Every finding on record at St Andrews

Based on observation, interview, and record review, the facility failed to ensure fortified diets (meal plan that increases a resident's caloric intake by adding high calorie items) were prepared as prescribed by the physician for five of 10 sampled residents (Resident 16, Resident 21, Resident 42, Resident 46, and Resident 51).This deficient practice had the potential for the residents not to meeting their nutritional needs.Findings:During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 11/20/2025 with diagnoses including sepsis (a severe body wide infection that can lead to organ failure), unspecified protein-calories malnutrition (not getting enough calories and protein, leading to weight loss and weakness), vitamin D deficiency (low vitamin D levels that can weaken bones).During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 9/27/2021 with diagnoses including complete traumatic amputation of the two or more left lesser toes (surgical or injury related loss of toes), unspecified protein-calories malnutrition, iron deficiency anemia (low iron causing low red blood cell, tiredness and weakness), basal cell carcinoma of the skin (form of skin cancer). During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 5/26/2022 with diagnoses including cachexia (severe weight loss and muscle wasting due to illness), unspecified protein-calorie malnutrition.During a review of Resident 46's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2024 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (type of stroke where part of the brain is damaged because blood flow is blocked, causing brain tissue death) affecting left non-dominant side, unspecified protein-calorie malnutrition, adult failure to thrive (significant decline in weight, strength, and overall health).During a review of Resident 51's admission Record, the admission Record indicated the facility admitted the resident on 8/13/2020 with diagnoses including aphasia (difficulty speaking or understanding language) following unspecified cerebrovascular disease (problems with blood flow in the brain), chronic obstructive pulmonary disease (long term lung condition that makes breathing difficult), unspecified protein-calorie malnutrition. During an observation on 6/3 /2026 11:50 a.m., in the kitchen, Dietary Staff (DS) 1 was preparing lunch meals and did not add the addition of extra caloric fortification (increasing calorie intake by adding calorie dense items) to meal designated as fortified diet for Resident 16, Resident 21, Resident 42, and Resident 46, and Resident 5. The residents' dietary cards (reference card that lists a resident's physician ordered diet, texture, and nutritional requirements to guide staff during meal preparation) indicated fortified diet.During an interview on 6/3/2026 at 12:03 p.m., with DS 1, DS 1 stated fortified diet meant the residents require extra food. DS 1 stated for residents on regular fortified meals, fortification was completed by adding margarine to the bread portion. DS 1 stated that for minced and moist fortified meals, margarine was applied to the meat portion.During an observation on 6/3/2026 12:12 p.m., in the resident's room, Resident 42's meal tray was observed without additional fortification.During an observation on 6/3/2026 12:13 p.m., in the resident's room, Resident 46's meal tray was observed without additional fortification.During an observation on 6/3/2026 12:14 p.m., in the resident's room, Resident 51's meal tray was observed without additional fortification.During an observation on 6/3/2026 12:15 p.m., in the resident's room, Resident 21's meal tray was observed without additional fortification.During an observation on 6/3/2026 12:19 p.m., in the dining room, Resident 16's meal tray was observed without additional fortification.During an interview on 6/3 /2026 at 15:38 p.m., with the Registered Dietitian (RD), the RD stated fortified diets are intended to increase caloric intake by adding calorie dense items such as butter, margarine, gravy, increasing milk or providing shake quantities to at least 8 ounces The RD stated that failure to fortify a diet as ordered may result in a resident not receiving sufficient calories to meet their estimated nutritional needs.During a review of the facility's policy and procedure (P&P) titled, Fortified Diet Policy and Procedure, undated, the P&P indicated, Residents identify as nutritionally at risk, experiencing significant weight loss, inadequate oral intake, pressure injuries, malnutrition, or increased nutritional requirement shall receive a fortified diet as ordered by the physician and implemented under the direction of the Registered Dietitian (RD).

Based on interview and record review, the facility failed to ensure two physical restraints weren't simultaneously used for one of eight sampled residents (Resident 35).This deficient practice resulted in the use of unnecessary restraints and restricted Resident 35's movement.Findings:During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 35's diagnoses included malignant neoplasm of the kidney (kidney cancer), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysarthria (a motor speech disorder caused by brain or nerve damage that weakens or paralyzes the muscles used for speech) and anarthria (the complete loss of the motor ability to articulate speech).During a review of Resident 35's history and physical (H&P) form, dated 4/7/2026, the H&P indicated Resident 35 had fluctuating capacity to understand and make decisions.During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 35's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 35 required substantial assistance (helper does more than half the effort) from staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation, on 6/2/2026 at 9:45 a.m., Resident 35 was observed with a soft mitten restraint on his right hand.During an observation, on 6/3/2026 at 9:30 a.m., Resident 35 was observed in the rehabilitation room exercising his legs with the soft mitten restraint on his right hand.During a record review of Resident 35's physician orders, dated 5/1/2026, the physician orders indicated Resident 35 had an abdominal binder for his gastronomy tube. The physician order, dated 6/1/2026, indicated to discontinue Resident 35's abdominal binder order. The physician order indicated Resident 35's right hand mitten was initiated on 5/3/2026. During a concurrent interview and record review, on 6/4/2026 at 12:29 p.m, with the Director of Nursing (DON), the DON stated the protocol for restraints was to begin with less restrictive measures such as distractions and allowing residents to express their feelings. The DON stated if the less restrictive measures were not effective then the doctor would be notified to obtain an order for physical restraints. The DON stated an abdominal binder was used for residents who try to remove their gastrostomy tube. The DON stated the soft hand mitten restraint was used to prevent pulling of tubes also. The DON stated Resident 35 had an abdominal binder from 5/1/2026 to 6/1/2026. The DON stated Resident 35's hand mitten was ordered on 5/3/2026. The DON stated the use of two restraints simultaneously on a resident was excessive. The DON stated the risk of using two restraints on a resident could result in the restriction of body movement.During a review of the facility's policy and procedures (P&P), titled Use of Restraints, dated 4/2017, the P&P indicated Restraints may only be used if and when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: treat the medical symptom; protect the resident's safety; and help the resident attain the highest level of his/her physical or psychological well-being.

Based on observation, interview and records review, the facility failed to ensure one of four sampled residents (Resident 24) was free from unnecessary medications when:1. There were two physician orders for Acetaminophen ([Tylenol] used to relieve mild to moderate pain) with the same indication.2. Tramadol (prescription painkiller used to treat moderate to severe pain) was administered routinely without a clinical indication.This deficient practice had the potential to result in medication errors, overdose, and unnecessary use of opioid (prescription drugs used to treat moderate to severe pain and carry significant risks of addiction, dependence, and overdose.Findings:During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 2/7/2025 with diagnoses including severe protein calorie malnutrition (body lacks both enough energy calories and protein), anxiety disorder (mental health condition characterized by excessive worry about everyday situations), and major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest).During a review of Resident 24's Minimum Data Set (MDS, a resident screening tool ), dated 4/8/2026 indicated Resident 24 was severely impaired with cognitive skills (ability to think and reason) for daily decision making and required extensive assistance with staff for her activities of daily living.During the review of Resident 24's Order Summary Report (a document containing active physician orders), dated 4/30/2026, indicated the following physician orders:1. Acetaminophen 325 milligrams (mg, a metric unit used for medication dosage) give 1 tablet by mouth every 4 hours as needed for mild pain. Order status: active dated 4/30/2026.2. Acetaminophen 325 mg, give 1 tablet by mouth every 4 hours as needed for mild pain. Order status: active dated 3/25/20263. Tramadol 50 mg PO (medication taken orally) three times daily for pain management dated 4/3/2026During an interview on 6/4 /2026 at 10:22 a.m., with Pharmacist Consultant (PC), the PC stated there should not be two active orders for the same medication, such as Tylenol 325 mg. PC stated the presence of duplicate orders poses a risk of administering a double dose to Resident 24, which could lead to potential harm or adverse effects. The PC stated medication orders for Tramadol must include a clearly defined pain scale (a communication tool used to measure the intensity of a person's pain) to prevent under or over medication. The PC stated that the Tramadol order written as one tablet by mouth three times daily for pain management lacked specificity and did not identify the medical condition being treated.During an interview on 6/4 /2026 at 12:20 p.m., with Registered Nurse (RN) 1, RN 1 stated RN 1 stated it was the RN's responsibility to check with the attending physician to determine which medication orders should continue to ensure they accurately reflect the resident's needs. RN 1 stated having two active orders for Acetaminophen 325 mg for Resident 24 can create confusion for staff responsible for medication administration and increase the risk of an overdose due to duplicate dosing for the resident. RN 1 stated there was no current clinical need for the medication and it should not be administered on a routine basis. RN 1 stated continue to give Tramadol creates an unnecessary risk for adverse opioid effects and potential dependency.During an interview on 6/4/2026 at 1:40 p.m., with Resident 24, Resident 24 stated she does not have any pain currently, and she experienced no pain this week.During an interview on 6/04 /2026 at 1:43 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated she was responsible for taking care of Resident 24. CNA 4 stated Resident 24 did not report having pain.During a concurrent interview and record review on 6/4 /2026 at 1:43 p.m., with the Director of Nursing (DON), Resident 24's Medication Administration Record ([MAR] - a daily documentation record used by licensed nurse to document medications and treatments given to a resident) from 4/1/2026 to 5/31/2026, were reviewed. The DON stated Resident 24 had duplicate active orders for Acetaminophen 325 mg, ordered every four hours as needed for mild pain. The DON stated that duplicate orders place the resident at risk for receiving both doses, which could lead to an accidental overdose. The DON stated Tramadol should be used only for pain management, and long term use of Tramadol, may result in dependency or addiction for the resident. DON stated none of the resident's diagnoses indicated a need for routine Tramadol administration and should be discontinued because the resident no longer had a clinical condition requiring ongoing opioid therapy.During a review of the facility's policy and procedure (P&P) titled, Pain and Pain Assessment, undated, the P&P indicated, The pharmacist, physician/provider nursing staff, and interdisciplinary team shall review pain medication use as appropriate, including effectiveness, side effect, duplicated therapy, continue need, and possible dose adjustment.

Based on interview and record review, the facility failed to ensure the Arbitration Agreement form (a legally binding contract where parties agree to resolve future disputes through a private, out-of-court arbitration process instead of suing in a traditional courtroom) was not signed by one of eight residents, (Resident 1), who had a responsible party (the individual designated to pay a patient's medical bills, manage their care decisions, or supervise daily support services), had cognitive impairment, did not have the capacity to understand and make decisions and who was legally blind (a government classification for significant vision impairment used to determine eligibility for disability benefits, tax exemptions, and rehabilitation services).This deficient practice had the potential that Resident 1 did not understand what he was signing and resulted in the arbitration agreement not explained to the resident's responsible party.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included legal blindness, chronic kidney disease (a condition in which the kidneys are damaged and can't filter blood as well as they should), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland) and hypertension (high blood pressure). Resident 1 had a Family Member as the responsible party. Resident 1 was not self-responsible (the state of being responsible, answerable, or accountable for something within one's power, control, or management).During a review of Resident 1's History and Physical (H&P) dated 2/27/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 1's cognitive (thinking) skills were moderately impaired. Resident 1 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a record review of Resident 1's Arbitration agreement form, dated 7/9/2024, the Arbitration agreement form indicated Resident 1 signed the form.During interview on 6/4/2026 at 2:54 p.m., with the admission Coordinator (AC), the AC stated she was responsible for explaining the Arbitration Agreement form to the residents and/or responsible parties. The AC stated if a resident was not self-responsible, then the Arbitration Agreement form should have been reviewed and signed by the resident's responsible party. Resident 1's responsible party should have signed the Arbitration Agreement form. The AC stated the risk of having Resident 1, who was not self-responsible, signed the Arbitration Agreement form could result in the Family Member taking legal action against the facility. The AC stated residents had the right to rescind an Arbitration form within 30 days. During a review of the facility's policy and procedure (P&P) titled Arbitration Agreement and Policy and Procedures, undated, the P&P indicated that the arbitration offered to residents or their responsible parties should be explained in a language and manner they understand and provide opportunities for questions. The resident or legal representative may accept or decline the agreement.

Based on interview and record review, the facility failed to ensure the use of lorazepam (brand name Ativan, a medication used to treat anxiety and aggressive behaviors) had an adequate indication for use for one of eight sampled residents (Resident 38).This deficient practice had the potential to result in the use of a chemical restraint which could cause oversedation for Resident 38.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 38's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and liver cirrhosis (the permanent scarring of the liver caused by long-term, chronic disease or injury).During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 38's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 38 required substantial assistance (helper does more than half the effort) from staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 38's History and Physical (H&P), dated 5/28/2026, the H&P indicated Resident 38 did not have the capacity to understand and make decisions.During an observation, on 6/2/2026 at 10:32 a.m., Resident 38 was observed in bed, asleep.During an observation, on 6/3/2026 at 11:04 a.m., Resident 38 was observed in bed, asleepDuring an observation, on 6/3/2026 at 2:02 p.m., Resident 38 was observed still asleep in bed.During a record review of Resident 38's physician orders, on 6/4/2026 at 8:26 a.m., the physician orders indicated to administer Ativan 0.5 milligrams (mg, a unit of measurement) every 6 hours as needed (PRN) due to aggressive behavior toward staff and trying to pull out G-tube (gastrostomy tube- a soft plastic tube placed directly into the stomach through a small, surgical opening in the stomach). During a record review of March 2026 Medication Regimen Review (MRR) binder, on 6/4/2026 at 8:37 a.m., the MRR binder indicated to administer Ativan PRN (as needed): If resident is asking for it frequently then inform MD (medical doctor) and or psychiatrist if a routine order for Ativan is clinically indicated instead of renewing it frequently. The response to that recommendation indicated Will refer to psych. During a record review of Resident 38's May 2026 and June 2026 Medication Administration Record (MAR- a legal document that tracks medications given to a patient), the MAR indicated Resident 38 had received Ativan 0.5mg daily three times a day.During a record review, on 6/4/2026 at 9:02 a.m., there was no psychiatric consult found in Resident 38's chart.During a telephone interview, on 6/4/2026 at 9:17 a.m., with the Pharmacist Consultant (PC), the PC stated Resident 38 had been taking Ativan as needed since 2023. The PC stated he asked Resident 38's physician to consider switching the Ativan order from as needed to routine since the medication was being administered frequently. The PC stated the facility should have offered the least restrictive interventions before administering Ativan frequently such as obtaining and a psychiatric consultation. The PC stated the risk of administering Ativan frequently could result in placing a resident at risk for dependence on the medication, decreased respirations and sedation.During a concurrent interview and record review, on 6/4/2026 at 10:08 a.m., with the Director of Nursing (DON), the DON stated there was no psychiatric consult for Resident 38 due to Resident 38's son preference for Resident 38 to be seen at Kaiser Permanente. The DON stated Resident 38's son stated he would set the psychiatric consult appointment for Resident 38 and did not. The DON stated Resident 38 had an abdominal binder to protect Resident 38 from pulling out his gastronomy tube. The DON stated Resident 38's Ativan order should have been changed to a routine order instead of as needed since it was given frequently. The DON stated aggressive behaviors exhibited by Resident 38 included spitting and cursing at staff members. The DON stated that administering Ativan three times a day as needed could be viewed as excessive. The DON stated the risk of administering Ativan frequently could result in serious side effects.During a review of the facility's undated policy and procedure (P&P), titled Chemical Restraints, the P&P indicated if antipsychotic medications were administered as PRN dosages repeatedly over several days, the Physician should discuss the situation with staff and evaluate the resident as needed to determine whether the use is appropriate and the symptoms are responding to the medication.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was coded accurately for one of 23 sampled residents (Resident 47) by failing to ensure Resident 47's MDS, dated [DATE], reflected his serious mental illness (a health condition that affects a person's thinking, mood, behavior, or ability to relate to others).This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 47's health status and had the potential to negatively affect the plan of care and delivery of care and services for Resident 47. Findings:During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnoses included personal history of other mental and behavioral disorders, hypertension (HTN, high blood pressure), and benign prostatic hyperplasia (BPH, enlarged prostate gland).During a review of Resident 47's a Preadmission Screening and Resident Review (PASARR) Level 1 Screening (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility), dated 10/16/2025, the PASARR Level 1 Screening indicated Resident 47 was diagnosed with a serious mental illness of schizophrenia (a mental illness that is characterized by disturbances in thought). The PASARR Level 1 indicated the case status was referred for PASARR Level II (a federally mandated, in-depth evaluation required for anyone applying to a Medicaid-certified nursing facility who screens positive for a suspected mental illness, intellectual disability, or related developmental condition).During a review of Resident 47's History and Physical, dated 5/23/2026, the H&P indicated Resident 47 did not have the capacity to understand and make decisions.During a concurrent interview and record review on 6/3/2026 at 11:12 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 47's MDS, dated [DATE], was reviewed. MDSN 1 stated Resident 47's MDS was completed inaccurately. MDSN 1 stated there should be a check marked on MDS Section A1510 (Level II PASRR Conditions) (A) Serious mental illness and there should be no check marked on (C) Other related conditions. MDSN 1 stated Resident 47 has a diagnosis of schizophrenia which is considered as serious mental illness. MDSN 1 stated it is important to have an accurate MDS assessment in order to reflect the actual condition of the resident. MDSN 1 stated Resident 47's inaccurate MDS assessment would result in inappropriate psychiatric intervention and delay of care and services.During a review of the facility's policy and procedure (P&P), titled Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to ensure a quarterly IDT (Interdisciplinary Team- a group of people with different training and skills who work closely together to solve a complex problem or care for someone) meeting was conducted for one of eight sampled residents (Resident 12).This deficient practice resulted in staff not updating Resident 12's care plan.Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 12's diagnoses included metabolic encephalopathy (a temporary brain malfunction caused by a chemical imbalance in the body), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing) and acute kidney failure (the sudden loss of your kidneys' ability to filter waste products from your blood).During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool), dated 3/16/2026, the MDS indicated Resident 12's ability to make decisions regarding tasks of daily life was consistent and reasonable. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility.During a review of Resident 12's History and Physical (H&P), dated 5/28/2026, the H&P indicated Resident 12 had the capacity to understand and make decisions.During a review of Resident 12's Interdisciplinary Team meeting notes, dated 12/16/2025, the IDT notes showed an IDT meeting was conducted on 12/16/2025.During a review of Resident 12's IDT note, dated 5/27/2026, the note indicated the IDT meeting was conducted with Resident 12 on 5/27/2026.During a concurrent interview and record review, on 6/4/2026 at 12:33 p.m., with the Director of Nursing (DON), the DON stated IDT meetings were conducted quarterly (every three months). The DON stated the IDT committee consisted of the resident's physician, the facility's MDS nurse, Social Services Director/Assistant, DON, Registered Nurse, Dietary Services and Activities Director/Assistant, Certified Nurse Assistant, the resident and/or resident's responsible party. The DON stated Resident 12 had an IDT meeting on 12/16/2025 and again on 5/27/2026. The DON stated there was no IDT meeting conducted for Resident 12 for March 2026. The DON stated the IDT committee should have conducted a meeting for Resident 12. The DON stated the risk of not conducting IDT meetings quarterly as required could result in staff not being able to be updated or provide necessary needs for residents.During a review of the facility's policy and procedures, titled Care Planning- Interdisciplinary Team, dated 3/2022, the P&P indicated comprehensive, person-centered care plans were based on resident assessments and developed by an interdisciplinary team (IDT).

Based on interview and record review, the facility failed to ensure a referral for cardiology (medical specialty focused on the diagnosis, treatment, and prevention of diseases and disorders related to the heart and the cardiovascular system) was completed for one of one sampled resident (Resident 11).This deficient practice had the potential not to keep track of Resident 11's underlying heart disease that could result in the delay of necessary care and services.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included chest pain, presence of cardiac pacemaker (medical device implanted to regulate heartbeats), and dementia (a progressive state of decline in mental abilities).During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 11 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 11 required supervision (helper provides verbal cues or contact guard assistance as resident completes activity) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of Resident 11's Progress Notes, dated 5/18/2026, the Progress Notes indicated to refer Resident 11 to other cardiologist for continuation of care because Resident 11's previous cardiologist was not covered by his insurance.During a concurrent interview and record review on 6/3/2026 at 11:55 a.m., with the Minimum Data Set Nurse 1 (MDSN 1), Resident 11's Progress Notes, from 5/19/2026 to 6/3/2026, were reviewed. MDSN 1 stated there was no follow-up by the facility staff to refer Resident 11 to other cardiologist for continuation of care. MDSN 1 stated it is important for Resident 11 to have a follow-up with a cardiologist in order to monitor his pacemaker and if there are any treatment recommendation.During an interview on 6/3/2026 at 1:07 p.m., with Registered Nurse 1 (RN 1), RN 1 stated he informed the Administrator (ADM) to follow up with Resident 11's insurance to refer Resident 11 to a cardiologist. RN 1 stated it is important to refer Resident 11 to a cardiologist to ensure his pacemaker device was working properly and for continuous monitoring of his heart condition.During an interview on 6/3/2026 at 2:00 p.m., with the ADM, the ADM stated he called Resident 11's insurance to obtain authorization for a cardiology referral but it was denied. The ADM stated he could not provide any documentation or denial letter from Resident 11's insurance that the request for a cardiology referral was denied. The ADM stated until now Resident 11 has not been referred to the cardiologist.During a review of the facility's undated policy and procedure (P&P) titled, Pacemaker Standard of Care, the P&P indicated, Staff shall ensure that outside appointments for pacemaker checks, cardiology follow-up, or device interrogation are scheduled and completed as ordered.

Based on observation and interview, the facility failed to ensure a floor mat was placed by the bed as ordered for one of eight sampled residents (Resident 3).This deficient practice had the potential to result Resident 3 sustaining injuries during a fall.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included lack of coordination, muscle weakness, dementia (a progressive state of decline in mental abilities) and Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event)During a review of Resident 3's history and physical (H&P) form, dated 2/12/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 4/10/2026, the MDS indicated Resident 3's cognition (ability to think and process) was intact. The MDS also indicated Resident 3 required supervision (helper provides verbal cues or touching or contact guard assistance as resident completes activity) from staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 3's fall risk care plan, titled Actual Fall- 2/8/2026 unwitnessed fall, sitting on floor, facing the cabinet, dated 2/8/2026, the care plan interventions indicated Low bed with landing pad due to history of fall every shift for Fall Prevention.During a concurrent observation and interview, on 6/4/2026 10:45 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 3 was on fall precautions. LVN 2 stated Resident 3 was ordered to have his bed in the lowest position and a floor mat placed on the left side of his bed to prevent falls. LVN 2 observed Resident 3's room and stated Resident 3's bed was not in the lowest bed position and there was no floor mat on the left side of his bed. LVN 2 stated the risk of having a resident's bed in a high position with no floor mat could result in a resident having a fall causing a fracture or worse.During a review of the facility's policy and procedures (P&P), titled Falls and Fall Risk- Managing, dated 3/2018, the P&P indicated the staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on interview and record review, the facility failed to ensure a resident who has a suprapubic catheter (a thin, flexible tube used to drain urine from the bladder) was changed monthly as per the physician's order for one of one sampled resident (Resident 9).This deficient practice had the potential to result in the recurrence of a urinary tract infection ([UTI] - an infection in the bladder/urinary tract) that could develop into urosepsis (a potentially life-threatening complication of urinary tract infection).Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included obstructive reflux uropathy (a condition where a blockage in the urinary tract stops urine from leaving the body, forcing it to flow backward into the kidneys), urinary retention (inability to completely empty your bladder), and dementia (a progressive state of decline in mental abilities).During a review of Resident 9's History and Physical (H&P), dated 1/12/2023, the H&P indicated Resident 9 can make needs known but could not make medical decisions.During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2026, the MDS indicated Resident 9 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 9 was independent (resident completes the activity with no assistance from a helper) on eating, oral hygiene, and personal hygiene. The MDS indicated Resident 9 has an indwelling catheter.During a review of Resident 9's physician order, dated 3/8/2026 the physician order indicated Resident 9 has an order to change suprapubic catheter monthly and as needed.During a review of Resident 9's care plan, titled Resident has suprapubic catheter, dated 3/12/2026, the care plan indicated a goal for the resident not to develop signs and symptoms of UTI, until the next review in 3 months. The care plan intervention included to change the suprapubic catheter as ordered.During an interview on 6/4/2026 at 8:44 a.m., with Treatment Nurse 1 (TN 1), TN 1 stated the last time Resident 9's suprapubic catheter was changed was March 2026 when Resident 9 was sent to the hospital. TN 1 stated Resident 9's suprapubic catheter was not changed for two months. TN 1 stated it was an oversight on her part by not scheduling to change Resident 9's suprapubic catheter monthly. TN 1 stated it is important to change the suprapubic catheter on a regular monthly schedule as ordered by the physician to prevent UTI, damage and accumulation of urine sediments (solid microscopic particles found in urine) in the tube. TN 1 stated a UTI could cause urosepsis and endanger Resident 9's health and safety that would require hospitalization.During an interview on 6/4/2026 at 9:32 a.m., with Registered Nurse 1 (RN 1), RN 1 stated it is important to change the suprapubic catheter regularly in order to prevent UTI and to maintain the patency of the tube.During a review of the facility's undated policy and procedure (P&P) titled, Suprapubic Catheter, the P&P indicated, Each resident with a suprapubic catheter shall receive care and monitoring in a manner that promotes dignity, comfort, infection prevention, urinary drainage, skin integrity, and the resident's highest practicable physical, mental, and psychosocial well-being. The P&P also indicated suprapubic catheter care shall be provided according to the physician orders, professional standards of practice, resident's condition, care plan, and facility infection control policies.

Based on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 3) with Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) received Trauma Informed Care (TIC- an intervention and approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health).This deficient practice had the potential to result in the staff's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) for Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included lack of coordination, muscle weakness, dementia (a progressive state of decline in mental abilities) and Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).During a review of Resident 3's initial Social Services assessment, dated 1/13/2026, the Social Services assessment indicated Resident 3 was a veteran who served in the Army.During a review of Resident 3's history and physical (H&P) form, dated 2/12/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 4/10/2026, the MDS indicated Resident 3's cognitive (thinking) skills were intact. The MDS also indicated Resident 3 required supervision from staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation, on 6/4/2026 at 8:38 a.m., Resident 3 was observed in his room, talking to unseen people. Resident 3 stated, You don't even know what I've been through in my life!During an interview, on 6/5/2026 at 9:03 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated the definition of PTSD was a mental condition caused by a traumatic event that occurred in a resident's life. CNA 2 stated signs and symptoms of PTSD could be cursing, paranoia, striking out and having flashbacks of a traumatic event if triggered by certain events such as loud noise. CNA 2 stated he was aware Resident 3 had PTSD. CNA 2 stated he has observed Resident 3 attempting to lash out at staff. CNA 2 stated when Resident 3 lashed out, the staff attempted to calm Resident 3 down by distracting and redirecting him. CNA 2 stated he had not received in-services on how to provide care for residents with PTSD. CNA 2 stated the risk of not being in-serviced on how to care for residents with PTSD could result in staff not being able to provide care to a resident.During an interview, on 6/5/2026 at 9:30 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she did not know the definition of PTSD nor what the abbreviation meant. CNA 1 stated she was not aware of Resident 3's PTSD diagnosis. CNA 1 stated she did not recall if she received PTSD in-services. During a concurrent interview and record review, on 6/5/2026 at 10:05 a.m., with the Director of Staff Development (DSD), the DSD stated PTSD was a traumatic event that happens in someone's life causing a resident to have flashbacks. The DSD stated he was responsible for providing in-services to the facility's staff members. The DSD stated he did not conduct any in-services to the staff regarding PTSD from January 2025 to present. The DSD stated the risk of not providing PTSD in-services to staff and PTSD care services to a resident could result in not providing the necessary care needs and services that a resident may require.During a review of the document titled Facility Assessment, dated 1/20/2026, under Part 2: Services and Care We Offer Based on our Resident's Needs, the Facility Assessment indicated, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairments, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.During a review of the facility's undated policy and procedures (P&P), titled Post-Traumatic Stress Disorder (PTSD) Resident Care Policy and Procedure the P&P indicated Staff shall receive education regarding trauma-informed care and PTSD management.

Based on observation, interview, and record review the facility failed to ensure an unopened Gabapentin (an anticonvulsant drug used primarily to treat nerve pain and seizure) oral solution was stored inside the medication room refrigerator for one of one sampled resident (Resident 35).This deficient practice had the potential for the loss of efficacy of the Gabapentin oral solution that would cause ineffective pain management of Resident 35.Findings:During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 35's diagnoses included neuralgia (sharp and burning nerve pain), malignant neoplasm of the kidney (kidney cancer), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and gastrostomy tube placement (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 35's History and Physical (H&P), dated 4/7/2025, the H&P indicated Resident 35 had altered mental status to understand and make decisions.During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 35's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 35 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 35's physician order, dated 5/1/2026, the physician order indicated to administer Gabapentin oral solution 100 milligrams (mg, unit of measurement) via GT three times a day (9:00 a.m., 1:00 p.m., 5:00 p.m.) for neuropathic pain.During a concurrent observation and interview on 6/3/2026 at 10:14 a.m., with Registered Nurse 1 (RN 1), at medication room storage 1, 1 bottle of unopened Gabapentin oral solution for Resident 35 was found in a box, stored at room temperature. RN 1 stated Resident 35's bottle of unopened Gabapentin oral solution had a sticker indicated Refrigerate. RN 1 stated Resident 35's bottle of unopened Gabapentin oral solution was received on 6/2/2026. RN 1 stated the facility did not follow the manufacturer's recommendation to refrigerate the Gabapentin oral solution. RN 1 stated the Gabapentin oral solution should be stored in the refrigerator to maintain the potency, strength, and effectiveness of the medication.During a review of online.[NAME].com (web portal for clinical drug information and medication decision-support tool), medication guide for the literature of Gabapentin oral solution, indicated to store the Gabapentin oral solution in the refrigerator between 36 to 46 degrees Fahrenheit.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 11/2020, the P&P indicated, medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station or other secured location.

Based on observation, interview and record review, the facility failed to properly store, label and monitor food items for use when: Ravioli was kept in the freezer beyond use by date of 6/1/2026.Tamales was taken out of its original packaging and placed in a zip lock bag without use by date label.These deficient practices had the potential to place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).Findings:1.During an observation on 6/2/20206 at 8:19 a.m., reach-in freezer (Freezer 1) contained frozen ravioli stored in a zip lock bag labeled use by: 6/1/2026.During an interview on 6/2/26 at 2:37 p.m. with Dietary Service Supervisor (DSS), the DSS stated all food items removed from the original container must be labeled with use by date. The DSS stated the use by date was the last day residents can consume food items and food past the use by date was expired and must be discarded. The DSS stated consuming expired foods had the potential to cause residents to have stomach ache and illness. During an interview on 6/3/26 at 3:46 p.m. with Registered Dietician (RD), the RD stated that the use by date was the expiration date of stored food. The RD stated all foods taken out of original package must be labeled with use by date and food items that were not labeled must be thrown away to prevent residents from consuming potentially expired foods and develop any food borne illness. During a review of Policy and Procedures (P&P) titled Storage of Food and Supplies dated 2017, P&P indicated Food and supplies will be stored properly and in a safe manner.No food will be kept longer than the expiration date on the product.2.During an observation on 6/2/26 at 8:19 a.m., reach-in freezer (Freezer 1) contained individually wrapped tamales in a zip lock container without use by date label.During an interview on 6/2/26 2:37 with Dietary Service Supervisor (DSS), the DSS stated that tamales in the zip lock container without expiration label was considered expired and must be discarded. The DSS stated expired food had the potential to cause illness in residents.During an interview on 6/4/26 at 12:04 p.m. with Infection Preventionist (IP), the IP stated monthly checks were performed on food supply expiration dates, expired items were removed and the DSS was notified. The IP stated residents will be at risk for food borne illness and infection if expired food items were consumed.During a review of Policy and Procedures (P&P) dated 2018, P&P indicated Food and supplies will be stored properly and in a safe manner.labels should be visible.All food will be dated - month, day, year.

Based on observation, interview, and record review, the facility failed to ensure one of one resident's (Resident 15) dislikes on the dietary card reflected the resident's preference.This deficient practice had the potential to result in dissatisfaction with meals leading to decreased intake and weight loss.Findings:During an observation in the kitchen on 6/3/2026 at 12:00 p.m., Resident 15's plastic dietary card indicated dislikes included rice. The resident's lunch tray was observed including chicken, bread, green vegetables and rice.During an interview with Resident 15 on 6/3/2026 at 12:05 p.m., Resident 15 stated that his lunch appeared fine, but he does not dislike rice. During an interview with Dietetic Services Supervisor (DSS) on 6/3/2026 at 12:15 p.m., the DSS stated he was responsible for updating dietary cards per physician orders and resident preferences. The DSS stated Resident 15's dietary card was not updated. The DSS stated that discrepancies in dietary cards may result in residents receiving meals inconsistent with physician orders and/or individual preferences. The DSS stated that disregarding residents' food preferences and inaccurate labels may cause them to refuse meals and face health complications like weight loss.During a review of facility's Policy and Procedures (P&P) titled Food Preference dated 2018, P&P indicated Food preferences will be adhered to within reason.Assessment must be completed within 7 days of admission by the FNS (Food and Nutrition Services) Director. Updating food preferences will be done as resident's need change and/or during the quarterly review.

Based on interview and record review, the facility failed to ensure a resident representative was informed of the dysphagia (difficulty of swallowing) screening result for one of one sampled resident (Resident 54).This deficient practice violated the resident representative's right to be fully informed of Resident 54's plan of care and had the potential to result in a delay of care and services.Findings:During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 54's diagnoses included cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain), dysphagia, and gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement.During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 54's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never and rarely made decisions). The MDS indicated that Resident 54 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. The MDS indicated Resident 54 had a feeding tube.During a review of Resident 54's Dysphagia Screening, dated 3/23/2026, the Dysphagia Screening indicated Resident 54 to continue nothing by mouth and not safe for oral intake at this time.During a review of Resident 54's History and Physical (H&P), dated 5/28/2026, the H&P indicated that Resident 54 did not have the capacity to understand and make decisions.During a telephone interview on 6/2/2026 at 4:43 p.m., with Resident 54's representative (RR 1), RR 1 stated he had made a request to facility staff several times for Resident 54 to have an oral diet, but nothing had been done. RR 1 stated no one told him if Resident 54 could swallow food and have an oral diet.During an interview on 6/3/2026 at 11:31 a.m., with Minimum Data Set Nurse 1 (MDSN 1), MDSN 1 stated the facility staff had an interdisciplinary team (IDT, team members from different disciplines who come together to discuss resident care) meeting with Resident 54's representative on 3/19/2026 and Resident 54's representative requested for Resident 54 to have an oral diet. MDSN 1 stated Resident 54 had a dysphagia screening completed on 3/23/2026 and it was determined that Resident 54 was not safe to have an oral diet. MDSN 1 stated the IDT was not able to inform Resident 54's representative regarding Resident 54's dysphagia screening result. MDSN 1 stated it is important to collaborate the resident's plan of care to his designated representative so they would be updated regarding the resident's condition.During an interview on 6/4/2026 at 9:42 a.m., with Registered Nurse 1 (RN 1), RN 1 stated it was a violation of resident rights by not informing the resident's designated representative about the outcome result of Resident 54's dysphagia screening.During a review of the facility's policy and procedure (P&P), titled Resident Rights, dated 2/2021, the P&P did not indicate the importance of informing resident's representative of resident medical condition, care planning and treatment.

Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents, Resident 1, who was on a pureed diet (foods modified to a soft, pudding-like consistency for residents who have difficulty chewing or swallowing solid foods), was not fed by an untrained facility staff (Recepitonist).This failure placed the resident at risk for choking and aspiration (the inhalation of foreign material, like food, liquid, or stomach contents, into the airway and lungs) of food, which could lead to resident injuries and hospitalization, including death.Findings: During an observation on 7/14/2025 at 12 noon, in the front lobby, the Receptionist was observed sitting in the hallway next to Resident 1 and fed him lunch of a puree textured diet. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including nausea and vomiting, cirrhosis of the liver (a condition where healthy liver tissue is replaced with scar tissue, causing the liver to become progressively damaged and unable to function properly), and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a review of Resident 1's Minimum Data Set (a resident assessment tool) dated 5/14/2025, the MDS indicated Resident 1 had unclear speech, difficulty communicating some words or finishing thoughts but was able, if prompted or given time. The MDS indicated Resident 1 was dependent (helper does all of the effort to complete the activity) on staff with eating, oral hygiene and personal hygiene. During a review of Resident 1's physician order dated 9/10/2024, the physician's order indicated the following orders:1). Oral gratification diet of pureed texture, honey-thick consistency. 2). Use teaspoon only.3). Monitor anxiety behavior manifested by physical aggression to the staff every shift.4). Monitor behavior of trying to get out of bed/ wheelchair unassisted, to record positive (+) if present, negative (-) if absent, every shift.5) Monitor food intake every meal using teaspoon only, all oral (po) trials at this time, one on one feeding three times a day.6). Monitor for any signs and symptoms of difficulty swallowing or coughing, (=) if present, (-) if absent. Notify the physician if noted three times a day. During an interview on 7/14/2025 at 12:30 p.m., with the Receptionist, the Receptionist stated she assists in feeding residents and monitors their behavior when at the lobby. The Receptionist stated the facility did not provide her with training on how to feed residents. The Receptionist stated the Director of Nursing (DON) and other nursing staff (unidentified) expected her to assist in feeding Resident 1 and in monitoring Resident 1's behavior when at the lobby. The Receptionist stated she could jeopardize Resident 1's safety by feeding him without adequate training. During a review of the facility's policy and procedures (P/P) titled, Assistance with Meals, dated 7/2017, the P/P indicated all employees who provide resident assistance with meals should be trained and should demonstrate competencies in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The P/P indicated residents should receive assistance with meals in a matter that meets the individual needs of each resident. The P/P indicated residents who cannot feed themselves, should be fed with attention to safety, comfort and dignity.

Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for two of five sampled residents (Residents 3 and 4) by failing to perform hand hygiene (washing hands or using an alcohol-based sanitizer) before and after assisting Resident 3 and Resident 4 with their lunch meals. This failure had the potential to spread germs and increase the risk of infections among residents and staff. Findings:During an observation and concurrent interview on 7/14/2025 at 12:20 p.m. in the activity room, Restorative Nurse Assistant (RNA) 1 was observed sitting down between Resident 3 and Resident 4 during lunch. RNA 1 was observed assisting Resident 3 with using his fork while the resident was eating and feeding Resident 4 with a spoon and failed to perform hand hygiene before and after assisting the residents. RNA 1 stated he should not be assisting two residents at the same time and failing to perform hand hygiene before and after assisting each resident would spread germs and could lead to residents becoming sick.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis (a condition where fatty deposits (plaque) build up in the arteries supplying blood to the brain, leading to narrowing and hardening of the arteries), dysphagia (difficulty swallowing), and hypertension (high blood pressure).During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 3 sometimes understood, and could respond adequately to simple, direct communication only. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs) such as eating, oral hygiene and personal hygiene.During a review of Resident 3's care plan titled, At Risk for ADL Functioning with Self Care Deficit related to impaired mobility, history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) and dysphagia, dated 05/12/2025, the care plan indicated nurses would assist with ADLS daily and as needed. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including dysphagia following cerebral infarction (type of CVA), failure to thrive (a decline caused by chronic diseases and functional impairments that can cause weight loss, decreased appetite, poor nutrition and inactivity) and lack of coordination.During a review of Resident 4's care plan titled, Self-Care Deficit (Feeding) related to impaired hand coordination and motor control as evidenced by difficulty handling utensils and frequent food spillage. dated 5/30/2025, the care plan indicated nurses would demonstrate proper use of the plate and ensure Resident 4 practices using it and monitor nutritional intake and ensure Resident 4 is consuming sufficient food despite physical limitations.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 could understand others and had the ability to express ideas and wants. The MDS indicated Resident 4 required supervision or touching assistance (helper provides verbal cues and/or touching as resident completes activity) with eating and partial/moderate assistance (helper does less than half the effort) with oral hygiene and personal hygiene.During a review of the facility's policies and procedures (P/P) titled, Handwashing/Hand Hygiene, dated 8/2019, the P/P indicated the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Staff should use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents; before and after eating or handling food; before and after assisting a resident with meals.

Based on observation, interview, and record review, the staff failed to ensure the residents and/or responsible party (RP) were informed of an alleged abuse on 2/24/2025 and dentist visit on 3/10/2025 for one of three sampled residents (Resident 1). The deficient practice led Resident 1 ' s responsible party feeling ignored and uninformed about the care of Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia (high cholesterol) and hypertension (high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 3/11/2025, H&P indicated that Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2024, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete activity) with eating, oral hygiene, toileting hygiene, showering/bathing, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During an interview on 6/3/2025 at 9:04 a.m. with Family Member (FM 1), FM 1 FM 1 stated on 5/5/2025 the Ombudsman (Patient Advocate) had called him to inform him that there had been an allegation of a staff member hitting Resident 1. FM 1 stated the facility staff should have called him to let him know about the incident. FM 1 stated he felt ignored and uninformed about the care of Resident 1. FM 1 stated he had requested the Administrator (ADM) for Resident 1 not to be seen by the dentist as Resident 1 was not eating and he did not want his benefits to be used on something Resident 1 did not need. During an interview on 6/3/2025 at 11:50 a.m. with ADM, ADM stated there was a mixed up with what was reported to FM 1. ADM stated Resident 1 had hit a night shift nurse and License Vocational Nurse (LVN 1) reported anonymously the resident to the Ombudsman. The ADM stated the Ombudsman had came a couple of weeks ago to investigate an allegation which was already investigated and cleared back in May. The ADM stated they did not inform FM 1 about the incident because the abuse allegation was anonymous. it was not substantiated and did not want to make it worse for the family. During an interview on 6/3/2025 at 3:51 p.m. with ADM, ADM stated he should have notified FM 1 regarding the incident to ensure open communication and assurance that Resident 1 was well cared for. During an interview on 6/11/2025 at 9:36 a.m. with Dental Office Staff, the Dental Office staff stated the mobile dental office saw all new residents and Resident 1 was seen on 3/10/2025 for initial visit and was seen again on 3/20/2025 for x-rays. During an interview on 6/11/2025 at 9:43 a.m. with ADM, the ADM stated Resident 1 was seen initially by dentist in March. The ADM stated he received the notice ofdental visit at the facility which he forwarded to FM 1. The ADM stated FM 1 requested for Resident 1 not to be seen after the notice was given to FM 1. The ADM stated social services was supposed to notify FM 1 of initial dental visit, but she did not. During a review of the facility ' s Policies and Procedures (P&P) titled Change of Condition, undated, the P&P indicated the facility shall promptly notify the resident, his or her attending Physician, and representative (Sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident tights, etc.).

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to: 1. Ensure food items were labeled in Refrigerator 1, Refrigerator 2, Refrigerator 3 and Freezer 2 in the kitchen. 2. Ensure expired food was discarded from Refrigerator 2 in the kitchen. 3. Ensure a dented can sign was on display in the dry storage area. 4. Ensure the kitchen mixer and processer was clean. 5. Ensure the juice dispensing nozzle was clean. This deficient practice had the potential to result in in foodborne illness and contamination. Findings: During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 8:44 a.m., with the Dietary Supervisor (DS), an opened bag of parmesan cheese was noted to not have a dated label in Refrigerator #1. The DS stated food items in the refrigerator are required to have an open date. The DS stated the risk of not labeling the bag of parmesan cheese could result in residents consuming expired food. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 8:48 a.m., with the DS, a bag of expired parsley was observed in Refrigerator 2 covered in brown liquid. The DS stated the bag of parsley should had been thrown away. The DS stated the risk of having expired parsley in refrigerator 2 could cause foodborne illness. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 8:51 a.m., with the DS, an opened bag of lettuce, celery and zucchini was labeled with an open date of [DATE] in Refrigerator 2. The DS stated the lettuce, celery and zucchini were labeled with the wrong date. The DS stated the risk of labeling the wrong date on food items could result in not knowing when the item was opened and expired food. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:01a.m., with the DS, an opened pack of roast beef in a metal container was observed in Refrigerator 3 with no label. The DS stated the roast beef was to have a label. The DS stated the risk of not labeling roast beef could result in not knowing what the contents were. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:03 a.m., with the DS, a clear container containing red jelly was observed with an expiration date of [DATE] in Refrigerator 3. The DS stated the jelly should had been thrown away. The DS stated the risk of not discarding expired jelly could result in residents becoming ill. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:06 a.m., with the DS, a bottle of lemon juice was observed in Refrigerator 3 with no open date. The DS stated the risk of not labeling the lemon juice bottle could result in not knowing if or when it expired. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:14 a.m., with the DS, an opened bag of tamales was observed in Freezer 2 with no label. The DS stated the risk of not labeling the opened bag of tamales could result in not knowing if or when it expired. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:22 a.m., in the dry storage, with the DS, it was observed there was no designated place or label for the dented cans area. The DS stated there should had been a label on the bottom of the shelf indicating a dented can area. The DS stated the risk of not having a designated dented can area could result in possible contamination of bacteria. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:28 a.m., with the DS, a mixer and mixer whisks was observed to be uncleaned with a white residue. The DS stated the mixer and mixer whisks were dirty with leftover food. The DS stated the mixer was to be cleaned after every use. The DS stated the risk of having an uncleaned mixer could result in a growth of bacteria. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:35 a.m., with the Dietary [NAME] (DC), the food processor was observed with debris in its container. The DC stated the food processor should had been free of debris. The DC stated the risk of having debris in the food processor could result in an infection control issue. During a concurrent observation and interview, of the initial kitchen tour, on [DATE], at 9:46 a.m., with the DS, the juice dispenser was observed with an orange residue on the nozzle. The DS stated the residue was a permanent stain. The DS wiped the nozzle and observed it was unclean. The DS stated the juice nozzles were to be cleaned after each use. The DS stated the risk of not cleaning the juice nozzle could result in an infection control problem. During a review of the facility's policy and procedures (P&P), titled Labeling and Dating of Foods, dated 2020, the P&P indicated Newly opened food items will need to be closed and labeled with an open date and used by date. During a review of the facility's policy and procedures (P&P), titled Procedure of Refrigerated Storage, dated 2018, the P&P indicated Food items should be arranged so that older items will be used first and Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used, free of any wilting or spoilage. During a review of the facility's policy and procedures (P&P), titled Storage of Food and Supplies, dated 2017, the P&P indicated Have a separate area labeled for dented cans and damaged food items, and All dented cans and rusty cans are to be separated from the remaining stock and placed in a specified labeled area for return to purveyor for refund. During a review of the facility's policy and procedures (P&P), titled Electrical Food Machines, dated 2018, the P&P indicated, Mixing Machines: Wash bowl and beater after each use. and Food Grinders: Wash after each use. The facility did not have a policy indicating how often the kitchen juice nozzles was to be cleaned.

Based on interview and record review, the facility failed to revise and provide an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services. Findings: During a review of the facility census for 4/15/2025, indicated 54 residents resided in the facility. During a concurrent interview and record review on 4/16/2025 at 8:21 a.m., with the Administrator (ADM), the Facility Assessment Tool, was reviewed. The ADM stated the Facility Assessment Tool was last updated on 12/6/2024. The ADM stated the assessment provided was an average daily census of 51 residents. The ADM stated the average daily census recorded on the Facility Assessment Tool did not match with the current census. The ADM stated the Facility Assessment Tool was not accurate because of the average daily census which is below the actual census. The ADM stated there were three residents who were not accounted for on the Facility Assessment Tool. The ADM stated he was responsible for updating the Facility Assessment Tool. The ADM stated the Facility Assessment Tool should be updated and revised yearly and as necessary if there was a change in the resident population and operation of the facility in order to provide the needs of the residents. The ADM stated it was important to indicate the correct average daily census in the Facility Assessment Tool for the facility to plan adequately for staffing needs and to be able to accommodate and determine what resources are necessary to provide the care services of the residents. During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, dated 10/2018, the P&P indicated, The Facility Assessment is reviewed and updated annually, and as needed. Facility or resident changes or modifications that may prompt a reassessment sooner include a significant change in the resident census and/or overall acuity of our residents. During a review of Centers for Medicare and Medicaid Services (CMS), reference QSO-24-13-NH, dated 6/18/2024, titled Revised Guidance for Long-Term Care Facility Assessment Requirements, indicated the new requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The facility must also review and update the assessment whenever there is, or the facility plans, for any change that would require a substantial modification to any part of the assessment.

Based on observation, interview, and record review, the facility failed to ensure one of 16 residents (Resident 1), who had behaviors of wandering (to walk aimlessly) and elopement (leaving unsupervised, undetected without authorization) had a risk for elopement and wandering assessment, care plan regarding elopement, and was monitored. Resident 1 eloped from the facility on [DATE] to the liquor store, across the street from the facility and was brought back to the facility by Licensed Vocational Nurse 1 (LVN 1). On [DATE], Resident 1 eloped form the facility a second time and was involved in a tragic incident. Also, the facility failed to ensure the front doors were locked and the alarm system was activated. These deficient practices resulted in Resident 1 leaving the facility unsupervised on two occasions. On [DATE] at 8:08 p.m., Resident 1 wandered into a busy street, resulting in Resident 1 being hit by a car and dying at 8:38 p.m. (approximately 30 minutes after eloping from the facility) from the injuries sustained from the car impact. On [DATE] at 5:18 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was declared in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) for the facility's failure to ensure the facility's alarm system was activated, supervise and create a care plan to prevent Resident 1 from eloping the facility. Resident 1 was hit by a car and died . The ADM and DON were notified of the immediacy and seriousness for 16 residents at risk for elopement to have a wandering assessments and care plans created and to be supervised. On [DATE], the facility submitted an acceptable Plan of Action (POA) and the IJ was lifted on [DATE] at 12:14 p.m., after the POA was verified and implemented through observation, interview, and record review. The POA included the following: 1. Reassess all residents with indications of wandering/elopement (including with history) and develop a comprehensive resident centered plan of care to mitigate or reduce, if not totally prevent, the risk of wandering or elopement. Sixteen residents were identified through assessment and evaluation by the Interdisciplinary Team ([IDT] team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. The facility installed an alarm system in all areas and will be activated between 8 p.m. to 7 a.m., to alert staff when a resident attempt to leave the facility. The alarm systems at the two back doors will be installed by [DATE]. In the meantime, a guard was assigned to monitor the two back doors from 7 p.m. to 7 a.m. Alarms will have scheduled maintenance and testing by Maintenance Supervisor (MS) to ensure proper functioning monthly and will be documented in the Maintenance log and will be monitored by the Administrator. 3. The facility's Patient Care Policy Committee composed of the Medical Director, Administrator, DON, and Director of Staff Development (DSD) developed policy and procedure (P/P) defining the mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement to help minimize the risk of a resident leaving a safe area without authorization and or appropriate supervision. 4. Staff retraining, due to the incident, was initiated by DSD on [DATE] and continuing until all staff are retrained on Accident Prevention with strong emphasis on Elopement/Wandering. The Administrator will ensure all scheduled training are completed monthly for the next three months and quarterly thereafter. The implementation of the POA will be implemented by the facility staff and the effectiveness of the POA will be monitored and evaluated by the ADM, DON, DSD, Social Services Director (SSD) through direct observation of staff performance. Significant findings shall be addressed in the Quality Assurance and performance Improvement (QAPI - team that aims to improve process involved in health care delivery and resident quality of life) for trending and root cause analysis. 5. New admissions will be assessed for wandering and or elopement and a resident centered care plan will be developed and implemented if the resident is at risk for wandering and or elopement. 6. Keep photographs of the residents in a central secure location and ensure staff members and others in a position to help, can prevent these residents from exiting this building when observed. 7. Instruct visitors to inform staff members when their visit has ended. 8. Consider the use of personal alarms such as wander guard and check to see if they're operational. The facility will supervise and monitor resident's whereabouts at a minimum of every two hours or more frequent as necessary. 9. Staff will not assume changes in routine will be of benefit without including the resident's plans and will not ignore the resident's protests. 10. Monitor the resident's whereabouts across all shifts every 2 hours at a minimum and will be documented in the Elopement & Wandering Monitoring form. If the resident's wandering or elopement behavior increases or escalates, one on one monitoring will be implemented. 11. QAPI committee will conduct root cause analysis, develop time limited goal and interventions. The outcome of the interventions shall be evaluated and revised as necessary. 12. All in-services regarding the POA will be completed on [DATE]. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included [CONDITION(S)] ([[CONDITION(S)]] a long-term lung disease that makes it hard to breath), [CONDITION(S)] (serious mental illness that causes shifts in a person's mood, energy, and ability to function), and [MEDICATION(S)] dependence (addiction to tobacco). During a review of Resident 1's History and Physical (H/P), dated [DATE], the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 was alert, yet severely cognitively (thought process) impaired. The MDS indicated Resident 1 required supervision with locomotion (moving) on and off the unit, walking in room and corridors, personal hygiene, and activities of daily living (ADLs). During a review of Resident 1's admit/re-admit evaluation, dated [DATE], the evaluation indicated Resident 1 was not identified as a high risk for wandering or elopement. The evaluation did not indicate a re-evaluation was done in the month of ,d+[DATE]. During a review of the facility's document titled, Internal Investigative Statements, the statements indicated Resident 1 eloped on [DATE] a formal investigation was not documented at the time of the incident. The investigation indicated on [DATE], social services director (SSD) provided a statement indicating receiving a call at approximately 8:30 p.m. on [DATE] and was made aware Resident 1 was out of the facility at the liquor store, which was located 420 feet away from the facility. SSD indicated on her statement Licensed Vocational Nurse 1 (LVN 1) brought Resident 1 back to the facility. The statement indicated Resident 1 had left the facility to go buy cigarettes. During a review of Resident 1's IDT Progress Note, dated [DATE], the IDT indicated no complications with Resident 1 smoking behavior. However, the IDT did not indicate an update to Resident 1's increased smoking urges, aggressive behavior increased, and the previous elopement from [DATE]. During a review of Resident 1's care plans and assessments, dated ,d+[DATE] through ,d+[DATE], the care plans did not indicate an assessment and care plan for elopement/wandering was developed. During an interview with the Activities Director (AD) on [DATE] at 2:33 p.m., the AD stated after 6:30 p.m., it was the responsibility of the charge nurse to monitor the entry and exit points. The AD stated the front doors were locked at 8 p.m. and the alarms activated until the next day at 7 a.m. During an interview with Certified Nursing Assistant 1 (CNA 1) on [DATE] at 3:20 p.m., CNA 1 stated she was assigned to Resident 1 on [DATE]. CNA 1 stated on the day of the incident ([DATE]) and everyday previously, Resident 1 was very busy, anxious, confused at times, easily agitated, and constantly walked around the facility. CNA 1 stated Resident 1 often spent time on the back patio and often requested to go outside for a cigarette. CNA 1 stated Resident 1 was a risk for wandering away from the facility. CNA 1 stated she was instructed to monitor Resident 1 every two (2) hours. CNA 1 stated she started her shift at 3 p.m., at 7:30 p.m. - 8:04 p.m., she took her lunch break. When she was clocking back-in she saw Resident 1 in the hallway. CNA 1 stated she was unaware Resident 1 was missing until someone told her later that night. During an interview with CNA 2 on [DATE] at 4:16 p.m., CNA 2 stated she was familiar with Resident 1 because she was always walking around requesting cigarettes and was at risk for leaving the facility. During an interview with SSD on [DATE] at 4:49 p.m., SSD stated she visited Resident 1 on [DATE] prior to the incident. SSD stated Resident 1 requested all day from all staff to take her outside to smoke and it was annoying. SSD indicated an undocumented meeting took place between SSD, DON, and ADM to increase Resident 1's smoking breaks every two hours. SSD 1 stated the team thought increasing smoke breaks would eliminate Resident 1's behavior to want to go outside. SSD stated Resident 1 was at high risk for elopement because she had a previous elopement ([DATE]). During an interview with DON on [DATE] at 5:24 p.m., the DON stated Resident 1 was ambulatory and walked around the facility most of the time. The DON stated Resident 1 was addicted to smoking and her addiction placed her at high risk for elopement due to her constantly wanting to go outside to smoke. The DON stated a care plan for elopement and wandering for Resident 1 was necessary and was not aware why it was not created. The DON stated the alarm system was placed on ,d+[DATE] to prevent elopements and ensure staff could hear the alarms when a resident opened the door at nighttime. The DON stated RN 1 forgot to set the alarms and lock the door on [DATE]. During an observation of the video surveillance on [DATE] at 4:47 p.m., in the presence of the ADM, the video surveillance dated [DATE], Resident 1 was observed exiting the front double doors of the facility at 8:08 p.m. The facility's double doors were observed not locked. The alarm did not sound when Resident 1 opened the double doors. There was no staff observed in the facility's front lobby. Resident 1 was dressed in pants, shoes, shirt, and coat. Resident 1 exited the facility front iron gate. Resident 1 walked westbound toward the liquor store. Resident 1 was observed in the crosswalk walking toward the liquor store. At approximately 8:12 p.m., Resident 1 was struck by a car. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 3:20 p.m., RN 1 stated Resident 1 was at high risk for elopement because of her previous elopement. RN 1 stated Resident 1 exited the facility looking for cigarettes on [DATE] and was found at the liquor store. RN 1 stated there were times Resident 1 was seen by an exit door and was redirected back to her room. RN 1 stated he was not able to find a care plan for elopement. RN 1 stated Resident 1 walked around the facility and often went towards the exit doors. RN 1 stated staff monitored Resident 1 with frequent visual checks but did not document in the resident's clinical record. RN 1 stated there were no other interventions implemented. RN 1 stated it was his responsibility to lock the front doors and set the alarms at 8 p.m. RN 1 stated on [DATE] he forgot to set the alarm and lock the front doors. RN 1 stated if the doors were locked, and alarms activated Resident 1 would not have eloped and died from a hit and run accident. During a concurrent interview with the DON and review of Resident 1's assessment on [DATE] at 3:43 p.m., the DON stated Resident 1 was at risk for elopement based on her constant walking around the facility and constant urge to go outside to smoke. The DON stated she was aware the resident eloped to the liquor store on [DATE], but no Situation Background Assessment Re-evaluation Communication form ([SBAR] internal communication tool), was created for the incident. The DON stated and confirmed an elopement/wandering assessment and care plan was not created for Resident 1. The DON stated the facility's staff were concerned with Resident 1's [MEDICATION(S)] dependence behavior and not her eloping from the facility. The DON stated Resident 1's wandering and elopement behaviors were overlooked. During an interview with ADM on [DATE] at 4:26 p.m., ADM stated there was no documentation of the meeting when Resident 1 first eloped from the facility in ,d+[DATE]. The ADM stated and acknowledge the staff did not develop an elopement/wandering care plan for Resident 1. ADM stated frequent visual checks meant always knowing where the resident was located. ADM stated on [DATE] from about 8:04 p.m. to 8:30 p.m., staff were not aware of the whereabouts for Resident 1. The ADM stated the facility staff were notified by the general acute care hospital (GACH) on [DATE] of Resident 1 being in critical condition in the Emergency Department (ED). ADM stated the staff were not aware Resident 1 was not in the facility. ADM stated outside of the facility was a very busy street. ADM stated due to the street being so busy it was important to ensure the facility doors were locked and facility alarms activated. During a review of the GACH's ED report, dated [DATE] and timed at 9 p.m., the ED report indicated Resident 1 arrived in the ED on [DATE] at 8:35 p.m., after being hit by a car. The ED report indicated Resident 1's entire body was mangled (severely disfigured, crushed), with multiple deformities, crepitus (crackling sound) bilateral (both sides) chest and neck and no pulse. The ED note indicated Resident 1 was declared dead at 8:38 p.m. During a review of the Traffic Collision Report, dated [DATE], the report indicated on [DATE] at 8:09 p.m., a call was received of a hit and run and a person laying on the road facing down. The report indicated [MEDICATION(S)] force trauma (injury to the body caused by forceful impact) to the body and head, both shoes and socks came off the resident, and human skin and blood was seen away from Resident 1's body. During a review of the facility's undated policy and procedures (P/P) titled, Elopement Prevention and Response, the P/P indicated it was the policy of the facility to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility to identify residents at risk for elopement through the completion of the Elopement Risk Assessment. The P/P indicated upon admission, residents who had history of elopement or wandering, would have a Wandering/Elopement Evaluation by Nursing or Social Services. If resident was determined to be an Elopement Risk, a Care Plan goal with approaches to ensure safety would be implemented. The assessment would be completed upon admission, quarterly, annually, or when there was a significant change in resident's condition. In addition, a resident who is observed with episode of wandering or incident of elopement who had no history of prior wandering or elopement will be assessed or evaluated immediately and develop a comprehensive resident centered care plan based on the evaluation and specific interventions will be implemented as written and will be evaluated for outcomes. The incident will be documented on an Incident/ Accident Report as well as in the resident's Clinical Record and other State required reports, in addition, the family and attending physician will be notified of the incident. The resident Care Plan will be updated with appropriate interventions implemented to prevent future elopement and ensure resident safety. A review of the facility's undated P/P titled, Alarm System, indicated Our facility maintains an operable alarm system at all time. Implementation included: 2. The facility has strategically located alarm stations and will periodically train personnel in their use. The-Alarms must be manually alarmed daily at 8:00 p.m 7. The date and time will be recorded in a log when the door alarm is initially activated and deactivated by staff.

Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (3), was free from physical abuse inflicted by a certified nursing assistant (CNA 1), who physically hit Resident 3 in the face. On 8/31/18, Resident 15 witnessed CNA 1 hit Resident 3 on the face. During further interviews, Resident 15 (Resident 3's roommate), 9, and 34, also complained about CNA 1. This deficient practice resulted in Resident 3 sustaining a bruise (discoloration of the skin) to the inner aspect of the left eye, and Resident 15, 9, and 35, verbalized CNA 1 was mean to them. Findings: On 4/30/19, during a Recertification survey, the facility reported incident (FRI) with allegation that on 8/31/18 that CNA 1 physically struck Resident 3 was investigated. On 4/30/19 at 8:50 a.m., Resident 3 was observed awake in bed, responding to questions but oriented to self only (able to state name). Resident 3 was observed to be hard of hearing and was unable to state if she was subject to any abuse. A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/29/19, indicated Resident 3 had severe cognitive impairment (ability to think, recall and understand) for daily decision making and required extensive assistance with personal hygiene and dressing. A review of Resident 3's history and physical examination [REDACTED]. A review of an Incident Report dated 8/31/18 timed at 1:00 p.m., completed by Licensed Vocational Nurse (LVN 1), indicated Resident 3 was noted with a discoloration to the inner corner aspect of the left eye, which was purplish in color, that measured 1.5 centimeter (cm) by 1.4 cm. A review of a Bruise/ Skin Tear/ Abrasion Assessment form, dated 8/31/18 at 1:00 p.m., indicated Resident 3 had a discoloration to the corner of the left eye measuring 1.5 cm by 1.4 cm in width. A review of MD 1's order dated 8/31/19 at 5:33 p.m., indicated a STAT (urgent) x-ray (pictures of inside the body) of the left eye. The x-ray results dated 8/31/19 at 7:01 p.m. showed no broken bones. On 5/01/19 at 1:25 p.m., during an interview with Resident 3's roommate (Resident 15), the resident stated she remembered CNA 1, who no longer worked at the facility, treated Resident 3 badly. A review of Resident 15's Admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 15's MDS, dated [DATE], indicated the resident had no cognitive impairment (ability to think, recall, understand and make daily decisions). Resident 15 was non English speaking and preferred to speak in her native language. On 5/01/19 at 1:35 p.m., during an interview with Resident 15, interpreted by the Director of Staff Development (DSD), the resident stated she witnessed CNA 1 hit Resident 3's face with both hands. Resident 15 demonstrated by closing both fists and repeatedly moving both fists towards Resident 3's face. Resident 15 stated Resident 3 would constantly ask for assistance to go to the restroom at night, calling out every 5 to 10 minutes and CNA 1 did not like that. On 5/01/19 at 2:07 p.m., during an interview with the director of nursing (DON), stated the alleged incident involving Resident 3 and CNA 1, happened on the 11 p.m. to 7 a.m. shift on 8/30/19. On 5/01/19 at 2:12 p.m., during a telephone interview with CNA 5, who was no longer working for the facility, stated on 8/31/18, she worked on the 7 a.m. to 3 p.m. shift. CNA 5 stated, while assisting Resident 3 with grooming, and personal hygiene, she noticed a bruise on the resident left eye area. CNA 5 stated when asked Resident 3 what happened, the resident told her somebody hit her on the face. CNA 5 stated Resident 3 could not identify the perpetrator because she was blind. CNA 5 stated, Resident 15 overheard the conversation between her and Resident 3, and identified CNA 1 as the staff who hit Resident 3. CNA 5 stated she reported the abuse allegation to licensed vocational nurse (LVN 1). During an interview with LVN 1 on 5/01/19 at 2:53 p.m., LVN 1 confirmed CNA 5 reported Resident 3's bruise, and abuse allegation. LVN 1 Resident 3's purple discoloration to the left eye measured about 1.5 cm. LVN 1 stated she asked Resident 3 what happened and whether she was hit by anybody, but Resident 3 did not provide an answer. LVN 1 stated she only interviewed Resident 3 and did not interview Resident 15 at that time. On 5/01/19 at 3:53 p.m., during an interview with Resident 34, the resident stated CNA 1 worked during the night shift and was sometimes mean. Resident 34 explained she got into verbal argument with CNA 1 once in the past (was unable to recall the date and time), because CNA 1 used a bad word, which caused Resident 34 to feel angry. A review of Resident 34's MDS, dated [DATE], indicated Resident 34 had no cognitive impairment (ability to think, recall, understand and make daily decisions). On 5/02/19 at 9:17 a.m., during an interview with Resident 9, she stated she knew CNA 1, who worked during the 11 p.m. to 7 a.m., shift. Resident 9 stated CNA 1 was mean and had a bad attitude when asked to assist with cleaning after a bowel movement. Resident 9 stated she reported Admissions Coordinator (AC) that she was uncomfortable with CNA 1's bad attitude. Resident 9 stated she did not report any neglect because she was scared of what CNA 1 would do to her in retaliation. A review of Resident 9's MDS, dated [DATE], indicated Resident 9 had no cognitive impairment (ability to think, recall, understand and make daily decisions). On 5/02/19 at 9:28 a.m., during an interview with AC, stated CNA 1 was reported to her for not answering the call lights on time, or asking them what they wanted, to that effect but did not recall any reports of attitude problems. The AC stated she would inform the DON of any reports from the residents. On 5/02/19 at 9:49 a.m., in the presence of the DON, an attempt to reach CNA 1 for an interview failed. On 5/02/19 at 10:09 a.m., during an interview with the DON, stated LVN 1 made her aware of the abuse allegation on 8/31/18 and the DON reported to the Administrator. The DON stated CNA 1 was placed on suspension pending the investigation. The DON stated she had not received any reports regarding CNA 1 from AC. On 5/02/19 at 10:47 a.m., during an interview, the Administrator confirmed the DON notified him of the alleged abuse on 8/31/19 and the DSD was responsible for the investigation. On 5/02/19 at 11:18 a.m., during an interview, the DSD stated CNA 1 was placed on preventative suspension on 8/31/18. The DSD stated CNA 1 denied physical abuse towards Resident 3. A concurrent record review indicated CNA 1 addressed a resignation letter to the DSD dated 9/1/18. On 5/02/19 at 1:18 p.m., during an interview, the DSD stated he unsubstantiated the allegation of abuse between Resident 3 and CNA 1, because CNA 1 resigned, and DSD was unable to do a follow up interview with her. On 5/02/19 at 1:19 p.m., in the presence of the DON and ADM, a second telephone call to reach CNA 1 for interview failed. A review of a facility's policy titled Abuse Program last revised on 3/11/19 indicated the facility will identify and investigate all suspicions or allegation of abuse; reviewing the occurrence, patterns and trends that may constitute abuse. This information will be used to determine the direction of the investigation. A review of the facility's policy and procedure titled Abuse Program, revised 3/11/9 indicated the facility was to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals.

Based on observation, interview and record review, the facility failed to maintain the highest practicable physical well-being for one of 14 sampled residents (1) by failing to: 1. Ensure Resident 1's left leg pain was assessed, documented, and managed in accordance with the plan of care. 2. Ensure the physician was notified when Resident 1 complained of severe left leg pain, after the certified nursing assistant 1 (CNA 1) bumped the resident's left leg against the bed rail on November 16, 2013, at 6:45 p.m. As a result Resident 1 continue to complain of severe leg pain, and did not receive appropriate treatment for [REDACTED]. Findings: A review of Resident 1's admission record indicated the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 20, 2013, indicated the resident was assessed with [REDACTED]. The MDS indicated the resident required extensive assistance from staff with transfers and bed mobility with one person assistance. The resident was also assessed as having frequent pain and on a scheduled pain medication regimen. A care plan was developed October 12, 2012, reviewed and updated December 2013, for risk of deformities, fractures and pain related to [MEDICAL CONDITION]. The interventions included to observe for joint bone pain and stiffness, and to notify the physician accordingly, to observe resident's ability to ambulate and to move all body parts functionality, and to handle gently during care especially when moving, turning, transferring and repositioning the resident. The resident had a physician's orders [REDACTED]. On December 13, 2013, at 5:30 p.m., an interview was conducted with Resident 1 who stated CNA 1 bumped her left leg against the bed rail while pushing her in the wheelchair towards the bed. The resident stated she screamed out in pain and staff ran in the room to help her back to bed. She stated she fractured her left ankle and is now wearing a cast, and her left ankle hurt all evening and all night long. She stated the staff gave "the usual" [MEDICATION NAME] pain medicine that she is receiving for her left shoulder pain, but it was not very effective in relieving the pain. On December 14, 2013, at 11a.m., an interview was conducted with licensed vocational nurse 2 (LVN 2) (11p.m. - 7 a.m. charge nurse). He stated LVN 1, the outgoing 3 p.m. - 11 p.m. charge nurse on November 16, 2013, did not inform him of the incident where CNA 1 bumped Resident 1's leg against the bed rail during a transfer from the wheelchair to the bed, or of the resident's complaint of pain to the left lower leg after the incident. On December 14, 2013, at 12:45 p.m., an interview was conducted with LVN 1 who stated on November 16, 2013, at 6:45 p.m., he was called out to help Resident 1 in the room who was yelling out. LVN 1 stated he found the resident sitting in the wheelchair complaining of pain to the left lower leg, and she informed him that she hit her leg against the bed rail. LVN 1 stated upon assessment, he did not see any redness or swelling. He then asked CNA 1 to transfer the resident back to bed and stated when CNA 1 transferred the resident back to bed, the resident complained of pain to her left leg. A review of the Licensed Personnel Progress Notes dated November 16, 2013, for 3 p.m. to 11 p.m. shift, indicated there was no documented evidence that the resident's left leg was assessed after the incident, nor was the resident's physician notified of the incident. There was a licensed nurse's note dated November 17, 2013, at 7 a.m., indicating the resident complained of right lower leg pain, with a pain level of 7 out of 10 (ten being the worst pain a person could experience). The note indicated as needed pain medication was given and was effective. There was no assessment as to why the resident was complaining of pain to her right lower leg and no documented evidence the physician was informed of why the resident was in pain, twelve hours after the incident. Further review of the resident's clinical record indicated the resident had no history of complaining of pain to her lower extremities. The Licensed Personnel Progress Notes dated November 17, 2013, at 8:30 a.m., indicated the resident was complaining of severe pain with a pain level of 9 out of 10 to her left lower leg. The note indicated the resident's left leg was assessed with [REDACTED]. The physician was notified and an order was obtained to apply an ice pack and continue the pain medication. However, there was no documented evidence the physician was notified of the incident of Resident 1's left leg being bumped against the side rail. The Licensed Personnel Progress notes dated November 17, 2013, at 2 p.m., 3 p.m. to 11 p.m. shift indicated the resident continued to complain of pain to her left lower leg. The notes dated November 18, 2013, for 11 p.m. to 7 a.m. shift indicated the resident had no complaint of pain. The nurse's note dated November 18, 2013, at 11 a.m. indicated the resident still complained of pain to her left lower leg and the physician was notified. an order for [REDACTED]. The physician was notified and the resident was transferred to the general acute care hospital at 8:45 p.m., 49 hours after the incident took place. A review of the Narcotic and Hypnotic Record indicated [MEDICATION NAME] ES 7.5/750 (7.5 milligrams (mg) of [MEDICATION NAME] and 750 mg [MEDICATION NAME]), two tablets every four hour as needed for severe pain was administered to Resident 1 on November 17, 2013, at 1 a.m., 5 a.m., 9 a.m., 12 p.m., 4 p.m., and 8 p.m. after the incident. Resident 1 received more than her usual intake of [MEDICATION NAME] ES, which exceeded the physician's orders [REDACTED]. The resident was readmitted back to the facility on [DATE], at 5:35 a.m., with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure undated for Pain Management System indicated it is the facility's policy to monitor residents for symptoms of pain and when identified, provide a detailed assessment and develop a care plan to provide treatment and services to prevent, minimize and alleviate pain. Qualified staff will monitor the resident's response to pain management according to facility Practice Guidelines. The overall goals of care of the resident with pain are prompt assessment and [DIAGNOSES REDACTED]. A review of the facility's policy and procedure undated for Change in a Resident's Condition or Status indicates the facility shall promptly notify the resident his or her Attending Physician of changes in the resident's medical condition or status. The Nurse Supervisor/Charge will notify the resident's Attending Physician or On-Call Physician when there has been an accident or incident involving the resident, a discovery of injuries of unknown sources, a significant change in the resident's physical condition, or a need to alter the resident's medical treatment significantly. A review of the facility's policy and procedure undated for Accidents and Incidents-Investigating and Reporting indicated regarding of how minor an accident or incident may be, including injuries of any unknown source, report the accident/incident to the Department Supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. An employee witnessing an accident or incident involving a resident, or employee must report to his/her immediate supervisor as soon as practical and inform the Nurse Supervisor/Charge Nurse immediately of accidents or incidents so that medical attention can be provided. The following data, as it may apply, must be included on the Confidential/Incident/Accident Investigation Report that includes the date, time and the accident or incident that took place, the nature of the injury/illness such as bruise or fall, circumstances surrounding the accident or incident, where the accident took place, the time the injured person's attending physician was notified, date and time the injured person's vital signs, any corrective action taken and any other pertinent data as necessary or required.