Every finding on record at Sherwood Oaks Post Acute Care, LLC

Based on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for one resident (Resident 1) of three sampled residents after Resident 1 was assessed as a high fall risk.This failure contributed to Resident 1's fall out of bed on 7/15/26.Findings:A review of Resident 1's Morse Fall Scale (an assessment tool used to determine a resident's likelihood of falling) dated 7/9/26 at 2:19 p.m. indicated a score of 75, which meant she had a high fall risk.A review of Resident 1's progress note dated 7/14/26 at 11: 25 p.m. and written by Licensed Nurse 1 (LN 1) indicated, [At 6:20 a.m.] CNA [Certified Nursing Assistant] herd [sic] a voice asking for help. CNA went to the room and observed that the patient [Resident 1] is on the floor and is a sitting position and notified the nurse/writer. When I asked how she fell, she stated 'don't talk to me.' When asked if she is in pain, she stated that she has pain to her neck and back. [Resident 1] left the facility via ambulance at [7:05 a.m.].During a concurrent observation and interview with Resident 1 on 7/21/26 at 11:30 a.m., Resident 1 stated she had no recollection of falling at this facility.During an interview with LN1 on 7/21/26 at 2:25 p.m., LN 1 stated Resident 1 had a non-compliant behavior. LN 1 stated he placed Resident 1 on visual checks and documented them on the progress notes. LN 1 stated he knew Resident 1 was a high fall risk but did not know if she had a care plan for falls. LN 1 stated he did not check if Resident 1 had a care plan for falls. LN 1 stated it was his understanding that the Director of Nursing (DON) wrote the care plans. LN 1 stated he has not yet initiated a care plan at this facility. LN 1 acknowledged Resident 1 was not wearing non-skid socks when she fell. LN 1 stated he decided to send Resident 1 to the ED prior to getting an order from the physician because of Resident 1's neck and back pain. LN 1 stated Resident 1 fell while he was doing the change of shift report with the oncoming morning nurse.During an interview with Certified Nursing Assistant 1 (CNA 1) on 7/23/26 at 8:57 a.m., CNA 1 started at around 6 a.m. on 7/15/26, she heard a sound and yelling from Resident 1's room where she found Resident 1 on the floor by the left side of her bed. CNA 1 stated Resident 1's bed was at a medium height and there were no floor pads on either side of the bed. CNA 1 stated Resident 1 was not wearing non-skid socks. CNA 1 stated Resident 1 told her she was trying to pick up something that was on the floor.During an interview with the DON on 7/23/26 at 1:30 p.m., the DON stated he completed Resident 1's Morse Fall Scale assessment on 7/9/26. The DON acknowledged he did not initiate a fall care plan for Resident 1 after his assessment on 7/9/26. The DON verified he initiated resident care plans, but other licensed nurses could also. The DON confirmed Resident 1 did not have care planned interventions for fall prior to her fall on 7/15/26. The DON stated he initiated a fall care plan for Resident 1 after she fell on 7/15/26.A review of a facility's P&P titled, Baseline Care Plans, undated, indicated, The facility will develop and implement an individualized Baseline Care Plan for every resident within 48 hours of admission. The admitting licensed nurse will review available hospital records.medications, diagnoses.therapy needs.The Baseline Care Plan will .include, as applicable.Fall, skin, elopement, behavior, infection, and other safety risks.Immediate interventions will be communicated to nursing assistants and other staff through the care plan, assignment sheet, shift report, or admission huddle. The DON, MDS [Minimum Data Set] Coordinator, or designee will audit new admissions for timely completion, individualized interventions, staff communication, and documentation.A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated December 2007 indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to ensure one of thirteen sampled residents (Resident 16) received quality nursing care that was resident-centered, based on a comprehensive assessment, and in accordance with her goals of care, as indicated in her Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when she experienced intermittent constipation (problem passing stool; associated with hardened feces [stool]; generally passing less than three stools per week) from 12/1/25 through 1/3/26, but nursing staff: 1. Did not treat her constipation with PRN (given as needed or requested) medication ordered by her physician; 2. Did not notify her physician when she was constipated despite receiving her regularly scheduled medication for constipation; and 3. Did not perform weekly nursing assessments (systematic, continuous collection of data to create a patient-centered care plan) after 8/31/2025 through 2/28/2026.These failures caused Resident 16: 1. To develop a large fecal impaction (hard stool that becomes stuck in the rectum [the final segment of the large intestine; primary function is to temporarily store feces] or colon [large intestine]), that placed her at risk for bowel (intestine) perforation (a hole or tear in the wall of the small or large intestine that allows intestinal contents to leak into the abdominal cavity, creating a life-threatening medical emergency); 2. To be transferred to the local hospital where she was admitted from 1/3/26 to 1/5/26; 3. To experience bladder (organ that stores urine) distention (an enlarged, stretched bladder caused when urine cannot empty properly) due to obstruction (blockage); this in turn necessitated placement of a Foley catheter (indwelling tube inserted into the bladder to continuously drain urine into a collection bag); and 4. To have her stool manually disimpacted (physical removal of hard, impacted stool from the rectum using a lubricated, gloved finger). Findings: A review of Resident 16's facesheet (front page of the medical record that contains a summary of basic information about the resident) indicated she was ninety years old and admitted on [DATE] with diagnoses of severe dementia (a progressive state of decline in mental abilities) with agitation, delusional disorders (having false or unrealistic beliefs), and fecal impaction.A review of Resident 16's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/24/25, indicated Resident 16 had severe cognitive impairment (a decline in mental abilities such as memory, reasoning, language, and judgment), was always incontinent (involuntary loss of bladder/bowel control, causing leakage of urine/feces) of urine and stool, and required substantial/maximal assistance from staff for toileting hygiene (the ability to maintain hygiene before/after voiding and bowel movements).Review of Resident 16's medical record revealed a document titled, Task: B&B - Bowel. Elimination. (CNA documentation of bowel activity), dated 11/3/2025 through 3/4/26, that indicated Resident 16 had nine bowel movements (BMs) in December 2025 (12/1/25, 12/10/25, 12/13/25, 12/14/25, 12/20/25 [two BMs],12/23/25, 12/27/25, and 12/28/25). The document indicated Resident 16 had no documented BMs for eight consecutive days (between 12/1/25 and 12/10/25) and no documented BMs for five consecutive days (12/29/25 - 1/3/26), immediately prior to her ED transfer.Review of Resident 16's medical record revealed Medication Administration Records (MARs; a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/1/25 - 12/31/25 and 1/1/26 through 1/3/26 (approximately five weeks prior to her hospital transfer), that indicated her physician ordered the following medication to be given on a scheduled/daily basis: Polyethylene Glycol 3350 Powder. give 17 gram by mouth in the morning for constipation. Start Date 8/8/24. and Seroquel [antipsychotic medication primarily used to treat psychosis and related mental health conditions] oral tablet. Give 25 mg [milligram] by mouth in the morning related to delusional disorder. Start date- 06/20/2025. Seroquel oral tablet. give 50 mg by mouth in the afternoon. Start date- 06/20/2520. Seroquel oral tablet 100 mg. give 1 tablet by mouth at bedtime . Start date- 09/05/2024 . D/C [discontinue] date-12/15/2025. Seroquel oral tablet 100 mg . give 1 tablet by mouth at bedtime. Start date- 12/15/2025. D/C date- 01/06/2026.Continued review of Resident 16's MAR, dated 12/1/25 - 12/31/25 and 1/1/26 through 1/3/26, indicated her physician ordered the following medication to be given on a PRN basis: Percocet [narcotic pain medication containing oxycodone] oral tablet 5-325 mg. Give 1 tablet orally every 6 hours as needed for severe pain -Start Date- 01/30/2024. Nursing staff documented Percocet was administered on 12/1/25, 12/2/25, 12/3/25, 12/5/25, 12/6/25, 12/8/25, 12/10/25, 12/12/25, 12/13/25, daily from 12/16/25 - 12/20/25, 12/21/25, 12/23/25, 12/26/25 and 12/27/25.Continued review of Resident 16's MAR, dated 12/1/25 - 12/31/25 and 1/1/26 through 1/3/26, indicated her physician ordered the following medications for constipation: Milk of Magnesia [MOM; liquid medication to treat constipation] suspension.30 ml. give 1 each by mouth as needed for NO BM x3 [for three] DAYS. Admin. [administrator] as ordered. If no results from MOM, proceed to Supp Tx. [suppository treatment with Dulcolax] as ordered . -Start Date- 01/30/2024. Dulcolax Suppository [medication to relieve constipation, inserted into the rectum] 10 mg. Insert 1 each rectally as needed for no results from MOM . -Start date- 03/07/2023. Fleet Enema [liquid medication to treat constipation, injected into the rectum] .Insert 1 each rectally as needed for no result from Supp TX. [Dulcolax suppository treatment] . If no BM, notify M.D. [medical doctor] immediately. Start date- 03/07/2023. Senna [laxative] Oral Tablet 8.6 mg. Give 1 tablet by mouth every 12 hours as needed for constipation -Start Date- 03/06/2023. Nursing staff did not document administration of MOM, Dulcolax Suppository, Fleet Enemas, or Senna from 12/1/25 through 1/3/26.Review of Resident 16's medical record revealed a MAR, dated 12/1/25 - 12/31/25 and 1/1/26 through 1/3/26, contained the following order: Monitor every shift for side effects of Seroquel: . constipation. -Start date- 03/07/2023.Review of Resident 16's nursing care plan, initiated 5/1/25 with target date 4/6/26, indicated, The resident is on pain medication therapy: Percocet. the resident will be free of any discomfort of adverse side effects from pain medication. The care plan interventions indicated, . Monitor/document side effects. Q-Shift [every shift] . Ask physician to review medication if side effects persist. Report [to physician] PRN adverse reactions . constipation.Review of Resident 16's nursing care plan, revised on 8/13/25 with target date 4/6/26, indicated, The resident uses psychotropic [drugs that affect behavior, mood, thoughts, or perception] medications [Seroquel.] . The resident will be/remain free of psychotropic drug related complications including . constipation/impaction. The care plan interventions indicated, . Monitor for side effects. Q-Shift. Monitor/document/report PRN [as necessary] any adverse reactions of Psychotropic medications.Review of Resident 16's medical record revealed a nurse progress note (documentation of a resident's clinical status, response to treatment, and care updates), dated 1/3/26 at 1:58 a.m., that indicated, . Pt [patient, Resident 16] was complaining of nausea and abdominal pain. projectile vomited onto the floor. proceeded to have more episodes of emesis [vomiting]. Send to acute [hospital] for further evaluation and treatment.Review of Resident 16's hospital History and Physical Examination, subtitled, History of Present Illness, dated 1/3/26 at 4:16 p.m. and written by Physician N, indicated, . Patient [Resident 16] has chronic constipation. she vomited once this morning. Nasogastric tube [tube inserted through the nose into the stomach for stomach decompression] was introduced [put into her stomach, through her nose] . The CT [CT scan] of the abdomen also demonstrated a very large fecal impaction which in turn is compressing the neck of the bladder [lower part of the bladder that controls urine flow] so that she has a very distended bladder. Foley catheter was placed. I discussed the case with Physician P, our general surgeon. Under the subtitle, Assessment/Plan, the physician indicated, . 3. Fecal impaction. she will need manual disimpaction. 4. Distended bladder. I think this is due to the large amount of stool in her rectum compressing the neck of the bladder. A Foley catheter is in place and is draining (urine) well and we will continue that in place until [sic] get the fecal impaction resolved.Review of Resident 16's hospital Discharge Summary (outline of the key details of a patient's hospital stay), subtitled, Final Diagnosis, dated 1/5/26 at 9:40 a.m. and written by Physician O, indicated, 2. Fecal Impaction. 4. Chronic constipation. needs an aggressive regimen. 9. Distended bladder. Under the subtitle, Hospital Course. 1/4/26, the document indicated, . presents [came to the hospital] with. a large Boulder in her rectum causing obstruction (a giant stool ball) and causing mechanical issues causing bladder outlet obstruction [blockage]. She got disimpacted [of stool] yesterday. I think the patient is simply severely backed up [constipated].During an observation on 03/04/2026 at 8:35 a.m., Resident 16 was sitting in her wheelchair outside of her room, talking to another Resident. Resident 16 was confused and the ideas she expressed verbally were disorganized.During an interview on 3/05/2026 at 2:31 p.m., Certified Nursing Assistant A (CNA A) stated when Resident 16 had a bowel movement, she documented it with a check mark on the Task: B&B Elimination flowsheet; she stated she was unsure if the nurses looked at her documentation. CNA A stated Resident 16 did not have many bowel movements; she stated she had a lot of bowel movements when she returned from the hospital (1/5/26) but that has slowed down.During an interview on 3/05/2026 at 2:37 p.m., Licensed Nurse E (LN E) stated she was Resident 16's nurse when she was sent to the hospital on 1/3/26. She stated prior to Resident 16's hospitalization, she was taking Percocet and Seroquel and was not eating or drinking much. When asked if Resident 16 was constipated prior to sending her to the hospital, LN E stated she, never had much out and had very little bowel movement. LN E stated laxatives (medication to relieve constipation) didn't work; she stated Resident 16 did not have much of a bowel movement after Dulcolax was given. She stated some days they did not give her anything (for constipation) because she was not eating.During a concurrent interview and record review on 3/05/2026 at 4:29 p.m., the Director of Nursing (DON) reviewed Resident 16's Task: B&B - Bowel Elimination flowsheet dated, 12/1/2025 through 1/3/26 and stated the empty boxes that contained no check marks (by the CNAs) indicated Resident 16 had no BMs on those days. The DON confirmed the multiple days without check marks indicated Resident 16 had no BMs on those consecutive days. The DON also confirmed Resident 16 was taking Percocet and Seroquel, both medications which can cause constipation; he stated Resident 16 was also inactive, which increased her risk of constipation.During the same concurrent interview and record review on 3/05/2026 at 4:29 p.m., the DON reviewed Resident 16's MARs, dated 12/1/25 through 12/31/25 and 1/1/26 through 1/3/26. The DON stated nursing staff did not give Resident 16 PRN medication to treat her constipation (including MOM, Dulcolax, Fleet Enema or Senna) during that timeframe. He stated the nurses should have given MOM after two days of constipation; he stated they should have given a Fleets enema on the third day of constipation and if that did not produce a bowel movement, they should have called the physician. The DON stated the directions for the PRN constipation medications were located in the MAR.During the same interview on 3/05/2026 at 4:29 p.m., the DON reviewed Resident 16's weekly nursing assessments (that included bowel assessments) and confirmed they were completed 8/31/25 and 2/28/26. The DON stated the weekly nursing assessments were missing from Resident 16's medical record after August 31, 2025, through February 28, 2026 (approximately five months). He stated Resident 16's weekly assessments were scheduled to be completed on Saturday afternoons and they should have been done timely.During a telephone interview on 3/06/2026 at 10:05 a.m., Physician F stated Resident 16's constipation was not brought to his attention. Physician F stated his expectation for nursing staff was for them to manage a resident's constipation using the ordered PRN medication. He stated if the PRN medications were not working for Resident 16, nursing staff should have called him because Resident 16 was his responsibility. Physician F stated fecal impaction could lead to hospitalization, could have created the inability to catheterize (insert a Foley catheter) Resident 16 (preventing her from urinating), and could potentially cause bowel perforation (a potentially life-threatening medical emergency).Review of facility policy titled, Charge Nurse, subtitled, Nursing Care Functions, dated 2003, indicated, . Consult with the resident's physician in providing the residents care, treatment. as necessary. Notify the resident's attending physician. when there is a change in the resident's condition. Implement and maintain established nursing objectives and standards. Under subtitle, Care Plan and Assessment Functions, the policy indicated, Review care plans daily to ensure that appropriate care is being rendered. ensure that your nurses' notes reflect that the care plan is being followed.Review of facility policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, subtitled, Assessment and Recognition, revised 9/2017, indicated, . 2. Examples of lower gastrointestinal tract [GI tract; a continuous hollow tube from the mouth to the anus that digests food, absorbs nutrients, and expels waste] conditions. include: . b. Fecal incontinence. 3. the nurse shall assess and document/report the following. d. presence of fecal impaction. f. Abdominal assessment. Under subtitle, Treatment/Management, the policy indicated, 1. The physician will identify and order pertinent. interventions: for example. institute a regimen to prevent constipation. Under subtitle, Monitoring and Follow-Up, the policy indicated, 1. The staff and physician will monitor the individual's response to interventions and overall progress; for example. frequency. of bowel movements.During an interview on 3/06/2026 at 2:40 p.m., the DON stated the facility did not have a policy for weekly nursing assessments.Review of facility policy titled, Administering Medications, revised 12/2012) indicated, . 3. Medications must be administered in accordance with the orders. Online record review of the Cleveland Clinic website indicated Percocet can cause constipation (https://my.clevelandclinic.org/health/drugs/21127-opioids) and online review of the Mayo Clinic indicated Seroquel can cause constipation (https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/description/drg-20066912).

Based on observation, interview, and record review, the facility failed to employ an Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) from early 10/2026 through 3/06/26, leading to Enhanced [NAME] Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria and other germs resistant to three or more classes of antibiotics, making infections difficult to treat and highly contagious] in nursing homes) not being implemented for residents with indwelling medical devices including central venous catheters (long, flexible tube inserted into a large vein and threaded to the heart for long-term delivery of medication, fluids, blood products, or nutrition), urinary catheters (a flexible tube inserted into the bladder used to drain urine), and suprapubic catheters (a thin, flexible tube inserted into the bladder through a small abdominal incision used to drain urine).This failure had the potential to significantly increase the risk of spreading MDROs, leading to higher infection rates and increased resident morbidity. (Cross-Reference: F880).Findings:During multiple observations, interviews and record reviews (Reference Federal Tag F880) during the Recertification Survey from 3/03/26-3/06/26, residents were not set up for EBP because there was no IPN. During an interview on 3/05/26 at 4:50 p.m., the Administrator stated the facility did not have an IPN.During an interview on 3/06/26 at 8:45 a.m., the Director of Nursing (DON) stated he could not recall when there was a full-time IPN. The DON stated there had been a few IPN that had filled in once in a while over the past year, but never a fulltime IPN. During an interview on 3/06/26 at 9:15 a.m., the Administrator stated there had not been an IPN in the facility since early 10/2025. A review of the facility Policy & Procedure titled (P & P), Infection Control Overview, revised on 7/2014, indicated, Policy Statement: The Infection Control Committee shall take an active and effective role in preventing and managing communicable illnesses within our facility. The Infection Control Committee shall include the following individuals: . d. Infection Preventionist.A review of the facility P & P titled, Monitoring Compliance with Infection Control, revised on 7/2014, indicated, Policy Interpretation and Implementation: The Infection Preventionist or designee shall monitor the effectiveness of our infection control work practices and protective equipment. This includes, but is not necessarily limited too: a. Surveillance of the workplace to ensure that established infection control practices are observed and protective clothing and equipment are provided and properly used.A review of the facility job description titled, Infection Control Nurse, dated 2003, indicated, Purpose of Your Job Description: The primary purpose of your job position is to plan, organize, develop, coordinate, and direct our infection control program and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs, and as may be directed by the Administrator and the Infection Control Committee to ensure that an effective infection control program is maintained at all times. Serve on, participate in, and attend Infection Control Committee meetings .

Based on observation, interview and record review, the facility failed to ensure three dryers' lint traps located in the laundry room were cleaned out after two uses per the facility's policy.This failure resulted in dryer lint traps accumulating lint, thereby presenting a potential fire risk and creating a hazardous environment for residents, staff, and visitors.Findings:During a concurrent observation and interview on 3/06/26 at 10:48 a.m. with Laundry Staff C with the help of translator CNA D, in the laundry room, all three dryer lint trap screens were full and there were no logs to indicate how often the lint traps were being cleaned. Laundry Staff C stated she had already dried four loads of laundry in each dryer. Laundry Staff C stated she cleaned the dryer lint traps twice a day. Laundry Staff C stated she was just about to clean the lint out of the dryer lint traps and she would clean the lint traps one more time before leaving, which was around 3:30 - 4 p.m. Laundry Staff C stated the number of loads of clothes/linen she dried per day was based on the census. Laundry Staff C stated she was not aware of needing to log the time she cleaned out the three dryer's lint traps or how often she was supposed to clean out the dryer lint traps. Laundry Staff C stated she has worked in the Laundry Room for a year. Laundry Staff C stated the staff member who trained her quit after training her. Laundry Staff C stated she cleaned the dryer lint traps out twice a day. Laundry Staff C was asked what could occur if there was a build-up of lint in the three dryer's lint traps. Laundry Staff C stated the dryers could catch fire.During an interview on 3/6/2026 at 12:35 p.m., the Administrator stated the laundry staff should be cleaning out the dryer lint traps after two loads and logging the time they cleaned out the lint traps. The Administrator stated logging the times the dryer lint traps were cleaned out have not occurred for at least the past two months. There were no logs presented. The Administrator stated Maintenance should be deep cleaning the dryers once a month and logging when all the dryers were deep cleaned.A review of the undated facility policy/procedure titled, Laundry Dryer Operation and Lint Removal Policy, indicated: Purpose: To ensure safe operation of laundry dryers and prevent fire hazards by maintaining a routine schedule for lint removal and dryer maintenance. Policy: The facility shall maintain all laundry dryers in a safe and sanitary condition. Dryer lint traps and surrounding areas shall be cleaned regularly to prevent lint accumulation, which may present a fire hazard. Procedure: 1. Daily Lint Removal - Laundry staff shall remove lint from dryer lint traps: After two dryer load, and At the end of each shift. 2. Daily Area Inspection - Laundry staff shall inspect and clean: lint traps dryer door seals floor area round dryers nearby surfaces where lint may accumulate. Documentation - A Dryer Lint Removal Log shall be maintained in the laundry area documenting: date time staff initial. Logs shall be reviewed periodically by the Environmental Services or Maintenance Supervisor. Staff Responsibility - Laundry staff are responsible for: proper dryer operation lint removal according to schedule reporting equipment problems.

Based on interview and record review, the facility failed to ensure dietary staff possessed required competencies (a combination of skills, knowledge, abilities, and behaviors that an individual needs to perform a job successfully) and certifications (an official document awarded by a professional organization verifying an individual's specific knowledge/skills required for a job) when the acting Dietary Manager (Manager J) was not certified to function in that position and did not have documented competencies of a Dietary Manager located in their employee file.These failures potentially prevented dietary staff from providing nourishing, palatable, and well-balanced diets that meet the daily nutritional and special dietary needs of residents.During an interview on 3/03/2026 at 11 a.m., Manager J stated he had been the Dietary Manager for two years.During a concurrent interview and record review on 3/05/2026 at 2:30 p.m., Dietary Consultant K reviewed the prior Registered Dietitian's (RD Q) kitchen inspection documentation titled, Sanitation and Food Safety Checklist, subtitled, General Sanitation and Safety, dated 11/23/25, that indicated, . 29. F/T [fulltime] Qualified Manager credentials meet Title 22/CMS (State and Federal) regulations: posted. Under subtitle, Comments, RD Q documented, DM [dietary manager] needs to be CDM [Certified Dietary Manager] or facility needs full-time RD. Dietary Consultant K confirmed Manager J was not certified (as a dietary manager).During a telephone interview on 3/06/2026 at 9:13 a.m., Consultant RD stated she thought Manager J was qualified (to function as a Dietary Manager). She stated if the facility did not have a qualified manager, they needed to employ a fulltime RD.During a concurrent interview and record review on 3/06/2026 at 11:40 a.m., Dietary Consultant K reviewed Manager J's competencies titled, Verification of Job Competency Demonstration - Cooks, dated 2023, and Competency Test for Cooks and FNS [food and nutrition services] Staff, dated 4/10/25, and confirmed the competency assessments were for cooks, not Dietary Managers.During an interview on 3/06/2026 at 11:47 a.m., the Administrator confirmed Manager J was not certified (to work as a Dietary Manager); she stated he was working as a high-level cook, really. The Administrator stated their current Consultant RD worked approximately five hours per week (she was not employed on a full-time basis at the facility).Review of facility policy titled, Personnel Management, dated 2018, indicated, . A qualified FNS (Food and Nutrition Services) Director, chosen by the Administrator, is responsible for the total operation of the Food & Nutrition Services Department. All Food & Nutrition service is performed under their direction.Review of facility job description titled, Job Description, subtitled, Position: FNS [Food and Nutrition Service] Director [Manager], further subtitled, Qualifications, dated 2023, indicated, 3. Must meet the qualifications of a FNS Director as stated under State & Federal regulations.Review of facility document titled, Facility Assessment, subtitled, Facility Resources, dated 7/26/25, indicated the facility required the following positions: Dietitian [RD]. 1 [number needed] . Food Service Manager. 1 [number needed] .

Based on observation, interview and record review, the facility failed to ensure infection prevention measures were implemented for a census of 32 when: 1. Enhanced [NAME] Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) were not implemented for three of 15 sampled residents (Resident 4, Resident 29, and Resident 35) with an indwelling medical device. Resident 4 with a central venous catheter (long, flexible tube inserted into a large vein and threaded to the heart for long-term delivery of medication, fluids, blood products, or nutrition), Resident 29 with a urinary catheter (a flexible tube inserted into the bladder used to drain urine), and Resident 35 with a suprapubic catheter (SP, a thin, flexible tube inserted into the bladder through a small abdominal incision used to drain urine). Effective 4/01/24, the Centers for Medicare Services mandated EBP, requiring gowns and gloves for high-contact care activities for residents with indwelling devices and wound care, and2. The facility did not have a current Legionella (a type of bacterium that thrives in warm, stagnant water within large HVAC [heating, ventilation, and air conditioning] systems and plumbing]) Water Test Program to prevent an outbreak of a pneumonia called Legionnaires' disease. These failures had the potential to cause the spread of infection among a vulnerable resident population.Findings: A review of Resident 4's admission Record (a facility demographic), dated 3/03/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (final, irreversible stage of chronic kidney disease, occurring when kidneys can no longer support life), dependence on renal dialysis (artificial process that filters waste, toxins, and excess fluid from the blood when kidneys have failed), immunodeficiency (the immune system is weakened or absent, making the body unable to effectively fight infections, viruses, and diseases), and urinary tract infection (infection in any part of the urinary system, including the kidneys, ureters, bladder and urethra). A review of Resident 4's Minimum Data Set (MDS-a federally mandated, standardized clinical assessment tool used in U.S. Medicare/Medicaid-certified nursing homes to evaluate resident functional, medical, and psychosocial status), dated 2/21/26, indicated Resident 4's memory was intact, and he was attentive and able to make independent decisions about daily life. A review of Resident 4's Order Summary Report, dated 3/11/26, indicated Resident 4 had a 2-lumen dialysis catheter (an invasive medical device with two separate channels that withdraws blood from the patient's body for dialysis filtration, then returns cleaned blood back into the patient's bloodstream) requiring care and monitoring. During an observation on 3/03/26 at 11:53 a.m., outside Resident 4's bedroom, no enhanced barrier precaution signage was posted, and no clean personal protective equipment (PPE, gloves, gowns, face shields) was present immediately outside the bedroom door. During an observation on 3/03/26 at12:31 p.m., Resident 29 was lying in her bed. There were no infection control precaution signs inside or outside of Resident 29's room and no PPE was located outside of her room. A review of Resident 29's MDS, dated [DATE], indicated she had an indwelling catheter. A review of Resident 35's admission Record, indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included neuromuscular dysfunction of bladder (loss of bladder control), and cystostomy (the surgical creation of an opening into the bladder, usually through the abdomen just above the pubic bone, to insert a catheter for urine drainage). Also known as a suprapubic (SP) catheter. A review of Resident 35's Order Summary Report, dated 3/2026, indicated Resident 35 had an order to change his SP catheter once every 2 weeks on Wednesday related to cystostomy status. The order indicated, Change Bi-monthly and if non-functioning or dislodged. May use 16Fr [French: size of catheter]/5-30ml [milliliter: balloon capacity for keeping catheter in place] size, start date, 12/31/25. A review of Resident 35's care plan, initiated on 10/24/25, indicated Resident 35 had recurring urinary tract infections related to abusive treatment and poor hygiene techniques of his SP catheter related to dementia (memory loss that gets worse over time). During an observation on 3/03/26 at 2:55 p.m., Resident 35 was transferring himself from his wheelchair to his bed. Resident 35's SP catheter bag was on the floor. Resident 35 stated he thought catheter bag was still hanging on his wheelchair. There was no signage outside Resident 35's room to indicate he was on EBP and no implementation of PPE setup outside Resident 35's room. During an observation on 3/05/26 at 2:14 p.m., Resident 35 had no EBP signage posted outside his room and no PPE cart set up. During an interview on 3/05/26 at 7:45 a.m., the Director of Nursing (DON) stated he was not familiar with EBP. The DON stated he did not know that the standard of practice was to have signage posted outside resident rooms and PPE carts set up for residents who had an indwelling medical device such as a SP catheter, [urinary] catheter, central line, feeding tubes (delivers essential nutrients, fluids, and medications directly into the stomach or small intestine for individuals unable to take adequate nutrition by mouth), and wound care. The DON stated that was a hole in the facility's Infection Control Practice. The DON stated nurses and Certified Nursing Assistants (CNAs) had not been in-serviced on EBP and the Infection Preventionist Nurse (IPN, a licensed nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) had not been setting up the residents' rooms for EBP. During an interview on 3/05/26 at 4:30 p.m., the Administrator did not realize residents with indwelling medical devices and/or with wound care should have EBP implemented. The Administrator stated she did not know that EBP signage should be posted outside those residents' rooms and PPE carts set up so staff giving direct care not only used gloves but disposable gowns as well to prevent the spread of infections. During an interview on 3/05/26 at 4:45 p.m., Certified Nursing Assistant (CNA) A and CNA B both stated they had not heard of EBP. They stated they had never seen signage posted to indicate a resident was on EBP and were not aware they should be wearing a disposable gown in addition to disposable gloves when providing personal care to a resident with a [urinary] catheter or a resident with a wound such as a pressure ulcer (PU, a localized damage to the skin and underlying soft tissue caused by prolonged, unrelieved pressure). CNA A and CNA B both stated they had never seen an IPN employed at the facility. CNA B stated she had never met the facility's IPN consultant. During an interview on 3/06/26 at 8:45 a.m., the DON stated nurses did have to flush Resident 35's SP catheter because of the buildup of sediment (appearing as cloudy, white particles, or sand-like grains) in Resident 35's urine, which could block the flow of urine through his SP catheter. The DON stated there was an order to change Resident 35's SP catheter routinely to prevent the blockage of urine flowing through his SP catheter. The DON stated because of Resident 35'd dementia, he would pull at his SP catheter, roll over the tubing with his wheelchair and even tie knots in the catheter tubing. The DON stated gloves were worn when Resident 35's SP catheter was flushed or changed but no disposable gown was worn. The DON stated he was not aware of the EBP recommendations that went into place. A review of the undated facility policy & procedure (P & P) titled, Enhanced Barrier Precautions – Policy Summary, indicated, Purpose: To reduce transmission of multidrug-resistant organisms and other epidemiologically important pathogens in the facility by implementing EBP during high-contact resident care activities. Guidance follows recommendations from the Centers for Disease Control and Prevention and regulatory expectations from the Centers for Medicare & Medicaid Services. EBP should be implemented for residents who: 1. are colonized [a person who carries multidrug-resistant organisms on or in their body without experiencing symptoms of illness] or infected with MDROs. 2. Have wounds, indwelling medical devices, or invasive lines and 3. Are identified by Infection Prevention as needing additional precautions. PPE – Staff must wear gloves and gown when performing high-contact resident care activities, including: 1. wound care, 2. dressing or bathing assistance, 3. transferring residents, 4. changing linens, and 5. device care [catheter, feeding tube, etc.]. Residents requiring EBP will have door signage indicating required PPE. 2. During a concurrent interview and record review on 3/04/26 at 10:54 a.m., with the Administrator (ADM), [Laboratory] Water Testing Results, dated 2/25/25, were reviewed. The ADM acknowledged testing for Legionella was not included in the test results and stated, I cannot find a place that does this testing. During a concurrent interview and record review on 3/06/26 at 2 p.m. with the Building Manager (Manager M), a binder containing water monitoring information was reviewed. The binder contained water temperature logs, emergency drinking water information, Legionella testing/emergency water management policy, and bacterial testing results of water for the year 2024. In the water management task log, it indicated the last facility water samples were sent for bacterial analysis in April 2024. In addition, this log indicated no other water management tasks had been completed since April 2024. Manager M did not provide any further documentation that any water management program activities took place in the facility after April 2024. A review of the facility P & P titled, Legionella Testing, Maintenance and Record Keeping, dated 8/01/20, indicated, At least annually Legionella specific testing will be completed by maintenance.at least annually every shower head and hose will be replaced.all sinks in resident bathrooms, kitchen, common bathrooms, and utility rooms will have aerators removed and cleaned with approved cleaner to kill Legionella bacteria.Ice machine will be cleaned and sanitized at least quarterly as per manufacturer's instructions.Water heaters will be drained and flushed at least annually.Maintenance supervisor will be responsible to maintain logs for the Legionella testing.

Based on interview and document review, the facility failed to comply with its Assurance Performance Improvement (QAPI, the process that will guide the nursing home's efforts in assuring care and services are continually improved upon) program by not having the mandated Infection Preventionist (IP, a licensed nurse responsible for designing, implementing, and managing programs that prevent the spread of infections within health care facilities) preset at the recert quarterly meeting, thereby, not meeting the required membership for the program.This failure could have resulted in the facility's inability to identify critical infection control issues, develop appropriate corrective plans, implement those strategies and monitor their effectiveness, all of which had the potential to negatively impact resident health and overall outcomes.Findings:During an interview on 3/05/26 at 4 :50 p.m., the Administrator (Adm.) stated the facility did not have an IP.During an interview on 3/06/26 at 9:15 a.m., the Adm. stated there had not been an IP in the facility since 10/2025. During an interview on 3/06/26 at 2:44 p.m., the Adm. stated she gave the surveyor a list of the QAPI Committee Members who should be attending the quarterly QAPI meetings. The Adm. stated the IP should have been attending the Quarterly QAPI Committee Meetings.A review of the QAPI document titled, QA/QAPI Committee Members: Quarterly, revised 3/01/26, indicated the IP was on the committee.A review of the Quarterly QA Meeting, sign in sheets, dated 4/29/25, 8/12/25, 12/9/25 and 2/24/26, indicated the IP was not in attendance for the 2/24/26 quarterly QA Meeting.

Based on observation, interview and record review, the facility failed to ensure food was prepared in a manner to maintain nutritive value and palatability (food that has a pleasant, agreeable taste and is enjoyable to eat ) for four of thirteen sampled residents (Resident 4, Resident 35, Resident 5, and Resident 27), in a census of 34, when vegetables were cooked for approximately one hour and held on a steam table (box-like table where food is kept warm by steam or hot water circulating beneath) for approximately one additional hour.These failures caused Resident 4 and Resident 35 to feel unhappy, Resident 5 to decrease her food intake and potentially lose weight, Resident 27 to experience diarrhea, and potentially decreased the nutritive value and palatability of foods being served, thereby negatively impacting heath status and quality of life for residents. During a concurrent observation and interview on 3/03/26 at 11:10 a.m., [NAME] H identified the food items located in the steam table as meat and vegetable lasagna prepared that day, green beans, mashed potatoes and gravy. She stated the food was set on the steam table at 11 a.m. and lunch service began at 12 noon. During an interview on 3/03/26 at 11:53 a.m., Resident 4 expressed her unhappiness with facility food, stating she was served runny eggs every day. Resident 4 also stated she was not offered substitutions after notifying the facility about this issue. During an interview on 3/03/26 at 12:53 p.m., Resident 35 stated the food was, institutional-like (refers to food served in public settings such as schools, hospitals, and senior living facilities) and the green beans were overcooked on that particular day. During a phone interview on 3/03/26 at 2:13 p.m., Resident 5's Responsible Party (RP) stated facility food had not been good since 2024, and Resident 5 doesn't eat much of it. In addition, Resident 5's RP stated he feared the resident might have lost weight because of the poor food quality. During an interview on 3/04/26 at 10:00 a.m., Resident 27 stated she was often served food she should not eat because of her medical conditions. Resident 27 stated facility food often gave her diarrhea, and when she complained to staff about her concerns she was not offered substitutions. During an observation on 3/05/26 at 9:35 a.m., mixed vegetables and green beans were placed in separate pots containing water and positioned over heat on the stovetop. At the time of the observation, neither pot had reached boiling point. During an observation on 3/05/26 at 9:50 a.m., the green beans were boiling. During an observation on 3/05/26 at 10 a.m., the green beans were boiling in their pot and the mixed vegetables were almost boiling. During an observation on 3/05/26 at 10:35 a.m., the mixed vegetables were taken off the stove, drained, and put onto the steam table. The green beans remained in their pot of hot water, but they were no longer boiling. During an observation on 3/05/26 at 11 a.m., [NAME] H drained the green beans and subsequently placed them on the steam table at 11:05 a.m. During an observation on 3/05/26 at 11:50 a.m., staff began plating the lunch meals for the residents. During a concurrent interview and observation on 3/05/26 at 12:15 p.m., Manager J, Dietary Consultant K and a surveyor performed a taste test of the lunch meal. Manager J conducted food temperature checks, recording the fish at 149 degrees F (Fahrenheit), the mixed vegetables at 146 degrees F, and the green beans at 132 degrees F. Dietary Consultant K stated the fish was a little fishy-tasting and it seemed like it was at room temperature. Consultant K also stated the green beans were cold. The surveyor stated the mixed vegetables were soggy while Consultant K did not offer additional comments regarding this observation. Manager J stated vegetables could be cooked for half an hour, but Consultant K stated they should be cooked for ten minutes. Consultant K stated that cooking vegetables for about one hour, followed by holding them on a steam table for another hour, was not okay. Consultant K stated overcooking vegetables and storing them for extended periods of time on the steam table could decrease the nutrition and flavor of food. Additionally, she stated cooks should follow the recipe. During a telephone interview on 3/06/26 at 9:13 a.m., the Consultant Registered Dietitian (RD) stated there was a good chance vegetables would be overcooked if they were cooked for one hour and then held on a steam table for another hour. She stated that this process might diminish the nutritional value of vegetables due to overcooking; negatively impact palatability and cause a loss of color and texture. The RD further clarified that her expectation was for food to remain on the steam table for no longer than thirty minutes. During a review of the facility's recipe titled, Green Beans with Red Peppers, dated 2026, the recipe indicated, . 1. Heat green beans and drain them well. 4. Serve on trayline at recommended temperature of 160 degrees F - 180 degrees F. A review of facility recipe titled, Stir Fry Vegetables, dated 2026, indicated, . 2.boil. until soft. 4. Serve on trayline at recommended temperature of 160 degrees F - 180 degrees F. A review of facility policy titled, Food Preparation, subtitled, Preparation of Vegetables, dated 2018, indicated, . 2. [NAME] vegetables in small amount of water for a short amount of time. 4. Serve vegetables promptly. Do not hold on the steam table for long periods of time.

Based on observation, interview and record review, the facility failed to store drugs and biologicals safely for a census of 32 residents when a medication cart and a treatment cart were left unlocked and unattended in the facility's lounge room, accessible to residents. Additionally, a second medication cart was observed locked in a hallway outside residents' rooms, with its keys left unattended on top of the cart.These failures could have resulted in unauthorized access to medications by residents leading to accidental ingestion of medications, risk of injuries, contaminated medications, and theft or misuse of controlled substances by residents and staff.During an observation on 3/04/26 at 7:14 a.m., Licensed Nurse L (LN L) was seen preparing morning medications at medication cart #1, in a lounge area containing a total of two medication carts and a treatment cart. The Director of Nursing (DON) entered the room, unlocked medication cart #2, placed some medications inside, and walked out without locking cart #2 again. LN L then locked cart #1 and walked out of the room as well. All three carts were left unattended, and it was noted that cart #2 and one of the treatments carts were left unlocked. During a concurrent observation and interview on 3/04/26 at 7:16 a.m., LN L returned to the lounge area, where it was pointed out that cart #2 and the treatment cart were both observed unlocked and unattended for a period of time. LN L stated residents were allowed to come into the lounge area if they wanted, to sit and, look out the windows. Upon inspection, the treatment cart contained several topical medications (external preparations for skin application) along with scissors and other sharp instruments and equipment. LN L explained that the DON forgot to lock cart #2 after placing medications inside. LN L further acknowledged that all carts should have been locked before staff left them unattended in any area accessible to residents.During an observation on 3/04/26 at 1:49 p.m. the treatment cart in the lounge area was again found unlocked and unattended. LN L stated this cart should always be locked because residents could open drawers and remove items that could harm them.During an observation on 3/05/26 at 10:30 a.m., in the facility hallway outside a Resident's room, a locked, unattended medication cart was seen. The medication cart keys, along with some medications and bandages were observed on top of the cart. After no nurses were present for about five minutes, the DON was notified. The DON confirmed that leaving keys on an unattended medication cart was unsafe and against facility policy.During a review of the facility policy and procedure (P & P) titled, Storage of Medications, dated 2007, indicated Compartments containing drugs and biologicals will be locked when not in use, and trays or carts used to transport such items will not be left unattended if open or otherwise available to others.only persons authorized to prepare and administer medications shall have access to the medication room, including the keys.

Based on observation, interview and record review, the facility Quality Assurance Performance Improvement/Quality Assessment and Assurance (QAPI/QAA, a program that involves a systematic approach to quality assurance and performance improvement designed to identify areas of improvement and develop strategies to improve the quality of care provided to the residents) program failed to identify system-wide problems to correct quality deficiencies when:Since 10/26 through 3/06/26 (see Cross Reference F880 and F882), the facility had not employed an Infection Prevention Nurse (IPN), responsible for overseeing potential infection risks, safeguarding residents' health, and providing staff education on infection prevention measures,2. Enhanced [NAME] Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) were not implemented for three of 15 sampled residents (4, 29, and 35) who had indwelling medical devices (instruments placed inside the body to assist with diagnostic, monitoring, or therapeutic functions),3. The facility did not maintain an updated Legionella (harmful bacteria) Water Test Program, to prevent the occurrence of Legionnaires' disease (a form of pneumonia caused by Legionella bacteria that thrive in warm, stagnant water within large heating, ventilation, and air conditioning systems) posing a significant risk to the health of residents (See Cross Reference F880), and;4. The facility had not employed a qualified Dietary Manager (DM) for more than a year (Cross Reference 801). These deficient practices had the potential to negatively impact the residents' safety, care and outcomes. Findings:During a concurrent interview and record review on 3/06/26 at 1:19 p.m. with the Administrator, a review of the facility's QAPI action plans did not address the systemic issues of non-compliance identified during the survey. Specifically, there were no QAPI/QAA plans or programs to resolve the following concerns: 1) Absence of an IPN; 2) Insufficient staff in-service training regarding EBP; 3) Lack of implementation of measures to prevent Legionella growth; and 4) Absence of a qualified RD. The Administrator confirmed these findings.A review of the facility's document titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 7/26/25, indicated, Guiding Principles: #4: QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals. Guiding Principle #5: Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, healthcare practitioners, families, and other stakeholders. Guiding Principle #6: Our organization sets goals for performance and measures progress toward those goals.

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 5) addressing weight refusals within seven days of a resident assessment indicating this issue.This failure could have resulted in the inability for staff to identify underlying reasons for weight refusals, offer alternatives, and mitigate health risks related to weight fluctuations. This oversight could have resulted in missed detection of nutritional decline for Resident 5, potentially leading to significant clinical complications. A review of Resident 5's admission Record (a facility demographic), dated 3/03/26, indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including depression, severe protein-calorie malnutrition (a life-threatening deficiency of protein, carbohydrates, and fats resulting in severe muscle wasting, fat loss, or extreme fluid retention), anemia (when low red blood cell levels reduce oxygen transport to tissues, causing fatigue, pale skin, and dizziness), delusional disorders (one or more persistent, fixed, false beliefs lasting at least one month), and muscle weakness.A review of Resident 5's Minimum Data Set (MDS-a federally mandated, standardized clinical assessment tool used in U.S. Medicare/Medicaid-certified nursing homes to evaluate resident functional, medical, and psychosocial status), dated 1/02/26, indicated Resident 5 had severe cognitive impairment, exhibited delusions, and had rejected treatment or care occasionally.A review of Resident 5's Progress Note, dated 2/04/26, indicated, patient again refused to be weighed. This is an ongoing issue for us.During a phone interview on 3/03/26 at 2:30 p.m., Resident 5's Responsible Party (RP) stated facility food was, really not that great, and that Resident 5, doesn't eat that much of it.During a concurrent interview and record review on 3/06/26 at 11:30 a.m. with the Director of Nursing (DON), the weight history and care plans for Resident 5 were reviewed. The DON agreed that Resident 5 had been refusing weights since last year. When asked if care planning had been implemented for these refusals, the DON replied, what should I have care planned? When asked if any education, counseling or family involvement had been documented as a possible solution, the DON replied, that could have been part of a care plan for this problem.A review of Resident 5's Weights and Vitals Summary, dated 3/11/26, indicated the last recorded weight for Resident 5 was 145 lbs. on 11/13/25.During a review of the facility policy and procedure (P & P) titled, Weighing and Measuring the Resident, dated 2011, indicated, the purpose of the procedure is to determine the height and weight, to provide a baseline and an ongoing record of the resident's body weight as an indicator of nutritional status and medical condition of the resident.documentation: if the resident refuses the procedure, the reasons why and interventions taken.notify the Nurse Supervisor if the resident refuses the procedure.A review of the facility P & P titled, Care Area Assessments, dated 2011, indicated, decisions about the care plan.evaluate resident's goals.design interventions.establish which items need further assessment or additional review.document interventions.include recommendations for monitoring and follow-up timeframes.

Based on interview and record review, the facility failed to develop care plans for one of six sampled residents (Resident 4), who suffered insomnia (inability to sleep) and was being administered an antipsychotic medication (a medication to treat mental illness and used off-label for insomnia symptoms) which required closed monitoring.These findings had the potential to result in increased physical and psychological symptoms associated with insomnia, and inability to track or monitor possible harmful side effects of antipsychotics. A review of Resident 4's admission Record (facility demographic), dated 3/03/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition where blood supply to part of the brain is blocked or reduced), borderline personality disorder (characterized by long-term instability in emotions, behavior, relationships, and self-image), and circadian rhythm sleep disorder (sleep disruptions occurring when the internal body clock misaligns with environmental cues or social schedules).A review of Resident 4's Minimum Data Set (MDS-a federally mandated, standardized clinical assessment tool used in U.S. Medicare/Medicaid-certified nursing homes to evaluate resident functional, medical, and psychosocial status), dated 2/21/26, indicated Resident 4's memory was intact, and she was able to independently make decisions about daily life.A review of Resident 4's Medication Administration Record, dated 3/05/26, indicated Resident 4 was administered Trazodone HCI (trazodone hydrochloride - a prescription antidepressant used mainly to treat major depressive disorder and off-label for insomnia) oral (by mouth) tablet 50 mg (milligram-a unit of measure) nightly for insomnia. The start date for this medication was 2/26/26.A concurrent interview and record review on 3/06/26 at 10:50 a.m. with the Director of Nursing (DON), Resident 4's care plans were reviewed. The DON acknowledged there were no nursing care plans initiated for the monitoring of Resident 4's psychotropic (antipsychotic) drug administration, including monitoring for signs and symptoms of overdose and/or unwanted side effects. In addition, the DON acknowledged there was no past or current care plan for the management and treatment of Resident 4's insomnia. The DON stated that these care plans should have been started to monitor Resident 4's treatment, to consider non-pharmacological interventions, and to prevent harm.A review of facility policy and procedure (P & P) titled, Care Area Assessments, dated 2011, indicated, decisions about the care plan.evaluate resident's goals.design interventions.establish which items need further assessment or additional review.document interventions.include recommendations for monitoring and follow-up timeframes.

Based on interview and record review, the facility failed to monitor the side effects of a psychotropic medication (a medication that influences brain chemistry to help treat mental health conditions by affecting mood, thoughts, behaviors, and perceptions. These types of medications may be hazardous because they carry a significant risk of severe side effects) for one of six residents (Resident 4) despite recommendations from a pharmacist and a subsequent review by the facility physician.This finding had the potential to result in inability for staff to identify significant side effects of the medication which could have resulted in serious harm for Resident 4. A review of Resident 4's admission Record (a facility demographic) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (condition where the blood supply to part of the brain is blocked or reduced), borderline personality disorder (characterized by long-term instability in emotions, behavior, relationships, and self-image), and circadian rhythm sleep disorder (sleep disruptions occurring when your internal body clock misaligns with environmental cues or social schedules).A review of Resident 4's Minimum Data Set (MDS-a federally mandated, standardized clinical assessment tool used in U.S. Medicare/Medicaid-certified nursing homes to evaluate resident functional, medical, and psychosocial status), dated 2/21/26, indicated Resident 4's memory was intact, was attentive, and was able to independently make decisions about daily life.A review of Resident 4's Medication Administration Record, dated 3/5/26, indicated Resident 4 was administered Trazodone HCI (trazodone hydrochloride - a prescription antidepressant used mainly to treat major depressive disorder and off-label for insomnia) oral (by mouth) tablet 50 mg (milligram-a unit of measure) nightly for insomnia. The start date for this medication was 2/26/26.A review of Resident 4's facility Consultant Pharmacist Medication Regimen Review, dated 1/07/26, indicated, CURRENT ORDER: Trazodone 50 mg po qHS [at every bedtime] for insomnia.RECOMMENDATION: Please include monitoring for side effects and behaviors for psychotropic above.During a concurrent interview and record review on 3/05/26 at 12:30 p.m. with the Director of Nursing (DON), Resident 4's Medication Administration Record was reviewed. The DON agreed monitoring for behaviors and side effects of trazodone were not ordered and therefore this task could not be assumed to be completed by nursing staff. During a subsequent interview on 3/06/26 at 10:50 a.m. with the DON, he stated nurses should have been monitoring for side effects of trazodone, including serotonin syndrome (a potentially life-threatening chemical drug reaction in the brain; symptoms include shivering, diarrhea, and fever, severe muscle rigidity, seizures, and unconsciousness), constipation, and suicidal ideations (having ideas or ruminations about the possibility of dying by suicide).During a review of the undated facility policy and procedure (P & P) titled, Psychotropic Medication Policy and Procedure, indicated, Nursing: Monitors psychotropic drug use daily noting any adverse side effects such as increased somnolence or functional decline.will monitor for presence of target behaviors on a daily basis.

Based on interview and record review, the facility failed to obtain signed consents for two of two sampled residents (Resident 2 and Resident 4), who were routinely administered psychotropic medications (also called antipsychotic medications used to treat mental health disorders), when:1. Resident 2's Seroquel (medication used to manage behavioral symptoms like agitation, aggression, or hallucinations [false perception of objects or events involving the senses]) dose went from 25 milligrams (mg) to 50 mg in the morning and 75 mg to 100 mg in the evening without Resident 2's consent, and;2. Resident 4 received trazodone (an anti-depressant used off-label for sleeplessness) to treat insomnia prior to her Responsible Party (RP, and individual designated to make certain decisions for a nursing home resident) giving written informed consent.These failures may have resulted in RPs receiving insufficient information regarding the significant risks associated with these antipsychotics, such as increased mortality among elderly dementia patients. As a result, RPs may have been unable to effectively make informed decisions, potentially allowing antipsychotics to be used for staff convenience instead of legitimate psychiatric indications.Findings: A review of Resident 4's admission Record (facility demographic) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including alcohol use, alcohol induced dementia, delusional (false beliefs) disorder, and bipolar (intense mood swings) disorder. During a concurrent interview and record review on 3/05/26 at 10:24 a.m., and at 1:10 p.m., with the Director of Nursing (DON), Resident 2's Informed Consent Verification, signed by the DON on 5/01/25 and by the physician on 5/20/25, indicated Seroquel 25 mg and Seroquel 75 mg were discussed with Resident 2. Resident 2's Medical Administration Record (MAR), and Order Summary Report, dated 3/20/25, indicated Resident 2 was to receive Seroquel 50 mg in the morning, starting on 10/29/25 and Seroquel 100 mg at bedtime, starting on 10/29/25. The DON acknowledged this information and stated he should have completed a new informed consent since Resident 2's Seroquel was increased on 10/29/25. A review of Resident 2's, Order Summary Report, dated 10/29/25, indicated, Patient has capacity to make medical decisions, order date, 12/03/19. A review of the facility document titled, Informed Consent Verification, indicated, This form is completed when initiating the use of, or increasing the dosage of a psychotherapeutic drug. 2. A review of Resident 4's admission Record dated 3/03/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition when blood supply to part of the brain is blocked or reduced), borderline personality disorder (characterized by long-term instability in emotions, behavior, relationships, and self-image), and circadian rhythm sleep disorder (sleep disruptions occurring when your internal body clock misaligns with environmental cues or social schedules). A review of Resident 4's Minimum Data Set (MDS-a federally mandated, standardized clinical assessment tool used in U.S. Medicare/Medicaid-certified nursing homes to evaluate resident functional, medical, and psychosocial status), dated 2/21/26, indicated Resident 4's memory was intact, and she was able to independently make decisions about daily life. A review of Resident 4's MAR dated 3/05/26, indicated Resident 4 was administered Trazadone HCI (trazodone hydrochloride, a prescription antidepressant used mainly to treat major depressive disorder and off-label for insomnia) oral (by mouth) tablet 50 mg (milligram-a unit of measure) nightly for insomnia. The start date for this medication was 2/26/26. During a concurrent interview and record review on 3/06/26 at 10:50 a.m. with the DON, the electronic medical record and hardcopy medical documentation binder for Resident 4 were reviewed. No informed consent document signed by Resident 4 or Resident 4's RP was found in either location, and the DON acknowledged it was not completed. During a review of facility undated policy and procedure (P & P) titled, Addendum to Psychotropic Drug Use Policy – Informed Consent, indicated, the facility's licensed nurse shall verify that the physician has obtained informed consent prior to the initiation of a antipsychotic or other psychotherapeutic medication; and prior to the increase in dosage of an antipsychotic medication.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean and sanitary condition for a census of 31 residents when food debris and dried liquids were present on the floor in food preparation and dishwashing areas, and a dust-covered fan was blowing onto clean utensils.This failure increased the risk of food contamination, pest attraction, and food borne illnesses for the residents of the facility.During an observation of the kitchen on 2/05/26 at 10:29 a.m., dried liquids were noted on the floor in front of the refrigerator. The floor under the refrigerators and the stove and along the baseboards was visibly soiled with food crumbs and dried food debris. The debris extended along the wall-floor seam into multiple areas. In the dish room area of the kitchen, a fan with a buildup of dark-colored dust was blowing onto clean utensils and other clean dishes on the clean side of the dishwasher deck.During a concurrent observation and interview in the kitchen on 2/05/26 at 12:30 p.m. with the Dietary Manager, the surveyor showed him the food debris build up under the refrigerators and stove. The Dietary Manager stated the evening staff were supposed to clean the floor. When asked when the floor was last cleaned, the Dietary Manager was unable to answer. When asked whether the floor met his standard of cleanliness, the Dietary Manager stated it did not meet his expectations of cleanliness. The Dietary Manager stated floors that were not clean and sanitary could attract pests (insects or rodents) and cause illness to residents.During a concurrent observation and interview on 2/05/26 at 12:48 p.m., the Infection Preventionist (IP) acknowledged the floors were visibly soiled and observed the fan blowing toward clean utensils in the dish room area.A review of the kitchen cleaning assignment and log for the month of January 2026, indicated daily cleaning tasks for the AM (morning) cook, PM (evening) cook, and dietary aide included cleaning the coffee machine, refrigerators, microwave, housekeeping closet, utility carts, trash cans, and stove; however, cleaning the kitchen floors was not listed on the cleaning log.During an interview on 2/5/26 at 3:32 p.m., [NAME] 2 stated cleaning the floors was not her job and stated the floors were not cleaned the previous night. [NAME] 2 was unable to identify which staff member was responsible for cleaning the kitchen floors on a regular basis.A review of the facility policy titled, General Cleaning of Food & Nutrition Services Department, dated 2023, indicated, kitchen floors must be mopped at least once per day, and described the procedure for correctly sweeping and mopping kitchen floors.

Based on interview and record review, the facility failed to prevent one of two sampled residents (Resident 3) from an avoidable fall, when Resident 3, assessed as high risk for falls, was found on the floor by the bathroom after she had attempted to transfer and ambulate without one staff assistance and supervision to prevent falls. This failure resulted in Resident 3 sustaining a left femoral neck fracture (left hip fracture) that required surgical repair placing Resident 3 at risk for surgical complications including pain, infection, and decreased mobility. Findings: A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in July 2024 with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following intracranial bleed (bleeding in the brain), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), heart failure (heart disorder which causes the heart to not pump the blood efficiently), and diabetes (disorder characterized by difficulty in blood sugar control). A review of Resident 3's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/16/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 8 out of 15 that indicated Resident 3 was moderately cognitively impaired, Resident 3 required one person staff assistance for toileting needs and mobility. A review of Resident 3's Morse Fall Scale [tool to assess risk for falling], dated 7/10 24, indicated Resident 3 was at a high risk for falling. A review of Resident 3's Progress Note, dated 7/10/24 at 2:35 p.m., indicated . Patient arrived here at approximately 1500 [3:00 p.m.] . She is a 85 yr [year] old female, alert and oriented x 2 [person and place], no obvious acute distress, she speaks only [name of language spoken]. She had a prior CVA [Cerebrovascular Accident- stroke- disrupted blood flow to the brain causing brain tissue death] with Left sided weakness and she is a max [maximum] assist for most ADLs [Activities of Daily Living] with setup for meals .She is incontinent of both bowel and bladder.she has a dx. [diagnosis] of schizoaffective d/o [disorder, mental illness] and has a very flat affect .She is a high fall risk, and we will have various family members sit with her as much as possible and every night. Call light in place as well as her bed control, Fx [fracture mats, padded mats to reduce injury from falls] pads placed on each side of the bed with the bed in its lowest position . A review of Resident's 3's Progress Note, dated 10/2/24 at 5:22 p.m., indicated .Writer was assisting Activities in the Dining room yesterday around 5pm and today around 4pm. On both days, [Resident 3] became agitated, tearful and exhibited some unsafe behaviors ie [that is]- trying to get out of her wheelchair unassisted and asking hysterically to leave and go find her family. She was inconsolable. She believes she should be leaving to go find her family and her house . A review of Resident 3's Progress Note, dated 10/6/24 at 12:50 p.m., indicated .Pt [Patient] was found on floor, complained of left hip and cranial [skull] pain. Slightly confused and could not explain how she fell .Pt was transferred to hospital to r/o [rule out] fracture . A review of Resident 3's Progress Note, dated 10/6/24 at 4:27 a.m., indicated .pt was observed on the floor by the bathroom, on 10/5, @ 2350 [at 11:50 p.m.], was slightly confused from her baseline. she was not sure how she fell . complained of left hip pain which got severe with movement .Also complained of left cranial [skull, head] pain no skin tear observed, Little elevated VS [ measurements of basic functions of the body] (168/99) [blood pressure, high], and pulse (116) [heart rate, high] .Transferred to hospital to r/o Fracture . A review of Resident 3's Progress Note, dated 10/6/24 at 12:14 p.m., indicated .There are several factors that contributed to the fall on 10/4/24: 1) The family did not want to continue the Seroquel [antipsychotic medication-medication to treat schizophrenia and mental health disorders] and therefore this was discontinued. The purpose of this medication was nightly active visual hallucinations and delusions for which the Seroquel was managing effectively and allowed this patient to have more effective sleep patterns. With out it she was unable to sleep as these symptoms overwhelmed the patient preventing sleep and increasing unsafe responses. 2) In the admission agreement, the family agreed to be present in the room allowing a nightly 1:1 [one-to-one sitter with resident to keep safe] to ensure the patient did not get off bed w/o [without] assistance and manage any other unsafe behaviors that would occur w/o constant supervision. This agreement was not continued for various family reasons leaving this safety support vacant. Finally, I had requested that [Physician] review, and if necessary, add another medication modality or increase the current dosage to alleviate our staff from spending excessive amounts of time to ensure the patient was safe and to strive for the best sleep patterns possible and his response is pending but did not occur d/t [due to] the family not wanting to continue the medication . A review of Resident 3's PT [Physical Therapy] Recert [Recertification, Progress Report & Updated Therapy Plan, dated10/5/24, indicated Resident 3 had decreased balance, decreased functional capacity. A review of Resident 3's Discharge Summary from hospital, dated 10/10/24, indicated Final Diagnosis: .Left displaced femoral neck fracture .Status post left hip hemiarthroplasty [surgical procedure to replace the hip with a prosthetic implant- artificial hip joint] . A review of Resident 3's Care Plan initiated 7/10/24 .Fall. Potential For D/T [due to] Impaired Gait, Impaired Balance r/t [related to] CVA w/ [with] left sided weakness. sundowner sx [symptoms such as behavioral and emotional changes that occur in people with dementia when the sun sets], difficulty to re-direct, non-compliance with agitation .Interventions .Provide staff assistance as needed for support and balance while resident is standing at bedside .Provide staff assistance of one person as needed for any Transfer activity .Observe resident for attempting to get out of bed, or attempting a self-transfer without staff assistance. Offer to assist the resident to the bathroom for a toileting activity before assisting the resident back to bed .Observe the resident closely for any unsafe actions or activities. Take actions as needed to minimize the risk of harm .Observe the resident closely for impulsive behaviors that put the resident at risk for falls. Take prompt actions as needed to minimize the risk of falls and harm . During an interview on 2/12/25 at 12:27 p.m. with the Director of Nursing (DON), the DON stated Resident 3 fell on [DATE] at approximately midnight. Resident 3 was found on the floor near the bathroom by the nurse. The DON stated Resident 3 complained of hip pain and was transferred to the hospital where an x-ray confirmed a left hip fracture. The DON stated Resident 3 was alert and oriented only to her name and place, was a fall risk, had a history of climbing out of bed at night, and had one or two falls prior to the fall on 10/5/24. The DON stated that Resident 3's family had agreed, upon admission to the facility, to stay with Resident 3 overnight in Resident 3's room to act as a one to one sitter but had stopped coming in to stay with Resident 3. The DON stated the family was not expected to stay with her any longer so Resident 3 was moved closer to the nurse's station. The DON stated several factors contributed to Resident 3's fall including dementia, a current urinary tract infection (bladder infection) that increased her confusion, and discontinuation of psychotropic medications [medications to treat mental health conditions], per family request, that controlled her delusions and hallucinations which increased her anxiety. The DON also stated Resident 3 had urge incontinence (an urgent, uncontrollable need to urinate frequently) so she wanted to get up every fifteen minutes to go to the bathroom. The DON further stated, In a perfect world, would have had one- to- one sitter. It was not possible due to staffing [not enough staff]. During an interview on 2/12/25 at 2:19 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 3 was confused and had sundowner's syndrome at night. CNA 1 stated that Resident 3 was able to move herself to the end of the bed and maneuver out of bed. CNA 1 stated Resident 3 was not able to use her call light [to call for help]. CNA 1 stated when Resident 3 returned to facility after hip fracture, the staff offered her a bedpan which helped keep her in bed. During an interview on 2/12/25 at 2:44 p.m. with the Physical Therapist (PT), the PT stated Resident 3 was a high fall risk due to decreased safety awareness and needed lots of care for safety. During a concurrent interview and record on 2/12/25 at 3:00 p.m. with the DON, the DON acknowledged that Resident 3's Morse Fall Scale, dated 7/10/24, indicated Resident 3 was a high fall risk. The DON stated that interventions to prevent falls were that bed was kept in lowest position and fracture mats were at bedside. When asked what other interventions or measures could have been used to prevent fall since family was no longer staying with Resident 3, the DON stated, One- to- one would have been ideal. Not done due to staffing. Family pulled out of agreement to provide one- to- one sitter. That agreement was made with family in order to accept resident at facility .The Administrator made that agreement because it was a big risk accepting her. A review of the facility's Policy and Procedure (P&P) titled Fall Risk Assessment, revised 12/2007, indicated .The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls .The staff will look for evidence of a possible link between the onset of falling .and recent changes in the current medication regimen .Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls .The staff .will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try and minimize the consequences of risk factors that are not modifiable . A review of the facility's P&P titled Falls and Fall Risk, Managing, revised 12/2007, indicated .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 placed Resident 1's hand on her genital area without Resident 1's consent. This failure resulted in Resident 1 experiencing emotional distress. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Care Plan indicated, .The resident has impaired cognitive function; impaired thought processes r/t [related to] dementia . initiated 7/24/24, indicated .Interventions .Keep the resident's routine consistent . A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. [resident's name] was pleasant, polite and cooperative throughout our conversation and he continued to smile and was friendly. He did not exhibit any signs or symptoms of anxiety or distress right after the incident . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation . A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [LN1] that while [Resident 2] was seated in the hallway near t[Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [ at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, but mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional distress for Resident 1 and behaviors for Resident 2 was initiated. During an interview on 2/12/14 at 12:19 with the Social Services Director (SSD), the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated that nurses should chart monitoring for 72 hours after incident. During a concurrent interview and record review on 2/12/25 at 3:00 p.m. with the Director of Nursing (DON), the DON acknowledged that nursing staff did not document monitoring for emotional distress for Resident 1 or for behaviors for Resident 2 for 72 hours after incident. The DON stated it was the expectation that nurses monitor and chart in the progress notes for 72 hours after incident. The DON also acknowledged that Resident 1 did not have a care plan created for this incident, and it should have been created by nursing at the time of the incident. The DON stated that facility uses traveling nurses frequently and procedures may not have been followed. A review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program, revised 8/2006, indicated .Our residents have the right to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including .other residents . A review of the facility's P&P titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .shall be thoroughly and promptly investigated by facility management . A review of the facility's P&P titled Charting and Documentation, revised 8/2008, .All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record .All observations .must be documented in the resident's clinical record .All incidents, accidents, or changes in the resident's condition must be recorded . A review of the facility's P&P titled Care Plans-Comprehensive, revised 9/10, indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .

Based on interview and record review, the facility failed to provide the Department a written report of the results of an abuse investigation within 5 working days of an incident that involved an abuse allegation of inappropriate touching for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the Department's investigation of abuse allegations which may have led to continued abuse. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in July 2024 with multiple diagnoses including wedge compression fracture of lumbar vertebra (fracture of the spinal column, lower back, caused by the front of the vertebra collapsing), dementia (a progressive state of decline in mental abilities), and metabolic encephalopathy (brain does not function properly due to an imbalance in the body's metabolism). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 0 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported that While [Resident 1] was seated in his wheelchair, in the hallway near [Resident 2], she took his hand and tried to place it in her genital area. Licensed Nurse [LN 1] observed the incident and responded immediately separating the 2. Writer took [Resident 1] to a private area to interview him regarding the incident. [Resident 1] has dementia a very poor short-term memory. I asked him how he was doing? He smiles and states good. I asked him if he remembered what had just happened? He smiles and looks a little confused. I asked him if anyone had touched him or made him feel uncomfortable? He smiles and states No. I asked him if he is being treated well here? He states yes. I asked him if he feels safe here? He states yes. Writer called [Resident 1]]'s wife to notify her of the occurrence and an . [a report of Suspected Adult/Elder Abuse] was documented and forwarded to CDPH [California Department of Public Health-The Department], The Ombudsman's office [an advocate for residents in nursing homes] and FBPD [Fort [NAME] Police Department]. Staff will monitor the residents and keep them separated . A review of Resident 1's Progress Note, dated 8/5/24 at 2:45 p.m., indicated .Resident was observed @ 1315 [at 1:15 p.m.] in the hallway having his hand grabbed by [Resident 2] and she placed it on her genitalia area. Nurse immediately separated residents. Resident was tearful, nurse asked if resident was ok to which he replies, why wouldn't I be. Resident has dementia and not oriented to situation. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP [Responsible Party] . A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in April 2019 with multiple diagnoses including dementia, cerebral infarction (stroke-loss of blood flow to a part of the brain), heart failure (a heart disorder which causes the heart to not pump blood efficiently), and diabetes (a disorder characterized by difficulty in blood sugar control). A review of Resident 2's MDS, Cognitive Patterns, dated 7/8/24, indicated Resident 2 had a BIMS score of 8 out of 15 that indicated Resident 2 was moderately cognitively impaired. A review of Resident 2's Care Plan .Behavior, Alteration In Inappropriate Sexual Touching of another resident . initiated 8/5/24, indicated .Interventions .Assess the resident's behavior for any causative or triggering factors .Do not seat the resident within reach of or in close proximity of another opposite sex resident during any activity or meal .Maintain awareness of the resident's location at all times .Observe the negatively affected resident for any S/SX [signs or symptoms] of being injured or emotionally negatively affected by the offending resident's actions or behaviors .Take action immediately .to prevent the resident from inappropriately touching the personal private parts of another resident, or other sexually oriented actions or behaviors .Take actions as needed to protect the helpless resident from inappropriate touching by another resident . A review of Resident 2's Progress Note, dated 8/5/24 at 1:30 p.m., indicated .It was reported by [Licensed Nurse 1] that while [Resident 2] was seated in the hallway near [Resident1], she took his hand and placed it near her genital area. [LN 1] separated the 2 immediately. Writer went to interview [Resident 2] regarding the incident. When I approached her she was visiting with her [Family Member] on the patio. I asked her if I could talk with her? She states What do you want to talk about? SEX!? I asked her if she would like to talk about anything? She states no. I asked her how she was feeling? She states okay. I asked her if she remembered her interaction with [Resident 1] in the hallway? She states no. I asked her if she feels safe here? She states yes. I asked her if everyone treats her well? She states yes. I reminded her that it is important to respect the personal space of others request their consent before touching and inappropriate touches aren't allowed. She was polite and respectful during our talk. She did not seem to remember or have any distress or anxiety related to the occurrence . A review of Resident 2's Progress Note, dated 8/5/24 at 3:30 p.m., indicated . Resident was observed [at 1:15 p.m.] in the hallway grabbing another resident's [Resident 1] and placed it on her genitalia area. Nurse immediately separated residents. Resident was informed that that was inappropriate and not okay, to which she replied oh whatever. Resident has dementia and intermittently confused. Notified SSD [Social Services Director], DON [Director of Nursing], Administrator and RP . A review of Resident 2's Progress Note, dated 8/5/24 at 5:24 p.m. indicated . [report name] regarding this incident was documented and faxed to CDPH . A review of the facility's Incident Investigation Report, report date 8/5/24, incident date 8/5/24, indicated .What happened? .Resident [Resident 1] was seated in the hallway near nursing station 2. Resident [Resident 2] was next to him (both in wheelchairs). Resident 2 took [Resident1]'s hand and tried to place it in her own private areas .What caused the incident? .Resident with dementia inappropriate behavior .List corrective actions to be taken? .Staff reminded & updated regarding potential for residents with dementia to behave inappropriately .reporting requirements. Care plans to monitor residents closely & redirect from inappropriate behavior . During an interview on 2/12/25 at 12:11 p.m. with Director of Staff Development (DSD), the DSD stated she was acting as LN 1 on 8/5/24. The DSD stated Resident 1 and Resident 2 were sitting in the hallway near the nurse's station when Resident 2 grabbed Resident 1's hand and tried to place it on her genital area. The DSD stated Resident 1 resisted and had tears in his eyes. The DSD stated Resident 1 was difficult to understand, mumbled his words, and mentioned his wife. The DSD stated residents were separated and she called Resident 1's wife. The DSD stated 72 hour monitoring for emotional distress for Resident 1 and behaviors for Resident 2 was initiated. The DSD stated she referred the incident to the SSD to follow up. During an interview on 2/12/14 at 12:19 p.m. with the SSD, the SSD stated she interviewed Resident 1 and Resident 2 but neither recalled the incident. The SSD stated she completed the Incident Investigation Report. The SSD stated she did not send the investigation report to the Department because, at the time of the incident, she was not aware that the report needed to be sent to the Department within 5 working days of the incident. The DSD stated she was not aware of the regulation because she was new to the position, but now she knows to send the report. A review of the facility's Policy and Procedure (P&P) titled Abuse Investigations, revised 4/14, indicated .All reports of resident abuse .Shall be thoroughly investigated by facility management .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident .

Based on interview and record review, the facility failed to ensure a resident was free from abuse when Resident 1 hit with her fist Resident 2's thigh while they were seated close to each other. This failure caused pain and potential mental anguish to Resident 2. Findings: A review of Resident 1's medical records indicated the following: - The Quarterly Minimum Data Set (MDS - federally mandated clinical assessment) dated 9/23/24 indicated Resident 1 had severe memory issues. - The MDS further indicated Resident 1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and exhibited verbal behavior symptoms directed towards others such as threatening, screaming, and cursing at others; - Resident 1's order summary report for 12/2024 indicated she was receiving Quetiapine Fumarate (an antipsychotic - medications used to treat several kinds of mental health conditions to regulate your mood, behaviors and thoughts) 50 milligram (mg, unit of measure) tablet in the afternoon and 25 mg in the morning for severe dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), with agitation. - Resident 1's care plan dated 8/1/24 indicated verbally abusive behaviors directed towards roommates, confused residents, and aggressive behaviors involving striking out at others, interfering with other resident's activities, etc. - Resident 1's care plan Interventions included: assist the resident from the confused resident's presence if the resident becomes abusive at the confused resident in a public environment or area; attempt to redirect the resident away from others if the resident is behaving aggressively or overly assertive manners or behaviors - be aware that the resident may not be easily redirected; do not locate or assist the resident to a location that enables the resident to be able to reach another resident by striking out when stimulated by the other resident. A review of Resident 2's medical records indicated the following: - The Quarterly MDS dated [DATE] indicated Resident 2 had minimal hearing difficulty, cognition severely impaired, difficulty focusing attention, easily distracted, difficulty keeping track of what was said, exhibits disorganized thinking manifested by incoherent, rambling and unclear or illogical flow of ideas. - Resident 2's face sheet (one-page summary of important information about a patient, includes patient identification, allergies, insurance status, or other pertinent information like diagnosis on admission) indicated she was admitted with multiple diagnoses which inlcuded unspecified dementia without behavior disturbance. During an interview on 12/23/24, at 11:39 AM, Unlicensed Staff A stated, on the day of incident residents including Resident 1 and Resident 2 were out in the hallway seated in their wheelchairs near each other across the nurses' station. Unlicensed Staff A stated, Resident 1 said something to Resident 2, then Resident 1 said: what, are you not gonna answer me? Resident 1 then hit with her balled fist Resident 2 on the thigh area and Resident 2 said, Ouch! Unlicensed Staff A told Resident 1: you could not be hitting others, as she took her back to her room. A review of the facility's policy titled: Preventing resident abuse taken from the Operational policy and procedure manual for long-term care 2021 Med Pass, Inc., revised 12/2013, indicated, the facility's goal was to achieve and maintain an abuse-free environment and assess residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavior issues.

Based on interview and record review, the facility failed to report an alleged resident abuse immediately when Resident 1 allegedly hit Resident 2 who was sitting near and opposite her. This failure reduced the faciltiy's potential to ensure resident safety. Findings: A review of facility Transmission Verification report sent 11/11/24 at 4:52 p.m. and received by the Department on 11/12/24 at 8:00 a.m., indicated an allegation of suspected dependent adult/elder abuse had been made related to a resident-to-resident altercation between Resident 1 and Resident 2. A review of the Report of Suspected Dependent Adult/Elder Abuse (documenting a report of abuse or neglect of an elder or dependent adult) between Resident 1 and Resident 2, indicated the incident happened on 11/10/24, at 4:18 p.m. During a review of record and concurrent interview on 12/23/24 at 11:45 a.m., the facility's abuse prevention policy did not indicate a timeframe for reporting suspected abuse incidents. The DON stated they follow the flowchart of Mandated Reporter (attached in facility documents) posted on his workstation. The DON was not familiar with the reporting requirement timeline for alleged abuse incident after he was informed by the Department that alleged incidents of abuse were reported not later than 2 hours after the allegation is made. A review of the facility's policy titled: Reporting abuse to State Agencies and other entities/individual, indicated, all suspected violations . of abuse will be immediately reported to appropriate state agencies . as maybe required by law.

Based on interviews and record reviews, the facility failed to implement its policies and procedures on abuse and ensure that one of three sampled residents, Resident 1, was free from mental abuse (Mental abuse is the use of threats, verbal insults, and other more subtle tactics to control a person's way of thinking. This form of abuse is especially disturbing because it is tailored to destroy self-esteem and confidence and undermine a personal sense of reality or competence) and mistreatment (a cruel, unkind, or unfair way of treating a person), when the door to Resident 1's room was deliberately closed by Licensed Nurse A, while Resident 1 requested for staff assistance. This failure, which was witnessed by Management Staff B on 12/24/22, at around 2:30 p.m., resulted in anxiety (Anxiety refers to the apprehensive anticipation of future danger or misfortune accompanied by a feeling of distress, sadness, or somatic (relating to the body) symptoms of tension) as evidenced by Resident 1 calling out in distress, and physical harm to Resident 1, as evidenced by shortness of breath and low oxygen level that required hospitalization . Findings: During an interview on 1/10/23, at 3:15 p.m., with Certified Nursing Assistant C (CNA C), she stated she worked the afternoon shift of 12/24/22. CNA C stated that at around 2:30 p.m., Resident 1 was calling for help and Licensed Nurse A shut the door of his room because Resident 1 had an infection. CNA C stated that at 3 p.m., she heard Resident 1 screaming for help, like someone was being murdered. CNA C stated that Licensed Nurse A slammed the door of Resident 1's room without asking him what he needed. CNA C stated that at around 3:10 p.m., Licensed Nurse A responded to Resident 1's calls for help and he was having a panic attack and his O2 (oxygen) at 85% (A normal level of oxygen is usually 95% or higher). During an interview on 1/10/23, at 3:25 p.m., with CNA D, she stated at around 2 p.m., while Licensed Nurse E and Licensed Nurse A were doing the change of shift report, Resident 1 started to scream in distress. CNA D stated that Resident 1 liked to keep his door open because he was claustrophobic (a person with extreme fear or irrational fear of confined spaces). CNA D stated that she and other aides would like to check on Resident 1, but Licensed Nurse A kept them from doing it. CNA D stated that Licensed Nurse E did not restrict the morning CNA'S from going into Resident 1's room and left the room door open. CNA D stated she left the facility at 3 p.m., and Resident 1 was still screaming inside the room while the door was shut. During an interview on 3/13/23, at 3:35 p.m., with Licensed Nurse A, she stated she could not remember if Licensed Nurse E told her what precaution (e.g. Contact Precaution- Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission; Droplet Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking; Airborne Precaution- Use Droplet Precautions for patients known or suspected to be infected with pathogens (organisms that can cause disease) transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking) Resident 1 should be on. Licensed Nurse A stated that she informed Resident 1 that she would close his door for now. Licensed Nurse A stated after she received report that Resident 1 was on contact precaution and not on droplet or airborne precaution, she opened Resident 1's door. Licensed Nurse A stated that Resident 1 was screaming at her because she closed his door. Licensed Nurse A stated that staff were hearing Resident 1 screaming in his room to have the door opened after she closed it. Licensed Nurse A stated that at 6:30 p.m., Resident 1's oxygen level dropped to 80%. Licensed Nurse A stated that Resident 1 declined to be transferred to the hospital but later agreed and was transferred. During an interview on 3/13/23, at 4:05 p.m., with the Administrator/Owner, she stated she investigated the incident regarding Licensed Nurse A and Resident 1. She stated Licensed Nurse A was not placed on suspension because there was no incident. The Administrator stated Licensed Nurse A opened the door after the change of shift when she confirmed that the isolation precaution was just contact and not droplet precaution. During an interview on 3/14/23, at 1:16 p.m., with Management Staff B, he stated he was on his way back to the kitchen when he passed by Resident 1's room and the door to his room was open. Management Staff B stated that he saw Resident 1 raised his hand to get his attention. Management Staff B stated that he peeked into Resident 1's room and observed that he was in a bad shape, health wise. Management Staff B stated that Resident 1 had a mask for his oxygen, which Resident 1 removed temporarily, and told him he needed CNA D. Management Staff B stated he talked to Licensed Nurse E informing her that Resident 1 was looking for CNA D. Management Staff B stated that Licensed Nurse E told him that CNA D will not be able to go to Resident 1's room at that time because she was in the Red Zone (isolated area for Covid positive residents). Management Staff B stated that another nurse, Licensed Nurse A held his arm and guided him towards the room of Resident 1. Management Staff B stated Licensed Nurse A told him, This is how to take care of that, and said bye to Resident 1, while Licensed Nurse A closed Resident 1's door abruptly. Management Staff B stated he reported the incident to the Management Staff F because Licensed Nurse A's conduct surprised him, because it lacked respect to Resident 1 and Licensed Nurse A did not ask Resident 1 what he needed. During a follow-up interview on 3/17/23, at 2:34 p.m., with CNA D, she stated she informed Licensed Nurse A that Resident 1's door did not need to be closed because he was on contact precaution only. CNA D stated that Licensed Nurse A closed the door of Resident 1 before getting the shift report from Licensed Nurse E. During a review of Resident 1's clinical record on 6/2/23, at 11 a.m., Resident 1's Progress Notes, dated 12/23/22, at 1:45 p.m., authored by Licensed Nurse G, indicated that Resident 1 was readmitted to the facility after a stay at a local hospital where he was treated for UTI (Urinary Tract (The series of organs in the urinary system in which urine is formed and excreted) Infection). Licensed Nurse G indicated on the progress notes that Resident 1 was alert and oriented x4 (alert and oriented to person, place, time, and event) and was placed on contact isolation (precaution). Licensed Nurse G indicated on the progress note that Resident 1 was ordered oxygen at three (3) liters per minute to maintain an oxygen saturation (the amount of oxygen you have circulating in your blood) level above 90%. On 12/24/22, at 6:40 p.m., a progress note authored by Licensed Nurse A indicated, Resident (Resident 1) was sent to the hospital because his oxygen kept dropping. His O2 (oxygen) on 3L (three liters) was only 83%. On 12/26/22, at 1:23 a.m., a progress note entry authored by Licensed Nurse H indicated, Resident (Resident 1) passed away at hospital on night of 12/25/22. A review of Resident 1's Hospital Progress Notes, dated 12/28/22, at 3:55 p.m., indicated Resident 1 passed away on 12/25/22, at 10:37 p.m., at the hospital's ICU (Intensive Care Unit). The progress note indicated that Resident 1's cause of death was Sepsis (Sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death. Symptoms include fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion. Treatment includes antibiotics and intravenous (within a vein) fluids). During an interview on 6/2/23, at 12:30 p.m., with the Director of Nursing (DON), he stated that he was not at the facility when the incident between Licensed Staff A and Resident 1 happened. The DON stated he learned about the incident from CNA D. The DON stated that Management Staff B was aware of what had happened. The DON stated that he was not a part of the staff that investigated the incident. The DON stated that the facility did not have a single person who acted as the abuse coordinator, but all suspected abuse would be reported to the Administrator. The DON stated that the Administrator at that time was the owner of the facility. During an interview with Licensed Nurse E on 6/2/23, at 3 p.m., she stated she was the AM (morning) nurse on 12/24/22. Licensed Nurse E stated she remembered giving shift report to Licensed Nurse A and she mentioned to Licensed Nurse A that Resident 1 had an infection that was contagious. Licensed Nurse E stated that Licensed Nurse A went to Resident 1's room and closed the door. Licensed Nurse E stated that she informed Licensed Nurse A that Resident 1's room did not need to be closed. Licensed Nurse E stated that during her morning shift on 12/24/22, Resident 1's room door remained open. Licensed Nurse E stated she continued to give report to Licensed Nurse A after Licensed Nurse A closed Resident 1's door. Licensed Nurse E stated that she left the facility at around 3 p.m. Licensed Staff E stated when she passed by Resident 1's room on her way out of the facility, she heard Resident 1 calling for help while his door was closed. Licensed Nurse E stated that there was another resident, Resident 2, who was across the hallway who looked perplexed as he was hearing the calls for help from Resident 1. During an interview on 6/2/23, at 3:35 p.m., with Resident 2, he stated that he remembered Resident 1 calling for help. Resident 2 stated he could not see if the door to Resident 1's room was closed, but he could definitely hear him calling out for help. Resident 2 stated that Resident 1 did not usually call for help. Resident 2 stated he was not sure how long Resident 1 was calling for help before somebody came to help him. During an interview on 6/2/23, at 4:24 p.m., with Management Staff F, she stated Management Staff B reported the incident to her on 12/26/22. Management Staff F stated she informed Management Staff B that his report should be in writing. Management Staff F stated that Management Staff B gave his account of the incident on 12/26/22. Management Staff F stated that she reported the incident to the administrator via phone call and it was investigated by the Administrator. Management Staff F stated it was not reported to the Ombudsman or to the State. A review of Resident 1's History and Physical (H&P) from the hospital, dated 12/25/22, at 11:57 a.m., indicated, Resident 1's chief complaint was SOB (Shortness of Breath) and Anxiety. The H&P did not indicate that Resident 1 had an active problem with anxiety disorder. The H&P indicated that Resident 1 was prescribed Lorazepam (Lorazepam is a medication that treats anxiety) 1 mg (milligram) IV (intravenous) Q2H (every two hours) for anxiety, and/or restlessness, and/or worried expression on face, PRN (as needed). A review of Resident 1's Order Summary Report, dated 12/1/22 - 12/31/22, indicated he did not have a medical diagnosis of Anxiety nor was he taking any medications for anxiety. A review of a facility document titled, Staff Complaint/Grievance Form, dated 12/26/22, indicated that a complaint/grievance was communicated by Management Staff B and Licensed Nurse I, concerning another staff, Licensed Nurse A. The document indicated that Management Staff B was concerned that Licensed Nurse A did not provide enough attention to address Resident 1's needs, by closing the door. The document indicated Licensed Nurse I complained that Licensed Nurse A ignored Resident 1's needs, did not pay enough attention to assess Resident 1, and caused his death. The document indicated that the department affected by the complaint/grievance was the Nursing department. During a follow-up interview on 6/5/23, at 2:55 p.m., with the Administrator, she stated that she did not report the complaint allegations of Management Staff B and Licensed Nurse I to the Ombudsman or the State because Licensed Staff A was justified in closing the door of Resident 1 because of infection precaution. The Administrator stated that the allegation of Licensed Staff I regarding Licensed Staff A not providing enough attention to assess Resident 1 and caused his death was absurd because Licensed Staff I was not even on duty that day and her complaint was hearsay. The Administrator stated that she and Management Staff F investigated the complaints. When the Administrator was asked why the DON was not involved in the investigation because on the complaint/grievance form, the department affected by the complaint/grievance was the Nursing department, she stated the DON was involved with the investigation. When the Administrator was asked why Licensed Staff A was not placed on suspension pending the investigation, she stated because Resident 1 was transferred to the hospital and had passed away. A review of a facility policy and procedure (P&P) titled, Abuse Prevention Program, dated 11/30/2017, indicated, Abuse, neglect, abandonment, isolation, financial abuse, will not be tolerated in this facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of abuse to any resident. Under Prevention, the P&P indicated, Administrative staff, Nursing supervisors/Charge Nurses are responsible for directing, supervising, and evaluating all resident care activities within their respective departments or assigned units on a daily basis. A review of a facility document titled, Abuse Investigation and Reporting Policy, dated 11/30/17, indicated, All reports of resident abuse, neglect, exploitation, misrepresentation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to the local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Under Procedure: Role of the Administrator: The P&P indicated: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented.

Based on observation, interview and record review, the facility failed to ensure effective administration of its operations, when the facility: 1) Did not have a licensed Administrator to oversee daily operations (including adequate staffing levels); 2) Did not have a Director of Nursing (DON); and, 3) Did not ensure the the Registered Dietitian (RD) executed her duties, per policy and contracted agreement. These deficiencies contributed to staffing issues, negatively impacted the use of resources (personnel), potentially impaired residents' ability to attain/maintain their highest practicable physical, mental, and psychosocial well-being, and created potential harm for 34 of 34 residents. A situation IMMEDIATE JEOPARDY (IJ) was identified on 1/21/2022 at 12:35 p.m., under §483.70 Administration, F835. Licensed Nurse B and General Manager A were notified of the IJ in the Administrator's office. A Facility Plan of Action (IJ removal plan) to abate the IJ was submitted to the State Survey Agency via email on 1/21/2022 at 3:02 p.m. The Facility Plan of Action was not acceptable to the State Survey Agency, and the facility was notified via email on 1/22/2022 at 9:56 a.m. No additional Plan of Action was submitted to the State Survey Agency prior to Exit. The IMMEDIATE JEOPARDY was not removed prior to exiting the survey on 1/27/2022 at 2:07 p.m. An additional Plan of Action was submitted on 2/14/2022 via email. This Plan of Action was approved by the Department on 2/15/2022. The Immediate Jeopardy was removed on 2/16/2022. Findings: 1. ADMINISTRATOR AND STAFFING During an interview on 1/20/2022 at 1:30 p.m., the Director of Staff Development (DSD; a licensed nurse) stated the facility had no Administrator since 12/15/2021 (over five weeks), because the previous Administrator had moved to another state. The DSD stated the prior Adminsitrator had provided telephone support (to the facility) after his departure but the telephone support had stopped a few day ago. The DSD stated CNA A (Certified Nursing Assistant) was currently functioning as the General Manager but she did not have an Administrator's license (required to administer a skilled nursing facility). During the same interview on 1/20/2022 at 1:30 p.m., the DSD was queried about staffing at the facility. The DSD stated the resident census was thirty-four, and the facility only had a few nurse, travelers (contracted, traveling, temporary staff). She stated, after the traveling staff contracts were completed, the facility had not replaced them, and facility department heads were filling the gaps. The DSD stated, in addition to performing DSD duties, she performed Infection Prevention duties (infection control such as Covid-19 testing and surveillance), and she also coordinated staff scheduling. When queried about Registered Nurses (RN) at the facility, the DSD stated Licensed Nurse C (LN C) was a Registered Nurse, worked full time, and was the facility's MDS nurse (MDS - Minimum Data Set; assessment tool facilitating resident care management; MDS nurses do not typically take resident care assignments). The DSD stated LN C was currently working some night shifts (providing direct patient care) due to staffing shortages at the facility. The DSD stated the facility had another part-time RN who worked three days a week. When asked if any staff had needed to work a twenty-four hour shift, the DSD stated she had worked over twenty-four consecutive hours months ago. The DSD stated staffing was, okay until Monday, and the coming weekend was covered (for adequate resident care staff). During a follow-up interview at 4:20 p.m.,the DSD stated she provided direct patient care on night shift and weekends, and the IP (Infection Prevention nurse) worked approximately twenty-four hours per week on the floor, providing direct patient care. During the same interview on 1/20/2022 at 1:30 p.m., the DSD was queried if the facility maintained the required 3.5 Direct Care Service Hours Per Patient Day (DHPPD), and she stated they did not. She stated night shift should have two licensed nurses and three CNA's but in the past, the facility has had one licensed nurse and two CNA's on weekend shifts. The DSD stated day shift was short one licensed nurse position and one CNA; PM shift (3 p.m. to 11:30 p.m.) was short one CNA position; and night shift was short one licensed nurse position. The DSD stated the staffing levels left no room for sick calls or any form of staff call-offs (calling off duty). The DSD stated she had spoken to the Medical Director about the staffing issue, and they had discussed, When is it not safe? During the same interview on 1/20/2022 at 1:30 p.m., the DSD was queried about the facility plan if a resident became positive for Covid-19 (when an isolation unit would need to be set up). The DSD stated the facility had the physical space to set up a Covid unit but they, don't have staff. The DSD stated the facility would, beg the local hospital to take their resident if he/she became Covid positive. The DSD stated the local county health officer was aware of the situation and would help facilitate transfers to the hospital. The DSD stated the facility had a Covid outbreak in the summer of 2021, and the State provided staffing assistance at that time. The DSD stated the facility had received a Federal grant at that time, but the facility did not have grant money currently. She stated the facility did not have enough money (for staffing). During a tour of the facility and concurrent interviews on 1/20/2022 at 2:20 p.m., Unlicensed Staff E (activity staff) and LN D were asked about staffing at the facility. Staff E stated the facility had, amazing staff; we help answer call lights, help with food trays, and help in general. LN D stated she has had to work extra shifts, and the staff, work together. During an interview on 1/20/2022 at 2:30 p.m., the Medical Director (MD) was queried about Administration and staffing at the facility. The MD stated the previous Administrator was now in another state, the facility did not currently have an Administrator and, to his knowledge, no one was coming to fill the position. The MD stated the facility had requested staffing from the State (two licensed nurses and two CNA's), but the Owner would need to pay for them. The MD stated he understood the facility could not afford to pay for the staff offered by the State. The MD stated the facility needed a licensed nurse on night shift and one on PM shift. The MD stated the facility had been using Travelers for staffing, and the resident census was decreased due to staffing issues. The MD stated the local hospital did not have staff to spare, and the hospital had five patients they wanted to transfer and admit to the facility, but were prevented from doing so secondary to the facility's low staffing. The MD stated Physical Therapy and Occupational Therapy services were gone due to funding and agencies (Registry and [MEDICATION(S)] companies) had not always been paid in full. When queried about the facility plan if a resident became Covid positive, the MD stated the facility should call the local hospital (for assistance). During an interview on 1/20/2022 at 3:05 p.m., the Owner of the facility was queried about open leadership positions at the facility. The Owner stated the prior Administrator's last day was 1/14/2022 (telephone support), and the facility was currently, in limbo. The Owner stated, We are without an Administrator, but CNA A was covering and performing duties as the General Manager. The Owner stated CNA A had been working at the facility for twenty years, did not have an Administrator's license, and was performing some Administrator duties without a license. The Owner stated both the DSD and the IP had worked closely with the prior Administrator and were helping (with administrative duties). The Owner stated the prior Administrator was in the process of moving to another state and may come (to the facility) for a brief time (to assist). The owner stated the prior Administrator had not agreed to that potential plan. The Owner stated the facility had been approved for emergency medical services from the state (for staffing) but stated it was very expensive. He stated the State wanted an [NAME] (Memorandum Of Understating/contract), and he stated the contract was for two licensed nurses and two CNA's. When asked if he planned to sign the staffing contract, the Owner stated, I might have to. When asked what the facility would do if a resident became Covid positive, the Owner stated he did not know; he stated the prior Administrator used to handle that. The Owner stated CNA A, the DSD, and the IP would handle it. During an interview on 1/20/2022 at 4:20 p.m., the DSD stated she and the IP shared Infection Control duties. She stated, in addition to working the floor providing direct patient care, they both conducted Covid testing and monitoring all week long, implemented the antibiotic stewardship program, and attended the Infection Control meeting. When asked how many hours she spent on DSD duties, the DSD stated she had, no time for that. The DSD stated the facility was in crisis since August, she spent her time on infection control and bedside nursing (direct care), and she, squeezed .in her DSD duties when she could. During an interview on 1/21/2022 at 10:10 a.m., CNA A stated she had worked at the facility for twenty-six years. She stated she worked as a CNA, was trained in Risk Management, and became the General Manager a few months before the prior Administrator left. CNA A stated that prior to the Administrator leaving, she worked as a CNA (providing direct patient care) and assisted the prior Administrator with central supply (management of supplies). CNA A stated, in addition to acting as the General Manager, she currently worked approximately two shifts per week as a CNA, providing patient care. During the same interview and concurrent record review on 1/21/2022 at 10:10 a.m., CNA A was queried about her current General Manager role at the facility. CNA A stated, the prior Administrator had left a list to help staff after his departure. CNA A reviewed the prior Administrator's list titled, List of Administrator Function (sic) Needing Replacement Person (undated). The list contained duties numbered #1 through #31, and individual staff were identified next to the various tasks. The list revealed, 2. Coordinate with travel nurse companies (Administrator) . When queried why no one but the prior Administrator was listed next to this task, CNA A stated the prior Administrator put his name alone (without other staff) on tasks he determined could only be executed by an Administrator. CNA A stated the prior Administrator had coordinated all staffing issues, and she was now working with the Travel nurse companies, but it had, not gone well. CNA A stated Registries (companies providing temporary staff) had called her, made offers, but the licensed nurse did not come to the facility. She stated the Registries stopped calling and stopped returning her emails. During the same interview and review of the Administrator's Task List, on 1/21/2022 at 10:10 a.m., eleven of the thirty-one tasks had only, Administrator, listed next to them. The following tasks had Administer (only) identified as able to perform the duty: 8. Coordination with travel nurse companies . 17. RSS system 2567 POC's . 18. Aspen System 2567 POC's . 20. QIES System [NAME] . 21. Coordinate surveys . 22. Coordinate state visits . 23. Write 2567 Plan of Correction . 24. Annual OSHPD Report due 15 February . 25. OSHPD Alert System . 27. Pepper Report . 29. QAPI (Quality Assessment and Performance Improvement) Program . CNA A stated the prior Administrator told her no one in the building was able to do a POC (Plan of Correction - interventions designed to address state survey identified deficiencies). CNA A was queried about the, Pepper Report (#27), and she stated she did not know what that was. When queried about QAPI (#29), CNA A stated no one was able to work on it now because, we are overwhelmed, with day-to-day staffing and taking care of the residents. During the same interview on 1/21/2022 at 10:10 a.m., CNA A was asked about DSD duties. CNA A stated the DSD was, spread kind of thin, and she focused on continuing education of staff and on-boarding new staff. CNA A stated she did not know if competency training/evaluation of staff was being done. When asked what activities were not being done in the prior Administrator's absence, CNA A stated the facility was not conducting Infection Control meetings nor Safety (falls) meetings, and [CONDITION(S)] medication review was not being performed. CNA A stated staffing issues were, taking over everybody's life every day. When asked what would help the situation, CNA A stated, having either an Administrator or DON would help. When asked what would happen if a resident became Covid positive, CNA A stated they, absolutely, did not have adequate staffing to cope with that. During the same interview on 1/21/2022 at 10:10 a.m., CNA A stated the prior Administrator's last day was 12/15/2021, he provided phone support from 12/15/21 through 1/15/2022, and he was now off payroll. CNA A stated she did not meet the qualifications for Administrator and stated, I don't have the education or training. Review of facility policy and procedure titled, Administrator (Revised October 2020), indicated, The primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards .to assure that the highest degree of quality care can be provided to residents at all times. Under subtitle, Duties and Responsibilities, the policy indicated, Assist the Medical Director in the development and implementation of medical and nursing services .Ensure that an adequate number of appropriately trained, competent, licensed professionals and non-licensed personnel are on duty at all times to meet the needs of the residents . Under subtitle, Personnel Functions, the policy indicated, Establish the planning, development, implementation, monitoring and execution of recruitment selection and retention practices .Assist in the recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etc. 2. DIRECTOR OF NURSING During an interview on 1/20/2022 at 1:30 p.m., the DSD stated the facility has had no Director of Nursing (DON) since the Spring of 2021 (approximately seven months). During an interview on 1/20/2022 at 2:30 p.m., the Medical Director (MD) was queried about Administration, the DON position, and staffing at the facility. The MD stated the facility did not have a DON, and to his knowledge, no one was coming to fill the position. He stated that a retired DON may come to help. During an interview on 1/20/2022 at 3:05 p.m., the Owner of the facility was queried about open leadership positions at the facility. The Owner stated the facility had, no options, regarding the open DON position. The Owner stated LN C (the MDS nurse) was an RN and was, Acting DON. During an interview on 1/21/2022 at 10:10 a.m., CNA A (the General Manager) stated the facility did not have a DON and they, had no prospects (of hiring one), that she was aware of. During an interview on 1/21/2022 at 11:15 a.m., LN C stated he was the MDS nurse and Clinical Coordinator. He stated he helped cover the duties of the DON, but he was not the DON. When asked what DON duties he performed, he stated he, signed forms. LN C stated staffing, got bad, in the middle of December (2021), and he was currently working six to seven days a week. He stated what was happening was, not sustainable. Review of the DON job description (dated 10/2020), indicated, The primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards .and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. 3. DIETARY SERVICES and REGISTERED DIETICIAN During a telephone interview on 1/21/2022 at 8:43 a.m., the Registered Dietitian (RD) was queried about her services at the facility. The RD stated the frequency of her onsite visits to the facility changed with Covid. She stated she normally made onsite visits two times per month but the facility was, hit hard, with Covid and the previous Administrator asked her to put her visits on hold. The RD stated she was onsite on 8/28/2021 and 11/30/2021. The RD confirmed she did not make onsite visits in September, October, or December of 2021. The RD stated, after the prior Administrator left the facility, the fact she did not make onsite visits was, my miss and further stated, It's on me. When asked if she was able to review resident medical records remotely, the RD stated it was challenging, and she would need to use Zoom or speaker phone to evaluate resident records. When asked if she provided remote kitchen inspections (using a camera to assess general sanitation and safety, food preparation by staff, and equipment maintenance), the RD stated, No, I hadn't thought of that. When asked if she did a kitchen inspection during her 11/30/2021, onsite visit, the RD stated, No and stated she had so much to catch up on. When queried about her remote services, the RD stated, if residents had issues such as weight loss, she would provide interventions. When asked when she last attended a weight meeting, she stated, I don't know. When queried about the frequency of remote services, the RD stated she had not provided any since 11/30/2021, and stated, That's on me. The RD stated she did not remember conducting remote services (via Zoom meetings or telephone) prior to 11/30/2021, and stated they were especially difficult since September, when the facility had a Covid outbreak. When asked if residents were receiving adequate RD services, the RD stated staff were in tune to residents, and CNA A knew the residents in detail, especially regarding their diets. Review of an email sent from the prior Administrator on 9/24/2021 at 5:46 p.m., revealed the following message: Hi (RD), No new admits. We are in a major COVID outbreak over 20 residents so far .with 9 staff infected. I would recommend not coming in until we get this past us. Review of an email sent from the prior Administrator on 11/22/2021 at 7:31 a.m., indicated, Hi (RD), We are past COVID again and hope to stay that way. I do need you to make a visit this month to check on all our post COVID patients. Review of a facility document titled, Monthly Weight Variance Committee Minutes of Meeting (dated 12/2022 [sic]), indicated two resident had weight gain. The document indicated actions taken were, Notify M.D (sic) and M.D (sic) aware. Under the column titled, Follow-up on Action Taken, the document indicated to, monitor. The December minutes were signed by CNA A, the DSD, the IP, CNA F, and Manager G (Certified Dietary Manager). The document was not signed by the RD. Review of a facility document titled, Monthly Weight Variance Committee Minutes of Meeting (dated 1/2022), indicated five residents were discussed at the meeting; one resident had an 8.6 pound weight loss. The document indicated actions taken were, Notify M.D (sic), Care Plan, and Weekly wts (weights). Follow-up on action taken indicated, monitor. The January meeting minutes were signed by by CNA A, the DSD, the IP, CNA F, and Manager G. The document was not signed by the RD. Review of facility document titled, (Company name) Weight Change Protocol (dated 2018), indicated, Early identification of a weight problem .can minimize complications. Assessment of residents experiencing weight changes should be completed .timely .Residents who experience significant changes in weight .will be assessed by the RD .The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate the success of interventions. During an interview on 1/21/2022 at 10:10 a.m., CNA A (the General Manager) stated the RD, hasn't really been coming in. During an interview on 1/21/2022 at 1:45 p.m., Manager G was asked about RD oversight in the Dietary department. Manager G stated RD oversight was not consistent, and the RD had not been to the facility in a couple of months. She stated the RD did not provide leadership, did not come to meetings, did not conduct staff training's, and did not provide telephone support. When asked about the Weight Committee, Manager G stated the RD did not often attend. Manager G stated she would like for the RD to conduct monthly kitchen inspections and have more interaction with the staff. Review of RD job description, subtitled, Duties and Responsibilities (dated 10/202), indicated, Review the dietary requirements of each resident .Assist the Certified Dietary Manager in planning menus, work scheduled, etc .Assist in developing diet plans for individual residents based on the comprehensive assessment and care plan .Develop a written dietary plan of care that identifies the dietary problems/needs of the resident and the goals to be accomplished for each dietary problem/need identified . Under subtitle, Miscellaneous Functions, the document indicated, Make scheduled inspections of all food and nutrition services functions to assure that quality control measures are continually maintained . Review of the Registered Dietitian's contract titled, Independent Contractor Agreement (signed and dated by the RD on 1/31/2019), indicated the facility offered RD employment in the capacity of, Clinical Dietitian .commencing on the week of 2/10/19. Under subtitle, Compensation, and Expenses, further subtitled, Allotted Contract hours, the contract indicated, Minimum 16 hours to a Maximum 18 hours of in facility consultation per month. Consultant will visit the facility every 2 weeks (minimum 8hrs [hours] per visit). Review of facility policy and procedure titled, Administrator, subtitled, Duties and Responsibilities (Revised October 2020), indicated, Ensure that the food and nutrition services program meets the nutritional needs of the residents. An IMMEDIATE JEOPARDY (IJ) was identified on 1/21/2022 at 12:35 p.m., under §483.70 Administration, F835. Licensed Nurse B and General Manager A were notified of the IJ in the Administrator's office. General Manager A called the Owner and asked him to join the meeting. The facility Owner joined the meeting at 12:40 p.m. Facility Plan of Action to abate the IJ was submitted to the State Survey Agency via email on 1/21/2022 at 3:02 p.m. The Facility Plan of Action was not acceptable to the State Survey Agency, and the facility was notified via email on 1/22/2022 at 9:56 a.m. During a telephone interview on 1/24/2022 at 2:50 p.m., the DSD was queried about the Plan of Action. The DSD stated the Owner and CNA A were currently working on the Plan of Action. A POA was not submitted to the State Survey Agency on 1/24/2022. During a telephone interview on 1/25/2022 at 2:40 p.m., the Owner was queried about progress on the Plan of Action. The Owner stated the facility was actively pursuing a solution to the issue of Administration, and he anticipated submitting a Plan of Action to abate the IJ on 1/26/2022. No additional Plan of Action was submitted to the State Survey Agency prior to Exit. The IMMEDIATE JEOPARDY was not removed prior to exiting the survey on 1/27/2022 at 2:07 p.m. An onsite visit was conducted on 2/16/2022. After observations, interviews, and record reviews, the facility Administrator was informed that the IJ at F835 was removed on 2/16/2022, at 4:52 p.m.

Based on observations, interviews, and record reviews, the facility failed to implement its policy and procedure in promoting dignity and respect to one out of two sampled residents, Resident 1, when the facility failed to ask Resident 1 for permission and consent prior to removing her personal belongings from her room. This failure resulted in increased anxiety and depressed mood to Resident 1. Findings: During a review of Resident'1's Admission Record, (undated), the admission record indicated, Resident 1's most recent hospital stay was from 6/10/2020 to 6/15/2020. Resident 1 had medical [DIAGNOSES REDACTED]. During a review of Resident 1's, History and Physical (H&P), dated 6/10/2020, the H&P authored by Physician A indicated, Resident 1 was admitted to the acute care hospital for left hip surgical repair of sub-capital fracture (Sub-capital fracture is the most common type of intra-[MEDICATION NAME] neck of femur (thigh bone) fracture . The H&P indicated, She (Resident 1) is awake, alert, oriented x 4 (A&O x 4, means the patient is alert and oriented to person, place, time, situation). Conversant. Showing me notes in her computer. However, she becomes tearful when talking about her lack of control in living at a skilled facility (A skilled nursing facility is an in-patient rehabilitation and medical treatment center staffed with trained medical professionals). During an interview on 7/29/2020, at 10:50 a.m., with Resident 1, Resident 1 stated she had a hip surgery six weeks ago on 6/11/2020. Resident 1 stated that she returned to the facility from the acute care hospital on [DATE], and was placed on a different room as an isolation precaution (Isolation precautions create barriers between people and germs. Facilities may implement isolation precautions around any new admissions that they bring in, as well as any residents that are returning from a hospital stay). Resident 1 stated when she came out of the isolation precaution on 6/29/2020, and was taken to her old room, she discovered that her personal belongings were taken away without her consent. Resident 1 stated, This was a breach (an act of breaking or failing to observe a law, agreement, or code of conduct) of my privacy, bigtime. Resident 1 gave examples of some of the missing items items that included, her dressers which contained her clothing, a collection of video discs, a walker, etc. Resident 1 stated there was no prior notice before her belongings were taken out from her room. During the interview, Resident 1 was crying and sobbing intermittently (at irregular intervals; not continuously or steadily). Resident stated that she was angry, anxious, and distressed about the incident. When Resident 1 was asked if she had reported the incident to a facility staff, Resident 1 stated she spoke to Administrative Staff B, but could not recall the date and time of their conversation. During an interview on 7/29/2020, at 11:40 a.m., with Administrative Staff B, Administrative Staff B stated that what happened to Resident 1's personal belongings was a violation of her (Resident 1's) rights. Administrative Staff B stated that Resident 1 was not given the chance to look at the personal belongings before these were taken out of her room. During an observation on 8/18/2020, at 3:30 p.m., at the facility's dining room, which was not being utilized at this time due to precautions for the transfer of infections, Resident 1's belongings were placed in multiple brown boxes. During a review of Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview on 10/26/2020, at 1:35 p.m., with Resident 1, when Resident 1 was asked to clarify the reason she gave to Licensed Staff C while requesting for [MEDICATION NAME] on 7/1/2020, was related to personal items. Resident 1 stated to clarify that anxiety related to personal items meant that she was having anxiety about her personal belongings that were taken out of her room without her permission. During a review of the facility's policy and procedure (P&P), titled, Quality of Life-Dignity, dated, 11/2010, provided by the facility as a current facility P&P, indicated, Policy Statement, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The Policy Interpretation and Implementation at number six indicated, Resident's private space and property shall be respected at all times .Staff will not handle or move a resident's personal belongings (including radios and television) without the resident's permission.

Based on interviews and record reviews, the facility failed to ensure that one out of three sampled residents, (Resident 1), was free from a significant medication error when, Resident 1 missed three doses of [MEDICATION NAME] 6 mg tablets ([MEDICATION NAME] is classified as a corticosteroid (a class of drug that lowers inflammation in the body) used to decrease the swelling around tumors (abnormal growth of tissue). By decreasing swelling around tumors in the spine, brain, or bone, it can decrease the pressure of the tumor on nerve endings and relieve pain or other symptoms caused by the pressing tumor) as part of Resident 1's discharge orders from a hospital physician because it was not available at the facility. When the [MEDICATION NAME] tablet was administered to Resident 1, the dose administered was [MEDICATION NAME] 4 mg tablets, an error made by the facility in transcribing (put into written or printed form) the admission orders [REDACTED]. Findings: During a review of Resident 1's History and Physical, (H&P) dated 11/20/2019, the H&P indicated, Resident 1 was a middle-aged male who was status [REDACTED]. The bone flap is temporarily removed, then replaced after the brain surgery has been done), resection, [MEDICAL CONDITION], and [MEDICAL CONDITION] for Glio[DIAGNOSES REDACTED] (Glio[DIAGNOSES REDACTED] is an aggressive type [MEDICAL CONDITION] that can occur in the brain or spinal cord). During a review of Resident 1's Discharge Summary, dated 11/21/19, at 12:48 p.m., the discharging hospital physician noted on Resident 1's discharge exam, He is awake, alert, oriented to me, to reason to be in the hospital, his diagnosis, and need for long-term supportive care as well, as he lives alone and is unable to care for himself. He moves all four limbs equally, no sensory or motor deficits, normal mood range and affect (emotional state). Resident 1's discharge medication orders include [MEDICATION NAME] 6 mg twice daily. The discharging hospital physician also stated, Patient is currently calm, not requiring any [MEDICAL CONDITION] (drugs that affect a person's mental state) / psychiatric (drugs used to treat mental illnesses) medications, able to follow simple commands and do simple activities. During a review of Resident 1's, Order Summary Report, dated 11/21/19, at 2:06 p.m., the Order Summary Report indicated, [MEDICATION NAME] Tablet 4 mg, give 1 tablet by mouth two times a day for anti-[MEDICAL CONDITION] related [MEDICAL CONDITION] treatment. The facility staff who created this report was Licensed Nurse B. During a review of Resident 1's Medication Administration Record, [REDACTED].p.m. dose of [MEDICATION NAME] Tablet 4 mg was not documented as administered to Resident 1. On 11/22/19, the 8 a.m. and 8 p.m. doses of [MEDICATION NAME] Tablet 4 mg were not documented as administered to Resident 1. On 11/23/19, the 8 a.m. and 8 p.m. doses of [MEDICATION NAME] Tablet 4 mg were signed off as administered, but a written note on the MAR for this medication indicated, Wrong dose. During a review of Resident 1's clinical record titled, Nursing Notes, an entry dated 11/21/19, at 8:10 p.m., indicated, Able to take pills whole without signs and symptoms of aspiration. This nursing note entry did not indicate that a prescribed medication, [MEDICATION NAME], was not administered as ordered and did not indicate that the physician was notified that it was not administered. A nursing note entry dated 11/22/19, at 10:05 p.m. indicated, Resident 1 had increased agitation and anxiety, stated he needed to go somewhere but did not know where. The physician was contacted for an order of anti-anxiety medication and was administered at 6 p.m. An entry on 11/23/19, at 3 a.m., indicated, For much of this shift, Resident 1 has been yelling out loud for his son .agitated that he is not here .difficult to redirect. This review of the nursing note entires for Resident 1 indicated that the missed doses of the [MEDICATION NAME] were not documented or reported to the physician as a medication error. During a review of Resident 1's clinical record titled, Nursing Notes, dated 11/24/19, at 9 a.m., Licensed Staff A's note indicated, Daughter (of Resident 1) noted that resident's medication [MEDICATION NAME] was originally ordered at 4 mg BID (twice a day), per daughter this should be 6 mg BID, one tablet at 8 a.m., and one tablet at 2 p.m . given later than 3 p.m., will affect his (Resident 1's) ability to sleep. Records from hospital state 6 mg BID, new dose ordered .will monitor. At 11:30 a.m., Licensed Staff A's note indicated, Family members at bedside upset about MEDICATION ORDERS FOR [REDACTED]. Secondary to lack of medication, family requested a loading dose (a loading dose is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose), and also requested oral [MEDICATION NAME] liquid for pain. This nurse (Licensed Staff A) contacted (name of clinic), spoke with a FNP (Family Nurse Practitioner), an on-call provider. N.O. (New Order) are as follows; Give [MEDICATION NAME] 4 mg now, then 6 mg at 8 a.m. and 2 p.m. Oral [MEDICATION NAME] (This medication is used to help relieve moderate to severe pain. [MEDICATION NAME] belongs to a class of drugs known as opioid [MEDICATION NAME]) 20 mg /ml, give 5 mg=0.25 ml SL (sub-lingual, under the tongue) every 2 hours for pain. Provider called (name of pharmacy), family will pick up, nurse will administer upon arrival. At 12:09 p.m., Licensed Staff A's note indicated, Family is very upset about this med (medication) error. Nsg (nursing) will continue to monitor resdident (Resident 1). During an interview on 1/23/2020, at 3 p.m., with Licensed Nurse B, Licensed Nurse B stated when the facility has new admissions, he transcribes the medication orders in the computer system and places the medication orders to their contracted pharmacy services. Licensed Nurse B stated that they may not get supply right away, and this happens most of the time because the pharmacy will have to travel quite bit to reach their facility. Licensed Nurse B stated that when a medication had to be administered as soon as possible, and they don't have it on their emergency supply, they can call a local pharmacy affiliated with their contracted pharmacy. Licensed Nurse B stated the facility had emergency medications but he was sure that [MEDICATION NAME] was not one of them. Licensed Nurse B acknowledged that the [MEDICATION NAME] dose for Resident 1 was entered in error as 4 mg twice a day instead of 6 mg twice a day. Licensed Nurse B also stated that if a medication was not available at its scheduled time of administration, the nurse who was assigned to administer that particular medication was responsible to call the physician that the medication was not given because the supply did not arrive. During an interview on 3/18/2020, at 1:52 p.m., with Resident 1's Responsible Party (RP- Resident 1's daughter), the RP stated she was concerned about her dad's (Resident 1's) medications, specially the [MEDICATION NAME] because in the past, his doctors tried to taper (gradually decrease) the dosage and he ended up going back to the hospital because he was in a lot of pain. The RP stated she knew something was wrong when she came to visit her dad, his condition had declined rapidly, he was in pain and discomfort, he never took pain medications even after his brain surgery. The RP stated that she became very upset when she found out from Licensed Nurse A, that her dad missed a few doses of [MEDICATION NAME] and that the wrong dosage was administered when the supply came. The RP stated, Dad (Resident 1) suffered needlessly and may have hastened his death and if I had known that the facility was not able to get the medication on time, I could have provided the facility with the medication ([MEDICATION NAME] 6 mg tablets) from dad's home supply. During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, dated April 2014, indicated, Policy Implementation and Interpretation: 5. A medication error is defined as the preparation or administration of drugs which is not in accordance with physician's orders [REDACTED]. 6. Examples of medication errors include: a. Omission- A drug is ordered but not administered c. Wrong dose (e.g., [MEDICATION NAME] 12 ml ordered, [MEDICATION NAME] 2 ml given) 12. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: d. Requiring treatment with a prescription medication e. Resulting in cognitive deterioration or impairment.