Every finding on record at Santa Maria Post Acute

Based on observations, interviews, and record review, the facility failed to ensure the dietitian reviewed the substituted lunch menu to be serve on 8/4/26.This failure had the potential to result in the facility serving substitution meals not approved and reviewed by the dietician per faciity protocol. During an observation on 08/04/2026 at 12:50 p.m. in the Kitchen, the lunch menu for Tuesday 8/4/26, indicated, modifications for polenta (an Italian dish made from boiled cornmeal) and fresh green salad which were substituted with mashed potato and carrots. During an interview on 08/04/2026 at 2:48 p.m. with Kitchen Supervisor (KS), KS stated the menu substitution on 8/4/26 was not discussed and approved by the registered dietitian (RD).During an interview on 08/05/2026 at 10 a.m., with RD, the RD stated not approving the lunch meal subtitution on 8/4/26. During a review of facility's Policy and Procedure (P&P), titled Dietary Services, dated 10/1/23, the P&P indicated food served should adhere to the written menu, and when a substitution is requested, the item should be reviewed by the KS and the RD for appropriateness per the diet order.During an interview on 08/05/2026 at 3:15 p.m., with the Administrator (Adm), ADM acknowledged all menu should be reviewed and approved by the RD as stated on the policy.

Based on observation, interview, and record review, the facility failed to implement pharmacy policy and procedures when: A refrigerated medication emergency kit (e-kit) was replaced within 72 hours.The narcotic endorsement count sheet between oncoming and outgoing nurses to indicate the narcotic counts were correct was signed each change of shift.These failures had the potential to result in unavailability of emergency medications when needed, secondary to unreplenish medication e-kit, and unaccounted controlled drugs with potential for drug diversion.a. During an observation on 8/4/26, at 10:47 a.m., in the medication room, the refrigerated e-kit was observed missing a Glargin insulin pen, which was used on 7/8/26 and Ativan which was used on 7/19/26. Review of the request for e-kit replacement was faxed by licensed nurses on 7/8/26 and 7/19/26. The e-kit was never replaced by the pharmacy. Record review of the facility P&P titled Medication Ordering and Receiving From Pharmacy, dated 2023, indicated, L. If exchanging kits, open kits are replaced with sealed kits within (72 hours) of opening. If replacing used medications, the replacement doses are added to the kit within (72 hours) of opening and sealed by a pharmacist. b. During a record review of the narcotic count sheet from 7/4/26 to 7/28/26, the signature line for incoming licensed nurses were missing 9 signatures. On 7/4/26 (oncoming nurse signature), 7/5/26 (outgoing nurse), 7/6/26 (oncoming nurse), 7/12/26 (outgoing nurse), 7/13/26 (outgoing nurse), 7/18/26 (oncoming nurse), 7/22/26 (outgoing nurse), 7/24/26 (outgoing nurse), 7/28/26 (outgoing nurse). During a concurrent record review and interview on 8/4/26, at 11:22 a.m., with the Director of Nursing (DON), the narcotic count sheet of outgoing and incoming licensed nurses with missing 9 signatures was discussed. The DON reviewed the document and acknowlegeds the e-lkit should have been replaced and the licensed nurses should have signed the narcotic count sheet by outgoing and oncoming licensed nurses every end/start of shift. When asked what consequence could result from the deficient practice.

Based on observation, interview, and record review, the facility failed to serve residents lunch at the scheduled mealtime.This failure had the potential to result in disruption of residents preference also in alignment with individual rights.Based on observation, interview, and record review, the facility failed to serve lunch at the scheduled mealtime.This failure had the potential to result in inadequate nutritional intake, hunger, and a negative impact on resident health and well-being due to the delay in receiving meals as scheduled. During an observation on 08/03/2026 at 9:35 a.m., in the kitchen, the lunch mealtime schedule was posted at 12:30 p.m.During an interview on 08/03/2026 at 9:39 a.m., with the Kitchen Supervisor (KS), KS stated that their lunchtime tray line (an assembly line used in nursing homes in preparing individual meal trays) begins at 12:30 p.m.During a kitchen observation on 08/04/2026 at 12:20 p.m., staff started the tray line at 12:30 p.m. and the trays reached the dining area at 12:45 p.m., 15 minutes late from the scheduled meal time.During an interview on 08/04/2026 at 1:30 p.m. with Resident 36, in the dining room, Resident 36 stated she had lunch around 1:00 p.m. and it was late already.During an interview on 08/04/2026 at 3:00 p.m., with Resident 10, Resident 10 stated lunch is always served between 12:45 to 1:15 p.m. which she considers late from her prefered lunch time. Resident 10 did not elaborate on her prefered lunch time. During an interview on 08/04/2026 at 10:15 a.m., with Registered Dietician (RD), the RD confirmed that tray line assembly time (which starts at 12:30 pm) is different from the mealtime schedule (12:30 pm -already served to the residents). The RD acknowledged the tray line assembly at 12:30 p.m. will lead to residents getting their lunch late. During a review of facility's Policy and Procedures (P&P), titled Meal Service, dated 2023, the P&P indicated Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner , and meal times at 7:30 am, Lunch at 12:30 pm, Dinner at 5:30 pm.During an interview on 08/05/2026 at 3:15 p.m., with the Administrator (Adm), the Adm acknowledged that meals should be served in accordance with residents preferences and the facility's established meal scheduled.

Based on record review and interview, the facility failed to ensure non-pharmacological interventions (evidence-based, non-chemical methods used to prevent, treat, or manage health conditions, symptoms, behaviors, and pain) were included in the care for two of six sampled residents (Residents 3 and 7) taking psychotropic medications (chemical substances that change how the brain works to affect mood, thought, feelings, or behavior).This oversight could potentially increase Residents 3 and 7's reliance on these medications and heighten their risk for serious side effects.Findings:During a review of Resident 3's admission Record (AR), dated 8/5/26, the AR indicated that Resident 3 is an [AGE] year-old female who was initially admitted to the facility on [DATE] with admitting diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make breathing hard), schizoaffective disorder, bipolar type (a chronic mental health condition combining symptoms of schizophrenia [such as hearing voices, seeing things that are not there, or holding fixed false beliefs] with mood episodes of mania (high energy) and often major depression (low energy, feeling of sadness/worthlessness/hopelessness) and adjustment disorder with mixed anxiety (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior) and depression.During a review of Resident 3's Medication Review Report (MRR), dated 8/10/26, the MRR indicated the medication orders: Alprazolam (a prescription medication used to treat anxiety and panic disorders) Oral Tablet 0.5 mg (milligram) give one (1) tablet by mouth at bedtime for anxiety manifested by uncontrolled worry causing restlessness (ordered: 3/20/26), Duloxetine Hydrocholoride (HCl) (a prescription medication used to treat depression and anxiety). 60 mg. give 1 capsule by mouth two (2) times a day for chronic pain (ordered: 4/1/26), and Trazodone HCl (a prescription medication used to treat major depression) 50 mg give 1 tablet by mouth at bedtime for depression as manifested by sleep disturbances. (ordered: 5/26/26). There were no separate orders for non-pharmacological interventions specific to these medications found in Resident 3's MMR.During a review of Resident 3's Medication Administration Records (MARs), for July and August 2026, the MARs failed to indicate separate orders for non-pharmacological interventions specific to Resident 3's use of Alprazolam., Duloxetine., and Trazodone.During a review of Resident 7's AR, dated 8/5/26, the AR indicated that Resident 7 a [AGE] year-old female who was initially admitted to the facility on [DATE], with admitting diagnoses including unspecified psychosis (a mental state where a person loses touch with reality), depression, adjustment disorder with mixed anxiety and depression, and dementia (a decline in mental ability severe enough to interfere with daily life).During a review of Resident 7's MRR, dated 8/10/26, the MRR indicated the medication orders: Mirtazapine (a prescription medication used mainly to treat major depressive disorder) oral tablet 15 mg give 1 tablet by mouth at bedtime for depression manifested by appetite changes. (ordered: 3/20/26) and Trazodone HCl (a prescription medication used to treat major depression) 50 mg give 1 tablet by mouth at bedtime for depression manifested by inability to sleep/stay asleep through the night (ordered: 11/9/24). There were no separate orders for non-pharmacological interventions specific to these medications found in Resident 7's MMR.During a review of Resident 7's MARs, for July and August 2026, the MAR failed to indicate separate orders for non-pharmacological interventions specific to Resident 7's use of Mirtazapine. and Trazodone.During a concurrent interview and record review on 8/5/26 at 3:40 p.m., with the facility's Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used by nursing homes and skilled nursing facilities) Coordinator (MDSC), Residents 3 and 7's MAR's, for the months of July and August 2026 were reviewed. MDSC verified that both residents receive psychotropic medications and stated that best practices for managing behavioral/psychological symptoms involves using non-pharmacological methods alongside medication. Upon further review, MDSC confirmed that these non-pharmacological methods were not used for Residents 3 and 7, even though they should have been.During a review of the facility's policy and procedures (P&P) titled, Psychotropic Medication Use, revised 7/22, the P&P indicated in part, 'Policy Interpretation and Implementation. 10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.A review of the Centers for Medicare and Medicaid Services (CMS - a federal agency within the United States Department of Health and Human Services [DHHS] that actively inspects and reports on every nursing home in the United States) Resident Assessment Instrument (RAI) Version 3.0 Manual, under Section N: Medications (N0415 - High Risk Drug Classes: Use and Indication) indicated in part, Item Rationale. Health-related Quality of Life. As part of all medication management, it is important for the interdisciplinary team to consider non-pharmacological approaches. Educating the nursing home staff and providers about non-pharmacological approaches in addition to and/or in conjunction with the use of medication may minimize the need for medications or reduce the dose and duration of those medications

Based on record review and interview, the facility failed to ensure the comprehensive assessments for two of six sampled residents (Residents 3 and 7) reflected their current health status.This oversight resulted in an inaccurate representation of Residents 3 and 7's health conditions which could potentially introduce health and safety risks for these residents.Findings:During a review of Resident 3's Quarterly Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used by nursing homes and skilled nursing facilities) Assessment, with assessment reference dates of 2/28/26 and 5/28/26 respectively, Section I: Active Diagnoses and Section N: Medications of the assessments indicated Resident 3 had a diagnosis of schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves) yet did not receive antipsychotic medications (prescription medications used mainly to treat mental health conditions like schizophrenia, bipolar mania, and severe depression) since admission.During a review of Resident 3's Medication Regimen Review (MRR), between the MDS assessment dates of 2/28/26 and 5/28/26, failed to indicate that Resident 3 was on any type of antipsychotic medication.During a review of Resident 7's Quarterly MDS Assessment, with assessment reference date of 6/19/26, Section N: Medications of the assessment indicated Resident 7 is taking antipsychotic medication.During a review of Resident 7's MRR, within the period the MDS assessment, dated 6/19/26, was created failed to indicate that Resident 7 was on any type of antipsychotic medication.During a concurrent interview and record review on 8/5/26 at 3:15 p.m. with the facility's MDS Coordinator (MDSC), Residents 3 and 7's MDS Assessments and MRRs from the specified reference dates were reviewed. MDSC verified the discrepancies identified between Residents 3 and 7's assessments and their medication regimen and acknowledged that these inaccuracies could potentially pose risks to these residents' health and safety.A review of the Centers for Medicare and Medicaid Services (CMS - a federal agency within the United States Department of Health and Human Services [DHHS] that actively inspects and reports on every nursing home in the United States) Resident Assessment Instrument (RAI) Version 3.0 Manual, revised 10/2024, under Section I: Active Diagnoses (Other), Coding Tips indicated, The following indicators may assist assessors in determining whether a diagnosis should be coded as active in the MDS . In the absence of specific documentation that a disease is active, the following indicators may be used to confirm active disease . ongoing therapy with medications or other interventions to manage a condition that requires monitoring . A medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring or is prescribed to decrease active symptoms associated with a condition .Further review of the CMS RAI Version 3.0 Manual, under Section N: Medications, indicated Steps for Assessment. 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period (or since admission or entry/re-entry if less than 7 days).

Based on observation, record review, and interview, the facility failed to ensure a comprehensive, person-centered care plan was developed and care plan interventions were implemented for two of 10 sampled residents (Residents 60 and 61) when:1. Care plan monitoring interventions were not implemented for Resident 60 who is on anticoagulant medication (a medication that slows down the body's process of making blood clots).2. A care plan did not include measurable objectives or timeframes for addressing Resident 61's nutritional needs and risk for weight loss.These failures had the potential to result in increased risks for adverse events resulting in poorer resident outcomes due to unmet needs.Findings:1. During a review of Resident 60's admission Record (AR), dated 8/5/26, the AR indicated that Resident 60 is a [AGE] year-old male who was initially admitted to the facility on [DATE] with admitting diagnoses including urinary tract infection, Type 2 Diabetes Mellitus with diabetic neuropathy (nerve damage caused by long-term high levels of blood sugar) and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm).During a review of Resident 60's Order Summary Report, dated 8/6/26, the report indicated the medication order, Eliquis (generic name: Apixaban - a medication used to help prevent blood clots) five (5) milligram (mg) give one (1) tablet by mouth two times a day for AFIB (Atrial Fibrillation) (ordered: 8/1/26).During a review of Resident 60's Care Plan Report, a care plan, initiated 8/4/26, indicated that Resident 60 is on anticoagulant therapy related to atrial fibrillation. The care plan also indicated interventions to be implemented including: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN (as necessary) adverse reactions of anticoagulation therapy: blood-tinged of red blood in urine, black tarry stools, dark or bright red blood in stools.During a review of Resident 60's Medication Administration Record (MAR), for August 2026, it was noted that staff documented giving Eliquis as ordered. However, the MAR did not include care plan interventions related to monitoring for potential side effects or adverse reactions to the medication.During a concurrent interview and record review on 8/5/26 at 4:25 p.m., with the facility's Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used by nursing homes and skilled nursing facilities) Coordinator (MDSC), Resident 60's Anticoagulation Care Plan and MAR for the current month, were reviewed. MDSC confirmed that Resident 60 takes the anticoagulant Eliquis and that there are orders to monitor for medication side effects and adverse reactions included in the care plan. When asked about documentation of these monitoring orders, MDSC explained that such orders are typically noted in the resident's MAR as reminders for staff, allowing them to sign off once completed. Upon reviewing Resident 60's August 2026 MAR, MDSC verified that the monitoring orders had not been transcribed and admitted that these checks were not being carried out.During a review of the facility's policy and procedures (P&P) titled, Anticoagulation - Clinical Protocol, revised 11/2018, the P&P indicated in part, Assessment and Recognition. a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Monitoring and Follow-Up. 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems.During a review of the facility's P&P titled, Care Planning, dated 10/1/23, the P&P indicated in part, Procedure. V. The facility may choose to develop a comprehensive care plan in place of a base line care plan. B. Show interventions to meet short- and long-term goals, C. Show interventions to prevent avoidable decline in function or functional level, D. Document interventions in ADL (activities of daily living) flowsheet and Kardex (a quick-reference, centralized documentation system) as necessary. 2. During an observation on 8/3/26 at 11:40 a.m. of Resident 61, Resident was sitting up in bed dressed in own clothing, elbows resting on knees, resident appeared to be extremely thin.During a review of Resident 61's Face Sheet (FS) (First page of Residents medical record) dated 7/31/26 the FS indicated residents' weight was 63 lbs. (pounds).During a review of Resident 61's History and Physical (H&P), dated 6/25/26 the H&P indicated Resident 61 has unspecified severe protein calorie malnutrition abnormal weight loss, body mass index BMI 19.9 or lessDuring a concurrent interview and record review on 8/5/26 at 4: 00 p.m. with Director of Nursing (DON), Resident 61's care plan(A formal written document that outlines a residence medical needs, diagnosis, treatments, and recovery goals) dated 7/31/26 was reviewed, DON acknowledged despite this significant indicator of nutritional risk, the facility's care plan did not reflect interventions, monitoring, or comfort focused nutritional strategies, the resident's care plan lacked measurable outcomes or interventions related to nutrition, verbalizing a care plan should have been established.During a review of the facility's P&P titled, Care Plans-Baseline, dated March 2022, the P&P indicated, A baseline care plan to meet the resident's immediate health and safety needs is developed for each resident within forty eight (48) hours of admission.

Based on record review and interview, the facility failed to ensure the clinical record contained accurate information for one of six sampled residents (Resident 60) when the resident's code status entered in the electronic health record and the signed Physician Order for Life-Sustaining Treatment (POLST - a set of portable medical orders that communicate a patient's wishes for end-of-life intervention) did not match.This failure had the potential to compromise Resident 60's right to self-determination and autonomy and increases the resident's risk of harm due to unwarranted medical interventions.Findings:During a review of Resident 60's admission Record (AR), dated [DATE], the AR indicated Resident 60 is a [AGE] year-old male who was admitted to the facility on [DATE] with admitting diagnoses including urinary tract infection and Type 2 Diabetes Mellitus (a chronic health condition where your blood sugar levels are too high. The record also contains details concerning Resident 60's advance directive, which specifies preferences for medical care in situations where the individual may be unable to communicate or make decisions. The directive states, Attempt CPR (Cardiopulmonary Resuscitation - an emergency procedure administered when cardiac or respiratory function ceases). Information from the advanced directive documented on the admission record is likewise reflected in the resident's electronic health records.In addition to electronic health records, Resident 60's paper medical records are stored in a physical chart. Included in the chart was a POLST form, dated [DATE], signed by the resident and the attending physician. A discrepancy was noted when the POLST specified directives including Do Not Attempt Resuscitation (DNR) and Comfort-Focused Treatment. During a concurrent interview and record review on [DATE] at 3:32 p.m., with the facility's Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used by nursing homes and skilled nursing facilities) Coordinator (MDSC), Resident 60's advance directive information documented in the clinical record was reviewed. MDSC confirmed that the advance directive information recorded in the electronic health records for Resident 60 did not correspond with the signed POLST located in the resident's physical chart. MDSC acknowledged that this discrepancy could present significant legal challenges to staff and emergency personnel for failing to honor the resident's expressed wishes.During a review of the facility's policy and procedures (P&P) titled, Advance Directives, revised 9/2022, the P&P indicated in part, Policy Statement . The resident has the right to formulate an advanced directive, including the right to accept or refuse surgical treatment. Advance directives are honored in accordance with state law and facility policy. The P&P indicated further, . 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing advance directive documents in prominent, accessible location in the medical record and discussing the resident's wishes in the care planning meetings . 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.

Based on interview, and record review, the facility failed to ensure rehabilitation services were rendered to resident under hospice care for 1 of 3 sampled residents (Resident 10). Resident 10 verbalized needing rehabilitation services, but was without coordination between facility and hospice.This failure has the potential for Resident 10 to be affected emotionally and physically which can affect activity of daily living while in hospice care. During a concurrent observation and interview with Resident 10, on 8/5/26, at 10:50 a.m., in room [ROOM NUMBER]C, Resident 10 was observed awake lying in bed, alert and oriented, has a BIMS = 15 (Brief Interview for Mental Status, 0-15 measurement of a person's memory, learning and orientation [13 - 15 means cognition is intact]). Resident 10 confirmed she requested rehab services but was told she cannot be in rehab since she is in hospice. Resident 10 stated she has requested rehab since she felt both her legs were getting weaker and was getting more difficult to walk. Resident 10 stated she is still able to walk from her bed to the bathroom, but it was getting more difficult each passing day. When asked if she remembers who she spoke with regarding her request for rehab, Resident 10 indicated not remembering. During an interview, on 8/5/26, at 9:54 a.m., with the rehab director (RhD) in the rehab room, the RhD indicated Resident 10 is currently enrolled in hospice care. The RhD stated, We do not provide rehab for hospice residents since we cannot bill hospice residents for rehab services. The RhD admitted Resident 10 had requested rehab due to decreasing bilateral lower extremities range of motion. However, the RhD said he explained to Resident 10 she was not eligible for rehab services due to her hospice enrollment. When questioned whether this practice was based on an official facility policy to deny rehabilitation services to all hospice residents, the RhD said he was uncertain but said it was consistently observed within the facility.During a review of a facility P&P titled, Hospice Program, dated July 2017, indicated, 5. Hospice providers who contract with this facility: a. Must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; . 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific task) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.During an interview with the director of nursing (DON), on 8/5/26, at 10:21 a.m., in DON's office, the DON confirmed hospice residents are not eligible for rehab due to billing purposes. The DON stated, Regular and palliative residents may receive rehab services; however, hospice residents are excluded from this eligibility.During an interview with the hospice doctor (HD) for Resident 10, on 8/5/26, at 2:16 p.m., in the nursing station, the HD said he is aware of Resident 10 requesting rehab in their conversations and has been up for discussion and deliberation in the Hospice agency but does not remember the specific date when the resident requested rehab. When asked when he was made aware, doctor said he does not remember. When asked if the facility communicated Resident 10's request for rehab, the doctor said he did not know. When asked if he communicated Resident 10's wishes for rehab to the facility, HD said he doesn't remember.During a review of hospice contract with the facility, indicated, Article 1 Definitions. Hospice Services include the following, Hospice will arrange for the provision of . therapy (physical, occupational, speech/language) in patient services.

Based on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician orders to monitor Wander Guard ( a wander management device that alarms) for proper placement and functioning for one of three residents (Resident 1) who was identified as an elopement risk. This facility failure compromised Resident 1's elopement prevention plan, placing the resident at an increased risk for unauthorized departure from the facility.Findings:During a review of Resident 1's admission Record (AR), dated 6/23/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that includes Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors), Unspecified Sequalae of Cerebral Infarction (a residual local and systemic damage that persists after tissue dies from a lack of blood flow), muscle weakness (reduced muscle strength), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or weakness on the right side of the body caused by a stroke). The Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 8 reflecting moderate cognitive impairment with episodes of forgetfulness.During a review of Resident 1's elopement evaluation, dated 12/17/25 indicated Resident 1 had a history of attempting to leave the facility, with expressions of desire to go home and pack belongings, stays by the exit doors and wanders. The evaluation identified a risk for wandering and elopement, with a plan to maintain Resident 1's safety.During a review of Resident 1's Physician's Order (PO) dated 2/14/26, PO indicated check Wander Guard location every shift and function every night shift. A review of Medication Administration Records (MAR), MAR indicated licensed staff failed to document the Wander Guard location on 3/7/26 and failed to document the Wander Guard functioning on 3/7/26 and 3/10/26 night shift.During a concurrent record review and phone interview conducted on 7/7/26 at 11:39 a.m. with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) dated March 2026 was reviewed. The MAR indicated that on 3/7/26, licensed staff failed to document the location of the Wander Guard. Additionally, on 3/7/26 and 3/10/26, licensed staff failed to document the functioning of the Wander Guard. DON acknowledged the documentation was missing on the identified dates and acknowledged the facility failed to follow the PO to monitor and document the Wander Guard placement and functioningDuring a review of facility's policy and procedures (P&P) titled, Utilization of Wanderguard System revision date July 2017, the P&P indicated in part, Policy. Resident assessed as unsafe to exit the facility without supervision and assessed as at risk to do so, shall be monitored by our facility's Wanderguard system. This will assist in maintaining the resident's safety by utilization of the least restrictive means possible. The P&P further indicated, Procedure. 3) Each bracelet will be checked every night for proper function and be recorded in the resident's medication administration record (MAR).

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for one of three sampled residents (Resident 1) when Resident 1, who was assessed as an elopement risk and provided with a Wander Guard (device that alarms), left the facility unmonitored. This facility failure compromised Resident 1's elopement prevention plan, placing the resident at an increased risk for accidents. Findings:During a review of Resident 1's admission Record (AR), dated 6/23/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that includes Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors), Unspecified Sequalae of Cerebral Infarction (a residual local and systemic damage that persists after tissue dies from a lack of blood flow), muscle weakness (reduced muscle strength), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or weakness on the right side of the body caused by a stroke). The Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 8 reflecting moderate cognitive impairment with episodes of forgetfulness. Further reviews showed Resident 1 needs supervision with mobility, specifically walking with the use of walkers and uses Wander Guard daily.During a review of Resident 1's elopement evaluation, dated 12/17/25 indicated Resident 1 had a history of attempting to leave the facility, with expressions of desire to go home and pack belongings, stays by the exit doors and wanders. The evaluation identified a risk for wandering and elopement, with a plan to maintain Resident 1's safety.During a review of Resident 1's Progress Notes (PN) dated 2/7/26, 2/13/26, 2/14/26, 2/15/25, 2/24/26 multiple episodes of elopement attempts were documented. Further review of the PN dated 3/8/26 revealed that Resident 1 successfully eloped from the facility and was found seated on a bench at the bus stop outside the facility, unsupervised at approximately 3:00 p.m.During a phone interview conducted on 6/30/26 at 11:07 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated was assigned to Resident 1 on 3/8/26. CNA 5 further stated was not aware that Resident 1 had eloped and was found outside the facility.During an interview on 6/30/26 at 11:46 a.m., with Registered Nurse Supervisor (RNS) in the Administrator's (ADM) office, RNS acknowledged that facility failed to keep Resident 1 safe when Resident 1 successfully eloped on 3/8/26.During an interview on 6/30/26 at 12:01 p.m., with Director of Nursing (DON) in the Administrator's office, DON stated that staff are expected to provide monitoring and supervision to Resident 1's assessed needs and elopement risk. DON further stated Wander Guards and door alarms supplement, but do not replace, the need of necessary supervision. DON acknowledged that facility failed to keep Resident 1 safe.During a review of facility's policy and procedures (P&P) titled, Safety and Supervision of Residents revision date July 2017, the P&P indicated in part, Policy Statement.Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P further indicated, Policy Interpretation and Implementation. Facility-Oriented Approach to Safety. 1) Our facility-oriented approach to safety address for groups of residents. Systems Approach to Safety. 1) The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2) Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview and record review, the facility failed to ensure physician order as reflected in the care plan was followed for one of three sampled residents (Resident 1) when Licensed Nurse (LN1) failed to notify the physician of Resident 1's elevated blood glucose level of 369 mg/dL (milligrams per deciliter; a unit of measurement used to describe the concentration of glucose in the blood) with physician order to notify for blood glucose levels greater than 351 mg/dL. This failure placed Resident 1 at risk for possible effects of high blood glucose level with delayed medical evaluation and treatment. During a review of Resident 1's admission Record (AR), Resident 1 was identified as an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema (diabetes-related eye disease causing swelling that may impair vision), Type 2 diabetes mellitus with diabetic neuropathy (diabetes-related nerve damage), Type 2 diabetes mellitus with diabetic dermatitis (skin complications related to diabetes), Chronic obstructive pulmonary disease (COPD) (a chronic lung disease causing breathing difficulty), and Essential hypertension (high blood pressure). Review of Resident 1's comprehensive care plan revealed interventions related to diabetes management, including monitoring/documentation for signs and symptoms of hyperglycemia, monitoring blood glucose abnormalities, administering diabetic medications as ordered, and monitoring for diabetic complications. Despite the resident's diabetic care plan interventions and the physician order requiring physician notification for blood glucose levels greater than 351 mg/dL, the physician was not notified when Resident 1's blood glucose level reached 369 mg/dL on 4/13/26. During a concurrent interview and record review on 5/1/26 at 9:45 a.m. with Licensed Nurse (LN) 1, review of Resident 1's Medication Administration Record (MAR) dated 4/13/26 revealed a documented blood glucose level of 369 mg/dL during the 9:00 p.m. insulin administration pass. Review of the physician orders dated 4/08/26 at 2:54 p.m. revealed the following physician notification parameter: 351+ = Please notify provider of elevated blood sugars. During a review of the Resident 1's medical record revealed no documented nursing assessment, physician notification, physician response, follow-up intervention, or documented clinical monitoring related to the critically elevated blood glucose level. LN 1 additionally reviewed the facility's secure cell phone communication log and confirmed there was no documented communication from the responsible nurse to the physician regarding Resident 1's blood glucose level of 369 mg/dL. During an interview on 5/1/26 at 12:45 p.m., the Director of Nursing (DON) confirmed that after speaking with the nurse responsible for the MAR entry, the DON confirmed nurse acknowledging she did not notify the physician regarding the elevated blood glucose level despite the physician's order requiring notification. During a review of the facility's policy and procedure titled Change in a Resident's Condition or Status, revised 2021, the policy stated: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical or mental condition and/or status. The policy further stated that nursing staff are responsible for notifying the attending physician or physician on-call regarding changes in the resident's condition requiring physician involvement or intervention. A review of the facility policy titled Goals and Objectives, Care Plans, revised April 2019, revealed that when goals and objectives are not achieved, the resident's clinical record will be documented as to why the resident's goals/objectives and what new goals and objectives/objective have established. The policy further stated that goals and objectives are reviewed and revised when there has been a significant change in the resident's condition and when desired outcomes have not been achieved. Review of [NAME] and [NAME], Fundamentals of Nursing, 7th Edition, page 419, under the section titled Legal Implications in Nursing Practice, indicated that nurses are obligated to carry out physician orders unless the order is believed to be erroneous or harmful to the resident.

Based on interview and record review, the facility failed to ensure that the five day follow-up investigation report regarding two of two residents (Resident 1 and 2) altercation incident was completed and forwarded to the DepartmentThis failure is a violation of reporting requirements.During a record review of facility SOC 341 dated 4/2/26 (Form use to report of suspected dependent adult/elder abuse) indicated that on 4/1/26 the abuse coordinator was made aware of Resident 1 and Resident 2 altercations with no injuries.During a record review of Resident 1's Progress Notes (PN), dated 4/2/26 indicated that an investigation was initiated.On 4/14/26 at 11:58 a.m., 12:32 p.m., 12:45 p.m., and 12:50 p.m., the surveyor requested the complete five day investigation report related to the incident involving Resident 1 and Resident 2 from the Administrator (ADM). The ADM was unable to provide documentation showing that the investigation had been completed and reported within the required timeframe.During an interview conducted on 4/14/26 at 12:56 PM in the Director of Nursing's (DON) office, with both the ADM and DON present, the ADM confirmed that the investigation related to Resident 1 and Resident 2 had not been completed within the required five working days. The ADM stated, This is on me; I was not able to complete the investigation report until now.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, the P&P indicated in part Policy Interpretation and Implementation, Follow-Up Report.1) Within five (5) business days of the incident, the administrator will provide a follow up investigation report.

Based on observation, interview and record review, the facility failed to ensure, the facility's policy and procedures on Substance Use Disorder was implemented for two of two sampled residents (Residents 1 and 2) when the:Nursing Screening Assessment for substance abuse for two sampled residents (Residents 1 and 2) did not reflect the use of tobacco, alcohol, and drug use.Care plan for substance abuse for two of two sampled residents (Resident 1 and 2), did not include approaches, interventions, and addressing risks which could lead to an overdose while in the facility.These failures resulted in Residents 1 and 2 being found unresponsive secondary to drug overdose, requiring emergency medical interventions and hospitalization with potential for harm.Findings During a review of the facility reported incident dated 4/10/26, the report indicated on 4/9/26 at 5:30 p.m., the Certified Nursing Assistant (CNA) went into Resident 1's room and observed the resident to be unresponsive (not reacting to words or touch). The nurse was called to the room and per assessment, resident was with eyes rolled back in head, unresponsive to stimulus but breathing and cyanosis to lips (blueish discoloration due to lack of oxygen). Emergency protocol followed and residents were placed in rescue position (to side to open airway for breathing). 911 was called immediately.Naloxone (medication used to rapidly reverse the effects of Opioid -controlled drug in cases of overdose) was administered, and resident was transferred to the hospital at 5:35 p.m., via 911. Resident 1 was discharged back to the facility at approximately 11p.m., (4/9/26) with diagnosis of Opioid overdose. Resident 1 was interviewed and stated, Was provided a cigarette by roommate while outside and once smoked the cigarette, can't remember anything. During an interview on 4/13/26 at 11:10 a.m. with Licensed Vocational Nurse (LVN 2), LVN2 stated a CNA called out for help to the patient's room. Resident 1 was unresponsive and a nurse started sternal rubs (painful stimuli to the breastbone) and the residents' eyes rolled back. LVN 2 called emergency services. Resident 2, who occupies the same room, was found lethargic (a state of decreased alertness) but verbal (able to respond to words). A second, emergency service was requested. Paramedics arrived, assessed both residents and initiated transfer to the hospital. During an interview on 4/13/26 at 11:19 a.m. with LVN1, LVN1 stated, prior to the incident, Residents 1 and 2 were outside in the front area of the facility in wheelchairs. They both went back to their shared room. During a review of Resident 2's medical record, the Facesheet dated 4/1/26, indicated, an admission date of 4/1/26, and diagnosis including fracture of right femur (a severe injury to the right thighbone) and sternum (a long, flat, [NAME]-shaped bone located in the center of the chest) and history of opioid abuse (the misuse of prescription pain medication ), and stimulant abuse (misuse of drugs that increases alertness of mind and body) and homelessness (lack of stable or permanent housing). During a review of the [Hospital Name] Discharge Summary dated 4/1/26, the discharge summary indicated diagnosis of surgical repair of right femur fracture, amphetamine (stimulant drug) and psychostimulant dependance and homelessness. During a review of the Nursing admission Screening/History dated 4/2/26, the section for Social History indicated, an entry of Unable to respond/no response for Tobacco, Alcohol and Drugs use. During a concurrent interview and record review on 4/13/26, at 12:00 p.m. with the DON Resident 2's care plan titled, History of Poly Substance Abuse, in Remission, dated 4/2/26, indicated interventions listed as follows: monitor for withdrawal symptoms (physical -mental symptoms when a person stops using abused substance), notify provider of any concerning symptoms, provide support. Further review of the care plan, no intervention or approaches were noted to address the resident's condition of amphetamine and psychostimulant dependence, nor interventions to prevent or minimize access to amphetamine or psychostimulant drugs. The DON confirmed no interventions to prevent obtaining any form of drugs while on remission, and no behavioral health care needs interventions. During a review of the facility reported incident dated 4/10/26 for Resident 2, the report indicated on 4/9/26 at approximately at 5:30 p.m., staff was assisting Resident 2's [Name] roommate when staff observed the same symptoms being displayed by Resident 2, which was unresponsive, shallow breathing (short breathing), was not able to track with eyes, eyes were rolling back in head. Oxygen was applied, fire department and medical took over treatment. Resident 1 [Name] was aroused by paramedics and taken to the hospital, for further treatment.On investigation Resident 2 [Name] stated discovering a rice grain [in appearance] in clothes, broke into half and gave half to roommate [Resident 1],consumed half and doesn't remember anything after. During a review of Resident 1's [Hospital Name] Discharge Summary dated 4/7/26, indicated diagnosis of Amphetamines and Psychostimulant dependence uncontrolled Diabetes, Smoker and Homelessness. During a review of Nursing admission Screening/History for Resident 1, dated 4/7/26. admission screening indicated under social history, entry of unable to determine/ no response to tobacco, alcohol and drug use. During a review of the Emergency Department Physician Notes dated 4/9/26, at 6:55 p.m., indicated in part . Patient came secondary to be found unresponsive, patient went outside of care facility to smoke cigarette with one other patient. Patient knew the cigarette was glazed [wet] with Opioid, both people went back to their beds and found unresponsive. Was given Narcan [brand name for Naloxone] via nasal [thru nose] 4 mg. Patient with history of Polysubstance abuse. Diagnosis on discharge was Opioid overdose . During an interview with Resident 1 on 4/13/26, at 10:22 a.m. in residents' room, Resident 1 acknowledged having a current drug issue and explained that the incident happened in parking lot of the facility. The roommate [Resident 2] handed over a cigarette, and Resident 1 smoked about three quarters of the cigarette. Resident 1 stated, It did not have any glazing to indicate drugs in cigarette. Both then went back to the room. Resident 1 stated not feeling ill or heavy headed but just waiting for dinner, I did not feel drugged but later woke up with oxygen mask on. During a review of Resident 1's care plan titled, Care Report dated 4/2/26, included the following in part . History of polysubstance use, in remission, goal- will remain free from withdrawal symptoms during Skilled Nursing Facility (SNF) stay, interventions: monitor for withdrawal signs, notify provider for any concerning symptoms, social services consult for substance abuse and having support, and housing . in part. Further review of the care plan, no intervention or approaches were noted to address the resident's condition of amphetamine and psychostimulant dependence, nor interventions to prevent or minimize access to amphetamine or psychostimulant drugs. During a review of facilities policy and procedure (P&P) titled, Substance Use Disorder(SUD), dated November 2022, the P&P indicated, Residents who are admitted to the facility with substance use disorder (SUD) will receive the necessary behavior health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being, provided by the facility. 1. Substance Use Disorder ( SUD) is defined as recurrent use of alcohol and /or drugs that causes clinically ad functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work. 2. The behavioral health care needs of those with SUD or other serious mental health disorders are evaluated as part of the facility assessment. During the facility assessment the facility determines whether the capacity, services and staff skills are available to meet the needs of those with SUD or other serious mental health disorders. 3. All residents are screened for serious mental health disorders, intellectual disabilities and related condition prior to admission to determine if specialized services under the Preadmission screening and Resident Review (PASSARR) requirements are necessary. 4. The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record. During an interview on 4/13/26 at 11:05 a.m. with DON and Administrator (ADM), the DON and ADM stated, the process for going outside the building, for Long term residents, staff know when to send a staff member with them, for short term need, staff or family should be with them. ADM stated No staff was present with both residents at time of incident.

Based on record review, observation, interview, the facility failed to implement care plan interventions to monitor a resident with a known history of elopement attempts for one of three sampled residents (Resident 1). These failures resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death. During a review of Resident 1's admission Record (AR), AR indicated Resident 1 was admitted to facility on 6/11/24 with diagnoses that includes muscle weakness (reduced muscle strength), history of falling and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or weakness on the right side of the body caused by a stroke).During a review of Resident 1's Brief Interview for Mental Status (BIMS) score (13-15: Cognitively Intact, 8-12: Moderate Impairment, 0-7: Severe Impairment) dated 12/17/2025, showed a score of 8.During a review of Resident 1's nursing notes dated 3/08/2026, the indicated that approximately 3:00 p.m., (1500) oncoming staff observed resident seated on a bench at the bus stop located outside the facility. Resident was noted to be in possession of wheelchair, purse, and coat. Resident 1 exited the skilled nursing facility without staff awareness.During a review of Resident 1's Care Plan (CP) titled Risk for Wandering/Elopement dated 8/5/24, indicated, Goal: Resident 1 will not leave the facility unattended. Resident 1 safety will be maintained. And Interventions dated 9/18/24 were: Engage Resident in purposeful activity Identify if there are triggers for wandering / eloping. Identify if there is a pattern and purpose of wandering Identify wandering / elopement de-escalation behaviors Identify if there is a certain time of day wandering / elopement attempts occur During concurrent phone interview and record review on 3/25/26 at 12:13 p.m. with the Director of Nursing (DON), DON confirmed Resident 1 had multiple prior elopement attempts before the successful elopement on 3/8/26.During a concurrent interview and record review on 4/6/26 at 11:15 a.m., with Director of Nursing (DON), revealed there was no evidence of documentation to indicate Resident 1's triggers for wandering / eloping Identified, no evidence to show there was a pattern and purpose of wandering identified, and no wandering/ elopement de-escalation behaviors were identified. The DON, was unable to produce documentation identifying Resident 1's behavioral triggers related to elopement risk, documentation addressing the triggers associated with the actual elopement event, or an elopement risk assessment completed upon admission on [DATE]. The only elopement evaluation the facility was able to provide was dated 3/17/26, which was completed after the successful elopement on 3/8/26.During an interview and concurrent record review on 4/6/26 at 11:30 a.m. with the Licensed Nurse (LN 1) LN 1 confirmed Resident 1 had multiple prior attempts to leave the facility, with the most recent attempt on 3/8/26 being successful.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001, the P&P indicated: If identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to ensure a routine medication was available for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving scheduled medication and caused the resident distress. Findings: During an interview on 3/7/25 at 3:40 p.m. with the director of nursing (DON), the DON stated Resident 1 was admitted on [DATE] at 5:30 p.m. The list of medications was sent electronically to the pharmacy and the facility eventually received delivery of the medications from the pharmacy. Missing from the medications was Alprazolam (medication for anxiety) 2 mg (milligrams). Resident 1 takes Alprazolam 2 mg. at bedtime routinely. During a telephone interview on 3/7/25 at 4:20 p.m. with the pharmacist, the pharmacist stated all controlled medications need to be faxed to the pharmacy. The facility can send medication requests, even controlled medications electronically but a fax still needs to be sent for any controlled medication. The only exception for not sending a fax for a controlled medication is when the doctor/prescriber sends the order electronically directly to the pharmacy. During an interview on 3/7/25 at 4:50 p.m. with admitting nurse (LN 1), LN 1 stated admitted Resident 1 on 3/4/25 at 5:30 p.m., reconciled the medications, sent the medication list electronically to the pharmacy and called the pharmacy to confirm they received the requested medication list sent. LN 1 admitted was not aware a fax had to be sent for the controlled medication, Alprazolam 2 mg. During a review of Resident 1's Nursing Progress Notes (Notes), dated 3/4/25 at 10:42 p.m., the Notes indicated, LN 2 documented, Medication did not arrive with pharmacist sender. Will call and get information on it . There were no further updates/documentation regarding the missing Alprazolam or attempt to call the physician to request an alternative medication. During a review of Resident 1's Notes, dated 3/5/25 at 10:56 p.m., LN 4 documented, Patient was upset Alprazolam wasn't here. This writer explained to pt (patient) that I will call pharmacy for ETA (Estimated Time of Arrival) of med.(medication) MD notified requesting alternative med d/t (due/to) Alprazolam not available. Resident 1's Representative was very upset and signed Resident 1 out of the facility AMA (Against Medical Advise) on 3/5/25 at 10 p.m. During an interview on 3/7/25 at 4:55 p.m with the DON, the DON stated LN 2 called the pharmacy to follow up on the medications. Pharmacy did not respond since it was close to midnight. LN 2 gave report to oncoming nurse, LN 3 (day shift [7A - 7P]) to follow up with the pharmacy. LN 3 did not document any follow up with pharmacy. LN 4 documented on 3/5/25 at 10:56 p.m., that Resident 1's Alprazolam 2 mg has still not been delivered by pharmacy. When DON was asked why LN 1 was unaware of faxing an order for controlled medication(s), why LN 2 & 3 did not call the doctor to request an alternate medication (Ativan) which was available in the e-kit, the DON did not have an answer. During a review of the facility's policy and procedure (P&P) titled, Ordering and Receiving Controlled Medications, dated 2023, the P&P indicated in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations. And C. New and refill orders for controlled medications are ordered as detailed in the procedure for Ordering and Receiving Medications from Dispensing Pharmacy. When a physician's signature is needed to validate a controlled drug refill, a facility specific Control Drug Order form can be completed by the physician or physician's agent, signed by the physician and faxed to the pharmacy.

Based on interview and record review, the facility failed to follow physician orders for one of two sampled residents (Resident 1), when pain medication was not ordered until two days post orders and incorrect frequency of medication recorded. This failure had the potential for Resident 1 to suffer unnecessary physical discomfort. Findings: During a review of Resident 1's Medication List, from discharging hospital, dated 1/31/25, Hydrocodone 10 mg oral tablet (controlled substance, pain medication) was prescribed for back pain to be given every 4 hours as needed. During a review of Resident 1's Order Summary Report (Orders), dated 2/3/25, Hydrocodone 10-325 mg oral tablet with instructions to give by mouth every 6 hours as needed for lower back pain was entered on 2/2/25. During a concurrent interview and record review on 2/19/25 at 4:40 p.m. with Director of Nursing (DON), Resident 1's Medication List and Orders were reviewed. DON confirmed the order for the pain medication should have been written to physician's specified frequency and submitted to the pharmacy on 1/31/25 instead of 2/2/25. During a review of facility's policy and procedure (P&P) titled, Medication and Treatment Orders, dated July 2016, the P&P indicated, Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on record review, interview, and observation, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1), to prevent elopement. The facility identified Resident 1 to be at risk for elopement and implemented a wander guard system (a wander management system that uses wearable bracelets, sensors, and a technology platform to help keep residents safe) but failed to provide adequate supervision and Resident 1 eloped on 12/30/24. Resident 1 was found five blocks away from the facility, unaccompanied. This failure resulted in Resident 1 eloping from the facility without staff knowledge, posing a potential risk for harm. Findings: During a review of Resident 1's Admission Record, undated, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses, Unspecified dementia (loss of brain function), essential hypertension (high blood pressure), age related osteoporosis (bones become weak and fragile), major depressive disorder (low mood, loss of interest or pleasure), need for assistance with personal care, adjustment disorder with mixed disturbance of emotions and conduct (a mental health condition that involves a combination of emotional and behavioral issues), and unspecified fall. During a review of Resident 1's Minimum Data Set (MDS), (a standardized assessment tool that measures health status in nursing home residents) dated 9/13/2024, the MDS indicated, a Brief Interview for Mental Status ([BIMS] a standardized assessment that is used to help identify cognitive patterns of a resident) score of 0 for Resident 1. A BIMS score can range from 0 to 15, severely impaired (0-7 points), moderately impaired (8-12 points), or cognitively intact (13-15 points). During a review of Resident 1's Health and Physical (H&P), dated 9/23/24, the H&P indicated, Resident 1 is unable to care for him/herself, therefore he/she is a long term care resident. During a review of Resident 1's Order Summary Report (OSR), dated 6/26/20, the OSR indicated, a physician's order dated 7/9/20, Placement of wanderguard due to increased confusion, elopement, poor judgment. During a review of the facility's Policy and Procedure (P&P) titled, Utilization of Wanderguard system, dated April 2014, the P&P indicated, 2) The Wanderguard bracelet is to be placed on the resident's left wrist unless there exists a medical contraindication or other circumstance requiring an alternate location. In such a case the right wrist or lower extremities may be utilized .5) Door alarm panels are located at the front entrance to the facility and at the entrance from the back patio. These devices shall be tested by the environmental services department weekly to monitor the devices continue to perform appropriately. Necessary repairs shall be completed timely. During a review of WanderGuard BLUE v1.5 User & Deployment Guide (WGBDG) (wanderguard manual), dated March 2022, WGBDG indicated, We recommend that you test the Controller at the door once a day and make sure it locks and issues alarms as expected. Staff should also check the WGB system status lights at least daily to verify that there are no system errors .The WanderGuard BLUE Door Controller will alarm when all the following conditions are met at the same time: 1. The monitored door is opened, or in the case of passageways, motion is detected in the passageway near the WanderGuard BLUE Door Controller. 2. The WanderGuard BLUE Door Controller detects a valid signal from a bracelet that is worn by a monitored resident. During an interview on 1/6/25 at 10:47 a.m. with the administrator (ADMIN), ADMIN stated, (Resident 1) had the wanderguard on. The police found (Resident 1), and I picked the resident up and brought the resident back. ADMIN verbalized ADMIN didn't know if the front door wanderguard alarm sounded when Resident 1 eloped, and it wasn't reported by staff that they heard it. During a concurrent observation and interview on 1/6/2025 at 12:10 p.m. with director of nursing (DON) and ADMIN in the facility's front lobby, the facility's wanderguard door alarm was observed mounted on a wall by the facility's front door inside the facility's lobby. DON assisted Resident 4, in a wheelchair with a wanderguard bracelet located on the wheelchair, past the wanderguard door alarm through the facility's front door to exit the facility. DON assisted Resident 4 outside and back inside the facility's front door, passing by the wanderguard door alarm for a total of 6 times. The wanderguard door alarm sounded 3 out of 6 times. ADMIN stated, It should alarm every time no matter where the wander guard is located, on a wheelchair or on a person. ADMIN verbally agreed the wanderguard door alarm located inside the lobby at the facility's front door did not go off each time Resident 4 was assisted past the alarm with the wanderguard bracelet and further verbalized they can't rely on the alarm if it doesn't go off each time a resident goes out the door. During a concurrent observation and interview on 1/6/25 at 12:21 p.m. with DON in Resident 1's room, DON checked Resident 1's wrist and leg for a wanderguard bracelet. DON verbalized there was no wander guard on Resident 1, and it was only on Resident 1's wheelchair. The wander guard was located on the left backside of Resident 1's wheelchair. During an interview on 1/6/25 at 12:38 p.m. with licensed nurse (LN 1), LN 1 verbalized Resident 1 can get confused. When Resident 1 wheels self out of the room, Resident 1 can be redirected. The day prior to Resident 1's elopement, the resident stated was going to go next door to watch the football game, but LN 1 kept an eye on Resident 1 and could redirect the resident. Resident 1 eloped that night, and stated wanted to go to a basketball game, but it was a football game on that day. During a telephone interview on 1/7/25 at 7:35 a.m. with LN 2, LN 2 verbalized before Resident 1 eloped that evening, at the beginning of LN 2's shift, LN 2 saw Resident 1 in their room, in bed, alert and watching TV. LN 2 verbalized Resident 1 would need help to transfer from the bed to the wheelchair. LN 2 last saw Resident 1 on 12/30/24 at 7:30 p.m., after report and around 8 p.m. A certified nurses asistant (CNA) told LN 2 Resident 1 wasn't in their room. LN 2 contacted police and family about 8:30 p.m. or 8:45 p.m. LN 2 stated, The nurse that I got report from told me that (Resident 1) was trying to go next door to watch a game. During a telephone interview on 1/7/25 at 3:15 p.m. with DON, DON stated the south side nurses check the front door wander guard alarm when they check the residents at night and there is no documentation that the tests have been done. During a telephone interview on 2/3/25 1:03 p.m., with Securitas health technician for wander guard system (TECH), TECH verbalized the wander guard system should alarm every time a resident with a wander guard exits through the door and if it doesn't then there's something wrong and they should call technical support and trouble shoot it. It should alarm every time.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) was treated with dignity when the resident's behavior was escalating, and de-escalation techniques were not utilized. This failure had the potential to cause psychosocial harm to Resident 1 Findings: During an observation on 12/2/24 at 12 p.m. with the administrator (ADMIN), in the Admin's office, video footage dated 11/17/24 was observed. The video indicated, Resident 1 was at the nurse's station and a licensed nurse (LN 1) was on the phone behind the station. Resident 1 was cursing and reaching over the station to grab the phone while LN 1 continued to sit at the station. During an interview on 12/2/24 at 11:09 a.m. with licensed nurse (LN 1), LN 1 stated Resident 1 kept asking for medication, by shouting and cursing. LN 1 stated Resident 1's medications were late and was upset the medications were not given at a specific time. LN 1 stated Resident 1 kept coming up to the nurse's station upset, swearing, and cursing and requesting LN 2 who was in another room and continued medication pass while Resident 1 was at the nurses station continuing to esculate. LN 1 stated she called Resident 1's representative to see if she could calm her down, Resident 1 stood yelling at the nurse's station and demanded the phone, reached over the station to grab the phone that LN 1 was on and in the process of pulling her arm back, sustained a skin tear to her left arm. LN 1 denied Resident 1 her requests and did not employ any de-escalation techniques to calm Resident 1. LN 2 continued to give the rest of her assigned residents medications and did not offer Resident 1 her medications sooner causing Resident 1 to wait until last to recieve hers while escalating Resident 1 behaviors further. During an interview on 12/2/24 at 11:19 a.m. with LN 2, LN 2 stated she was Resident 1's primary nurse on 11/26/24 p.m. shift, which was the morning of 11/27/24. LN 2 stated she went into Resident 1's room to give Resident 2's medications and was explaining Resident 2's medications during administration. Resident 1 overheard the discussion and became upset and requested her medications. LN 2 stated to Resident 1 she was helping Resident 2 and told Resident 1 to relax, Resident 1 then called LN 2 a bitch. The activities director came in and tried to redirect Resident 1. LN 1 stated Resident 1 came to the nurse's station and called her a fat pig. LN 2 stated she gave Resident 2's medications and left the room. Additionally, LN 2 continued medication administrations which escalated Resident 1's behaviors. LN 2 stated Resident 1 would follow her on medication pass to each room until Resident 1 received her medications. LN 2 stated she witnessed an altercation between LN 1 and Resident 1 when LN 1 asked Resident 1 to go back to her room and Resident 1 kept cursing. LN 2 stated LN 1 denied Resident 1 requests or any de-escalation. LN 2 stated she did not provide medications at that moment, the use of the phone or employ and de-escalation techniques other than asking Resident 1 to go back to her room. During an interview on 12/2/24 at 12:45 p.m. with the director of nursing (DON), the DON stated Resident 1 was alert and oriented, difficult to please at times and behaviors on 11/26/24 p.m. DON stated de-escalation techniques should have been utilized by LN 1 and LN 2. The DON stated staff have training in de-escalation training. During a concurrent interview and record review on 12/2/24 at 1:15 p.m. with ADMIN, the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated revised April 2021 was reviewed. The P&P indicated in part . a facility wide commitment to support the following objective . Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. ADMIN stated de-escalation and compassion could have prevented the escalation of Resident 1's behavior on 1/26/24 p.m. shift and staff are trained in de-escalation.

Based on observation, interview, and record review, the facility failed to ensure a call light was functioning for one of two sampled residents (Resident 2). This failure had the potential to result in Resident 2 not having their needs met and sustain complications. Findings: During a concurrent observation and interview on 12/2/24 at 10:40 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 stated staff did not come when the call light was pushed. Resident 2 pressed the call light and waited five minutes. There was no response, no ringing heard and the light outside of the room above the doorway was not lit. The call bell was observed not plugged into the wall. During a concurrent observation and interview on 12/2/24 at 10:45 a.m. in Resident 2 ' s room, with certified nursing assistant (CNA 1), CNA 1 stated could not hear the call bell ring and the light outside of the room above the doorway was not lit. CNA 1 observed call light plug was not plugged into the wall and stated the call light should always be plugged into the wall. During a concurrent interview and record review on 12/2/24 at 1 p.m. with the administrator (ADMIN), the facility ' s Policy & Procedure (P&P) titled, Answering the Call Light, dated revised September 2022 was reviewed. The P&P indicated in part .Be sure the call light is plugged in and functioning at all times . answer the call light immediately. The ADM stated call lights should always be functioning.

Based on observation, interview, and record review, the facility failed to ensure food safety standards were followed when: 1. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices during lunch tray preparation. 2. The frequency of the facility's ice machine sanitization schedule was not followed according to manufacturer's recommendations. These failures had the potential to cause food-borne illness to vulnerable residents currently residing in the facility. Findings: 1. During a lunch tray line observation on 11/19/24 at 12:15 p.m. inside the facility kitchen, with the registered dietitian (RD), certified dietary manager (CDM), and DAC, DAC was observed preparing cooked food for resident lunch tray distribution. DCA was noted measuring the food temperatures with gloved hands. Using the same pair of gloves, DCA continued to open/close cabinets and drawers, taking out spoons and scoops placing them onto the food trays for serving. Upon further observation, DCA was noted resting the plate against her body while scooping food onto the plate. DCA's apron and identification (ID) badge were noted touching the edge of the plate. During a concurrent observation and interview on 11/19/24 at 12:20 p.m. with CDM, CDM was informed of DCA's food handling practices who confirmed them through direct observation. CDM acknowledged that DCA should have changed gloves and performed hand hygiene frequently and should have been mindful and cautious not to contaminate plated foods which will be served to the residents. During a review of the facility's policy and procedure (P&P) titled, Food Handling, dated 2023, the P&P indicated in part, POLICY: Food will be prepared in a safe and sanitary manner. During a review of the facility's P&P titled, Food Preparation and Service, dated 11/22, the P&P indicated in part, General Guidelines . 3) Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness 50657 2. During a review of the facility ice machine's, Manitowoc S Model Ice Machines Installation, Use and Care Manual, dated 10/2009, the manual indicated in part .Sanitizing Procedure: This procedure must be performed a minimum of once every six months. During a concurrent observation and interview on 11/18/24 at 4:32 p.m. with the facility's maintenance supervisor (MS), MS was asked how often the ice machine was sanitized. MS opened the ice machine's top access panel to reveal the dates when sanitization was performed. The most recent sanitization date noted was on 3/18/24. MS verbalized the sanitization procedure is performed by an outside vendor and would look for the service record/invoices for the said date. During a concurrent interview and record review on 11/19/24 at 10:50 a.m. with MS, MS presented the ice machine service record/invoice and acknowledged the ice machine was last sanitized on 3/18/24. MS could not produce any other ice machine sanitization service records/invoices after 3/18/24 and acknowledged it was not done in the past six months. During an interview on 11/19/24 at 11:31 a.m. with the Director of Nursing (DON), DON confirmed the ice machine was not sanitized within the last six months as recommended by the ice machine care manual. During a review of the facility's P&P titled, Ice Machine Policy, (undated), the P&P indicated in part, Policy: It is the policy of (name of facility) to clean/disinfect exterior and interior of the ice machine . Person Responsible: (name of outside vendor) (six months) During a review of the FDA (Food & Drug Administration) Food Code Annex, 2017, the FDA Food Code indicated, Ice that has been in contact with unsanitized surfaces .may contain pathogens and other contaminants (3-303.11). The FDA Food Code indicated further, Pathogens can be transferred to food from utensils that have been stored in surfaces which have not been cleaned and sanitized (3-304.11).

Based on record review, interview, and observation, the facility failed to implement interventions and provide adequate supervision for one of three sampled residents (Resident 1). This failure resulted in Resident 1 leaving her bed unassisted and falling face first onto the hallway floor. Resident 1 was taken to the emergency room and treated for [REDACTED]. Subsequently, Resident 1 was admitted to the hospital and treated for [REDACTED]. Findings: Record review on 7/29/14, revealed, Resident 1's [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE], revealed, Resident 1 had a memory problem and her decision making skills were moderately impaired. Resident 1 required assistance from staff for walking. Review of the physician's history and physical, dated 3/10/14, noted, Resident 1 had weakness on both legs and dementia. Review of the the admission nursing assessment, dated 3/7/14, stated, Resident 1 had numerous falls prior to admission, generalized weakness, and needed the assistance of staff for transferring and ambulating. Also noted was the need for a tab alarm (warning system to alert caregivers) due to Resident 1 getting out of bed unassisted. Review of a care plan for prevention of falls was developed on 3/7/14, due to Resident 1's unsteady gait and numerous falls prior to admission to the facility. Interventions included having the bed in the lowest position and a tab alarm. According to the care plan, the tab alarm was discontinued on 3/9/14 because Resident 1 could remove it and a bed alarm (caregivers can hear an alert when a resident is about to get up from a bed) was implemented instead. Review of a plan of care related to Resident 1's cognitive loss, dated 3/11/14, indicated, the resident's decision making was poor and she required supervision. Review of an undated social service note, stated, Resident 1 tries to get out of bed unattended. Review of a nurse's note, dated 3/7/14 at 5 p.m., revealed, Resident 1 needed to be reoriented and redirected due to confusion. Resident 1 was taken from her room and sat in the hallway to get used to other residents and her new environment. At 9 p.m., the nurse documented Resident 1 had gotten up four times asking, "what is this place" and looking for her daughter and her belongings. At 10 p.m., the nurse's note indicated, the night shift nurse was instructed to do frequent checks on Resident 1 due to the resident detaching the tab alarm and then walking around. Review of a nurse's note, dated 3/8/14 at 9 p.m., indicated, Resident 1 was often redirected due to getting out of bed and was monitored closely one to one. On 3/9/14 at 1:30 p.m., Resident 1 got out of bed unassisted and was able to detach the tab alarm. At 9 p.m., the nurse indicated Resident 1 had to be monitored closely for safety due to attempts to take the bed alarm off. Review of a nurse's note, dated 3/13/14 at 3:05 a.m., stated, a certified nursing assistant (CNA) responded to Resident 1's bed alarm and as the CNA approached the resident's room, saw Resident 1 fall face down. 911 was called following an examination by the nurse and the resident was transported to the emergency room . Review of the hospital emergency room report, dated 3/13/14, revealed, Resident 1 sustained the following injuries secondary to falling: right side forehead bruise, cut lips, bilateral nasal bone fractures, fracture of the nasal bony septum, fractured left cheek bone. During an interview, on 10/14/14 at 7:25 a.m., Resident 1's responsible party (RP) indicated, no one from the facility discussed the option of having the family provide a private care giver for one to one observation as an intervention for preventing Resident 1 from getting up unassisted and falling. Nor did the facility recommended moving Resident 1 closer to the nurses' station. Resident 1's RP stated, "I thought she would be watched." During an interview on 10/2/14 at 6:30 a.m., CNA 1 confirmed, she was assigned to Resident 1 at the time of the fall on 3/13/14. CNA 1 indicated, she was at the nurses' station when a bed alarm sounded. CNA 1 was approaching Resident 1's room (room 7) when CNA 1 observed Resident 1 standing at the door of the resident's room and witnessed the resident fall face down into the hall. The nurse was summoned and 911 was called. During an interview on 10/2/14 at 9:40 a.m., licensed nurse (LN 1) confirmed, she was in charge at the time of Resident 1's fall on 3/13/14. LN 1 indicated, she and CNA 1 were at the nurses' station when an alarm was heard and CNA 1 responded. LN 1 responded to CNA 1's call for assistance and found Resident 1 face down on the floor and blood was coming from the resident's face. Resident 1 was responsive when LN 1 assessed for injuries and 911 was called. LN 1 further indicated, Resident 1 had a history of [REDACTED]. During an interview, on 7/29/14 at 10:40 a.m., the administrator confirmed, Resident 1 resided in room 7 bed A during her stay. A concurrent observation and interview, on 10/6/14 at 12:30 p.m., revealed, the response time for staff to get from the nurses' station to room 7 was 16 seconds. The administrator confirmed, based on the time for staff to respond to Resident 1's bed alarm was not an adequate intervention for preventing Resident 1's fall. During an interview on 10/6/14 at 12:45 p.m., the administrator confirmed, beds in rooms 10 and 11 were available on 3/10/14 and Resident 1 could have been placed closer to the nurses' station providing increased monitoring by staff and a quicker response to an alarm notifying staff of Resident 1's attempts to get out of bed unassisted.