Every finding on record at Shoreline Care Center

Based on interview and record review, the facility failed to follow nursing standards of practice when duplicate medication orders were not clarified with the physician prior to administration for one (1) of two (2) sampled residents (Resident 1). This failure resulted in confusion and a medication error resulting in Resident 1 receiving three (3) extra doses of medication jeopardizing Resident 1's health and safety.Findings:During a review of [NAME] and [NAME], Tenth Edition, Elsevier, Fundamentals of Nursing, page 609 in the section titled, Medication Administration, indicated, If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication.During a review of the facility's policy and procedure (P&P) titled, Medication Errors and Adverse Reactions, dated 4/2025, the P&P indicated that, It is the policy of this facility that medication errors and adverse drug reactions must be reported to the resident's attending physician.Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: The prescriber's order; Manufacturer's specifications (not recommendations) regarding the preparation and administration of medication or biological; or Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted established by national organizations, boards and councils.During a review of Resident 1's Face Sheet (FS), dated 7/2/26, the FS indicated that Resident 1 was admitted to the facility on [DATE]. During Resident 1's stay in the facility, Resident 1 was diagnosed with anxiety disorder on 5/27/21.During a review of Resident 1's Minimum Data Set (MDS - Resident's assessment in a nursing homes),dated 4/3/26, the MDS indicated that, Resident 1 had a BIMS of 15 (cognitively intact), diagnosis of anxiety disorder (a mental condition characterized by excessive, persistent and irrational worry, fear or dread), and received a medication for anxiety while in the facility.During a review of Order Summary Report (OSR),dated 6/2026, the OSR indicated a duplicate order for Lorazepam (type of medication to treat anxiety) 1 milligram (mg - unit of measurement) by mouth to be given one time a day every Tuesday, Thursday and Saturday to be administered 30 minutes before dialysis due to Resident 1's overly concern with his medical condition. There were 2 physician's orders for Lorazepam, dated 12/20/25 and 5/1/26. Further review of the OSR indicated that Resident 1's dialysis treatment time was from 9:30 a.m. until 1:15 p.m.During a review of the Medication Administration Record (MAR), dated 6/2026, the MAR indicated that duplicate orders for Lorazepam 1 mg were both signed on 6/16/26, and was administered at 8:00 a.m.During a review of Resident 1's Controlled Drug Record (CDR), dated 5/19/26, the CDR indicated that Resident 1 were administered Lorazepam 1 mg on 6/16/26, 2 doses at 7:38 in the morning and 2 doses at 2:00 in the afternoon.During a concurrent interview and record review on 7/2/26, at 1:41 p.m. with the Assistant Director of Nursing (ADON), the OSR, MAR, CDR and the facility's P&P were reviewed. The ADON stated that that during the course of the investigation on 6/16, the Licensed Vocational Nurse (LN 1) reported administering 2 doses of Lorazepam at 7:38 a.m. Additionally, LN 1 explained that 2 more doses were given to Resident 1 when the resident was picked up for dialysis. The second 2 doses of Lorazepam were signed administered in CDR by LN 1 at 2:00 p.m. upon return of Resident 1 from dialysis. LN 1 further explained that the presence of duplicate medication orders in Resident 1's clinical record made her confused. The ADON admitted that a medication error occurred for the administration of Lorazepam to Resident 1. The ADON stated that the duplicate medication orders should have been clarified with the physician prior to administration and was not.During interview on 7/2/26, at 3:45 p.m. with the Director of Nursing (DON), the DON acknowledged the error in medication administration and record keeping.

Based on observation, interview, and record review, the facility failed to ensure:1. One of four behavior-emotional sampled residents (Resident 51) had a comprehensive care plan (CP) that included an intervention that was not implemented and an intervention that was not supportive of Resident 51's CP goal. This failure resulted in Resident 51's psychosocial needs not being met.2. One of eight Preadmission Screening and Resident Review (PASRR-an evaluation to confirm that an individual has a mental illness) sampled residents (Resident 26) had the PASRR recommendations incorporated into their CP and had interventions (actions to be taken to maintain or improve a goal) that were measurable and clearly identified what was being measured. This failure resulted in Resident 26's psychosocial needs not being met. 1. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 1/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident. to meet a resident's. mental and psychosocial needs that are identified in the comprehensive assessment. During an observation on [DATE] at 10:42 a.m., in Resident 51's room, Resident 51 was in bed, in a hospital gown, anxious, tearful, and repeating the statement, I don't want to die. During a review of Resident 51's Minimum Data Set (MDS-a federally mandated, standardized evaluation tool) Comprehensive Assessment section D, titled, Mood, dated [DATE], the MDS indicated, Little interest or pleasure in doing things. frequency. nearly every day. Feeling down, depressed, or hopeless. frequency. half or more of the days. Trouble falling or staying asleep, or sleeping too much. frequency. half or more of the days. Feeling bad about yourself - or that you are failure or have let yourself or your family dawn. frequency. nearly every day. During a concurrent interview and record review on [DATE] at 10:52 a.m., with medical records (MR), Resident 51's care plan report (CP) titled, At risk for depression r/t [related to] Admission, dated [DATE] was reviewed. The CP indicated, Arrange for psych [psychiatric] consult [consultation], follow up as indicated. Observe for side effects of anti-depressant medication. MR reviewed Resident 51's medical record and stated there was no evidence of a psychiatric consultation. MR further stated there was no order for an antidepressant. During a concurrent interview and record review on [DATE] at 11:30 a.m., with Director of Social Services (SS), Resident 51's CP titled, At risk for depression r/t Admission, dated [DATE] and Order Summary Report (OSR), were reviewed. SS stated the CP intervention for a psychiatric consultation was not followed and the intervention for observing the side effects of antidepressant medication did not apply to Resident 51. 2. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 1/2026, the P&P indicated, Interventions - are actions, treatments, procedures, or activities. Measurable - is the ability to be evaluated or quantified. The facility IDT will develop and implement a. care plan for each resident's needs identified. any specialized services as a result of PASARR recommendation. During a concurrent interview and record review on [DATE] at 2:14 p.m., with the Director of Nursing (DON), Resident 26's:PASRR Individualized Determination Report (PASRR-IDR), dated [DATE], was reviewed. The PASRR-IDR indicated, Recommended Specialized Services. Psychotherapy/Counseling. Individual and/or group and/or family treatment provided by a licensed mental health professional.Care Plan Report (CPR) titled, [Resident 26's name] has Potential for a behavior problem r/t [related to] Schizophrenia [a type of mental illness] AEB [as evidenced by] auditory or visual hallucinations, initiated [DATE] and last revised [DATE], was reviewed. The CP indicated, Interventions. Administer medications as ordered. Monitor/document for side effects and effectiveness. Behavior Symptoms. Document behaviors.DON stated the facility social services is not a licensed mental health professional. DON also stated the PASRR recommended service is not incorporated into the care plan. DON further stated the interventions do not identify the medication to be administered/monitored, what behaviors to be documented/monitored, or the frequency of documenting.

Based on observation, interview, and record review, the facility failed to ensure an appropriate audiology (hearing) referral was implemented for one of 35 sampled residents (Resident 136) with hearing impairment. This failure resulted in a delay in the provision of care, treatment, and services for all residents requiring a referral for care.During a review of the facility's policy and procedure (P&P) titled, Hearing Services, dated 11/2011, the P&P indicated, The resident will be referred as needed for a hearing evaluation. The SSD will keep at least one hearing amplifier available for new residents who are hard of hearing or as a temporary intervention if a resident's hearing aid is missing or lost.During a review of Resident 136's admission Record (AR), dated 4/24/2026, the AR indicated, Resident 136 was admitted in the facility on 1/7/2026 with diagnoses including, muscle weakness, gastrostomy tube (tube inserted through the belly that brings nutrition directly to the stomach), and type 2 diabetes mellitus (a condition where your body either doesn't produce enough insulin, or your cells don't respond properly to insulin). The Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 15, reflecting cognitive intact.During an interview on 4/21/26 at 3:16 PM, Resident 136 stated that he has difficulty of hearing and needs a hearing aid. Resident 136 reported that they informed facility staff of his hearing problem and no action had been taken.During a review of Resident 136's Physician Orders (PO), dated 1/7/2026, the PO indicated, May have hearing consultation with follow up treatments as indicated.During a review of Resident 136's Social Services Assessment (SSA), dated 1/8/2026, the SSA indicated, no hearing aids, but sometimes hard to hear.During an interview on 4/24/2026 at 8:48 AM, with Social Services (SS), stated that when a resident reports hearing problems and there is a physician's order for a hearing consultation, social services department is responsible for following up with the resident regarding the consultation.During an interview on 4/24/2026 at 10:00 AM, with Director of Nursing (DON), the DON stated that follow-up is required when a resident reports difficulty hearing. The DON confirmed there was no documentation to support that a follow-up or referral had been completed for Resident 136. DON further stated that the facility does not provide hearing amplifies for a new resident experiencing hearing loss.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 133), had their smoking privileges restricted when they refused to comply with the facility smoking policy to store their cigarette lighter in a secure box. This failure had the potential to result in avoidable accidents by other residents having access to the lighter. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy, dated [DATE], the P&P indicated, If IDT [interdisciplinary team is a group of medical professionals who work together with the resident to focus on resident-centered care] determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept in a secured cabinet, only accessible to staff. Upon quarterly review by the IDT. smoking residents will be re-assessed as to their ability to smoke safely. and their ability to understand and comply with facility smoking policy. During a concurrent observation and interview on [DATE] at 4 p.m. with Resident 133 in their room, a green lighter was observed on their bedside table. Resident 133 stated the lighter belonged to him and he uses it when he smokes. During a concurrent observation and interview on [DATE] at 4:10 p.m. with a licensed nurse (LN3) in Resident 133's room, Resident 133 had a green lighter on his bedside table. LN3 stated it should not be there. Resident 133 became belligerent and was yelling at LN3, Leave my fucking stuff alone. During an interview on [DATE] at 4:30 p.m. with the Director of Social Services (SS), SS stated SS saw a message about Resident 133 refusing to sign the last smoking policy review. SS also stated Resident 133's smoking care plan was not reviewed at Resident 133's last IDT meeting. SS further stated, I think it fell through the cracks. During a review of Resident 133's Care Plan Report (CP- an individualized plan for consistently managing a resident's care needs) titled, [Resident 133's name] is at risk for injury due to smoking, dated [DATE], the CP indicated, Goal: Resident will Adhere to the Tobacco/Smoking Policies of the Facility. Interventions [actions to prevent a negative outcome] . Conduct Smoking Safety Evaluation on admission and PRN [as needed]. No revisions were made to the CP. During a review of Resident 133's IDT - Care Plan Review (IDT - CPR), dated [DATE] at 1:34 p.m., the IDT - CPR indicated, Person-Centered Assessment and Risk Assessment tools . were completed as a basis to establish the Resident's Plan of Care. [NAME] all that apply [Smoking Safety Evaluation was not marked] . Social Service Plan of Care. Resident appears to be adjusting well to facility without significant mood or behavioral concerns at this time. During a review of Resident 133's Progress Note (PN), titled, Social Services, dated [DATE] at 3:26 p.m., the PN indicated, SS met with resident to review facility smoking policy. Resident refused to sign smoking policy.

Based on observation, interview, and record review, the facility failed to ensure the observance of infection control practices and protocols for one of six sampled residents (Resident 140), when 1. a foley catheter dignity bag (a discreet pouch/bag to keep/hide urine drainage bags for privacy and dignity) was observed in contact with the floor and 2. the facility stored outdated food products in the kitchen refrigerator.These failures had the potential to result in a significant infection control risk such as a catheter associated urinary tract infection (CAUTI) and food-born illness to all residents. 1) During an observation, on 4/21/26, at 9:43 a.m., in room [ROOM NUMBER]A, Resident 140 was lying in bed. The bed was positioned at its lowest setting. Foley catheter urine tubing was observed on the left side of the bed, with the urine collection bag placed inside a dignity bag. The urine dignity bag bottom was in contact with the floor. During an interview, on 4/21/26, at 1:49 p.m. , with the Wound Care Nurse (WCN), in front of the DSD's (Director of Staff Development) office. The WCN was shown a picture of Resident 140's dignity bag's bottom in contact with the floor. The WCN looked at the picture and stated, The dignity bag should not be touching the floor. The WCN agreed with the finding. During an interview with the Director of Nursing (DON), on 4/21/26, at 1:55 p.m., in the DON's office, the DON was shown the picture of Resident 140's dignity bag's bottom in contact with the floor. The DON said the dignity bag should not be in contact with the floor. The DON agreed with the finding. During a review of the facility's policy and procedure titled, Catheter Care, Policy, revised 8/2025, indicated,. To promote hygiene, comfort and decrease risk of infection for catheterized residents. According to the National Library of Medicine, Chapter 21 Facilitation of Elimination, To prevent the development of a urinary tract infection, the bag should not be permitted to touch the floor. 2. During a concurrent observation and interview in the facility kitchen on 4/21/26 at 9:44 a.m. with the Dietary Assistant Supervisor (DAS), multiple food and liquid items stored in the kitchen refrigerators were observed with use by dates ranging from 4/17/26 through 4/20/26. The DAS acknowledged that the items were past their use by dates. The DAS continued to state that these items should not have remained in the refrigerators and should have been discarded. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, The Use By date will be the absolute date in which the food must be consumed or discarded by the facility.

Based on observation, interviews and record review, the facility failed to ensure compliance with required equipment maintenance standards when: 1. Medication refrigerators were not maintained at the proper temperatures and safe dry conditions 2. The kitchen ice machine was not maintained in safe and sanitary working conditionThese failures had the potential to result in compromising the integrity and potency of refrigerated medications and exposing residents to contaminated ice from an improperly maintained ice machine.1. During an observation, on 4/22/26, at 10:15 a.m., in the North Station medication room, the medication refrigerators' thermometer recorded a temperature at 40 degrees Fahrenheit (normal acceptable range +36 to 46 degrees Fahrenheit [2 to 8 degrees Celsius]). There was no thermometer in the freezer to record the freezer temperature (normal +5 degrees Fahrenheit or colder [-15 degrees Celsius]). The freezer compartment, positioned at the top of the medication refrigerator, was undergoing defrosting, resulting in water dripping down and accumulating on the medications stored at the lower section. The medication packaging appeared saturated and damp; additionally, a black metal box exhibited rust on its handle hinges, and water was found pooled within the insulin medication container. During an interview, on 4/22/26, at 10:20 a.m., in the North Station medication room, with licensed nurse 2 (LN 2), LN 2 inspected the medication refrigerator and confirmed that the freezer was defrosting even with the temperature was within range. LN 2 acknowledged the medication packaging were saturated/damp, the black metal box exhibited rust on its handle hinges and water was pooled within the insulin medication container. LN 2 said they were not aware the medication refrigerator was defective. During an interview, on 4/22/26, at 10: 35 a.m., in the North Station medication room, with the Environmental Services Director [ESD]), the ESD said he was not aware the medication refrigerator was defective. ESD said he will call the Pharmacy to request a new medication refrigerator since it is the Pharmacy's property. ESD said he never inspected or performed any preventive maintenance (PM) or had any maintenance logs on the medication refrigerator since it was the Pharmacy's property. During an interview, on 4/222/26, at 11 a.m., in the DON's office, the DON said the medication refrigerator was the facility's property and not that of the pharmacy. The DON said the EDM was misinformed about who owned the refrigerator. During a review of the facility's policy and procedure titled, Medications Refrigerators, revised 08/2025,, indicated, 1. Refrigerator's maintenance will be done by nursing and maintenance on a routine basis. Nursing staff will defrost and clean refrigerator weekly. Maintenance staff will inspect refrigerator and ensure its functionality per nursing staff request. 2. During an observation and inspection of the ice machine on 04/21/26 at 10:20 a.m. in the side room kitchen area, a white tissue test was performed on the lower stainless steel bin inside the unit of the ice dispenser. After wiping the inside of the ice dispenser, the tissue showed a moderate amount of yellowish residue. In addition, the ice within the machine was observed to contain black speckles. The Dietary Assistant Supervisor (DAS) and Environmental Services (ES) staff were present during this inspection and validated these findings. During an interview on 04/21/26, at 10:24 a.m., with ES, ES stated that the ice machine is cleaned monthly. ES further explained that the machine is sanitized using Nugon, which is poured into the ice dispenser to initiate the sanitizing process and flush the system. ES reported that all ice is removed and the interior of the machine is cleaned during this procedure. ES also verbalized that they did not know why the ice dispenser was found to be dirty. During a review of the manufactures' manual, titled Scotsman Ice System dated 12/14, the Scotman Ice System Installati9on and User's Manual for Modular Cuber indicated: It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. The manual states that without human intervention, sanitation will not be maintained. It further specifies that ice machines also require occasional cleaning of their water systems with a specifically designed chemical. This chemical dissolves mineral build up that forms during the ice making process.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 26) had the Preadmission Screening and Resident Review (PASRR-an evaluation to confirm that an individual has a mental illness) Determination Report recommended specialized services (services that exceed the services ordinarily provided by the nursing facility) for psychotherapy/counseling implemented. This failure had the potential to result in Resident 26 having increased psychiatric symptoms.During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 5/2025, the P&P indicated, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Evaluation must be completed by an approved state contractor, and a Determination made by the appropriate MI [mental illness] . state authority. During a concurrent interview and record review on 4/23/26 at 2:14 p.m., with the Director of Nursing (DON), Resident 26's PASRR Individualized Determination Report (PASRR-IDR), dated 1/4/22, was reviewed. The PASRR-IDR indicated, Recommended Specialized Services. Psychotherapy/Counseling. Individual and/or group and/or family treatment provided by a licensed mental health professional. DON stated the facility social services is not a licensed mental health professional. DON further stated the recommended service is not being provided.

Based on observation, interview and record review, the facility failed to ensure staff knocked and announced their presence prior to entering a resident's room for one of six sampled resident (Resident 5).This failure had the potential to negatively impact the residents' dignity and right to privacy, and cause embarrassment, discomfort or loss of respect.Findings:During an observation on 4/21/26 at 11:02 a.m., the Maintenance Assistant (MA) was observed entering room [ROOM NUMBER] without knocking on the door or announcing presence. Resident 5 was observed lying in bed. The MA proceeded into the room without obtaining permission to enter.During an interview on 4/21/26 at 11:05 a.m. outside the south dining room with MA, MA stated I usually enter if the door is open. I don't always knock because I'm just there to do something quickly.During an interview on 4/22/26 at 4:32 p.m. with the Director of Nursing (DON), DON stated, The facility expectation is for all staff to knock and announce themselves prior to entering residents' rooms to promote resident dignity and privacy.During an interview on 4/23/26 at 4:10 p.m. with the Director of Staff Development (DSD), DSD stated All staff should knock before entering residents' rooms.During a review of the facility's policy and procedure (P&P) titled Nursing Administration, under the section Resident Rights with the subject Dignity and Privacy, the policy states that it is the policy of the facility that all residents be treated with kindness, dignity, and respect. Subpart 3 states that residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passer-by. People not involved in the care of the Resident shall not be present without the residents' consent while they are being examined or treated. Staff members shall knock before entering the Resident's room.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 133), had a care plan (CP- an individualized plan for consistently managing a resident's care needs) reviewed and revised by the interdisciplinary team (IDT-a group of medical professionals who work together with the resident to develop a CP) after an assessment of Resident 133's ability to comply with the facility's smoking policy. This failure resulted in Resident 133 storing his smoking material in an unsafe location and becoming belligerent to staff who tried to enforce the smoking policy.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 1/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident. The resident's comprehensive care plan will be reviewed and/or revised by the IDT after each assessment. During a review of the facility's P&P titled, Smoking Policy, dated [DATE], the P&P indicated, If IDT determines that the resident is unable to safely store their smoking materials. smoking products will be kept in a secured cabinet, only accessible to staff. Upon quarterly review by the IDT, or any time a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely. and their ability to understand and comply with facility smoking policy. During a concurrent observation and interview on [DATE] at 4 p.m. with Resident 133 in their room, a green lighter was observed on their bedside table. Resident 133 stated the lighter belonged to him and he uses it when he smokes. During a concurrent observation and interview on [DATE] at 4:10 p.m. with a licensed nurse (LN3) in Resident 133's room, Resident 133 had a green lighter on his bedside table. LN3 stated it should not be there. Resident 133 became belligerent and was yelling at LN3, Leave my fucking stuff alone. During a review of Resident 133's Care Plan Report (CP) titled, [Resident 133's name] is at risk for injury due to smoking, dated [DATE], the CP indicated, Goal: Resident will Adhere to the Tobacco/Smoking Policies of the Facility. Interventions [actions to prevent a negative outcome] . Conduct Smoking Safety Evaluation on admission and PRN [as needed]. No revisions were made to the CP. During a review of Resident 133's IDT - Care Plan Review (IDT - CPR), dated [DATE] at 1:34 p.m., the IDT - CPR indicated, Person-Centered Assessment and Risk Assessment tools . were completed as a basis to establish the Resident's Plan of Care. [NAME] all that apply [Smoking Safety Evaluation was not marked]. During a review of Resident 133's progress note (PN) titled, Social Services, dated [DATE] at 3:26 p.m., the PN indicated, SS [social services] met with resident to review facility smoking policy. Resident refused to sign smoking policy. During an interview on [DATE] at 4:30 p.m. with the Director of Social Services (SS), SS stated SS saw a message about Resident 133 refusing to sign the last smoking policy review. SS also stated Resident 133's smoking care plan was not reviewed at Resident 133's last IDT meeting. SS further stated, I think it fell through the cracks.

Based on interview and record review, the facility failed to adhere to its policy and procedure requiring staff to use English as the primary language of communication, as outlined in the facility's Official language Designation policy. This failure resulted in noncompliance with established administrative standards and oversight practices. These failures have the potential to impede effective communication, compromise residents' rights to receive information in a manner they can understand, and place residents at risk for diminished safety and quality of care.During an interview on 03/25/26 at 2:45 p.m. with the Certified Nursing Assistant (CNA 1) stated, that staff of certain descent were being given preferential treatment at the facility. CNA 1 stated that they had been instructed by their superiors not to speak in their native language in the presence of others and had complied with that directive. CNA 1 further stated that other staff members continued to speak their native language in front of staff and residents without corrective action, and that residents had expressed discomfort about conversations occurring in a language they could not understand. During an interview on March 25, 2026, at 2:49 p.m. with CNA 2 stated, that staff of certain backgrounds were perceived as receiving preferential treatment regarding shift assignments and other work related matters. CNA 2 further reported that residents had expressed concerns, noting that they felt disrespected when staff communicated in languages the residents did not understand. During an interview on March 25, 2026, at 2:52 p.m. with the Hospitality Aide (HA) stated, that certain staff members of certain descent were perceived as receiving preferential treatment regarding vacation scheduling, call offs, and shift assignments. HA further stated that some residents had expressed concerns about staff communicating in languages the residents did not understand, noting that this made the residents uncomfortable. During an interview on 03/25/26 at 3:16 p.m. with Resident 4 stated, that staff speaking in other languages does not bother them, noting that many people speak different languages and Resident 4 has become accustomed to this. During an interview on 03/25/26 at 3:23 p.m. with Resident 5 stated, that it is extremely bothersome when staff speak in a language that Resident 5 does not understand. Resident 5 stated feeling as though staff may be speaking negatively about other residents, which causes Resident 5 to feel anxious. Resident 5 reported asking staff repeatedly to speak in English to ensure understanding. Resident 5 further explained that they have resided in the facility for five (5) years and that this concern has continued despite multiple requests for staff to communicate in a language that Resident 5 can understand. During an interview on 03/25/26 at 3:29 p.m. with Resident 6 stated, that it does not bother Resident 6 when staff speak in other languages in front of Resident 6. Resident 6 continued to state that people in California have been speaking in other languages in front of me all my life. During a review of the facility's policy and procedure titled, The Official Language Designation, dated 08/2025, indicated English is the official language of the company to respect and protect the residents' dignity and rights to communicate and to be communicated in their own language; to increase and promote harmony on the units and between employees through the use of a uniform system of communication; to decrease the amount of tension and anxiety among residents and employees which can result when multiple languages are spoken in and around patient care areas; and all employees on duty must speak English.

Based on observation, interview and record review, the facility failed to transcribe and implement an x-ray as ordered by the physician in one out of three sampled residents (Resident 1) after Resident 1 sustained a fall.This failure resulted in a delay of treatment and care of a right hip fracture for Resident 1 that went unnoticed and untreated by the facility for 7 days. During a review of Resident 1's admission Record (AR) undated, the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including Anemia (condition where the body does not have enough healthy red blood cells), Dementia (a progressive state of decline in mental abilities), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (mental health condition characterized by excessive worry, fear, and nervousness).During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/19/25, Section C indicated a brief interview of mental status score of 05 (BIMS - a measurement of cognitive abilities that ranges from 0 to 15 with scores of 0 - 7 indicates severe cognitive impairment).During an observation 1/6/26 3:25 p.m. in Resident 1's room, Resident 1 was observed awake in the wheelchair and well groomed. Resident 1 was asked about the fall incident but was unable to recall and stated, my memory is not good right now.During a review of Resident 1's Change in Condition Evaluation (CIC), dated 11/21/25, the CIC indicated Resident 1 had a fall onto her bottom. The CIC further indicated that the physician was notified with orders for a hip and sacrum (bone at the base of the spine) x-ray and an order for PRN (as needed) Tylenol 500 mg (milligrams) every 6 hours for pain. During a review Resident 1's Progress Notes (PN), PN dated 11/21/25 indicated Licensed Nurse (LN2) left a message with Resident 1's daughter regarding Resident 1's fall and new order for X- Ray to be taken the following day.Review of Resident 1's clinical records shows there were no orders for X- Ray taken following the fall as ordered by the physician.During a phone interview on 2/5/26 at 4:20 p.m., with Licensed Nurse (LN) 2, LN2 confirmed she was the nurse working during Resident 1's fall incident on 11/21/25. LN2 stated a Certified Nursing Assistant (CNA) was assisting Resident 1's roommate when Resident 1 was observed attempting to transfer from bed to wheelchair unassisted and subsequently fell onto her bottom. LN2 stated she notified the physician and received verbal orders, including an x-ray order. LN2 confirmed she did not transcribe the order or call the diagnostic company to perform the x-ray. LN2 stated I should have stayed late and called it in myself instead of assuming the next nurse was going to do it. LN2 acknowledged the x-ray was never done.During an interview on 1/6/26 at 2:55 p.m., with the Registered Nurse Supervisor (RNS), the RNS stated when a verbal x-ray order is received, the order is transcribed into the Electronic Health Record (EHR), a paper requisition form is completed, and the diagnostic company is called to be informed that there is an x-ray to be performed. RNS confirmed there are no x-ray results in Resident 1's medical records on or around 11/21/25. During an interview on 1/12/26 at 3:56 p.m., with the Director of Nursing (DON), DON stated Resident 1 did not complain of pain until 11/28/25 during a transfer of the resident from wheelchair to bed, Resident 1 complaint of hip pain. It was at that time, during the review of medical records, that the facility discovered that the request for an x-ray of the hip was not performed. DON stated the x-ray was never done as ordered by the physician and it should have. Resident 1 was then later diagnosed with a right hip fracture after being transferred to the acute care hospital on [DATE].During a review of ED (Emergency Department) Physician Notes (EDPN), dated 11/29/25, the EDPN indicated [Resident 1] presents to the Emergency Department with pain to the right hip and knee. patient does have a intertrochanteric fracture noted on the right hip at this time. During a review of the facility's policy and procedure (P&P) titled Physician Orders, Telephone Orders and Recapitulation Process, dated 11/2024, the P&P indicated, The facility personnel receiving the verbal or telephone order shall transcribe the order into the PCC system.Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe the orders are in error or would harm clients.During a review of the facility's policy and procedure (P&P) titled Fall Prevention and Response, dated 08/2023, the P&P indicated, 9. When any Resident experiences a fall, the Interdisciplinary Team should. d. Coordinate appropriate care and referrals to address underlying circumstances, including. labs/diagnostics.

Based on interview and record review, the facility failed to ensure physician's order to monitor the respiratory rate (RR - the number of breaths per minute) was followed for one of two residents (Resident 1) prior to administration of morphine sulfate (a highly controlled substance given for severe pain). This deficient practice had the potential to cause serious side effects including respiratory depression (slow, shallow, difficulty breathing).Findings:During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, undated, the P&P indicated in part, .B. Administration.2. Medications are administered in accordance with written orders of the attending physician.During a review of Resident 1's clinical record, Resident 1 was admitted to the facility under hospice care with the diagnosis of Vascular dementia (decline in thinking, memory and reasoning caused by damaged blood vessels), anemia (a blood condition), physical debility (physical general weakness) and COPD (lung disease).During a review of Resident 1's current Order Summary Report (OSR), dated 1/4, 1/7 and 1/14/26, the OSR indicated, the following information: Order date 1/4/26: Morphine Sulfate Oral Solution 10mg/5ml, give 0.25 ml by mouth every 8 hours as needed for severe pain (7 - 10/10 pain scale) hold if RR is less than 12. The medication was administered on 1/5 and 1/6/26. The order was discontinued on 1/7/26. Order date 1/7/26: Morphine Sulfate Oral Solution 10mg/5ml, give 0.25 ml by mouth every 4 hours as needed for severe pain (7 - 10/10 pain scale) hold if RR is less than 12. The medication was administered from 1/8 to 1/14/26. The order was discontinued 1/14/26. Order date 1/14/26: Morphine Sulfate Oral Solution 10mg/5ml, give 0.25 ml by mouth every 8 hours for severe pain hold if RR is less than 12. The medication was to be given routinely at 6 a.m., 2 p.m., and 10 p.m. The medication was administered on 1/14/26 at 10 p.m., and 1/15/26 at 6 a.m.During a review of Resident 1's Medication Administration Record (MAR), dated 1/4 and 1/7, and 1/14/26, the MAR indicated,Order dated 1/4/26: MS 10mg/5ml, to give 0.25ml by mouth every 8 hours as needed for severe pain 7-10/10 hold for RR less than 12. The medication was administered on 1/5 and 1/6/26 and the order was discontinued on 1/7/26. Order dated 1/7/26: MS 10mg/5ml, give 0.25 ml by mouth every 4 hours as needed for severe pain (7 - 10/10 pain scale) hold if RR is less than 12. The medication was administered from 1/8 to 1/14/26 and the order was discontinued 1/14/26.Order dated 1/14/26: MS 10mg/5ml, give 0.25 ml by mouth every 8 hours for severe pain hold if RR is less than 12. The medication was to be given routinely at 6 a.m., 2 p.m., and 10 p.m. The medication was administered on 1/14/26 at 10 p.m., and 1/15/26 at 6 a.m.There was no evidence Resident 1's RR was obtained prior to administration of the medication.During a concurrent interview and record review with Licensed Nurse (LN 2), dated 1/22/26, at 2:38 p.m. Resident 1's OSR and MAR were reviewed. LN 2 verbalized Resident 1's current order for morphine sulfate to be given routinely every 8 hours and not to give the medication if the RR is less than 12. LN 2 further verbalized checking Resident 1's RR before administering the medication. LN 2 was unable to provide evidence of documentation of Resident 1's RR and acknowledged the missing documentation.During a concurrent interview and record review dated 1/22/26 at 3:57 p.m. with the Assistant Director of Nursing (ADON), Resident 1's OSR and MAR were reviewed. The ADON stated the RR must be documented prior to the administration of the morphine sulfate and acknowledged the missing documentation.During a phone interview on 1/26/26 at 9:20 a.m. with the Director of Nursing (DON), the DON verbalized that the RR should have been included in the MAR so the resident's RR can be monitored before administration of the morphine sulfate. The DON further verbalized that the doctor's instructions are already in place and yet the nurses are not paying attention and did not clarify the MAR to include the RR. The DON acknowledged the missing documentation.

Based on interview and record review, the facility failed to ensure care and services provided met professional standards and principles for one of two residents (Resident 1) when mild swelling was observed on Resident 1's left hip five days after the fall incident which was not documented or monitored.This failure had the potential to result in Resident 1's care being compromised without the appropriate nursing follow-up monitoring and documentation in place.Findings:According to ANA's (American Nurses' Association) book titled, Principles for Nursing Documentation (Guidance for Registered Nurses), copyright 2010, the guidance indicated, in part, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines .Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals .to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care.During a review of Resident 1's clinical record, Resident 1 was admitted to the facility under hospice care with the diagnosis of Vascular dementia (decline in thinking, memory and reasoning caused by damaged blood vessels), anemia (a blood condition), physical debility (physical general weakness) and COPD (lung disease).During a review of the Minimum Data Set (MDS - a required residents' assessment in a nursing home), dated 12/10/25, the MDS indicated that Resident 1's cognitive skills (mental status) was severely impaired and never or rarely make decisions. During a review of the document titled, Change of Condition Evaluation (COC), dated 1/4/26, the COC indicated, Resident 1 had unwitnessed fall, without injury, without swelling. Resident 1 complaint of pain in the left elbow and left hip. Further review of the COC indicated a notification to Resident 1's responsible party (RP) and the physician with an order for pain medication.During a review of the Nursing Progress Notes (NPN), dated 1/4 to 1/12/26, the NPN indicated that paramedics were called and the RP was offered for Resident 1 to be transferred to the hospital, but the RP refused the transfer and x-ray be taken. On 1/9/26, a slight swelling was observed on Resident 1's left hip and an x-ray was taken. Further review of the NPN, a documentation indicating RP's refusal to send Resident 1 to the hospital. No follow-up documentation was found if Resident 1's swollen left hip was being monitored.During an interview on 1/15/26, at 12:28 p.m. with the Certified Nursing Assistant (CNA 1), CNA 1 verbalized arriving in Resident 1's room on 1/4, when Resident 1 had a fall. CNA 1 confirmed caring for Resident 1 at the time of fall and there were no skin discoloration and swelling were observed during care. The CNA further verbalized taking care of Resident 1 after the fall up until when a slight swelling was observed on the left hip on 1/9 and reported the observation to the nurse. During an interview on 1/15/26, at 1:32 p.m. with the Licensed Vocational Nurses (LN 1), LN 1 acknowledged checking Resident 1's left hip after receiving an order for an x-ray from the hospice agency physician. LN 1 admitted not initiating the COC assessment electronically since a COC assessment was already initiated on 1/26. During an interview on 1/22/26, at 2:38 p.m. with LN 2, LN 2 verbalized that a COC and the follow up nurses' notes must be initiated electronically in PCC (Point Click Care - an electronic site for clinical documentation used by the facility). LN 2 further verbalized that without the COC, the 72 hours follow up monitoring for Resident 1's swollen left hip would not be monitored and documented.During a concurrent interview and record review on 1/26/26, at 3:57 p.m. with the Assistant Director of Nursing (ADON), the Interdisciplinary Team notes (IDT), and NPN were reviewed. The ADON acknowledged the 1/9 observation on Resident 1's mild left hip swelling. The ADON further acknowledged the missing COC and 72-hour follow-up monitoring and documentation. The ADON was not able to provide proof of documentation if Resident 1's swollen left hip was monitored by the nurses. During a review of the facility's policy and procedure (P&P) titled, Change in Condition Reporting, dated 8/25, the P&P indicated in part, .Acute Medical Change.4. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.Follow up.1. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabled.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care-screening tool) accurately reflected the behavior status of one of two sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE], with diagnoses that include Alzheimer's disease (disease characterized by a progressive decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Order Summary Report (OSR), dated 8/28/25, the OSR indicated Quetiapine Fumarate (antipsychotic medication used to improve mood, thoughts, and behaviors) tablet 25 mg(milligrams) by mouth two times a day for Psychosis m/b (manifested by) visual and auditory hallucination (the perception of the presence of something that is not actually there) and monitor behavior for anti-psychotic Seroquel for Psychosis m/b auditory/visual hallucinations and tally every shift.During a review of Resident 1's Medication Administration Record (MAR), dated June 2025, the MAR indicated there were episodes of hallucinations on 6/4/25, 6/7/25, 6/9/25, and 6/10/25.A review of Resident 1's Change In Condition Evaluation report dated 8/26/25 indicated, that screaming was heard from nurses' station and staff was calling out for assistance. When staff proceeded down the hallway it was noted that staff had separated two residents. And when asked what happened Certified Nursing Assistant (CNA) stated I overheard them screaming at each other and both started hitting and slapping one another. Unable to determine who initiated the altercation or verbalize the reason for altercation. During a concurrent interview and record review on 9/4/25 at 3:56 p.m., with the Health Information Manager (HIM), Resident 1's MDS dated [DATE]. Section E0100 potential indicators for psychosis, the hallucinations box was not checked, indicating Resident 1 had no episodes of hallucinations. HIM acknowledged Resident 1's MDS Assessment was not accurate, and the box for hallucinations should have been marked. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument, dated 10/2024, the P&P indicated, The Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual V. 1.19.1 October 2024 will be the source of guidance for the RAI Process. 7) Each person completing a section of the MDS attests to its accuracy.

Based on interview and record review, the facility failed to:1. Ensure two of three sampled residents (Resident 1 and 2) were provided with a written bed-hold notification upon transfer to general acute care hospitals. 2. Ensure Resident 1's wife was provided with the bed hold private payment information before the resident was transferred to the veteran (VA) emergency department (ED).These failures resulted in the residents not having a bed-hold and were at risk of not being able to return to the facility.1. A review of the facility's policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated Upon transfer or discharge, a notice of transfer and discharge, as well as the bed-hold notification will be completed and given to the resident at the time of transfer or discharge or as soon as practicable. In the BED HOLD and readmission section of the policy indicated the facility will notify the resident or resident representative at the time of admission and again prior to hospital transfer or therapeutic leave, of the bed hold and readmissions policies.a) A complaint was submitted to California Department of Public Health (CDPH) on 7/14/25 indicating Resident 1 was transferred to [name of facility] for a medication evaluation and adjustment. The complainant agreed to the transfer after being notified by the facility that the facility would save Resident 1's bed, and that Resident 1 would be re-admitted back to the facility. However, the facility declined to readmit Resident 1 back to the facility.During an interview with Resident 1's responsible person (RP - person who makes healthcare decisions for a patient who is unable) on 7/14/25 at 12:15 p.m., RP reported the facility did not provide a written bed-hold notice upon Resident 1's transfer to [name of facility].A record review for Resident 1 was conducted on 7/15/25. Resident 1's Notice of Transfer or Discharge dated 7/2/25 indicated Resident 1 was transferred to [name of facility] on 7/2/25 at 2:40 p.m. On the Part B, Bed Hold (process of reserving a bed for a resident who is temporarily absent) section of the document indicated a Bed hold was authorized for Resident 1. The document titled Bed Hold Notification dated 9/4/24 indicated on 9/4/24 the (first notice) admission bed hold notification was performed. The (second notice) bed hold section of the notice that was supposed to be completed upon transferring of the resident, was not completed, the section was blank.During an interview on 7/17/25 at 2:23 p.m., with licensed vocational nurse (LVN) 1 who transferred Resident 1 to [name of facility] on 7/2/25 indicated not remembering if the written bed hold notice (second notification) was provided to the Resident 1's RP.During an interview with the assistant director of nursing (ADON) on 7/23/25 at 11:18 a.m., ADON acknowledged the Bed Hold Notification Form was not completed and not provided to the resident or representative upon the resident's transfer to the hospital.b) A record review for Resident 2 was conducted on 7/15/25. The [name of facility] Notice of Transfer or discharge date d 6/30/25 document indicated Resident 2 was transferred to Saint John's Regional Medical Center at 5:05 a.m. On part B- Bed Hold Section of the document indicated a Bed-hold was authorized for this resident. The document titled Bed Hold Notification Form, dated 6/19/25, indicated on 6/19/25 the (first notice) admission bed hold notification was performed. The (second notice) bed hold section of the notice that was supposed to be completed upon transferring of the resident, was not completed, the section was blank.During an interview with the assistant director of nursing (ADON) on 7/23/25 at 11:18 a.m., ADON acknowledged the Bed Hold Notification Form was not completed and not provided to the resident or representative upon the resident's transfer to the hospital.2. A review of the facility policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, in the BED HOLD and readmission section of the policy indicates The notification will include the duration of the bed hold allowance in which the resident is permitted to return and resume residence within the facility and the reserve bed- payment requirements.During an interview with Resident 1's RP on 7/14/25 at 12:15 p.m., RP reported the facility did not provide her with any bed-hold private payment information for the resident's bed to be reserved or held while resident was at the [name of facility]. During an interview with the business office manager (BOM) on 7/16/25 at 12:30 p.m., the BOM was asked if Resident 1's RP was provided with private pay or the reserve bed-payment requirements information to hold the bed for the resident. BOM stated No, I did not.

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after the resident was transferred to the veteran VA hospital for medication evaluation and adjustment.The facility's failure placed Resident 1 at risk of being admitted to another facility which is far from the wife's residence therefore unable to visit frequently.A complaint was received by the California Department of Public Health (CDPH) on 7/14/25 alleging that Resident 1 had been transferred to an acute care hospital for medication evaluation and adjustment. According to the information provided, a representative of the resident was informed by facility staff that the resident's bed would be held and that the resident would be readmitted to the facility following hospitalization. However, the facility subsequently declined to readmit the resident upon discharge from the hospital.During an interview on 7/14/25 at 12:15 p.m., with Resident 1's responsible person (RP - person who makes healthcare decisions for a patient who is unable), the RP reported that the facility declined to readmit Resident 1 following a hospital transfer. According to the RP, nursing staff notified them on 7/2/25 that Resident 1 would be transferred to [name of facility] for a medication evaluation and adjustment. The RP stated they were informed by facility staff that Resident 1 would be able to return following the hospital stay. However, the hospital case manager later informed the RP that the facility would not readmit Resident 1, and alternate placement would be required.During a review of Resident 1's Notice of Transfer or Discharge dated 7/2/25, the document indicated Resident 1 was transferred to [name of facility] on 7/2/25 at 2:40 p.m. The document indicated the transfer was necessary for Resident 1's welfare and that Resident 1's needs could not be met at the facility. However, there was no documentation indicating which needs could not be met. There was no documentation as to what attempts were made to meet Resident 1's needs. The sections were not completed on the document, these sections were left blank.During an interview on 7/17/25 at 2:23 p.m. with Licensed Vocational Nurse (LVN) 1, who transferred Resident 1 to [name of facility] on 7/2/25, LVN 1 stated that Resident 1 required a medication adjustment. LVN 1 confirmed marking/documenting on the transfer form that the transfer was necessary for Resident 1's welfare and that Resident 1's needs could not be met at the facility. Furthermore, when asked if the responsible person ([RP]) was informed there would be a Bed Hold (process of reserving a bed for a resident who is temporarily absent) for Resident 1, LVN 1 stated, Yes, I told the [RP] there was a bed hold for Resident 1 because that's our policy. During an interview on 7/16/25 at 12:30 p.m. with the Business Office Manager (BOM), the BOM was asked if information regarding private pay or reserve bed payment requirements was provided to the responsible person ([RP]) to hold the bed for Resident 1. The BOM stated, No, I did not. I did not have to because the resident was not going to be readmitted back. you need to speak with the administrator. During a telephone interview with the facility administrator (Admin) on 7/16/25 at 12:34 p.m., the Admin indicated the facility did not have to readmit Resident 1 because Resident 1 had attacked another resident. The Admin indicated the facility declined readmission due to Resident 1's behavior.Further review of Resident 1's Notice of Transfer or Discharge dated 7/2/25 did not indicate that Resident 1's transfer was due to the safety of individuals in the facility being endangered by the resident's clinical or behavioral status, or that the health of individuals in the facility would otherwise be endangered.A review of Resident 1's Physician's Discharge Summary dated 7/7/25, did not indicate that the reason Resident 1 was discharged was because the health and safety of individuals in the facility would be endangered.A review of the facility policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, in the BED HOLD and readmission section of the policy indicates A resident, whose leave exceeds the bed hold period. will be allowed to return to the facility to their previous room if available or immediately upon the first availability of a bed in a semi- private room, if the resident requires the services provided by the facility and is eligible for.skilled nursing facility services.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) when: 1. Female staff were not consistently assigned to Resident 1 as care planned. This failure had the potential to cause emotional distress and compromise Resident 1's psychosocial well-being. 2. Resident 1's cam boot (foot/ankle brace) was replaced with a non-weight-bearing immobilizer cast (a stiff wrap that keeps an injured area stable) on the left foot with no protocol in place for care. This failure had the potential to result in poor circulatory function and delayed healing of Resident 1's left foot fracture. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, psychosis (loss of contact with reality, hallucinations, delusions and disorganized thinking) and unspecified schizophrenia (mental disorder characterized by disruptions in thinking, perception, emotions, and social interactions) and fracture of right and left calcaneus (breaks in both heel bones). Resident 1's primary purpose for admission was for physical therapy. 1. During a review of Resident 1's Care Plan (CP), dated 5/26/25, the CP indicated, risk for decline in psychosocial well-being. CP interventions included, Assign a female staff to do 1:1 (one-to-one; one staff member to provide direct, continuous supervision and/or care) CNA (certified nursing assistant) to help with ADL's (activities of daily living). During a review of Resident 1's Interdisciplinary Team (IDT) notes, dated 5/26/25, the IDT indicated, continue 1:1 supervision with female staff. During a review of the facility's Daily Assignment Sheets (DAS), dated 5/24/25 through 6/2/25, the DAS indicated, male staff were assigned as 1:1 caregivers for Resident 1 on 5/29/25 and 5/30/25. During an interview on 6/13/25 at 11:13 a.m. with the Director of Nursing (DON), the DON acknowledged male staff were assigned to provide 1:1 care for Resident 1 on 5/29/25 and 5/30/25, contrary to the formulated care plan dated 5/26/25 specifying that only female staff should be assigned. 2. During a review of Resident 1's Orthopedic Progress Note (OPN), dated 4/11/25, the OPN indicated, a non-weight bearing immobilizer cast to left foot. During a review of Resident 1's Care Plan (CP), dated 3/5/25, the CP titled, Alteration in musculoskeletal status r/t (related to) fracture of left and right calcaneus had no update for the 4/11/25 order of non-weight bearing immobilizer cast to left foot. Further review of the care plan indicated, no interventions in relation to the circulatory function of the left foot while wearing an immobilizer cast. During an interview on 6/13/25 at 11:13 a.m. with the Director of Nursing (DON), DON acknowledged Resident 1's cam boot was changed to a non-weight bearing immobilizer cast on left foot. DON confirmed Resident 1's care plan was not updated to reflect the current immobilizer cast in use/care.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), had their health status accurately documented on the admission Minimum Data Set (MDS: a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This failure had the potential to result in an inaccurate plan of care, compromising the resident's quality of life and leading to unmet needs, inappropriate interventions, and negative health outcomes. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, fracture of right and left calcaneus (breaks in both heel bones), psychosis (loss of contact with reality, symptoms of hallucinations delusions and disorganized thinking), unspecified schizophrenia (psychotic symptoms that do not meet the criteria for a more specific schizophrenia spectrum or other psychotic disorder), chronic pain, opioid (moderate to severe pain medication) dependence, anxiety (feeling of apprehension, tension, and uneasiness) disorder, and depression (persistent sadness or loss of interest that interferes with daily life). During a review of Resident 1's MDS, dated [DATE], the MDS sections (I) Active Diagnoses and (J) Fall History on Admission/Entry or Reentry did not accurately reflect Resident 1's health status when questions J1700A, J1700B, and J1700C were marked no which indicated, Resident 1 did not have a fall any time in the last month, in the last 2-6 months, or had sustained a fracture related to a fall in the 6 months prior to admission/entry or reentry. During review of Resident 1's Psych (psychiatric) Discharge Note (PDN), dated 3/06/25, and Health and Physical (H&P), dated 3/7/25, the PDN and H&P did not indicate a diagnosis of schizophrenia. The PDN indicated, Resident 1 was discharged with diagnoses of, anxiety disorder, opiate dependency, and psychosis. The H&P indicated, Resident 1 had diagnoses of, left and right calcaneus fractures, anxiety, and opiate dependency. During review of Resident 1's Order Summary Report (OSR), dated 6/5/2025, the OSR indicated, Resident 1 was prescribed aripiprazole (medication used to manage and treat mental conditions) for psychosis and sertraline (medication used to treat depression, anxiety, and improve mood) for depression. During a concurrent interview and record review on 6/12/25 at 3:18 p.m., with the Minimum Data Set Coordinator (MDS-C), Resident 1's Medication Administration Record (MAR) and MDS were reviewed. MDS-C stated questions J1700A, J1700B, and J1700C in section J of the MDS were incorrectly answered as no and should have been answered as yes. MDS-C acknowledged the MAR indicated Resident 1 was prescribed aripiprazole for psychosis and that the H&P did not include a diagnosis of schizophrenia. MDS-C stated schizophrenia was selected as an active diagnosis in section I of the MDS because the PDN indicated Resident 1 had a history of schizophrenia. During a concurrent interview and record review on 6/13/25 at 11:13 a.m. with the MDS-C and the Director of Nursing (DON), the CMS manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0 (a manual that provides guidance on completing the MDS), dated 10/2025, section I for Active Diagnoses was reviewed. DON and MDS-C acknowledged the absence of a comprehensive psychiatric evaluation and documentation of currently treating Resident 1 for the diagnosis of schizophrenia. Review of the CMS manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0, dated 10/25, the Manual indicated, on page 341, in the section titled, Steps for Assessment, Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current .medical treatments .during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses .Listing a disease/diagnosis (e.g., arthritis) on the resident's medical record problem list is not sufficient for determining active or inactive status. To determine if arthritis, for example, is an active diagnosis, the reviewer would check progress notes (including the history and physical) during the 7-day look-back period for notation of treatment of symptoms of arthritis, doctor's orders for medications for arthritis, and documentation of physical or other therapy for functional limitations caused by arthritis.

Based on observation, interview, and record review, the facility's Interdisciplinary Team (IDT - a group of medical staff that work together to provide care of residents) failed to initiate a Significant Change in Status Assessment (SCSA - a comprehensive assessment) for one of four sampled residents (Resident 1) when: 1. Resident 1 refused to take schizophrenia (mental disorder that affects how a person thinks, feels, and behaves), depression (persistent feelings of sadness that interfere with daily life) and other medications. As a result, Resident 1 developed severe symptoms of distress including psychosis (loss of touched with reality), delusions, hallucinations, and paranoia. 2. Resident 1 showed physical and verbal aggression towards other residents and staff, and refused to follow the facility's smoking rules. These failures resulted in Resident 1's escalating behavior becoming more erratic, with increased aggressiveness toward others. No appropriate clinical interventions were implemented, which placed residents and staff at risk for danger and harm when Resident 1 started a fire in the facility. Findings: Review of Centers for Medicare & Medicaid Services (CMS), version 1.20.1 dated October 2025, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, page 45, in the section titled, Significant Change, in Status Assessment (SCSA) the Manual indicated, The SCSA .must be completed when the IDT has determined that a resident had a major decline .in status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, fracture of right and left calcaneus (breaks in both heel bones), psychosis (loss of contact with reality, symptoms of hallucinations, delusions and disorganized thinking), schizophrenia, chronic pain, opioid (controlled pain medication) dependence, anxiety (feeling of apprehension, tension, and uneasiness) disorder, and depression. Resident 1 was admitted with orders for Physical Therapy (PT) to address admitting condition of right and left heel bone fractures. 1. During a review of Resident 1's Medication Administration Record (MAR), dated 5/1/25 to 5/31/25, the MAR indicated on: 5/8/25 - Resident 1 began refusing the Pro-Stat supplement and incentive spirometer treatments (use of a handheld device to help take slow, deep breaths and expand lungs). The refusal continued the month of May. 5/18/25 - Resident 1 began refusing to take aripiprazole (medication used to manage and treat mental conditions such as schizophrenia, and depression) and sertraline (medication used to treat depression, anxiety, and improve mood). The refusal of Resident 1 to take the medications (aripiprazole and sertraline) continued 5/20, 5/21, 5/24, 5/25, 5/26, 5/27, and 5/28/25. According to Talkspace.com-Abrupt discontinuation of Aripiprazole (Abilify) can lead to a range of withdrawal symptoms, which may include: Neuropsychiatric: Anxiety, restlessness, agitation, irritability, decreased concentration, and mood changes, cause neuroadaptation in the brain, where the brain adjusts to having a new level of dopamine. Suddenly stopping the medication can disrupt this balance, potentially leading to withdrawal symptom and can also increase the risk of a relapse or return of the symptoms that the medication was intended to treat. It's crucial to consult with a doctor before stopping Abilify to ensure a safe and effective tapering plan. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA from 5/18/25 to 5/28/25 when the resident started refusing the regular ordered dose of aripiprazole and sertraline. 2. During a review of Resident 1's PNR dated 5/24/25, the PNR indicated, Resident 1 left facility without signing self out per facility's policy. During a review of Resident 1's Change in Condition Nurse's Notes (CIC), dated 5/25/25, the CIC indicated, the evaluation was due to behavioral symptoms (e.g. agitation, psychosis). The physical assessment outcome indicated, new or worsened delusions or hallucinations and other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) for mental status and physical and verbal aggression, danger to self or others, other behavioral symptoms for behavioral status. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA in reference to the CIC for behavioral symptoms dated 5/25/25. During further review of Resident 1's clinical record, the PNR indicated on: 5/9/25 - Resident 1 began displaying symptoms of agitation (restlessness, inability to stay calm, paranoia, suspiciousness, irritability, hostility, confusion, disorientation, inability to communicate, and violent behavior) starting on 5/9/25 and continued 5/13, 5/21, 5/24, and 5/26/25. 5/21/25 - Resident 1 started displaying increased symptoms of verbal aggression towards others. 5/24/25 - Resident 1 had a verbal and physical altercation with a roommate (Resident 2) on 5/24/25, resulting in Resident 2 sustaining bruises on the left arm. 5/25/25 - Resident 1 became verbally and physically aggressive towards a licensed staff (LN 8). 5/25/25 - The crisis team was called to address the physical aggression of Resident 1 in the facility. The facility was informed the crisis team can't respond to any physical aggression secondary to a hands-off approach. 5/27/25 - The crisis team was called again regarding Resident 1's behavior, history of slapping another resident, refusing medication administration, and for being verbally and physically aggressive. The crisis team arrived at the facility, talked to Resident 1 and offered to take the resident to the hospital. Resident 1 refused and claimed not wanting to go back to the psychiatric hospital and will sue the psychiatric hospital. Resident stated her cigarettes and medications were poisoned including that people were being raped. The crisis team stated they can't do anything for the resident or the facility but if the resident continued to refuse medications and meals to call them again to reassess. 5/28/25 - Resident 1 became verbally and physically aggressive towards LN 6. 5/28/25 - Resident 1 took the one-on-one caregiver s notes away, tore several pages from the notebook and started a fire with the torn pages in the patio smoking area. 5/28/25 - The crisis team was called again regarding Resident 1's behavior outside the facility (referring to the fire started in the facility patio area). The crisis team responded, Since there is no suicidal ideation or homicidal ideation, we can't do anything about her behavior. 5/28/25 - The police were called regarding resident's behavior of lighting a fire in the facility's smoking area. LN 1 asked Resident 1 for her lighter, Resident 1 attempted to hit LN 1's arm but the police stopped the resident. The police indicated they can't take the resident out of the facility due to a mental health condition and that the resident had to be moved to a different facility by social services or administration. 5/29/25 - The police were called back to the facility again in regard to Resident 1 starting a fire in the room. While waiting for the police to arrive, Resident 1 took a cell phone from nearby, LN 7 asked the resident to give the cell phone back and Resident 1 threatened to kill LN 7. The resident refused to return the cell phone until the police showed up. The police were able to retrieve the lighter that was used to start a fire inside the Resident 1's room. 5/29/25 - A resident informed LN 7 of being assaulted when Resident 1 ran into his wheelchair. 5/29/25 - Resident 1 threatened the Administrator (ADM) by throwing coffee at the ADM when resident was asked to surrender her lighter for safe keeping. Resident 1 refused to turn in the lighter. 5/29/25 - MD notes indicated a visit to see Resident 1 in the facility. The police and crisis team had been at the facility numerous times over the past four days. Resident 1 stopped taking ordered behavioral medications, is psychotic, paranoid, and delusional, has assaulted several staff and residents, last night started a fire in her room. The police had confiscated her lighter last night, but the resident was able to obtain more this morning. The police were not able to arrest the resident despite the arson and assault on staff and residents due to mental health. Resident was admitted from a psychiatric facility secondary to jumping off a table and breaking both feet. Resident is now refusing to eat and take medications. The crisis team in the building with MD to assess the resident but the crisis team will not take the resident on a 5150 (involuntary 72-hour psychiatric hold) due to resident not posing a threat to self or others. The plan indicated the facility will continue 1:1 staffing, call 911 as needed, and file an APS (Adult Protective Services) report. On 6/1/25, Resident 1 left the facility again (first episode on 5/24/25) without signing self out as per facility's policy. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA in reference to behavioral changes/escalation which began on 5/9/25. During an interview on 6/2/25 at 5 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had an altercation with Resident 2 one week prior. The DON stated that Resident 1 slapped Resident 2. Resident 1 was having behavioral issues. During a concurrent observation and interview on 6/2/25 at 5:18 p.m. with Resident 2, Resident 2 was observed with a large bruise on left forearm (purplish/reddish skin discoloration). Resident 2 stated that Resident 1 had accused her of stealing cigarettes and shampoo and then slapped her on the left arm. A Certified Nursing Assistant (CNA) pulled Resident 1 off of Resident 2. Resident 2 further stated not feeling safe being in the same room with Resident 1 and did not want to move to another room unless the other roommate (Resident 3) changed rooms too. During an observation on 6/2/25 at 5:52 p.m. in the facility's smoking area, Resident 1 was smoking in the same area a few steps away from Resident 2. No facility staff/supervision was visible within the perimeter smoking area. R 1 was observed to be heading towards the unlocked smoking area gate leading to the facility parking lot. Resident 1 then stopped and laid down on the grassy area near the gate. During an interview on 6/2/25 at 6:05 p.m. with Resident 4, who was within the smoking area with other residents also smoking, Resident 4 stated that Resident 1 went bonkers when she stopped taking meds, would push other residents with the wheelchair, would make other residents spill their coffee on themselves, and was verbally abusive to residents and staff. Resident 4 further stated that Resident 1 started a fire with a lighter and was concerned she will burn the whole place down. A review of the facility's initial admission assessment dated [DATE] indicated Resident 1 had no behavioral symptoms, including physical (hitting, grabbing), and verbal. The MDS assessment additionally indicated Resident 1 did not have behavioral symptoms that impacted any other residents. During an interview on 6/2/25 at 10 p.m. with the Minimum Data Set Registered Nurse (MDS-RN), and the DON, the MDS RN stated that an MDS assessment was performed on Resident 1 upon admission, but no other assessments were done. The DON confirmed that no SCSA or other additional MDS assessments were completed when Resident 1 had changes in behavior. The DON indicated no assessments had been performed since Resident 1's admission. During a review of the facility's policy & procedure (P&P) titled, Psychoactive Medication Management, dated August 2014, the P&P indicated, in part, When a resident presents with symptoms or behavior that causes impairment in function, alteration in emotional well-being, or a danger to the resident or others, it is the responsibility of the IDT to determine if the emotional or behavioral symptoms may be caused by a transient medical condition, or reversible environmental and/or psychological stressor. This can be assessed through the MDS/CAA process or by a team evaluation documented in the IDT notes.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 2) was protected from physical and verbal abuse from a fellow resident (Resident 1) who was having undirected behavioral symptoms and outbursts. This facility failure resulted in Resident 2 being slapped by Resident 1 and sustaining bruises (purplish/reddish skin discoloration) to the left arm and hand. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 had diagnoses including, chronic obstructive pulmonary disease (lung disease that makes breathing difficult), acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), anxiety disorder (excessive feelings of worry, fear, and unease that significantly interfere with daily life), and depression (feeling of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 5/24/25, the SBAR indicated, around 1 a.m. Resident 2 was slapped by another resident (Resident 1), staff intervened and separated both residents. The SBAR further indicated, on 5/24/25 evening shift 3-11 p.m., Resident 2 was observed with physical signs of injury described as bruising to the right arm and hand. The SBAR with evening nursing notes dated 5/26/25 indicated dark red colored bruise on left shoulder, arm, and hand. Further review of the SBAR which was started on 5/24/25 by night shift - 5/27/25, the bruises found on Resident 2 were identified not on the right hand and arm but on the left shoulder, arm, and hand. During a review of Resident 2's Care Plan (CP), dated 5/26/25, the CP indicated, bruising (purplish/reddish skin discoloration) on the resident's left arm and shoulder. During a concurrent observation and interview on 6/2/25 at 5:18 p.m. with Resident 2, Resident 2 was observed with a large bruise on the left forearm. Resident 2 stated that Resident 1 had accused her of stealing cigarettes and shampoo and then slapped her on the left arm. Resident 2 stated, A Certified Nursing Assistant (CNA) had to pull Resident 1 off of me. Resident 2 further stated not feeling safe being in the same room with Resident 1 and did not want to move to another room unless the other roommate (Resident 3) changed rooms too. In addition, Resident 2 stated the police had been at the facility at least six to seven times that week because of Resident 1's behavior. During a review of Resident 1's Clinical Record, the Clinical Record indicated, Resident 1 had multiple mental and behavioral undirected outbursts secondary to existing behavioral diagnoses including, psychosis (loss of contact with reality, symptoms of hallucinations, delusions and disorganized thinking) and unspecified schizophrenia (mental disorder characterized by disruptions in thinking, perception, emotions, and social interactions). Further review of Resident 1's Clinical Record, indicated, on 5/24/25, Resident 1 had a verbal and physical altercation with a roommate (Resident 2), resulting in Resident 2 sustaining bruises on the left arm. Resident 1's clinical record further indicated, from 5/9/ through 5/29/25 the facility had numerous documentation regarding the resident having undirected aggressive behaviors towards staff and other residents. The crisis team and law enforcement were also called in to the facility due to the escalation of behaviors. The psychiatrist plan was to provide 1:1 staff for Resident 1. During an observation and record review on 6/2/25 at 5:52 p.m. in the facility's smoking patio, Resident 2 was smoking in the same area as Resident 1 with no visible 1:1 staff. During a review of Resident 1's Physician Progress Notes, dated 5/29/25 at 12:10, the Notes indicated, PLAN: facility will continue 1:1 staffing. During an interview on 6/2/25 at 6 p.m. with the Director of Nurses (DON), the DON acknowledged that it is the facility's responsibility to protect the residents. During a review of the facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, dated 10/2022, the P&P indicated in part, Each resident has the right to be free from abuse .Resident to Resident abuse means the willful infliction of injury .with resulting physical injury, pain or mental anguish by one resident towards another.

Based on observation, interview and record review, the facility failed to: Provide adequate supervision for one of two sampled residents (Resident 1) to prevent accidents. Additionally, the facility failed to: -Accurately assessed Resident 1's risk for elopement. -Follow interventions for the administration of anti-anxiety medications. -Call the physician/medical practitioner for change in condition (increased agitation) to seek appropriate care intervention for Resident 1. -Place Resident 1 in a room farther away from the fire exit door which opens to a busy street. These failures resulted in Resident 1 opening an exit door on 2/14/25 between 5:30 a.m. to 5:35 a.m., walked to a busy street, was hit by a moving vehicle, sustained fatal injuries, and was pronounced dead at a local hospital on 2/14/25 at 6:40 a.m. Findings: A review of Resident 1's face sheet indicated Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking), psychotic disturbance (a mental health condition characterized by a loss of touch with reality), mood disturbance (prolonged periods of sadness, irritability, or extreme highs), and anxiety (feeling of fear, dread, and uneasiness) per the facility's Admission Record. A review or Resident 1's care plan dated 8/6/24, indicated anxiety manifested by aggressiveness or wandering/pacing agitated behavior, and poor impulse control with the goals of reducing anxiety, to keep self and others safe. Interventions include to provide reassurance, redirection or diversion, to administer anti-anxiety medication as ordered, refer to psychiatrist for possible medication adjustment and to reassess and evaluate the appropriateness of his current psychotropic medication regimen. A review of Resident 1's care plan included a focus area initiated on 10/28/2024, indicated the Resident 1 had struck another resident using an empty coffee cup. Interventions included instructions to keep the residents away from each other when in a common area (initiated 10/18/2024). The care plan also indicated a focus area revised on 12/19/2024, of the Resident having episodes of physical aggression related to dementia and poor impulse control. The care plan further indicated Resident 1 had hit another resident on 12/19/2024. Interventions to analyze the time of day, place, circumstances, triggers, and what Resident 1's behavior (initiated 12/15/2024); monitor the resident for behaviors of aggressiveness and document the behavior (initiated 12/15/2024); intervene when the resident becomes agitated (initiated 12/15/2024); and indicated the resident was to receive one-to-one staff supervision, pending an interdisciplinary team (IDT) review (initiated 12/19/2024). A review of the IDT notes dated 1/14/25 , indicated the IDT met following an incident involving the resident grabbing another resident by the jacket and pushing the other resident against a wall. Per care plan dated 1/14/25, to refer for Psych evaluation to review medications for possible adjustment. During a review of Resident 1's psychiatric practitioner's (PP) progress notes dated 2/5/25, indicated Resident was seen for ongoing episodes of physical striking out at other residents, resident is secured in the facility's south wing due to the risk of elopement, self-harm or the need for extensive supervision. During an interview on 2/28/25 at 1:45 p.m., with a certified nurse assistant (CNA2), CNA2 stated there was an instance in January 2025 when Resident 1 went outside the main entrance door in South station by following a visitor who was going out when the door opened. During an interview on 3/7/25 at 11:50 a.m., with Nurse Supervisor 3 (NS 3), NS 3 confirmed she did the elopement risk assessment of Resident 1 on 1/10/25 and evaluated him without elopement risk. NS 3 confirmed not reviewing any records and only based her evaluation to the best of her knowledge of the resident through interview but admitted not reviewing past evaluations, history and other pertinent information. During an interview on 3/8/25 at 12:15 a.m., CNA1 stated that Resident 1 was able to get out of the facility between 5:30 a.m. and 5:35 a.m. on 2/14/25. Resident 1 just got up from bed, went outside room [ROOM NUMBER], Resident 1 pushed the rear emergency exit door (few steps from room [ROOM NUMBER] door), alarm went off, Resident 1 stepped out the door on to the U-shaped handicapped ramp that connects to the street. CNA1 described that while Resident 1 was walking towards the middle of the road; Resident 1 was struck by a car and fell face down to the ground and towards the side of the road. A review of the hospital's trauma progress note dated 2/14/25, indicated, Patient in full arrest after auto vs pedestrian with head trauma .Patient pronounced dead in trauma bay at 6:40 am. During an interview on 3/12/25 at 2:50 p.m., with Licensed Nurse (LN 3), LN3 stated that on 1/2/25, she observed Resident 1 being restless (pacing back and forth) and on 1/6/25, she observed Resident 1 with episode of being suspicious that someone will steal from him. A review of the record titled Elopement Evaluation dated 1/10/25, indicated Resident 1 was not at risk for elopement. During interview on 3/12/25 at 3:05 p.m., the License Nurse (LN 4) stated that on 1/4/25, Resident 1 was observed to have restlessness as manifested by pacing back and forth. During a review of Resident's 1 Medication Administration Record (MAR) dated February 2025, indicated on 2/12/25 anxiety episodes were observed four times during morning shift, 2 times during evening shift, and two times during night shift, and paranoia (suspiciousness) three times in morning shift, two times in evening, and two times at night shift. Moreover, on 2/13/25 anxiety episodes were observed six times during morning shift, two times during evening shift, and two times during night shift, and paranoia (suspiciousness) four times in morning shift, two times in evening, and two times at night shift. However, there were no indications that staff provided non-pharmacological interventions prior to medication administration, nor administered medication (Lorazepam 0.5 mg tablet every six hours) as needed for anxiety. During an interview on 3/14/25 at 3:55 p.m. with LN 5, LN 5 stated that during her afternoon shifts (3pm to 11pm) on 2/12/25 and 2/13/25, Resident 1 told LN 5, I want to go home, someone was out to get me prompting LN 5 to enter 2 behavior episodes in the MAR under behavior monitoring dated February 2025. LN 5 stated she did not call the physician for the behaviors. During an interview on 3/15/25 at 5:22 a.m., a Nursing Supervisor (NS 2), stated during the night shift (11 pm to 7 am) on 2/13/25, she helped Charge Nurse (CN 1) enter a behavior monitoring observation for Resident 1 in the MAR dated 2/12 and 2/13 for behaviors manifested as restlessness (pacing back and forth), and a belief that someone will get him. During an interview on 3/15/25 at 4:15 p.m., LN 2 stated during her morning shifts (7 am to 3 pm) on 2/12/25 and 2/13/25 not administering the antianxiety medication because Resident 1 calmed down with redirection but admitted there was no documentation of the nonpharmacological interventions done and stated not calling the physician for the increased episodes in behavior. During an interview on 3/18/25 at 1:00 p.m., the Psychiatric Practitioner (PP) stated not receiving a call from the facility staff on 2/12/25 and 2/13/25 and further stated he could have ordered medication if he was told of the increased episodes in Resident 1's behavior. A review of the facility's P&P titled Elopement and Missing Resident dated 12/17 indicated, It is policy to monitor and evaluate residents at risk for wandering and elopement. The Interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs . A review of the facility's policy and procedure (P&P) titled Resident Assessment, dated 2006, P&P under Care Plan Documentation Guidelines indicated, Nursing service has the overall responsibility to coordinate care among all disciplines to achieve the established goals. A review of the facility's P&P titled Behavioral Health Services, dated 10/22, this indicated, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . 36708 On 2/27/25 at 5:40 p.m., during a supervisory visit, a concurrent observation and interview was conducted with the Administrator (Admin), Director of Nursing (DON) and the Manager for Environmental Services (MES). The DON stated the South wing of the facility was not a 'secured unit' but a unit with doors with alarms. Further observations with the DON and MES were conducted. The 2nd fire exit door exit was observed and was towards end of hallway. Four resident rooms were close by, room [ROOM NUMBER] was where Resident 1 was, with 1:1 sitter and a roommate at the time. The DON stated the sitter sits by the door of the resident's room. A sign code pink was posted on exit door with information on what to do with resident elopement. The DON confirmed code pink referred to a resident trying to elope/have eloped. This fire exit door with STOP sign in red color, opens easily, loud alarms on when opened, leads to a ramp, and one gate, the other side is a fence (not high). Ramp was very close to the street (J St.). The DON stated this ramp was not used for ambulance transport, and was the door where Resident 1 used to exit to the street. The plan of correction submitted on 2/18/25 was observed and confirmed implemented.

Based on interview, and record review, the facility failed to provide assistance devices to maintain an accident free environment for one of 27 sampled residents (Resident 25). The facility failed to follow the physical therapy recommendations for transferring Resident 25 from bed to the wheelchair with a mechanical lift, failed to follow their policy and procedure for using a gait belt when transferring Resident 25 with a two person assist, resulting in Resident 25 falling to the ground and sustaining actual harm. Resident 25 experienced severe pain, was transferred to an acute hospital for treatment of [REDACTED]. Cross refer to F309 Findings: Record review on 7/12/11 revealed Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 25 began physical therapy on 2/18/11 for a decline in functional mobility due to weakness and respiratory failure. The initial physical therapy assessment dated [DATE] revealed Resident 25 was alert and oriented, required maximum assist for rolling in bed, maximum assist for sitting up, was unable to walk, and was unable to sit to stand transfer due to lack of strength in both legs. The assessment indicated Resident 25 was unable to perform siting to a standing position at this time. The plan of care dated 2/17/11 indicated Resident 25 required limited assistance with transfer with interventions including two person transfer and a mechanical lift. On 2/27/11, a comprehensive assessment indicated Resident 25 was alert and oriented, had no behavioral problems, no long term or short term memory problems, required extensive assistance (staff to provide weight bearing support) with transfers with one person physical assist. Resident 25 weighed 249 pounds. The Progress Notes Listing dated 2/27/11 (part of the assessment) indicated Resident 25 required extensive assistance to total dependence with her activities of daily living. On 3/11/11 Resident 25 was discharged from physical therapy. The physical therapist's discharge summary stated Resident 25 was to remain at the skilled nursing facility on restorative nursing assistant (RNA) program, assessed Resident 25 as functioning at a level of moderate assist with 2 person assist for sit to standing activity, recommended a Maxi-lift (mechanical lifting device) for bed mobility and transfers from bed to wheel chair, and indicated Resident 25 was unable to ambulate. During an interview on 7/14/11 at 9:40 a.m., Physical Therapist 1 (PT1) confirmed that he discharged Resident 25 from physical therapy on 3/11/11, and for safety reasons he recommended that a Maxi-lift be used when staff transferred Resident 25 from her bed to a wheelchair. A nurse's note on 3/28/11 at 3 p.m. stated a certified nursing assistant (CNA) informed the charge nurse that Resident 25 was able to transfer from the bed to the wheelchair using a front wheel walker and the assistance of 2 people without using a lift. Documentation in the nurse's notes, nursing weekly summaries, and interdisciplinary care conference notes did not reveal an assessment by a registered nurse or reassessment by the physical therapist to confirm this change in Resident 25's status, or the appropriateness of modifying Resident 25's device/level of assistance for transferring. The plan of care was revised on 3/28/11, directing staff to assess the resident's physical ability, mood, and respiratory status which all varied based on the time of day and shift, to determine which device/level of assistance; i.e., Maxi-lift, Sara-lift (mechanical lifting device), or two person assist, to use when transferring the resident. A Nursing Weekly Summary Review dated 5/26/11 to 6/2/11 revealed Resident 25 was dependent on staff for transferring, bed mobility and toileting. A comprehensive assessment dated [DATE] revealed that Resident 25 during the preceding seven day period had not performed any type of transfer, including going back and forth from the bed to the wheelchair. Review of a nurse's note and a change of condition report dated 6/6/11 at 10:30 a.m. revealed that CNA1 and licensed vocational nurse 1 (LVN1) attempted to transfer Resident 25 from the bed to a wheelchair with the assistance of a walker. Resident 25 was unable to maintain her standing position and collapsed to the floor. With the assistance of four staff the resident was assisted to the wheelchair. LVN1 documented Resident 25 denied pain, refused range of motion (not a typical behavior), and no injury was noted. No further information regarding an assessment of Resident 25's condition was documented. During an interview on 7/12/11 at 2:25 p.m., CNA1 stated that a little before lunch on 6/6/11 she and LVN1 were transferring Resident 25 from the bed to a wheelchair. CNA1 indicated Resident 25 was a big woman. CNA1 stated that a mechanical lift was not used, but a walker was placed in front of the resident for her to hold onto. CNA1 stated she and LVN1 provided support for Resident 25 by holding her under each arm, and did not use a transfer belt. According to CNA1 Resident 25 was standing up and about to pivot to the wheelchair when the resident suddenly "let go of her legs." CNA1 stated she and LVN1 eased the resident to the floor. CNA1 indicated the resident's left leg was extended forward and her right leg was back to the side. CNA1 stated, "I took her right leg and straightened it out in front of her." CNA1 stated that it took four people to get Resident 25 up from the floor and into the wheelchair. When CNA1 was asked about transfer methods and the type of equipment used to transfer Resident 25, she stated that when she first began working with the resident a Maxi-lift was used. Later a Sara-lift was used, and eventually only 2 people were helping the resident transfer with the assistance of a walker. When CNA1 was asked how a decision was made regarding which type of device/level of assistance to use in transferring Resident 25 she stated, "The patient directs what assistance is needed." During an interview on 7/12/11 at 3 p.m., LVN1 stated on 6/6/11 she helped CNA1 bring Resident 25 to a seated position on the side of the bed and with one of them on each side of Resident 25 they helped her stand up with a walker. LVN1 stated, "She (Resident 25) was standing up holding onto the walker when she put herself down. She didn't give us any warning." LVN1 further stated that the decision not to use a lift was determined by the resident's mood, and the resident would tell the CNA if she wanted to stand up. LVN1 admitted she had not performed an assessment of the resident's physical status prior to attempting to transfer the resident. LVN1 stated Resident 25 did not complain of pain, and moving Resident 25 from the floor to the wheelchair took four staff members, including two male staff. LVN1 further stated Resident 25 was only up in the wheelchair for a little bit, and then with assistance from CNA3 a Maxi-lift was used to return Resident 25 to bed. During an interview on 7/12/11 at 3:35 p.m. physical therapy assistant 1(PTA1) stated he was summoned by LVN1 to assist in getting Resident 25 off the floor. PTA1 stated, "When we tried to get her up it wasn't an easy thing. She (Resident 25) stated that she couldn't get up because of pain. Because of the size of the lady it was challenging just to get her into the seat of the wheelchair. It took us two tries to get her off the floor" PTA1 stated that Resident 25 did not bare weight in the process of getting the resident from the floor to the wheelchair, and Resident 25 complained of her legs hurting. During an interview on 7/14/11 at 10:50 a.m. with the administrator and the director of nursing (DON) the DON stated a nursing assessment would have occurred to determine if Resident 25's physical status improved to the extent that the resident was able to transfer with the assistance of 2 people versus PT1's discharge recommendation, to use a Maxi-lift when transferring Resident 25 from her bed to a wheelchair. When asked to provide the licensed nursing assessment for Resident 25 documenting an improvement in the resident's physical condition, and ability to transfer without the Maxi-lift neither the administrator nor DON could find documentation of an assessment. The administrator confirmed it is the facility's procedure to use a gait belt when staff are transferring a resident. The administrator stated that based on the size of CNA1 and LVN1 it would be appropriate to use a mechanical lift. Review of the facility's undated policy and procedure titled, "Transfer Activities" revealed that step 5, of the procedure for transferring a resident from bed to wheelchair, directed staff to "Apply transfer belt." During an interview on 7/18/11 at 4:30 p.m., Resident 25's daughter stated that her mother called her around 11 a.m. on 6/6/11. The daughter stated her mother was crying and said, "I'm hurt, they dropped me." The daughter indicated her mother stated that she told staff she only wanted to get up with the mechanical lift. The daughter stated that on a Monday, two weeks prior to the fall, she observed staff getting her mother up to the wheelchair using a sling lift. The daughter indicated that her mother had not walked in two years, and since her mother's admission to the facility she had not observed her mother using a walker. During an interview on 7/19/11 at 12:45 p.m. CNA3 stated that when Resident 25 first came to the RNA program she used a Maxi-lift. The resident progressed to a Sara-lift, and then was able to transfer with the assistance of two people. When asked the timeframe for this progression CNA3 stated that a couple of months after Resident 25 started the RNA program the resident could use the Sara-lift. CNA3 stated, "She (Resident 25) would let you know how much assistance she needed." CNA3 further stated that between the RNA, CNA, and resident they decided how much assistance was needed and what equipment to use. CNA3 stated that on 6/6/11, around 10:30 a.m. she was notified by CNA1 that Resident 25 was on the floor. CNA3 stated, "When I saw her (Resident 25) on the floor she was saying, Get me up ...I want to get up. " CNA3 stated even with the assistance of five staff, including two male staff , who were doing the lifting, they had a hard time getting the resident to the wheelchair, because the resident's feet kept slipping. Once Resident 25 was in the wheelchair CNA3 stated she went to the dining room and approximately five to 10 minutes later LVN1 came and said Resident 25 wanted to go back to bed, and CNA3, CNA1, and LVN1 used the Maxi-lift to return Resident 25 to her bed. During an interview on 7/19/11 at 12:15 p.m. the NP stated Resident 25 was weak due to respiratory problems. The NP further stated that she spoke with LVN1 and was surprised to hear that LVN1 had tried to get the resident up with only the assistance of another person because Resident 25 was so weak, stating, "I never saw her out of bed." Review of a change of condition report dated 6/7/11 at 7 a.m. revealed Resident 25 complained of severe pain in both her lower legs. According to the nurse's physical assessment there was no swelling or discoloration noted on the resident's legs. On 7/12/11 at 2:25 p.m., CNA1 revealed she worked at the facility on 6/7/11, and was assigned to Resident 25. CNA1 stated that while providing care Resident 25 complained of pain in both legs and bruising was noted on both legs, but mostly on the right ankle. CNA1 stated she informed LVN1 about Resident 25's pain and bruising. Review of the June 2011 medication administration record revealed Resident 25 received medication for severe pain on 6/7/11 at 6 a.m. and again at 8:30 p.m. On 6/7/11 at 5 p.m. a telephone order was received, from the NP, to x-ray both of Resident 25's ankles. On 6/8/11, x-rays completed at the acute care hospital revealed a fracture of the left leg above the ankle, and two fractures in the the right leg above the ankle and at the level of the ankle.