Every finding on record at Oceana Healthcare Center

Based on interview and record review the facility failed to provide a copy of requested resident records upon written request for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's legal representative to obtain requested copies of Resident 1's records.Findings: During a review of Resident 1's admission Records, the Records indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including lack of coordination (unsteady movement affecting how you walk and reach for objects), major depressive disorder ( a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), unspecified dementia, (loss of memory, thinking, and reasoning). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on selfcare activities. During a review of Resident 1's legal representative Sent Fax Report record, the Fax Report indicated eleven pages of Resident 1's record request document was successfully sent to the facility on 5/1/2026 at 6:35 PM. During a telephone interview on 5/27/2026 at 11:22 AM with Resident 1's legal representative staff, Resident 1's legal representative staff stated a record request was submitted on 5/1/2026 and follow up phone call was made on 5/5/2026. During the follow up call on 5/5/2026 the legal representative staff spoke to Medical Records director (MR). Resident 1's legal representative staff stated, MR denied receiving a fax sent on 5/1/2026. A second record request was faxed on 5/5/2026. During a follow-up call by Resident 1's legal representative staff on 5/7/2027 with MR, MR informed Resident 1's legal representative, the record request is being processed. Resident 1's representative made a phone call on 5/20/2026 and facility staff failed to call back as promised. During an interview on 6/2/2026 at 9:30 AM with Resident 1, Resident 1 stated, Resident 1's family member has the power of attorney (POA), the POA can make decisions on behalf of Resident 1 including requesting for record. During an interview on 6/2/2026 at 10:28 AM with MR, the MR stated, resident record access is usually provided within a day or two depending on type of records requested. MR acknowledged receiving a medical record request on 5/7/2026 from Resident 1's legal representative. MR stated, the record request is being processed and approval from the facility administrator (ADM), and corporate office is required to release the records. MR will release Resident 1's records once completed processing and approvals from ADM and corporate office of the facility. During an interview on 6/2/2026 at 11:04 AM with the director of nursing (DON), the DON stated, according to the state law and facility policy, resident record should be released within five days after a written request provided. The DON acknowledged reviewing Resident 1's records about a week ago and unaware if the records were released. DON stated, delaying or denying resident medical records can cause harm by delaying needed resident care. During an interview on 6/2/2026 at 11:30 AM with ADM, the ADM stated, resident record access is processed by medical records office. ADM stated, the facility follows the most stringent regulations for releasing medical records. ADM acknowledged Resident 1's medical records access was requested at least three weeks ago. The reason for the delay is due to a complicated electronic and hard copy record keeping process at the facility. ADM stated, delaying or denying access to resident records is a violation of resident rights. During a review of the facility's Policy and Procedure (P&P) titled Release of Records reviewed 07/11/2025, the P&P indicated It is the policy of the facility to provide access by any resident or their authorized representative, to insect and /or obtain copies of health information/records. The time requirements for release of records are specified by HIPAA Omnibus, OBRA Federal regulations and the State of California. These are as follows: State of California Health and Safety Code- Access within 5 working days after written request and copies available within 15 days. It is recommended that the most restrictive time requirements be followed.

Based on interview and record review the facility failed to implement its policy and procedure (P&P) by failing to ensure prompt physician notification of one of one of three sampled residents, Resident 1 when Resident 1 refused ordered medication Asperflex lidocaine 4% patch (a topical medication used to provide temporary relief for minor muscle, joint, and nerve pain) on multiple occasions. This deficient practice had the potential for significant medication errors and timely medication review and intervention by the physician. Findings: A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on [DATE] including a diagnoses of malignant neoplasm of female breast (the development of cancer in the breast), secondary malignant neoplasm of unspecified lung (the development of cancer in the lungs), muscle weakness (a lack of strength in the muscles) Type 2 diabetes mellitus (a condition in which the body is unable to control blood sugar and using it for energy). A review of Resident 1's minimum data set (MDS-a comprehensive resident assessment tool) dated 3/30/2026, the MDS indicated Resident 1's cognitive skills (ability to think and process information) for daily decision making was moderately impaired. A review of Resident 1's History and Physical (H&P) dated 3/26/2026, the H&P indicated, Resident 1 has the capacity for medical decision making. A review of Resident 1's Order Summary Report dated, 4/27/2026 indicated, Asperflex lidocaine 4.0% patch apply to one time a day for pain management and remove per schedule. Apply to the back topically one time a day for pain management. Apply at 9 AM then off at 9PM and remove per schedule. During an interview on 4/27/2025 at 9:57 AM with Resident 1, Resident 1 has been refusing the ordered Asperflex Lidocaine patch when offered by the nurses. Despite the refusals, Resident 1 stated, the Medication Administration Record (MAR) revealed documentation indicating that the Lidocaine patch had been applied and removed as scheduled. This discrepancy had raised Resident 1's concerns that the documentation entries do not reflect the resident's expressed refusals and actual care provided. During a concurrent interview and record review on 4/27/2026 at 12:03 PM with licensed vocational nurse (LVN)1, MAR presented by Resident 1 for April 1 to April 13, 2026, was reviewed. LVN1 stated, Resident 1 has been declining the ordered Asperflex Lidocaine 4% patch several times. LVN 1 is unaware whether Resident 1's refusal for the Lidocaine patch has been reported to the physician or not. LVN 1 further stated, when a resident refuses a medication, staff must find out why the resident is refusing and report to the resident's primary physician. During a concurrent interview and record review on 4/27/2026 at 2:29 PM with the director of nursing (DON), Resident 1's MAR for April 2026 was reviewed. DON stated, when a resident refuses medication, staff will have to find out why, report to the DON and the resident's physician. DON stated, licensed staff did not bring to the attention of the DON Resident 1 had been declining the ordered medication Asperflex Lidocaine 4% patch. During a telephone interview on 4/30/2026 at 2:24 PM with LVN 3, LVN 3 stated Resident 1 refuses Lidocaine patch because Resident 1 does not need the medication. When a resident refuses medication, the physician should be notified so the physician assesses the resident and provides alternative medication or discontinue the order. LVN 3 also stated, keeping a medication that is not being administered on a resident's record could lead to a medication error. During a telephone interview on 5/4/2026 at 2:43 PM with LVN 7, LVN 7 was informed Resident 1 had refused Asperflex Lidocaine 4% patch at least more than two or three times. A medication refusal for more than two or three times had to be reported to the physician and clinical supervisors. LVN 7 acknowledged not reporting Resident 1's refusal to the physician and unaware if staff reported or not. A review of the facility's policy and procedure (P&P) titled Resident Rights-Refusal of Care revised on 7/11/2025, the P&P indicated, If a resident refuses care or treatment, medications or food, the resident's attending physician will be notified within a 72-hour time frame.

Based on interview and record review, the facility staff failed to record accurately by failing to document the ordered medication Asperflex lidocaine 4% patch (a topical medication used to provide temporary relief for minor muscle, joint, and nerve pain) as administered and removed when a resident refused Asperflex lidocaine 4% patch medication more than twice for one of three sampled residents Resident 1. This deficient practice resulted in Resident 1's electronic medication administration records to be inaccurate. Findings: A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on [DATE] including a diagnoses of malignant neoplasm of female breast (the development of cancer in the breast), secondary malignant neoplasm of unspecified lung (the development of cancer in the lungs), muscle weakness (a lack of strength in the muscles) Type 2 diabetes mellitus (a condition in which the body is unable to control blood sugar and using it for energy). A review of Resident 1's minimum data set (MDS-a comprehensive resident assessment tool) dated 3/30/2026, the MDS indicated Resident 1's cognitive skills (ability to think and process information) for daily decision making was moderately impaired. A review of Resident 1's History and Physical (H&P) dated 3/26/2026, the H&P indicated, Resident 1 has the capacity for medical decision making. A review of Resident 1's Order Summary Report dated, 4/27/2026 indicated, Asperflex lidocaine 4.0% patch apply to one time a day for pain management and remove per schedule. Apply to the back topically one time a day for pain management. Apply at 9 Am then off at 9Pm and remove per schedule. During an interview on 4/27/2025 at 9:57 AM with Resident 1, Resident 1 has been refusing the ordered Asperflex Lidocaine patch when offered by the nurses. Despite the refusals, Resident 1 stated, the Medication Administration Record (MAR) revealed documentation indicating that the Lidocaine patch had been applied and removed as scheduled. This discrepancy had raised Resident 1's concerns that the documentation entries do not reflect the resident's expressed refusals and actual care provided. During a concurrent interview and record review on 4/27/2026 at 12:03 PM with licensed vocational nurse (LVN)1, MAR presented by Resident 1 for April 1 to April 13, 2026, was reviewed. LVN1 stated, Resident 1 has been declining the ordered Asperflex Lidocaine 4% patch. Resident 1's MAR indicated Asperflex Lidocaine 4% patch applied on Resident 1's lower back by LVN1 on the following dates:4/3/2026 at 8:10 AM 4/4/2026 at 9:32 AM4/8/2026 at 9:56 AM4/10/2026 at 9 AMLVN1 stated, Resident 1 has been declining the Lidocaine patch for reasons the resident does not believe the medication is working. LVN1 is unable to recall the dates Resident 1 declined the Lidocaine patch. LVN 1 stated, the last couple documentations must be a documentation error because the resident had refused the medication. LVN 1 further stated, documentation errors can be considered a medication error, it could provide inaccurate information for health care providers. During a concurrent interview and record review on 4/27/2026 at 1:56 PM with the assistant director of nursing (ADON), Resident 1's MAR presented by Resident 1 for April 1 to April 13, 2026, was reviewed. ADON stated, inaccurate documentation is a medication error and could result in affecting Resident 1's wellbeing. During a concurrent interview and record review on 4/27/2026 at 2:29 PM with the director of nursing (DON), Resident 1's MAR presented by Resident 1 for April 1 to April 13, 2026, were reviewed. DON stated, when a resident refuses medication, staff will have to find out why, report to the DON and the resident's physician. DON was not informed by licensed staff Resident 1 had been refusing the ordered medication Asperflex Lidocaine 4% patch. After reviewing Resident 1's MAR, DON stated, the nurse's documentation implied medication was given. DON further stated, it is misleading and inappropriate to document inaccurately. Durin a telephone interview on 4/30/2026 at 2:24 PM with LVN 3, LVN 3 stated Resident 1 refuses Lidocaine patch because Resident 1 does not need the medication. When a resident refuses medication, the physician should be notified so the physician assesses the resident and provides alternative medication or discontinue the order. LVN 3 also stated, keeping a medication that is not being administered on a resident's record could lead to a medication error. During a telephone interview on 5/4/2026 at 2:43 PM with LVN 7, LVN 7 stated, staff are aware and have informed LVN7 the resident had declined the medication at least more than two or three times. LVN 7 further stated, documentation error could lead to medication errors resulting in harms and provide wrong information to staff during medication regimen review. A review of the facility's policy and procedure (P&P) titled Medication Administration, reviewed on 7/11/2025, the P&P indicated, medication must be administered in accordance with the physician orders, including any required time frame.A review of the facility's P&P titled Resident Rights-Refusal of Care revised on 7/11/2025, the P&P indicated, If a resident refuses care or treatment, medications or food, the resident's attending physician will be notified within a 72-hour time frame.

Based on observation, interview, and record review, the facility failed to ensure that a resident received necessary physical and occupational therapy (PT/OT) services by not facilitating a resident's secondary insurance coverage for one of three sampled residents, Resident 1 according to the facility's policy and procedures (P&P) titled Specialized Rehabilitative Services revised 7/11/2025. This failure resulted in delay of medically necessary therapy services and had the potential for Resident 1 to decline in activities of daily living (ADL). Findings: A review of Resident 1's Admissions Record indicated, Resident 1 was originally admitted to the facility on [DATE] with a diagnoses including spinal stenosis (narrowing of the tunnel in your backbone that houses your spinal cord and nerves), acute kidney failure (drop in kidney function where the kidneys stop filtering waste from the blood properly), muscle weakness (a lack of strength in the muscles). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026 indicated, Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact, has impairment on both sides of upper and lower extremities and is dependent on wheelchair for mobility, dependent on staff for ADL. The same MDS indicated, Resident 1 did not receive special treatments, procedures, and programs in the last seven days. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes Certification Period: 10/4/2025 - 10/30/2025 indicated the following:Musculoskeletal assessment -range of motion (ROM) and strength of right and left lower extremities ROM were within functional limits. Right and left lower extremities strength were 4-/5. Right and left knee and ankles were impaired.Resident 1's goal is to walk again. A review of Resident 1's Physical Therapy Discharge Summary dates of service: 12/3/2025 - 12/10/2025 indicated, Resident 1 was discharged to Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility). A review of Resident 1's Social Services (SS) email notes dated 3/12/2026 indicated, Resident 1's insurer General Acute Care Hospital (GACH) was contacted per GACH physician request to access Resident 1's facility rehabilitation notes. During an interview on 3/13/2026 at 10:06 AM with Resident 1, Resident 1 stated, during the initial admission in October 2025 to the facility the recommendation from GACH physician was to receive at least 90 days of physical and occupational therapy. Resident 1 stated My therapy was discontinued within a month because the insurance coverage from GACH was only for 32 days. Resident 1 provided existing secondary insurance to the facility. Since November 2025, Resident 1 did not receive PT/OT due to the facility's failure to access Resident 1's existing secondary insurances. Resident 1 stated, It makes me feel like I am left out, I could have been waking by now. During an interview on 3/13/2026 at 12:05 PM with the Director of Rehabilitation Services (DOR), the DOR stated Resident 1 could have benefited from more PT/OT services. The therapy did not continue because Resident 1's primary insurance coverage for skilled nursing was limited to 32 days. Resident 1's secondary insurance was not paying due to technicality between the facility's business office and Resident 1's insurance. Resident 1 had expressed his concern that he needs to be on more therapy days. During an interview on 3/13/2026 at 12:29 PM with (RNA) 2, RNA 2 stated, before RNA therapy Resident 1 could not move his upper extremities, after RNA therapy Resident 1 is able to lift his shoulder up to 90 degrees with assistance and up to 60 degrees without assistance. Resident 1 could have benefited from more PT/OT to have a better mobility and functionality of his extremities. During an interview on 3/13/2026 at 12:53 PM with the Social Services Director (SS), the SS stated, I didn't know if SS was responsible to get more resources and if the facility had any responsibility to accommodate a required therapy when an insurance coverage is not adequate. SS is not aware Resident 1's PT/OT was interrupted due to insurance coverage. SS stated, I started contacting and sending records to Resident 1's secondary insurer GACH as of 1/16/2026. During an interview on 3/13/2026 at 12:53 PM with Registered Nurse Supervisor (RN), the RN stated, Resident 1 was in PT/OT program, he was improving, the staff was doing great working with him, but he was not satisfied with the length of therapy provided. Resident 1 could have benefited from more PT/OT, the challenges were financial and insurance coverages. During an interview on 3/13/2026 at 2:26 PM with the Director of Nursing (DON), the DON stated, Resident 1 did not present his concerns about PT/OT. None of the clinical staff brought the residents' concerns to the DON. DON stated DON is not aware of the required or needed PT/OT interruptions for Resident 1 due to insurance coverage. A review of the facility's policy and procedures (P&P) titled Specialized Rehabilitative Services revised 7/11/2025 indicated If specialized rehabilitative services are required in accordance with the resident's comprehensive plan of care, the facility will provide these services. The facility must provide the services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs.

Based on observation, interview, and record review, the facility failed to provide showers according to predetermined and scheduled dates for two of three sampled residents, Resident 1 and Resident 3 according to the facility's policy and procedures (P&P) titled Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services revised 7/11/2025. This deficient practice resulted in Resident 1 and Resident 3 missing at least two showers in the last month or two and had the potential to negatively impact Resident 1 and Resident 3's rights. Findings: A review of Resident 1's Admissions Record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnoses including spinal stenosis (narrowing of the tunnel in your backbone that houses your spinal cord and nerves), acute kidney failure (drop in kidney function where the kidneys stop filtering waste from the blood properly), muscle weakness (a lack of strength in the muscles). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026 indicated, Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact, has impairment on both sides of upper and lower extremities and is dependent on wheelchair for mobility, dependent on staff for (activities of daily living) ADL. A review of Resident 3's Admissions Record indicated Resident 3 was admitted to the facility on [DATE] with a diagnoses including lack of coordination (unable to control muscle, poor balance, unsteady), generalized muscle weakness (a lack of strength in the muscles), essential primary hypertension (when the pressure in your blood vessels is too high). A review of Resident 3's MDS dated [DATE] indicated, Resident 3's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact, dependent on staff to transfer to shower tub, to bath including washing, rinsing, and drying self. Requires Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). During an interview on 3/13/2026 at 10:06 AM with Resident 1, Resident 1 stated, he supposedly should have gotten a shower twice a week. Resident 3 reported missing a couple shower in the last month. When asking the reasons why he was not getting a shower, Resident 3 stated, The CNAs, tell me sometimes staff is not available, sometime recently there was construction, I was given different reasons. During an interview on 3/13/2026 at 10:49 AM with Resident 3, Resident 3 stated, In the last month or two I have missed tow or more showers because the CNAs tell me they don't have enough staff. Resident 3 did not want to complain to facility leadership because the staff works hard and try to accommodate him, but they are busy. Resident 3 stated, Missing showers and services frustrates me. During an interview on 3/13/2026 at 10:55 AM with certified nursing assistant (CNA) 1, CNA 1 stated, I am assigned to average 12 residents during the morning shift, I do not enough time to complete tasks CNA 1 spends average ten to forty-five minutes per resident depending on the level of care each resident needs. During an interview on 3/13/2026 at 11:12 AM with Licensed Vocational Nurse (LVN), the LVN stated, when there is a staffing shortage the LVNs on the floor assist CNAs to provide showers for residents. Most residents receive a shower twice a week. It is important residents get showers at least in their scheduled shower days, it is their rights. During an interview on 3/13/2026 at 2 PM with Registered Nurse supervisor (RN), the RN stated, Sometimes we are short staffed with CNAs, we get a lot of sick calls. Staffing affects residents' ADL care. During an interview on 3/13/2026 at 2:26 PM with the director of nursing (DON), the DON stated, residents have pre planned shower schedules. At least twice a week shower is provided. ADL is one of the primary responsibilities of the facility staff, most residents are dependent on staff for their ADLs. A review of the facility's policy and procedures (P&P) titled Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services revised 7/11/2025, the P&P indicated Ensure that the following ADL functions are monitored, supervised, assisted with and or provided to the Resident population that the facility is servicing to include but not limited to Bathing/Showering and or personal hygiene. The facility will provide hygiene, bathing, dressing, grooming, and oral care.

Based on interview and record review, the facility failed to ensure that Certified Nursing Assistant (CNA) 4 was not assigned to provide care to two out of five sampled residents (Resident 4) on 2/17/2026 on the 11pm to 7 am shift according to f the facility 's policies and procedures (P&P) titled , Abuse Reporting and Prevention date 7/11/2025, and Rules of conduct dated 01/2026. The facility was aware that Resident 4 had requested that CNA4 not be assigned to Resident 4.This deficient practice resulted in:A loud argument and possible physical altercation between Resident 4 and CNA4.Resident 5 complaining that he did not like how CNA4 turned him when providing care to him. Findings: On 2/23/2026 at 10:40 am, an unannounced visit was made to the facility to investigate facility reported allegations of staff on resident abuse. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis) following cerebral infarction (brain tissue death resulting from a severe, prolonged lack of oxygen and nutrients) affecting the left non-dominant side, cellulitis (acute bacterial infection of the deep middle layer and subcutaneous skin tissues) of the left lower limb, Type 2 diabetes mellitus (a chronic condition characterized by high blood sugar), hypertension (elevated high blood pressure), gastro-esophageal reflux disease (GERD- digestive disorder where stomach acid or contents frequently flow back (reflux) into the esophagus), asthma (inflammatory disease of the airways that causes them to swell, produce excessive mucus, and tighten, resulting in reversible airflow obstruction) and lack of coordination. A review of Resident 4's history and physical dated 10/21/2025, indicated Resident 4 has the capacity to make decisions. A review of Resident 4's Minimum Data Set (MDS - resident assessment tool) dated 11/6/2025, indicated the resident 4's cognition (The mental ability to make decisions of daily living) was intact. The MDS indicated Resident 4 required setup/clean up assistance with eating, substantial/maximal assistance with oral hygiene, toileting, hygiene, shower/bath, and personal hygiene. A review of Resident 5's admission record indicated Resident 5 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that include non-[NAME] lymphoma (a group of blood cancers that develop in your lymphatic system), benign neoplasm of the pancreas (noncancerous, tumor slow-growing, and do not spread (metastasize) to other parts of the body), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), lack of coordination, difficulty walking bilateral osteoarthritis (a degenerative joint disease) of the hip, and polyneuropathy (widespread, simultaneous damage to multiple peripheral nerves) A review of Resident 5's MDS dated [DATE] indicated Resident 5's cognition was severely impaired. The MDS indicated Resident 5 required setup/clean up assistance with eating, is dependent for oral hygiene, toileting hygiene, shower/bath, upper body dressing and personal hygiene, Resident 5 requires substantial maximal assistance with rolling from left and right and moving from sitting to lying position. During an interview on 2/23/2026 at 12:01 pm, Resident 4 stated she (Resident 4) told Licensed Vocational Nurse (LVN) 2 on 2/17/2026 at the beginning of the 11pm to 7 am shift, that she (Resident4) did not want CNA4 assigned to provide care to her (Resident 4). Resident 4 stated that LVN2 told Resident 4 that the CNA who was assigned her (Resident 4) was running late because it was raining heavily. Resident 4 stated that in the past (unable to recall the date/time), CNA4 had forced a glove into Resident 4's hand, applied some A&D (topical medication/skin protectant and emollient used to treat and prevent skin diaper rash) on the same glove that CNA4 had forced into the resident's hand. Resident 4 continued to state that CNA4 then told Resident 4 to apply the A&D on herself (Resident 4). Resident 4 stated that again on 2/18/2026 during the 11pm-7am shift (unable to recall exact time), CNA4 gave Resident 4 a towel and told Resident 4 to clean herself (Resident 4). Resident 4 stated she cleaned herself and then placed the used towel on the side of the bed, however, the towel fell to the floor. Resident 4 stated CNA4 picked up the towel of the floor and told Resident 4 that, don't throw it (towel) at me. Resident 4 stated CNA4 told her (Resident 4) that, next time it will be worse for you if you do that (towel on the floor). Resident 4 stated CNA4 told Resident 4 I am from [NAME]; we do not play that in [NAME]. Resident 4 stated (CNA4) makes me feel like I am less than them. During an interview on 2/23/2026 at 12:27pm, CNA2 stated that Resident 4 told her (CNA2) that Resident 4 does not like the staff who work the 11pm-7am shift. CNA2 also stated that Resident CNA4 told CNA2 that CNA4 had an attitude, and that Resident 4 and CNA4 had argued. During a telephone interview on 2/23/2026 at 2:23pm LVN2 stated she (LVN2) completed the facility staff to Resident assignment for the 11pm-7am shift on 2/17/2026. LVN2 stated my understanding is the only Resident CNA4 cannot be assigned is Resident 5. LVN2 stated the previous shift 3pm-11pm Resident 5 had requested not to be assigned CNA4. LVN2 stated LVN3 reported to RN1 during the 11pm-7pm shift that CNA4 and an altercation with Resident 4. During an interview on 2/23/2026 at 2:41pm Registered Nurse (RN1) stated he did not witness the alleged abuse on Resident 4 by CNA4. RN1 stated that on 2/17/2026 at 11pm to 7 am shift, one (1) staff had called in sick and therefore CNA4 was assigned to Resident 4. RN1 stated CNA4 did not want to be assigned to Resident 4, and that RN1 asked Resident 4 to give CNA4 a chance. RN1 stated that Resident 4 and CNA4 agreed to work together. RN1 stated CNA4 insisted on working with Resident 4, and that CNA4 did not mention any history that prohibited her (CNA4) from working with Resident 4. RN1 stated CNA4 told RN1 that while assisting Resident 4 with ADL cleaning, Resident 4 did not want CNA4's help, and that Resident 4 cleaned her (Resident 4) own perianal area (between the private area and the rectum) and then threw the dirty towel on the floor and that Resident 4 kicked CNA4. RN1 stated that CNA4 told RN1 that there was no trigger for Resident 4's behavior. RN1 stated that CNA4 told RN1 that Resident 4 threw the used towel at CNA4 because Resident 4 doesn't like CNA4. RN1 further stated he later found out from CNA4 after the altercation between Resident 4 and CNA4, that CNA 4 was not supposed to be assigned to Resident 4. RN1 stated he (RN1) reported the incident to the Administrator (ADM), ADM told RN1 to tell CNA4 that CNA4 is suspended to and send CNA4 home. During an interview on 2/24/2026 at 6:45am CNA4 stated on Resident 4 asked LVN2 if there was anyone other CNA other than CNA4 to work with Resident4. CNA4 stated RN1 said that he (RN1) would accommodate Resident 4's request by not assigning CNA4tof Resident 4 had objected to not wanting CNA4. CNA4 stated LVN2 knew/was aware that CNA4 could not work with Resident 4 but LVN2 told CNA4 that she (LVN2) could not change the assignment. CNA4 further stated RN2 usually makes the work assignment and never assigns CNA4 to Resident 4, however, RN2 was on vacation. CNA4 stated that on 2/18/2026 on the 11 pm to 7 am shift, she (CNA4) went to introduce herself to Resident 4 who had requested for incontinent brief change. CNA4 stated that as soon as she (CNA4) walked into Resident 4's room, Resident 4 said, no, no, no. and asked for another CNA. CNA4 stated LVN3 told Resident 4, If you don't want (CNA4) to change (incontinent care) you then you will not be changed. We are short of staff. You must let CNA4 change you. CNA4 stated she cleaned Resident 4 and asked Resident 4 to turn, and then Resident 4 told CNA4 that she (Resident 4) was still wet in the perineal area and requested for a dry clean washcloth to dry herself. CNA4 stated that when Resident 4 was finished/ done drying herself, Resident 4 threw the dirty washcloth (towel) at CNA4 which hit CNA4 in the stomach (abdomen). CNA4 stated while still cleaning Resident 4, Resident 4 resisted and kicked CNA4 in the stomach. CNA4 stated she reported the sequence of events to RN1, and RN1 investigated and reported Resident 4 complaint incident to the administrator. CNA4 stated that the administrator told RN1 to tell CNA4 that because it is abuse, CNA4 was placed on a 3-day suspension. CNA4 stated that was not the first time Resident 4 had reported CNA4 to the director of nursing and Administrator. CNA4 stated Resident 5 did not want CNA4 to take care of him (Resident 5) because CNA5 had told Resident 5 to file a grievance against CNA4. During an interview on 2/24/2026 at 7:12 am, LVN3 stated she was unaware CNA4 could not be assigned to Resident 4 until Resident 4 and CNA4 had an altercation. LVN 3 stated on 2/18/2026 at 1:30 am, CNA4 came out of Resident 4's room and called LVN3 stating please come. LVN3 stated when she got to Resident 4's room, CNA4 and Resident 4 were arguing, Resident 4 told LVN3, CNA4 hit her (Resident 4) with a towel on her (Resident 4's) face. LVN3 sated that CNA4 said, I did not through a towel at Resident 4's face and that CNA4 said you (Resident 4) hit me too and I just came out of the hospital. LVN3 stated that Resident 4 said yes you did hit me and that CNA4 repeated you hit me too. LVN3 stated she asked CNA4 to step outside of Resident 4's room and told CNA4 that LVN3 would finish changing Resident 4. LVN3 stated Resident 4 said that she (Resident 4) asked CNA4 to dry her (Resident 4) because she (Resident 4) was still feeling wet on the front of the private area but CNA4 gave Resident 4 an attitude and said, I'm done, if you want to do it (dry the vaginal area) yourself, here is the towel. LVN3 stated Resident 4 said that even though she felt uncomfortable when CNA4 spoke to her in that manner and that she (Resident 4) dried herself and then gave the towel to CNA4. LVN3 stated Resident 4 said that CNA4 got upset and said, why did you throw that towel at me? CNA4 then grabbed the same towel and threw it at Resident 4's face. LVN3 stated Resident 4 stated she felt abused and she (Resident 4) kicked CNA4 with her (Resident 3's) right leg. LVN 3 stated CNA4 ran out of the room and called LVN3. LVN3 stated after listening to Resident 4, I assessed her (Resident 4) again. LVN3 stated that CNA4 is not allowed to have (be assigned) Resident 5. LVN3 stated that CNA4 was upset because she was not assigned Resident 5 on 2/23/2025 on the 11 pm-7 am shift, gave the charge nurses including LVN3 an attitude and told LVN3 that the only Resident she (CNA4) is not allowed to have is Resident 4. During an interview on 2/24/2026 at 7:34 am CNA5 stated on 2/16/2026 on the 7am-3pm shift the while picking up Resident 5 breakfast tray in the morning, Resident 5 told CNA5 I want to speak to your supervisor. I need to make a report of abuse. CNA5 stated she reported Resident 5's request to the charge nurse, supervisor and administrator. CNA5 stated the Administrator spoke to Resident 5 and that CNA4 can no longer provide care to Resident 5. During an interview on 2/24/2026 at 8:05 am, Resident 5 stated last week (unable to recall date) a CNA4 grabbed his (Resident 5's) left arm, swung Resident 5 to the left side, and was rude to Resident 5. Resident 5 stated the Administrator spoke to him (Resident 5) and told him that the CNA4 will no longer be assigned to him (Resident 50. During an interview on 2/24/2026, Social Services Director (SSD) stated Resident 5 had a grievance last week (unable to recall date), Resident 5 stated CNA4 placed very greasy lotion on him, (SSD does not know type of lotion) SSD stated she is aware that CNA4 was removed from taking care of Resident 5 but does not know why. SSD stated she does not know how Resident 5 developed the bruise to his arm and fore fingers. SSD stated Resident 4 informed SSD that she (Resident 4) placed towel on side of the bed, the CNA4 picked up the towel and threw it at Resident 4's face. SSD stated that Resident 4 said that Resident 4 kicked CNA4 in self-defense. SSD stated, I know they (CNA4 and Resident 4) have a history but Resident 4 did not go into details about her previous experience with CNA4. During an interview on 2/24/2026, Administrator (ADM) stated, if a Resident does not want a staff to care for them, staff should honor Residents request. Administrator stated that Resident4 alleged that when she was done cleaning herself with towel, CNA4 took towel and threw it on Resident 4's face. CNA4 stated Resident 4 cleaned herself with towel, Resident 4 dropped it (towel) on the floor at CNA4's feet, CNA4 asked Resident4 why she (Resident 4) dropped towel on the floor and Resident 4 kicked her without provocation. Administrator stated CNA4 was barred from being assigned to Resident 5, it was Resident 5's preference. Resident 5 stated he did not like the care he received when the CNA4 changed him. I asked Resident 5 what the appropriate step to take was, Resident 5 stated he does not want CNA4 assigned to him. Resident 5 stated he did not like how the CNA4 turned him. He was not upset with the physical part but CNA4 did not communicate what she was going to do. Administrator stated he is exploring options, and he (ADM) is concerned about CNA4's code of conduct and how this will affect other Residents. Administrator stated he (ADM) is hesitant to bring CNA4 back to full duty. A review of the facility 's policy and procedures (P&P) titled , Abuse Reporting and Prevention date 7/11/2025 indicated, abuse means the willful infliction of.Physical Abuse - A willful physical action that is meant to inflict physical harm. Mental abuse, humiliation, harassment, threats of punishment or deprivation resulting in harm, pain, or mental anguish that are necessary to attain or maintain physical, mental, and psychosocial well being. A review of facility P&P titled Rules of conduct dated 01/2026 indicated, It is important to us that all employees maintain proper standards of conduct and observe certain rules to ensure the orderly and efficient operation. employees who do not comply with Company policies, rules and directives will be disciplined or terminated, examples of misconduct Abuse or neglect of the residents. Rude, discourteous or un-business-like behavior, creating a disturbance on Company premises or creating discord with ., employees.

Based on interviews, observation and record review, the facility failed to maintain a safe, functional and comfortable environment for residents, staff, and visitors by failing to ensure three of five sampled rooms (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) were free of water leaks according to the facility's policies and procedures (P&P) titled, General Maintenance, reviewed on 7/11/2025, and Physical Environment, reviewed on 7/11/2025. This deficient practice had the potential to cause incidental accidents and have the potential for the residents' physical discomfort for residents staff, and visitors. Findings: A. During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), polyneuropathy (a condition in which a person's peripheral nerves are damaged), and type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/4/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 2 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview with Resident 2 on 2/17/2026 at 5:08 p.m., Resident 2's room (room [ROOM NUMBER]) was observed with water leaks from the ceiling, the ceiling had a concentric ring, water bubble. Resident 2 stated, he felt water dripping from the ceiling that started yesterday (2/16/2026) and his bed was moved to the middle of the room, so he won't get wet. Resident 2's room was observed with towels and blankets on the floor with basin that collected water from the ceiling. B. During a review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following unspecified cerebrovascular disease (a group of conditions that disrupt blood flow to the brain, acting as a brain attack) affecting right dominant side, epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and muscle weakness (weakening, shrinking, and loss of muscle). A review of the MDS dated [DATE] indicated Resident 3's cognitive skills for daily decisions were intact. The MDS indicated Resident 3 required moderate to clean-up assistance from staff for ADLs. During a concurrent observation and interview with Resident 3 on 2/18/2026 at 12:25 p.m., water was observed dripping from the ceiling in Resident 3's room (room [ROOM NUMBER]). The ceiling had a visible rusty, brown discoloration and a water basin, blankets and towels were observed on the floor. Resident 2 stated there's been water leaks in the facility, and they did not move him to a different room while there's water leaking from his room's ceiling. During a concurrent observation and interview with Maintenance Director (MTD) on 2/17/2026 at 4:45 p.m., the ceiling in room [ROOM NUMBER] was observed. MTD stated, the roof of the facility had been repaired in the past but there are still issues with water leaking especially after rains. MTD stated that the ceiling on room [ROOM NUMBER] has a bubble dent due to weigh of the water that accumulates on the ceiling, as well as water stains that are visible on the ceiling on room [ROOM NUMBER]. MTD further stated, room [ROOM NUMBER]'s window also has some issues with water leaking from the outside to the windows; therefore, they are placing towels and blankets by the window to stop water from coming in. MTD stated, the company that repaired their roof had to come and assess the roof to check and assess why they are still having water leaks.During an interview with Director of Nursing (DON) on 2/18/2026 at 4:35 p.m., DON stated, water leaks in resident's room and water on the floor, puts residents at risk of injury as residents may slip and fall. DON stated they have done repairs of the facility due to water leaks, but they are still having issues with the facility. DON stated, they should have moved the residents to prevent any accident and to provide residents with safe environment. During a review of the facility's policy and procedures (P&P) titled, Physical Environment, reviewed on 7/11/2025, the P&P indicated, The facility will be equipped and maintained to protect the health and safety of residents, personnel and the public. During a review of the facility's P&P titled, General Maintenance, reviewed on 7/11/2025, the P&P indicated, It is the policy of the facility to provide general maintenance and housekeeping services daily. Maintenance will ensure that inspection and services are provided to repair and maintain all functional equipment.

Based on observation, interview and record review, the facility failed to implement facility's policy and procedures (P&P) titled, Scabies - Prevention and Control, when one of three sampled residents (Resident 5) was noted with signs and symptoms (s/sx) of scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite that burrow into the skin) by failing to:1. Properly identify possible cases of scabies infection as soon as possible.2. Develop contact list (tracing) and to notify and educate facility's employees, family members and visitors. This deficient practice had the potential to further spread infection to the residents, visitors, and the community.Findings: During a record review of the admission Record, the admission record indicated that Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), and type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/19/2025, the MDS indicated that Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 5 required setup or clean-up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 5's Skilled Nursing Facility Progress Note (SNFPN) for the months of 1/2026 and 2/2026 indicated that the physician documented the following:Date of service 1/4/2026, the SNFPN indicated, (Resident 5) noted to have significant itching, was treated with permethrin (a prescription, topically applied medicine used to treat scabies) in case residual scabies. (Resident 5) has received repeated treatments with ivermectin (a medication that reduces facial redness caused by rosacea) for scabies in the past and including during most recently hospitalization with permethrin cream.Date of service 2/15/2026, the SNFPN indicated, Physical exam, Skin: diffuse scattered excoriations (widespread, broken skin from scratching or picking)Date of service 2/17/2026, SNFPN indicated, (Resident 5's) Chief Complaint: weakness, scabies. (Resident 5) has been treated for scabies twice. During a review of Resident 5's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/30/2026, the SBAR indicated, unknown generalized skin condition: generalized redness and rash on body, resident (5) complained of itching. The SBAR also indicated, recommendations of primary clinician: permethrin 5 percent (% - unit of measurement) weekly for four weeks. During a review of Resident 5's medical record as of 2/18/2026, the medical records indicated there was no laboratory diagnostic test done by the facility to diagnose and identify Resident 5's generalized redness and rash on body with complaints of itching. During an interview with Infection Preventionist Nurse/Director of Staff and Development (IPN/DSD) on 2/18/2026 at 12:44 p.m., IPN/DSD stated, [Resident 5] has generalized rash and is currently on treatment of permethrin cream. IPN/DSD stated, permethrin cream is for treatment of scabies and that [Resident 5] has signs and symptoms (s/sx) of scabies. IPN/DSD stated, scabies is passed on through contact and are contagious. IPN/DSD stated, to diagnose scabies, they must do skin scraping and send the sample to lab for diagnostic test. IPN/DSD stated, the facility did not do any skin scraping on Resident 5 to diagnose and identify scabies. IPN/DSD further stated, he (IPN/DSD) had not done any education or in-services to staff regarding scabies in the facility, and that he had not started/developed a contact list to to identify residents, staff and visitors that may have had contact with Resident 5. During an interview with Treatment Nurse (TXN) 1 on 2/18/2026 at 2:24 p.m., TXN 1 stated,[ Resident] is on treatment for scabies with generalized rash. TXN 1 stated, Resident 5 has a lot of scratches on his trunk and extremities, red, scattered skin rash and Resident 5 is constantly scratching. During a review of facility's P&P titled, Scabies - Prevention and Control, reviewed on 7/11/2025, the P&P indicated that, This facility has established and implemented policies for the prevention and control of scabies that include notification and education of facility employees, family members and visitors. As soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had direct, physical contact with the case within the previous month. This list should contain the following:1. Include the nursing unit, room number, name, date of onset of symptoms, results of skin scrapings, date of initial treatment, date of follow-up treatment, results of treatments (e.g. condition resolved or not resolved) and the date and results of repeat skin scrapings, if performed.2. Identify roommates of the case. Include roommates who have been discharged , moved to other nursing units or to another health care facility within the previous month.3. Determine the daily routines of the case for the previous month and identify exposed residents located on the same nursing unit or on other nursing units.4. Determine if the case was transferred to another health care facility for treatment, such as dialysis, within the past month. Notify the other facility's infection control practitioner.5. Notify visitors (spouse, family members or friends) who may have visited the case within the past month.6. Identify health care workers and volunteers who have had direct physical contact with the case within the past month. Determine if these contacts are symptomatic or asymptomatic.7. Determine if household contacts or the sexual partner of symptomatic health care worker, volunteer or visitor has signs or symptoms of scabies infestation.8. Determine if there are symptomatic health care workers, residents, volunteers or visitors on other nursing units. If an initial evaluation indicates no unusual complaints of pruritus or changes in the condition of the skin, treatment may not be indicated. However, a follow-up evaluation should be done at least every other day for four (4) weeks.After developing a contact identification list, the infection control practitioner should determine who should receive treatment and the treatment schedules to be followed. Resident, health care worker, visitor and volunteer contacts determined to be symptomatic should be treated as soon as possible, preferably within the first 24 - 48 hour treatment period. Health care workers must maintain a high degree of suspicion and take immediate action when signs and symptoms suggestive of infestation are observed. The first and most important step in preventing an outbreak is educating health care workers to perform a frequent and thorough skin assessment on all residents. Skin assessments should be documented and any findings suggestive of infestations should be communicated to the infection control practitioner. Once a suspect case is identified, appropriate diagnostic procedures should be performed. Controlling the transmission of scabies once a case has been identified requires immediate action. Contacts must be identified, isolation precautions must be implemented and a determination of who should be treated must be made. During the post treatment period, residents, health care workers, volunteers and visitors must be observed for possible treatment failure or re-infestation.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to accommodate the residents' needs and request according to the facility's policy and procedures (P&P) titled, Staffing reviewed on 7/11/2025 for seven of ten sampled days (on 2/8/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/15/2026, 2/16/2026 and 2/17/2026).This deficient practice resulted in residents not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to the residents. Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following unspecified cerebrovascular disease (a group of conditions that disrupt blood flow to the brain, acting as a brain attack) affecting right dominant side, epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and muscle weakness (weakening, shrinking, and loss of muscle). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/24/2025, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 3 required moderate to clean-up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview with Resident 3 on 2/18/2026 at 12:25 p.m., Resident 3 stated, the facility has been short-staffed that when he requests to shower on his shower days, he is told that his shower will be delayed till the afternoon because facility does not have enough staff. During an interview with Certified Nursing Assistant (CNA) 1 on 2/18/2026 at 12:35 p.m., CNA 1 stated, she was unable to provide shower to Resident 3 because the facility is short-staffed today (2/18/2026). CNA 1 stated that, when residents have a private caregiver (often called an independent or private-duty caregiver, is a professional hired directly by a patient or their family to provide personalized, non-medical, or custodial assistance in the home), the facility lets the caregiver to do the responsibilities of CNAs such as feeding, repositioning, changing and cleaning of residents to help ease with their workload. During a review of facility's Direct Care Services Hours Per Patient Day (DHPPD) form on the skilled nursing unit, the following information was indicated:On 2/8/2026, the actual DHPPD was 3.38, and the actual CNA (Certified Nursing Assistant) DHPPD was 2.37On 2/10/2026, the actual CNA DHPPD was 2.06On 2/11/2026, the actual CNA DHPPD was 2.22On 2/12/2026, the actual DHPPD was 3.34 and the actual CNA DHPPD was 2.30On 2/15/2026, the actual DHPPD was 3.32 and the actual CNA DHPPD was 2.25On 2/16/2026, the actual DHPPD was 3.39 and the actual CNA DHPPD was 1.90On 2/17/2026, the actual DHPPD was 3.29 and the actual CNA DHPPD was 2.00 During a concurrent interview and record review with Director of Nursing (DON) on 2/18/2026 at 4:27 p.m., DON stated, the facility is currently working on staffing shortage in the facility. DON reviewed facility's staffing on 2/17/2026 during the morning shift, and stated they only had five CNAs for 79 residents in the skilled facility unit. DON stated, facility needs to provide adequate staffing to ensure that the staff provide care and services to the residents. During a review of the facility's policy and procedures (P&P) titled, Staffing, reviewed on 7/11/2025, the P&P indicated, The facility goal is to provide adequate staffing to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility will provide nursing staffing on the skilled nursing units that will not be below 3.5. The facility will provide certified nursing assistant staffing that will not be below 2.4 unless the facility has applied for and been granted a waiver.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 8) who was identified as at risk for falls did not experience a fall by failing to: Ensure Resident 8 was properly assessed and monitored after Resident 1 slipped out of the wheelchair on 1/16/2026 according to facility's policy and procedures (P&P) titled, Falls by a Resident, reviewed on 7/11/2025. Ensure Resident 8's Fall Risk Assessments were accurately documented by licensed nurse according to facility's P&P titled, Fall Risk & Prevention of Injury to include pathological Fractures, reviewed on 7/11/2025, and P&P titled Falls by a Resident reviewed on 7/11/2025. These deficient practices placed Resident 8 at risk for further falls and/or injuries. Findings: During a review of the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, abnormalities of gait and mobility (changes in normal walking, running, or movement patterns, often resulting in limping, shuffling, unsteadiness, or difficulty balancing) and history of falling. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 1/15/2026, indicated Resident 8's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were mildly impaired. The MDS indicated Resident 8 required moderate to supervision assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated, Resident 8 used manual wheelchair for mobility assistive devices. During a review of Resident 8's Care Plan (CP) for fall risk, dated 7/17/2025, the CP indicated (Resident 8)'s problems and concerns of falls, and potential for injury related to balance, cognitive impairment, physical impairment, generalized weakness, lack of coordination and hemiparesis/hemiplegia. The CP indicated interventions included to keep the environment hazards free, keep the call light and frequently used items within the resident's reach, and a person to assist with transfers. During a review of Resident 8's fall risk evaluation for the months of 10/2019, 1/2026, and 2/2026, indicated the following: Dated 10/22/2019, indicated Resident 8's fall risk score was 11 (high risk of fall) Dated 1/16/2026, indicated Resident 8's fall risk score was 8 (moderate risk of fall) Dated 2/17/2026, indicated Resident 8's fall risk score was 13 (high risk of fall) During a review of Resident 8's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) for the months of 1/2026 and 2/2026, indicated the following: Dated 1/16/2026, Resident 8 slipped out of wheelchair during transfer Dated 2/17/2026, Resident 8 was found on the floor in a sitting position in his room in front of the bathroom. During a review of Resident 8's 72-hr neurological (neuro- relating to the nerves or the nervous system, including the brain, spinal cord, and peripheral nerves) check (after a fall, a series of checks performed by nurses to ensure a resident has not suffered a brain injury, such as a slow-developing brain bleed or concussion), indicated the following: Post (after)-fall neuro check assessment was documented on 1/17/2026 (7 a.m. - 3 p.m. shift), and 1/19/2026 (11 p.m. - 7 a.m. shift). During a concurrent interview and record review with Registered Nurse (RN) 1 on 2/17/2026 at 3:56 p.m., Resident 8's fall risk evaluation dated 1/16/2026 was reviewed. RN 1 stated, Resident 1 had history of falls in the facility and uses assistive devices for mobility. RN 1 stated that the fall risk evaluations were not documented and assessed accurately because Resident 8's score of 8 does not accurately reflect Resident 8's risk for fall. RN 1 stated the response for fall risk evaluations were answered incorrectly on the following questionnaire i (letter I): (Resident 8) history of falls (past 3 months) was documented as 0 (no falls in the past 3 months), however, the facility 2. Gait/Balance not documented/left blank, however, the facility it should have documented as 1 on balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, gait problems; jerking unstable when making turns, unsteady gait, shuffling gait and requires use of assistive devices. During the same concurrent interview and record review with RN 1 on 2/17/2026 at 3:56 p.m., Resident 1's 72-hr neuro checks post-fall on 1/16/2026 was reviewed. RN 1 stated that the 72-hr neuro checks were incomplete and inconsistent. RN 1 stated, after residents' fall, residents must be checked for 72-hr by licensed nurses in the morning shift, evening shift and night shift. RN 1 stated that according to Resident 1's medical record, neuro check after-fall was done on 1/17/2026, morning shift and on 1/19/2026, evening shift. RN 1 stated, there was no neuro check done on 1/16/2026 evening and night shift, on 1/17/2026 on evening and night shift, and no neuro check done on all three shifts (7a.m-3 p.m., 3 p.m.-11 p.m., and 11 p.m-7 a.m., on 1/18/2026. During an interview and concurrent record with Director of Nursing (DON) on 2/18/2026 at 4:08 p.m., Resident 8's 72-hr neuro check and fall risk evaluation were reviewed. DON stated there should be complete documentation a after each incident of a resident falling. The DON stated that s there were inconsistencies in the licensed nurses charting regarding Resident 8 falling on 1/16/2026. DON stated assessment and evaluation must be completed such as 72-hr neuro check and fall risk evaluation after each fall. DON stated, there should be preventative measures, if not, residents may possibly have more fall incidents and injuries. During a review of facility's P&P titled Falls by a Resident, reviewed on 7/11/2025, the P&P indicated that, It is the policy of the facility that if a resident sustains a fall, an incident report will be completed. A post fall assessment is also completed to identify factors that may have contributed to the fall. A care plan or an update to an existing care plan will then be generated. A post fall assessment is completed to identify possible causative factors that could have contributed to a fall. The information is then used to formulate a plan of care in an attempt to prevent further falls or accidents. During a review of facility's P&P titled, Fall Risk & Prevention of Injury to include pathological Fractures, reviewed on 7/11/2025, the P&P indicated that, Upon admission, a Fall Risk Assessment will be completed for all residents. The incident report and the investigation will be reviewed by the Interdisciplinary Team with recommendations for additional approaches in an attempt to prevent further falls. A Post Fall Risk Assessment will be completed by IDT. Any additional approaches will be included on the resident's plan of care.

Based on observation, interviews and record review, the facility failed to ensure one of four sampled residents (Resident 1), received care consistent with professional standards of practice to promote healing of pressure ulcers/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), prevent infection and prevent new ulcers from developing by failing to:Ensure Resident 1 was repositioned every two hours according to Resident 1's comprehensive plan of care and facility's policy and procedures (P&P) titled Activities of Daily Living, Quality of Care, Routing Resident Monitoring, and Score of Services, reviewed on 7/11/2025.Skin assessments were accurate upon admission for Resident 1 according to facility's P&P titled, admission Assessment - Nursing, reviewed on 7/11/2025,Ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for Resident 1 according to facility's P&P titled, Low Air Loss Mattress, reviewed on 7/11/2025, .These deficient practices had the potential to delay the provision of necessary care and services and deterioration of residents' current wounds/pressure injuries(pressure ulcers). Findings: During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including malignant melanoma of the left upper limb and shoulder (an aggressive form of skin cancer arising from pigment-producing cells on the arm or shoulder), pressure ulcer of Left Buttock, Stage 4 (a severe, full-thickness wound extending through the skin to expose muscle, tendon, or bone), Pressure Ulcer of Sacral region Stage 4, metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), and dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/16/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Progress Notes by Wound Care Provider 1 (WCP 1), dated 11/25/2025, the Progress Notes indicated, (Resident 1) with Stage 4 Pressure Ulcer (a severe, deep, and open crater-like wound that extends through the skin, fat, and muscle to expose tendons or bone) in sacrococcyx (small bone at the bottom of the spine) with physician's noted for offloading/repositioning education: throughout 24 hours, including at night, reposition resident (1) with wedges for support, change incontinence garments frequently to prevent moisture-associated skin damage and maintain skin integrity, thereby promoting optimal wound healing. During a review of Resident 1's Care Plan (CP) for risk for impaired skin/tissue integrity, dated 2/5/2026, the CP indicated a goal of (Resident 1) will remain free from development of further skin breakdown daily, with interventions including, to turn and reposition every two hours and more frequently, if needed, use appropriate pressure reducing mattress, change incontinence pads frequently. During a review of Resident 1's Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need), meeting dated 12/3/2025, the IDT meeting indicated, discussed plan of care with Resident 1's power of attorney (POA - a legal document authorizing a designate person to make healthcare decisions for a patient who is incapacitated). Conference pertains to: turning and repositioning - facility will ensure that resident is turn and reposition as scheduled and as needed. Turning and repositioning will only be on side to side to keep pressure off the sacral open area. During a review of Resident 1's Activities of Daily Living - Turn and Repositioning Log, dated 1/20/2026 to 2/17/2026, the Turn and Repositioning Log indicated, Resident 1 was turned two to three times a day. During an interview with Resident 1's Private Caregiver (R1CG) on 2/17/2026 at 4:32 p.m., R1CG stated, she stays with Resident 1 from 7 a.m. to 7 p.m., where she turns and repositions every two hours, feeding, and changing incontinent briefs on Resident 1. R1CG stated, there are times that Certified Nursing Assistant (CNA) help her with repositioning and turning, but most of the time, she does the turning and repositioning, changing incontinent brief and feeding for Resident 1. During an interview with Certified Nursing Assistant 1 (CNA 1) on 2/18/2026 at 12:35 p.m., CNA 1 stated, Resident 1 has a private caregiver at bedside, and the private caregiver does the ADLs for Resident 1 such as turning, repositioning, feeding and changing incontinent brief for Resident 1. CNA 1 stated, she would ask if the private caregiver needed help but for the most part, the R1CG does all the ADLs for Resident 1. During a concurrent interview and record review with Director of Nursing (DON) on 2/18/2026 at 3:41 p.m., Resident 1's ADL - turn and repositioning log and Medical Records were reviewed. DON stated, CNAs and staff are responsible for doing ADL care for residents. DON reviewed Resident 1's ADL - turn and repositioning log from 1/20/2026 to 2/17/2026 and stated and confirmed, the ADL log indicated, Resident 1 was documented as turned and repositioned two to three times a day. DON stated, the log only showed Resident 1 was being turned two to three times per day by staff, instead of every two hours as indicated in Resident 1's CP and in their IDT meeting. Resident 1's Medical Records indicated there were no documentation of Resident 1's skin assessment and pressure ulcer/injury risk assessment tool upon readmission on [DATE]. DON stated there should be a skin evaluation and documentation by the admitting nurse upon admission. DON stated, if there were no documentation of skin assessment and evaluation upon residents' admission, it means it was not done. During a concurrent interview and record review with Treatment Nurse (TXN) 1 on 2/18/2026 at 1:59 p.m., Resident 1's Medical Records, weight record and Order Summary Report (OSR) dated 2/4/2026 were reviewed. Resident 1's OSR dated 2/4/2026 indicated physician's order included the following:Alternating pressure mattress for skin and wound management. Check for proper setting and function every shiftWeekly weight times (x) four then every month if stable. Resident 1's weight record indicated the following:Dated 1/1/2026, Resident 1's weight was 158 lbs.Dated 2/4/2026, Resident 1's weight was 156 lbs.During the same concurrent interview and record review, TXN 1 stated that residents' skin must be assessed, evaluated and documented during residents admission and readmission. TXN 1 stated that there were no skin assessments and documentation if Resident 1's skin was assessed and evaluated upon readmission on [DATE]. During an observation of Resident 1 with TXN 1 on 12/18/2026 at 2:15 p.m., Resident 1 was observed lying on a LAL mattress with knob setting at 250 pounds (lbs - unit of measurement). During a concurrent observation and interview with TXN 1 on 2/18/2026 at 2:20 p.m., TXN 1 stated, the LAL mattress setting is set according to resident's weight. TXN 1 observed Resident 1's LAL mattress and stated, Resident 1's LAL mattress was set to firm and at 250 lbs. TXN 1 stated, the LAL mattress was not set to the correct setting. TXN 1 stated, the LAL mattress is used to help offload and for wound prevention and management. TXN 1 further stated, if the setting is not correct, it would not assist with wound prevention and management. During an interview with DON on 2/18/2026 at 3:41 p.m., DON stated the LAL mattress setting is according to residents' weight. DON stated, if the LAL mattress is not set according to residents' weight, it can possibly not assist with wound healing or may have the opposite effect. During a review of facility's policy and procedures (P&P) titled, Prevention of Pressure Ulcers/Injuries, reviewed on 7/11/2025, the P&P indicated that, Interventions and Preventive Measures: Identify risk factors for pressure ulcer/injury development. For resident in bed: change position at least every two hours or more frequently as needed. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees. During a review of facility's P&P titled, Pressure Ulcer/Injury Management, reviewed on 7/11/2025, the P&P indicated that, The facility's pressure ulcer/injury risk assessment tool is to be completed to assess a resident's pressure ulcer/injury risk upon admission and weekly for the first four weeks, then quarterly, or whenever there is a significant change in the resident's condition or functional ability. Ongoing Programs: CNA to report each shift to charge nurse on skin status of residents if any changes are noted. CNAs do weekly skin observations and report changes in skin, during showers/bed bath, Emphasis on turning schedule by all supervisory staff. During a review of facility's P&P titled Activities of Daily Living, Quality of Care, Routing Resident Monitoring, and Score of Services, reviewed on 7/11/2025, the P&P indicated that, Staff will ensure that ADL are monitored, assisted with, and provided for those residents who are unable to perform ADL. The certified nursing assistants should check and change residents; if necessary, assist residents to the toilet if needed and turn and reposition residents at least every two hours. The facility will provide hygiene, bathing, dressing, grooming and oral care, mobility-transfer and ambulation including walking, toileting, dining-eating, including meals and snacks and communication to residents assessed to require these services. During a review of facility's P&P titled, admission Assessment - Nursing, reviewed on 7/11/2025, the P&P indicated that, The admission assessment is to be completed by the licensed nurse and includes the following: The assessment form has a diagram of the front and back of a body. All body marks are to be indicated on this diagram to include old or recent scars, bruises or discolorations, lacerations, pressure sores and other ulcerations, rashes or questionable markings considered other than normal, any amputations, dialysis shunts, presence of any dressing. The licensed nurse is to assess and document the resident's skin and skin turgor. During a review of facility's P&P titled, Low Air Loss Mattress, reviewed on 7/11/2025, the P&P indicated that, It is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident. The manufacturer's guidelines should be reviewed for each individual mattress to ensure that this policy is what is recommended.

Based on interview and record review, the facility failed to follow its policy and procedures (P&P) titled Change of Condition - SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] -Assessment reviewed by the facility on 7/11//2025, for one of three sampled residents (Resident 1). By failing to notify Resident 1's physician on 2/10/2026, when the resident was assessed as a high risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice resulted in Resident 1 not receiving orders for a wander guard (an electronic safety technology used in care facilities to prevent residents with dementia or cognitive impairment from wandering off or eloping [leaving]) and eloping from the facility without staff knowledge on 2/11/2026. Placing Resident 1 at risk for serious injury, harm, or death.Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted the resident on 2/10/2026, with diagnoses that included dementia (a progressive state of decline in mental abilities) with other behavioral disturbance, depression (a common, serious mood disorder characterized by a persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities), and psychoactive substance (is a chemical that enters the brain and changes how a person feels, thinks, or behaves by affecting the central nervous system, like alter mood, perception, and consciousness, and include everything from legal substances like caffeine and alcohol to prescription medication and illegal drugs) abuse (physical or psychological dependence). During a review of Resident 1's undated preadmission inquiry, the inquiry indicated Resident 1 was admitted to [General Acute Care Hospital - GACH] since 1/17/26 for FTT [Failure to Thrive] had lost 20 lbs. [pounds] drank only beer and not food, PSUD [psychostimulant Use Disorder]. The same document indicated, Resident 1 had severe dementia and did not have capacity to make decisions. During a review of Resident 1's elopement risk assessment dated [DATE], the elopement risk assessment indicated Resident 1 scored at 24 (17 or higher deemed high risk). During a review of Resident 1's Visual hourly check log initiated on 2/10/2026 at 3pm, the log indicated the resident attempted to exit the building at the following times in the west hallway: 7 pm - Resident 1 was attempting to exit the building, was able to redirect him from doing so and brought him back to his room. 9 pm - Residents attempted to exit the building, successfully redirected him and walked him back to his room.2/11/2026 1 am - Resident 1 attempted to exit the building, was successful in redirecting him and assisting him back to his room. 4 am - Resident 1 was no longer in his room. During a review of Resident 1's nursing progress notes dated 2/10/2026 at 8 pm, the progress notes indicated Resident 1 Was seen on bed during room rounds lying down with the head of the bed elevated with no signs of respiratory distress or facial grimacing. Later in the night residents were seen walking the hallway looking for an exit. Redirected him and talked to him about the reason for an exodus from the facility, He verbalized he wants to leave because he wants to live his life to the fullest. Told him that he should stay here as his doctor ordered it. He is still insistent so hard to redirect him even more. Eventually he returned to his room. During an interview with Certified Nursing Assistant (CNA) 1 on 2/17/2026 at 4:26 pm, CNA 1 stated Resident 1 was admitted to the facility on the morning of 2/10/2026. CNA 1 stated that he had not observed any exit seeking behaviors throughout the afternoon until after dinner when Resident 1 started wandering around and asking for exits. CNA 1 stated that at one point, Resident 1 got a little upset because the Registered Nurse Supervisor (RNS) assisted him (Resident 1) back to his room when he was trying to leave. CNA 1 stated that Resident 1 slept around 1 am and remained asleep even when he left for his break at 3:30 am. CNA 1 stated when he went to check Resident 1 at 4:20 am, he found that Resident 1 was not in his room or anywhere around the facility. During an interview with Resident 1's family member (FM) 1 12/17/2026 at 4:26 pm, FM 1 stated FM 1 had gone to tour the facility before Resident 1 was admitted about a week and a half prior. During the tour, FM 1 stated the staff member (unidentified) who was showing her (FM 1) around the facility was asked by FM 1 if residents could get out of the facility and was told that there was someone at the door during the day and at night, the alarm was set and the door was locked. FM 1 stated that on the day of admission, while in the company of facility staff unidentified), Resident 1 asked FM 1 if he could go home a few times and reminded him that he needed to stay at the facility. FM 1 stated that she was shocked when she received a call from the facility on 2/11/2026 at 5 am informing her that Resident 1 was not in the facility, and no one knew when the resident had left or where the resident was. FM 1 stated that police eventually called her (Fm 1) around 9 pm on 2/11/2026, informing FM 1 the resident was located in a city far away from the facility with bruises and scratches. FM 1 believed Resident 1 had walked all night and stated that Resident 1 kept stating that he 9resident 1) had fallen. During an interview with RNS 1 on 2/18/2026 at 3:23 pm, RNS 1 stated that admission process included a thorough assessment including an elopement risk assessment. RNS 1 stated that abnormal findings such as a high elopement risk had to be reported to the physician for orders for wander guard. RNS 1 confirmed that t Resident 1 was assessed to be a high elopement risk but that the resident's physician was not informed. During an interview with the Director of Nursing (DON) on 2/19/2026 at 12:26 pm, the DON stated that once a resident was identified as an elopement risk, protocol was initiated such as alerting staff, and a wander guard placed with the consent of the resident or their representative. The DON stated a wander guard required a physician order. The DON stated the protocol had to be initiated as soon as possible to avoid adverse side effects such as a resident leaving the facility without staff knowledge. During a review of a P&P titled, Wandering/Exit Seeking Behavior, reviewed by the facility on 7/11/2025, indicated The facility will evaluate residents for wandering and/or exit seeking behavior and implement appropriate interventions as indicated via the evaluation process. The same P&P indicated under procedure which included the following: Nursing completes the Wandering/Exit Seeking Evaluation form as appropriate.Based on the results of the evaluation, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented.If the resident exhibits wandering and/or exit seeking behavior, the episodes should be documented in the progress notes of the medical record. Documentation should include interventions used and their effectiveness. During a review of a P&P titled, Change of Condition - SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] -Assessment reviewed on 7/11//2025 indicated, It is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated using the SBAR process with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. The same P&P indicated, The assessment results should assist the physician in determining the course of clinical management for the resident.

Based on observation, interview, and record review the facility to develop and implement and individualized and comprehensive care plan to meet the individual needs for one out of three sampled residents (Resident 1), who was identified to be at high risk for elopement (the act of leaving a facility unsupervised and without prior authorization) risk. As a result, on 2/11/2026 Resident 1 eloped (left) from the facility unsupervised without staff knowledge and the resident's whereabouts unknown for 17 hours. Placing Resident 1 at risk for serious injury, harm, or death.Findings:A review of Resident 1's admission record indicated the facility admitted the resident on 2/10/2026, with diagnoses that included dementia (a progressive state of decline in mental abilities) with other behavioral disturbance, depression (a common, serious mood disorder characterized by a persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities), and psychoactive substance (is a chemical that enters the brain and changes how a person feels, thinks, or behaves by affecting the central nervous system, like alter mood, perception, and consciousness, and include everything from legal substances like caffeine and alcohol to prescription medication and illegal drugs) abuse (physical or psychological dependence). During a review of Resident 1's undated preadmission inquiry, the inquiry indicated Resident 1 was admitted to [General Acute Care Hospital - GACH] since 1/17/26 for FTT [Failure to Thrive] had lost 20 lbs. [pounds] drank only beer and not food, PSUD [psychostimulant Use Disorder]. The same document indicated, Resident 1 had severe dementia and did not have capacity to make decisions. During a review of Resident 1's elopement risk assessment dated [DATE], the elopement risk assessment indicated Resident 1 scored at 24 (17 or higher deemed high risk). During a review of Resident 1's Visual hourly check log initiated on 2/10/2026 at 3pm, the log indicated the resident attempted to exit the building at the following times in the west hallway: 7 pm - Resident 1 was attempting to exit the building, was able to redirect him from doing so and brought him back to his room. 9 pm - Residents attempted to exit the building, successfully redirected him and walked him back to his room.2/11/2026 1 am - Resident 1 attempted to exit the building, was successful in redirecting him and assisting him back to his room. 4 am - Resident 1 was no longer in his room. During a review of Resident 1's nursing progress notes dated 2/10/2026 at 8 pm, the progress notes indicated Resident 1 Was seen on bed during room rounds lying down with the head of the bed elevated with no signs of respiratory distress or facial grimacing. Later in the night residents were seen walking the hallway looking for an exit. Redirected him and talked to him about the reason for an exodus from the facility, He verbalized he wants to leave because he wants to live his life to the fullest. Told him that he should stay here as his doctor ordered it. He is still insistent so hard to redirect him even more. Eventually he returned to his room. During an interview with Certified Nursing Assistant (CNA) 1 on 2/17/2026 at 4:26 pm, CNA 1 stated Resident 1 was admitted to the facility on the morning of 2/10/2026. CNA 1 stated that he had not observed any exit seeking behaviors throughout the afternoon until after dinner when Resident 1 started wandering around and asking for exits. CNA 1 stated that at one point, Resident 1 got a little upset because the Registered Nurse Supervisor (RNS) assisted him (Resident 1) back to his room when he was trying to leave. CNA 1 stated that Resident 1 slept around 1 am and remained asleep even when he left for his break at 3:30 am. CNA 1 stated when he went to check Resident 1 at 4:20 am, he found that Resident 1 was not in his room or anywhere around the facility. During an interview with Resident 1's family member (FM) 1 12/17/2026 at 4:26 pm, FM 1 stated FM 1 had gone to tour the facility before Resident 1 was admitted about a week and a half prior. During the tour, FM 1 stated the staff member (unidentified) who was showing her (FM 1) around the facility was asked by FM 1 if residents could get out of the facility and was told that there was someone at the door during the day and at night, the alarm was set and the door was locked. FM 1 stated that on the day of admission, while in the company of facility staff unidentified), Resident 1 asked FM 1 if he could go home a few times and reminded him that he needed to stay at the facility. FM 1 stated that she was shocked when she received a call from the facility on 2/11/2026 at 5 am informing her that Resident 1 was not in the facility, and no one knew when the resident had left or where the resident was. FM 1 stated that police eventually called her (Fm 1) around 9 pm on 2/11/2026, informing FM 1 the resident was located in a city far away from the facility with bruises and scratches. FM 1 believed Resident 1 had walked all night and stated that Resident 1 kept stating that he 9resident 1) had fallen. During an interview with RNS 1 on 2/18/2026 at 3:23 pm, RNS 1 stated that admission process included a thorough assessment including an elopement risk assessment. RNS 1 stated that abnormal findings such as a high elopement risk had to be reported to the physician for orders for wander guard. RNS 1 confirmed that t Resident 1 was assessed to be a high elopement risk but that the resident's physician was not informed and t a care plan for elopement risk was not developed which could have prevented him (Resident 1) from eloping. During an interview with the Director of Nursing (DON) on 2/19/2026 at 12:26 pm, the DON stated that once a resident was identified as an elopement risk, protocol was initiated such as alerting staff, and a wander guard placed with the consent of the resident or their representative. The DON stated a wander guard required a physician order. The DON stated the protocol had to be initiated as soon as possible to avoid adverse side effects such as a resident leaving the facility without staff knowledge. The DON stated that a care plan had to be initiated upon discovering a resident was an elopement risk to ensure staff across all shifts were aware of the interventions to provide for the residents. During a review of a policy and procedure (P&P) titled, Comprehensive Care. Planning reviewed by the facility on 7/11/2026, the policy indicated It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The same P&P indicated, On admission, based on information accompanying the resident and results of admission assessments completed by the licensed nurses, a baseline care plan will be developed to address minimum health care information required to properly care for each resident, including goals and objectives. The care plan must address effective and person-centered care that meets professional standards for quality of care. During a review of a P&P titled, Wandering/Exit Seeking Behavior, reviewed by the facility on 7/11/2025, indicated The facility will evaluate residents for wandering and/or exit seeking behavior and implement appropriate interventions as indicated via the evaluation process. The same P&P indicated under procedure which included the following: Nursing completes the Wandering/Exit Seeking Evaluation form as appropriate.Based on the results of the evaluation, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented.If the resident exhibits wandering and/or exit seeking behavior, the episodes should be documented in the progress notes of the medical record. Documentation should include interventions used and their effectiveness.

Based on interview and record review, the licensed nursing staff failed to offer the pneumonia vaccine as required or appropriate to one of five sampled residents (Resident 13 and Resident 32). This deficient practice placed Resident 13 and Resident 32 at increased risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: a. A review of Resident 13's admission Record indicated the facility readmitted the resident on 3/5/2025, with diagnoses of cerebral infarction (also known as a stroke in which blood flow stops to part of the brain) respiratory failure (a condition in which there's not enough oxygen in the body) and high blood pressure. A review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 1/16/2026, indicated the resident had severely impaired cognition (never/rarely made decisions). The MDS also indicated the resident was totally dependent on staff for transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 13's Immunization Report, dated 2/6/2026, indicated Resident 13 had never received the pneumonia vaccine. A review of Resident 13's Immunization Consent Form, dated 2/7/2025, did not indicate the resident received education on the pneumococcal vaccine. A review of Resident 13's medical chart did not indicate Resident 13 had been offered the Pneumonia vaccine. b. A review of Resident 32's admission Record indicated the facility originally admitted the resident on 4/30/2022 and re-admitted the resident on 2/15/2024, with diagnoses including Stage 4 pressure ulcer/injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), atrial fibrillation (AFib - an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications) and high blood pressure. A review of Resident 32's Immunization Consent Form, dated 1/30/2025, indicated Resident 32 received education on the COVID-19 vaccination. The immunization consent form did not indicate the resident received education on the pneumococcal vaccine. A review of Resident 32's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2026, indicated Resident 32's cognition (ability to think and learn) was intact. The MDS indicated the resident required partial to substantial assistance from staff for toileting hygiene, showering/bathing, lower body dressing and personal hygiene. The MDS also indicated Resident 32's pneumococcal vaccination was not up to date. During an interview on 2/6/2026 at 2:36 PM the Director of Nursing (DON) stated the facility offer the residents vaccines at admission and during the active season. The DON further stated facility offers residents all vaccinations, that are required, or the resident is eligible for. The DON also stated vaccines are offered in order to decrease the risk of becoming infected and to decrease the risk spreading viruses in the facility. During a concurrent interview and record review on 2/6/2026 at 2:41 PM, the Infection Preventionist (IP) stated upon a review of Resident 13's and Resident 32's Informed Consent Forms indicated the facility did not offer the residents the pneumococcal vaccination. IP stated vaccines are offered to residents in order to prevent the spread of viruses in the facility to residents and staff. A review of the facility's policy and procedures (P&P) titled, Pneumonia Vaccine for Residents, revised 1/2024, indicated On admission, all residents will be evaluated for pneumococcal vaccination status. The P&P also indicated: The resident's clinical record should include documentation that the resident or their responsible party was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal. The pneumonia vaccination status of the resident will be determined, and vaccines will be offered as recommended by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC).

Based on interview and record review, the facility failed to ensure two of21 sampled residents (Resident 75 and Resident 115), received care, treatment, and services in accordance with the physician's order and policy and procedure by failing to:Follow doctor's orders to perform oral care with Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (a solution used to treat gingivitis (inflammation of the gum), reduce gum swelling, redness, and bleeding by decreasing mouth bacteria (germs) and provide 5 milliliters (ml - unit of measurement) of water every shift; per doctor's orders.Initiate a Situation, Background, Assessment, Request (SBAR-a formal written communication tool used to provide essential, concise information during crucial medical situations) Form when Resident 115 complained of abdominal pain. As a result, on 11/26/2025 Residen115 was transferred to a General Acute Care Hospital (GACH), due to lethargy (extreme weakness), nausea and poor appetite. This deficient practice had the potential to delay the recovery of Resident 75.Findings: a. A review of Resident 75's admission Record indicated Resident 75 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure). Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood) and depression (a constant feeling of sadness and loss of interest). A review of Resident 75's Minimum Data Set (MDS – a resident assessment tool), dated 12/07/2025 indicated Resident 75's cognition (the mental ability to make decisions of daily living) was intact. Resident 75 required maximal assistance from staff for toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene. During a concurrent observation and interview on 02/04/2026 at 2:02 PM, Residents Representative of Resident 75 was sitting at bedside. Resident 75 was able to understand and respond to questions with yes or no. Resident 75 pointed to Resident Representative (RR) 1 as the person to speak to during an interview. During an interview on 02/04/2026 at 2:02 PM, RR 1 was sitting at Resident 75's bedside stated that Resident 75 came back from the Veterans Administration (VA) hospital after surgery, and he was supposed to get ice chips and later he was supposed to transition to 5 teaspoons of water after oral care. RR 1 stated the facility started by giving him ice chips until the ice machine broke down and then Resident 75 did not get any more ice chips. Resident 75 then went to the VA and got a swallow evaluation and prescribed oral care twice a day with 5 teaspoons of water after each oral care treatment. RR 1 stated that Resident 75 had not received any oral care treatments or any of the teaspoons of water up until now. During a record review of Resident 75 doctor's phone orders dated 01/28/2026 as transcribed by licensed vocational nurse (LVN) 3, the doctor's telephone order indicated, ok for teaspoons water after oral care ok for ice chips also (see progress note for additional details) for Resident 75. During a record review of the doctor's phone orders dated 02/06/2026 at 14:59 as transcribed by Director of Nursing (DON), indicated Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (Chlorhexidine Gluconate (Mouth-Throat)) Give 15ml orally every shift for PROPHYLAXIS MAY HAVE 5oz of H20 FOLLOWING SOLUTION for Resident 75. During an interview on 02/04/2026 at 2:30 PM, Registered Nurse Supervisor (RNS) 1 stated that there is an order to give ice chips and perform oral care in the paper chart however, it is not clear how much water to give to the resident or how many times to perform the patient care action. RNS 1 stated she will have the person that transcribed the order to clarify the order and put it in the resident's chart, or she will clarify the order herself with the doctor. During an interview on 02/05/2026 at 1:37 PM, LVN 3 stated, the order is right here in the chart, it says to provide oral care and provide teaspoons of water and ice chips. LVN 3 stated he (LVN 3) has to find the progress note with the details because he is not sure of where it is (order) at this time. During an interview on 02/05/2026 at 2 PM, Dietary Supervisor (DS) stated the ice machine is currently in working order and ice can be used by the residents in the facility. The DS stated the ice machine went down within the last two months and was out of order for at least one week however, the facility purchased bags of ice for the residents. During an interview on 02/05/2026 at 2:13 PM, Environmental Director (ED) stated an ice machine was purchased after the one in the kitchen broke down and was replaced about two months ago. During an interview on 02/06/2026 at 1:49 PM, the Director of Nursing (DON) stated the transcription of the doctor's phone orders for Resident 75 dated 1/28/2026 is confusing and the progress note for Resident 75 is also confusing, this could lead to a delay in care for Resident 75 or the MD orders not being followed at all. During a record review of the facility's policy and procedures entitled, Physician Services and Orders dated Reviewed: 7/11/2025, indicated that the Policy: It is the policy of the facility that each resident remain under the care of a physician. Drug, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services. Procedure: Verbal orders for drugs and treatments shall be received only by licensed nurses, psychiatric technicians, pharmacists, nurse practitioners, physicians, physicians' assistants and certified respiratory therapists when the orders relate specifically to respiratory care. Orders for medications must include: Name and strength of the drug; Quantity or specific duration of therapy; Dosage and frequency of administration; Route of administration if other than oral; Reason or problem for which it is given. b. A review of Resident 115's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form, dated 11/25/2025, indicated the resident was being transferred to GACH due to lethargy, nausea and poor appetite A review of the Resident 115's MDS, dated [DATE], indicated Resident 115's cognition (ability to think and learn) was severely impaired. The MDS indicated Resident 115 was dependent upon staff for toileting hygiene, bathing, and lower body dressing. The MDS also indicated the resident did not have any pain and did not take any pain medication in the previous five days. A review of Resident 115's Licensed Nurses Progress Notes, dated 11/17/2025 indicated the resident had abdominal pain. The Progress Notes also indicated the physician ordered an abdominal x-ray to evaluate the cause of the resident's pain. The Progress Notes further indicated the resident's responsible party (RP) refused the abdominal x-ray and the nursing staff would continue to monitor the resident's abdominal pain, bowel patterns, vitals signs and would notify the physician if there were any changes. A review of Resident 115's medical chart indicated nursing staff did not initiate a change of condition form or continue to monitor the resident's abdominal pain or bowel patterns for 72 hours. A further review of Resident 115's medical chart indicated there was no abdominal pain care plan initiated. A review Resident 115's admission record indicated the facility admitted the resident on 11/4/2025 with diagnoses including chronic kidney disease, acute cystitis and hydronephrosis. A review of the Physician's Order, dated 11/25/2025, indicated to transfer the resident to GACH for lethargy, nausea and poor appetite. During an interview on 2/5/2026 at 3:57 PM with the Assistant Director of Nursing (ADON), Resident 115's clinical record was reviewed. The ADON stated the ADON wrote the progress note regarding Resident 115's abdominal pain on 11/17/2025. The ADON stated on 11/17/2025, Resident 115 was having new onset abdominal pain. The physician ordered an x-ray to assess the residents pain however Resident 115's responsible party (RP) refused the x-ray. The ADON stated due to the RP refusing the x-ray, facility staff were then to continue to monitor the resident's abdominal status which consisted of monitoring the resident's bowel movements, vital signs, bowel pattern and pain for the next three days. The ADON stated a change of condition or SBAR form should have been initiated in order to notify nursing staff that they were to monitor the resident for 72 hours. During a concurrent review of Resident 115's clinical chart, the ADON was unable to find an SBAR form and did not find that nursing staff continued to monitor Resident 115's bowel movements bowel patterns or abdominal pain. The ADON stated it was important to continue to monitor the resident in order to evaluate any worsening of the resident's condition. During an interview on 2/6/2026 at 2:34 PM, the DON stated the SBAR form notifies staff that the resident has had a change of condition. The DON further stated the SBAR form then activates the staff to continue monitoring the resident every shift for at least 72 hours. The DON stated not initiating the SBAR or continued monitoring could lead to a lapse in care and the resident's condition could decline. A review of the facility's policy and procedures (P&P) titled, Change of Condition - SBAR-Assessment, reviewed 7/11/2025, indicated, It is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated using the SBAR process with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals.

Based on interview and record review, the facility failed to provide accurate and complete medical records and documentation based on professional standards for three of 22 sampled residents (Residents 23, 32, and 8) when:1. For Resident 23, Restorative Nursing Assistant program (RNA, nursing assistant program that help residents to maintain their function and joint mobility) documentation indicated Resident 23 received RNA treatment on 2/4/2026 when Resident 23 did not receive RNA treatment.2. For Resident 32, a Certified Occupational Therapy Assistant (COTA) 2 signed on behalf of the Physical Therapist (PT) 1 on a physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatment encounter note.3. For Resident 8, a Certified Occupational Therapy Assistant (DOR/COTA) 1 signed on behalf of PT 1 on a PT treatment encounter note. These deficient practices caused inaccurate medical records and had the potential for inadequate care planning and physical therapy interventions for Residents 23, 32, and 8.Findings: 1. During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to right femur fracture (broken leg bone) and atrial fibrillation (irregular heart rate that can cause poor blood flow). During a review of Resident 23's Minimum Data Set (MDS, resident assessment tool) dated 10/16/2025, the MDS indicated Resident 23 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 23 required dependent assistance with eating, oral hygiene, dressing, and rolling left and right. During a review of Resident 23's Order Summary Report (OSR) dated 2/5/2026, the OSR indicated the following orders:-Dated 10/31/2025 RNA program for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on left lower extremity (LE, hip, knee, ankle/foot) three times a week as tolerated.-Dated 9/4/2025 RNA program for PROM exercises on left upper extremity (UE, shoulder, elbow, wrist/hand) three times a week or as tolerated.-Dated 10/31/2025 RNA program for PROM exercises on right LE three times a week as tolerated.-Dated 9/4/2025 RNA program for PROM exercises on right UE three times a week or as tolerated. During a concurrent interview and record review on 2/4/2026 at 1:31 p.m. with the Director of Staff Development (DSD), Resident 23's February 2026 RNA treatment flowsheet was reviewed. DSD stated there were no RNAs working today (2/4/2026), because two of the scheduled RNAs called off and another RNA was reassigned to Certified Nursing Assistant (CNA) duties today. DSD reviewed Resident 23's February 2026 RNA treatment flowsheet and stated Restorative Nursing Assistant (RNA 2) initialed 2/4/2026 RNA treatment indicating RNA 2 completed RNA treatment for Resident 23 today. DSD stated this was not accurate because RNA 2 called off from work today and had not been at the facility today to perform the RNA treatment for Resident 23. During an interview on 2/4/2026 at 4:01 p.m., the Assistant Director of Nursing (ADON) stated RNA 2 had not come to work today. During an interview and record review on 2/5/2026 at 1:41 p.m., RNA 2 stated she started work yesterday (2/4/2026) around 5:30 p.m. RNA 2 reviewed Resident 23's February 2026 RNA flowsheet and stated the documentation for 2/4/2026 was not accurate. RNA 2 stated she must have initialed the documentation by accident and mistakenly initialed the RNA treatment as completed on 2/4/2026. RNA 2 stated she did not mean to initial Resident 23 received RNA treatment that day. RNA 2 stated staff should not initial when the RNA treatment was not completed because it meant Resident 23 received the RNA treatment when the resident did not receive any RNA treatment. During an interview on 2/5/2026 at 4:00 p.m., the Director of Nursing (DON) stated staff should follow documentation standards. DON stated if staff perform a treatment, then staff sign and document for that treatment. DON stated if staff did not complete the treatment, then staff should not sign and document for the treatment. During a review of the facility's policy and procedures (P&P) titled, Documentation Principles, reviewed 7/11/2025, the P&P indicate, entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive. During a review of the facility's Restorative Nursing Assistant Job Description dated 11/2024, the RNA Job Description indicated the general duties and responsibilities of an RNA include record entries on flow sheets, notes, and charts when applicable, documents daily on residents in the restorative program. 2. During a review of Resident 34's admission Record (AR) dated 1/26/2026, the AR indicated Resident 34 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to complete paraplegia (loss of movement and/or sensation of the legs) and lack of coordination. During a review of Resident 34's Minimum Data Set (MDS, resident assessment tool) dated 10/27/2025 indicated Resident 34 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 34 was independent in eating, oral hygiene, and upper body dressing. The MDS indicated Resident 34 required dependent assistance with bed to chair transfers. During an interview and record review on 2/5/2026 at 11:34 a.m., the Director of Rehabilitation/Certified Occupational Therapy Assistant (DOR/COTA 1) reviewed Resident 32's PT treatment encounter notes dated 5/21/2025, 5/26/2025, 5/30/2025, and 6/30/2025, and stated Certified Occupational Therapy Assistant (COTA 2), who no longer worked at the facility, signed on behalf of PT 1, who was required to co-sign a physical therapy assistant's (PTA) treatment note. DOR/COTA 1 stated a PTA required supervision of a PT and a PTA's treatment note required supervision and co-signing of the supervising PT. DOR/COTA 1 stated it was the responsibility of each therapist to sign their own treatment note and for the supervising therapist to review a PTA's treatment note and co-sign the notes. DOR/COTA 1 stated if another therapist signed on behalf of another person, it meant that the therapist reviewed the PTA notes and treatment and agreed that the treatment was valid and this was not part of a COTA's scope of practice. DOR/COTA 1 stated a COTA was not qualified to verify if a PTA treatment was valid and within a resident's plan of treatment and care. DOR/COTA 1 stated the therapy company informed her that she could sign on behalf of another therapist. During an interview on 2/5/2026 at 12:04 p.m., Occupational Therapist (OT 1) stated an OT's responsibility was to supervise COTAs which included meeting with the COTA to talk about each resident and to revise the plan of care as needed. OT 1 stated OTs and PTs were required to supervise COTAs and PTAs because OTs and PTs had the higher level of education, skill level, and training. OT 1 stated it was the OT and PT's responsibility to review the COTA and PTA's treatment notes and see how the resident was progressing in therapy and to co-sign the note. OT 1 stated when she co-signed the treatment note, it meant that OT 1 reviewed the note, that the note was good and the assistant was following the plan of care for that specific resident. OT 1 stated this process helped to keep the level of excellence in the therapy department. OT 1 stated an OT could not co-sign a PTA's notes, because a PTA was another discipline and only a PT could co-sign a PTA's notes. OT 1 stated it was like an OT could not perform a PT eval, because it was a whole separate profession and training. During an interview on 2/5/2026 at 4:00 p.m., the Director of Nursing (DON) stated staff should follow documentation standards. DON stated staff could not sign on someone else's behalf. DON stated it was not ethical. DON stated staff do not sign for someone else because the staff did not do the treatment or the work. DON stated an COTA is a whole different entity than PT and you cannot sign for a person in a different profession. DON stated staff needed to follow the correct procedures. During a review of the facility's policies and procedures (P&P) titled, Documentation Principles, reviewed 7/11/2025, the P&P indicated it is the policy of the facility that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. The P&P indicated an entry should never be signed by someone other than the person making the entry. During a review of the facility's Physical Therapist Job Description dated 5/19/2023, the PT Job Description indicated the PT maintains all necessary documentation of services in the patient's medical records, supervise up to two Physical Therapy Assistants, and comply with facility rules, policies and procedures. 3. During an interview and record review on 2/5/2026 at 11:34 a.m., the Director of Rehabilitation/Certified Occupational Therapy Assistant (DOR/COTA 1) reviewed Resident 32's PT treatment encounter notes dated 5/21/2025, 5/26/2025, 5/30/2025, and 6/30/2025, and stated she signed on behalf of PT 1, who was required to co-sign a physical therapy assistant's (PTA) treatment note. DOR/COTA 1 stated a PTA required supervision of a PT and a PTA's treatment note required supervision and co-signing of the supervising PT. DOR/COTA 1 stated it was the responsibility of each therapist to sign their own treatment note and for the supervising therapist to review a PTA's treatment note and co-sign the notes. DOR/COTA 1 stated if another therapist signed on behalf of another person, it meant that the therapist reviewed the PTA notes and treatment and agreed that the treatment was valid and this was not part of a COTA's scope of practice. DOR/COTA 1 stated a COTA was not qualified to verify if a PTA treatment was valid and within a resident's plan of treatment and care. DOR/COTA 1 stated the therapy company informed her that she could sign on behalf of another therapist. During an interview on 2/5/2026 at 12:04 p.m., Occupational Therapist (OT 1) stated an OT's responsibility was to supervise COTAs which included meeting with the COTA to talk about each resident and to revise the plan of care as needed. OT 1 stated OTs and PTs were required to supervise COTAs and PTAs because OTs and PTs had the higher level of education, skill level, and training. OT 1 stated it was the OT and PT's responsibility to review the COTA and PTA's treatment notes and see how the resident was progressing in therapy and to co-sign the note. OT 1 stated when she co-signed the treatment note, it meant that OT 1 reviewed the note, that the note was good and the assistant was following the plan of care for that specific resident. OT 1 stated this process helped to keep the level of excellence in the therapy department. OT 1 stated an OT could not co-sign a PTA's notes, because a PTA was another discipline and only a PT could co-sign a PTA's notes. OT 1 stated it was like an OT could not perform a PT eval, because it was a whole separate profession and training. During an interview on 2/5/2026 at 4:00 p.m., the Director of Nursing (DON) stated staff should follow documentation standards. DON stated staff could not sign on someone else's behalf. DON stated it was not ethical. DON stated staff do not sign for someone else because the staff did not do the treatment or the work. DON stated an COTA is a whole different entity than PT and you cannot sign for a person in a different profession. DON stated staff needed to follow the correct procedures. During a review of the facility's policies and procedures (P&P) titled, Documentation Principles, reviewed 7/11/2025, the P&P indicated it is the policy of the facility that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. The P&P indicated an entry should never be signed by someone other than the person making the entry. During a review of the facility's Physical Therapist Job Description dated 5/19/2023, the PT Job Description indicated the PT maintains all necessary documentation of services in the patient's medical records, supervise up to two Physical Therapy Assistants, and comply with facility rules, policies and procedures.

Based on observation, interview and record review, the facility failed to provide competent Restorative Nursing Assistant (RNA, nursing assistant program that help residents to maintain their function and joint mobility) nursing staff when:1. The facility failed to complete annual competencies for putting on and taking off splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and braces (an external device to support, align, or correct a movable part of the body) for two sampled RNAs.2. Restorative Nursing Assistant (RNA) 1 did not follow and perform RNA treatment as ordered by a physician during an RNA treatment session on 2/4/2026 with Resident 74. These deficient practices had the potential to cause injury and harm to residents who require splints during RNA and to Resident 74 during the RNA program.Findings: 1. During a concurrent interview and record review on 2/4/2026 at 3:08 p.m. with the Director of Staff Development (DSD), RNA 1 and Restorative Nursing Assistant (RNA) 2's employee files were reviewed. DSD reviewed RNA 1's Annual Competency Evaluation Nursing Skills Performance dated 9/15/2025 and stated RNA 1's Annual Competency Evaluation did not evaluate skills for putting on and taking off splints. DSD reviewed RNA 2's Annual Competency Evaluation Nursing Skills Performance dated 9/2/2025 and stated RNA 2's Annual Competency Evaluation did not evaluate skills for putting on and taking off splints. DSD stated part of a RNA's duties and skills included to put on and take off splints as part of the RNA program. DSD stated the facility should evaluate every RNA's competency and skill in putting on and taking off splints to ensure the RNAs knew the procedure and could put on and take off splints correctly. During an interview on 2/5/2026 at 4 p.m., the Director of Nursing (DON) stated the RNA program was to ensure a resident maintained their current functional status. DON stated all staff required annual competencies to cover all areas and skills that a staff member performed in their daily job to make sure staff were competent in their roles and assignments. DON stated the facility would not know if RNA staff could safely and correctly apply and remove a splint if the facility did not assess a RNA's competency to put on and remove a splint. DON stated if RNA staff did not have an annual competency for splinting, the facility would not know if an RNA was putting on a splint incorrectly and it could cause harm or damage to a resident. During a review of the facility's Restorative Nursing Assistant Job Description dated 11/2014, the RNA Job Description indicated RNA's general duties and responsibilities included: ensure placement of restorative devices and equipment. The RNA Job Description indicated specific requirements included an RNA must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. During a review of the facility's policy and procedures (P&P) titled, Staff Competencies, reviewed 7/11/2025, the P&P indicated, performance evaluations are to ensure that staff has the appropriate competencies and skills to assure resident safety. RNAs will receive in-services related to the services they perform and RNAs will have annual performance evaluations. 2. During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 74 required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. The MDS indicated Resident 74 had functional limitations in range of motion (ROM, full movement potential of a joint) on both sides of the upper extremities (UE, shoulder, elbow, wrist/hand) and both sides of the lower extremities (LE, hip, knee, ankle/foot). During a review of Resident 74's Order Summary Report (OSR) dated 2/4/2026, the OSR indicated Resident 74 had the following orders:-dated 11/3/2025 for RNA program for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises on left UE four times a week as tolerated-dated 11/3/2025 for RNA program for AAROM on right UE four times a week as tolerated-dated 1/19/2026 for RNA program for omnicycle (type of arm and/or leg exercise bicycle) three times a week as tolerated. During a review of Resident 74's Restorative Nursing Program Referral and Care Plan (CP) dated 10/31/2025, the CP indicated Resident 74 had an increased risk for a decline in mobility. The CP goal indicated Resident 74 would maintain both UE and both LE ROM. The CP approach indicated for RNA to provide both LE exercise using omnicycle level seven for 15 minutes and both UE AAROM exercise as tolerated once a day four times a week. During an observation and interview on 2/4/2026 at 4:15 p.m., RNA 1 performed RNA treatment with Resident 74 in Resident 74's room. Resident 74 was lying bed and RNA 1 proceeded to perform AAROM exercises on Resident 74's right hand, right elbow, and right shoulder. RNA 1 then performed AAROM exercises on Resident 74's left hand, left elbow, and left shoulder. RNA 1 then performed AAROM exercises on Resident 74's left and right ankles, left knee, left hip, right knee, and right hip. RNA 1 stated to Resident 74 that they would do the omnicycle tomorrow for RNA. RNA 1 stated Resident 74's RNA treatment orders were for right and left upper extremities AAROM and omnicycle if Resident 74 gets up in a wheelchair. RNA 1 stated Resident 74 did not want to get out of bed today so RNA 1 alternatively performed ROM exercises for Resident 74's legs. During an interview on 2/5/2026 at 12:04 p.m., the Occupational Therapist (OT 1) stated the RNA program was a restorative nursing program that usually followed a therapy program. OT 1 stated depending on the specific needs of the resident, a therapist will create an RNA program and train the RNAs on how to complete the program for the resident. OT 1 stated an RNA program was established by therapists, because therapists have assessed the resident and were aware of their abilities and what they can and cannot do. OT 1 stated an RNA could not revise an RNA treatment order, because the RNAs did not have the level of skill or training therapists had. OT 1 stated that RNAs were trained to do the task that was ordered, but RNAs could no change the task. During an interview on 2/5/2026 at 4:00 p.m., the Director of Nursing (DON) stated the RNA program was to ensure a resident maintained their current functional status. DON stated an RNA program order needed to be followed because that was the physician's order and staff could not pick and choose what part of the order they wanted to follow. DON stated an RNA program was ordered for a reason and it was tailored for that specific resident for a specific purpose by a qualified professional who was a therapist. DON stated an RNA was not a professional and did not have the education, training, or expertise to change or amend any RNA program order. DON stated RNA staff could not do any alternative RNA treatments that was not ordered. DON stated if staff did not follow an order, it could affect a resident's joint mobility and their level of function. During a review of the facility's policies and procedures (P&P) titled, Physician Services and Orders, reviewed 7/11/2025, the P&P indicated drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services. During a review of the facility's Restorative Nursing Assistant Job Description dated 11/2024 indicated the primary purpose of your job is to provide each of your assigned residents with routine nursing care and services in accordance with resident's assessments and care plan. The RNA Job Description indicated to follow work assignments in performing and completing your assigned tasks.

Based on observation, interview, and record review, the facility failed to follow infection control procedures to help prevent the development and transmission of communicable diseases (illnesses caused by organisms that can be passed from person to person) and infections by failing to ensure:1. Provide hand soap and hand sanitizer supplies in Resident 56 and 74's room.2. Properly sanitize and disinfect a cloth gait belt (an assistive device that is secured around a person's waist to assist in moving a person) between multiple resident use. 3. Staff handled soiled linen in a sanitary manner per facility's policy and procedures titled, Infection Control Policy - Laundry Services. These deficient practices had the potential to spread infections and illnesses between residents, staff, and visitors. Findings: 1. During a review of Resident 74's admission Record (AR) dated 1/26/2026, the AR indicated Resident 74 admitted to the facility on [DATE] with diagnoses including, but not limited to spinal stenosis (spaces inside bones of the spine get too small), polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and unsteadiness on feet. During a review of Resident 74's Minimum Data Set (MDS, resident assessment tool) dated 1/13/2026, the MDS indicated Resident 74 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 74 required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. During a review of Resident 56's AR dated 1/26/2026, the AR indicated Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to low back pain, metabolic encephalopathy (any damage or disease that affects the brain), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 was cognitively intact. The MDS indicated Resident 56 required dependent assistance with toileting hygiene, dressing, and maximal assistance with rolling left and right. During an observation and interview on 2/4/2026 at 12:31 p.m., in Resident 56 and 74's room, Certified Nursing Assistant (CNA 2) stated and demonstrated both the soap dispenser to the left of the sink and the hand sanitizer dispenser to the right of the sink were both not working. CNA 2 stated she could not properly wash her hands inside the room and needed to go outside the room to wash her hands. CNA 2 stated she needed to wash her hands in between helping Resident 56 and Resident 74. During an observation and interview on 2/4/2026 at 2:11 p.m., in Resident 56 and 74's room, the Maintenance Director (MTD) attempted to use the hand soap dispenser to the left of the sink and stated the hand soap dispenser was not working. MTD stated it may be the batteries were not working. MTD attempted to use the hand sanitizer dispenser to the right of the sink and stated the hand sanitizer dispenser was not working. MTD stated it may be the batteries were not working. MTD stated both the hand soap dispenser and the hand sanitizer dispenser should be working at all times so that staff could wash their hands and keep their hands clean. During an interview on 2/5/2026 at 12:51 p.m., the Infection Preventionist Nurse (IPN) stated handwashing was the number one method to prevent the transmission of bacteria. IPN stated handwashing required water and soap or an alcohol based hand sanitizer. IPN stated hand soap or an alcohol based hand sanitizer was required inside a resident's room to prevent cross contamination and transmission of bacteria. During an interview on 2/5/2026 at 4:00 p.m., the Director of Nursing stated hand soap and hand sanitizer dispensers should be working at all times so that staff can perform hand hygiene and handwashing to prevent the spread of germs. During a review of the facility's policies and procedures (P&P) titled, Hand Hygiene, reviewed 7/11/2025, the P&P indicated alcohol-based hand rub should be available inside and outside of all resident rooms in order to improve access and compliance with hand hygiene. Handwashing is a vigorous, brief rubbing together of all surfaces of lathered hands with soap, followed by rinsing under a stream of water. 2. During an observation and interview on 2/4/2026 at 10:36 a.m. with the Director of Rehabilitation (DOR/COTA 1) inside the therapy gym, Resident 69 was sitting in a wheelchair and had a pink cloth gait belt around the waist. There was another pink gait belt hanging on the therapy equipment rack. During an interview on 2/5/2026 at 11:34 a.m., the DOR confirmed Resident 69 used a pink cloth gait belt during a therapy session on 2/4/2026. DOR stated therapy staff used pink cloth gait belts with multiple residents on therapy throughout the day. DOR stated therapy staff used disinfectant wipes to clean the pink cloth gait belts in between resident use and did not launder the cloth gait belts in between resident use. During an interview on 2/5/2026 at 12:51 p.m., the Infection Preventionist Nurse (IPN) stated staff used cloth gait belts with multiple residents in the facility and used disinfectant wipes to disinfect the cloth gait belts in between resident use. IPN read the indications for use for the disinfectant wipes and stated the disinfectant wipes were to be used only on non-porous surfaces. IPN stated cloth gait belts were porous surfaces and the disinfectant wipes should not be used on cloth gait belts and could not properly disinfect the cloth gait belts. IPN stated if staff did not properly disinfect the cloth gait belts in between resident use, then it could potentially transmit infections or bacteria in between residents who used the same gait belt. During a review of the facility's policy and procedures (P&P) titled, Infection Control DME reviewed 7/11/2025 indicated the facility will properly and routinely sanitize durable medical equipment (DME) and the manufacturer's instructions will be followed for cleaning non-critical care items. During a review of the facility's P&P titled, Infection Control Program System, reviewed 7/11/2025 indicated the facility has an established infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 3. During a concurrent observation and interview inside the laundry room on 2/6/2026 at 8:13 AM, laundry worker (LW) 1 stated the laundry chute was completely filled with linens from the floor climbing up into the chute. Feces soiled towels were observed in the laundry chute area which were not stored in plastic bags and was open to air. LW1 stated the linens were not stored in a sanitary manner due to the washing machine being broken. Do the current observation interview inside the laundry room on 2/6/2026 at 8:26 AM with the infection preventionist the IP stated the shoot was overfilled. Failed the IP stated the linens were not stored in a sanitary manner in order to prevent cross contamination all linens should be stored inside plastic bags until separated. During an interview on 02/06/2026 2:29 PM Interview , the DON stated soiled linens are bagged prior to being sent down the laundry chute. The DON stated linens are placed inside bags for infection prevention. A review of the facility's policy and procedures (P&P) titled, Infection Control Policy – Laundry Services, Indicated It is the policy of the facility to assure a clean supply of linens and to protect employees who handle and process the laundry. The P&P also indicated All soiled linen should be bagged or put into carts at the location where they have been used; it should not be sorted or pre-rinsed in resident care areas. Linen that is saturated with blood or body fluids should be deposited and transported in impervious bags.

Based on interview and record review, the facility failed to ensure that the resident or their representative was notified timely in writing the reason for the transfer/discharge to the hospital for one of eight sampled residents, (Resident 38). This deficient practice resulted in resident 38 and/or their representatives not being provided with their options and rights by the facility staff.Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 9/30/2011, and readmitted Resident 38 on 2/27/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and gastrostomy tube (a small, flexible feeding tube inserted directly into the stomach through a small hole in the belly). A review of resident 38's physician order dated 12/14/2025, at 11:17 A.M., indicated . may transfer the patient to general acute care hospital (GACH) . A review of resident 38's notice of transfer/discharge date d 12/14/2025 indicated person notified was resident 38. A review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 12/18/2025, indicated Resident 38 was cognitively intact (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 38 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 2/5/2026, at 12:49 P.M., with Registered Nurse Supervisor (RNS) 1, Resident 38's notice of transfer/discharge form, dated 12/14/2025, was reviewed. The notice of transfer/discharge indicated person notified was Resident 38. RNS 1 stated that a notice of proposed transfer is done at the time of the resident transfer to GACH. RNS 1 stated the notification provided to the resident/and or their representative and then faxed to the Ombudsman (an independent official who works to resolve disputes fairly and impartially). RNS 1 stated the notice of proposed transfer is done to notify the resident representative and the Ombudsman that the resident is no longer in the facility. RNS 1 stated that the facility only notifies the resident and/or their representative via telephone only. During an interview, on 2/6/2026, at 4:27 P.M., with the Director of Nursing (DON), the DON stated a notice of proposed transfer is mailed to the resident representative to notify them of the transfer and is done at the time of the resident's transfer. If the notice of proposed transfer is not done, the resident representative may not be aware of the residents' whereabouts. A review of the facility's Policy &Procedures (P&P) titled Notice Before Transfer of a Resident reviewed 7/11/2025, indicated, Policy: In accordance with the State Operations Manual, 483 .12( a)( 4) before a facility transfers or discharges a resident, the facility must Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.Notice may be made as soon as practicable before transfer or discharge when- An immediate transfer or discharge is required by the resident's urgent medical needs.

Based on interview and record review, the facility failed to ensure residents' Minimum Data Set (MDS- a resident assessment tool) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS - is a federal agency within the U.S. Department of health and Human Services (HHS) that provides health coverage to over 160 million people through Medicare, Medicaid, the children's Health Insurance Program (CHIP), and the Health Insurance Marketplace) within 14 days after completion for one-of-one sampled residents (Resident 75). This deficient practice resulted in the delay to transmit MDS report to CMS for 61 days or Resident 75.Findings: A review of Resident 75's admission Record indicated Resident 75 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood), and depression (a constant feeling of sadness and loss of interest). A review of Resident 75's MDS, dated [DATE], indicated Resident 75's cognition (the mental ability to make decisions of daily living) was intact, and that Resident 75 required maximal assistance from staff for toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene. During an interview and record review with Registered Nurse MDS (RN/MDS) on 2/6/2026 at 10:29 PM, Resident 75 MDS Medicare -5 day was reviewed. RN/MDS identified and stated that the facility completed Resident 75's MDS Medicare - 5 day report on 12/7/2025 and did not transmit the MDS 5 day report until 2/6/2026 (61 days late) to the Centers for Medicare and Medicaid (provides health coverage to more than 100 million people through Medicare and Medicaid) as follows: A review of the facility's Resident Assessment Instrument (RAI) Process dated Reviewed: 07/11/2025 Indicated the following: Policy: The facility will utilize the Resident Assessment Instrument (RAI - is the standardized assessment framework used in long-term care setting especially nursing home to evaluate a resident's clinical status, functional abilities, and care needs) process for the accurate assessment of each resident's functional capacity and health status.Procedure:Each CAA (Care Area Assessment) will be completed by the responsible individual as designated.The facility will transmit MDS assessments in accordance with the transmission dates outlined.

Based on observation, interview, and record review the facility failed to provide effective pain management for one of six sampled residents (Resident 2), who had a left shoulder fracture (break in a bone), bladder surgery, and left hip fracture all sustained from a motorcycle accident, by failing to: 1. Administer the as needed pain medication, hydromorphone (Dilaudid- a strong pain reliever to treat moderate to severe pain) when Resident 2 complaint of a lot of pain on 5/24/2025 morning. Resident 2 received a dose of hydromorphone 4 milligrams (mg) on 5/24/25 at 4 PM. 2. Administer the as needed pain medication (hydromorphone) when Resident 2 complaint of pain on 5/27/2025 at 1:15 PM. Hydromorphone is not available. 3. Accurately assess and document the pain level (a pain scale or pain rating scale). 4. Evaluate the effectiveness of analgesic medication (medications that relieve pain) in relieving pain within two hours of administration based on the facility Policy and Procedures (P&P) titled Pain Assessment & Management revised 7/12/2024. These deficient practices resulted in Resident 2 suffering uncontrolled and continuous pain before receiving hydromorphone for the pain. On 5/26/2025 at approximately 9:15 PM, Resident 2 was transferred to a General Acute Care Hospital (GACH) emergency room (ER) for blood in the urine and 9/10 (0 representing no pain and 10 representing the worst possible pain) lower abdomen pain. Findings: During a record review, Resident 2's admission Record indicated Resident 2 was initially admitted to the Skilled Nursing Facility (SNF) on 3/14/2025 and readmitted on [DATE] with a diagnoses including nondisplaced fracture of lower end of right and left humerus (upper arm bone), injury of the bladder, lack of coordination, fracture of left shoulder, essential primary hypertension (HTN-high blood pressure). During a record review, Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 3/20/2025, indicated Resident 2's cognitive (ability to acquire and understand knowledge) skills for daily decision making were intact. The MDS indicated Resident 2 experienced pain occasionally, had difficulty sleeping, and had limited participation in rehabilitation (the process of restoring mental and/or physical abilities lost due to injury or disease, aiming to enable individuals to function at a normal or near-normal level) therapy sessions due to occasional pain. The MDS indicated that occasionally, Resident 2 experienced pain, that pain made it hard for the resident to sleep at night, limited the resident's participation in rehabilitation sessions, and limited the resident's day-to-day activities excluding rehabilitation therapy sessions. During a record review, Resident 2's Care Plan (CP) dated 4/2/2025, indicated Resident 2 is at risk for alteration in comfort due to pain related to multiple fractures, recent surgery. The CP goal indicated that Resident 2, Will remain free of signs and symptoms of pain such as grimacing, crying, moaning, guarding, verbal expression of pain daily x 90 days. Will report pain is relieved or controlled 30 minutes to 1 hour after pain medication is administered x 90 days. Will verbalize sense of control and enhanced enjoyment of life x 90 days. The CP interventions included to assess location, characteristics, onset, duration, frequency, and intensity of pain, determine acceptable level of pain and pain control goals, and provide comfort measures with touch, repositioning, use of heat and or cold packs. The CP indicated to administer hydromorphone 2 milligrams (mg) q [every] 4 hours (hrs) PRN (as needed). The CP also indicated to administer and Hydromorphone 4 mg q 4 hrs PRN. During a record review, Resident 2's Skilled Nursing Facility History and Physical (H&P) Examination dated 4/4/2025, indicated, Resident 2 was readmitted to GACH on 3/27/2025 and had closed left proximal humerus (upper arm bone) fracture, bladder rapture repair, and discharged to skilled nursing facility for rehabilitation. The H&P indicated Resident 2 had left hip incision (cut or wound made in the body tissues) staple (small, metallic clips used to close wounds or incisions) from prior operation, had persistent bladder pain/pressure consistent with spasms that limited discharge. The H&P indicated on day of discharge, Resident 2's pain was well controlled with an oral regimen. During a record review, Resident 2's Physician History and Physical (H&P) dated 4/5/2025, indicated, Resident 2 had persistent bladder pain/pressure consistent with spasms (a sudden involuntary and painful tightening of a muscle/s) improved with oral (by mouth) pain medications. During a record review, Resident 2's Pain Flow Sheet for the month of 5/2025, indicated the following: - On 5/20/2025 at 8:15 AM., Resident 2 was experiencing upper arm pain, aggravated by movement. The interventions included to administer Hydromorphone 4 mg for pain intensity 8/10. - No documented pain level and intervention on 5/21, 5/22, 5/23, 5/24, and 5/26/2025 - On 5/26/2025 at 2 PM., Resident 2 was experiencing upper arm pain, aggravated by movement. The interventions included to administer Hydromorphone 4 mg for pain intensity 8/10. During a record review, Resident 2's Medication Administration Record for 5/2025, indicated the following: - Hydromorphone 2 mg tablet, give one tablet by mouth every 4 hours as needed for moderate pain scale 5-7. Diagnosis multiple fractures. - Hydromorphone 4 mg tablet, give 1 tablet by mouth every 4 hours as needed for moderate pain scale 8-10. Diagnosis multiple fractures. The same Resident 2's MAR Record for 5/2025 indicated the following entries: - On 5/24/2025 at 4 PM, Resident 2 received a dose of hydromorphone 4 mg. The MAR document did not indicate the pain level and reassessment of the pain after two hours of the pain medication was administered. - On 5/24/2025 at 8:30 PM, Resident 2 received a dose of hydromorphone 4 mg. The document did not indicate the pain level and reassessment of the pain after two hours of the pain medication was administered. During a record review of Resident 2's MAR for 5/2025 Pain Assessment Every Shift for the 5/2025, indicated that on 5/24/2025 for 11PM to 7 AM shift, 7 AM-3 PM shift, and 3 PM to 11 PM shift, Resident 2's pain scale was documented as 0/10. During a record review, Resident 2's Physician and Telephone Order dated 5/26/2025 at 5:08 PM indicated, to transfer Resident 2 to GACH emergency room via regular ambulance related to blood in the urine and 9/10 (severe pain) lower abdomen pain. During a record review, Resident 2's GACH Emergency Department Service Report dated 5/26/2025 at 9:47 PM, indicated, Resident 2 presented with hematuria (blood in the urine) that began in the morning, 5/26/2025 and with an 8/10 pain level. The GACH Emergency Department Service Report indicated that on 5/27/2025 at 8:48 AM, Resident 2 was discharged back to SNF. During an interview with Resident 2 on 5/27/2025 at 1 PM, Resident 2 stated he was involved in a motorcycle accident and is on hydromorphone which helps him with severe pain. Resident 2 stated he returned to the facility (SNF) on 5/27/2025 morning. Resident 2 stated that the weekend (5/24/2025-5/26/2025) he was in a lot of pain, was asking for pain medication, but was told that he had to wait because they (facility) did not have the pain medication (hydromorphone). Resident 2 stated, They (nurses) bring all the medication except hydromorphone. Resident 2 stated that on Saturday (5/24/2025), I went to the nursing station to ask for the hydromorphone. I asked twice for the medication they told me to wait. I used the walker and went to the nurse station to ask for the hydromorphone few times and I didn't get it until late evening. I was in a lot of pain throughout the weekend. I had to go to hospital because the pain has not been controlled. I have pain in a lot of places, shoulder, hip, and bladder. Resident 2 stated he is happy with the medication orders for pain management, I just want to get them on time. When they have the medication (hydromorphone), they give it me every 4 hours. They (nurses) have been telling me they don't have them (hydromorphone) even to give me every 4 hours. During a telephone interview and concurrent record review with Registered Nurse (RN) 2 on 5/27/2025 at 11:12 AM, Resident 2's MAR and Pain Assessment Sheet for 5/2025 were reviewed. The MAR indicated that on 5/24/2025, there was no documented evidence that Resident 2 received hydromorphone for pain and the pain level assessed after 2 hours of receiving hydromorphone. RN 2 stated that Resident 2 does not get physical therapy on the weekend because of missing pain scale documentation. RN 2 stated that resident pain assessment should be done before and after medicating a resident with pain medication. RN 2 was unable to provide post pain medication administration assessment logs and stated, the facility uses the two pain assessment sheets (MAR and pain assessment sheet). During a concurrent observation in Resident 2s room, interview, and concurrent record review on 5/27/2025 at 1:15 PM with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR for 5/2025 was reviewed. LVN 1 entered then Resident 2's room to administer pain medications to Resident 2. Resident 2 was in bed and was complaining of pain. The MAR indicated for Resident 2 was also on Robaxin (muscle relaxing medication), gabapentin (medication for nerve pain), Tylenol (mediation for mild pain and to relieve fevers), and hydromorphone. LVN 1 stated, Hydromorphone is not available, I am about to call pharmacy to authorize to access the emergency medication kit. LVN 1 stated and acknowledged it was not according to standard of nursing care to ignore a resident's pain leading to hospitalization. LVN 1 stated LVN 1 is waiting for the pharmacist to give authorization to remove hydromorphone from the emergency medication kit. LVN 1 further stated, Not managing pain can lead to decline in rehabilitation progress. During an interview on 5/27/2025 at 1:48 PM, Certified Nursing Assistant (CNA) 1 stated, I have been assigned to Resident 2. I have heard him (Resident 2) today complaining about pain medication. I have seen him come out of his room to ask for pain medications and I do not have the details of the conversations with the nurses. CNA 1 stated Resident 2 is not happy when he does not get his medications on time. During an interview on 5/27/2025 at 2:58 PM, the Director of Staff Development (DSD) stated licensed staff are trained to manage residents' pain, contact a medical doctor (MD) about a resident's pain, and communicate with facility leadership to address unmet resident's needs. DSD stated, It is not the facility policy and standard of care to ignore pain. It is the practice and policy for licensed staff to call the pharmacy and get preauthorization to access emergency medication kits for narcotic medications. During an interview on 5/27/2025 at 3:50 PM, LVN 1 stated, I have called pharmacy three times, they have not responded to me yet. LVN 1 further stated the pharmacy has to preauthorize the facility to access the emergency medication kit. LVN 1 stated LVN 1 administered scheduled Robaxin 1000 mg, Tylenol 1000 mg, and gabapentin 900 mg to Resident 2 on 5/27/2025 at 1:15 PM. LVN 1 also stated hydromorphone was missing from the medication cart, not delivered by pharmacy. During an interview on 5/27/2025 at 4:38 PM, the facility administrator (ADM) stated, pain complaints should be addressed immediately and a MD notified of any change of condition or uncontrolled pain. ADM stated, I believe staff should be able to open the emergency medication kit to access medications then call pharmacy for replacement. The ADM stated pharmacy is required to respond immediately. During a record review, Resident 2's Order Summary Report (OSR) dated 5/28/2025, it indicated: - Hydromorphone HCL Oral Tablet 2 mg give one tablet by mouth every four hours as needed for moderate pain scale of 5-7 for diagnosis of multiple fractures. The hydromorphone order date was 4/2/2025. - Hydromorphone HCL Oral Tablet four mg, give one tablet by mouth every four hours as needed for severe pain scale of 8-10 for diagnosis of multiple fractures. The hydromorphone order date was 5/10/2025. - To call MD (medical doctor) if current pain medication regimen is ineffective for evaluation. The order to call MD was dated 5/10/2025. During a telephone interview on 5/28/2025 at 11:08 AM, RN 3 stated that on 5/24/2025, RN 3 was assigned to pass medications. RN 3 stated, I was too busy trying to figure things out. RN 3 stated Resident 2 has been walking from his room to the nursing station. RN 3 stated, I have no idea if there was a delay for his medications. I don't remember if I gave him hydromorphone. I have given him his scheduled medications. I was too busy, I was trying to figure things out, I was not oriented properly to pass medication because I was hired as RN supervisor. During a telephone interview on 5/28/2025 at 3:40 PM, the Pharmacy supervisor (PharmD) stated that the last delivery of hydromorphone 2 mg tablet for Resident 2 to the facility was on 5/20/2025. PharmD stated that on 5/26/2025, the facility staff (unidentified) called to obtain authorization to access the emergency medication kit for hydromorphone. PharmD stated the pharmacy authorized the facility three times to take hydromorphone from the emergency medication kit on 5/26/2025 for 7 AM, 2 PM, and 5:50 PM. PharmD stated that on 5/27/2025, the pharmacy authorized the facility to take 2 tablets (Hydromorphone 2 mg per tablet) for one dose as requested by the facility staff. PharmD stated, There was no call or request for authorization for hydromorphone from the facility staff on 5/24/2025. If there was a call or request for authorization, we would have authorized the medication to be accessed and given to (Resident 2). PharmD stated the facility emergency medication kit is stocked with 6 tablets of Hydromorphone 2 mg. During a telephone interview on 5/29/2025 at 1:56 PM, LVN 2 stated that on 5/24/2025, LVN 2 worked the 3 PM to 11 PM shift and that Resident 2 was in pain. LVN 2 stated LVN 2 initially contacted the pharmacy on 5/24/2025 at 1:30 PM and called the pharmacy twice more before 3:50 PM. LVN 2 stated, I had to call pharmacy to get authorization for hydromorphone. At around 6 pm (5/24/2025), I gave him (Resident 2) his first does of Hydromorphone 4 mg and Tylenol for pain. LVN2 stated Resident 2 has an ongoing pain and his pain has been increasing. LVN 2 stated that on 5/26/2025 at approximately at 9:15 PM, Resident 2 was transferred to GACH due to uncontrolled pain. During a record review, the facility Policy and Procedures (P&P) titled Pain Assessment & Management revised 7/12/2024, indicated, Assessment will occur daily and will focus on identifying the cause of pain and developing a pain management plan. Evaluation of the effectiveness of analgesic medication in relieving pain to a level that I acceptable to the resident will occur within 2 hours of administration. Medicate the resident as the physician ordered. Notify the physician of any unrelieved pain.

Based on interviews, and record review, the facility failed to follow its policy and procedures (P&P) titled, Abuse Prevention/Investigation/Reporting and Resolution, which indicated the facility will protect the rights, safety, and wellbeing of each resident, by failing to prevent one of three sampled residents (Resident 2) from hitting Resident 1. This deficient practice resulted in Resident 1 sustaining a laceration (cut) and contusion (a bruise which is when blood leaks into the surrounding area due to an injury) to the forehead and was transferred to the general acute care hospital (GACH) for evaluation and treatment of the head. Cross Reference F689 Findings: A review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (complete or partial loss of muscle strength that affects only one side of the body) following cerebral infarction (stroke) affecting the left side. Metabolic encephalopathy (condition of brain dysfunction), bipolar disease (a mental illness caused by unusual shifts in moods ranging from extreme highs to extreme low). Depression (mental condition that causes persistent low mood), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing generalized body shaking) and hyperlipidemia (high cholesterol). A review of Resident 1's Care Plan dated 3/13/2023 revised 6/2024 (n.d.) indicated Resident 1 had episodes of touching staff and residents. The goal indicated Resident 1 will have no injuries, misunderstandings or conflicts with staff and residents. The interventions included indicated to monitor Resident 1's whereabouts and keep safe distance to ensure residents and staff avoid being in contact. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/6/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 was totally dependent (helper does all the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. A review of Resident 1's Smoker's Risk assessment dated [DATE] indicated Resident 1 had poor vision, limited mobility, needed redirection with safety awareness, and required supervision while smoking. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR- a form used to communicate between the nursing team and the physician) dated 6/8/2024 timed at 2:05 p.m., indicated Resident 1 was bleeding from the left side of the forehead after fighting with Resident 2. A review of Resident 1's GACH Emergency Department Encounter note dated 6/8/2024, indicated Resident 1 was diagnosed with a contusion of the head and laceration of the scalp. The noted indicated Resident 1 underwent laceration repair with high pressured saline wash to cleanse the area, total length 1/2 centimeter (cm- unit of measurement) in depth through the top layer of the skin. The noted indicated the area was closed with Dermabond (skin glue that holds wound edges together). The noted indicated Resident 1 was discharged back to the facility on [DATE] evening. A review of Resident 1's Interdisciplinary Team Conference Record (IDT- team members from different disciplines work together to review the root cause of the problem and develop a solution) dated 6/10/2024, indicated Resident 1 was informed of the facility zero tolerance rule for violence and instructed to notify staff in the future if Resident 1 has any conflict with any other residents immediately and remove self from situation. The note also indicated Resident 1 was instructed to participate in activities. A review of Facility Designated Smoking Times indicated smoking hours as follows: 8:30 a.m. - 8:45 a.m. 10 a.m. - 10:15 a.m. 12:45 p.m. - 1 p.m. 2 p.m. - 2:15 p.m. 4 p.m. - 4:15 p.m. 6 p.m. - 6:15 p.m. 8 p.m. - 8:15 p.m. 2. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnoses included Acquired absence of right leg above the knee, diabetes mellitus (DM- abnormal blood sugar), hyperlipidemia (high cholesterol), unspecified kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), depression, acute (sudden onset) embolism and thrombosis of deep vein (blood clot in an unspecified vein), acquired absence of right hip joint and hypertensive heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). The Face Sheet indicated Resident 2 was discharged home on 6/12/2024. A review of Resident 2's MDS-a dated, 4/21/2024 indicated Resident 1's cognition was intact. Resident 2 was independent with toileting hygiene and transfers (moving between surfaces) from bed to chair. A review of the facility's investigation of a handwritten statement report from Resident 2, dated 6/8/2024, the statement indicated Resident 2 said that Resident 1 was trying to get a cigarette lit but no one would help and moved away. The statement indicated Resident 2 told Resident 1 come back so that Resident 2 light the cigarette for Resident 1, but Resident 1 flipped off (gave the middle finger) Resident 2. Resident 1 later returned with a cigarette asking Resident 2 for a light and Resident 2 took the cigarette from Resident 1 and threw it on the ground. Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 2 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead then Resident 1 stated ok. Resident 2's statement further indicated Licensed Vocational Nurse 1 (LVN 1) Showed up and took [Resident 1] away. During an interview on 6/24/2024 at 12:13 p.m., the Activities Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking. The residents that require supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke. The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters. The AD stated Resident 1 required supervision while smoking to prevent Resident 1 from fighting with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset. During an interview on 6/24/2024 at 12:20 p.m., the AD stated, Only myself and my assistant have the key to the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office. Nursing staff do not have access to the activity office or any of the residents' cigarettes. I was not here for the fight between (Resident 1 and Resident 2) but my assistant was here. Unfortunately, my assistant at the time no longer works here. Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside. During an interview on 6/24/2024 at 12:44 p.m., LVN 1 stated, On 6/8/2024 at approximately 2:00 p.m. I was walking around looking for one of my residents and passed by the sliding glass door to the smoking patio. I looked outside and saw [Resident 1] in the wheelchair (wc) from the back holding a broom in hand and Resident 2 in front holding a dustpan in the hand over the head as if to hit Resident 1, so I went outside immediately. LVN 1 stated Resident 1 turned around in the wc and LVN 1 saw Resident 1 bleeding on the left side of forehead. LVN 1 stated, I did not see any other staff members out there. LVN 1 stated LVN 1 wheeled Resident 1 to the west station and informed the charge nurse and supervisor who immediately rendered first aid to Resident 1 and called 911. LVN 1 stated Resident 2 did not smoke and would go out to the patio to draw or just to get some air. LVN 1 stated on 6/8/2024 in the patio, Resident 2 told LVN 1 that Resident 1 had a cigarette and was asking for a lighter. LVN 1 stated Resident 1 turned around and wheeled away in a wc. LVN 1 stated Resident 2 then called Resident 1 back to help find a lighter and Resident 1 flipped the middle finger at Resident 2. LVN 1 stated Resident 1 returned and asked Resident 2 again for a lighter. LVN 1 stated Resident 2 took the cigarette from Resident 1 and threw the cigarette on the ground. LVN 1 stated Resident 1 went over to the housekeeping cart, grabbed a dust broom, and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 1 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead and that is when I walked outside. LVN 1 stated, I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking. LVN 1 stated we don't have anyone designated to sit out there so it's up to all of us to collectively watch the residents. I'm not sure what [Resident 1] needed when smoking but I would have guessed [Resident 1] needed to be supervised. During an interview on 6/24/2024 at 1:15 p.m., LVN 2 stated LVN 2 was the charge nurse on 6/8/2024. LVN 2 stated Resident 1 smoked and required supervision when smoking. LVN 2 stated Resident 1 was alert and oriented to person, place, and time. LVN 2 stated Resident 2 was at risk for injury if unsupervised when smoking. LVN 2 stated the Activities Department provides cigarettes to residents. LVN 2 stated Resident 1 would go directly to Activities Department to get cigarettes and a lighter. LVN 2 stated the Activities Department would let the nurses know that Resident 1 was smoking. LVN 2 stated, No one from the Activities Department told me that [Resident 1] was outside smoking that day, 6/8/2024. LVN 2 stated on 6/8/2024 at around 2:00 p.m., LVN 1 wheeled Resident 1 in wc to the nurses' station and observed Resident 1 bleeding on the forehead. LVN 2 stated LVN 2 applied ice pack, called 911, and informed Resident 1's doctor and Residents 1's family. LVN 2 stated the facility transferred Resident 1 to the GACH on 6/8/2024. During an interview on 6/24/2024 at 3:00 p.m., the Administrator (Adm) stated, Yes, this incident (between Resident 1 and Resident 2) could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times. A review of facility's P&P titled Abuse Prevention/Investigation/Reporting and Resolution, effected 11/28/2026, indicated, The facility will protect the rights, safety, and wellbeing of each resident (regardless of physical and mental condition), for whom we provide care and treatment against any and all forms of physical . abuse, . or any treatment that would result in physical harm, pain, mental suffering . The P&P further indicated Physical abuse includes assault . and hitting .

Based on interview, and record review the facility failed to provide supervision while smoking for one of three sampled residents (Resident 1). This deficient practice resulted in a fight between Resident 1 and Resident 2 on 6/8/2024. Resident 2 hit Resident 1 on the forehead. Resident 1 sustained a laceration (cut) to the forehead and was transferred to the general acute care hospital (GACH) on 6/8/2024. GACH diagnosed Resident 1 with contusion (a bruise [This happens when small blood vessels get torn and leak blood under the skin], a result of a direct blow or an impact) of the head. Cross Reference F600 Findings: 1. A review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (complete or partial loss of muscle strength that affects only one side of the body) following cerebral infarction (stroke) affecting the left side, metabolic encephalopathy (condition of brain dysfunction), bipolar disease (a mental illness caused by unusual shifts in moods ranging from extreme highs to extreme low), depression (mental condition that causes persistent low mood), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing generalized body shaking) and hyperlipidemia (high cholesterol). A review of Resident 1's Care Plan (CP) dated 3/13/2023 revised 6/2024 (n.d.) indicated Resident 1 had episodes of touching staff and residents. The CP goal indicated Resident 1 will have no injuries, misunderstandings or conflicts with staff and residents. The CP interventions indicated to monitor Resident 1's whereabouts and keep safe distance to ensure residents and staff avoid being in contact. A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/6/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 was totally dependent (helper does all the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. A review of Resident 1's Smoker's Risk assessment dated [DATE] indicated Resident 1 had poor vision, limited mobility, needed redirection with safety awareness, and required supervision while smoking. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR a form used to communicate between the nursing team and the physician) dated 6/8/2024 timed at 2:05 p.m. indicated Resident 1 was bleeding from the left side of the forehead after fighting with Resident 2. A review of Resident 1's GACH Emergency Department Encounter note dated 6/8/2024, indicated Resident 1 was diagnosed with a contusion of the head and laceration of the scalp. Resident 1 underwent laceration repair with high pressured saline wash to cleanse the area, total length 1/2 centimeter (CM- Unit of measurement) in depth through the top layer of the skin. The note indicated the area was closed with Dermabond (skin glue that holds wound edges together). The note indicated Resident 1 will require close follow-up in the next 2-3 days with primary physician otherwise to return to ER (emergency room ) with worsening of any symptoms. The note indicated Resident 1 was discharged back to the facility on [DATE] evening. A review of Resident 1's Interdisciplinary Team Conference Record (IDT- team members from different disciplines work together to review the root cause of the problem and develop a solution) dated 6/10/2024, indicated Resident 1 was informed of the facility zero tolerance rule for violence and instructed to notify staff in the future if Resident 1 has any conflict with any other residents immediately and remove self from situation. The note also indicated Resident 1 was instructed to participate in activities. A review of Resident 1's care plan titled, resident is at risk for injury and accident related to smoking, dated 6/14/2024, indicated interventions included to provide Resident 1 with physical supervision during scheduled smoking hours. A review of Facility Designated Smoking Times indicated smoking hours as follows: 8:30 a.m. - 8:45 a.m. 10 a.m. - 10:15 a.m. 12:45 p.m. - 1 p.m. 2 p.m. - 2:15 p.m. 4 p.m. - 4:15 p.m. 6 p.m. - 6:15 p.m. 8 p.m. - 8:15 p.m. 2. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnoses included Acquired absence of right leg above the knee, diabetes mellitus (DM- abnormal blood sugar), hyperlipidemia (high cholesterol), unspecified kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), depression, acute (sudden onset) embolism and thrombosis of deep vein (blood clot in an unspecified vein), acquired absence of right hip joint and hypertensive heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). The Face Sheet indicated Resident 2 was discharged home on 6/12/2024. A review of Resident 2's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated, 4/21/2024 indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. Resident 2 was independent with toileting hygiene and transfers (moving between surfaces) from bed to chair. A review of the facility's investigation of a handwritten statement report from Resident 2, dated 6/8/2024, the statement indicated Resident 2 said that Resident 1 was trying to get a cigarette lit but no one would help and moved away. The statement indicated Resident 2 told Resident 1 to come back so that Resident 2 light the cigarette for Resident 1 but Resident 1 flipped off (to show someone in an offensive way that you are annoyed with them) Resident 2. Resident 1 later returned with a cigarette asking Resident 2 for a light and Resident 2 took the cigarette from Resident 1 and threw it on the ground. Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 2 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead then Resident 1 stated ok. Resident 2's statement further indicated Licensed Vocational Nurse 1 (LVN 1) Showed up and took [Resident 1] away. On 6/12/24, Resident 2's face sheet indicated the resident was discharged home. During an interview on 6/24/2024 at 12:13 p.m., the Activity Director (AD) stated, We have designated smoking times and a list of residents that need supervision while smoking. The residents that requires supervision we keep their cigarettes and lighters locked in the office and give them out one at a time when a Residents wants to go and smoke. The Residents that are safe to smoke independently can come out on their own and they can keep their cigarettes and lighters. The AD stated Resident 1 required supervision while smoking to prevent fights with other residents because sometimes the residents don't understand what [Resident 1] is saying and when that happens [Resident 1] tends to get upset. During the same interview on 6/24/2024 at 12:13 p.m., the AD stated, Only myself and my assistant have the key to the activity office where the cigarettes are kept. On the weekend we have a manager on duty that could be any department head and they will have the keys to the office. Nursing staff do not have access to the activity office or any of the residents' cigarettes. I was not here for the fight between [Resident 1 and Resident 2] but my assistant was here. Unfortunately, my assistant at the time no longer works here. Supervision is provided by all staff through frequent visual checks. We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door because there is a direct line of sight to the smoking area in case myself or my assistant could not be outside. During an interview on 6/24/2024 at 12:44 p.m., LVN 1 stated, On 6/8/2024 at approximately 2:00 p.m. I was walking around looking for one of my residents and passed by the sliding glass door to the smoking patio. I looked outside and saw [Resident 1] in the wheelchair (wc) from the back holding a broom in hand and Resident 2 in front holding a dustpan in the hand over the head as if to hit Resident 1, so I went outside immediately. LVN 1 stated Resident 1 turned around in the wc and LVN 1 Resident 1 bleeding on the left side of forehead. LVN 1 stated, I did not see any other staff members out there. LVN 1 stated that LVN 1 wheeled Resident 1 to the west station and informed the charge nurse and supervisor who immediately rendered first aid to Resident 1 and called 911. LVN 1 stated Resident 2 did not smoke and would go out to the patio to draw or just to get some air. LVN 1 stated on 6/8/2024 in the patio, Resident 2 told LVN 1 that Resident 1 had a cigarette and was asking for a lighter. LVN 1 stated Resident 1 then got upset when Resident 2 told Resident 1 that Resident 2 did not have a lighter. LVN 1 stated Resident 1 turned around and wheeled away in a wc. LVN 1 stated Resident 2 then called Resident 1 back to help find a lighter and Resident 1 flipped the middle finger at Resident 2. LVN 1 stated Resident 1 returned and asked Resident 2 again for a lighter. LVN 1 stated Resident 2 took the cigarette from Resident 1 and threw the cigarette on the ground. LVN 1 stated Resident 1 went over to the housekeeping cart and grabbed a dust broom and hit Resident 2 with the dust broom [ROOM NUMBER]-5 (four to five) times on the head, shoulder, and hands. Resident 2 wrestled the dust broom away from Resident 1 and held it; then Resident 1 went back to the housekeeping cart and grabbed a dustpan and hit Resident 2 again. Resident 2 took the dustpan away from Resident 1 and hit Resident 1 on the forehead and that is when I walked outside. LVN 1 stated, I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking. LVN 1 stated, we don't have anyone designated to sit out there so it's up to all of us collectively watch the residents. I'm not sure what [Resident 1] needed when smoking but I would have guessed [Resident 1] needed to be supervised. During an interview on 6/24/2024 at 1:15 p.m., LVN 2 stated LVN 2 was the charge nurse on 6/8/2024. LVN 2 stated Resident 1 smokes and requires supervision when smoking. LVN 2 stated Resident 1 was alert and oriented to person, place, and time. LVN 2 stated Resident 2 was at risk for injury if unsupervised when smoking. LVN 2 stated the Activities Department provides cigarettes to residents. LVN 2 stated Resident 1 would go directly to Activities Department to get the cigarettes and lighter. LVN 2 stated Activities Department would let the nurses know that Resident 1 was smoking. LVN 2 stated, No one from the activity department told me that [Resident 1] was outside smoking that day, 6/8/2024. LVN 2 stated that on 6/8/2024 at around 2:00 p.m., LVN 1 wheeled Resident 1 in wc to the nurses' station and observed Resident 1 bleeding on the forehead. LVN 2 stated LVN 2 applied ice pack, called 911, and informed Resident 1's doctor and Residents 1's family. LVN 2 stated the facility transferred Resident 1 to the GACH on 6/8/2024. During an interview on 6/24/2024 at 3 p.m., the Administrator (Adm) stated, Yes, this incident [fight between Resident 1 and Resident 2) could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times. A review of the facility's policy and procedures (P&P) titled, Smoking Policy and Procedures reviewed on 7/14/2023, indicated, The facility shall inform all residents of their right to smoke in the designated smoking patio. The designated smoking patio is located outside of the dining room . 2. The facility shall follow a smoking schedule and assign a designated smoking staff to oversee smoking activity during specified hours. The smoking schedule shall be posted in the designated smoking area. 3. The facility shall assess residents expressing a desire to smoke for safety and appropriateness to smoke using the Smoking Assessment within 72 hours (about 3 clays) upon admission, quarterly in conjunction with their quarterly care plan review and as needed. 4. The facility shall collect the smoking materials of residents identified to be unable to smoke independently or unsupervised based on the Smoking Assessment. 5. The facility shall store smoking supplies in the medication carts. 6. The designated smoking staff shall ensure that all smoking materials are available during the posted smoking schedule . 9. The designated smoking staff shall gather smoking supplies at the end of the smoking period and return them to the medication cart for safekeeping. The same P&P indicated, The facility shall make provisions to accommodate the smoking policy during inclement. The facility shall hold an IDT conference with residents who are non-compliant with the facility's smoking policy and procedure to explain the risks of unsafe smoking behavior.

Based on interview, and record review, the facility failed to ensure the licensed nurses notified the physician of a significant change in condition for one of three sampled residents (Resident 1), who had a clogged indwelling catheter (a soft flexible tube inserted into the bladder to drain urine) with urinary output of 1800 cubic centimeters (cc-a unit of measure), blood-tinged urine, after changing the catheter, and an increased heart rate. The failure of the licensed nurses to recognize Resident 1's change in condition, notified the physician, and transfer the resident to a higher level of care at an acute care hospital resulted in the resident's death. Findings: A review of Resident 1's admission record indicated Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. characterized by irregular and often faster heartbeat). A review of Resident 1's Minimum Data Set (MDS- an assessment and care planning tool) dated 10/2/19, indicated Resident 1 could not speak, required full staff performance with bed mobility, dressing, and toilet use. The MDS also documented the resident had an indwelling catheter. A review of Resident 1's care plan, dated 9/25/18, for being at risk for urinary for infection related to Foley (indwelling) catheter secondary to a [MEDICAL CONDITION] (lack of bladder control due to a brain, spinal cord or nerve problem) bladder indicated interventions that included assess for fever, change of level of consciousness, reviewing lab results and notify physician of abnormal findings. A review of Resident 1's physician order [REDACTED]. Check catheter output every shift, check for cloudiness, blood mucus shreds (thin mucus secretions that may appear in the urine), and sediment (gritty particles, mucus, white or red cells that can be detected in a urine). A review of Resident 1's interdisciplinary progress notes (IDT-professionals from different disciplines (nursing, dietary, therapies, etc.) who worked together to manage the resident's needs), dated 2/10/20 at 1 a.m., indicated Resident 1 had facial grimacing and appeared in pain. The licensed nurse gave the resident Tylenol (a medication to treat pain or fever) 325 milligrams (mgs-a unit of measure) two tablets. A review of Resident 1's IDT progress note dated 2/10/20 at 4:30 a.m., indicated Resident 1 was diaphoretic (sweating), blood sugar was 205 mg/dl (normal 60 - 120), heart rate fluctuating from 69 to 80 beats a minute to 128 to 134 beats a minute, then back to 88 to 90 beats a minute., temperature 99.9) (normal 98.6) , blood pressure 133/79. The licensed nurse notified the physician at 4:35 a.m. but did not document that she informed the physician about the 1800 cc urinary output and blood tinged urine. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR-provides a framework for communication between members of the health care team about a patient's condition) Communication form dated 2/10/20 at 4:53 a.m., indicated Resident 1 heart rate was 104 to 134 (normal 60 - 100), increased respiration (rate not indicated) and facial grimacing. Resident 1's primary physician ordered a complete blood count (CBC - a blood test used to evaluate your overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection) and a basic metabolic panel (BMP- used to check the status of the kidneys (remove waste products from the blood and produces urine) stat (immediately). A review of Resident 1's IDT Progress Notes dated 2/10/20 during the 11:30 a.m. indicated Resident 1 had an elevated temperature of 102.7 (normal 98.6), low blood pressure of 91/41 (normal 120/80), increased respiration rate of 33 breaths per minute (normal range 12 -16 per minute) and elevated pulse rate of 134 beats per minute (normal 80 - 100). The licensed nurse notified the physician at 11:35 a.m. about the above vital signs (temperature, pulse, and respirations) and received an order to get a stat (immediate) chest X-ray. A review of Resident 1's SBAR dated 2/10/2020 at 11:30 a.m. indicated Resident 1's oxygen saturation level (the amount of oxygen in the blood-normal reading is between 95 and 100 percent) decreased to 91% and he had a low grade fever of 100.5, a low B/P 90/34, and an elevated pulse rate 101. A review of Resident 1's License Nurses Progress Notes dated 2/10/20 at 12:45 p.m. included an entry timed at 12:32 p.m. indicating desaturation (low oxygen levels) of Resident 1's oxygen level to 88 %, a decrease in blood pressure to 58/35, a detectable pulse at 98 beats per minute. The licensed nurse called the respiratory therapist who started manual ventilation with an ambu bag (a hand-held device commonly used to provide ventilation to patients who are not breathing or not breathing adequately). Paramedics (911) called and arrived at 12:43 p.m. A review of a paramedic run disposition sheet dated 2/10/202 at 12:53 p.m., indicated, Resident 1 appeared to be dead upon (paramedics) arrival. Resident had lividity, asystole (no heart activity) on monitor, rigor (stiff) and mottling (the skin presents as a red or purple marbled appearance). Resident was blue and mottled from top of head down all limbs. Resident had lividity on back and was cold to touch, feet and jaw stiff. Resident showing asystole on multiple leads, however blood pressure (BP) registered 61/42. Resident unconscious, unresponsive, apneic (without respirations) and pulseless. Facility staff member stated the resident was last well at approximately 7 a.m. (2/10/20). Determination of death at 2/20/20 at 12:53 p.m. Local police department on scene. During an interview on 2/12/20 at 12:45 p.m., Licensed Vocational Nurse (LVN) 1 stated, Stat means immediately. Resident 1 had an unstable heart rate and we should have requested an EKG along with a transfer to the general acute care hospital for evaluation. During a telephone interview on 2/25/20 at 9:30 a.m. the primary care physician stated he wanted the lab results before diagnosing the elevated heart rate and was willing to wait 4 hours for the results. The primary physician further stated he would have ordered an EKG, but it depended on the resident's condition. During an interview on 2/25/2020 at 2:22 p.m., a Sub-Acute Registered Nurse Director (RN) 1 stated she received report on Resident 1's indwelling catheter and [MEDICAL CONDITION] of 1800 cc output, which is a lot. RN 1 stated, There's a problem that may cause [MEDICAL CONDITION] and we may need to clamp catheter off. RN 1 further stated, The nurse should have clamped the catheter and report the output to the physician . During a telephone interview on 4/8/2020 at 11:20 a.m., the primary physician stated he was not aware of the resident's 1800 cc urine output or the low blood pressure, because he would have sent Resident 1 to the acute care hospital. During a telephone interview on 4/10/2020 at 9:41 a.m., the Registered Nurse Supervisor (RN) 2 stated she was the RN supervisor on duty and called the resident's primary physician and made him aware of the elevated heart rate, and clogged indwelling catheter that drained blood-tinged urine on 2/10/20 at 4:35 a.m. RN 2 stated she received orders for a CBC and BMP and made it stat. RN 2 verbalized that she could not recall if she made the physician aware of the 1800 cc urinary output. RN 2 stated she should have clamped the catheter to prevent Resident 1 from going into shock. When asked why the physician was not notified of the clogged catheter when she called at 1:00 a.m. RN 2 stated Resident 1 had a stable heart rate, but when the resident's heart rate elevated she called the physician and made him aware of the elevated heart rate and blood-tinged urine. RN 2 further stated she did not document contacting the physician on the SBAR because Resident 1 had blood tinged urine in the past. The facility policy titled, Change of Condition, dated 11/30/2018 indicated any sudden change in a resident's condition, manifested by a marked change in physical or mental behavior, will be communicated to the physician as soon as identified. Licensed staff will use the Advanced SBAR Change of Condition Documentation /COC (change of condition)/form to evaluate the situation, identify the problem, gather information on applicable systems and report key items to the physician. The facility policy titled, Foley Catheter Care, dated 11/28/2018, indicated to check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Unless specifically ordered, do not apply a clamp to the catheter. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. Observe for other signs and symptoms of urinary tract infection or [MEDICAL CONDITION]. Report findings to the physician or supervisor immediately.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had chronic [MEDICAL CONDITION] (condition in which blood does not have enough oxygen), elevated vital signs, and had a change of condition, was provided with necessary care and services, including but not limited to: 1. Failure to assess heart sounds and pulses, and investigate reports of difficulty breathing, per Resident 1's care plan. 2. Failure to notify Resident 1's physician immediately when Resident 1 was noted to have abnormal vital signs, in accordance with the facility's policy. This failure resulted in Resident 1 continuing to have abnormal breathing and rapid heart rate on [DATE], and at 6:40 a.m. Resident 1 became unresponsive and cold at the facility. Resident 1 was transferred to a general acute care hospital (GACH) and was pronounced dead at the hospital on [DATE] at 7:35 a.m. The immediate cause of death was cardiopulmonary arrest (cessation of heart beating). Findings: On [DATE], at 8:55 a.m., an unannounced visit was conducted at the facility regarding quality of care. A review of the clinical record indicated Resident 1 was admitted to the facility, on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Resident 1 was to receive [MEDICATION NAME] 2.5 milligrams (mg) (medication used to open up medium and large airways of the lungs) / 3 milliliters (ml) unit dose every six hours and every two hours as needed, for shortness of breath. Resident 1 was to receive Atrovent (medication used to open up medium and large airways of the lungs) 0.5 mg /3 ml unit dose via hand held nebulizer (HHN) every six hours and every two hours as needed, for shortness of breath. A review of the care plan, dated [DATE], indicated Resident 1 was at risk for ineffective airway clearance related to [MEDICAL CONDITION]-lung disease ([MEDICAL CONDITION], [MEDICATION NAME] of airways) and with [MEDICAL CONDITION] (surgical opening in the neck to assist with breathing) connected to ventilator (machine used to assist with breathin). The care plan interventions indicated to monitor respirations and breath sounds, noting rate and sounds, auscultate breath sounds and assess air movement, monitor vital signs, noting changes in blood pressure and heart rate. The care plan did not indicate the frequency of monitoring Resident 1's respirations and breath sounds. A review of the care plan, dated [DATE], indicated Resident 1 was at risk for decreased cardiac tissue perfusion and cardiac output related to [MEDICAL CONDITION] (reduction of blood flow to the heart), cardiac [MEDICAL CONDITION] (abnormal heart rhythm), [MEDICAL CONDITION] (weakness of the heart that leads to a build up of fluid in the lungs), and [MEDICAL CONDITION] during hospitalization . The care plan interventions were to monitor vital signs, especially noting hypertension (high blood pressure) or [MEDICAL CONDITION] (low blood pressure), assess heart sounds and pulse, assess for restlessness, diminished peripheral pulses, and pale, cool skin. The care plan also indicated to investigate reports of difficulty breathing or respiratory rate outside acceptable parameters. The care plan did not indicate the frequency of monitoring Resident 1's vital signs. A review of the Minimum Data Set (MDS, a care planning and assessment tool), dated [DATE], indicated Resident 1 had severe cognitive impairment, had heart failure, and hypertension. A review of the physician's orders [REDACTED]. A review of facility's Vital Signs form, dated ,[DATE] - [DATE] indicated Resident 1's baseline vital signs were respirations 16 - 20 per minute (normal range 16 - 20), heart rate 60 - 84 per minute (normal 60 - 80), and for blood pressure ,[DATE] - ,[DATE] mmHG (normal range >,[DATE] and <,[DATE]). A review of the Licensed Nurses Progress Note, dated [DATE], at 12 a.m., indicated Resident 1 was opening eyes in response to touch and was afebrile (normal temperature). At 2 a.m., the Licensed Nurses Progress Note indicated Resident 1 was in no acute distress. A review of the clinical records there were no vital signs documented at those times. A review of the Licensed Nurses Progress Note, dated [DATE], indicated at 4:15 a.m., Resident 1's breathing became labored at 32 respirations per minute, heart rate was increased at ,[DATE], blood pressure was elevated at ,[DATE]. The progress note indicated the respiratory therapist suctioned Resident 1 and administered [MEDICATION NAME] (pain medicine) due to facial grimacing. At 4:25 a.m., Resident 1's heart rate remained elevated at 124, and the registered nurse called 911 at 4:43 a.m. The progress note indicated when the paramedics arrived the vital signs were within normal limits. A review of the Pre hospital care report (paramedics report), dated [DATE], at 4:43 a.m., indicate initially called out for elevated heart rate, on arrival paramedics assessed resident and vitals. Nursing staff advised they had just given [MEDICATION NAME] treatment prior to paramedic's arrival. Ambulance advised elevated heart rate was a side effect of medication given. Resident 1 was not transported to GACH at this time. A review of the Pre hospital care report (paramedics report), dated [DATE], at 4:56 a.m., indicated Resident 1's vital signs were ,[DATE], heart rate 102, respirations 18. A review of the Respiratory Therapy (RT) Flowsheet, dated [DATE], at 6:25 a.m., documented by the respiratory therapist, indicated Resident 1 was on ventilator and according to the registered nurse, Resident 1 was having trouble breathing during the night. The RT Flowsheet indicated Resident 1 was breathing fast, heart rate increased, blood pressure increased, and Resident 1 was unstable. The respiratory therapist documented that she received Resident 1 in respiratory distress, with respiratory rate of ,[DATE], Resident 1 was not awake, and Resident 1's fingers were cold. The RT Flowsheet indicated the respiratory therapist was unable to obtain Resident 1's oxygen saturation, the resident appeared pale, was diaphoretic, and his skin did not feel warm. The RT Flowsheet indicated a small amount of yellow secretions was suctioned and Resident 1's condition did not change. The RT Flowsheet indicated 10 L of supplemental oxygen was provided to Resident 1, but there was no change. The respiratory therapist documented that she then started bagging the resident with 15 L oxygen at 6:40 a.m., and the charge nurse called [DATE]. Resident 1 remained unresponsive. A review of the Licensed Nurses Progress Note, dated [DATE], at 6:40 a.m., indicated Resident 1 was noted to be in respiratory distress, staff continued to bag Resident 1 when paramedics returned at 7 a.m. The vital signs were ,[DATE], heart rate was 60, and respirations were ,[DATE]. Resident 1 was transferred to hospital via 911 at 7:05 a.m. A review of the Situation, Background, Assessment, Recommendation (SBAR - method of prompt communication with the healthcare team) Communication Form, dated [DATE], indicated the physician was notified at 7 a.m. of Resident 1's change of condition (approximately 3 hours after the first abnormal vital signs on [DATE] at 4:15 a.m.). A review of the Prehospital Care Report Summary (paramedics report), dated [DATE], indicated the paramedics arrived again at the facility at 7:03 a.m. and found Resident 1 unconscious and unresponsive, with absent lung sounds, pale skin, delayed capillary refill (time taken for color to return after pressure applied). Upon assessment, Resident 1 was apneic (cessation of breathing) and was being ventilated. The ambulance crew found Resident 1 with warm skin, pupils reactive (pupils constricts to light and dilates to dark), but sluggish with weak thready (difficult to feel) pulse at 32 bpm (beats per minute). Electrocardiogram (EKG - record of person's heartbeat) could not be obtained on scene. Ventilations (assisted breathing) were continued by ambulance crew. A review of the GACHs Emergency Department Service Report, dated [DATE], at 7:26 a.m., indicated Resident 1 was brought in by ambulance as a code blue (requiring immediate efforts by medical team). Per emergency medical services, staff member of the skilled facility found resident in respiratory arrest 30 minutes prior to arrival. Resident 1 went into asytole (no blood flow to the heart) during the transport and CPR was started during that time. The Service Report indicated Resident 1 was noted to have arrested four times at the skilled facility and at 7:35 a.m., Resident 1's time of death was called. During an interview, on [DATE], at 11:18 a.m., the Registered Nurse Supervisor 1 (RNS 1) stated if the resident had increased, abnormal vital signs, there needed to be interventions from the doctor and physician should be called immediately. During concurrent record review, RNS 1 stated there was no documented evidence the physician was notified promptly after 4:15 a.m., on [DATE], when Resident 1 was noted to have abnormal vital signs. There was no documented evidence of any interventions from the physician. During an interview, on [DATE], at 11:34 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had two changes of condition on [DATE]. LVN 1 stated Resident 1's baseline heart rate was never greater than 100 and that Resident 1 had never had labored breathing or respiratory rate greater than ,[DATE]. LVN 1 stated that the facility's protocol for medical emergencies was to send the resident to the hospital via ambulance services if the resident was in respiratory distress. LVN 1 stated if Resident 1 had a rapid heart rate and was diaphoretic, this would be a medical emergency. LVN 1 stated the nurses should have called the physician immediately, at 4 a.m. on [DATE]. A review of the Certificate of Death, dated [DATE], indicated Resident 1's immediate cause of death was cardiopulmonary arrest with an underlying cause as [MEDICAL CONDITION]. A review of the facility's policy titled, Physician Notification, revised [DATE], indicated a physician shall be notified promptly of the following types of events in the facility: Any sudden and/or marked adverse change in signs, symptoms or behavior, such as: abnormal vital signs. A review of the facility's policy titled, Change of Condition, dated [DATE], indicated to clearly define guidelines for complete documentation and timely notification of a change in resident condition. An acute change of conditon (C[NAME]) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, or functional domains that without intervention, may result in complications. Responsible Discipline: RN, LVN. The policy indicated all changes in resident condition will be documented in the medical record and communicated to the physician and resident/responsible party.

Based on observation, interview, and record review, the facility failed to have a system in placed to ensure 100 residents including one of 20 sampled residents (Resident 19), and two of three randomly selected residents (Resident 23 and Resident 24) non-narcotic and narcotic medications were handled safely by failing to: 1. Implement facility's policy and procedures of safe disposal of discontinued and expired residents' medications from three of three nurses station. 2. Ensure accurate accountability of each resident's non narcotics and narcotics medications from receipt, administration, to disposition. 3. Ensure two of three medication refrigerators that contains controlled medications were kept locked as indicated in the facility's policy and procedures 4. Ensure only authorized licensed staff will have access to discontinued and expired controlled medications, and the medications were stored in a secured locked area, and disposed of as indicated in the facility's policy and procedures. 5. Implement the facility's Consultant Pharmacist Services Provider Requirements to monitor facility medication storage for proper storage of medication, and proper accounting and reconciliation of discontinued controlled medications. 6. Ensure Resident 23 and Resident 24, discharged medication list, indicated the number of narcotic medications given to the residents upon discharged . 7. Ensure Resident 19's Norco (a combination of hydrocodne 5 milligrams (mg) an Acetaminophen 325 mg) narcotic count sheet and available tablets in the bubble pack had no discrepancy. These deficient practices had the potential for residents to not receive their medications as ordered by the physician with the potential to negatively affect residents care and increased the risk for misuse of controlled drugs that included schedule two drugs (medications with a high abuse potential) or diversion and the inability to readily reconcile and account for each dose of medication. Findings: a. On May 20, 2016, at 11:35 a.m., during West, Subacute, and East medication room inspection with the licensed vocational nurse (LVN 2), the following was observed inside each medication room: 1. A white bucket labeled, Discontinued Medications - Expired Pharm - Incineration Only. The white bucket was lined with a clear plastic trash bag that was filled with medications in their original form that included but not limited to, tablets, capsules, bottles of eye drops, vials containing injectable medication, ampules containing inhalation medication, and Novolog FlexPen syringe (a diabetic injectable medication) labeled with the name of Resident 20. During a concurrent interview, LVN 2 looked through log books in the West Nursing Station medication room and stated she did not see any medication destruction logs to account for the medications in the bucket. LVN 2 was not able to determine which residents medications were placed in the bucket for disposal. 2. The medication refrigerators at West and Subacute medication room were observed unlocked and had the injectable emergency kit (E-kit) that contain vials of Ativan (controlled antianxiety medication) 2 milligrams (mg) per milliliter (ml). On May 20, 2016, at 12:58 p.m., during an interview LVN 2 stated all three medication room (West, Subacute, and East) refrigerators were supposed to be locked because they contained narcotic medications that included injectable Ativan. LVN 2 acknowledged the West and Subacute refrigerators were not locked. On May 20, 2016, at 1:10 p.m., during an interview LVN 2 stated she did not know what medications were in the bucket in the East Nursing Station medication room or which residents they had belonged. LVN 2 acknowledged there was no destruction log to account for the medications in the bucket marked for incineration at the East Nursing Station medication room. b. On May 20, 2016, at 3:15 p.m., during an interview the director of nursing (DON 1) stated, The non-controlled medication destruction log is not current. No one followed through. We need the nurses (licensed) to log all medications for disposal. Without a log we will not be able to identify or account for the medications and who they belonged to. DON 1 further stated he disposes of the narcotic medications monthly with the facility's pharmacist consultant and the last disposal was on May 11, 2016. He stated together they punched out the tablets and capsules from the bubble packs into a plastic bag, he stated he tied the plastic bag with controlled medications inside and then handed the unsealed plastic bag to central supply staff member. DON 1 stated the central supply staff member (an unlicensed facility staff) would take the plastic bag filled with controlled medications, call the drug disposal company, seal and handle the final transfer and disposition of the controlled medication. When asked if he has any record of the controlled medications being picked up or destroyed, DON 1 stated there is no log or handover document given to central supply and that he does not give or receive from the drug disposal company any forms to account for the destruction of the controlled medications. On May 23, 2016, at 10:05 a.m., a review of the Narcotic and Hypnotic Records destruction with the DON 1 indicated Prepared for Destruction, May 11, 2016. The DON 1 stated the disposal company last picked up medications from the facility for destruction on May 13, 2016. DON 1 stated he and the facility's pharmacist consultant both signed the narcotic destruction form that included but not limited to the disposal of the following: · Oxycodone 10 mg total quantity of 34 tablets · Oxycodone 5 mg total quantity of 69 tablets · Methadone 10 mg total quantity of 73 tablets · Oxycodone 5 mg with Acetaminophen 325 mg total quantity of 60 tablets · Morphine 100 mg/5ml quantity 30 ml · Hydrocodone 10 mg with Acetaminophen 325 mg quantity 30 tablets · Hydrocodone 5 mg with Acetaminophen 325 mg total quantity of 183 tablets · Lorazepam 1 mg total quantity of 89 tablets · Lorazepam 0.5 mg total quantity of 35 tablets · Lorazepam 2 mg/ml quantity of 10 - 1 ml vials (total quantity 10ml) · Vimpat 200 mg total quantity of 7 tablets · Vimpat 10 mg/ml total quantity of 10 ml · Diazepam 2 mg total quantity of 30 tablets · Zolpidem 10 mg total quantity of 9 tablets · Zolpidem 5 mg total quantity of 25 tablets · Phenobarbital 20 mg/5 ml total quantity of 92 ml On May 23, 2016, at 10:10 a.m., during an interview in the presence of DON 1, central supply staff member stated he takes care of both the non-controlled and the controlled drug disposal. He receives from DON 1 a clear plastic trash bag filled with colorful tablets, capsules, and bottles of liquid medications. The nurses place medication in buckets in each Nurses Station medication room and call central supply when it is time to come pick the medication up. The central supply staff member stated Like picking up trash, then he returns the buckets to the Nurse's Stations after placing the plastic bags full of medication into the disposal container. He stated the disposal container is not locked until the day the disposal service comes because, I have to keep taking the lid off to add more medicine into the container. During a concurrent interview DON 1 and central supply staff member were asked the location of medications waiting for disposal. The central supply staff member and DON 1 exited the back door of the building, there was a metal screen door with a single lock next to a large trash bins. The metal screen door has a posted signs indicated Stop, Caution: Biohazardous Waste Storage Area Unauthorized Persons Keep Out! Inside the door were two unlocked medication disposal containers, central supply staff member opened the one container which was filled with retrievable medications contained in four to five clear plastic trash bags that included, but not limited to, inhalers, tablets, capsules, bottles and vials of liquid and injectable medications. During an interview on May 23, 2016, at 10:20 a.m., in the presence of DON 1, central supply staff member, the administrator stated, liquids are not mixed in with the disposed discontinued or expired medications and the disposal company picks up for disposal every two weeks. The DON stated the facility disposes both controlled and non-controlled medication in the same container. At a closer observation, the label outside the drug disposal container indicated No controlled substances or red bag waste (including sharps). Both DON 1 and central supply staff member stated the facility only has one disposal company and they send both controlled and non-controlled in the same drug disposal container. During a concurrent interview, central supply staff member, DON 1, and the administrator each acknowledged that maintenance and others non licensed staff had keys to the drug storage waiting to be pick up by the drug disposal company. The DON 1 acknowledged that the drug disposal container was unlocked and contains retrievable controlled and non-controlled medications. On May 23, 2016, at 11:25 a.m., during record review, DON 1 indicated different types of controlled medications such as Oxycontin, Diazepam, Ativan, Morphine Sulfate, and Hydrocodone were documented as destroyed on the following dates: · May 11, 2016, 42 discontinued/expired orders of controlled medication · April 8, 2016, 36 discontinued/expired orders of controlled medication · March 15, 2016, 38 discontinued/expired orders of controlled medication · February 11, 2016, 59 discontinued/expired orders of controlled medication · January 11, 2016, 72 discontinued/expired orders of controlled medication During a concurrent interview DON 1 stated, There is no way to know if a bag of controlled medication was missing. The bags are not labeled. It would be really hard to tell. On May 23, 2016, at 12:16 p.m., during an interview DON 2 stated, a night shift nurse handles nonnarcotic medication returns and destruction; the liquids are kept intact and handed to central supply staff member. DON 2 further stated she does not know how the drugs are handled once they leave the nursing stations. c. On May 23, 2016, at 5:25 p.m., during a record review and interview registered nurse (RN 1) stated, Resident 24 was discharged from the facility on May 20, 2016. The resident was given all of his medications to take with him that included two prescriptions for Oxycodone 5 mg with Acetaminophen 325 mg. A review of the Discharge List of Medications, with RN 2 indicated Resident 24 was discharged with medications that included the following two narcotic medication orders [REDACTED] · Oxycodone 5 mg with Acetaminophen 325 take one tablet by mouth every four hours as needed for moderate pain · Oxycodone 5 mg with Acetaminophen 325 take two tablets by mouth every four hours as needed for severe pain However under the column that indicated, Number of Remaining Meds (Sent to Resident), was left blank. RN 2 stated, We did not fill out the quantity because we have on the Narcotic Count Sheet how many tablets there are. A review of the Resident 24's Narcotic Count Sheet with medical record staff member indicated a quantity of 45 tablets. Medical Record staff member indicated the signature across the middle of the form belonged to the resident and the signature below the form belonged to a licensed vocational nurse (LVN 4). However, the form was undated and did not include an authorized signature as the form required. During a concurrent interview, the medical record staff member stated, One person may endorse controlled medication to the Resident 24. Not required for DON, RN or other licensed nurse to verify resident received the medication. d. A Review of a Discharge List of Medications, for Resident 25 with a discharge date of [DATE] indicated the resident was discharged with the following narcotic medication order: · Hydrocodone 5 mg with Acetaminophen 325 take two tablets by mouth every four hours as needed for moderate to severe pain However the quantity of controlled medication released to the resident was left blank. On May 24, 2016, at 9:20 a.m., during an interview the facility's pharmacist consultant he stated that he pops out the discontinued, expired, and controlled medication left behind by discharged resident together with DON 1. He stated that they should empty liquid into the container and destroy the drugs and render them unusable. On May 24, 2016, at 10:50 a.m., during an interview the facility's pharmacist consultant stated he has not yet checked the facility's controlled medication inventory; however a pharmacy nurse consultant from the pharmacy comes monthly to check for expired medications and controlled drug discrepancies. The facility's pharmacist consultant stated he has not had to follow-up on any discrepancies identified by the pharmacy nurse consultant since the nurse consultant communicates directly to the facility nurses and the DON. Pharmacist Consultant further stated refrigerators that contain controlled medication should be kept locked; two nurses should outdate and log non-controlled medications; and he would have the pharmacy nurse consultant do a full medication audit of the facility. According to August 1, 2008, facility's policy and procedures titled, Disposal of Medications and Medication-Related Supplies - Medication Destruction, indicated the discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed . Tablets, capsules and liquids are returned to the pharmacy or to be destroyed by a certified medication destruction company . Controlled substances are retained in a securely locked area with restricted access by the facility director of nursing and/or consultant pharmacist and/or administrator. Medication destruction occurs only in the presence of two individuals, including, two licensed nurses or (one) licensed nurse and a pharmacist. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form for individual resident medications. The medication disposition form is kept in the facility for two years. 1) Date of destruction 2) Resident's name 3) Name and strength of medication 4) Prescription number 5) Amount of medication destroyed 6) Signatures of witnesses A review of March 1, 2016, facility's disposal company contract indicated, (Disposal Company) will not accept improperly identified or unidentified wastes . The parties agree Hazardous Drug Disposal Service shall not include collection, transportation, treatment or disposal of controlled substances listed under the Drug Enforcement Administration and Customer shall not provide such items as part of its waste for collection. Review of August 1, 2008, facility policy and procedures titled, Consultant Pharmacist Services Provider Requirements, indicated the Consultant Pharmacist provides consultant pharmacist services, including but not limited to the following; monitoring the medication storage facilities and the medication carts at least quarterly, for proper storage of medications, cleanliness, and removal of expired medications .Assisting in the accounting and reconciliation of unused controlled substances and noncontrolled substances . e. According to the admission record, Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. On May 23, 2016, at 2:00 p.m., during a narcotic count inspection at the East Nursing station, Resident 19's narcotic count was conducted with licensed vocational nurse (LVN 1), the medication nurse. The resident had a hydrocodone 5/325 mg in a bubble pack with five remaining bubbles with two tablets in each bubble, which total to 10 tablets. The Narcotic Count Sheet indicated a total of six tablets remaining. During an interview with LVN 1 on May 23, 2016, at 2:30 p.m., she stated that Resident 19 was admitted on [DATE], from another facility and he came in with his medications. LVN 1 stated there were 11 bubbles in the pack with two tablets in each. The two tablets were counted as a dose, so in the narcotic count sheet they recorded 11 tablets instead of 22 tablets. She further stated that she gave Resident 19 two tablets of Norco at 8 a.m., in the morning and has not recorded in the narcotic count sheet. During an interview with the director of nursing (DON) on May 24, 2016, at 2:45 p.m., he stated all licensed staff were trained to count narcotics at the end of their shift and to report any discrepancy to the nursing supervisor or DON. He stated the licensed staff should document in the Medication Administration Record [REDACTED]. The May 23, 2016, facility policy and procedures titled Monitoring of Narcotic Medications Each shift indicated immediately after a dose of controlled medication is administered, the nurse is to enter the following on the narcotic medication record: · Date and time of administration. · Dose administered. · Signature of the nurse that administered the dose.

Based on observation, interview and record review, the facility failed to ensure three of 20 sampled residents (Residents 3, 11, and 19), and one of three randomly selected residents (Resident 22) were provided the necessary care and services by failing to: 1. Follow the physician's orders [REDACTED]. This resulted in Resident 22 complaining of severe right leg pain, and being readmitted to a general acute care hospital (GACH) on two occasions April 11, 2016, and May 19, 2016, for uncontrolled pain. Resident 22 was transferred to the SNF (skilled nursing facility) post fall with a [MEDICAL CONDITION] leg involving the right tibia (weight bearing large bone below the knee) and fibular (stabilizing smaller bone parallel to the tibia). 2. Notify the attending physician, in accordance to the facility's policy and procedure, after three doses of Resident 3's blood pressure medications, [MEDICATION NAME] 10 milligrams (mg) and [MEDICATION NAME] 25 mg., were held for a total of 16 times from May 1, 2016 to May 26, 2016, when his systolic blood pressure (SBP, the blood pressure when the heart is contracting) was below the set parameter of 110 milligrams (mg). This deficient practice had a potential to result in a delay in treatment and services and placed Resident 3 at risk of complications associated with high blood pressure. 3. Immediately notify the charge nurse and/or supervisor when Resident 11 was having difficulty breathing during a bed bath, in accordance to the facility's change of condition policy and procedure, which notes to report a change in condition to the charge nurse and/or supervisor. This deficient practice had the potential to result in a delay in treatment and services, and in Resident 11 experiencing worsened breathing difficulty, unnecessary discomfort, and possible death. 4. Assess the reason for Resident 19's continuous complaints of severe pain and assess the effectiveness of his as needed (prn) pain medication, [MEDICATION NAME] 5/235 (milligram). This deficient practice resulted in poor pain management and pain control, which resulted in Resident 19 experiencing unnecessary pain, and having to continuously ask for pain medication two times a day, which had the potential to have a profound effect on Resident 19's quality of life, cause increase stress, disrupt sleep, cause anxiety, depression and delay healing. Findings: 1. A review of Resident 22's Admission Record, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS an assessment and care screening tool), dated April 6, 2016, Resident 22's speech is unclear; usually able to make herself understood and understands others. The resident required extensive assistance with eating, personal hygiene, and totally dependent requiring one person assistance from the nursing staff with dressing and toilet use and two plus person physical assistance for transferring. Resident 22 physician's order [REDACTED]. 1. March 31, 2016, Tylenol 325 mg two tablets (650 mg) by mouth every six hours as needed (PRN) for mild pain, not to exceed (NTE) 3 gm per 24 hours. 2. March 31, 2016, [MEDICATION NAME] 5 mg one tablet by mouth every four hours PRN for moderate pain. 3. April 12, 2016, Tylenol ([MEDICATION NAME]) 500 mg one tablet by mouth every eight hours (maximum dose of 4 grams (gm) of [MEDICATION NAME] per day) around the clock (ATC) for mild pain. 4. May 26, 2016, [MEDICATION NAME] ([MEDICATION NAME] an antipsychotic used to treat [MEDICAL CONDITION]) 2.5 mg one tablet by mouth daily for [MEDICAL CONDITION] manifested by screaming and yelling for no apparent reason. During an observation and interview, on May 26, 2016, at 1 p.m., Resident 22 was lying awake and alert in her bed. The resident stated her right leg hurts, it is uncomfortable. When asked if she let the staff know, the resident stated, I told a nurse and when I tell the nurse they transfer me to the hospital. On May 26, 2016, at 1:10 p.m., during an interview a licensed vocational nurse (LVN 30) stated Resident 22 speech is slurred, and she yells and screams when she wants to go to get up, eat, go to the dining room, back to bed, or when she has pain, and once her needs are taken care of Resident 22 is quiet. LVN 30 further stated she asked the resident if she had pain about a week ago, and the resident stated she was sent to the general acute care hospital (GACH). LVN 30 stated the GACH sent her back the same day. LVN 30 stated the resident was on [MEDICATION NAME] (an antipsychotic medication) for screaming and yelling, she has never seen the resident try to hit anyone. On May 26, 2016, at 1:25 p.m., during a follow-up interview, Resident 22 stated her pain was a seven out of 10 (on a scale from one to 10 with a 10 being the most severe pain), and Both legs hurt right now, I tell the nurses. They (facility nurses) do not ask how bad the pain is. I cannot walk on my legs. On May 26, 2016, at 1:30 p.m., LVN 2 was called to Resident 22's room and pulled back the blanket to show Resident 22's leg. The resident's right leg was observed with a hard cast that covered most of her foot to below her knee, lying flat on the bed. LVN 2 stated, She was complaining of pain the other day. So we sent her to the GACH, and GACH sent her back. During a concurrent interview in the presence of LVN 2, the wound nurse (LVN 6) stated, Resident 22 was saying she wants to go to the hospital. She was in pain about a week ago. On May 26, 2016, at 1: 30 p.m., LVN 2 stated, I have never seen her use the call light. She screams that is how we know she wants something. I have never seen her try to hit anyone. LVN 2 stated The resident has a [DIAGNOSES REDACTED]. Maybe boredom is the reason for some of the behavior. A review of a SNF Admission Pain Assessment form, dated March 31, 2016, indicated Resident 22 had no history of or current problem with pain. However, the form listed resident's current pain medications as follow: · Tylenol 325 milligrams (MG), two tablets (650 mg) by mouth every four hours as needed for mild pain. · [MEDICATION NAME] 5 mg, one tablet by mouth every four hours as needed (PRN) for moderate pain. A review of a Pain Assessment form, dated April 12, 2016, indicated Resident 22 had a history of [REDACTED]. · Tylenol 500 mg every eight hours ATC · [MEDICATION NAME] 5 mg PRN · Tylenol 325 mg, two tablets every six hours PRN The Medication Administration Record [REDACTED]. A review of Resident 22's MARs from April 1, 2016, through May 26, 2016 documented the resident's pain level as zero (0) for a total of 56 days. A review of Narcotic Record and MARs for the months of April 2016 and May 2016 indicated discrepancies in the documentation for [MEDICATION NAME] 5 mg administration to Resident 22 for pain. However, the Narcotic Record documented that Resident 22 received five doses of [MEDICATION NAME] 5 mg on: · March 4, 2016 (prior to Resident 22's March 31, 2016 admission to the facility), · May 18, 2016 · May 19, 2016 · May 26, 2016, Resident 22 received two doses However the April 2016 and May 2016 MARs indicated Resident 22 received four doses of [MEDICATION NAME] not five doses on: · April 3, 2016, not March 4, 2016 · May 17, 2016, no documentation for May 18 or May 19, 2016 · May 26, 2016, indicated Resident 22 received two doses as indicated on the Narcotic Record A review of the GACH physician medication order dated March 31, 2016, included a handwritten physician order [REDACTED]. A review of the GACH records indicated Resident 22 arrived at the GACH for an appointment on April 11, 2016 and the GACH documented under instructions, Recommendation to SNF MD: Patient and (family member) concerned about inadequate pain relief. Consider ATC dosing with Tylenol or [MEDICATION NAME] (controlled medication for pain) with PRN breakthrough dosing of [MEDICATION NAME] 5 mg. A review of the GACH emergency room (ER) records indicated Resident 22 arrived in the emergency roiagnom on [DATE] and was diagnosed with [REDACTED]. The GACH's Discharge Summary dated May 19, 2016 indicated increased pain on lower extremities. A review of February 23, 2015 facility's policy and procedure, titled, Pain Assessment and Management, indicated, The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan .All assessment data obtained during the procedure including location of pain, level of pain, using the pain scale, and type of pain relief used. Document the resident's response to the pain relief. Notify the physician of any unrelieved pain. 2. A review of Resident 3's admission records indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a resident assessment), dated February 16, 2016, indicated Resident 3 had the ability to understand others and the ability to be understood by others, and required extensive assistance from the staff with dressing, and supervision with personal hygiene and bathing. Resident 3 had a physician's orders [REDACTED]. than 60. A review of Resident 3's Medication Administration Record [REDACTED]. During an interview, and record review with licensed vocational nurse 30 (LVN 30), on May 25, 2016, at 3:30 p.m., LVN 30 stated the physician was not notified that the [MEDICATION NAME] and [MEDICATION NAME] medications were held due to low blood pressures ranging from 92/66, 94/49, 102/59, to 116/82 (Reference range 120/80 mm Hg). LVN 30 stated the policy was to call the physician after the medication was held three doses. 3. On May 23, 2016, at 9:45 a.m., upon entering Resident 11's room with certified nursing assistance (CNA 1), the resident was observed with his oxygen cannula below his chin. The resident put it back on his nostrils after instructed by CNA 1. Resident 11 stated he took it off his nose because the oxygen makes his nose dry. Then CNA 1 lowered the Resident 11 's head of the bed down resulting in resident lying flat on his back. CNA 1 then proceeded with the bed bath, starting by cleaning resident's face with wet wash cloth. Resident 11 who was still flat on his back, started having difficulty in breathing, he was audibly wheezing with each breath and he was breathing with all his abdominal muscles. CNA 1 was asked by the surveyor if the breathing was normal for the resident. CNA 1 stated that resident will feel better after the bath as she continue with the bed bath. Charge nurse 1 was called into the room by the surveyor to observe Resident 11. The Charge Nurse stopped the bed bath and raised the head of the bed up and proceeded in giving Resident 11 a breathing treatment. Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with Charge Nurse 1 on May 23, 2016, at 10:40 a.m., she stated CNA 1 should have stopped the bed bath and reported the resident's change in condition to the charge nurse or nursing supervisor. During an interview with CNA 1 on May 23, 2016, at 11:05 a.m., she stated she should have stopped the bed bath and notify the charge nurse of Resident's condition. During an interview with the director of nursing (DON) on May 24, 2016, at 2:45 p.m., he stated all CNAs were trained to report any changes in residents condition to the charge nurse or nursing supervisor. The facility policy and procedures titled Acute Change of Condition indicated all interdisciplinary team members are expect to report and documented symptoms findings that might represent ACOCs (acute change of conditions) to the Nursing- in-charge. 4. Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with Resident 19 on May 24, 2016, at 1:00 p.m., he stated he was always in pain because he only got pain medication two times a day, one in the morning and one at night. He said he wished he could have another dose of pain medication in between like in the afternoon; it would help a lot with his pain especially during physical activities. He said his pain level was s always at level 7, in the pain rating scale of 0 to 10, with 10 being the worst pain. The resident stated he usually feels the pain mostly on his back, both legs and on his shoulders. The resident had physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no documentation of pain location. During an interview with the licensed vocational nurse (LVN 1) on May 23, 2016, at 2:36 p.m., she stated the doctor did not provide numeric parameters for the pain medication, and the order should have been clarified with the physician. She further stated that Resident 19 always complained of pain on his legs, his back and generalized body pain and that his pain location should have been documented. During an interview with director of nursing (DON), conducted on May 25, 2016, at 2:45 p.m., he stated all nurses were trained on pain assessment and documentation. He stated for alert resident, the nurses should use the numeric pain rating scale level of 0-10 with 0 being no pain and 10 being the worse pain. The February 23, 2015, facility policy and procedures titled Pain Assessment and Management indicated to ask resident if he/she is experiencing pain. Note the location of pain and the level of pain using the numerical pain rating scale.