Every finding on record at Miracle Mile Healthcare Center, LLC

Based on observation and interview, the facility failed to maintain clean linen was stored in a manner that protected from contamination and linen storage shelf and linen cart were maintained in a clean condition. This deficient practice had he potential to expose residents to allergens (a substance that can cause an allergic reaction), and infectious agents. During an observation on 8/28/2026, the surveyor observed linen shelf and linen cart located on the ground floor at the back of the building, the linen cart and shelf were not covered and protected. A visible accumulation of dirt and dust was observed on the surfaces of a blue rolled up cover where clean linen was stored. Grey and light orange comforters and white towel were observed on top of visibly dusty blue crate and black fan box. During an interview on 8/28/2026 at 10:31 AM with laundry services (LS), the LS stated, linen carts are kept in the laundry room, linen carts need to be covered. The LS observed and agreed with the surveyor, the linen carts and shelves are not covered and visibly dirty and covered with dust. During an interview on 92/2026 at 3:5 5 PM with the laundry and maintenance services supervisor (LMS), the LSM stated, laundry services are responsible to keep resident items such as linen, pillowcase, towels, and comforters clean and kept in a cart and shelves covered with a netted cover. LMS stated, maintenance services are responsible for cleaning shelves and carts and laundry areas. The LMS reviewed pictures taken by the surveyor and stated, clean and dirty items should be separated, buildup dirt and dust in in the linen shelf are potential risks to trigger allergy and transmit infections. The LMS acknowledged it is a deficiency not to maintain clean laundry services environment. During a review of the facility's policy and procedures (P&P) titled Departmental (Environmental Services)- Laundry and Linen revised on 1/20/2026, the P&P indicted, Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

Based on observation, interview, and record review, the facility failed to assure one of three resident, (Resident 7) received a therapeutic snack based off their diet order. This deficient practice had the potential to alter the resident 7s' sugar and could have caused severe medical complications leading to hospitalization.,During a review of Resident 7's admission Record, the admission record indicated that Resident 7 was admitted on [DATE]with a diagnosis of but not limited to Type 2 Diabetes Mellitus (DM2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), Hyperlipidemia (high cholesterol), Dementia (decline in mental ability sever enough to interfere with daily life). During a review of Resident's 7's Minimum Data Set (MDS-a resident assessment tool) dated 8/17/2026, the MDS indicated that Resident 7 has a Brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13. A BIMS score of 13 means that the resident's cognitive function is intact with no or very little impairment. During a review of Resident 7's Order Summary Report (OSR) dated 8/28/2026, the OSR indicated that Resident 7 has a dietary order of Consistent Carbohydrate diet (CCHNO - a diet that requires eating a steady set amount of carbohydrates at every meal and snacks to help control sugar levels). The OSR indicated that Resident 7 has an order for Metformin (medication that helps lower high blood sugar levels) tablet 500mg every morning for his type 2 DM. During an observation on 8/28/2026 at 11:58am in the hallway Infront of the smoking area. Resident 7 was observed calling out to a CNA and asked for a pepsi cola please. Resident 7 then approached the CNA in front of the activities office door and told the CNA he is in room [ROOM NUMBER]. Resident 7 walked over to his room and waited for his drink. At 12:06pm the CNA was observed walking into the residents room. During an interview on 8/28/2026 at 12:08pm with Resident 7, Resident 7 confirmed the Pepsi cola they were drinking was provided by the CNA that just left the room and it came from the snack closet in front of the nurse's station. Resident 7 stated he purchased the soda for one dollar. The Pepsi cola was confirmed to be a regular Pepsi and not a diet, or zero sugar Pepsi. During an interview on 9/1/2026 at 3:50pm with the Director of Nursing (DON), the [NAME] stated there is a snack closet in front of the nurses station. Those snacks are suppose to be for the staff to purchase and not for the residents. The DON stated providing residents with snacks that are not made for their therapeutic diet can cause them harm. The DON stated the risk of a diabetic resident getting high sugar snacks from the snack closet can alter their sugar levels. If the resident is on a CCHNO diet the carbohydrates are very closely monitored. Providing the resident with sugary snacks or drinks can lead to medical complications like Diabetic Ketoacidosis (DKA - a medical emergency where the body does not have enough insulin to move the sugar out from the blood stream and into the cell). The DON stated providing residents with snacks outside of their therapeutic diet is also not following physicians' orders. During a review of the facility's policy and procedures (P&P) titled, Diet Orders, dated 1/20/2026, the P&P indicated that diet orders are prescribed by the physician and will be provided by the food and nutrition services department.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Aide (CNA) 5 was not seen at the bedside feeding Resident 10 lunch without personal protective equipment (PPE, which is specialized clothing or gear worn to minimize exposure to hazards that cause serious workplace injuries, illnesses, or infections ) to maintain proper enhanced barrier precautions (EBP - staff wear protective gown and gloves during close, hands-on care to residents) This deficient practice had the potential to cause cross contamination between vulnerable residents, therefore, leading to decline in health, increased risk of infection and possible hospitalization. During a review of Resident 10's admission Record, the admission record indicated that Resident 10 was admitted to the facility on [DATE], with a diagnosis of but not limited to Stage 4 Sacral Pressure Ulcer (deep bedsore on the lower back above the tailbone where skin and fat are completely gone, exposing the muscle, tendons, and bone), Multiple sclerosis (condition where the body's immune system attacks the protective coating around nerve cells in the brain and spine), and dysphagia (difficulty swallowing). During a review of Resident's 10's Minimum Data Set (MDS-a resident assessment tool) dated 2/15/2026, the MDS indicated that Resident 10 has Brief Inventory of Mental Status (BIMS - Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) Score of 3. Meaning Resident 10 is severely cognitive impaired. The MDS indicated Resident 10 is dependent on staff for all daily needs. During a review of Resident 10's Order Summary Report (OSR) dated 8/28/2026, the OSR indicated that Resident 10 is on enhance barrier precautions (EBP) due to open wound management. During an observation on 8/28/2026 at 12:50pm in Resident 10's room. The CNA 5 was seen at the bedside feeding Resident 10 lunch. CNA 5 was observed feeding the resident without PPE. During an interview 8/28/2025 at 12:50pm with CNA 5, CNA5 could not state what the EBP sign outside of Resident 10's door meant. CNA 5 stated they wear a gown and gloves when the resident is being changed out of a soiled diaper, and when they are given a bath. CNA 5 stated a gown, or gloves are not used when feeding the resident. During an interview on 9/1/2026 at 3:50pm with the Director of Nursing (DON), the DON stated EBP are designed for residents who have tubes, wounds or are on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The DON stated staff must ensure to wear full PPE when caring for a resident on EBP. The DON stated if a resident is on EBP, the CNA must always wear PPE. The DON stated if staff are not wearing their PPE while performing care on EBP residents it places residents at risk for infection, cross contamination, worsening of medical condition, sepsis and hospitalization. During a review of facility's policy and procedures (P&P) titled Infection control, dated 4/1/2024, the P&P indicated that EBPs are used as an infection prevention and control intervention to reduce the spread of Multi drug resistant organisms (MDRO's) The P&P indicated that EBP's use targeted gown and glove use during high contact activities with a resident.

Based on interview and record review, the facility failed to follow the policy and procedures (P&P) for Release of Information for one of three sampled residents (Resident 1). This failure resulted in the Resident 1's Responsible Party (RP) 1 not receiving requested medical records within the 48-hour timeframe outlined in the policy.During a review Resident 1's admission Record dated 8/14/26 indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder (symptoms of intense anxiety of panic that are directly caused by a physical health problem), schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/31/26 indicated the resident had intact cognition (mental process of thinking, understanding, learning, reasoning and judgement) and required moderate assistance to being independent with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. During a review of Resident 1's Authorization for the Release of Clinical Information dated 8/6/26, the release indicated Resident 1's Responsible Party (RP) 1 requested most recent D/C (discharge) summary, most recent H&P (history and physical), care and treatment plans, consultation reports, physician's orders, diagnoses, lab/x-ray reports, progress notes, medication records, nursing notes and other (specify) all medical records, police notes/records/info be released to them. During an interview on 8/13/26 at 12:00 pm with the Medical Records Direct (MRD), she stated the email request was received on 8/6/26 and she made the copies of the medical records and those were sent to the corporate compliance for verification and after which they will be sending them out to RP 1 who requested the records. The MRD further stated the timing for delivery is what the policy indicates and to her knowledge there was not a set timeframe. During an interview on 8/13/26 at 4:20 pm with the Director of Nursing (DON), the DON stated a medical records request should be done within 48 hours. During a review of the facility's P&P titled Release of Information reviewed on 1/26/26, indicated A resident may obtain photocopies of his or her records by providing the facility with at least forty-eight (48) hour (excluding weekends and holidays) advance notice of such a request.

Based on interview and record review, the facility failed to document the resident's conservatorship (a legal arrangement where a court appoints a responsible adult or agency as a conservator, who makes medical and financial decisions for someone that is unable to care for their own basic needs) status in the medical record (Resident 1) once they were made aware. This failure resulted in the Resident 1 leaving Against Medical Advice (AMA - when a person at a medical facility chooses to leave before the recommendation of the health care team) on 7/31/26, instead of the incident being handled as an elopement (the act of leaving a facility unsupervised and without prior authorization) by the facility since the resident was not able to make decisions for his own care needs. Cross reference with F745During a review Resident 1's admission Record dated 8/14/26 indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder (symptoms of intense anxiety of panic that are directly caused by a physical health problem), schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/31/26 indicated the resident had intact cognition (mental process of thinking, understanding, learning, reasoning and judgement) and required moderate assistance to being independent with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. During a review of Resident 1's History and Physical (H&P) dated 7/27/26 indicated the resident had capacity to make medical decisions. During a review of Resident 1's IDT (interdisciplinary team) note dated 7/27/26 by the Social Services Assistant (SSA) indicated the facility was made aware of the conservatorship status of Resident 1 during the meeting which included and the Responsible Party (RP) 1 who was also the resident's designated conservator. During a concurrent interview and record review on 8/13/26 at 2:23 pm with the SSA an email containing Resident 1's conservatorship paperwork was reviewed. The SSA stated the email contained the resident's conservatorship paperwork and she did not open said email until after the resident left the facility AMA on Monday 8/3/26. The SSA acknowledged she failed to review the email received on 7/27/26 in a timely manner and stated the risk of not keeping up with emails received is not having important information that can affect the resident's care on time, by not having the information in the chart. During an interview with Registered Nurse (RN) 1 on 8/13/26 at 3:28 pm, RN 1 stated the resident left AMA on 7/31/26 around 11 pm. The resident had become verbally and physically aggressive with staff and did not want to wait. RN 1 stated he called the police before the resident left AMA and they came to talk with the resident the resident went back to his room. The resident later came out again insisting he had to leave the facility. RN 1 spoke with the resident about the risks of leaving AMA and put a call out to the attending physician. RN 1 reviewed the resident's chart that indicated he was alert and oriented and had capacity to make his own decisions, there was no indication in the chart that he was conserved. RN 1 stated the resident took the elevator down to the lobby and then began swinging at staff and then left the facility AMA, refusing to sign the AMA acknowledgment form. RN 1 was surprised to find out afterwards, when the Responsible Party (RP) 1 called the facility the next day that the resident was conserved, further stating if that information (the conservatorship paperwork) was on the chart at the time of the AMA they would have know to change the process to that of an elopement. During a review of the facility's policy and procedures for Charting and Documentation reviewed 1/26/26 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.

Based on interview and record review, the facility failed to document the resident's conservatorship (a legal arrangement where a court appoints a responsible adult or agency as a conservator, who makes medical and financial decisions for someone that is unable to care for their own basic needs) status in the medical record (Resident 1) once they were made aware. This failure resulted in the Resident 1 leaving Against Medical Advice (AMA - when a person at a medical facility chooses to leave before the recommendation of the health care team) on 7/31/26, instead of the incident being handled as an elopement (the act of leaving a facility unsupervised and without prior authorization) by the facility.Cross reference with F689During a review Resident 1's admission Record dated 8/14/26 indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder (symptoms of intense anxiety of panic that are directly caused by a physical health problem), schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/31/26 indicated the resident had intact cognition (mental process of thinking, understanding, learning, reasoning and judgement) and required moderate assistance to being independent with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. During a review of Resident 1's IDT (interdisciplinary team) note dated 7/27/26 by the Social Services Assistant (SSA) indicated the facility was made aware of the conservatorship status of Resident 1 during the meeting which included and the Responsible Party (RP) 1 who was also the resident's designated conservator. During a concurrent interview and record review on 8/13/26 at 2:23 pm with the SSA an email containing Resident 1's conservatorship paperwork was reviewed. The SSA stated the email contained the resident's conservatorship paperwork and she did not open said email until after the resident left the facility AMA on Monday 8/3/26. The SSA acknowledged she failed to review the email received on 7/27/26 in a timely manner and stated the risk of not keeping up with emails received is not having important information that can affect the resident's care on time, by not having the information in the chart. During a review of the facility's policy and procedures for Charting and Documentation reviewed 1/26/26 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.

Based on observation, interviews, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was protected from intimidation and potential harm by Resident 2. This failure resulted in Resident 4 verbalizing she was afraid Resident 2 might hurt her after Resident 2 insulted her in the facility.During a review of Resident 4's admission Record, dated 8/11/2026, indicated Resident 4 was admitted to the facility on [DATE], with diagnosis of acute respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs). During a review of Resident 4's Minimum Data Set (MDS- resident assessment tool), dated 7/24/2026, indicated Resident 4 had intact cognition (ability to think, remember and reason) for decisions of daily living. Resident 4 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, personal hygiene, and chair to bed transfers. Resident 4 was independent (Resident completes the activity by themself with no assistance from a helper) for oral hygiene, toileting, upper and lower body dressing, taking off putting on footwear, rolling left and right, sit to lying, lying to sitting on side of bed, and required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand. During a review of Resident 2's admission Record, dated 8/6/2026, indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of Hemiplegia (loss of ability to move one one side of the body). During a review of Resident 2's MDS, dated [DATE], Resident 2 had intact cognition for decisions of daily living. Resident 2 was independent for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, and walking 50 feet. Resident 2 required set up for sit to stand and chair to bed transfer. During a review of Resident 2's Care Plan, dated 8/5/2026, indicated Resident 2 had impaired social interaction manifested by verbal aggression, harassment, intimidation, use of provocative language toward staff and other residents. The Care Plan acknowledged that Resident 2 required a psychiatric evaluation, but Resident 2 had refused. The Care Plan indicated Resident 2 continued the identified aggressive and threatening behaviors after Resident 2 refused the psychiatric evaluation. The Care Plan indicated Resident 2 had a history of interfering with other resident's care and walks into other resident rooms without permission. The Care Plan indicated Resident 2 refused to take his prescribed medications to treat behavioral symptoms. During a review of Resident 2's Psychiatric Follow Up note, dated 6/23/2026 and 7/16/2026, indicated Resident 2 had refused a psychiatric evaluation and no other interventions were implemented to protect staff and other residents from Resident 2's aggressive behaviors. During observation on 8/6/2026 at 12 pm , Resident 2 was observed [describe only what was actually observed: entering office areas, yelling, approaching staff/residents, directing staff, etc.]. Staff responded by [describe response]. No staff intervention was observed to [redirect Resident 2/remove Resident 1 from the situation/obtain assistance/etc.], if applicable. During an interview on 8/6/2026 at 1:13 PM with Resident 4 , in Resident 4's room, Resident 4 sat on her wheelchair and stated she did not feel safe around Resident 2 and was afraid that Resident 2 might hurt her. Resident 4 described Resident 2's behavior as intimidating and stated that on 8/3/2026 at approximately 2 PM, Resident 2 called her a drug addict, substance abuse and thief making her feel threatened and fearful. Resident 4 stated that she had not yet reported the issue to staff because the staff seem frightened of Resident 2 also. Resident 4 stated Resident 2 walks around intimidating other residents and has seen Resident 2 stand outside her door looking into her room in a threatening manner making her feel like Resident 2 might hurt her. During an interview on 8/6/2026 at 1:17 PM with the Registered Nurse Supervisor 1 (RNS1), the RNS1 stated she had been working at the facility for one month, and in that month she had witnessed Resident 2 act aggressively toward staff and witnessed Resident 2 bicker with another resident (unknown of who it was) on 8/5/2026. RNS1 stated she was there to try and de escalate the bicker but the more she tried to stop Resident 2 the more aggressive he became. RNS 1 stated she did not report to the Administrator because everyone is used to his behavior and even the staff especially the Certified Nursing Assistants (CNAs) are afraid of Resident 2. RNS1 stated recently Resident 2 had harassed one of the CNAs by following her around in very close proximity that the staff felt threatened and cried. During an interview on 8/6/2026 at 1:24 PM with the Social Services Worker (SSW), the SSW stated that Resident 2 had come into her office on 8/6/2026 at approximately 1 PM yelling at her for not doing her job correctly. The SSW stated she has reported Resident 2's behavior to management and the Administrator but nothing gets resolved. During an observation on 8/6/2026 at 1:36 PM, in front of the nurses station, Resident 2 was observed standing against a wall on the hallway, with one hand on another resident's wheelchair, as he directed staff how to do their jobs. Resident 2 was observed attempting to tell residents in line for a smoking break how to stand in line. Resident 2 kept merging into other people's business making comments trying to control the environment in his preferred manner. Resident 2 stared at me as I walked down the [NAME] trying to hear what I was saying to staff and residents. Resident 2 had a demeaning look on staff and residents. During an interview on 8/6/2026 at 1:59 PM with CNA2, CNA2 stated she did not feel safe when interacting with Resident 2 and that he had been harassing one of the CNAs by following her around in a threatening manner. CNA2 stated Resident 2 frequently yells at staff, speaks to them in a demeaning manner, and attempts to direct staff on how to do their job. CNA2 stated the staff have reported Resident 2 various times but nothing seems to make Resident 2 stop his aggressive behavior. During an interview on 8/6/2026 at 2:06 with the Administrator, the Administrator stated Resident 2 had disrespectfully entered her office while she was in a meeting and started yelling and complaining to her about another resident in the facility calling the resident names like fraudster, and despite the Administrator trying to calm Resident 2 down, Resident 2 kept exhibiting intimidating and aggressive behaviors. The Administrator stated Resident 2 repeatedly entered administrative and department offices without appropriate boundaries and talked negatively about other residents. The Administrator stated Resident 2 told the receptionist she looks like she is a good cleaner and therefore should go clean his room and walked away. During an interview on 8/6/2026 at 2:41 PM with the Director of Nursing (DON), DON acknowledged the facility was aware of Resident 2's ongoing behavioral concerns and that Resident 2 had demonstrated behaviors that were concerning to staff and/or residents. The DON stated the facility had requested a psychiatric/psychological evaluation for Resident 2; however, Resident 2 refused the evaluation when the psychiatrist came to talk to him and Resident 2 kicked the psychiatrist out of his room. The DON stated the facility had called the police on Resident 2 in the past, but this did not stop Resident 2 from his continued aggressive, attention seeking behaviors, and the facility's next step would be to attempt to discharge Resident 2 from the facility. The DON stated despite facility attempts to reduce his aggressive and harassing behaviors, Resident 2 kept displaying these behaviors, even when the police tried to calm him down and stated Resident 2 needed to be evaluated by a psychiatrist. During a review of the facility's policy titled Abuse Prevention dated 1/20/2026 indicated the facility involves qualified psychiatrists and other mental health professionals to help facility staff manage difficult or aggressive residents. The facility conducts mandatory staff training annually and as needed to understand behaviors of residents that may increase the risk of abuse and how to respond. Verbal abuse is defined as any use of oral, written or gestured languages that willfully includes disparaging and derogatory terms directed to residents such as aggressive reactions outbursts or yelling out. The Abuse Coordinator and all staff are responsible for providing a safe environment for the residents as indicated by the situation. If a suspected perpetrator is another resident, separate the residents so they do not interact with each other until the circumstances of the reported incident can be clarified.

Based on interview and record review, facility failed to ensure one of three sampled residents (Resident 1) care plan was updated quarterly per facility policy.This deficient practice resulted in Resident 1 not having up to date goals and interventions to reflect his current care and needs and negatively affect his care. During a review of Resident 1's admission record dated 7/20/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses that included but not limited to dysfunction bladder (bladder [an organ in our body and it is like a small balloon that holds pee until you're ready to go to the bathroom] is not working the way it is supposed to, such as trouble holding pee, peeing too often and needing help to empty the bladder, like a catheter), depression ( a condition that affects a person's thought and feelings, a person may feel really sad, empty, or hopeless most of the day), insomnia (a condition where a person has a hard time sleeping, even when they want to sleep and have the time to do it), alcohol abuse (a person drinks too much alcohol in a way that hurts their health, feelings, or daily life). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/14/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was intact. During a review of Resident 1's care plan (CP) dated 2/18/2026, the CP indicated latest Resident 1's care plan target date was 3/1/2026, no updated or revised after that date. During an interview on 7/20/2026 at 1:55 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1's care plan was last updated on 2/18/2026 with a target date on 3/1/2026. It was not updated, but it should be updated per their policy. During an interview on 7/20/2026 at 2:05 PM with Registered Nurse (RN) 1, RN 1 acknowledge Resident 1's care plan was last updated on 2/18/2026. RN stated that nurses are responsible for updating resident's care plans according to per facility policy. During an interview on 7/20/2026 at 2:15 PM with Director of Nursing (DON), DON stated any resident's care plan should be updated yearly and quarterly, and as needed for any change of condition. Care plan should be updated or revised to reflect resident's latest condition with new goals and interventions. Resident 1's care plan was not updated per facility policy; the old care plan would not accurately address Resident 1's current needs and care and negatively affect Resident 1's care. During a review of facility's policy and procedures (P&P) titled care plan, comprehensive person-centered dated 1/20/2026, the P&P indicated Interdisciplinary team (IDT, a group of people who all have different skills and jobs, and they work together to make sure a resident gets the best care) must review and update the care plan at least quarterly.

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, comfortable, and well-kept environment for one of three sampled residents (Resident 4) as evidenced by excessive clutter and hoarding behaviors in the resident's room. This deficient practice created a fire hazard and impeded safe mobility for both Resident 4 and facility staff.During a review of Resident 4's admission record indicated that Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry), and Chronic Obstructive Pulmonary Disorder (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 4's History and Physical (H&P - when a physician assesses and interviews a patient then documents findings) dated 5/21/2026 indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 4 was cognitively intact (a person's mental abilities-such as memory, reasoning, attention, and decision-making-are functioning normally without signs of decline or impairment). The MDS indicated Resident 4 required staff supervision or touching assistance to independently performing most of Activities of Daily Living (ADLs such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, sit to lying, sit to stand, toilet transfer, tub shower transfer, walk 10 feet, and personal hygiene). During a review of Resident 4's document titled, SOCIAL SERVICE HISTORY, INITIAL ASSESSMENT AND QUARTLY NOTE, dated 5/27/2026 at 9:03 am, indicated, No changes have been observed in the resident's acceptance of care or in any behaviors related to rejection of care or resident choices. well she refused to participate on her plan of care, also refused to place a inventory list. During a review of Resident 4's Interdisciplinary Team conference (IDT - a group of various healthcare professionals who work together to manage a resident's care) dated 7/8/2026 at 1:06 pm indicated, continue to provide education and support as needed. Social Services provided education to the resident regarding maintaining the bed in the assigned location between the privacy curtains to respect shared room boundaries and avoid disturbing the roommate. Resident has received repeated reminders but continues to reposition the bed outside the designated area. Education was reinforced; however, Resident has not demonstrated compliance with the instructions. The same IDT indicated, Social Services educated the resident regarding the importance of minimizing personal belongings in the room to maintain a safe and clean environment. The resident was advised that excess personal items should be reduced so the room can be properly swept and mopped in accordance with infection control standards. The resident was offered the option to store excess personal belongings in the Social Services storage area to help reduce clutter and maintain a safe living space. Staff will continue to provide education and follow up as needed. During a review of Resident 4's care plan initiated on 3/19/2026 with a focus, Resident moves the bed closer to the roommate bed refusing to keep her bed 3inches away from [NAME], indicated a goal of ensuring that Resident 4's bed remained in its designated area. The same care plan included:- Educate the resident on the safety reasons for maintaining the required 3-inches distance between beds, including emergency access, infection control, and resident safety.- supervisor /charge nurses will make sure bed will stay in her area psychosocial reassurance at all times. educate resident to be considerate of others check resident to make sure needs are attended according to her needs. frequent visual checking to ensure safety. During an observation of Resident 4's room on7/15/2026 at 1:52 pm, Resident 4 was observed sitting at the side of her bed with her feet on the floor (to the left side of her bed). Resident 4 appeared unkempt and wearing multiple layers of clothing, a sweater, head covering and an ammonia and organic matter decay odor noted. Resident 4's bed was covered in items such as clothing, bags and was touching her (Resident 4) roommate's bed to her right ride (length wise). Resident 4's foot of the bed as well as the left side of her were covered in excessive clutter including stacks of paper, clothing, plastic bags, uneaten food items, tables, nightstand, bedside commode were completely covered in additional clutter with no path or walkway allowing access to Resident 4 or access for Resident 4 away from the room. During an interview with Licensed Vocational Nurse (LVN) 6 on 7/20/2026 at 11:57 am, LVN 6 stated that Resident 4 was ambulatory with use of a walker and was able to walk with Physical Therapy (around the hallway). LVN 6 confirmed that Resident 4's room was covered in clutter such as her (Resident 4) bedside commode which she could not immediately access because it was covered in items such as a top from a Tupperware container, books, spices and other random stuff. LVN 6 stated that the rest of Resident 4's room was also cluttered with clothing, books, boxes, takeout containers, old left over food, and most times soiled adult diapers with no path way or access to her (Resident 4) which she (LVN 6) made it challenging to administer medications or perform other activities such as checking her (Resident 4) vital signs. LVN 6 stated that the clutter created a safety and fire hazard. During an interview with the Director of Nursing (DON) on 7/20/2026 at 12:50 pm, the DON stated that Resident 4's belongings were discussed during an IDT on 7/8/2026 as a potential for infection. The DON stated that Resident 4's clutter could potentially be a fire hazard as well as a safety hazard. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, reviewed 1/20/2026 indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The same P&P indicated the following: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:Clean, sanitary and orderly environment;Comfortable (minimum glare) yet adequate (suitable to the task) lighting;Inviting colors and decor;Personalized furniture and room arrangements;Clean bed and bath linens that are in good condition;Pleasant, neutral scents;Plants and flowers, where appropriate;Comfortable and safe temperatures (71 F - 81 F). During a review of the facility's P&P titled, Safety and Supervision of Residents, reviewed on 1/20/2026, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The same P&P indicated the following:Our facility-oriented approach to safety addresses risks for groups of residents.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/ accident data; and a facility-wide commitment to safety at all levels of the organization.When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. During a review of the facility's P&P titled, Infection Prevention and Control Program, reviewed 1/20/2026 indicated, An infection prevention and control program (IPCP) Is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The same P&P indicated, The IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.The program is based on accepted national infection prevention and control standards.The IPCP is. a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

Based on observation and interview, the facility failed to ensure a licensed nursing staff were competent in identifying and safe management of a portable oxygen cylinder. One registered nurse supervisor (RN) was unable to identify whether a portable oxygen cylinder pressure gauge (an indicator for amount of oxygen remaining in the cylinder) was full or empty. This deficient practice had the potential to place residents requiring portable oxygen therapy by interrupting and delaying oxygen delivery during respiratory and cardiac arrest. During a facility tour observation on [DATE] at 11:11 AM, an empty portable oxygen cylinder was placed on a crash cart (a mobile set of drawers on wheels containing airway equipment such as oxygen mask, nasal and oral airway, oxygen cylinder, suction machine) used to treat life threatening emergencies. During a concurrent observation and interview on [DATE] at 1:51 PM with RN, near the nurse station on second floor, an empty oxygen cylinder was observed on a crash cart. RN was asked to demonstrate the response process during cardiopulmonary resuscitation (CPR -refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased). RN was asked about the likely outcome of using an empty oxygen cylinder during CPR. RN was unable to correctly interpret the oxygen pressure gauge indicator and stated the oxygen cylinder is full. RN was assertive an empty oxygen cylinder is full and ready for resident use. RN stated, Patient will die if you don't have oxygen during emergencies. During an interview on [DATE] at 2:10 PM with licensed vocational nurse (LVN) 3, LVN 3 was able to interpret the oxygen cylinder gauge indicator pin at the red marker, indicating the oxygen cylinder is empty. LVN 3 stated, oxygen is one of the important items used during CPR and emergencies. LVN 3 acknowledged a licensed staff are expected to be proficient in use of portable oxygen cylinder. LVN 3 further stated, lack of proficiency in determining whether a portable oxygen cylinder is full or empty may result in inadequate supply of needed oxygen to residents potentially leading to harm, brain damage, and death. During a telephone interview on [DATE] at 1:14 PM with the director of nursing (DON), the DON stated, portable oxygen cylinder on crash carts should be checked regularly and kept at full level, and all licensed nursing staff should be knowledgeable to utilize emergency response items including portable oxygen cylinder. The DON acknowledged that all licensed staff are expected to be competent in assessing and maintaining portable oxygen cylinders prior to use. The DON stated, likely unwanted outcome is delay of care, organ damage, and potential death. During a review of the facility's Registered Nurse (RN)- SNF New Hire Core Competency Check dated [DATE], the competency check list indicated, RN was competent demonstrating safe oxygen therapy. During a review of the facility's Policy and Procedures (P&P) titled Staffing, reviewed [DATE], the P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review, the facility failed to accurately calculate the Direct Care Services Hours Per Patient Day (DHPPD) for Certified Nursing Assistants (CNA) for five of five sampled days ([DATE], [DATE], [DATE], [DATE] and [DATE]). This deficient practice resulted in inaccurate DHPPD hours being reported and posted and had the potential to affect the quality of care and services given to the residents because of a decrease in direct nurse care hours. During a telephone interview on [DATE] at 9:59 am with CNA 5, she stated her CNA certification expired in September of 2023 and she was assigned as hall monitor, sitter or caregiver depending on the need at the facility (which were all non-CNA roles). She further stated the Director of Staff Development (DSD) at the time was really bad and never ended up signing her in-service hours to renew her CNA certification so she ended up working there in non-CNA roles for another few months then left. Further stating she should not have been included with the CNA hours during that time.During a review of facility's Direct Care Services Hours Per Patient Day (DHPPD) forms dated [DATE], [DATE], [DATE], [DATE] and [DATE], the forms indicated:On [DATE] the actual DHPPD for CNA was 2.46 with total actual CNA hours as 289.45On [DATE] the actual DHPPD for CNA was 2.45, with total actual CNA hours as 279.80On [DATE] the actual DHPPD for CNA was not calculated, but the estimated number was 2.31, nothing indicated for total actual hours CNAOn [DATE], the actual CNA DHPPD was 2.31, with total actual CNA hours as 259.95On [DATE], the actual CNA DHPPD was 2.34, with total actual CNA hours as 257.77.During a concurrent telephone interview and record review with the Director of Staff Development (DSD) on [DATE] at 4:43 pm the DHPPD for the dates above were reviewed and the DSD recalculated the numbers using the NHPPD report. The DSD further stated she removed the CNA 5 from the total actual CNA hours for all dates and the calculations were as follows:[DATE]: total actual CNA hours 247.52, CNA DHPPD 2XXX[DATE]: total actual CNA hours 250.23, CNA DHPPD 2XXX[DATE]: total actual CNA hours 265.27, CNA DHPPD 2XXX[DATE]: total actual CNA hours 242.68, CNA DHPPD 2XXX[DATE]: total actual CNA hours 242.36, CNA DHPPD 2.22The DSD verified the above numbers and stated the form could be manipulated by putting in a higher number in the total actual CNA hours and they should not have been using the CNA 5 hours because of an expired certification in the calculation. The minimum CNA DHPPD per the regulation should be 2.4, so all the dates reviewed do not meet the requirement.During a review of the Census and Direct Care Service Hours Per Patient Day (DHPPD) Instructions dated 07/19 indicated 8. Enter the Actual Total Direct Care Service Hours for the entire patient day. The Average Patient Census is automatically calculated as the sum of the Beginning Census of the three census periods divided by three. The Actual DHPD is automatically calculated as the Actual Total Direct Care Service Hours divided by the Average Patient Census. The Actual CNA DHPPD is automatically calculated as the Actual Total CNA Direct Care Service Hours divided by the Average Patient Census.During a review of All Facilities Letter 19-16 indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facilities - nursing homes). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census. Only direct caregivers shall count toward the 3.5 and 2.4 DHPPD staffing standards.

Based on interview and record review, the facility failed to ensure the required Interdisciplinary Team (IDT, a group of people from different jobs or specialties who work together to help take care of a resident in a healthcare facility) members-specifically the attending physician-participated in the development of the resident's comprehensive care plan, and failed to document the physician's participation or any attempt to obtain input, for one of three sampled residents (Resident 2)These deficient practices had the potential to result in Resident 2's needs and care not been met.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to facility on 3/2/2026 with the diagnosis that included but not limit to: acute respiratory failure (a condition body isn't getting enough oxygen), asthma (a long term condition that affects your lungs and makes it hard to breathe), pulmonary embolism (a condition that a blood clot is travels to the lungs and get stuck there), obesity a condition body having too much body fat) , DTV ( Deep Vein Thrombosis, a condition a blood clot has formed in a deep vein, usually in the leg) on both legs.During a review of Resident 2's MDS (Minimum Data Set, a resident assessment tool) dated 3/8/2026, the MDS indicated Resident 2 is cognitive intact.During an interview with Resident 2 on 5/19/2026 at 3:30 pm, Resident 2 stated, attending physician did not participate during her comprehensive care plan meeting on 3/6/2026.During an interview with RN (Registered Nurse) 1 on 5/20/2026 at 11:33 am, RN 1 stated physicians do not need to attend or on the phone during the comprehensive care plan meeting.During a concurrent interview and record review on 5/20/2026 at 12:48 pm with the Director of Nursing (DON), resident 2' multidisciplinary care plan meeting notes dated 3/6/2026 were reviewed. The notes indicated the attending physician did not participate, and no documentation was provided regarding his involvement. The DON stated the attending physician should be present or on the phone during the meeting to participate. No documentation or input from attending physician means he did not participate, that will negatively affect Resident 2's care and treatment.During a review of the facility's policy and procedures (P&P) titled, Care Planning-Interdisciplinary Team dated 1/20/2026. The P&P indicated comprehensive person-centered care plan are developed by an interdisciplinary team (IDT), IDT must include resident's attending physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2)'s physician order dated 3/16/2026 was being placed and implemented.This deficient practice had the potential to negatively affect Resident 2's care and treatment.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to facility on 3/2/2026 with the diagnosis that included but not limit to: acute respiratory failure (a condition body isn't getting enough oxygen), asthma (a long term condition that affects your lungs and makes it hard to breathe), pulmonary embolism (a condition that a blood clot is travels to the lungs and get stuck there), obesity a condition body having too much body fat) , DTV ( Deep Vein Thrombosis, a condition a blood clot has formed in a deep vein, usually in the leg) on both legs.During a review of Resident 2's MDS (Minimum Data Set, a resident assessment tool) dated 3/8/2026, the MDS indicated Resident 2 is cognitive intact.During a concurrent interview and record review on 5/20/2026 at 11:33 am with Registered Nurse (RN) 1, Resident 2's physician order dated 3/16/2026 was reviewed. the physician's order indicated SCD (Sequential Compression Device, a special machine that squeezes the legs gently, over and over, to help blood keep moving) as soon as available.keep both feet elevated when supine. RN 1 stated those handwritten orders were not in their computer system yet, which means it had not been placed and carried out. RN 1 stated it is Licensed Vocational Nurse (LVN) and RN's duty to follow up with physician's handwritten order and place them into the system.During an interview with the Director of Nursing (DON) on 5/20/2026 at 12:48 pm, the DON stated, the Resident 2's physician order on 3/16/2026 did not get put into their system. Failing to follow up and implement physician orders may delay Resident 2's treatment and negatively affect Resident 2's care.During a review of facility's LVN job description, Charge Nurse-LVN, [undated], the job description indicated LVN should performs tests, treatment, and procedure as ordered by the physician.During a review of facility's RN job description, RN Nurse Supervisor, [undated], the job description indicated RN should supervises all licensed nurse for completion of duties.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2)'s History and Physical (H&P) was completed within 72 hours per the facility policy. This deficient practice had potential to result in Resident 2's needs not been met. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to facility on 3/2/2026 with the diagnosis that included but not limit to: acute respiratory failure (a condition body isn't getting enough oxygen), asthma (a long term condition that affects your lungs and makes it hard to breathe), pulmonary embolism (a condition that a blood clot is travels to the lungs and get stuck there), obesity a condition body having too much body fat) , DTV ( Deep Vein Thrombosis, a condition a blood clot has formed in a deep vein, usually in the leg) on both legs.During a review of Resident 2's MDS (Minimum Data Set, a resident assessment tool) dated 3/8/2026, the MDS indicated Resident 2 is cognitive intact.During a concurrent interview and record review on 5/20/2026 at 12:48 pm with the DON, Resident 2's H&P dated 3/16/2026 were reviewed. the H&P did not indicated it was completed on time. The DON stated Resident H&P should be completed by the attending physician within 72 hours after admission, failing to complete Resident 2's H&P on time negatively affected Resident 2's care and treatment.During a review of the facility's policy and procedures (P&P) titled, Physician Visits dated 1/20/2026, the P&P indicated the attending physician will visit residents in a timely manner consistent with applicable state and federal requirements.

Based on interview and record review the facility failed to ensure medication left at resident's bedside was taken by one of four sampled residents (Resident 2).This failure resulted in Resident 2 not receiving the morning doses of their blood pressure, heart, and cancer medications, and had the potential to negatively affect her health.During a review of Resident 2's admission Record dated 5/1/26 indicated the resident was admitted to the facility on [DATE] with diagnoses including; hypertensive (high blood pressure) heart disease with heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen), atrial fibrillation (Afib - a heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), muscle wasting, low back pain, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and benign neoplasm (non-cancerous, abnormal growth of cells) of right breast.During a review of Resident 2's Minimum Data Set (MDS, resident assessment tool) dated 1/23/26 indicated the resident had intact cognition (the ability to think, learn, remember, reason and judge). The same MDS further indicated Resident 2 required setup to clean-up assistance from staff for eating and partial/moderate assistance to substantial/maximal assistance for other activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility.During a review of Resident 2's History and Physical (H&P) dated 6/24/25 indicated the resident can make needs known but can not make medical decisions.During a review of Resident 2's Order Summary Report indicated resident had orders for anastrozole oral tablet 1 milligram (mg) give by mouth once a day for breast CA (cancer), aspirin EC (enteric coated special coating on the tablet to protect stomach lining from irritation) 81 mg orally one time a day for CVA (Cerebrovascular Accident - stroke) PPX (prophylaxis - prevention, preservation of health), digoxin (medication to treat irregular heart rhythm and heart failure) oral tablet 125 micrograms (mcg) orally one time a day for Afib, metoprolol succinate (medication for hypertension) ER (extended release) tablet 25 mg orally two times a day for hypertension (HTN - high blood pressure).During an interview on 5/1/26 at 1:04 pm with Resident 2 the resident stated there was a one-time incident recently where she did not take her medicine, but that she ended up taking all her meds that day, it was no big deal, nothing happened. The resident further stated her family member was visiting that afternoon and found the cup with the pills, it was taken care of.During an interview on 5/1/26 at 1:41 pm with the Director of staff Development (DSD) she stated that charge nurses are not allowed to leave medications at the bedside of a resident who is not able to self-administer medications. Self-administration of medications would require a meeting, assessment, doctor's order and care plan.During a telephone interview on 5/1/26 at 1:55 pm with Registered Nurse Supervisor (RNS) 1, he stated on 4/18/26 he worked the 3pm-11pm shift and was made aware by Resident 2's family member there was a cup of pills at the bedside. RNS 1 further stated he asked the Licensed Vocational Nurse (LVN) 1 assigned to Resident 2 to identify the pills and give the ones that were ordered once a day, and stated LVN 1 would call the doctor to let them know the resident had missed a dose of her blood pressure medication and the others had been given.During a telephone interview on 5/1/26 at 3:44 pm with LVN 1, she stated the day she was made aware of the medication cup with pills that was left at Residents 2's bedside, she went immediately to identify the medications in the cup and compared them to the ones from the day shift medication bubble packs (a secure, and organized, plastic-and-foil packaging method where pills are sorted by date and time into individual, sealed compartment). LVN 1 further stated once she reviewed the medications there was one blood pressure pill that she would not give (because it was twice a day and too close to the next dose), but the rest of the medications were once a day so those were given to the resident to take. LVN 1 further stated she did not call the doctor to report it because she thought RNS 1 had done so. During an interview on 5/1/26 with the director of nursing (DON), the DON verified medications should not be left at beside for the resident to take later, and in the situation where there were pills found at the beside the physician should have been made aware.During a review of the facility's policy and procedures titled Administering Medications revised 1/20/26 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. Residents may self-administer their own medications only if they Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on interview, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS - resident assessment tool) for one of seven sampled residents (Resident 2).This failure resulted in an inaccurate assessment for Resident 2 and had the potential to affect the delivery of care and services.During a review of Resident 2's admission Record, dated 4/16/26, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including; bradycardia (slow heart rate), hypertensive heart disease with heart failure (occurs when chronic high blood pressure causes the heart to work harder, resulting in thickened (hypertrophied) or weakened heart muscle), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood), and hemiplegia (muscle weakness on one side of the body) of the left nondominant side.During a review of Resident 2's Minimum Data Set (MDS-resident assessment tool) dated 4/1/26 indicated Resident 2 had intact cognition (ability to reason, make decisions, remember, judge).During a concurrent interview and record review on 4/16/26 at of the Resident 2's MDS dated [DATE] indicated the resident was independent for self-care, indoor mobility, stairs and functional cognition (resident's need for assistance with regular tasks, such as remembering tasks or to take medication prior to the current illness) and required setup or clean-up assistance with eating and upper body dressing, and supervision touching assistance with other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), as well as, mobility actions of sit-to-stand, chair-to-stand, toilet transfer and walking 10 feet. The MSD nurse stated she goes to the resident's bedside to do the assessment and acknowledged the discrepancy in the assessment reviewed, which indicated the resident was independent to later indicating the resident needed assistance. The MDS states her assessment is correct and Resident 2 needs assistance further stating all residents need assistance or they wouldn't need to be here.During an interview on 4/16/26 with Licensed Vocational Nurse (LVN) 3, outside of Resident 2's room. LVN 3 stated Resident 2 is independent of all ADLs and does not need any help. He ambulates down the hall with a steady gait and does not require setup assistance with meals. He will have the certified nursing assistant (CNA) put the tray inside his room and he will do everything to eat independently further stating the resident dresses and toilets alone.During an interview with the Director of Nursing (DON) on 4/16/26 at 4:22 pm, the DON stated Resident 2 is known to be independent for ADLs an walking, she doesn't know why the MDS coded the record as him needing assistance and added she maybe she needs some training she is new.During a review of the facility's policy and procedures (P&P) titled Electronic Transmission of MDS reviewed 1/20/26 indicated, All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system. Staff members are trained on updates/revisions to the MDS form.During a review of the facility's P&P titled Charting and Documentation reviewed 1/20/26 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. 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 ensure interventions performed during a change of condition incident were documented in the medical record for one of seven sampled residents (Resident 1)This failure resulted in an incomplete medical record for Resident 1 and had the potential to affect the delivery of care and services.During a review of Resident 1's admission Record, dated 4/16/26, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including; chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and muscle weakness.During a review of Resident 1's History and Physical (H&P), dated 3/27/26, indicated the resident lacks decision making capacity.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 3/24/26 indicated Resident 1 short- and long-term memory problems and had severely impaired daily decision making. The same MDS indicated the resident required substantial/maximal to total dependance on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility.During a concurrent interview and record review on 4/15/26 at 3:32 pm with Licensed Vocational Nurse (LVN) 1, Resident 1's Change of Condition (COC) progress note and Facility Transfer Form dated 3/27/26 were reviewed. Neither form indicated the resident had an intervention for the low oxygen saturation (oxygen saturation (SpO2) normal level 95%-100%, indicating the percentage of hemoglobin carrying oxygen) indicated in on the COC progress note of 86%. LVN 1 verified there was no documentation in either the progress note of form for the intervention for low SpO2 level and stated the doctor was there during the incident (indicated in the record) and ordered a nonrebreather mask with oxygen (NRM - medical device used in emergency situations to deliver high concentrations of oxygen (60%-100%) to patients who are breathing on their own but experiencing severe respiratory distress or low blood oxygen levels (hypoxia)) which was placed on the resident but it was not documented.During a review of the facility's policy and procedures (P&P) titled Change in a Resident's Condition or Status reviewed 1/20/26 indicated The nurse will record in the residents 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 Charting and Documentation reviewed 1/20/26 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 following information is to be documented in the resident medical record:. Treatments or services performed. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details, including:. How the resident tolerated the procedure/treatment.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accidents and hazards for ambulatory cognitively impaired residents, by failing to provide adequate supervision and monitoring for two out of three sampled residents, (Resident 1 and Resident 2) according to the facility's policy and procedures (P&P) titled, Safety and Supervision of residents with a review date of 1/20/2026. This deficient practice resulted in an unexpected and unintentional resident altercation that had the potential to result in significant physical injury and burns. Findings: A review of Resident 1's admission record indicated the Resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included depression (mood disorder characterized by persistent sadness, low mood, and a loss of interest in activities), circadian rhythm sleep disorder (conditions where a person's internal biological clock is out of sync with their environment, causing severe sleep disruptions), psychoactive substance abuse (abuse of chemical compound-legal or illicit-that alters brain function, affecting perception, awareness, mood, consciousness, or behavior), muscle wasting and atrophy (thinning, or loss of muscle tissue, resulting in decreased muscle mass, strength, and mobility) and glaucoma (progressive optic neuropathy (damage to the optic nerve) that leads to irreversible vision loss or blindness.). A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated, 3/31/2026, indicated Resident 1's cognitive (mental ability to make decisions for daily living) was intact, Resident 1 required setup or clean-up assistance with eating, partial moderate assistance with putting on/taking off footwear, Resident 1 required substantial/ maximum assistance with oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing and personal hygiene, Resident 1 was non-ambulatory and wheelchair dependent for mobility. A review of Resident 2's admission record indicated the Resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness, or organ failure), epilepsy (recurrent, unprovoked burst of electrical activity in the brain that causes temporary changes in movement, behavior, sensation, or awareness), heart failure (a condition in which the heart muscle cannot pump blood efficiently enough to meet the body's metabolic needs), type 2 diabetes mellitus (high levels of sugar in the blood), bipolar disorder (mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels) and Dementia with agitation (a behavioral syndrome characterized by persistent, excessive motor activity, verbal aggression, or physical aggression, causing significant emotional distress). A review of Resident 2's MDS, dated , 3/24/2026 indicated Resident 2's cognitive (mental ability to make decisions for daily living) was moderately impaired, Resident 2 was required setup or clean -up assistance with eating, supervision or touching assistance with oral hygiene and upper body dressing, partial moderate assistance with toileting hygiene, shower/bathes, lower body dressing and, putting on/taking off footwear. Resident 2 once standing, required supervision or touching assistance with walking up to 50 feet with two turns. During an interview on 4/7/2026 at 12:24 pm, Resident 1 stated that on 3/23/2026 at approximately 8:00 pm, he (Resident 1) was by the Coffee cart that was parked by the elevator waiting to pour some coffee for himself. Resident 1 stated he became impatient because Resident 2 who was ahead of him (Resident 1) at the coffee cart was taking too long to pour his (Resident 2's) own coffee. Resident 1 decided to wheel himself to the smoking area without getting coffee. Resident 1 stated, shortly thereafter (about 5-minutes later) 2 to 3 nurses (unable to recall names) walked Resident 2 towards the smoking area where he (Resident 1) was waiting for the smoking area patio to be opened so he could smoke a cigarette. Resident 1 stated, without provocation and for reasons unknown to him (Resident 1), Resident 2 threw hot coffee on Resident 1's face, Resident 1 states the nurses started laughing. Resident 1 states his eyes were burning, states he does not remember any nurse offering him first aid and/or assisting him with cleaning his face. During an interview on 4/7/2026 at 1:48 pm Certified Nurse Assistant (CNA2) stated Resident 1 had reported to her (CNA2) that Resident 2 had poured hot coffee on his (Resident 1's) face, CNA2 stated Resident 1 said his eyes were bothering him and he (Resident 1) is unable to see well out of 1 of his eyes (unable to state which eye is affected). During a concurrent interview on 4/7/2026 at 3:48 pm, Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 stated they did not witness Resident 2 spill coffee on Resident 1. RN1 and LVN1 stated that on 3/23/2026 Resident 1 came to the nursing station and said that Resident 2 had spilled coffee on him (Resident 1). RN1 stated Resident 2 denied spilling coffee of Resident 1 but was holding a cup with very little coffee left in the cup, Resident 1 was observed to have coffee on his face and clothes. RN1 stated she assessed Resident 1 and called Paramedics (highly trained healthcare professional providing advanced, life-saving emergency medical care) and the Police (law enforcement). RN1 stated when paramedics and police arrived to assist Resident 1, however, Resident 1 refused to go to the hospital and did not want to talk to the police. RN1 stated Resident 2 was placed on a 5150 (an involuntary, 72-hour emergency detention of an adult deemed a danger to themselves, danger to others, or gravely disabled due to a mental health crisis) hold and transferred to a higher level of care on 3/24/2026 at 1:00 am in the morning. During an interview on 4/8/2026 at 10:58 am, the Dietary Supervisor (DS) stated the facility kitchen is closed at 8 pm., and prior to closing the kitchen, the kitchen staff usually take 2 (two) coffee carts with hot coffee containers upstairs and park the carts in-front of the nursing station. DS stated that the cart has one container have 4.7 gallon(unit of measurement) of coffee insulated container with hot coffee and the other container has 4.7-gallon hot water dispenser for tea (temperature range 175-180 degrees Fahrenheit), and condiments (tea bags, sugar, and hot chocolate packets) are placed in the cart and parked hallway Infront of the nursing station. During a telephone interview on 4/8/2026 at 11:07 am certified nursing assistant (CNA) 3 stated she did not witness Resident 2 spilling coffee on Resident 1. However, the coffee cart with hot coffee is usually parked was placed at the nursing station and the residents pour coffee by themselves. CNA3 stated Resident 2 pours his own coffee. CNA3 stated Resident 2 can be combative without provocation, yells and if re-directed he (Resident 2) will get agitated. During a follow-up interview on 4/8/2026 at 11:40 am LVN1 stated that on 3/23/2026, the coffee cart was parked by the hallway in-front of the nursing station. LVN1 stated the residents usually pour their own coffee except when they need assistance, LVN1 stated she was unsure who gave Resident 2 coffee. LVN1 stated Resident 2 is forgetful, is unable to remember his room and needs re-direction, LVN1 stated Resident 2 can get very agitated, is paranoid and will interrupt other people's conversations. LVN1 stated Resident 2 frequently ambulates in the hallways and occasionally uses a wheelchair to get around. During an interview on 4/8/2026 at 12:21pm, LVN2 stated, a confused and/or agitated resident accessing hot coffee without supervision can get scalded by the hot coffee and/or throw hot coffee on/at another resident or staff resulting in scalding, unnecessary hospitalization, pain and suffering, prolonged healing and permanent scarring. During an interview on 4/8/2026 at 12:38pm, Director of Nursing (DON) stated a confused and/or agitated Resident pouring and or drinking hot coffee unsupervised could cause severe second- degree (partial-thickness burn - damages the top layer (epidermis) of the skin and the underlying layer (dermis) of the skin) or third-degree burns ( is a severe injury destroying all layers of skin (epidermis and dermis and underlying fat, sometimes muscles and bones requiring skin grafts), resulting in immediate skin destruction, blistering, permanent scarring, and potential nerve damage on themselves and/or other residents and staff, unnecessary hospitalization and prolonged pain and suffering. A review of facility policy and procedures (P&P) titled, Safety and Supervision of Resident with a review date of 1/20/2026, indicated, Our facility strives to make the environment as free from accidents hazards as possible. For example, resident supervision may need to be increased when there are temporary hazards in the environment.

Based on observation, interview and record review, the facility failed to ensure five of 10 sampled residents (Residents 15, 55, 3, 11, and 46) received appropriate services to prevent a decline or maintain joint range of motion (ROM, full movement potential in a joint) and mobility by failing to:1a. For Resident 55, provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) as ordered for both upper extremities (UE, shoulder, elbow, wrist/hand) active range of motion (AROM, movement at a given joint when the person moves voluntarily) three times a week from 3/2/26 to 3/17/26. 1b. Indicate objective range of motion measurements for impaired joints on Resident 55's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation dated 2/3/2026.2. For Resident 3, provide Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and treatment to assess proper fit and wear time for right elbow splint (an external device to support, align, or correct a movable part of the body) prior to starting an RNA program to wear a right elbow splint for four to six hours.3. For Resident 11, provide PT and OT evaluation and treatment to assess proper fit and wear time for left elbow splint, left resting hand splint, and both knee splints prior to starting an RNA program to wear a left elbow splint, left resting hand splint, and both knee splints for four to six hours.4. For Resident 46, provide PT and OT evaluation and treatment to assess proper fit and wear time for both elbow splints, both resting hand splints, and both knee splints prior to starting an RNA program to wear both elbow splint, both resting hand splint, and both knee splints for four to six hours.5. For residents 15, provided treatment and services to prevent a further decrease in ROM according to the facility policy and procedure (P&P) titled Resident Mobility and Range of Motion, reviewed 1/20/2026. These deficient practices had the potential to cause injury and pain due to ill-fitting and prolonged wear time of splints for Residents 3, 11, and 46, and a decline in ROM due to delayed RNA treatment in Resident15 and Resident 55 and prevent accurate monitoring of changes in ROM and provision of appropriate care for decline in ROM and mobility for Resident 55. Findings: 1. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to metabolic encephalopathy (any damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (involuntary movements of extremities). During a review of Resident 55's Order Summary Report (OSR) dated 3/18/2025, the OSR indicated an order dated 3/2/26 for RNA program: RNA to perform BUE AROM in all available planes once a day three times a week as tolerated with rest breaks. During a review of Resident 55's care plan (CP) initiated on 3/17/26, the CP indicated Resident 55 was at risk for decline in mobility status. The CP interventions indicated to maintain ROM as tolerated and RNA program for RNA to perform BUE AROM in all available planes once a day, three times a week as tolerated with rest breaks. During a review of Resident 55's Minimum Data Set (MDS, resident assessment tool) dated 2/25/26, the MDS indicated Resident 55 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 55 had no functional limitations in ROM in both sides of the upper extremities and had functional limitations in ROM on both sides of the lower extremities. The MDS indicated Resident 55 required supervision for eating, substantial assistance with upper body dressing, personal hygiene, and sit to lying, and dependent assistance with toileting, bathing, sit to stand, and chair to bed transfers. During an observation and interview on 3/16/26 at 11:58 a.m., Resident 55 was lying in bed and was able to adjust the bed independently. 1a. During a review of Resident 55's March 2026 RNA task schedule, the RNA task schedule indicated X on all days for RNA task of RNA BUE AROM. During an interview and record review on 3/19/26 at 10:16 a.m., Minimum Data Set Coordinator Nurse (MDSC) 2 reviewed Resident 55's orders and stated Resident 55 had an order dated 3/2/26 for RNA to perform BUE AROM in all planes three times a week. MDSC 2 reviewed Resident 55's March 2026 RNA tasks and stated there was no RNA completed for BUE AROM in all planes three times a week until today 3/19/26. MDSC 2 stated nursing staff did not create an RNA task for the RNA order BUE AROM in all planes three times a week until today 3/19/26 and the RNA task should be completed right away so that there was no delay in starting RNA treatment. MDSC 2 stated RNA treatment for BUE AROM three times a week was missed during 3/2/26 and 3/18/26 and Resident 55 was at risk for a decline in ROM and functional mobility due to delay in starting RNA treatment. During an interview on 3/19/26 at 11:18 a.m., the Director of Nursing (DON) stated RNA was a restorative nursing program to help residents maintain their functional level. DON stated if an RNA program was ordered, then the RNA orders had to be carried out, or the residents were at risk for decline in their ROM or functional level. During a review of the facility's policies and procedures (P&P) reviewed 1/20/26, titled, Restorative Nursing Services, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1b. During a review of Resident 55's PT Evaluation and Plan of Treatment dated 2/3/2026, the PT Evaluation indicated Resident 55 had impaired ROM in both LE at both hips, both knees, and both ankles. The PT Evaluation did not indicate objective measurements and degrees of ROM movement. During an interview and record review on 3/18/26 at 2:16 p.m., the Director of Rehabilitation (DOR) stated during PT evaluations, PTs assessed ROM in normal ranges or optimal ranges of motion, because ROM help determined if residents could perform functional tasks safely and independently. DOR stated if there was an impairment at a specific joint, then PTs should get specific measurements in degrees and document the actual degrees of motion so that therapy staff could assess for changes such as improvements or declines. DOR reviewed Resident 55's PT Evaluation dated 2/3/26 and stated the PT Evaluation did not indicate specific ROM measurements and was not objective. DOR stated if a PT evaluation did not document objective ROM measurements, then it would be difficult to detect any declines or improvements. During a review of the facility's undated PT Job Description, the PT Job Description indicated key responsibilities to evaluate resident's physical conditions, provide therapy to improve strength, flexibility, mobility, and maintain accurate documentation of resident care. During a review of the facility's P&P, reviewed 1/20/26, titled, Joint Mobility Nursing Protocols, the P&P indicated to assess resident's current function and degree of contractures. 2. During a review of 3's admission Record dated 3/18/26, the AR indicated Resident 3 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 3 had functional limitation in ROM on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 3 required dependent assistance with toileting, bathing, dressing, hygiene, rolling, and bed to chair transfers. During a review of Resident 3's care plan (CP) dated 3/17/26, the CP indicated Resident 3 was at risk for decline in ROM of upper extremity and lower extremity. The CP goal indicated to maintain level of function. The CP intervention indicated to maintain ROM as tolerated. During a review of Resident 3's Order Summary Report (OSR), the OSR indicated the following order: -Dated 1/7/2026 for RNA once a day, three times a week to position right elbow in extension (to straighten a joint) with rolled up towel or right elbow splint four to six hours as tolerated with skin checks every two to three hours. During an observation and interview on 3/16/26 at 9:04 a.m., Resident 3 was lying in bed and saying ah, ah. Resident 3 was able to bend and straighten both elbows a little and both hands were in a fisted position, and both knees were straight. During an interview and record review on 3/18/26 at 2:16 p.m., DOR stated PT and OT assessed residents for appropriateness for a splint. DOR stated it was PT's responsibility to assess if a splint was appropriate for a resident. DOR stated PT should initially apply the splint and ensure proper fit and design and slowly increase a resident's tolerance to wear the splint. DOR stated usually a therapist would start and observe a resident wearing a splint for 30 minutes and see if they were tolerating the splint well. DOR stated if a resident could tolerate it well, then a therapist could slowly increase the splint by one hour. DOR stated it required a therapist to assess a resident's fit and safe tolerance to wear a splint. DOR stated the process was the best practice to avoid potential risk and harm to the resident, because a splint that was not properly assessed and fitted could cause skin damage, irritation, and pain. DOR reviewed Resident 3's RNA orders and confirmed Resident 3 had orders for RNA to put on a right elbow splint for four to six hours. DOR reviewed Resident 3's therapy records and stated Resident 3 did not receive any OT evaluation or treatment prior to ordering RNA program to put on right elbow splint for four to six hours and there should have been an OT assessment and treatment for splinting and establishing a safe wear time before RNA was ordered. During an interview on 3/19/26 at 10:03 a.m., Occupational Therapist (OT) 1 stated OT assessed whether a resident could benefit from a splint. OT 1 stated an OT would trial the splint first to see if it worked and was appropriate for a resident. Then if the splint was appropriate, the OT would train the RNAs and RNAs would continue to provide the splint with a ROM and stretching program. OT 1 stated it required an OT to trial the splint first by trying it for 30 minutes to one hour to two hours to three hours to make sure the resident tolerated the splint and did not have discomfort or skin issues when wearing the splint. OT 1 stated OTs generally recommended splints for residents who could not move the extremity and were at risk for a decline in ROM so the residents did not have a further decline in ROM. During a review of the facility's P&P reviewed 1/20/26, titled, Resident Specific Rehabilitation Medical Supplies, orthosis, and positioning devices, the P&P indicated if a problem is identified, physician's orders shall be obtained for a complete evaluation by the appropriate therapist, usually PT or OT; therapists shall complete the assessment and make recommendations addressing prevention of contractures, orthosis, positioning needs to ensure resident's safety, comfort, and functional independence. 3. During a review of 11's admission Record (AR) dated 3/18/26, the AR indicated Resident 11 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic kidney disease stage five (gradual loss of kidney function to filter waste and excess fluid from the blood), muscle wasting and atrophy. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 11 had functional limitations in ROM on one side of the upper extremities and no impairment on the lower extremities. The MDS indicated Resident 11 required substantial assistance with eating, dependent assistance with toileting, bathing, dressing, hygiene, rolling, and bed to chair transfers. During a review of Resident 11's care plan initiated on 2/6/26, the CP indicated Resident 11 was at risk for decline in ROM BUE. The CP intervention indicated RNA five times a week for left elbow splint or rolled up towel four to six hours or as tolerated with skin checks every two to three hours, RNA five times a week for left resting hand splint or hand roll four to six hours or as tolerated with skin checks every two to three hours, and RNA five times a week for both knee splints four to six hours or as tolerated with skin checks every two to three hours. During a review of Resident 11's Order Summary Report (OSR), the OSR indicated the following orders: -Dated 2/6/26 for RNA once a day, five times a week for left elbow splint or rolled up towel four to six hours as tolerated with skin checks every two to three hours. -Dated 2/6/26 for RNA once a day, five times a week for left resting hand splint or hand roll four to six hours as tolerated with skin checks every two to three hours. -Dated 3/16/26 for RNA once a day, five times a week for both knee splints four to six hours or as tolerated with skin checks every two to three hours. During an observation and interview on 3/17/26 at 8:42 a.m., Restorative Nursing Aide (RNA) 1 stated he completed RNA treatment with Resident 11 already. Resident 11 was lying in bed and was wearing knee splints on both knees. Resident 11's knees were bent more than halfway and both hips were rotated to resident's right side. Resident 11 was able to move the right elbow straight a little from a bent position and the right hand was relaxed. Resident 11's left elbow was bent more than halfway and was able to straighten the left elbow a little. RNA 1 stated Resident 11 was not able to move the left arm very much. RNA 1 stated Resident 11 did not wear any splints on the arms. During an interview and record review on 3/18/26 at 2:16 p.m., DOR stated PT and OT assessed residents for appropriateness for a splint. DOR stated it was PT's responsibility to assess if a splint was appropriate for a resident. DOR stated PT should initially apply the splint and ensure proper fit and design and slowly increase a resident's tolerance to wear the splint. DOR stated usually a therapist would start and observe a resident wearing a splint for 30 minutes and see if they were tolerating the splint well. DOR stated if a resident could tolerate it well, then a therapist could slowly increase the splint by one hour. DOR stated it required a therapist to assess a resident's fit and safe tolerance to wear a splint. DOR stated the process was the best practice to avoid potential risk and harm to the resident, because a splint that was not properly assessed and fitted could cause skin damage, irritation, and pain. DOR reviewed Resident 11's RNA orders and confirmed Resident 11 had orders for RNA to put on a left elbow splint, left resting hand splint, and both knee splints. DOR reviewed Resident 11's therapy records and stated Resident 11 did not receive any PT or OT evaluation or treatment prior to ordering an RNA program to put on the left elbow splint, left resting hand splint, and both knee splints. DOR stated that Resident 11 should have received PT and OT evaluation and treatment to fully assess and establish a safe wear time for the splints prior to referring to RNA for splinting. During an interview on 3/19/26 at 10:03 a.m., Occupational Therapist (OT) 1 stated OT assessed whether a resident could benefit from a splint. OT 1 stated an OT would trial the splint first to see if it worked and was appropriate for a resident. Then if the splint was appropriate, the OT would train the RNAs and RNAs would continue to provide the splint with a ROM and stretching program. OT 1 stated it required an OT to trial the splint first by trying it for 30 minutes to one hour to two hours to three hours to make sure the resident tolerated the splint and did not have discomfort or skin issues when wearing the splint. OT 1 stated OTs generally recommended splints for residents who could not move the extremity and were at risk for a decline in ROM so the residents did not have a further decline in ROM. During a review of the facility's P&P reviewed 1/20/26, titled, Resident Specific Rehabilitation Medical Supplies, orthosis, and positioning devices, the P&P indicated, if a problem is identified, physician's orders shall be obtained for a complete evaluation by the appropriate therapist, usually PT or OT; therapists shall complete the assessment and make recommendations addressing prevention of contractures, orthosis, positioning needs to ensure resident's safety, comfort, and functional independence. 4. During a review of 46's admission Record dated 3/18/26, the AR indicated Resident 46 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to dysphagia, Alzheimer's disease, and aphasia. During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 46 had functional limitations in ROM on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 46 required dependent assistance with toileting, bathing, dressing, hygiene, rolling, and bed to chair transfers. During a review of Resident 46's care plan initiated on 11/2/24 and revised 3/17/26, the CP indicated Resident 46 was at risk for decline in ROM of UE and LE related to muscular weakness. The CP goal indicated to maintain and prevent decline in resident's ROM. The CP intervention indicated RNA program to apply both elbow splints four to six hours once a day, five days a week as tolerated with routine skin checks every two hours, RNA program for application of both resting hand splint or hand roll four to six hours five times a week as tolerated with skin checks every two to three hours, and RNA for application of both knee splints three to four hours five times a week as tolerated with routine skin checks every two hours. During a review of Resident 46's Order Summary Report, the OSR indicated the following orders: -Dated 5/24/25 for RNA program to apply both elbow splints four to six hours once a day, five days a week as tolerated with routine skin checks every two hours. -Dated 3/17/26 for RNA program for application of both resting hand splint or hand roll four to six hours five times a week as tolerated with skin checks every two to three hours. -Dated 3/11/26 for RNA for application of both knee splints three to four hours five times a week as tolerated with routine skin checks every two hours. During an observation and interview on 3/17/26 at 9:04 a.m., Restorative Nursing Aide (RNA) 2 performed RNA treatment with Resident 46 in bed. Resident 46's eyes were closed and did not speak. RNA 2 moved Resident 46's shoulders up and down below shoulder level and both elbows could straighten and bend a little from a bent position. Resident 46's knees and hips were bent about halfway. RNA 2 put splints on Resident 46's left wrist/hand, right wrist/hand, right elbow, and both knees. RNA 2 stated Resident 46 usually wore the splints for about four hours. During an interview on 3/17/26 at 1:33 p.m., DOR stated Resident 46 had not received any PT or OT services since Resident 46 was admitted to the facility and there were no PT or OT records in the facility's system. During an interview and record review on 3/18/26 at 2:16 p.m., DOR stated PT and OT assessed residents for appropriateness for a splint. DOR stated it was PT's responsibility to assess if a splint was appropriate for a resident. DOR stated PT should initially apply the splint and ensure proper fit and design and slowly increase a resident's tolerance to wear the splint. DOR stated usually a therapist would start and observe a resident wearing a splint for 30 minutes and see if they were tolerating the splint well. DOR stated if a resident could tolerate it well, then a therapist could slowly increase the splint by one hour. DOR stated it required a therapist to assess a resident's fit and safe tolerance to wear a splint. DOR stated the process was the best practice to avoid potential risk and harm to the resident, because a splint that was not properly assessed and fitted could cause skin damage, irritation, and pain. DOR reviewed Resident 46's orders and confirmed Resident 46 had RNA orders for splints on both elbows and resting hand splints and both knees. DOR reviewed Resident 46's therapy records and confirmed Resident 46 never received any PT or OT services prior to starting to wear splints and ordering an RNA program to put on splints, but Resident 46 should have received PT and OT evaluation and treatment for splinting to properly and safely assess Resident 46's fit and tolerance and wear time for each splint prior to transitioning to an RNA program. During an interview on 3/19/26 at 10:03 a.m., Occupational Therapist (OT) 1 stated OT assessed whether a resident could benefit from a splint. OT 1 stated an OT would trial the splint first to see if it worked and was appropriate for a resident. Then if the splint was appropriate, the OT would train the RNAs and RNAs would continue to provide the splint with a ROM and stretching program. OT 1 stated it required an OT to trial the splint first by trying it for 30 minutes to one hour to two hours to three hours to make sure the resident tolerated the splint and did not have discomfort or skin issues when wearing the splint. OT 1 stated OTs generally recommended splints for residents who could not move the extremity and were at risk for a decline in ROM so the residents did not have a further decline in ROM. During a review of the facility's P&P reviewed 1/20/26, titled, Resident Specific Rehabilitation Medical Supplies, orthosis, and positioning devices, the P&P indicated, if a problem is identified, physician's orders shall be obtained for a complete evaluation by the appropriate therapist, usually PT or OT; therapists shall complete the assessment and make recommendations addressing prevention of contractures, orthosis, positioning needs to ensure resident's safety, comfort, and functional independence. 2. A review of Resident 15's admission Record indicated the facility admitted Resident 15 on 9/30/2025 with diagnoses including hemiplegia (a form of paralysis that causes severe or complete loss of muscle function, weakness, or stiffness on only one side of the body) affection right nondominant side, Parkinsonism (a brain disorder that slowly breaks down nerve cells, reducing a chemical called dopamine needed for smooth muscle control), and traumatic brain injury (TBI - a sudden, physical disruption to normal brain function caused by an external force, such as a bump, blow, or jolt to the head, or a penetrating injury). A review of Resident 15's Joint mobility assessment (JMA -a check-up by a professional [like a physical therapist] to see how well and how far your joints can move on their own.)-Rehab dated 10/1/2025, at 2:46 P.M., the JMA indicated wrist (flexion [movement of bending a joint that decreases the angle between two body parts or bones] and extension[increasing the angle between two body parts]); Right moderate (50-75 percent [% - expressing a number as a fraction of 100]), the comment and recommendation section indicated resident is at his functional baseline, resident referred to Restorative Nursing Assistant (RNA - a certified nursing assistant with special training who helps patients regain or maintain their highest level of independence after an illness or injury) program to maintain upper extremity/Lower extremity strength/ROM. A review of Resident 15's Order Summary Report, physicians order with order date 10/13/2025 indicated the resident to have RNA every day three times a week for right upper passive ROM exercise in all planes of motion (as tolerated) . A review of Resident 15's MDS dated [DATE], indicated Resident 15 was cognitively intact. The MDS indicated Resident 15 required partial/moderate to substantial/maximal assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 15's JMA dated 1/7/2026, at 3:26 P.M., the JMA wrist (flexion and extension); Right moderate/Severe (25-50%), the comment and recommendation section was blank. During an interview on 3/19/2026, at 1 PM, with Restorative Nursing Assistant (RNA) 1, RNA 1 stated that he is familiar with Resident 15 and has worked with resident 15 for the last six months. RNA 1 stated that Resident 15 has an order for bilateral lower extremity active ROM and upper right extremity active ROM and that the orders have been the same for the last six months and have not changed. During a concurrent interview and record review on 3/19/2026, at 1:20 P.M., with the Director of Rehabilitation (DOR), Resident 15's JMA for 10/1/2025 and 1/7/2026 and physician's orders were reviewed. The DOR stated that he was familiar with resident 15, and that Resident 15 had orders for lower extremity and upper extremity range of motion with no splinting order. The DOR stated that resident 15 had a JMA done on 10/25/2025 which indicated that right hand/wrist extension/flexion was moderate 50-75% and had a consequent JMA done on 1/7/2026 which indicated that Resident 15's right hand/wrist extension/flexion was moderate/severe 25-50%. The DOR stated that Resident 15's wrist JMA worsened from 10/25/2025 when it was moderate 50-75% to moderate/severe 25-50% when there was a reassessment done 1/7/2026. The DOR stated that the facility did not adjust resident 15's program when the assessment indicated that the ROM had changed/worsened. The DOR the facility should have made alterations to the program to prevent further decline such as fitting the resident for an orthotic (specialized brace designed to support, align, or improve function) and skilled nursing interventions would have been a reasonable response. During an interview on 3/20/2026, at 2:04 P.M., with the Director of Nursing (DON), the DON stated that if the residents JMA indicates that their ROM has worsened, the residents need to be re-evaluated by the rehabilitation department and ensure that resident receives proper treatment based on the assessment. The DON stated that if resident is not provided proper treatment, there may be further deterioration of the resident which may lead to skin breakdown, infection and possibly hospitalization. A review of the facility's P&P titled Resident Mobility and Range of Motion, with review date 1/20/2026, indicated, Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.

a. Based on interview and record review, the facility failed to ensure that a physician was notified and documentation pertaining to the resident's refusal of medication was done for one of three sampled residents (Resident 89) according to the facility's policy and procedures (P&P) titled Requesting, Refusing, and/or Discontinuing Care or Treatment, reviewed 1/20/2026, when Resident 89 frequently refused the following medications;1. Antiseizure (calm overactive electrical signals in the brain to prevent or stop seizures) medications, 18 times in January 2026, 27 times in February 2026, and 22 times from 3/1/2026 to 3/19/2026.2. Antipsychotic (used to treat serious mental health conditions by managing symptoms such as hallucinations, delusions, or severe loss of touch with reality) medications 20 times in January 2026, 27 times in February 2026, and 17 times from 3/1/2026 to 3/19/2026. b. Based on interview and record review, for two of three residents (Residents 75 and 81), the facility failed to implement the facility's policies and procedures (P&P) titled, Seizures and Epilepsy - Clinical Protocol, review date 1/202/2026, Requesting, Refusing and/or Discontinuing Care or Treatment, review date 1/20/2026, and Administering Medications, review date 1/20/2026, by failing to: 3. Administer to Resident 81 Metformin with food as ordered on 3/18/2026.4. Reassess and evaluate Resident 81 for appropriateness of antiseizure medication, Keppra, after resident refused Keppra 126 times between 12/2025 - 3/19/20265. Inform Resident 75 of medications being administered during medication pass observation. This deficient practice had the potential to prevent Resident 75 from exercising his right to accept or refuse care and treatment. These failures had the potential to:Result in adverse reactions for Resident 81 and failing to inform Resident 75 of medications being administered in accordance with the facility's policies and procedures titled, Administering Medications, and Requesting, Refusing and/or Discontinuing Care or Treatment, both review date 1/20/2026.Result in Resident 89's change in behavior, seizures and hospitalization. Findings: 1.A review of Resident 89's admission Record indicated the facility admitted Resident 89 on 7/3/2025 with diagnoses including schizoaffective disorder (a chronic mental health condition including hallucinations, delusions, disorganized thinking), epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical surges in the brain), and major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, and low energy lasting at least two weeks). A review of Resident 89's Minimum Data Set (MDS – resident assessment tool) dated 1/9/2026, indicated Resident 89 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 89 required supervision to partial/moderate assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent interview and record review on 3/19/2026, at 11:17 A.M., with Licensed Vocational Nurse (LVN) 1, Resident 89's physicians orders, medication administration record (MAR - a legal, daily checklist used by nurses and caregivers to document every medicine given to a patient) from 1/2026 to 3/2026 and nursing progress notes from 1/2026 to 3/2026 were reviewed. LVN 1 stated that Resident 89 was on Aripiprazole (antipsychotic medication), Mirtazapine (antipsychotic medication), and was also on Divalproex (antiseizure medication). LVN 1 stated that the number 2 documented on Resident 89's MAR indicates that Resident 89 refused the medication. LVN 1 stated that Resident 89 refused his antipsychotic medications 64 times and antiseizure medications 67 times from 1/2026 to 3/19/2026. LVN 1 stated that the facility's process when resident refuses their medication, is that the facility staff must try 3 (three) times and if resident continues to refuse, then the doctor is notified and documentation of the refusal and doctor notification is done in the residents nursing progress notes. LVN 1 stated that facility did not have any documented evidence that Resident 89's physician was notified that Resident 89 had been refusing medications. LVN 1 stated that the physician needs to be notified of the resident's refusal of medication to see if the physician would like to order something else. LVN 1 stated if the residents do not take their antipsychotic medications and antiseizure medications may lead to a decline in their health and possible transfer to the hospital. During an interview on 3/20/2025, at 12:10 P.M., with Resident 89's physician (MD 4), MD 4 stated that the facility staff expectation when resident refuses medication is to notify the physician and document it. MD 4 stated that when a resident misses antipsychotic and antiseizure medication over a prolonged period, the residents may lose the effects for which the medication was being used to prevent, and what was being prevented from happening would happen such as changes in behaviors and seizures. During an interview on 3/20/2025, at 2:07 P.M., with the Director of Nursing (DON), the DON stated that the facility expectations when a resident refuses medication is to notify the physician and document the refusal. The DON stated that refusal of antiseizure and antipsychotic medication may lead to seizures, increased behaviors or lack of behavior control which may lead to hospitalization. A review of the facility's P&P titled Requesting, Refusing, and/or Discontinuing Care or Treatment, reviewed 1/20/2026, indicated, Documentation pertaining to a resident's request, discontinuation or refusal of treatment shall include at least the following: . g. The date and time the practitioner was notified as well as the practitioner's response; . The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious conseqt1ences of the reqt1est. A review of the facility's P&P titled Administering Medication, reviewed 1/20/2026, indicated, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. A review of the facility's P&P titled Charting and Documentation, reviewed 1/20/2026, indicated, Goals, or any changes in the resident's medical, physical, functional or psychosocial co11dition, shall be docume11ted h1 the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 7. Documentation of procedures and treatments will include care-specific details, including: . e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other . 3. and 4. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included Epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity) and acute kidney failure (the sudden, temporary loss of the kidneys' ability to filter waste products from the blood, balance fluids, and manage electrolytes), Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose [BG], also called blood sugar [BS], is too high) with Hyperglycemia (high blood sugar [glucose]), and Hypocalcemia (abnormally low levels of calcium in the blood). During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated that Resident 81 was independent for eating, oral hygiene, toileting, upper and lower body dressing, transfer from bed to chair, and required setup or clean up assistance for shower/bathing self and personal hygiene. During a review of Resident 18's Physician Order Summary Report, dated 3/17/2026, the order summary report indicated but not limited to the following physician order: a. Keppra (levetiracetam) oral tablet 1000 milligram ([mg] a unit of measurement for mass), give 1000 mg by mouth two times a day for Seizure Disorder (a chronic neurological condition characterized by recurrent, unprovoked seizures), order date 10/21/2024. b. Monitor seizure episodes every shift. Document (Y) or (+) if noted, (N) or (-) if none. Ensure safety, notify MD immediately if noted, order date 12/4/2020. c. Metformin oral tablet 500 mg, give 500 mg by mouth two times a day for DM (diabetes mellitus). Take with meals, order date 10/15/2024 During a medication pass observation on 3/17/2026 between 9:41 AM to 10:01 AM, with a Licensed Vocational Nurse (LVN) 4 at Medication Cart (MedCart) 2, LVN 4 was observed preparing the following morning medications for Resident 81: Metformin 500 mg, one tablet Amlodipine (treat high blood pressure) 5 mg, one tablet Oyster Shell Calcium (treat low calcium levels) 500 mg, five tablets (2500 mg) Docusate Sodium (treat or prevent constipation) 250 mg, one gel capsule Folic Acid (is a B vitamin supplement) 1 mg, one tablet Keppra (generic name – levetiracetam) 1000 mg, one tablet Acetaminophen (a pain reliever and fever reducer) 325 mg, two tablets (650 mg) Vitamin B1 (Thiamine, supplement) 100 mg, one tablet Vitamin B Complex with Vitamin B12 (supplement), one tablet During a concurrent medication pass and observation on 3/17/2026 at 9:57 AM, LVN 4 entered Resident 81's room administered the morning medications, except for Keppra, which the resident refused. Resident 81 was observed accepting the remaining medications. LVN 4 stated that he will let Resident 81's physician know that the resident refused the Keppra. 3. During an interview on 3/17/2026 at 10:01 AM with Resident 81, in the presence of LVN 4, Resident 81 stated that he has not had a seizure in over four years and was started on the seizure medication, Keppra after admission to the facility. Resident 81 stated, I don't need it, referring to the Keppra medication. During an interview on 3/17/2026 with LVN 4, LVN 4 stated that Resident 81 has been refusing Keppra and that the doctor was already aware the resident was refusing the seizure medication. LVN 4 stated the code 2 entered on the MAR indicated, drug refused During a concurrent interview and record review on 3/18/2026 at 12:28 PM with the DON, Resident 81's Nursing Progress Notes and Administration Detail Report for the month of 3/2026 for the administration of Keppra were reviewed. DON stated the code 0, means the medication was administered and code 2, means the drug was refused. The DON reviewed the Administration Detail Report dated 3/15/2026, documented at 18:45 (6:45 PM) with a code 0, meaning administered, and the Nursing Progress Note dated 3/15/2026, documented at 20:31 (8:31 PM) indicated, Resident refused scheduled Keppra tablet this evening. The DON stated that the dose documented the administration of Keppra to Resident 81 on 3/15/2026 in the evening was incorrect, because the resident was documented to have refused the Keppra medication. During a telephone interview on 3/18/2026 at 4:03 PM with Pharm 1, in the presence of the DON, Pharm 1 stated that she reviews all residents in the facility's medications. Pharm 1 stated that she do not look at the residents' MARs regularly. Pharm 1 stated that she reviews the physician order recaps and the nursing notes. Pharm 1 stated the records she reviewed for Resident 81 did not document observation of seizure activity for the resident since admission in 2020. Pharm 1 stated that she did not send any recommendations to Resident 81's physician when the resident was noted to frequently refuse seizure medications. Pharm 1 stated that she did not see Resident 81's MARs and was not aware of how many times the resident refused Keppra. Pharm 1 stated that disruptions of seizure medications can lead to seizures. Pharm 1 stated if a resident is not having seizures, Pharm 1, would not expect the resident to be on the medication. During a concurrent interview and record review on 3/19/2026 at 9:31 AM with the DON, Resident 81's MARs were reviewed between 12/1/2025 through 3/19/2026. The DON acknowledged and counted the amount of times Resident 81 refused Keppra, the seizure medication as follow: - During the month of 12/2025 the resident refused seizure medication Keppra 37 times - During the month of 1/2026 the resident refused seizure medication Keppra 39 times - During the month of 2/2026 the resident refused seizure medication Keppra 33 times - During the month of 3/1/2026 through 3/19/2026 the resident refused seizure medication 17 times (for a total of 126 refusals of seizure medication between 12/2025 through 3/19/2026) During a review of Resident 81's MAR indicated zero seizure activity across all three shifts (Day, Evening, and Night) for the months of 12/2025, 1/2026, 2/2026, and through 3/17/2026. During a telephone interview on 3/19/2026 at 10:33 AM with Resident 81's Responsible Party (RP) 2, RP 2, stated that Resident 81's seizure started happening at the facility, shortly before COVID. RP 2 stated they were not aware of Resident 81 having seizures prior to getting sick, was malnourished and had low potassium when the resident was first placed in the facility in 2020. RP 2 stated Resident 81 sounds better than he was before, and they want the resident to remain at the facility. RP 2 stated they do not remember the facility calling to notify them of Resident having a seizure in more than three years. RP 2 stated that facility has not mentioned that Resident 81 was refusing seizure medications. RP 2 stated the facility will call when Resident is sick or have an outburst. During a telephone interview on 3/19/2026 at 12:27 PM with Resident 81's physician (MD 1) in the presence of the DON, MD 1 stated that Resident 81 constantly refusing the seizure medication, Keppra. MD 1 stated that Resident 81 had a possible seizure while seen in the hospital. MD 1 stated that Resident 81 just do not want to take the medication (Keppra). MD 1 stated Resident 81 was started on Keppra 1000 mg twice a day prior to admission to the facility at an acute hospital. MD 1 stated that he had continued the Keppra order upon Resident 81's admission to the facility. MD 1 stated he would not make any change to Keppra order, must be done by a neurologist. MD 1 stated that he has not seen any neurologist notes for Resident 81 but requested that the resident be seen by a neurologist. MD 1 stated his expectation is for the facility to follow up on his request for the resident to be seen by a neurologist and an endocrinologist. MD 1 stated a seizure may be triggered in Resident 1 with the wide swings from receiving the seizure medications sometimes and not receiving the medication. DON stated there were no neurologist notes, and no documentation of a physician ordered request for Resident 81 to be seen by a neurologist in the resident's clinical records. DON stated she will write the order now for Resident 81 to be seen by a neurologist under MD 1's stated request. MD 1 acknowledged and agreed for the DON to order a neurologist referral for Resident 81. A review of the facility's P&P titled, Seizures and Epilepsy – Clinical Protocol, review date 1/202/2026, indicated, Assessment and Recognition. 1b. Acute seizure may occur in relation to a metabolic disturbance (for example, hypoglycemia, hyponatremia [low sodium in the blood] or hypocalcemia) or an acute central nervous system (CNS) illness such as a stroke or head injury. Epilepsy refers to repeated, unprovoked seizures. Treatment/ Management The physician will treat underlying causes and risk factors, where possible; for example, correct sodium or calcium imbalance, or taper, stop, or change medications associated with an increased seizure risk. The physician will identify and order appropriate treatment for an acute seizure and a seizure disorder. Antiepileptic medications should be instituted if there is a reasonable chance that seizures will recur but may not be necessary if a single seizure with an identified cause (for example, hyponatremia or an adverse drug reaction) does not indicate an underlying tendency toward recurrent seizures. The physician will explain and/or document when an antiepileptic medication is not indicated. Antiepileptic medications should be used in the lowest possible dose, consistent with seizure control. Most antiepileptic medications have prominent side effects, including lethargy, dizziness, and ataxia Monitoring.1. The staff and physician will monitor the progress of individuals with a new seizure or a seizure disorder, and will modify interventions accordingly. For individuals who have been seizure-free for an extended time, the physician will periodically consider tapering antiepileptic medications especially when their initial use was for idiopathic seizures, an underlying acute medical cause was corrected, or seizure prophylaxis had been initiated in the absence of an identifiable structural cortical lesion. The physician will document clinically valid reasons for maintaining a current dose without attempting any reduction. A review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, review date 1/20/2026, indicated, Residents have the right to request, refuse and/or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care.If a resident requests, discontinues or refuse care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to: a. Determine why the resident is requesting, refusing or discontinuing care or treatment b. Try to address the resident's concerns and discuss alternative options; and c. Discuss the potential outcomes or consequences (positive and negative) of the resident's decision. The resident will not, under any circumstances be coerced, intimidated, manipulated or threaten for refusing, discontinuing or requesting care or treatment. 3. A review of Resident 81's physician orders and Medication Administration Record (MAR, a legal document that provides a comprehensive account of all medications administered to a resident) for Metformin indicated the resident was ordered to be administered Metformin with meals and was scheduled to be administered at 7:30 AM. Resident 81 was observed receiving Metformin on 3/17/2026 at 9:57 AM without a meal. During an interview on 3/17/2026 at 3:00 PM with LVN 4, LVN 4 stated that Resident 81's breakfast is served daily between 7:30 AM to 8:00 AM. During an interview on 3/17/2026 at 3:02 PM with Resident 81 in the presence of LVN 4, LVN 4 asked Resident 81, when did he eat breakfast this morning (3/17/2026). Resident 81 stated, I did not eat breakfast. I ate lunch at 12 PM. Resident 81 stated that he usually do not eat breakfast. During a concurrent interview and record review on 3/17/2026 at 3:04 PM with LVN 4, Resident 81's physician order and scheduled administration time for Metformin was reviewed. LVN 4 stated that Resident 81's Metformin was scheduled to be given at 7:30 AM with a meal. LVN 4 stated that Resident 81's Metformin is given with a meal to control the resident's blood glucose level and if given on an empty stomach can cause hypoglycemia (low blood sugar). LVN 4 stated if Resident 81's blood sugar drops too low the resident could become unresponsive and could lead to hospitalization. LVN 4 stated if the resident does not eat breakfast the physician should have been called. During a concurrent interview and record review on 3/18/2026 at 12:09 PM with the Director of Nursing (DON), Resident 81's physician order, scheduled administration time, and administration detail report for the resident's Metformin administration on 3/17/2026 were reviewed. The DON stated that Resident 81 was ordered Metformin 500 mg two times a day with meals and was scheduled to be administered daily at 7:30 AM and 5:30 PM with meals. The DON reviewed Resident 81's administration detail report and stated the resident was documented to have received Metformin 500 mg on 3/17/2026 at 10:03 AM. The DON stated giving Metformin on an empty stomach could result in adverse reactions, that may include hypoglycemia, sweats, shock, coma, or hospitalization. The DON stated the licensed nurse could have offered the resident a snack or something to eat when Resident 81 was not having a full meal. A review of the facility's P&P titled, Administering Medications, review date 1/20/2026, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: Enhancing optimal therapeutic effect of the medication; Preventing potential medication or food interactions; and Honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 5. During a review of Resident 75's admission record, the admission record indicated that Resident 75 was admitted to the facility on [DATE] with diagnoses that included Post-laminectomy syndrome (also called failed back surgery syndrome, is when a patient still has pain after spine surgery), Muscle Spasm, Post-traumatic stress disorder, chronic (PTSD, is a long-term [chronic] mental health condition that is caused by an extremely stressful or terrifying event), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Bipolar disorder (a mental health condition characterized by severe, unpredicted shifts in mood, energy, and activity levels), and Anxiety (excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 75's MDS dated [DATE], the MDS indicated that Resident 75's cognitive skills (ability to think and reason) were intact. During a record review of Resident 75's Order Summary Report, dated 3/18/2026, the order Summary Report included the following orders for the resident: Morphine Sulfate Extended Release (ER) Oral Tablet (an opioid [narcotic] that is used to manage pain severe enough to require daily around-the-clock, long-term treatment), instructions indicated to give one tablet by mouth two times a day for pain management, order date 2/21/2026 Gabapentin (used to seizures and nerve pain) Oral Capsule 300 mg, instructions indicated to give 300 mg by mouth one time a day for neuropathy. Hold for respiration rate less than 12 or if drowsy, order date 2/20/2026 Aripiprazole (used to treat mental disorders) Oral Tablet 5 mg, instructions indicated to give one tablet by mouth one time a day for bipolar disorder easily angered AEB (as evidenced by) screaming and yelling with no provocations, order date 2/21/2026 Baclofen (used to treat muscle spasms) Oral Tablet 10 mg, instructions indicated to give one tablet by mouth one time a day for muscle spasms, order date 2/21/2026 Bupropion Hydrochloride (used to treat major depression) Oral Tablet 75 mg, instructions indicated to give one tablet by mouth one time a day for major depressive disorder M/B (manifested by) verbalization of sadness and loss of interest in pleasurable activities, order date 2/21/2026 Acetaminophen Oral Tablet 500 mg, instructions indicated to give two tablets by mouth three times a day for pain management, not to exceed three (3) grams of Acetaminophen in 24 hours from all sources, order date 2/20/2026 Sennosides (used to treat constipation) Oral Tablet 17.2 mg, instructions indicated to give one tablet by mouth two times a day for bowel management, hold if loose stools, order date 2/20/2026 During a medication pass observation on 3/18/2026 at 9:16 AM, with a Licensed Vocational Nurse (LVN) 2 at MedCart 3, LVN 2 was observed preparing the following morning medications for Resident 75: Acetaminophen 500 mg, two tablets (1000 mg) Sennosides 8.6 mg, two tablets (17.2 mg) Aripiprazole 5 mg, one tablet Baclofen 10 mg, one tablet Bupropion HCL 75 mg, one tablet Gabapentin 300 mg, one capsule Morphine Sulfate ER 15 mg, one tablet During a concurrent interview and observation on 3/18/2026 at 9:27 AM, with LVN 2, LVN 2 stated that she prepared a total of seven medications for Resident 75. LVN 2 entered Resident 75's room and administered the seven medications to resident without explaining to the resident what medications the resident was being administered or what the medications were for. During an interview on 3/18/2026 at 9:32 AM, with LVN 2 at MedCart 3, LVN 2 stated that she did not let Resident 75 know what medications she was administering to the resident this morning, 3/18/2026. LVN 2 stated Resident 75 does have the right to know what medications he is being administered. During an interview on 3/18/2026 at 12:45 PM with the DON, the DON stated the licensed nurses must explain the medications to the residents during medication pass. The DON stated the licensed nurses must let the residents know what they are getting and the details of the medications. A review of the facility's P&P titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, review date 1/20/2026, indicated, Residents/representatives will be informed (in advance) of the care that will be furnished or made available to the resident based on his or her assessment and plan of care.The resident is not forced to accept any medical care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously.

Based on observation, interview, and record review the facility failed to ensure the safety of one of the three residents (Resident 1) by failing to: 1. Complete the Wandering Risk and Elopement (a patient, often cognitively impaired, leaves a healthcare facility or safe area unsupervised and unnoticed, posing serious risks of injury or death) Screening Assessment on 9/26/2025 (initial admission) on 10/20/2025.2. Update Wandering and Elopement Risk Assessment as Resident one is known to have observed displaying exit seeking behavior and trying to leave the facility on 10/11/2025 and 11/4/2025.3. Develop a comprehensive care plan for elopement to prevent injuries. 4. Ensure Licensed Vocational Nurses (LVN) 1 and LVN 2, immediately intervened and continuously monitored Resident 1 who was gradually experiencing aggressive behavior by continuously kicking a window on 11/4/2025 while Resident 1 is on 1:1. As a result, On 11/4/2025 at 9:16 pm, Resident 1 was transferred to General Acute Care Hospital (GACH) 1 via 911 (the telephone number used to reach emergency medical, fire, and police services), where the resident was diagnosed with a right tibial plateau fracture (a break in the flat top surface of the shinbone [tibia] where it meets the thigh bone [femur] to form the knee joint and is often caused by high-impact trauma) and comminuted fracture of the fibular head and neck (a severe injury where the top, thinner bone on the outside of your lower leg (near the knee) has shattered into three or more pieces).Findings: A review of Resident 1's admission record indicated the facility initially admitted the resident on 9/26/2025 and readmitted on [DATE], with diagnoses that included major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in enjoyable activities, lasting at least two weeks and significantly interfering with daily life, work, or relationships, differing from temporary sadness by its severity and long-lasting impact on feelings, thinking, and behavior), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and hypertension (HTN-high blood pressure). A review of Resident 1's Order Summary dated 9/26/2025 indicated, may have psychiatric eval (evaluation) and follow-up treatment as indicated. A review of Resident 1's care plan dated 9/26/2025 with a focus on, The resident is Not an elopement risk/wanderer. The same care plan indicated a goal of, the resident's safety will be maintained through the review. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers) dated 10/11/2025 at 3:05 pm, indicated, The Resident 1 had two episodes of exit seeking and trying to leave the facility. Resident 1 was redirected multiple times. Explained to resident the risk of leaving facility without doctors' orders and that it is not safe for her to just leave. Resident expressed that she wants to go home. Resident was redirected back to her room. IDT [Interdisciplinary Team - is a coordinated group of various healthcare professionals (nurses, doctors, therapists, social workers, dietitians, activities staff, etc.) who work together with the resident and family to create and manage a personalized, holistic care plan, ensuring all medical, social, and functional needs are met for optimal recovery and well-being] was notified. MD [Medical Doctor] was notified. A review of Resident 1's SBAR dated 10/11/2025 at 8:45 pm, indicated, Resident was noted by morning shift with change of behavior attempting to get-out of fire door causing alarm to be activated. In evening shift, she [Resident 1] was noted with physical aggressiveness / combativeness during care. She [Resident 1] was very delusional [having a strong, false belief that isn't based in reality and persists even when presented with clear evidence against it, often stemming from mental health conditions] verbalizing she is Jehova, claiming she is GOD & calling staff devils. Her Physical Aggressiveness poses danger to self & to others. The NP was notified and ordered Haldol 5 mg (milligrams- unit of measurement and Benadryl 50 mg. A review of Resident 1's physician order dated 10/12/2025, indicated Resident 1 to, transfer to acute hospital [GACH 2] on 5150 [California law code that allows a qualified officer or clinician to involuntarily detain someone on a 72-hour psychiatric hold] for evaluation and management of delusion of grandeur (false, unshakable beliefs that one possesses exceptional abilities, wealth, fame, power, or a special identity [like being a deity or historical figure] that she is Jehovah [God saying she is god leading to physical aggressiveness posing danger to self and others). A review of Resident 1's physician orders for readmission dated 10/20/25, indicated that Resident 1 was readmitted to the facility on [DATE]. A review of Resident 1 document titled, Wandering Risk and Elopement Screening Assessment, dated 10/20/2025, with columns to indicate wandering and elopement behaviors, was left all blank and no initial of the nurse completing the assessment. The only entry is the date 10/20/2025. A review of Resident 1's Order Summary Report Active Orders, indicated that on 10/20/2025, Resident 1 had a physician's order to, monitor behavior of delusional disorder M/B (manifested by) claiming she [Resident 1] was a millionaire that have money cause she was selling cookies. Monitor for behavior: psychosis schizophrenia [a serious brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality through symptoms like hallucinations (hearing voices, seeing things) and delusions (false beliefs)] vs schizoaffective [psychosis like hallucinations/delusions with a mood disorder] m/b [manifested by] delusion of grandeur. A review of Resident 1's history and physical (H&P) dated 10/30/2025 indicated that Resident 1 was able to make needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2025, indicated the resident had memory problems and had moderate cognitive impairment (poor decision-making requiring cues and supervision). The same MDS indicated Resident 1 had not exhibited wandering behaviors and required between supervision or touching assistance to set up or clean-up-assistance for Activities of Daily Living (ADLs) such as toileting hygiene, Shower/bathe, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 1's SBAR progress note dated 11/4/2025 at 7:10 pm, indicated, after dinner, Resident 1 was observed displaying exit seeking behavior and aggression towards staff when re-directed. The same SBAR indicated at approximately 6:30 pm, Resident 1 climbed on her bed and began kicking the window next to her bed. The SBAR indicated, NP (Nurse Practitioner - is a registered nurse who has advanced clinical education and training. NP share many of the same duties as doctors) gave order of Haldol [used to treat nervous, emotional, and mental conditions e.g., schizophrenia] 5mg IM [intramuscular - Inject into a muscle] x 1 [one dose] and Benadryl [medications used to treat allergies] 25mg IM x 1 dose. and 1:1 (one to one - refers to dedicated, personalized care where one healthcare professional provides constant, focused support to a single patient provided immediately) however, despite medication and 1:1. The same SBAR indicated that Resident 1 continued to kick the windows using her knees, resulting in the window breaking; Called 911 for emergency assistance. Following this, she stops and got down from bed; and continue with non-sensical verbal outburst. The same SBAR indicated that Resident 1 then started complaining on bilateral (both) knee pain pointing towards the knees with limited rom [Range of motion - is the full extent or limit a joint can move in various directions] at this time, sat by the bed. A review of Resident 1's 911 Runsheet (often referred to as an incident report which details of an incident) dated 11/4/2025 at 9:16 pm indicated the paramedics [a highly trained emergency medical professional who provides advanced, life-saving care to critically ill or injured people at the scene of an emergency] arrived on scene (facility) at 9:27 pm. The same 911 Runsheet indicated the chief complaint of blunt leg injury (damage to the lower limb caused by a forceful impact, collision, or fall where the skin is not broken or pierced) and provider primary impression of traumatic injury (a sudden, severe physical harm to the body from an external force, like a car crash, fall, or blow, requiring immediate medical attention due to its severity, which can range from broken bones and severe bleeding to life-threatening internal damage needing urgent care to save life or limb). A review of Resident 1's GACH document titled, ISP Hospitalist Discharge Summary dated 11/4/2025, indicated, Resident (Resident 1) was admitted to GACH on 11/4/2025 and discharged on 11/29/2025. The ISP discharge summary document indicated Resident 1 had a consultation with an orthopedic surgeon (orthopedist - is a medical doctor specializing in diagnosing, treating, preventing, and rehabilitating injuries and diseases of the musculoskeletal system such as bones, joints, ligaments, tendons, muscles, and nerves-using both surgical and non-surgical methods). The ISP discharge summary documentation indicated Resident 1 was status post (after/following) right lower extremity (RLE) external fixator (ex-fix - a medical device used to stabilize broken bones from the outside of the body). The ISP discharge summary document indicated Resident 1's admission diagnosis was right tibial plateau fracture and comminuted fracture of the fibular head and neck. A review of Resident 1 GACH ISP discharge under summary of the internal medicine notes indicated Resident 1 had, cerebrovascular accident [CVA - stroke, happens when blood flow to part of the brain is cut off (by a clot or bleed)] x2 [twice], and dementia. The GACH ISP discharge under summary of the internal medicine notes indicated Resident 1 was admitted on [DATE] after sustaining right knee pain following a self-inflicted traumatic event in which she [Resident 1] kicked through a window, resulting in a right bicondylar [a joint where two distinct, rounded surfaces (condyles) on one bone fit into corresponding depressions on another bone, allowing movement in two planes, like flexion/extension and side-to-side motion] tibial plateau fracture and a comminuted fracture of the right fibular head and neck. Resident 1 was diagnosed with a Schatzker type [a system used to categorize tibial plateau fractures based on the pattern of the break and severity. It consists of six types, with higher numbers generally indicating higher-energy trauma, more damage, and a worse prognosis] VI [six] bicondylar right tibial plateau fracture with associated lipohemarthrosis [the presence of both fat and blood within a joint, usually caused by an intra-articular fracture {a break in the bone that extends into the joint} and a comminuted fracture of the right fibular head and neck was confirmed by right knee x-ray and CT imaging. Orthopedic surgery was consulted, and she [Resident 1] underwent right lower extremity external fixator placement on 11/5/2025, followed by removal of the external fixator and open reduction internal fixation [ORIF - a surgery to fix severe broken bones where a surgeon makes an incision] of the right tibial plateau on 11/7/2025. Both procedures were performed by orthopedist, with intraoperative findings of an unstable, displaced bicondylar tibial plateau fracture. During an observation and interview with Resident 1 on 12/9/2025 at 11 am, Resident 1 was in her room sitting in a wheelchair. Resident 1 was observed with dressing to the inner and outer potions of the right knee. Resident 1 stated that she recalled climbing on some sort of table and tried to escape at the facility. Resident 1 stated she saw the window as a way out because she just wanted to go home and that no one was listening to her. During an interview on 12/9/2025 at 12:26 PM, Certified Nursing Assistant) 1 stated that Resident 1 was ambulatory, alert, but mostly confused. During an interview on 12/9/2025 at 12:26 PM, Certified Nursing Assistant (CNA) 1 stated that Resident 1 was ambulatory, alert, but mostly confused. CNA 1 stated that the resident would run away when confused, would push the door and try to run to the elevator in the facility. CNA 1 stated that most of the times Resident 1, was with it (moments of mental clarity), related well and communicated well. CNA 1 stated that she was not aware Resident 1 had 1:1 sitter (a designated staff member-such as a CNA, technician, or nurse-assigned dedicated staff member to monitor/stay with a single high-risk patient providing constant supervision to prevent falls, self-harm (suicide), wandering, or harm to others, acting as a safety measure often when patients are confused, suicidal, or agitated). CNA 1 stated that Resident 1 would say things like I see your millions (money) coming through. During an interview on 12/9/2025 at 2:04 PM, LVN 1 stated that Resident 1 has periods of confusion, is an elopement (a vulnerable patient leaves a healthcare facility or safe area without permission, often resulting in serious harm, injury, or even death) risk, and tried to find exits/entrances. LVN 1 stated that Resident 1 had verbalized that she wanted to go home on multiple times. LVN 1 stated that on 11/4/2025 after dinner at around 5 pm to 6 pm, LVN 1 contacted a NP when Resident 1 was exhibiting exit seeking behavior and got agitated when staff tried to redirect the resident. LVN 1 stated that this was the first time he had observed Resident 1 get agitated and was not aware of any other episodes/incidents of Resident 1 getting agitated before 11/4/2025. LVN 1 stated the NP ordered 1:1 and some intramuscular medications (Haldol and Benadryl). LVN 1 stated that he sat (as a 1:1 sitter) with the resident and would switch out with someone when other residents needed something. LVN 1 stated that he administered the IM medication to Resident 1 and the resident remained in bed. LVN 1 stated that he was sitting at the resident's bedside when Resident suddenly got up in bed and started kicking the window with both legs at approximately 6:30 pm but was unable to state how long. LVN 1 stated that he yelled for help in the hallway and that LVN 2, who was working as desk nurse (an administrative nurse who works primarily at a central nursing station rather than providing direct, hands-on care at the bedside) that day (11/4/2025), came into the room. LVN 1 stated that the window was shattered, and a few pieces of glass fell on Resident 1's bed. LVN 1 stated that he did not stop the resident because he did not want to risk getting injured because he is relatively smaller. LVN 1 stated that the resident stopped kicking the window and then complained of right knee pain. LVN 1 stated Resident 1 was assisted off the bed onto the wheelchair (WC) by a few other nurses (LVN 1, LVN 2 and other nurses that he could not recall). LVN 1 stated Resident 1 was evaluated by himself as well as LVN 2 (who was working as a desk nurse) with no visual injuries however, Resident 1 had decreased range of motion (to the right knee). LVN 1 stated that he provided 1:1 service continuously from the time 1:1 was ordered at 6:30 pm until Resident 1 was transferred to GACH via 911 around 9 pm. LVN 1 stated he was also assigned 28 residents to provide care too. LVN 1 also stated that all CNAs were busy, so he took it upon himself to be the 1:1 sitter for Resident 1. LVN 1 stated that he did not inform the DON or the administrator that Resident 1 neededan extra staff to supervise and 1:1 monitoring for safety even though he (LVN 1) still had the full assignment and duties as a charge nurse. During an interview on 12/9/2025 at 3:12 PM, LVN 2 who was working as the desk nurse on 11/4/2025 and also covers as a charge nurse (LVN). LVN 2, stated that she worked on 11/4/2025 on the 3 pm to 11 pm shift and is familiar with Resident 1. LVN 2 stated that Resident 1 has days when she displayed behaviors such as exit seeking as well as talking about stories that did not make sense such as stating that she was God and could fly. LVN 2 stated the resident was at risk for elopement and could be redirected. LVN 2 stated she remembered that on 11/4/2025 sometime after dinner, LVN 1 was calling for help because Resident 1 was in the room and on top of the resident's bed and was kicking and broke the window because the resident was trying to leave. LVN 2 stated that LVN2 did not observe Resident 1 with bleeding or cuts even from kicking and breaking the window. LVN 2 stated Resident 1's bed had broken shards of glass and that LVN 1 and LVN 2 assisted Resident 1 from the bed onto a wheelchair. LVN 2 stated that Resident 1 complained of right knee pain. LVN 1 stated she completed a body check on Resident 1 and observed that Resident 1 had decreased ROM to the right knee with no swelling. LVN 2 stated she called 911 twice the first time was when Resident 1 started to kick the window while standing in bed. LVN 2 stated after 5 minutes she called 911 a second time because Resident 1 complained of right knee pain. LVN 2 stated that the potential of the resident kicking the window included injuries such as falls, cuts, and fractures. During a follow up interview with LVN 2 on 12/9/2025 at 3:35 pm, LVN 2 denied LVN 1's claim that on 11/4/2025, she (LVN 2) relieved LVN 1 as 1:1 sitter for Resident 1. During a telephone interview on 12/9/2025 at 4 pm, CNA 2 stated that on 11/4/2025 on the 3 pm to 11 pm shift, she was assigned Resident 1. CNA 2 stated that while she was making her rounds at the beginning of her shift, Resident 1 sitting in her bed. CNA 2 stated she asked Resident 1 how the resident was doing however the resident immediately got up and ran to another resident's room. CNA 2 stated Resident 1 was trying to jump while seeking the exit/entrances doors. CNA 2 stated she redirected and assisted Resident 1back to bed and reported about Resident 1's behavior to LVN 1 because the resident appeared anxious. CNA 2 stated that on 11/4/2025 at 3:35 pm she went to check on Resident 1 and found that Resident 1 had pulled out a bed railing from a bed of which took from Resident 1 and gave it to LVN 1 because CNA 2 feared that Resident 1 could hurt herself with the bed side rail. CNA 2 stated that she felt that LVN 1 was ignoring her concerns for Resident 1's safety because LVN 1 failed to assess Resident 1 despite reporting to LVN 2 three times about Resident 1's behaviors and that LVN 1, LVN 2 and Registered Nurse Supervisor (RNS) continued to sit at the nurse's station. CNA 2 stated that while she was providing personal care to a different resident later on 11/4/2025 that approximately 8:30 pm to almost 9 pm, she heard a very loud banging sound coming from Resident 1's room. CNA 2 stated that she rushed to Resident 1's room and observed Resident 1 attempting to hit the window with a metal pole (IV pole- a pole used to hang intravenous medications and formulars for feeding) which CNA 2. CNA 2 stated that she observed Resident 1 fall from the nightstand to the floor/ground and landed on the (Resident 1) right side and that she (CNA 2) yelled loudly for help. CNA 2 stated that Resident 1 reported that she was trying to leave through the window. CNA 2 stated that LVN 1 approached CNA 2 and told CNA 2 to say that Resident 1 did not fall but that the resident kicked the window. CNA 2 further stated that LVN 1 instructed CNA 2 to state (if asked) that LVN 2 was present in the room with Resident 1 when the incident occurred. CNA 2 stated that she firmly refused and told LVN 2 that she did not want to lie. CNA 2 stated that on 11/5/2025, the facility Director of Nursing (DON) called her to the DON's office and pressured CNA 2 to sign a falsely already prepared statement that indicated LVN 1 was in Resident 1's room and that the resident was kicking the window instead of the resident falling down. CNA 2 stated that under duress she signed the already prepared statement in order to keep her job. CNA 2 stated that on 11/6/2025, the DON called her and told that the Department of Public Health (DPH) was in the facility and that whenever DPH called her to let DPH know that she did not know anything about the incident with Resident 1. CNA 2 stated that she continued to insist that she would tell the truth. However, CNA 2 stated that on 11/14/2025, the DON contacted her to go to the facility. However, the DON fired/terminated her when she arrived at the facility. On 12/9/2025 at 5:30 pm, the author requested the DON for Resident 1's elopement risk/wanderer assessment was requested for the initial admission dated 9/26/2025 however, the facility did not provide any documents that the assessment was completed. During an interview on 12/10/2025 at 2:20 pm, RNS stated that she worked on 11/4/2025 on the 3 pm to 11 pm shift and noted that Resident 1 was confused and wanted to exit from every exit door. RNS stated that she attempted to deescalate (did not specify methods used) the resident but unfortunately, Resident 1 got hurt. RNS stated that when a resident is attempting to elope, the physician must be notified immediately to prevent further escalation which may result in injuries. RNS confirmed and stated that LVN 1 and herself (RNS) were both at the nurse's station and that RNS was completing admission documentation when CNA 2 informed her and LVN 1 that Resident 1 fell. RNS stated that CNA 2 had informed both LVN 1 and herself about Resident 1's behaviors that included seeking exits, being aggressive towards staff, and was not directable. During an interview and concurrent record review of Resident 1's Physician Order on 12/11/2025 at 5 PM, the DON stated that for consult orders such as psychiatry evaluation for Resident 1 dated 9/26/2025, the facility must complete and follow up within seven days to ensure resident was seen as ordered. The DON stated that the psychiatry consultation was ordered because Resident 1 had psychosis due to delusion of grandeur stating she (Resident 1) can fly. The DON stated the psychiatry consultation order was not done which placed Resident 1 at risk to result in behaviors that may lead to accidents/injuries. During the same interview and concurrent record review of Resident 1's of Wandering Risk and Elopement Screening Assessment, the DON confirmed and stated that Resident 1's Wandering Risk and Elopement Screening Assessment had a handwritten date of 10/20/25 and the rest of document had unchecked/blank boxes. The DON stated that the elopement risk assessment was not done. The DON stated that elopement assessment helps to identify residents at risk for elopement. The DON stated that the potential for not accurately identifying residents at risk for elopement could result in residents easily eloping or attempting to elope from the facility. The DON stated staff must intervene immediately to prevent injury/ies such as fractures when a resident is engaged in an activity that will cause injury/ies. The DON stated unreported resident behavioral issues can result in injury/ies to the resident. A review of the facility P&P titled Behavioral Assessment, Intervention and Monitoring reviewed on 1/26/2025, indicated, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical (unusual or different) behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress . A review of the facility P&P titled, Safety and Supervision of Residents dated 1/25/2025, indicated that, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review of facility P&P titled Wandering and Elopement Intervention Protocol Based on Risk Score dated 1/25/2025, indicated . Provide 1:1 monitoring until discharge to an appropriate facility that can handle resident's exit seeking wandering behavior.

Based on interview and record review the facility failed to ensure a resident, who had periods of confusion, did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Implement the care plan to Monitor/document/report PRN (whenever necessary) any changes in cognitive (of, relating to, being, or involving conscious intellectual activity (such as thinking, reasoning, or remembering) function when Resident 1 exhibited periods of confusion on [DATE]. 2. Monitor and supervise Resident 1 when Certified Nursing Assistant (CNA 3) observed Resident 1 on [DATE] at around 1 pm close to the elevator. Resident 1 was wearing a double gown (one on front and one on the back) with a sweater and had a black bag with some belongings. 3. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. These deficient practices resulted in Resident 1 eloping from the facility on [DATE] and subsequently found by police deceased (dead) in a park two days later ([DATE]). On [DATE] at 5:22 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility'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) situation for the facility's failure to: 1.Establish or have a system in place to identify significant changes in behavior and report to the physician, on [DATE] when Resident 1 displayed confusion, aggressive behavior, and refusal of care. 2. Identify and document the frequency of changes in behavior of Resident 1 and report to the Physician. 3. Supervise Resident 1 as exhibited confusion on [DATE]. 4. To have a system in place to supervise and monitor residents leaving the facility unaccompanied. As a result, Resident 1 eloped on [DATE] around 12 pm and 2 pm, just after the last smoke break. The exact time of Resident 1's elopement was unknown. Police found Resident 1 at a park deceased on [DATE] at 1 pm. On [DATE] at 7:08 pm, the IJ was removed after the Administrator (ADM) and the facility's two consultants submitted an acceptable removal plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: 1. All four residents currently identified as risk for elopement (Resident 2, 3, 4 &5) were reassessed for wandering/elopement by the Minimum Data Set (MDS, a resident assessment tool) nurse on [DATE]. Monitoring of location will be documented by licensed nurses. Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) participation will be documented by CNAs in EMR [electronic medical record] in the task section. 2. The Governing Body (Medical Director, ADM, VPO [Vice President for Operations], CNO (Chief Nurse Officer) and An interdisciplinary team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need) members, which consisted of MDS RN [registered nurse], DOR (Director of Rehabilitation), Activities Director, SSD [Social Service Director], MRD [Medical Record Director], QA [Quality Assurance] Nurse) convened on [DATE] at 11 am to: i. Revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing. Following the review and update of the policy, an emergency meeting of the Quality Assurance Performance Improvement (QAPI, Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee was held on [DATE] at 11 am to review, update and approve the new wandering and elopement policy, including the wandering and elopement assessment. ii. Review the change of condition policy. The review focused on verifying that the policy includes procedures for assessing and notifying attending physicians of condition changes, including behavioral changes in residents. Following this review and update, an emergency meeting of the QAPI Committee was also held. During the emergency QAPI Committee meeting on [DATE] at 11 am, a root cause analysis (RCA-a structured process used to identify the underlying causes of a medical error or adverse event in healthcare) revealed key issues in the wandering and elopement process, including lack of oversight, communication breakdowns, inconsistent documentation, and training gaps in high risk monitoring protocols/interventions for change of conditions such as behavioral and cognition changes. Staff were found to lack clear guidance on monitoring frequency, specific elopement prevention protocols, and proper documentation of care plans for high-risk residents. These findings underscore the need for improved communication, consistent documentation, and targeted training to enhance care quality for residents at risk of elopement. 3. The Administrator contacted an independent consultant to review the facility's policy and procedures related to the deficient practice, with policies for review by the QAPI committee: a. Elopement and Wandering Assessment, b. Elopement and Wandering Interventions, c. Post Elopement Review, d. Elopement Drills, f. Procedure for Locating Missing Residents, g. Discharge Against Medical Advice, h. Leave of Absence and Out on Pass Order, and i. Change of Condition and Identifying Behavior in Change of Condition. 4. The IDT convened on [DATE] at 11 am, to review discharge against medical advice and out on pass policy. The updated policy includes updates on how out on pass will be allowed including how residents will be accompanied by a resident representative in cases where the resident does not have mental capacity or decision-making skills. Following the review and update of the policy, an emergency meeting of the QAPI Committee was held on [DATE] to review, update and approve the out on pass and leave of absence policy for residents. 5. The Facility Administrator will oversee corrective actions initiated on [DATE] and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, wandering and elopement system audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. Any new issues found during medical record audits and wandering, and elopement system audit will be presented to the Wandering/Elopement IDT members for immediate action. RN supervisor will monitor the immediate actions for implementation of monitoring/audit need at least monthly for the next 3 months or until compliance is 100% or is achieved. 6. The elopement/wandering binder that already contained the list of all the residents with moderate/ serious/ significant risk for wandering and elopement was reviewed on [DATE] at 4 pm. The elopement binder will be updated at least weekly by each QA and/or with new admissions that meet the significant/serious risk score. The wandering/elopement binder will be audited for completion and verification of list of patients every week by Medical Records Designee and any inconsistencies from the list will be provided to QA nurse to update and make corrections. 7. A 24-hour receptionist and elevator monitor were hired on [DATE] at 5 pm. 8. Starting [DATE] at 8 am, the Medical Records Department will use a monitoring tool to audit the documented frequency of routine checks/location for residents identified with a risk for wandering or elopement, based on their established care plans. Audits will be conducted daily for three days, then weekly for two weeks and monthly thereafter. The Medical Records Designee will submit the findings of the audits to the RN Supervisor. Immediately following the audit completion, issues found by the RN Supervisor will be referred to the Wandering and Elopement IDT for further review and revision of the action plan and/or to determine any further training needed for staff involved. 9. On [DATE], at around 4 pm, the faulty alarm on back door on the first floor was replaced and tested for function. The front door was repaired to ensure that it properly engages with the lock. Currently, all possible exit doors have working alarms. 10. The Director of Staff development (DSD), the facility's consultants, and or designee provided ln-service training for licensed staff was provided to all the nursing staff and non-nursing staff related to the following topics below and will continue to provide in-services per policy upon new hire, annually, and as needed: i. How to notify California Department of Public Health (CDPH) and other state agencies according to facility policy for any episodes of resident elopement. ii. Updating comprehensive care plan for residents that have been identified as wandering/elopement risk. iii. How to assess residents with elopement/wandering risks iv. How to determine frequent monitoring needs based on elopement/wandering episodes and how to document the monitoring. v. How to recognize behaviors that place residents at risk for elopement and how to report and follow up. vi. How to identify residents that are at high risk for wandering using an orange band vii. On elopement drill and what to do for missing residents viii. That even if resident requests to be discharged against medical advice, to offer options for transition of care such as referral for home health, local contact agencies. ix. How to document, recognize and identify new significant changes in behavior and how to report to the attending physician and monitor such behavior x. On out on pass and leave of absence for residents, and need for resident representative including how residents will be accompanied by a resident representative in cases where resident does not have mental capacity of decision-making ability. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), metabolic encephalopathy (a problem with how the brain works caused by a chemical imbalance in the blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute (sudden) kidney failure. A review of Resident 1's elopement evaluation dated [DATE] at 12:25 pm, indicated the resident was not a risk for elopement. The note indicated the resident did not have a history of elopement or an attempted elopement while at home. A review of Resident 1's history and physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated [DATE], indicated the resident had the capacity for medical decision making. The same H&P further indicated Resident 1 had a history of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and had been recently hospitalized for acute on chronic psychiatric decompensation (a period when the person's mental state becomes unbalanced, and symptoms return) and aggressive behavior towards others. The H&P indicated the resident was to have a psychiatric consult (a meeting with a psychiatrist to evaluate a patient's mental health and create a treatment plan). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated Resident 1 had mild cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated the resident was able to recall words after cueing. A review of Resident 1's care plan titled The resident has impaired cognitive function or impaired thought processes related to (r/t) psychotropic (drugs that affect the mind, emotions, and behaviors) drug use Acute Metabolic Encephalopathy and Acute Confusion d/t [due to] medical condition dated [DATE], indicated three goals marked as overdue the resident will be able to communicate basic needs on a daily basis through review date (OVERDUE), The resident will develop skills to cope with cognitive decline and maintain safety by review date (OVERDUE), The resident will improve current level of cognitive function through the review date (OVERDUE). The listed interventions included Cue, reorient and supervise as needed, Discuss concerns about confusion, disease process, NH (nursing home) placement with resident/family/caregivers, and Monitor/document/report PRN (whenever necessary) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of conscious, mental status. A review of Resident 1's health status note dated [DATE] at 10:39 pm, indicated the resident was found trying to smoke in the room. A review of Resident 1's multidisciplinary care conference note dated [DATE], indicated the resident was admitted to the facility on [DATE] and was noted to have some memory problem, with episodes of inconsistency, requires assistance with mobility and self-care . A review of Resident 1's Health Status note dated [DATE] at 7:11 pm, indicated Resident is on monitor for unscheduled smoke times inside bathroom. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a structured communication tool) form dated [DATE] at 12 am, indicated resident smoked inside room unscheduled, redirection, explanation, education gave to comply facility room and to smoke in the patio with schedule time . The SBAR indicated the primary care physician was notified and the facility staff were awaiting a call back for recommendations. A review of Resident 1's Nutrition/Dietary note dated [DATE] at 4:21 pm, indicated the resident required feeding supervision/assistance with all meals. A review of Resident 1's health status note dated [DATE] at 6:44 am, indicated Resident refused to be change. Resident alert and awake with period of confusion. Noted resident agitated and verbally aggressive. The note did not indicate Resident 1's physician was notified of Resident 1's refusal to be changed, confusion, or verbally aggressive behavior. A review of Resident 1's health status note dated [DATE] at 5:45 pm, indicated at 2 pm on [DATE] Licensed Vocational Nurse 2 (LVN 2) saw Resident 1 walking in the hallway towards the patio. The note indicated at 2:45 pm LVN 2 noted the resident was not in room and could not be found. The note indicated at 2:50 pm a code green [facility code for elopement] was initiated, facility and surrounding area searched, and the resident was not found. The note indicated the resident's family was not notified until 4:50 pm, the Nurse Practitioner (NP) at 5:08pm, and 911 was not called to assist in finding the resident until 5:11 pm. A review of Resident 1's health status note dated [DATE] at 7 pm, indicated Resident 1's physician notified that resident was not found during search of the facility and surrounding area, and left without notifying staff. Per MD, discharge AMA as resident is AOx4 [alert and oriented to person, place, time, situation] and is able to and has the capacity to make his own decisions as stated on MD's recent H&P. order read back and verified with MD. The detailed view of the progress note revealed the note was created on [DATE] at 2:51 pm (the day after the resident had eloped from the facility). A review of Resident 1's physician's orders dated [DATE] at 2:41 pm, indicated and order was received to Discharge AMA [DATE] (the day prior). During an interview on [DATE] at 11:29 am with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated no one saw Resident 1 leave on [DATE], and they had initiated a code green (at 2:30 pm) to look for the resident, called the police, the doctor the resident's family, and Adult Protective Services (APS). The last time the RNS 2 saw the resident was in the hallway around 2 p.m. walking to the smoking patio area. During a telephone interview on [DATE] at 12:37 pm with LVN 2, LVN 2 stated Resident 1 had behaviors of wandering around and going outside, he would disappear without anyone knowing. He would go outside and come back, a couple of times she had seen the Resident at the corner coffee shop. LVN 2 further stated his leaving was considered an elopement because he did not tell anyone, and they started the elopement procedures to look for him inside and outside of the building. LVN 2 stated it happened late in her shift, and the last time she saw the resident was around 2 pm walking in the hallway, the resident was wearing a gown and did not know if the resident would know how to call his family or get back to the facility. A review of Resident 1's Alert Note dated [DATE] at 1:11 pm, indicated Received a call from [MD] approximately 1300 [1pm] informing the facility that he received a call from law enforcement to inform him [Resident 1] was found dead at the park today ([DATE]). During an interview on [DATE] at 3:15 pm with Activities Assistant 1 (AA 1), AA 1 stated Resident 1 was forgetful often forgetting the smoking times and asking when they were. They would have to remind him frequently, and the resident would often refuse to take a shower or be changed. He would need a lot of encouragement. During an interview on [DATE] at 12:25 pm with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the last time he saw Resident 1 on [DATE] was around 1 pm when he saw him close to the elevator, he was wearing a double gown (one on front and one on the back) with a sweater. CNA 3 stated he (Resident 1) had a black bag with some belongings. CNA 3 stated he (Resident 1) left some clothing and other items at his bedside. CNA 3 stated Resident 1 was an avid smoker and would need assistance with changing his incontinence brief (a type of underwear designed for people who have lost bladder or bowel control) and showers. Sometimes he (Resident 1) would refuse and would need some negotiation to get him to change and shower. The resident would need frequent reorientation because he was forgetful. Liked to drink his coffee, juice, and milk. During a telephone interview on [DATE] at 12:02 pm with Medical Doctor 1 (MD 1), MD 1 stated the police had called him on [DATE] and informed him Resident 1 had been found deceased in a park. MD 1 further stated the facility had texted him on [DATE] at 6 pm the resident took some cash and left the facility without notifying anyone, which would be considered an elopement. MD 1 further stated no one notified him about the aggressive behaviors and confusion the day before on [DATE]. MD 1 also explained for someone with a diagnosis of metabolic encephalopathy that would affect the cognition (thought, reasoning, understanding) it is a broad term which is like a spectrum the way it would affect someone could make them act aggressively or could make them non-verbal obtunded (diminished responsiveness to stimuli, dulled or reduced level of alertness). A review of a facility's policy and procedures (P&P) titled Wandering and Elopements with a revised date of [DATE], indicated: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). A review of the facility's P&P titled Discharging a Resident without a Physician's Approval with a reviewed [DATE], indicated: 3. If the resident or representative (sponsor) insists upon being discharged without the approval of the Attending Physician, the resident and/or representative (sponsor) must sign a Release of Responsibility form. Should either party refuse to sign the release. such refusal must be documented in the resident's medical record and witnessed by two staff members. The policy indicated The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative (sponsor) of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended.

Based on interview and record review the facility failed to implement fall prevention measures by monitoring for the effectiveness of the interventions and modify the interventions based on the needs of the resident to prevent recurrent falls and injury for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 having multiple falls on 10/10/23, 11/20/23, 2/25/24, 5/24/24, 7/5/24, and 8/21/24. On 8/21/24 at 5:25 pm, Resident 1 had a fall and was transferred to a general acute care hospital (GACH) via 911 (emergency response telephone number), where Resident 1 with a traumatic head injury (injury to the head acquired from an outside force, usually a violent blow) resulting in a left subdural (area between the brain and skull) hematoma (a collection of blood outside of blood vessels usually caused by injury or surgery that damages the blood vessels) and nondisplaced (connected) left 3rd to 6th rib fractures. GACH admitted Resident 1 to the Intensive Care Unit (ICU, a special department or unit of a hospital or health care facility that provides intensive care medicine, for patients that are seriously ill), for further management and care. Findings: During a review of Resident 1's Admission Record dated 9/10/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition affecting the brain due to a chemical imbalance in the blood), dementia (a condition of the brain that causes memory loss, confusion, trouble finding, words, misjudging distances and problems performing familiar tasks) with other behavioral disturbance, aphasia (a condition involving language, effecting the ability to communicate) following cerebral infarction (stroke), impulse disorder (behavioral conditions affecting the way one controls their actions and reactions) , and epilepsy (seizure disorder). During a review of Resident 1's fall risk assessment dated [DATE], indicated Resident 1 had a score of 14 (a score of 10 or above represents high risk for fall). The fall assessment further indicated Resident 1 had balance problems while standing, balance problems while walking, decreased muscular coordination, and used of assistive devices for mobility. During a review of Resident 1's fall risk care plan dated 9/19/23, indicated Resident at risk for fall due to recent fall, use of psychotropic medication (drugs that affect mood, thoughts and behaviors used to treat mental illness), balance problem, and poor safety awareness. The same care plan further indicated prevention interventions included, to place the call light within reach and staff to answer/respond to the residents call lights promptly. The same care plan indicated to maintain safe environment, room free of cluster, remind resident to use assistive device, toileting schedule, refer to PT (physical therapy, treatment that to help manage pain, improve movement, regain strength after surgery)/OT (occupational therapy, treatment that helps people overcome physical, sensory or cognitive problems, with basic tasks people do every day to care for themselves e.g., grooming, dressing), lap buddy (cushioned device that fits the wheelchair and assists with reminding a persona not to get up by themselves) in wheelchair check and release every two hours and reposition, keep frequently used items within reach, siderails/padded as per Medical Doctor (MD) order. During a review of Resident 1's Short Term Care Plan for status post (after) fall (10/10/23) left leg pain initiated on 10/10/23 indicated interventions included to monitor the resident for 72 hours, notify MD, notify Resident 1's family responsible party (RP) and STAT (without delay) x-ray. During a review of Resident 1's Interdisciplinary Team (IDT, a meeting where team members from different heads of department get together and plan and review resident's care) meeting notes dated 11/20/23 indicated resident is impulsive continues to get up unassisted due to impaired cognition. Frequent urge to get up unassisted. Reinforce use of call light. During a review of Resident 1's Care Plan Short Term Fall and Incidence dated 11/29/23, indicated interventions of: provide safe environment at all times, encourage resident to use call light and an intervention written in by hand but illegible. During a review of Resident 1's Care Plan Short Term Fall and Incidence dated 2/25/24, indicated Resident 1 was found on floor going to/coming from bathroom transferring self without nursing assistance on 2/25/204 at 8 am. The care plan further indicated interventions included to provide the resident with a safe environment at all times, handle gently, encourage resident to use call light for all needs, provide resident with free of cluster, place all personal belongings within reach, encourage resident to ask for assistance from staff for all transfers (to and from wheelchair, bed, etc.), anticipate resident need to use the restroom, neurological check (neurological exam, a way to evaluate a patient's nervous system, to detect threatening conditions) for 72 hours, monitor for pain every shift. During a review of Resident 1's Fall Risk care plan dated 2/25/24, indicated, Resident 1 was at risk for fall related to dementia, impulse control disorder, and epilepsy, recent fall, history of multiple falls, balance problem, memory problem, poor safety awareness and refuses to use call light. The care plan further indicated interventions included to place the call light within the resident's reach and staff to answer the call light promptly. The care plan further indicated to encourage the resident to call for assistance if needed, maintain a safe environment, the resident's room be free of clutter, assist with ADLs (Activities of Daily Living) as needed, and to remind the resident to use assistive device, monitor for adverse side effect (ASE, undesirable or harmful effect) from medications. During a review of Resident 1's IDT meeting notes dated 2/26/24 indicated no injury, fell when coming from bathroom. Resident 1 is being closely monitored by staff, grouped in a room with roommates on closed monitoring meaning the other two residents were being monitored by sitter (healthcare worker who provides care and support to patients: by monitoring, assisting, providing safety, and/or companionship). During a review of Resident 1's Fall Risk care plan with a revision date on 2/25/24 indicated status post fall (2/25/24) resident is move close to nursing station and on close supervision. During a review of Resident 1's Nursing Progress Note dated 2/26/24, Licensed Vocational Nurse (LVN) indicated that on 2/25/24 at 8 am Resident 1 had slid out of his wheelchair while transferring self, coming from the bathroom. The nursing progress note further indicated the resident's Responsible Party (RP, is the individual or entity that has the legal control, manages, or directs the entity and the disposition of the entity's funds and assets, and at least [AGE] years older) had requested a sitter nurse to monitor Resident 1 because he has dementia and has fallen multiple times. The LVN documented that staff were encouraging Resident 1 to ask for assistance with all transfers even if the resident believed he could transfer himself. The nursing progress note further indicated RP again mentioned Resident 1 had dementia and cannot remember to use the call light (to call for assistance) and could barely remember anyone's name. The nursing progress note further indicated RP was offered to have a pad alarm (pressure-sensitive pad that can be placed under a person in bed or chair, which will alarm when the person starts getting up) placed on the resident's wheelchair for safety but was told that Resident 1 did not qualify for a sitter. The nursing progress note indicated that RP is tired of Resident 1 falling and that RP would feel bad if the resident was to die, break a hip, or hurt himself from falling. During a review of Resident 1's Physician Orders dated 3/4/2024, indicated for pad alarm on bed while Resident 1 is in bed to alert nursing staff when the resident is attempting to get out of bed by self, apply pad alarm on wheelchair while resident is in wheelchair to alert nursing staff when resident is attempting to get out of wheelchair by self, wheelchair and monitor pad alarm placement and functioning/mark ON is Pad Alarm is in place and functioning/mark OFF if pad Alarm is not in place and not functioning. During a review of Resident 1's Fall Risk care plan for the fall on 3/4/24, indicated no revision was indicated for the use of the tab or pad alarm, or interventions indicated for the behaviors of the resident removing the tab or pad alarm. During a review of Resident 1's Renew SBAR form (Situation, Background, Assessment, and Recommendation, used to communication critical information in a change of condition) dated 3/4/24, indicated Resident 1 was having multiple episodes of taking/removing the tab alarm. The SBAR indicated that staff were conducting rounds to visually monitor Resident 1 who was a high fall risk. The SBAR indicated the resident was refusing the tab alarm (alarm connected to resident's clothes that will monitor movement) and change of tab alarm (a personal alarm clipped to person's garment, which will alarm when pulled) to pad alarm. During a review of Resident 1's Renew SBAR dated 5/24/24 at 5:50 pm, indicated Resident 1 had fall, witnessed by a staff who reported that the resident is on the floor sitting down beside his bed, and resident stated he was trying to get up on the wheelchair and lost balance. During a review of Resident 1's Fall Risk care plan for the fall on 5/24/24, no revision was indicated after the fall on 5/24/24. During a review of Resident 1's Short Term Care Plan dated 6/3/24, indicated, change of condition (COC - significant decline or improvement in their health that requires intervention) status post fall on 5/24/24, with interventions to monitor Resident 1 for 72 hours, notify MD, and notify family/RP. No new interventions noted. During a review of Resident 1's Minimum Data Set (MDS a standardized assessment and care screening tool) dated 6/25/24, indicated Resident 1 had a moderately impaired (confusion about where one is and what is happening) cognition (ability to think, understand and make daily decisions). Resident 1's MDS further indicated Resident 1 required supervision or touching assistance, where a helper provides verbal cures and/ or touching/ steadying and/or contact guard assistance as resident completes activity; for toileting, sit to lying, sit to stand, chair to chair transfer, and toilet transfer. During a review of Resident 1's Renew SBAR dated 7/7/24 at 4:30 pm, indicated, RP visited Resident 1 today (7/7/2024) and informed a Registered Nurse (RN) that on 7/5/24 at around 11:20 pm while sleeping, Resident 1 fell , rolled out of bed, complained of intermittent rib pain during inspiration (breathing in), and an x-ray was ordered. During a review of Resident 1's Incident of fall care plan dated 7/7/24 indicated, [Resident 1] claimed he fell on Friday 7/5/24 at 11:20 pm. The incident of fall indicated the resident stated he was asleep and rolled out of bed on the right side, and reported incident to RP. The care plan interventions included, monitor vital signs, medicate for pain, rehabilitation (restoring someone to health or normal life through training and therapy) post fall assessment, keep environment free of hazards ., place call light within reach, answer promptly, keep frequently used items within reach, discuss, with resident the necessity for use of preventative equipment to ensure safety, bed in lock position, fall precaution every shift x-ray will report the result to MD. During a review of Resident 1's SBAR Communication Form dated 8/21/24, indicated Resident 1 had an unwitnessed fall (8/21/24 at 5:25 pm) and was noted on the floor lying on the floor on his back with his head against the wall, bed in lowest position, skin intact, no visible injuries, resident stated he felt dizzy due to fall and was immobilized until paramedics arrived. During a review of Resident 1's care plan titled Post Unwitnessed Fall dated 8/21/24 indicated interventions including, check range of motion, continue interventions on the at-risk plan, monitoring and report change in status pain bruises, new onset confusion, sleepiness, inability to maintain posture, agitation, neuro (means nerve and nervous system) checks for 72 hours, resident transferred to a GACH. During a review of GACH Emergency Department (ED) Provider Note dated 8/21/2024 at 11:43 pm, indicated Resident 1 with a witnessed non-syncopal (without loss of consciousness) fall with head trauma and back pain. The ED provider note indicated computed tomography scan (CT scan-is a medical imaging technique used to obtain detailed internal images of the body) brain, c-spine (neck region of your backbone, spinal column) . ordered. The ED provider note indicated Resident 1 diagnoses included traumatic injury of the head initial encounter. During a review of GACH Neurocritical (pertaining to intensive care management of patients with life-threatening neurological and neurosurgical illnesses such as massive stroke, bleeding in or around the brain) Progress Note dated 8/22/2024 indicated Resident 1 complained of headache and back pain (pain level for both not documented). The neurocritical progress note indicated that the CT imaging for Resident 1, Revealed 10 millimeter (mm-unit of measurement) left (L) parasagittal (situated alongside of or adjacent to) subdural hematoma (SDH), 15mm acute (of sudden onset) L tentorial (a tent-shaped duplicated fold) SDH, 8mm acute L hemispheric (relating to, or involving one of the two parts of the brain) SDH, trace left middle cranial fossa (a depression, commonly it refers to bones) subarachnoid hemorrhage (bleeding) with 15mm rightward midline shift. He [Resident 1] is admitted to the Neuro ICU for close neurologic monitoring. In addition . patient (pt- Resident 1) was also found with subacute nondisplaced L 3rd-6th rib fractures . The neurocritical progress note indicated Resident 1 was awake and oriented to self and place . During a review of GACH CT Brain for Resident 1 dated 8/22/2024 at 5:11 am, indicated the following: 1. The ventricular system was moderately enlarged with right midline shift measuring 6.62 mm . 2. Acute left parasagittal subdural hematoma measuring 8.5 mm 3. Acute left tentorial subdural hematoma measuring up to 14.1 mm, 4. Acute left hemispheric subdural hematoma extending toward frontal lobe measuring up to 8.8 mm 5. Small interval increase in left hemispheric subdural hematoma. 6. Small subarachnoid hemorrhage in temporal lobe measuring 2.5 mm During a review of Resident 1 GACH physician progress note dated 8/22/24 at 6:51 am indicated, Resident 1 was admitted to ICU on 8/21/24 with a traumatic brain injury, subdural hematoma, subarachnoid hemorrhage, and multiple fracture of ribs (initial encounter for closed fracture) on the left side. During a review of GACH CT Brain for Resident 1 dated 8/22/2024 at 4:25 am, indicated Resident 1 had Large left hemispheric mixed attenuating subdural hematoma is noted measuring up to 29 mm. Blood products along the interhemispheric falx (sickle-shaped structure along the longitudinal slit separating the two hemispheres of the brain) is noted . Midline shift to the right measures 14 mm . Actionable Finding: Urgent . During a review of GACH Internal Medicine Progress Note dated 8/24/2024 at 12:48 pm, indicated Resident 1 Became unresponsive and L pupil became sluggish (slow to react). CT Head (CTH) showed worsening left hemispheric subdural hematoma with worsening midline shift to the left. Patient (pt) [Resident 1] was urgently intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) and taken to operating room (OR) for craniotomy (the surgical removal of part of the bone from the skull to expose the brain) . During an interview on 9/10/24 at 11:10 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated interventions to prevent falls included the call light be within reach, bed in low position, maybe fall mats at the bedside after a fall, and if the resident is non-compliant, then a sitter (staff to assist resident who need additional supervision and / or companionship). LVN 1 further stated Resident 1 needed assistance with transfers, used a wheelchair and had fallen recently. During an interview on 9/10/24 at 3:21 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was aware Resident 1 had a fall and there was no sitter assigned to the resident the day the resident fell . CNA 1 further stated nurses are informed during the morning stand up meeting of residents at high fall risk. During a telephone interview on 9/16/24 at 4:59 pm with Sitter 2, Sitter 2 stated, she was in the room when Resident 1 fell , and was assigned as a sitter for the two other residents in the same room as Resident 1. Sitter 2 stated she was assisting one of the two residents in the room and saw Resident 1 stand. Sitter 2 stated she asked Resident 1 if the resident needed help and the resident told Sitter 2, he was OK. Sitter 2 stated she was dealing with an agitated resident [Resident 1's roommate] and when Sitter 2 turned to look again to look at Resident 1, Resident 1 on the floor on the back with the head up against the wall in between the bed and the wall. Sitter 2 further stated she yelled for help and staff came to assess the Resident 1. Sitter 2 stated 911 was called, and Resident 1 was immobilized until the paramedics arrived. Sitter 2 further stated Resident 1's fall could have been avoided had the resident had a one-to-one sitter. During an interview on 9/19/24 at 12:58 pm, with CNA 2, CNA 2 stated he was aware Resident 1 fell but was not aware the resident was a high fall risk or had fallen before. CNA 2 further stated Resident 1's bed was in the normal position the day the resident fell and there were no fall mats at the bedside. CNA 2 stated it looked like the resident fell back into the wall when getting out of the wheelchair after dinner to get back into bed. During an interview on 9/19/24 at 1:30 pm with Medical Records Director (MRD), the MRD stated all the care plans and records related to Resident 1's falls were provided. During a telephone interview on 9/19/24 at 2:05 pm with Registered Nurse (RN) 1, RN 1 stated Resident 1 was a fall risk, and the resident's room was close to the nursing station for closer monitoring. RN 1 stated the resident would not use the call light or call for assistance, and that there were no other interventions in place to the resident from repeated falls. RN 1 further stated she was unaware the resident had previous falls and to qualify for a sitter a resident would have to have behaviors, be a fall risk non-complaint with interventions. During a telephone interview on 9/19/24 at 2:20 pm with LVN 3, LVN 3 stated she was unaware Resident 1 had fallen before, was aware the resident was quiet and would be in the wheelchair and that the resident had shaky legs. LVN 3 stated, If he [Resident 1] had fallen before, they would have to have put him [Resident 1] on a sitter, because that would have been high, high risk (for falls). During a review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, managing dated 1/25/24, the P&P indicated, fall risk factors environmental . incorrect bed height or width . resident conditions . other cognitive impairment, pain, lower extremity weakness, medication side effects . medical factors . balance and gait disorders. Resident-centered approaches to managing falls and fall risk . staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring subsequent falls and fall risk . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. During a review of the facility's P&P titled 1:1 Supervision/Sitters undated, the P&P indicated, Purpose to assist resident who need additional supervision and/or companionship in obtaining sitters or companion care. The facility will hire, train, and provide monitoring aides to those residents in need of extra supervision due to their medical, physical, or psychosocial wellbeing in accordance with IDT (Interdisciplinary Team) assessment.

Based on observation, interview, and record review, the facility failed to notify the physician when there is a significant change in resident's health condition for one of five sampled residents (Resident 1) by failing to: 1. Notify the attending physician and/or the Psychiatrist (PSYCH 1) when Resident 1 (R1) had increased paranoia (the unwarranted or delusional belief that one is being persecuted, harassed, or betrayed by others, occurring as part of a mental condition) episodes. Resident 1 stating, I was being poisoned, and refusing to take prescribed Risperdal (used to treat certain mental/mood disorders such as schizophrenia) and Keppra (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain]). 2. Notify the attending physician when Resident 1 is refusing to take prescribed Risperdal (used to treat certain mental/mood disorders such as schizophrenia) and Keppra two or more consecutive times as indicated in the facility's P&P titled, Change in a Resident's Condition or Status. 3. Notify the physician regarding Resident 1 s last Keppra blood level when Resident 1 had an episode of seizure in 1/9/2024 according to facility's policy and procedure (P&P) titled, Seizure and Epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) - Clinical Protocol. Resident 1 was transferred and hospitalized at general acute care hospital 1 (GACH1) for altered level of consciousness on 4/18/2024. While at GACH1, R1's blood was drawn for Keppra Level. On 4/20/2024, laboratory (lab) result of Keppra level in GACH1, was below the therapeutic level (result is less than two, normal is 6 to 46 micrograms per deciliter [mcg/m], a lab tests to look for the amount of a drug or medicine in the blood). This deficient practice resulted to resident 1's physician unaware of resident condition, delayed ordering the potential necessary interventions and placed the resident at risk for having seizures with associated complication and at risk for delayed preventative interventions. On 4/26/2024 at 8:27 p.m., while at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of facility's Administrator (ADM), Director of Nursing (DON) and Assistant Director of Nursing/Registered Nurse 1 (ADON/RN 1) regarding the facility's failure to ensure a system is in place for staffs to notify physician for any change of condition and missed/refused medications and assess residents with increased signs and symptoms of paranoia and seizures. These deficient practices significantly increased increase the risk of early death from seizures include falls or other injuries that happen because of seizures. These injuries can be life-threatening. On 5/1/2024 at 2:54 p.m., the IJ was removed in the presence of the DON and ADON/RN 1 after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed through observation, interview, and record review onsite the facility's implementation of the IJ Removal Plan. The acceptable removal plan included the following actions: 1. As of 4/27/2024 Medical Director, who was also the R1's Medical Doctor (MD 1) was made aware by the nurses regarding R1's history of refusal of Risperdal and Keppra medication. As of 4/30/2024, R1 has been taking medications: Keppra and Risperdal. As of 4/30/2024, there are no refusals noted at this time for all 10 residents receiving Keppra and six residents receiving Risperdal. On 4/30/2024, the Director of Nursing Services informed the psychiatrist regarding the history of refusals of prescribed medication: Risperdal for R1. 2. On 4/26/2024, the Nurse Health Practitioner 1 (NP 1) was made aware of the R1'S blood Keppra Level and have ordered to have a repeat of blood Keppra Level on 5/1/2024. As of 4/26/2024, Keppra level was within normal range of 29.9 microgram - (ug - unit of measurement) /millimeter (ml - unit of measurement); normal range is 6 - 46 ug/ml and made aware MD 1. As of 4/26/2024, Keppra level was obtained from MD 1 by the ADON to all 10 residents on Keppra medications. As of 4/27/2024, the NP 1 seen R1 and was agreeable with the plan of care. 3. As of 4/27/2024, licensed nurse updated the Care Plan for history of refusal of medication of R1. As of 4/27/2024, licensed nurse has informed NP 1 history of R1's refusal of medications and documented in the clinical record of R1. On 4/30/2024, there are no refusal noted at this time for all 10 residents receiving Keppra. Licensed nurses will initiate change of condition (COC) if resident will have any refusal on medications and will notify the health practitioner. R1 has no episode of further refusal since 4/26/2024. 4. As of 4/29/2024, Licensed Nurses were provided in-services by the facility nurse leaders with regards to and not limited to the following: initiating COC for refusal of medications, missed doses, notifying health practitioners of the refusal to medications, monitoring resident's episode of refusal to medications every shift, monitoring of episodes of behaviors such as paranoia and aggressive behaviors. 85 percent (% - unit of measurement) of licensed nurses was provided education by the DON/designee. The facility's nurse leader/designee will continue to provide in-services to all remaining nurses (15%) on their next work schedule. The Director of Staff Developer (DSD) followed up regarding implementation of the in-services and conducted skilled competency training to 85% of licensed nurses as of 4/30/2024 (remaining 15% of licensed nurses will be trained on skills competency upon upcoming shifts). 5. As of 4/27/2024, the Comprehensive and personalized care plan for R1 for fall management is developed and revised by the DON and coordinated to the staff for continuity of care. As of 4/29/2024, care plan for fall management is updated by the DON and collaborated with staff for continuity of care and implementation of the plan of care. 6. As of 4/27/2024, licensed nurse updated the R1 care plan for seizure management and seizure activity. Nurses will continue to document seizure monitoring in the MAR every shift as ordered. On 4/30/2024, all 10 residents on Keppra medication have orders for monitoring for seizure every shift by their primary physicians. The licensed nurses will inform the primary physicians regarding seizure activity and re-education provided by the DON regarding sign and symptoms of seizure. 7. Quality Assurance and Performance Improvement (QAPI- a program to improve the quality of life and care for services in nursing homes) meeting was conducted on 4/29/2024 with Medical Director, ADM, DON, Administrative personnel and ADON regarding concerns with IJ: Physician notification, informed consents, COC-episode of refusals, MAR missing documentations and manifested behaviors, seizure and fall management and precautions; the DON will continue to monitor twice a week for four weeks then once a month then quarterly and ensure the audits done in timely manner. Findings: A review of R1's Face sheet indicated the facility originally admitted the resident on 4/15/2022 and readmitted on [DATE] with diagnoses including epilepsy, unspecified, intractable (not easily managed or relieved), without status epilepticus (refers to a prolonged seizure that manifests primarily as altered mental status as opposed to the dramatic convulsions), schizophrenia, respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and dysphagia (difficulty swallowing food or liquid). A review of Resident 1's Fall Risk assessment dated [DATE] indicated R1's fall risk total score was 10 (10 or above represents high risk of falls). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 1/19/2024, indicated R1 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required moderate assistance to supervision from staff for activities of daily living (ADLs-toileting hygiene, personal hygiene, roll left and right, sit to stand repositioning, and toilet transfer). The same MDS also indicated that R1 uses manual wheelchair. A review of R1's Progress Notes dated 1/9/2024 at 11:26 p.m., R1 noted to be having a seizure. Timed and lasted three minutes, placed R1 on left side, surrounding area kept clear for safety . post seizure disoriented, unable to answer questions. A review of R1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 1/15/2024 indicated, R1 found in sitting position between his bed and roommates' bed with wheelchair at the end of his bed. A review of R1's SBAR dated 1/31/2024 indicated, R1 refused Keppra tablets (times refusals) . R1 stated angrily, you guys are trying to poison me, this medical makes me sleepy. A review of R1's MAR for January 2024 indicated four doses (a.m. and p.m.) of Keppra documented as N (refused), two doses were refused consecutively on 1/6/2024 for morning and afternoon dose, three doses (a.m. and p.m.) of Keppra documented as blank (no annotation), one dose of Risperdal is refused on 1/5/2024, one dose of Risperdal was documented as blank on 1/6/2024, 48 paranoia episodes was documented, and four shift had no documentation for monitoring episodes of seizures, two episodes of seizures was documented. A review of R1's Keppra blood level lab test collected on 2/21/2024, date resulted 2/21/2024, indicated Keppra level was 7.2. A review of R1's MAR for February 2024 indicated eight doses of Keppra documented as N (refused), two doses were refused consecutively on 2/1/2024 for morning and afternoon dose and on 2/5/2024 and 2/6/2024, three doses (a.m. and p.m.) of Keppra documented as blank (no annotation), six doses of Risperdal is refused on 2/16, 2/17, 2/18, 2/20, 2/21, and 2/22/2024, two doses of Risperdal was documented as blank on 1/6/2024, 23 paranoia episodes was documented, and seven shift had no documentation for monitoring episodes of seizures. A review of R1's SBAR dated 3/7/2024 indicated, at around 3:22 p.m., notified by Activity Staff 1 (AS1), R1 sitting in wheelchair at patio with other residents, AS1 suddenly heard a thud sound and turned his head towards residents and saw R1 on floor lying on right side and possibly hit his head on the floor . A review of R1 Progress Notes dated 3/7/2024 indicated, R1 was asked how the incident happened but not able to relay how the incident happened, and simply stated, my medicine taken this morning makes me dizzy and slip to the floor off wheelchair. A review of R1's MAR for March 2024 indicated five doses (a.m. and p.m.) of Keppra documented as N (refused), three doses were refused consecutively on 3/8, 3/9, and 3/11/2024 for morning dose and on 3/10/2024 documented as blank (no annotation), 10 doses of Risperdal is refused on 3/2,3/6, 3/8, 3/9,11,12,13,16,25 and 3/312024, two doses of Risperdal was documented as blank on 3/10 and 3/17/024, 32 episodes of paranoia was documented and 22 shifts had no documentation for monitoring episodes of seizures. A review of R1's MDS dated [DATE], indicated R1 has severely impaired cognition for daily decision-making and required moderate assistance to supervision from staff for ADLs-toileting hygiene, personal hygiene, roll left and right, sit to stand repositioning, and toilet transfer. The same MDS also indicated that R1 uses manual wheelchair. A review of R1's SBAR dated 4/18/2024 indicated, on 4/17/2024 at 10:55 p.m., R1 was sitting near the nursing stations when Registered Nurse 2 (RN2) noticed R1 mental status is altered after assessment, he (R1) was not oriented to person, place and time . transferred on 4/18/2024 to GACH1 for further evaluation. A review of R1's GACH1 Emergency Department Notes indicated the following: i. R1 presented in the Emergency Department (ED) on 4/18/2024 with chief complaints of altered mental status. ii. R1 was shouting, having flights of ideas, not answering questions appropriately on triage (methods used to assess patients' severity of injury or illness within a short time after their arrival), stated his name was [NAME], and was staring into space. iii. R1 appeared severely confused, was speaking slowly & was giving verbal responses that had no relation to Psychiatrist evaluation, R1 started speaking in English so then encounter was done in English. R1 was alert and oriented times zero and appeared detached from his (R1) immediate environment. Patient (R1) is not responding to internal stimuli nor appear hypervigilant. iv. GACH1 with Keppra blood level undetectable until discharge back to the facility on [DATE]. A review of R1's Keppra blood level lab test collected at GACH1 on 4/18/2024, date resulted 4/20/2024, indicated Keppra level was less than two. A review of R1's Psychotropic Medication Care plan, initiated on 4/22/2024 indicated, R1 requires the use of psychoactive medications for schizophrenia with approaches/plan included, to supervise and give reassurance of well-being, evaluate behaviors/medication as necessary and report any COC to Physician. A review of R1's Behavioral Patterns Care plan, initiated on 4/22/2024 indicated, R1 have behavioral patterns related to schizophrenia with goals that R1 will not have more than 1 episodes of paranoia, with approaches/plan included to monitor R1's behavior frequently and record every shift, explain that his (R1) behavior is inappropriate and unacceptable and redirect behavior, evaluate effectiveness and adverse side effects (ASE) of medications for possible reduction of meds and notify Physician of any significant findings or changes immediately. A review of R1 Physician's Orders, dated 4/22/2024 indicated, i. Keppra 500 milligram (mg - unit of measurement) tablet, give two tablets by mouth twice daily for seizure disorder (9 a.m. and 5 p.m.) ii. Risperdal 1 mg tablet by mouth daily for schizophrenia manifested by paranoia and fear others are trying to poison him. (9 a.m.) iii. Monitor for seizure activity every shift (three times daily) iv. Monitor for diagnosis schizophrenia manifested by (m/b) paranoia and fear others are trying to poison him every shift and indicate total number of behaviors. A review of Resident 1's Fall Risk assessment dated [DATE] (readmission) indicated R1's fall risk total score was 17. During a concurrent interview and record review of R1's SBAR and Progress Notes (November 2023 through April 2024) with Assistant Director of Nursing/Registered Nurse 1 (ADON/RN1) on 4/24/2024 at 3:20 p.m., ADON/RN 1 reviewed R1's Progress Notes and stated, R1's SBAR and Progress Notes did not indicate if MD1 was notified on 1/9/2024 regarding R1's latest Keppra blood level according to their P&P. ADON/RN 1 further stated no documented that PSYCH 1 was notified regarding Resident 1 increasing episodes of paranoia. ADON/RN1 further indicated, R1's incident of falls could be an indication that R1 had seizure as these fall incidents were not observed and seizure have many different forms of s/sx. A review of R1's MAR for April 2024 indicated 10 paranoia episodes was documented. During a concurrent interview and record review of R1's MAR for the months of January to April 2024 with ADON/RN1 on 4/26/2024 at 6:40 p.m., ADON/RN1 stated, if MAR for Keppra and Risperdal is blank, if means it was not documented, and it did not happen and was not given. ADON/RN1 stated, the monitoring for paranoia episodes did not indicate if MD1 was notified for the multiple episodes of paranoia and what the interventions was implemented by the nurses. ADON/RN1 further stated, if MAR for seizure monitoring is blank in the MAR, it did not indicate if R1 had an episode of seizures, therefore, unable to indicate if medications were effective. During a concurrent observation and interview with R1 on 4/24/2024 at 10:52 a.m., R1 stated, he had epilepsy since he was [AGE] years old, and he does not like taking his medications because it makes him sleepy. During an interview with AS1 on 4/24/2024 at 3:20 p.m., AS1 stated, he heard a loud thump sound in the patio where R1 was and then found him lying on the floor. AS1 stated, he did not see how R1 fell on the floor. AS1 further stated, he thought he (R1) had a seizure as he was known to have multiple of seizure episodes in the past. A concurrent observation and interview with R1 on 4/25/2024 at 9:06 a.m., R1 was observed lying on very right-side edge of the bed with eyes closed. R1 then opened his eyes and asked for a coffee. R1 stated, he had not taken his morning medications today because he doesn't like taking them. When asked if the medications were offered yet, R1 stated no, and growled, R1 further stated, he does not want to talk anymore. During an interview with Licensed Vocational Nurse 2 (LVN2) on 4/25/2024 at 10:18 a.m., LVN2 stated, she had not administered R1's medications because he was hallucinating this morning (4/25/2024). LVN2 stated, R1 growled when she came and saw him when they passed the breakfast tray. LVN2 stated, she did not offer his medications, and explained the risk and benefits of refusing medications. LVN2 stated, she would always assess R1's mood in the morning and would wait until he is calm to administer his medications. LVN2 stated, R1's medications are usually given after 10 a.m., or sometimes, medications are not given at all as he (R1) tends to refuse medications and treatment. LVN 2 further stated Resident 1 refuses his medication because he (R1) thinks was being poisoned. LVN2 further stated, she did not notify MD1 regarding medications not being administered on timed schedule. During an interview with MD1 on 4/26/2024 at 9:56 a.m., MD1 stated, he was not notified regarding R1's medication refusal and/or not administered on scheduled yesterday (4/25/2024). MD1 stated, if Keppra level is below therapeutic level, it may mean that residents were not receiving the medications as ordered which may cause residents to have seizures that causes falls and injury. MD1 further stated, nurses are to ensure residents take their medications as ordered, but if they refuse, they need to notify the physicians and update the plan of care. MD1 stated, staffs should also document in detail what the interventions are if they (residents) refuses care and treatment. MD1 stated, staffs should document in each MAR and MAR should not be left blank. MD1 stated, he was also the Medical Director in the facility, and he is unsure if all staffs are following the protocol. During an interview NP2 on 4/26/2024 at 5:55 p.m., NP2 stated, R1 was selective with medications and treatment. NP2 stated, she was not aware of the multiple episodes of R1's refusal of Risperdal and paranoia episodes when reviewed MAR for 1/2024, 2/2024, 3/2024 and 4/2024. NP2 stated, if she would've known, she could have increased the dose of Risperdal as R1's current medication treatment for his schizophrenia was ineffective. A review of facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, reviewed on 1/25/2024, the P&P indicated, the nurse shall assess and document/report the following . whether resident has a known seizure disorder or history of actual seizure activity; date of most recent actual seizure activity; last blood level of any anticonvulsants being given . The staff will identify and report individuals who may be having a seizure; examples of s/sx include sudden onset of confusion, aura, visual or auditory hallucinations, difficulty speaking or understanding speech, severe dizziness, loss of consciousness, loss of balance or coordination, sudden numbness, tingling, or weakness of the face or in an arm or leg . the physician should help the staff distinguish seizure activity from other abnormal movements and reasons for change in mental status or level of consciousness . the physician will monitor antiepileptic medication blood levels periodically, where applicable, the physician should document why additional doses may not be needed to address low blood levels. A review of facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, reviewed on 1/25/2024, the P&P indicated, residents have the right to request, refuse and/or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care . If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the residents' concerns and discuss alternative options; and discuss the potential outcomes or consequences of the resident's decision . Detailed information relating to the request, refusal or discontinuation of care or treatment will be documented in the resident's medical record . the healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. A review of facility's P&P titled, Change in a Resident's Condition or Status, reviewed on 1/25/2024, the P&P indicated, facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition . refusal of treatment of medications two or more consecutive times. According to the Epilepsy Foundation, Missed doses of seizure medications is the most common cause of breakthrough seizures. According to the Centers for Disease Control and Prevention (CDC - the nation's leading science-based, data-driven, service organization that protects the public's health), factors that increase the risk of early death from seizures include falls or other injuries that happen because of seizures. These injuries can be life-threatening.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 1[R1]) received Risperdal (medication used to treat certain mental and or/mood disorders such as schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) as prescribed by the attending physician (MD1). Resident 1's diagnoses included schizophrenia. 2. Ensure the MD1 were made aware that one of five sampled residents (R1) was refusing to take Risperdal as ordered and was exhibiting increased paranoia episodes manifested by (m/b) R1 stating, I was being poisoned, and hearing voices. 3. Ensure the Pharmacist (Pharm1) conducted a monthly medication regimen review (MRR - an important component of the overall management and monitoring of a resident's medication regimen) for one of five sampled residents' (R1) used of Risperdal. 4. Ensure a gradual dose reduction (GDR the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was performed quarterly (three-month period for one of five sampled resident (R1) use of Risperdal. These deficient practices resulted in R1's having continued paranoia and leading to the R1's subsequent refusal of the medication Risperdal; leading to R1's to have unmanaged schizophrenia requiring R1 to be transferred to General Acute Care Hospital 1(GACH 1) due to altered level of consciousness on 4/17/2024. R1 did not receive the care and medications needed for the resident's condition placing R1 at increased risk for serious injury, serious harm, serious impairment and/or death. On 4/26/2024 at 8:27 p.m., while at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of facility's Administrator (ADM), Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the facility's failure to ensure the attending physician is notified when any resident refuses to take prescribed medications for resident's care and management. On 5/1/2024 at 2:54 p.m., the IJ was removed in the presence of the DON and ADON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed through observation, interview, and record review, onsite the facility's implementation of the IJ Removal Plan. The acceptable removal plan included the following actions: 1. As of 4/26/2024, R1 received the Risperdal medication as ordered by the physician On 4/27/2024, the Medical Director who was also R1's primary physician was made aware by the nurses on R1's history of refusal of Risperdal medication. 2. R1's informed consent for Risperdal, was updated by the Nurse Practitioner 2 (NP 2) on 4/27/2024 upon patient's re-evaluation. Informed consent is verified by the nurse during NP 2's visit on 4/27/2024. On 4/30/2024, licensed nurses provided education regarding Informed Consent by the DON. 3. On 4/30/2024, R1 has been taking R1's Risperdal medication. The health practitioner was made aware on 4/27/2024 by the nurses on R1's history of refusal of Risperdal medication. As of 4/28/2024, Resident 1's refusal of medication is being monitored by the licensed nurses every shift along with an order to inform the practitioner for any refusal and/ or missed doses. The medical records designee will conduct daily audits (Monday-Friday) and findings will be reported to the DON for immediate action. 4. As of 4/29/2024, Licensed nurses were provided in-services by the facility nurse leaders with regards to and not limited to the following: initiating change of condition (COC) for refusal of medications, missed doses, notifying health practitioners of the refusal to medications, monitoring resident's episode of refusal to medications every shift, monitoring of episodes of behaviors such as paranoia and aggressive behaviors. 85 percent (% - unit of measurement) of licensed nurses was provided education by the DON/designee. The facility's nurse leader/designee will continue to provide in-services to all remaining nurses (15%) on their next work schedule. The Director of Staff Developer (DSD) followed up regarding implementation of the in-services and conducted skilled competency training to 85% of licensed nurses as of 4/30/2024 (remaining 15% of licensed nurses will be trained on skills competency upon upcoming shift). 5. On 4/27/24, NP2 came to the facility and was made aware by the licensed nurse of R1's paranoia episodes. NP 2 re-evaluated the resident on 4/27/2024 and updated R1's behavior manifestations. On 4/27/2024, licensed nurses updated R1's manifestations monitoring in the Medication Administration Record (MAR- a report detailing the drugs or care administered to a resident by a healthcare professional). 6. As of 4/27/2024, R1'S MRR for Risperdal was done by the Pharm1 and evaluated by NP2. 7. As of 4/27/2024, R1's Risperdal medication was reviewed by the Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) with NP 2. At this time, per NP 2 and IDT, GDR is not warranted and to continue the current dose for Risperdal. 8. Licensed nurses will initiate COC if a resident has any refusal episode and will notify the health practitioner. On 4/29/2024, the Director of Nursing Services informed MD1 regarding the following refusals of prescribed medications: Risperdal for R1. As of 4/29/2024, 85% of all licensed nurses were provided education by the DON/designee on continuously documenting refusals and notifying the MDs on any refusals in the residents' records. The facility's nurse leader/designee will continue to provide in-service to all remaining nurses (15%) who were not educated at this time during their next work schedule. The DSD will follow up on competency skills check and implementation of the in-services and training. On 4/30/2024, IDT spoke with R1 regarding his refusal, fall precaution, seizure precaution, and was educated about the risk of non-compliance, resident verbalized understanding. Next IDT meeting will be conducted on 5/7/2024. 9. Quality Assurance and Performance Improvement (QAPI- a program to improve the quality of life and care for services in nursing homes) was conducted on 4/29/2024 with Medical Director, ADM, DON, Administrative personnel, and ADON regarding concerns with IJ: MD notification, informed consents, Change of Condition-episode of refusals, MAR missing documentations and manifested behaviors, seizure and fall management and precautions. DON will continue to monitor twice a week for four weeks then once a month then quarterly and ensure the audits done in timely manner. Findings: 1. A review of R1's Facesheet indicated the facility originally admitted the resident on 4/15/2022 and readmitted R1 on 4/20/2024 with diagnoses including Schizophrenia. A review of R1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/17/2024, indicated R1 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required moderate assistance to supervision from staff for activities of daily living (ADLs-toileting hygiene, personal hygiene, roll left and right, sit to stand repositioning, and toilet transfer). A review of R1 Physician's Orders, dated 4/22/2024 indicated the following orders: i. Risperdal one (1) milligram (mg-unit of measure) tablet by mouth daily for Schizophrenia manifested by (m/b) paranoia (an extreme fear and distrust of others) and fear others are trying to poison him. ii. Monitor for diagnosis of Schizophrenia m/b paranoia and fear others are trying to poison him every shift and indicate total number of behaviors. A review of R1's Care plan (CP-a plan for an individual's specific health needs and desired health outcomes) indicated the following: i. a CP for psychotropic medication (medications that that affects behavior, mood, thoughts, or perception) initiated on 4/22/2024 indicated, R1 requires the use of psychoactive medications for Schizophrenia with approaches/to evaluate behaviors/medication as necessary and report any change of condition to Physician. ii. a CP for behavioral patterns, initiated on 4/22/2024 indicated, R1 has behavioral patterns related to Schizophrenia with goals that R1 will not have more than 1 episodes of paranoia, with approaches and or plan that includes to monitor R1's behavior frequently and record every shift, explain that his (R1) behavior is inappropriate and unacceptable and redirect behavior, evaluate effectiveness and adverse side effects (ASE) of medications for possible reduction of meds and notify Physician of any significant findings or changes immediately. A review of R1's SBAR dated 4/18/2024 indicated that on 4/17/2024 at 10:55 p.m., Registered Nurse 2 (RN2) noticed R1 to be altered after assessment, he (R1) was not oriented to person, place and time. The SBAR further indicated that R1 was transferred to GACH1 for further evaluation. A review of R1's GACH1 Emergency Department Notes indicated the following: i. R1 presented in the Emergency Department (ED- a part of a hospital for treating people who have just come to the GACH, need to be treated quickly even without an appointment) on 4/18/2024 with chief complaints of altered mental status. ii. R1 was shouting, having flights of ideas (occurs when someone talks quickly and erratically, jumping rapidly between ideas and thoughts), not answering questions appropriately on triage (methods used to assess patients' severity of injury or illness within a short time after their arrival), stated his name was [NAME], and was staring into space. R1 appeared severely confused, was speaking slowly and was giving verbal responses that had no relation to Psychiatrist evaluation, R1 started speaking in English so then encounter was done in English. R1 was alert and oriented times (x) zero and appeared detached from his (R1) immediate environment. Resident (R1) is not responding to internal stimuli (changes, experiences, or feelings that occur within someone such as hunger or thirst) nor appear hypervigilant (a chronic state of heightened alertness and awareness). During a concurrent observation and interview with R1 on 4/24/2024 at 10:52 a.m., R1 stated, he does not like taking his medications because it makes him sleepy. During a follow-up interview with R1 on 4/25/2024 at 9:06 a.m., R1 stated, he (R1) had not taken his (R1) morning medications today because he (R1) does not like taking them. When asked if the medications were offered, R1 stated no, and growled. R1 further stated, he (R1) does not want to talk anymore. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/25/2024 at 10:18 a.m., LVN 2 stated that LVN 2 had not yet administered R1's morning medications because R1 was hallucinating. LVN 2 stated, R1 growled when LVN 2 came and saw the resident. LVN 2 stated that LVN 2 did not offer R1's medication nor did LVN 2 explained the risk and benefits of refusing medication. LVN 2 stated that LVN 2 would assess R1's mood in the morning and would wait until R1 is calm to administer R1's due medications. LVN 2 stated that R1's medications are usually given after 10:00 a.m.; or sometimes, medications are not given at all as R1 tends to refuse medications. A review of the facility's P&P titled, Administering Medications, reviewed on 1/25/2024, the P&P indicated, medications are administered within one hour of their prescribed time, unless otherwise specified . 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 MAR space provided for the drug and dose. A review of the facility's P&P titled, Change in a Resident's Condition or Status, reviewed on 1/25/2024, the P&P indicated, our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's Attending Physician or physician on call when there has been a: refusal of treatment or medications two or more consecutive times. 2. A review of R1's MAR for January 2024 indicated one dose of Risperdal is refused on 1/5/2024, one dose of Risperdal was documented as blank on 1/6/2024, and 48 paranoia episodes were documented. A review of R1's MAR for February 2024 indicated six doses of Risperdal is refused on 2/16, 2/17, 2/18, 2/20, 2/21, and 2/22/2024, two doses of Risperdal was documented as blank on 1/6/2024, and 23 paranoia episodes were documented. A review of R1's MAR for March 2024 indicated 10 doses of Risperdal is refused on 3/2,3/6, 3/8, 3/9,11,12,13,16,25 and 3/312024, two doses of Risperdal was documented as blank on 3/10 and 3/17/024, and 32 episodes of paranoia were documented. A review of R1's MAR for April 2024 indicated 10 paranoia episodes was documented. A review of R1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) indicated the following: i. R1's SBAR dated 1/31/2024 indicated, R1 refused Risperdal tablets (three times refusals) . R1 stated angrily, you guys are trying to poison me, this medication makes me sleepy. During a concurrent interview and record review with ADON on 4/26/2024 at 6:40 p.m., reviewed R1's MAR for 1/2024, 2/2024, 3/2024, and 4/2024. ADON stated that there were: i. One dose of Risperdal is refused on 1/5/2024, one dose of Risperdal was documented as blank on 1/6/2024 for 1/2024 MAR. ii. Six doses of Risperdal are refused on 2/16, 2/17, 2/18, 2/20, 2/21, and 2/22/2024, two doses of Risperdal were documented as blank on 1/6/2024, for 22/2024 MAR. iii. 10 doses of Risperdal are refused on 3/2,3/6, 3/8, 3/9,11,12,13,16,25 and 3/312024, two doses of Risperdal were documented as blank on 3/10 and 3/17/024 for 3/2024 MAR. ADON stated that the blank spaces in R1's MAR for Risperdal means that the medication was not given as it was not documented. During a concurrent interview and record review with ADON on 4/26/2024 at 6:40 p.m., reviewed R1's MAR for 1/2024, 2/2024, 3/2024, and 4/2024. ADON stated that there were: i. 48 paranoia episodes documented that R1 had episodes of paranoia for 1/2024 ii. 23 paranoia episodes documented that R1 had episodes of paranoia for 2/2024 iii. 32 episodes of paranoia documented that R1 had episodes of paranoia for 3/2024 iv. 10 paranoia episodes documented that R1 had episodes of paranoia for 4/2024 ADON stated after reviewing R1's MAR from 1/2024 to 4/2024 that there was no indication that MD 1 was notified of the multiple episodes of paranoia. During an interview Nurse Practitioner 2 (NP 2) on 4/26/2024 at 5:55 p.m., NP2 stated that R 1 was selective with medications and treatment. NP 2 stated that NP 2 was not aware of the multiple episodes of R1's refusal of Risperdal and paranoia episodes noted in R1's MAR for 1/2024, 2/2024, 3/2024 and 4/2024. NP 2 stated that had NP2 known of R1's refusal and episodes of paranoia, NP 2 would have increased the dose of R1's Risperdal as R1's current medication treatment for his schizophrenia was ineffective. A review of the facility's P&P titled, Antipsychotic Medication Use, reviewed on 1/25/2024, the P&P indicated, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. A review of the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, reviewed on 1/25/2024, the P&P indicated, residents have the right to request, refuse and/or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care . If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the residents' concerns and discuss alternative options; and discuss the potential outcomes or consequences of the resident's decision . Detailed information relating to the request, refusal or discontinuation of care or treatment will be documented in the resident's medical record . the healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. A review of the facility's P&P titled, Charting and Documentation, reviewed on 1/25/2024, the P&P indicated, the following information is to be documented in the resident medical record: objective observations; . changes in the resident's condition . Documentation in the medical record will be objective, complete, and accurate . Documentation of procedures and treatment will include care-specific details, including: whether the resident refused the procedure/treatment. 3. A review of R1's monthly medication regimen review (MRR - an important component of the overall management and monitoring of a resident's medication regimen) for Risperdal for the months of 1/2024, 2/2024 and 3/2024 indicated that the pharmacist consultant had no recommendations for R1. A review of R1's MAR for January 2024 indicated one dose of Risperdal is refused on 1/5/2024, one dose of Risperdal was documented as blank on 1/6/2024, and 48 paranoia episodes were documented. A review of R1's MAR for February 2024 indicated six doses of Risperdal is refused on 2/16, 2/17, 2/18, 2/20, 2/21, and 2/22/2024, two doses of Risperdal was documented as blank on 1/6/2024, and 23 paranoia episodes were documented. A review of R1's MAR for March 2024 indicated 10 doses of Risperdal is refused on 3/2,3/6, 3/8, 3/9,11,12,13,16,25 and 3/312024, two doses of Risperdal was documented as blank on 3/10 and 3/17/024, and 32 episodes of paranoia were documented. A review of R1's MAR for April 2024 indicated 10 paranoia episodes was documented. During an interview with Pharm1 on 4/26/2024 at 9:03 a.m., Pharm1 stated that R1's MRR for Risperdal was reviewed and evaluated for the months of 1/2024, 2/2024 and 3/2024. Pharm1 stated that there were no recommendations required for R1 as R1 was compliant with the medication Risperdal. When asked if Pharm 1 was aware of R1's refusal of medications from 1/2024 to 4/2024; and paranoia episodes 1/2024 to 4/2024, Pharm1 did not answer. A review of the facility's P&P titled, Medication Regimen Review reviewed on 1/25/2024, the P&P indicated, the Consultant Pharmacist reviews the medication regimen of each resident at least monthly . The MRR involves thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: medication regimes that appear inconsistent with the resident's stated preferences, duplicative therapies or omissions of ordered medications . an acute change of condition may prompt a request for a MRR, the staff member who identifies the change of condition follows reporting procedures to notify the physician. The physician may request a MRR be conducted within a specific timeframe. 4. During an interview with Pharm1 on 4/26/2024 at 9:03 a.m., Pharm1 stated that R1's last GDR for Risperdal was done on 9/2023. Pharm1 stated that R1's GDR evaluation for R1's Risperdal should be conducted quarterly (three-month periods). When asked how come R1's last GDR was done seven (7) months ago on 9/2023, Pharm 1 did not answer. A review of the facility's P&P titled, Antipsychotic Medication Use, reviewed on 1/25/2024, the P&P indicated, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review . The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications.

Based on observation, interview, and record review the facility failed to ensure, for one of seven residents (Resident 1), who was on 1:1 (an observation whereby a patient/person at no time is left alone) supervision for safety while on 5150 (is the Welfare and Institutions Code number, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for danger to others and elopement (a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety), was not left unattended on 8/13/2023. The facility was aware Resident 1 had a history of elopement at a general acute care hospital 1 (GACH 1), attempted to open his room window twice while at the skilled nursing facility (SNF), had exhibited increased agitation, and was verbally and physically threatening staff for two days. This failure resulted in Resident 1 escaping and falling from a second floor window on 8/13/2023 and landed 11.5 feet on the ground (asphalt). Resident 1 sustained fractures to the right leg and right wrist, right femoral neck head, and ribs. On 8/13/2023 at 11:30 p.m., Resident 1 was transferred and admitted at GACH 2 for evaluation and further management. On 8/17/2023, at 6:45 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility'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) in the presence of the Administrator and the Director of Nursing (DON) because of the seriousness related to the facility 's failure to provide care and continuous supervision to prevent accident for Resident 1 who was on 5150 hold (a 72-hour long involuntary treatment hold in a hospital or mental health facility) and one to one (1:1) supervision for danger to others (DTO - means the condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon to themselves or to another person). On 8/18/2023, at 3:29 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through observation, interview, and record review, and the SSA removed the IJ in the presence of the Administrator and the DON on 8/18/2023, at 5:20 p.m. A review of the IJ removal plan included the following: The facility transferred Resident 1 was transferred to GACH 2 via 911 (the telephone number used to reach emergency medical, fire, and police services) on 8/13/2023. On 8/14/2023, The Administrator educated the maintenance staff to ensure the windows in resident rooms were secure for resident safety, on weekly log window inspection, and on maintain safe and hazard free environment. On 8/17/2023, during an observation, the facility's Administrator and Maintenance staff initiated resident room round inspection and identified 36 windows that were not secured for safety to prevent residents from opening and escaping through the windows. Upon hire and on orientation day, staff will be educated by the Director of Staff Development (DSD)/Designee on the importance of window safety, and management and prevention of elopement. On 8/17/2023, the Administrator, the DON and DSD and a certified nurse assistant (CNA) identified all residents with 1:1 sitters and plotted a 1:1 sitter schedule. The schedule will address the 1:1 sitter needed daily and the 1:1 sitter replacement during mealtimes. The 1:1 sitter will be responsible to remain with the resident at all times, monitor the residents' actions and to prevent harm such as elopement, wandering, fall risk, suicidal ideations, aggressive behavior, self-inflicted injury, etc. On 8/17/2023 and 8/18/2023, the DSD/DON/licensed nurse designee initiated a 5150 and 1:1 sitter competency evaluation. The 1:1 sitters will have to complete and pass competency evaluation prior to being assigned a resident as a sitter. Beginning 8/21/23 and on every Monday, the maintenance staff will inspect windows to ensure security and safety of residents. The Maintenance supervisor will provide a summary report of findings from window inspection to the Quality Assessment Assurance (QAA - is responsible for identifying and responding to quality deficiencies that are identified in the facility) committee during monthly QAA committee meeting. Licensed nurse will provide companionship and close supervision to residents who require 1:1 supervision to reduce potential accidents and incidents such as elopement, falls, resident to resident altercations, self-inflicted harm and harm towards others and avoid recurrence of incident as with Resident 1. The DSD/DON/Designee on a monthly basis will provide a summary report of completed competency for staff regarding 5150 and 1:1 sitter to the QAA committee. The QAA committee, including the attendance of the Medical Director will review findings for further corrective actions as needed. Every quarter, beginning 11/2023 and every quarter, the DSD/designee will educate the licensed nurses, CNAs, and other non-nursing department staff on the importance of window safety, and elopement management and prevention. Findings: A review f Resident 1's Face Sheet (Admission Record) indicated the facility admitted Resident 1 on 8/8/2023 from GACH 1 with diagnoses including schizoaffective disorder (a serious mental health condition which include hallucinations [A perception of having seen, heard, touched, tasted, or smelled something that was not actually there] or delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder), unspecified affective mood disorder (marked disruption of emotions), and unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). A review of Resident 1's Interdisciplinary Team Conference (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) dated 8/9/2023, indicated, sitter provided to [Resident 1] for adjustment to placement, elopement risk and behavior. A review of Resident 1's history and physical (H&P) dated 8/10/2023, indicated Resident 1 diagnoses included . schizoaffective, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) . who presented to emergency room (ER - The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) for severe psychosis and disorganization, refusal of care, non-compliant with medications (meds), and spitting at staff. [Resident 1] kicked down a secured door and eloped and was brought back by police to the hospital [GACH 1]. The H&P indicated Resident 1 had the capacity for medical decision making. A review of the facility's Physician Orders for Resident 1 dated 8/2023, indicated effective 8/8/2023, Resident 1 may have psychology (is the study of mind and behavior in humans) consult and follow up treatment as needed. The physician orders further indicated to monitor Resident 1 for behavior episodes of restlessness ., refusal of care ., and spitting on staff. A review of Resident 1's Elopement Risk Assessment, dated 8/8/2023, indicated Resident 1's elopement risk total score was 16 (above 10 represents high risk) which placed Resident 1 was a high risk for elopement. The elopement risk indicated Resident 1 had expressed a desire to go back to a shelter at . A review of Resident 1's Care Plan on At Risk for Elopement, dated 8/8/2023, indicated Resident 1 will not have incidents of elopement through next review of 11/2023. The care plan interventions included to monitor Resident 1's whereabouts frequently and attempt to find out why the resident wants to leave the facility. The care plan indicated a 1:1sitter for Resident 1 effective 8/9/2023. A review of Resident 1's Care Plan on Schizoaffective, dated 8/8/2023, indicated Resident 1 will be discharged to appropriate level of care .The care plan approach included safety supervision . A review of Resident 1's Progress Notes dated 8/11/2023, timed at 12:31 a.m., indicated Resident 1 on supervision for attempts to elope . A review of the facility's document titled Situation Background Assessment Recommendation (SBAR) Communication Form, dated 8/10/2023 timed at 12 a.m., indicated Resident 1, noted with multiple behaviors throughout the shift. pacing down the hallways, restless, agitated and making absurd comments towards residents and staff members. Resident 1 whispered in the charge nurse ears I am going to stab the lady at the front desk in the heart. Resident 1 was running down the hallway attempting to escape from the facility multiple times. The hallway monitor watching resident. The SBAR communication form indicated a physician was notified on 8/9/2023 who gave an order to, call 911 if resident becomes increasingly aggressive and emergency medical transport, and transfer to hospital. A review of Resident 1's Physician Orders dated 8/13/2023, indicated to transfer Resident 1 to GACH 1 for psychiatry (medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions) evaluation via private ambulance on 8/14/2023. A review of Resident 1's Physician Orders dated 8/13/2023, indicated to transfer Resident 1 to GACH 2, via 911 for evaluation status post (S/P- after) fall out of the window. A review of Resident 1's Psychiatric Evaluation Team (PET - a clinician designated to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others, or who are unable to provide food, clothing, or shelter for themselves) Assessment Form, dated 8/13/2023 timed at 6:45 p.m., indicated Resident 1 was placed on 5150 hold for DTO. A review of the facility's document titled SBAR Communication Form, dated 8/14/2023, indicated Licensed Vocational Nurse 1 (LVN 1) documented the following: On 8/13/2023 at 3:30 p.m., Resident 1 was sitting in the patio with 1:1 sitter. On 8/13/2023 at 3:55 p.m., a female charge nurse took a cart to block Resident 1 from touching her and getting too close to her. Resident 1 was seen walking up and down the hallways in an agitated pace and sitter had difficulty keeping up with Resident 1. Resident 1 was saying sexually inappropriate words to LVN 1. On 8/13/2023 at around 4 p.m., and 5:30 p.m., Resident 1 refused his medications and threw the medications at the charge nurse [LVN 1]. Resident 1 began pacing up and down after eating dinner. On 8/13/2023 at 6:37 p.m., GACH 1 staff member contacted the facility to interview an unnamed nurse, conducted face time with Resident 1, and then placed Resident 1 on 5150 hold and that he would be transferred to GACH 1. The SBAR form indicated that staff member for a physician and for a nurse practitioner (NP) would arrange for transportation for Resident 1 once GACH 1 had a room was available. The SBAR form indicated Resident 1 said, .slit her throat [LVN 1]. The SBAR form further indicated Resident 1 had tried to open the window and failed, . and had asked Registered Nurse Supervisor (RNS) for a screwdriver or tool to open a window in Resident 1's room. Resident 1 became agitated when the facility denied his request for a screwdriver. On 8/13/2023 at 8:45 p.m., Resident 1 fell asleep. On 8/13/2023 at 11:05 p.m., Resident 1 was asleep. On 8/13/2023 at 11:20 p.m., CNA 2 alerted the nurses that Resident 1 was lying in the alley. The nurses immediately went to alley and found Resident 1 in semi-Fowlers position (is a position in which a patient/person is lying on their back with the head and chest raised between 15 and 45 degrees), the resident's head/back was against the facility's wall and was right under his [Resident 1's] window which was open.The nurses assessed Resident 1 and called 911. Resident 1 was alert and oriented times three (awareness of person, place and time) and complained of pain to the right leg and wrist. A small amount of blood was noted on the ground next to Resident 1, and on the resident's beard on the right chin. The SBAR form indicated resident 1 said, he walked out. The SBAR indicated 911 arrived and took over Resident 1's care on 8/13/2023 at 11:30 p.m. and transferred Resident 1 to GACH 2. The SBAR form document indicated GACH 2 informed the facility that Resident 1 suffered a right hip fracture and was admitted at GACH 2. A review of the facility's document titled SBAR Communication Form, dated 8/14/2023 timed at 11:11 a.m., indicated that . [Resident 1] was found outside the facility in the alley . on 8/13/2023 at 11:20 p.m. Resident 1 refused vital signs (blood pressure, pulse, respiration, and temperature) to be taken. A review of GACH 2 Xray (is an imaging study that takes pictures of bones and soft tissues) report for Resident 1 dated 8/14/2023 timed at 12:03 a.m., indicated Resident 1 with displaced right femoral (thigh bone) neck fracture. A review of GACH 2 computerized tomography (CT- a medical imaging technique used to obtain detailed internal images of the body) scan brain report for Resident 1 dated 8/16/2023 timed at 9:48 a.m., indicated Resident 1 with non-displaced fracture of the left mandible condyle (jaw bone) with right facial soft tissue swelling. A review of GACH 2 CT chest report for Resident 1 dated 8/16/2023 timed at 9:48 a.m., indicated resident 1 with multiple bilateral (both sides) subacute rib fractures. A review of GACH 2 Xray report for Resident 1 dated 8/16/2023 timed at 9:48 a.m., indicated Resident 1 with displaced right ulnar (forearm) styloid fracture (usually occur from direct trauma such as in sports or a fall), right triquetral avulsion (is often caused by a fall onto an outstretched hand) fracture, and bilateral wrist soft tissue swelling. A review of GACH 2 Xray report for Resident 1 dated 8/16/2023 timed at 9:48 a.m., indicated Resident 1 with comminuted intra-articular (are wrist fractures that affect the wrist joint) distal (it refers to parts of the body further away from the center) radius (near the wrist) fracture and displaced ulnar styloid fracture noted again. During an interview on 8/13/2023 at 1:30 p.m., the Administrator stated the outside agency terminated Resident 1's 1:1 sitter. During an interview and concurrent record review with the Director of Nursing (DON) on 8/17/2023 at 2:58 p.m., Resident 1's Progress Notes dated 8/12/2023 was reviewed. The DON stated Resident 1 was assigned 1:1 sitter supervision on 8/9/2023 with stop date. The DON further stated that on 8/10/2023, Resident 1 was on supervision for elopement risk because the resident had a history of elopement. The DON stated that 1:1 sitter supervision means the sitter should be within line of eye sight of the resident and the sitter is not assigned any other duties/resident care. The DON stated the PET clinician evaluated and placed Resident 1 on 5150 on 8/18/2023 at 6:26 p.m. The DON stated Resident 1 was not transferred to GACH 1 because GACH 1 did not admit patients at night. The DON further stated that on 8/13/2023, Resident 1 jumped through a window when the resident's assigned 1:1 sitter was on break. The DON stated that LVN 1 was watching Resident 1 when the 1:1 sitter was on break and that CNA 1 (not the sitter) last saw Resident 1 on 8/13/2023 at 11 p.m. The DON stated CNA 2 was leaving the facility on 8/13/2023, when she saw Resident 1 outside on the ground. The DON stated CNA 2 went back into the facility and alerted LVN 1 and RNS that Resident 1 was outside on the ground. The DON stated she was not sure if any staff member knew that Resident 1 was outside the facility. During an observation of the residents' room windows with the Assistant Maintenance Supervisor (AMS) on 8/17/2023 at 3:25 p.m., 22 windows were inspected and were identified with a metal or a wooden reinforcement to prevent the windows from sliding open and prevent the residents from opening and jumping out of the windows. During an interview on 8/17/2023, at 3:39 p.m., CNA 2 stated she got off work on 8/14/2023 at 11 p.m., went to her car and saw Resident 1 on the road alone. CNA 2 stated she went back into the facility and called the nurses. CNA 2 stated all the nurses were at the nurses' station charting (documenting). CNA 2 stated the RNS said that Resident 1 has 1:1 sitter. How did he leave? CNA 2 stated the last time she saw Resident 1 was around 8 p.m. CNA 2 stated on 8/13/2023 from 9 p.m., Resident 1 did not have a sitter and that the facility did not ask her [CNA 2] to sit with Resident 1. CNA 2 stated she made the decision to sit with Resident 1 in the resident's room on 8/13/2023 at 9 p.m. because Resident 1, was confused and I did not want him to elope. CNA 2 stated she sat with Resident 1 till 11 p.m. During an interview on 8/17/2023, at 5 p.m., the DSD stated the facility uses sitters from a staffing agency. The DSD stated she talks/educates the sitters at the bed when assigned as a 1:1 sitter. The DSD stated the 1:1 sitters are expected to monitor/supervise a resident to prevent falls, injuries, report any behaviors of attempting to leave the facility, and to make sure the resident is continuously monitored even when on breaks. During an interview on 8/17/2023, at 5:32 p.m., RNS stated, I don't know. I did not see him in the room. when asked where Resident 1's sitter was when Resident 1 jumped through the window. RNS stated CNA 2 clocked out on 8/13/2923 after 11 p.m., returned to the facility and, told us that [Resident 1] was outside. RNS further stated on 8/13/2023, Resident 1 gave her a written requesting for a screwdriver or a flat blade. RNS stated Resident 1 then snatched the written note back from her. During an interview on 8/17/2023 at 5:57 p.m., LVN 1 stated Resident 1 started pacing after he was placed on 5150. LVN 1 stated GACH 1 did not have a bed on 8/13/2023 and the facility had to wait until 8/14/2023 morning. LVN 1 stated she did not know where the sitter on 1:1 went the day Resident 1 jumped through the window and the sitter did not respond when LVN 1 called him. LVN 1 stated she observed the sitter leave the facility a few hours before and that is why LVN 1, or CNA, or a RN always checked on Resident 1. LVN 1 stated the facility did not have enough CNAs to be assigned as a sitter for Resident 1. A review of the facility's policy and procedures titled, Monitors/Sitters revised 10/2018, indicated, Monitor are used to enhance monitor and supervision of residents. 1:1 sitters are used to provide companion care and supervision for one singular resident for current behaviors that place the resident at higher risk for falls, self-inflicted injuries, elopement, suicidal behaviors and/or aggressive/threatening behaviors that place the resident or others at immediate risk. Definition of 5150- Patients with mental health illness who poses harm or danger to himself or others. 1:1 Sitters will be responsible only for the one assigned resident. They are to remain with the resident at all times within the line of sight and resident adjacent. Close enough to respond quickly to event but not close enough to be harmed by combative resident.

Cross Reference F609 and F697 Based on interviews and record review, the facility failed to protect the resident ' s right to be free from mental abuse, verbal abuse, and neglect for one of three sampled residents (Resident 2) when 1. Licensed Vocational Nurse 2 (LVN 2) did not give oxycodone (controlled medication used to treat moderate to severe pain) and carisoprodol (a muscle relaxer medication) when Resident 2 complained of nine out of 10 pain level (9/10 - numerical pain assessment tool wherein zero is no pain and 10 is severe pain) pain level. 2. LVN 2 responded to the Resident 2 with such word as wait a *d* minute and I don ' t give a *d* if you tell the president. I do what I want to do. These failures resulted in Resident 2 suffering from pain, stress, humiliation, and frustration. Findings: A review of Resident 2 ' s admission record indicated the facility admitted Resident 2 on 1/9/2023 with diagnoses including fusion of the spine lumbar region (surgery to connect two or more bones in the lower back region of the backbone), cellulitis and abscess (inflammation beneath the skins connective tissue containing accumulation of pus) of mouth, and morbid obesity (weight that is more than 80 to 100 pounds above the ideal body weight). A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/16/2023 indicated Resident 2 ' s cognitive skills (mental ability to make decisions of daily living) was intact. A review of Resident 2 ' s history and physical (H&P) dated 1/18/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s physician orders dated 1/31/2023, indicated oxycodone 30 milligrams (mg - unit of measurement) one tablet every three hours as needed for pain and carisoprodol 350 mg one tablet four times daily. The physician order did not indicate the facility could not administer both oxycodone and carisoprodol at the same time. A review of the facility ' s Nursing Staffing Assignments and sign-in sheets dated 1/23/2023, 1/28/2023 and 1/31/2023, indicated LVN 2 worked an eight hour shift on 1/23/2023, a 16-hour shift on 1/28/2023 and, an eight-hour shift on 1/31/2023 at the Facility (SNF). On 2/9/2023 at 12:20 p.m., during an interview, Resident 2 stated on 1/23/2023 at about 8 a.m., she asked LVN 2 for oxycodone 30 mg medication for nine out of 10 pain level. Resident 2 stated LVN 2 ignored her request by failing to acknowledge and/or respond to her (Resident 2) request for oxycodone. Resident 2 stated at about 8:30 a.m., she told LVN 2 she was still in pain and again asked LVN 2 for oxycodone. Resident 2 stated LVN 2 quickly and irritably responded and told her, wait a *d* minute, I am working with a dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys fail to function) resident. Resident 2 stated she waited for LVN 2 to finish attending to the dialysis resident. Resident 2 stated, after the dialysis resident left the facility, she (Resident 2) told LVN 2, now that the dialysis patient is gone can I have my pain medication and LVN 2 said No. Resident 2 stated she told LVN 2 she was going to report her to the supervisor. Resident 2 stated she reported LVN 2 to the Registered Nurse 1 (RN1), but RN 1 told Resident 2 to wait. Resident 2 stated LVN 2 started to prepare her medications after Resident 2 reported LVN 2 to RN 1. Resident 2 stated LVN 2 gave her all her scheduled morning medications except for oxycodone. LVN 2 told Resident 2 that she would not give Resident 2 carisoprodol 350 mg and oxycodone 30 mg at the same time. Resident 2 stated she told LVN 2 that she (Resident 20) always took her pain medication and muscle relaxer at the same time. Resident 2 stated she told LVN 2 that her pain management doctor said it was okay to take the carisoprodol and oxycodone at the same time. Resident 2 stated that other nurses always gave her the carisoprodol and oxycodone at the same time. Resident 2 stated she told LVN 2 to call her doctor if LVN 2 was concerned about administering both the carisoprodol and oxycodone at the same time. Resident 2 stated LVN 2 ignored her and did not to respond to Resident 2 ' s request for oxycodone and the request to contact Resident 2 ' s doctor to clarify the order for oxycodone. On the same interview on 2/9/2023 at 12:20 p.m., Resident 2 stated she told LVN 2 she was going to report her to the Director of Nursing (DON). Resident 2 stated while on her way to report her concerns with LVN 2 to the DON, LVN 2 told Resident 2, I don ' t give a *d* if you tell the president. I do what I want to do. Resident 2 stated she told the DON that LVN 2 refused to give her (Resident 2) pain medication and that LVN 2 was rude and disrespectful towards her (Resident 2). Resident 2 stated the DON told LVN 2 to give Resident 2 the muscle relaxer and oxycodone together, but LVN 2 said No to the DON. Resident 2 stated LVN 2 told the DON, According to the law she could not administer a pain medication and muscle relaxer at the same time. Resident 2 stated LVN 2, told the DON that she (LVN 2) had the key to medication cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel) and that she (LVN 2) could do what she wanted to do. Resident 2 stated the DON said, Well it ' s her cart (medication cart). I cannot force her (LVN 2) to do what she does not want to do. Resident 2 stated her pain level was a 9/10, she was stressed, humiliated, frustrated, and cried. A review of Resident 2 ' s Medication Administration Record (MAR) for 1/2023, indicated Resident 2 was on the following medications: a. Calcium Carb (medication for treat upset stomach) 500 mg 1 tablet chew by mouth as needed three times daily. b. Famotidine (medication to reduce stomach acid) 20 mg 1 tablet by mouth twice daily before meals (AC). c. Acidophilus capsule (supplement) 1 capsule by mouth one time a day. d. Breo Ellipta 100-25 micrograms (mcg- unit dose measurement) INH (inhaler) I puff inhaled orally (by mouth) daily (QD) for Asthma (a disease in which the lung airways become narrowed and swollen, making it difficult to breathe) d. Ferrous Sulfate (iron supplement) 325 mg 1 tablet by mouth once daily for anemia (low blood count). e. Lexapro (medication for depression [low mood] 10 mg 1 tablet by mouth once daily for depression manifested by (m/b) inconsolable crying. f. Xarelto (medication to prevent blood clots) 20 mg 1 tablet by mouth once daily g. Pantoprazole sod (medication to reduce stomach acid) 40 mg 1 tablet by mouth twice a day AC. On 2/9/2023 at 12:30 p.m., Resident 2 stated a Family Member (FM 1) happened to call her (Resident 2) and heard her (Resident 2) cry. Resident 2 stated she told FM 1 that LVN 2 was rude, disrespectful, would not listen to her (Resident 2) and that LVN 2 had refused to give her pain medication and muscle relaxer together like the doctor ordered. Resident 2 stated she put her telephone on speaker so that FM 1 could speak to LVN 2. Resident 2 stated LVN 2 said I don ' t give a *d* what you say and walked away, before FM 1 could speak to LVN 2. On the same interview, 2/9/2023 at 12:30 p.m., Resident 2 stated she complained to the DON three more times (unspecified times) between about 8:30 a.m. to 2 p.m. about the incident with LVN 2. Resident 2 stated the DON and RN 1 decided RN 1 should administer oxycodone to Resident 2. Resident 2 stated every time she asked RN 1 for oxycodone, RN 1 would send her (Resident 2) back to LVN 2. Resident 2 stated one staff member (name unknown) observed how LVN 2 mistreated her and suggested to Resident 2 to call the ombudsman (a government official who acts as patient ' s advocate or go-between). Resident 2 stated LVN 2 overheard the aforementioned conversation and told Resident 2, What are you going to do. You are going to report me to the ombudsman? I don ' t give a *d* go ahead and do it. Resident 2 stated LVN 2 spell her name (LVN 2) loudly. Resident 2 stated LVN 2 further said, You can do whatever you want. I guarantee you I am still going to work here (facility). You are not going to have me working at *** (retail store). Resident 2 stated she reported LVN 2 to the Ombudsman. On 2/09/2023 at 1:16 p.m., during an interview, LVN 2 stated Resident 2 requested for oxycodone and another medication together and she (LVN 2) did not feel comfortable giving the medications together. LVN 2 stated Resident 2 was due to leave the facility for an appointment when she (Resident 2) asked for oxycodone and would not be able to assess the Resident 2 ' s response to oxycodone. LVN 2 stated, Resident 2 told her (LVN 2) that all the other medication nurses have always administered the medications together. LVN 2 stated she told Resident 2 I am registry (from staffing agency), I don ' t work here all the time. Surveyor asked LVN 2, if she (LVN 20 contacted Resident 2 ' s doctor to clarify if oxycodone and carisoprodol at the same time. LVN 2 stated I know technically what I am supposed to do, but reality is I don ' t have time. I am executing and just doing my job. On 2/9/2023 at 1:40 p.m., during an interview, the DON stated on 1/23/2023 morning during the 7 a.m.to 3 p.m., Resident 2 complained to her that LVN 2 refused to give Resident 2 oxycodone for pain. The DON stated she was not aware LVN 2 was verbally and mentally abusive towards Resident 2 until the ombudsman contacted the facility and inquired about the alleged abuse and mistreatment towards Resident 2. On 3/4/2023 at 10:38 a.m., during an interview, RN 1 stated Resident 2 had issues with pain management, often requested pain medication and would look for RN 1 if Resident 2 unable to find her medication nurse. RN 1 stated on 1/23/2023 morning, the DON asked him (RN 1) to observe and make sure Resident 2 received pain medication as ordered by the doctor. RN 1 stated he asked LVN 2 why she was not giving Resident 2 her medications as ordered by the doctor. RN 1 stated LVN 2 said she did not know Resident 2 very well and was concerned about the potential side effects like fall risk and breathing issues that could occur if the medications (carisoprodol and oxycodone) were administered at the same time. RN 1 stated he directed LVN 2 to call the doctor if she was concerned or give Resident 2 the medications and to closely observe and assess Resident 2 ' s response to the medications. RN 1 stated Resident 2 told him that she always takes carisoprodol and oxycodone together. On 3/14/2023 at 10:56 a.m., during an interview, Resident 2 ' s FM 1 stated she contacted Resident 2 via telephone and Resident 2 was crying. FM 1 stated she told Resident 2 if your medication is due let your medication nurse know. FM 1 stated Resident 2 said LVN 2 refused to administer pain medication as ordered by the doctor to Resident 2. FM 1 stated she asked Resident 2 to speak with LVN 2 and Resident 2 placed the telephone on speaker and FM 1 asked LVN 2. FM 1 stated that before she could say anything on the telephone, she heard LVN 2 say I know what I am doing. FM 1 stated she heard Resident 2 tell LVN 2 Please give me my medicine and LVN 2 responded According to the law you are not supposed to take both medications together. FM 1 stated she told LVN 2, If you are concerned, please call the doctor. FM 1 stated she told LVN 2, You are not the doctor. It is not your decision to make. FM 1 stated LVN 2 started talking louder over her (FM 1) while saying, It ' s the law, she (LVN2) knows what she is doing. Nobody is going to tell her what to do. FM 1 stated Resident 2 sounded stressed and was crying hysterically. On 3/29/2023 at 2:30 p.m. during an interview with LVN 4, he stated all medications are administered according to physician ' s orders. LVN 4 stated medication can only be withheld if the Resident verbalizes an allergy to the medication, a medication is not listed in the MAR, or a prior adverse reaction (unwanted undesirable effects that are possibly related to a drug) has been observed and documented not limited to excessive sleepiness, delirium (disturbed state of mind) or respiratory distress all of which must be documented and reported immediately to the resident ' s doctor. LVN 4 further stated, withholding a resident ' s medication without a clinical justification is neglect (failure of a health care provider or caregiver to observe due care and diligence in performing services or delivering medicine or other products) and should be reported to the DON and Administrator immediately for further action. A review of the facility ' s policy and procedures titled Abuse and Neglect Prohibition dated June 2022, indicated, It is the facility ' s policy to prohibit abuse, mistreatment, neglect through, prevention of occurrences, identification of possible incidents or allegations which need investigation, the policy further states, Abuse is defined in part as the willful infliction of or mental anguish or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health.

Cross Reference F600 and F609 Based on interview and record review, the facility failed to administer oxycodone (controlled medication used to treat moderate to severe pain) for pain management (the process of alleviating pain) for one of three sampled residents (Resident 2). Resident 2 complained of nine out of 10 (9/10 - numerical pain assessment tool where zero is no pain and 10 severe pain) on 1/23/2023 at 8 a.m. This is deficient practice resulted in Resident 2 remaining in severe pain level of 9/10. Resident 2 left the facility for outside appointment without receiving oxycodone on 1/23/2023 between 1:30 p.m. and 2 p.m. Findings: A review of Resident 2 ' s admission record indicated the facility admitted Resident 2 on 1/9/2023 with diagnoses including fusion of the spine lumbar region (surgery to connect two or more bones in the lower back region of the backbone), cellulitis and abscess (inflammation beneath the skins connective tissue containing accumulation of pus) of mouth, and morbid obesity (weight that is more than 80 to 100 pounds above the ideal body weight). A review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/16/2023, indicated Resident 2 was cognitively (mental ability to make decisions of daily living) intact. A review of Resident 2 ' s history and physical (H&P) dated 1/18/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s plan of care dated 1/9/2023, indicated Resident 2 had a chronic (on going) pain to the lower back. Resident 2 ' s plan of care indicated Resident 2 will be: a) Monitored for pain every shift. b) Medications will be administered as ordered by the doctor. c) The doctor will be notified if pain medication was not effective The goal of the plan of care indicated Resident 2 ' s pain will be resolved within one hour after pain medication is given. A review of Resident 2 ' s physician orders for 2/2023, indicated Resident 2 to receive the following medications effective 1/31/2023: a) Oxycodone Immediate Release (IR) of 30 (dose amount) milligrams (mg - unit dose measurement) by mouth every 3 (three) hours (q 3 hrs) as needed (prn) for moderate to severe pain of (4-9/10 - Pain scale). b) Dilaudid (controlled strong pain medication) 4 mg tablet give one tablet by mouth every three hours as needed for breakthrough pain. A review of Resident 2 ' s Medication Administration Record (MAR) for the month of 1/2023, indicated Licensed Vocational Nurse 2 (LVN 2) did not administer Oxycodone 30 mg or the Dilaudid 4 mg to Resident 2 for pain relief during the entire work eight hour shift (7am -3PM) on 2/9/2023. On 2/9/2023 at 12:20 p.m., during an interview, Resident 2 stated on 1/23/2023 at about 8 a.m., she asked LVN 2 for her oxycodone 30 mg for pain level of 9/10 and her other scheduled (routine) medications. Resident 2 stated LVN 2 ignored her request by failing to acknowledge and/or respond to her request for oxycodone. Resident 2 stated at about 8:30 a.m., she told LVN 2 she was still in pain and again asked LVN 2 for oxycodone together with her scheduled medications. Resident 2 stated LVN 2 quickly and irritably responded and told her Wait a *d .* minute, I am working with a dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys fail to function) resident. Resident 2 stated she waited for LVN 2 to finish attending to the dialysis resident. Resident 2 stated, after the dialysis resident left the facility, she (Resident 2) told LVN 2 now that the dialysis patient is gone can I have my pain medication and my scheduled medications and LVN 2 said No. Resident 2 stated she told LVN 2 she was going to report her to the supervisor. Resident 2 stated she reported LVN 2 to the Registered Nurse 1 (RN 1), but RN 1 told Resident 2 to wait. Resident 2 stated LVN 2 started to prepare her medications after Resident 2 reported LVN 2 to RN 1. Resident 2 stated LVN 2 gave her all her morning medications except for oxycodone. LVN 2 told Resident 2 that she would not give Resident 2 carisoprodol (muscle relaxer) 350 mg and oxycodone 30 mg at the same time. Resident 2 stated she told LVN 2 that she always takes her pain medication and muscle relaxer at the same time. Resident 2 stated she told LVN 2 that her pain management doctor had said it was okay to take the carisoprodol and oxycodone at the same time. Resident 2 stated that other nurses always gave her the carisoprodol and oxycodone at the same time. Resident 2 stated she told LVN 2 to call her doctor if LVN 2 was concerned about administering both the carisoprodol and oxycodone together. Resident 2 stated LVN 2 ignored her and did not to respond to Resident 2 ' s request for oxycodone nor Resident 2 ' s request to contact the doctor and clarify the order for oxycodone. On the same interview on 2/9/2023 at 12:20 p.m., Resident 2 stated she told LVN 2 she was going to report her to the Director of Nursing (DON). Resident 2 stated the DON told LVN 2 to give Resident 2 the muscle relaxer and oxycodone together, but LVN 2 said No to the DON. Resident 2 stated LVN 2 told the DON According to the law she could not administer a pain medication and muscle relaxer at the same time and that she (LVN 2) had the key to medication cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel) and that she (LVN 2) could do what she wanted to do. Resident 2 stated the DON said, Well it ' s her cart (medication cart)., I cannot force her (LVN 2) to do what she does not want to do. Resident 2 stated her pain level was a 9/10, and that she was stressed, humiliated, frustrated, and cried. On 2/9/2023 at 1:16 p.m., during an interview LVN 2 stated Resident 2 requested oxycodone and another medication together and she (LVN 2) did not feel comfortable giving carisoprodol and oxycodone at the same time. LVN 2 stated, Resident 2 told her (LVN 2) that all the other medication nurses have always administered the medications together. LVN 2 stated she told Resident 2 I am registry (from staffing agency), I don ' t work here all the time. The surveyor asked LVN 2, if she (LVN 2) contacted Resident 2 ' s doctor to clarify if oxycodone and carisoprodol could be given at the same time. LVN 2 stated I know technically what I am supposed to do, but reality is I don ' t have time. I am executing and just doing my job. On 2/9/2023 at 1:40 p.m., during an interview, the DON stated on 1/23/2023 morning during the 7 a.m. to 3 p.m., Resident 2 complained to her that LVN 2 refused to give her [Resident 2] oxycodone. The DON stated, LVN 2 told the DON that LVN 2 was not comfortable giving both the pain medication and muscle relaxer together to Resident 2. The DON stated she told LVN 2 to call Resident 2 ' s doctor if she (LVN 2) was concerned about administering carisoprodol and oxycodone at the same time. On 3/4/2023 at 10:38 a.m., during an interview, RN 1 stated Resident 2 had issues with pain management, often requested pain medication and would look for RN 1 if Resident 2 was unable to find her medication nurse. RN 1 stated on 1/23/2023 morning, the DON asked him (RN 1) to observe and make sure Resident 2 received pain medication as ordered by the doctor. RN 1 stated he asked LVN 2 why she was not giving Resident 2 her medications as ordered by the doctor. RN 1 stated LVN 2 said she did not know Resident 2 very well and was concerned about the potential side effects like fall risk and breathing issues that could occur if the medications (carisoprodol and oxycodone) were administered at the same time. RN 1 stated he directed LVN 2 to call the doctor if she was concerned or give Resident 2 the medications and to closely observe and assess Resident 2 ' s response to the medications. RN 1 stated Resident 2 told him that she always takes the medications together. RN 1 stated he observed LVN 2 give Resident 2 medications (unidentified). On 3/15/2023 at 12:34 p.m. during an interview and record review with the DON, Resident 2 ' s Medication Administration Record (MAR) for the month of 1/2023 was reviewed. The MAR did not indicate LVN 2 administered pain medication to Resident 2 on 1/23/2023 during the 7 a.m. to 3 p.m. shift. The DON stated she did not follow up with Resident 2 if LVN 2 administered carisoprodol and oxycodone to Resident 2. The DON stated she told RN 1 to follow up and to make sure Resident 2 received her pain medication (oxycodone). On 3/29/2023 at 2:30 p.m. during an interview, LVN 4 stated all medications are administered according to a physician ' s orders. LVN 4 stated, a medication can only be withheld if a resident is allergic to a particular medication ., the resident is excessively sleepy, or has trouble breathing. LVN 4 further stated, withholding a resident ' s medication without a clinical justification is neglect (failure of a health care provider or caregiver to observe due care and diligence in performing services or delivering medicine or other products) and should be reported to the DON and Administrator immediately for further action. A Review of the facility ' s policy and procedures (P&P) titled Pain assessment and Management revised 3/2020 indicated, Pain Management is defined as the process of alleviating the resident ' s pain based on his or her clinical condition and established treatment goals. A review of the facility ' s policy and procedures titled Administering Medications revised 2019 indicated, Medications are administered in a safe and timely manner and as prescribed. The P&P further indicated: a) Medications are administered in accordance with prescriber ' s orders, including any required time frame. b) Medications administration times are determined by resident need and benefit, not staff convenience. c) 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 concerns.

Based on observation, interview, and record review, the facility failed to provide supervision during wandering behavior and follow their policy and procedure titled, Nursing-Wandering and Elopement, to ensure four of six sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) did not elope from the facility. The facility failed to identify the risk of elopement, failed to care plan for the risk of elopement for Resident 1, 2, 3 and 4 and failed to ensure the exit alarms were working properly. As a result, Resident 1 eloped from the facility on 5/7/2022 and remains missing. Resident 1 did not receive the physician ordered medications needed for her condition which could lead to serious injury, serious harm, serious impairment and/or death. On 5/17/2022 at 3:14 p.m., 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) was identified in the presence of the facility's Administrator (ADM) regarding the facility's failure to properly assess and identify residents who were at risk for elopement and to prevent Resident 1 from eloping from the facility. On 5/19/2022 at 4:20 p.m., while onsite at the facility, the IJ was lifted after the ADM and Director of Nursing (DON) submitted an acceptable Removal Plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview and record review. The IJ was removed in the presence of the ADM and DON. The acceptable removal plan was as follows: -The Elopement Risk Assessments and care plans for elopement for Resident 2, Resident 3, and Resident 4 were initiated and completed on 5/17/2022. The facility held Interdisciplinary Team Meetings (IDT- A team that includes different healthcare members such as a physician, social worker, and nurse that meet to discuss the care and needs of a resident) for Resident 2, Resident 3, and Resident 4 on 5/18/2022 to discuss the residents elopement risks. -All residents of the facility were re-assessed for risk of elopement on 5/17/2022 to 5/18/2022. Those who were identified as risk for elopement were provided interventions per care planning. -In-service education was provided to the licensed nurse staff and certified nursing assistant staff from 5/17/2022 to 5/20/2022 on the elopement policy and procedure. In-services on completion of the elopement risk assessment upon admission, quarterly, and as needed, the immediate response to checking all exit doors of the facility, designated licensed nurses on duty can turn off alarms, and signage indicating no resident is allowed to turn off the alarm sound. -One-on-one education was provided to Resident 4 regarding no resident shall turn off exit alarms. -Installation on 5/17/2022 of a secure box for the facility alarm with a key that staff can access. -A designated 24-hour elevator monitor to ensure to residents do not leave the floor unless they were escorted by facility staff. -Random daily inspection by the Administrator (ADM) for four weeks, then twice per week for one month, of monitoring staff to ensure they identify any resident at risk for elopement and confirm with the nursing supervisor and elevator monitor that no residents have left the floor unattended. -Re-evaluation of compliance of the above processes during the Quality Assurance monthly meeting. Findings: a. A review of the General Acute Care Hospital (GACH) 1 Psychiatry Consult Note dated 4/19/2022, indicated Resident 1 was on a 5250 hold (a 14-day involuntary stay in the hospital due to a person being a danger to themselves, a danger to others, or gravely disabled due to a mental disorder), was refusing treatments from staff, was agitated, yelling, and wanted to go outside. A review of Resident 1's Face sheet (Admission Record) indicated the facility admitted Resident 1 on 4/25/2022 with diagnoses including hypertensive [CONDITION(S)] (heart problems caused by high blood pressure), generalized [CONDITION(S)] (swelling of the body caused by excess fluid trapped in the body's tissues), mood affective disorder (a disorder that affects a person's emotional state, that impacts the way a person thinks, feels, and go about daily life), and [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). A review of Resident 1's Physician's Orders dated 4/25/2022 indicated to monitor behavior for [CONDITION(S)] manifested by striking out at staff every shift, and to monitor behavior for anxiety manifested by restlessness every shift. A review of the Elopement Risk assessment dated [DATE], indicated Resident 1 was not cognitively impaired, did not wander, was not recently admitted within the past 30 days, and did not receive any medications that increased restlessness. The elopement risk assessment indicated Resident 1 scored a two, and a score of ten or higher indicated a high risk for elopement. A review of the Physician's Orders dated 4/28/2022, indicated Resident 1 was to receive [MEDICATION(S)] (medication that helps remove excess fluid from the body) 40 milligrams (mg) by mouth twice daily for heart failure, [MEDICATION(S)] (medication that improves thinking, mood, and behavior) 5 mg by mouth daily for [CONDITION(S)], and [MEDICATION(S)] 10 mg by mouth at bedtime for [CONDITION(S)]. According to a review of Resident 1's Medication Administration Record dated 4/2022 and 5/2022, Resident 1 had episodes of restlessness and striking out at staff. A review of Saunders Nursing Drug Guide, dated 2021, indicated [MEDICATION(S)] was a high alert drug with a black box warning (a notice that indicates the medication may cause serious side effects) that large doses could lead to profound diuresis (increase urine production and frequency) with water and electrolyte depletion, and indicated the medication had side effects that included increased urinary frequency / volume, dizziness, light-headedness, restlessness, and diaphoresis (sweating). A review of Saunders Nursing Drug Guide, dated 2021, indicated [MEDICATION(S)] had side effects that included agitation, nervousness, hostility, anxiety, and restlessness. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 5/2/2022, indicated Resident 1 had moderately impaired cognition (decisions poor; cues/supervision required), exhibited verbal behavioral symptoms (such as threatening others, screaming at others, and cursing at others), and other behavior symptoms not directed towards others (such as pacing, screaming, and disruptive behaviors) daily. The MDS indicated the resident had wandering behavior, required limited assistance and one-person physical assistance for activities of daily living (ADLs, such as transferring, dressing, toilet use, and personal hygiene). A review of Resident 1's Impaired Behavior Status Care Plan dated 5/5/2022, indicated Resident 1 had an episode of taking other people's belongings. A review of Resident 1's Medical Record indicated Resident 1 did not have a care plan for elopement. According to a review of Resident 1's Elopement Risk assessment dated [DATE] (the day Resident 1 was missing), the resident scored a 7 and was not at risk for elopement. The assessment indicated Resident 1 was not cognitively impaired, did not wander, and did not receive medications that increased restlessness. A review of Resident 1's Situation Background Assessment Response 4.0 Communication Form dated 5/8/2022 indicated Resident 1's elopement started on 5/7/2022 at 10 pm. The form indicated at 3 pm. Resident 1 was up sitting on a wheelchair propelling around the facility. At 5 pm Resident 1 received her routine medications and at 7 pm Resident 1 continued to be seen on her wheelchair. At 8:20 pm, Resident 1 was seen on her wheelchair while the nurse was administering medications to another resident. At 10 pm, the nurse went to Resident 1's room to administer medications but was unable to locate the resident. The Registered Nurse (RN) Supervisor notified staff and the search for Resident 1 was initiated. The form indicated staff searched for Resident 1 throughout the facility and around the surrounding perimeter of the facility, but the resident could not be located. The form further indicated the police were called at 11 pm, and Resident 1's physician was notified. Resident 1's family members could not be reached. During an interview on 5/10/2022 at 11:18 am, the Administrator (ADM) stated he arrived at the facility on 5/7/2022 at around 11:30 pm, checked all the facility exits, and stated all exit alarms were working. The ADM stated staff indicated they did not hear the alarm go off that night. The ADM stated the resident had not been located. During an interview on 5/10/2022 at 12:43 pm, the ADM stated the facility did not know which exit Resident 1 left through. The ADM stated the facility had cameras, but the cameras did not work during the time Resident 1 eloped from the facility. During an interview on 5/10/2022 at 2:21 p.m., Family Member (FM) 1 stated at home Resident 1 would come and go and leave the house for periods of time. FM 1 stated he would have to go and look for Resident 1 when she left home and that Resident 1 was a cigarette smoker and would wander around picking up cigarette butts to use. FM 1 stated Resident 1 liked to come and go and that neither he nor his mother have heard from Resident 1. FM 1 stated he informed the hospital that it would be good for the resident to go to a locked facility because she would try to go out and leave. During an interview on 5/10/2022 at 3:31 p.m., Licensed Vocational Nurse (LVN) 1, stated she was working the 3 p.m. to 11 p.m. shift on 5/7/2022 and that she did not hear the exit alarm go off that night. On 5/10/2022 at 3:42 pm during an interview, Certified Nursing Assistant (CNA) 1 stated he worked the 3 pm to 11 pm shift on 5/7/2022 and that he did not hear the facility alarms go off that night. CNA1 stated he would have heard the alarms go off because they were really loud. During an interview on 5/10/2022 at 4 p.m., Resident 5 stated she knew Resident 1 because their rooms were across from each other. Resident 5 stated Resident 1 did not need a wheelchair, the resident could walk, was always getting upset, and always wanted cigarettes and money. Resident 5 stated she did not see Resident 1 leave the facility and stated she did not hear the alarms going off that night on 5/7/2022. During an interview on 5/11/2022 at 1:43 pm, CNA4 stated she was working the 3 pm to 11 pm shift on 5/7/22 and was assigned to take care of Resident 1. CNA4 stated that night Resident 1 had asked her for change for a $20 bill when she had gone to break that night. CNA4 stated when she returned from break, she stated the nurse taking care of Resident 1 could not find her. During an interview on 5/11/2022 at 2:39 pm, RN 2 stated she was working the 3 pm to 11 pm shift on 5/7/2022. RN 2 stated at the start of her shift she did rounds and saw Resident 1 in her wheelchair go in and out of her room. RN 2 stated around 10 pm, she went to give Resident 1 her medications in her room but Resident 1 was not there. RN 2 stated she asked the CNA if she had seen Resident 1, and the CNA stated she last saw Resident 1 at 9 pm before her break. RN 2 stated she looked room to room and asked the other charge nurses to look as well and no other staff saw Resident 1. RN 2 stated she then called the ADM and drove around the vicinity to see if she could locate Resident 1 but did not see her. RN 2 stated she did not recall hearing any alarms that night. On 5/17/2022 at 12:59 pm, during an interview, Minimum Data Set Nurse (MDS) 1, reviewed Resident 1's Elopement Risk assessment dated [DATE] and the MDS assessment record dated 5/2/2022 and stated Resident 1's elopement risk score of two was inaccurate. MDS 1 re-assessed Resident 1's elopement risk score and indicated a score of 13. MDS 1 stated a score of 10 or above indicated a high risk for elopement and indicated a care plan for elopement should have been initiated. During an interview on 5/17/2022 at 3:05 pm with the ADM, the Medical Records for Resident 1 were reviewed. The ADM indicated Resident 1's Elopement Risk assessment dated [DATE] was done inaccurately and confirmed Resident 1 did not have a care plan for the risk of elopement. During an interview on 5/18/2022 at 11:32 am, the DON reviewed the medical records for Resident 1 and stated, I am sorry the Elopement Risk Assessment was not done properly. The DON stated every resident should have an Elopement Risk Assessment done on admission, re-evaluated quarterly, when the resident has a change, and as needed. The DON stated care planning for elopement needs to be done for every resident who was at risk of eloping. The DON stated residents could elope from the facility and potentially be harmed if the risk of elopement was not properly identified, or care planned. The DON stated the alarm alerts staff to residents who may possibly be leaving the facility. b.A review of Resident 2's Face sheet indicated the facility admitted the resident on 3/30/2022 and the MDS dated [DATE] indicated Resident 2 had severely impaired cognition (never/rarely made decisions), wandered daily, required limited assistance and one-person physical assistance for ADL's such as transferring, dressing, toilet use and personal hygiene. The MDS further indicated Resident 2 had active diagnoses of depression (persistent feeling of sadness and loss of interest that affect daily living), [CONDITION(S)], persistent mood affective disorder, alcohol dependence, and [CONDITION(S)] (difficulty sleeping at night). A review of Resident 2's undated Elopement Risk Assessment indicated a score of 4 and was not fully completed. A score of 10 or higher indicated a high risk for elopement. A review of Medical Record indicated Resident 2 did not have a care plan for Elopement. During an interview on 5/17/22 at 1:03 pm, MDS 1 reviewed Resident 2's undated Elopement Risk Assessment and stated he did not know when Resident 2's Elopement Risk Assessment was done because the assessment was not dated and was not completed. MDS 1 stated an elopement risk assessment should be done on admission, quarterly and as needed. A review of Resident 2's updated Elopement Risk assessment dated [DATE] at 4:48 pm indicated a score of 12, which showed the resident was at high risk for elopement. c.A review of Resident 3's Face sheet indicated the facility admitted the resident on 12/14/2020 and the MDS dated [DATE] indicated the resident had moderately impaired cognition, wandering behavior, required supervision and set up help for ADL's such as transferring, toilet use, dressing, and personal hygiene. The MDS further indicated Resident 3 had active diagnoses of [CONDITION(S)] (a disease that affects the brain and spinal cord), anxiety, depression, [CONDITION(S)] disorder (a disorder that causes extreme mood swings), [CONDITION(S)], and obsessive-compulsive disorder (OCD a pattern of movement or behavior caused by unwanted thoughts and feelings). A review of the facility's current Elopement Risk Binder indicated the facility identified Resident 3 as a risk for elopement. A review of Resident 3's Medical Record indicated an Elopement Risk Assessment was last performed on 9/20/2021, which indicated Resident 3 was not at risk for elopement. Further review of Resident 3's Elopement Risk assessment dated [DATE] indicated the elopement risk assessment score was calculated incorrectly. A review of Resident 3's Medical Record indicated Resident 3 did not have a care plan for Elopement. During an interview on 5/17/2022 at 1:07 pm, MDS 1 reviewed Resident 3's Elopement Risk Assessment and stated the last time Resident 3's Elopement Risk Assessment was done was on 9/20/2021. MDS 1 stated Resident 3's elopement risk assessments should have been done quarterly in 12/2021 and 3/2022. MDS 1 stated Resident 3 was known to be a risk for elopement and stated a care plan for elopement should have been initiated. A review of Resident 3's updated Elopement Risk assessment dated [DATE] at 5:05 pm, indicated a score of 15, which showed the resident was at high risk for elopement. d. A review of Resident 4's Face sheet indicated the facility admitted the resident on 4/22/2022 and the MDS dated [DATE] indicated the resident had severely impaired cognition, had wandering behavior daily, required limited assistance and one-person physical assistance with ADL's such as transferring, dressing, toilet use, and personal hygiene. The MDS further indicated Resident 4 had active diagnoses of anxiety disorder and [CONDITION(S)]. A review of Resident 4's Elopement Risk assessment dated [DATE] indicated a score of 0, which showed the resident was not at high risk for elopement. A review of Resident 4's Medical Record indicated Resident 4 did not have a care plan for elopement. During an observation on 5/17/2022 at 12:09 pm, Resident 4 was observed turning off the exit alarm sound by pressing a button on the wall across from the nurses' station. During a concurrent interview, Resident 4 stated the alarm was too loud and he did not want to hear it anymore, so he pressed the button to turn the alarm off. Resident 4 stated no one told him he could not press the button. During this observation there were no staff around witnessing Resident 4 pressing the button to turn off the alarm sound. Resident 4 stated he did not want to be in the facility anymore and he wanted to leave. During an observation on 5/17/2022 at 12:14 pm, Resident 4 was observed turning off the alarm sound a second time. CNA5 was observed witnessing Resident 4 pressing the button that turned off the alarm sound. CNA5 stated to Resident 4, Thank you. During an interview on 5/17/2022 at 12:16 pm, CNA5 stated she saw Resident 4 turning off the alarm sound. CNA5 stated she did not tell Resident 4 not to turn off the alarm sound or that staff should be the designated person turning off the alarm sound. CNA5 stated the alarm makes noise if the doors of the facility open. CNA5 stated, The sound let's us know if the door opens. When asked why she told Resident 4 Thank you, CNA5 stated, I don't know. During an interview on 5/17/2022 at 1:12 pm, MDS 1 reviewed Resident 4's Elopement Risk assessment dated [DATE] and the MDS assessment dated [DATE]. MDS 1 stated the elopement risk score of 0 calculated on 3/31/2022 was incorrect. Resident 4's elopement risk score was recalculated and indicated a score of 11. MDS 1 stated a score above 10 indicated a high risk for elopement and indicated a care plan for elopement should have been initiated for Resident 4. On 5/17/2022 at 1:44 pm during an interview, LVN 2 stated the button across the nurses' station turns off the sound of the alarm. LVN 2 stated only staff should be pressing that button, no resident should be pressing that button. LVN 2 stated if residents turn off the alarm sound it cannot alert the staff to the notion that the doors are opened; and residents can easily get out, elope, and hurt themselves. During an interview on 5/17/2022 at 3:05 pm, the ADM reviewed the medical records for Resident 2, Resident 3, and Resident 4 and stated the resident's Elopement Risk Assessments were done inaccurately, not done completely, or not done timely as indicated by the policy. The ADM stated and confirmed Resident 1, Resident 2, Resident 3, and Resident 4 did not have care plans for the risk of elopement; and stated care plans should be initiated. The ADM stated residents should not be turning off the alarm sound, because it was a big risk and could cause staff to be unaware of a resident eloping. The ADM stated the alarms were in place to make sure staff were aware of the residents' location and provide care accordingly. During a telephone interview on 5/18/2022 at 10:01 am, with the Assistant Director of Nursing (ADON), the ADON stated the Elopement Risk Assessment for Resident 2 was not completed and done timely. The ADON stated the Elopement Risk Assessment for Resident 3 should have been done in 12/2021 and stated the risk of elopement for Resident 4 was not identified. The ADON stated the Elopement Risk Assessments were re-done on 5/17/2022 for Resident 2, Resident 3, and Resident 4 which indicated all residents were at risk for elopement. The ADON stated when the elopement risk assessments were not done timely and the actual risk elopement was not identified, This could possibly place the resident at harm. During an interview on 5/18/2022 at 11:32 am with the Director of Nursing (DON), the medical records for Resident 1, Resident 2, Resident 3, and Resident 4 were reviewed. The DON stated, The Elopement Risk Assessments for those residents were not done properly. The DON stated care planning for elopement needs to be done for every resident who is at risk of eloping. The DON stated staff should be the only ones to be turning off the alarm sounds and stated residents should not be turning off the alarm sound or touching the button. The DON stated residents could elope from the facility and potentially be harmed if the risk of elopement was not properly identified, care planned, and if they can turn off the alarm sounds. A review of the policy and procedure titled, Nursing-Wandering and Elopement, released 6/2018, indicated risk for elopement and preventative intervention will be documented in the Resident's medical records, and will be re-evaluated by IDT quarterly and as needed. The policy indicated the facility will reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement. The IDT will develop a plan of care considering the individual risk factors of the Resident Person-centered approach/interventions to prevent elopement and/or divert wandering behavior will be included in the plan-of-care. The policy further indicated how to identify residents who are at risk: Resident with a history of wandering or elopement prior to admission to facility, who was assessed to be at risk for wandering or elopement, and those who have impaired cognition and decision-making skills yet verbalizes wanting to leave the facility without supervision. The policy indicated prevention/planning: Use device (s) that signals when the door and/or windows opened, if possible.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and a safe environment to prevent accidents for one of two sampled residents (Resident 93). For Resident 93, who was diagnosed with [CONDITION(S)] ([CONDITION(S)] - stage when the kidneys can no longer support the body's needs of removing waste and excess water from the body), received [CONDITION(S)] (a treatment for kidney failure that rids your body of unwanted toxins, waste products), and was a fall risk, the facility failed to provide assistance with one person assist while Resident 93 waited for [CONDITION(S)] transportation. This deficient practice resulted in Resident 93 having an unwitnessed fall while waiting for the [CONDITION(S)] transportation outside the facility lobby on 6/19/2021. Within the next several days Resident 93 yelled out, complained of excruciating pain to the right ankle, and was transferred to the General Acute Hospital (GACH), where he was diagnosed with a closed fracture of the right ankle (a broken bone that does not penetrate the skin). Findings: A review of Resident 93's Admission Record indicated the facility admitted the resident on 6/14/2021 with diagnoses including heart failure (the heart is unable to provide adequate blood flow to other organs), hypertension ([CONDITION(S)] - elevated blood pressure), and [CONDITION(S)] ([CONDITION(S)] - stage when the kidneys can no longer support the body's needs of removing waste and excess water from the body). A review of the Physician's Orders dated 6/15/2021, indicated Resident 93 received [CONDITION(S)] (a treatment for kidney failure that rids your body of unwanted toxins, waste products and excess fluids by filtering your blood) on Tuesdays, Thursdays and Saturdays at 7 AM, via transportation to [CONDITION(S)] center. A review of Resident 93's Fall Risk assessment dated [DATE], indicated Resident 93 had a Fall Risk score of 8 (a score of 10 or higher indicated a high risk for falls) with balance problem while standing and decreased muscular coordination. A review of Resident 93's Fall Risk care plan dated 6/15/2021, indicated resident was at risk for falls due to [CONDITION(S)] and poor safety awareness. The care plan goal indicated Resident 93 would have a reduced risk for falls for 90 days and the approach / plan indicated to assist the resident with activities of daily living as needed and to maintain a safe environment. According to a review of Resident 93's [CONDITION(S)] transportation record dated 6/19/2021 Resident 93 was picked up on 6/19/2021 at 6:15 AM from the facility and returned to the facility at 11:20 AM. A review of Resident 93's Quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/21/2021 indicated the resident was mildly cognitively impaired (some difficulty in new situations). The MDS indicated Resident 93 required limited assistance with one person assist for activities of daily living including transfer, walk in corridor, and locomotion off unit. A review of Resident 93's change of condition (COC) form, dated 6/19/2021 indicated Resident 93 returned from [CONDITION(S)] stating, I sprained my ankle. I fell at the steps and I fell again at the gas station. Resident 93 stated he fell at the front of the facility first, then walked to the gas station to get cash and fell again while waiting for his [CONDITION(S)] transportation. A review of Resident 93's pain assessment dated [DATE] indicated Resident 93 had a pain score of 0 out of 10, no pain. A review of Resident 93's x-ray of right ankle conducted at the facility on 6/19/2021 indicated no evidence of acute fracture. According to a review of Resident 93's nursing notes dated 7/4/2021 at 9:30 AM, Resident 93 complained of right ankle swelling and was administered two tablets of acetaminophen 500 milligrams and tea bags were placed on ankle. A review of Resident 93's nursing notes dated 7/4/2021 at 12:15 PM, indicated Resident 93 complained of 10 out 10 right ankle pain (using scale of zero to 10, 10 indicating the most severe pain) and was administered [MEDICATION(S)] (an opiod used to treat moderate to severe pain) 2 milligrams for breakthrough pain. A review of Resident 93's change of condition (COC) form dated 7/4/2021 indicated Resident 93 had a pain score of 10 out of 10 to right ankle. Resident 93 described the pain as excruciating pain. A review of Resident 93's nursing notes dated 7/4/2021 at 1:15 p.m., indicated Resident 93 was yelling and 911 was called related to the excruciating pain. A review of Resident 93's Physician's Orders dated 7/4/2021 indicated transfer to GACH for right ankle pain. According to a review of Resident 93's General Acute Care Hospital emergency department notes dated 7/4/2021, Resident 93 fell a week ago with a negative xray for fracture and woke up in the morning with excruciating pain radiating proximally into the calf. Resident 93 was administered [MEDICATION(S)] (narcotic medication used to treat severe pain) intravenous 4 milligrams at 3:17 PM and [MEDICATION(S)] (opiod medication to treat pain) intravenous (through the vein) 1 milligram at 3:26 PM. A review of Resident 93's hospital x-ray record of the right ankle, dated 7/4/2021 indicated minimally displaced avulsion fracture of the tip of the lateral malleolus (fracture where a fragment of the bone on the outside of the ankle joint is pulled away at the ligament [fibrous connective tissue which connects two bones or cartilages or holds together a joint] or tendon [a flexible but inelastic cord of strong fibrous collagen tissue attaching a muscle to a bone] attachment). During an observation on 7/13/2021 at 7 AM, the front entrance to the facility was locked preventing unauthorized entry into the facility; however, the front entrance was unlocked from inside of the lobby, allowing for unauthorized exit from the facility. The front entrance was noted without any alarm to notify facility staff of unauthorized exit by residents. During an interview with Director of Nursing (DON) on 7/15/2021 at 7:02 AM, the DON stated residents were brought down to the lobby by the facility staff to be picked up by transportation to be taken to [CONDITION(S)]. The DON stated on 6/19/2021 Resident 93 was left in the lobby without supervision to wait for [CONDITION(S)] transportation, exited the facility through the unlocked front entrance doors, fell outside the facility and suffered an injury. The DON stated the facility front doors did not have an alarm to alert staff residents were exiting without permission. The DON stated the facility failed to provide supervision and ensure the safety for Resident 93 while in the facility lobby waiting for [CONDITION(S)] transportation. The DON stated the outcome was Resident 93 suffered a fracture of the right ankle. During an interview with Director of Rehabilitation (DOR) on 7/15/2021 at 9:15 AM, and a concurrent record review of Resident 93's physical therapy evaluation dated 6/17/2021, the DOR stated the resident was ambulatory (able to walk) with impaired coordination, gait was noted as impulsive (acting or done without forethought) with decreased safety and reduced reactive balance. On 7/15/2021 at 3 PM, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 93 was ready to go to [CONDITION(S)] around 6 AM on 6/19/2021. LVN 1 stated the resident took the elevator to the lobby by himself and was not escorted to the lobby by facility staff. LVN 1 stated there was no receptionist at the lobby at that time and facility staff did not observe or witness Resident 93's fall in front of the facility door and no one witnessed him go across the street to the gas station. LVN 1 stated there was no alarm on the facility front doors. During an interview with Administrator (Admin) on 7/16/2021 at 9:13 AM, Admin stated Resident 93 was in the lobby unsupervised, waiting for a ride to go to [CONDITION(S)] on 6/19/2021 around 6 AM. The Admin stated on weekends the receptionist did not begin work until 8 AM and the front doors did not have an alarm to alert staff of unauthorized exits of residents. The Admin stated Resident 93 walked out the unlocked front doors and fell outside on the front steps and later fell at the gas station across the street. The Admin stated the facility failed to provide supervision and ensure the safety for Resident 93 while he was being picked up for [CONDITION(S)]. During an interview on 7/19/2021 at 3:27 PM, Resident 93 stated he was dressed and waiting for [CONDITION(S)] transportation in the facility lobby around 6 AM. He was alone and there was no staff at the time. Resident 93 stated he wanted to get some cash from the automated teller machine (ATM-machine for withdrawal of cash) and he exited the facility to walk to the gas station. He stated there was no staff watching him in the lobby when he exited at 6 AM and no alarm sounded when he exited the facility. Resident 93 stated he missed the first step in front of the lobby doors and fell on [DATE] around 6 AM. He stated as he was going to the gas station across the street and missed the curb on the sidewalk and fell again. Resident 93 stated when he fell everything was Ok, he felt some sprain, but no pain, and he continued to go to [CONDITION(S)] and returned to the facility on [DATE]. Resident 93 stated several days later he had excruciating pain on the right foot, and he went to the hospital where he was told he had a fracture on the right foot. A review of the facility's policy and procedure titled, [CONDITION(S)] Care, no revision date, indicated the facility would ensure the resident had viable means of transportation to and from the [CONDITION(S)] appointment, and facility staff would supervise the resident to ensure a safe departure.

Based on interview and record review, the facility failed to identify for one sampled resident (Resident 1) accident risks and hazards and provide one-person physical assistance with walking, as indicated in the comprehensive assessment and plan of care, to prevent accidents and injuries. As a result, on 7/2/2020 at 3:30 p.m., when Resident 1 was walking in the hallway without staff assistance and using a front wheel walker (FWW), she fell on her left side sustaining a fracture (break) of the left hip requiring transfer to General Acute Care Hospital 1 (GACH 1) on the same day. On 7/5/2020, Resident 1 underwent surgery to repair the fracture. Findings: A review of the Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 1/7/2020 with [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Assessment, dated 1/7/2020, 3/11/2020 and 6/10/2020, indicated Resident 1 had a balance problem when walking or standing. Resident 1 had a total score of 10, indicating a high risk for fall. A review of the Resident 1's Care Plan, dated 1/7/2020, indicated Resident 1 was at high risk for falls due to impaired balance. The interventions included monitoring, assisting and maintaining a safe environment. The care plan did not include the level of assistance required for Resident 1's safety. A review of Resident 1's Care Plan dated 1/7/2020, indicated Resident 1 needed assistance in performing activities of daily living (ADLs - bed mobility, transfers, walking, personal hygiene, toilet use, and bathing). The Care Plan indicated Resident 1 needed support during transfer and ambulation. The goal was to meet and anticipate Resident 1's needs. The interventions included identifying and assessing Resident 1's needs and assist as needed. According to a review of the Physical Therapy (PT) Treatment Care Plan, dated 6/5/2020, Resident 1 had problems with gait (manner of walking), muscle weakness, decline in functional mobility skills, balance deficits, safety awareness problems and at risk for falls. The PT Treatment care plan goal was to improve functional mobility by providing supervision when Resident 1 used the FWW and improve safety awareness. The care plan intervention included gait training, therapeutic exercises and safety awareness training. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 6/10/2020, indicated Resident 1 was oriented to year, month and day. The MDS indicated Resident 1 needed one-person physical assistance with bed mobility, transfers and while walking inside and outside her room. A review of Resident 1's Physical Therapy PT Discharge Summary dated 7/1/2020, indicated Resident 1 needed contact guard assist (CGA, assisting person has one or two hands on the body but provides no assistance to perform the functional mobility) to safely ambulate on level surfaces 75 feet using FWW to return to prior living and supervision levels. A review of Resident 1's Situation, Background, Assessment, and Request (SBAR) dated 7/2/2020, at 3:30 p.m., indicated Resident 1 was walking around the hallway by herself, lost her balance and slid to the floor hitting her left thigh. Resident 1 complained of pain on her left thigh, the physician was notified, and gave an order for [REDACTED].>A review of Resident 1's final X-Ray Report dated 7/2/2020, indicated Resident 1 had an acute intertrochanteric (in the hip joint) femoral fracture (broken thigh bone). A review of Resident 1's Physician's Telephone Order, dated 7/2/2020, timed at 11 p.m., indicated to transfer Resident 1 to GACH 1 for further evaluation and management of the left [MEDICAL CONDITION]. A review of Resident 1's GACH 1 Orthopedic (doctors who focus on caring for the bones, joints, ligaments, nerves and tendons) Consultation dated 7/5/2020, recommended hip nailing (type of surgery that would use pins, screws or plates to help hold broken bones together). The orthopedist indicated without surgery, Resident 1 would not be able to weight bear (ability of a part of the body to resist or support weight) and not be able to mobilize. A review of Resident 1's GACH 1's Report of Operation indicated Resident 1 underwent surgery on 7/5/2020. On 7/15/2020 at 10:46 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she saw Resident 1 walking in the hallway with the FWW. CNA 1 stated she did not assist Resident 1. When Resident 1 reached the end of the hall, CNA 1 saw Resident 1 losing her balance and fell on her left side. CNA 1 stated she could not reach Resident 1 in time to prevent her from falling. On 7/15/2020 at 10:54 a.m., during an interview, Registered Nurse Supervisor (RNS) stated he saw Resident 1 walking past the Nursing Station using the FWW. RNS stated Resident 1 was walking independently, did not need assistance when walking, and walked in the hallway every afternoon. RNS stated Resident 1 walked towards the end of the hall and fell . Resident 1 complained of left hip pain. During an interview, on 7/15/2020 at 11:12 a.m., the PT Director of Rehabilitation stated Resident 1 should have been supervised while walking and provided standby assist to CGA when walking. On 8/14/2020 at 1:34 p.m., during interview with Licensed Vocational Nurse 1 (LVN 1) and concurrent review of the Fall Risk Assessment, LVN 1 stated Resident 1 had a high risk for falls. On 8/14/2020 at 2:32 p.m., during an interview with LVN 2 and a review of the MDS functional, LVN 2 stated Resident 1 required supervision when walking in the hallway. On 8/14/2020, during an interview, the Director of Nursing (DON) stated Resident 1 was able to ambulate using the FWW and CNA 1 was watching Resident 1 from afar while Resident 1 was walking in the hallway. The DON stated when Resident 1 walks in the hallway, a staff member must be within reach of Resident 1. A review of the facility's undated policy titled, Providing Assistance with ADL Care, indicated the assistance with activities of daily living depending on the level of assistance needed and the number of person (s) needed to assist the resident.

Based on interview and record review, the facility failed to implement accident risks and hazards for one sampled resident (Resident 1). For Resident 1, who was totally dependent on staff and required two-person assist while transferring per the comprehensive assessment, the facility failed to implement care plan interventions to assist Resident 1 to the extent as needed and prevent accidents and injuries. This deficient practice resulted in Certified Nurse Assistant 1 (CNA 1) attempted to solely transfer Resident 1 from bed to the wheelchair, during the transfer and pivot, Resident 1 twisted his left ankle. Resident 1 sustained a left ankle fracture (broken) and required transfer to the general acute care hospital for treatment. Findings: On 9/9/19, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported incident regarding quality of care and treatment. A review of Resident 1's Admission Record indicated an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the care plan dated 5/2/19, (not titled) indicated Resident 1 was at risk for fall due to impaired balance, muscle weakness, lack of coordination. The care plan goal indicated Resident 1 would experience minimal or no injuries from falls. The care plan interventions indicated to monitor the resident and assist resident to extent as needed and to maintain a safe environment. A review of another care plan, dated 5/2/19 (not titled) indicated Resident 1 will need assistance in performing activities of daily living (ADL) secondary to weakness and required extensive assistance for transfers. The care plan interventions included for facility staff to assist the resident in performing ADLs such as dressing, eating, toilet use, assist the resident to be up on the wheelchair and to encourage to participate in activities. According to a review of the Minimum Data Set (MDS - standardize assessment and care screening tool), dated 5/10/19, Resident 1 was cognitively intact. The MDS indicated that Resident 1 was totally dependent on staff with two-person physical assist while transferring from bed onto wheelchair. A review of CNA 1's statement, dated 8/31/19, indicated at 8:45 a.m. on 8/31/19, CNA 1 was assisting Resident 1 to transfer from bed onto the wheelchair. During the transfer and pivot, Resident 1 twisted his left ankle. A review of the Change of Condition / Interact Assessment Record, dated 8/31/19, at 12:34 p.m., indicated Resident 1 had pain in the left ankle and his left ankle was twisted. The record indicated the assigned CNA (CNA 1) reported the resident twisted his left ankle during transferring from bed to wheelchair in the morning around 8:45 a.m. Resident 1 was assessed immediately with no redness, bruising or swelling noted, but the resident complained of pain rated at an 8 out of 10 (10 = severe pain, 0 = no pain) to the left ankle. The record indicated Resident 1 was given an ice pack but the resident stated he wanted pain medication. The charge nurse administered pain medication. The physician was notified with an order for [REDACTED]. At 10:30 p.m., the physician ordered to transfer Resident 1 to an emergency room (ER) for evaluation. A review of the GACH orthopedic consultation report, dated 9/3/19, indicated Resident 1 came to the ER for having swelling and pain on the left foot and ankle. Resident 1 could not move his foot and complained of pain rated at a 9 out of 10 on the left ankle. The record indicated he was diagnosed with [REDACTED]. lungs). A review of Resident 1's History and Physical Record, dated 9/6/19, indicated Resident 1 had the capacity to understand and make decisions. During an interview, on 9/9/19, at 12:38 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that the CNA transferred Resident 1 from bed to chair and the resident hit his leg on the chair. LVN 1 stated that the Registered Nurse (RN) then assessed the resident afterwards and Resident 1 complained of pain. LVN 1 stated that only one CNA was involved during the bed to wheelchair transfer for Resident 1. On 1/25/20, at 4:03 p.m., during an interview the Registered Nurse Supervisor (RNS) stated that when she interviewed Resident 1 on 8/31/19, he stated that he twisted his ankle when he was transferring from bed to wheelchair. The RNS stated that Resident 1 was a total transfer and he required two-person assistance during transfer. The RNS stated CNA 1 rushed him to get up. The RNS stated that the CNA wrote a statement about what happened. A review of the facility's policy titled, Falls and Fall Risk, Managing, revised December 2007, 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 from falling and to try to minimize complications from falling. The policy indicated the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of fall. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who had [DIAGNOSES REDACTED]. This deficient practice was not consistent with professional standards of practice and caused an adverse consequence, pain and suffering to Resident 2, who banged on the side rails and screamed out, Please help. The pain is killing me a lot. Findings: A review of Resident 2's Admission Record, indicated the resident was readmitted to the facility, on 4/19/19, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. According to a review of the [DIAGNOSES REDACTED] Care Plan, dated 3/20/19, Resident 2 was at risk for increased severity of pain and muscle spasms secondary to [DIAGNOSES REDACTED]. The care plan goal indicated Resident 2's pain level would be minimized to a tolerable level daily. The care plan interventions indicated to assess resident's level of pain and administer medications as ordered, but did not include how often to assess Resident 2's pain. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/21/19, indicated the resident's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were impaired. and required extensive to total assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and personal hygiene. A review of the Pain Risk Assessment, dated 5/23/19, indicated Resident 2 was assessed with [REDACTED]. A review of the Weekly Nursing Summary, dated 8/21/19, indicated Resident 2 had a pain change in the past seven days and to see the flow sheet. The weekly summary indicated Resident 2's mental, emotional behavior was screaming out in pain and that [MEDICATION NAME] was helpful. According to a review of the Pain Assessment Flowsheet, dated 8/1 - 8/25/19, Resident 2 had pain rated from 7 - 9 out of 10 (7-9 being severe pain, 10 being the worse possible pain). During an observation and interview, on 8/26/19, at 7:44 a.m., Resident 2 was lying in her bed screaming for pain medication. Resident 2 was banging the siderail and repeating she needed her pain medication. Resident 2 stated she had right side pain, rated at a 9 out of 10. Resident 2 stated, The pain is killing me a lot. Michael help. Michael pain medicine. At 7:45 a.m., a facility staff member entered Resident 2's room and instructed the resident to calm down. During an interview and concurrent record review, on 8/26/19 at 7:46 a.m., the Licensed Vocational Nurse 1 (LVN 1) stated this was Resident 2's behavior all shift. LVN 1 stated the last pain medication was administered to Resident 2 on 8/25/19 at 8 p.m. LVN 1 further stated she had not administered pain medication to Resident 2 because she thought pain medication was administered at 2 a.m. During an observation, on 8/26/19, at 7:58 a.m., LVN 1 prepared to administer the pain medication to Resident 2. LVN 1 stated she needed to crush the medicine. Resident 2 stated, Don't crush it. Give it to me now. LVN 1 administered the medication and asked the resident if she wanted breakfast. Resident 2 stated, I don't know. I'm in pain. At 8:03 p.m., Resident 2 banged on the side rail and stated, Please help. During an observation and concurrent interview, on 8/26/19, at 8:43 a.m., Certified Nursing Assistant 1 (CNA 1) was providing care to Resident 2 and stated Resident 2's call light was not connected and not within the resident's reach to call for assistance. CNA 1 stated Resident 2 used the call light to tap on the siderails. CNA 1 stated Resident 2 screams when she has pain and becomes calm after she receives her medication. Resident 2 was calm in bed. During a phone interview, on 10/11/19, at 12:20 p.m., the Licensed Vocational Nurse 2 (LVN 2) stated nursing staff should assess resident's level of pain every time they make rounds, answering the call light, or when the resident requests it. LVN 2 stated the care plan for Resident 2 did not indicate how often the staff should assess the level of pain. LVN 2 stated it was important for the care plan to include the frequency for staff to follow a more detailed process. A review of the undated facility policy titled, Pain Management, indicated for those residents with complaints of pain, further assessment shall be completed by licensed registered nurse to determine nature, quality, intensity, and effects of pain on daily activities. The policy indicated to ensure residents were provided with care and services necessary for resident to be free of pain and or discomfort within the limits of resident's medical condition or achieve acceptable level of pain. The plan of care shall reflect the resident's acceptable level of pain. The policy indicated the licensed nurse in charge of resident's care shall, on a continuous basis evaluate and monitor for effectiveness of treatment plan in managing resident pain and update the plan of care as necessary and applicable.

Based on interview and record review the facility failed to ensure nursing staff had appropriate competency skills sets and orientation to the facility to assure resident safety to attain or maintain the highest practicable physical well-being for each resident for 95 of 95 facility residents by: 1. Failing to ensure five of five registry agency licensed nurses had evidence of orientation to the facility prior to providing medication to the residents Licensed Vocational Nurse (LVN) 11, 12, 13, 14 and Registered Nurse (RN) 11. 2. Failing to ensure five of five registry agency licensed nurses had evidence of facility skills competency assessment prior to providing care and services to the residents to ensure (Licensed Vocational Nurse (LVN) 11, 12, 13, 14 and Registered Nurse (RN) 11, were knowledgeable of how to provide for the residents' special care needs. As a result, on (MONTH) 6, (YEAR), morning medication pass, the facility's medication error rate was 23.68 percent (5) including significant error of omission of [MEDICATION NAME] (a blood thinner) to Resident 42, who had a history of [REDACTED]. Omission of medications spiralonadactone and [MEDICATION NAME] for Resident 30, eye drops for Resident 44 to treat [MEDICAL CONDITION] and by failing to administer pain medications timely for Resident 43. This deficient practice increase the risk of blood clots to Resident 42 and had the potential to result in adverse reactions to all of the residents who are administered medications in error. Findings: On (MONTH) 5, (YEAR) at 2:15 p.m. during an interview, LVN 11 stated she worked for Staffing Agency 3 and started coming to the facility on (MONTH) 29 as a treatment nurse. A review of the LVN 11's personnel file indicated no documented evidence of a competency skills test. There was no documented evidence of an orientation to the facility. A review of the contract between the skilled nursing facility and Staffing Agency 3 agreed upon on (MONTH) 1, (YEAR) indicated the following: 1. The facility will orient contractors to the facility and its rules and regulations, including the physical layout and equipment on any unit to which such contractors are assigned. 2. The facility staffing supervisors will assist Registry 3 on an ongoing basis with evaluation of the registry contractors by providing performance evaluations. On (MONTH) 5, (YEAR) at 2:27 p.m. during an interview, Licensed Vocational Nurse 12 (LVN 12) stated she works for Staffing Agency 2 but did not have an orientation, by following a nurse. LVN 12 stated she learned about the residents care by asking the other licensed nurses, checking the residents new and existing orders. A review of the LVN 12's personnel file indicated no documented evidence of a competency skills test from the skilled nursing facility. There was no documented evidence of an orientation to the facility. A review of the contract between the skilled nursing facility and Staffing Agency 2 signed on (MONTH) 18, (YEAR) indicated the following: 1. The patient care provider record, based on client's specification shall contain at a minimum the following information, which will be provided to the client upon request. 2. Skills profile -self-assessment 3. Clinical competency exam, by clinical specialty. 4. Pharmacological competency exam, including pediatric pharmacology exam if applicable. On (MONTH) 5, (YEAR) at (YEAR) at 2:38 p.m., during an interview, LVN 15 stated she was a permanent staff of the facility and felt that orientation was lacking with the registry staff working in this facility. LVN 15 stated for this reason medications are not being provided to the resident in a timely manner. LVN 15 stated this can have negative consequences and for example, if a resident does not get his or her [MEDICAL CONDITION] medication she or he can have a [MEDICAL CONDITION]. On (MONTH) 5, (YEAR) at 2:41 p.m. during an interview, the Registered Nurse Supervisor (RN11) stated she worked Staffing Agency 2. RN 11 stated she did not have a formal orientation in the facility. RN 11 stated the Director of Nursing did verbalize the duties of the RN supervisor. RN 11 stated she learns about the resident's treatments and conditions by talking to the residents, asking questions, making observations and doing the treatment sometimes. RN 11 stated it would be good to have more orientation about the forms the facility uses for care of the residents. A review of the RN 11's personnel file indicated no documented evidence of a competency skills test from the skilled nursing facility. There was no documented evidence of an orientation to the facility. RN 11's personnel file indicated a Skills Profile (assessment) from Staffing Agency 2. On (MONTH) 5, (YEAR) at 3:04 p.m. during an interview LVN 13 who worked for Staffing Agency 1 stated this day was his second day working in this facility. LVN 13 stated he did not get any orientation to the facility. LVN 13 stated he learns about the residents care by looking at the care plan, the Medication Administration Record [REDACTED]. A review of the LVN 13 personnel file indicated no documented evidence of a competency skills test from the skilled nursing facility. There was no documented evidence of an orientation to the facility for LVN 13. Resident 13 had a clinical competency checklist from the Registry dated (MONTH) 6, (YEAR). A review of the contract between the skilled nursing facility and Staffing Agency 1 (one of the temporary staffing agencies) signed by the administrator on (MONTH) 17, (YEAR) indicated the following: 1. Hospital shall provide a written and electronic information to agency of the purpose of orienting a staff prior to an assignment at hospital. This information shall be provided to staff by agency and shall address relevant hospital policies and methods of delivering patient care. When the staff commences work at a hospital, the staff shall be provided with information about location, of emergency exits, how to call an emergency, the location of the emergency carts, and other information that hospitals require a staff to know. 2. Hospitals shall provide each staff with employment orientation prior to staff's first assignment at the hospital. Hospital further agrees to complete a performance evaluation of staff when reasonably requested by Agency, but not less than at the completion of each contract assignment. On (MONTH) 5, (YEAR) at 3:09 p.m. during an interview LVN 14 sated she had been working for Staffing Agency 2. LVN 14 stated she did not get any orientation in the facility. LVN 14 stated she learns about how to care for the residents by asking the residents questions, looking in the charts, reading the residents' history and physical notes, checking the orders, physical therapy notes, and dietary notes. LVN 14 stated she could have used orientation regarding the facility protocol, and where things are kept and the forms the facility uses pertaining to the care of the residents. A review of the LVN 14 personnel file indicated no documented evidence of a competency skills test from the skilled nursing facility. LVN 14 personnel file only indicated a skills profile and performance evaluation from Staffing Agency 2. On (MONTH) 5, (YEAR) at 5:49 p.m. during an interview, LVN 17 stated she worked for a staffing agency (unspecified). LVN 17 stated no one has told her about any issues with medication administration in the facility. LVN 17 stated no one directly talked about an Immediate Jeopardy (IJ). On (MONTH) 5, (YEAR) at 6:19 p.m. during an interview RN 12 stated she could see there were issues with medication administration when she would look at the residents' Medication Administration Record [REDACTED]. On (MONTH) 5, (YEAR) at 6:05 p.m. during an interview Resident 43 who was alert and oriented to name, time and place stated, she gets her medications late. Resident 43 stated if I get my medicine when I am supposed to, then my pain will not be 10 out 10 (on a pain scale of 1 to 10 (0 being no pain and 10 being the most severe pain possible the resident has ever experienced). A review of admission record indicated Resident 43 was admitted on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 10/325 milligram (mg), one tablet to give every four hours as needed for severe pain. 2. [MEDICATION NAME] 75 mg 1 capsule twice a day for neuropathic pain (pain caused by damage or disease). 3. [MEDICATION NAME] solution 0.2-0.5%, instill 1 drop in both eyes twice a day for [MEDICAL CONDITION] at 9 am and at 9 pm. The section of the MAR indicated [REDACTED]. 4. [MEDICATION NAME] solution 0.01%, instill 1 drop in both eyes at bedtime for [MEDICAL CONDITION] at 9 pm. The section of the MAR indicated [REDACTED]. 5. Folic acid 1 mg, one tablet every day for [MEDICAL CONDITION] (a deficiency of red blood cells.) The section of the MAR indicated [REDACTED]. Severity and Scope: E On 11/16/18 at 9:48 a.m., during verification of accepted written Plan of Action dated 11/15/18, for the immediate jeopardy called on 11/5/18, at 7:05 p.m., and 11/6/18, at 1:45 p.m. Based on observation, interview and record review, the facility failed to ensure that licensed nurses have the skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of four sampled residents (Resident 44), including but not limited to: 1. Failure to follow the physician order [REDACTED]. Resident 44, complaint of moderate to severe pain on 11/1, 11/7, 11/9, 11/10, 11/13/18 at 9 a.m. and 2 p.m., and 11/16/18, Tylenol two tablets was administered. 2. Failure to notify the physician, when Resident 44 had an increase pain level and there was no pain medication order that correspond to resident moderate to severe pain. This deficient practice resulted to and had the potential for resident to experience unnecessary pain. Findings: On 11/17/2018 at 4:47 p.m., during the medication pass (MedPass) Registry Licensed Vocational Nurse (RLVN 17) was observed preparing the evening medications for Resident 44. RLVN 17 asked Resident 44 if she had pain, and Resident 44 stated she has right upper arm pain and about 4/10 on pain scale. On 11/17/2018 at 4:55 p.m., RLVN 17 administer the prepared medications that included two (2) tablets of Tylenol 325 milligrams (mg). On 11/17/2018 at 8 p.m., during an interview, Resident 44 stated most of the time Tylenol is enough to relieve the pain, other times she need to ask for another dose of Tylenol. A review of Resident 44's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 44's physician order [REDACTED]. A review of Resident 44's Pain Assessment Flow Sheet indicated a word descriptive of pain scale as follows: 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, and 10 worse possible pain. Further review indicated the following: - 11/1/18 at 12:40 pm pre-[MEDICATION NAME] pain rating 8/10, two tablets of Tylenol 325 mg was given - 11/7/18 at10 am pre-[MEDICATION NAME] pain rating 5/10, two tablets of Tylenol 325 mg was given - 11/9/18 at 10 am pre-[MEDICATION NAME] pain rating 6/10, two tablets of Tylenol 325 mg was given - 11/10/18 at 7 am pre-[MEDICATION NAME] pain rating 8/10, two tablets of Tylenol 325 mg was given - 11/13/18 at 9 am pre-[MEDICATION NAME] pain rating 6/10, two tablets of Tylenol 325 mg was given - 11/13/18 at 2 pm pre-[MEDICATION NAME] pain rating 7/10, two tablets of Tylenol 325 mg was given - 11/16/18 at 10 am pre-[MEDICATION NAME] pain rating 5/10, two tablets of Tylenol 325 mg was given On 11/17/2018 at 8:17 p.m., during an interview and concurrent review of Resident 44's Pain Assessment Flow sheet and Medication Administration Record [REDACTED]. RLVN 17 stated that the licensed nurses should give the pain medication base on the resident pain level. RLVN 17 stated that the physician should have been called if pain level is above mild pain. RLVN 17 stated she will call the physician to get new order for pain medication. The facility policy titled Administering medications, revised (MONTH) 2012; indicated medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of nine medication errors out of 38 opportunities for error, to yield a cumulative error rate of 23.68 % for three out of two residents observed (Resident 30 and 44). 1. For Resident 30 the facility's licensed vocational nurse (LVN 18) failed to ensure Resident 30's medications that included but not limited to [MEDICATION NAME] ([MEDICATION NAME], a medication to treat mental and mood disorders), [MEDICATION NAME] ([MEDICATION NAME], used to remove excessive fluid from the body in [MEDICAL CONDITION]), [MEDICATION NAME] ([MEDICATION NAME], medication to lower cholesterol and fat in the blood), [MEDICATION NAME] ([MEDICATION NAME], medication to reduce the production of uric acid in the blood that may cause gout attacks or kidney stones), Vitamin D ([MEDICATION NAME], a vitamin supplement to help strengthen the bones) were documented accurately and administered correctly at the right time, right dosage, and for [MEDICATION NAME] with food as ordered by the physician. These failures increased Resident 30's risk for avoidable adverse reactions that included but not limited to dizziness, drowsiness, unsteadiness, diarrhea and stomach irritation and/or pain. 2. For Resident 44, the facility failed to administer [MEDICATION NAME] 2% eye drop as ordered by the physician. A second IJ was called on (MONTH) 6, (YEAR), at 1:45 p.m., in the presence of the Administrator, the Assistant Administrator and the Interim Director of Nurses for F759, for medication error rate of 23.68 percent (%). The Administrator, the Assistant Administrator and the Interim Director of Nurses were notified to submit a written plan of action. Findings: a. A review of Resident 30's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] (infection of the bone), heart failure (heart cannot pump enough blood to meet the body's needs), [MEDICAL CONDITION] (high cholesterol), [MEDICAL CONDITION] (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), difficulty walking, and lack of coordination. A review of Resident 30's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/11/18 indicated Resident 30 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was interviewable (8-15= interviewable). According to the MDS, the resident was assessed as requiring facility's supervision for walking, eating, toilet use, dressing and personal hygiene. On 11/6/18 at 7:25 a.m., during the medication pass (MedPass) observation LVN 18 was observed preparing the following morning medications for Resident 30 that included: [MEDICATION NAME] 25 mg, one tablet [MEDICATION NAME] 3 mg, one tablet [MEDICATION NAME] 54 mg, one tablet On 11/6/18 at 7:48 a.m., Resident 30 was standing at LVN 18 medication cart (MedCart) as LVN 18 stated he had a total of 14 pills inside of one medication cup. LVN 18 poured a cup of water and began to hand the medication cup to Resident 30 to take his morning medications; LVN 18 was stopped by the surveyor and asked to review Resident 30's [MEDICATION NAME] 25 mg and [MEDICATION NAME] 3 mg medication orders. Resident 30 stated clearly that he was only to receive one-half tablet of [MEDICATION NAME] and that his [MEDICATION NAME] was to be administered to him at bedtime. During a concurrent record review LVN 18 reviewed Resident 30's prescription labels and the Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 3 mg - one tablet by mouth at bedtime 2. [MEDICATION NAME] 25 mg - one-half (12.5 mg) by mouth daily LVN 18 stated that he should not give the [MEDICATION NAME] in the morning. LVN 18 took out the [MEDICATION NAME] tablet and handed the medication cup back to Resident 30. Resident 30 stated again to LVN 18, I suppose to have a one-half tablet of [MEDICATION NAME]. You did not give me half. This is a full pill. On 11/6/18 at 8:06 a.m., during an interview, Resident 30 stated that most of the time he gets the correct medications. Resident 30 stated that he had not had breakfast that morning and that he did not want it. A review of Resident 30 medication orders indicated that the [MEDICATION NAME] 54 mg, one tablet was to be administered with food. However, Resident 30 stated that he had not eaten breakfast and no food was observed being offered to the resident with the medication as order by the physician. A review of Resident 30 MAR for (MONTH) (YEAR) indicated by licensed nurse's initial that Resident 30 was administered on 11/6/18 during the morning medication pass two additional medication, [MEDICATION NAME] 100 mg and [MEDICATION NAME] 2,000 units, however neither medication was observed administered to Resident 30; and seven out of the 11 medications that were administered to Resident 30 were not initialed as administered. On 11/6/18 at 12:04 p.m., during an interview and record review in the presence of the facility's consultant pharmacist (CP 1), LVN 15 stated that she had not administered any of Resident 30's morning medications and that LVN 18 had verbally stated to her that he had given Resident 30 all of his morning medications, and acknowledged that medication administration must be documented. After reviewing Resident 30's MAR indicated [REDACTED]. LVN 15 further stated that Resident 30 sometimes do not want to eat breakfast, but he does like Jell-O and pudding and she would encourage him to eat because he receives diabetic medications and cholesterol medications that should be taken with food. During a concurrent interview CP 1 stated that Resident 30's cholesterol medication [MEDICATION NAME] should be taken with food to increase the absorption and effectiveness of the medication. A review of the facility's undated policy titled, Policy and Procedure on Medication Error Rate, indicated, All medications shall be administered as prescribed and in accordance with required medication administration techniques. A review of another facility's undated policy titled, Policy and Procedure on Oral Medications, indicated, Licensed nurse shall verify physician's orders [REDACTED]. a) Right patient b) Right medication and drug form (tablet, capsule, liquid) c) Right dosage/strength d) Right route of administration e) Right timing (oral drugs may irritate the GI (gastrointestinal) tract therefore, it is important to follow instructions on how to administer medication, whether with food or without food) . f) Always compare the name of an ordered medication with the name printed on the container label. IJ onsite verification of written Plan of Action accepted on 11/15/18. On 11/16/18 at 9:48 a.m., during verification of accepted written Plan of Action dated 11/15/18, for the immediate jeopardy called on 11/5/18, at 7:05 p.m., and 11/6/18, at 1:45 p.m. Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of ten medication errors out of 25 opportunities for error, to yield a cumulative error rate of 40 % for one out of six residents observed (Resident 2). Facility failed to ensure medications for administration through a gastrostomy tube ([DEVICE], a surgically opening for administration of food, medications and fluids directly into the stomach) were not crushed and combine prior to administration to Resident 2. This deficient practice had the potential to affect any resident that received medication through a [DEVICE], increasing the risk for drug incompatibilities, altered therapeutic response, and/or feeding tube occlusions (blockage). On 11/16/18, around 3 p.m., the Temporary Management, Interim Director of Nurses and Administrator were notified that the IJ was not removed. A written Plan of Action to remove the immediate jeopardy was requested. Findings: A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2 [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/8/18 indicated that Resident 2 was rarely or never able to make herself understood and rarely are never able to understand others. According to the MDS, Resident 2 was totally dependent upon facility's staff for one person physical assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. On 11/16/18 at 9:48 a.m., during the medication pass (MedPass) observation with a Licensed Vocational Nurse (LVN 22) on Medication Cart (MedCart) 1, LVN 22 was observed preparing the following morning medications for Resident 2 that included: 1. [MEDICATION NAME] (Keflex, an antibiotic to treat an infection) 250 milligrams (mg), one capsule 2. [MEDICATION NAME] (to treat high blood pressure) 10 mg, one tablet 3. [MEDICATION NAME] [MEDICATION NAME] (to treat [MEDICAL CONDITION], low red blood cells) 220 mg/5 ml (milliliters), 30 ml 4. Losartan Potassium ([MEDICATION NAME], treat high blood pressure and reduce the risk of a stroke) 100 mg, one tablet 5. Multivitamin with Minerals (a daily vitamin supplement), one tablet 6. [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME], controlled pain medication) 5/325 mg, one tablet 7. [MEDICATION NAME] Sodium (Stool Softener) 100 mg, 2-1/2 tablets (250 mg) 8. [MEDICATION NAME] HCL (treat high blood pressure) 300 mg, one tablet 9. Levetiracetam ([MEDICATION NAME], medication to prevent [MEDICAL CONDITION], involuntary muscle tremors) 100 mg/ml, 5 ml (500 mg) 10. Magnesium Oxide (a supplement to maintain adequate magnesium in the body), LVN 22 stated, I do not have this medication. On 11/6/18 at 9:58 a.m., LVN 22 was observed punching out and placing into one medication cup the following six medications [MEDICATION NAME], Losartan Potassium, [MEDICATION NAME] HCL, and Multivitamin with Minerals, [MEDICATION NAME]/[MEDICATION NAME], and adding two and one-half tablets of [MEDICATION NAME] Sodium to the medication cup. At 10:01 a.m., in a cup LVN 22 opened and emptied the contents of the antibiotic [MEDICATION NAME] Capsule into the [MEDICATION NAME] [MEDICATION NAME], and then added to the same medication cup Resident 2's [MEDICAL CONDITION] medication Levetiracetam Oral liquid. During a concurrent interview LVN 22 stated, I usually mix all the liquids (medications) together. LVN 22 was observed placing six different medications inside of one pouch and crushing the combined medications together; then emptied the crushed medications into a second cup. LVN 22 was observed pouring water into the two different cups and stated. I added about 200 ml of water to each of the two medication cups. At 10:16 a.m., LVN 22 put on a pair of gloves without washing or sanitizing her hands and entered Resident 2's room to administer the resident her medication. After checking the resident's [DEVICE] placement and checking for residual LVN 22 stated she was going to administer the combined medications that were contained in the two medications cup she had placed beside the resident's bed. LVN 22 was stopped before medication was administered to Resident 2 and was asked if she knew if it there were any interactions between the medications that she had crushed and mixed together. LVN 22 stated, I do not know if the medications have any interactions. The doctor ordered the medications and she has the same doctor for all of her medications. At 10:24 a.m., in the presence of LVN 22, a second nurse (LVN 19) entered Resident 2's room and was asked to look at the medications in the medication cup that was to be administered to Resident 2. During a concurrent interview after leaving Resident 2's room with the two cups of medication and in the presence of LVN 22, LVN 19 stated, We (facility's licensed nurses) administer one medication in a separate cup at a time; so you would know which medication you are giving. We have to call the pharmacy that we are going to waste these medications. LVN 22 stated that she had not received training on [DEVICE] medication administration until now. A review of Resident 2's written physician order [REDACTED]. However, the order was handwritten on the facility's telephone order sheet as [MEDICATION NAME] 250 mg via [DEVICE] four times a day for 10 days, which was half the prescribed dosage of 500 mg and was not in the oral suspension form as ordered by the physician. A review of Resident 2's Medication Review Report indicated the physician ordered: 1. [MEDICATION NAME] [MEDICATION NAME] with an order date of 8/31/18 to administer 25 ml to equal 1100 mg; however LVN 22 prepared a dose of 30 ml (1320 mg). The facility failed to clarify the order to prevent over medication of iron for Resident 2. 2. [MEDICATION NAME] Sodium Capsule 250 mg with an order date of 6/29/18 to administer one capsule two times a day for Bowel Management, hold for loose stool. LVN 22 was observed preparing [MEDICATION NAME] Sodium 100 mg tablets, two and one-half tablets with no documentation that the order had been changed from the capsule to the tablet formulation. 3. Magnesium Oxide 240 mg with an order date of 8/6/18 with instructions to administer 240 mg via [DEVICE] two times a day for supplement. Medication is available as 400 mg (containing 240 mg Elemental Magnesium per Tablet). The facility failed to clarify the order to prevent confusion and to ensure that Resident 2 would receive the correct dosage of medication as prescribed. On 11/16/18 at 1:14 p.m. during a medication cart audit on MedCart 1 with another LVN, LVN 23 opened MedCart 1 and was able to show that both [MEDICATION NAME] Sodium Capsule 250 mg with an open date of 11/10/18 and an expiration date of 1/21 and Magnesium Oxide 400 mg (containing 240 mg Elemental Magnesium per Tablet) with an open date of 10/24/18 and an expiration date of 11/20 were both available in MedCart 1 and could have been administered to Resident 2 as prescribed. A review of the facility's undated policy titled, Medications Administered via an Enteral Feeding Tube, indicated, Refer to medication reference text for administration of any medications when added to any substance such as applesauce, juice, or milk .Properly identify the Resident/Patient and explain the type of medication to be administered .Wash hands before starting; gloves should be worn .Administer each of the medications separately, flushing with 5-10 ml of water between each medication. A review of another facility's policy titled, Administering Medications, with a revised date of 12/2012, indicated, Medications shall be administered in a safe and timely manner, and as prescribed . a. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions . b. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. c. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned . b. On 11/6/2018 at 10:27 a.m., during the medication pass (MedPass) facility's Licensed Vocational Nurse (LVN 10) was observed preparing the morning medications for Resident 44 that included [MEDICATION NAME] 2% (medication use to lower the pressure inside the eyes) eye drops. On 11/6/2018 at 10:35 a.m., LVN 10 entered Resident 44's room to administer the prepared medications. Resident 44 was awake, lying on bed, alert, oriented, and had clear speech. LVN 10 started to administer [MEDICATION NAME] 2% to Resident 44 right eye, however, no medication was coming out from bottle. LVN 10 confirmed the medication bottle was empty. During concurrent interview with Resident 44, she stated she gets her eye medication three times a day. Resident 44 stated she did not received her eye medication since 11/2/18 in the afternoon. On 11/6/2018 at 11:20 a.m. during interview, LVN 10 stated that she did not know when was the medication ran out. She further stated she will order the medication. A review of Resident 44's Medication Administration Record [REDACTED]. A review of Resident 44's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] [DIAGNOSES REDACTED]. A review of Resident 44's physician order [REDACTED]. A review of Proof of Prescription Delivery for Resident 44 dated 10/10/18 indicated [MEDICATION NAME] 2% eye drop was delivered 10/10/18 at 9:09 am. On 11/6/2018 at 11:20 a.m. during interview, Dispensing Pharmacist stated medication [MEDICATION NAME] 2% eye drop was last delivered 10/10/18. The Dispensing Pharmacist stated the eye drop medication is only good for 16 days. She further stated that if the medication was administered correctly this eye drop will be empty by 10/27/18. However, a review of the pharmacy record indicated there was no eye drop medication delivered to the facility after 10/27/18.

Based on observation, interview and record review, the facility administration failed to effectively and efficiently maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 95 of 95 residents by: 1. Failing to implement the Plan of Action accepted by the Department of Health Services on (MONTH) 1, (YEAR), for an Immediate Jeopardy (IJ) including to ensure medications are given as ordered. 2. Failing to ensure registry-licensed staff had competency skills enough to administer medications accurately and safely. 3. Failing to ensure registry licensed staff were oriented to the facility as indicated in the licensed nurse registry (Agency 1, 2, 3 and 4's) contract. 4. Failing to advise registry-licensed staff of the facility's Immediate Jeopardy (IJ) status in order to minimize significant medication errors and a high medication error rate of 23.68 percent (%). On (MONTH) 5, (YEAR), at 7:05 p.m., an Immediate Jeopardy was called in the presence of the Administrator, the Assistant Administrator, and the Director of Staff Development and a written Plan of Action was requested to resolve the immediate jeopardy for a significant medication error of Resident 42's [MEDICATION NAME] not administered from (MONTH) 1 to 5, (YEAR). Registry licensed staff lack of competency in medication pass, lack of orientation to the facility for registry licensed staff, and failure to implement the Immediate Jeopardy Plan of Action accepted by the Department of Health on (MONTH) 1, (YEAR). On (MONTH) 6, (YEAR), at 9:40 a.m., a written Plan of Action was not submitted and a written Plan of Action was requested. The Administrator stated the facility would submit a written Plan of Action after the arrival of an Interim Director of Nurses (DON). On (MONTH) 6, (YEAR), at 1:45 p.m., a written Plan of Action was not submitted and a written Plan of Action was requested. On (MONTH) 6, (YEAR), at 4 p.m., a written Plan of Action was submitted and reviewed. The written Plan of Action was not accepted and the facility Administrator and Interim DON were notified. On 11/16/18 at 9:48 a.m., during verification of accepted written Plan of Action dated 11/15/18, for the immediate jeopardy called on 11/5/18, at 7:05 p.m., and 11/6/18, at 1:45 p.m. Based on observation, interview and record review, the facility failed to maintain effectively and efficiently the accepted Plan of Action as manifested by failure to clarify orders and update Medication Administration Records (MAR) for one of three sampled residents (Resident 19) which had the potential to result in an adverse reaction or ineffectiveness of the medication. Findings: During a medication pass observation on 11/17/2018, at 4 p.m., on Station one. Licensed Vocational Nurse 22 (LVN 22) administered [MEDICATION NAME] 2.5 milligrams (mg), oyster shell calcium 500 mg, humalin R 6 units, [MEDICATION NAME] 2 scoops, refresh eye drops, deep sea saline nasal spray, [MEDICATION NAME] ointment to both nostrils, and [MEDICATION NAME] polymyin ointment to both eyes of Resident 19. During a medication reconciliation indicated an order dated 3/12/2018 for [MEDICATION NAME] (a topical antibacterial agent) nasal ointment to both nostrils three times daily for dryness. Another order dated 10/22/2018 for Vaseline gel to both nostrils twice daily for nosebleed. During an interview with LVN 24 on 11/17/2018 at 4:40 p.m., an inquiry was made regarding the [MEDICATION NAME] nasal ointment and Vaseline gel orders; she was not able to explain the reason for the two orders and stated the orders should have been clarified. The written Plan of Action (POA), accepted by the department on 11/15/18, indicated that on 11/7/18, the facility initiated facility wide three-way medication audit by the pharmacy consultant with the completion date of 11/8/18. The POA indicated pharmacy consultant and licensed staff conducted a thorough three way cart audits, which comprises of the following: a. Review of the physicians orders and clarifications were done as needed, b. Medication supply checked against the Medication Administration Record, c. Medications that needed to be reordered and received. A review of monitoring medication audit dated 11/12, 11/13, 11/14, 11/15, 11/16, 11/19, 11/20, 11/21, 11/23, 11/26, 11/27 and 11/30/18, indicated a pharmacy conducted residents' medication review audit. The audit did not specify if the physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure that nursing staff had specific competencies and skills sets necessary to care for 99 of 99 residents' needs by failing to: Ensure that staff were competent and received full orientation before providing care to residents in the facility. Seven of seven registry-licensed nurses had no documentation receiving orientation and competency assessment before providing care to the residents. Ensure licensed nurses were competent in basic nursing skills of medication administration and following the plan of care of eight of 53 sampled (Residents 121, 122, 124, 126, 129, 131, and 127). Residents 121, 122, 124, 126, 129, 131, and 127 did not receive their medications timely, per the physician order. Ensure the licensed nurses were competent on documentation of actual care provided to the residents such as when the medication are not given on time, reason as to why the medication are not given and notification of the physician when holding the medication for more than three consecutive days. Ensure the facility implement the facility's policy on Administering Medications for the Director of Nursing Services to supervise and direct all nursing personnel who administer medications and/or have related functions. The Director of Nurses was not aware of the facility bubble pack medication card (a blister pack with each tablet or capsule individually sealed and label with date) cycle system (a procedure on how to use the bubble pack medication card) to ensure licensed nurses are adhering on this procedure. These deficient practices had the potential to increase the risk of medication error, may cause physical and psychosocial harm, effecting the resident's therapeutic drug levels (the amount of the drug found in blood), risk of [MEDICAL CONDITION] (a burst of abnormal electrical activity in the brain), and hypertensive crisis (when a blood pressure is extremely high). Cross reference F755 During a complaint investigation on 10/31/18, at 2:15 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 to a resident) was called. The facility failed to provide registry staff sufficient orientation and competency screening before passing medications. Findings: On 10/27/18, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. a. A review of the admission record indicated Resident 121 was admitted , on 12/28/17, with [DIAGNOSES REDACTED]. A review of Resident 121's Minimum Data Set (MDS - an assessment and care-screening tool), dated 10/7/18, indicated Resident 121 had clear speech, the ability to express ideas and wants, and responds adequately to simple direct command. The MDS indicated the resident required extensive assistance from staff with bed mobility, dressing, and personal hygiene. During an observation, on 10/27/18, at 10:15 a.m., the Registry Licensed Vocational Nurse (RLVN 3) was observed administering medications (a multivitamin and potassium chloride packet) scheduled for 9 a.m. to Resident 121, at 10:15 a.m. RLVN 3 stated she was not familiar with each resident's preference of taking the medication. RLVN 3 stated she was a registry LVN, and she received orientation about the residents and the facility yesterday, 10/26/18. RLVN 3 stated this was her second shift working at the facility and several residents would be affected by administering medications late. RLVN 3 provided a list of eight residents affected by late administration of medications and stated late delivery of medications may have a negative impact on residents' health depending on the medication. A review of the Medication Administration Record [REDACTED]. A review of the care plan, dated 7/21/18, indicated Resident 121 had a risk for pain, [MEDICAL CONDITION] (swelling), discoloration of extremities, and skin breakdown, secondary to circulatory problems. The nursing interventions indicated nurses would give medications as ordered. b. A review of the admission record indicated Resident 122 was admitted , on 10/24/18, with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident 122 had clear speech, the ability to express ideas and wants, and clear comprehension (understanding). The MDS assessed Resident 122 as requiring extensive assistance from staff with bed mobility, dressing, and personal hygiene. During an observation, at 10:50 a.m., RLVN 3 was observed administering medications scheduled for 9 a.m. to Resident 122. Per the physician's orders [REDACTED]. A review of the MAR, (MONTH) (YEAR) indicated RLVN 3 administered the medications at 9 a.m. to Resident 122, but the medications were observed given at 10:50 a.m. A review of the care plan, dated 10/24/18 indicated Resident 122 was admitted for skilled care with a long-term goal of no injury from [MEDICAL CONDITION]. The care plan intervention indicated to administer medications as ordered. During an interview RLVN 3 on 10/27/2018 at 12:30 p.m., RLVN 3 provided a list of residents that she gave the medication after 10:50 a.m., which should have received the medication at 9 a.m. The list included the following residents: Resident 124, 126, 129, 131, and 127. c. A review of Resident 124 admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 124's (MONTH) MAR, the following medications was scheduled to be given by 9 a.m. on 10/27/18: [MEDICATION NAME] Allergy tablet (allergy medication) tablet by mouth one time a day for allergy, Tiotripium [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 18 mcg capsule, one puff inhale orally one a day for [MEDICAL CONDITION]. [MEDICATION NAME] Diskus Aerosol Powder 500-50 microgram (mcg) per dose one puff inhale orally every 12 hours for [MEDICAL CONDITION], [MEDICATION NAME] (medication used to treat high blood pressure) 50 mg tablet, by mouth two times a day for high blood pressure. Losartan Potassium (medication used to treat high blood pressure) 50 mg tablet, by mouth every 12 hours for high blood pressure [MEDICATION NAME] Aerosol Solution (medication used to treat [MEDICAL CONDITION]) 20-100 MCG/ACT 18 grams, inhale orally three times a day. Dorzolamide HCI solution 2% eye drops to instill one drop in both eyes three times a day for [MEDICAL CONDITION] (a condition of increased pressure within the eyeball, causing gradual loss of sight). [MEDICATION NAME] (medication used to treat high blood pressure) 50 mg tablet, give one tablet by mouth every 12 hours for high blood pressure. A review of Resident 124's (MONTH) MAR, RLVN 3 documented the eight medications was administered at 9:00 a.m. on 10/27/18. However, RLVN 3 stated she administered the medications to Resident 124 after 10:50 a.m. on 10/27/18. A review of Resident 124's MDS dated (MONTH) 4, (YEAR) indicated the resident had clear speech, had ability to express ideas and wants, and clear comprehension (understanding). The MDS assessed Resident 124 requiring assistance from staff with bed mobility, dressing, and personal hygiene. d. A review of Resident 126's Admission Record indicated Resident 126 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 126's (MONTH) MAR, the following medications were scheduled to be given by 9 a.m. on 10/27/18: [MEDICATION NAME] Sodium (stool softener) 100 mg tablet [MEDICATION NAME] (medication used to treat and prevent ulcers in the stomach and intestines) 20 mg tablet [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorders and nerve damage) 300 mg tablet [MEDICATION NAME] (medication used to treat high blood pressure) 10 mg tablet Aspirin (medication used medicinally to relieve mild or chronic pain and to reduce fever and inflammation) 81 mg tablet Xarelto (medication used as a blood thinner) 15 mg tablet On the same date, a review of Resident 126's (MONTH) MAR, indicated RLVN 3 documented the six medications were administered at 9:00 a.m. on 10/27/18. However, RLVN 3 stated she administered the medications to Resident 126 after 10:50 a.m. on 10/27/18. e. A review of Resident 129's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 129's (MONTH) MAR, the following medications were scheduled to be given by 9 a.m. on 10/27/18: [MEDICATION NAME] sodium 250 mg capsule Vitamin D 1000 units tablet [MEDICATION NAME] 10 mg tablet A review of Resident 129's (MONTH) MAR, RLVN 3 documented the three medications was administered at 9:00 a.m. on 10/27/18. However, RLVN 3 stated she administered the medications to Resident 129 after 10:50 a.m. on 10/27/18. f. A review of Resident 131's Admission Record indicated the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 131's (MONTH) MAR, the following medications were scheduled to be given by 9 a.m. on 10/27/18: [MEDICATION NAME] (used to treat high blood pressure) tablet 50 mg [MEDICATION NAME] (used to treat high blood pressure) 50 mg tablet Volaren (used for the treatment of [REDACTED]. [MEDICATION NAME] (used to lower the pressure inside the eyes) 1 drop Multi-vitamin minerals 1 tablet [MEDICATION NAME] (used to lower the pressure inside the eyes) 1 drop in right eye [MEDICATION NAME] 100 mg capsule [MEDICATION NAME] (used to lower the pressure inside the eyes) Solution 1 drop in each eye Gatifloxacin (antibiotic) Solution 1 drop in left eye Artificial tear solution 1.4% 1 drop both eyes A review of Resident 131's (MONTH) MAR, RLVN 3 documented the eight medications was administered at 9:00 a.m. on 10/27/18. However, RLVN 3 stated she administered the medications to Resident 131 after 10:50 a.m. on 10/27/18. [MEDICATION NAME] 50 mg tablet not documented as given and no reason why it was not given for the 9 a.m. dose on 10/27/18. g. A review of Resident 127's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 127's (MONTH) MAR, the following medications were scheduled to be given by 9 a.m. on 10/27/18: Nephro Vite 0.8 mg tablet [MEDICATION NAME] Patch 0.1 mg [MEDICATION NAME] [MEDICATION NAME] sodium 5000 units subcutaneously In addition, Resident 127's Nephro Vite 0.8 mg tablet, [MEDICATION NAME] Patch 0.1 mg [MEDICATION NAME] and [MEDICATION NAME] sodium 5000 units subcutaneously, RLVN 3 initials and circled. There was no documentation why the licensed nurse initial was circled or if the medication was refused. The facility policy and procedure titled Administering medications, revised (MONTH) 2012, indicated the Director of Nursing Services would supervise and direct all nursing personnel who administer medications and / or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example before and after meal orders). The Charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. h. On (MONTH) 31, (YEAR), at 1:20 p.m., during an interview with director nurses (DON), he stated that the facility has many systems that are broken. The DON stated he is currently not aware of the facility pharmacy bubble pack cycle and he is not in charge of the registry licensed staff orientation. The DON stated that he is new to the facility and there was no skills competency check done prior to registry-licensed nurses provides care to the residents i. On (MONTH) 31, (YEAR), at 10:45 a.m., during an interview and inspection of medication Cart 3 with Registry Licensed Nurse 14 (RLVN 14), she stated that this would be the fourth time she is passing medication for the facility. When asked what type of orientation she received prior to passing medication, she stated that she has been a nurse for a while and knows how to give medication. RLVN 14 stated that she did not receive a formal orientation from the facility. RLVN 14 stated she learn on her own about the residents care needs and preferences every day. On (MONTH) 31, (YEAR), at 2 p.m., during an interview with the Director of Staff Development (DSD), she provided seven registry licensed nurses names and one certified nursing assistant name. When asked what type of orientation was provided to the registry staff she stated that the agency would email her the name and credential of the registry staff prior to working to the facility. The DSD was not able to provide documentation of what type of orientation and skills competency assessment was done prior to registry-licensed nurses providing care to the residents.

Based on obsevation, interview, and record review, the facility failed to ensure pharmaceutical services were provided accurately and safely for 99 of 99 residents, involving four of four-medication cart, by failing to: Ensure residents received their medication as ordered by the physician as manifested by consistent documentation in the Medication Administration Record [REDACTED]. Ensure the medications are reconcilable with the available amount in the bubble pack medication card (a blister pack with each tablet or capsule individually sealed and label with date), the date and the quantity the dispensing pharmacy dispensed the medication. For 26 of 53 sampled residents (Residents 17, 3, 18, 20, 24, 27, 28, 31, 32, 37, 41, 6, 7, 8, 9, 10, 11, 12, 120, 126, 129, 132, 133 and 134) the bubble packs should have been empty but medications were observed in the bubble packs card and in the nasal bottle. Ensure residents' medications are available in the medication cart as ordered by the physician for three of 53 sampled residents (Residents 8, 9 and 10). Ensure medication records for controlled drugs were in order and accounted for on Medication Cart 2. The facility licensed nursing staff did not sign the Narcotic Inventory sheet for Medication Cart 2, which contains the medications for 27 residents. This deficient practice placed the residents at risk for unsafe resident care. Ensure medication removed from six of eight emergency kits (E-Kits) were documented and the E-Kits were replaced timely. These deficient practices increased the risk for unsafe residents care due to confusion over what medications have or have not been administered (given) and could lead to the omission of medications. These deficient practices could result in residents not maintaining therapeutic range level (the amount of medication in the blood) for medication such as [MEDICATION NAME] (prevent [MEDICAL CONDITION]), may experience unnecessary pain, high blood sugar, high blood pressure, high [MEDICAL CONDITION] levels, respiratory distress, [MEDICAL CONDITION], stroke or death. Cross reference F726 During a complaint investigation on 10/31/18, at 2:15 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 to a resident) was called due to facility missed administering dosages of critical residents' medications for [MEDICAL CONDITION], insulin, blood pressure, antiarrhythmic and antianxiety medication, involving four of four-medication carts. The facility was unable to reconcile the amount of medications received from the pharmacy, current available medications on the bubble packs and amount the residents received. Findings: 1. A review of Resident 17's Admission Record indicated the resident was admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 17's physician's orders [REDACTED]. - [MEDICATION NAME] (prevents [MEDICAL CONDITION]) Suspension 125mg/mL, give 10mL by mouth one time a day to be given at 9 a.m. - [MEDICATION NAME] (prevents [MEDICAL CONDITION]) 500mg, give one tablet by mouth two times a day to be given at 9 a.m. and 5 p.m. - [MEDICATION NAME] (treats high blood pressure) 25mg, give one tablet by mouth two times a day to be given at 9 a.m. and 5 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 17's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/10, 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. - [MEDICATION NAME] had missing initials on 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. and missing initials for 10/28/18, for 5 p.m. The [MEDICATION NAME] bubble pack for the morning dose of 9 a.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. and missing initials for 10/28/18, for 5 p.m. The [MEDICATION NAME] bubble pack for the morning dose at 9 a.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. The [MEDICATION NAME] bubble pack for the evening dose at 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. A review of Resident 17's blood laboratory results dated (MONTH) 4, (YEAR) indicated the resident's [MEDICATION NAME] level was 15.1 which was within the therapeutic range of 10-20. A review of Resident 17's most recent blood laboratory results dated (MONTH) 1, (YEAR) indicated the resident's [MEDICATION NAME] level was 8.5 which was below the therapeutic range of 10-20. 2. A review of the Admission Record indicated Resident 3 was originally admitted on (MONTH) 27, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 3's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 850mg, give 1 tablet through the [DEVICE] (Gastrostomy Tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach) two times a day, to be given at 9 a.m. and 5 p.m. - [MEDICATION NAME] (treats high blood pressure) 25mg, give 1.5 tablet through the [DEVICE] one time a day, to be given at 9 a.m. - [MEDICATION NAME] (treats high blood pressure) 12.5 mg, give one tablet through the [DEVICE] one time a day, to be given at 9 a.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 3's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. and missing initials for 10/28/18, for 5 p.m. The [MEDICATION NAME] bubble pack for the morning dose of 9 a.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/24 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/24 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. 3. A review of the Admission Record indicated Resident 18 was originally admitted on (MONTH) 13, 2011 with [DIAGNOSES REDACTED]. A review of Resident 18's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 5mg, give 0.5 tablet by mouth in the morning, to be given at 6:30 a.m. - [MEDICATION NAME] (treats low [MEDICAL CONDITION] levels) 88mcg, give 1 tablet by mouth in the morning, to be given at 6:30 a.m. - Amlodopine (treats high blood pressure) 5 mg, give 1 tablet by mouth one time a day, to be given at 9 a.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 18's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/3, 10/21, 10/23, 10/30 and 10/31/18, for 9 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/3, 10/6, 10/21, 10/23, 10/24, 10/30 and 10/31/18, for 9 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 10 tablets remaining and should have been empty on 10/29/18. - Amlodopine had missing initials on 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. The Amlodopine bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. 4. A review of the Admission Record indicated Resident 20 was originally admitted on (MONTH) 8, 2010 with [DIAGNOSES REDACTED]. A review of Resident 20's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood pressure) 60 mg, give 1 capsule by mouth one time a day, to be given at 9 a.m. - [MEDICATION NAME] (treats high cholesterol) 20mg, give 20mg by mouth in the evening, to be given at 5 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 20's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/18, for 9 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/24, 10/25 and 10/28/18, for 5 p.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 11 tablets remaining and should have been empty on 10/29/18. 5. A review of the Admission Record indicated Resident 24 was originally admitted on (MONTH) 30, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 24's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 500mg, give 1 tablet by mouth two times a day, to be given at 7:15 a.m. and 5:15 p.m. - [MEDICATION NAME] (treats the symptoms associated with dementia such as confusion) 10mg, give 1 tablet by mouth at bedtime, to be given at 9 p.m. - Trazadone (treats depression) 25mg, give 25mg by mouth at bedtime, to be given at 9 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 20's (MONTH) Medication Administration Record [REDACTED] -[MEDICATION NAME] had missing initials on 10/24, 10/25, 10/26, 10/27 and 10/28/18 for 7:15 a.m and missing initials on 10/25 and 10/28/18 for 5:15 p.m. The [MEDICATION NAME] bubble pack for the evening dose at 5:15 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/19, 10/22, 10/25, 10/27 and 10/28/18, for 9 p.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. - Trazadone had missing initials on 10/19, 10/25, 10/27 and 10/28/18, for 9 p.m. The Trazadone bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. 6. A review of the Admission Record indicated Resident 27 was originally admitted on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 27's physician's orders [REDACTED]. - [MEDICATION NAME] (treats muscle spasms caused by MS) 10mg, give 1 tablet by mouth three times a day, to be given at 9 a.m., 1 p.m. and 5 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 10 p.m., indicated it was prepared and delivered on 10/9/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have only 8 tablets remaining. 7. A review of the Admission Record indicated Resident 28 was originally admitted on (MONTH) 4, 2005 with [DIAGNOSES REDACTED]. A review of Resident 28's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 500mg, give 1 tablet by mouth two times a day, to be given at 7:15 a.m. and 5:15 p.m. - [MEDICATION NAME] (treats high blood pressure) 5 mg, give 1 capsule by mouth in the evening, to be given at 5 p.m. - [MEDICATION NAME] (treats low [MEDICAL CONDITION] levels) 25mcg, give 1 tablet by mouth in the morning, to be given at 6:30 a.m. - [MEDICATION NAME] (treats and prevents convulsions) [MEDICATION NAME], 20mg/5mL, give 15mL every 8 hours, to be given at 6 a.m., 2 p.m. and 10 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 20's (MONTH) Medication Administration Record [REDACTED] -[MEDICATION NAME] had missing initials on 10/10, 10/24, 10/25 10/26, 10/27, 10/28 and 10/29/18 for 7:15 a.m and missing initials on 10/25, 10/27 and 10/28/18 for 5:15 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5:15 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/25 and 10/28/18, for 5 p.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/3, 10/6, 10/21, 10/23, 10/24, 10/27, 10/30 and 10/31/18, for 6:30 a.m. The [MEDICATION NAME] bubble pack indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 9 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/3, 10/6, 10/13, 10/20, 10/23, 10/24, 10/25 10/26, 10/27, 10/28 and 10/31/18 for 6 a.m., missing initials on 10/10, 10/24, 10/25 10/26, 10/27 and 10/28/18 for 2 p.m., and missing initials on 10/25, 10/27, and 10/28/18 for 10 p.m. 8. A review of the Admission Record indicated Resident 32 was originally admitted on (MONTH) 2, (YEAR) with [DIAGNOSES REDACTED]. to think clearly, manage emotions, make decisions and relate to others). A review of Resident 32's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 500mg, give 1 tablet by mouth two times a day, to be given at 7 a.m. and 5 p.m. - [MEDICATION NAME] (treats the symptoms of [MEDICAL CONDITION] such as muscle spasms, stiffness, tremors, poor muscle control) 0.5 mg, give 1 tablet by mouth one time a day, to be given at 9 a.m. - [MEDICATION NAME] (treats the symptoms of [MEDICAL CONDITION] and aids in thinking clearer) 1mg, give 1 tablet three times a day, to be given at 9 a.m., 1 p.m. and 5 p.m. 9. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 31's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/23, 10/24, 10/26, 10/27, 10/28, 10/29 and 10/31/18 for 7 a.m and missing initials on 10/25 and 10/28/18 for 5:15 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 13 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/23, 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/18 for 7 a.m and missing initials on 10/25 and 10/28/18 for 5 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 13 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/18 for 9 a.m., missing initials on 10/21, 10/25, 10/26, 10/27, 10/28 and 10/29/18 for 1 p.m. and missing initials on 10/24, 10/25 and 10/28/18 for 5 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 13 tablets remaining and should have been empty on 10/29/18. 10. A review of the Admission Record indicated Resident 37 was originally admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 37's physician's orders [REDACTED]. - [MEDICATION NAME] (treats high blood sugar) 10mg, give 1 tablet by mouth in the evening, to be given at 4:30 p.m. - [MEDICATION NAME] 20mg, give 1 tablet by mouth in the morning, to be given at 6:30 a.m. - [MEDICATION NAME] (treats high blood pressure) 100mg, give one tablet by mouth two times a day to be given at 9 a.m. and 5 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 37's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/3, 10/13, 10/21, 10/23, 10/24, 10/30 and 10/31/18 for 6:30 a.m and missing initials on 10/21, 10/25 and 10/28/18 for 4:30 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 4:30 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 13 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/10, 10/24, 10/25, 10/26, 10/27, 10/28 and 10/29/18 for 9 a.m and missing initials on 10/25 and 10/28/18 for 5 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. 11. A review of the Admission Record indicated Resident 41 was originally admitted on (MONTH) 23, 2014 with [DIAGNOSES REDACTED]. A review of Resident 41's physician's orders [REDACTED]. - [MEDICATION NAME] (treats nerve pain associated with Type 2 diabetes) 100mg, give 1 capsule by mouth three times a day, to be given at 9 a.m., 1 p.m. and 5 p.m. - [MEDICATION NAME] (treats anxiety disorder) 25mg, give 1 tablet by mouth four times a day, to be given at 9 a.m., 1 p.m., 5 p.m. and 9 p.m. - [MEDICATION NAME] (treats [DIAGNOSES REDACTED]) 100mg, give four tablets by mouth two times a day to be given at 9 a.m. and 5 p.m. On (MONTH) 31, (YEAR), at 10:40 a.m., a review of Resident 37's (MONTH) Medication Administration Record [REDACTED] - [MEDICATION NAME] had missing initials on 10/10, 10/12, 10/24, 10/25, 10/26, 10/27, 10/28, and 10/29/18 for 9 a.m., had missing initials on 10/10, 10/12, 10/25, 10/26, 10/27, 10/28, and 10/29/18 for 1 p.m. and missing initials on 10/25 and 10/28/18 for 5 p.m. The [MEDICATION NAME] bubble pack for the evening dose of 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 10 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/24, 10/25, 10/26, 10/27, 10/28, and 10/29/18 for 9 a.m., had missing initials on 10/24, 10/25, 10/26, 10/27, 10/28, and 10/29/18 for 1 p.m., missing initials on 10/4, 10/25 and 10/28/18 for 5 p.m., and missing initials on 10/4, 10/25 and 10/28/18 for 9 p.m. The [MEDICATION NAME] bubble pack for the evening dose at 5 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 10 tablets remaining and should have been empty on 10/29/18. The [MEDICATION NAME] bubble pack for the bedtime dose at 9 p.m., indicated it was prepared and delivered on 9/29/18 and had quantity of 31 tablets. The bubble pack had 12 tablets remaining and should have been empty on 10/29/18. - [MEDICATION NAME] had missing initials on 10/9, 10/10, 10/24, 10/25, 10/26, 10/27, 10/28, and 10/29/18 for 9 a.m. and missing initials on 10/22, 10/25 and 10/28/18 for 5 p.m. The two [MEDICATION NAME] bubble packs for the evening dose of 5 p.m., indicated they were prepared and delivered on 9/29/18 and had quantity of 31 tablets each. The bubble packs had 12 doses left, for a total of 22 tablets remaining and both should have been empty on 10/29/18. During an interview and concurrent check of the (MONTH) MARs for Medication Cart #2 with LVN 1 on (MONTH) 31, (YEAR) at 10:40 a.m., LVN 1 confirmed there were several dates left blank on the MARs. When asked what the procedure was for signing the MAR, LVN1 stated that once a medication is removed, the nurse is supposed to initial on the MAR. LVN 1 continued to state that if the resident refused the medication, the nurse is supposed to circle their initials for that date and write an explanation on the back of the MAR. When asked if the dates on the MAR indicated [REDACTED]. When asked what is the reason that the medication bubble pack card still has medications and it should have been empty, LVN 1 stated I do not know. A review of the policy and procedure titled, Administering Medications, and revised (MONTH) 2012, indicated that medications shall be administered in a safe and timely manner, and as prescribed. The policy and procedure also indicated the individual administering the medication must initial the resident's MAR indicated [REDACTED]. c. On (MONTH) 31, (YEAR), at 10:45 a.m., to 12:25 p.m., a review of the Medication Administration Record [REDACTED]. The following were observed: 12. A review of Resident 6's (MONTH) MAR indicated [REDACTED] - [MEDICATION NAME] (medication to treat high blood pressure) one tablet 25 milligrams (mg) by mouth twice a day, to be given at 9 a.m. and 5 p.m. The [MEDICATION NAME] MAR indicated [REDACTED]. The bubble pack had two tablets remaining and should have been empty on 11/31/18 at 9 a.m. medication pass. - [MEDICATION NAME] (medication to treat high cholesterol) 20 mg one tablet by mouth, to be given at 5 p.m. The [MEDICATION NAME] MAR indicated [REDACTED]. The [MEDICATION NAME] bubble pack indicated prepared and delivered on 10/17/18, and the quantity was 14 tablets. The bubble pack had two tablets remaining and should have been empty on 10/30/18. There was no documentation that the medication was placed on hold. On (MONTH) 31, (YEAR) at 10:47 a.m. during an interview with RLVN 14, regarding the missing licensed nurses' initial and the discrepancies of the medication on hand, RLVN 14 stated she is from registry and today was her my fourth time she is passing medication to the facility. When asked how the bubble pack system works, RLVN 14 stated, I do not know. RLVN 3 stated, I removed the medication from the bubble pack not by the dates and give to the residents. RLVN 14 stated she received minimal orientation on where the residents' medications are on the medication cart, not on the bubble pack system and/or medication pass. A review of the Admission Record indicated Resident 6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. 13. A review of Resident 7's MAR physician medication orders dated 11/22/17 included the following: - [MEDICATION NAME] (prevent gout attack) 300 mg one tablet by mouth one time a day to be given at 9 a.m. The [MEDICATION NAME] MAR indicated [REDACTED]. The bubble pack had two tablets remaining and should have been empty on 10/26/18. - [MEDICATION NAME] (treat ulcers in the stomach and reduce too much acid) 20 mg one tablet at bedtime, to be given at 9 p.m. The [MEDICATION NAME] MAR indicated [REDACTED]. The bubble pack had 17 tablets remaining and should have been empty on 10/29/18. A review of the Admission Record indicated Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. 14. A review of Resident 8's MAR physician medication orders dated 1/30/18 included the following: - [MEDICATION NAME] (used to treat high blood pressure, heart failure, and heart problems after a [MEDICAL CONDITION]) 25 mg, give 0.5 tablet (12.5 mg) by mouth two times a day every Monday, Tuesday, Thursday and Saturday for hypertension (high blood pressure). Hold if systolic blood pressure (SBP) is less than 100 and heart rate less than 60 beats per minute. The MAR indicated [REDACTED] 11/6, 11/11, 11/13, 11/15, 11/20, and 11/27/18, at 5 p.m. The [MEDICATION NAME] 12.5 mg bubble pack indicated prepared and delivered on 9/29/18, and had quantity of 17 tablets. The bubble pack had 16 tablets remaining and should have been empty on 10/16/18. - [MEDICATION NAME] 25 mg give one tablet by mouth two times a day every Sunday, Wednesday, and Friday. Hold if SBP is less than 100 and heart rate less than 60 beats per minute. The MAR indicated [REDACTED]. However, each bubble pack had two tablets remaining, which should have been empty. During an interview with RLVN 14 on (MONTH) 31, (YEAR), at 10:55 a.m., RLVN 14 was unable to explain the discrepancies of the available medication on the [MEDICATION NAME] 12.5 mg bubble pack and as to why [MEDICATION NAME] 25 mg has two bubble packs for morning shift. RLVN 14 was unable to locate the evening bubble packs for [MEDICATION NAME] 12.5 mg and [MEDICATION NAME] 25 mg. Resident 8, also has a physician order [REDACTED]. The MAR indicated [REDACTED]. the label on the [MEDICATION NAME] bottle indicated prepared 8/13/18, with 60 dosages (dispensed squirt). The bottle was opened on 8/15/18; during closed inspection, the bottle was half-full. The [MEDICATION NAME] medication should have been empty around 9/15/18. RLVN 14 stated the resident administered the medication herself. A review of the Admission Record indicated Resident 8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 8's medical record, there was no documented evidence that the resident was assessed for self-medication administration. There was no documented evidence the resident refused the nasal spray or the medication was temporarily held. 15. A review of Resident 9's MAR physician medication orders dated 1/19/18 included the following: - [MEDICATION NAME] (helps relieve spasms and cramping of muscles) 10 mg, give one tablet by mouth three times a day. The MAR indicated [REDACTED]. The morning bubble pack had 10 tablets remaining and should have been empty by 10/30/18. The noon bubble pack had 17 tablets remaining and should have been empty by 10/30/18. Concurrent interview and inspection of the medication cart on 10/31/18 at 11:05 a.m., RLVN 14 was unable to locate the [MEDICATION NAME] bubble pack for the evening shift. - [MEDICATION NAME] ER 25 mg give