Every finding on record at Princeton Manor Healthcare Center, LLC

Based on observation, interview and record review, the facility failed to involve the resident representative in the development of the discharge plan for one of two residents (Resident 1) when Resident 1's Family Member (FM) 1, who was the healthcare decision maker, did not receive a written notice of the proposed discharge.This failure resulted in Resident 1's FM 1 to be uninvolved with the discharge planning process and was unable to appeal the Resident 1's discharge from the facility.Findings:During a review of Resident 1's Face Sheet, dated 7/15/26, the Face Sheet indicated Resident 1 was admitted in the facility on 1/26/23 with a diagnosis of unspecified dementia (a diagnosis given when a patient clearly exhibits cognitive decline or memory loss that impacts daily functioning, but the exact underlying cause cannot be definitively determined or requires further testing). The Face Sheet indicated Resident 1's FM 1 contact type was Responsible Party (RP, Healthcare Decision Maker), Emergency Contact # 1 and Durable Power of Attorney (DPOA, a document by which one person authorizes another to take actions on his/her behalf).During a record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide plan of care) dated 2/3/26, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 7 out of 15, indicating severe cognitive impairment. The MDS indicated there was no active discharge planning for Resident 1 to return to the community.During a review of Resident 1's Order Summary Report dated 11/11/25, the Order Summary Report indicated, Resident 1 was incapable of making healthcare decisions.During a review of Resident 1's Care Plan Report, undated, the Care Plan Report indicated Resident 1 had cognitive loss/dementia related to impaired decision making with one of the interventions was to communicate with family regarding resident's needs.During a review of Resident 1's Health Status Note, dated 3/3/26, the Health Status Note indicated Resident 1 was discharged from the facility.During an interview on 7/10/26 at 1:00 p.m. with the Director of Nursing (DON), the DON stated Resident's capacity to make healthcare decisions were identified through the BIMS or were documented in the Medical Doctor's Progress NotesDuring a review of Resident 1's Progress Note dated 3/1/26, the Progress Note indicated Resident 1's POA was FM 1.During a concurrent interview and record review on 7/15/26 at 1:21 p.m. with Social Services Director (SSD), Resident 1's Notice of Proposed Transfer and Discharge, dated 3/2/26, was reviewed. The Notice of Proposed Transfer and Discharge indicated, the notification of proposed discharge was through a telephone call to FM 1. The Notice of Proposed Transfer and Discharge indicated, the process on how to appeal the proposed discharge. The SSD stated Resident 1's RP was the FM 1. The SSD stated Resident 1's Notice of Proposed Transfer and Discharge did not indicate a copy was given or was sent to FM 1. The SSD stated the purpose of notifying FM 1 was to involve FM 1 to get the process of discharge started. The SSD stated RP should be involved with discharge planning anytime the resident is not self-responsible. The SSD stated Resident 1 should not have been discharged because she was not self responsible.During a concurrent interview and record review on 7/15/26 at 3:32 p.m. with SSD, Resident 1's Social Services Note, dated 3/2/26, was reviewed. The Social Services Note indicated, the Social Worker (SW) spoke to Resident 1 about discharging to community and agreed. The Social Services Notes indicated FM 1 did not return the SW phone call. The SSD stated the SW no longer works in the facility.During an observation and interview on 7/15/26 at 3:35 p.m., the SSD was observed reading Resident 1's Social Services Notes in the Electronic Health Record (EHR). The SSD stated there was no documentation of the SW attempting to call FM 1 again. The SSD stated the best practice was to call three times or to call until getting a response because ultimately FM 1 was Resident 1's the decision maker.During a telephone interview on 7/20/26 at 10:39 a.m. with FM 1, the FM 1 stated not knowing that the facility discharged Resident 1. The FM 1 stated not receiving paper works regarding the proposed discharge and not being able to appeal the discharge. The FM 1 stated she was not involved in selecting the Resident 1's new discharge location. The FM 1 stated the discharge did not align with her goals and treatment preferences for Resident 1During a review of facility's policy & procedure (P&P) titled, Discharge and Transfer Residents, dated 2/27/25, indicated 5. Prior to discharge, the facility will provide the resident representative with the Notice of Proposed Transfer and Discharge document.

Based on observation, interview, and record review, the facility failed to ensure the resident was free from unnecessary medications (medications used in the presence of unwanted, unintended, or dangerous effects which indicate the dose should be reduced or discontinued) for one of three sampled residents (Resident 2). Resident 2 was administered Norco (also known as hydrocodone-acetaminophen) a controlled substance pain medication that causes dizziness and drowsiness), Lorazepam (also known as Ativan, a controlled substance medication that depresses the central nervous system [CNS] causing drowsiness, dizziness, weakness, and unsteadiness), and gabapentin (a medication used to treat nerve pain that causes extreme sleepiness, dizziness, and unsteadiness) in (one medication given along with either of the others) during the period of 12/11/23 to 12/15/23. Following Resident 2's return from the acute care hospital (ACH) on 12/18/23, the facility continued to administer lorazepam and Norco, despite ACH discontinuing these medications and identifying them as contributing to Resident 2's somnolence (a strong, persistent state of drowsiness, heavy sleepiness, or a desire to sleep during the day). This failure resulted in Resident 2 experiencing somnolence and placed Resident 2 at increased risk for excessive sedation and other adverse effects associated with CNS depression (brain and nervous system are slowed down).During a review of Resident 2's Face Sheet, dated 7/16/26, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of spastic hemiplegia affecting left dominant side (damage to the right hemisphere of the brain, leading to severe muscle stiffness, paralysis, and impaired fine motor control on the left side of the body). The Face Sheet indicated one of Resident 2's emergency contact was Family Member (FM) 2.During a review of Resident 2's Medication Administration Record (MAR) dated 12/1/23 through 12/31/23, the MAR indicated Resident 2 had physician orders for gabapentin (medication to treat nerve pain; causes extreme sleepiness, dizziness, and unsteadiness) 600 milligrams (mg) one tablet by mouth three times a day, Norco 5-325 mg one tablet by mouth every 8 hours as needed for moderate to severe pain, and lorazepam oral tablet 0.5 mg one tablet by mouth every 6 hours as needed for anxiety. The MAR further showed these medications were administered to Resident 2 in combination on the following dates and times: 12/11/23 at 5:00 p.m. - gabapentin 12/11/23 at 5:00 p.m. - lorazepam 12/13/23 at 4:03 a.m. - lorazepam 12/13/23 at 5:00 a.m. - Norco 12/14/23 at 5:00 p.m. - gabapentin 12/14/23 at 5:00 p.m. - lorazepam 12/15/23 at 11:49 a.m. - Norco 12/15/23 at 12:00 p.m. - gabapentin 12/15/23 at 1:17 p.m. - lorazepam During a review of Resident 2's Health Status Note, dated 12/16/23, the Health Status Note indicated Resident 2's FM 2 came by to visit and requested Resident 2 to be sent to the hospital and 911 was called. The Health Status Note indicated Resident 2 was transferred to Acute Care Hospital (ACH).During a phone interview on 7/14/26 at 2:50 p.m. with FM 2, FM 2 stated Resident 2 was overly medicated. FM 2 stated on 12/16/23 Resident 2 was unresponsive and an Emergency Medical Technician (EMT, a trained health professional who provides emergency first aid, basic life support, and safe transport to a hospital for people who are sick or hurt) was called. FM 2 stated on 12/18/23 the doctor from the hospital discontinued Resident 2's Norco and the lorazepam. FM 2 stated facility staff continued to give Resident 2 Norco and lorazepam when Resident 2 returned to the facility.During a review of Resident 2's ACH Discharge Summary, dated 12/18/23, the ACH Discharge Summary indicated, Resident 2's date of admission to the ACH was 12/16/23 and the reason for ACH admission was somnolence. The ACH Discharge Summary indicated Resident 2 presented with somnolence after getting both Norco and Ativan (lorazepam) in addition to her usual gabapentin dose. The ACH Discharge Summary indicated both opioids (a class of drugs such as Norco) and benzodiazepine (a class of drug such as Ativan) can lead to altered mental status (AMS, sudden or significant change in a person's baseline awareness, cognition, or consciousness). The ACH Discharge Summary indicated Resident 2 had some improvement in somnolence after receiving Narcan (medication that rapidly reverses the effects of opioid overdose). The ACH Discharge Summary indicated Resident 2 should not receive Norco and Ativan and gabapentin at the same time as all have unintended consequences of somnolence/AMS.During a review of Resident 2's Order Summary Report, dated 12/19/23, the Order Summary Report indicated Resident 2 had an order for gabapentin 600 mg one tablet by mouth three times a day.During a review of Resident 2's Order Details, dated 12/19/23, the Order Details indicated Resident 2 had a prescriber written order for Norco 5-325 mg, give one to two tablets by mouth every 8 hours as needed for moderate to severe pain and Ativan 0.5 mg, give two tablets by mouth every 6 hours as needed for anxiety were entered by LVN (Licensed Vocational Nurse) 2.During a review of Resident 2's MAR, dated 12/22/23 and 12/24/23, the MAR indicated, gabapentin, Norco and lorazepam were administered to Resident 2.During an interview on 7/16/26 at 3:33 p.m. with Registered Nurse (RN) 1, RN 1 stated her role was to enter medication orders during readmission. RN 1 stated medications that were not listed in the discharged medications would not be entered in the orders.During an interview on 7/16/26 at 3:42 p.m. with LVN 2, LVN 2 stated not remembering why she entered Norco and lorazepam in Resident 2's orders.During an interview on 7/20/26 at 12:00 p.m. with the Director of Nursing (DON), the DON stated all of Resident 2's medical records were in the Electronic Health Record (EHR).During an interview on 7/20/26 at 1:07 p.m. with RN 2, RN 2 stated the paper physician order sheet were used by doctors for handwritten orders. RN 2 stated handwritten orders in the physician order sheet were entered as prescriber written orders in the EHR.During a concurrent interview and record review on 7/20/26 at 1:29 p.m. with the DON, Resident 2's ACH Discharge Summary, dated 12/18/26 was reviewed. The ACH Discharge Summary indicated Resident 2's discharge medication list included gabapentin. The ACH Discharge Summary indicated Norco and lorazepam were not included in the discharge medication list. The DON stated a triplicate (form used by doctors to prescribe high-risk controlled substances) could be a source of prescriber written order when the physician order for Resident 2's Norco and lorazepam were requested. The DON stated the facility did not have a copy of the Norco and lorazepam triplicates because triplicates were picked up by pharmacy.During a concurrent observation and interview on 7/20/26 at 2:31 p.m. with the DON, the DON was observed looking for the physician order sheet in the uploaded document section of Resident 2's EHR. The DON stated she could not find the physician order sheet for Norco and lorazepam in Resident 2's medical records.During a phone interview on 7/20/26 at 4:27 p.m. with the Pharmacy Technician (PT), the PT stated there was no triplicate prescription on 12/19/23 for Resident 2's Norco and lorazepam.During a follow up interview on 7/20/26 at 4:48 p.m. with the DON, the DON stated the purpose of having the physician order sheet was to validate the order for medication reconciliation. The DON stated resident's medical records should be available upon request.During a review of Food and Drug Administration (FDA, a federal agency of the United States government responsible for protecting and promoting public health ensuring the safety, efficacy, and security of human and veterinary drugs biological products and medical devices) for Neurontin (gabapentin) revised in 2025, the FDA indicated 7 DRUG INTERACTIONS 7.1 Opioids Respiratory depression and sedation, sometimes resulting in death, have been reported following coadministration of gabapentin with opioids (e.g hydrocodone [Norco].) .Especially tell your healthcare provider if you take. any opioid pain medicine such as.hydrocodone.any medicines for anxiety (such as lorazepam) . or any medicines that make you sleepy. You may have a higher chance for dizziness, sleepiness, or breathing problems if these medicines are taken with NEURONTIN (gabapentin).

Based on observation, interview and record review, the facility failed to protect three of three sampled residents (Resident 1, Resident 2, Resident 3) from aggressive and inappropriate sexual behaviors exhibited by Resident 4. Resident 4 inappropriately touched Residents 1, 2, and 3 on their thighs, scrotum and buttocks areas without their consent. Resident 4 threw hot coffee at Resident 2.This failure resulted in feelings of emotional distress, embarrassment, anger and a loss of personal security on Resident 1, 2 and 3.Findings:During a record review of Resident 4's admission Record printed on 2/10/26, the record indicated, Resident 4 was admitted to the facility in 2020. The record indicated she was a [AGE] year-old female with history of mental and behavioral disorders.During a record review of Resident 4's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 2/3/26, the MDS indicated, Resident 4's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was seven (7) out of 15, indicating cognitive (mental) impairment.During a record review of Resident 1's admission Record printed on 2/10/26, the record showed Resident 1 was admitted to the facility in 2019. The record indicated Resident 1 was a [AGE] year-old male with diagnosis of limitations of activities due to disability.During a record review of Resident 1's MDS assessment dated [DATE], the assessment indicated Resident 1 was able to make himself understood and understood others.During an observation and interview on 2/10/26 at 10:00 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1 stated, a few weeks ago while he was in the Activity Room, Resident 4 wheeled herself to Resident 1, licking her lips at him, sticking her tongue out and rubbing his thighs without his consent. Resident 1 stated Resident 4 then grabbed his balls and made sexual comments at him. Resident 1 stated as a man, he was embarrassed to say the comments that Resident 4 made. Resident 1 stated it made him feel embarrassed, angry and unsafe.During an interview on 2/10/26 at 10:30 a.m. with Activity Director (AD 1), AD1 stated he did not witness the specific incident that occurred between Resident 1 and Resident 4. AD 1 stated however, he was aware that over time, the interactions between Resident 1 and Resident 4 became more explicit where Resident 4 would physically touch Resident 1. AD 1 stated he did not recall the dates for such incidents; however, he recalled that he had to keep both residents separated in the activity room. AD 1 also stated that when Resident 4's needs were not met immediately, Resident 4 would start yelling and getting aggressive. AD 1 stated on one occasion, Resident 4 threw coffee at Activity Assistant 1 (AA 1) and Resident 2 in the activity room. AD 1 stated he has reported Resident 4's inappropriate and aggressive behavior to facility management but he was told to continue to just separate her from other residents, when those behaviors are observed.During an observation and interview on 2/10/26 at 11:40 a.m. Resident 4 was up in her wheelchair and scooting herself to the activity room. Resident 4 refused to participate in the investigation.During a record review of Resident 2's MDS assessment dated [DATE], the MDS indicated Resident 2 was usually able to understand others and able to make himself understood.During an observation and interview on 2/10/26 at 11:05 a.m., with Resident 2 in his room, Resident 2 was sitting in a wheelchair. Resident 2 stated Resident 4 was always causing problems with staff and other residents in the facility. Resident 2 stated Resident 4 tried to touch and grab his genitals. Resident 2 stated Resident 4 was a violent person when she did not get what she wanted. Resident 2 stated on one occasion, he witnessed that Resident 4 got so angry, that she hit AA 1, pulled her hair, threw hot coffee at AA 1 and him (at Resident 2). Resident 2 stated it made him upset and angry.During a record review of Resident 3's MDS assessment dated [DATE], the MDS indicated Resident 3's BIMS score was 14 out of 15, indicating Resident 3 was cognitively intact/coherent.During an interview on 2/10/26 at 11:20 a.m. Resident 3 stated he recalled an incident when Resident 4 grabbed his butt while his back was towards her. Resident 3 stated he got startled. Resident 3 stated he has seen Resident 4 getting very angry, yelling at others in the hallways of the facility or in the activities area. Resident 3 stated he felt uncomfortable when Resident 4 was near him.During a phone interview on 2/12/26 at 2:15 p.m. Registered Nurse (RN 1), RN 1 stated Resident 4 was known for having a hot temper. RN 1 stated she recalled an incident where Resident 4 was wheeling herself in the hallway, telling other resident to move out of her way. RN 1 stated when another resident did not move right away, Resident 4 got up from wheelchair and started screaming at them. RN 1 stated Resident 4 yelled I will beat the cowboy shit out of you and call my brothers to beat your ass. RN 1 stated she did not recall which resident got yelled at that time.During an interview on 2/10/26 12:01 p.m. with Director of Nursing (DON), the DON stated he was aware that Resident 4 exhibited hyper-sexualized behaviors towards male staff and residents. The DON stated on an occasion, Resident 4 grabbed him 'on the butt' and made explicit sexual comments. The DON stated Resident 4 could get very aggressive with the residents, often tried to touch them inappropriately and get mad easily if they try to stop her. The DON stated he had witnessed Resident 4 touching residents inappropriately but was unable to name the residents.During a review of facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, the P&P indicated, .Verbal abuse is defined as any use of oral , written , gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability . Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.Prevention. The facility identifies, corrects, intervenes, in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.Immediate Actions. The administrator or designated representative will provide for a safe environment for the resident as indicated by the situation.

Based on interview and record review the facility failed to conduct a thorough investigation for an allegation of abuse involving two of four sampled residents (Resident 1, and Resident 4). Resident 1, a male resident alleged Resident 4 (female) touched him inappropriately and made sexual comments at him.This failure placed Resident 1 and other vulnerable residents at the facility to experience Resident 4's inappropriate sexual behaviors.Cross Reference F600.Findings:During a record review of Resident 1's admission Record printed on 2/10/26, the record showed Resident 1 was admitted to the facility in 2019. The record indicated Resident 1 was a [AGE] year-old male with diagnosis of limitations of activities due to disability.During a record review of Resident 1's MDS assessment dated [DATE], the assessment indicated Resident 1 was able to make himself understood and understood others.During an observation and interview on 2/10/26 at 10:00 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1 stated, a few weeks ago while he was in the Activity Room, Resident 4 wheeled herself to Resident 1, licking her lips at him, sticking her tongue out and rubbing his thighs without his consent. Resident 1 stated Resident 4 then grabbed his balls and made sexual comments at him. Resident 1 stated as a man, he was embarrassed to say the comments that Resident 4 made. Resident 1 stated it made him feel embarrassed, angry and unsafe.During a concurrent interview and record review on 2/10/26 at 1:35 p.m. with Social Worker (SW) 1, Resident 1's progress notes dated 11/14/25 were reviewed. The progress notes indicated, .yesterday morning .a female resident [Resident 4] inappropriately [touched] him on his private area in the activity room . SW 1 stated the facility was unaware of Resident 1's complaint against Resident 4, until they were notified by the Ombudsman (an advocate for long term care residents) on 11/14/25.During a record review of Resident 4's admission Record printed on 2/10/26, the record indicated Resident 4 was admitted to the facility in 2020. The record indicated she was a [AGE] year-old female with history of mental and behavioral disorders.During a record review of Resident 4's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 2/3/26 indicated Resident 4's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was seven (7) out of 15, indicating cognitive (mental) impairment.During an observation and interview on 2/10/26 at 11:40 a.m. Resident 4 was up in her wheelchair and scooting herself to the activity room. Resident 4 refused to participate in the investigation.During an observation and interview on 2/10/26 at 11:05 a.m., with Resident 2 in his room, Resident 2 was sitting in a wheelchair. Resident 2 stated Resident 4 had tried to touch and grab his genitals and it made him upset and angry.During an interview on 2/10/26 at 11:20 a.m. Resident 3 stated he recalled an incident when Resident 4 grabbed his butt while his back was towards her. Resident 3 stated he got startled. Resident 3 stated he has seen Resident 4 getting very angry, yelling at others in the hallways of the facility or in the activities area. Resident 3 stated he felt uncomfortable when Resident 4 was near him.During an interview on 2/10/26 12:01 p.m. with Director of Nursing (DON), the DON stated he was aware that Resident 4 exhibited hyper-sexualized behaviors towards male staff and residents. The DON stated on an occasion, Resident 4 grabbed him 'on the butt' and made explicit sexual comments. The DON stated he had witnessed Resident 4 touching residents inappropriately but was unable to name the residents.During a concurrent interview and record review on 2/10/26 at 2:01 p.m. with Administrator (ADM) and Director of Nursing (DON), facility's investigation summary dated 11/21/25 was reviewed. The report indicated it was five (5)- day report for incident between Resident 1 and Resident 4 on 11/14/25. The report indicated, [Resident 1] reported to Ombudsman that [Resident 4] has been touching him inappropriately .in activities room. [Resident 1] and [Resident 4] kept apart, report given to the nursing team and activities team to ensure both residents are supervised and kept apart . [Activity Director-AD 1] interviewed by ADM, AD 1 states, I never seen that happen before. The investigation summary further indicated, allegations could not be proven factual. The ADM stated he was not the one who conducted above investigation, that is not how he would have conducted the investigation. The ADM stated he would have interviewed at least few more residents. ADM stated however, by the time he realized that facility did not complete a thorough investigation, it was too late and it was not re-done.During a record review of facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated J 6/12/2024 , the P&P indicated, .The facility identifies, corrects, and intervenes in which an abuse. is more likely to occur. Allegations of abuse.are to be reported to the Administrator or designated representative immediately.When the Administrator or designated representative receives a report of an allegation of resident abuse.the Administrator or designated representative, will initiate an investigation immediately.The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation .Witnesses includes but are not limited to the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc .

Based on interview and record review, for four of four sampled residents (Resident 7, 90, 80, and 63) who were investigated for accidents, the facility failed to ensure adequate supervision and assistive device when: 1.Resident 7 fell out of bed when Certified Nursing Assistant (CNA) 3 looked away while changing Resident 7's brief. Resident 7 sustained multiple injuries that included, a hematoma (when blood collects outside a blood vessel) on the right cheek and around the right eye, intraparenchymal hemorrhage (bleeding that occurs within the brain tissue), and fractures of the left 10th and 11th ribs (when one of the bones in the rib cage cracks, usually as a result of a fall or an accident). Resident 7 was transferred to the hospital for further treatment. 2. Resident 90 fell out of bed while CNA 4 assisted with toileting hygiene. Resident 90 was taken to the hospital via 911 with injuries that included frontal scalp hematoma, displaced fracture (when broken bone fragments move out of alignment, resulting in a gap or misalignment between the bone ends) through the left anterior arch of C1 (front side of the topmost bone in the neck spine), and non-displaced bilateral posterior arch C1 (curved bony arch on the back of the neck spine) fracture (also called [NAME] fracture, a burst fracture of the first bone in the cervical spine, usually results from falls from heights onto the top of the head). 3. Resident 80 fell out of bed while CNA 4 provided personal hygiene. This failure had the potential to result in major injuries that included fractures, head trauma or death. 4. Resident 63 left the facility unaccompanied and unsupervised and was found missing for several hours. This failure placed Resident 63's safety at risk and could potentially result in harm. Findings: 1. During a review of Resident 7's admission Record (AR) dated 9/30/25, the AR indicated Resident 7 was admitted to the facility in April 2015 with multiple diagnoses that included contracture (type of scarring in your soft tissues that causes them to tighten and stiffen) of the right upper arm, muscle spasm, and cerebral infarction (when the blood flow to the brain is disrupted leading to brain tissue death, main reason for disability among people). During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/27/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive (the mental processes involved in gaining knowledge and comprehension) status regarding attention, orientation, and ability to register and recall information) score of zero. A BIMS score of zero is an indication of severe cognitive impact. The MDS also indicated Resident 7 required substantial/maximal assistance when rolling left and right in bed (helper does more than half the effort, helper lifts and holds trunk or limbs and provides more than half the effort). During a review of Resident 7's Fall Risk Evaluation dated 3/27/25, the Fall Risk Evaluation indicated Resident 7's score as six (a score of 10 or higher indicates a resident is a HIGH risk for falls). During a review of Resident 7's fall care plan last revised 5/21/21, the care plan indicated to anticipate Resident 7's needs, and to provide prompt response to request for assistance. During a review of Resident 7's Situation, Background, Assessment, Recommendation (SBAR, a written communication tool to simplify and effectively share patient status updates among healthcare providers) dated 5/30/25, the SBAR indicated, on 5/30/25 at 6 p.m., Resident 7 was found on the floor and was assisted back to bed. During a review of Resident 7's Post-Fall Evaluation dated 5/30/25, the Post-Fall Evaluation indicated the reason for Resident 7's fall was due to poor positioning and the bed being at an improper height. During a telephone interview on 10/2/25 at 11:22 a.m., with CNA 4, CNA 4 stated, on 5/30/25, Resident 7 had just finished dinner when CNA 4 lowered the bed's head. CNA 4 stated Resident 7 had no bed rails. CNA 4 stated using the bathroom and returning to the hallway when the charge nurse said Resident 7 was on the floor, next to the bed, inside Resident 7's room. During a review of Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Progress Notes dated 6/2/25, the IDT Progress Notes indicated recommendations to prevent future falls that included keeping the bed in the lowest position, and for staff to monitor Resident 7's position and reposition as needed. During a review of Resident 7's Progress Notes dated 6/4/25, the Progress Notes indicated, five days after the fall incident on 5/30/25, CNA 3 was caring for Resident 7 when CNA 3 turned his back to respond to Resident 7's roommate's call. Resident 7 Fell out of .bed to the floor, that resulted in swelling on the right eye and forehead. Resident 7 was taken to the hospital. During a telephone interview on 9/30/25 at 10:29 a.m. with CNA 3, CNA 3 stated, on the evening shift of 6/4/25, after cleaning Resident 7's perineal area (the area between the anus and the scrotum), CNA 3 turned Resident 7 to the right side of their body, facing away from CNA 3, without ensuring Resident 7 was positioned safely in the center of the bed. CNA 3 stated that while changing Resident 7's brief, CNA 3 got distracted by Resident 7's roommate. CNA 3 stated, while Resident 7 was on the right-side lying position, CNA 3 looked away from Resident 7 to face Resident 7's roommate, that was when Resident 7 fell out of bed, landing on the floor headfirst, followed by the right side of their body. CNA 3 stated there were no bed rails attached to the bed. Following the fall incident, CNA 3 stated receiving training on providing distraction-free care and prioritizing the residents being attended to. During a joint interview on 9/30/25 at 3:50 p.m. with Director of Nursing (DON) and Registered Nurse Consultant (RNC), DON stated, during resident care, such as changing briefs or performing perineal care, staff should turn residents towards them, not away. RNC stated there was no policy for this as it is a basic skill learned in school. During an interview on 9/30/25 at 10:17 a.m. with CNA 7, CNA 7 stated, when changing a resident, the resident should be pulled towards the CNA to face them. CNA 7 stated, the resident should be turned while ensuring enough space on the opposite side of the bed to prevent the resident from rolling off. CNA 7 also stated to never divert attention from the residents and the task to ensure safety. CNA 7 also stated Resident 7 was able to stay and hold position when turned on the side and did not have involuntary movements that could cause falling out of bed. During a review of Resident 7's Hospital Trauma History and Physical (THP) dated 6/4/25, the THP indicated Resident 7 arrived at the Emergency Department with a large hematoma around the right eye and swelling resulting in the right eye being swollen shut. Imaging (process of making pictures of the parts of the body not visible to the naked eye such as x-rays or scans) results indicated Resident 7 had mildly displaced (when broken ends of a bone do not align properly) acute fractures of posterior left 10th and 11th ribs and a 9 mm x 7 mm x 11 mm acute intraparenchymal hemorrhage in posterior right frontal lobe (one of the four major lobes of the brain, located in the front portion of the skull). Resident 7 was given Keppra (an anticonvulsant) 750 milligrams (mg) twice daily for seven days. During a review of Resident 7's Progress Notes dated 6/16/25, the Progress Notes indicated Resident 7 returned to the facility after 12-day stay at the hospital. 2. During a review of Resident 90's AR dated 10/1/25, the AR indicated Resident 90 was admitted to the facility in September 2024 with diagnoses that included muscle weakness, limitation of activities due to disability and repeated falls. During a review of Resident 90's SBAR Summary for Providers (SBAR) dated 5/9/25, the SBAR indicated CNA 4 called for help after Resident 90 rolled out of bed while being cleaned. The SBAR indicated Resident 90 was found face down on the floor, having tried to reach something beside the bed. Resident 90 sustained a bump on the forehead and blood pressure was 177/100 millimeter mercury (mmHG) (normal 120/80). During a review of Resident 90's Health Status Note (HSN) dated 5/10/25, the HSN indicated the following blood pressure readings for Resident 90: 01:00- BP 166/101 01:30- BP 188/106 02:00- BP 200/106 02:30- BP 210/106 0:300- BP 210/109 The HSN indicated, Resident 90 received BP medications which were ineffective. Resident 90 became unresponsive and was transported to the hospital via 911. During a telephone interview on 10/2/25 at 11:22 a.m. with CNA 4, CNA 4 stated being a new and unaware that Resident 90 required two-person assistance for daily activities. CNA 4 stated turning Resident 90 on the side to clean Resident 90's back when Resident 90 reached for something and fell out of bed. CNA 4 stated if he had known Resident 90 needed two people for assistance, CNA 4 stated he would have asked for help. During a telephone interview with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 90 required full assistance from two people with turning, repositioning, and toileting. During a concurrent interview and record review on 10/3/25 at 12:09 p.m. with Minimum Data Set Coordinator (MDSC), Resident 90's MDS dated [DATE] was reviewed. MDSC stated Resident 90's MDS indicated total dependence to roll from lying on back to left and right side and vice versa. MDSC stated Resident 90 was coded as totally dependent, which meant Resident 90 required two-person assistance. During a review of Resident 90's Emergency Department Note (EDN) dated 5/10/25 at 4:39 a.m., the EDN indicated Resident 90 arrived at the ED with a cervical collar (neck collar designed to prevent one's head or neck from moving after an injury) in place and a hematoma on top of the head. The EDN also indicated diagnoses that included a large right frontal scalp hematoma and nondisplaced fractures of bilateral posterior C1 arch and a slightly displaced fracture of left anterior C1 arch. During a review of Resident 90's CT (computerized tomography) of cervical spine dated 5/10/25, the CT indicated Resident 90 had a displaced fracture through the left anterior arch of C1 and bilateral posterior C1 arch fractures. During a review of Resident 90's Internal Medicine Discharge Summary (IMDS) dated 5/14/25, the IMDS indicated Resident 90 should wear a cervical collar for three months around the clock. 3. During a review of Resident 80's AR, the AR indicated Resident 80 was admitted to the facility in December 2011 with diagnoses that included dementia (decline in mental ability, including memory, thinking, and problem-solving skills, severe enough to interfere with daily life) weakness, parkinsonism (slow movements and tremors) and glaucoma (buildup of fluid in the eye, which increases the pressure and damages the nerve leading to vision loss). During a review of Resident 80's HSN, dated 9/25/25, the Progress Notes indicated, on 9/25/25 at 9:30 p.m., Resident 80 fell out of bed while CNA 4 changed Resident 80's brief. Resident 80 was found on the floor lying on the left side. During a telephone interview on 10/2/25 at 11:22 a.m. with CNA 4, CNA 4 stated Resident 80 was turned on the left side while CNA 4 cleaned Resident 80's back. CNA 4 stated he cleaned Resident 80 with his left hand while his right hand was on Resident 80's shoulder. CNA 4 stated releasing his hold to grab a brief, causing Resident 80 to fall from the bed and land on the opposite side. During an interview on 10/1/25 at 12:03 p.m. with Director of Staff Development (DSD), DSD stated CNA 4 had experienced missteps while providing care for three residents. DSD stated all three residents (Resident 7, 80 and 90) fell out of bed during CNA 4's care and that CNA 4's employment was terminated as of 10/1/25. 4. During a review of Resident 63's Face Sheet (FS), the FS indicated Resident 63 was admitted on [DATE] with multiple diagnoses that included dementia, chronic kidney disease stage (a condition where the kidneys gradually lose its ability to filter waste products from the blood, leading to buildup of toxins and other substances in the body), cirrhosis of the liver (a liver disease characterized by the irreversible destruction of liver cells and the formation of scar tissue), and alcohol dependence (the state of relying on alcohol for support). During a review of Resident 63's Elopement Evaluation (EE), dated 6/13/25, the EE score indicated the resident is at risk for elopement (unsupervised departure of a patient). During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool) dated 9/18/25, Resident 63 indicated a score of 8 on his Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) indicating moderate cognitive impairment. During an interview on 9/29/25 with the administrator (ADM) on 9/29/25 at 10:35 a.m., ADM stated the elopement of Resident 63 was an unusual occurrence and was a mystery how the resident left the facility. ADM stated Resident 63 had a wanderguard (a discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area). ADM stated he did not know how the resident was able to leave without triggering the alarm, because they checked the wanderguard and it was functioning when he was found in the morning and assisted back to the facility. During a review of the progress note (PN) for Resident 63, dated 9/10/25 02:57 a.m., the PN indicated Certified Nursing Assistant (CNA) 5 made round few minutes to 2 a.m., and did not find Resident 63 and informed the nurse. Staff searched for Resident 63 but the resident was not found, and the police was called. During a review of the PN dated 9/10/25 at 9:32 a.m., the PN indicated Resident 63 was found wandering on the street of facility and three staff walked the resident back to the facility. During a review of the IDT (Interdisciplinary team) note dated 9/10/25, the IDT note indicated Resident 63 was missing at approximately 2 a.m. The IDT note indicated Resident 63 was found at approximately 8:30 a.m During a review of Acute Care note dated 9/12/25, the note indicated Resident eloped last night and was found in the morning of 9/10/25 two blocks from the facility, sweeping floors outside a nearby store. During a concurrent interview and record review on 10/1/25 at 4:15 p.m., with the Director of Staff Development (DSD), DSD stated the elopement for Resident 63 was on 9/10/25 night and Licensed Vocational Nurse (LVN) 8 was the charge nurse that night and came on duty at 11 p.m. DSD stated they were supposed to check on the resident every two hour maximum. DSD stated if everything happened in between, they should be checking. When asked if they had documentation for checking rounds for Resident 63 every two hours, DSD looked at Resident 63's electronic record and stated there was nothing and printed out the bowel incontinence flowsheet, indicated the record for task: B&B – Bowel elimination. There was no documentation of the staff rounding every two hours on Resident 63 and no evidence of it being done. During a telephone interview on 10/1/25 at 5:58 p.m., with LVN 8, LVN 8 stated on the day Resident 63 eloped, she had asked CNA 5 to do rounds, and CNA 5 did not find Resident 63 in his room. LVN 8 stated they searched for Resident 63 and went outside but could not find him. LVN 8 stated she last saw Resident 63 sleeping at 11 p.m. and CNA 5 last saw Resident 63 at 11:30 p.m. LVN 8 stated she asked CNA 5 to take a wandering resident back to their room, around 1:30 a.m. LVN 8 stated she was in the front nursing station standing there and also went to station 2 to sign her assignment sheet. LVN 8 stated while at station 2, she was in the hallway, and she could see the front from there. When asked if she checked the wanderguard for functioning, LVN 8 stated, I can't remember, I can't be remembering because it was three weeks ago. LVN 8 stated normally she rounds on the residents every two hours, and CNA 5 also does his own rounds. LVN 8 was asked if they checked Resident 63 at two hours interval that night after they saw him last at 11:30 p.m. LVN 8 stated CNA 5 had to redirect the patient that was wandering back to his room. When asked if it took CNA 5 half an hour to redirect the wandering resident and if there was an assigned CNA to the resident. LVN 8 stated she did not know whether the CNA for the wandering patient was busy. LVN 8 stated she did not hear any alarm sound that night. When asked further questions about checking Resident 63's wanderguard that night if functioning, LVN 8 stated, I really don't know, I can't say right now. During a telephone interview on 10/2/24 at 5:43 p.m. with CNA 5, CNA 5 stated he saw Resident 63 at 11:30 p.m. on the bed with his cap on. CNA 5 stated he then went to his position in the hallway. CNA 5 stated there was a resident from the back location walking around. CNA 5 stated LVN 8 asked him to take the resident back to his room around 1:30 p.m. – 2 a.m. CNA 5 stated it took him maybe 20 minutes or less than 30 minutes to take that patient to his room. CNA 5 stated he came back around 2 a.m., and it occurred to him to check his residents. CNA 5 stated Resident 63 used to get up and wander around from 2 a.m. to 4 a.m. CNA 5 stated he looked in Resident 63's room and did not find him. He made LVN 8 aware, and they checked the bathroom and patio. He stated the other CNAs also searched for Resident 63. CNA 5 stated he did not know if Resident 63 had a wanderguard, and there was no sound of alarm during the night. He stated staff do not use the side door and the side door is always locked. CNA 5 stated resident 63 had history of elopement but not in the facility and this was his first time. CNA 5 stated the interventions the facility had in place for Resident 63 to prevent elopement were to just to be alert and to check on Resident 63 at least every two hours. CNA 5 stated only CNAs checked the residents, and the charge nurse sometimes reminded them about doing rounds. CNA 5 acknowledged they were supposed to check the resident at least every two hours, and he should have checked Resident 63 at 1:30 a.m. and anything could have happened within the 30 minutes of not checking Resident 63. During a telephone interview on 10/2/25 at 6:55 p.m. CNA 5 (who was assigned to Resident 63 the night he eloped) stated that rounding every two hours was important to ensure the residents are okay, on their beds sleeping, and safe. During the facility's Policy and Procedure (P&P) titled, Policy and Procedure Implementation Form – Person-Centered Care Planning, dated August 2017, the P&P indicated The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives, and timeframes to meet a resident' s medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment. During a review of the care plan initiated on 6/13/25, Resident 63's care plan indicated, Risk for wandering/elopement identified, use of wanderguard with goals: The resident will not leave facility unattended, the resident's safety will be maintained, and the facility will not leave the facility unaccompanied. The care plan indicated the wanderguard on the right wrist. Resident 63's care plan did not include checking on the resident every 2 hours by facility staff. During review of the facility's policy and procedure (P&P) titled, Wandering and Elopement revised 1/31/23, the P&P indicated, The licensed nurse, in collaboration with the .(IDT), will assess residents.and upon identification of significant change in condition according to the to determine their risk of elopement.The resident's risk for elopement and preventative interventions will be documented.and will be reviewed and re-evaluated by the IDT.and upon change in condition.The IDT will develop a plan of care considering the individual risk factors for the resident.

Based interview and record review, for one of five (Resident 2) sampled residents reviewed for unnecessary medication use, the facility failed to act on the Consultant Pharmacist's (CP) recommendations for monthly Medication Regimen Review (MRR, in-depth evaluation of a patient's complete list of medications by a pharmacist to ensure safety and effectiveness) for three consecutive months.This failure had the potential to result in unnecessary medication use.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in December 2023 with diagnoses that included anxiety disorder (repeated episodes of sudden feelings of intense fear or worry) depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and insomnia (difficulty falling or staying asleep). During a concurrent joint interview and record review on 10/2/25 at 1:48 p.m., with Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 7, Resident 2's Order Summary Report (OSR) and Medication Administration Record (MAR) for September 2025 were reviewed. RN 1 stated the OSR indicated lorazepam was ordered every 8 hours as needed. LVN 7 stated Resident 2 received lorazepam daily around 12 noon to 1 p.m. for verbalization of anxiety. During a review of the MAR for September 2025, the MAR indicated lorazepam PRN was administered once daily between 12 noon to 1 p.m. for anxiety manifested by restlessness. The MAR also indicated staff monitored for episodes of intense anger as the behavioral indication for the use of lorazepam PRN. During a review of the OSR, the OSR indicated, lorazepam oral tablet 0.5 milligram (mg) one tablet by mouth every 8 hours as needed for anxiety manifested by restlessness, was ordered 5/14/25. The OSR also indicated an order dated 1/4/25 to monitor for target behavior related to the use of lorazepam manifested by intense anger. During a review of Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 7/1/25, 8/1/25, 9/5/25, the CPMRR indicated, episodes of intense anger (lorazepam PRN behavioral) do not coincide with lorazepam PRN usage. Lorazepam PRN should be given in response to a specific behavior, so behavior charting should coincide with PRN medication usage. The CPMRR dated 8/1/25 also indicated a recommendation to change lorazepam from one tablet by mouth every 8 hours PRN to one tablet by mouth daily at 12 noon for anxiety. None of these recommendations have been implemented. During an interview on 10/2/25 at 1:55 p.m. with Director of Nursing (DON), DON stated CP conducted the MRR, which along with recommendations, was sent to the facility. DON stated the Nursing Department was responsible for communicating recommendations to the physician and ensuring any new orders were transcribed. DON stated there was no clear process for conducting MRR at the facility. During a review of the facility's policy and procedure (P&P) titled Consultant Pharmacist Reports effective June 2021, the P&P indicated, .the consultant pharmacist reviews each resident's medication regimen monthly. Any irregularities or clinically significant risks are reported to the Director of Nursing and/or prescriber. Recommendations are implemented and documented by the staff or prescriber. Physicians must respond to recommendations and explain any disagreements by the next visit.

Based on interview and record review, the facility failed to protect belongings for one sampled resident (Resident 63), when his clothes and personal items were missing and were not accounted for. This failure had compromised the right of Resident 63 to retain personal possessions. Findings:A review of the admission record for Resident 63 indicated, Resident 63 was admitted on [DATE] with diagnoses that included chronic kidney disease (progressive loss of kidney function). Resident 63 was discharged on 9/18/25.During a telephone interview on 10/2/25 at 9:45 a.m., with Resident 63's Responsible Party (RP), RP stated Resident 63 was missing clothes and personal items while he was in the facility and that the facility were not returning his clothes. RP stated she had noted other residents were wearing Resident 63's clothes during Resident 63's stay in the facility and had notified staff. RP stated she was not given Resident 63's inventory of personal items upon the resident's discharge and that no one went over the resident's personal item inventory list with her.During a concurrent interview and record review of the theft and loss log on 10/2/25 at 11:15 a.m., with the Social Services Director (SSD), SSD stated she did not have the old logs because she was new in the facility. SSD stated she only had the logs for August and September 2025. SSD stated the missing personal property for Resident 63 was not in the August and September theft and loss log. Further review of the facility's grievance log for August and September 2025, revealed no report of Resident 63's missing items in the log. During an interview on 10/2/25 at 11:43 a.m., with the SSD, SSD stated Resident 63's RP reported to her that Resident 63 were missing clothes and gave SSD a list. SSD stated she did not put the missing items in the log because the list of items that RP claimed were missing were not in the inventory list.During an interview on 10/2/25 at 1:40 p.m., with CNA 9, CNA 9 confirmed that sometimes residents do have other residents' clothes on, especially when residents were moved to different rooms. CNA 9 stated when residents' clothes were laundered, laundered clothes were returned to the same rooms from where they came from, and residents may have moved to different rooms. CNA 9 stated sometimes residents would put someone else's clothes on, and CNAs made an effort to get them back to the resident. During a review of a copy of Resident 63's inventory titled, Personal Effects Inventory form, signed 8/28/25, the form had a list of clothes and personal items that included: one black easy rider SS Tee shirt, one burgundy, blue grey stripes Tee shirt SS polo, One sleeveless burgundy T-shirt - Game time label, 10 white hangars, one blue, whitegrey- mixed jacket, one fleece Azter blue, greywhite jacket, two baseball caps - blue, grey solid, one grey and white quilt, one white sleeveless undershirt, one green, elastic bottom North pole sweat pants, one grey/black Game time sweats.During an interview with SSD on 10/3/25 at 1 p.m., SSD confirmed the inventory form provided for Resident 63 was for admission. SSD stated she could not find Resident 63's inventory form for discharge. SSD stated she did not know if Resident 63's property was given upon discharge. SSD stated she was not present when Resident 63 was discharged .During an interview on 10/3/25 at around 1:20 p.m., with the Director of Staff Development (DSD), DSD stated she looked and could not find the discharge copy of Resident 63's inventory form. DSD stated she did not know if clothing and/or personal items were given back to Resident 63 and/or the RP.During an interview on 10/3/25 with Director of Nursing (DON), DON stated staff should be getting an inventory sheet, go over the property with the RP and sign it off and upload upon admission and discharge.During the facility's policy and procedure (P&P) titled, Personal Property revised 7/14/17, the P&P indicated, To ensure the facility takes reasonable steps to protect resident's personal property.the facility will return inventoried personal items to residents or their representative upon discharge in a timely manner, and take reasonable steps to safeguard the belongings in the interim.Upon discharge home, the resident/resident representative will review the Resident inventory to ensure all personal items are taken. The resident/ resident representative will sign the inventory indicating that all personal property is released to them.During a review of the facility's P&P titled, Theft and Loss, revised 7/11/17, the P&P indicated, To assist residents in safeguarding their personal property. The facility is committed .maintains documentation of all reports of lost and stolen property.At time of admission and discharge, Facility staff complete a Resident inventory. When personal property is reported missing.A Theft and Loss report is to be initiated.Social Services staff documents reports of lost and stolen resident property.

Based on interview and record review, for one of two sampled residents (Resident 6) who were reviewed for PASRR (Pre-admission Screening and Resident Review, required to determine if the resident needs specialized services for serious mental illness or mental retardation before admission to a Medicaid certified nursing facility) evaluation, the facility failed to coordinate PASRR Level II (a more in-depth evaluation for individuals identified by the Level I screen) determination after a positive PASRR I evaluation.This failure had the potential to result in Resident 6 receiving care that is not appropriate for their needs.Findings:During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility in July 2025 with diagnoses that included schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia such as disorganized thinking, false beliefs, hallucinations, and bouts of mania and depression).During an initial observation and interview on 9/29/25 at 11:38 a.m., with Resident 6, Resident 6 stated being the second Son of God and claimed past sexual immorality. The conversation shifted to devils, demons, seeing angels, and wanting to go home. During a concurrent interview and record review on 10/2/25 at 10:59 a.m., with the Director of Staff Development (DSD), Resident 6's PASARR I screening dated 7/24/25 was reviewed. The PASARR I screening indicated positive results for PASARR II evaluation. DSD confirmed there was no PASARR II evaluation in the clinical record.During a review of Resident 6's Medication Administration Record (MAR) for September 2025, the MAR indicated several behaviors that included paranoid delusional thinking (persistent, irrational, and unfounded beliefs that others are trying to harm, deceive, or persecute you, often leading to deep distrust, suspicion, and a hostile attitude) that staff are working with the CIA and claims of being Jesus.During a concurrent interview and record review on 10/2/25 at 12:20 p.m., with the MDS Coordinator (MDSC), MDSC stated the PASARR I screening done at the hospital did not have PASARR II evaluation. The facility did not verify if a PASARR II evaluation was performed before Resident 6's admission. MDSC stated a new PASARR I screening was completed today, 10/2/25, to initiate a PASARR II evaluation.During a review of Resident 6's After-Visit Summary (AFS) dated 7/29/25, the AFS indicated Resident 6 was hospitalized from [DATE] to 7/29/25 for disorganized behavior and emotional lability (sudden, dramatic mood changes).

Based on observation, interview and record review, the facility failed to treat skin rash for one of five sampled residents (Resident 42) when nursing staff was not aware of Resident 42's skin rash. This failure resulted in Resident 42 having an untreated skin rash for unknown of length of time. Findings: During a review of Resident 42's admission Record AR, printed on 10/1/25, the AR indicated that Resident 42 was admitted to the facility on [DATE]. During a review of Resident 42's Minimum Data Set (MDS, resident assessment instrument used to identify resident problems to be addressed in an individualized care plan) dated 9/26/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 . A BIMS score of 8 to 12 is an indication of moderately impaired cognitive status. During an interview on 9/29/25, at 12:30 p.m., with Resident 42, Resident 42 stated that she had rashes in the groin area which were itchy and burning. During an observation on 10/2/25, at 8:55 a.m., Resident 42 was observed to have bright red rashes on both inner thighs and extended to bilateral buttocks. Resident 42 stated that area itched and burned after urination. Resident 42 stated that she had told multiple Certified Nursing Assistants (CNAs) about the rashes and the CNA's responses were I don't have cream. or I already told the nurse. Resident 42 stated that the rashes had been present for approximately two months. Resident 42 stated the CNAs only changed her diapers but did not apply any (barrier) cream (a topical product applied to the skin to protect it from irritation or moisture). During an interview on 10/2/25, at 8:55 a.m., with CNA 1 in Resident 42's room, CNA 1 stated that she had applied A and D ointment (a topical skin protectant that contains vitamins A and D) on Resident 42, and stated she should have informed the nurse about the rashes. During a concurrent interview and observation on 10/2/25, at 9:13 a.m., with the Nurse Practitioner (NP) and Licensed Vocational Nurse (LVN) 5, NP evaluated Resident 42's skin rash and prescribed topical medication for Resident 42. NP stated incontinent skin care was a basic nursing measurement when asked if the facility should have a routine incontinent skin care program. NP further stated Resident 42 was prone to have urinary traction infections and that could lead to the skin rash. During an interview on 10/2/25, at 9:31 a.m., with LVN 5, LVN 5 stated she was not aware of Resident 42's skin rash. LVN 5 stated it should be identified and treated. During an interview on 10/3/25, at 9:03 a.m., with CAN 2, CNA 2 stated that she had reported Resident 42's skin rash to a nurse on 9/30/25, prior to her two days off, and was instructed to apply barrier cream to the affected area. CNA 2 stated she was not sure which nurse she had reported the information to and was unsure what cream she had applied to Resident 42's bilateral inner thigh and buttocks. During an interview on 10/3/25, at 9:30 a.m., with Director of Staff Development (DSD), DSD stated that CNA should report skin issues to the charge nurse so the nurse could assess resident and request appropriate treatment. DSD stated that she was not sure whether the facility had other process to identify resident's skin issues. During an interview on 10/3/25, at 9:51 a.m., with LNV 4, the designated treatment nurse, LVN 4 stated that they were not aware of Resident 42's skin rash until 10/2/25. During a record review on 10/3/25, at 11:30 a.m., Resident 42's September 2025 (weekly) N Adv-Skin Check records were reviewed and indicated that skin check was not performed on 9/19/25. During a review of facility's Policy and Procedure (P&P) titled, Skin Integrity Management, revision date 6/27/24, the P&P indicated, As Licensed Nurse will complete the skin evaluation weekly.

Based on observation, interview and record review, facility failed to provide the prescribed Bi-level positive airway pressure (BiPAP is a non-invasive ventilation machine that automatically adjusts the air pressure according to patient's requirement at a particular time) therapy as ordered for one of five sampled residents (Resident 8). This failure placed Resident 8 at risk for poor sleep quality, respiratory compromise and worsening chronic conditions. Findings:During a review of Resident 8's admission Record (AR), printed on 10/2/25, the AR indicated, Resident 8 was admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure (lungs are not working well to get enough oxygen into blood or to remove enough carbon dioxide from the body) with hypoxia (low oxygen in the blood), Chronic Obstructive Pulmonary Disease (COPD, a long-term lung condition that makes it hard to breath because the airway become narrowed or blocked), and obstructive sleep apnea (OSA, breathing stops for short periods while sleeping because the airway gets blocked). During a review of Resident 8's Minimum Data Set (MDS, an assessment tool used to direct patient care), dated 8/21/25, the MDS indicated, Resident 8 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information score of 14. A BIMS score of 13 to 15 is an indication of intact cognitive status. During a concurrent interview and observation on 9/29/25, at 11:47a.m., Resident 8 was observed lying in bed with head of bed elevated. Resident 8 stated that the oxygen tank and BiPAP machine with mask had been missing since they moved to this room at the end of July of 2025. Resident 8 stated needing oxygen and BiPAP at times because of shortness of breath. No oxygen tank or BiPAP machine was observed in Resident 8's room at the time of the observation. During a concurrent interview and record review of Resident 8's MDS, dated 2/26/25 and 8/21/25, on 10/2/25, at 9:00 a.m., the MDS Coordinator (MDSC) confirmed that Resident 8 used BiPAP and had diagnoses of COPD, Respiratory failure, and OSA. During an interview on 10/2/25, at 9:11a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated they had never seen a BiPAP machine in Resident 8's room. LVN 5 stated that Resident 8 had episode of shortness of breath and anxiety which was related to pain and those episodes were resolved after administering pain medication. During an interview on 10/3/25, at 8:30 a.m., with the Infection Preventionist (IP), IP stated that if a resident had a physician order for BiPAP, they should have one with them. IP stated the resident could stop breathing during sleep without using BiPAP. During a concurrent interview and record review on 10/3/25, at 9:21 a.m., with Registered Nurse (RN) 1, Resident 8's Order Summary Report (OSR) and September Respiratory/Medication/Treatment Administration Record (a document where nurses record all medication, treatment given to a resident) were reviewed. The OSR indicated a physician's order for BiPAP Mask type: Full Face Mask, Frequency: when sleeping at bedtime for COPD and Oxygen at two liter per minute via nasal canula to keep oxygen saturation as needed for COPD. RN 1 stated the BiPAP order was not completed and should include (equipment) settings.During a record review of Resident 8's September 2025 Medication Administration Record (MAR), on 10/3/25, at 9:25 a.m., with RN 1, the MAR indicated, BiPAP treatments were not administered on multiple dates, including 9/5, 9/6, 9/10, 9/11, 9/12, 9/13, 9/17, 9/18, 9/23, 9/29 and 9/30. RN 1 stated that the BiPAP treatment should have been administered according to the physician's order. During an interview on 10/3/25, at 9:40 a.m., with Director of Staff Development (DSD) and Administrator (ADM), DSD stated that she saw the BiPAP machine when Resident 8 was admitted to the facility. DSD went to Resident 8's previous room to locate the BiPAP machine but was unable to find it. ADM stated that the BiPAP may have been returned to the rental company. During a concurrent phone interview and record review on 10/3/25, at 11:05 a.m., with LVN 2, Resident 8's September 2025 MAR was reviewed. LVN 2 stated that there was no BiPAP machine in Resident 8's room and she had mistakenly signed the BiPAP treatments on the MAR for 9/1, 9/2, 9/3, 9/4, 9/7, 9/8, 9/9, 9/14,9/15, 9/16, 9/19, 9/21, 9/22, 9/25, 9/26, 9/27 and 9/28. During a record review of Resident 8's History & Physical (H&P), dated 2/21/25, the H&P indicated, Resident (8) was found to have OSA which caused them to have the AV block.During a review of Resident 8's active care plan, the care plan indicated, interventions for BiPAP via Full Mask.when sleeping; Encourage Resident's use of BiPAP; Educate Resident on the importance of BiPAP therapy.During a review of facility's Policy and Procedure (P&P) titled, Physician Order, revision date 11/16/22, the P&P indicated .orders will include a clear and complete description to provide clarity on the physician's plan of care.

Based on interview and record review, the facility failed to schedule a registered nurse (RN) for eight consecutive hours a day, seven days a week for three days in January 2025.This failure had the potential to put residents at risk and not receive sufficient care.During a concurrent interview and record review on 10/3/25 at 9:20 a.m., with the Payroll Account Payable Coordinator (PAPC), PBJ (Payroll - Based Journal) Staffing Data Report [NAME] Report 171705D FY (Fiscal Year) Quarter 2 2025 (a method of staffing data from nursing facilities) January 1- March 31, dated 9/22/25 was reviewed. PAPC stated she was not aware that there were days in January with no RN on duty for 8 hours a dayDuring a concurrent interview and record review on 10/3/25 at around 12:18 p.m., with the PAPC, the Payroll document titled, DHPPH (Direct Care Service Hours Per patient Day - form to accurately capture the direct care service hours provided to patients in skilled nursing facilities) Worksheet - Totals was reviewed. PAPC confirmed that there were three days in January 2025 namely 1/19/25, 1/25/25, 1/30/25, wherein the facility did not have an RN on duty for 8 hours a day.During an interview on 10/3/25 at 12:26 p.m., with the Staff Scheduler (SS), SS acknowledged they were short-staffed in January 2025. SS stated it was important to have an RN on duty 8 hours a day so that RNs can assess the patients, give IVs (intravenous such as IV antibiotics) and manage the care of the patients with IVs.During an interview on 10/3/25 at 12:48 p.m., with the SS, SS stated there were three days with no RN on duty on 1/19/25,1/25/25, and 1/30/25.

Based on observation, interview, and record review, the facility failed to ensure medications were available and provided to residents when: 1. Resident 78 did not receive Xarelto (a blood thinner) medication as ordered by the physician. 2. Two medication E-kits (Emergency kits) were opened and not replaced within 72 hours. These failures had the potential to put patients at risk for harm due to missed doses of medications including delayed treatment during emergency situations when medications are not available for use. Findings:1.During a medication pass observation on 9/30/25 at 8:04 a.m., Licensed Vocational Nurse (LVN) 9 prepared five oral medications for Resident 78. LVN 9 stated Xarelto medication was supposed to be given at this time but was not available. LVN 9 stated it was requested from pharmacy. During record review of Resident 78's admission Record (AR), undated, the AR indicated Resident 78 was admitted in October 2025, with diagnoses that included pain in the lower leg, and current use of anticoagulants (blood thinners). During a review of Resident 78's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/14/25, the MDS indicated a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 14 indicating no cognitive impairment. During a follow up interview on 9/30/25 at 5 p.m., with LVN 9, LVN 9 confirmed that Resident 78 did not get her Xarelto because it was not yet delivered by pharmacy. During a record review of physician order (PO), dated as of 10/1/25, the PO indicated, Xarelto oral tablet 10 mg (Rivaroxaban) Give 1 tablet by mouth one time a day for DVT (Deep Vein Thrombosis- a blood clot in a deep vein, usually in the legs) prevention. During a record review on 10/1/25 of the Medication Administration Record (MAR), the MAR dated September 2025 indicated a code, 9 entered for 9/30/25 indicating the medication was not given due to the reason on the chart code with 9 indicating, Other/See progress notes. During a record review of the Orders - Administration Note dated 9/30/25, the note indicated Xarelto oral tablet 10 mg one time a day for DVT prevention, med on progress, pharmacy will deliver today, and will be given today, MD is aware. During an interview on 10/2/25 at 12:21 p.m. with Resident 78, Resident 78 stated she did not receive Xarelto medication on Tuesday 9/30/25 because pharmacy did not deliver it. During a telephone interview on 10/2/25 at 2:56 p.m., with the Consultant Pharmacist (CP), CP stated if it is a medication refill, the facility can request a refill. CP stated that if a medication is requested, the facility should request five days before the medication runs out. CP acknowledged that it was not okay for Resident 78 to miss a dose. CP stated he did not have access to the dispensing information in order to know when it was requested. During a review of the facility's Policy and Procedure (P&P), titled Organizational Aspects - Provider Pharmacy Requirements dated April 2008, the P&P indicated, .The provider pharmacy agrees to perform the following pharmaceuticals services, including but not limited to: Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week.Providing, maintaining, and replenishing emergency medication supply.in a timely manner. 2.During a concurrent observation and interview on 9/30/25 at 1:50 p.m., in the medication room, with Licensed Vocational Nurse (LVN) 7, two E-kits were opened, with a yellow log form on top of the contents inside each E-kit, indicating documentation of the medications removed. LVN 7 stated the first E-kit, (medium size), labeled Oral Emergency Kit that contained 38 medications had been opened and sealed with yellow plastic ties and was last used on 9/10/25. LVN 7 stated the second E-kit (small), labeled Narcotic Emergency Ekit that contained 10 medications was also opened, had the yellow ties, and last used on 9/17/25. LVN 7 explained that the process on E-kit use and provided the originals of the pharmacy logs for each opened E-kit. The Oral E-kit pharmacy log indicated the E-kit was opened on 9/10/25 at 6:50 p.m. and 2 tablets of cephalexin antibiotics were taken out. The Narcotic E-kit pharmacy log indicated the E-kit was opened on 9/17/25 at 8 p.m. and 1 tablet of oxycodone for pain was taken out. LVN 7 was unable to show evidence that the staff requested a replacement for the opened E-kits. During a telephone interview on 10/2/25 at 3:15 p.m. with the CP, CP stated the facility was supposed to request a replacement for opened E-kits within 72 hours by phone or fax. During an interview on 10/3/25 at 8:35 a.m., with Director of Nursing (DON), DON stated they needed a code, needed to fill out the form, and fax the form to pharmacy to renew the E-kits. DON acknowledged opened E-kit requests were not being faxed to the pharmacy. DON stated it was important to replace E-kits to decrease drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purpose). During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, revised January 2025, the P&P indicated, .When an emergency or stat dose of a medication is needed, the nurse unlocks the container.After removing.complete the emergency e-kit slip and re-seal the emergency supply.As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply by faxing a request utilizing the prescription refill sticker.the used sealed kits are replaced with the new sealed kits within 72 hours of opening.

Based on observation, interview, and record review, the facility failed to ensure the safe storage and labeling of medications when:1. Three medications - Adult Gummies C, Extra strength D 3, and Magnesium Extra strength were observed at Resident 71's bedside.2. One over the counter (OTC) eye drop in the medication (med) cart 1 was not labeled with name.These failures had the potential for medication errors and unsafe use of medications and biologicals.Findings:1.During a concurrent observation and interview during an initial tour on 9/29/25 at 10:45 a.m., in Resident 71's room, there were three medication bottles containing vitamin supplements - Kirkland Adult Gummies C 250 mg, Kirkland extra strength D3 50 mcg, and Nature made magnesium extra strength 400mg inside a basin that contained other stuff on top of Resident 71's bedside table. Resident 71 stated they were his vitamins but did not elaborate.During an observation on 10/1/25 at 12:24 p.m. in Resident 71's room, the three medication bottles containing vitamin supplements - Kirkland Adult Gummies C 250 mg, Kirkland extra strength D3 50 mcg and Nature made magnesium extra strength 400 mg were still inside the basin on Resident 71's bedside table. Resident 71 was agitated at this time and declined to talk about it.During a concurrent observation and interview on 10/1/25 at 12:26 p.m. with Licensed Vocational Nurse (LVN) 6, the supplements were observed at Resident 71's bedside, LVN 6 stated she had just seen the medications by Resident 71's bedside and was not aware Resident 71 had those medications there. LVN 6 stated Resident 71 did not have an order for medication self-administration and no resident in the facility was on medication self-administration. LVN 6, then removed the medications and put them in a plastic bag.During an interview on 10/2/25 at 1:12 p.m. with the Certified Nursing Assistant (CNA) 6, CNA 6 stated she was Resident 71's regular CNA. CNA 6 stated the medication supplements on Resident 71's bedside table had been there for a while now, for 2- 3 months. CNA 6 stated she did not know who it belonged to and did not ask Resident 71 because he would start cursing.During an interview on 10/3/25 at 8:40 a.m. with the Director of Nursing (DON), DON stated that at no time should medications be left at the resident's bedside because of safety. DON stated somebody could come and take the medications and it was not a safe practice.During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the facility, dated April 2008, the P&P indicated, .medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized.2. During an observation on 9/29/25 at around 4:25 p.m., of medication cart 1, there was an over the counter (OTC) artificial tears (used for eye dryness) with an opened date but no identifying label on the carton and the bottle. LVN 3 stated it had an opened date and was being used. LVN 3 stated he did not know who they were using it for. LVN 3 stated they were supposed to be identified with a resident's name.During an interview on 10/3/25 at 9:02 a.m. with DON, DON stated the eye drops should have a label and to be used for one patient. DON stated the eye drops was not supposed to be in the med. cart and discarded if they could not identify who it was for.During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy undated, the P&P indicated, .Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name. Facility personnel may write the resident's name on the container or label as long as the required information is not covered.

Based interview and record review, for one of five sampled residents (Resident 2) reviewed for unnecessary medication use, the facility failed to ensure Resident 2 did not receive unnecessary psychotropic (also referred to as psychoactive medications, including antianxiety medications) medications when:-Lorazepam (antianxiety) was given for PRN (as needed) beyond 14 days.-Monitoring for behavioral manifestation for lorazepam use did not coincide with physician-ordered lorazepam PRN use. This failure had the potential to result in increased risk of adverse drug effects, such as dependence, sedation, confusion, and falls. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in December 2023 with diagnoses that included anxiety disorder (repeated episodes of sudden feelings of intense fear or worry) depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and insomnia (difficulty falling or staying asleep). During a concurrent joint interview and record review on 10/2/25 at 1:48 p.m. with Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 7, Resident 2's Order Summary Report (OSR) and Medication Administration Record (MAR) for September 2025 were reviewed. RN 1 stated the OSR indicated lorazepam was ordered every 8 hours as needed for anxiety manifested by restlessness. LVN 7 stated Resident 2 received lorazepam daily around 12 noon to 1 p.m. for verbalization of anxiety. During a review of the MAR for September 2025, the MAR indicated lorazepam PRN was administered once daily between 12 noon to 1 p.m. for anxiety manifested by restlessness. The MAR also indicated staff monitored for episodes of intense anger as the behavioral indication for the use of lorazepam PRN. The MAR did not indicate behavior monitoring for restlessness. During a review of Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 7/1/25, 8/1/25, 9/5/25, the CPMRR indicated, episodes of intense anger (lorazepam PRN behavior) do not coincide with lorazepam PRN usage. Lorazepam PRN should be given in response to a specific behavior, so behavior charting should coincide with PRN medication usage. The CPMRR dated 8/1/25 also indicated a recommendation to change lorazepam from one tablet by mouth every 8 hours PRN to one tablet by mouth daily at 12 noon for anxiety. None of these recommendations have been implemented. During a review of the facility's policy and procedure (P&P) titled Behavior/Psychoactive Drug Management last revised November 2018, the P&P indicated, any psychoactive medication ordered on a prn basis must be ordered not to exceed 14 days. The physician must document the need to continue the medication, and the order should not exceed the 14-day limit.

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse when two of five sampled residents (Resident 3 and Resident 26) were involved in a physical altercation. This failure resulted in Resident 3 sustaining a skin tear on the left arm. Findings:During a record review of Resident 3's admission Record (AR), printed on 9/19/25, the AR indicated that Resident 3 was admitted to the facility on [DATE]. During a record of Resident 26's AR, printed 9/18/25, the AR indicated that Resident 26 was admitted to the facility on [DATE]. During a record of review of Resident 3's Minimum Data Set (MDS, resident assessment instrument used to identify resident problems to be addressed in an individualized care plan), dated 8/8/25, the MDS indicated, Resident 26 had a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12. A BIMS score of 8 to 12 is an indication of moderate cognitive impairment. During a record review of Resident 26's MDS, dated 8/29/25, the MDS indicated, Resident 26 had a BIMS score of 11. During a concurrent observation and interview on 10/1/25, at 1:04 p.m., Resident 3 was observed to have a healed skin tear on the left arm. Resident 3 stated Resident 26 grabbed him on the left arm and hit him on the left shoulder during an argument over television use. Resident 3 stated that he wanted to watch television (TV), but Resident 26 wanted him to go to the TV room. During an interview on 10/1/25, at 1:32p.m., Resident 26 stated Resident 3 had just moved into the room the previous day. Resident 26 stated that Resident 3 turned on the TV and kept walking in and out of the room. Resident 26 stated he asked Resident 3 to either sit down and watch TV, turn it off, or go to the TV room. Resident 26 stated Resident 3 then came over and hit him on the right arm. Resident 26 stated he hit Resident 3 back, and Resident 3 swung his arm, hit the furniture and started bleeding on the left arm. During a concurrent interview and record review of Resident 3's Change in Condition Evaluation, dated 9/18/25, on 10/3/25 at 10:07 a.m., with the Administrator (ADM), the Change in Condition Evaluation indicated that Resident 3 sustained a skin tear on the left arm during the altercation. ADM stated that staff was expected to monitor Resident 3 closely to prevent resident altercations since Resident 3 had been involved in another incident prior to this altercation.During a record review of Resident 26's Progress Notes (PN), Summary, dated 9/18/25, and Interdisciplinary Team (IDT, a group composed of individuals from different department of the facility) Note, dated 9/19/25, the PN Summary and IDT note indicated that Resident 26 had no injuries. During an interview on 10/3/25, at 2:59 p.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated, on 9/18/25, she was in the hallway and heard loud argument coming from Resident 3 and Resident 26's shared room. Upon entering the room, CNA 8 observed Resident 26 standing at the foot of the bed, and Resident 3 was in the restroom using a paper towel to wipe blood from his left arm. During a review of facility's Policy and Procedure (P&P) titled, Abused Prevention and Management, revision date 5/30/24, the P&P Indicated, The Facility does not condone and form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner when: 1. Fresh lettuce stored inside the reach-in refrigerator was exposed and had no cover 2. A plastic container bin with single packs of graham crackers had no use by date or open dates Failure to store food in accordance with facility policy and/or professional standards had the potential to not meet food service safety standards and prevent food borne illnesses for 76 residents who received food from the kitchen out of a facility census of 76. Findings: 1.During an initial kitchen tour observation and concurrent interview on 6/10/24 at 10:13 a.m., with the Dietary Supervisor (DS), the contents of Refrigerator 1, were inspected. The bottom rack had a clear storage bin with fresh lettuce inside. The lettuce was exposed and had no cover. DS stated the lettuce should be covered with a plastic wrap to keep it fresh and to make sure spills do not get in contact the lettuce. During an interview on 6/13/23 at 1:10 p.m., with the Regional Registered Dietitian (RRD), when asked what the expectation was when storing fresh produce in the refrigerator, RRD stated, it [produce] should be covered to prevent anything from spilling into it. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing . Policy - Food items will be stored . in accordance with good sanitary practice . Procedure .IX. Fresh Vegetable Storage Guidelines .E. Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture . 2. During an observation and concurrent interview on 6/10/24 at 10:28 a.m., with the DS, the kitchen dry storage room was inspected. One of the storage shelving racks had a clear storage bin that contained multiple, individually packed graham crackers. The storage bin had no label and did not indicate open and use by dates for the graham crackers. DS stated the person who poured the items in the storage bin did not label and date the graham crackers. During an interview and concurrent record review on 6/13/24 at 12:40 p.m., with the DS, the facility's Dry Goods Storage Guidelines, dated 2023, was reviewed. The Dry Storage Guidelines indicated, This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise . Food Item . [NAME] crackers . Unopened on shelf - 6 months, Opened on Shelf - N/A [not applicable]. DS explained that unopened on shelf referred to original packaging in box [of food item]. DS confirmed the graham crackers found in the dry storage room on 6/10/24 was in a clear storage bin and not in its original packaging in box. DS stated the graham crackers should have an open and use by dates indicated. Review of the facility's policy and procedure (P&P) titled, Food Storage - Operation Manual -Dietary Services, revision dated 7/25/19, the P&P indicated, Purpose - To establish guidelines for storing . Policy - Food items will be stored . All items will be correctly labeled and dated. Procedure .XIII. Dry Storage Guidelines .H. Label and date all storage products .

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 6/13/24 at 9:54 a.m. with Payroll (PAYROLL), payroll data was reviewed from Q3/2023 (April 1 - June 30) until Q4/2023 (July 1 - September 30). Payroll confirmed there were no RN working for the following dates: 1. For the month of April 2023: 4/23/23 2. For the month of May 2023: 5/28/23 3. For the month of June 2023: 6/25/23 4. For the month of July 2023: 7/9/23 5. For the month of August 2023: 8/27/23 6. For the month of September 2023: 9/2/23 During a concurrent interview and record review on 6/13/24 at 10:17 a.m. with Central Supply/Scheduler (CS/S), staffing schedule was reviewed. CS/S confirmed a RN was not scheduled to work on 4/23/23, 5/28/23, 6/25/23, 7/9/23, 8/27/23, 9/2/23. During an interview on 6/12/24 at 3:56 p.m., with the Director of Nursing (DON), DON stated, it was important to have RN coverage eight hours a day. DON further added, resident safety were at risk without RN available.

Based on interview, and record review, the facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for two of 20 sampled residents reviewed for Range Of Motion (ROM) functions (Resident 2 and 69). This failure had the potential for decline in the resident's range of motion and mobility. Findings: 1. During a review of Resident 2's face sheet dated, 6/12/24, showed Resident 2 was admitted to the facility in 10/2020 with multiple diagnoses that included Brain Stem Stroke Syndrome (when a blood supply to the base of the brain is stopped which can potentially affect many functions in the body). During a review of Resident 2's Physical Therapy (PT) Discharge Summary, dated 11/29/20, revealed under Assessment and Summary of Skilled Services: Prognosis to maintain Current Level of Functioning (CLOF) = Excellent with consistent staff support, excellent with participation in Restorative Nursing Program (RNP). Under Discharge Recommendations: Functional Maintenance Program/Restorative Nursing Program (FMP/RNP). During a review of Resident 2's Order Summary, dated 2/28/24, revealed RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination status post (s/p) CVA with L side paresis (left side weakness). RNP to increase transfer to wheelchair (w/c) from bed, bed to w/c with two person assist and sit in w/c for at least 30 minutes. Reassess by PT/OT as necessary. During a review or Resident 2's Order Summary Report, dated 5/7/24, revealed RNA Program: Pt to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis. Passive Range Of Motion (PROM)TO Left Upper Extremity (LUE ) 2 X A WEEK. During a review of Resident 2's care plan, dated, 2/28/24, revealed Resident 2 had ADL (Activities of Daily Living) Self Care Performance Deficit related to hemiplegia (paralysis on one side of the body). According to the care plan, one of the interventions was RNA Program: Patient (Pt) to participate in RNP 2x/week x 90 days to address muscle weakness and lack of coordination s/p CVA with L side paresis . 2. During a review of Resident 69's face sheet date, 6/12/24, showed Resident 69 was admitted to the facility in 5/22/23 with multiple diagnoses that included Hemiplegia and Hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side and weakness. During a review of Resident 69's Order Summary, dated 3/19/24, revealed RNA Program: PROM to bilateral. Upper Extremity (UE) & Lower Extremity (LE) 3x/week to prevent decline in ROM & functional mobility. 3x/week every Mon, Wed, Fri for Prevent decline in ROM and functional mobility until 06/21/24. During a review of Resident 69's PT Discharge Summary, dated 6/25/23, revealed under Discharge Recommendations and Status: Discharge Recommendations RNA services. During a review of Resident 69's care plan, dated, 3/20/24, revealed Resident 69 had limited physical mobility r/t Hemiplegia and Hemiparesis . Furthermore, the care plan indicated one of the interventions was RNA program for PROM to strengthen muscles and increase mobility status. During a concurrent interview and record review on 6/12/24, at 12:45 p.m., with Restorative Nurse Assistant (RNA), RNA could not show evidence Resident 2 and Resident 69 received ROM exercises. During a concurrent interview and record review on 6/12/24, at 2:00 p.m., with the Director of Nursing (DON), DON stated RNP was stopped during the period Resident 2 and 69 was supposed to receive RNA services. DON verified Resident 2 and Resident 69 did not receive ROM exercises as ordered by the physician. During an interview on 6/12/24, at 2:52 p.m., with the Director Of Rehabilitation (DOR), DOR stated, all residents had the potential for decline in functioning an mobility so it was important for residents to receive ROM exercises once done with physical therapy, to maintain range of motion and prevent decline in functioning. During a review of facility's policy and procedure (P&P), titled, Restorative Nursing Program Guidelines, dated 9/2019, showed under Purpose: .This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning . Under Procedure: .I. B. Frequency of the RNA program will be determined b the medical necessity and physician order.E. A Licensed Nurse must supervise the activities in the Restorative Nursing Program .members of the nursing staff are still responsible for overall coordination and supervision of the Restorative Nursing Program. II. A Restorative Nursing Program may include: A. Passive or active range of motion exercises.

Based on observation, interview, and record review, the facility failed to ensure three of 78 sampled residents' (Resident 2, Resident 6, and Resident 8), call lights were within reach and easily accessible. This failure placed the Resident 2, Resident 6 and Resident 8 at risk of not being able to ask for assistance. Findings: Resident 2 was admitted to the facility in late 2020, with diagnoses which included cerebral infarction (disrupted blood flow does to the brain), stenosis (narrowing of the spinal cord) and convulsions (irregular movement of arms and legs). Resident 6 was admitted to the facility in late 2020 with diagnoses which included heart disease, bradycardia (slow heartbeat) and blindness of the right eye (vision loss). Resident 8 was admitted to the facility in mid-2022, with diagnoses which included seizure (irregular body movement), Parkinson (tremors, stiffness, and loss of balance) and repeated falls. During an observation on 4/11/24 at 1:15 p.m. in Resident 2's, Resident 6's and Resident 8's rooms, the call lights were on the floor behind or under the beds. During a concurrent observation and interview on 4/11/24 at 2 p.m. with Medical Records Director (MR), in Resident 2's, Resident 6's and Resident 8's rooms, the MR confirmed the call lights were on the floor behind the beds and out of reach of the Residents and stated, They should be within reach so they can call the staff. During an interview on 4/11/24 at 2:40 p.m. with the Administrator (ADM), the ADM stated, I would expect that everyone should have their call lights. Requested a copy of facility's policy and procedure for answering the call lights. The facility was not able to provide,

Based on interview and record review the facility failed to ensure one out of three residents (Resident 1) had written Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to help them decide if they want to authorize the given procedure or intervention) before they were administered a psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure had the potential to cause Resident 1 to take a psychoactive medication without knowledge of the medication ' s risks, benefits, and alternatives. A review of Resident 1's Admission Record printed 3/21/24, indicated Resident 1 was admitted to the facility in 2022 with a diagnosis of Spastic Hemiplegia (a nerve and muscle condition that results in the muscles on one side of the body being in a constant state of contraction). The record indicated Resident 1 was their own Responsible Party (health care decision maker). During a concurrent interview and record review on 3/21/24 at 3:59 p.m., with Registered Nurse (RN) 1, Resident 1 ' s Doctors Orders, dated November through December 2023 and Informed Consents, were reviewed. RN 1 confirmed Resident 1 had multiple doctor ' s orders for Ativan (a psychoactive medication used to treat anxiety) that started on 11/28/2023. RN 1 stated they could not find Resident 1 ' s written Informed Consent for Ativan. RN 1 stated Resident 1 should have had an informed consent for Ativan. RN 1 stated Informed Consent for Ativan was important so Resident 1 could have known the medication risks, benefits, and alternatives and could have had the right to refuse the medication. During a concurrent interview and record review on 3/26/24 at 1:14 p.m., with Regional Director of Staff Development (RDSD), Residents 1 ' s Informed Consents were reviewed. RDSD stated nurses were supposed to ensure residents had Informed Consent for Ativan signed by the resident or their responsible party and the doctor before starting the medication. RDSD stated Resident 1 did not have written Informed Consent for Ativan. During an interview on 4/17/24, at 2:58 p.m., with Director of Nursing (DON), DON stated their policy for all psychoactive medications was to get informed consent before starting the medication. DON stated the doctor was responsible to get the Informed Consent, explain the medication risks, benefits, alternatives, and the right to refuse, to the resident or responsible party. DON stated the nurse was responsible to verify the Informed Consent was done. DON stated Informed Consent was important because Residents are entitled to know the risks and benefits of a medication before they take it, especially a psychoactive medication. DON stated when Informed Consent was not obtained, residents may not have been aware of the medication risks, benefits and alternatives. During a review on Resident 1 ' s History and Physical, (H&P) dated 12/5/22, the H&P indicated the resident had capacity (the ability to utilize information about an illness and proposed treatment options to make a choice that is fitting with one's own values and preferences). During a review of Resident 1 ' s Order Summary Report, dated 3/21/24, the report indicated Resident 1 had Physician ' s orders for Lorazepam (a generic name for Ativan) and Ativan. The report indicated Resident 1 had a Physician ' s Order for Lorazepam oral tablet 0.5mg (milligrams) . Give 1 tablet by mouth every 6 hours as needed for anxiety, dated 11/28/23. The report indicated Resident 1 had a Physician ' s Order for Ativan oral tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/15/23. The report indicated Resident 1 had a Physician ' s Order for Ativan Oral Tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/19/23. During a review of Resident 1 ' s Medication Administration Record (MAR), dated December 2023, the MAR indicated Resident 1 was given Ativan and Lorazepam nineteen times in December 2023. The MAR indicated Resident 1 received Lorazepam oral tablet 0.5mg .1 tablet, one time each day on 12/1/23, 12/2/23, 12/5/23 through 12/8/23, 12/11/23, 12/13/23, and 12/15/23 and two times each day on 12/12/23 and 12/14/23. The MAR indicated Resident 1 received Ativan oral tablet 0.5mg . 2 tablet, one time each day on 12/16/23, 12/22/23, and 12/25/23, and three times on 12/24/23. During a review of the facility ' s policy and procedure (P&P) titled, Informed Consent, revised December 2020, the P&P indicated, The ordering physician must obtain informed consent before the facility can administer new orders (or increased dosages) for psychoactive medication . The P&P indicated Physician documentation of informed consent should contain the date and who gave informed consent (Resident of surrogate decisionmaker). The P&P indicated Before administering the first dose or first increased dose of psychoactive medications . the licensed nurse will confirm that the physician obtained informed consent and will document the verification in the Resident ' s medical record.

Based on observation, interview and record review, for three (Residents 2, 3, and 4) of four sampled residents, the facility failed to protect the residents from abuse. 1. For Residents 2 and 3, the facility failed to call 911 and adequately monitor Resident 1 after he physically assaulted Resident 2. Resident 1 punched Resident 2 in the face, then went out for a cigarette. A few minutes later, Resident 1 returned to the building, went to his room, and struck his roommate (Resident 3)with the footboard of a bed. This deficient practice resulted in a fractured jaw for Resident 1, and a laceration on the ear for Resident 3. 2. The DSD (Director of Staff Development) and the DON (Director of Nursing) were notified of a pillow case being placed over Resident 4's face, and failed to act upon the report. This failure had the potential that CNA 1 would continue to place a pillow case over Resident 4's face. Resident 4 was not interviewable. Therefore it is unknown what affect the action had on Resident 4. The Administrator was notified at 4:50 p.m., on 8/27/15 that these events constituted an Immediate Jeopardy (IJ) because of the facility's failure to protect the residents from abuse, and to take appropriate action to prevent further abuse. These failures resulted in harm to Residents 2 and 3, and had the potential to place other residents at risk for injury. On 8/27/15 at 9:50 p.m., the IJ was abated after ADM submitted an acceptable plan of correction. The DSD was on duty, 8/27/15, and would inservice all night shift staff on abuse prevention and mandatory reporting protocol. Also prior to working the night shift, 8/28/15, the DSD would ensure each night shift staff person would view the Department of Justice video on abuse prevention. The balance of the staff will be provided an educational tool as they report for duty which includes the facility procedures and standard steps to follow in the case of physical altercations with a proposed completion date of 9/1/15. Findings: 1. Review of the clinical records, on 8/25/15, showed Resident 1 was admitted with multiple [DIAGNOSES REDACTED]. Resident 1's care plans (measurable objectives and timeframes to meet residents' physical, mental, and psychosocial needs), for Resident 1 included 1) Behavior Care plan, dated 7/15/15, for aggressive or threatening behavior. During an initial tour of the facility, on 8/25/15 at 9 am, it was observed that Residents 1 and 3's room was located around the corner from the nurses' station 2, at the end of a hallway and was not visible from the nurses' station. The smoking patio was located directly across the hall from the nurses' station 2. During a telephone interview, on 8/26/15 at 10 am, CN (charge nurse) 1 stated on 8/7/15 between 12:15 a.m. and 12:20 a.m., she was in the medication room at nurse station 2, when CNA (certified nurse assistant) 1 called out and told her that Resident 1 had hit Resident 2. CN1 stated she separated the residents and told Resident 1 to go to the smoking patio. Because Resident 1 asked for a cigarette, CN1 asked CNA1 to give the Resident a cigarette. CN1 stated she called the hospice nurse, because Resident 1 was under hospice, and told her that she would call the police. CN1 stated while she was on the phone, Resident 1 came in from the smoking patio and said he was going to sleep and went to his room alone. CN1 stated, A few minutes later (unable to determine how many minutes) she heard something and called for CNA1 to come with her. CN1 stated they went to Resident 1's room and found Resident 1 standing next to Resident 2's bed. Resident 2 was bleeding. CN1 stated she had CNA1 take Resident 1 back to the patio. CN1 was asked the facility's protocol for a resident to resident altercation and stated, make sure the victim is safe, separate victim and abuser, call 911. CN1 stated, I should have called 911 right away. Review of the facility's policy titled, Abuse Prevention, Intervention, Investigation & Crime Reporting Policy with a revision date of December 2012, indicated: 1. It is the basic responsibility of facility Administrator, or designee and all facility employees. 2. Every resident has the right to be free from verbal, sexual, physical and mental abuse 3. The facility shall identify, analyze, and assess situations to minimize the likelihood of abuse; such as secluded areas of the facility that may make abuse or neglect more likely to occur 4. The facility will monitor the adequacy of assessment care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as physically aggressive or self-injurious behaviors. During a telephone interview, on 8/26/15 at 12:50 p.m., RN (registered nurse) 1 stated she was the charge nurse at nurse station 1, located at the front of the facility, and heard CN1 call and ask for help. RN1 stated when she arrived to the residents' room; Resident 3 stated Resident 1 hit him over the head four times with the footboard of a bed. RN1 stated the footboard was on the floor with two metal hooks sticking out from the board. RN1 stated Resident 3 was bleeding and she had to clean him before she could assess the blood was coming from his left ear. RN1 stated CN1 called the police and an ambulance. RN1 stated she never saw the facility's protocol for abuse and did not know what to do in the case of an assault. On 8/27/15, review of the personnel file of RN1 showed blank unsigned attestations related to viewing the Department of Justice video that provides information about mandatory abuse reporting and a facility attestation of the following: .By signing below I acknowledge receipt of my responsibilities as a covered individual to report any reasonable suspicion of a crime committed against a resident of this facility to local law enforcement and to the state survey agency within required time frames. A New Hire & Orientation Checklist was signed by RN1 on 7/22/15, the date of hire, however RN1 did not check any of the 31 items on the checklist, including the following: I have received and read the facilities 'Abuse Prevention, Intervention, Investigation and Crime Reporting' policy and understand my reporting requirements . Review of the sign in sheets of the abuse prevention training classes did not include the name of RN1. In an interview, on 8/26/15 at 2:55 p.m., CNA1 stated on the 8/7/15, she was sitting at the nurses' station 2 observing Resident 2, who was a fall risk and had been trying to get up on his own. CNA1 stated she could hear Resident 1 yelling for a cigarette. CNA1 stated Resident 1 walked up to Resident 2 and With all of his might, balled up his fist and hit Resident 2. CNA1 stated she called for CN1 to come because Resident 1 had hit Resident 2. CNA1 stated she gave Resident 1 a cigarette and he went to the smoking patio. CNA1 said CN1 stated she was going to call Resident 1's hospice nurse and CNA1 told her to call 911. CNA1 stated after Resident 1 finished the cigarette (which she stated took five minutes), he went to his room. CNA1 stated she heard a hard, bumping noise. CNA1 and CN1 went to Resident 1's room. CNA1 stated Resident 1 had taken the bottom board of the bed and hit Resident 3. CNA1 stated she tried to redirect Resident 1 to the smoking patio and told CN1 to call 911. CNA 1 stated she gave Resident 1 three cigarettes to keep him distracted. CNA1 stated Resident 1 told her, When I finish smoking these cigarettes, I'm going to finish the job. Review of clinical records, on 8/25/15, showed Resident 2 was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. The MDS (Minimum Data Set, or assessment tool) dated 7/24/15 showed Resident 2 had severe cognitive impairment. The document titled, Change of Condition SBAR (Situation, Background, Assessment, Request/Responsible Party Notification/Response) - Mental Status Change, dated 8/8/15 at 1 p.m., showed Resident 2 had increased confusion, disorientation and unable to redirect. Resident 2 was transported to an acute care hospital emergency room for evaluation. Review of the emergency room report showed that Resident 2 was treated for [REDACTED].) Resident 2 was released from the emergency room back to the facility the same day with a follow appointment with the Oral Maxillo-Facial Surgery clinic (specializes in treating many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the mouth and jaws and face region.) Review of the clinical records, on 8/25/15, showed Resident 3 was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. A Nurses Progress Note, dated 8/7/15 at 1 a.m., had the following: Resident (3) stated he was hit by the footboard four times on his left side face while sleeping. Called 911. The report from the acute care hospital emergency department showed that Resident 3 was treated for [REDACTED]. 2. Review of the clinical records, on 8/25/15, showed Resident 4 was admitted to the facility with multiple medical [DIAGNOSES REDACTED].) In an interview, on 8/25/15 at 2:45 p.m., the DON stated on 8/12/15, she conducted an in-service on Resident's Rights. During the in-service, CN asked if it was abuse to put a sheet over a resident's face. The DON stated she told CN yes, it is abuse and CN asked what if the resident spits. The DON stated she suggested CNA1 could wear a mask. CN asked if she could put a mask on the resident, the DON told her absolutely not. During an interview, on 8/26/15 at 12:50 p.m., RN1 stated on 8/7/15 she walked into Resident 4's room and observed CNA1 take a pillow case away from the resident's face. RN1 stated CN told her that she put the pillow case over Resident 4's face because the resident spits. RN1 stated she told CN that was not the appropriate thing to do and reported the incident to the DSD (Director of Staff Development) when she arrived at 7 a.m RN1 stated during a conversation with the DON several days later, she mentioned the incident and was told she should have completed a report of the incident. RN1 stated she was not aware of the process and had been waiting for the DSD to follow up with the next steps. In a telephone interview, on 8/26/15 at 2:55 p.m., CNA1 stated, I know I was in the wrong. It was poor judgement on my part. CNA1 stated, during an in-service conducted by the DON, she told the DON she was involved in an incident in which the CNA1 placed a pillow case over the residents head. CNA1 stated the DON told her that was abuse. On 8/27/15, at 4:55 p.m., during an interview, the DON stated CNA1 worked her normal, night-shift, schedule during the week of 8/21/15 without an update on abuse training. DON stated CNA1 was scheduled for abuse prevention retraining when she reported tonight (8/27/15) for the night shift. The Interim Administrator did not know CNA1 was working without having the retraining and stated that CNA1 should have had the training before coming back to work, That's our practice.

Based on interview and record review, the facility failed to keep one of 3 sampled residents (1) free from physical and mental abuse when a certified nursing assistant (CNA 1) "punched her (Resident 1) in the shoulders and hips". When CNA 1 was told of the accusation by Resident 1, she went to the resident and said "nobody will believe you." This resulted in Resident 1 having pain, being frightened and angry. Resident 1 was angry and wanted to "press charges" against CNA 1 for "beating her up." Findings: On 6/18/12 at 12:20 p.m. a review of the medical record "Admission" sheet revealed that Resident 1 was a [AGE] year old female was was originally admitted to the facility on [DATE] and currently readmitted to the facility on [DATE] after a stay at the acute care hospital. She also had the [DIAGNOSES REDACTED]. A review of the Nurses Progress Note dated 6/17/12 at 6:15 p.m., revealed that Resident 1 stated that CNA 1 beat her up that morning. The notes indicated that Resident 1 remained alert and verbally responsive but became agitated when asked about the incident, saying "I don't want to go with this over and over again, just ask the people who know. I don't want to be bothered anymore..." On 6/18/12, during an interview, Resident 2 (Resident 1's roommate) was asked if she had witnessed anything the day before with Resident 1. Resident 2 stated that she was half awake about 6 to 6:30 a.m. the day before (Sunday, 6/17/12) and she heard a lot of arguing. She heard Resident 1 say "stop you hurting me" and CNA 1 said, "I have to change you." She said that they were "going back and forth, and Resident 1 kept saying "you're hurting me." She stated that the curtain was closed and she could not see anything. Resident 1 stated she had heard arguing in the past between Resident 1 and CNA 1 but she had never heard Resident 1 say "ow - you're hurting me." According to a medical record review on 6/18/12, Resident 2, a [AGE] year old resident who was admitted to the facility on [DATE] for rehabilitation after fracturing her pelvis, also had no problems with her memory and was able to recall information as reflected on her quarterly MDS dated [DATE]. During a telephone interview on 6/20/12 at 8:58 a.m. CNA 1 stated that on the morning of 6/17/18 (Sunday), she didn't remember what time it was, she went in to room [ROOM NUMBER]C and saw Resident 1's left hand/arm hanging out of the bed between the side rails and she tapped her on the shoulder to wake her up and the resident asked her for help. CNA 1 stated that she put her hand/arm back through the side rail and repositioned her. She left the room and later LVN 1, the charge nurse, told her "(Resident 1) said you was rough to her." CNA 1 said she told him, "I don't believe it." LVN 1 told her, "Yes, she did, go ask her." CNA 1 stated that she went to Resident 1's room and said to her, "(LVN 1) said you said I was rough with you." Then she said that Resident 1 started yelling, "get out of here, get out of here." On 6/20/12 at 1 p.m. the Business office manager said she stopped by Resident 1's room on 6/18/12 around 7:45 a.m. and asked Resident 1 how she was doing. Resident 1 responded that she was "terrified" and told the Business Office Manager that she was beat up by CNA 1. During an interview on 6/21/12 at 1:10 p.m. Resident 1 was asked about the incident with CNA 1 and responded "She beat me, punched me on my shoulders and hip in places she knew where bruises wouldn't show." When asked if her hand was between the rail and did CNA 1 repositioned her and put a pillow behind her shoulder? She stated "no." She said, "I don't know why she did that, nothing like that has ever happened to me before." When asked if she told anybody about it, she replied, "LVN 1." When asked if CNA 1 came back in the room after that, Resident 1 was quiet for a few seconds and then stated, "she (CNA 1) said, 'Nobody will believe you.'" When asked how that made her feel, she said she was frightened and in a lot of pain. She thought that LVN 1 and CNA 1 were in "cahoots." She stated she was frightened of CNA 1.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that require employees to promptly report alleged abuse and protect residents from harm or retaliation for one of three sampled residents (1). On 6/17/12, Resident 1 told LVN (licensed vocational nurse) 1 that CNA (certified nurses aide) 1 hit her. LVN 1 told CNA 1 about the allegation and allowed CNA 1 to question Resident 1 about the incident unsurpervised and LVN 1 failed to report the incident timely to the facility administration and the State and other agencies. Failure to report the alleged abuse timely and protect the resident from futher interactions with CNA1 led to the Resident experiencing intimidation by CNA 1 Findings: On 6/18/12 a review of Resident 1's record showed that on 6/17/12 at 6:15 p.m. Resident 1 stated that CNA 1 beat her up that morning. In an interview with LVN 2 on 6/18/12 at 12:35 p.m. she stated that she worked on 6/17/12 and at about 4 or 4:30 p.m. Resident 1 told the Director of Nurses (DON) that somebody on the previous shift was "rough with her." She stated that "the roommate also said she heard screaming or something like that at about 6 to 6:30 a.m." During a telephone interview on 6/20/12 at 8:58 a.m. CNA 1 stated that on the morning of 6/17/18 (Sunday), she didn't remember what time it was, she saw Resident 1's left hand/arm hanging out of the bed between the side rails. She tapped Resident 1 on the shoulder to wake her up and the resident asked her for help. CNA 1 stated that she put her hand/arm back through the side rail and repositioned her. She left the room and later LVN 1, the charge nurse, told her "(Resident 1) said you was rough to her." CNA 1 said "I don't believe it." LVN 1 told her, "Yes, she did go ask her." CNA 1 then stated that she went to Resident 1's room and said to her, "(LVN 1) said you said I was rough with you." Then she said that Resident 1 started yelling, "get out of here, get out of here." Resident 1 was interviewed on 6/21/12 at 1:10 p.m. She was awake and alert. When asked if she remembered reporting an incident that happened to her on "Sunday" morning, she said, "You mean with CNA 1?" She then stated, "She beat me, punched me on my shoulders and hip in places she knew where bruises wouldn't show." When asked if she told anybody about it, she replied, "LVN 1." When asked if CNA 1 came back in the room after that, she was quiet for a few seconds, then stated, "she (CNA 1)said, 'Nobody will believe you.'" When asked how that made her feel, she said she was frightened and in a lot of pain. She thought that LVN 1 and CNA 1 were in "cahoots." She wanted to know what would happen now and that she was worried that she wouldn't be able to go back to the facility, but was frightened of CNA 1. There was no record of LVN 1 reporting the alleged abuse to the facility administration or to the State and no evidence that LVN 1 protected the resident from further interaction with CNA 1. (Cross reference F223)

Based on observation, interview and record review, the facility failed to acknowledge a resident's crying out for pain relief and failed to develop a care plan specific for pain management and comfort measures for one of 15 sampled residents (Resident 3). Resident 3, admitted for comfort care had been observed moaning and complaining of pain during the day and during wound care. These failures resulted in inadequately managed pain and the lack of intended and ordered comfort care. Findings: Clinical record review for Resident 3 indicated a [AGE] year old, readmitted to the facility on [DATE] for comfort care. physician's orders [REDACTED]. (milliliter) sublingual (under the tongue) po (orally) every 6 hours, as needed for pain. [MEDICATION NAME]: ([MEDICATION NAME]: Narcotic [MEDICATION NAME] used for moderate to severe pain relief). Review of Resident 3 clinical record indicated the resident had a Stage II pressure ulcer on the coccyx (tail bone) which measured 0.6 cm(centimeters) in length, 0.7 cm, wide and 0.1 cm. deep and a Stage III pressure ulcer of the left heel which measured 1.4 cm by, 1.7 cm, by 0.1 cm. Both pressure ulcers had been identified on 4/16/12. (Pressure ulcer: Any lesion caused by unrelieved pressure that results in damage to the underlying tissues. Stage II: Partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed without slough (necrotic, avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy); may present as a blister. Stage III: Full thickness loss, subcutaneous fat may be visible, bone or muscle not exposed. National Pressure Ulcer Advisory Panel, 2007) During the initial tour of the facility on 4/30/03 at 8:30 a.m., the surveyor heard Resident 3 screaming and calling for the nurse. The surveyor entered the room and noted Resident 3's call light out of reach, on the back of her bedside table. Resident 3 informed the surveyor that she had been instructed by the nurse to "push the red button" when she needs medication. In an interview with registered nurse (RN)1 on 4/30/12 at 8:30 a.m., she stated Resident 3 has orders for and comfort care may be a candidate for hospice care. RN 1 stated that for comfort care residents, specific care is provided for pain management. On 4/30/12 at 12:45 p.m., the surveyor heard Resident 3 screaming and moaning. The surveyor entered Resident 3's room and again observed the resident's call button out of her reach. Resident 3 told the surveyor, "My tail bone hurts." During an interview with certified nursing assistant (CNA) 1, at 1 p.m., on 4/30/12, stated she got Resident 3 and into a wheelchair at 8:30 a.m., returned her to bed after lunch at 12:30 p.m. In interview with licensed vocational nurse (LVN 2), the medication nurse, 4/30/12 at 2:59 p.m., the surveyor asked LVN 2 how she assessed Resident 3. LVN 2 stated he asked Resident 3 during medication pass between 8:30 a.m. and 9:00 a.m., if the resident needed pain medication. LVN 2 did not assess Resident 3 again unless the resident requested pain medication. On 5/1/12 at 11:30 a.m. , the surveyor observed in the Activity Room Resident 3's sitting in her wheelchair, leaning towards her right side. The surveyor noted Resident 3's right arm hanging over the wheelchair armrest, and very swollen. The surveyor heard Resident 3 moaning, " Lord help me, Please help me.' Resident 3 had said this several times. CNA 2 noted standing directly in front of Resident 3 did not response to the residents anguished pleas. When the surveyor asked CNA 3 why he failed to notify a nurse or respond to Resident 3 moaning, CNA 3 stated that the residents in the room were there waiting for lunch which would be served at 12 noon and he needed to be in the Activity Room when the food arrived. In the meantime, Resident 3 continued to moan for help. At 11:40 a.m., Director of Staff Development (DSD) entered the Activity room and asked Resident 3, " are you ok?" . Resident 3, still moaning responded, " Oh Lord help me". DSD did nothing to assist reposition from her leaning position nor to reposition her dangling arm during her inquiry to the resident. CNA 3 entered the Activity Room while pushing another resident in a wheelchair and the DSD instructed CNA 3 to return Resident 3 her room. CNA 3 wheeled Resident 3 out of the Activity Room and the surveyor observed CNA 3 as he left Resident 3 in the hallway in front of her room. At 11:42 a.m., the surveyor observed Resident 3 in the hallway, in front of her room, still leaning to the right side in her wheelchair with her arm dangling. LVN 2 asked Resident 3 "Are you having pain" to which Resident 3 responded, " Lord help me." LVN 2, turned and left Resident 3 still moaning for help. As the surveyor approached Resident 3, to ask the resident what was bothering her, Resident 3 told the surveyor, " I can't breathe". The surveyor called LVN 2 for help and informed LVN 2 of Resident 3's complaint of difficulty breathing. LVN 2 and the staff returned Resident 3 to bed, assisted by a Hoyer lift (mechanical transfer device) lift). During the Hoyer lift transfer the surveyor noted Resident screaming for help. Neither of the two CNA's assisting with the transfer, stopped to asked Resident 3 the reason for her screaming. LVN 2 failed to assess Resident 3's pain level, but administered pain medication and a respiratory treatment for [REDACTED]. On 5/2/12 at 8:00 a.m., the surveyor interviewed CNA 2 regarding the incident in the Activity Room were CNA 2 observed Resident 3's moaning and asking for help. CNA 2 stated that she heard Resident 3 moaning and asking for help, CNA 2 , but she had been given direction to care for another resident which is why she did respond to Resident 3. When asked why she failed to notify nursing of Resident 3 moaning by using the facility's VoCollect system, CNA 2 stated she forgot to use it. (VoCollect: A mobile communication device with a phone and ear piece; communication is similar to an intercom; all direct care staff wear and carry the device). During an interview on RN 1 on 5/3/12 at 9:05 with RN 1, she a.m., she stated that Resident 3 had been transferred to the acute care hospital on [DATE] for emergency treatment of [REDACTED]. Resident 3 had been readmitted to the facility on [DATE] with physician's orders [REDACTED]. Review on 5/3/12 of Resident 3 clinical record with RN 1, indicated a care dated 3/2812, titled, Comprehensive Care Plan: Pain/Opioid Therapy. The Care Plan identified the following problem: High risk for severe to moderate severe pan experience related to Left heel ulcer, Stage II pressure ulcer. Med Regim containing opioid [MEDICATION NAME]: [MEDICATION NAME] Care plan goal: 1. To prevent eliminate, or alleviate moderate to severe pain symptoms 2. To prevent, eliminate or minimize side effects every day for ninety days. 3. To improve Quality of Life; Maintain comfort with End-of-life or terminal care every day for ninety days. Interventions: 1. Observe for indicators of pain QS (every shift) during routine care interactions. 2. Administer pain meds as indicated/ prescribed 3. Observe effectiveness of pain management Rx (prescribed). Adjunctive pain management. During review of Resident 3's clinical record failed to reflect pain assessment every shift or during routine care interactions. RN 1 stated that the staff usually documents pain assessment in the record titled, Pain Monitoring Flowsheet or in the nurses progress notes. Review of Resident 3's Pain Monitoring Flowsheet for the month of March indicated that on 3/29/12, a pain assessment performed once during the a.m., shift (no specific time entered) and once during the p.m . ( afternoon) shift (no specific time entered . On 3/30/12, a pain assessment had been performed in the afternoon and once on the night shift. There were no documented pain assessment noted for Resident 3 for the entire month of April. RN 1 presented another Care Plan for Resident 3's titled, Actual Pressure Ulcer Care plan dated 3/29/12. The care plan problems identified were: 1. Alterations in skin integrity due to actual pressure ulcer located on the left heel and coccyx area 2. Terminal condition Care plan goals included: 1. Pressure ulcer progress towards healing... Interventions included: Assess for pain and treat per physician orders On 5/2/12 at 11:20 a.m. during observation of pressure ulcer dressing change, the surveyor observed CNA 1 as she turned Resident 3 onto her right side and held in that position. During the turning process, Resident 3 began to moaning then started to and scream. LVN 1 removed the packed dressing from the pressure ulcer wound on Resident 3 coccyx are and stopped only to tell Resident 3 to take a deep breath; then LVN 1 resumed removal of the packing. Resident 3 continued to scream and LVN 1 stopped and requested the DSD, to check the medication record and find out when Resident 3 had her last pain medication. The DSD returned in told LVN stated that [MEDICATION NAME] was given at 11:00 a.m.. LVN 1 then returned to the dressing change while Resident 3 continued to scream out in pain. Neither LVN 1 or the DSD demonstrated concern for Resident 3's crying out in pain during the dressing change.