Every finding on record at Modesto Post Acute Center

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from a preventable injury when Resident 1 spilled hot coffee onto his lap. This failure resulted in a second-degree burn (involving the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) to the skin on Resident 1's scrotum (private male area), causing pain and risk for infection. (Exposure of skin to water temperatures of 155 degrees Fahrenheit (F) for as little as 1 second may result in burns as severe as third-degree, which are more severe than second-degree).During a review of Resident 1's admission Record (AR), dated 7/19/26, the AR indicated he was discharged from the facility on 7/5/26.During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 6/16/26, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment).The MDS indicated at Question GG0130 A, a score of 5, which indicated that for Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident, Resident 1 needed Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.During a review of Resident 1's Progress Notes (PN), dated 6/25/26, at 10:42 a.m., the PN indicated Resident reported he dropped coffee on his scrotum. Per resident, he dosed [sic] off and dropped coffee on him. MD [Medical Doctor] notified.During a review of Resident 1's PN from his MD, dated 6/27/26, no time, the PN indicated, Patient seen today for follow up. Patient sustained a second-degree burn to the scrotum after accidentally spilling hot coffee. Patient reports persistent pain at the burn site, and Norco [a strong pain reliever that is strictly controlled with high potential for addiction and abuse] has been changed to a scheduled regimen [drug is prescribed to be given routinely instead of 'as needed'] for improved pain control. Monitor wound healing, erythema [redness], drainage, blistering, pain, skin integrity, medication effectiveness, and signs of infection.During a review of Resident 1's PN from his MD, dated 7/4/26, no time, the PN indicated, Burn involving the scrotum has not completely resolved. Continue monitoring wound healing and signs of secondary infection. A request for a measurement of Resident 1's second-degree burn was made; no measurement was provided by the facility. During a review of Resident 1's PN, dated 7/5/26, at 10:12 p.m., the PN indicated he was transferred to a nearby hospital for breathing issues (unrelated to the second-degree burn on scrotum).During a concurrent interview and observation on 7/16/26, at 3:28 p.m., with the Dietary Supervisor (DS), in the facility kitchen, a large coffee maker was noted. The DS stated all the facility's coffee is brewed in this machine, the coffee is then transferred to dispensers, the dispensers are placed on carts, staff bring the carts out to the resident care areas, and pour into cups and served to residents by staff. The DS stated, The coffee maker is calibrated to 150 degrees Farenheit (F). I expect the coffee to be at 120 degrees F when it is served to the residents. The DS then made a full pot of coffee, which was completed at 3:39 p.m. The DS then poured a cup of coffee from the machine, and it was measured using a calibrated probe thermometer, with a result of 160 degrees F. The DS confirmed the measurement and stated, That is hot. If I were to put my hand in that cup, it would burn. The coffee was then transferred from the brewing machine to a dispenser and placed on a cart. At 3:53 p.m., the coffee from the dispenser was poured into a cup and measured again using a calibrated probe thermometer, with the DS, and the result was 160 degrees F. The DS confirmed the measurement. The DS stated 160 degrees F would be the temperature of the coffee served to the first residents wanting coffee but would cool over time. The DS stated staff measures and records the coffee temperatures when it is first brewed, and again after the last cup is served.During a concurrent interview and record review on 7/16/26, at 4 p.m., with the DS, several of the facility's Food Temperature Logs (FTL) were reviewed. The FTL dated from 7/12/26 to 7/16/26, indicated 170 or above beverages, hot ranged from 110 degrees F to 170 degrees F. The DS stated these were the temperatures of the coffee. The FTL dated 6/25/26, the date of the burn injury to Resident 1, was reviewed with the DS, and it indicated the initial temperature of the coffee was 163 degrees F.During a review of the facility's policy and procedure (P&P) titled, Nutrition Inservice, dated 6/26, the P&P indicated, Hot coffee/water may be served 120-160 [degrees F].During an interview on 7/16/26, at 4:20 p.m., with the Administrator, the Administrator stated, We will ensure coffee temperatures do not exceed 140 degrees F. We will call [the coffee machine vendor] and have them calibrate the machine tomorrow. If a resident wants coffee above 140 degrees F, then we will evaluate that request on a case-by-case basis, checking for safety awareness and risk vs. benefits.

Based on observation, interview and record review the facility failed to ensure garbage storage area was maintained in safe and sanitary conditions when:1. Grayish fluids from the sewer and thick yellowish drainage from the grease trap were draining creating a pool into the driveway on 3/17/26.2. Two of the three garbage bins did not have a lid and were open to air on 3/18/26.These failures had the potential for unwanted pest ((any organism-insect, rodent, or microbe-those damages structures or threatens human health) which could have led to disease transmission causing foodborne illness (results from eating food contaminated with germs [bacteria, viruses, parasites] or toxins) leading to hospitalization for 98 residents, vendors, guests and staff.Findings:During an observation on 3/17/26 at 10:02 a.m. in the backway alley, a water outlet had grayish fluids gushing out and a grease trap to the right, had thick yellowish fluids flowing down gathering with the grayish fluids creating a pool in front of the garbage bins in the driveway. There was a musty, rotten, foul odor resembling sewage draining from the fluids.During a concurrent observation and interview on 3/17/26 at 10:14 a.m. with the Maintenance Director (MND), the MND confirmed that both the grayish fluids and yellow discharge from the grease trap originated from the kitchen area. The MND reported that the fluids had been present for two days. However, the MND was uncertain about the specific source or location of the clog that led to this drainage issue.During an interview on 3/20/2026 at 2:03 p.m. with the Maintenance Director (MND) the MND stated. We had a plumber come out and pulled out wipes from the sewer line. The MND stated the area should have been cleaned. The MND stated pool of fluids was a breeding ground for mosquitoes and unwanted pests. The MND stated unwanted pests could lead to disease transmission and cause foodborne illness. The MND stated residents could have gotten sick. The MND stated the driveway should have been cleaned for residents, guests and vendors safety. The MND stated vendors coming to the facility could have tripped and fallen.During a concurrent interview and record review on 3/20/2026 at 2:30 p.m. with the Registered Dietician (RD) the water outlet with grayish fluids gushing out and a grease trap with thick yellowish fluids pooling at the driveway were reviewed. The RD stated there should be no water in the driveway. The RD stated the grayish, cloudy fluids and yellowish drainage from the grease trap were a safety hazard for residents, staff and guests. The RD stated the fluids could have harbored pests. The RD stated pests could have gotten inside the kitchen and caused cross-contamination. The RD stated residents could have gotten foodborne illness from consuming cross-contaminated food. The RD stated residents could have been hospitalized from nausea, vomiting, diarrhea and dehydration.2. During an observation on 3/18/25 at 8:08 a.m. garbage bin number 1 lid was left open.During an observation on 3/18/25 at 12:46 p.m. garbage bin number 2 was filled to the top with garbage bags, preventing the lids from closing properly.During an interview on 3/20/2026 at 1:54 p.m. with the Certified Dietary Manager (CDM), the CMD stated the garbage bins were used by every department. The CDM stated garbage bins should always be closed. The CDM stated the open garbage bins could have attracted unwanted pests. The CDM stated, We want to avoid pests, and we should keep it clean and closed. The CDM stated, We do not want pests anywhere in the building. The CDM stated, pests could have gotten in food, and residents and staff could have gotten foodborne illness.During an interview on 3/20/26 2:26 p.m. with the RD, the RD stated garbage bins should be covered at all times and there should be no trash spilled over that prevents the lids from closing. The RD stated the garbage bins should be covered to prevent attraction of pests. The RD stated pests could have gone inside the kitchen. The RD stated, We should keep everything nice, neat and free from contamination. The RD stated there could be cross-contamination from the pests and it could have caused residents to have foodborne illness. The RD stated residents could have been hospitalized from nausea, vomiting, diarrhea and dehydrated.During a concurrent interview and record review on 3/20/2026 at 4:47 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Food Service Equipment and Waste Management Policy, undated was reviewed. The P&P indicated, 3. Garbage and Refuse Containers. All garbage and Refuse containers shall be maintained in good condition.Dumpsters and compactors shall be equipped with lids or otherwise adequately covered at all times. 4. Areas designated for garbage disposal shall be kept clean and free from offensive odors, grease, and waste fats. These area shall be maintained in a manner that prevents the attraction, harborage, or breeding of pest. The ADM stated we did not follow our P&P.

Based on interview and record review the facility failed to promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS- designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when:Infection screening evaluations (ISE-completed before starting antibiotics to ensure the medication is necessary, effective, and targeted) were not completed before residents started antibiotics.Antibiotics discontinued after initiation, for not meeting infection screening evaluation criteria, were not included in antibiotic stewardship data review or monitoring for 2/2026.This failure resulted in the administration of unnecessary and inappropriate antibiotic use, as well as inaccurate monitoring of antibiotic use which could lead to antibiotic-resistant organisms and inaccurate data monitoring and reporting.During a concurrent interview and record review on 3/20/26 at 12:54 p.m. with the Infection Preventionist (IP), the facility's document titled, Infection Prevention and Control Surveillance Log (SL), and Monthly Infection Prevention and Control Report (CR), dated 2/2026, were reviewed. The IP stated she completed infection screening evaluations (ISE) on all residents before residents started an antibiotic to assess for appropriateness. The IP stated licensed nursing staff reported suspected signs and symptoms of infection to the provider, and if the provider ordered an antibiotic, an ISE needed to be completed to assess for antibiotic appropriateness. The IP stated if residents did not meet suspected infection screening criteria it needed to be reported to the provider, documented, and ordered antibiotics needed to be discontinued, if the provider agreed. The IP stated there was no other designee to complete ISE's in her absence. The IP stated not having another designee to complete ISE's meant not all residents received an ISE prior to starting an antibiotic until she returned to work, resulting in an unknown number of residents who were started on antibiotics before an ISE was completed. The IP stated during 2/2026, Resident 10, did not receive an ISE prior to the start of antibiotic treatment. The IP stated Resident 10 was administered an antibiotic for two days before an ISE was completed. The IP stated Resident 10's ISE indicated he did not meet infection criteria and the antibiotic was discontinued, with provider approval. The IP stated Resident 10 was not included in the 2/2026 SL or CR data reports. The IP stated the SL and CR data reports had sections to include residents who met ISE criteria and those who did not meet ISE criteria. The IP stated it was important to record and report accurate data to ensure antibiotic prescription and use were accurately monitored to identify trends and improve quality care within the facility. The IP stated not completing an ISE prior to starting an antibiotic posed the risk of unnecessary or ineffective antibiotic use.During an interview on 3/20/26 at 3:16 p.m. with the Consultant Pharmacist (CP), the CP stated pharmacy completed independent monthly antibiotic reviews which included residents with antibiotics discontinued early for not meeting ISE's. The CP stated the IP completed her own antibiotic review reports, as well. The CP stated pharmacy reports were sent to the facility and the IP was responsible for monitoring the quality of the antibiotic stewardship and surveillance program (ATBS). The CP stated he could not locate a pharmacy report for Resident 10's antibiotic. The CP could not state why Resident 10's antibiotic had not been reviewed by pharmacy. The CP stated it was important to review all antibiotic orders and use to ensure appropriateness and prevent antibiotic resistance. The CP stated it was important to have all antibiotic data, including data of residents with early antibiotic discontinuation for not meeting ISE, in monthly reports for Quality Assurance and Performance Improvement (QAPI- data driven practice approaches to improve quality, safety and resident outcomes). The CP stated the facility could not accurately track, trend or monitor antibiotic use if data was missing. The CP stated ISE's were expected to be completed prior to starting all antibiotics to ensure appropriateness. The CP stated starting antibiotics prior to completing an ISE could lead to antibiotic resistance. The CP stated the facility held quarterly QAPI meetings to discuss the ATBS, but if accurate data was not being reported, antibiotic use could not be accurately evaluated.During an interview on 3/20/26 at 5:30 p.m. with the Nurse Consultant (NC), the NC stated it was important to perform ISE's prior to starting a resident on an antibiotic and report unmet criteria to the provider for clarification to continue with antibiotic initiation. The NC stated ISE's, prior to antibiotic initiation, reduced the risk for unnecessary antibiotic use and antibiotic resistance. The NC stated Resident 10's antibiotic initiation without an ISE and early discontinuation for not meeting ISE should have been included in the IP's and pharmacy's ATBS review. The NC stated she expected IP and pharmacy ATBS data to be accurate and complete to ensure effective QAPI metrics. The NC stated if accurate ATBS data was not reported the facility could not track, trend or identify potential issues or implement improvement plans.During a review of the facility's policy and procedure (P&P) titled, Infections-Clinical Protocol, dated 3/2018, the P&P indicated, .when a resident is suspected of having an infection.nursing staff will obtain a complete set of vitals.and will identify, report and document details of symptoms and physical findings.based on the preceding information, the physician and staff will discuss and determine whether an infection exists or likely, whether additional evaluations or testing is indicated.the staff and physician or provider will identify and document when limited or no antibiotic treatment is indicated.During a review of the facility's P&P titled, Surveillance for Infections, dated 9/2017, the P&P indicated, .the Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved in interpretation of the data.the surveillance should include a review of any or all of the following information to help identify possible indicators of infection.infection control rounds or interviews.antibiotic review.During a review of the facility's P&P titled, Antibiotic Stewardship-Orders for Antibiotics, dated 12/2016, the P&P indicated, .appropriate indications for use of antibiotics include.criteria met for clinical definition of active infection.During a review of the facility's P&P titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, dated 12/2016, the P&P indicated, .antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility- wide antibiotic stewardship.as part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee.The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.During a review of the facility's P&P titled, Antibiotic Stewardship-Staff and Clinician Training and Roles, dated 12/2016, the P&P indicated, .the facility will educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes.nurses will receive initial and ongoing training on.the facility's antibiotic stewardship program, including the need for judicious use of antibiotics.how to utilize the standardized assessment and communication tool for residents suspected of having an infection.specific information that should be obtained when an order for an antibiotic is received.administrative and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on.the rationale for judicious use of antibiotics.how and when to gather data to present to the infection prevention and control committee.during the drug regimen review, the consultant pharmacist will identify, and flag, orders for antibiotics that are not consistent with the antibiotic stewardship practices.During a review of the professional reference retrieved from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html titled, The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 9/10/25, the professional reference review from The Centers for Disease Control and Prevention (CDC) stated, .standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic.perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards of food service safety for 95 out of 98 residents receiving food at the facility when:1. An open bag of potato chips inside a zip lock bag did not have a use by (a crucial safety indicator found on perishable foods like meats and salads, marking when it is no longer safe to eat, even if it appears fine) date.2. The food preparation sink did not have an air gap (space between the end of sink pipe and top of sink to prevent backflow). These failures had the potential to result in the serving of expired, spoiled, or contaminated food and items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to 95 residents receiving food from the kitchen.Findings:During an observation current observation on 3/17/26 at 9:31 a.m. in the storage room with the Certified Dietary Manger (CDM), a zip lock bag containing an open bag of potato chip was not labeled with a use by date.During an interview on 3/20/2026 at 1:34 p.m. with the Certified Dietary Manager (CDM) the CDM stated products should have used by date. The CDM stated labeling the products was needed to ensure there was no spoilage. The CDM stated labeling the products was needed to prevent residents from consuming items beyond the use by date. The CDM stated residents could have gotten sick from foodborne illness from consuming items past their use by date. The CDM stated all dietary staff should be labeling all items when they are open with a use by date.During a concurrent interview and record review on 3/20/2026 at 2:10 p.m. with the Registered Dietician (RD), the RD stated all food items should have been labeled to prevent residents from consuming expired items. The RD stated, residents could have nausea, vomiting and diarrhea from consuming items past their use by date. The RD stated not labeling items could have potential for food poisoning and foodborne illness. The RD stated the facility's policy and procedure were not followed. During a review of the facility's policy and procedure (P&P) titled, Food Storage Policy Undated, the P&P indicated, To ensure the safe storage and handling of non-refrigerated food items and related supplies in order to maintain food quality, prevent contamination, and comply with health and safety standards.clearly labeled with the product name and a use by date.2. During an observation on 3/19/26 at 11:35 a.m. in the food prep sink, a pipe from the food prep sink was draining into the ground, there was no air gap between the pipe and drainage area. During an interview on 3/20/26 at 1:39 p.m. with the Certified Dietary Manager (CDM), the CDM stated the sink should have an air gap to prevent cross-contamination. The CDM stated backflow from dirty water from the sewer could have gotten into the sink and caused cross-contamination. The CDM stated the sink was used to prep vegetables and the vegetables could have been cross-contaminated. The CDM stated residents could have gotten sick with foodborne illnesses causing nausea and vomiting which could have led to hospitalization. During an interview on 3/20/26 at 2:14 p.m. with the Registered Dietician (RD), the RD stated there should be a one-inch air gap between the pipe and the drainage. The RD stated the air gap was needed to create a space to prevent the dirty water from coming up into the food prep sink. The RD stated the backflow could have caused cross-contamination to food items washed in the sink prep area. The RD stated residents could have gotten foodborne illness from consuming food that was cross-contaminated. The RD stated residents could have been hospitalized from foodborne illness from nausea, vomiting, diarrhea and dehydration. During an interview on 3/20/26 at 4:52 p.m. with the Administrator (ADM) the ADM stated she has been an administrator for 29 years and was not aware the food prep sink needed an air gap. The ADM stated she understands why we need to prevent back flow and cross-contamination. The ADM stated she had one for the ice machine but not the food prep sink and will have it done.During a review of the professional reference titled, FDA Food Code 2022, section 5-402.11 Backflow Prevention, .(A) A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (B) Equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.

Based on observation, interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 74 and Resident 75) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when:1. Resident 74 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications Mirtazapine (a drug used to treat depression) and buspirone (a medication used to treat generalized anxiety disorder).2. Resident 75 had an order for [Brand name for lorazepam] (psychotropic, anti-anxiety medication used to alter mood and behavior) as needed and the informed consent was not signed by the provider.These failures resulted in the violation of Resident 74 and Resident 75's Responsible Party's (RP-individual authorized to act on a residents behalf regarding care) right to be informed, in advance of alternative treatment options and the risks and potential side-effects (unintended or unwanted effects that can occur when taking a medicine) of the psychoactive medications which could have led to illness or hospitalization. Findings: 1. During a concurrent observation and interview on 3/18/2026 at 12:32 PM with Resident 74, in Resident 74's room, Resident 74 was observed wearing a gown in bed, laying on her left side with a wound covered with a clear dressing on her right outer thigh and her left hand contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). Resident 74 stated she was unable to get up due to her wound. A food tray was observed in front of Resident 74 covered with a lid. Resident 74 stated she did not want to eat her meal. During a review of Resident 74's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/20/26, the AR indicated Resident 74 was admitted to the facility from an acute care hospital on 2/11/26 with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left non-dominant side, cellulitis (a deep infection of the skin caused by bacteria) of the back, infection of intervertebral disc (one or more of the discs that separate the bones of the spine, [vertebrae]), sacral (the triangular shaped bone at the base of the back) and sacrococcygeal (pertaining to both the sacrum and coccyx [tailbone] region), bed confinement status (completely confined to bed with no ability to move independently), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). During a review of Resident 74's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/13/26, the MDS section C indicated Resident 74 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 74 was cognitively intact. During a concurrent interview and record review on 3/20/2026 at 9:08 a.m. with Charge Nurse (CN) 1, Resident 74's Order Summary Report (OSR,) dated 3/20/26 was reviewed. The OSR indicated, .buspirone HCI oral tablet 7.5 milligram [MG – a unit of measurement] give 1 tablet by mouth two times a day for anxiety.verified informed consent obtained by physician [MD] from Responsible Party [RP].mirtazapine oral tablet 7.5 MG give 1 tablet by mouth at bedtime for depression. verified informed consent obtained by MD from RP.venlafaxine HCI [a medication used to treat depression] extended release [ER] oral capsule.24 hour 75 MG give 1 capsule by mouth one time a day for depression. verified informed consent obtained by MD from RP CN 1 stated the orders indicated an informed consent was obtained by the physician from Resident 74's RP. During a concurrent interview and record review on 3/20/2026 at 9:08 a.m. with CN 1, Resident 74's electronic record was reviewed. CN 1 stated there were no consents in Resident 74's record for buspirone or mirtazapine. During an interview on 3/20/2026 at 2:32 p.m. with the Nurse Consultant (NC), the NC stated Resident 74 should have had a signed consent before receiving psychotropic medications. The NC stated consents were important so residents knew the risks and benefits of taking the medication and would have been able to determine if they wanted to take the medications or not. The NC stated the residents may not have known what the potential side effects were and may not have wanted the medications. During a review of the facility policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, .resident's right to.be informed of, and participate in, his or her care planning and treatment. During a review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022 indicated, .a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.drugs in the following categories are considered psychotropic medications.anti-depressants.anti-anxiety medications.when determining whether to initiate, modify, or discontinue medication therapy, the Interdisciplinary Team {IDT} conducts an evaluation of the resident. the evaluation will attempt to clarify whether.the actual or intended benefit of the medication is understood by the resident/representative.residents [and/or representatives] have the right to decline treatment with psychotropic medications.the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. 2. During a concurrent interview and record review on 3/20/26 at 10:57 a.m. with Charge Nurse (CN) 1, Resident 75's Order Summary Review, dated 3/20/26, Informed Consent-Psychoactive Medication (IC), dated 3/9/26, and Medication Administration Record, dated 3/20/26, was reviewed. CN 1 stated Resident 75 was on hospice and had a Responsible Party (RP) making informed decisions on his behalf. CN 1 stated on 3/9/26 [Brand name for lorazepam] 1 MG as needed (PRN) for 14 days was ordered for anxiety related to behaviors of yelling, restlessness and agitation. CN 1 stated the [Brand name for lorazepam] order had not been administered to Resident 75 since it had been ordered because he had not had any more behaviors. CN 1 stated [Brand name for lorazepam] was an antianxiety medication that required informed consent. CN 1 stated the provider had not signed Resident 75's [Brand name for lorazepam] IC. CN 1 stated Resident 75 was at risk of being administered [Brand name for lorazepam] without a complete IC. CN 1 stated without a provider signature, on Resident 75's [Brand name for lorazepam] informed consent, it could not be ensured Resident 75 and Resident 75's RP were informed of, in advance of, medication treatment risks and benefits by a provider. CN 1 stated licensed nursing staff were responsible for ensuring informed consents were completed after psychotropic medications were ordered. CN 1 stated the Medical Records (MR) was responsible for reviewing informed consents for completion and accuracy. During a concurrent interview and record review on 3/20/26 at 11:07 a.m. with Medical Records (MR), Resident 75's Informed Consent-Psychoactive Medication (IC), dated 3/9/26, was reviewed. The MR stated Resident 75's IC for [Brand name for lorazepam] did not include a provider's signature. The MR stated she could not locate any additional documentation which indicated the provider obtained informed consent for Resident 75's [Brand name for lorazepam] order. The MR stated that without a providers' signature Resident 75's [Brand name for lorazepam] informed consent was not complete or valid. The MR stated it was important that the provider signed psychotropic informed consents to ensure the RP was made aware of, and agreed to, the medication treatment, risks, benefits, and/or side effects, in advance. The MR stated without a provider's signature it could not be ensured a provider spoke to Resident 75's RP and obtained informed consent. During an interview with the Nurse Consultant (NC) on 3/20/26 at 5:30 p.m. the NC stated she reviewed Resident 75's [Brand name for lorazepam] order and IC. The NC stated Resident 75's [Brand name for lorazepam] informed consent was not complete or valid because it did not have a provider's signature. The NC stated Resident 75's [Brand name for lorazepam] had not been administered since it was ordered on 3/9/26. The NC stated Resident 75 was at risk of being administered [Brand name for lorazepam] at any time because it was an as needed medication. The NC stated without a provider's signature on the informed consent it could not be guaranteed Resident 75's RP was made aware of, and agreed to, the medication treatment, risks, benefits, and/or side effects, in advance. The NC stated facility policy and procedures were not followed when Resident 75's [Brand name for lorazepam] informed consent did not contain a provider's signature. During a review of Resident 75's AR, dated 3/20/26, the AR indicated Resident 75 was admitted to the facility on [DATE] with diagnoses of Alzheimer's (progressive, irreversible brain disorder that destroys memory and thinking skills), vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to the brain), and anxiety disorder. The AR indicated Resident 75's daughter was his RP (individual authorized to act on a resident's behalf regarding care). During a review of Resident 75's OSR, dated 3/20/26, the OSR indicated, .[Brand name for lorazepam] oral tablet 1 MG.give 1 tablet by mouth every 6 hours as needed for anxiety.for 14 days.order date 3/9/26.start date 3/9/26.end date 3/23/26. During a review of Resident 75's document titled, Informed Consent-Psychoactive Medication (IC), dated 3/9/26, the IC indicated, .[Brand name for lorazepam] oral tablet 1 MG.give 1 tablet by mouth every 6 hours as needed. The IC did not indicate a provider signature was present, physically or electronically. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications.anti-anxiety medications.residents (and/or representatives) have the right to decline treatment with psychotropic medications.the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was maintained for one of eight sampled residents (Res 2) when the Resident's Clothing and Possession Inventory on admission (RCPIA-a sheet used for inventorying residents' personal items) was not updated to reflect current items in the closet on 3/20/26.This failure resulted in Res 2's personal items being inaccurately inventoried, which could lead to clothing and items being unaccounted for when missing and has the potential to cause upset and inconvenience for residents and their families.Findings:During a review of Res 2' s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/20/26, the AR indicated Res 2 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), acute kidney failure (sudden decrease in kidney function occurring over hours or days, causing waste buildup, fluid retention, and electrolyte imbalances), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (condition where the body does not have enough healthy red blood cells) and gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Res 2's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 2/4/26, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 1 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Res 2 had severe cognitive impairment.During an interview on 3/17/26 at 2:39 p.m. with Family Member (FM)1, FM 1 stated Res 2 had blankets and personal items missing in the past. FM 1 stated she stopped taking items to the facility due to items gone missing. FM1 stated Res 2's cellular phone was missing for one year. FM 1 stated Res 2 used her cellular phone to play games. FM 1 stated Res 2 was attached to her personal items. During an interview on 3/20/26 at 8:51 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated, The family will give us the items, and we should have updated in the RCPIA. CNA 5 stated residents have the right to have personal items with them in the facility without it going missing. CNA 5 stated staff were responsible for safeguarding resident's personal items. CNA 5 stated residents could have been upset and anxious when their personal items went missing. CNA 5 stated residents have a right to have their personal belongings in a safe and homelike environmentDuring a concurrent record review and interview on 3/20/26 at 9:42 a.m. with Registered Nurse (RN) 3, Res 2's RCPIA dated 12/22/24 was reviewed. The RCPIA indicated, sweater [with] hood, pants.color: black.sweatshirts.color: pink. The RCPIA had FM 1's signature without a date and facility representative signature dated 2/26/25. RN 3 stated, There should be another sheet with new inventory update. RN 3 stated all staff were responsible for ensuring residents' items were not missing. RN 3 stated personal items meant a lot to residents. RN 3 stated residents could have been upset when their personal items went missing. RN 3 stated It is their right to have personal items here. RN 3 stated It is their home. RN 3 stated residents have the right to have their items protected and not missing. RN 3 stated Res 2 did not have an updated RCPIA.During an observation and interview on 3/20/26 at 3:04 p.m. with CNA 6, Res 2's closet was observed. CNA 6 stated Res 2 had one beige short, one gray pajama pant, one green pajama top, one green long sleeve top, one green shirt, basket with hair products, four underwear, one baby doll and a plushie (stuff animal). CNA 6 stated, I did not know she has stuff here. CNA 6 sated All items were not on the inventory list.During an interview on 3/20/26 at 3:15 p.m. with the Social Services Director (SSD) the SSD stated, When family brings items in, the CNAs should be doing an inventory and it should be in the resident's chart. The SSD stated, Each time the family brings in the items they should be signing a new inventory sheet, and it should be kept in the nursing station. The SSD stated residents' personal items should be inventoried to know what they had. The SSD stated the main purpose of keeping an inventory list was to make sure the facility was keeping track of residents' personal items. The SSD stated it was important to keep updated RCPIA to keep track of lost or missing items. The SSD stated residents have their right to have their personal items. The SSD stated residents could have mood changes, behavior changes and family and could be upset when items went missing. The SSD stated it was a not homelike environment when items go missing. The SSD stated, Residents are entitled to their own personal belongings and should not have it missing. During an interview on 3/20/26 at 6:06 p.m. with the Administrator (ADM) the ADM-stated residents have the right for their property to not be lost or stolen. The ADM stated, We should keep items from being missing. The ADM stated, We did not follow our policy and procedure.During a review of the facility's policy and procedure (P&P) titled, Resident Rights dated 2/2021, the P&P indicated, Federal and state law guarantee certain rights to all residents of this facility. These rights include the resident's right to.c. be free from.misappropriation of property.During a review of the facility's policy and procedures (P&P) titled, Homelike Environment dated 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview and record review, the facility failed to revise and implement, in a timely manner, a person-centered comprehensive care plan (CP- a personalized, written document detailing an individual's health needs, goals, and the specific services or support required to manage them) for two of eight residents (Res 2 and Res 70) when:1. Res 2 's had continued CP' for not swallowing and pocketing (the act of holding food in the mouth) food when returned from the hospital with a percutaneous endoscopic gastrostomy (PEG tube-a feeding tube inserted through the abdomen into the stomach) and was NPO (nothing by mouth) on 12/22/24.2. Res 70's had a continued short term care plan to observe for dark amber urine past the 48-to-72-hour timeframe.These failures had the potential to result in the goals and care interventions for Res 2 and Res 70 not being resident-centered and failing to adequately meet their needs.Findings:1.During an interview on 3/17/26 at 2:47 p.m. with Family Member (FM) 1, FM 1 stated she was not aware when Res 2 was seen by the dentist.During a concurrent interview and record review on 3/19/26 at 9:59 a.m. with Charge Nurse (CN) 3, Res 2 CP dated 11/26/24 was reviewed. The CP indicated, [focus box Res 2] . not swallowing and pocketing food. CN 3 stated the Minimum Date Set Registered Nurses (MDS) were responsible for creating and updating the long term [for residents. CN 3 stated the CP should have been updated when Res 2 stopped eating by mouth. CN 3 stated Res 2 was no longer eating and pocketing food. CN 3 stated nurses should have used the CPs to monitor residents' interventions were effective. CN 3 stated CPs were needed to ensure the nurses were providing the right care for residents. CN 3 stated CP should be individualized and specific to each resident's needs. CN 3 stated without CPs residents' need would not be met.During a concurrent interview and record review on 3/20/26 at 3:33 p.m. with the MDS, Res 2 Order Summary Report (OSR- a written order from a licensed practitioner (physician, nurse practitioner, or physician assistant) that authorizes specific care, tests, treatments, or medications for a residents) dated 3/20/26 was reviewed. The OSR indicated, .Enteral Feed Order NPO.Order date: 12/22/24. The MDS stated admission nurses were responsible for the initial the CPs for new admits. The MDS stated she checked and added more CPs after interviewing the residents or family members. The MDS stated We should be reviewing the care plan as needed. The MDS stated long term 'CP' should be updated every three months. The MDS stated the nurses should be discontinuing any CPs which no longer apply to the residents. The MDS stated CPs should have been developed to identify areas of concern for residents. The MDS stated the CPs should have goals and appropriate interventions for each resident. The MDS stated the CPs were used to communicate among nurses for provide care for the residents. The MDS stated all CPs should have been resident centered. The MDS stated Res 2 return to the facility on with a PEG tube on 12/22/24 and was NPO. The MDS stated Res 2's CP should have been revised the moment she had a physician order (PO- a written, verbal, or electronic directive from a licensed practitioner (physician, PA, or NP) authorizing specific care, treatments, medications, or tests for a residents) for NPO. The MDS stated CP for swallowing and pocketing food could have caused confusion for the nurse who provided care for her and was not appropriate. The MDS stated Res 2's goals, interventions and needs could have been missed when the CPs were not specific. The MDS stated the nurses were responsible for updating the CPs. During a review of Res's 2 admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/20/26, the AR indicated Res 2 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), acute kidney failure (sudden decrease in kidney function occurring over hours or days, causing waste buildup, fluid retention, and electrolyte imbalances), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (condition where the body does not have enough healthy red blood cells) and gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Res 2' OSR dated 12/22/24, the OSR indicated, [Dietary line] NPO diet NPO texture, NPO consistency. This OSR was indicating Res 2 was to have nothing by mouth.2. During a concurrent interview and record review on 3/19/26 at 4:11 p.m. with CN 3, Res 70's CP dated 12/23/25 was reviewed. The CP indicated, [ focus box] Observed resident to have dark amber urine.[ goal box] the resident will demonstrate improved hydration as evidence by urine color changing from dark amber to pale yellow and maintaining adequate urine output within 48 [to]72 hours, with staff encouragement and assistance with fluid intake as needed.[intervention box] collect UA [urinalysis-a urine sample], [Medical Doctor and Responsible Party] MD&R/P notified.monitor for pain and discomfort. CN 3 stated Res 70 had a short-term CPs for dark amber urine that should have been updated and discontinued. CN 3 stated CPs should have been updated every three months. CN 3 stated nurses would not have known if residents declined or improved without the CP being specific to their needs.During a review of Res 70's AR dated 3/20/26, the AR indicated Res 70 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and depression.During an interview on 3/20/26 at 5:24 p.m. with the Nurse Consultant (NC) the NC stated CPs should have been updated quarterly and as needs to reflect the care for the residents. The NC stated residents' needs could have not been met. The CP stated we did not follow our policy and procedure. During a record review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered Revision dated 3/2022, the P&P indicated, A comprehensive., person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident.11: assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions changes.at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure professional standards of practice for two of six sampled residents (Resident 87 and 104) when:1.Resident 87 was administered amiodarone (blood pressure [force of blood pushing against artery walls] medication used to treat irregular heart rhythms), four times, outside of ordered parameters. This failure resulted in Resident 87 receiving amiodarone on 2/3/26, 2/5/26, 2/13/26 and 3/11/26 when it should have been held, according to order parameters, which could lead to decreased blood pressure, cardiac distress and adverse effects. 2.The facility failed to ensure a physician order was received for an Incentive Spirometer (IS - handheld plastic device that acts as exercise equipment for the lungs, helping take slow, deep breaths to keep them active and clear after surgery or illness), for one of nine residents (Resident 104).This failure had the potential to delay strengthening of respiratory muscles, lung capacity, and clearing of mucus after surgery. Findings: 1.During a concurrent interview and record review on 3/19/26 at 3:10 p.m. with Charge Nurse (CN) 2, Resident 87's Order Summary Report (OSR) and Medication Administration Record (MAR), dated 3/19/26 was reviewed. CN 2 stated Resident 87 was admitted to the facility with low blood pressure (BP) which was amplified when standing or working with physical and/or occupational therapy. CN 2 stated Resident 87 received amiodarone 100 milligrams (mg- a unit of medication measurement) two times a day for atrial fibrillation (AFib- rapid irregular heart rhythm) with order parameters to hold the medication if his systolic blood pressure (SBP- top number in blood pressure reading which measures the maximum pressure in the arteries when the heart contracts and beats) was less than 100 or if his heart rate was less than 60 beats per minute. CN 2 stated Resident 87 was administered his 4:00 p.m. amiodarone dose, outside of ordered BP parameters, on 2/3/26 for a BP of 96/58, on 2/5/26 for a BP of 99/58, on 2/13/26 for a BP of 99/61, and on 3/11/26 for a BP of 98/59. CN 2 stated amiodarone worked by lowering blood pressure and heart rate. CN 2 stated Resident 87 had low BP's on 2/3/26, 2/5/26, 2/13/26 and 3/11/26 and by administering amiodarone Resident 87 was placed at risk for further decreasing his blood pressure which could result in cardiac distress or inability to participate in therapy sessions. CN 2 stated it was important to ensure Resident 87 received medication as prescribed to meet his care needs. CN 2 stated it was expected licensed nursing staff administered medication as prescribed. During an interview on 3/19/26 at 3:27 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 87 was admitted to the facility with low BP and when Resident 87 stood or worked with therapy his BP decreased further. The DOR stated Resident 87's therapy sessions were modified when his BP was low and resumed when his BP improved. The DOR stated Resident 87 met his therapy goals, but was at risk of not meeting his goals if amiodarone was administered outside of ordered parameters and he was unable to participate in therapy due to low BP. During a concurrent observation and interview on 3/19/26 at 4:02 p.m. with Resident 87, in Resident 87's room, Resident 87 was observed lying in bed. Resident 87 stated he had low BP and took amiodarone for AFIB. Resident 87 stated amiodarone further decreased his BP. Resident 87 stated his BP was frequently low when he stood or worked with therapy. Resident 87 stated therapy would resume or restart once his BP increased. During an interview on 3/20/26 at 5:30 p.m. with the Nurse Consultant (NC), the NC stated Resident 87 had systolic BP's less than 100 on 2/3/26, 2/5/26, 2/13/26 and 3/11/26. The NC stated Resident 87 was at risk, four times, for further decreasing his blood pressure, cardiac distress and adverse effects when he was administered amiodarone outside of provider parameters. The NC stated licensed nursing staff were expected to administer medication as prescribed for Resident 87's plan of care to uphold his quality of care. During a review of Resident 87's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/20/26, the AR indicated Resident 87 was admitted to the facility on [DATE] with diagnoses of AFIB, heart failure (chronic, progressive condition where the heart muscle cannot pump enough blood to meet the body's needs) and hypotension (low BP). During a review of Resident 87's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/20/26, the MDS indicated Resident 87 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 87 was cognitively intact. During a review of Resident 87's OSR, dated 3/20/26, the OSR indicated, Resident 87 had an active order for, .amiodarone HCI oral tablet 100 mg.give 1 tablet by mouth two times a day for AFIB hold if [systolic blood pressure] is less than 100 or [heart rate] is less than 60.order start date 1/18/26. and .monitor for blood pressure closely while on amiodarone.inform [Medical Doctor] for any changes and call.for any changes. During a review of Resident 87's Care Plan Report (CP), dated 1/17/26, the CP indicted, administer anti-hypertensive medications as ordered. amiodarone is intended for use only in patients with indicated life-threatening arrythmias. for additional information see physician orders. During a professional reference review retrieved from https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications titled, Recommendations to Enhance Accuracy of Administration of Medications, dated 3/30/23, the professional reference review from the National Coordinating Council for Medication Error Reporting and Prevention indicated, . any order that is incomplete, illegible, or poses any concern should be clarified before preparation and administration.the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason. 2. During a concurrent observation and interview on 03/17/2026 at 11:21 a.m. with Resident 104 in her room, Resident 104 stated she wanted to use the IS to prevent her from having lung and breathing problems after receiving back surgery. Resident 104 stated she received the incentive spirometer from the nursing staff at the acute care hospital after her surgery and had been using the IS while in the acute care hospital. During a review of Resident 104's Admissions Record (AR - a document containing pertinent resident profile information), dated 3/19/26, the AR indicated, Resident 63 was admitted to the facility on [DATE] with diagnoses which included, Lumbago with Sciatica ( lower back pain [lumbago] combined with pain, numbness, or tingling that radiates from your lower back, through the hips, and down one or both legs [sciatica]), Spinal Stenosis, Lumbar Region without Neurogenic Claudication (narrowing of the spinal canal in the lower back that squeezes nerves, causing pain or stiffness, but without the specific, severe leg cramping/weakness [claudication] triggered by walking), Spinal Fusion (a surgery that permanently joins two or more vertebrae [back bones] together into one solid bone to stop painful movement between them) ,Lumbar region (a surgical procedure that permanently connects two or more vertebrae in the lower spine using bone grafts and metal hardware to treat instability, severe pain, or herniated discs). During a concurrent interview and record review on 03/20/26 at 5:12 p.m. with Registered Nurse (RN) 2, Resident 104's Electronic Medical Record (EMR) dated 3/20/26 was reviewed. The EMR indicated there was not an order for Resident 104 to use an IS. The RN 2 stated, . there is not an order for Resident 104 to use an IS, there should be an order for everything the resident uses ., During an interview on 3/20/26 at 6:15 p.m. with the Administrator (ADM), the ADM stated there should have been an order for the IS, Resident 104 came to the facility after having a back infusion. The IS would help the resident prevent respiratory illness. During an interview on 03/20/2026 at 6:17 p.m. with Director of Nursing (DON), the DON stated that she had provided Resident 104 with a new IS when Resident 104 requested to use an IS. The DON stated she did not check to see if Resident 104 had an order or a care plan to use an IS. The DON stated she looked for a policy regarding the usage of the IS and the facility did not have one. During a professional reference titled, What is the proper procedure for prescribing and incentive spirometer to a pharmacy?, undated, retrieved from https://www.droracle.ai/articles/158406/what-is-the-proper-procedure-for-prescribing-an-incentive, the professional reference indicated, . Incentive spirometers are not prescribed through a pharmacy as they are considered medical devices rather than medications . providers can write a prescription . indicating the specific type of incentive spirometer needed and usage instructions .

Based on observation, interview and record review the facility failed to ensure vegetables were prepared to conserve appearance and palpability for three of eight sampled residents (Res 25, Res 60 and Res 69) when the Italian blend vegetables with carrots and squashes were soft and mushy, and string beans were split in half with bean pods exposed for lunch served on 3/19/26.,This failure had the potential to result in vegetables not being consumed for Res 25, Res 60 and Res 69 and not meeting their recommended daily allowance (RDA- the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97.5 percent) healthy) leading to malnutrition (a dangerous imbalance between the nutrients the body needs and those it receives).Findings:During a review of Res's 25 admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/20/26, the AR indicated Res 25 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease ( a progressive neurological disorder and the most common cause of dementia), low back pain, and falls.During a review of Res 25's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 12/30/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Res 25 had no cognitive impairment.During a review of Res 25's Meal Card (MC- a versatile tool used for either meal planning) dated 3/19/26, the MC indicated, Regular diet, regular texture.Italian blend [vegetables].During a record review of Res 60's AR dated 3/20/26, the AR indicated Res 60 was admitted on [DATE] with a diagnoses of Hemiplegia (severe or total paralysis ( loss of the ability to move ) affecting one side of the body), diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and muscle weakness.During a review of Res 60's MDS dated 2/3/26, the MDS indicated, Res 60 had a BIMS of 15 indicating she had no cognitive impairment.During a review of Res 60' MC dated 3/19/26, the MC indicated, Consistent Carbohydrate [CC- diet a meal plan designed to manage blood sugar by eating roughly the same amount of carbohydrates at the same time each day] diet. regular texture.Italian blend [vegetables].During a record review of Res 69's AR dated 3/20/26, the AR indicated Res 69 was admitted on [DATE] with diagnoses of anemia (a condition where the body does not have enough healthy red blood cells), muscle weakness, and shortness of breath (difficulty breathing). During a review of Res 69's MDS dated 2/24/26, the MDS indicated, Res 60 had a BIMS of 12 indicating he had moderate cognitive impairment.During a review of Res 69 's MC dated 3/19/26, the MC indicated, Regular diet, regular texture.Italian blend [vegetables].During an interview on 3/19/26 at 9:23 a.m. during resident council meeting (formal, independent group run by residents to discuss concerns, improve quality of life, and influence care decisions) Res 25, Res 60 and 69 stated the vegetables during mealtime were soft and overcooked. Res 60 stated she liked her vegetables crunchy. Res 60 stated she notified the kitchen staff about the vegetables being overcooked. Res 60 stated there were no changes.During an observation and interview on 3/19/26 at 12:08 p.m. with the Certified Dietary Manager (CDM), Registered Dietician (RD) and another nurse evaluator, during lunch time, a regular diet (nutritionally adequate, balanced meal plan for individuals without health conditions) test tray (a tray from the kitchen use to evaluate meal quality) was observed. The regular diet test tray had Italian mixed vegetables consisting of carrots, green beans and squash. The regular diet test tray had carrots with soft texture which melted in the mouth when consumed and did not require chewing. The squash was disintegrating and did not hold the texture or form. The green beans fell apart and were split in half exposing the pods appearing more as peas. There was no crunch to the Italian mixed vegetables. The CDM stated the squash and carrots were too soft. The CDM stated the Italian blend vegetable texture should have been harder with the squash holding its form. The CDM stated residents should have the vegetables served like they were served at home. The CDM stated residents on regular diet would not have wanted their carrots, green beans, and squash soft. The CDM stated We should have made sure it was within their diet and texture should have been within their food preferences.During an interview on 3/20/26 at 1:19 p.m. with Dietary [NAME] (DC), the DC stated, We put the vegetables in the steamer and transfer it to the warmer. The DC stated she should have ensured the vegetable texture was followed according to the recipes. The DC stated the vegetables should have had the texture of what the residents wanted. The DC stated residents would not be happy with their vegetables texture being soft and mushy and would not consume their vegetables. During an interview on 3/20/2026 at 1:46 p.m. with the CDM, the CDM stated she was responsible for updating the food preferences for the residents. The CDM stated the kitchen staff should have ensured the vegetables were more palpable and held their texture. The CDM stated residents would not consume their vegetables when it was not in their food preferences. The CDM stated the facility should have ensured it was not overcooked during tray- line. During an interview on 3/20/26 at 2:17 p.m. with the RD, the RD stated, Each vegetable should have each own bite each vegetable should have its own bite [ meaning that each type of vegetable served should maintain its individual form and texture.] The RD stated, the squash and the beans did not hold their form and was not there anymore. The RD stated residents would not consume their vegetables when they were not served to their preferences. The RD stated the residents would not get 100 percent of their RDA when they did not consume their vegetables. The RD stated, Residents could have malnutrition.During a review of the facility's policy and procedures (P&P) titled, Menus dated 10/2017, the P&P indicated, Menus are developed and prepared to meet resident choices.menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of four sampled residents (Resident 103) when Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was not worn during care for Resident 103 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities). This failure placed Resident 103 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings:During an observation on 3/17/26 at 11:19 a.m. outside Resident 103's room, an EBP sign was observed on Resident 103's door, and a green sticker was observed next to Resident 103's name.During a concurrent observation and interview on 3/17/2026 at 11:20 a.m. with Resident 103 in Resident 103's room, Resident 103 was observed dressed, in bed, wearing an oxygen (O2) nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) with pillows supporting her legs. Resident 103 grimaced in pain when she moved. Resident 103 stated her back and leg hurt and she received pain medication which helped her pain.During a review of Resident 103's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/20/26, the AR indicated Resident 103 was admitted to the facility from an acute care hospital on 2/24/26 with diagnoses of acquired loss of left leg (surgical removal of finger, toe, hand, foot, arm or leg) above the knee, peripheral vascular disease (the reduced circulation of blood to the arms or legs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer Stage 2 (a pink or red open wound, resulting from an injury that causes the first layer of skin to be lost, exposing the dermis[the middle layer of skin]) of the sacral region (the triangular shaped bone at the base of the back), resistance to multiple antibiotics, and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 103's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/2/26, the MDS section C indicated Resident 103 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 103 was cognitively intact.During an observation on 3/18/2026 at 10:20 a.m., Certified Nursing Assistant (CNA) 1 was observed with another staff member repositioning Resident 103 by moving her linens off Resident 103, grabbing the sheet underneath her and pulling her up towards the head of her bed. Both staff members did not wear gowns when they repositioned Resident 103.During a review of Resident 103's Care Plan (CP), undated, the CP indicated, .resident [103] requires Enhanced Barrier Precautions [EBP] related to surgical wound.date initiated: 2/25/26.use gown and gloves during high contact resident care activities [dressing, bathing, transfers, hygiene, toileting, brief changes, changing linens, device care, wound care].During an interview on 3/19/2026 at 8:07 a.m. with CNA 1, CNA 1 stated residents on EBP had a sign posted on their door and a green dot by their name. CNA 1 stated EBP means staff needed to wear a gown and gloves for resident care. CNA 1 stated EBP were for residents who had a catheter (a common type of indwelling catheter inserted into the bladder, used to drain urine), residents with COVID-19 (a highly contagious respiratory disease, C. diff (a bacterium [germ] that causes an infection of the colon [the longest part of the large intestine]), or any infection that could have spread to other residents. CNA 1 stated close contact included touching the resident's skin, repositioning, or changing the resident. CNA 1 stated she should have worn a gown when she repositioned Resident 103. CNA 1 stated a gown limited germs the resident might have had, from getting on the CNAs or other staff and protected other residents from getting germs transmitted to them. During an interview on 3/19/2026 at 3:10 p.m. with the Director of Staff Development (DSD), the DSD stated residents on EBP had a sign on their door and green dot by their name, which signified which resident was on EBP. The DSD stated her expectation was for CNAs to wear appropriate PPE when providing personal care, transferring the residents, positioning residents in bed, or handling resident's linens. The DSD stated wearing the appropriate PPE was to protect residents from getting germs from staff. The DSD stated if staff came in contact with an infectious resident they could have transferred the germs to another resident. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, .Enhanced barrier precautions [EBPs] are utilized to prevent the spread of multi-drug resistant organisms [MDROs] to residents.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.gloves and gown are applied prior to performing the high contact resident care activity.personal protective equipment [PPE] is changed before caring for another resident.examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.transferring.changing linens.wound care [any skin opening requiring a dressing].EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.During a review of the facility's P&P titled, Policies and Practices - Infection Control, dated 10/2018, the P&P indicated, .this facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.the objectives of our infection control policies and practices are to.establish guidelines for implementing isolation precautions.

Based on observation, interview, and record review during the survey period of 3/17/26 through 3/20/26, the facility failed to provide the minimum of at least 80 square feet per resident in 27 of 37 multiple resident rooms (rooms 101, 102, 103, 104, 105, 106, 107, 108, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 128, 130, 131, 132, 133, 134, 135, 136, and 137).This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.Findings:During a concurrent observation and interview on 3/20/2026 at 9:16 a.m. with the Maintenance Director (MND), an environmental tour was conducted. The MND measured two rooms and stated the rooms did not meet the minimum square footage per resident as required by regulation. However, variations were in accordance with the particular needs of the residents. There was sufficient room observed for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible. The closets and storage space were adequate. Bedside stands were available. The waiver will not adversely affect the health and safety of residents.During a review of the facility document titled, Client Accommodations Analysis, undated, the document indicated:Room Beds Square Feet101 3 229.99 102 3 229.99103 3 229.99104 3 229.99 105 3 229.99106 3 229.99107 3 229.99108 3 229.99115 3 216 116 3 216117 3 216118 3 216119 3 216120 3 219121 3 219122 3 219123 3 219124 3 219128 3 254.57130 3 228.99131 3 228.99132 3 228.99133 3 228.99134 3 228.99135 3 228.5136 3 228137 3 218.5Recommend waiver continue in effect._____________________________________HFES Signature Date Request waiver continue in effect.____________________________________ Facility Administrator Signature Date

Based on interview and record review, the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was noted to have pain, bruising, and swelling to her right hand and wrist; and discoloration to her left wrist. This failure resulted in Resident 1's injuries of an unknown source to not be investigated, placing Resident 1 at potential risk for harm and/or abuse, and delayed medical intervention. Findings: During a review of Resident 1's Admission Record (AR) , dated 5/20/25, the AR indicated Resident 1 was a [AGE] year-old female with medical diagnoses that included dementia (progressive disease of the brain affecting memory, judgement, and mood), schizophrenia (mental illness affecting perceptions of reality), disorders of the bone, other disorders of the brain, disorientation, need for assistance with personal care, bipolar disorder (mental illness with extreme shifts in mood, behavior, and energy), muscle weakness, and others. During a review of Resident 1's Care Plan (CP), dated 4/21/25, the CP indicated Resident 1 skin discoloration to left wrist. During a review of Resident 1's CP dated 4/29/25, the CP indicated Resident 1 has swelling to right hand and wrist. During a review of Resident 1's Progress Notes (PN), dated 4/21/25, at 3:36 p.m., the PN indicated, Resident noted with these new skin issues: . skin discoloration to left wrist. During a review of Resident 1's PN, dated 4/28/25, at 6:30 p.m., the PN indicated Resident 1 was complaining of pain in right wrist and unable to twist wrist. Resident described pain as sharp continuous pain with a pain level of [10 out of a possible 10, 10 being worst pain]. During a review of Resident 1's PN, dated 4/29/25, at 2:41 p.m., the PN indicated a Change in Condition , and noted swelling to right hand and wrist. During a review of Resident 1's PN, dated 4/29/25, at 11:16 p.m., the PN indicated, Applied ice pack to Right and wrist due to swelling. During a review of Resident 1's PN, dated 4/30/25, at 9:53 p.m., the PN indicated a physician's order was received to x-ray Resident 1's right hand. During a review of Resident 1's Patient Report (PR), dated 4/30/25, the PR indicated x-rays were done on Resident 1's right and left hand, due to Right [and] Left hand pain. The PR indicated there was no fracture, and no abnormality. During a concurrent record review and interview on 5/14/25, at 1:20 p.m., with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON stated she was not aware of Resident 1's issues of pain and swelling of her wrists and hands. The DON was not able to produce documentation of a facility investigation into the source of the pain and swelling to the Resident 1's hands, or documentation that this possible Injury of Unknown Source was reported to The Department. The DON stated one possible reason it was not reported was because the x-ray did not show a fracture or injury to the wrists or hands. During a concurrent record review and interview on 5/14/25, at 2:45 p.m., with Registered Nurse (RN) 2, Resident 1's clinical record was reviewed. RN 2 stated she recalled caring for Resident 1. RN 2 stated she recalled making the PN entry on 4/28/25, at 6:30 p.m., when Resident 1 complained of 10 out of 10 pain to her right wrist. RN 2 stated, I assessed the resident. I asked her the pain level, she screamed at me ' 10/10 pain!' During a concurrent record review and interview on 5/14/25, at 3 p.m., with RN 3, Resident 1's clinical record was reviewed. RN 3 stated she recalled caring for Resident 1. RN 3 stated that on 4/29/25, I looked at her [right] wrist. It was swollen with discoloration. I . got the order for the x-ray. During a concurrent record review and interview on 5/28/25, at 11:40 a.m., with the Clinical Resource Corporate Registered Nurse (CRCRN), Resident 1's clinical record was reviewed. The CRCRN stated he recalled Resident 1. The CRCRN stated Resident 1's swollen, discolored, and painful right wrist was not investigated by the facility as an Injury of Unknown Source, nor was it reported to The Department as an Injury of Unknown Source. The CRCRN stated the right wrist could have been an injury because of a fall Resident 1 experienced on 4/12/25, but could not explain why Resident 1's clinical record did not contain documentation of any injury to Resident 1's right wrist until 16 days later. During a concurrent interview and record review on 6/10/25, at 12:25 p.m., with Treatment Registered Nurse (TRN), Resident 1's PN dated 4/21/25, at 3:36 p.m. was reviewed. The TRN stated she was the facility's Treatment Nurse (a nurse who performs all the bandage and dressing changes, monitors wound care, healing progress, and administers medications to the skin). The TRN stated she recalled making the PN and stated she was doing a head-to-toe assessment on Resident 1. The TRN stated she recalled making the entry, skin discoloration to the left wrist and stated she probably updated Resident 1's CP . The TRN stated she was unaware that resident injuries of unknown source needed to be investigated and reported to The Department. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/17, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment, and/or injuries of unknown source (abuse ) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations . including injuries of an unknown source . will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The state licensing/certification agency responsible for surveying/licensing the facility [The Department.]

Based on interview and record review, the facility failed to honor six out of six sampled residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) rights when they all were given written notices they would have to move into different rooms in the facility with no existing reason to do so, despite some of the residents having resided in their rooms for several years. This failure resulted in: 1. The potential for more than minimal harm for Resident 1, Resident 2, Resident 3, Resident 5, and Resident 6 when their collective right to a respectful and dignified existence was not honored by failing to allow all six residents ' rights to self-determination, affecting their right to a respectful and dignified environment, by not allowing them to remain in their rooms that had been their home for years which the residents strongly objected to, and, 2. Actual harm to Resident 4 when her mood and behavior changed, exhibiting increased irritability, depression, sadness, loss of health or independence, frustration, anxiety, anger and upset over the proposed room change, and stating she wanted to end her life due to the room change. These mood and behavior changes directly resulted in her physician prescribing a significant increase in two of her anti-depressant medications (prescription medications used to treat depression and other mental health disorders), increasing her risk of side effects from the medications, such as an increased risk for falls and bone fracture, a risk that is increased due to Resident 4 ' s advanced age and numerous other medications. Findings: 1. During an interview on 10/22/24, at 4 p.m., with the Ombudsman (a government official who advocates for the rights of nursing home residents and helps resolve issues), the Ombudsman stated that Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6 were all given a 30-day notices from the facility that they would have to move to different rooms within the facility. The Ombudsman stated the facility sent out mandatory room transfer notices impacting the six residents, only because they each resided in the facility ' s only 2-bed rooms and informed them they are being moved into 3-bed rooms elsewhere in the facility. The Ombudsman stated there were only three rooms in the facility with 2 beds, and these six residents resided in these three rooms. The Ombudsman stated the facility is doing this for the need for possible future quarantine rooms, in the possible event they need to isolate residents in the future, to control a potential infectious disease from spreading to others that was not currently occurring in the facility. The Ombudsman stated some residents had been in their rooms for years and stated as an example that Resident 6 had been in his room for [AGE] years. The Ombudsman stated the residents understood the need for a quarantine room, and they have no problem moving into different rooms for short periods of time, but this move would be permanent, and the residents strongly opposed the move, preferring to stay in the same rooms they had been in for years. The Ombudsman stated, These [six] residents are really upset. During an interview on 10/23/24, at 12:25 p.m., with Resident 1 and Resident 2, in their shared room, Resident 2 stated, I ' ve been in this room for five years. I ' ve had the same roommate [Resident 1] for five years. I don ' t like it at all, being told we have to move. I want to stay here in this room. Resident 1, who was non-verbal during the interview, nodded her head in agreement with her roommate, Resident 2, as Resident 2 spoke. During an interview on 10/23/24, at 12:30 p.m., with Resident 6, in his room, Resident 6 stated, I ' ve been in this room for [AGE] years. They told me they were going to move me to a different room. I don ' t like it at all. They haven ' t given me any information on who my new roommates are going to be. We are supposed to move on 10/30/24. All my things are here, my medical supplies are here, just where I want them. I want to stay in my room. During an interview on 10/23/24, at 12:45 p.m., with the Administrator, the Administrator stated, The room changes are being done because I am short on isolation rooms. The Administrator stated in the event of a future outbreak of an infectious disease, the facility would need more rooms to isolate residents from other residents to prevent the spread of the potential infectious disease. The Administrator stated there were no such needs in the facility at the present time. During an interview on 10/23/24, at 12:45 p.m., with the Infection Prevention Nurse (IPN), the IPN stated in the event some residents in the facility catch an infectious disease, and the facility needs to isolate them from other residents, the facility could place three residents with the same infectious disease (a process called cohorting) in the rooms with three beds. The IPN stated, We want to get those three 2-bed rooms available, in the possible event that isolation rooms are needed in the future because it is easier to cohort two residents with the same infectious disease in a 2-bed room than it is with three residents in a 3-bed room. The IPN stated there was no current infectious disease in the facility that required the proposed room changes. During a review of a letter from the facility to the Ombudsman (letter), dated 10/2/24, the letter indicated, Enclosed are copies of the 30-day notices given to six [Resident 1, Resident 2, Resident 3, Resident 4, Resident 5 and Resident 6] Residents for room changes. I met with the Residents today, with the Ombudsman present, and I explained that I need those semi-private [2-bed rooms] rooms to accommodate the infectious diseases. During a review of Resident 1 ' s document titled, Notice of Proposed Transfer/Discharge (NOPTD), dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 1] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 2 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 2] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 3 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 3] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 5 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 5] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. During a review of Resident 6 ' s document titled, NOPTD, dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 6] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. The NOPTD indicated Resident 6 refused to sign the document. During a review of Resident 1 ' s Admission Record (AR), dated 10/30/24, the AR indicated Resident 1 was a [AGE] year-old female and had been a resident of the facility since 2012. The AR indicated Resident 1 ' s diagnoses included Major Depressive Disorder (a serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working). During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 10/2/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident ' s environment). During a review of Resident 1 ' s Progress Notes (PN), dated 10/1/24, at 11:37 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident ' s mother was contacted due to mother being resident ' s [Responsible Party]. Mother did refuse to sign and stated they would not like for her daughter to move. Resident 1 ' s PN dated 10/8/24, at 11:12 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 2 ' s AR, dated 10/24/24, the AR indicated Resident 2 was an [AGE] year-old female and had been a resident of the facility since 2015. The AR indicated Resident 2 ' s diagnoses included Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed); and Major Depressive Disorder. During a review of Resident 2 ' s Order Summary Report (OSR), dated 10/24/24, the OSR contained a physician ' s order that indicated Resident has capacity to make decision for self[.] During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 2 was cognitively intact. During a review of Resident 2 ' s PN, dated 10/1/24, at 1:22 p.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident refused to move. Resident 2 ' s PN dated 10/1/24, at 3 p.m., indicated Resident daughter . was notified [of notice of room change] and refused to sign document. Resident 2 ' s PN dated 10/8/24, at 10:24 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated that they did not want to move rooms and did not feel comfortable with change. During a review of Resident 3 ' s AR, dated 10/30/24, the AR indicated Resident 3 was a [AGE] year-old female and had been a resident of the facility since 2021. The AR indicated Resident 3 ' s diagnoses included Aphasia (a language disorder that makes it hard for a person to read, write, and speak clearly). During a review of Resident 3 ' s OSR, dated 10/30/24, the OSR contained a physician ' s order that indicated Resident has capacity to make her own decisions[.] During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 13 out of a possible 15, which indicated Resident 3 was cognitively intact. During a review of Resident 3 ' s PN, dated 10/1/24, at 8:39 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident did refuse to sign and stated they would not like to move. Resident 3 ' s PN dated 10/8/24, at 11:22 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 5 ' s AR, dated 10/24/24, the AR indicated Resident 5 was a [AGE] year-old male and had been a resident of the facility since 2023. The AR indicated Resident 5 ' s diagnoses included Legal blindness, as defined in USA. During a review of Resident 5 ' s OSR, dated 10/24/24, the OSR contained a physician ' s order that indicated Resident has the capacity to make his own medical decision[.] During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 5 was cognitively intact. During a review of Resident 5 ' s PN, dated 10/1/24, at 8:46 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident . stated they would not like to move. Resident 5 ' s PN dated 10/8/24, at 9:43 a.m., indicated, Social services went to visit resident to check on his mental status from initiated room change that will be happening at the end of the month of October. Resident stated they did not like the idea of moving rooms and was not open to moving rooms. Resident stated this has been his room since admission and did not feel comfortable to change. During a review of Resident 6 ' s AR, dated 10/24/24, the AR indicated Resident 6 was a [AGE] year-old male and had been a resident of the facility since 2009. The AR indicated Resident 6 ' s diagnoses included Generalized Anxiety Disorder and Major Depressive Disorder. During a review of Resident 6 ' s OSR, dated 10/24/24, the OSR contained a physician ' s order that indicated Resident is capable to make his own medical decision[.] During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 6 was cognitively intact. During a review of Resident 6 ' s PN, dated 10/1/24, at 8:49 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident did refuse to sign and stated they would not like to move. Resident 6 ' s PN dated 10/8/24, at 11:22 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of the facility ' s Policy and Procedure (P&P), titled Multidrug-Resistant Organisms, dated 8/19, the P&P indicated, in part: Infection Precautions: Consider the individual resident ' s clinical situation and facility resources in deciding whether to implement contact precautions. 2. During an interview on 10/22/24, at 4 p.m., with the Ombudsman (a government official who advocates for the rights of nursing home residents and helps resolve issues), the Ombudsman stated that Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6 were all given a 30-day notice from the facility that they would have to move to different rooms within the facility. The Ombudsman stated the facility sent out mandatory room transfer notices impacting the six residents, only because they each resided in the facility ' s only 2-bed rooms, and informed them they are being moved into 3-bed rooms elsewhere in the facility. The Ombudsman stated there were only three rooms in the facility with 2 beds, and these six residents resided in these three rooms. The Ombudsman stated the facility is doing this for the need for possible future quarantine rooms, in the possible event they need to isolate residents, in the future, to control an infectious disease that was not currently occurring in the facility. The Ombudsman stated some residents had been in their rooms for years and stated as an example that Resident 6 had been in his room for [AGE] years. The Ombudsman stated the residents understood the need for a quarantine room, and they have no problem moving into different rooms for short periods of time, but this move is permanent, and the residents strongly opposed the move, preferring to stay in the same rooms they had been in for years. The Ombudsman stated, These [six] residents are really upset. During an interview on 10/23/24, at 12:45 p.m., with the Administrator, the Administrator stated, The room changes are being done because I am short on isolation rooms. The Administrator stated in the event of a future outbreak of a potential infectious disease, the facility would need more rooms to isolate residents from other residents to prevent the spread of the infectious disease. The Administrator stated there were no such needs in the facility at the present time. During an interview on 10/23/24, at 12:45 p.m., with the Infection Prevention Nurse (IPN), the IPN stated in the event some residents in the facility catch an infectious disease, and need to isolate them from other residents, the facility could place three residents with the same infectious disease (a process called cohorting) in the rooms with three beds. The IPN stated, We want to get those three 2-bed rooms available, in the possible event that isolation rooms are needed in the future because it is easier to cohort two residents with the same infectious disease in a 2-bed room than it is with three residents in a 3-bed room. The IPN stated there was no current infectious disease in the facility that required the proposed room changes. During a review of a letter from the facility to the Ombudsman (letter), dated 10/2/24, the letter indicated, Enclosed are copies of the 30-day notices given to six [including Resident 4] Residents for room changes. I met with the Residents today, with the Ombudsman present, and I explained that I need those semi-private [2-bed rooms] rooms to accommodate the infectious diseases. During a review of Resident 4 ' s document titled, Notice of Proposed Transfer/Discharge (NOPTD), dated 10/1/24, the NOPTD indicated, For the reasons explained below, a decision has been made to transfer [Resident 4] from current room to another room. Date of this Notification to Resident: 10/1/24. Date of Transfer: 10/30/24. [Reason:] The health of individual in the facility would otherwise be endangered. The NOPTD indicated Resident 4 refused to sign the document. During an interview on 10/23/24, at 1:10 p.m., with Resident 4, Resident 4 stated, Hell no, I don ' t want to move! I ' ve been in this bed for over a year. I ' d be more willing to go to the mortuary [a facility that processes dead bodies for burial]. During a review of Resident 4 ' s Admission Record (AR), dated 10/24/24, the AR indicated Resident 4 was a [AGE] year-old female and had been a resident of the facility since 2014. Resident 4 ' s diagnoses included Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and Major Depressive Disorder (a serious mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working). During a review of Resident 4 ' s Order Summary Report (OSR), dated 10/24/24, the OSR contained a physician ' s order that indicated Resident is capable to make her own decision by herself. During a review of Resident 4 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 9/13/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 4 was cognitively intact. During a review of Resident 4 ' s Progress note, dated 9/3/24, written by her attending physician (Physician 1), the PN indicated Resident 4 was seen at bed side for follow up. No new nursing concerns reported. [Resident 4] has history of depression, symptoms stable with current management. Assessment and Plan: Depression . We will continue current medication and consider mental health evaluation if needed. During a review of Resident 4 ' s Progress Notes (PN), dated 10/1/24, at 8:52 a.m., the PN indicated Resident was issued with a 30 day notice to move rooms in the facility in order to be able to increase our isolations rooms to accommodate our resident ' s needing isolation for recovery. Resident did refuse to sign and stated they would not like to move. Resident 4 ' s PN dated 10/8/24, at 11:20 a.m., indicated, Social services went to visit resident to check on Resident ' s mental status from initiating the room change that will be happening at the end of the month in October. Resident stated they did not want to move rooms and won ' t be moving. Resident stated this has been her room for a while and did not feel comfortable to change. During a review of Resident 4 ' s OSR, dated 10/22/24, the OSR indicated Resident 4 was prescribed: Fluoxetine 10 mg [milligrams, a unit of measurement] once daily for verbalization of sadness, prescribed on 7/8/24; and, Trazadone 100 mg at bedtime for depression manifested by unable to sleep, prescribed on 10/22/23. Resident 4 ' s OSR indicated nursing staff was monitoring her for side effects from the Fluoxetine such as nausea, vomiting, anxiety, sexual dysfunction, insomnia, dizziness, weight loss or gain, tremors, sweating, drowsiness, fatigue, dry mouth, diarrhea, constipation, headaches and increase risk for fall. The OSR indicated nursing staff were monitoring Resident 4 for side effects from the Trazadone such as daytime drowsiness, confusion, loss of appetite in the morning, increased risk for fall and fractures, dizziness. The OSR indicated Resident 4 was prescribed 12 different routine medications, and an additional six different medications on an as needed basis. Resident 4 ' s PN dated 10/22/24, at 8:30 a.m., indicated, Resident [4] verbalize to [Certified Nursing Assistant, or CNA] during shower suicidal thoughts due scheduled room change. Per resident she does not want to move from her room. [Physician] notified, new order for psych[iatric] consult[ation]. Resident placed on spot checks. During a review of Resident 4 ' s Care Plan (CP), dated 10/22/24, the CP indicated, Resident [4] verbalizes suicidal ideation. Resident 4 ' s PN dated 10/23/24, at 4:34 p.m., indicated, Stated she doesn ' t understand why she has to change rooms. Resident 4 ' s PN dated 10/24/24, at 8:14 a.m., indicated, Resident was evaluated by facility psychologist [Doctor 1] . [due to] recent suicidal ideations. Resident chief complaint was noted as depression, sadness, loss of health or independence, anger, frustration, anxiety in adjusting to care, confusion or memory loss impairing her capacity to receive care or treatment. The resident ' s compliance was noted as resistive and argumentative. The resident ' s mood was noted as depressed, anxious, irritable, angry, and labile [a state of emotional instability characterized by frequent and dramatic mood swings]. [Doctor 1] recommends to increase . psychotropic medications [medications that affect the mind, emotions, and behavior] for continued mood / behavior management. Resident 4 ' s PN dated 10/24/24, at 12:45 p.m., indicated, Resident asked . what room will she be moved to. Told resident I don ' t know the room number yet . Resident stated she does not want to move but if she does, she wants the same roommate. Resident 4 ' s PN dated 10/26/24, dated 0:37 a.m., indicated, Resident is on behavior monitoring for increasing Fluoxetine [a psychotropic medication used for depression] from 10 mg to 20 mg and Trazadone [also a psychotropic medication used for depression] from 100 mg to 150 mg . During a review of Resident 4 ' s Progress Note - 30 Day Follow Up (PN30FU), dated 10/29/24, written by Nurse Practitioner 1, the PN30FU indicated Resident 4 ' s medication Fluoxetine was increased from 10 mg daily to 20 mg daily on 10/26/24; and Resident 4 ' s medication Trazadone was increased from 100 mg to 150 mg at bedtime on 10/25/24. During a concurrent record review and interview on 11/12/24, at 1:39 p.m., with the Social Services Director (SSD), Resident 4 ' s clinical record was reviewed. The SSD stated she had worked in the facility since February 2024, and was familiar with Resident 4. The SSD stated Resident 4 had informed a Certified Nursing Assistant that she didn ' t want to be alive anymore due to her impending room change. The SSD stated she then interviewed Resident 4 about this statement, but during her interview, Resident 4 did not express to her that Resident 4 wanted to end her life. The SSD stated Resident 4 stated she was concerned about the room change and did not want to do it. The SSD stated, To me, she seemed more irritable. The SSD stated facility staff had been expressing to her that Resident 4 had seemed more depressed since the first of October [the date Resident 4 received the 30-day notice to change rooms]. The SSD stated, We can ' t infringe on their rights to not want to move. It was hard to give the notice. I agree that the resident who have been in their rooms for years matters. This situation could have been approached differently. There was no pressing need at that time for isolation rooms in the facility. The SSD stated she reviewed Doctor 1 ' s notes after his visit to Resident 4 on 10/24/24, and stated it is within her job expectations to speak to the psychologist and review residents ' psychotropic medications. The SSD stated, My understanding, based on [Doctor 1 ' s] note, was that [Resident 4 ' s] behavior change was due to the room change. The SSD stated, I would agree that after 10/1/24, [Resident 4] was depressed, irritable, angry, and labile. The resident is often irritable, but I noticed an increase in her irritability. During a concurrent record review and interview on 11/12/24, at 2:03 p.m., with the Activities Director (AD), Resident 4 ' s clinical record was reviewed. The AD stated, [Resident 4] was very upset [about the room change]. I talk to her every day. Her biggest concern was what room she was going to go to. I felt bad for the residents having to move rooms. I told the residents if they are not happy with moving rooms, they can call the Ombudsman. When I spoke to [Resident 4], I heard her say she would take pills. I assumed it meant an overdose for a lethal event. I did let the team know and a psych consult was made. After the medication dosage increase, [Resident 4] never made a comment like that to me again. During a concurrent record review and interview on 11/12/24, at 2:20 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 4 ' s clinical record was reviewed. LVN 1 stated, I ' ve worked here about [AGE] years, I know [Resident 4]. LVN 1 stated she recalled when a Certified Nursing Assistant told her that during a shower that Resident 4 had expressed suicidal ideations, and she was upset over her proposed room change. The CNA told me [Resident 4] wanted to kill herself over this. I wrote the note in the Progress Notes, I wasn ' t more specific on how she would do it. I then spoke to [Resident 4], she denied any suicidal ideations to me, but stated she did not want to move. During a review of Resident 4 ' s untitled document from her clinical record, but commonly referred to as a physician telephone order (PTO) dated 10/22/24, at 8:35 a.m., the PTO indicated Resident 4 had a physician ' s order for May have Psych eval[uation] and treat[ment related to] suicidal ideation verbalized. During a review of Resident 4 ' s Psych Referral Form (PRF), dated 10/22/24, the PFR indicated, Emotional and Behavioral Problems [-] Suicidal Thinking or Gestures. During a concurrent record review and interview on 11/12/24, at 2:30 p.m., with the Director of Nursing (DON), Resident 4 ' s Psychologist Consultation / Follow-Up (PCFU), written by Doctor 1, dated 10/24/24, was reviewed. The DON verified Doctor 1 had documented on the PCFU Resident 4 demonstrated Depression, sadness, loss of health or independence with Chief Complaints of Anger, frustration, anxiety in adjusting to care, and Presenting problems and History of Confusion or memory loss impairing capacity to receive care, treatment. The PCFU indicated Resident 4 ' s Current Medication were fluoxetine 10 mg and Trazadone 100 mg. The PCFU indicated Resident [4] presents as alert, lucid, communicative, mood and affect angry, upset over room change, threatening to harm herself, denied any intent or plan during contact. [Complains of] depression, [decreased] sleep, can be tried on fluoxetine 20 mg [every day], Trazadone 150 mg [at bedtime.] The DON confirmed the documentation. During a review of the National institute of Health, National Library of Medicine, National Center for Biotechnical Information website titled, Depression: Learn More - How effective are antidepressants?, dated 4/15/24, the website indicated, in part: Antidepressants are a key part of treating depression. They aim to relieve symptoms and prevent depression from coming back. The main aim of treatment with antidepressants is to relieve the symptoms of severe depression, such as feeling very down and exhausted, and prevent them from coming back. They are also meant to make you feel emotionally stable again and help you follow a normal daily routine. They are also taken to relieve symptoms such as restlessness, anxiety and sleep problems, and to prevent suicidal thoughts. This information is about using medication to treat the most common form of depression, known as major depressive disorder. Like all medications, antidepressant can have side effects. Ove half of all people who use antidepressants report experiencing side effects. Some of these side effects are believed to be a direct consequence of the medication ' s effect on the brain. Examples include a dry mouth, headaches, dizziness, restlessness and sexual problems. The risk of side effects increases if you are also taking other medication. One of the drugs may make the side effects of the other worse. These kinds of drug interactions are common in older people and people with chronic illnesses who are taking several different kinds of medication. Severe side effects - Antidepressants can cause dizziness and unsteadiness, increasing the risk of falls and bone fractures, especially in older people. Interactions with other medications increase this risk. During a review of the facility ' s Policy and Procedure (P&P), titled Multidrug-Resistant Organisms, dated 8/19, the P&P indicated, in part: Infection Precautions: Consider the individual resident ' s clinical situation and facility resources in deciding whether to implement contact precautions.

Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During a concurrent observation and interview on 10/1/24 at 1:20 p.m. with Resident 1 outside on the patio, Resident 1 was sitting in her wheelchair playing a card game on an electronic tablet. Resident 1 stated, she was given a 30-day notice to be discharged because she had not complied with the smoking policy that was recently enforced. Resident 1 stated, her mother called the ombudsman for assistance after the 30-day notice was issued to Resident 1. During a telephone interview on 10/3/24 at 8:41 a.m. with Social Services Director (SSD), SSD stated, Resident 1 needed care from a skilled nursing facility (SNF) because she was diagnosed with anoxic brain damage (an injury to the brain that happens when it has a lack of oxygen), muscle spasm, generalized anxiety disorder (severe, ongoing worry that interferes with daily activities), unspecified psychosis (showing symptoms of a mental disorder without an exact diagnosis) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). SSD stated, Resident 1 was wheelchair dependent for ambulation. SSD stated, Resident 1 was given the 30-day notice on 8/6/24 however her mother was given the 30-day notice on 9/5/24. SSD stated, Resident 1 refused to participate in the discharge planning so Resident 1 ' s mother was contacted. SSD stated, Resident 1 ' s discharge plan included Resident 1 being discharged home with her mother to an apartment. SSD stated, Resident 1 was unable to discharge home with her mother because the apartment was too small and both parents were disabled. SSD stated, Resident 1 ' s discharge plan lacked placement at an accepting SNF. SSD stated, it was important to provide Resident 1 with sufficient preparation and orientation to ensure a safe discharge from the facility, to effectively transition to post-discharge care and to prevent readmissions. During a telephone interview on 10/3/24 at 1:47 PM with Director of Nursing (DON), DON stated, Resident 1 had diagnoses of unspecified psychosis, anoxic brain damage, insomnia, cognitive communication deficit, muscle weakness and major depressive disorder. DON stated, Resident 1 was provided with a 30-day notice on 8/6/24 however there is no documentation in Resident 1 ' s chart that her responsible party received the 30-day notice. DON stated, SSD had done discharge planning with Resident 1 on 8/27/24 and not prior to this date. DON stated, there was no documentation in Resident 1 ' s chart or copies of faxes indicating that referrals had been sent to any SNFs to assist Resident 1 in transfer to another facility. DON stated, Resident 1 should have been provided with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. DON stated, Resident 1 ' s safety was at risk due to a lack of discharge planning. During a telephone interview on 10/3/24 at 3:17 PM with Administrator (ADM), ADM stated, Resident 1 was given a 30-day notice on 8/6/24 but Resident 1 ' s responsible party was not issued a 30-day notice until 9/5/24. ADM stated, ADM had wrongly assumed Resident 1 could have discharged home with her mother because that was where Resident 1 used to reside prior to being admitted to the SNF. ADM stated, Resident 1 ' s mother had said that the apartment was too small for Resident 1 to return to. ADM stated, DON and SSD had not submitted documentation regarding Resident 1 ' s current ability to perform Activities of Daily Living (ADLs). During a review of Resident 1's Admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 10/1/24, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included .ANOXIC BRAIN DAMAGE .ABNORMALTIES OF GAIT AND MOBILITY .MUSCLE WEAKNESS .UNSTEADINESS ON FEET .MAJOR DEPRESSIVE DISORDER .CONTRACTURE [a stiffening/shortening at any joint, that reduces the joint ' s range of motion], RIGHT ANKLE .CONTRACTURE, LEFT ANKLE .TOBACCO USE .GENERALIZED ANXIETY DISORDER . During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 7/3/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's Nursing Care Plan (CP), undated, the CP indicated, .The resident has limited physical mobility r/t ANOXIC BRAIN DAMAGE, CONTRACTURE, RIGHT ANKLE, CONTRACTURE, LEFT ANKLE, MUSCLE WEAKNESS Date initiated 10/14/2016 . During a review of Resident 1's CP, undated, the CP indicated, .Resident requires LTC [Long Term Care] due to family unable to provide care needed Date Initiated: 01/08/2016 . During a review of Resident 1 ' s Progress Notes (PN), dated 8/27/24, the PN indicated, .Social services spoke with resident and resident ' s mother in regard to resident not following smoking guidelines per facility policies, she would receive a notice to discharge home with her mother or alternative placement .Social services spoke with Resident ' s mother in regard to a discharge plan. The resident ' s mother stated that resident cannot return home due to limited space .resident ' s mother stated ' They lived in a 2-bedroom [ROOM NUMBER] bath apartment with no space for her wheelchair or for her to get around, we are low on income because both me and my husband are both on disability ' . During a review of the Department of Health Care Services Office of Administrative Hearings and Appeals (a government entity that handles discharge appeals for long-term care residents) document titled, Decision and Order, dated 9/25/24, the document indicated, .SUMMARY .The appeal is GRANTED. [Facility] has not complied with the legal requirements to involuntary discharge [Resident 1] in that it did not provide Resident with sufficient preparation and orientation to ensure a safe and orderly discharge from Facility. Therefore, the discharge is improper, and Resident shall be permitted to remain in Facility .On August 6, 2024, Facility issued a Notice of Proposed Transfer/Discharge .to resident .Authorized Representative testified they did not receive the Notice until September 5, 2024. Administrator ' s testimony confirmed that Notice was not given to Authorized Representative until September 5, 2024 .Resident ambulates with a wheelchair .Facility did not submit medical records documenting Resident ' s current ability to perform the activities of daily living .Facility did not submit a post-discharge plan of care identifying Resident ' s post-discharge needs and how those need would be met at Location .Authorized Representative identified Location as the apartment she resides in with her husband .she and her husband are both disabled, living alone .Additionally, Location is not wheelchair accessible or equipped with handicap accessories . During a review of the facility's policy and procedure titled, Transfer or Discharge, Facility- Initiated, dated 10/22, indicated, .Facility-initiated transfers or discharges .require resident/representative notification and orientation, and documentation .the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .A post-discharge plan is developed for each resident prior to his or her transfer or discharge .A member of the interdisciplinary team will review the final post-discharge plan with resident and family .

Based on interview, record review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident #46) of 5 residents reviewed for unnecessary medications. Specifically, facility staff failed to follow a physician's order to hold midodrine hydrochloride (a medication used to treat low blood pressure) when the resident's systolic blood pressure (SBP, the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg) and failed to only administer losartan potassium (a medication used to treat high blood pressure) when the resident's SBP was greater than 130 mmHg. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. An Admission Record indicated the facility admitted Resident #46 on 02/27/2024. According to the Admission Record, the resident had a medical history that included diagnoses of essential (primary) hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an active diagnosis to include hypertension. Resident #46's care plan, included a focus area initiated 06/02/2024, that indicated the resident had episodes of syncope (temporary loss of consciousness). Interventions directed staff to assess orthostatic blood pressure (blood pressure taken after standing from a lying or sitting position) twice a day, monitor, and notify the physician accordingly. Resident #46's care profile contained a physician's order with a start date of 03/11/2024 for midodrine hydrochloride 2.5 milligrams (mg) two tablets by mouth three times a day, with instructions to hold if the resident's SBP was greater than 130 mmHg. Resident #46's medication administration record (MAR) for the timeframe 06/01/2024 to 06/30/2024, revealed evidence to indicate staff administered midodrine hydrochloride 2.5 mg to the resident when the resident's SBP was greater than 130 mmHg on 06/01/2024 at 8:00 AM, 06/04/2024 at 8:00 AM, 06/05/2024 at 8:00 AM, 06/06/2024 at 8:00 AM, 06/07/2024 at 8:00 AM, 06/09/2024 at 8:00 AM, 06/10/2024 at 12:00 AM and 8:00 AM, 06/12/2024 at 8:00 AM, 06/13/2024 at 8:00 AM, 06/15/2024 at 4:00 PM, 06/16/2024 at 8:00 AM and 4:00 PM, 06/18/2024 at 8:00 AM, 06/24/2024 at 8:00 AM, 06/25/2024 at 8:00 AM and 06/29/2024 at 8:00 AM. Resident #46's MAR for the timeframe 07/01/2024 to 07/31/2024, revealed evidence to indicate staff administered the midodrine hydrochloride 2.5 mg to the resident when the resident's SBP was greater than 130 mmHg on 07/03/2024 at 4:00 PM, 07/08/2024 at 4:00 PM, 07/09/2024 at 4:00 PM, 07/10/2024 at 4:00 PM, 07/12/2024 at 8:00 AM, 07/15/2024 at 8:00 AM, 07/16/2024 at 8:00 AM, 07/17/2024 at 8:00 AM, 07/19/2024 at 8:00 AM, 07/23/2024 at 4:00 PM and 07/24/2024 at 8:00 AM. Resident #46's MAR for the timeframe 08/01/2024 to 08/13/2024, revealed evidence to indicate staff administered the midodrine hydrochloride 2.5 mg to the resident when the resident's SBP was greater than 130 mmHg on 08/05/2024 and 08/06/2024 at 8:00 AM. Resident #46's care profile also contained a physician's order with start date of 03/21/2024, for losartan potassium 50 mg one tablet by mouth one time a day with instructions to give the medication if the resident's SBP was greater than 130 mmHg. Resident #46's MAR for the timeframe 06/01/2024 to 06/30/2024, revealed evidence to indicate staff administered the losartan potassium 50 mg when the resident's SBP was not greater than 130 mmHg on 06/11/2024, 06/17/2024, 06/19/2024, 06/20/2024, 06/22/2024, 06/26/2024, and 06/30/2024 at 8:00 AM. Resident #46's MAR for the timeframe 07/01/2024 to 07/31/2024, revealed evidence to indicate staff administered the losartan potassium 50 mg when the resident's SBP was not greater than 130 mmHg on 07/01/2024, 07/13/2024, 07/27/2024, and 07/30/2024 at 8:00 AM. Resident #46's MAR for the timeframe 08/01/2024 to 08/13/2024, revealed evidence to indicate staff administered the losartan potassium 50 mg when the resident's SBP was not greater than 130 mmHg on 08/02/2024, 08/11/2024, and 08/12/2024 at 8:00 AM. During an interview on 08/14/2024 at 2:09 PM, Registered Nurse (RN) #2 confirmed that it was her initials on the MAR for 07/23/2024 at 4:00 PM and that based on the resident's blood pressure reading, the midodrine should have been held. RN #2 stated she should have paid closer attention to the orders. During an interview on 08/14/2024 at 2:41 PM, RN #1 reviewed the June 2024 and July 2024 MARs for Resident #46 and confirmed that it was her initials on the midodrine on 06/15/2024, 06/16/2024, 07/08/2024, 07/09/2024, and 07/10/2024 at 4:00 PM and stated that according to the resident's blood pressure reading, the medication should have been held. RN #1 stated she should have put in the code to indicate the blood pressure was out of parameter and a progress note as to why it was held and then notified the resident, resident representative, and physician. During an interview on 08/15/2024 at 9:59 AM, RN #3 stated she checked the resident's blood pressure before giving the medication. RN #3 reviewed Resident #46's June 2024, July 2024, and August 2024 MARs and agreed that according to the orders and the resident's blood pressure readings, the medication should not have been given. RN #3 stated she should have followed the five rights - right resident, right medication, right dose, right time, right route, and should have verified the label of the medication and the order on the MAR three times. During an interview on 08/15/2024 at 9:36 AM, the Medical Director (MD) stated it was important for the nurses to follow the parameters for blood pressure medications to ensure there were no adverse effects. The MD stated the midodrine was used to keep the resident's blood pressure from going too low and the losartan was to keep the blood pressure from going too high. The MD stated it was his expectation that the order be followed and if the medication was being held consistently, then he would expect to be notified. During an interview on 08/15/2024 at 10:11 AM, the Director of Nursing (DON) stated the nurse should look at the parameters and follow the directions as ordered. The DON stated the nurse should check the orders with the medication the label and notify the physician if parameters were out of range or if clarification was needed. During an interview on 08/15/2024 at 11:57 AM, the Administrator stated when administering medications, the nurses should follow the parameters put into place by the physician.

Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure residents rooms measured at least 80 square (sq) feet (ft) per resident in 26 (Rooms 101-108, Rooms 115-124, and Rooms 130-137) of 36 resident rooms in the facility. Findings included: A facility policy titled, Bedrooms, revised 05/2017, revealed, 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet per resident in double rooms, and at least 100 square feet of space in single rooms. The Client Accommodations Analysis, completed by the Administrator and dated 08/15/2024 revealed: - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 216 sq ft and three beds occupied the room, which yielded 72 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 216 sq ft and three beds occupied the room, which yielded 72 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 216 sq ft and three beds occupied the room, which yielded 72 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 216 sq ft and three beds occupied the room, which yielded 72 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 216 sq ft and three beds occupied the room, which yielded 72 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 219 sq ft and three beds occupied the room, which yielded 73 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 219 sq ft and three beds occupied the room, which yielded 73 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 219 sq ft and three beds occupied the room, which yielded 73 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 219 sq ft and three beds occupied the room, which yielded 73 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 219 sq ft and three beds occupied the room, which yielded 73 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.99 sq ft and three beds occupied the room, which yielded 76.33 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.99 sq ft and three beds occupied the room, which yielded 76.33 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.99 sq ft and three beds occupied the room, which yielded 76.33 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.99 sq ft and three beds occupied the room, which yielded 76.33 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.99 sq ft and three beds occupied the room, which yielded 76.33 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228.5 sq ft and three beds occupied the room, which yielded 76.16 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 228 sq ft and three beds occupied the room, which yielded 76 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 218.5 sq ft and three beds occupied the room, which yielded 72.83 sq ft for each resident. During an interview on 08/14/2024 at 9:11 AM, Registered Nurse (RN) #2 revealed there had been issues with staff completing mechanical lift transfers of residents in the rooms. RN #2 said if a mechanical lift was used, there was not enough space for the nurse assistant to complete the transfer. During an interview on 08/14/2024 at 9:25 AM, Certified Nurse Assistant (CNA) #12 stated the rooms were too small and the resident's bed got in the way of providing care to residents. She stated sometimes they must move other residents' beds to ensure care was provided adequately. During an interview on 08/14/2024 at 9:30 AM, CNA #13 stated when they performed transfers with the mechanical lift, there was not enough space. CNA #13 said some of the residents complained about the rooms being too small. She stated it was difficult to provide care when there were three residents in the room. During an interview on 08/15/2024 at 9:41 AM, the Director of Nursing (DON) stated that sometimes the residents complained the rooms were too small for three residents. The DON said there had also been issues with staff completing transfers with the mechanical lift in the residents' rooms. During an interview on 08/15/2024 at 11:16 AM, the Administrator stated she was not aware the room size was too small and was not aware of any resident complaints or concerns about the room size.

Based on interview, record review, facility document review, and facility policy review, the facility failed to provide 1 (Resident #40) of 1 sampled resident reviewed for preadmission screening and resident review (PASARR) with the recommended specialized services identified by the resident's PASAR) Level II. Specifically, the PASARR determination report dated 04/18/2024 for Resident #40 recommended specialized services of psychotherapy/counseling which were not provided by the facility. Findings included: A facility policy titled, Admission Criteria, revised 03/2019, indicated, c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. An Admission Record revealed the facility admitted Resident #40 on 03/02/2017. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder and post-traumatic stress disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #40 had active diagnoses that included post-traumatic stress disorder, anxiety, and depression. Resident #40's Preadmission Screening and Resident Review Individualized Determination Report dated 04/18/2024, revealed recommended specialized services that included psychotherapy/counseling. During an interview on 08/13/2024 at 2:10 PM, the Social Services (SS) Supervisor stated nursing staff should have obtained an order for a psychological referral. The SS Supervisor stated the referral had not been completed and it appeared to have been an oversight. During an interview on 08/14/2024 at 10:10 AM, the Director of Nursing (DON) stated it was her expectation that the SS Supervisor made sure the appropriate referrals were in place for residents. The DON stated there had been a delay with psychiatric services, but she had escalated the referral after the surveyor inquiry. During an interview on 08/15/2024 at 11:13 AM, the Administrator stated PASARR was a gray area to her, but if there were recommendations for services, the facility should have completed the referral.

Based on observation, interview, and facility policy review, the facility failed to ensure windows on the secure unit were locked and secure for 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 9 residents' rooms located on the secure unit. Specifically, room [ROOM NUMBER] and room [ROOM NUMBER] had missing and/or damaged window screens and no locking mechanism to prevent the windows from opening fully. Findings included: A facility policy titled, Safety and Supervision of Residents, revised 07/2017, revealed, 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 policy indicated, 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. During an observation of the secure unit on 08/14/2024 at 1:45 PM, room [ROOM NUMBER] and room [ROOM NUMBER] windows were both observed fully opened. The window screen in room [ROOM NUMBER] was damaged with enough space for a resident to exit through the damaged screen. room [ROOM NUMBER] did not have a window screen. Additionally, room [ROOM NUMBER] and room [ROOM NUMBER] were observed to not have a locking mechanism to prevent the windows from opening fully. The windows for room [ROOM NUMBER] and room [ROOM NUMBER] led into the parking lot. During an interview on 08/14/2024 at 1:53 PM, the Maintenance Supervisor stated the facility staff documented any repair issues into a binder kept at the nurses' station. The Maintenance Supervisor said there were no current reports in the binder regarding any windows or screens in the secure unit that needed to be repaired. He stated he put in some new screens last month. During a concurrent observation and interview on 08/14/2024 at 1:55 PM, of rooms [ROOM NUMBERS] on the secure unit, the Maintenance Supervisor stated he was not aware of the windows missing screens or not having a locking mechanism. He stated visual checks were performed monthly to ensure screens were in place and said the last check was completed on 07/16/2024. The Maintenance Supervisor stated the screen in room [ROOM NUMBER] was not damaged at the time of that check. The Maintenance Supervisor stated he purchased devices to prevent the windows from opening completely, but had not had a chance to put the devices on the windows. During an interview on 08/14/2024 at 2:03 PM, Certified Nurse Assistant (CNA) #10 stated there had not been any issues with any of the residents attempting to leave the facility through a window. During an interview on 08/14/2024 at 2:18 PM, Licensed Vocational Nurse (LVN) #11 stated staff were required to monitor the door and windows in the secure unit. LVN #11 said if the windows needed to be repaired, the staff should notify the Maintenance Supervisor. She was not aware of any issues currently with the windows and said the residents were not able to fully open the windows but could only open them a little. During an interview on 08/14/2024 at 2:24 PM, the Maintenance Supervisor stated room [ROOM NUMBER] had an emergency in which the room had smoke, and the fire department requested the locking mechanism be removed. He said room [ROOM NUMBER]'s window was replaced after a resident broke it, but the window locking mechanism was not. During an interview on 08/15/2024 at 9:43 AM, the Director of Nursing (DON) stated she did not expect the windows on the secure unit to be fully opened. The DON said there had not been any elopements from the facility. The DON said she expected the staff to identify any dangerous items in the unit including if screens were falling off and to notify the Maintenance Supervisor. During an interview on 08/15/2024 at 11:16 AM, the Administrator stated the windows on the secure unit should be locked. The Administrator stated the window locking mechanism and screens not being replaced was a mistake by the facility and was just missed.

Based on interview, record review, facility document review, and facility policy review, the facility failed to obtain psychiatric consultation as ordered for 1 (Resident #58) of 19 sampled residents. Findings included: A facility policy titled, Physician Services, revised 02/2021, indicated, 8. Consultative services are made available from community-based consultants or from a local hospital or medical center. An Admission Record revealed the facility readmitted Resident #58 on 07/15/2024. According to the Admission Record, the resident had a medical history that included diagnoses of vascular dementia, moderate with other behavioral disturbance and depression. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/2024, revealed Resident #58 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #58 had physical and behavioral symptoms directed toward others and behaviors not directed toward others one to three days during the assessment period. Resident #58's care plan, included a focus area initiated 07/18/2024, that indicated the resident used psychotropic medications (Olanzapine) related to behavior management. Interventions directed staff to administer medications as ordered, to monitor/document for side effects and effectiveness, and to consult with pharmacy/physician to consider dosage reduction when clinically appropriate. A document titled, Note To Attending Physician/Prescriber, for Resident #58, dated 08/01/2024, indicated the consultant pharmacist recommended to re-evaluate if the medication olanzapine was still needed as the resident had not been on an antipsychotic prior to their hospitalization . The physician/prescriber response revealed the physician agreed and documented Consult Psych for recommendation. An untitled document for Resident #58, revealed an order dated 08/03/2024 that indicated Resident may have psych [psychiatric] evaluation. Resident #58's Progress Notes revealed a note dated 08/03/2024 at 4:44 PM, that indicated an order was received for a psychiatric consultation recommendation due to re-evaluate if olanzapine still needed. The Progress Notes revealed no evidence of a psychiatric evaluation. During an interview on 08/15/2024 at 8:36 AM, the Social Services Supervisor stated she was not aware of a psychiatric evaluation for Resident #58 until the previous day, 08/14/2024. During an interview on 08/15/2024 at 8:51 AM, Licensed Vocational Nurse (LVN) #4 said Resident #58 was supposed to have a psychiatric evaluation to see if the resident needed they psychotropic medication. During an interview on 08/15/2024 at 9:27 AM, the Medical Director (MD) stated he had not been notified that the psychiatric consultation he ordered for Resident #58 had not been scheduled until he spoke with the Director of Nursing (DON) on 08/15/2024. The MD stated he thought it was necessary to have the resident evaluated to see if the resident needed Olanzapine. During an interview on 08/15/2024 at 10:22 AM, the DON stated she expected the staff to follow the physician orders. During an interview on 08/15/2024 at 10:38 AM, the Administrator stated she expected the staff to follow physician orders and all consultations needed to be scheduled.

Based on interview, record review, and facility policy review, the facility failed to ensure nursing staff did not document the monitoring of peripheral intravenous (IV) site when the resident no longer had the IV because it had been removed for 1 (Resident #297) of 19 sampled residents. Findings included: A facility policy titled, Medication and Treatment Orders, revised 07/2016, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. An Admission Record revealed the facility admitted Resident #297 on 07/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of adult failure to thrive and liver disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2024, revealed Resident #297 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include malnutrition and failure to thrive. Resident #297's care plan included a focus area, initiated 08/01/2024, that indicated the resident faced a nutritional issue related to poor meal and fluid intake. Interventions directed staff to administer medications as ordered. An order detail for Resident #297 revealed an order dated 08/09/2024, to monitor peripheral intravenous (IV) site to right hand dorsum for signs or symptoms (s/s) of infection, infiltration every shift. Resident #297's Medication Administration Record [MAR] for the timeframe 08/01/2024 to 08/31/2024, revealed an order entry for staff to monitor the resident's peripheral IV site to the right hand dorsum for s/s of infection, infiltration every shift. Staff documented on the MAR on 08/12/2024 and 08/13/2024 for all three shifts, and on 08/14/2024 for the 6:00 AM to 2:00 PM shift to indicate they monitored the resident's IV site. An observation on 08/12/2024 at 1:42 PM, revealed Resident #297 did not have an IV site to their right hand. During an interview on 08/14/2024 at 2:20 PM, Registered Nurse (RN) #5 said Resident #297's IV came out prior to 08/13/2024 and that she should not have signed off that she monitored the IV site because the resident did not have an IV to monitor. During an interview on 08/15/2024 at 7:38 AM, Registered Nurse (RN) #3 said Resident #297's IV site was removed on the night shift on 08/11/2024. RN #3 said she should not have charted on 08/12/2024 because the resident did not have an IV site at that time. During a telephone interview on 08/15/2024 at 11:18 AM, RN #7 said that she was told Resident #297 had pulled out their IV on the night shift on 08/11/2024. She said she should not have charted on the MAR for monitoring of the IV site because the resident did not have an IV. During a telephone interview on 08/15/2024 at 9:27 AM, the Medical Director said he expected the staff to document accurately on the MAR. During an interview on 08/15/2024 at 10:38 AM, the Administrator stated she expected the staff to chart accurately on the resident's MAR.

Based on interview and record review, the facility failed to ensure a safe and orderly discharge for one of three sampled residents, Resident 1. Resident 1 was discharged after she left the facility with Family Member (FM) 1 on a day pass and did not return. FM 1, who had no training in caring for elderly persons with dementia and was known to the facility to have aggressive and inappropriate behaviors refused to return Resident 1 to the facility. The Facility did not enlist the aid of the local police department or Resident 1's primary physician to ensure Resident 1's safety, but rather abdicated their responsibility and discharged Resident 1 to the care of FM 1. As a result of this failure, Resident 1 was placed at risk for serious harm from lack of medical supervision and did not receive physician prescribed medications from 11 a.m. on 2/14/18 until admission to the General Acute Care Hospital (GACH) on 2/16/18. Resident 1 was admitted to the GACH on 2/16/18 for hypertension (high blood pressure) and [MEDICAL CONDITION] (infection in the airways of the lungs) and remained in the GACH until 2/26/18 when she was transferred back to the Skilled Nursing Facility (SNF). Findings: Review of Resident 1's clinical record titled, Face Sheet (document containing resident personal information) indicated Resident 1 was an [AGE] year-old female who had resided in the facility since 7/9/15. The Face Sheet indicated Resident 1 had [DIAGNOSES REDACTED]. The Face Sheet indicated FM 1 was the Responsible Party for making decisions regarding Resident 1's care. The Face Sheet listed a phone number for FM 1, but no physical address. Review of Resident 1's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool used to plan resident care) assessment, dated 2/8/18, indicated a Brief Interview for Mental Status (BIMS, an assessment of memory and recall) score of five points out of 15 possible points which indicated severe memory and recall impairment. The MDS indicated Resident 1 was ambulatory (able to walk) with the aid of a walker, required assistance of one person to use the toilet, required extensive assistance to dress and was totally dependent on staff assistance to bathe. Review of Resident 1's Order Summary Report (physician's orders [REDACTED].[MEDICATION NAME] (medication to treat nerve pain) 100 mg 1 capsule by mouth two times a day .Aspirin (medication to treat mild pain and to prevent [MEDICAL CONDITION] and stroke) 81 mg 1 tablet by mouth at bedtime .Atorvastatin Calcium (medication to treat high blood fat levels that could lead to stroke) 80 mg daily .[MEDICATION NAME] ER (extended release) (medication used to treat [MEDICAL CONDITION]) 30 mg by mouth 1 time a day .[MEDICATION NAME] Tablet (medication to treat high blood pressure) 1 time a day .[MEDICATION NAME] Tablet (medication to treat high blood pressure) 1 tablet by mouth two times per day .[MEDICATION NAME] Tablet (medication to treat chest pain caused by poor blood supply to the heart) Sublingually (given under the tongue) 0.4 mg. Give 1 tablet sublingually as needed for chest pain every 5 min. (minutes) Repeat X (times) 3 doses, if pain does not relieve call MD (physician). The Order Summary Report indicated (MONTH) go out on pass with RP (Responsible Party) if stable .order dated 2/14/18. On 2/21/18 at 9:35 a.m., during an interview, the Director of Nursing (DON) stated on 2/14/18 FM 1 arrived at the facility and told the receptionist he was taking Resident 1 out to lunch. The DON stated FM 1 had a history of [REDACTED]. The DON stated Resident 1 had a physician's orders [REDACTED]. The DON stated Resident 1 and FM 1 left the facility at 11:20 a.m. on 2/14/18 to go to lunch. The DON stated Resident 1 did not return to the facility the night of 2/14/18 and the facility Administrator (Admin) made a decision to discharge Resident 1 to the care of FM 1 on the morning of 2/15/18. On 2/21/18 at 10:06 a.m., during an interview, the facility Social Services Director (SSD) stated FM 1 called her on 2/13/18 and asked for a pass to take Resident 1 to lunch on 2/14/18. The SSD stated she checked the physician orders [REDACTED]. The SSD stated, (FM 1) said no more than two hours - they would just be gone for lunch. The SSD stated, Around 11:20 a.m. (FM 1) arrived. He brought documents for a passport. (FM 1) asked if I could help him get a passport for (Resident 1). I told him I was not the right person to ask .We had quite a few behavior problems with (FM 1). He was harassing the staff and residents. In fact one resident got a temporary restraining order on him. Ultimately (FM 1) was not allowed inside the facility. The SSD stated at 4 p.m. on 2/14/18 Resident 1's nurse wondered why she had not yet returned to the facility. The SSD stated the nurse called FM 1 15 to 20 times and received no answer. The SSD stated the night shift nurse continued to call FM 1 and on 2/15/18 at 12:30 a.m. FM 1 answered his phone. FM 1 told the night nurse he would keep Resident 1 with him for 14 days. The SSD stated the night nurse reminded FM 1 that Resident 1 needed her medication and did not have any medication or clean clothing with her. The SSD stated FM 1 brought Resident 1 back to the facility the afternoon of 2/16/18. The SSD stated, We told him (Resident 1) was already discharged (from the SNF). (FM 1) called 911 (emergency response phone number) outside in the parking lot. A fire truck showed up. (FM 1) would not let them take (Resident 1) to the hospital. (Local police department) was called by EMS (emergency medical services). (Resident 1) was taken to (local GACH) to be evaluated since she had been gone since 2/14/18. The SSD stated Resident 1 was still in the GACH, her room had been reassigned to another resident on 2/15/18 when she did not return from her luncheon outing. The SSD stated, Knowing what we know now, we would have not allowed (FM 1) to sign (Resident 1) out. On 2/21/18 at 10:40 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 had dementia, had her own routines she followed and seemed to like staying in the facility. LN 1 stated FM 1 was aggressive, threatening .he got in staffs' face .he would talk about shootings, bombings, how he had a black belt .almost harassing, he was being that to staff, residents and families . LN 1 stated she called FM 1 on 2/14/18 at 5 p.m. and left a voice message on his phone that Resident 1 needed to return to the facility for her medications. On 2/21/18 at 11:37 a.m., during an interview, LN 2 stated she was assigned to Resident 1 on 2/14/18. LN 2 stated Resident 1 received her medications and was given a shower prior to leaving for lunch with FM 1. LN 2 stated, (FM 1) can be a problem. We had several bad encounters with him. He made threats to the staff, residents and even family members .The facility had called the police on him a few times. On 2/21/18 at 12 p.m., during an interview, the DON stated, We tried to contact (FM 1) on 2/14/18 multiple times and left him messages about (Resident 1's) medications that she needed to take and he did not respond. By doing that - not getting in touch with us, we considered that (leaving the facility) against medical advice. On 2/21/18 at 12:21 p.m., during an interview, the facility Admin stated FM 1 was permitted to take Resident 1 out on a day pass only. The Admin stated when Resident 1 did not return to the facility on [DATE] the SSD called Adult Protective Services (APS) do a wellness check on Resident 1. The Admin stated APS was not able to do a wellness check because the facility had no record of a physical address for FM 1, only a post office box because FM 1 refused to give the facility his physical address. The Admin stated FM 1 did not have Resident 1's medications when she left the building and did not have the training to take care of a dementia patient such as Resident 1. The Admin stated he made a decision to discharge Resident 1 Against Medical Advice (AMA) on 2/15/18 because she was gone overnight with FM 1 and FM 1 had refused to return Resident 1 to the facility. The Admin stated, I made the decision to discharge (Resident 1). The Admin stated he did not consult Resident 1's physician for advice or orders prior to making the decision to discharge Resident 1. The Admin stated he did not contact the local police department to assist in locating Resident 1 for a wellness check when FM 1 refused to bring her back to the facility. The Admin stated the facility Interdisciplinary Team (IDT, a team of health care providers including nursing, social services, dietary staff and physicians that meet to plan resident care) did not meet to review the situation before he made the decision to discharge Resident 1. The Admin stated it was not a safe discharge; FM 1 was not trained to provide care to Resident 1, who had dementia. On 2/26/18 at 8:17 a.m., during a telephone interview, GACH Medical Social Services (MSS) 1 stated Resident 1 arrived at the GACH on 2/16/18 by ambulance and was sent to the Emergency Department (ED) for a medical clearance to return to the SNF. The MSS stated Resident 1 was cleared medically later that day. The MSS stated ED staff called the SNF regarding sending Resident 1 back but the SNF stated they did not have a bed available. The MSS stated the GACH could not find a SNF for Resident 1 so she was admitted as an inpatient to the GACH. On 5/8/18 at 10:20 a.m., during a telephone interview, the Business Office Manager (BOM) stated Resident 1 was discharged from the SNF on 2/15/18 at 10:51 a.m. On 5/8/18 at 1:30 p.m., during a telephone interview, the DON stated there was no physician discharge order for Resident 1. The DON stated the licensed nursing staff should obtain and document a physician discharge order. The DON stated, It doesn't look like we have an official order for discharge (for Resident 1). Review of Resident 1's clinical record titled Progress Notes dated 2/15/18 at 6:19 p.m., indicated Able to reach (FM 1) on his phone and stated he isn't able to bring back (Resident 1). Writer did let him know that as of this time (Resident 1) is discharged from facility and need to come pick up her medication. Then he goes on and said, I thought she will be happy and smiling to see me, but she is like a baby. I was looking for her love and affection but she looks indifferent . The progress note was electronically signed by LN 4. Review of Resident 1's clinical record titled Progress Notes dated 2/16/18 at 1:46 p.m., indicated (FM 1) in this afternoon with (Resident 1) attempting to bring Resident back. Explained that resident is now discharged from facility and we are unable to accept (Resident 1) back at this time. He stated that he did not sign up for discharge .continued to say we needed to assist (Resident 1) back into her room and Administrator and writer explained that we were unable to do that. (FM 1) then called 911. Firefighters showed up, resident continued to sit in the car, firefighters unable to convince (FM 1) to allow resident to go to the hospital since she had not had her medications in the last 2 days. (Local PD) showed up and spoke with resident and (FM 1), he was able to convince to allow to go to hospital. 2 EMTs (emergency medical technicians) showed up and resident was assisted to the gurney. The progress note was electronically signed by the SSD. Review of Resident 1's GACH clinical record titled, ED (Emergency Department) Note indicated Time seen: Date and time 2/16/18 12:31 (p.m.) .Arrival mode: Ambulance .History of Present Illness: The patient (Resident 1) presents with medical screening and Afib ([MEDICAL CONDITION] Fibrillation, a fast, irregular heart beat) .risk factors consist of no afib medication for 2 days .Diagnosis: [REDACTED].will treat with doxy ([MEDICATION NAME], an antibiotic to treat infection). Review of Resident 1's GACH clinical record titled, Discharge Plan Update dated 2/17/18, indicated Patient (Resident 1) is ready for D/C (discharge). Review of Resident 1's GACH clinical record titled, Discharge Plan Update dated 2/24/18, indicated Per (SNF Marketing and Admissions Director) they do not have a bed today; possibly Wed. (Wednesday) 2/28/16. Review of Resident 1's GACH clinical record titled, Discharge Summary dated 2/26/18 indicated, Dis (discharge) date: 2/26/18. Discharge Diagnoses: [REDACTED]. (irregular heart beat) 2. Hypertension 3. [MEDICAL CONDITION] .She was supposed to be discharged back to (SNF) but her bed was given away. Patient was found to have [MEDICAL CONDITION] and completed the course of [MEDICATION NAME] .Patient will be discharged back to (SNF). The facility policy and procedure titled, Discharging a Resident without a Physician's Approval, dated (MONTH) 2012, indicated Policy Statement: A physician's orders [REDACTED]. Policy Interpretation and Implementation: 1. Should a resident or his or her representative (sponsor) request an immediate discharge, the resident's Attending Physician will be promptly notified. 2. The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record. 3. If the resident or representative insists upon being discharged without the approval of the Attending Physician, the resident and/or representative 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 facility policy and procedure titled, Discharging the Resident dated 12/16 indicated, Preparation .5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions .

Intakes: CA 578 Based on observation, staff interview, clinical record and administrative document review, the facility failed to ensure the correct use of an assistive device for 1 of 1 residents (Resident (Res) 1), when the total body lift (mechanical device that provides assistance to transfer residents) sling used to transfer Resident 1 broke. This failure resulted in Res 1's fall from the total body lift where he sustained a scalp hematoma (collection of blood) near the brain. Findings: Res 1's Quarterly Minimum Data Set (MDS) assessment (a tool used to perform a basic total assessment) dated 12/21/12, indicated he had been totally dependant on facility staff for all transfers. Res 1 had been unable to communicate, had contractures (muscle wasting and inability to move) of both legs, and had uncontrolled movement of his arms. Res 1 had required the transfer assistance of two staff members using the mechanical body lift. On 3/15/13 at 8:45 a.m., during an interview, CNA 1 stated on 3/2/13 at 6:40 a.m., she and CNA 2 had lifted Res 1 out of bed and transferred him to the Geri chair (special chair with high back for supporting residents) with the total body lift. CNA 1 stated the sling (fabric hammock-like device that attaches to lift in which resident is suspended during transfer) "broke" while Res 1 had been suspended in the air. CNA 1 stated after the sling had broken, Res 1 immediately fell to the floor and hit his head on the ground. CNA 1 stated she had received training on the use of the total body lift during facility orientation in February 2012. CNA 1 stated she had visually inspected the lift prior to transfer of Res 1 and the lift had "looked fine." On 3/15/13 at 9 a.m., during a telephone interview, CNA 2 stated she had assisted CNA 1 with Res 1's transfer from the resident's bed to the Geri chair on 3/2/13 at 6:40 a.m. CNA 2 stated Res 1's transfer had been assisted by use of the total body lift. CNA 2 stated while Res 1 had been suspended in the air the sling had broken and Res 1 had fallen to the floor and hit his head. CNA 2 stated she had received training on use of the body lift approximately four months ago during her facility orientation. CNA 2 stated she had inspected the sling used on the body lift before Res 1 had been transferred and there had been no fraying or damage observed on the sling. On 3/15/13 at 9:15 a.m., during an interview, Licensed Nurse 1 (LN 1) stated she had been the charge nurse for the day shift on 3/2/13. LN 1 stated she had been informed of Res 1's fall at 6:45 a.m. LN 1 stated she had assessed Res 1 after the fall, and following notification of Res 1's Medical Doctor (MD) Res 1 had been transported to the Emergency Department (ED) by ambulance for evaluation and treatment of [REDACTED]. On 3/15/13 at 9:55 a.m., during an observation and concurrent interview in the Administrator's office, the sling used to transfer Res 1 in the total body lift had been observed. The sling had a broken strap at the shoulder level on one side. The Administrator identified the sling as the same sling which had been used on the total body lift to transfer Res 1 when he fell on [DATE]. When the sling was viewed, the Administrator stated the sling was visibly frayed. The strap on the sling was observed as visibly frayed on both sides. During the interview the Administrator stated the Director of Nurses (DON) had previously shared the results of her investigation into Res 1's fall with him. The Administrator stated the DON had specifically told him the CNAs involved in the transfer of the resident told her they had noticed the sling was frayed before they used it. She stated they "had decided it would hold" and used it to transfer the resident anyway. On 3/15/13 at 12:05 p.m., during an interview, the Administrator stated the facility was using the "Maxi Twin" (name of the total body lift) "Instructions for use" as the facility's policy and procedure for use of the lift. The manufacturer's "Instructions for use" indicated on page 8, "Pre-inspect the sling prior to use. If any part is missing or damaged - do NOT use the product!" Also on page 40, "Visually check the slings. Check for fraying, holes, cuts, loose stitching and damaged plastic clips. If the sling is found damaged in any way, take out of use immediately and replace the sling." On 3/15/13 at 12:40 p.m., during interview, CNA 4 stated she had been employed with the facility for 5 years. CNA 4 stated he had found two slings in the facility which were frayed and worn. CNA 4 stated he had not used the worn and frayed slings and had reported the slings' condition to the Director Staff Development (DSD). On 3/15/13 at 12:45 p.m., CNA 5 stated she had worked at the facility for 7 years. CNA 5 stated she used the body lifts "regularly." CNA 5 stated a month ago she had found a sling that was worn and frayed which she took to the laundry staff and had asked them to give to the DSD "later." On 3/15/13 at 2:30 p.m., during interview, the Central Supply Supervisor (CSS) stated CNA's or laundry staff would bring her damaged slings used for the lift. CSS stated she would throw away slings brought to her. The CSS stated she had been told by the mechanical lift manufacturer representative the "life expectancy" of slings was two years. The CSS stated she had no idea how long some of the slings had been in the facility. Res 1's acute care hospital record, "ED Provider Notes" indicated, "Right occipital (part of the skull) scalp hematoma (collection of blood). . .[DIAGNOSES REDACTED].) Res 1 had been admitted to the hospital for close neurological monitoring and further evaluation. On 3/15/13 at 2:45 p.m., during a telephone interview, the DSD stated she had viewed the sling that had broken during transfer of Res 1 following the fall and stated "it should never have been in use." On 3/15/13 at 3 p.m., during an interview, the CSS stated at the Safety Committee meeting in January 2013, she and the Administrator had discussed a shortage of slings and she was to check the slings to determine how many needed to be replaced. The CSS stated she had not looked at all of the slings. On 3/15/13 at 4:15 p.m., during an interview, the Administrator stated the process to ensure the safe use of the total body lift had not been followed. The Administrator stated the facility was ultimately responsible for the safety of Res 1 when the process for ensuring safety had not been followed.