was symptomatic (with possible COVID-19 infection), residents and staff were at risk of getting infected. 4. Allowing the share use of four smoking aprons that were to be used by designated residents with potential COVID-19 infection, and not disinfecting the aprons between use, which could result on transmission of COVID-19 infection. 5. Not re-directing Resident 2, who was confused and incontinent (unable to control urination and bowel movement), to prevent her from laying down on Resident 77's bed. If Resident 2 had an episode of incontinence, it was likely to she would soil Resident 77's bed placing the resident at risk of cross contamination. Cross Reference F812 and F925 Findings: 1. On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall. On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings. On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place. The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition. The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe). A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches). On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired. On 5/18/2021 at 9:33 a.m., Kitchen Staff 1 (KS 1) stated she had observed a cockroach or two recently (did not recall dates) and would kill them and had reported to DS. On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches. A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services. A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects. A review of the facility's undated policy and procedure titled, Sanitation Audit, indicated the RD and/or DS will conduct audit a minimum of once per month or more often if deemed necessary. A form would be competed as specific as possible with comments then review findings with staff and administrator as appropriate. Develop a plan of correction for any problems and follow up within one to two weeks. 2. On 5/17/2021 at 8:43 a.m., during an observation of the ice machine and concurrent interview with DS, there was dark substance underneath the running water and the collection bin had buildup matter of light-yellow color. Upon interview, DS stated maintenance staff cleaned the ice machine monthly. DS stated kitchen staff did not have the manufacturer's guidelines for cleaning and disinfecting the ice machine and they did not open the upper compartment to clean the inner components or the lower bin. DS stated the ice machine was used to provide ice to the residents in the water pitcher at bedside and iced water or drinks with or between meals. DS was not sure who was responsible to ensure the ice machine was in sanitary condition to prevent contamination of the ice and subsequent risk for the resident to develop water-borne illness. On 5/17/2021 at 10:15 a.m., during an interview, Maintenance Supervisor (MS) stated the contracted pest control technician came monthly and last month the technician recommended to come twice a month to treat the cockroach infestation, but this was not implemented. MS also stated he cleaned the ice machine once a month with the last cleaning on 4/22/2021. MS stated he saw a video from the manufacturer on how to clean the ice machine and the process included emptying all the ice from the machine, using a cleaning product, then a disinfectant to run through in the machine's cleaning load, and remove the front panel to put it in the dishwasher. MS stated he did not follow the manufacturer's cleaning and sanitizing recommendations. On 5/17/2021 at 2:56 p.m., during an observation and concurrent interview, MS opened the ice machine upper compartment and removed the stainless-steel cover. There was thick and dark substance buildup on the inner cover (water curtain), lower and upper plastic where ice was produced, and on the water trough. There was black, brown, and pink residue buildup, heavy black substance buildup inside the crevices of the lower section towards the back. MS stated he had never gone that far back into the machine because he could not reach that far and did not know it had to be done. MS stated monthly cleaning was not enough and he could not be sure if it was 100% clean after running the machine with cleaner and sanitizer because he could not see the back section. MS stated he thought it was normal to have buildup and did not know there were professional cleaning services for ice machines. MS stated he had not followed the manufacturer's recommendations for cleaning and disinfecting. On 5/18/2021 at 9:18 a.m., a concurrent interview with RD consultant and a review of a kitchen report dated 9/8/2020 and 4/2/2021 indicated the ice machine was clean. The RD consultant stated the report did not specify an inspection of the ice machine internal components was conducted to ensure cleanliness. The RD Monthly Kitchen Rounds Checklist forms dated 2/17/2021, 3/10/2021, and 4/23/2021, were reviewed with RD consultant. RD consultant verified the checklist form did not include an inspection of the ice machine condition. RD consultant stated she was responsible to ensure staff followed the ice machine manufacturer's cleaning and sanitizing guidelines to prevent ice contamination. A review of the ice machine manufacturer's manual titled Maintenance, indicated cleaning and sanitizing of ice machine procedure must be performed a minimum of once every six months . machine and bin must be disassembled, cleaned, and sanitized. The procedure states to clean all components in the water flow path. All ice produced must be discarded and mineral deposits should be removed from areas or surfaces that are in direct contact with water. Removing the ice machine top cover may allow easier access. Use a soft bristle nylon brush, sponge, or cloth to carefully clean the parts, soak for 5 minutes, then rinse with clean water. While components soaking, use nylon brush or cloth to thoroughly clean the following ice machine areas including side walls, base (area above water trough), evaporator plastic parts(top, bottom, and sides), bin or dispenser and rinse all thoroughly with clean water. Spray a mix of sanitizer and water on all the components and areas without rinsing after. After waiting 20 minutes, the ice machine could be used again. 3. On 5/21/2021, at 9:38 a.m. during an interview with the IP Nurse and concurrent review of the Staff/Visitor Screening Log, IP Nurse stated on 5/19/2021, Certified Nursing Assistant 6 (CNA 6) did not completely fill out the screening questionnaire (left blank responses regarding the presence of COVID-19 symptoms). IP Nurse explained that prior to the employees' shift they get their temperature checked and indicate on the screening log if they have any signs and symptoms of COVID-19. IP Nurse stated the form should have been filled out entirely because the purpose is to determine if a staff member has any signs and symptoms prior to starting their work assignment. On 5/21/2021, at 9:47 a.m. during an interview, DON stated the importance of screening staff prior to the start of their shift is to protect the residents because they were vulnerable. A review of the facility's policy and procedure titled, Policy for Emergent Infectious Diseases for Skilled Nursing Care Centers, revised 3/17/2021, indicated the following: -Screen all visitors and staff who enter facility: -Must sign entrance with date and time -Must take temporal reading for temperature -Free of shortness of breath -Free of persistent cough -Free of diarrhea, nausea, & vomiting -Free of fever, sore throat, chills or other respiratory symptoms -Free of loss of taste and smell -Free of headache or confusion -Free of muscle pain or joint pain -International travel within the last 14 days to restricted countries -Contact with someone who is confirmed or under investigation for COVID-19 A review of the County of Los Angeles Public Health Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, updated 4/11/2021, indicated, All persons, regardless of vaccination status, should be screened for signs and symptoms of COVID-19 infection, including a temperature check. Additionally, all persons who are not fully vaccinated should be screen for any recent travel in the past 14 days. Persons requiring symptoms and travel screening includes facility staff, essential visitors, and general visitors. Symptoms include but are not limited to the following: fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well. All staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts. 4. On 5/20/2021 at 1:15 p.m., Resident 479 was observed wearing a protective apron and smoking in the smoking patio, in the designated Yellow Zone (area reserved for newly admitted resident and residents who have been exposed to or have symptoms of COVID-19). Activity Assistant 1 (AA 1) was supervising Resident 479. When Resident 479 finished smoking, AA 1 hung the apron on a wall within the patio without disinfected it. On 5/20/2021 at 1:21 p.m., during an interview, AA 1 stated the smoking apron are not sanitized before and after each use but in the morning, in the afternoon between 2-3 p.m., and at the end of the day. AA 1 stated each resident had their own apron with their names written on the apron ties. Upon observation, the aprons did not have names written on the ties. AA 1 explained that the names could not be read due to being washed in laundry. On 5/20/2021 at 3:56 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated the smoking aprons were sanitized before and after each use since the aprons are not dedicated but shared among all Yellow Zone residents. On 5/21/2021 at 10:38 a.m., during an interview, DON stated smoking aprons are shared among Yellow Zone residents and should be sanitized with a disinfectant between each use. DON further stated there was potential risk of spread of infection if the aprons were not disinfected. On 5/21/2021 at 12:38 p.m., during an interview, DON clarified that aprons are dedicated for each smoking resident instead of being shared and the resident's name should be on a label and stapled on the ties of the apron. Upon closer observation of four aprons in the Yellow Zone smoking patio, DON confirmed there were no names written anywhere on all four aprons. Three of the gowns were observed hung together and touching each other. A review of the facility's policy and procedures titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, indicated, reusable items are cleaned and disinfected or sterilized between residents. 5. During an observation on 5/18/2021, at 12:35 p.m., Resident 2 was wandering through the hallway while Resident 77 was sitting in a wheelchair outside her room. Resident 2 was observed entering Resident 77's room and laid down on Resident 77's bed for 10 minutes. At 12:45 p.m., LVN 1 redirected the resident back to her room. During an interview on 5/18/2021, at 12:51 p.m., CNA 1 stated Resident 2 was incontinent (inability to control urination or bowel movement) and could soil other resident's bed. CNA 1 stated Resident 2 should have been redirected to her room upon entering Resident 77's room or use 'STOP' sign barrier across the door as a reminder. During an interview on 5/18/2021 at 12:57 p.m., LVN 1 verified Resident 2 was laying on Resident 77's bed and stated it should have not occurred. LVN 1 stated it was important to prevent cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another). A review of the facility's policy and procedures titled, Policies and Practices- Infection Control, revised on 7/2014, indicated, the policy was intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives were to prevent, detect, investigate, and control infection in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. A review of the facility's policy and procedure titled, Wandering (moving aimlessly from place to place) and Elopements (leaving the facility without staff noticing and without permission due to safety needs), revised in 3/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and effectiveness of the pest control service to prevent and eradicate (destroy/kill) cockroach infestation (presence of an unusually large number of cockroaches [small insects that carry and spread infectious diseases]) and eliminate harborage conditions in the kitchen for 75 of 75 residents residing in the facility and who ate food prepared in the kitchen. The kitchen had live cockroaches on the floor, between the dishwasher counter and a wall, in the dishwashing area between the counter and the wall, and live nymph (baby) cockroaches behind the stove. The kitchen had structural cracks and crevices (narrow opening) in the walls, around the plumbing, peeling paint on walls and ceilings, holes and gaps in the walls under the dishwashing machine, cockroach fecal matter in the dishwashing area between the counter and the wall which provided both food and places for harborage of pests and the warm kitchen conditions necessary to encourage the cockroaches to thrive. These deficient practices placed the total of 75 residents at risk of food-borne illness (eating live microorganisms, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death. On 5/17/2021 at 12:10 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared in the presence of the Administrator and Director of Nursing (DON). On 5/20/2021 at 3:19 p.m., IJ situation was abated (removed) in the presence of the Administrator, DON, and the Administrator Designee, after on-site verification of the implementation of the written Plan of Action (POA, interventions to immediately correct the deficient practice) through observation, interview and record review. The acceptable POA included the following: a. MS inspected structural problems to repair and clean. b. Pest control service was provided immediately c. DS procured food and water from sister facility, while the kitchen was closed for pest elimination. d. All non-sealed food items were disposed of immediately. e. All residents were assessed by licensed nurses for any potential signs and symptoms of food-borne illness each shift for 72 hours. f. Staff were provided with training in kitchen sanitation and infection control. Cross Reference F880 and F812 Findings: On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall. On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings. On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place. The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition. The Environmental Health Specialist (EHS - inspector) report titled, Official Inspection Report, dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe). A review of the EHS's report titled, Retail Food Service Inspection Report, indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches). On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired. On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches. A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, Effective Management of Cockroach Infestation, retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated cockroaches found in health-care facilities can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the facility's policy and procedure titled, Pest Control, revised on 05/2008, indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services. A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects.

Based on interview, and record review, the facility failed to ensure one of three sampled residents, Resident 1, who was assessed as high risk for fall and injury due to confusion, impaired vision, physical limitations, unstable balance, medication use, in need of one-person assistance for transfer and walking with the use of a front wheel walker (FWW), and was at risk for bleeding due to the use of blood thinner, was provided with supervision and assistance to prevent fall and injury by failing to: 1. Ensure Resident 1 was monitored for unassisted transfers and walking. 2. Ensure all nursing personnel caring for Resident 1 were aware of the resident's fall risk and the need to assist her with transfers and walking, re-direct her behavior of unassisted tranfers/walking , and remind to call for assistance. 3. Implement the plan of care interventions to provide assistance and monitor the resident's gait disturbances. 4. Re-evaluate the plan of care to address the resident's continued episodes of independent transfers from the low-height bed and walking unassisted to develop additional interventions, such as bed and chair alarm, and to indicate the frequency of visual checks. 5. Implement the facility's policy and procedure on Prevention of Falls to use appropriate measures and instruments to prevent falls. 6. Implement the facility's policy and procedure on Falls, Risk For and Actual Fall to have further assessment, enhance the plan of care, minimize the risk for falls and improve communication with the necessary personnel. On [DATE], Resident 1 fell in her room near her bed, sustained a head injury, developed an intracranial hemorrhage (bleeding in the brain), and died on [DATE]. The immediate cause of death was blunt force head trauma. Findings: A review of the closed clinical record indicated Resident 1 was admitted to the facility, on [DATE], and was discharged on [DATE], to a general acute care hospital (GACH). Resident 1's [DIAGNOSES REDACTED]. forming, and helps to keep existing blood clots from getting worse. This medicine increases the risk for bleeding). A care plan developed on [DATE], for Resident 1's risk for falls and injuries related to her mental and physical conditions, included in the approaches a low bed with half-length side rails, landing pads (fall safety cushion placed at the side of the bed for protection), assistance with transfer activities, monitor gait disturbance, and ambulation as desired with a FWW. A review of the Physical Therapy (PT) Evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 was referred for PT services due to new onset of decreased strength, functional mobility, transfers, ability to safely ambulate, neuro-motor control, and decreased postural alignment. The PT functional assessment indicated Resident 1 required one-person assistance with bed mobility, rolling, bridging, scooting, sitting, transfers, sit to stand, and stand pivot. The Fall Risk Evaluation form, dated [DATE], indicated a score of 18. A total score of 10 or above represented a high risk for falls. A review of the Licensed Nurses Weekly Summary Report, dated [DATE], indicated Resident 1 required supervision with transfers, limited one-person assistance with ambulation and bed mobility, extensive assistance with activities of daily living (ADLs) and toileting. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated [DATE], indicated Resident 1 had severely impaired cognitive skills for daily decision-making, required one-person physical assistance with all her ADLs, including transfers and ambulation. The Fall Care Area Assessment (CAA - used to develop a resident-specific care plan based on identified problems, needs, and strengths), dated [DATE], indicated the following: Resident 1 was prescribed psychotropic medications (mind altering medications) for psychosis (when a person has a break from reality, often involving seeing, hearing, and believing things that are not real - antipsychotic), anxiety (nervousness), and depression (persistent feeling of sadness and loss of interest). Resident 1 had impaired balance during transitions and walking, moving from seated to standing, walking with assistive device (front wheeled walker), moving on and off toilet, turning and facing opposite direction while walking, and doing surface to surface transfers. Resident 1 was considered at risk for injuries due to her [DIAGNOSES REDACTED]. She was described as forgetful, disoriented, and confused. The Psychotropic Medication Use CAA, dated [DATE], indicated Resident 1 was at risk for falls/injuries due to her [DIAGNOSES REDACTED]. A review of the PT treatment notes, dated [DATE], 27, 28, 2014 and [DATE], 3, 4, 5, 2014 indicated there was no change in the resident's bed mobility and transfer abilities; Resident 1 required one-person assistance with bed mobility and transfers throughout her stay in the facility. The nursing Weekly Summary Report, dated [DATE], indicated Resident 1 required supervision with transfers, limited one-person assistance with ambulation and bed mobility, and extensive assistance required with ADLs and toileting. This weekly summary report contradicted Resident 1's mobility and level of assistance from the MDS and PT assessments. There was no documentation by nursing staff to indicate the resident when attempting unassisted walking and transfers was re-directed and reminded to call for assistance to prevent falls. A review of the Nursing Assistant Daily Flow Sheet for August and [DATE] indicated Resident 1 was independent with bed mobility and ambulated on all shifts from [DATE] to [DATE]. The documentation did not include the level of assistance required with walking/ambulation. For the 7 a.m. to 3 p.m. and the 3 p.m. to 11 p.m. shifts from [DATE] to 9, 2015, the documentation indicated the resident was assisted with ADLs, but on the 11 p.m. to 7 a.m. shift documented the resident was independent with ADLs. A Licensed Nurses Progress Note by Staff 3, dated [DATE], timed at 11:45 p.m., indicated Resident 1 was seen on the floor mat moaning, in a sitting position facing the door, noted with a bump on the right temporal (the side of the head behind the eyes), with the skin intact, and a bluish discoloration. The note indicated that with a certified nurse assistant (CNA), the resident was placed back in the bed, ice pack was applied on the right temporal area, and Tylenol 325 mg two tablets were given orally for pain. A complete body check was done and no other injury was found. At 12:10 a.m., Resident 1's physician was notified of the resident's fall and ordered an X-ray of the right temporal area, ice packs, and neurological checks. After the fall, Resident 1 was able to ambulate with a walker with a slow gait to the dining room. According to the following shift Licensed Nurses Progress Note dated [DATE], timed at 7:30 a.m., Resident 1 ate 10% of her breakfast. At 7:45 a.m., the resident was noted with a lump/bump to the back of the head. At 8:30 a.m., the resident complained of pain to the right rib cage area while the X-ray was being taken. The attending physician was notified and ordered an X-ray of the right rib area. At 11:15 a.m. the result of a laboratory blood test ordered on [DATE], obtained earlier in the morning, indicated Resident 1's international normalized ratio (INR - used to monitor the blood thinning medication) was 5.28 (above the laboratory parameter for [DIAGNOSES REDACTED]from 2.0 to 3.0 - an elevated INR indicates the blood is too thin and the person is at greater risk of bleeding). The attending physician was notified and ordered the resident to be transferred to the emergency room (ER) for evaluation. A review of the ER admission report, dated [DATE], indicated Resident 1 was non-responsive on arrival, did not speak or open her eyes, and had some moaning sounds. A computerized tomography (CT scan - combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside the body) indicated the resident had a right-sided subdural hematoma (accumulation of blood on the brain's surface beneath the skull, usually resulting from head injury) with associated subarachnoid hemorrhage (bleeding in the area between the brain and the tissues that cover the brain, hemorrhage in this space can cause coma, paralysis, and death). The CT scan also indicated a left temporal parenchymal hemorrhage (bleeding within the brain itself) with associated left-sided subarachnoid hemorrhage. A review of the GACH discharge summary (from intensive care - ICU) to another hospital unit, dated [DATE], indicated the physician recommended a nasogastric tube (special tube that carries food and medicine to the stomach through the nose) and intravenous nutritional support, but the family declined and decided to place the resident on hospice care for comfort measures only. Resident 1 expired at the GACH on [DATE]. A review of the Los Angeles City Coroners Report signed on [DATE], indicated Resident 1 died on [DATE] and the resident's death was caused by intracranial hemorrhage due to blunt force head trauma, resulting from a fall suffered at the facility on [DATE]. During an interview with Staff 4, the MDS coordinator, on [DATE], at 4 p.m., she stated Resident 1 required limited assistance, meaning someone had to be with her to assist/guide her with ambulation and transfers. Staff 4 stated Resident 1 was not independent with ambulation and transfers. During an interview with the Director of Nursing (DON), on [DATE], at 4:50 p.m., she stated Resident 1 was independent with ambulation and transfers, which contradicted the PT and MDS assessment of Resident 1. On [DATE], at 7:45 a.m., during an interview with Staff 3, the nurse who found Resident 1 on the floor, he stated he made rounds on [DATE], about 11 p.m. and Resident 1 was sleeping in bed. Staff 3 stated shortly after rounds, he heard moaning coming from the resident's room and found the resident sitting on the floor between the beds. Resident 1 had a blue-tinged bump on her right temple. Staff 3 stated Resident 1 was independent with ambulation and transfers and the resident had a low bed with floor mats. Staff 3 stated Resident 1 could not say what happened to her and also stated the resident routinely went to the bathroom by herself, unassisted, and did not use her call light. Staff 3 stated staff tried to provide visual checks frequently. Staff 3 could not explain why the assistance indicated in the MDS and care plan was not provided. During an interview with Staff 2 (Physical Therapist), on [DATE], at 11:15 a.m., she stated Resident 1 required minimal assistance with ambulation and transfers, which meant the resident required at a minimum, one-person assistance with ambulation and transfers. Staff 2 stated Resident 1 was not independent with ambulation and transfers. According to the Accident/Incident Investigation form, dated [DATE], on [DATE] at 11:45 p.m., the charge nurse (Staff 3) heard a loud 'bang' noise in Resident 1's room, immediately went to check and the resident was on the floor on a sitting position. The investigation report indicated Resident 1 ambulated with a walker, and was able to go to the bathroom independently. During an interview with Staff 5 (CNA), on [DATE], at 11:45 a.m. and a review of the Nursing Assistant Daily Flow Sheets for Resident 1, she explained the forms were incomplete and the CNAs were to document the resident's mobility status and the level of assistance provided. The facility's policy and procedure titled, Prevention of Falls, revised [DATE], indicated it was the policy of the facility to assess residents for falls and to use appropriate measures to prevent falls. The policy indicated every effort was utilized to prevent falls and, if a resident was identified as at risk for falls, an appropriate instrument of prevention was put in place. The facility's policy and procedure titled, Falls, Risk For and Actual Fall, revised [DATE], indicated following the completion of the MDS, if a resident triggers a risk for falls, the resident would have further assessment. The plan of care would be enhanced, if indicated, to further minimize the risk for fall and improve communication with the necessary personnel. There was no documented evidence the plan of care was re-evaluated/revised since Resident 1's admission to ensure the staff interventions were appropriate based on the resident's needs.