Every finding on record at North Valley Nursing Center

Based on interview and record review the facility failed to implement their discharge planning process policy by failing to document residents' discharge needs and discharge plan timely for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/24/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required supervision/touching assistance from staff for all activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily)During a review of Resident 1's physician order dated 1/5/2026, the physician order indicated to discharge Resident 1 on 1/5/2026 per the resident's request.During a concurrent interview and record review on 8/6/2026 at 12:46 p.m. with the Social Services Director (SSD), the SSD stated that the discharge process starts upon admission. The SSD stated the IDT will meet with the resident and/or resident representative to discuss discharge planning. Once a resident is cleared to go home by the physician, the SSD will check if the resident needs durable medical equipment (DME- medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions) or home health (a wide range of health care services that an individual can receive in their home) for discharge. On the day of discharge nursing staff will provide education and discharge resident home with medications. The SSD reviewed Resident 1's Interdisciplinary Team (IDT-group of professionals from two or more disciplines who collaborate, share decision making, and integrate their expertise to achieve common goals) Care Confrence documentation dated 1/5/2026 timed a 4:49 p.m. and stated that Resident 1 requested to be discharged home with her roommate. The SSD stated that Resident 1 has been wanting to go home and that the SSD has been assisting her in the transition. The SSD stated that on 1/5/2026, the day of the actual discharge, was not the first time Resident 1 had expressed wanting to go home. The SSD stated that the SSD and Resident 1 would have frequent discussions about Resident 1's discharge to home. When asked for the SSD's documentation of Resident 1's discharge process, the SSD stated that she did not document her efforts in Resident 1's discharge planning process. When asked why the SSD did not document her efforts in Resident 1's discharge process, the SSD did not answer. The SSD stated that it is important to document Resident 1's discharge planning process so that staff will be informed of Resident 1's discharge plan.During an interview on 8/7/2026at 2:00 p.m. the Director of Nursing (DON), the DON stated that when a resident is preparing for discharge, an IDT meeting will be completed to discuss the residents' continuing care, resident's needs and services required following discharge. The DON stated that the SSD should have documented each interaction with Resident 1 so facility staff will have a clear picture of Resident 1's discharge plan and process.During a review of the facility's policy and procedure (P&P) titled, Discharge Planning Process, reviewed on dated 1//14/2026, the P&P indicated It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the residents discharge goals the preparation of residents to be active partners and effectively transition them to post-discharge care end the reduction of factors leading to preventable readmissions. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. If discharged to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented. The ongoing process of developing the discharge plan will include a regular reevaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of their residents' interest in returning to the community. The facility will assist residents and their resident representatives in choosing an appropriate post acute care provider that will meet the residents' needs goals and preferences. The evaluation of the residence discharge needs and the discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or residence representative.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of three sampled residents (Resident 1), who had a diagnosis of dementia (a progressive state of decline in mental abilities).This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified dementia.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/24/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated that Resident 1 required supervision/touching assistance from staff for all activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident I had non-Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia.During a concurrent interview and record review on 8/7/2026 at 10:45 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's care plans. The ADON stated that Resident 1 did not have a care plan specific to Resident 1's diagnosis of dementia. The ADON stated that staff responsible for the development of Resident 1's care plan for dementia is the MDS Nurse. The ADON stated that it is important for Resident 1 to have a care plan specific to dementia so that facility staff can provide optimum dementia care for the resident. If there is no care plan for dementia in place facility staff will not be able to provide specific interventions pertaining to dementia care for the resident.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care plans, last reviewed on 1/14/2026, the P&P indicated it is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and a mental and cycle social needs that are identified in the residence comprehensive assessment.

Based on interview and record review the facility failed to implement the facility's dementia care policy by failing to provide dementia and dementia care annual competencies to one of three sampled staff (LVN 2)This deficient practice has a potential to place residents with a diagnosis of dementia at risk for not receiving appropriate care.During a concurrent interview and record review on 8/7/2026 at 12:58 p.m. with the Director of Staff Development (DSD), the DSD stated that dementia and dementia care training are conducted upon hire, annually, and on an as needed basis. The DSD stated that staff watch a video and after the video staff will take a dementia posttest to evaluate understanding of the video. The DSD reviewed Licensed Vocational Nurse 2's (LVN 2) employee file and stated that LVN 2 was hired on 2/3/2022. The DSD reviewed LVN 2's personal file and stated that LVN 2 does not have documented evidence of completing a dementia and dementia care competency for the year 2026. The DSD stated that LVN 2's annual dementia and dementia care competency should have been conducted in 2/2026, however it was missed. The DSD stated that LVN 2 should have watched the video on dementia and dementia care and should have taken a post test. The DSD stated that it is important for all facility staff to be provided annual competencies on dementia and dementia care to ensure staff have knowledge what dementia is and how to provide appropriate care to the facility's residents.During a review of the facility policy and procedure (P&P) titled Dementia Care, reviewed on 1/14/2026, the P&P indicated It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. All staff will be trained on dementia and dementia care practices upon higher, annually, and as needed to ensure they have the appropriate competencies, and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.During a review of the Facility Assessment (a systematic review of a healthcare facility's resources, services, and environment to ensure it can provide safe, effective, and person centered care to its residents) date 1/14/2026, the Facility Assessment indicated in addition to the regulatory-required training, the facility takes account the diagnosis, characteristics and new conditions of its resident population, and develops additional trainings and skills competencies as needed to provide the level and types of support and care needed by our resident population.

Based on interview and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1), when on 5/22/2026, Resident 2 punched Resident 1 in the face and body several times with a closed fists (a person's hands with the fingers bent inward toward the palms and held tightly closed). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care and supervision of the facility. Resident 1 sustained a skin tear (a wound that happens when the layers of skin separate or peel back) on the right forearm (part of the arm between the elbow and the wrist), redness on the left temple (the sunken area on the sides of the head, located just behind the eyes, between the forehead and the ears), and pain on the right side of body, including the face, shoulder and foot. Resident 1 also reported feeling sad and depressed (a mood disorder that causes persistent feeling of sadness and loss of interest and can interfere with daily activities) following the physical altercation (a confrontation that involves physical force or contact between two or more people).During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident (Resident 1) on 10/22/2025 with diagnoses that included intestinal hernia (a condition in which part of the intestine [long, tube-shaped organ in the abdomen {known as belly or stomach}] pushes through a weak area in the abdominal wall, creating a bulge), and osteoarthritis (a degenerative joint [physical point where two or more bones connect] disease where the protective cartilage [strong tissue that protects the joints and bones] that cushions the ends of the bones wears down over time) of right knee. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions). The MDS further indicated Resident 1 was independent with activities of daily living (ADLs- activities related to personal care such as bathing, dressing and toileting). During a review of Resident 1's History and Physical Examination (H&P - medical evaluation consisting of a detailed resident interview regarding their health history and a structured physical assessment) dated 10/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Change in Condition (CIC- any noticeable or significant alteration in a person's physical health, mental status, or functional ability) Evaluation dated 5/22/2026, the CIC Evaluation indicated that on 5/22/2026, Resident 1 received physical aggression (any behavior that intentionally inflicts, or threatens to inflict, physician harm or bodily injury on another person) by Resident 2. The CIC Evaluation form indicated that according to Resident 1, Resident 1 was sitting in a wheelchair near the dining room when Resident 2 suddenly came out of Resident 2's room and struck Resident 1, causing both residents (Resident 1 and Resident 2) to fall to the floor. The CIC Evaluation further indicated that Resident 1 sustained an unsized skin tear to the right forearm and unsized redness to the left temple. During a review of Resident 1's Psychiatric (anything related to diagnosing, treating, and preventing mental, emotional and behavioral disorders) Examination dated 5/26/2026, the Psychiatric Examination indicated that Resident 1 was assessed following a physical assault (the intentional use of physical force or violence against another person, resulting in bodily injury or unwanted, offensive contact) by Resident 2 on 5/22/2026. The Psychiatric Examination indicated that the incident occurred in the kitchen area, where Resident 2 repeatedly stared at Resident 1, before grabbing, hitting, pushing, and kicking him (Resident 1). The Psychiatric Examination indicated that as a result of the incident, Resident 1 sustained pain to the head, shoulder, and right foot. The Psychiatric Examination further indicated that Resident 1 experienced sadness, decreased appetite, concerns about safety and emotional well-being, and reported feeling sad and depressed due to both the physical assault and its emotional impact. During a review of Resident 1's CIC Evaluation dated 5/28/2026, the CIC Evaluation indicated that on 5/28/2026, Resident 1 continued to experience pain to the right side of the head, arms, and legs, rated at four on a zero (0) to ten pain scale (zero representing no pain and ten representing the worst possible pain), indicating moderate pain. The CIC Evaluation indicated Resident 1 requested transfer to an acute care hospital, and Resident 1's physician ordered transfer to General Acute Care Hospital 1 (GACH 1). During a review of Resident 1's Nurses' Progress Notes dated 5/29/2026, timed at 3:13 p.m., the Nurses' Progress Notes indicated that Resident 1 returned to the facility from the hospital (GACH 1). During a review of Resident 1's Physician Progress Notes dated 6/3/2026, timed at 11:16 a.m., the Physician Progress Notes indicated a date of service of 6/2/2026. The Physician Progress Notes indicated that Resident 1 was seen for a psychiatric evaluation (a comprehensive mental health assessment conducted by a mental health professional to determine how a specific traumatic event has impacted an individual's psychological [refers to the mind or mental processes], emotional and cognitive functioning) following the assault by another resident (Resident 2) on 5/22/2026 and continued to report ongoing pain related to the incident. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident (Resident 2) on 5/11/2026, with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities), and epilepsy (brain disorder in which nerve cells in the brain sometimes send the wrong signals and cause seizures [a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness {term used to describe a person's awareness and understanding of what is happening in his or her surroundings}]). During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 had intact cognition. The MDS further indicated Resident 2 required moderate assistance (a resident actively participates in an activity, but requires physical help from a staff) from staff with bed mobility (movement), transfers, and walking. During a review of Resident 2's GACH 2 Physician H&P, updated on 5/8/2026, the Physician H&P indicated the following:The status history of depression was active.The status history of schizophrenia was active.The review of system was positive for anxiety (a feeling of fear, dread, or unease that makes the persons worry about what might happen next) and mood-related concerns. During a review of Resident 2's facility H&P, dated 5/11/2026, the H&P indicated diagnoses that included schizophrenia and major depressive disorder. The H&P further indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's CIC Evaluation dated 5/22/2026, timed at 8:22 p.m., the CIC Evaluation indicated that on 5/22/2026, Resident 2 initiated physical aggression towards another resident (Resident 1), which was witnessed by Certified Nursing Assistant 2 (CNA 2). When Resident 2 was asked what happened, Resident 2 stated that Resident 1 poked him (Resident 2) in the eye while he (Resident 2) was walking on the patio. The CIC Evaluation indicated that according to Resident 1, he (Resident 1) was sitting in a wheelchair in the hallway near the dining room when Resident 2 suddenly came out of a room and struck him (Resident 1), resulting in both residents (Resident 1 and Resident 2) falling to the floor. The CIC Evaluation further indicated that Resident 2's physician ordered to transfer Resident 2 to GACH 2 for further psychiatric evaluation, which was carried out. During a review of the facility's investigation conclusion letter dated 5/27/2026 regarding the resident-to-resident altercation (refers to physical aggressive conflicts between residents such as hitting, pushing, kicking or biting) involving Resident 1 and Resident 2, the conclusion letter indicated that Resident 2 approached Resident 1 outside the kitchen area and hit Resident 1. The conclusion letter further indicated that the facility concluded that the incident was substantiated (a claim is true by providing solid evidence or facts) because the incident occurred. During an interview on 6/5/2026 at 8:28 a.m., with Resident 1, Resident 1 stated he remembered the incident involving Resident 2. Resident 1 stated that Resident 2 approached and punched him (Resident 1) without warning while he (Resident 1) was sitting in a wheelchair and returning a meal tray to the kitchen after dinner. Resident 1 stated that Resident 2 punched him (Resident 1) multiple times in the face and body with closed fists, causing injuries to the right forearm and face. Resident 1 further stated that he (Resident 1) continued to experience pain on the right side of his face, shoulder, flank areas (the areas on the sides and back of abdomen, between the lower ribs and hips), and leg. Resident 1 stated he (Resident 1) was transferred to the hospital about a week later (5/28/2026) due to unrelieved pain. Resident 1 stated he (Resident 1) reported to staff (did not specify) ongoing emotional distress and low mood related to the incident. Resident 1 stated that the incident involving him (Resident 1) and Resident 2 should not have happened. During a concurrent interview on 6/5/2026 at 1:20 p.m., with Dietary Aide 1 (DA 1) and Licensed Vocational Nurse 2 (LVN 2), assisting with interpretation (translated English to DA 1's own language and translated DA 1's answer to English), DA 1 stated that on 5/22/2026 at around 8 p.m., DA 1 heard noise coming from the hallway outside the kitchen. DA 1 looked through the kitchen door window and saw two residents (referring to Resident 1 and Resident) on the floor hitting each other while CNA 2 attempted to separating them. DA 1 stated that he and another dietary staff member (did not specify) sought additional staff assistance. DA 1 described the incident as resident-to-resident physical abuse. During an interview on 6/5/2026 at 2:02 p.m., with CNA 2, CNA 2 stated that on 5/22/2026, while CNA 2 was charting (the systematic process of documenting a resident's medical data, treatments and responses to care) in the dining room, she (CNA 2) heard noise from the hallway (near the kitchen area) and responded immediately. CNA 2 stated that upon arrival, she (CNA 2) observed Resident 2 standing in front of Resident 1, who was seated in a wheelchair. CNA 2 stated that Resident 2 grabbed Resident 1's wheelchair, and both residents ended on the floor. CNA 2 further stated that Resident 2 punched Resident 1 in the face and body multiple times with closed fists using both hands, while Resident 1 attempted to defend himself. CNA 2 stated that the incident was resident-to-resident physical abuse and that based on her (CNA 2) observations, Resident 2 was the primary aggressor (a person that attacks first or starts a conflict). During a concurrent interview and record review on 6/5/2026 at 3:22 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed the CIC Evaluation dated 5/22/2026 for both residents (Resident 1 and Resident 2) documented by LVN 3. LVN 3 stated that on 5/22/2026, after hearing screaming from the hallway near the kitchen area, LVN 3 immediately responded. LVN 3 stated that upon arrival, staff (did not specify) had already separated the residents (Resident 1 and Resident 2). LVN 3 stated that Resident 1 reported he (Resident 1) had been sitting in his wheelchair when Resident 2 suddenly came out of his room and struck Resident 1. LVN 3 further stated that another licensed nurse (referring to Licensed Vocational Nurse 4 [LVN 4]) assessed Resident 1 and identified a skin tear on Resident 1's right forearm and redness to the left temple. LVN 3 stated that based on information obtained from staff and the involved residents, LVN 3 concluded that physical abuse had occurred between the residents (Resident 1 and Resident 2). During a concurrent interview on 6/5/2026 at 4:03 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated that what occurred between Resident 1 and Resident 2 was resident-to-resident physical abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect (failure to provide necessary care, supervision, or basic needs to a resident) and Exploitation (illegal, improper, or unauthorized use of a resident's funds, property or assets for someone else's personal profit or advantage), last reviewed on 1/14/2026, the P&P indicated, It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse. Abuse means the willful infliction of injury. with resulting physical harm, pain or mental anguish, which can include. certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes . physical abuse. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review, the facility failed to ensure accurate measurement and documentation of a skin tear (a wound that happens when the layers of skin separate or peel back) in accordance with professional standards of practice and the facility's policy and procedure (P&P) for one of four sampled residents (Resident 1). This deficient practice had the potential to adversely affect wound assessment, monitoring, treatment planning, and the delivery of care and services necessary for wound healing.During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident (Resident 1) on 10/22/2025 with diagnoses that included intestinal hernia (a condition in which part of the intestine [long, tube-shaped organ in the abdomen {known as belly or stomach}] pushes through a weak area in the abdominal wall, creating a bulge), and osteoarthritis (a degenerative joint [physical point where two or more bones connect] disease where the protective cartilage [strong tissue that protects the joints and bones] that cushions the ends of the bones wears down over time) of right knee. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions). The MDS further indicated Resident 1 was independent with activities of daily living (ADLs- activities related to personal care such as bathing, dressing and toileting). During a review of Resident 1's Change in Condition (CIC- any noticeable or significant alteration in a person's physical health, mental status, or functional ability) Evaluation dated 5/22/2026, the CIC Evaluation indicated that on 5/22/2026, Resident 1 received physical aggression (any behavior that intentionally inflicts, or threatens to inflict, physician harm or bodily injury on another person) by Resident 2. The CIC Evaluation form indicated that according to Resident 1, Resident 1 was sitting in a wheelchair near the dining room when Resident 2 suddenly came out of Resident 2's room and struck Resident 1, causing both residents (Resident 1 and Resident 2) to fall to the floor. The CIC Evaluation further indicated that Resident 1 sustained an unsized skin tear to the right forearm and unsized redness to the left temple. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident (Resident 2) on 5/11/2026, with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities), and epilepsy (brain disorder in which nerve cells in the brain sometimes send the wrong signals and cause seizures [a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness {term used to describe a person's awareness and understanding of what is happening in his or her surroundings}]). During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 had intact cognition. The MDS further indicated Resident 2 required moderate assistance from staff with bed mobility (movement), transfers, and walking. During a review of Resident 2's CIC Evaluation dated 5/22/2026, timed at 8:22 p.m., the CIC Evaluation indicated that on 5/22/2026, Resident 2 initiated physical aggression towards another resident (Resident 1), which was witnessed by Certified Nursing Assistant 2 (CNA 2). When Resident 2 was asked what happened, Resident 2 stated that Resident 1 poked him (Resident 2) in the eye while he (Resident 2) was walking on the patio. The CIC Evaluation indicated that according to Resident 1, he (Resident 1) was sitting in a wheelchair in the hallway near the dining room when Resident 2 suddenly came out of a room and struck him (Resident 1), resulting in both residents (Resident 1 and Resident 2) falling to the floor. During an interview on 6/5/2026 at 8:28 a.m., with Resident 1, Resident 1 stated he remembered the incident involving Resident 2. Resident 1 stated that Resident 2 approached and punched him (Resident 1) without warning while he (Resident 1) was sitting in a wheelchair and returning a meal tray to the kitchen after dinner. Resident 1 stated that Resident 2 punched him (Resident 1) multiple times in the face and body with closed fists, causing injuries to the right forearm and face. During a concurrent interview and record review on 6/5/2026 at 12:54 p.m., with Treatment Nurse 1 (TN 1), TN 1 reviewed Resident 1's CIC Evaluation dated 5/22/2026 and skin checks dated 5/22/2026. TN 1 stated that the documentation identified a right forearm skin tear and left temple redness but did not include wound measurements. TN 1 further stated wound measurements should have been obtained and documented to establish a baseline and monitor wound healing progress. During a concurrent interview and record review on 6/5/2026 at 3:05 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's CIC Evaluation dated 5/22/2026 and skin checks dated 5/22/2026, and stated that licensed nursing staff should measure and document wound dimensions/wound sizes when skin tears are initially identified to facilitate monitoring of the healing process. The DON further stated that at a minimum, wound measurements should have been obtained during subsequent treatment assessments. The DON stated that wound measurements for Resident 1's injuries were not obtained until 6/5/2026. During a concurrent interview and record review on 6/5/2026 at 3:42 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4, who completed the skin check on 5/22/2026, reviewed Resident 1's skin check dated 5/22/2026. LVN 4 stated he assessed Resident 1's skin injuries on 5/22/2026 but did not measure the right forearm skin tear or left temple (the sunken area on the sides of the head, located just behind the eyes, between the forehead and the ears) redness. LVN 4 stated that wound measurements were required only for pressure ulcers (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) and not for skin tears, or other skin conditions. During a review of the facility's P&P titled, Skin Integrity- Skin Tears last reviewed on 1/14/2026, the P&P indicated, it is the policy of the facility to provide proper treatment and care to maintain skin integrity. This policy pertains to the prevention and management of skin tears. According to the policy and procedure, Interventions will be modified in a resident's plan of care as needed. Considerations for needed modifications include.Changes in medical condition or factors affecting the risk for skin tears. New onset or recurrent skin tear. Lack of progression towards healing, During a review of the facility's P&P titled, Skin Assessment last reviewed on 1/14/2026, the P&P indicated, this policy includes the following procedural guidelines in performing the full body skin assessment. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Documentation of skin assessment. Include date and time of the assessment, name, and position title. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). Document type of wound. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Document if residents refused assessment and why. Document other information as indicated or appropriate.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the ice machine bin was kept clean. 2. Ensure drinks were maintained below 41 degrees Fahrenheit ( F- unit for temperature). These failures had the potential to result in foodborne illness (illness caused by eating or drinking contaminated foods or beverages) for 84 of 87 residents who receive water and drinks from the facility. Findings: 1. During a concurrent observation and interview on 5/18/2026 at 8:30 a.m., with [NAME] 1 in the ice machine room, observed a dark greenish and black residue when the inside bin and door of the ice machine were wiped with a clean paper towel. [NAME] 1 stated the residue was dust and if ice gets contaminated it can cause residents' illnesses. During a concurrent observation and interview on 5/18/2026 at 2:56 p.m., with the Maintenance Supervisor (MS) in the ice machine room, observed a light brown and black residue collected when the inside of the ice bin, door molding, and the door were wiped with a clean paper towel. The MS stated it was dust, and the ice machine should be kept clean to prevent infections in residents. During a review of the Maintenance-Ice Machine Cleaning Schedule log, the ice machine was last cleaned on 4/24/2026. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Policy, revised 8/18/2025, the P&P indicated there should be a focus on cleaning the door molding and the lid of the machine to ensure there are no rust or calcium deposits. 2. During a concurrent observation and interview on 5/20/2026 at 12:26 p.m., with the Registered Dietitian (RD) in the kitchen, the temperatures of lunch drinks were tested: - The temperature of whole milk from cups in three trays was measured: the first tray's cup registered at 64 F, the second tray's cup at 50.5 F, and the third tray's cup at 43 F. - The temperature of apple juice from one cup tested was measured at 56.8 F. - The temperature of orange juice from one cup tested was measured at 62.4 F. The RD stated drinks served to residents need to be lower than 50 F and served within two hours if the temperature is in the danger zone (bacterial growth and/or toxin production can occur when food remains in temperatures between 41 F and 135 F for too long). The RD stated residents can get foodborne illness if the drinks are not kept within safe temperature levels. During an interview on 5/20/2026 at 12:56 p.m., with the Kitchen Supervisor (KS), the KS stated lunch drinks are pre-filled at 6:00 a.m. and kept refrigerated until 10:00 a.m., then put in the freezer until 11:30 a.m. when they start preparing for tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet). The KS stated the kitchen staff maintain the drinks in ice trays during tray line, check temperature, and log temperature in the Food Temperature Chart. The KS stated the drinks stayed out too long and were not maintained under 41 F. During a concurrent interview and record review on 5/20/2026 at 2:35 p.m., with the RD, reviewed the facility's policy and procedure titled, Food Safety and Food Storage, revised 11/4/2024. The P&P indicated, Maintain food at proper temperature and out of the Danger Zone. The RD stated the lunch drinks were not maintained out of the danger zone.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a resident to signal his or her need for assistance from staff) was within reach for one of one sampled resident (Resident 97). This deficient practice had the potential to result in Resident 97 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being. Findings: During a review of Resident 97's admission Record, the admission Record indicated the facility admitted Resident 97 on 5/12/2026 with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that causes shortness of breath and narrowing of the airways), chronic (long-standing) congestive heart failure (CHF - progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently), and dependence on supplemental oxygen. During a review of Resident 97's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2026, the MDS indicated Resident 97 is able to make herself understood and understand others. The MDS indicated Resident 97 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bath self, putting on/taking off footwear, required partial/moderate assistance (helper does less than half the work) with personal hygiene, upper and lower body dressing. The MDS further indicated Resident 97 required substantial/maximal assistance with sit to stand, chair-bed-to chair transfer, and toilet/tub/shower transfer. During a review of Resident 97's History and Physical (H&P) dated 5/14/2026, the H&P indicated Resident 97 had the capacity to understand and make decisions. During a concurrent observation and interview on 5/18/2026 at 10:57 a.m., with the Director of Nursing (DON), Resident 97's call light was observed on the floor near the head of Resident 97's bed. The DON stated that the call light should always be within the resident's reach to allow residents to alert staff when assistance is needed. The DON stated that if the call light is inaccessible, care could be delayed. The DON stated that there's a potential for injury if the resident tried to get out of bed due to not being able to have access to the call light to call for help and also the potential for harm if the resident is having a change of condition and they cannot access help promptly. During a review of Resident 97's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, The resident is at risk for falls, initiated 5/13/2026, the care plan indicated an intervention to place the resident's call light within reach and encourage the resident to use it for assistance as needed. The care plan also indicated the resident needs prompt response to all request for assistance. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, last reviewed 1/14/2026, the P&P indicated, Staff will ensure the call light is within reach of resident and secured, as needed.The call system will be accessible to residents while in bed or other sleeping accommodations within the resident's room. During a review of the facility's P&P titled, Fall Prevention Program, last reviewed 1/14/2026, the P&P indicated, Fall interventions include, but not limited to:.call light and frequently used items are within reach.

Based on interview and record review, the facility failed to provide two of two sampled residents (Resident 22 and Resident 54) quarterly financial statements. This failure had the potential to result in mismanagement of the residents' funds and to prevent the residents from making informed financial decisions regarding their finances. Findings: During a review of Resident 22's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 22 to the facility on 1/4/2020 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial paralysis or weakness of one side of the body caused by brain damage), and gout (a painful form of arthritis that cause inflammation in the joints). During a review of the Minimum Data Set (MDS - a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 22's cognition (the mental processes involved in acquiring, processing, storing, and retrieving information) was intact. During a review of Resident 22's History and Physical (H&P), dated 10/10/2025, the H&P indicated Resident 22 had capacity to understand and make own decisions. During an interview on 5/18/2026 at 11:55 a.m. with Resident 22, Resident 22 stated the facility had not provided quarterly financial statements for several months. During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 to the facility on [DATE] and readmitted on [DATE] with diagnoses including sequelae following unspecified cerebrovascular disease (a condition with unknown cause that affects blood vessels and blood supply to the brain often leading to brain damage), obstructive hydrocephalus (a blockage in the brain that prevents the normal flow of cerebrospinal fluid through brain passages), and presence of cerebrospinal fluid drainage device (a surgically implanted device to remove excess fluid from the brain). During a review of the MDS, dated [DATE], the MDS indicated Resident 54's cognition was moderately impaired. During a review of Review of Resident 54's H&P dated 4/6/2026, the H&P indicated Resident 54 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 5/22/2026 at 1:03 p.m. with the Business Office Manager (BOM), the facility's policy and procedure (P&P) titled, Resident Trust Funds, last reviewed 1/14/2026, was reviewed. The P&P indicated the facility: -Provide a quarterly statement each quarter to each resident or resident representative (RP) reflecting all transactions and balances. -Date and document when the statement is provided. -Requests the signature of the resident or RP as proof of receipt of quarterly statement. -All reports printed and placed in a Patient Trust Binder. The BOM stated the facility did not follow the P&P by not providing Resident 54 and Resident 22 quarterly statements for the quarter period of 1/1/2026 to 3/31/2026. During an interview on 5/22/2026 at 1:51 p.m. with the Administrator, the Administrator stated quarterly statements should be provided to each resident or RP and the BOM office maintains records of quarterly statements given to residents or RP. During an interview on 5/22/2026 at 3:08 p.m. with Resident 54's RP, the RP stated the facility had not provided quarterly statements of Resident 54's account for about one year and is not aware of Resident 54's account balance.

Based on interview and record review, the facility failed to provide two of two sampled residents (Resident 22 and Resident 54) receiving Medicaid (a joint federal and state program that provides free or low-cost health coverage to people with limited income and resources) benefits notification when the amount in the resident's account reached $200 less than the resource limit for one person, specified in section 1611(a)(3)(B) of the Act.This failure had the potential to result in the residents losing Medicaid eligibility. Findings: During a review of Resident 22's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 22 to the facility on 1/4/2020 with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial paralysis or weakness of one side of the body caused by brain damage), and gout (a painful form of arthritis that cause inflammation in the joints). During a review of the Minimum Data Set (MDS - a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 22's cognition (the mental processes involved in acquiring, processing, storing, and retrieving information) was intact.During a review of Resident 22's History and Physical (H&P), dated 10/10/2025, the H&P indicated Resident 22 had capacity to understand and make own decisions. During an interview on 5/18/2026 at 11:55 a.m. with Resident 22, Resident 22 stated the facility had not provided quarterly financial statements for several months. During a review Resident 22's Resident Fund Statement, dated 1/1/2026 to 3/31/2026, the Resident Fund Statement indicated an account balance of $4,851.02. During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 to the facility on [DATE] and readmitted on [DATE] with diagnoses including sequelae following unspecified cerebrovascular disease (a condition with unknown cause that affects blood vessels and blood supply to the brain often leading to brain damage), obstructive hydrocephalus (a blockage in the brain that prevents the normal flow of cerebrospinal fluid through brain passages), and presence of cerebrospinal fluid drainage device (a surgically implanted device to remove excess fluid from the brain). During a review of the MDS, dated [DATE], the MDS indicated Resident 54's cognition was moderately impaired. During a review of Review of Resident 54's H&P dated 4/6/2026, the H&P indicated Resident 54 did not have the capacity to understand and make decisions. During a review Resident 54's Resident Fund Statement, dated 1/1/2026 to 3/31/2026, the Resident Fund Statement indicated an account balance of $4,423.84. During a concurrent interview and record review on 5/22/2026 at 1:03 p.m. with the Business Office Manager (BOM), the facility's policy and procedure (P&P) titled, Resident Trust Funds, last reviewed on 1/14/2026, was reviewed. The P&P indicated the facility will provide written notification to recipients of Medicaid or their Resident Representative (RP) when their Resident Fund Trust balance approach $200 of the resource limits. The BOM stated the facility did not follow the P&P to provide notification to Resident 22 and Resident 54 when their resource limits were approaching $2000; and Resident 22 and Resident 54 could be at risk of losing Medicaid benefits.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) addressing the use of an arm splint (medical device that stabilizes a part of your body and holds it in place) for one of 18 sampled residents (Resident 7). This deficient practice had the potential to negatively affect the delivery of care and services. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted Resident 7 on 11/29/2023 and re-admitted the resident on 4/16/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), pleural effusion (an abnormal buildup of excess fluid in the lungs), and need for assistance with personal care. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 4/19/2025, the MDS indicated Resident 7 sometimes understood others and sometimes understands others. The MDS indicated Resident 7 was dependent (helper does all of the effort) with activities of living (ADL - routine activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated Resident 7's was dependent for all mobility. During a review of Resident 7's History and Physical (H&P) dated 3/15/2026, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During a concurrent observation and interview on 5/19/2026 at 10:45 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 7 with a blue device wrapped around Resident 7's right arm. LVN 3 stated the device applied to Resident 7's right arm was a splint. During a concurrent interview and record review on 5/21/2026 at 11:33 a.m., with the Director of Rehabilitation (DOR), reviewed Resident 7's care plans. The DOR stated Resident 7 had a right elbow splint as an intervention under the occupational therapy treatment. The DOR stated that Resident 7's right elbow splint and Occupational Therapy goals and interventions for Resident 7's right elbow splint were not documented in Resident 7's interdisciplinary care plan. During a concurrent interview and record review on 5/21/2026 at 1:42 p.m., with the Minimum Data Set Nurse (MDS Nurse), the MDS Nurse stated the purpose of the care plan is to list the residents' concerns, problems, and the goals and interventions for each identified concern or problem. The MDS Nurse stated a comprehensive care plan guides the resident's care. The MDS Nurse stated that Resident 7's right elbow splint was not in Resident 7's interdisciplinary care plan. The MDS Nurse stated that Resident 7's right elbow splint should have been in the interdisciplinary care plan for the care plan to be comprehensive. During an interview on 5/21/2026 at 4:05 a.m., with the Director of Nursing (DON), the DON stated that a comprehensive care plan is a complete care plan. The DON stated that not having Resident 7's right elbow splint in Resident 7's interdisciplinary care plan does not make Resident 7's care plan comprehensive. The DON stated that a complete and comprehensive care plan is important to ensure care teams are all working together towards providing the best care to the residents. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed 1/14/2026, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identifies in the resident's comprehensive assessment.The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: iv. Licensed therapists.

Based on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) received the necessary services to maintain neatly trimmed fingernails and toenails for one of two sampled residents (Resident 25). This deficient practice had the potential to negatively affect Resident 25's dignity. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility admitted Resident 25 on 2/17/2026 with diagnoses that included type two (2) diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, and muscle weakness. During a review of Resident 25's History and Physical (H&P) dated 2/18/2026, the H&P indicated Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool) dated 2/24/2026, the MDS indicated Resident 25 did have the capacity to make himself understood and understand others, and was dependent (helper does all the effort) on staff for activities such as toileting, dressing, bathing and personal hygiene. During a concurrent observation and interview on 5/18/2026 at 8:17 a.m., in Resident 25's room, Resident 25 stated the last time the podiatrist was at the facility, he was told he was not on the list to be trimmed. Resident 25 stated his fingernails, and toenails were too long, and his toenails were too yellow and thick and he is unable to care for them himself. Resident 25's fingernails and toenails appeared long, jagged, yellow and thick. Resident 25 stated only a podiatrist can cut his toenails because he has DM. Resident 25 stated he likes to be groomed especially his hair and his nails. During a concurrent observation and interview on 5/18/2026 at 8:33 a.m., with the Infection Preventionist (IP), observed Resident 25's fingernails and toenails. The IP stated Resident 25's fingernails and toenails were too long and the toenails appeared yellow and thick, especially the big toes. The IP stated the right big toe had what appeared to be an ingrown nail affecting the outside wall of the right big toe. During an interview on 5/22/2026 at 11:52 a.m., with the Director of Nursing (DON), the DON stated that having untrimmed or jagged nails can affect Resident 25's dignity because he is very alert and likes to be groomed. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed on 1/14/2026, the P&P indicated residents have a right to a dignified existence. During a review of the facility's P&P titled, Activities of Daily Living (ADLS), Supporting, last reviewed on 1/14/2026, the P&P indicated residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, dressing, and personal and oral hygiene.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow up on a reoccurring right big toe ingrown nail after a 30-day treatment from 4/2/26/ to 5/2/26 when on 5/18/26 the resident had an ingrown again on the same toenail without orders to treat for one of two sampled resident (Resident 25) investigated under non-pressure skin conditions. This deficient practice placed Resident 25, who has a diagnosis of type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), at risk for infection and pain. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility admitted Resident 25 on 2/17/2026 with diagnoses that included type 2 diabetes and need for assistance with personal care and muscle weakness. During a review of Resident 25's History and Physical (H&P) dated 2/18/2026, the H&P indicated Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool), dated 2/24/2026, the MDS indicated Resident 25 did have the capacity to make himself understood and understand others, and was dependent (helper does all the effort) on staff for activities such as toileting, dressing, bathing and personal hygiene. During a concurrent observation and interview on 5/18/2026 at 8:20 a.m. in Resident 25's room, Resident 25 was lying in bed watching television. Resident 25 stated the last time the podiatrist was at the facility, he was told he was not on the list to be trimmed. Resident 25 stated there was an ingrown toenail on his right big toe that came back but it only bothers him if someone puts pressure on it. Resident 25 stated it has been a very long time since he had any treatment to his right big toe, and he has had the ingrown toenail for at least a week or longer. Resident 25 stated he told staff but did not remember who he told. During a concurrent observation and interview on 5/18/2026 at 8:36 a.m. with the Infection Preventionist (IP), the IP looked at Resident 25's feet and stated the right big toe had what appeared to be an ingrown nail affecting the outside wall of the right big toe. The IP stated there appeared to be some swelling and a dry crust on the left side of Resident 25's right big toe and needed to notify the doctor or podiatrist to get orders to provide treatment for it. The IP stated treatment should have started as soon as the symptoms came back and that there should have been follow-up after the treatment ended on 5/2/2026 by either getting an order to continue treatment or document it was healed, if fully healed. The DON further stated for residents with DM, licensed staff should be assessing their lower extremities for any wounds or suspected wounds daily and CNAs should be checking the resident's body for any wounds or discoloration when they are being showered or provided perineal (simple gentle cleaning of the genital area) care. During an interview 5/22/2026 at 11:59 a.m. with the Director of Nursing (DON), the DON stated that Resident 25 has diabetes and wounds such as ingrown toenails should be addressed as soon as possible. The DON stated the treatment nurses should have followed up after the orders to treat the same wound ended on 5/2/2026. During a review of the facility's P&P, titled Podiatry Services, last reviewed 1/14/2026, the P&P indicated, it is the policy of the facility to ensure residents receive proper treatment and care within professional standards of practice to maintain mobility and good foot health. During a review of the facility's P&P titled, Nursing Care of the Resident with Diabetes Mellitus, last reviewed 1/14/2026, the P&P indicated the purpose of these guidelines are to recognize, mange, and document the treatment complications commonly associated with diabetes . Foot complications may be associated with prolonged, poorly controlled diabetes.

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries/ulcers (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to ensure the low air loss mattress (LALM, a mattress designed to prevent and treat PIs) was on for one of four sampled residents (Resident 1). This deficient practice had the potential for the worsening of, or development of new PI/PUs to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2026 with diagnoses that included type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), pressure ulcer of sacral region (the area at the base of your spine, just above the tailbone and between the hips), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/9/2026, indicated Resident 1 was understood by others and was able to understand others and was dependent (helper does all the effort) on facility staff for toileting, bathing, lower body dressing and taking off/putting on footwear. The MDS further indicated Resident 1 had a PU/PI and was using a pressure-reducing device for his bed. During a review of Resident 1's Care Plan titled, At Risk for Development of PI, initiated on 1/31/26, the care plan indicated an intervention to use pressure reducing mattress. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for LALM for wound management. Charge Nurses to check proper placement and function. Setting according to resident's weight every shift. During a concurrent observation and interview on 5/18/2026 at 9:33 a.m., with Licensed Vocational Nurse 4 (LVN 4) in Resident 1's room, observed Resident 1 lying on his bed, flat with his LALM off. LVN 4 stated the LALM should always be on when the resident is in bed to help prevent new or worsening PI/PU. LVN 4 stated Resident 1 had a PU on his sacrum, and it was important for the LALM to be on and functioning. During an interview on 5/22/2026 at 1:37 p.m., with the Director of Nursing (DON), the DON stated Resident 1's LALM must be on at all times when he is in bed to prevent further breakdown. The DON stated the licensed staff is in charge of making sure the LALM is functioning properly and at the right setting according to weight. During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention Guidelines, last reviewed 1/14/2026, the P&P indicated to prevent pressure injuries to residents by repositioning and using pressure relieving /reducing and redistributing devices including but not limited to pressure relieving mattresses, wedges and pillows. The P&P further indicated when physician orders are present, the facility will follow the specific physician orders.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) that includes and supports dementia care needs for one of three sampled residents (Resident 7) with dementia. This deficient practice had the potential to negatively affect the delivery of services to residents living with dementia. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted Resident 7 on 11/29/2023 and re-admitted the resident on 4/16/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), pleural effusion (an abnormal buildup of excess fluid in the lungs), and need for assistance with personal care. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 4/19/2025, the MDS indicated Resident 7 sometimes understood others and sometimes understands others. The MDS indicated Resident 7 was dependent (helper does all of the effort) with activities of living (ADL - routine activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated Resident 7's was dependent for all mobility. During a review of Resident 7's History and Physical (H&P) dated 3/15/2026, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During a concurrent observation and interview on 5/18/2026 at 10:20 a.m., with Resident 7, observed Resident 7 lying in bed. Resident 7 did not directly respond to questions and instead spoke about unrelated topics. During a concurrent interview and record review on 5/20/2026 at 10:27 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 7's care plans. The ADON stated that she reviewed Resident 7's care plans and did not find a care plan for dementia. The ADON stated Resident 7 had a diagnosis of dementia and should have a care plan for dementia interventions tailored to address Resident 7's needs. The ADON stated a care plan is the blue print and is the guide that shows the care for the resident with the specific condition and situation. The ADON stated residents with dementia have impaired cognitive status and require specific interventions and approach with their care. During an interview on 5/21/2026 at 4:05 p.m., with the Director of Nursing (DON), the DON stated a care plan is the foundation for a resident's overall plan of care. The DON stated that there should be a specific care plan for dementia, created specifically for the resident. The DON stated interventions within these care plans must address residents' cognitive needs. The DON stated that the care plan identifies problems, establishes goals and interventions, and facilitates evaluation to ensure intervention effectiveness, requiring adjustments when necessary. The DON stated that the absence of a care plan for dementia can result in delays in care and unmet resident needs. During a review of the facility's policy and procedure (P&P) titled, Dementia Care last reviewed 1/14/2026, the P&P indicated, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being.The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible.

Based on observation, interview, and record review, the facility failed to maintain infection control measures by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not place her personal bag on a chair inside the resident's room for one of three sampled residents (Resident 48). This deficient practice placed Resident 48 at risk for exposure and possibly contracting infectious microorganisms. Findings: During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 4/2/2022 and re-admitted the resident on 1/16/2023 with diagnoses that included chronic (long-standing) congestive heart failure (CHF - progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently), rhabdomyolysis (a medical condition where damaged muscle tissue rapidly breaks down and dies), and immunodeficiency (body's defense system to fight infection is weakened) due to conditions. During a review of Resident 48's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2026, the MDS indicated Resident 48 can make herself understood and understand others. The MDS indicated Resident 48 was dependent (helper does all the effort) with shower/bath self, required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying as resident completes activity) with oral hygiene, toileting hygiene, upper body dressing and eating. During a review of Resident 48's History and Physical (H&P) dated 4/9/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a concurrent observation and interview on 5/18/2026 at 11:35 a.m., with Resident 48, a female staff entered Resident 48's room and reached into a bag that was resting on a chair next to Resident 48's bed and quickly left the room. Resident 48 stated the bag belongs to her nurse. Resident 48 stated her nurse asked if she could leave her bag in Resident 48's room because Resident 48 stated, I guess they have some problems where staff can leave their things, not sure what problems. During an interview on 5/18/2026 at 12:00 p.m., with Resident 48 in the presence of the Director of Nursing (DON), Resident 48 stated the bag on the chair next to her bed is CNA 1's lunch bag. Resident 48 stated, She always comes and brings it here. She sometimes leaves her sweater too. During an interview on 5/18/2026 at 12:05 p.m., with the DON, the DON stated the facility provides a designated space where staff can store their belongings. The DON stated that staff should not keep any personal belongings in residents' rooms. The DON explained that staff's personal items brought into resident's room pose an infection control risk because the contents or cleanliness of those items are unknown. The DON stated that personal items may carry microorganisms that could potentially cause infections to the residents. During a review of Resident 48's care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled, The resident has impaired immunity related to chronic illness initiated 10/24/2025, the care plan indicated the resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infections away. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed 1/14/2026, the P&P indicated, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of the communicable diseases and infections per accepted national standards and guidelines . All staff are responsible for following all policies and procedures related to the program.

Based on observation, interview, and record review, the facility failed to protect, promote, and honor one of three sampled residents (Resident 23) right of not receiving cardiopulmonary resuscitation (CPR - emergency measures including manual chest compressions and rescue breaths to revive a person when breathing or heartbeat has stopped) measures as indicated in the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for end-of life decisions communicated by a resident able to make informed decisions and if unable, by the resident's representative), dated [DATE]. Resident 23's POLST indicated Do Not Resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do CPR) instructing staff not to do CPR. The facility failed to ensure: 1. Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) verified Resident 23's code status (a person's wishes regarding CPR and other life-sustaining treatments in the event of cardiac arrest ([heartbeats stop] or respiratory arrest [breathing stops]) in Resident 23's POLST and Admission Record face sheet), on [DATE] at 2:04 pm, when Resident 23 was not breathing. RN 1 and LVN 1 started CPR on Resident 23 based solely on an unidentified person shouting that Resident 23 was a full code (all possible life-saving measures including CPR are attempted). 2. RN 2 and Registered Nurse Consultant 1 (RNC 1) verified Resident 23's POLST before assisting RN 1 and LVN 1 with performing CPR on Resident 23 on [DATE] from 2:04 pm to 2:11 pm (seven minutes) until paramedics (healthcare professional trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived and after paramedics reviewed Resident 23's POLST and Admission Record and informed the staff that were present in Resident 23's room that Resident 23 had a DNR order. 3. RN 1, RN 2, RNC 1, and LVN 1 followed the facility's P&P on Communication of Code Status which indicated the resident had the right to request, refuse and/or discontinue medical or surgical treatment and the facility is to adhere to the resident's rights. 4. RN 1, RN 2, RNC 1, and LVN 1 followed the facility's P&P on POLST that indicated the facility will honor a resident's POLST. The failure to verify Resident 23's code status in the POLST and performing CPR for seven minutes violated Resident 23's wish of DNR. Not affording Resident 23's right to exercise his rights could cause distress to Resident 23 and his family had the CPR been effective. Resident 23 may have experienced unnecessary pain and suffering including broken ribs, unnecessary pain, and brain injury from lack of oxygen from receiving CPR. On [DATE] at 6:22 p.m., while onsite at the facility, the State Survey Agency (SSA) identified and called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation under 42CFR S483.10 (a) Residents Rights & (b) Exercise of Rights in the presence Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to honor Resident 23's POLST after finding Resident 23 not breathing. On [DATE] at 7:53 am, the ADM submitted an acceptable IJ Removal Plan (a detailed plan to address and correct the IJ findings). While onsite at the facility, the SSA verified the IJ situation was no longer present and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews. The SSA removed the IJ Situation in the presence of the ADM and the DON on [DATE] at 12:31 pm. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the Social Services Director (SSD), the DON, and the Assistant DON (ADON) conducted an in-house audit of each resident's POLST, Advance Directive, and History & Physical (H&P) exam to determine if the resident had the capacity to make decisions and to verify the resident's responsible party (if the resident did not have the capacity to make decisions). There was a total of 82 residents residing at the facility on [DATE]. There were 21 residents with confirmed DNR status and 61 residents with confirmed Full Code status. 2. On [DATE], the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the resident) reviewed the medical record of all 82 residents and verified that 61 residents were Full Code, and 21 Residents were DNR. There were 11 residents with advanced directives. 3. On [DATE] and [DATE], RNC 2 provided reinforcement training to LVN 1, RN 1, RN 2, and RNC 1 on Resident Rights, POLST, Communication of Code Status, CPR, DNR), Advance Directive, and Medical Emergency Response. 4. On [DATE], the SSD and the DON met with residents who had the capacity to make their own decisions and verified that their POLST was current. 5. On [DATE], the SSD and the DON spoke with the resident representative of each resident who did not have the capacity to make decisions, to verify if their POLST is current. All the resident representatives stated that the POLST is current and there are no changes. 6. On [DATE], the Medical Records Director (MRD) printed current Admission Record (face sheets) of each resident reflecting the verified POLST. 7. On [DATE], the ADON printed out the list of all residents with their Code Status Orders Report (based on the POLST) and visibly posted the list at each nurses' stations, emergency cart, and in a binder at the medication carts. The Code Status Order Report will be updated daily by the 11pm to 7am licensed nurses and checked for accuracy. The 7am to 3pm licensed nurses will update any report not completed during the prior 11pm to 7am shift. 8. On [DATE], the DON placed DNR stickers on the outside of the 21 confirmed DNR residents' medical records to clearly display their DNR status. The 11pm to 7am licensed nurses were tasked to reconcile the Code Status Order Report daily with the DNR stickers and update as necessary. The MRD will audit the DNR stickers on the medical records and reconcile it with the Code Status Order Report weekly to ensure accuracy. The audit will be documented utilizing a Code Status audit form. Any inaccurate findings will be immediately corrected by MRD. The Code Status audit form will be available in the facility's binder with all documents related to the IJ Situation (IJ Binder). 9. On [DATE] and thereafter, the licensed nurse assigned to the desk work will discuss resident code status during huddle (a short meeting for the arriving staff prior to the start of their shift) for all three shifts (7am-3pm, 3pm-11pm, and 11pm-7am). During the huddle the nursing supervisor will assign a licensed nurse as the Shift Code Leader (a licensed nurse in charge of resident emergencies in the facility) should any incident occur. 10. On [DATE], the SSD placed red wristbands (to visually identify DNR status) on the wrists of 19 residents with DNR orders with their consent. Two residents with DNR status agreed to wear the red wristbands on [DATE]. On [DATE], all 21 with DNR orders agreed to wear the red wristbands. By [DATE], the IDT updated the Care Plans of the 21 residents with DNR orders. All licensed nurses are tasked to print the code status report and visually verify that red wristbands are worn by the residents with orders for DNR and document it on the DNR Form list. The MRD will audit residents' care plans weekly utilizing the Code Status audit form to ensure compliance and accuracy. 11. On [DATE], the ADM updated the Person-Centered Interview and Rounding Worksheet to reflect the wristband section for department managers to visually verify that the wristband is intact on their assigned residents on Monday through Friday basis. Registered Nurse (RN) supervisor will conduct the audit on weekends utilizing Weekend Room Round form. Department Managers and RN supervisor will utilize the Code Status Order Report to ensure accuracy during rounds. The Person-Centered Interview and Rounding Worksheet and Weekend Room Round forms will be available the Room Rounds binder. 12. Starting on [DATE], a mandatory facility-wide in-service training was conducted to reinforce the facility's P&P including Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. By [DATE], 100% of the staff received the in-service training. New hires will be educated prior to the start of their first scheduled shift. 13. Starting on [DATE], the ADM or the DON will interview employees from different shifts on weekly basis to validate understanding of the in-service training on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. Employee response will be recorded utilizing an Employee Validation form. The form will be available in the IJ Binder. 14. Starting on [DATE], regular audits during IDT meetings will include verification of the residents' clinical record for the current code status. Newly admitted residents' code status will be reviewed during IDT meetings. The audit will be done upon admission and readmission of residents, weekly for current residents or when where there is a change in residents' code status. The audits will be documented utilizing the Code Status audit form and will be reported by the MRD during Monday through Friday operations meeting for appropriate follow up. 15. On [DATE], the IDT conducted Root Cause Analysis (RCA) and identified the following: a. Code status was not immediately visible during an emergency requiring life-saving measures if appropriate. b. There was a lack of visual cues such as DNR sticker or resident identifier such as red wristbands. 16. On [DATE] a QAPI (Quality Assurance & Performance Improvement) was implemented to track and report on above audit findings. The findings will be presented at the monthly QA) Committee meeting for a minimum of three months for review and recommendations. After the initial three months, the QA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance. During a review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], the MDS indicated Resident 23 had intact cognition (thought processes). The MDS also indicated Resident 23 required assistance with eating and dressing and was dependent on staff for bathing and toileting. During a review of Resident 23's POLST, dated [DATE], signed by Medical Doctor 1 (MD 1) and Resident 23, the POLST indicated DNR and to allow natural death. During a review of Resident 23's Advance Directive (a legal document that allows you to express your wishes regarding medical care in the event you become unable to make those decisions for yourself, such as due to illness or injury) Acknowledgement form, signed dated by Resident 23 on [DATE], the Advance Directive indicated Resident 23 had completed a POLST form on [DATE]. During a review of Resident 23's Advanced Directive Status Care Plan (CP) initiated on [DATE], the CP indicated a code status of DNR. The CP included interventions to follow the POLST. During a review of Resident 23's Physician's Orders, a physician order dated [DATE], indicated MD 1 ordered DNR. During a concurrent observation and interview with Resident 23 on [DATE] at 9:42 am in Resident 23's room, Resident 23 was sitting up in bed and watching television. Resident 23 stated he lived at an assisted living facility (ALF) before he got sick and was admitted to a hospital where doctors found cancer in his abdomen. Resident 23 stated he was admitted to the facility because he was too sick to return to the ALF. Resident 23 stated he chose DNR because of his cancer diagnosis. During an observation on [DATE] at 2:06 pm in the hallway, outside of Resident 23's room, the door was open, the privacy curtain drawn and the counting of 1,2,3, 30 repeatedly could be heard coming from Resident 23's room. A crash cart was positioned outside Resident 23's room. At 2:11 pm paramedics arrived at Resident 23's room, Paramedic 1 (PM 1) went into the room immediately. A staff member met PM 2 outside Resident 23's room and handed PM 2 a packet of documents (copies from Resident 23's medical record). PM 2 reviewed the documents and asked out loud why was the facility staff was performing CPR against Resident 23's DNR wishes. PM 2 pointed at the Admission Record and the POLST and stated that DNR was written on both forms. Four staff members were in the room assisting with performing CPR on Resident 23, LVN 1, RN 1, RN 2 and RNC 1. During an interview with LVN 2 on [DATE] at 2:16 pm, LVN 2 stated he called code blue (term that signals a medical emergency) over the intercom and called 911 at the direction of his supervisor, RN 1. LVN 2 stated he did not check for Resident 23's code status because he heard a female voice (unidentified) yell out full code. LVN 2 stated he should have checked Resident 23's chart to ensure they had the right code status to respect Resident 23's wishes. During a concurrent interview and record review with LVN 3 on [DATE] at 2:18 pm, Resident 23's POLST and Admission Record were reviewed. LVN 3 stated Resident 23's POLST and Admission Record indicated Resident 23 had a DNR order. LVN 3 stated the DNR order could also be found in the electronic medical record and staff must check and verified the resident's POLST before starting CPR to ensure the resident's end-of-life decisions are followed. LVN 3 stated he was assigned to nurse station 1 but ran over to help at nurse station 2 when he heard the overhead page Code Blue. LVN 3 stated his role during the time CPR was being performed on Resident 23 was filling out a transfer form in case Resident 23 needed hospitalization . LVN 3 stated he did not check Resident 23's POLST because he heard a female voice calling out full code and assumed Resident 23 had a full code status. During a phone interview with Physical Therapy Assistant (PTA) on [DATE] at 9:35 am, the PTA stated she entered Resident 23's room to provide physical therapy at about 2:00 pm on [DATE] and stated Resident 23 did not respond to questions when Resident 23 was normally very able to respond. PTA stated moments later the Certified Occupational Therapist Assistant (COTA) arrived and retrieved the vital signs machine. The PTA stated at that point they checked Resident 23's oxygen saturation level (amount of oxygen in the blood in percentage, normal reading is 95% to 100%) and the reading was 32% (indicating medical emergency). PTA stated that while the COTA stayed with Resident 23, she went to the nurses' station to get LVN 1. During an interview with LVN 1 on [DATE] at 2:23 pm, LVN 1 stated she was the Charge Nurse at Nurses' Station 2 and PTA called her over to Resident 23's room at 2:03 pm. LVN 1 stated she quickly assessed Resident 23 and determined Resident 23 was not breathing, LVN 1 left the room to grab the crash cart as RN 1 entered the room. LVN 1 stated RN 1 yell out near the doorway to the hallway for Resident 23's code status and heard a female voice (unidentified) yelled back the resident was full code. LVN 1 stated RN 1 began chest compressions (use of hands to push down hard and fast in a specific way on the person's chest to keep blood flowing to vital organs until a regular heartbeat returns) while she (LVN 1) began rescue breaths (to provide oxygenation of the blood) Resident 23 with a bag-valve-mask (BVM - a handheld device used to manually ventilate to a person who is not breathing or having difficulty breathing). LVN 1 stated RN 1 switched compressions off with RNC 1 and RN 2. LVN 1 stated the staff members who assisted with CPR was herself, RN 1, RN 2 and RCN 1 and they did not stop CPR until paramedics arrived. LVN 1 stated PM 2 read Resident 23's Admission Record and POLST and asked why CPR was done on a person that is a DNR. LVN 1 stated she did not check Resident 23's code status but relied on the voice (unidentified) that yelled out full code. LVN 1 stated the staff did not respect Resident 23's right to be DNR and chest compressions could result in broken ribs. During a concurrent interview and record review with RN 1 on [DATE] at 2:29 pm, reviewed Resident 23's medical record including POLST and Admission Record. RN 1 stated Resident 23's code status was DNR, and it could be found on his POLST, Admission Record and in the electronic health record (EHR). RN 1 stated when he went to Resident 23's room and he determined Resident 23 was unresponsive, he yelled out in the hallway for code status and heard a female voice (unidentified) yell back two times full code. RN 1 stated although he was already in Resident 23's room, he should have confirmed who yelled out full code or asked someone to bring the chart into the room so he could verify Resident 23's code status. RN 1 stated it was wrong to go against Resident 23's wishes to die naturally and if he was resuscitated, he could have suffered more pain from broken ribs or a punctured lung. During an interview with RN 2 on [DATE] at 2:36 pm, RN 2 stated she was the supervisor of nurse station 1 and ran over to station 2 to help when she heard the code blue page. RN 2 stated while at nurse station 2, she saw Resident 23's chart open on the desk and made copies of the Admission Record and order summary report (list of current doctor's orders) to give to the paramedics when they arrived. RN 2 stated she never took the time to check for Resident 23's code status because she heard a voice yell out full code. RN 2 stated she should have checked the Admission Record at that point to confirm Resident 23' code status. RN 2 stated she then went into Resident 23's room to help and switch off compressions with RN 1 and RNC 1. During a concurrent interview and record review, on [DATE] at 3:45 pm, the facility's P&P on CPR, revised on [DATE] and Resident 23's POLST, dated [DATE] were reviewed with RNC 1. RNC 1 stated Resident 23 had a DNR code status. RNC 1 stated CPR should have stopped immediately after a staff member confirmed Resident 23 had a DNR, but the facility failed to check and confirm the resident's code status. RNC 1 stated she went into Resident 23's room during the emergency and assisted with giving chest compressions to Resident 23. RNC 1 stated she heard a female voice (unidentified) yell out from the hallway, full code when RN 1 asked for Resident 23's code status. RNC 1 stated because of the facility's actions, Resident 23 did not have a peaceful death, very frail and could have suffered broken bones or other complications had Resident 23 been successfully revived. During a concurrent interview and record review, on [DATE] at 4:05 pm, Resident 23's POLST dated [DATE] and the facility's P&P on Communication of Code Status, revised on [DATE], were reviewed with the DON. The DON stated Resident 23's code status was DNR. The DON stated Resident 23's wishes were not fulfilled because CPR went on for seven minutes until paramedics arrived and determined the resident's code status. The DON stated the staff should have followed the P&P which indicated the resident had the right to request, refuse and/or discontinue medical treatment. The DON stated Resident 23 had a signed POLST indicating DNR in the medical record and staff did not check and verify Resident 23's code status. The DON stated Resident 23 could have suffered broken ribs, a punctured lung or injury to his brain from the lack of oxygen. During a telephone interview with Family Member (FM 1), on [DATE] at 5:21 pm, FM 1 stated she received a call from the ADM of Resident 23' passing on [DATE]. FM 1 stated that Resident 23 was suffering while alive from many different ailments and had wished DNR. During a concurrent interview and record review, on [DATE] at 11:08 am, the CPR Inservice training conducted on [DATE] was reviewed with the Director of Staff Development (DSD). The DSD stated the code status must be confirmed as soon as CPR is started. The DSD reviewed the CPR lesson plan and stated staff must be able to verbalize when CPR should be initiated and can identify when CPR is to be continued and/or discontinued. During a telephone interview with Medical Director Doctor (MDD), on [DATE] at 1:20 pm, the MDD stated staff must respect the residents' wishes and what happened to Resident 23 was unusual occurrence (an event that deviates from the norm, often posing a risk or threat to the health, safety or well-being of the residents) which and at least one staff member should have checked the code status immediately. The MDD stated that if Resident 23 was resuscitated and intubated, it would have been unfortunate and there would have been two different scenarios once transferred to a hospital; the resident would never be able to live without mechanical ventilation (a machine that breaths for a person that cannot breathe on their own) or living with an anoxic brain injury (when the brain goes without oxygen for a prolonged period of time), causing many complications. During a telephone interview with MD 1 on [DATE] at 1:58 pm, MD 1 stated Resident 23's code status should have been verified immediately after CPR was started. MD 1 stated staff must honor each resident's rights and choices. During a telephone interview with PM 1, on [DATE] at 10:55 am, PM 1 stated it is the facility staff's responsibility to know and respect the resident's wishes. During a review of facility's (P&P) titled, Cardiopulmonary Resuscitation (CPR), revised on [DATE], the P&P indicated, if a resident experience cardiac arrest (heartbeats stop), staff will provide basic life support, including CPR, prior to the arrival of EMS, or until DNR order is known. During a review of the facility's P&P titled, Communication of Code Status, revised on [DATE], the P&P indicated the facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. The P&P indicated when an order is written pertaining to a resident's presence or absence of an advanced directive, the directions will be reflected in the medical record, for example, Do not Resuscitate. During a review of the facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST), revised on [DATE], the P&P indicated the facility will provide the resident the option to complete or honor a POLST at the time of admission. The P&P indicated the POLST would be reviewed for completeness to confirm that the wishes for life-sustaining treatment indicated in the document remain the wishes of the resident. The P&P further indicated the complete, fully executed POLST form is a legal physician order and is immediately actionable.

Based on observation and interview, the facility failed to ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication, affecting one (1) of five (5) residents observed for medication administration (Resident 3). This deficient practice violated Resident 3's rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial harm. Findings: During a review of Resident 3's Admission Record (a document containing demographic and diagnostic information,) dated 3/24/2025, the record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (a disease characterized by high blood sugar levels,) pain, osteoporosis (a condition where the bones become fragile) and anemia (a condition characterized by a lower-than-normal number of red blood cells.) During a review of Resident 3's Minimum Data Set ([MDS] - a resident assessment tool,) dated 12/20/2024, the MDS indicated Resident 3 had moderate cognitive impairment (a condition that involves increased confusion and memory loss, as well as difficulty with language and completing tasks). During an observation on 3/24/2025 at 9:29 a.m., Licensed Vocational Nurse (LVN) 4 was observed administering docusate (a medication used for bowel [intestine] management,) cranberry (a supplement used to prevent urine infections,) bisacodyl (a medication used for bowel management,) and multivitamin with mineral tablets orally to Resident 3. Resident 3 was observed swallowing the docusate, bisacodyl and multivitamin with mineral tablets with a glass of water. LVN 4 was not observed informing Resident 3 the name of each medication and its indication during administration of the medications. During a concurrent observation, Resident 3 asked LVN 4 to cut the large pill and LVN 4 stepped out of the room with the cranberry tablet. During a concurrent interview with Resident 3, Resident 3 stated she was not aware of the medications she was administered by LVN 4 and that she would like to know. LVN 4 was observed entering Resident 3's room with the cranberry tablet cut in half. LVN 4 handed a small plastic cup containing the cut cranberry tablet to Resident 3 with a glass of water. LVN 4 was not observed informing Resident 3 the cut tablet was cranberry. The state surveyor asked Resident 3 if she would like to know what medication LVN 4 handed her, and Resident 3 stated yes. LVN 4 was observed stating to Resident 3 the medication was cranberry used to prevent urine infections. Resident 3 was observed swallowing the cranberry tablets with a glass of water. During an interview on 3/24/2025 at 9:35 a.m., with LVN 4, LVN 4 stated during the medication administration on 3/24/2025 at 9:29 a.m., LVN 4 administered docusate, bisacodyl and multivitamin with mineral tablets to Resident 3 and failed to inform Resident 3 the names of the medications and their indications prior to the resident swallowing each medication. LVN 4 stated that LVN 4 usually informs the residents of each medication and the indication prior to administration but forgot to do so this time. LVN 4 stated according to facility policy LVN 4 should have informed Resident 4 the name and indication of the medications administered that morning, to give Resident 4 the right to be involved in their care and treatment and be able to make choices such as refusing a specific medication. During an interview on 3/25/2025 at 12:08 p.m., with the Director of Nursing (DON,) the DON stated that LVN 4 failed to inform the name of the medications and their indications prior to medication administration on 3/24/2025 to Resident 3. The DON stated that it was important to follow this process to ensure residents have the right to be informed about their care and make decisions about their treatments. The DON stated not providing this information during medication administrations restricts the residents from this right. During a review of Resident 3's Medication Administration Record ([MAR] - a record of mediations administered to residents), dated March 2025, the MAR indicated Resident 3 was prescribed the following medications: -cranberry tablet to be given by mouth once a day for Urinary Tract Infection ([UTI] - urine infection) prophylaxis ([PPX] - prevention) at 9 a.m. -bisacodyl four (4) tablets to be given by mouth once a day for bowel (intestine) management at 9 a.m. -docusate tablet to be given by mouth twice a day for bowel management at 9 a.m. and 5 p.m. -multivitamin with mineral tablet to be given by mouth once a day every Monday and Thursday for supplement at 9 a.m. During a review of the facility's policy and procedures (P&P), titled Resident Rights, last reviewed 1/15/2025, the P&P indicated: 2. The resident has the right to be informed of, and participate in, his or her treatment, including: e. The right to request, and/or discontinue treatment.

Based on interview and record review the facility failed to: 1. Include the witness signatures on the Medication Disposition Record/Pass Log for seven (7) non-CMs disposed on 2/14/2025, 13 on 2/28/2025, and eight (8) on 3/23/2025. 2. Account for one (1) dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 21, in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit (ekit) containing CMs for March 2025, in one (1) of tw2 (2) inspected medication carts (Medication Cart Station 1 Cart 1.) As a result, control and accountability of medications and CS's did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) the risk that Residents 21 and other residents in the facility could have accidental overdose (administering more than the prescribed dose causing adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) and exposure to harmful medications, and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization . Findings: During an observation and record review on 3/25/2025 at 9:58 a.m. with Licensed Vocational Nurse (LVN) 1 in Medication Room Station 2, the Medication Disposition Record/Pass Logs were reviewed. The Medication Disposition Record/Pass Logs indicated: 1. Seven (7) non-CM disposals did not contain the witness signatures on the log dated 2/14/2025. 2. 13 non-CM disposals did not contain the witness signatures on the log dated 2/28/2025. 3. Eight (8) non-CM disposals did not contain the witness signatures on the log dated 3/23/2025. During a concurrent interview, LVN 1 stated LVN 1 was unable to locate the witness signatures of licenses nurses on the reviewed disposition logs. LVN 1 stated licensed nurses failed to follow policy of signing the logs with a witness when disposing medications, including herself and per facility policy a witness signature was required to ensure there was no diversion of medications. During an observation on 3/25/2025 at 10:22 a.m., with LVN 3, in Medication Cart Station 1 Cart 1 there was: 1. One (1) medication ekit labeled314 containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for March 2025. 2. A discrepancy in the count between the Antibiotic or Controlled Drug Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following resident: a. One (1) dose of pregabalin (a CS used for neuropathy [condition where nerves become damaged]) 25 milligram ([mg] - a unit of measure of mass) capsule was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 21. The Antibiotic or Controlled Drug Record accountability log for pregbalin indicated the medication bubble pack should have contained a total of 9 pregabalin 25 mg capsules, after the last administration of pregabalin 25 mg capsule documented/signed-off on 3/24/2025 at 5 p.m., however the medication bubble pack contained 8 pregabalin 25 mg capsules and contained no other documentation of subsequent administrations. During a concurrent interview, LVN 3 stated that all CMs, including medication ekits containing CMs should be reconciled at every shift. LVN 3 stated that the ekit labeled 314 containing CMs in Station 1 Cart 1 was not reconciled at every shift in March 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During the same interview, LVN 3 stated LVN 3 administered pregabalin 25 mg capsule to Resident 21 that morning (3/25/2025) at 9 a.m. and forgot to sign the Antibiotic or Controlled Drug Record accountability log. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CS dose on the Antibiotic or Controlled Drug Record accountability log after preparing the dose for the resident. LVN 3 stated LVN 3 understood it was important to sign each dose once administered to ensure accountability, prevent CS diversion and accidental overdose to Resident 21. During an interview on 3/25/2025 at 12:08 p.m., with the Director of Nursing (DON,) and in the presence of Registered Nurse Consultant 1 (RNC 1) the DON stated that medication ekits containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated one (1) eKit containing CMs in Station 1 Medication Cart 1 was not reconciled at each shift change for March 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKit at each shift change in Station 1 Medication Cart 1. During the same interview, the DON stated that LVN 3 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 21. The DON stated not documenting the Antibiotic or Controlled Drug Record accountability log timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. The DON stated she was unable to locate the witness signatures on the identified Medication Disposition Record/Pass Logs for non-CMs disposal. The DON stated licensed nurses failed to include the signatures of witnesses when destroying medications. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. During a review of Resident 21's Admission Record (a document containing demographic and diagnostic information,) dated 3/25/2025, the record indicated Resident 21 was originally admitted to the facility on [DATE] with diagnoses including polyneuropathy (condition where multiple nerves are damaged.) During a review of Resident 21's Medication Administration Record ([MAR] - a record of mediations administered to residents), for March 2025, the MAR indicated Resident 21 was prescribed pregabalin 25 mg capsules one (1) capsule by mouth twice a day for neuropathy, to be given at 9 a.m. and 5 p.m. During a review of the facility's policy and procedures (P&P), titled Destruction of unused drugs, last reviewed 1/15/2025, the P&P indicated: 5. The actual destruction of drugs by our facility must be witnessed by facility staff as per state requirements. During a review of the facility's P&P, titled Controlled Substance Administration & Accountability, last reviewed 1/15/2025, the P&P indicated The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. e. All controlled substances are accounted for in one of the following ways: i. All controlled substances obtained from non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic (controlled medication) disposition and patient administration. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy. 9. For areas without automated dispensing systems, two (2) licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.72% affecting two (2) of five (5) residents observed for medication administration (Resident 45 and 48.) The medication errors were as follows: 1. Resident 45 did not receive a form of vitamin B complex (a supplement containing several B vitamins used in production of red blood cells) as ordered by Resident 45's physician. 2. Resident 48 received docusate (docusate (a medication used for bowel [intestine] management,) and cyanocobalamin (a medication used to treat low levels of vitamin B12), at a different time than ordered by Resident 48's physician. These failures had the potential to result in Resident 45 and 48 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 45's and 48's health and well-being to be negatively impacted. Findings: During an observation on 3/24/2025 at 9:15 a.m., in Medication Cart Station 1 Cart 1, Licensed Vocational Nurse (LVN) 4 was observed administering vitamin B with vitamin C tablet to Resident 45. Resident 45 was observed swallowing the tablet with a glass of water. During an interview on 3/24/2025 at 11:15 a.m., with LVN 4, LVN 4 stated that LVN 4 administered a form of vitamin B complex tablet that contained vitamin C to Resident 45 during the morning medication administration at 9:15 a.m. to Resident 45. LVN 4 stated that LVN 4 failed to follow the physician order to administer vitamin B complex without vitamin C to Resident 45. LVN 4 stated that LVN 4 failed to follow 5 rights of medication administration and as a result administered the incorrect medication to Resident 45. LVN 4 stated this was considered a medication error and needed to inform the physician. During an observation on 3/24/2025 at 9:53 a.m., in Medication Cart Station 1 Cart 2, LVN 2 was observed preparing several medications for Resident 48. During an observation on 3/24/2025 at 10:10 a.m., LVN 2 was observed administering several medications to Resident 48. LVN 2 was not observed administering docusate and cyanocobalamin. During an interview on 3/24/2025 at 11:10 a.m., with LVN 2, LVN 2 stated that LVN 2 administered docusate and cyanocobalamin tablets at 7:27 a.m. and documented the administration at 10:18 a.m. to Resident 48 in error. LVN 2 acknowledged the physician's order specified to administer docusate and cyanocobalamin at 9 a.m. LVN 2 stated, per facility policy, there was a 60-minute window before and after the scheduled time for medication administration and LVN 2 administered the cyanocobalamin earlier than that timeframe. LVN 2 stated that LVN 2 failed to follow 5 rights of medication administration, failed to document the correct time of administration and that these were considered medication errors. During an interview on 3/25/2025 at 12:08 p.m., with the Director of Nursing (DON,) and in the presence of Registered Nurse Consultant 1 (RNC 1) the DON stated that LVN 4 failed to administer the correct vitamin B complex to Resident 45, and LVN 2 failed to administer docusate and cyanocobalamin tablets to Resident 48 at the scheduled time, according to the physician orders. The DON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications at the right times are administered to residents. During a review of Resident 45's Admission Record (a document containing demographic and diagnostic information,) dated 3/24/2025, the record indicated Resident 45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anemia (a condition with low red blood cells.) During a review of Resident 45's Order Summary Report, dated 3/24/2025, indicated Resident 45 was prescribed vitamin B complex one (1) tablet once a day in the morning orally for supplement, starting 3/5/2025. During a review of Resident 45's Medication Administration Record ([MAR] - a record of mediations administered to residents), for March 2025, the MAR indicated Resident 45 was prescribed vitamin B complex to give one (1) tablet orally once a day in the morning for supplement, at 9 a.m. During a review of Resident 48's Admission Record dated 3/24/2025, the record indicated the facility originally admitted Resident 48 on 3/8/2024 and readmitted on [DATE] with diagnoses including anemia. During a review of Resident 48's Order Summary Report, dated 3/24/2025, indicated Resident 48 was prescribed: 1. cyanocobalamin 1000 microgram ([mcg] - a unit of measure of mass) tablet once a day for supplement, starting 2/25/2025. 2. docusate 100 milligram ([mg]- a unit of measure of mass) tablet twice a day for bowel management, starting 3/15/2025. During a review of Resident 48's MAR for March 2025, the MAR indicated Resident 48 was prescribed: 1. cyanocobalamin 1000 mcg tablet to give one (1) tablet once a day orally for supplement, at 9 a.m. 2. docusate 100 mg tablet to give one (1) tablet twice a day orally for bowel management, at 9 a.m. and 5 p.m. During a review of Resident 48's medication administration details, dated 3/24/2025, the documentation indicated: 1. cyanocobalamin was scheduled at 9 a.m. and LVN 2 administered cyanocobalamin 1 tablet to Resident 48 on 3/24/2025 at 10:18 a.m. 2. docusate was scheduled at 9 a.m. and LVN 2 administered docusate 1 tablet to Resident 48 on 3/24/2025 at 10:18 a.m. During a review of the facility's policy and procedures (P&P), titled Administering Medications, last reviewed 1/15/2025, the P&P indicated that Medications are administered as prescribed . Preparation 3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Administration 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . Documentation 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. During a review of the facility's P&P, titled Medication Errors, last reviewed 1/15/2025, the P&P indicated It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications .which is not in accordance with the prescriber's order . Medication error rate is determined by calculating the percentage of errors observed during medication administration observation. 1. The facility shall ensure medications will be administered as follows a. According to physician's orders. 2. The facility must ensure that it is free of medication error rate of 5% or greater as well as significant medication error events. 4. The facility will consider factors indicating error in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration ii. Medication omission iii. Incorrect medication 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: b. Right medication, dose, route, and time of administration.

Based on observation, interview, and record review the facility failed to: 1. Label one open insulin (medication used to regulate blood sugar levels) Humulin N (intermediate-acting insulin) Kwikpen (a type of device containing insulin) stored at room temperature for Resident 70, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart Station 1 Cart 1.) This deficient practice increased the risk that Resident 70 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in the negative impact to residents' health and well-being possibly leading to health complications, hospitalization , or death. Findings: During an observation on [DATE] at 10:22 a.m., in Medication Cart Station 1 Cart 1, and in the presence of Licensed Vocational Nurse (LVN) 3, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) open and used insulin Humulin N Kwikpen for Resident 70 was found stored at room temperature without a date indicating when storage or use at room temperature began. Additional label indicated pharmacy prepared the medication on [DATE] and once pen was opened to discard unused medication after 14 days. According to the manufacturer's product labeling, opened and used Humulin N kwikpens should be stored at room temperature up to 86 degrees Fahrenheit and to discard pen after 14 days even if it still contains. During a concurrent interview with LVN 3, LVN 3 stated the insulin Humulin N Kwikpen for Resident 70 was open, used, stored at room temperature, and not labeled with a date when use at room temperature began. LVN 3 stated insulin pens were multi-use (used more than once) medications that had different expiration dates once opened. LVN 3 stated according to the medication label the Kwikpen needed to be discarded after 14 days of use, and after that day the insulin loses potency (the strength of medication) and considered expired. LVN 3 stated that LVN 3 was unaware when the insulin Humulin N Kwikpen for Resident 70 was opened or stored at room temperature therefore unknown when it would expire. LVN 3 stated the Kwikpen needed to be removed from the medication cart to ensure expired insulin was not administered in error to Resident 70. LVN 3 stated administering expired insulin in error will not be effective in keeping the blood sugar stable and can harm Resident 70 by causing high blood sugar levels, leading to shock and coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. LVN 3 stated the insulin Humulin N kwikpen needed to be immediately replaced with new ones from pharmacy for 70. During an interview on [DATE] at 12:08 p.m., with the Director of Nursing (DON,) and in the presence of Registered Nurse Consultant 1 (NC ,) the DON stated the insulin Humulin N Kwikpen for Resident 70 was not labeled with a date when the pen was first opened and used. The DON stated several LVN's failed to label the date the pen was opened and used. The DON stated without knowing when the Kwikpen was opened it was unknown when the Kwikpen expired potentially leading to the administration of expired insulin to Resident 70. The DON stated expired insulins have lost potency and effectiveness and when administered in error were not effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar level) and adverse effects for Resident 70, potentially resulting in hospitalization due to Diabetic Ketoacidosis ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening.) The DON stated the Humulin N Kwikpen was considered expired and needed to be replaced with a new one from pharmacy because pen had an unknown expiration date due to lack of labeling. During a review of the facility's Policy & Procedures (P&P,) titled Labeling of Medications and Biologicals, last reviewed [DATE], the P&P indicated All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 1. Labels for multi-use vials must include: a. The date the vial was initially opened b. All opened .vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. 2. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1), when the facility discharged Resident 1, who required continuous supplemental oxygen (therapy that helps people with lung disease or breathing problems get the oxygen [a colorless, odorless gas, an essential component of air] their bodies needs to function), to Family Member 1 ' s (FM 1) home on 9/6/2023 without durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which include supplemental oxygen equipment [medical device that gives resident ' s extra oxygen]) in place. This deficient practice resulted in Resident 1 experiencing an episode of hypoxia (low levels of oxygen in the blood) while at FM 1 ' s home on 9/6/2023, the same day Resident 1 was discharged from the facility. Resident 1 required emergency transfer to General Acute Care Hospital 1 (GACH 1) as a result of the oxygen deprivation (absence of enough oxygen in the tissues to sustain bodily functions). On 9/12/2023 at 3:40 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Assistant Director of Nursing (ADON) due to the facility ' s failure to ensure Resident 1 was free from neglect when the facility discharged Resident 1 to FM 1 ' s home without the needed supplemental oxygen equipment. On 9/14/2023 at 4:46 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: 1. Resident 1 no longer resided at the facility as of 9/6/2023. 2. One to One (1:1- one trainer assigned to one employee to provide training) in-service was provided by the ADM to the Director of Social Service (DSS) regarding abuse and neglect pertaining to the importance of arranging proper DME prior to Resident 1 ' s charge on 9/12/2023. 3. On 9/13/2023, 1:1 in-service was provided by the Director of Staff Development (DSD), to Licensed Vocational Nurse 1 (LVN 1), and the Director of Nurses (DON) to ensure proper discharge instructions for DMEs to resident and or resident ' s responsible party are completed and documented in the resident ' s record. The Resource Nurse Consultant (RNC) will provide the DON with an in-person in-service prior to reporting to the floor after the DON ' s vacation. The DSD provided an in-person in-service training to LVN 1 on 9/14/2023. 4. An audit of all discharge documentation such as pertaining to DMEs like oxygen for the last 30 days were completed by the DON and or designee to determine if any other residents were discharged without proper DME. 5. A total of 20 discharged residents were reviewed and completed with no concerns identified on 9/12/2023 based on the audit of the previously discharged residents with other DME. 6. All discharges planned within the next five (5) days were reviewed by the ADM, ADON, DSS and the Director of Rehabilitation (DOR) to ensure needed DMEs such as oxygen, is arranged prior to discharge. This audit was completed on 9/12/2023 and will be on-going with the audit tool. 7. Two (2) residents (Resident 3 and Resident 11) were identified with a projected discharge date of [DATE]. The need of oxygen DME was provided as ordered. 8. The DSS will coordinate care plan meetings for residents and or resident ' s responsible party seeking discharge. Resident ' s goals, barriers to discharge, safety concerns, and all other issues will be discussed with the resident and or their responsible party. 9. The DSS will ensure that the resident will have ordered DMEs. Residents will not be discharged without participating in a meeting and all discussion will be documented in the resident ' s medical record. The facility process in the event the resident and or responsible party insist to be discharge and DMEs are not set up will be the DSS or designee will provide education on risks and benefits, and or offer the resident a leave Against Medical Advice (AMA- when a resident insist on being discharged from the facility despite safety concerns related to their medical issues). The DSS will also contact the resident ' s physician, and adult protective services (APS- a social services program that serves older adults and adults with disabilities who are in need of assistance). 10. The DON or designee will oversee the resident ' s discharge and the DSS to ensure ordered DMEs are being arranged three (3) days prior to a resident ' s discharge home, and in a manner in which the resident and responsible party can understand. 11. Weekly case management meetings will take place and will be attended by the ADM, DON, DSS, and the DOR. Residents with planned discharge date s within seven (7) days will be reviewed to facilitate an orderly and safe discharge. 12. Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their resident) will meet with the resident and or the resident ' s responsible party with planned discharge to discuss current status of the resident, health teachings, goals, DMEs needed and appropriate referrals a week prior discharge. 13. The facility ' s abuse and neglect policy were reviewed by ADM and DON on 9/12/2023 to ensure the facility was compliant with the policy and procedure. No changes were made at this time. 14. New hires will receive education on abuse and neglect prevention and resident safety provided by the DON, DSD, or designee(s) upon hire and annually thereafter. 15. The RNC, DON and or designee provided education to licensed nurses and IDT members regarding abuse and neglect including providing safe orderly discharge planning on 9/12/2023 and 9/13/2023. Licensed nurses who were not able to attend the in service will be provided with reeducation on their next scheduled shift. 16. A Quality Assurance and Performance Improvement (QAPI- data driven and proactive approach to quality improvement) Performance Improvement Projects (PIP- a concentrated effort on a particular problem in one area of the facility) had been initiated for Abuse and Neglect pertaining to continued safety and well-being of the resident once they have returned home. The DSS or designee will contact the resident or their representative within seven days post-discharge to ensure the resident is safe at home. This monitoring process will continue with each new discharge for three months or until the pattern of compliance is maintained. All findings from the PIP will be presented at the monthly Quality Assurance Assessment (QAA- assessment that coordinates and evaluate activities under the QAPI program) meeting. On 9/14/2023 at 5:01 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ removal plan, the SSA removed the IJ situation in the presence of the Regional Director and RNC. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 8/11/2023 and with diagnoses including end stage renal disease (ESRD- kidneys no longer function well enough to meet the needs of daily life), dependent on hemodialysis (HD - a procedure that helps removes waste from the blood when the kidneys can no longer do their job), pleural effusion (water in the lungs) and acute embolism (blood clots). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/20/2023, indicated that Resident 1 had intact cognition (ability to think and make decisions). The MDS further indicated that Resident 1 required the use of oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen). A review of Resident 1 ' s IDT Care Conference form dated 9/5/2023, timed at 3:51 p.m., indicated that an IDT meeting was conducted with FM 1, Family Member 2 (FM 2), DON, DSS, and Social Service Assistant. The IDT Care Conference form indicated that FM 1 and FM 2 requested for Resident 1 to be discharged to the Board and Care 1 (BC 1) however, due to Resident 1 ' s complex medical conditions, BC 1 was unable to accept Resident 1. The IDT Care Conference form indicated that FM 1 and FM 2 then requested that Resident 1 be discharged to FM 1 ' s home. A review of Resident 1 ' s Physician Orders indicated orders for the following: a. Oxygen via nasal cannula (NC- a medical device that delivers extra oxygen through a tube and into the nose) at two liters (L- unit of measure) per minute, may titrate (to increase or decrease the amount of oxygen being delivered) oxygen to maintain oxygen saturation (level of oxygen in the blood) greater or equal to 92 percent (%- unit of measure; a normal level of oxygen saturation is between 95% to 100%) every shift for shortness of breath (difficult or labored breathing) dated 8/11/2023. b. Discharge home as per resident and family request on 9/6/2023 with home health agency (HHA - skilled care or services that are provided to a resident while at home by a licensed health care professional): Physical therapy (PT- a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts), Occupational therapy (OT- rehabilitation services to help resident to live their lives more independently), Registered Nurse (RN), Home health aide (HH aide- a medical professional who is responsible for helping their clients with everyday tasks) need for 24 hours and seven (7) days a week caregiver. DME: front wheel walker (a device that helps with walking and lowers the risk for falls), wheelchair (chair with wheels to help people move around), shower bench (bath safety device on which the user sits to get into a bathtub) and to follow up with primary physician in one week dated 9/6/2023. During a record review of Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023, noted was that the form was blank. There was no documentation that a follow-up appointment for a physician visit was made; no documentation HHA was arranged which includes PT. OT, RN, HH aide visit; no documentation DME needs were sent or will be delivered and there was no documented evidence of special training instructions provided to Resident 1 and FM 1. During a record review of Resident 1 ' s Paramedic Report (PR) dated 9/6/2023 timed at 6:47 p.m., the PR indicated that Resident 1 complained of cough and congestion (excess fluid blocks airflow, making it difficult to breathe) for seven (7) hours. The PR indicated Resident 1 is normally on oxygen. The PR indicated Resident 1 ' s medical complaints occurred when Resident 1 did not have any oxygen at home and there was no delivery of oxygen once Resident 1 was home. The PR further indicated that Resident 1 required transfer to GACH 1 from home. A review of Resident 1 ' s GACH 1 Emergency Department (ER) Reports dated 9/6/2023 and timed at 10:53 p.m., indicated that Resident 1 was brought from FM 1 ' s home for concerns of shortness of breath and cough. The report indicated that Resident 1 has been on oxygen therapy while previously admitted at the facility, but the facility did not arrange for any home oxygen therapy. The report indicated that FM 1 called 911 (an emergency response and disaster preparedness system that dispatches medical personnel for emergency situation). The report indicated that Resident 1 was initially found with her oxygen saturation levels to be 80% to 85%. The report indicated that Resident 1 showed improvement to oxygen saturation levels up to the mid 90% after being provided with supplemental oxygen. The report indicated a diagnosis for Resident 1 with cough, hypoxia, and pneumonia (an infection that inflames the air sacs in one or both lungs). During an interview on 9/8/2023 at 2:19 p.m. with LVN 1, LVN 1 stated that on 9/6/2023, Resident 1 was discharged to FM 1 ' s home. LVN 1 stated that he was not aware that Resident 1 was to be discharged on [DATE] until DSS told LVN 1 that Resident 1 was to be discharged after HD. LVN 1 stated that Resident 1 required continuous oxygen via NC while in the facility. LVN 1 stated that he was not aware that Resident 1 did not have the needed oxygen therapy equipment ready at home. LVN 1 further stated that he did not provide Resident 1 or FM 1 with oxygen therapy equipment, nor did he provide teaching to Resident 1 and FM 1 regarding the use and need of oxygen therapy equipment. LVN 1 stated that if he had known that Resident 1 did not have her needed oxygen therapy equipment at home, he would have not sent her home because it would not be a safe discharge as Resident 1 needed continuous oxygen therapy. During an interview on 9/12/2023 at 9:56 a.m. with the Admission Coordinator (AC), AC stated that on 9/6/2023 at around 5:45 p.m., the DON asked her to drop off an oxygen concentrator (a medical device that gives you extra oxygen) at FM 1 home. AC stated that she arrived at FM 1 ' s home at around 7:05 p.m. on 9/6/2023. AC stated that when she called to notify FM 1 that she was outside FM 1 ' s house to drop off Resident 1 ' s oxygen concentrator, FM 1 told her that it was too late, and that Resident 1 needed to be transferred to GACH 1. During an interview on 9/12/2023 at 10:05 a.m. with DSS, DSS stated that on 9/5/2023, Resident 1, FM 1 and FM 2 requested for Resident 1 to be discharged from the facility. DSS stated that Resident 1, FM 1 and FM 2 were insistent that Resident 1 be discharged to FM 1 ' s home on 9/6/2023 after HD. DSS stated that Resident 1 ' s physician was notified, and that the physician had ordered to discharge Resident 1 home with DME and HHA. DSS stated that Resident 1 should have been provided with supplemental oxygen therapy equipment prior to being discharged to FM 1 ' s home on 9/6/2023. The DSS stated that the facility ' s nursing staff was supposed to provide Resident 1 with a supplemental oxygen therapy equipment and a front wheel walker (FWW- a medical device to help residents walk) before discharging Resident 1 from the facility. The DSS stated that she was not aware that the supplemental oxygen therapy equipment was not provided to Resident 1 upon discharge. The DSS further stated that if a resident and or family member of a resident insists on being discharged prior to obtaining needed DMEs such as oxygen therapy equipment, the resident ' s physician should be notified. DSS stated that if the resident and or family member continued to insist on being discharged despite the lack of needed DME, the facility should have informed that resident and or family member that leaving would be considered AMA. During an interview on 9/12/2023 at 11:31 a.m. with FM 1, FM 1 stated that Resident 1 was discharged home on 9/6/2023 after her HD treatment. FM 1 stated that when FM 1 went to the facility on the morning of 9/6/2023, the facility had only given her a paper to sign along with Resident 1 ' s medication. FM 1 stated that the facility did not provide her nor Resident 1 with any oxygen therapy equipment. FM 1 further stated that she was not provided any teachings regarding the use of oxygen equipment. FM 1 stated that she was not informed by facility staff that Resident 1 needed oxygen therapy at home. FM 1 stated that had the facility informed her of Resident 1 ' s need for oxygen therapy, FM 1 would not have agreed to have Resident 1 discharged from the facility. FM 1 stated that on 9/6/2023 upon Resident 1 ' s arrival at FM 1 ' s home sometime between 12:00 p.m. and 1:00 p.m., Resident 1 started experiencing shortness of breath. FM 1 stated that they had called the facility and spoke to the DON, unable to recall exact time, informing the DON that Resident 1 was complaining of shortness of breath. FM 1 stated that the DON had informed her that a facility staff will deliver oxygen therapy equipment to FM 1 ' s house. FM 1 stated that they could not wait for the oxygen therapy equipment to be delivered and had to call 911 at approximately 6:30 p.m. on 9/6/2023. FM 1 stated that AC had arrived at her house at approximately 7:00 p.m. FM 1 stated that she had informed AC that it was too late, and that Resident 1 had to be emergently transferred to GACH 1. During an interview on 9/12/2023 at 12:06 p.m. with Medical Doctor 1 (MD 1- Resident 1 ' s physician), MD 1 stated that on 9/6/2023, the facility had informed him that Resident 1 and her family had requested to be discharged to FM 1 ' s home. MD 1 stated that he provided the facility with the order to discharge Resident 1 to FM 1 ' s home with all necessary DMEs including the needed oxygen therapy equipment on 9/6/2023. MD 1 stated that he had not been made aware by the facility that Resident 1 was being discharged to FM 1 ' s home without the needed oxygen therapy equipment. MD 1 stated that had he known that Resident 1 was being discharged without the needed oxygen therapy equipment, MD 1 would not have agreed with the discharge because it would not be considered a safe discharge. During a concurrent interview and record review on 9/13/2023 at 2:59 p.m. with DSS, the facility ' s policy and procedure titled Abuse, Neglect and Exploitation last reviewed on 7/12/2023, was reviewed. The DSS stated that the facility failed to provide goods and services to Resident 1 which included ensuring Resident 1 had the needed oxygen therapy equipment prior to Resident 1 being discharged to FM 1 ' s home. DSS stated that the oxygen therapy equipment is of vital importance for Resident 1 to have at home. DSS stated that it was negligent (failing to take proper care or action in doing something) for the facility to discharge Resident 1 to FM 1 ' s home without confirming that the resident had the needed oxygen therapy equipment at home. During a concurrent interview and record review with the Medical Record Director (MRD) on 9/15/2023 at 9:35 a.m., Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was reviewed. MRD stated that Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was blank. The MRD further stated there was no documented evidence that the facility staff arranged for Resident 1 ' s follow up physician visit as well as no documented evidence that arrangements were made for a home health agency to follow up with Resident 1 after discharge including DMEs needed. A review of facility ' s policy and procedure titled Abuse, Neglect and Exploitation, reviewed on 7/12/2023, indicated that it is the policy of the 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 policy further indicated that neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1) who required the need for continuous supplemental oxygen (therapy that helps people with lung disease or breathing problems get the oxygen [a colorless, odorless gas, an essential component of air] their bodies need to function) by: 1. Failing to ensure that Resident 1 and Family Member 1 (FM 1) were provided durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which includes supplemental oxygen equipment [medical device that gives resident ' s extra oxygen] and front wheel walker [FWW - a device that helps with walking and lowers the risk for falls]) prior to discharging resident home. 2. Failing to ensure that the facility provided health teaching related to supplemental oxygen equipment use and safety, FWW use, home health agency (HHA - skilled care or services that are provided to a resident while at home by a licensed health care professional) arrangement and physician follow up appointment to Resident 1 and FM 1. 3. Failing to ensure the nursing staff notified Medical Doctor 1 (MD 1) about Resident 1 ' s wishes to be discharged to a setting that does not appear to meet her post-discharge needs and unsafe discharge. These deficient practices resulted in Resident 1 experiencing an episode of hypoxia (low levels of oxygen in the blood) while at home on 9/6/2023, the same day Resident 1 was discharged from the facility. Resident 1 required emergency transfer to General Acute Care Hospital 1 (GACH 1) as a result of the oxygen deprivation (absence of enough oxygen in the tissues to sustain bodily functions). On 9/12/2023 at 3:40 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Assistant Director of Nursing (ADON) due to the facility ' s failure to ensure Resident 1 was provided a safe and orderly discharged when the facility discharged Resident 1 to FM 1 ' s home without the needed supplemental oxygen equipment. On 9/14/2023 at 4:46 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: 1. Resident 1 no longer resides at the facility as of 9/6/2023. 2. One to One (1:1- one trainer assigned to one employee to provide training) in-service was provided by the ADM to the Director of Social Services (DSS) regarding implementation for safe discharges specifically for arranging any DME (if needed) prior to discharge of residents on 9/12/2023. 3. 1:1 in-service was provided by the Director of Staff Development (DSD) to Licensed Vocational Nurse 1 (LVN 1) and the Director of Nurses (DON) to ensure proper discharge instructions for DMEs to resident and or resident ' s responsible party are completed and documented in the resident ' s record on 9/13/2023. The Resource Nurse Consultant (RNC) will provide the DON with an in-person in service prior reporting to the floor after the DON ' s vacation. The DSD provided an in-person in-service training to LVN 1 on 9/14/2023. 4. An audit of all discharge documentation such pertaining to DMEs like oxygen, for the last 30 days were completed by the DON and/or designee to determine if any other residents were discharged without proper DME. 5. A total of 20 discharged residents were reviewed and completed with no concerns identified on 9/12/2023 based on the audit of the previously discharged residents with other DME. 6. All discharges planned within the next five (5) days were reviewed by the ADM, ADON, DSS and the Director of Rehabilitation (DOR) to ensure proper DMEs such as oxygen, is arranged prior to discharge. This audit was completed on 9/12/2023 and will be on-going with the audit tool. 7. Two (2) residents (Resident 3 and Resident 11) were identified with a projected discharge date of [DATE] and the need of oxygen DME will be provided as ordered. 8. The DSS will coordinate care plan meetings for residents and or resident ' s responsible party seeking discharge. Resident ' s goals, barriers to discharge, safety concerns, and all other issues will be discussed with the resident and or their responsible party. 9. The DSS will ensure that the resident will have proper DME. Residents will not be discharged without participating in a meeting and all discussion will be documented in the resident ' s medical record. The facility process in the event the resident and or responsible party insist to be discharge and DMEs are not set up will be the DSS or designee will provide education on risks and benefits, and or offer the resident a leave Against Medical Advice (AMA- when a resident insist on being discharged from the facility despite safety concerns related to their medical issues). The DSS will also contact the resident ' s physician, and adult protective services (APS- a social services program that serves older adults and adults with disabilities who are in need of assistance). 10. The DON or designee will oversee resident and DSS to ensure proper DME is being arranged three (3) days prior to a resident ' s discharge home in a manner in which the resident and responsible party can understand. 11. Weekly case management meetings will take place and will be attended by the ADM, DON, DSS, and the DOR. Residents with planned discharge date s within seven (7) days will be reviewed to facilitate an orderly and safe discharge. 12. Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their resident) will meet with the resident and or the resident ' s responsible party with planned discharge to discuss current status of the resident, health teachings, goals, DMEs needed and appropriate referrals a week prior discharge. 13. The RNC provided education to department heads on regulations surrounding safe discharges and facility policy and procedure on 9/13/2023. This education will become part of new hire education for department heads and licensed nurses will also be conducted annually. 14. The RNC, DON and or designee provided education to licensed nurses on regulations surrounding discharge planning and facility policy and procedure focusing on DME needs especially oxygen and supplies on 9/12/2023. Licensed nurses who were not able to attend the in service will be provided with reeducation on their next scheduled shift. 15. A Quality Assurance and Performance Improvement (QAPI- data driven and proactive approach to quality improvement) Performance Improvement Projects (PIP- a concentrated effort on a particular problem in one area of the facility) to ensure safe and orderly resident discharges, as well as the continued safety and well-being of the resident once they have returned home. The DSS or designee will contact the resident or their representative within seven days post-discharge to ensure the resident is safe at home. This monitoring process will continue with each new discharge for three months or until the pattern of compliance is maintained. All findings from the PIP will be presented at the monthly Quality Assurance Assessment (QAA- assessment that coordinates and evaluate activities under the QAPI program) meeting. On 9/14/2023 at 5:01 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ removal plan, the SSA removed the IJ situation in the presence of the Regional Director and RNC. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 8/11/2023 and with diagnoses including end stage renal disease (ESRD- kidneys no longer function well enough to meet the needs of daily life), dependent on Hemodialysis (HD- a procedure that helps removes waste from the blood when the kidneys can no longer do their job), pleural effusion (water on the lungs) and acute embolism (blood clots). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/20/2023, indicated that Resident 1 had intact cognition (ability to think and make decisions). The MDS further indicated that Resident 1 required the use of oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen). A review of Resident 1 ' s Physician Orders indicated orders for the following: a. Oxygen via nasal cannula (NC- a medical device that delivers extra oxygen through a tube and into the nose) at two liters (L- unit of measure) per minute, may titrate (to increase or decrease the amount of oxygen being delivered) oxygen to maintain oxygen saturation (level of oxygen in the blood) greater or equal to 92 percent (%- unit of measure; a normal level of oxygen saturation is between 95% to 100%) every shift for shortness of breath (difficult or labored breathing) dated 8/11/2023. b. Discharge home as per resident and family request on 9/6/2023 with HHA: Physical therapy (PT- a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts), Occupational therapy (OT- rehabilitation services to help resident to live their lives more independently), Registered Nurse (RN), Home health aide (HH aide- a medical professional who is responsible for helping their clients with everyday tasks) need for 24 hours and seven (7) days a week caregiver. DME: front wheel walker, wheelchair (chair with wheels to help people move around), shower bench (bath safety device on which the user sits to get into a bathtub) and to follow up with Primary physician in one week dated 9/6/2023. A review of Resident 1 ' s IDT Care Conference form dated 9/5/2023, timed at 3:51 p.m., indicated that an IDT meeting was conducted with FM 1, Family Member 2 (FM 2), DON, DSS, and Social Service Assistant. The IDT Care Conference form indicated that FM 1 and FM 2 requested for Resident 1 to be discharged to the Board and Care 1 (BC 1) however, due to Resident 1 ' s complex medical conditions, BC 1 was unable to accept Resident 1 because of the level of care Resident 1 required. The IDT Care Conference form indicated that FM 1 and FM 2 then requested that Resident 1 be discharged to FM 1 ' s home. During a review of Resident 1 ' s care plans from 8/11/2023 to 9/6/2023, there were no care plans for Resident 1 ' s discharge plans that addresses Resident 1 ' s goals and discharge needs were found. During a review of Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023, the form was blank. There was no documentation that a follow-up appointment for a physician visit was made, no documentation HHA was arranged which includes PT. OT, RN, HH aide visit, no documentation DME needs were sent or will be delivered and there was no documented evidence of special training instructions provided to Resident 1 and FM 1. During a review of Resident 1 ' s Paramedic Report (PR) dated 9/6/2023 timed at 6:47 p.m., the PR indicated that Resident 1 complained of cough and congestion (excess fluid blocks airflow, making it difficult to breathe) for seven (7) hours. The PR indicated Resident 1 is normally on oxygen. The PR indicated Resident 1 ' s medical complaints occurred when Resident 1 did not have any oxygen at home and there was no delivery of oxygen once Resident 1 was home. The PR further indicated that Resident 1 required transfer to GACH 1 from home. A review of Resident 1 ' s GACH 1 Emergency Department (ER) Reports dated 9/6/2023 and timed at 10:53 p.m., indicated that Resident 1 was brought from FM 1 ' s home for concerns of shortness of breath and cough. The report indicated that Resident 1 has been on oxygen therapy while previously admitted at the facility, but the facility did not arrange for any home oxygen therapy. The report indicated that FM 1 called 911 (an emergency response and disaster preparedness system that dispatches medical personnel for emergency situation). The report indicated that Resident 1 was initially found with her oxygen saturation levels to be 80% to 85%. The report indicated that Resident 1 showed improvement to oxygen saturation levels up to the mid 90% after being provided with supplemental oxygen. The report indicated a diagnosis for Resident 1 with cough, hypoxia, and pneumonia (an infection that inflames the air sacs in one or both lungs). During an interview on 9/8/2023 at 2:19 p.m. with LVN 1, LVN 1 stated that on 9/6/2023, Resident 1 was discharged home. LVN 1 stated that he was not aware that resident was going home on 9/6/2023, but the DSS told him that Resident 1 was to be discharged home after HD. LVN 1 stated that he provided discharge instruction to FM 1 regarding Resident 1 ' s medications on the morning of 9/6/2023. LVN 1 stated that Resident 1 required continuous oxygen via NC while in the facility. LVN 1 stated that he was not aware that Resident 1 did not have oxygen therapy equipment ready at home. LVN 1 further stated that he did not provide Resident 1 or FM 1 with oxygen therapy equipment, nor did he provide teaching to Resident 1 and FM 1 regarding the use and need of oxygen therapy equipment or FWW. LVN 1 stated that if he had known that Resident 1 did not have her needed oxygen therapy equipment at home, he would have not sent her home because it would not be a safe discharge as Resident 1 needed continuous oxygen therapy. During an interview on 9/12/2023 at 9:56 a.m. with the Admission Coordinator (AC), AC stated that on 9/6/2023 at around 5:45 p.m., the DON asked her to drop off an oxygen concentrator (a medical device that gives you extra oxygen) at FM 1 home. AC stated that she arrived at FM 1 ' s home at around 7:05 p.m. on 9/6/2023. AC stated that when she called to notify FM 1 that she was outside FM 1 ' s house to drop off Resident 1 ' s oxygen concentrator, FM 1 told her that it was too late, and that Resident 1 needed to be transferred to GACH 1. During a concurrent interview and record review on 9/12/2023 at 10:05 a.m. with DSS, Resident 1 ' s progress notes and social service notes from 8/11/2023 to 9/6/2023 were reviewed. DSS stated that there was no documented evidence found that Resident 1 or Resident 1 ' s Responsible Party were provided education on Resident 1 ' s discharge needs. DSS stated that on 9/5/2023, Resident 1, FM 1 and FM 2 requested for Resident 1 to be discharged from the facility. DSS stated that Resident 1, FM 1 and FM 2 were insistent that Resident 1 be discharged to FM 1 ' s home on 9/6/2023 after HD. DSS stated that Resident 1 ' s physician was notified, and that the physician had ordered to discharge Resident 1 home with DME and HHA. The DSS stated that Resident 1 should have been provided with supplemental oxygen therapy equipment prior to being discharged to FM 1 ' s home on 9/6/2023. The DSS stated that the facility ' s nursing staff was supposed to provide Resident 1 with a supplemental oxygen therapy equipment and a FWW before discharging Resident 1 from the facility. The DSS stated that she was not aware that the supplemental oxygen therapy equipment was not provided to Resident 1 upon discharge. The DSS further stated that if a resident and or family member of a resident insists on being discharged prior to obtaining needed DME such as oxygen therapy equipment, the resident ' s physician should be notified and if the resident and or family member continued to insist on being discharged despite the lack of needed DME, the facility should have informed that resident and or family member that leaving would be considered AMA. During an interview on 9/12/2023 at 11:31 a.m. with FM 1, FM 1 stated that Resident 1 was discharged home on 9/6/2023 after having completed her HD treatment. FM 1 stated that when she went to the facility on the morning of 9/6/2023, the facility had only given her a paper to sign along with Resident 1 ' s medication. FM 1 stated that the facility did not provide her nor Resident 1 with any oxygen therapy equipment. FM 1 further stated that she was not provided any teachings regarding the use of oxygen equipment. FM 1 stated that she was not informed by facility staff that Resident 1 needed oxygen therapy at home. FM 1 stated that had the facility informed her of Resident 1 ' s need for oxygen therapy, FM 1 would not have agreed to have Resident 1 discharged from the facility. FM 1 stated that on 9/6/2023 upon Resident 1 ' s arrival at FM 1 ' s home sometime between 12:00 p.m. to 1:00 p.m. Resident 1 started experiencing shortness of breath. FM 1 stated that they had called the facility and spoke to the DON, unable to recall exact time, informing the DON that Resident 1 was complaining of shortness of breath. FM 1 stated that the DON had informed her that a facility staff will deliver oxygen therapy equipment to FM 1 ' s house. FM 1 stated that they could not wait for the oxygen therapy equipment to be delivered and had to call 911 at approximately 6:30 p.m. on 9/6/2023. FM 1 stated that AC had arrived at her house at approximately 7:00 p.m. FM 1 stated that she had informed AC that it was too late, and that Resident 1 had to be emergently transferred to GACH 1. During an interview on 9/12/2023 at 12:06 p.m. with MD 1, MD 1 stated that on 9/6/2023, the facility had informed him that Resident 1 and her family had requested to be discharged to FM 1 ' s home. MD 1 stated that he provided the facility with the order to discharge Resident 1 to FM 1 ' s home with all necessary equipment including the needed oxygen therapy equipment on 9/6/2023. MD 1 stated that he had not been made aware by the facility that Resident 1 was being discharged to FM 1 ' s home without the needed oxygen equipment. MD 1 stated that had he known that Resident 1 was being discharged without the needed oxygen equipment, MD 1 would not agree with the discharge because it would not be considered a safe discharge. During an interview on 9/12/2023 at 1:21 p.m. with DON, the DON stated that on 9/6/2023, Resident 1 and FM 1 insisted for Resident 1 to be discharge to FM 1 ' s home without the proper DME. The DON stated that Resident 1 needed continuous supplemental oxygen therapy while at the facility. The DON stated that she spoke to MD 1 and that MD 1 ordered for Resident 1 to be discharged with all the necessary equipment including the oxygen therapy equipment. The DON stated that Resident 1 was supposed to be provided with an oxygen concentrator and a FWW before Resident 1 was to be discharged from the facility. The DON stated that she was not aware that FM 1 had not been provided with an oxygen concentrator or FWW on 9/6/2023. The DON stated that it is the discharging nurse ' s responsibility to provide health teachings and special instructions to the resident and or family member regarding the need for oxygen therapy and safety prior to going home. During a concurrent interview and record review on 9/14/2023 at 11:02 a.m. with the ADON, Resident 1 ' s care plans from 8/11/2023 until 9/6/2023 were reviewed. ADON stated that Resident 1 did not have any care plan regarding discharge plans that addresses Resident 1 ' s goals and discharge needs. The ADON further stated a resident- centered care plan regarding discharge plans that addresses Resident 1 ' s goals and discharge needs should have been developed upon admission to ensure a smooth and safe transition. During a concurrent interview and record review with the Medical Record Director (MRD) on 9/15/2023 at 9:35 a.m., Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was reviewed. MRD stated that Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was blank. The MRD further stated there was no documented evidence that the facility staff arranged for Resident 1 ' s follow up physician visit as well as no documented evidence that arrangements were made for a home health agency to follow up with Resident 1 after discharge including DMEs needed. A review of the facility ' s policy and procedure titled Transfer and Discharge last reviewed and or revised on 12/19/2022, indicated that it is the policy of the facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident form the facility, except in limited circumstances. The policy indicated that for resident-initiated discharges: a. Obtain physician ' s orders for discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident ' s stay that includes diagnoses, course of illness, treatment or therapy, and pertinent laboratory, radiology (use of imaging technology to diagnose and treat an illness) and consultation results. ii. A final summary of the resident ' s status. iii. Reconciliation of all pre-discharge medications with the resident ' s post discharge medications. iv. A post discharge plan of care that is developed with the participation of the resident, and the resident ' s representative(s) which will assist the resident to adjust to his or her new living environment. c. Orientation for discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. e. The comprehensive, person-centered care plan shall contain the resident ' s goals for admission and desired outcomes and shall be in alignment with the discharge. g. Supporting documentation shall include evidence of the resident ' s or resident representative ' s verbal or written notice of intent to leave the facility, a discharge plan and documented discussions with the resident and/or resident representative.

Based on interview and record review, the facility failed to ensure an effective discharge plan to meet the health and safety need was provided to one of three sampled residents (Resident 1) by: 1. Failing to ensure that Resident 1 and Family Member 1 (FM 1) were provided durable medical equipment (DME- equipment and supplies ordered by healthcare provider for everyday use which includes supplemental oxygen equipment [medical device that gives resident ' s extra oxygen] and front wheel walker [FWW - a device that helps with walking and lowers the risk for falls]) prior to discharging resident home. 2. Failing to ensure that facility staff provided health teaching related to supplemental oxygen equipment use and safety, FWW use, home health agency (HHA - skilled care or services that are provided to a resident while at home by a licensed health care professional) arrangement, and physician follow up appointment to Resident 1 and FM 1. 3. Failing to ensure that the facility developed an individualized resident centered discharge care plan that addressed Resident 1 ' s goals and discharge needs to assure a smooth and safe transition from the facility to FM 1 ' s home. 4. Failing to ensure the nursing staff notified Medical Doctor 1 (MD 1) about Resident 1 ' s wishes to be discharged to a setting that does not appear to meet Resident 1 ' s post-discharge needs and unsafe discharge. These deficient practices resulted in Resident 1 experiencing an episode of hypoxia (low levels of oxygen in the blood) while at home on 9/6/2023, the same day Resident 1 was discharged from the facility. Resident 1 required emergency transfer to General Acute Care Hospital 1 (GACH 1) as a result of the oxygen deprivation (absence of enough oxygen in the tissues to sustain bodily functions). On 9/12/2023 at 3:40 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Assistant Director of Nursing (ADON) due to the facility ' s failure to ensure Resident 1 was provided with an effective discharge plan that met the health and safety needs of Resident 1 when the resident was discharged to FM 1 ' s home without the needed supplemental oxygen equipment, FWW, needed health teachings, and without making arrangements for a needed HHA and physician follow up visit. On 9/14/2023 at 4:46 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: 1. Resident 1 no longer resides at the facility as of 9/6/2023. 2. One to One (1:1- one trainer assigned to one employee to provide training) in-service was provided by the ADM to the Director of Social Services (DSS) regarding the importance of effective discharge planning including arranging any DME (if needed) prior to discharge of residents on 9/12/2023. 3. 1:1 in-service was provided by the Director of Staff Development (DSD) to Licensed Vocational Nurse 1 (LVN 1) and the Director of Nurses (DON) to ensure proper discharge instructions for DMEs to resident and or resident ' s responsible party are completed and documented in the resident ' s record on 9/13/2023. The Resource Nurse Consultant (RNC) will provide the DON with an in-person in service prior to reporting to the floor after the DON ' s vacation. The DSD provided an in-person in-service training to LVN 1 on 9/14/2023. 4. An audit of all discharge documentation which included discharge orders, baseline care plan, social service assessment discharge plan, pertaining to DMEs such as oxygen and FWW for the last 30 days were completed by the DON and/or designee to determine if any other residents were discharged without proper DME. 5. A total of 20 discharged residents were reviewed and completed with no concerns identified on 9/12/2023 based on the audit of the previously discharged residents with other DME. 6. All discharges planned within the next five (5) days were reviewed by the ADM, ADON, DSS and the Director of Rehabilitation (DOR) to ensure proper DMEs such as oxygen and FWW were arranged prior to discharge. This audit was completed on 9/12/2023 and will be on-going with the audit tool. 7. Two (2) residents (Resident 3 and Resident 11) were identified with a projected discharge date of [DATE] and the need of oxygen DME will be provided as ordered. 8. The DSS will coordinate care plan meetings for residents and or resident ' s responsible party seeking discharge. Resident ' s goals, barriers to discharge, safety concerns, and all other issues will be discussed with the resident and or their responsible party. 9. The DSS will ensure that the resident will have proper DME. Residents will not be discharged without participating in a meeting and all discussion will be documented in the resident ' s medical record. The facility process in the event the resident and or responsible party insist on being discharge and DMEs are not set up will be that the DSS or designee will provide education on risks and benefits, and or offer the resident a leave Against Medical Advice (AMA- when a resident insist on being discharged from the facility despite safety concerns related to their medical issues). The DSS will also contact the resident ' s physician, and adult protective services (APS- a social services program that serves older adults and adults with disabilities who are in need of assistance). 10. The DON or designee will oversee resident and DSS to ensure proper DME is being arranged three (3) days prior to a resident ' s discharge home in a manner in which the resident and responsible party can understand. 11. Weekly case management meetings will take place and will be attended by the ADM, DON, DSS, and the DOR. Residents with planned discharge date s within seven (7) days will be reviewed to facilitate an orderly and safe discharge. 12. Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their resident) will meet with the resident and or the resident ' s responsible party with planned discharge to discuss current status of the resident, health teachings, goals, DMEs needed and appropriate referrals a week prior discharge. 13. The RNC provided education to department heads on regulations surrounding safe discharges and facility policy and procedure on 9/13/2023. This education will become part of new hire education for department heads and licensed nurses will also be conducted annually. 14. The RNC, DON and or designee provided education to licensed nurses and IDT members regarding effective discharge planning on 9/12/2023 and 9/13/2023. IDT members and licensed nurses who were not able to attend the in-service will be provided with reeducation on their next scheduled shift. 15. A Quality Assurance and Performance Improvement (QAPI- data driven and proactive approach to quality improvement) Performance Improvement Projects (PIP- a concentrated effort on a particular problem in one area of the facility) to ensure safe and orderly resident discharges, as well as the continued safety and well-being of the resident once they have returned home. The DSS or designee will contact the resident or their representative within seven days post-discharge to ensure the resident is safe at home. This monitoring process will continue with each new discharge for three months or until the pattern of compliance is maintained. All findings from the PIP will be presented at the monthly Quality Assurance Assessment (QAA- assessment that coordinates and evaluate activities under the QAPI program) meeting. On 9/14/2023 at 5:01 p.m. while onsite and after verifying the facility ' s full implementation of the accepted IJ removal plan, the SSA removed the IJ situation in the presence of the Regional Director and RNC. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 8/11/2023 and with diagnoses including end stage renal disease (ESRD- kidneys no longer function well enough to meet the needs of daily life), dependent on hemodialysis (HD - a procedure that helps removes waste from the blood when the kidneys can no longer do their job), pleural effusion (water on the lungs) and acute embolism (blood clots). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/20/2023, indicated that Resident 1 had intact cognition (ability to think and make decisions). The MDS also indicated that Resident 1 needed extensive assistance from staff with bed mobility (how resident moves to and from lying position, turn side to side and positions while in bed), locomotion (how resident moves between locations) on and off the unit, dressing and personal hygiene. The MDS further indicated that Resident 1 required the use of oxygen therapy (a treatment that provides you with supplemental, or extra oxygen). Further review of Resident 1 ' s MDS indicated that Resident 1 and Resident 1 ' s family member participated in assessment and goal setting. The MDS indicated that Resident 1expects to be discharged to another facility and or institution and that there was an on-going active discharge planning occurring for Resident 1 to return to the community. A review of Resident 1 ' s Physician Orders indicated orders for the following: a. Oxygen via nasal cannula (NC- a medical device that delivers extra oxygen through a tube and into the nose) at two liters (L- unit of measure) per minute, may titrate (to increase or decrease the amount of oxygen being delivered) oxygen to maintain oxygen saturation (level of oxygen in the blood) greater or equal to 92 percent (%- unit of measure; a normal level of oxygen saturation is between 95% to 100%) every shift for shortness of breath (difficult or labored breathing) dated 8/11/2023. b. Discharge home as per resident and family request on 9/6/2023 with HHA: Physical therapy (PT- a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts), Occupational therapy (OT- rehabilitation services to help resident to live their lives more independently), Registered Nurse (RN), Home health aide (HH aide- a medical professional who is responsible for helping their clients with everyday tasks) need for 24 hours and seven (7) days a week caregiver. DME: front wheel walker, wheelchair (chair with wheels to help people move around), shower bench (bath safety device on which the user sits to get into a bathtub) and to follow up with Primary physician in one week dated 9/6/2023. A review of Resident 1 ' s IDT Care Conference form dated 9/5/2023, timed at 3:51 p.m., indicated that an IDT meeting was conducted with FM 1, Family Member 2 (FM 2), DON, DSS, and Social Service Assistant. The IDT Care Conference form indicated that FM 1 and FM 2 requested for Resident 1 to be discharged to the Board and Care 1 (BC 1) however, due to Resident 1 ' s complex medical conditions, BC 1 was unable to accept Resident 1 because of the level of care Resident 1 required. The IDT Care Conference form indicated that FM 1 and FM 2 then requested that Resident 1 be discharged to FM 1 ' s home. During a review of Resident 1 ' s care plans from 8/11/2023 to 9/6/2023, there were no care plans for Resident 1 ' s discharge plans that addresses Resident 1 ' s goals and discharge needs were found. During a review of Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023, the form was blank. There was no documentation that a follow-up appointment for a physician visit was made, no documentation HHA was arranged which includes PT. OT, RN, HH aide visit, no documentation DME needs were sent or will be delivered and there was no documented evidence of special training instructions provided to Resident 1 and FM 1. During a review of Resident 1 ' s Paramedic Report (PR) dated 9/6/2023 timed at 6:47 p.m., the PR indicated that Resident 1 complained of cough and congestion (excess fluid blocks airflow, making it difficult to breathe) for seven (7) hours. The PR indicated Resident 1 is normally on oxygen. The PR indicated Resident 1 ' s medical complaints occurred when Resident 1 did not have any oxygen at home and there was no delivery of oxygen once Resident 1 was home. The PR further indicated that Resident 1 required transfer to GACH 1 from home. A review of Resident 1 ' s GACH 1 Emergency Department (ER) Reports dated 9/6/2023 and timed at 10:53 p.m., indicated that Resident 1 was brought from FM 1 ' s home for concerns of shortness of breath and cough. The report indicated that Resident 1 has been on oxygen therapy while previously admitted at the facility, but the facility did not arrange for any home oxygen therapy. The report indicated that FM 1 called 911 (an emergency response and disaster preparedness system that dispatches medical personnel for emergency situation). The report indicated that Resident 1 was initially found with her oxygen saturation levels to be 80% to 85%. The report indicated that Resident 1 showed improvement to oxygen saturation levels up to the mid 90% after being provided with supplemental oxygen. The report indicated a diagnosis for Resident 1 with cough, hypoxia, and pneumonia (an infection that inflames the air sacs in one or both lungs). During an interview on 9/8/2023 at 2:19 p.m. with LVN 1, LVN 1 stated that on 9/6/2023, Resident 1 was discharged home. LVN 1 stated that he was not aware that resident was going home on 9/6/2023, but the DSS told him that Resident 1 was to be discharged home after HD. LVN 1 stated that he only provided discharge instruction to FM 1 regarding Resident 1 ' s medications on the morning of 9/6/2023 and no other teaching related to DMEs or post discharge plan of care including follow up visits and home health agency arrangements were provided. LVN 1 stated that Resident 1 required continuous oxygen via NC while in the facility. LVN 1 stated that he was not aware that Resident 1 did not have oxygen therapy equipment ready at home. LVN 1 further stated that he did not provide Resident 1 or FM 1 with oxygen therapy equipment, nor did he provide teaching to Resident 1 and FM 1 regarding the use and need of oxygen therapy equipment. LVN 1 stated that if he had known that Resident 1 did not have her needed oxygen therapy equipment at home, he would have not sent her home because it would not be a safe discharge as Resident 1 needed continuous oxygen therapy. During an interview on 9/12/2023 at 9:56 a.m. with the Admission Coordinator (AC), AC stated that on 9/6/2023 at around 5:45 p.m., the DON asked her to drop off an oxygen concentrator (a medical device that gives you extra oxygen) at FM 1 home. AC stated that she arrived at FM 1 ' s home at around 7:05 p.m. on 9/6/2023. AC stated that when she called to notify FM 1 that she was outside FM 1 ' s house to drop off Resident 1 ' s oxygen concentrator, FM 1 told her that it was too late, and that Resident 1 needed to be transferred to GACH 1. During a concurrent interview and record review on 9/12/2023 at 10:05 a.m. with DSS, Resident 1 ' s progress notes and social service notes from 8/11/2023 to 9/6/2023 were reviewed. DSS stated that there was no documented evidence found that Resident 1 or Resident 1 ' s Responsible Party were provided education on Resident 1 ' s discharge needs. DSS stated that on 9/5/2023, Resident 1, FM 1 and FM 2 requested for Resident 1 to be discharged from the facility. DSS stated that Resident 1, FM 1 and FM 2 were insistent that Resident 1 be discharged to FM 1 ' s home on 9/6/2023 after HD. DSS stated that Resident 1 ' s physician was notified, and that the physician had ordered to discharge Resident 1 home with DME and HHA. The DSS stated that Resident 1 should have been provided with supplemental oxygen therapy equipment prior to being discharged to FM 1 ' s home on 9/6/2023. The DSS stated that the facility ' s nursing staff was supposed to provide Resident 1 with a supplemental oxygen therapy equipment and a FWW before discharging Resident 1 from the facility. The DSS stated that she was not aware that the supplemental oxygen therapy equipment was not provided to Resident 1 upon discharge. The DSS further stated that if a resident and or family member of a resident insists on being discharged prior to obtaining needed DME such as oxygen therapy equipment, the resident ' s physician should be notified and if the resident and or family member continued to insist on being discharged despite the lack of needed DME, the facility should have informed that resident and or family member that leaving would be considered AMA. During an interview on 9/12/2023 at 11:31 a.m. with FM 1, FM 1 stated that Resident 1 was discharged home on 9/6/2023 after having completed her HD treatment. FM 1 stated that when she went to the facility on the morning of 9/6/2023, the facility had only given her a paper to sign along with Resident 1 ' s medication. FM 1 stated that the facility did not provide her nor Resident 1 with any oxygen therapy equipment. FM 1 further stated that she was not provided any teachings regarding the use of oxygen equipment, needed follow up visits, and home health agency arrangements. FM 1 stated that she was not informed by facility staff that Resident 1 needed oxygen therapy at home. FM 1 stated that had the facility informed her of Resident 1 ' s need for oxygen therapy, FM 1 would not have agreed to have Resident 1 discharged from the facility. FM 1 stated that on 9/6/2023 upon Resident 1 ' s arrival at FM 1 ' s home sometime between 12:00 p.m. to 1:00 p.m. Resident 1 started experiencing shortness of breath. FM 1 stated that they had called the facility and spoke to the DON, unable to recall exact time, informing the DON that Resident 1 was complaining of shortness of breath. FM 1 stated that the DON had informed her that a facility staff will deliver oxygen therapy equipment to FM 1 ' s house. FM 1 stated that they could not wait for the oxygen therapy equipment to be delivered and had to call 911 at approximately 6:30 p.m. on 9/6/2023. FM 1 stated that AC had arrived at her house at approximately 7:00 p.m. FM 1 stated that she had informed AC that it was too late, and that Resident 1 had to be emergently transferred to GACH 1. During an interview on 9/12/2023 at 12:06 p.m. with MD 1, MD 1 stated that on 9/6/2023, the facility had informed him that Resident 1 and her family had requested to be discharged to FM 1 ' s home. MD 1 stated that he provided the facility with the order to discharge Resident 1 to FM 1 ' s home with all necessary equipment including the needed oxygen therapy equipment on 9/6/2023. MD 1 stated that he had not been made aware by the facility that Resident 1 was being discharged to FM 1 ' s home without the needed oxygen equipment. MD 1 stated that had he known that Resident 1 was being discharged without the needed oxygen equipment, MD 1 would not agree with the discharge because it would not be considered a safe discharge. During an interview on 9/12/2023 at 1:21 p.m. with DON, the DON stated that on 9/6/2023, Resident 1 and FM 1 insisted for Resident 1 to be discharged to FM 1 ' s home without the proper DME. The DON stated that Resident 1 needed continuous supplemental oxygen therapy while at the facility. The DON stated that she spoke to MD 1 and that MD 1 ordered for Resident 1 to be discharge with all the necessary equipment including the oxygen therapy equipment. The DON stated that Resident 1 was supposed to be provided by the facility staff with an oxygen concentrator and FWW before Resident 1 was to be discharged from the facility. The DON stated that she was not aware that FM 1 had not been provided an oxygen concentrator on 9/6/2023. The DON stated that it is the discharging nurse ' s responsibility to provide health teachings and special instructions to the resident and or family member regarding the need for oxygen therapy and safety prior to going home. During a concurrent interview and record review on 9/13/2023 at 2:59 p.m. with DSS, Resident 1 progress notes and care plans dated from 8/11/2023 to 9/6/2023 were reviewed; including Resident 1 ' s MDS dated [DATE]. The DSS stated that discharge planning for a resident starts upon admission and the discharge care planning should be based on the resident ' s preference and goals. The DSS stated that Resident 1 ' s MDS indicated Resident 1 wanted to return to the community. The DSS stated that community can mean a home, board and care (houses in residential neighborhoods that are equipped and staffed to care for a small number of residents) and or assisted living facility (communities that personalized care to residents in a residential setting). The DSS further stated that according to Resident 1 ' s MDS dated [DATE], the MDS indicated that there was an on-going active discharge planning occurring for Resident 1 to return to the community. The DSS was unable to find any documented evidence that there was a discharge plan developed upon Resident 1 ' s admission and throughout Resident 1 ' s stay in the facility. The DSS stated there should have been a discharge planning in place for Resident 1 and that the facility should have assessed and identified Resident 1 ' s needs before discharging Resident 1 to FM 1 ' s home. The DSS stated that she was not able to order the oxygen therapy equipment, made HH Agency arrangements and obtain the DMEs needed as ordered. The DSS stated that the licensed nurses should have explained to Resident 1 and FM 1 the risk involved with being discharged without the needed DMEs. The DSS further stated that the licensed nurses should have informed MD 1 of the unsafe discharge because the needed DME ' s including the oxygen therapy equipment have not been ordered and discharge arrangements including HH Agency, and physician follow-up visit were not set-up. During a concurrent interview and record review on 9/14/2023 at 11:02 a.m. with the ADON, Resident 1 ' s care plans from 8/11/2023 until 9/6/2023 were reviewed. ADON stated that Resident 1 did not have any care plan regarding discharge plans that addresses Resident 1 ' s goals and discharge needs. The ADON further stated a resident- centered care plan regarding discharge plans that addresses Resident 1 ' s goals and discharge needs should have been developed upon admission to ensure a smooth and safe transition. During a concurrent interview and record review with the Medical Record Director (MRD) on 9/15/2023 at 9:35 a.m., Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was reviewed. MRD stated that Resident 1 ' s Post Discharge Plan of Care dated 9/6/2023 was blank. The MRD further stated there was no documented evidence that the facility staff arranged for Resident 1 ' s follow up physician visit as well as no documented evidence that arrangements were made for a home health agency to follow up with Resident 1 after discharge including DMEs needed. A review of the facility ' s policy and procedure titled Discharge Planning Process last reviewed and or revised on 12/29/2022, indicated that it is the policy of the facility to develop and implement an effective discharge planning process that focuses on the resident ' s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility will determine the resident ' s expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle and as needed. a. Initial information and discharge goals will be included in the resident ' s baseline care plan. b. Subsequent assessment information and discharge goals will be included in the resident ' s comprehensive plan of care. The Discharge Planning Process policy indicated that in cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a. The facility will discuss with the resident, (and or his or her representative, if applicable) and document the implications and or risks of being discharged to a location that is not equipped to meet her needs and attempt to ascertain why the resident is choosing that location. b. The facility will offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented. c. The facility will document refusals of other options that could meet the resident ' s needs. d. At time of discharge, the facility will follow polices regarding discharges against medical advice and refer to Adult Protective Services (or other state entity charged with investigation abuse and neglect), as necessary. The Discharge Planning Process policy indicated in discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented and will address, at a minimum the discharge destination, with assurances the destination meets the resident ' s health, safety needs and preferences including identified needs such as medical, nursing, equipment, educational or psychosocial needs; caregiver availability and capability to perform required care and resident ' s goals of care and treatment preferences. The Discharge Planning Process policy indicated the results of the evaluation, and the final discharge plan will be discussed with the resident or resident ' s representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident ' s discharge or transfer, and to assist the resident in adjustment to his or her new living environment. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1), Resident 1 ' s assigned one-to-one sitter (one staff remains with one resident at all times to prevent elopement [leaving the facility without notice or permission]), did not leave Resident 1 unsupervised on 8/20/2023. 2. Failing to ensure CNA 1 followed the facility policy and procedures to call a code grey (code used in the facility to alert all staff that a resident is missing) when CNA 1 first discovered Resident 1 missing on 8/20/2023. 3. Failing to ensure Certified Nursing Assistant 2 (CNA 2) did not turn off the facility wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) alarm on 8/20/2023 when it was on without first identifying the cause of the alarm. These deficient practices resulted in the neglect of Resident 1 when the resident was able to elope from the facility on 8/20/2023 after the resident had taken the personal vehicle keys of Licensed Vocational Nurse 1 (LVN 1) and used LVN 1 ' s vehicle to drive away from the facility. This had the potential to result in harm, injury, and or death. Resident 1 was found by Local Law Enforcement (LLE) on 8/21/2023 at approximately 5:09 p.m. in a park after Resident 1 had contacted Family Member 2 (FM 2). On 8/21/2023 at 6:09 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure staff did not act negligently towards Resident 1, when they failed to provide the necessary care and services to prevent elopement for Resident 1. On 8/23/2023 at 8:10 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: a. Facility staff conducted a facility search and perimeter search including the neighboring park and street for Resident 1 on 8/20/2023. b. FM 2 and Resident 1 ' s primary physician was notified on 8/20/2023 of the residents ' elopement. c. Facility staff reported the incident to LLE on 8/20/2023. d. Facility staff and the ADM called local hospitals inquiring if anybody was admitted matching Resident 1 ' s description starting on 8/20/2023 until Resident 1 was found on 8/21/2023 at approximately 5:09 p.m. e. FM 2 called the facility at approximately 4:23 p.m. on 8/21/2023 with the known location of Resident 1. At approximately 5:09 p.m. on 8/21/2023 Resident 1 was taken into custody by the LLE. f. CNA 1 assigned to Resident 1 on 8/20/2023 received a one-on-one in-service education as it relates to monitoring and supervising of assigned residents; abuse (cruel, violent or unfair treatment of a resident) prevention and neglect on 8/20/2023 by the ADM. g. CNA 1 and CNA 2 received a one-on-one (one teacher to one student) in-service education regarding immediate response to alarms on 8/23/2023 by the DON and ADM. h. Other staff working on 8/20/2023 received in-service regarding monitoring and supervision; immediate response to alarms, securement of personal belongings, and abuse prevention and neglect on 8/20/2023 by DON and or ADM. i. The Medical Director was notified on 8/20/2023 regarding Resident 1 ' s elopement. j. A head count (an act of counting the number of people at a place) was completed of in-house residents on 8/20/2023 by the ADM and found that all residents totaling 64 were accounted for. k. The DON, and designee(s) re-evaluated all residents for risk for elopement and wandering (to walk around without any clear purpose or direction) using an elopement risk assessment tool on 8/21/2023. DON and designee identified one new resident (Resident 3) at risk for elopement and implemented the use of wander-guard. In addition, three (3) other existing residents (Residents 2, 4 and 11) care plans were reviewed and updated by the DON and designee(s). l. An in-service education regarding wander-guard training, and abuse prevention and neglect was provided by Director of Staff Development (DSD) to facility staff: facility licensed nurses, Certified Nursing Assistant (CNAs), therapists, environmental services, social services, activities, dietary services, and administrative personnel on 8/21/2023, 8/22/2023 and 8/23/2023. All staff on leave will receive education on their next scheduled workday. m. On 8/21/2023 an Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of a resident) meeting was conducted for resident ' s who are identified as at risk for elopement with documentation in the IDT notes to evaluate individualized plan of care. n. The facility licensed nurses, CNAs, therapist, environmental services, social services, activities, dietary services, and administrative personnel received education on wandering/elopement, wander-guard use, securement of personnel belongings, resident safety as per facility policy and procedure, and abuse prevention and neglect on 8/20/2023, 8/21/2023, 8/22/2023 and 8/23/2022 from DON and DSD. o. On 8/22/2023, The Resource Nurse Consultant (RNC) initiated re-education to facility licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel on wandering, elopement, wander-guard use, securement of personal belongings, resident safety as per facility policy and procedure, and abuse prevention and neglect. All staff on leave will receive education on their next scheduled workday. p. Abuse and Neglect policies were reviewed by ADM and DON on 8/21/2023 to ensure the facility was compliant with the policy and procedure. No changes were made at that time. q. New hires will receive education on abuse prevention and neglect, wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s) upon hire and annually thereafter. Facility will continue to perform on going in-service trainings regarding wandering, elopement, resident safety, wander-guard use, and resident monitoring and or supervision to facility staff monthly for three (3) months. r. Elopement code drills were initiated on all shifts starting on 8/20/2023 and the facility will continue to perform drills monthly for three months; then quarterly thereafter by ADM, DON or DSD. s. An ongoing weekly check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. An increase to bi-weekly frequency of facility door and alarm checks were initiated on 8/21/2023. On 8/23/2023 at 9:13 p.m. while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the SSA removed the IJ situation in the presence of the ADM and the DON. Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses that included metabolic encephalopathy ( an alteration in consciousness caused due to brain dysfunction), epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), subdural hemorrhage (bleeding in the area between the brain and the skull), urinary tract infection (UTI, an infection in any part of your urinary system)) and unspecified psychosis (conditions that affect the mind, in which people have trouble distinguishing between what is real and what is not). A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 8/18/2023, indicated the resident usually had the ability to understand others and had the ability to make herself understood. The MDS indicated the Resident 1 required extensive staff assistance with dressing, personal hygiene, and required supervision with bed mobility, transfer, and toilet use. The MDS further indicated Resident 1 required the daily use of a wander-guard alarm. A review of Resident 1 ' s Elopement Risk form, dated 8/10/2023, indicated that Resident 1 was at risk for elopement. The form further indicated that Resident 1 had a history of elopement and or attempted elopement while at home; Resident 1 had a history of attempting to leave the facility without informing staff; Resident 1 had verbally expressed desire to go home, packed belongings to go home or stayed near an exit door; and that Resident 1 wanders. A review of Resident 1 ' s Physician Orders indicated orders for the following: a) Apply wander-guard to left wrist to alert staff of resident ' s whereabouts, dated 8/9/2023. b) Monitor wander-guard if functioning properly every shift, dated 8/9/2023. c) Check placement of wander-guard bracelet every shift, dated 8/9/2023. d) One-to-one sitter every shift for 30 days, dated 8/11/2023. A review of Resident 1 ' s Care Plan titled, The Resident is an elopement risk/wanderer (a resident who walks around without any clear purpose or direction) related to history of homelessness, initiated 8/10/2023, indicated a goal that the resident would not leave the facility unattended, and safety would be maintained. The care plan interventions included to provide a one-to-one sitter, monitor Resident 1 ' s location, distract the resident from wandering by offering pleasant diversions, and the use of a wander-guard device. A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR - a tool used to communicate a resident ' s condition among members of the health care team) dated 8/10/2023 timed at 5:08 p.m. indicated Resident 1 was noted wandering into rooms and taking belongings. A review of Resident 1 ' s Care Plan titled, Patient taking other people ' s belongings initiated 8/11/2023, indicated a goal that the resident would remain safe and respect other people ' s belongings. The care plan intervention included to provide a one-to-one sitter and resident will be re-oriented when observed attempting to take belongings. A review of Resident 1 ' s Nursing Progress Notes dated 8/11/2023 at 11:56 p.m. indicated Resident 1 wanders around the facility and has tendency to collect other resident ' s stuff and hide it in her room. Further review of Resident 1 ' s Nursing Progress Notes indicated: - On 8/13/2023 at 10:56 p.m. indicated Resident 1 was identified as a high risk for elopement due to continuously attempting to leave the facility to go to the store. - On 8/14/2023 at 3:30 p.m. Resident 1 observed wandering in the hallway. - On 8/15/2023 at 4:39 a.m. Resident 1 observed wandering in the hallway. - On 8/16/2023 at 4:52 a.m. Resident 1 observed wandering in the hallway. - On 8/17/2023 at 4:14 p.m. Resident 1 observed wandering throughout the shift. - On 8/18/2023 at 7:32 a.m. Resident 1 took another resident ' s phone, was found and was returned. A review of the Social Services Progress Notes for Resident 1 dated 8/14/2023 at 2:34 p.m. indicated resident is ambulatory (able to walk), has confusion and is at risk for elopement. Resident 1 walks around the facility and takes other resident ' s and staff belongings. A review of Resident 1 ' s SBAR form dated 8/20/2023 timed at 7:35 p.m. indicated Resident 1 was taken to the restroom by CNA 1. While CNA 1 was waiting for Resident 1 outside the restroom, CNA 1 heard the wander-guard alarm go off, CNA 1 ran to the door where alarm was heard however was unable to catch Resident 1. During an interview on 8/21/2023 at 12:40 p.m., with the ADM, the ADM stated she was notified on 8/20/2023 after 6:00 p.m. that Resident 1 had eloped from the facility. The ADM stated that Resident 1 had a one-to-one sitter and wander-guard on at the time of elopement. The ADM stated CNA 1 had taken Resident 1 into a [NAME] and [NAME] layout restroom (a restroom that has two doors and is accessible from two bedrooms), exited the adjoining room ' s restroom door leading to a sliding door exiting to an enclosed patio. From the enclosed patio, Resident 1 then re-entered the facility in possession of LVN 1 ' s personal vehicle keys (left unattended behind the computer) and exited through the Nursing Station Two exit door leading to the back of the facility parking lot without the one-to-one sitter ' s knowledge. Resident 1 eloped in LVN 1 ' s vehicle. During an interview on 8/21/2023 at 1:54 p.m. with CNA 1, CNA 1 stated she was the assigned one-to-one sitter for Resident 1 on 8/20/2023 evening shift (3:00 p.m. to 11:00 p.m.). CNA 1 stated Resident 1 liked to grab everything and had a behavior of going back and forth from the dining room, activities room, and restroom. CNA 1 stated on 8/20/2023 at approximately 6:15 p.m. she assisted Resident 1 to the restroom. CNA 1 stated she was unable to see Resident 1 because Resident 1 closed the restroom door. CNA 1 stated she did not notify anyone that Resident 1 was out of sight. CNA 1 stated at approximately 6:20 p.m., she heard the facility wander-guard alarm at Nursing Station Two exit door leading to the back of the facility parking lot activate. CNA 1 stated she then ran to the activated alarm at Nursing Station Two exit door and saw Resident 1 in the facility parking lot but chose not to follow Resident 1 out the door. CNA 1 stated that instead, she walked to the front lobby exit door and exited to the front of the facility parking lot in hopes of catching Resident 1. CNA 1 stated at approximately 6:30 p.m. a black vehicle exited the facility parking lot, but she did not see who was driving. CNA 1 stated she was later made aware that Resident 1 had driven away from the facility in LVN 1 ' s vehicle. CNA 1 stated she did not know when and how Resident 1 obtained LVN 1 ' s vehicle keys. During an interview on 8/21/2023 at 2:55 p.m. with LVN 1, LVN 1 stated on 8/20/2023 evening shift (3:00 p.m. to 11:00 p.m.) she was assigned to Resident 1. LVN 1 stated Resident 1 needed a one-to-one sitter to ensure supervision was provided to Resident 1 at all times because Resident 1 verbalized she wanted to go out, had attempted to leave the facility, and had a behavior of taking things. LVN 1 stated on 8/20/2023 at approximately 6:45 p.m. she was notified by CNA 1 that Resident 1 eloped. LVN 1 stated she then called a code grey. LVN 1 stated it was her routine practice to leave her personal vehicle key behind the computer in the nursing station. LVN 1 stated the vehicle keys were visible to anyone walking by the nurse ' s station. During an interview on 8/21/2023 at 12: 50 p.m. with DON, DON stated that on 8/20/2023, after code grey was called, facility staff went outside the building, and it was at that point that LVN 1 realized her vehicle and vehicle keys were missing. During a follow-up interview on 8/22/2023 at 10:29 a.m. with the DON, the DON stated CNA 1 was assigned solely to monitor Resident 1 and should have immediately sought assistance when Resident 1 was out of sight, but CNA 1 did not. The DON stated when CNA 1 heard the wander-guard alarm activate, CNA 1 could have intervened and prevented Resident 1 from getting into the vehicle had CNA 1 followed Resident 1 out the exit door that alarmed. The DON stated facility staff is responsible to secure personal belongings including vehicle keys in a place not accessible to the residents. During a concurrent interview and record review on 8/22/2023 at 11:39 a.m. with the DON, the facility ' s policy and procedure titled, Abuse, Neglect and Exploitation, last reviewed on 9/2/2022 was reviewed The DON stated the facility had the responsibility to provide the needed care and services to ensure Resident 1 ' s safety. The DON stated when CNA 1 did not always remain at Resident 1 ' s side, CNA 1 did not fulfill the duties of a one-to-one sitter. The DON stated according to the facility policy and procedure, the meaning of neglect is, failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The DON stated that if CNA 1 had always remained at Resident 1 ' s side, Resident 1 would not have been able to obtain LVN 1 ' s vehicle key and used the vehicle to elope from the facility. The DON stated Resident 1 potentially could have had a car accident and caused harm to herself and or others. The DON stated that not providing the needed services to a resident is to be considered neglect. During a follow-up interview on 8/24/2023 at 9:50 a.m. with CNA 1, CNA 1 stated on 8/20/2023 she was aware that there were multiple exit points inside the restroom. CNA 1 stated the restroom layout made it difficult to have eyes on Resident 1. CNA 1 stated she did not monitor all the exit points from the restroom, and she did not ask for assistance to monitor the adjoining room ' s restroom door. During an interview on 8/25/2023 at 9:33 a.m. with the Social Services Director (SSD), the SSD stated on 8/15/2023 during the stand up (a daily, short meeting of department heads) facility staff was notified to ensure all staff ' s personal belongings were secured due to Resident 1 ' s behavior of taking things. During a concurrent interview and record review on 8/25/2023 at 11:45 a.m. with the DON, the facility policy and procedure titled, Abuse, Neglect and Exploitation, last reviewed on 9/2/2022 was reviewed. The DON stated the facility ' s policy and procedure was not followed on 8/20/2023, which resulted in the actual elopement of Resident 1. The DON further stated Resident 1 ' s elopement could have been prevented. The DON stated it was hard to admit, but she knew the facility were wrong. 2. During an interview on 8/21/2023 at 2:55 p.m. with LVN 1, LVN 1 stated on 8/20/2023 at approximately 6:45 p.m. she was notified by CNA 1 that Resident 1 eloped. LVN 1 then stated that she called a code grey. During an interview and record review on 8/23/2023 at 9:30 a.m. with the DON, the facility ' s policy and procedure titled, Elopement, last reviewed on 12/19/2022 was reviewed The DON stated the elopement policy indicated the facility process for a code grey was, any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (for example [e.g.] internal alert code). The DON stated the internal alert code at the facility is to call a code grey for resident elopement. The DON stated CNA 1 had the responsibility to follow the code grey protocol and call the code grey upon discovering Resident 1 was missing to alert other facility staff personnel. The DON stated the importance of calling a code grey is to get the attention of all staff to search for the missing resident. The DON stated CNA 1 took it upon herself to search for Resident 1 instead of calling a code grey which resulted in Resident 1 eloping using LVN 1 ' s vehicle. During an interview on 8/24/2023 at 9:50 a.m. with CNA 1, CNA 1 stated a code grey can be called by anyone in the facility and she should have called the code in less than a minute from when the resident went missing on 8/20/2023, but she did not. During an interview with the DON on 8/25/2023 at 11:45 a.m., the facility ' s policy and procedure titled, Abuse, Neglect and Exploitation, last reviewed on 9/2/2022 was reviewed DON stated CNA 1 acted negligently by not following the facility ' s code grey protocol upon discovering Resident 1 was missing. 3. During an interview on 8/22/2023 at 3:45 p.m. with CNA 2, CNA 2 stated on 8/20/2023 some time after 5:30 p.m., but unsure of exact time, CNA 2 heard Station Two ' s exit door wander-guard alarm activate. CNA 2 stated he then went to the exit door. CNA 2 stated he opened the alarming door twice and did not see anyone. CNA 2 stated he leaned out the door and that it was raining hard. CNA 2 stated he turned off the wander-guard alarm without determining why it was activated. CNA 2 stated about five minutes later he heard a code grey announced. During an interview on 8/23/2023 at 8:32 a.m. with the DSD, the DSD stated the facility process is that when the wander-guard alarm is activated any and all staff that hears the alarm should run towards the alarming door and determines why the alarm was activated. The DSD stated CNA 2 did not determine what activated the wander-guard alarm before CNA 2 turned the wander-guard alarm off. The DSD stated the facility has the responsibility to provide a safe environment for the resident, but the interventions in place were not properly implemented because Resident 1 eloped. The DSD stated Resident 1 ' s elopement was preventable. During a concurrent interview and record review on 8/25/2023 at 11:45 a.m. with the DON, the facility ' s policy and procedure titled, Abuse, Neglect and Exploitation, last reviewed on 9/2/2022 was reviewed The DON stated CNA 2 acted negligently by turning off the wander-guard alarm without determining what activated the alarm. The DON further stated Resident 1 ' s elopement could have been prevented. The DON stated it was hard to admit, but she knew they were wrong. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, last reviewed 9/2/2022 indicated it is the policy of the 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 and neglect. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. New Employees and existing staff will be educated on abuse and neglect. Training topics will include understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as wandering or elopement-type behaviors. The facility will implement policies and procedures to prevent and prohibit all types of abuse and neglect that achieves: identifying and intervening in situations in which neglect is more likely to occur with the deployment of trained and qualified staff on each shift in sufficient numbers to meet the needs of the resident and assure assigned staff have knowledge of the individual residents care needs and behavioral symptoms; monitoring of residents with needs and behaviors which might lead to conflict or neglect; address features of the physical environment that may make neglect more likely to occur.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as a high risk for elopement (leaving the facility without notice or permission), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician, and with an assigned one-to-one sitter (one staff remains with one resident at all times to prevent elopement) was kept free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1), Resident 1 ' s assigned one-to-one sitter, did not leave Resident 1 unsupervised on 8/20/2023. 2. Failing to ensure CNA 1 followed the facility policy and procedures to call a code grey (code used in the facility to alert all staff that a resident is missing) when CNA 1 first discovered Resident 1 missing on 8/20/2023. 3. Failing to ensure Certified Nursing Assistant 2 (CNA 2) did not turn off the facility wander-guard alarm on 8/20/2023 when it was activated without first identifying the cause of the alarm. These deficient practices resulted in Resident 1 eloping from the facility on 8/20/2023 after the resident had taken the personal vehicle keys of Licensed Vocational Nurse 1 (LVN 1) and used LVN 1 ' s vehicle to drive away from the facility. This had the potential to result in harm, injury, and or death. Resident 1 was found by Local Law Enforcement (LLE) on 8/21/2023 at approximately 5:09 p.m. in a park after Resident 1 had contacted Family Member 2 (FM 2). On 8/21/2023 at 6:09 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure staff provided the necessary care and services to prevent elopement for Resident 1. On 8/23/2023 at 8:10 p.m. the ADM provided an IJ Removal Plan which included the following summarized actions: a. Facility staff conducted a facility search and perimeter search including the neighboring park and street for Resident 1 on 8/20/2023. b. FM 2 and Resident 1 ' s primary physician was notified on 8/20/2023 of the residents ' elopement. c. Facility staff reported the incident to LLE on 8/20/2023. d. Facility staff and the ADM called local hospitals inquiring if anybody was admitted matching Resident 1 ' s description starting on 8/20/2023 until Resident 1 was found on 8/21/2023 at approximately 5:09 p.m. e. FM 2 called the facility at approximately 4:23 p.m. on 8/21/2023 with the known location of Resident 1. At approximately 5:09 p.m. on 8/21/2023 Resident 1 was taken into custody by the LLE. f. CNA 1 assigned to Resident 1 on 8/20/2023 received a one-on-one in-service education as it relates to monitoring and supervising of assigned residents on 8/20/2023 by the ADM. g. CNA 1 and CNA 2 received a one-on-one in-service education regarding immediate response to alarms on 8/23/2023 by the DON and ADM. h. Other staff working on 8/20/2023 received in-service regarding monitoring and supervision; immediate response to alarms and securement of personal belongings on 8/20/2023 by DON and or ADM. i. The Medical Director was notified on 8/20/2023 regarding Resident 1 ' s elopement. j. A head count (an act of counting the number of people at a place) was completed of in-house residents on 8/20/2023 by the ADM and found that all residents totaling 64 were accounted for. k. The DON, and designee(s) re-evaluated all residents for risk for elopement and wandering (to walk around without any clear purpose or direction) using an elopement risk assessment tool on 8/21/2023. DON and designee identified one new resident (Resident 3) at risk for elopement and implemented the use of wander-guard. In addition, three (3) other existing residents (Residents 2, 4 and 11) care plans were reviewed and updated by the DON and designee(s). l. An in-service education regarding wander-guard training was provided by Director of Staff Development (DSD) to facility staff: facility licensed nurses, Certified Nursing Assistant (CNAs), therapists, environmental services, social services, activities, dietary services, and administrative personnel on 8/21/2023, 8/22/2023 and 8/23/2023. All staff on leave will receive education on their next scheduled workday. m. On 8/21/2023 an Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of a resident) meeting was conducted for resident ' s who are identified as at risk for elopement with documentation in the IDT notes to evaluate individualized plan of care. n. The facility licensed nurses, CNAs, therapist, environmental services, social services, activities, dietary services and administrative personnel received education on wandering/elopement, wander-guard use, securement of personnel belongings and resident safety as per facility policy and procedure on 8/20/2023, 8/21/2023, 8/22/2023 and 8/23/2022 from DON and DSD. o. On 8/22/2023, The Resource Nurse Consultant (RNC) initiated re-education to facility licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel on wandering, elopement, wander-guard use, securement of personal belongings and resident safety as per facility policy and procedure. All staff on leave will receive education on their next scheduled workday. p. Elopement and wandering policies were reviewed by ADM and DON on 8/21/2023 to ensure the facility was compliant with the policy and procedure. No changes were made at that time. q. New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s) upon hire and annually thereafter. Facility will continue to perform on going in-service trainings regarding wandering, elopement, resident safety, wander-guard use, and resident monitoring/supervision to facility staff monthly for three (3) months. r. Elopement code drills were initiated on all shifts starting on 8/20/2023 and the facility will continue to perform drills monthly for three months, then quarterly thereafter by ADM, DON or DSD. s. An ongoing weekly check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. An increase to bi-weekly frequency of facility door and alarm checks were initiated on 8/21/2023. On 8/23/2023 at 9:13 p.m. while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the SSA removed the IJ situation in the presence of the ADM and the DON. Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses that included metabolic encephalopathy (a problem in the brain), epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), subdural hemorrhage (bleeding in the area between the brain and the skull), urinary tract infection (UTI, an infection in any part of your urinary system)) and unspecified psychosis (conditions that affect the mind, in which people have trouble distinguishing between what is real and what is not). A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 8/18/2023, indicated the resident usually had the ability to understand others and had the ability to make herself understood. The MDS indicated the Resident 1 required extensive staff assistance with dressing and personal hygiene, and required supervision with bed mobility, transfer, and toilet use. The MDS further indicated Resident 1 required the daily use of wander-guard alarm. A review of Resident 1 ' s Elopement Risk form, dated 8/10/2023, indicated that Resident 1 was at risk for elopement. The form further indicated that Resident 1 had a history of elopement and or attempted elopement while at home; Resident 1 had a history of attempting to leave the facility without informing staff; Resident 1 had verbally expressed desire to go home, packed belongings to go home or stayed near an exit door; and that Resident 1 wanders. A review of Resident 1 ' s Physician Orders indicated orders for the following: a) Apply wander-guard to left wrist to alert staff of resident ' s whereabouts, dated 8/9/2023. b) Monitor wander-guard if functioning properly every shift, dated 8/9/2023. c) Check placement of wander-guard bracelet every shift, dated 8/9/2023. d) One-to-one sitter every shift for 30 days, dated 8/11/2023. A review of Resident 1 ' s Care Plan titled, The Resident is an elopement risk/wanderer (a resident who walks around without any clear purpose or direction) related to history of homelessness, initiated 8/10/2023, indicated a goal that the resident would not leave the facility unattended, and safety would be maintained. The care plan interventions included to provide a one-to-one sitter, monitor Resident 1 ' s location, distract the resident from wandering by offering pleasant diversions, and the use of a wander-guard device. A review of Resident 1 ' s Situation Background Assessment Recommendation form (SBAR - a tool used to communicate a resident ' s condition among members of the health care team)) dated 8/10/2023 timed at 5:08 p.m. indicated Resident 1 was noted wandering into rooms and taking belongings. A review of Resident 1 ' s Care Plan titled, Patient taking other people ' s belongings initiated 8/11/2023, indicated a goal that the resident would remain safe and respect other people ' s belongings. The care plan intervention included to provide a one-to-one sitter and resident will be re-oriented when observed attempting to take belongings. A review of Resident 1 ' s Nursing Progress Notes dated 8/11/2023 at 11:56 p.m. indicated Resident 1 wanders around the facility and has tendency to collect other resident ' s stuff and hide it in her room. Further review of Resident 1 ' s Nursing Progress Notes indicated: - On 8/13/2023 at 10:56 p.m. indicated Resident 1 was identified as a high risk for elopement due to continuously attempting to leave the facility to go to the store. - On 8/14/2023 at 3:30 p.m. Resident 1 observed wandering in the hallway. - On 8/15/2023 at 4:39 a.m. Resident 1 observed wandering in the hallway. - On 8/16/2023 at 4:52 a.m. Resident 1 observed wandering in the hallway. - On 8/17/2023 at 4:14 p.m. Resident 1 observed wandering throughout the shift. - On 8/18/2023 at 7:32 a.m. Resident 1 took another resident ' s phone, was found and was returned. A review of the Social Services Progress Notes for Resident 1 dated 8/14/2023 at 2:34 p.m. indicated resident is ambulatory (able to walk), has confusion and is at risk for elopement. The note further indicated that Resident 1 walks around the facility and takes other resident ' s and staff belongings. A review of Resident 1 ' s SBAR form dated 8/20/2023 timed at 7:35 p.m. indicated Resident 1 was taken to the restroom by CNA 1. While CNA 1 was waiting for Resident 1 outside the restroom, CNA 1 heard the wander-guard alarm go off, CNA 1 ran to the door where the alarm was heard, however, CNA 1 was unable to catch Resident 1. During an interview on 8/21/2023 at 12:40 p.m., with the ADM, the ADM stated she was notified on 8/20/2023 after 6:00 p.m. that Resident 1 had eloped from the facility. The ADM stated that Resident 1 had a one-to-one sitter and wander-guard on at the time of elopement. The ADM stated CNA 1 had taken Resident 1 into a [NAME] and [NAME] layout restroom (a restroom that has two doors and is accessible from two bedrooms), exited the adjoining room ' s restroom door leading to a sliding door exiting to an enclosed patio. From the enclosed patio, Resident 1 then re-entered the facility in possession of LVN 1 ' s personal vehicle keys (left unattended behind the computer) and exited through the Nursing Station Two exit door leading to the back of the facility parking lot without the one-to-one sitter ' s knowledge. Resident 1 eloped in LVN 1 ' s vehicle. During an interview on 8/21/2023 at 1:54 p.m. with CNA 1, CNA 1 stated she was the assigned one-to-one sitter for Resident 1 on 8/20/2023 evening shift (3:00 p.m. to 11:00 p.m.). CNA 1 stated Resident 1 liked to grab everything and had a behavior of going back and forth from the dining room, activities room, and restroom. CNA 1 stated on 8/20/2023 at approximately 6:15 p.m. she assisted Resident 1 to the restroom. CNA 1 stated she was unable to see Resident 1 because Resident 1 closed the restroom door. CNA 1 stated she did not notify anyone that Resident 1 was out of sight. CNA 1 stated at approximately 6:20 p.m., she heard the facility wander-guard alarm at Nursing Station Two exit door leading to the back of the facility parking lot activate. CNA 1 stated she then ran to the activated alarm at Nursing Station Two exit door and saw Resident 1 in the facility parking lot but chose not to follow Resident 1 out the door. CNA 1 stated that instead, she walked to the front lobby exit door and exited to the front of the facility parking lot in hopes of catching Resident 1. CNA 1 stated at approximately 6:30 p.m. a black vehicle exited the facility parking lot, but she did not see who was driving. CNA 1 stated she was later made aware that Resident 1 had driven away from the facility in LVN 1 ' s vehicle. CNA 1 stated she did not know when and how Resident 1 obtained LVN 1 ' s vehicle keys. During an interview on 8/21/2023 at 2:55 p.m. with LVN 1, LVN 1 stated on 8/20/2023 evening shift (3:00 p.m. to 11:00 p.m.) she was assigned to Resident 1. LVN 1 stated Resident 1 needed a one-to-one sitter to ensure supervision was provided to Resident 1 at all times because Resident 1 verbalized she wanted to go out, had attempted to leave the facility and had a behavior of taking things. LVN 1 stated on 8/20/2023 at approximately 6:45 p.m. she was notified by CNA 1 that Resident 1 eloped. LVN 1 stated she then called a code grey. LVN 1 stated it was her routine practice to leave her personal vehicle key behind the computer in the nursing station. LVN 1 stated the vehicle keys were visible to anyone walking by the nurse ' s station. During an interview on 8/21/2023 at 12: 50 p.m. with DON, DON stated that on 8/20/2023, after code grey was called, facility staff went outside the building, and it was at that point that LVN 1 realized her vehicle and vehicle keys were missing. During a follow-up interview on 8/22/2023 at 10:29 a.m. with the DON, the DON stated CNA 1 was assigned solely to monitor Resident 1 and should have immediately sought assistance when Resident 1 was out of sight, but CNA 1 did not. The DON stated when CNA 1 heard the wander-guard alarm activate, CNA 1 could have intervened and prevented Resident 1 from getting into the vehicle had CNA 1 followed Resident 1 out the exit door that alarmed. The DON stated facility staff is responsible to secure personal belongings including vehicle keys in a place not accessible to the residents. During a follow-up interview on 8/24/2023 at 9:50 a.m. with CNA 1, CNA 1 stated on 8/20/2023 she was aware that there were multiple exit points inside the restroom. CNA 1 stated the restroom layout made it difficult to have eyes on Resident 1. CNA 1 stated she did not monitor all the exit points from the restroom, and she did not ask for assistance to monitor the adjoining room ' s restroom door. During an interview on 8/25/2023 at 9:33 a.m. with the Social Services Director (SSD), the SSD stated on 8/15/2023 during the stand up (a daily, short meeting of department heads) facility staff was notified to ensure all staff ' s personal belongings were secured due to Resident 1 ' s behavior of taking things. During a concurrent interview and record review on 8/25/2023 at 11:45 a.m. with the DON, the DON reviewed the facility policy and procedure regarding elopement last reviewed on 12/19/2022. The DON stated the facility ' s policy and procedure was not followed on 8/20/2023, which resulted in the actual elopement of Resident 1 using LVN 1 ' s vehicle, and placing Resident 1 at risk of harming herself or others. The DON further stated Resident 1 ' s elopement could have been prevented. The DON stated it was hard to admit, but she knew they were wrong. 2. During an interview on 8/21/2023 at 2:55 p.m. with LVN 1, LVN 1 stated on 8/20/2023 at approximately 6:45 p.m. she was notified by CNA 1 that Resident 1 eloped. LVN 1 then stated that she called a code grey. During a concurrent interview and record review on 8/23/2023 at 9:30 a.m. with the DON, the facility policy and procedure regarding elopement was reviewed. The DON stated the policy indicated the facility process for a code grey was, any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). The DON stated the internal alert code at the facility is to call a code grey for resident elopement. The DON stated CNA 1 had the responsibility to follow the code grey protocol and call the code grey upon discovering Resident 1 was missing to alert other facility staff personnel. The DON stated the importance of calling a code grey is to get the attention of all staff to search for the missing resident. The DON stated CNA 1 took it upon herself to search for Resident 1 instead of calling a code grey which resulted in Resident 1 eloping using LVN 1 ' s vehicle. During an interview on 8/24/2023 at 9:50 a.m. with CNA 1, CNA 1 stated a code grey can be called by anyone in the facility and she should have called the code in less than a minute from when the resident went missing on 8/20/2023, but she did not. 3. During an interview on 8/22/2023 at 3:45 p.m. with CNA 2, CNA 2 stated on 8/20/2023 some time after 5:30 p.m., but unsure of exact time, CNA 2 heard Station Two ' s exit door wander-guard alarm activate. CNA 2 stated he then went to the exit door. CNA 2 stated he opened the alarming door twice and did not see anyone. CNA 2 stated he leaned out the door and that it was raining hard. CNA 2 stated he turned off the wander-guard alarm without determining why it was activated. CNA 2 stated about five minutes later he heard a code grey announced. During an interview on 8/23/2023 at 8:32 a.m. with the DSD, the DSD stated the facility process is that when the wander-guard alarm is activated any and all staff that hears the alarm should run towards the alarming door and determines why the alarm was activated. The DSD stated CNA 2 did not determine what activated the wander-guard alarm before CNA 2 turned the wander-guard alarm off. The DSD stated the facility has the responsibility to provide a safe environment for the resident, but the interventions in place were not properly implemented because Resident 1 eloped. The DSD stated Resident 1 ' s elopement was preventable. During an interview and record review on 8/25/2023 at 11:45 a.m. with the DON, the DON reviewed the facility policy and procedure regarding elopement last reviewed on 12/19/2022. The DON stated the policy indicated the facility had alarms to help avoid elopements. The DON stated CNA 2 had the responsibility to determine what activated the alarm. A review of the facility policy and procedure titled, Elopement, last reviewed 12/19/2022 indicated the facility must ensure that residents who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Interventions to increase staff awareness of the resident ' s risk, modify the resident ' s behavior, or to minimize risks associated with hazards will be added to the resident ' s care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code). The designated facility staff will look for the resident.

Based on interview and record review the facility failed to ensure one of two sample residents (Resident 1), who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SLE can affect the joints, skin, kidneys, blood cells, brain, heart, and lungs) and [CONDITION(S)] (is a chronic, long-term illness, that causes all-over muscle pain, joint pain, and fatigue), received pain management, consistent with professional standards of practice, facility's policies, the resident's comprehensive plan of care, assessment, goals, and preferences by: 1. Not administering Resident 1 [MEDICATION(S)] (brand name [MEDICATION(S)], a medication used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Not administering Resident 1 [MEDICATION(S)] 200 mg twice daily as ordered by the covering (on call) physician on 8/28/2021, via cellphone text but misinterpreted by Licensed Vocational Nurse 1 (LVN 1) as giving the medication only on Saturdays and Sundays. Resident 1 missed a total of 86 doses during 43 weekdays between 08/30/2021 and 10/27/2021. 3. Not transcribing LVN 1's misinterpreted order to administer Resident 1 [MEDICATION(S)] 200 mg twice daily only on Saturdays and Sundays (instead of daily) into the Medication Administration Record (MAR) for the month of 10/2021, for nine weekend days and a total of 18 doses (excluding 10/2/2021). 4. Not performing assessment of Resident 1's pain from 08/23/2021 through 08/31/2021 and from 10/1/2021 to 10/31/2021, and document it in the Pain Assessment Flow Sheet every shift as per plan of care and facility's policy. 5. Not re-evaluating the pain medication regimen for lack of effectiveness when Resident 1 was complaining of continued pain and was asking for her usual daily [MEDICATION(S)] medication between 08/24/2021 to 10/27/2021. As a result, Resident 1 suffered unnecessary continued severe pain and anguish since after admission to the facility, on 8/22/2021 until 10/27/2021, when the medication regimen with [MEDICATION(S)] was adjusted. Cross-reference F760 Findings: On 11/05/2021 at 11:39 a.m., during an interview, Resident 1 stated the nurses were not giving her the [MEDICATION(S)] medications for lupus and her body pain became so bad she needed to go to the hospital on 10/2/2021. Resident 1 stated the nurses did not do anything when she complained the [MEDICATION(S)] medication should be daily and not just on the weekends and did not call the attending physician to verify what she was telling them. Resident 1 stated that finally about a week ago, the doctor fixed the [MEDICATION(S)] order. On 11/05/2021 at 1:52 p.m., during an interview, Resident 1 stated she had to suffer so much pain when [MEDICATION(S)] was not administered properly. Resident 1 burst into tears stating, it was unnecessary pain I wouldn't have to go through if the medication was given right. Resident 1 the nurses and the doctor messed up her medication orders and took too long to make it right despite her continued severe pain and her requests to give her the medication daily. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on 08/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Pain Assessment form dated 08/22/2021 indicated the resident had chronic pain on the left hip. The resident's pain intensity was zero out of 10 (0/10, a pain rating scale from zero which indicated no pain to 10 which indicated the worst possible pain). The form indicated movement increased pain and ice packs and as needed (PRN) pain medication relieved the pain. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Administer [MEDICATION(S)] 10-325 mg (brand name, narcotic medication that contains a combination of an opioid pain reliever [[MEDICATION(S)]] and a non-opioid pain reliever [acetaminophen]. It can treat moderate to moderately severe pain), one tablet by mouth every eight hours (scheduled at 6 am, 2 pm and 10 pm) routine for pain management. - Administer [MEDICATION(S)] 150 mg ([MEDICATION(S)], a nerve pain medication. It can treat nerve and muscle pain, including [CONDITION(S)]. It can also treat seizures) one capsule twice a day for pain management. - Administer [MEDICATION(S)] 30 mg tablet (a brand name for controlled-release [MEDICATION(S)] sulfate, a narcotic pain reliever used to treat moderate to severe pain) by mouth every twelve hours PRN severe pain (10/10). - Administer Acetaminophen two 500 mg tablets every 8 hours for pain management. - Administer [MEDICATION(S)] ([MEDICATION(S)]) one capsule of 200 mg twice a day for pain management. - Administer [MEDICATION(S)] ([MEDICATION(S)]) 150 milligrams (mg) one tablet by mouth twice a day every weekday (Monday, Tuesday, Wednesday, Thursday, and Friday) and 200 mg twice a day on Saturdays and Sundays for SLE. A review of Resident 1's Care Plan developed on 08/24/2021 for the resident's pain problem, included in the interventions to monitor and record pain characteristics every day and PRN: Quality (sharp, burning); Severity (0 to 10 scale); Anatomical location; Onset (start of the pain); Duration (continuous, intermittent); Aggravating factors; and Reliving factors. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated on 08/31/2021 indicated Resident 1 had no memory problems, required limited assistance with one-person physical assist with bed mobility and transfer. Resident 1 needed extensive assistance with dressing and toilet use. Resident 1 was expected to return home soon after recovering from the hip surgery. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/05/2021 at 4:14 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 stated on 8/28/2021 she communicated by text with the physician covering for Resident 1's attending physician using her cellphone informing him that the pharmacy did not carry the medication in 150 mg. LVN 1 showed the Evaluator the text messages. The physician texted back to give Resident 1 [MEDICATION(S)] 200 mg tablet daily. The physician did not discontinue the [MEDICATION(S)] scheduled Monday through Friday. LVN 1 acknowledged discontinuing the weekday order of [MEDICATION(S)] was a mistake and she misunderstood the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review Resident 1's Nursing Notes and MAR indicated no documentation the resident was assessed for pain every shift as the physician had ordered and as per plan of care from 8/23/2021 to 8/31/2021 and from 10/1/2021 to 10/31/2021. A review of Resident 1's MAR between 08/23/2021 (Monday) and 08/27/2021 (Friday) indicated [MEDICATION(S)] 150 mg was not administered for five days and a total of 10 doses. A review of Resident 1's MAR between 08/30/2021 and 10/27/2021 indicated [MEDICATION(S)] not administered twice daily during 43 weekdays for a total of 86 doses. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Administer [MEDICATION(S)] tablet 10-325 mg one tablet by mouth every eight hours PRN moderate pain (4-6/10). A review of Resident 1's MAR between 10/01/2021 and 10/27/2021 indicated [MEDICATION(S)] 150 mg or 200 mg was not administered during the entire month, a total of 31 days and 61 doses, not including one dose on 10/2/2021, when Resident 1 was at General Acute Care Hospital 1 (GACH 1). A review of Resident 1's Nursing Progress Notes, dated 10/02/2021, indicated the resident was sent to GACH 1 emergency room (ER) at 9:30 am for evaluation of severe left hip pain. Resident 1 returned to the facility the same day at 10 pm. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/05/2021 at 4:41 p.m., during an interview, Director of Nursing (DON) stated LVN 1 should have clarified the order before she discontinued the 150 mg of [MEDICATION(S)] Monday through Friday. DON validated the medication [MEDICATION(S)] was not administered to Resident 1 as ordered, resulting on Resident 1 to suffer uncontrolled pain. On 11/05/2021 at 05:02 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 was unable to find documentation of Resident 1's pain assessment every shift and a description of the pain documented in 8/2021. LVN 1 stated that there was an order, but no documentation found to reflect the pain evaluation was assessed every shift. LVN 1 stated that there should be the pain evaluation documented in MAR as ordered by the physician. A review of Resident 1's MAR indicated Resident 1's pain level when the routine [MEDICATION(S)] 10-325 mg was given every eight hours for pain management: - On 08/24/2021, at 6 am, 2 pm and 10 pm, Resident 1's pain was 10/10. - On 08/25/2021, at 2 pm Resident 1's pain was 10/10. - On 08/26/2021, at 6 am Resident 1's pain was 8/10. - On 08/27/2021, at 6 am Resident 1's pain was 6/10, at 2 pm was 10/10, and at 10 pm was 8/10. - On 08/28/2021, at 6 am and 2 pm Resident 1's pain was 10/10 - On 08/29/2021, at 2 pm Resident 1's pain was 10/10 and at 10 pm was 8/10. - On 08/30/2021, at 6 am, 2 pm, and 10 pm, Resident 1's pain was 10/10. - On 09/01/2021, at 6 am and 2 pm Resident 1's pain was 8/10 and at 10 pm was 6/10. - On 09/02/2021, at 2 pm Resident 1's pain was 6/10. - On 09/03/2021, at 2 pm Resident 1's pain was 8/10 and at 10 pm was 6/10. - On 09/04/2021, at 6 am and 2 pm Resident 1's pain was 8/10. - On 09/05/2021, at 2 pm Resident 1's pain was 8/10. - On 09/06/2021, at 2 pm Resident 1's pain level was 9/10 and at 10 pm was 8/10. - On 09/10/2021, at 2 pm Resident 1's pain was 8/10. - On 09/14/2021, at 2 pm Resident 1's pain was 8/10. On 11/10/2021 at 4:31 p.m., during an interview with DON and concurrent review of Resident 1's MAR, DON stated during 8/2021 and 9/2021, the resident's pain was not managed, and the intensity of the pain was high. DON stated the licensed nurses should have reviewed the pain medications for effectiveness and discuss with the physician to re-evaluate the medication regimen. DON stated the Interdisciplinary Team (IDT - group of healthcare professionals from different disciplines) should have held a meeting to discuss Resident 1's pain management. DON stated Resident 1 reported worsening pain on 10/01/2021, the attending physician was notified and ordered transfer to GACH 1. Resident 1 went to GACH 1 on 10/02/2021 and returned to the facility the same day. DON confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated that the licensed nurses should have assessed pain and document in MAR because it would be used as a tool to see the pain medications were effective or not. DON confirmed the lack of Pain Flow Sheet for 9/2021 and 10/2021. DON stated the licensed nurses are to monitor pain and document in the Pain Flow Sheet as per facility's policy. On 12/28/2021 at 11:01 a.m., during a telephone interview, Resident 1's attending physician (Physician 1) stated Resident 1 should have been taking [MEDICATION(S)] twice daily for SLE and missing doses aggravated the resident's body pain. On 12/28/2021 at 11:20 a.m., during an interview with LVN 4 and concurrent review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/28/2021 at 1:45 p.m., during the concurrent interview with DON and concurrent review of the MAR, DON stated there was no documentation [MEDICATION(S)] was given from 10/1/2021 to 10/26/2021. DON stated Resident 1 was discharged home on 11/27/2021 per the resident's request. A review of the facility's policy and procedure updated 10/2019 titled, Medication Administration - General Guidelines indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. A review of the facility's policy and procedures on Pain Management, revised 04/2021, indicated its purpose was to alleviate the resident's pain to a level that is acceptable to the resident while minimizing negative effects on the resident to the extent possible. 1. Pain Assessment A. Upon admission the licensed nurse will assess each resident for pain. B. The licensed nurse will initiate care plan and interventions according to the RAI guidelines upon admission, annually, significant change of condition, new onset of pain, worsening of pain, new pain medication, pain medication change, and or other. C. The Pain Assessment Flow Sheet will be initiated for residents who require PRN pain medications. D. The licensed nurse will develop a care plan for pain management, including non-pharmacological interventions. E. The IDT will review the pain assessment for newly admitted resident identified by the licensed staff to have pain annually, significant change of condition, new onset of pain, worsening of pain, new pain medication, pain medication change, and or other using the COMS - Vitals and Pain Only Evaluation. A review of the facility's policy and procedures, revised 09/2011, titled, Pain Assessment and Management indicated the following: 1. Pain Assessment will be completed on admission and readmission to the facility, when there is a new complaint of pain during or related to care, as the result of an accident or injury, when there is a new onset of pain, when there is a new behavior exhibited in a nonverbal resident or a resident with dementia, and when current pain management program is ineffective. 2. All residents will be monitored for the presence of pain daily. 3. Pain will be recognized as the fifth vital sign and will be included when vital signs are obtained. 4. After the Pain Assessment is completed the nurse will contact the physician to discuss findings and obtain orders for analgesia and/or other non-drug interventions and document the discussion and orders in the clinical record if appropriate. 5. Any new or unrelieved pain, change in location, quality, or intensity of pain and side effects from the analgesia shall be reported to the physician. 6. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. 7. A change in pain medication for previously assessed pain, will not necessitate a full assessment for pain management. 8. Evaluation of the effectiveness of analgesic medication in relieving pain to a level that is acceptable to the resident will occur within 1 hours of administration. a. The effectiveness of PRN pain medication will be assessed and recorded on the medication administration record within 2 hours of administration of the medication. b. The effectiveness of routine pain medication administration will be monitored and documented on the medication administration record every shift utilizing the appropriate pain scale to determine effectiveness.

Based on interview and record review the facility failed to ensure one of two sample residents (Resident 1), who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . SLE can affect the joints, skin, kidneys, blood cells, brain, heart, and lungs) was free from significant medication errors by: 1. Not administering Resident 1 [MEDICATION(S)] (brand name [MEDICATION(S)], a medication used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Not administering Resident 1 [MEDICATION(S)] 200 mg twice daily as ordered by the covering (on call) physician on 8/28/2021, via cellphone text but misinterpreted by Licensed Vocational Nurse 1 (LVN 1) as giving the medication only on Saturdays and Sundays. Resident 1 missed a total of 86 doses during 43 weekdays between 08/30/2021 and 10/27/2021. 3. Not transcribing LVN 1's misinterpreted order to administer Resident 1 [MEDICATION(S)] 200 mg twice daily only on Saturdays and Sundays (instead of daily) into the Medication Administration Record (MAR) for the month of 10/2021, for nine weekend days and a total of 18 doses (excluding 10/2/2021). As a result, Resident 1 suffered unnecessary continued severe pain and anguish since after admission to the facility, on 8/22/2021 until 10/27/2021, when the medication regimen with [MEDICATION(S)] was adjusted. Cross-reference F760 Findings: On 11/05/2021 at 11:39 a.m., during an interview, Resident 1 stated the nurses were not giving her the [MEDICATION(S)] medications for lupus and her body pain became so bad she needed to go to the hospital on 10/2/2021. Resident 1 stated the nurses did not do anything when she complained the [MEDICATION(S)] medication should be daily and not just on the weekends and did not call the attending physician to verify what she was telling them. Resident 1 stated that finally about a week ago, the doctor fixed the [MEDICATION(S)] order. On 11/05/2021 at 1:52 p.m., during an interview, Resident 1 stated she had to suffer so much pain when [MEDICATION(S)] was not administered properly. Resident 1 burst into tears stating, it was unnecessary pain I wouldn't have to go through if the medication was given right. Resident 1 the nurses and the doctor messed up her medication orders and took too long to make it right despite her continued severe pain and her requests to give her the medication daily. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on 08/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Pain Assessment form dated 08/22/2021 indicated the resident had chronic pain on the left hip. The resident's pain intensity was zero out of 10 (0/10, a pain rating scale from zero which indicated no pain to 10 which indicated the worst possible pain). The form indicated movement increased pain and ice packs and as needed (PRN) pain medication relieved the pain. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Administer [MEDICATION(S)] ([MEDICATION(S)]) 150 milligrams (mg) one tablet by mouth twice a day every weekday (Monday, Tuesday, Wednesday, Thursday, and Friday) and 200 mg twice a day on Saturdays and Sundays for SLE. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated on 08/31/2021 indicated Resident 1 had no memory problems, required limited assistance with one-person physical assist with bed mobility and transfer. Resident 1 needed extensive assistance with dressing and toilet use. Resident 1 was expected to return home soon after recovering from the hip surgery. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/05/2021 at 4:14 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 stated on 8/28/2021 she communicated by text with the physician covering for Resident 1's attending physician using her cellphone informing him that the pharmacy did not carry the medication in 150 mg. LVN 1 showed the Evaluator the text messages. The physician texted back to give Resident 1 [MEDICATION(S)] 200 mg tablet daily. The physician did not discontinue the [MEDICATION(S)] scheduled Monday through Friday. LVN 1 acknowledged discontinuing the weekday order of [MEDICATION(S)] was a mistake and she misunderstood the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review Resident 1's Nursing Notes and MAR indicated no documentation the resident was assessed for pain every shift as the physician had ordered and as per plan of care from 8/23/2021 to 8/31/2021 and from 10/1/2021 to 10/31/2021. A review of Resident 1's MAR between 08/23/2021 (Monday) and 08/27/2021 (Friday) indicated [MEDICATION(S)] 150 mg was not administered for five days and a total of 10 doses. A review of Resident 1's MAR between 08/30/2021 and 10/27/2021 indicated [MEDICATION(S)] not administered twice daily during 43 weekdays for a total of 86 doses. A review of Resident 1's MAR between 10/01/2021 and 10/27/2021 indicated [MEDICATION(S)] 150 mg or 200 mg was not administered during the entire month, a total of 31 days and 61 doses, not including one dose on 10/2/2021, when Resident 1 was at GACH 1. A review of Resident 1's Nursing Progress Notes, dated 10/02/2021, indicated the resident was sent to General Acute Care Hospital 1 (GACH 1) emergency room (ER) at 9:30 am for evaluation of severe left hip pain. Resident 1 returned to the facility the same day at 10 pm. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/05/2021 at 4:41 p.m., during an interview, Director of Nursing (DON) stated LVN 1 should have clarified the order before she discontinued the 150 mg of [MEDICATION(S)] Monday through Friday. DON validated the medication [MEDICATION(S)] was not administered to Resident 1 as ordered, resulting on Resident 1 to suffer uncontrolled pain. On 12/28/2021 at 11:01 a.m., during a telephone interview, Resident 1's attending physician (Physician 1) stated Resident 1 should have been taking [MEDICATION(S)] twice daily for SLE and missing doses aggravated the resident's body pain. On 12/28/2021 at 11:20 a.m., during an interview with LVN 4 and concurrent review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/28/2021 at 1:45 p.m., during the concurrent interview with DON and concurrent review of the MAR, DON stated there was no documentation [MEDICATION(S)] was given from 10/1/2021 to 10/26/2021. DON stated Resident 1 was discharged homeon 11/27/2021 per the resident's request. A review of the facility's policy and procedure updated 10/2019 titled, Medication Administration - General Guidelines indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on observation, interview, and record review, the facility failed to ensure a resident, who is dependent on a mechanical ventilator for breathing and required suctioning for maintaining an open airway, was provided immediate care for one of 19 sample residents (6) by failing to: 1. Ensure that the facility staff was knowledgeable with the mechanical ventilator in assessing and responding to the resident's respiratory needs and change of condition, such as respiratory distress. 2. Ensure staff monitored and intervened for serious medical conditions, and responded to the resident's change of condition in a timely manner as indicated in the resident's care plan. 3. Implement the facility's policy and procedure in taking care of a resident on a ventilator to immediately identify and correct audible alarm situations. This failure resulted in an immediate jeopardy situation for Resident 6 who had a high potential for serious harm, injury, impairment, or death due to the staff negligence of timely care for Resident 6, a ventilator dependant resident. Findings: a. An immediate jeopardy was called in the presence of the Administrator and Director of Nurses on September 25, 2015, at 7:10 p.m. A plan of correction was submitted to the survey team on September 27, 2015, at 2:18 p.m., and included: 1. Assigning nursing staff to each room for the next 48 hours to notify nursing staff or the respiratory therapist of any ventilator flashing indicators. 2. Inservices for nursing staff before the start of their next shift on how to identify flashing ventilator indicators and to report to the licensed nurses or respiratory therapist. 3. The ventilator alarms will be checked twice a shift and will be documented. 4. The vendor for the ventilators will be contacted to check all the ventilator machines for proper functioning of alarms. The IJ was abated on September 27, 2015 at 2:18 p.m. when evidence of onsite confirmation of the immediacy was removed and corrections were completed. On September 22, 2015, between 8:40 a.m. to 11:30 a.m., during the initial tour observation of the subacute unit of the facility, residents who were ventilator dependent, were connected to ventilator model LTV 1100. In an interview with Licensed Vocational Nurse 1 (LVN 1) present during the observation, she stated there were 20 residents who were ventilator dependent, with one resident who was ventilator dependent only at night, out of 28 residents. This was confirmed with the Director of Nursing (DON). When asked LVN 1 stated her title is desk nurse but she also functions as a subacute coordinator. On September 23, 2015, at 10:20 a.m., during an observation, Resident 6 was lying in bed, and was awake, confused, and disoriented. The resident was reclining at a 45 degree angle and his head and chest were leaning forward. Both of his legs were flexed at the knee up toward the chest. Resident 6 was connected to a ventilator. The ventilator's display, indicated high pressure of 50. The high pressure display was blinking, the remote alarm board in the hallway near the subacute nursing station did not sound, and no visual sign of Resident 6's room was displayed in the alarm board. At 10:35 a.m., (fifteen minutes later), Resident 6's face was red in color. High pressure alert at 55 was displayed on the screen of the ventilator. The alert wall board (wireless remote alarm) in the hallway near the subacute nursing station did not sound and did not have a visual of room [ROOM NUMBER] A (Resident 6's room). The resident was observed with retractions (sucking in of the skin in between or around the bones of the chest when inhaling) and the use of accessory (muscles of the neck, back, and abdomen that may assist in breathing) muscles to breathe, inability to lie flat, and was restless (indicating the resident may be in respiratory distress, http://www.jems.com/articles/print/volume-38/issue-8/patient-care). There was no audible ventilator alarm heard at that time. (The audible alarm is triggered when the high pressure limit had been exceeded and stops if the pressure drops below the high pressure limit.) There was no staff in the room. The staff members were not observed responding to the ventilator visual alarm (blinking) light to determine/assess if Resident 6 required immediate respiratory/medical care, such as suctioning to clear the resident's secretions and open the airway. On September 23, 2015, at 10:20 a.m., another observation was made outside the room, between the hallway and Resident 6's room to observe if any staff were coming to provide care to Resident 6. The Surveyor asked Staff 1 who was passing by the hallway to look at the resident. Staff 1 stated that she will look for somebody. Then, Licensed Vocational Nurse 2 (LVN 2) went inside Resident 6's room and closed the privacy curtain. The Surveyor went immediately to Resident 6's bedside. While LVN 2 was preparing to suction Resident 6, Respiratory Therapist 1 (RT 1) went inside the resident's room and suctioned Resident 6. RT 1 took the resident's oxygen saturation (amount of oxygen that is dissolved or carried in a medium) by using a portable pulse oximeter. The resident's oxygen saturation was 93 percent, (normal pulse oximeter readings range from 95 to 100 percent, Medline) and a heart rate of 79 beats per minute. After suctioning, the resident's oxygen saturation was 97 percent. Resident 6's face was no longer red in color, tense, and was calm and relaxed. On September 23, 2015, at 11:30 a.m., during an interview with LVN 1, she stated we (staff) respond to the ventilator/resident alarm as soon as possible and in a timely manner. On September 23, 2015, at 3:44 p.m., during an interview with RT 1, he stated the ventilator needs to sound/alarm. The facility had two remote wireless boards that provide visual and sound alarms which were located in the hallway. One was located near the subacute nursing station and the other one between rooms [ROOM NUMBERS]. The RT determines the ventilator high and low limit pressure. When a resident had a high pressure, the staff are required to assess the resident, to determine the cause of the alarm, such as when the resident is coughing or the resident needed suctioning. All licensed personnel are responsible for suctioning the resident. We suction every two hours and as necessary (PRN). Everybody was inserviced regarding ventilators. When a ventilator is silenced, it will be silent for up to 30 seconds, and then it resets/defaults. After silence, the ventilator sound/alarm will trigger right away. We adjust it in the volume. The highest is 85 decibel and the lowest, I haven't checked it. According to the admissions record, Resident 6 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (standardized assessment form), dated July 1, 2015, indicated Resident 6's cognitive skills for daily decision making was severely impaired and Resident 6 was totally dependent on staff members for all activities of daily living. Under special treatments, procedures, and programs indicated the resident required and received respiratory treatments such as oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator while a resident in the facility. A review of the Physician order [REDACTED]. 1. Assist control (AC) 14 (a term used to describe the number of breaths a resident is receiving from the breathing machine. AC refers to a specific method for giving the resident mechanical breaths. An AC of 14 means that the resident is getting 14 guaranteed breaths per minute from the ventilator). 2. Tidal volume of 600 milliliters (ml) (amount of air displaced between normal inhalation and exhalation). 3. PEEP of plus five centimeters of water (positive end expiratory pressure, pressure needed to prevent collapse of small airways at the end of expiration). 4. Suction tracheal and/or oral secretion every two hours and PRN. A review of the Resident 6's care plan for alteration in respiratory function due to [MEDICAL CONDITIONS], ventilator dependent, hyperventilation due to shortness of breath (SOB) secondary to [MEDICAL CONDITIONS]/ [MEDICAL CONDITION] dated October 17, 2014, indicated the resident was a high risk for accidental decannulation (planned or accidental removal of a [MEDICAL CONDITION]), congestion, dyspnea (difficulty of breathing), respiratory infections, [MEDICAL CONDITION] site irritations and infections, mucous plug, and desaturation (decrease oxygen saturation). The care plan approach included to monitor for congestion, suction as needed, monitor episodes of increased SOB, oxygen saturation, implement interventions as needed, set ventilator at AC of 14, tidal volume of 600, PEEP of +5 and oxygen at five liters per minute. It also included to listen for and answer ventilator alarms. This care plan was updated and revised on September 16, 2015 with a revision that included to monitor episodes of increased hyperventilation leading to shortness of breath, listen for and answer ventilator alarms timely, and to give [MEDICATION NAME] (anti-anxiety drug) as ordered PRN for hyperventilation. A review of the clinical record with LVN 1, of Resident 6's admissions and discharges from June 26, 2013, to October 17, 2014, from the skilled nursing facility to the acute hospital indicated the resident had a prior oxygen saturation change that required hospitalization as follows: 1. A review of the Nurses Notes dated October 4, 2014, at 10:15 p.m., indicated Resident 6 was transferred to the hospital via 911 secondary to increased respiratory rate and became more lethargic than usual. Vital signs were checked. Blood pressure was 113/85 mmHg (millimeters of mercury), heart rate of 139 beats per minute, temperature of 96.8 degrees Fahrenheit, respiratory rate of 30 breaths per minute and arterial oxygen saturation (SaO2) (a symbol for percentage of available hemoglobin that is saturated with 92 percent on five liters per minute of oxygen. Normal vital sign ranges for the average healthy adult while resting are: Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg; Breathing: 12 - 18 breaths per minute; Pulse: 60 - 100 beats per minute; Temperature: 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit. No facial grimace or any signs of pain noted. Remains responsive to tactile stimuli and close monitoring done. The licensed nurses notes indicated on October 4, 2014, at 10:15 p.m. Resident 6 had a change in condition and his heart rate and respiratory rate were elevated. The nursing documentation did not indicate how or the method used when the staff monitored the resident or the resident's response to the close monitoring. The licensed nurses notes indicated on October 4, 2014, at 11:05 p.m., resident was unresponsive to tactile stimuli, respiratory rate of 16 breaths per minute, blood pressure of 99/78 mmHg, temperature of 96.6 Fahrenheit, heart rate of 146 beats per minute, and SaO2 of 72 percent. The resident was becoming more cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). Manual ventilation done and called 911. At 11:10 p.m., the paramedics came, report was given, and necessary paperwork were submitted. At 11:20 p.m., the resident was transferred to the hospital via 911. At 11:30 p.m., the physician was made aware regarding the transfer by leaving a message. On September 29, 2015, between 11 a.m. to 1 p.m., during an interview with LVN 1, when asked what nursing interventions are implemented when a resident's ventilator indicates a high pressure and a low pressure alarm, she smiled but did not answer the question. LVN 1 stated she needed more education. On September 29, 2015, at 12:22 p.m., during an interview with Registered Nurse 1 (RN 1), she stated the ventilator alarm is supposed to sound continuously until a staff assesses the resident and silences the alarm. She stated the audible alarm sound is very important and the staff should respond to the ventilator alarm timely. The facility's policy and procedure titled, Positive Pressure, Volume Limited Ventilators, dated November 2008, indicated it is the Policy of the facility to promote consistency and safety in the use, maintenance and techniques of positive pressure volume limited ventilators. Operation of the portable ventilator will be accomplished by following the Operating Manual for the specific ventilator in use. According to the LTV 1100 Ventilator Operator's Manual dated March 2013, indicated under the section for Warnings, indicated Only properly trained personnel should operate the ventilator. The LTV 1100 ventilator is a restricted medical device designed for use by respiratory therapists or other properly trained and qualified personnel under the direction of a physician and in accordance with applicable state laws and regulations. Under resident monitoring, residents who are dependent on a ventilator should be constantly monitored by qualified personnel. Qualified personnel should be familiar with emergency ventilation procedures. Any time a high pressure condition persists for more than three seconds, the audible alarm will be sounded, regardless of the delay setting. Failure to immediately identify and correct audible alarm situations may result in a serious injury. The Low Minute Volume control should be set to its highest clinically appropriate value. If there is a clinical need to set the Low Minute Volume alarm to lower values or off, perform a clinical assessment to determine if an alternative monitor (such as pulse oximeter with an audible alarm, or a cardio respiratory monitor) should be used. There was no evidence the facility had a system to ensure the staff consistently implemented the facility's policy and procedure to ensure a ventilator dependent resident's alarm was immediately identified and corrected. Resident 6 was not provided immediate attention, care, and support as dictated by the situation. The potential harm in not following the facility's policy to immediately respond to the ventilator alarm placed Resident 6, at a high risk for a serious injury.