Every finding on record at Noble Care Center

Based on interview, and record review, the facility failed to implement comprehensive care plan (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) interventions for 1 of 3 sampled residents (Resident 1) by not consistently providing oral care to Resident 1. This deficient practice had the potential to place Resident 1 at risk for not receiving effective, individualized care that could negatively affect the resident's oral health, comfort, safety, and overall well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including metabolic encephalopathy (a brain function failure caused by illness, toxins, or chemical imbalances with signs included confusion, memory loss, feeling sleepy or low energy, seizures or coma in severe cases), dysphagia (difficulty swallowing), dementia (a decline in mental ability severe enough to interfere with daily life), and adult failure to thrive (a complex syndrome of gradual physical, mental, and functional decline marked by unintended weight loss, reduced appetite, and inactivity). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/6/26, indicated Resident 1 required maximal assistance with oral hygiene (helper does more than half the effort, including lifting or holding the resident's trunk or limbs while providing oral care). Further review of the MDS indicated a Brief Interview for Mental status (BIMS) score of 4, reflecting severe cognitive impairment. During a concurrent interview and record review on 7/29/26, at 8:43 AM, with Licensed Nurse (LN) 1, Resident 1's Care Plan Report was reviewed. The care plan included the focus, .Resident [Resident 1] has oral/dental health problems r/t [related to] edentulous status [lacking or missing natural teeth] ., initiated on 1/28/26. The care plan also included the intervention, .Provide mouth care as per ADL [Activities of Daily Living] personal hygiene ., which was initiated on 1/28/26. LN 1 stated that nurses were responsible for developing residents' care plans upon admission and updating them as needed in response to changes in condition, identified concerns, or resident preferences, with oversight provided by the Minimum Data Set (MDS) coordinator to ensure timely revisions. LN 1 further stated that care plans served as a communication tool to guide staff in meeting residents' needs and that staff were expected to follow the outlined interventions to support residents' health and well-being. LN stated that Resident 1 required staff assistance with oral care and that Certified Nursing Assistants (CNAs) had access to the resident's care plan, including oral care interventions. Upon review of Resident 1's oral care task, LN 1 confirmed that oral care was charted at Not Applicable on several occasions including 7/3/26 at 6:29 AM, 7/4/26 at 12:50 AM, 7/5/26 at 6:29 AM, 7/6/26 at 7:52 PM and 11:46 PM, 7/8/26 at 12:51 AM, 7/9/26 at 12:53 AM, and 7/13/26 at 12:12 AM. LN 1 stated that expectation for Certified Nursing Assistants (CNAs) was to provide oral care/oral hygiene to help prevent oral health problems and promote Resident 1's comfort. LN 1 further stated that documenting oral care as Not Applicable did not confirm whether oral care had been provided. LN 1 stated that inconsistent oral care and implementation of interventions suggested that Resident 1's oral health needs were not consistently met, placing the resident at risk for decline in oral and overall health. During an interview on 7/29/26, at 9:18 AM, CNA 1 stated that each resident had individualized care plans containing interventions related to their specific care needs, and that CNAs had access to the areas of focus and interventions they were expected to implement and follow. CNA 1 further stated that CNAs were required to review residents' care plans at least once every shift to ensure the identified interventions were implemented and residents' needs were met. CNA 1 stated that he was routinely assigned to the hallway where Resident 1 resided, and provided care for Resident 1 on multiple occasions during her stay. CNA 1 further stated that Resident 1 required assistance with Activities of Daily Living (ADLs), including oral care and oral hygiene. CNA 1 stated that CNAs were responsible for providing oral care to Resident 1 every shift. CNA 1 further stated care plans were tools to provide proper care to residents. CNA 1 explained that CNAs were responsible for following the care plan interventions, including assisting Resident 1 with oral care every shift to maintain proper oral hygiene and help prevent oral health problems. During a concurrent interview and record review on 7/29/26, at 12:12 PM, with the MDS coordinator, the facility's undated policy and procedure (P&P) titled, Comprehensive Care Plans, was reviewed. The policy indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.services that are identified.meet professional standards of quality.Policy Explanation and Compliance Guidelines.8. Qualified staff responsible for carrying out interventions.of their roles and responsibilities for carrying out the interventions. The MDS coordinator stated that nurses were responsible for initiating care plans and implementing appropriate interventions upon a resident's admission and whenever there was a change in the resident's condition. The MDS coordinator further stated that his responsibilities included reviewing, updating, and revising care plans quarterly and whenever changes in condition occurred, in collaboration with the interdisciplinary (IDT) team. The MDS coordinator stated that care plans served as communication tools to guide staff, including nursing personnel, in providing appropriate care and services to promote residents' health, maintain their wellbeing, and prevent further complications. The MDS coordinator further stated that the care plan interventions provided guidance to staff to ensure residents identified needs were consistently addressed and met. The MDS coordinator explained that his expectation of the nursing staff was to assist Resident 1 consistently with oral care and to follow the guidelines as outlines in the P&P for Comprehensive Care plans, to maintain proper oral hygiene throughout Resident 1's stay in the facility. The MDS coordinator stated that the expectation was not met.

Based on interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), who was dependent on staff for activities of daily living (ADL, basic activities required to care for oneself such as eating and bathing), received the necessary care and services to maintain oral hygiene when oral care was not consistently provided to Resident 1. This deficient practice had the potential to negatively affect Resident 1's oral health, comfort, self-esteem, and overall well-being.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including metabolic encephalopathy (a brain function failure caused by illness, toxins, or chemical imbalances with signs included confusion, memory loss, feeling sleepy or low energy, seizures or coma in severe cases), and dysphagia (difficulty swallowing), dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/6/26, indicated Resident 1 required maximal assistance with oral hygiene (helper does more than half the effort, including lifting or holding the resident's trunk or limbs while providing oral care). Further review of the MDS indicated a Brief Interview for Mental status (BIMS) score of 4, reflecting severe cognitive impairment. During a concurrent interview and record review on 7/29/26, at 8:43 AM, with Licensed Nurse (LN) 1, Resident 1's medical record was reviewed. LN 1 stated Resident 1 required staff assistance with ADLs, including oral care. After reviewing Resident 1's oral care task, LN 1 confirmed that oral care was charted at Not Applicable on several occasions, including 7/3/26 at 6:29 AM, 7/4/26 at 12:50 AM, 7/5/26 at 6:29 AM, 7/6/26 at 7:52 PM and 11:46 PM, 7/8/26 at 12:51 AM, 7/9/26 at 12:53 AM, and 7/13/26 at 12:12 AM. LN 1 stated the expectation for Certified Nursing Assistants (CNAs) was to provide oral care/oral hygiene to help prevent oral health problems and promote Resident 1's comfort. LN 1 further stated that documenting oral care as Not Applicable did not confirm whether oral care had been provided. Accor LN 1 stated that CNAs were expected to document oral care as Yes, No, Refused, or resident Not Available. LN 1 further stated that there was no evidence that oral care had been provided during the identified time frames. LN 1 explained that inconsistent oral care would place Resident 1 at risk for oral health complications, including oral thrush and other oral infections. During an interview on 7/29/26, at 9:18 AM, with CNA 1, CNA 1 stated Resident 1 required assistance with oral care/oral hygiene. CNA 1 further stated that staff were expected to remain with Resident 1, provide guidance, apply toothpaste to the toothbrush, and supervise while Resident 1 brushed her teeth and rinse her moth. CNA 1 stated that CNAs were required to document whether oral care was provided, as documentation served as evidence that the care had been completed. CNA 1 further stated that CNAs were expected to chart as Yes, No, Refused, or Not Available in the Facility, and to notify the charge nurse whenever oral care was refused or not provided. CNA 1 stated that documenting oral care as Not Applicable indicated there was no evidence that oral care had been provided during that time frame. CNA 1 further stated inconsistent oral care could place Resident 1 at risk for poor oral hygiene, and oral health complications. During a concurrent interview and record review on 7/29/26, at 1:08 PM, with the Director of Staff development (DSD), Resident 1's medical record was reviewed. The DSD stated that Resident 1 required staff assistance with ADLs, including oral care. Resident 1's oral care task was reviewed and the DSD verified that oral care was charted at Not Applicable on several occasions including 7/3/26 at 6:29 AM, 7/4/26 at 12:50 AM, 7/5/26 at 6:29 AM, 7/6/26 at 7:52 PM and 11:46 PM, 7/8/26 at 12:51 AM, 7/9/26 at 12:53 AM, and 7/13/26 at 12:12 AM. The DSD stated that he was responsible for reviewing CNAs documentation/charting daily to ensure charting was completed correctly. The DSD further stated that he did not notice that charting for Resident 1's oral care had been completed as Not Applicable, and he was unsure how this was missed. The DSD stated that upon reviewing Resident 1's oral care task documentation, he was unable to confirm whether oral care had been provided to Resident 1 on those several occasions during multiple time frames. The DSD stated that the purpose of providing oral care to Resident 1 was to ensure quality of care, prevent gum and dental issues, and reduce the risk of oral infections. The DSD further stated that his expectation of CNAs was to consistently assist Resident 1 with oral care/oral hygiene to maintain oral health and reduce the possibility of further complications. During a subsequent concurrent interview and record review on 7/29/26, at 1:21 PM, with the DSD, the facility's undated policy titled, Activities of Daily Living (ADLs), was reviewed. The policy indicated, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices.Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain.personal and oral hygiene. The DSD stated that the expectation for CNAs was to follow the facility's ADLs policy and that the expectation was not met.

Based on observation, interview, and record review, the facility failed to ensure its resident care equipment was maintained in safe operating condition when two of two washing machines used to wash resident linens were without water temperature gauges for over six months for a resident census of 93. These failures resulted in unmaintained laundry equipment and no method to verify the water temperature used during the laundering process based on facility policy.Findings: During a concurrent observation and interview on 7/10/26 at 8:23 AM with the Environmental Supervisor (ES) and the Maintenance Supervisor (MAT), in the facility's laundry area, it was observed that the facility had two washing machines that lacked water temperature gauges. The ES stated there was no method available to verify the water temperature of either washing machine and suggested to consult the MAT for further information. The MAT stated replacement temperature gauges had been ordered but had not yet been received from the supplier. The MAT further stated the facility had no method to verify the water temperature of either washing machine.During a concurrent observation and interview on 7/10/26 AT 8:59 AM with the MAT, the MAT checked the boiler (a closed, metal pressure vessel that heats water) located near the laundry area to assess its water temperature. To obtain an accurate reading, the MAT drained a water sample from the boiler and measured its temperature using a thermometer, which registered at 135 F.During an Interview on 7/10/26 at 11:32 AM with the Infection Preventionist (IP), Staffing Coordinator (SC) and the MAT, the MAT stated both washing machines had been operating without temperature gauges for approximately six months. The MAT stated the facility could not verify the water temperature used during the laundering process. The IP and the SC stated without the ability to verify water temperatures, there is uncertainty regarding whether linens are being adequately cleaned. During a review of the facility's policy titled, Laundry dated 2026, indicated, .The facility launders linens.in accordance with current CDC guidelines to prevent transmission of pathogens.Aligning with the principles of standard precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated.wash with detergent in a water temperature of 160 F.for laundry that is not hot water compatible, low temperature washing at 71 F to 77 F . During a review the facility's policy titled, Environmental Services Inspection Copyrighted 2026, indicated, .It is the policy of this facility to regularly monitor and assess environmental services, to ensure the facility is maintained in a safe and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure safe infection prevention and control practices for a resident census of 93 when:1. Staff failed to offer hand hygiene (cleaning your hands with soap and water, alcohol-based sanitizer, or antibacterial hand wipes to remove germs and prevent infection) prior to meal services for three residents (Resident 2, Resident 94, and Resident 61); and,2. The laundry hand washing/eye washing station was not maintained in a sanitary condition; and,3. The initial drop of blood from Resident 56's pricked finger was not wiped off before collecting a sample specimen for Finger Stick Blood Sugar (FSBS) level readings (a method used to measure blood sugar level by piercing the skin with a tiny needle so that a drop of blood can be used for testing); and4. A urinal (a portable plastic container that male residents use to urinate when they cannot get to the bathroom) was full of urine and placed on the ground without a lid cover for Resident 24.These failures had the potential to increase the transmission of infectious microorganisms (tiny living organisms that can cause infection or illness) which could place residents and staff at risk for infection.Findings: 1. During a concurrent observation and interview on 7/7/26 at 12:41 PM, Certified Nursing Assistant (CNA) 3 delivered a meal tray to Resident 2, who was lying in bed. CNA 3 did not provide or assist Resident 2 with hand hygiene before Resident 2 began eating. CNA 3 stated hand hygiene was important before meals to ensure that residents' hands were clean before eating to reduce the risk of illness. During a concurrent observation and interview on 7/7/26 at 12:45 PM, Resident 2 was observed with a towel that appeared visibly stained placed across his chest. Resident 2 reported that he used the towel to wipe his hands prior to eating. During an interview on 7/7/26 at 12:47 PM with the Infection Preventionist (IP), the IP stated the facility's practice was to provide handwipes before meals. The IP acknowledged that failure to perform hand hygiene prior to meals increased the risk of germ transmission and illness. During a concurrent observation and interview on 7/8/26 at 7:35 AM, with CNA 4 in Resident 94's room, CNA 4 did not provide hand hygiene to Resident 94 prior to eating breakfast. Resident 94 stated that staff had never offered hand wipes or hand sanitizer before meals. CNA 4 stated staff had only recently been instructed to begin offering hand wipes before meals and acknowledged that this had not previously been standard practice. CNA 4 emphasized the importance of hand hygiene for infection control, noting that it served as protection from germs. During an interview on 7/8/26 at 7:37 AM with Resident 61 in her room, Resident 61 stated that staff never provided hand wipes or sanitizer prior to meals. During a review of the facility's policy titled, Infection Prevention and Control Program, dated 2026, indicated, .4.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. During a review of the facility's policy titled, Hand Hygiene, copyrighted 2026, indicated, .perform proper hand hygiene procedures to prevent the spread of infection to.residents.2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to.before and after eating . 2. During a concurrent observation and interview on 7/9/26 at 4:19 PM with the Environmental Supervisor (ES), it was observed that the handwashing station located in the laundry room was a white utility sink with chrome faucets equipped with two red handled lever controls. An eye wash station sign was mounted higher on the wall above the utility sink. The interior of the utility sink was observed to be heavily soiled with dark stains, black/brown residue, and visible buildup concentrated around the drain and along the bottom and sides of the basin. The basin contained visible debris and discoloration. According to ES, the utility sink serves as the designated handwashing station and eye wash station for laundry staff. The ES stated that the utility sink was dirty and had dried stains. The ES further stated that she would not use the utility sink to wash her eyes because it posed a possible risk for infection. During an interview on 7/10/26 at 8:23 AM with the Maintenance Director (MAT) and the ES, the MAT stated that he had cleaned the utility sink the previous day using an SOS scrub pad (a scouring pad used for tough cleaning), and clarified that he had not been informed about the sink's condition in advance. The MAT further reported that the utility sink was currently cleaned on a monthly basis, but there were plans to increase the cleaning frequency to every two weeks. He emphasized that maintaining a clean sink was essential, as a dirty sink can present a risk for infection. A review of the facility's policy titled, Routine Cleaning and Disinfection, updated 7/2019, indicated, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. A review of the facility's policy titled, Infection Prevention and Control Program, dated 2026, indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment.Environmental cleaning and disinfection shall be performed according to facility policy. 3. During a review of Resident 56's admission RECORD, dated 7/9/26, the record indicated Resident 56 was admitted to the facility with diagnoses including type 2 diabetes mellitus (the body's inability to control blood sugar levels). During a review of Resident 56's Order Summary Report, active orders as of 7/9/26, the order indicated, .FSBS (Finger Stick Blood Sugar).in the morning every Mon [Monday], Wed [Wednesday], Fri [Friday].The Order Summary Report also indicated, .Merilog [medication that helps to lower blood sugar spikes to improve control of blood sugar] Subcutaneous [injected under the skin] Solution 100 UNIT/ML [how many units of active medication are contained within one milliliter of liquid].Inject as per sliding scale [method of managing blood sugar where the dose is determined by pre-meal or bedtime glucose levels obtained by FSBS].subcutaneously before meals. During a medication administration observation on 7/9/26, at 11:14 a.m. with Licensed Nurse (LN) 1 in the East Unit outside Resident 56's room, LN 1 prepared the supplies to obtain Resident 56's FSBS level reading. The supplies included the glucometer ( a small, portable, battery-powered device used to measure the concentration of sugar or glucose in a small sample of blood), lancet (used to puncture the skin to obtain a small blood specimen), test-strip (strip of paper or other material used for biological testing}, and an alcohol pad (antiseptic to sterilize skin before glucose monitoring) and were placed on a tray and brought into Resident 56's room. LN 1 took the alcohol pad to sterilize Resident 56's fingertip, pricked his fingertip with the lancet, a drop of blood sample appeared, took the glucometer with the test-strip and collected the blood sample into the test-strip. The glucometer registered a blood sugar level reading. During a subsequent interview on 7/9/26, at 11:14 a.m. with LN 1, LN 1 stated she did not wipe the initial blood sample and went on to say that she should have wiped off the first blood sample and should have collected the second blood sample for a more accurate blood glucose level reading. LN 1 further stated that the initial sample should be discarded due to possible contamination from the alcohol pad or the skin and the second sample would have been cleaner. During an interview on 7/9/26, at 1:47 p.m. with the Assistant director of Nursing (ADON) and the Director of Staff Development (DSD), both stated the best practice for obtaining a FSBS was to wipe off the first drop of blood and then collect the second drop for a sample specimen for a more accurate reading free from contamination from the alcohol pad and/or the skin. During an interview on 7/9/26, at 3:45 p.m. with the Infection Preventionist (IP), the IP explained the best practice to obtain an accurate FSBS level reading was to wipe off the first blood sample and to collect the second sample for reading. The IP stated that collecting the first drop of blood would be getting a mixture of blood with alcohol and might get an error reading when the first blood sample was used. The IP stated it would be the preference to wipe off the first drop of blood and collect the second blood for a sample. 4. During a review of Resident 24's clinical record titled, admission RECORD, the record indicated that Resident 24 had diagnoses that included, but were not limited to, anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin, impairing its ability to carry oxygen to the body's tissues), vascular dementia (a decline in thinking and memory skills caused by restricted blood flow or damage to blood vessels in the brain), difficulty in walking, encephalopathy (a broad term for any disease, damage, or malfunction of the brain that alters mental state. Rather than a single disease, it is a syndrome characterized by diffuse brain dysfunction, leading to symptoms like confusion, memory loss, personality changes), and carrier or suspected carrier of methicillin resistant staphylococcus aureus (a type of staph bacteria resistant to many common antibiotics. It typically causes red, swollen, and painful skin boils or abscesses. It spreads through skin-to-skin contact or shared items, requiring good hygiene). During a concurrent observation and interview on 7/7/26 at 9:19 AM with CNA 3, Resident 24's urinal was observed. CNA 3 confirmed that Resident 24's urinal was placed directly on the ground without a lid covering and had urine inside of it. CNA 3 stated that Resident 24's urinal should have had a covered lid on it and been emptied out. CNA 3 also stated that Resident 24's urinal should not have been on the ground with urine present. During an interview on 7/7/26 at 9:25 AM with the IP, the IP stated that her expectation was for urinals to have lids on them. The IP also stated that urinals that do not have covers or lids on them could tip over and spill. The IP further stated that urinals should have been emptied out as soon as possible after use. During an interview on 7/8/26 at 11:07 AM with the ADON, the ADON stated urinals should have been emptied out as soon as possible. The ADON also stated that her expectation was for urinals to have lids on them. The ADON further stated that having uncovered urinals posed an infection control risk for the residents residing in the facility because they could tip over and spill out. During a review of the facility's undated policy and procedure (P&P) titled, Disinfection of Bedpans and Urinals, the P&P indicated, .urinals are handled in a manner to prevent the spread of infection through personal equipment .Cover the bedpan or urinal before taking it to the bathroom .

Based on interview and record review, the facility failed to ensure pharmacy services were maintained for a census of 93 when narcotic (sometimes called opioids prescribed to manage moderate to severe pain and have high addiction potential) and controlled (any substance strictly regulated by the government due to its potential for abuse or addiction) prescription medication destruction records were not co-signed by a licensed nurse for twelve (12) pages of destruction records reviewed during a medication storage inspection on [DATE].This failure had the potential risk for medication misuse and/or drug diversion (unlawful use of prescription drugs by unauthorized individuals) of narcotic drugs and controlled substances due to unsafe disposition practices.Findings:During a concurrent interview and record review on [DATE], at 3 p.m. with the Assistant Director of Nursing (ADON) in the Director of Nursing (DON) office, the narcotic and controlled medication destruction records titled, CONTROLLED DRUG DISPOSITION LOG, dated [DATE] were reviewed. The ADON explained that unused or discontinued narcotic and controlled medications were destroyed by the Pharmacy Consultant (PC) and the DON with both signatures on the destruction records to verify that the medications were disposed of properly. The ADON confirmed and stated that the twelve (12) pages of destruction records reviewed did not have signatures under the RN (Registered Nurse) Signature column. The ADON stated the destruction records were not complete and did not have the signature of the DON who should be destroying the narcotic drugs and controlled substances with the Pharmacist. The ADON went on to say that the RN signature was needed on every medication destroyed in all twelve pages of the CONTROLLED DRUG DISPOSITION LOG. During an interview on [DATE], at 1:47 p.m. with the ADON and the Director of Staff Development (DSD), both stated that they would have expected the destruction records to be complete and have the RN signature, who normally was the DON, signing the destruction records with the Pharmacists to ensure witnesses were present during the destruction of the narcotic drugs and the controlled substances to prevent any potential misuse or any risk for drug diversion.During a review of the facility's undated Policy titled, Destruction of Unused Drugs, the Policy indicated, .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individual.The director of nursing services.An inventory of dangerous drugs and controlled substances destroyed will be verified by the consultant pharmacist. This information shall be recorded on our Destruction of Dangerous Drugs and Controlled Substances Record. Such record contains the following information.The signature of the consultant pharmacist.and.The signature of the person(s) witnessing the destruction of the medications.

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for 3 of 28 sampled residents (Resident 31, Resident 71, and Resident 11) when:1. Resident 31 smoked without supervision on 7/8/26.2. Resident 71 did not have his smoking evaluation assessments (are clinical tools used to measure nicotine dependence, gauge readiness to quit, and identify smoking triggers. These structured questionnaires and medical evaluations help healthcare providers tailor targeted cessation plans, monitor withdrawal, and evaluate overall health risks) completed quarterly (every 3 months); and,3. There was no oxygen in use sign posted outside of Resident 11's room while he was on oxygen.These failures had the potential to place Resident 31, Resident 71, and Resident 11, as well as other residents in the facility at risk for accidental burns, fire-related injuries, and other smoking-related accidents.Findings:1. A review of Resident 31's admission RECORD, indicated that Resident 31 was admitted to the facility in the winter of 2025 with diagnoses including adult failure to thrive (a syndrome of progressive physical, cognitive, and functional decline), history of falling, abnormalities of gait and mobility (refer to deviations from a normal walking pattern, such as limping, shuffling, unsteadiness, or foot drop), unspecified dementia (a clinical diagnosis used when a patient shows clear signs of cognitive decline or memory loss, but the exact underlying cause or specific type [like Alzheimer's or vascular dementia] cannot be definitively determined), muscle weakness, chronic pain, and rhabdomyolysis (a serious and potentially fatal medical condition involving the rapid breakdown of damaged skeletal muscle).During a review of Resident 31's Care Plan Report, (a form where you can summarize a person's health conditions, specific care needs, and current treatments) dated 6/1/26, the care plan indicated, .[Resident 31] is a smoker and is at risk for injury.Complete smoking assessment. Reassess [Resident 31] quarterly, annually, and with change of condition that affects the ability to smoke.[Resident 31] has been oriented to the facility's designated smoking areas and times.During a review of Resident 31's Smoking Safety Evaluation, dated 5/26/26, the evaluation indicated, .Resident is able to smoke.Yes.If able to smoke.With Supervision Only.Adaptive/Safety Equipment.Needed.Smoking Apron.During a review of an undated facility provided document titled, SMOKING SCHEDULE, the document indicated, .DESIGNATED SMOKING AREA EAST SIDE BACK PATIO9 AM (ACT) [Activities staff]11 AM (ACT)2 PM (ACT)4 PM (ACT)6 PM (CNA) [Certified Nursing Assistant]PLEASE FOLLOW THE SCHEDULE. THANK YOU.During an interview on 7/7/26, at 9:24 AM, with Resident 31, Resident 31 stated that she had been a smoker since she was [AGE] years old and that she smoked outside all the time. Resident 31 further stated that no staff members watched her when she smoked.During a concurrent observation and interview on 7/8/26, at 11:08 AM, with Resident 31, Resident 31 was observed smoking in the designated smoking area at the backyard patio area of the facility. Resident 31 was further observed smoking without an apron and without any staff present. Resident 31 confirmed that she did not wear a smoking apron while she was smoking. During a concurrent interview and record review on 7/9/26, at 11:35 AM, with the Assistant Director of Nursing (ADON), Resident 31's electronic health record (EHR) and the facility's smoking schedule were reviewed. The ADON confirmed that a staff member from the activities department was scheduled to oversee the 11 AM resident smoke break. The ADON further confirmed that Resident 31 required supervision with a smoking apron while smoking. The ADON stated that a staff member from the activities department should have been watching the residents smoke. The ADON further stated that if residents were not being supervised while smoking, potential skin issues and burns could happen as well as other fire safety risks. The ADON stated that her expectation was for a staff member to be present during all assigned resident smoke breaks throughout the day.2. A review of Resident 71's admission RECORD, indicated that Resident 71 was admitted to the facility in the summer of 2024 with diagnoses including chronic pulmonary edema (a long-term buildup of fluid in the lungs, usually caused by ongoing conditions like congestive heart failure), muscle weakness, anemia (a condition marked by a lack of enough healthy red blood cells or hemoglobin to carry adequate oxygen to the body's tissues), paraplegia (a medical condition characterized by the partial or complete paralysis of the lower half of the body, which typically affects both legs and often the lower trunk), and cardiomegaly (an enlarged heart, an underlying condition that strains the heart muscle, such as high blood pressure, coronary artery disease, or heart valve defects).During a review of Resident 71's Care Plan Report, dated 8/6/24, the care plan indicated, .[Resident 71] at risk for smoking-related injury related to smoking independently .Complete smoking assessment. Reassess [Resident 71] quarterly, annually, and with change of condition that affects the ability to smoke .During a concurrent interview and record review on 7/8/26, at 10:37 AM, with the Director of Staff Development (DSD) and the ADON, Resident 71's EHR was reviewed. The ADON and DSD both confirmed that Resident 71's care plan stated that smoking evaluations should have been completed quarterly. The ADON further confirmed that Resident 71's Smoking Safety Evaluation, was completed on 2/10/25 and then his next Smoking Safety Evaluation did not occur until 11/20/25. The ADON confirmed that the facility did not conduct a Smoking Safety Evaluation, for nine months. The ADON stated that smoking evaluation assessments should have been completed quarterly for Resident 71 to make sure that he was still safe to smoke. The ADON further stated that by not completing quarterly smoking evaluation assessments, residents' health conditions could change and their ability to smoke safely could be impacted.During a review of the facility's policy and procedure (P&P) titled, Resident Smoking, dated 4/25, the P&P indicated, .All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all.All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.3. A review of Resident 11's admission RECORD, indicated that Resident 11 was admitted to the facility in the fall of 2024 with diagnoses including muscle weakness, adult failure thrive, bed confinement status (a medical classification for patients unable to ambulate or sit in a chair without assistance), low back pain, and history of recurrent pneumonia (two or more episodes in a single year, or three or more episodes in a lifetime, with complete radiographic clearing between infections. It is a major clinical warning sign that indicates an underlying, unmanaged health issue).During a review of Resident 11's Order Summary Report, dated 7/8/26, the report indicated, .May use oxygen concentrator 2-4 liters per minute as needed via nasal cannula.During a concurrent observation and interview on 7/7/26, at 9:53 AM, with the Respiratory Therapist (RT) 1, Resident 11's room was observed. RT 1 confirmed that Resident 11 was on oxygen and did not have an oxygen in use sign posted outside his room's doorway. RT 1 stated that her expectation was for any resident who was using oxygen to have an oxygen in use sign posted outside their room. RT 1 further stated that having an oxygen in use sign posted would help warn others that the area could be hazardous. RT 1 stated flames or items that could be dangerous for residents on oxygen could be prevented by having warning signs posted.During an interview on 7/8/26, at 11:02 AM, with the ADON, the ADON stated that it was her expectation for any resident who was using oxygen to have an oxygen in use sign posted outside their room. The ADON further stated that if oxygen usage signs were not posted, it could be a potential fire hazard. The ADON stated that oxygen signs acted as warning signs for other residents and visitors to be mindful around those residents to maintain their safety.During a review of the facility's P&P titled, Oxygen Administration, revised 2/23, the P&P indicated, .Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. Possible risks and complications include, but are not limited to.Fire.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact and kitchen surfaces in accordance with professional standards for food safety for the 89 residents who received facility prepared meals when:1. Food preparation equipment was not cleaned or maintained.2. Glassware was damaged and not replaced.3. Food items were not properly labeled and/or stored; and,4. Kitchen building surfaces were not maintained. These failures had the potential to place residents at risk for foodborne illnesses.Findings:1. During a concurrent observation and interview on 7/7/26, at 8:35 a.m., with the Certified Dietary Manager (CDM), during the initial kitchen tour, five (5) roasting pans and six (6) cupcake trays were found with brown crusty buildup on the inside edges. The CDM confirmed that these should have been replaced.During an interview on 7/8/26, at 3:16 p.m., the Registered Dietitian (RD), the RD stated the dirty trays and roasting pans with buildup on the sides were unacceptable and should have been cleaned properly or replaced if needed as they could lead to cross contamination.A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .2. During a concurrent observation and interview on 7/7/26, at 8:58 a.m., with the CDM, during the initial kitchen tour, eight (8) out of fifteen (15) plastic cups were noted with a foggy surface on the inside. The CDM confirmed the finding and stated the cups should have been replaced when they started turning foggy.During an interview on 7/8/26, at 3:17 p.m., with the RD, the RD stated foggy and cloudy cups could lead to cross-contamination and should have been replaced.A review of the facility's P&P titled, Handling Tableware, revised 2020, indicated, .Dining Services Staff will provide clean, well maintained tableware.All table ware will be in good condition, be free from chips, cracks, permanent stains, and not bent .3a. During a concurrent observation and interview on 7/7/26, at 9:05 a.m., with the CDM, during the initial kitchen tour, cane sugar, powdered sugar, and salt were found not closed properly in the kitchen. 3b. During a subsequent concurrent observation and interview on 7/7/26, at 9:23 a.m., with the CDM, during the initial kitchen tour, one bag of mashed potatoes was found not closed properly in the dry storage area.3c. During a concurrent observation and interview on 7/7/26, at 9:38 a.m., with the CDM, during the initial kitchen tour, one (1) bag of shredded cheese was found not closed properly in the fridge.3d. During a subsequent concurrent observation and interview on 7/7/26, at 9:48 a.m., with the CDM, during the initial kitchen tour, multiple boxes of turkey, pork, ham and breadsticks were found not closed properly in the freezer. The CDM confirmed the findings and stated that all the food products should have been closed tightly.During an interview on 7/8/26, at 3:20 p.m., with the RD, the RD stated the food items needed to be closed properly as leaving food open to air could have led to contamination. The RD further stated that leaving foods open in the freezer could have led to freezer burn and could affect the quality, nutritional value, and taste of foods.3e. During a concurrent observation and interview on 7/7/26, at 9:30 a.m., with the CDM during the initial kitchen tour, a box of rubbed sage (spice) and 4 packets of gelatin were found expired. The CDM confirmed the findings and stated that these should have been discarded upon expiration.During an interview on 7/8/26, at 3:23 p.m., with the RD, the RD stated the expired food items and spices could affect the quality of foods, leading to foods not tasting good and ultimately leading to food borne illnesses.3f. During a concurrent observation and interview on 7/7/26, at 9:42 a.m., with the CDM during the initial kitchen tour, one (1) bottle of milk and one (1) box of vegetable base were found without an open date. The CDM confirmed the findings and stated that these items should have been dated upon opening.During an interview on 7/8/26, at 3:27 p.m., with the RD, the RD stated the food items needed to be dated upon opening as that would indicate how long it was good for. The RD further stated that without an open date, there was a risk of serving expired food leading to food borne illnesses.3g. During a concurrent observation and interview on 7/7/26, at 9:15 a.m., with the CDM during the initial kitchen tour, one (1) can of pumpkin was found dented and placed on the rack along with the good undented cans. The CDM confirmed the finding and stated that the dented can should have been removed from the rack and placed together with the other dented cans.During an interview on 7/8/26, at 3:31 p.m., with the RD, the RD stated dented cans should have been inspected and placed away with the other dented cans. The RD further stated this could have led to serving food from a dented can which had a risk of botulism (a foodborne illness).3h. During a concurrent observation and interview on 7/10/26, at 8:33 a.m., with Licensed Nurse (LN) 3, during the inspection of the refrigerator in the dining room designated for the residents' food, two (2) white unlabeled and undated packages were found in the freezer. Another two (2) packages of frozen food had an open date of 7/6/26 and were not closed properly. LN 3 confirmed the findings and stated that the packages should have been labeled properly and the packages with an open date of 7/6/26 should have been discarded after 72 hours on 7/9/26, per facility policy. LN 3 stated that the food in the freezer should have been closed properly and not left open to air. During an interview on 7/10/26, at 8:45 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that food packages in residents' refrigerator should have been labeled and dated properly as it would not be possible to tell what that item was or when it expired. The ADON further stated that all food items in the refrigerator should be closed properly and thrown away after 3 days as per facility policy.A review of the facility's P&P titled, Food Storage (Dry, Refrigerated, and Frozen, revised 2020, indicated, .General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration.Leftover contents of cans and prepared food will be stored uncovered, labeled and dated containers in refrigerators and/or freezers.Wrap food properly. Never leave any food item uncovered and not labeled.Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure.A review of the facility's P&P titled, Labeling and Dating Foods (Date Marking), revised 2020, indicated, .All foods stored will be properly labeled according to the following guidelines.Once a package is opened, it will be re-dated with the date the item was opened.A review of the facility's undated P&P titled, Use and Storage of Food Brought in by Family or Visitors, indicated, .All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.If not consumed within 3 days, food will be thrown away by facility staff.A review of the US FDA 2022 Food Code, section 3-602.11, titled, Food Labels, indicated, .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients.A review of the US FDA 2022 Food Code, section 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container, 1/18/23 version, indicated, .The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination .A review of the US FDA 2022 Food Code, section 3-302.11, titled, Packaged and Unpackaged Food -Separation, Packaging, and Segregation, 1/18/23 version, indicated, .(A) FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings .4a. During a concurrent observation and interview on 7/7/26, at 9:27 a.m., with the CDM during the initial kitchen tour, cracks were observed in the walls along with chipped paint in the dry food storage area. The CDM confirmed the findings and stated these should have been repaired and maintained.4b. During a concurrent observation and interview on 7/7/26, at 9:55 a.m., with the CDM, during the initial kitchen tour, floors were found to be excessively dirty in the dry food storage area, in the refrigerator and freezer along with a lot of dirt and debris. The CDM confirmed the findings and stated they could not tell when these areas were last cleaned. The CDM further stated that these areas should be cleaned every day, every week and deep cleaned every month.During an interview on 7/8/26, at 3:31 p.m., with the RD, the RD stated the walls should not be cracked or have chipped paint as dirt and paint particles could get into food and lead to contamination. The RD further stated that the kitchen, refrigerator and freezer floors should have been cleaned properly and on a regular basis as debris and dirt could have entered food and caused food borne illnesses.A review of the facility's undated P&P titled, Sanitation Inspection, indicated, .All food service areas shall be kept clean, sanitary, free from litter, rubbish.Inspections will be conducted but not limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area - walls - floors g. Food preparation area - walls - floors.During a review of the facility's P&P titled, Cleaning Rotation, revised 2020, the P&P indicated, .Equipment and utensils will be cleaned and sanitized according to the following guidelines.Items cleaned monthly: Refrigerators, Freezers, Ingredient bins, Ice Machines, Food containers, Walls.During a review of the facility's P&P titled, Cleaning Instructions: Floors, revised 2020, the P&P indicated, .Floors will be kept clean and sanitary, washed daily or as needed.Kitchen floors will be swept and cleaned after each meal.Floors will be washed daily, using hot water and detergent.Additional steps may be taken to use degreaser or other appropriate floor cleaners in high-traffic cooking areas.At least once a month, large appliances will be moved to clean behind and underneath them.

Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 95) with a health representative, in a total sample of 26, was informed in advance of the care to be furnished, the risks and benefits of proposed care, and treatment options when upon admission to the facility, Resident 95 was deemed incapable of understanding diagnoses, prognoses, or treatment options and a representative was not contacted to sign paperwork which included an informed consent (information explained by a physician to a resident/representative about the medication, diagnoses, alternatives, and the ability to decline treatment) for one psychotropic medication (a chemical substance that changes nervous system function and results in alterations in perception, mood, cognition, or behavior) prescribed to Resident 95.These failures resulted in Resident 95 making important healthcare decisions which may not have been understood.Findings:During a review of Resident 95's document titled admission RECORD, the record indicated that Resident 95 was admitted to the facility in June 2026, with diagnoses which included dementia with psychotic disturbance (a medical diagnosis given when a patient experiences a significant loss of memory and exhibits symptoms like hallucinations or delusions (seeing and hearing things that are not real)) and adult failure to thrive (unintentional weight loss, poor appetite, inactivity, and social withdrawal usually driven by a combination of underlying medical, psychological, and social factors). The document also indicated that a public patient representative (a trained, state-appointed advocate who participates in medical decision-making for long-term care residents) was the responsible party for the resident.A review of a document titled Order Details dated 6/11/2026 indicated, .Resident is Not Capable of Understanding Rights, Responsibilities, And Informed Consent.A review of a document titled Psychotherapeutic Drug Informed Consent Form dated 6/11/26, indicated Resident 95 had signed the document consenting to receive treatment using an antipsychotic (prescription medication primarily used to treat mental health conditions) medication quetiapine.A review of a document titled Order Details dated 6/12/26 indicated, .Quetiapine.Give 75mg [milligram, a unit of measure] by mouth at bedtime for continuous pacing causing impairment in functional capacity related to .DEMENTIA, UNSPECIFIED SEVERITY, WITH PSYCHOTIC DISTURBANCE.During a concurrent interview and record review on 7/10/26, at 9:22 a.m., the Medical Records Clerk (MR) confirmed that the informed consent was signed by Resident 95. The MR also confirmed that there was an order which stated that Resident 95 did not have the capacity to make decisions for himself.During an interview on 7/10/26, at 11:02 a.m. with the Assistant Director of Nursing (ADON), the ADON confirmed the informed consent was signed by Resident 95. ADON also confirmed Resident 95 did not have capacity to do so. The ADON further stated that it was very important for a person who has capacity to sign the consent form so that they can understand and can make decisions about their care.A review of the facility's undated policy and procedure (P&P) titled Use of Psychotropic Medication(s) indicated, .Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication.

Based on observation, interview, and record review, the facility failed to ensure call lights (a communication tool or network allowing residents to alert staff when they need assistance or have an emergency) were within reach for 2 of 26 sampled residents (Resident 3 and Resident 25) when:1. Resident 3's call light was found under his roommate's bed and was not within Resident 3's reach; and,2. Resident 25's call light was on the floor and was not readily accessible while Resident 25 was in bed.These failures had the potential to result in Resident 3 and Resident 25 not receiving necessary care in a timely manner and had the potential to receive delayed services. Findings: 1. A review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses including unsteadiness on feet, muscle wasting, and atrophy (the partial or complete wasting away of a body part, tissue, or organ, resulting in a decrease in cell size and number). During a review of Resident 3's Care Plan Report, (a form where you can summarize a person's health conditions, specific care needs, and current treatments) dated 5/27/26, the care plan indicated, .[Resident 3] is at risk for falls r/t [related to] History of falls, Incontinence [accidentally leaking urine or stool], unsteadiness on feet.Be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 7/7/26, at 9:27 AM, with Resident 3, Resident 3's call light was observed to be located under his roommate's bed. Resident 3 stated that he could not find his call light and was not sure where it was located. Resident 3 further stated that he would like his call light to be close to him so he could use it when he needed it. During a concurrent observation and interview on 7/7/26, at 9:30 AM, with Certified Nursing Assistant (CNA) 2, Resident 3's call light was observed. CNA 2 confirmed that Resident 3's call light was under his roommate's bed. CNA 2 stated that Resident 3's call light should have been close to Resident 3. CNA 2 further stated that Resident 3 would not be able to call for help by not having his call light within reach. 2. A review of Resident 25's admission RECORD, indicated Resident 25 was admitted to the facility with diagnoses including a history of falling and muscle weakness. During a review of Resident 25's Fall Care Plan Report, dated 4/1/25, the care plan indicated, .[Resident 25] is at risk for further falls.Be sure the Resident's call light [call bell-a communication tool or network allowing residents to alert staff when they need assistance or have an emergency] is within reach and encourage the resident to use it for assistance as needed. During a review of Resident 25's ADL Self-Care Performance Care Plan Report (ADL, Activities of Daily Living-basic tasks required to care for oneself on a day-to-day basis), dated 7/2/25, the care plan indicated, .The resident has an ADL self-care performance deficit.Encourage the resident to use bell to call for assistance. During a review of Resident 25's Call Bell System Care Plan Report, dated 2/3/26, the care plan indicated, .Resident utilizing a call bell system to summon assistance.Resident will have continuous access to call bell and receive timely assistance.Place call bell within reach at all times. During an interview on 7/7/26, at 11:41 a.m. with the Unit Manager (UM), the UM explained that Resident 25's room at the South Unit was no longer a Memory Care Unit (a safe, long-term living space for people with memory problems such as individuals with dementia or Alzheimer's Disease) and the doors leading to the other units were now open and residents at the South Unit were free to move to other areas of the facility. The UM stated some residents were provided with hand bells, and some residents had a call light installed. During a concurrent observation and interview on 7/8/26, at 10:32 a.m., with CNA 1, CNA 1 stated call lights were being installed in each of the rooms at the South Unit. CNA 1 explained that when the South Unit was a Memory Care Unit there were no call lights due to most of the residents having memory problems with behavior and the call lights were safety hazards to the residents. CNA 1 stated that residents who knew how to use a call light were provided with hand bells. CNA 1 further stated that call lights (call bells) were now being installed in each room and Resident 25's room was one of the rooms with a call light installed. While in Resident 25's room checking for the call light (call bell), Resident 25 was observed in bed, and his call light (call bell) was found on the floor where he could not reach to use for assistance. CNA 1 confirmed that Resident 25's call light (call bell) was on the floor. CNA 1 stated it should not have been on the floor and should have been clipped on to the bed where Resident 25 could reach. CNA 1 further stated Resident 25 would not be able to call for help, had the potential for his needs to not be met timely, and could have the potential to fall. During an interview on 7/8/26, at 11:06 a.m., with the Assistant Director of Nursing (ADON), the ADON stated call lights (call bells) should have been within reach of the residents and should have been placed close to the resident for easy accessibility and readily be used to call for assistance. The ADON further stated that this practice could increase the risk for delayed response for assistance and the residents' needs may not be met in a timely manner. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 8/24, the P&P indicated, .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Staff will ensure the call light is within reach of resident and secured.The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview and record review, the facility failed to report the findings of two of three abuse allegation investigations to the State Survey Agency (the Department), within 5 working days of the incident occurring, when:1. The results of the investigation into the alleged allegation of abuse that occurred on 4/11/26 between Resident 64 and Resident 8 was not reported to the Department; and 2. The results of the investigation into the alleged allegation of abuse that occurred on 5/31/26 between Resident 79 and Resident 92 was not reported to the Department.These failures had the potential to compromise the facility's ability to ensure that appropriate corrective actions were taken as a result of the investigations and could have compromised Resident 64, Resident 8, Resident 79, and Resident 92's safety. Findings:1. A review of Resident 64's admission RECORD, indicated that Resident 64 was admitted to the facility in the winter of 2022 with diagnoses including adult failure to thrive (a syndrome of progressive physical, cognitive, and functional decline), unspecified dementia (a clinical diagnosis used when a patient shows clear signs of cognitive decline or memory loss, but the exact underlying cause or specific type [like Alzheimer's or vascular dementia] cannot be definitively determined), and major depressive disorder (a serious mental health condition characterized by a persistent low mood and a loss of interest in activities).A review of Resident 8's admission RECORD, indicated that Resident 8 was admitted to the facility in the spring of 2026 with diagnoses including unspecified dementia, major depressive disorder, and generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday issues).During a concurrent interview and record review on 7/9/26 at 4:04 PM with the Administrator (ADM), the facility reported incident folder between Resident 64 and Resident 8 was reviewed. The ADM confirmed that an altercation between Resident 64 and Resident 8 occurred on 4/11/26 and that there was no follow-up report that was submitted to the Department. The ADM stated that it was his expectation for all reports of abuse to be investigated and submitted to the Department within five days of an incident occurring. The ADM also stated that it was important for investigations to be done to help support the residents and prevent further harm from occurring. The ADM further stated that the due diligence of an investigation should be done to ensure the residents safety.During an interview on 7/10/26 at 12:01 PM with Assistant Director of Nursing (ADON), the ADON stated that it was her expectation for all abuse investigations to be submitted to the Department and other relevant agencies within a five-day timeframe. The ADON also stated that if the results of the investigation were not submitted, there could be a delay in making sure the residents are safe. The ADON further stated that it was important for proper investigations to be conducted to ensure that it would not happen to others residing in the facility. 2. A review of Resident 79's admission RECORD, indicated that Resident 79 was admitted to the facility in the fall of 2025 with diagnoses including generalized anxiety disorder, unspecified dementia, and adult failure to thrive.A review of Resident 92's admission RECORD, indicated that Resident 92 was admitted to the facility in the fall of 2025 with diagnoses including unspecified dementia, adult failure to thrive, Alzheimer's disease (a progressive, irreversible brain disorder that accounts for 60% to 80% of dementia cases), restlessness, and agitation.During a concurrent interview and record review on 7/9/26 at 4:06 PM with the ADM, the facility reported incident folder between Resident 79 and Resident 92 was reviewed. The ADM confirmed that an altercation between Resident 79 and Resident 92 occurred on 5/31/26 and that there was no follow-up report that was submitted to the Department. The ADM acknowledged that a report should have been submitted to the Department within five days of the incident.During a review of the facility's undated policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, the P&P indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies .

Based on observation, interview and record review, the facility failed to ensure completion and follow-up of the Preadmission Screening and Resident Review (PASRR- a screening that checks if a person needs specialized services before being admitted to a nursing facility) process for one of twenty-six sampled residents (Resident 1) when the facility did not respond to California Department of Health Care Services (DHCS) attempts to complete the PASRR Level II evaluation for Resident 1 after the initial Level I Screening dated 9/9/25 and did not submit a new Level I Screening as instructed after the evaluation was closed. This failure resulted in the facility not ensuring timely completion of the PASRR evaluation process which could have resulted in Resident 1 not receiving necessary mental health services in a timely manner, potentially impacting his well-being.Findings:During a review of the Preadmission Screening and Resident Review (PASRR) Level I Screening dated 9/9/25, it was noted that the screening represented Resident 1's initial preadmission assessment. The screening identified a positive finding for Serious Mental Illness (SMI) and negative findings for Intellectual Disability (ID), Developmental Disability (DD), and Related Condition (RC). Section III of the screening documented schizophrenia (a brain disorder that can make it difficult to distinguish reality from what is not real) as the resident's serious mental illness diagnosis. Resident 1's documented prescribed psychotropic medications (drugs that affect a person's mental state by altering mood, behavior, or cognition) included Divalproex, Risperidone, Paroxetine, and Quetiapine.A review of the DHCS NOTICE OF ATTEMPTED EVALUATION, dated 9/13/25, indicated, .UNABLE TO COMPLETE LEVEL II EVALUATION FOR SERIOUS MENTAL ILLNESS (SMI).for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. The notice indicated the case was closed and instructed the facility to submit a new Level I Screening to reopen the evaluation process.During a review of the PASRR Level I Screening, dated 4/1/26, it was noted that the screening represented Resident Review (RR) - Status Change for Resident 1. The screening identified negative findings for ID/DD/RC. Section III documented diagnoses of Bipolar Disorder (a mental illness that causes extreme changes in mood, energy, and behavior) and Major Depressive Disorder (a mental illness that causes persistent sadness and loss of interest). Resident 1's documented prescribed psychotropic medications included Lorazepam, Paroxetine, and Valproic acid. Section IV, item 14, identified HOSPICE/DEMENTIA as the severe condition preventing Resident 1 from participating in specialized add-on services (services intended to address behavioral health, psychiatric, cognitive, and functional needs).A review of the DHCS NOTICE OF LEVEL I CATEGORICAL DETERMINATION REPORT, dated 4/3/26, for Resident 1, indicated Resident 1 required Nursing Facility Services due to a medical and/or mental health condition. The report documented that specialized services were not recommended and identified the resident as having a severe physical condition. A review of the facility's admission RECORD indicated, Resident 1 was admitted to the facility on [DATE] and was receiving Hospice care with diagnoses of Bipolar disorder, Major Depressive Disorder and Dementia (condition that affects memory, thinking, and ability to perform daily activities) among others.During an interview and record review on 7/8/26 at 2:50 PM with the Social Services Director (SSD) and the Medical Records/Ward Clerk (MR), the MR retrieved Resident 1's PASSR documentation. The SSD stated she was responsible for overseeing the PASRR process. The SSD stated that for Resident 1's September PASRR Level II evaluation, DHCS made two attempts to contact the facility; however, the facility did not respond to the attempts, resulting in closure of the Level II evaluation process. The SSD stated she was uncertain who may have received the calls or failed to communicate the messages. The SSD stated that any staff member with computer access could assist with the Level II screening process. The SSD stated that the appropriate procedure after the Level II evaluation was closed would have been for the facility to complete and submit a new Level I Screening; however, this was not completed. The SSD stated the PASRR portal was not monitored diligently. The SSD further stated that the facility did not have a tracking process in place at that time to ensure timely follow-up of PASRR Level II evaluations. The SSD stated she does not document PASRR-related phone calls; however, she maintains a PASRR tracking log, which was initiated after September 2025 in preparation for a PASRR audit. During an interview and record review on 7/9/26 at 8:45 AM, with the Assistant Director of Nursing (ADON) and the SSD, the ADON stated that the facility's PASRR policy required coordination of assessments during preadmission screening and resident review to ensure individuals with mental disorders, intellectual disabilities, or related conditions receive appropriate services based on their needs. The SSD stated that level II determinations completed by DHCS assist in identifying specialized service needs for residents with complex diagnoses. The SSD stated that failure to complete required PASRR process could result in delays in identifying resident-specific service needs.During a review of the facility's policy titled Resident Assessment - Coordination with PASARR Program, copyrighted 2024, indicated, .Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. and .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority.

Based on interview and record review, the facility failed to ensure timely follow-through of a physician-ordered Modified Barium Swallow study (MBS - a diagnostic test used to evaluate swallowing function and determine whether food or liquids are being aspirated into the lungs) for 1 of 26 sampled residents (Resident 66) when, Resident 66's order for a MBS study, ordered on 5/6/26 by the Medical Doctor, had not yet been scheduled or completed as of 7/8/26. This failure delayed further evaluation of Resident 66's swallowing function and placed the resident at risk for aspiration and complications associated with dysphagia.Findings: A review of Resident 66's admission RECORD revealed diagnoses that include Huntington's Disease (brain disorder that impacts a person's physical movements, thinking abilities, and emotional regulation), dysphagia (difficulty swallowing), and dementia (decline in mental abilities that is severe enough to disrupt daily life), among other diagnoses.During a review of Resident 66's medical record, the following were noted on 12/3/25, at 3:42 PM, a Physician Order indicated, May refer to [Hospital Name] Imaging/radiology for Barium swallow r/t [related to] difficulty swallowing.During an interview on 07/07/2026 at 12:11 PM with Resident 66's Family Member (FM) 1, FM 1 stated that earlier in 2026 he accompanied Resident 66 to the hospital for a Barium Swallow (an imaging exam). FM 1 stated the procedure could not be completed because Resident 66 was unable to stand upright. FM 1 stated the hospital nurse instructed him to request that the facility obtain an order for a Modified Barium Swallow Study (MBSS). FM 1 further stated that he contacted the facility's front desk staff on multiple occasions to follow up regarding the status of the MBSS but did not receive return calls or updates regarding scheduling of the test for Resident 66. During a review of Resident 66's medical record, a physician order, dated 5/6/26, at 11:38 AM indicated, .May have Modified Barium Swallow Study (MBSS) with Speech language Pathology related to.DYSPHAGIA. During a concurrent interview and record review on 7/8/26 at 4:43 PM with the Unit Manager (UM) and the Assistant Director of Nursing (ADON), the UM presented the referral packet of Resident 66 and reviewed a handwritten instruction on a document titled, Master Appointment Schedule - April 27. 2026 - Department. which indicated, .Please ask MD [Medical Doctor] to order MBS w/ [with] speech. The UM also presented and reviewed the facility's REFERRALS log and explained the log indicated that on 5/6/26 the Modified Barium Swallow Study with speech referral for Resident 66 was entered into the facility's system. The UM stated that staff were expected to document follow-up efforts in the progress notes when diagnostic referrals remained pending. After reviewing Resident 66's progress notes, the UM stated she found documentation reflecting follow-up for the original December referral. However, there was no documented evidence the facility followed through for the Modified Barium Swallow study ordered on 5/6/26. The UM stated the purpose of the Modified Barium Swallow study was to evaluate Resident 66's swallowing ability in order to determine the safest diet consistency. The UM further stated that failure to timely obtain the study could delay appropriate dietary recommendations and place the resident at risk for worsening swallowing function. The ADON stated Resident 66 was at risk for aspiration if the Modified Barium Swallow study was not followed up and scheduled.During an interview on 7/8/26 at 5:32 PM with the Medical Doctor (MD), the MD stated he was unaware that the Modified Barium Swallow study had not been scheduled and stated that this did not meet his expectations. The physician explained that staff are expected to follow through with physician orders and notify him if ordered procedures are not scheduled or if staff believe an order is no longer necessary so that he can make the clinical decision. Although the physician stated no known harm had occurred, he emphasized that failure to complete the communication loop placed Resident 66, who has a progressive neurological disorder and dysphagia at continued risk for aspiration and demonstrated the need for improved tracking systems to ensure ordered procedures are completed and physicians are notified when barriers occur.During a review of the facility's policy titled, Radiology and other Diagnostic Services and Reporting, revised in 2025, indicated, The facility must provide.radiology and other diagnostic services when ordered by a physician.in accordance with state law.1. The facility must provide.radiology and other diagnostic services to meet the needs of its residents.During a review of the facility's policy titled, Notification of Changes, revised 2/23, indicated, .to ensure the facility promptly informs the resident, consult the resident's physician; and notifies.the resident's representative when there is a change requiring notification.Circumstances that require a need to alter treatment, this may include .New treatment.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate (measures the frequency of mistakes made during the medication administration process) was more than 5% ( % or percentage-number or ratio that expressed as a fraction of 100) with a resident census of 93. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 significant medication errors (is an event that could or should have been prevented) out of 31 opportunities (every dose a nurse successfully administers, omits, or improperly administers) which resulted in a facility wide medication error rate of 6.45% for 1 of 8 residents (Resident 18) observed for medication administration. The medication errors were as follows:An anti-convulsant medication (medications used to treat seizures and neuropathic pain-also called neuralgia-a pain caused by the nerves due to damage or dysfunction in the nervous system) and a Vitamin B-1 supplement (medication that helps the body convert carbohydrates into energy and supports the nervous system function) were mixed together in a medication cup with a small amount of water for medication administration via a Gastrostomy Tube (also called G-Tube, is a medical device inserted directly through the abdomen into the stomach to deliver liquid nutrition, hydration, and medications directly to the stomach for residents who cannot safely swallow) for Resident 18.These failures had the potential to result in unsafe medication use and medication errors affecting the health and well-being of Resident 18.Findings:During a review of Resident 18's admission RECORD, dated 7/9/26, the record indicated Resident 18 was admitted to the facility with diagnoses including unspecified convulsions (are rapid, involuntary muscle contractions causing uncontrollable shaking of the body), seizure disorder, gastrostomy status, and neuralgia (a severe, recurring, sharp or shooting nerve pain).During a review of Resident 18's Order Summary Report, active orders as of 7/9/26, the order indicated, .Gabapentin Capsule [anti-convulsant and also used for Neuropathic pain] 100 MG Give 1 capsule via G-Tube three times a day for Neuropathic pain. The order also indicated, .Thiamine HCL [HCL-hydrochloride, thiamine has been combined with hydrochloric acid to create a stable salt] [Vitamin B-1 medication] Oral Tablet 100 MG (Thiamine HCL) Give 1 tablet via G-Tube one time a day for Supplement.During a medication administration observation and interview on 7/8/26, at 4:49 p.m. with LN 2 at the South Unit hallway outside Resident 18's room, LN 2 prepared Resident 18's medications for G-Tube administration as scheduled. After pouring 2 liquid medications into each different medication cups, LN 2 took out one capsule of the Gabapentin from the bubble pack (a method of organizing pills into individual, sealed compartments), separated the capsule shell and poured the powdered contents into a medication cup. LN 2 also took out one Thiamine HCL tablet from the bottle, placed it in a small plastic bag and crushed it with a crusher device to turn it into fine powder. LN 2 then poured the crushed Thiamine HCL medication together with the Gabapentin powder in the same medication cup. LN 2 then added a small amount of water to mix the 2 medications. LN 2 then took the mixture to Resident 18's room together with the other medications and a glass of water. After checking the G-Tube placement and residual volume with a 60 ml syringe, flushed with 15 ml of water, poured the liquid medications and, while the syringe was still attached to the tip of the G-Tube, she then poured the mixture of medications into the syringe. LN 2 finished the medication administration by flushing with another 15 ml of water after the mixture of medication had passed through the tube by gravity. LN 2 confirmed she mixed the Gabapentin and the Thiamine medications together in one medication cup. LN 2 stated that the medications should have been separated into 2 different medication cups and should have been delivered separately. LN 2 went on to say that this practice could have affected the efficacy of the medications and could increase the risk of medication interaction (a reaction that occurs when a drug's effectiveness or safety is altered by another substance like another drug, food, or supplement that can cause a medication to stop working or unexpected adverse reactions).During an interview on 7/9/26, at 1:47 p.m. with the ADON and the DSD, both the ADON and the DSD, stated the Gabapentin and the Thiamine should have been separated during G-Tube administration and should not have been mixed because it could have potential for medication interaction, could decrease or increase the efficacy of the medication that could lead to negative effects, and could potentially cause the G-Tube to be clogged.During a review of the facility's undated Policy titled, Medication Administration via Enteral Tube, this policy indicated, .It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines.Each medication will be administered separately.

Based on observation, interview, and record review, the facility failed to provide safe and effective use of medications including administering, storing, destruction, and dispensing of all drugs for a census of 93 and 1 out of 4 residents (Resident 18) who were on Gastrostomy Tube (also called G-Tube, is a medical device inserted directly through the abdomen into the stomach to deliver liquid nutrition, hydration, and medications directly to the stomach for residents who cannot safely swallow) when:1. Prescribed medications found in the pharmaceutical waste container (where unused and/or discontinued prescribed medications were held for ultimate safe disposal) in the medication room were not disposed of properly where eye drop bottles, insulin vials (a small, sealed glass bottle used to store insulin-necessary to keep blood sugar levels stable in the body), and insulin pens (an injection device that can be used to deliver preloaded insulin) were still recognizable and retrievable by hand on 7/7/26 during a medication storage inspection; and,2. An anti-seizure medication (medications used to stop seizures from happening, seizure is a sudden, uncontrolled surge of electrical activity in the brain leading to brief changes in movement, awareness, behavior or feelings) for Resident 18 did not have a printed pharmacy label on the bottle and was used to dispense the medication during a medication administration observation on 7/8/26. These failures could contribute to unsafe medication use, medication error, and the potential for medication misuse and drug diversion (unlawful use of prescription drugs by unauthorized individuals).Findings:1. During a medication storage inspection and interview on 7/7/26, at 8:30 a.m. with the Unit Manager (UM), the medication room for all units was inspected. A pharmaceutical waste container was discovered with discarded eye drop bottles, insulin vials, and insulin pens that were identifiable, recognizable, and retrievable by hand. The UM confirmed the contents discarded in the pharmaceutical waste container and stated the labels should have been removed and shredded, and the eye drop bottles, insulin vials and pens should have been emptied first into the container with drug destroyer/buster (drug disposal product used to safely and effectively dispose of unwanted or expired medications) such as used coffee grounds before disposing to prevent from unauthorized use.During an interview on 7/9/26, at 1:47 p.m. with the Assistant Director of Nursing (ADON) and Director of Staff Development (DSD), both the ADON and DSD stated that they expected the nurse handling the medications to be disposed should have removed the labels, emptied the eye drop bottles and insulin pens and contents from the insulin vials should have been drawn out first before disposing. Both the ADON and the DSD stated this practice would prevent misuse of the medications by unauthorized individuals.During a review of the facility's undated Policy titled, Destruction of Unused Drugs, the Policy indicated, .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with current and applicable state and federal requirements.During a review of the facility's undated Policy and Procedure (P&P) titled, Disposal of Medications, the P&P indicated, .Mixing medications with an undesirable substance such as used coffee grounds or kitty litter, and putting them in impermeable, non-descript containers.will further ensure the drugs are not diverted.2. During a review of Resident 18's admission RECORD, dated 7/9/26, the record indicated Resident 18 was admitted to the facility with diagnoses including unspecified convulsions (are rapid, involuntary muscle contractions causing uncontrollable shaking of the body), gastrostomy status, and dysphagia (difficulty swallowing).During a review of Resident 18's Order Summary Report, active orders as of 7/9/26, the order indicated, .Keppra [anti-seizure medication] Oral Solution 100 MG/ML [MG/ML-milligram per milliliter, unit of measurement] (Levetiracetam) [generic name for Keppra] Give 15 ml via G-tube two times a day for Seizure disorder.During a review of Resident 18's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 7/3/24, the care plan indicated, .The resident has a seizure disorder r/t [related to] Disease process Convulsions.Give medications as ordered.During a medication administration observation and interview on 7/8/26, at 4:49 p.m. with Licensed Nurse (LN) 2 at the South Unit outside Resident 18's room, LN 2 prepared Resident 18's medications for administration via the G-Tube. LN 2 took out a 16 fluid ounce (fl oz-unit of measurement) bottle of Levetiracetam Oral Solution 100 mg/ml and poured 15 ml of the medication into a medication cup. LN 2 explained that this bottle was not a house supply (a limited selection of medications that the facility maintains in bulk of common stock on the nursing units, medication carts, or in the medication room for immediate or emergency use) and it belonged to Resident 18. The bottle had Resident 18's name handwritten on the top part of the bottle and the label from the pharmacy that included the name of the resident, the name of the medication, the dosage, the frequency, the time, the expiration date, and the route of administration was missing. LN 2 stated that the printed label from the pharmacy was missing from the bottle. LN 2 further stated the label came off and the medication should have the label from the pharmacy.During an interview on 7/9/26, at 1:47 p.m. with the ADON and the DSD, both ADON and DSD stated the bottle of Levetiracetam Oral Solution 100 mg/ml for Resident 18 did not have proper labeling from the pharmacy. The ADON and DSD both explained that the medication should have been reordered from the pharmacy with proper labeling. They both went on to say that without proper labeling it would increase the risk for medication errors.During a review of the facility's undated Policy titled, Medication Storage, this policy indicated, .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.During a review of the facility's undated Policy titled, Medication Administration, this policy indicated, .Compare medication source (bubble pack, vials, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to ensure the facility's previous recertification survey (a comprehensive, on-site inspection conducted by state agencies) results were available and accessible for viewing for a census of 93 residents.This deficient practice placed the residents and visitors at risk of not being able to examine the facility's previous survey results and the plan of corrections without having to ask the facility staff.Findings:During the facility's Resident Council (an independent organization formed by people living in a shared community such as public housing, assisted living, or nursing homes to collectively advocate for their rights, improve their quality of life, and advise management on community operations) meeting on 7/8/26, at 9:45 AM, with Resident 40, Resident 39, Resident 34, Resident 89, Resident 52, Resident 43, and Resident 63, the residents all stated that they did not know the location of the binder that contained the facility's previous survey results. Resident 40 and Resident 39 both stated they would like to know the results of the annual survey process.During a concurrent observation and interview on 7/9/26, at 8:27 AM, with the Assistant Director of Nursing (ADON), the facility's main licensing board at the front of the facility was observed. The ADON confirmed that the previous survey results binder was not posted and available for review. The ADON stated that the previous survey results binder should have been located at the front of the building near the social services office. The ADON further stated that the residents should have knowledge and access to previous survey results in order for them to understand what was being worked on in the facility and how the facility was correcting those issues.During an interview on 7/10/26, at 12:40 PM, with the Administrator (ADM), the ADM stated that it was his expectation for the previous survey results binder to be readily available at the front entrance of the facility. The ADM further stated that the residents should always have access to survey results so that they would know how the facility was correcting any deficiencies.During a review of an undated facility provided document titled, Consumer Information, the document indicated, .Current licensing survey is located in the binder to the left side of the Consumer Information board in the Main Entry lobby.During a review of the facility's undated policy and procedure (P&P) titled, Resident Rights, the P&P indicated, .The resident has a right to .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

Based on interview, and record review, the facility's Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members when the Medical Director (MD) did not attend the scheduled quarterly meetings as required.This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents for a census of 93.Findings:During a concurrent interview and record review on 7/9/26, at 4:13 PM, with the Administrator (ADM), the Quality Assurance and Performance Improvement (QAPI- a data-driven, proactive approach mandated by the Centers for Medicare & Medicaid Services [CMS] for healthcare facilities to continuously monitor, analyze, and improve the quality of care and services) folders were reviewed. The ADM confirmed that the MD did not attend the quarter 4 meeting of 2025 on 11/20/25. The ADM further confirmed that the MD did not attend any of the scheduled meetings for quarter 2 of 2026 that were held on 4/29/26, 5/29/26, and 6/30/26. The ADM stated that it was important for the MD to attend the quarterly QAPI meetings so that he could oversee the overall care of the residents residing in the facility. The ADM further stated that it was his expectation that the MD attend the QAPI meetings at least once every three months. The ADM stated that the MD could share his knowledge and provide feedback to the staff so they could provide better care.During an interview on 7/10/26, at 12:04 PM, with the Assistant Director of Nursing (ADON), the ADON stated that it was her expectation for the MD to attend the QAPI meetings at least once every three months. The ADON further stated that the MD could provide guidance to the staff at the facility to better direct their care. The ADON stated that by attending the QAPI meetings, the MD would be aware of any issues happening at the facility and could offer the necessary interventions to improve resident outcomes. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI), revised 2025, the P&P indicated, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.The QAA Committee shall be interdisciplinary and shall.Consist at a minimum of.The Medical Director or his/her designee.Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program.

Based on interview, and record review, the facility failed to maintain an accurate medical record for two of three sampled residents (Resident 2 and Resident 3) when:Wound care treatments were not documented daily as ordered by the physician for Resident 2 in February 2026 and March 2026; and,Wound care treatments, skin assessments, and skin treatments were not documented daily as ordered by the physician for Resident 3 in February 2026 and March 2026.These failures resulted in an inaccurate representation of the residents' progress in their plan of care and had the potential to result in a decreased well-being for Resident 2 and Resident 3.Findings:1. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2023 with diagnoses which included paraplegia (paralysis of the legs and lower body making it impossible to stand or walk), amputation of left and right legs above the knee (surgical removal of both legs), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high which causes the heart to work harder to pump blood).A review pf Resident 2's Physician Order Summary, indicated, .Treatment: Stage 4 pressure ulcer [A localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or a pressure in combination with friction] to left ischium [A bone in the pelvis]: cleanse with NS [A mix of salt and water used to cleanse wounds], apply silver alginate [An absorbent wound dressing that inhibits the growth of germs], and cover with dry dressing [Bandage].every day shift.Start Date.11/18/2025 0830. D/C [Discontinue] Date.03/05/2026 1916.A review of Resident 2's Physician Order Summary, indicated, .TX [Treatment]: Monitor skin tear [A traumatic wound caused when the skin is pulled or stretched] to left posterior thigh; notify MD [medical doctor] for any significant changes.every shift.Start Date.10/07/2025 0630.A review of Resident 2's Physician Order Summary, indicated, .Treatment: Stage 4 pressure ulcer to left ischium: cleanse with NS, apply skin prep [A skin protectant that prepares skin for tapes and adhesive bandages] to peri wound [the skin surrounding the wound], apply silver alginate to wound bed, and cover with dry dressing.every day shift.Start Date.02/21/2026 0630.D/C Date.03/05/2026 1916.A review of Resident 2's TAR February 2026, indicated that the treatment order to monitor Resident 2's skin tear to the left posterior thigh was not documented every shift per the physician order.A review of Resident 2's TAR February 2026, indicated that the treatment order for wound care to Resident 2's left ischium Stage 4 pressure ulcer was not documented every shift per the physician order.A review of Resident 2's TAR March 2026, indicated that the treatment order for wound care to Resident 2's left ischium Stage 4 pressure ulcer was not documented every shift per the physician order.During an interview on 4/15/26, at 9:50 a.m., with Licensed Nurse (LN) 1, LN 1 stated that if a resident refused treatment, she would tell the resident that she would come back later and then return to see if the resident changed their mind. LN 1 further stated that if the resident still refused treatment, she would again leave and return to the resident's room at a later time. LN 1 stated that if the resident still refused she would provide teaching to the resident on the risks of refusing the treatment, she would notify the charge nurse and the resident's physician, and document the refusal in the resident's electronic medical record (EMR) on the Treatment Administration Record (TAR, a list of prescribed treatments), in the progress notes, and in the care plan.During an interview on 4/15/26, at 9:55 a.m., with LN 2, LN 2 stated that she documented resident refusals of treatments and education provided in the medical record on the TAR, in the progress notes, and in the care plan. LN 2 further stated that the facility Administrator, Director of Nursing, and the resident's physician were also notified whenever residents refused treatments. During a concurrent interview and record review on 4/15/26, at 12:16 p.m., with the Director of Nursing (DON), Resident 2's February 2026 TAR, and March 2026 TAR, were reviewed. The DON stated that her expectation was that staff documented wound treatments and wound and skin assessments per the physician orders in the TAR, and documented any refusals by the residents in the TAR and in the progress notes. The DON confirmed that facility staff did not document monitoring of Resident 2's skin tear for twelve days and did not document wound care to Resident 2's Stage 4 pressure ulcer for two days in February 2026. The DON further confirmed that facility staff did not document wound care to Resident 2's Stage 4 pressure ulcer for three days. The DON stated that Resident 2 had a history of refusing care. The DON further stated that when residents refused wound care and/or treatments, facility staff should have not left blanks on the TAR but needed to document a chart code that indicated refused and document the refusal in the resident's progress notes. The DON confirmed that there was no refusal codes documented in Resident 2's TARs and confirmed by a review of Resident 2's Progress Notes, that there was no documentation that Resident 2 refused wound treatments in February 2026 and in March 2026. The DON stated that the risk of not documenting wound care, treatments, and assessments per the physician orders was that staff reviewing the record would not have a clear picture of Resident 2's wound healing status. The DON acknowledged that the facility policy was not followed.2. A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility in 2025 with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), blepharitis (a condition that causes swelling, itching, and other irritation of the eyelids), and amputation of right leg below the knee (surgical removal of right lower leg).A review pf Resident 3's Physician Order Summary, indicated, .Blepharitis [inflammation of the eyelids] Both eyes: Eyelid Scrub-cleanse with 50:50 [half and half] H20 [water] and baby shampoo, clean eyelash margins [the edge of the eyelids where the eyelashes grow] QHS [hour of sleep] at bedtime for Blepharitis.Start Date.02/25/2026 2100.A review pf Resident 3's Physician Order Summary, indicated, .TX [treatment]: skin tear [a traumatic wound caused when the skin is pulled or stretched] to Left first knuckle [the joint at the base of the finger where the hand bone meets the finger bone]: cleanse with normal saline [NS, mix of salt and water used to cleanse wounds], pat dry, apply triple antibiotic ointment [a product prescribed to apply to skin containing three medications that work together to kill germs], cover with dry dressing [bandage].one time a day.Start Date.02/10/2026 0900.D/C [Discontinue] Date.03/20/2026 1010.A review pf Resident 3's Physician Order Summary, indicated, .Cleanse with Normal Saline, apply triple antibiotic and cover with a dry dressing two times a day for open area to Lateral aspect near left great toe [outer side of big toe facing toward the second toe].Start Date.02/08/2026 0900.D/C Date.02/15/2026 0900.A review pf Resident 3's Physician Order Summary, indicated, .TX: Diabetic Ulcer [a slow-healing wound on the foot of a person with Diabetes] to Left, Medial, Anterior Foot [the side of the left foot near the ankle]: cleanse with NS, apply silver alginate [an absorbent wound dressing that inhibits the growth of germs], and cover with dry dressing two times a day.Start Date.02/15/2026 0900.D/C Date.03/24/2026 0915.A review pf Resident 3's Physician Order Summary, indicated, .Treatment: Monitor Callous [a thickening of skin in response to prolonged rubbing] to the Left Heel, notify MD [medical doctor] for any changes.every shift for treatment monitoring.Start Date.12/02/2025 2230.D/C Date.03/24/2026 0915.A review pf Resident 3's Physician Order Summary, indicated, .TX Monitoring: Monitor for Skin tear to the Left Knuckle, Notify MD for any s/sx [signs/symptoms] of infection [presence of germs] or any significant changes.every shift for TX monitoring.Start Date.02/17/2026 2200.D/C Date.03/20/2026 1010.During a concurrent interview and record review on 4/15/26, at 12:16 p.m., with the DON, Resident 3's February 2026 TAR, and March 2026 TAR, were reviewed. The DON stated that her expectation was that staff documented wound care and assessments per the physician orders in the TAR and documented any refusals by the residents in the TAR and in the progress notes. The DON acknowledged that for Resident 3's February 2026 TAR, the eyelid scrub for both eyes was not documented for three days, the skin care for the left knuckle skin tear care was not documented for ten days, the left great toe dressing changes were not documented for three days, and the monitoring of a callous to the left heel was not documented every shift as ordered for fourteen days. The DON further acknowledged that for Resident 3's March 2026 TAR, the eyelid scrub for both eyelids was not documented for 20 days, the skin care for the left knuckle was not documented for four days, the diabetic foot ulcer care to the left foot was not documented for 17 days, the monitoring of the callous to the left heel was not documented for 19 days, and the monitoring for the skin tear to the left knuckle every shift was not documented for 17 days. The DON stated that the risk of not documenting wound assessments and treatments per the physician order was that the staff would not know Resident 3's status if it was not documented. The DON further stated that the treatments should have been documented in the TAR and the progress notes. The DON acknowledged that the facility policy was not followed.A review of an undated facility policy and procedure (P&P) titled, Documentation In Medical Record, indicated, .Policy.Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines.1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care.occurred.4. Principles of documentation include, but are not limited to.b. Documentation shall be accurate, relevant, and complete.

Based on observation, interview, and record review, the facility failed to ensure safe infection prevention practices were used for a census of 96 when a staff member changed bed linens in the room of a resident on Enhanced Barrier Precautions (EBP, infection control interventions designed to reduce the spread of multidrug resistant organisms [MDRO, germs that are more difficult to kill with antibiotics] in nursing homes) on 4/15/26.This failed practice could contribute to the spread of infection by cross-contamination (physical movement or transfer of harmful germs from one person, object, or place to another) in the facility.Findings:A review of Resident 3's admission RECORD, indicated that Resident 3 was admitted to the facility in 2025 with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), blepharitis (a condition that causes swelling, itching, and other irritation of the eyelids), and amputation of right leg below the knee (surgical removal of right lower leg).A review of Resident 3's Physician Order Summary, indicated, .Enhanced Barrier Precautions per MD [medical doctor] order.Order Status.Active.Order Date.12/05/2025.During an observation on 4/15/26, at 11:57 a.m., outside of Resident 3's room, an EBP sign was posted outside the door. Certified Nursing Assistant (CNA) 2 changed bed linens in Resident 3's room without wearing a gown and gloves (Personal Protective Equipment [PPE], gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs).During a concurrent observation and interview on 4/15/26, at 11:57 a.m., with CNA 2 outside of Resident 3's room, the EBP sign posted on the door was observed. CNA 2 acknowledged that the EBP sign indicated that PPE was required to be worn during bed linen changes. CNA 2 confirmed that she was not wearing PPE when she changed the bed linens in Resident 3's room. CNA 2 stated that the risk of not wearing PPE while changing the bed linen was infection (to affect or contaminate with disease-producing germs).During an interview on 4/15/26, at 12:16 p.m., with the Director of Nursing (DON), the DON stated that her expectation was that facility staff would wear the appropriate PPE provided when caring for residents in EBP. The DON further stated that the risk of not wearing the appropriate PPE as indicated was the spread of infection. The DON acknowledged that the facility policy was not followed.During a review of an undated facility policy and procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated, .Policy.It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions.'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.Policy Explanation and Compliance Guidelines.2. Initiation of Enhanced Barrier Precautions.b. An order for enhanced barrier precautions will be obtained for residents with any of the following.Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers).even if the resident is not known to be infected or colonized with a MDRO.3. Implementation of Enhanced Barrier Precautions.a. Make gowns and gloves available immediately near or outside of the resident's room.4. High-contact resident care activities include.e. Changing linens.10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound.that placed them at higher risk.

Based on interview and record review the facility failed to protect one of three sampled residents (Resident 2) from physical abuse by another resident when Resident 1 allegedly pushed his wheelchair into Resident 2's knees on 3/17/26 and punched her in the abdomen on 3/19/26. This failure resulted in Resident 2 being physically assaulted by Resident 1 on two occasions and had the potential to negatively affect her psychosocial well-being.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a condition that causes a decline in cognitive abilities such as memory, thinking, reasoning, and problem solving) and psychosis (a mental disorder characterized by disconnection from reality). During a review of Resident 1's clinical document titled, Brief Interview for Mental Status (BIMS [a tool used to screen for cognitive impairment]), the document indicated a score of 4 which suggested severe cognitive impairment. During a review of Resident 1's clinical document titled, Care Plan Report, dated 9/12/25, the document indicated, .Focus.Risk for Violence r/t [related to] impaired impulse control.as evidenced by escalating agitation and irritability and physical restlessness.Goal.Resident will not harm self or others.Interventions/Tasks.Maintain safety: place resident in calm low stimulus environment. Remove objects that could be used as weapons to prevents [sic] harm to patient, staff and others. A review of Resident 2's admission RECORD, indicated she was admitted to the facility with diagnoses which included osteoarthritis (disease that causes joint pain and stiffness) and depression (mental health condition that causes a persistent feeling of sadness). During a review of Resident 2's clinical document titled, Brief Interview for Mental Status (BIMS), the document indicated a score of 15 which suggested that cognition was intact. During an interview on 4/3/26 at 8:59 AM with Resident 2, Resident 2 stated she woke up in her bed on 3/17/26 and Resident 1 was in her room. Resident 2 stated she told Resident 1 to leave and he did not move. Resident 2 further stated Resident 1 had a cart with blankets on it, and he hit her left knee with it. Resident 2 stated she told staff and they did nothing, so she called the police. Resident 2 further stated, she should not be subjected to perverts like that. Resident 2 stated she and Resident 1 had an altercation in the past. During an interview on 4/3/26 at 9:55 AM, with Licensed Nurse (LN) 1, LN 1 stated Resident 1 went in and out of other patient rooms frequently and was redirected by staff. LN 1 stated Resident 1 could become angry and agitated at times. LN 1 stated she was not aware of the incident that occurred on 3/17/26 until the police showed up around 10 AM. During a review of Resident 1's progress notes titled, Nurse Notes, dated 3/17/26 at 3:32 PM, the note indicated, .At approximately 10:25am [AM].Police department came into facility asking to speak to [Resident 1].other resident reported that [Resident 1] allegedly, 'went into her room at approximately 4:00am and was looking through her closet. When she woke up and told him to get out, he then went over to her with his wheelchair and rammed her knees/legs 4 times and walked out' . During a telephone interview on 4/6/26 at 7:56 AM with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 1 frequently went into other residents' rooms, and the residents told him to get out. CNA 3 further stated during her shift on 3/17/26 she observed Resident 1 in the doorway of Resident 2's room. CNA 3 stated Resident 2 was awake and yelling at Resident 1 to leave the room. CNA 3 stated Resident 2 told her Resident 1 pushed something and hit her leg. CNA 3 stated she did not report it to her supervisor because she was not sure if it happened that day or on another day. During a review of Resident 2's progress notes titled Nurse Notes, dated 3/19/26 at 11:19 PM, the note indicated, .Resident -to- resident altercation occurred in the hallway near medication cart. [Resident 2] was seated in a wheelchair awaiting medication administration. [Resident 1] exited the dining room with an angry affect [sic] and visible agitation. [Resident 1] was moving to the medication area.Verbal redirection was attempted; however, resident remained escalated. [Resident 2] verbally engaged [Resident 1], stating, Don't come nearme! [sic] despite no prior direct interaction. Following [Resident 2's] statement, [Resident 1] redirected attention toward [Resident 2] and advanced in her direction [Resident 1] then made physical contact with [ Resident 2] striking her in the stomach with a closed fist. A review of Resident 2's progress notes titled, Social Services Progress Note, dated 3/20/26 at 5:31 PM, indicated .Pt. [Resident 2] stated, I just want him to stay away from me. I don't care if he doesn't realize what he is doing. During an interview on 4/3/26 at 12:55 PM with the Director of Nurses (DON), the DON stated Resident 1 had been monitored every 30 minutes by staff after the incident on 3/17/26 and the monitoring increased to every 15 minutes after the incident on 3/19/26. The DON stated the facility was doing the best they could to continually monitor Resident 1's behaviors and adjust his medications to decrease his anxiety and agitation. During a review of a facility policy titled, Abuse, Neglect and Exploitation, dated 2025, the policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Responding immediately to protect the alleged victim and the integrity of the investigation.Examining the alleged victim for any sign of injury.Increased supervision of alleged victim and residents.

Based on interview and record review the facility failed to ensure an allegation of potential abuse was reported in a timely manner for one of three sampled residents (Resident 2). This failure resulted in a delay in the abuse investigation and decreased the facility's potential to protect residents from physical and psychosocial harm. Findings: A review of Resident 2's admission RECORD, indicated she was admitted to the facility with diagnoses which included osteoarthritis (disease that causes joint pain and stiffness) and depression (mental health condition that causes a persistent feeling of sadness). During a review of Resident 2's clinical document titled, Brief Interview for Mental Status (BIMS), (a tool used to screen for cognitive impairment), the document indicated a score of 15 which suggested that cognition was intact. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (condition that causes a decline in cognitive abilities such as memory, thinking, reasoning, and problem solving) and psychosis (a mental disorder characterized by disconnection from reality). During an interview on 4/3/26 at 8:59 AM with Resident 2, Resident 2 stated she woke up in her bed on 3/17/26 and Resident 1 was in her room. Resident 2 stated she told Resident 1 to leave and he did not move. Resident 2 further stated Resident 1 had a cart with blankets on it, and he hit her left knee with it. Resident 2 stated she told staff and they did nothing, so she called the police. Resident 2 further stated, she should not be subjected to perverts like that. During an interview on 4/3/26 at 9:55 AM with Licensed Nurse (LN) 1, LN 1 stated Resident 1 went in and out of other patient rooms frequently and was redirected by staff. LN 1 stated Resident 1 could become angry and agitated at times. LN 1 stated she became aware of the incident that occurred between Resident 1 and Resident 2 when the police showed up around 10 AM on 3/17/26. During a review of Resident 1's progress notes titled, Nurse Notes, dated 3/17/26 at 3:32 PM, the notes indicated, .At approximately 10:25am .Police department came into facility asking to speak to [Resident 1].other resident reported that [Resident 1] allegedly, 'went into her room at approximately 4:00am and was looking through her closet. When she woke up and told him to get out, he then went over to her with his wheelchair and rammed her knees/legs 4 times and walked out' . During a telephone interview on 4/6/26 at 7:56 AM with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 1 frequently went into other residents' rooms, and the residents told him to get out. CNA 3 further stated during her shift on 3/17/26 she observed Resident 1 in the doorway of Resident 2's room. CNA 3 further stated Resident 2 was awake and hollering at Resident 1 to leave her room. CNA 3 stated Resident 2 told her Resident 1 pushed something and hit her leg. CNA 3 stated she did not report it to her supervisor because she was not sure if it happened that day or on another day. During an interview on 4/14/26 at 12:38 PM with the Director of Nurses (DON), the DON stated CNA 3 should have reported the incident to her supervisor on 3/17/26 after Resident 2 reported it to her. The DON stated it was important to report the allegation of abuse in order for the facility to follow up and put interventions in place to prevent further incidents. During an review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 2025, the policy indicated, .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment.immediately to the Administrator of the facility and to other appropriate agencies.When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur.The Licensed Nurse will.Respond to the needs of the resident and protect him/her from further incident. During a review of a facility policy titled, Abuse, Neglect and Exploitation, dated 2025, the policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Responding immediately to protect the alleged victim and the integrity of the investigation.Examining the alleged victim for any sign of injury.Increased supervision of alleged victim and residents.Reporting of all alleged violations to the Administrator, state agency.and all other required agencies within specified time frames.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse for one of two sampled residents (Resident 1) when the facility did not address Resident 2's escalating behaviors and noncompliance of his medications which resulted in Resident 2 hitting Resident 1 multiple times in the face on 12/4/25.This failure resulted in Resident 1 sustaining multiple injuries to his face and required him to be transferred to an acute care hospital on [DATE] for immediate treatment. This failure also has the potential for psychosocial harm to Resident 1.Findings: A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of, but not limited to dementia (a range of conditions involving a significant loss of mental abilities such as memory, thinking, and reasoning skills severe enough to interfere with a person's daily life and activities), schizophrenia (a serious brain condition that affects how a person thinks, feels, and behaves, making it difficult for them to tell what was real and what was not), noncompliance with other medical treatment and regimen, and history of traumatic brain injury (a brain injury that is caused by an outside force).A review of Resident 2's clinical record titled, [Name of Hospital] Discharge Summary Final Report, dated 11/18/25, indicated, .Final Diagnosis.History of traumatic brain injury with added progressive dementia.Personal history of noncompliance with medical treatment.Poor short-term memory .can be impulsive .A review of Resident 2's clinical record titled, Psychiatric Visit Progress Report, dated 11/20/25, indicated, .Initial NP [nurse practitioner] Psychiatric Evaluation.History of schizophrenia, depression (a serious mood disorder causing persistent sadness and loss of interest in activities), insomnia (difficulty falling asleep), and angry outburst.[Resident 2] was in bed, disorganized, bizarre.Staff report that the [Resident 2] recently threw his breakfast, has difficulty following directions.A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to encephalopathy (a condition affecting the brain's function causing confusion, memory loss, personality changes, and trouble concentrating), major depressive disorder (a condition characterized by persistent feelings of sadness and loss of interest in activities which interfere with daily life), and psychosis (a mental health condition when a person experiences a significant break from reality). A review of Resident 1's clinical record titled, [Name of facility] History and Physical, dated 2/12/25, indicated, .ASSESSMENT AND PLAN.Agitation and violent behavior.Depression.consider mental health evaluation if needed.A review of Resident 1's clinical record titled, Psychiatric Visit Progress Report, dated 11/21/25, indicated, .[Resident 1].was seen and evaluated for a follow up assessment of psychiatric symptoms and to make recommendations to assist with person-centered treatment planning.Objective: [Resident 1] is seen in his bed, irritable, irritable, and poorly cooperative.Staff reported aggressive behavior toward others. A review of Resident 1's Nurses Note, dated 12/4/25, indicated, .Around 0450 [4:50 AM] .[Resident 1] walked out of room with a bloody face .Claiming roommate [Resident 2] punched him repeatedly in the face and chest 25 times .Has wounds to right head laceration [deep cut], [NAME] [sic] to right forehead, wound to right lip, bleeding from right ear, nd [and] skin tear to right hand. Victim [Resident 1] and assaulter [Resident 2] separated immediately, 911 called. Around 0510 [5:10 AM] Cops arrived and [paramedics] arrived .took [Resident 1] to [acute care hospital] .A review of Resident 1's Nurses Note, dated 12/4/25, at 5:20 AM, indicated, .[Resident 1] face covered in blood, resident stated my roommate attacked me, he punched me 25 times, all over in my face, bump noted to right eyebrow with laceration, skin tear to left brow, bleeding from his mouth, bleeding from his right ear, and a skin tear to his right hand .[Resident 1] stated, look at what he did to my ear, while pointing at his ear with his right hand.A review of Resident 1's clinical record titled, Emergency Documentation, dated 12/4/25, indicated, .[Resident 1] is a [AGE] year old male presenting from nursing home for assault.[Resident 1] per report was assaulted in his sleep by another nursing home resident. He was hit multiple times in the face with a fist.[Resident 1] has lacerations to the face and scalp as well as bleeding from the right ear lobe. [Resident 1] is complaining of generalized pain mostly across the head.Presentation is consistent with a closed head injury and soft tissue trauma.A review of Resident 1's Nurses Note, dated 12/4/25, at 12:45 PM, indicated, .[Resident 1] back in facility.[Resident 1] noted with stitches to middle left eyebrow, laceration to right earlobe and scattered bruising to the face.A review of Resident 1's Nurses Note, dated 12/4/25, at 9:36 PM, indicated, .[Resident 1] is on day 1 s/p [status post] hospitalization d/t [due to] resident [Resident 1] to resident [Resident 2] altercation.Noted resident [Resident 1] with laceration to forehead with stitches and some dry blood of resident (Resident 1) face.A review of Resident 1's Social Services Progress Note, dated 12/5/25, indicated, .SSD [Social Services Director] asked pt [patient] how he was doing. [Resident 1] stated, I feel like I got hit by a truck.SSD asked pt if recalls incident from yesterday .[Resident 1] replied, Yes, a man that I thought was trustworthy hit me with his fist at least 12 times.During a concurrent observation and interview on 12/4/25, at 2:54 PM, with Resident 1, in his room (a resident room with 3 beds), Resident 1 was observed to be seated on the bed farthest from the door. Resident 1 was noted to have dark purple discolorations on both eyebrows, stitches were noted on the left eyebrow, stitches were noted on the forehead between the brows, and a dark bluish-purple discoloration noted on the right earlobe. Resident 1 stated that he was hurt badly and Resident 2 smashed his face and beat him up. Resident 1 further stated he was lying in bed but was awake in the morning of the incident. Resident 1 stated he saw his roommate (Resident 2) who stood up from his bed (the middle bed in the room next to Resident 1's bed) and started hitting him. Resident 1 further stated there was no curtain between them, and they were the only two persons in the room. Resident 1 stated he did not fight back. Resident 1 further stated when he realized he was hurt; he walked out of the room and asked the staff for help.During an interview on 12/4/25, at 3:07 PM, with Resident 1's Family Member (FM) 1, FM 1 stated she had visited him the day before on 12/3/25, and had not seen any injuries on his face. FM 1 further stated she was worried that the physical aggressiveness episode would likely have a possible negative impact on Resident 1's personality, especially given his dementia. FM 1 stated she felt terrible about what had happened to Resident 1.During an interview on 12/4/25, at 3:34 PM, with licensed nurse (LN) 1, LN 1 stated the AM (morning) shift told her about the altercation between Resident 1 and Resident 2. LN 1 further stated the fight happened during the (latter part) of night shift on 12/4/25, and Resident 1 came out of the room (in the early morning) with a bloody face. LN 1 stated Resident 1 was sent to the hospital and returned the same day around 12:45 PM during the AM shift. LN 1 further stated that Resident 2 was admitted to the facility in mid- November and was observed with a bad mouth as Resident 2 was heard yelling expletives (swear words) to others. LN 1 stated she witnessed Resident 2 throwing food, medicines, and trays if Resident 2 was unhappy. LN 1 stated Resident 1 had dementia and sometimes showed behaviors like increased agitation and restlessness. LN 1 further stated that it was not a good idea to have Resident 1 and Resident 2 in the same room because both had known behavioral issues. LN 1 explained with the history of Resident 1 and Resident 2, they should not have been placed together. LN 1 stated the incident (12/4/25) could have been prevented if Resident 2 had been admitted to a different room that suited him better.During an interview on 12/4/25, at 3:49 PM, with certified nurse assistant (CNA) 1, CNA 1 stated Resident 1 had been in his current room for a while. CNA 1 further stated Resident 1 got anxious easily and needed to be handled with patience. CNA 1 further stated she needed to adjust her tone of voice because Resident 1 could become agitated quickly. CNA 1 stated Resident 1's dementia sometimes made him act out, and he had the potential to hurt others. CNA 1 further stated Resident 2 had been observed displaying aggressive behavior since his admission, such as throwing things and breaking the hand sanitizer attached by the room door. CNA 1 stated if the facility had reviewed Resident 1 and Resident 2's behavior history before placing them in the same room, the incident might have been prevented. CNA 1 further stated the room assignment should have been carefully considered to avoid conflicts between Resident 1 and Resident 2.During a concurrent interview and record review on 12/5/25, at 9:50 AM, with LN 2, Resident 2's electronic health record (EHR) was reviewed. LN 2 stated she had heard about the altercation between Resident 1 and Resident 2. LN 2 further stated Resident 2 often behaved aggressively, like throwing plates and yelling. LN 2 stated Resident 2 refused to take his morning psychotropic (any substance that primarily affects the mind, emotions, and behavior) medication even after being told about the risks and benefits. LN 2 further stated Resident 2's behavior was very unpredictable, being calm one moment and suddenly aggressive the next. LN 2 stated she had noticed a change in Resident 2's behavior on 11/28/25, when Resident 2's aggressive actions escalated from verbal outbursts to physical actions, such as breaking things like the hand sanitizer dispenser on the wall, the sliding window, and trying to confront other residents. LN 2 further stated Resident 2 showing both verbal and physical aggression was becoming a danger to himself and others. LN 2 stated she called the Medical Doctor (MD) at that time (11/28/25), who ordered that Resident 2 be sent out for further care. LN 2 further stated the MD agreed with LN 2 that Resident 2 was becoming a danger to himself and others. LN 2 checked the Medication Administration Record (MAR - used to record all medications given to a patient) for November and December 2025 and confirmed that Resident 2 did not get his morning psychotropic medication since he was admitted . LN 2 stated she informed the MD about Resident 2's refusal to take his psychotropic medication. LN 2 further stated Resident 2's refusal to take his psychotropic medication caused his behavior to get worse. LN 2 stated Resident 2's noncompliance put him at increased risk of becoming more aggressive. LN 2 further stated Resident 2's compliance in taking his medication was very important for managing his behavior.During an interview on 12/5/25, at 10:59 AM, with LN 4, LN 4 stated she conducted the Nursing Clinical admission Evaluation for Resident 2 on 11/18/25. LN 4 confirmed that when Resident 2 was admitted , Resident 2 was disoriented and confused. LN 4 stated Resident 2 showed signs of agitation and Resident 2 cursed at the staff (on 11/18/25). LN 4 further stated Resident 2 refused the skin assessment and cursed at her when LN 4 tried to explain why it was necessary. LN 4 stated Resident 2 reported multiple hallucinations during the assessments. LN 4 confirmed that she documented a change in condition on 11/19/25 because Resident 2 had refused a new admission blood draw. LN 4 explained to Resident 2 the importance of blood draw, but Resident 2 replied, No one is putting any [expletive] needles in me.During an interview on 12/5/25, at 11:26 AM, with LN 5, LN 5 stated Resident 2 had behaved very aggressively towards the staff on 12/4/25, making threats and using curse words. LN 5 further stated Resident 2 was very agitated when the police arrived to check on him. LN 5 stated Resident 2 was offered assistance on the day of the incident, but Resident 2 became more agitated. LN 5 further stated when the ambulance arrived to take Resident 2 to the hospital as ordered by the MD, Resident 2 continued to threaten the staff aggressively. LN 5 stated it was a bad idea to have Resident 1 and Resident 2 in the same room together because both residents had aggressiveness. During a concurrent interview and record review on 12/5/25, at 12:30 PM, with the Social Service Director (SSD), Resident 1 and 2's EHR were reviewed. The SSD stated that when she arrived on the morning of 12/4/25, she received a report about the altercation between Resident 1 and Resident 2. The SSD further stated Resident 1 was sent to the hospital. The SSD stated Resident 2 was sitting in the hallway outside of his room and was very agitated. The SSD confirmed Resident 2 had a history of behaviors such as: cussing at staff, refusing all basic care, angry outbursts, breaking a hand sanitizer machine off the wall and used it to break sliding door, verbalizing racial comments towards staff when staff attempting to provide care, and multiple episodes of urinating on the floor. The SSD stated it was suggested to move Resident 2 to a different room because of Resident 2's behavior. The SSD stated the suggestion was documented by a licensed nurse on 12/2/25, attempting to move Resident 2 to another room, but Resident 2 refused. The SSD confirmed that on 11/28/25, Resident 2's condition changed as Resident 2's verbal aggression turned into physical aggression. The SSD stated this issue was not addressed when the Interdisciplinary Team (IDT - group of professionals who work together toward a common goal for usually a patient or client) met on 12/1/25. The SSD further stated it was important to review and discuss Resident 2's behavior and appropriate interventions during the IDT meeting to ensure the safety of both Resident 1 and Resident 2.During a concurrent interview and record review on 12/9/25, at 2:07 PM, with the Director of Nursing (DON), the DON confirmed that a change in condition was documented on 11/28/25, when Resident 2 grabbed the pill crusher and slammed it on the floor. The DON stated it was a new behavior for Resident 2. The DON further stated Resident 2 was moved to the back for better visibility, but the DON later clarified that no room change happened, and Resident 2 stayed in the same room since admission. The DON confirmed that she knew Resident 2 was not consistent in taking his psychotropic medication. The DON stated Resident 2's noncompliance with psychotropic medication contributed significantly with Resident 2's worsening behavior.During an interview on 12/10/25, at 2:52 PM, with the Mental Health Nurse Practitioner (NP), the NP confirmed that she had examined and evaluated Resident 2 on 11/20/25. The NP stated she recommended (ordered) increasing the psychotropic medication to 100 mg (milligram) in the morning and at bedtime, for a total of 200 mg per day, to manage Resident 2's schizophrenia shown by anger outbursts. The NP further stated she did not know that Resident 2's MD had recommended (ordered) increasing the psychotropic medication to 150 mg twice a day 11/19/25. The NP stated she was not aware that Resident 2 was not taking his morning psychotropic medication but was taking his evening psychotropic medication. The NP further stated that she was not aware that Resident 2's psychotropic medication recommendation was not carried out, and no changes were made since admission. The NP stated that she had not known about Resident 2's change in condition, which led to his behavior worsening from verbal to physical aggression on 11/28/25. The NP stated that she had examined and evaluated Resident 1 previously. The NP further stated that she managed Resident 1's moodiness and schizophrenia symptoms, such as anger outbursts, by adjusting his psychotropic medications. The NP stated that Resident 1 and Resident 2 should not have been in the same room because they both had known behavior issues. The NP further stated that Resident 2's refusal to take his psychotropic medication contributed to his behavior getting worse. The NP stated that if she had known Resident 2 was still taking his bedtime medication, she would have recommended increasing the dose at night. The NP further stated that it was everyone's responsibility to keep all residents safe. The NP explained that this was a top priority because residents were here to heal and not to get injured.During an interview on 12/10/25, at 3:40 PM, with Medical Doctor (MD), the MD confirmed that both Resident 1 and Resident 2 were under his care. The MD stated that he did not remember the nurses informing him about the Mental Health NP's visit on 11/20/25 or the recommendation for psychotropic medication for Resident 2. The MD further stated that Resident 2's behavior escalated on 11/28/25. The MD stated that looking back on what happened with Resident 1 and Resident 2, it was clear they should not have been placed in the same room for safety reasons. The MD explained if a resident was agitated with escalating behaviors then it would need to be addressed sooner such as placing the resident in a single room or a room with direct line of sight (maintaining clear, unobstructed visual access between staff and resident for safety). When asked if the facility followed the abuse policy to ensure residents safety, the MD stated, not in retrospect. The MD stated it was everyone's responsibility to ensure the residents' safety.Review of an undated facility policy and procedure titled, Abuse, Neglect and Exploitation, indicated, .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse.III. Prevention of Abuse.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict.

Based on interview and record review, the facility failed to ensure quality care and services were provided to one of four sampled residents (Resident 1) when: 1. Resident 1 had a change in condition and was not sent to the hospital for higher level of care per his wishes and Resident 1 ' s physician was not contacted, and, 2. CPR (Cardiopulmonary Resuscitation: an emergency lifesaving procedure performed when the heart stops beating) was not attempted for Resident 1 per physician order and his wishes. As a result, Resident 1's wishes were not honored, and Resident 1 passed away at the facility. Findings: Review of Resident 1 ' s Admission Record indicated Resident 1 was admitted to the facility in February 2022 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's MDS (Minimum Data Set: a standardized assessment tool that measures health status in nursing home residents) dated [DATE], indicated Resident 1 had moderately impaired cognition, was receiving hospice services (care and services provided at the end of life), and indicated to attempt CPR and to provide full treatment (to provide IV fluids [fluids given through a needle inserted into a vein], antibiotics, CPR, and all other intensive medical care including transfer to a hospital). Review of Resident 1's POLST (Physician Orders for Life Sustaining Treatment) dated [DATE], indicated, .First follow these orders, then contact Physician/NP [nurse practitioner]/PA [physician ' s assistant]: A copy of the signed POLST form is a legally valid physician order .A .CARDIOPULMONARY RESUSCITATION (CPR): If patient has no pulse and is not breathing .Attempt Resuscitation/CPR .B .MEDICAL INTERVENTIONS .Full Treatment - primary goal of prolonging life by all medically effective means . Resident 1's POLST was signed by the physician. Review of Resident 1's nurses' progress notes dated [DATE], timed 1:34 a.m., indicated, .The Change In Condition [CIC] .Shortness of breath [CONDITION(S)] .Nursing observations, evaluation and recommendations are: resident is twitching and has SOB [Shortness of Breath], O2 [Oxygen] sat. [Saturation of oxygen in the blood] low 74 % [90% and above is normal]. Hospice [Hospice company name] notified with order of PRN [as needed] O2 and to give 1x [1 time] dose of [MEDICATION(S)] [medicine used to treat seizures] 125mg [milligram: unit of measurement] for twitching or seizures . Further review of Resident 1's nurses' progress notes failed to show continued monitoring of Resident 1's health condition and notification of his CIC to his primary care provider. Review of Resident 1's nurses' progress notes dated [DATE], timed 2:30 a.m., indicated, Resident found unresponsive, no V/S [vital signs: body temperature, pulse rate, respiration rate, blood pressure, O2 sat.] appreciated, pupils fixed and dilated [when the black center of your eyes are larger than normal and unmoving] . Called [hospice company name] hospice nurse .and was here to pronounce expiration . Further review of nurses' progress notes failed to show CPR was attempted for Resident 1 when he was found unresponsive, or was sent to the hospital. Review of Resident 1's care plan dated [DATE], indicated, The resident has Heart Failure diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Notify MD of significant abnormalities . Review of Resident 1's care plan dated [DATE], indicated, The resident has a terminal prognosis .Interventions .Assess resident .and respect resident wishes . During an interview on [DATE] at 5 p.m., the Administrator (ADM) stated Licensed Nurse (LN) 1 reported to the hospice nurse Resident 1's low O2 sat. of 74% and she found Resident 1 unresponsive on [DATE] at 2:30 a.m. The ADM stated the hospice nurse told LN 1 not to send Resident 1 to the hospital. The ADM stated, [Resident 1] has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The POLST was prepared by Hospice, and [Resident 1] came in with it in February. It states Full Code [Attempt CPR and provided full treatment]. During an interview on [DATE] at 2:12 p.m., the ADM verified Resident 1's POLST indicated Resident 1 was full code and CPR was not performed when he was found unresponsive. The ADM stated Resident 1's 02 sat. was in the 70's which was critical, an emergency, and LN 1 should have called 911. The ADM further stated LN 1 should have never left Resident 1 by himself when his O2 sat. was in the 70's. The ADM added LN 1 should have monitored Resident 1 continuously until his O2 sat. was stable, above 90% or until paramedics arrived, and Resident 1 was sent to the hospital. The ADM stated LN 1 should have initiated CPR when Resident 1 was found unresponsive. During an interview on [DATE] at 2:40 p.m., the Director of Nursing (DON) stated Resident 1 should have been sent to the hospital when his O2 sat. dropped to 74% since he was a full code. The DON verified Resident 1's primary care provider was not notified of Resident 1 ' s CIC on [DATE], of the low 02 sat., or the twitching/[CONDITION(S)]. The DON stated, Nurse should check the POLST and initiate CPR if resident is full code and shouldn't depend on what hospice said. The DON further stated LN 1 should have initiated CPR when Resident 1 was found unresponsive and called 911 to honor his wishes and to save his life. During an interview on [DATE] at 3:29 p.m., the ADM stated it was important to follow the POLST to honor the resident's wishes, It is giving resident a chance . [Resident 1's] chance was taken away. During an interview on [DATE] at 11:56 a.m., the hospice nurse stated the call center took the calls from nursing facilities at night and then connected the facility caller to the hospice nurse. The hospice nurse stated the following events happened on the night of [DATE] for Resident 1: - Hospice nurse received the first call on the night of [DATE] from the facility that Resident 1's oxygen level was going below 90% and the facility needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - Around 2:41 a.m., he received another call from LN 1 who reported Resident 1 passed away at 2:30 a.m. He told LN 1 that he would come to the facility for Resident 1's death visit. - Around 2:45 a.m., he received another call from LN 1 to bring Resident 1's updated POLST that would indicate Resident 1 was DNR [Do Not Resuscitate]. He told LN 1 there was no updated POLST and Resident 1 was full code. At that point LN 1 was panicking and he thought LN 1 did not check Resident 1's POLST until after Resident 1 was expired when it was too late to perform CPR. The hospice nurse stated LN 1 assessed Resident 1 and only asked him for an oxygen order. The hospice nurse further stated a drop in O2 level was common in hospice residents. The hospice nurse added he did not know Resident 1 had a dramatic CIC, LN 1 at the facility assessed Resident 1,I am not on site assessing the patient [Resident 1]. The hospice nurse further stated LN 1 only asked him for an O2 order. The hospice nurse stated he did not tell LN 1 not to send Resident 1 to the hospital or not to perform CPR. Review of the hospice call log for Resident 1 dated [DATE], indicated the following; 0115 .[LN 1], facility staff nurse, calling from [facility name] to report patient's 02 sat is very low and she is asking if she may have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . With permission, caller placed on hold to contact the NOC [night shift hospice staff] . 0118 .Call placed to [hospice nurse] License Vocational Nurse. Warm transfer [LN 1 was successfully connected with hospice nurse] successful . 0241 . [LN 1] .Calling to report the pt [patient] passed at 230 [2:30 a.m.]. Pt is under conservatorship [legal guardian appointed by the court]. Placed caller on hold . 0245 .Called [hospice nurse] License Vocational Nurse, message relayed. [Hospice nurse] states he will send a nurse. Returned to caller to update . 0248 . [LN 1] .Caller The caller states the patient is a full code. She needs to speak with [hospice nurse] right away. The caller agreed to hold . 0251 . [hospice nurse] License Vocational Nurse warm transfer completed . Review of a hospice document titled Statement dated [DATE], indicated, [hospice nurse] . On [DATE] I received a call from .facility nurse [LN 1] was requesting for an order of oxygen since his [Resident 1's] oxygen saturation was very low .advised to give oxygen for comfort measures per facility protocol. Nurse verbalized understanding and was informed to call .hospice with any concerns. [DATE] at 0241 am Received a call from .facility nurse [LN 1] who reported that patient passed on at 2:30am. Hospice nurse advised that he will go or send someone. [DATE] at 0245 am Received another call from .nurse [LN 1] asking if Hospice nurse is coming and was advised he was enroute. Before I started my journey, I received another call from [Hospice Call Center] with nurse [LN 1] on hold, she stated she wanted to talk to [hospice nurse], I talked to [LN 1] who stated that patient was a full code and she wanted me to bring updated POLST form. Hospice nurse explained to [LN 1] that even on the Hospice records the patient [Resident 1] is full code and if the patient has already expired, I am still on my way for the death visit . During an interview on [DATE] at 5:42 p.m., LN 2 stated she worked on [DATE] alongside LN 1. LN 2 stated LN 1 told her that night that Resident 1's O2 sat. was dropping and she was going to call hospice. LN 2 stated LN 1 started Resident 1 on oxygen. LN 2 stated she was assigned to the South unit at the back and when she came back to the nurses' station from South unit, within an hour she told me he expired. She called hospice, when she was on phone with hospice, she went through his chart. She said he's full code. She looked at me and said he's full code. I was like what? LN 2 further stated she heard LN 1 telling hospice on the phone, I have him as full code . Do you have an updated POLST? LN 2 stated she did not hear what the hospice nurse told LN 1 on the other end of the phone. LN 2 stated CPR was not attempted for Resident 1. LN 2 stated CPR should be initiated right away on a full code resident when found not breathing. LN 2 stated, It doesn't matter if resident on hospice, when full code, follow the POLST, put O2 on to keep the O2 sat. up, contact the MD [Medical Doctor], let him know of resident condition and send resident out. Multiple attempts were made to interview LN 1 with no success. Review of Resident 1's CERTIFICATE OF DEATH issued [DATE], indicated immediate cause of death was [CONDITION(S)] (the heart suddenly and unexpectedly stops pumping). Review of the facility procedure titled Emergency Procedure - Cardiopulmonary Resuscitation revised [DATE] indicated, .If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR .Instruct a staff member to activate the emergency response system (code) and call 911 instruct a staff member to verify the DNR or code status of the individual .Continue with CPR . until emergency medical personnel arrive . Review of the facility policy titled Change in a Resident's Condition or Status revised ,d+[DATE], indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition . Review of the facility policy titled, Advance Directives revised ,d+[DATE], indicated, .The plan of care for each resident will be consistent with his or her documented treatment preferences .A resident will not be treated against his or her own wishes .

Based on observation, interview and record review, the facility failed to provide a safe environment and adequate supervision for 1 of 3 sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall and being unable to achieve her prior level of physical and ambulatory (walking) functioning. Findings: Resident 1 was admitted to the facility in the middle of (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record for Resident 1 included: A Fall Care Plan, initiated 5/30/15, which indicated Resident 1 was at risk for falls related to the diagnoses, as well as having poor safety awareness, a behavior of refusing redirection, and wandering as a normal behavior. Review of the Fall Care Plan on 6/3/18 at 10 a.m. reflected interventions which included: Keep environment well lit and free of clutter, revised on 12/1/16; Non skidded footwear to prevent slipping., revised 12/1/16 and Observe for side effects of Medications, revised 12/1/16. No mention was made of keeping the environment safe. Review of a CLINICAL HEALTH STATUS document, dated 6/3/18 at 10:10 a.m., indicated Resident 1's RISK FOR FALLS was a score of 14. The document also indicated, Total score of 10 or above deems (indicates) resident at risk. The document further indicated that Resident 1 had short-term and long-term memory problems. Review of Section C-Cognitive (learning, understanding) Patterns of Resident 1's MDS (Minimum Data Set, an assessment tool), dated 6/7/18, indicated a total BIMS (Brief Interview for Mental Status-an assessment tool) score of 2 (scale from a low of 1 to a high of 15), which indicated severe cognitive impairment. Review of Section G-Functional Status of Resident 1's MDS, dated [DATE], indicated, Bed mobility .Self Performance .Supervision; .Transfer .Limited assistance; Walk in room .Limited assistance; Walk in corridor .Limited assistance; Locomotion on unit .Limited assistance; Locomotion off unit .Limited assistance; Dressing .Limited assistance; Eating .Supervision; Toilet use .Limited assistance; Personal hygiene .Limited assistance .Balance During Transitions and Walking .Moving from seated to standing position .Steady at all times; Walking .Steady at all times; Turning around and facing the opposite direction while walking .Steady at all times; Moving on and off toilet .Steady at all times; Surface-to-surface transfer .Steady at all times; Mobility devices .Wheelchair .No . Review of Section K-Swallowing/Nutritional Status of Resident 1's MDS, dated [DATE], indicated, .Mechanically altered diet .No . An undated, immediate post-fall document titled FACILITY REPORTED EVENT, indicated, .Resident has STM (short-term memory) and LTM (long-term memory) impairment with episodes of confusion, poor safety awareness and poor judgment. Resident has behaviors of wandering . A 6/17/18 SBAR (Situation, Background, Assessment, Recommendation) Post Fall note by the Director of Nursing (DON) stated regarding the resident, .(Resident 1) tripped on the uneven sur (surface) . A Care Plan, initiated 6/17/18, indicated, .found Resident on 6/18/18 (sic) sitting on the ground outside the patio by room [ROOM NUMBER], sustained injuries: 1)skin tear to R (right) hand 2)bruise to L (left) knee 3)multiple bruise (sic) to face 4) laceration (cut) to nose bridge 5) swelling on left index finger . The SKIN CONDITIONS section of a facility document titled, CLINICAL HEALTH STATUS dated 6/18/18 at 1:45 p.m. recorded, .Nasal Bridge sutured wound .Skin tear to Right hand .Bruise to left elbow .Bruise to L knee .multiple bruises to all over (sic) face . A CLINICAL HEALTH STATUS document, dated 6/18/18 at 1:45 p.m., indicated Resident 1's RISK FOR FALLS was a score of 16. The document also indicated, Total score of 10 or above deems resident at risk. The record further indicated Resident 1 had a memory problem, needed assistance with making decisions, resisted care, and had a history of [REDACTED]. Review of a Resident 1's Functional Limitations Assessment, dated 6/19/18, indicated, Current Value .(80%-99% impaired) .based on Amount (sic) of assistance required for ambulation and bed-w/c (bed to wheelchair)transfers .Goal Value: .1%-19% impaired .walking and moving around .at discharge . Review of a Speech Therapy Initial Assessment, dated 6/19/18, indicated Resident 1's level of function prior to the 6/17/18 fall included swallowing within functional limits and no deficit, and Resident 1's diet was NDD (National Dysphagia (difficulty swallowing) Diet) Level 3: Dysphagia Advanced Soft Foods. The assessment indicated that after the fall there was a moderate oral deficit in swallowing, and Resident 1's condition dictated a NDD Level 1: Dysphagia-Pureed (a paste or pulp made by straining or grinding food). A Speech Therapy Plan of Care, dated 6/19/18 indicated, .The patient had been on a level 3 (moist foods in bite-size pieces) dysphasia diet with thin liquids prior to recent hospitalization . Thin liquids may need to be thickened if they are hard for you to swallow. Pt (patient) sustained fall on 6/17/18 .referral to ST (speech therapy) d/t (due to) pt w/ significant weakness s/p (status [REDACTED]. Skilled ST is now required to evaluate and treat for dysphagia as indicated. Without St (sic), pt is at risk for aspiration (inhaling food or liquids into the lungs), choking, lack of nutrition and dehydration. The Speech Therapy Plan of Care for Resident 1 further indicated, the following underlying swallowing impairments: Lip strength-moderate impairment (70-74% accuracy), tongue strength-mild/moderate impairment (75-79% accuracy), jaw strength-mild/moderate impairment (75-79% accuracy), Mastication (chewing)-moderate impairment (70-74% accuracy), bolus (a small rounded mass of a substance, especially of chewed food at the moment of swallowing) formation-moderate impairment (70-74% accuracy), moderate pocketing (holding food in the mouth without swallowing) noted with mechanical soft solids (soft foods cut into small pieces). A Care Conference, dated 6/19/18, indicated Resident 1 had sustained facial fractures and other lacerations, and was walking with assistance as well as using a wheelchair. A review of the Physical Therapy Plan Of Care, Initial Assessment, dated 6/19/18 at 3:39 p.m., indicated, Functional Deficits .Bed Mobility .Rolling .Prior Level .Supervision (cueing/no assist) .Current Level Minimal Assistance (1-25% assist); .Transfers, Supine to Sit .Prior Level .Supervision .Current Level .Moderate Assistance (26-75% assist); Transfers, Sit to Stand .Prior Level .Supervision .Current Level .Minimal Assistance; Transfers, Stand Pivot .Prior Level .Supervision .Current Level .Minimal Assistance; Gait (manner of walking) .Distances on unit (self) .Current Level .20 feet; Gait, Assistive Device .Prior Level .None .Current Level .front wheeled walker; Gait, Level Surfaces .Prior Level .Supervision .Current level .Minimal Assistance. A Physical Therapy Plan Of Care, dated 6/19/18, indicated Resident 1 began care on 6/19/18, .Reason for Referral: .patient .who presents with complaints of overall weakens (sic), impaired sitting balance and decreased ability to ambulation (sic) and functional transfers. This change in function came about due to fall .Due to overall weakness, dementia .impaired (sic) standing balance and functional decline, this patient will require skilled PT in order to regain PLOF (prior level of functioning). A Physical Therapy Initial Assessment, dated 6/19/18, indicated Resident 1's level of functional deficits prior to the 6/17/18 fall all required supervision and that Resident 1 could ambulate around the unit without limits, without an assistive device. The assessment further indicated Resident 1's level of functioning after the fall required minimal to moderate assistance for all tasks, the use of a front wheeled walker, and that the resident was able to ambulate 20 feet. Review of a document titled, CONSULTATION/CLINIC REFERRAL, dated 6/21/18, indicated Resident 1 was diagnosed with [REDACTED]. A review of Resident 1's Progress Note, dated 6/21/18 at 10:37 p.m., reflected, .Wheelchair bound at this time due to recent fall . Review of a Care Conference, dated 6/26/18, indicated Resident 1 had a significant change as a result of re-admission from the hospital after the 6/17/18 fall. The clinical record indicated that prior to the 6/17/18 fall, Resident 1 required, supervision with most ADLs (activities of daily living), and after the fall; limited to extensive assist. (assistance) with ADLS. Uses wheelchair for locomotion. Review of Resident 1's Progress Note, dated 6/28/18 at 3:26 p.m., stated, Resident is non ambulatory at this time. Resident can stand but has trouble standing by herself, resident is extensive assistance and two person assist at this time . On 6/29/18, Resident 1 was observed sitting in a wheelchair in the hallway wearing a helmet and making unintelligible remarks and responses to questions. In an interview on 6/29/18 at 9:45 a.m., Licensed Nurse 1 (LN 1) stated she was the charge nurse on the day shift on 6/17/18 and was working at the medication cart on the Alzheimer's Unit. She stated Resident 1 came out of the dining room and began to exit the building, going outside to the fenced area. LN 1 stated she called, Don't go out! but was unable to leave the medication cart to follow Resident 1. LN 1 further stated Resident 1 was an independent walker before the fall. LN 1 stated CNA 1 was working with Resident 1 on 6/17/18 and later found Resident 1 outside with blood on her face and hands. LN 1 also stated that Resident 1 was currently in a wheelchair until she gets her strength back. In an interview on 6/29/18 at 10:02 a.m., Speech Therapist 1 (ST 1) indicated Resident 1 was currently on pureed food due to the facial injuries she had sustained. In an interview on 7/2/18 at 10:49 a.m. the DON indicated that Resident 1 was assumed to have tripped on uneven pavement. The DON stated, What else could have happened? The DON indicated the area where Resident 1 fell was closed down immediately after the fall and that maintenance purchased materials to fill in the gaps and even out the surface. The DON indicated the surface was smooth now. In an interview on 7/2/18 at 11 a.m. the administrator (ADM) confirmed the DON's explanation that Resident 1 was believed to have tripped on an uneven surface and that the area had been closed down and subsequently repaired. Review of facility records on 7/2/18 at 1:50 p.m. indicated a Proof of Delivery of quickset cement. In an interview on 7/3/18 at 8:15 a.m., CNA 1 stated, I went outside and saw her (Resident 1) sitting on the ground with blood on her face. CNA 1 indicated that at that time, staff were finishing assisting residents with breakfast in the dining room and her (CNA 1)'s next assignment was to go outside and watch the residents. CNA 1 indicated that no staff were assigned outside to watch residents during breakfast time. Review of Resident 1's Functional Limitations Assessment, dated 7/5/18, indicated, .Current Value .(40%-59% Impaired) Mobility .based on need for min A (sic) .Goal Value .(1%-19% impaired) Mobility . Review of Resident 1's Functional Limitations Assessment, dated 7/17/18, indicated, .Current Value .(20%-39% impaired) Mobility .based on Min (minimal) a (assistance) required for ambulation and bed-w/c (wheelchair) transfer (sic) Review of Resident 1's PT (physical therapy) DAILY TREATMENT NOTE, dated 8/3/18, indicated, Max/mod (maximum to moderate) A (assistance) sit to stand from WC and all aspects of transfers. Review of Resident 1's PT DAILY TREATMENT NOTE, dated 8/5/18, indicated, Max/mod A sit to stand from WC and all aspects of transfers. Review of Resident 1's Functional Limitations Assessment, dated 8/7/18, indicated, .Current Value .(20%-39% Impaired) Mobility .Goal Value .(1%-19% impaired) Mobility . Review of Resident 1's PT DAILY TREATMENT NOTE, dated 8/7/18, indicated, .Patient appears to be close to maximum rehab (rehabilitation) potential at this time .goals adjusted accordingly. Review of Resident 1's Functional Limitations Assessment, dated 8/10/18, indicated, Discharge value .20%-39% impaired .goal value .1%-19% impaired . Review of Resident 1's PT DAILY TREATMENT NOTE, dated 8/10/18, indicated, All functional transfers: min to mod assist .Patient appears to be at maximum potential at this time. discharged to RNA (restorative nursing assistant) .goals adjusted accordingly. On 9/20/18 at 4:45 p.m., the repair work to the concrete outside room [ROOM NUMBER] was observed. It was fashioned to serve as a mini transitional slope from a lower section of sidewalk to a higher section of sidewalk. The height difference between the two sidewalks prior to the repair had been approximately one and one-half inches. The width of the discrepancy extended approximately 15 inches. Review of Section K-Swallowing/Nutritional Status of Resident 1's MDS, dated [DATE], indicated, Mechanically altered diet .Yes . In an interview on 9/25/18 at 10:39 a.m., PT 1 confirmed Resident 1 had her last PT appointment on 8/10/18. PT 1 indicated Resident 1 at that time was walking 40 feet with a walker with hand-held assistance and that she had not reached her prior level of functioning. In an interview on 9/25/18 at 10:46 a.m., PT 2 indicated Resident 1 had been discharged from therapy due to not making any further progress. In an interview on 9/26/18 at 1:29 p.m., ST 2 indicated that prior to the fall Resident 1 was on a mechanically altered diet, which was a regular diet that had been cut up (Level 2-3). ST 2 indicated that Resident 1 currently tolerated a pureed (Level 1) diet but became agitated when advancement to a mechanical soft (Level 2) diet was attempted. Review of Section G-Functional Status of Resident 1's MDS, dated [DATE], indicated, Bed mobility .Self Performance .Extensive assistance; .Transfer .Extensive assistance; Walk in room .Activity did not occur; Walk in corridor .Activity did not occur; Locomotion on unit .Extensive assistance; Locomotion off unit .Extensive assistance; Dressing .Extensive assistance; Eating .Limited assistance; Toilet use .Limited assistance; Personal hygiene .Extensive assistance .Balance During Transitions and Walking .Moving from seated to standing position .Not steady, only able to stabilize with staff assistance; Walking .Not steady, only able to stabilize with staff assistance; Turning around and facing the opposite direction while walking .Activity did not occur; Moving on and off toilet .Activity did not occur; Surface-to-surface transfer .Not steady, only able to stabilize with staff assistance; Mobility devices .Wheelchair .Yes . In an interview on 10/16/18 at 3:35 p.m., the ADM indicated Resident 1 had continued on a pureed (Level 1) diet. The ADM indicated that Resident 1 had ambulated independently before the fall and had continued to use a wheelchair for locomotion (movement) since the fall. The ADM stated Resident 1 had, plateaued as far as progress goes, and indicated she was not expected to achieve her prior level of functioning. In an interview on 11/13/18 at 15:48 p.m., the DON indicated that there had been, about 1 inch difference in the height of the two concrete slabs that had been repaired. In an interview on 11/14/18 at 9:00 a.m., the Maintenance Supervisor (MS) described the height difference between the two concrete slabs as, no more than an inch and the width of the repair, about two feet.