Every finding on record at Sunland Post Acute

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for two of four sampled residents (Resident 1 and Resident 2), when on 5/4/2026, in the dining room, Resident 1 stated offensive language toward Resident 2 and Resident 2 responded by stating offensive language back to Resident 1.This deficient practice resulted in Resident 1 and Resident 2 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others).Findings:a. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 to the facility on 1/14/2022 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), hyperlipidemia (excess fat in the blood), unspecified, and essential (primary) hypertension (HTN-high blood pressure).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/23/2026, the MDS indicated that Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependent on staff with toileting hygiene, lower body dressing, lying to sitting on side of bed, and tub/shower transfer.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 5/4/2026 timed at 4:00 p.m. The SBAR indicated Resident 1 was involved in a resident-to-resident altercation. During a review of Resident 1's progress note dated 5/4/2026, timed at 3:00 p.m., the progress note indicated Activity Assistant 1 (AA 1) reported to the Administrator (ADM) that Resident 1 was involved in an altercation with another resident (Resident 2) in the dining room at approximately 11:45 a.m. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 to the facility on 7/16/2025 with diagnoses including malignant (cancerous) neoplasm (tumor) of the colon (large intestine), unspecified, ventral hernia (bulge in the abdominal wall) without obstruction or gangrene, and hyperlipidemia (excess fat in the blood).During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2 had intact cognition and required moderate assistance on staff with lower body dressing, sit to lying, lying to sitting on side of bed, toilet transfer and tub/shower transfer.During a review of Resident 2's SBAR Communication Form dated 5/4/2026 at 4:00 p.m., the SBAR indicated Resident 2 was observed with aggressive behavior and was involved in a resident-to-resident altercation. During a review of Resident 2's progress note dated 5/4/2026 at 11:50 a.m., the progress note indicated Activity Assistant 1 (AA 1) reported to the Administrator (ADM) that resident (Resident 2) had altercation with another resident (Resident 1) in the dining room around 11:45 a.m.During an interview on 5/5/2026 at 10:50 a.m., with AA 1. AA 1 stated at approximately 11:35 a.m. to 11:50 a.m. on 5/4/2026 in the dining room Resident 1 was heading out of the dining room in his electric wheelchair when he (AA 1) heard Resident 2 called Resident 1 a gossiper in Spanish. Resident 1 then responded, F*** your mother in Spanish, and Resident 2 also shouted, F***your mother, toward Resident 1.During an interview on 5/6/2026 at 4:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1 and Resident 2's exchange of offensive language toward each other constituted verbal abuse.During a review of the facility`s policy and procedure (P&P) titled, Abuse Reporting and Prevention, last revised on 4/29/2026, indicated that the facility purpose to ensure that resident rights are protected by providing a method of investigation involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation of resident property. This also includes any physical or chemical restraint not required to treat a resident's symptoms.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Residents 4) was provided with information regarding the resident's Medi-Cal (the state's Medicaid program) share of cost (the amount of money a beneficiary must pay on medical expenses each month before Medi-Cal begins covering eligible services) in a timely manner.This deficient practice had the potential to result in negatively affect the resident's ability to make informed financial decisions.Findings:During a review of Resident 4's admission Record, the admission Record indicated that the facility initially admitted Resident 4 to the facility on 9/3/2022 and readmitted on [DATE] with diagnoses including idiopathic (unknown cause) progressive neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) lumbar region (lower back), heart failure, unspecified (a condition in which the heart muscle cannot pump enough blood to meet body's needs for blood and oxygen), and leukemia (a blood cancer cells that crowd out healthy blood cells, hindering the body's ability to fight infection and transport oxygen).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 9/3/2025, the MDS indicated that Resident 4 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and required maximal assistance from staff with toileting hygiene, lower body dressing, lying to sitting on side of bed, and tub/shower transfer.During a review of Resident 4's itemized invoice statement dated 5/5/2026, the invoice indicated that in May 2025, the share of cost was $1,818.00 with a current balance of $18,497.00.During a review of Resident 4's financial general notes report dated 3/8/2026, the report indicated the Business Office Manager (BOM) spoke to Resident 4 that her share of cost will change effective 4/1/2026. The report did not contain documented entries prior to 3/8/2026. During an interview on 5/5/2026 at 12:05 p.m., with the BOM, the BOM stated that she should have informed Resident 4 back in May 2025 regarding her share of cost because it is Resident 4's right to be informed of her financial responsibilities to the facility in a timely manner which has resulted in Resident 4 not having enough time to make an informed financial decision.During an interview on 5/6/2026 at 4:30 p.m., with the Director of Nursing (DON), the DON stated the BOM should have informed Resident 4 back in May 2025 regarding her share of cost because it is Resident 4's right to be informed of her financial responsibilities to the facility in a timely manner. The DON stated that as a result, Resident 4 did not have ample time to make informed financial decisions.During a review of the facility`s policy and procedure (P&P) titled, Private Collection Process last reviewed on 4/29/2026, the facility policy indicated the purpose to ensure consistent, timely communication and collection of all patient -responsible financial liabilities while maintaining compliance, transparency, and proper escalation. Applies to all privately responsible balances, including but not limited to share of cost. Review all patient responsible financial liabilities with the patient or the patient's designated Financial Responsible Party. Clearly explain types of charges (share of cost). Document the discussion in the patient's financial record.

Based on interview and record review, the facility staff failed to ensure that a Significant Change in Status Minimum Data Set (MDS- a resident assessment tool) assessment was completed for one of five residents (Resident 5) when the resident had a significant decline in two areas (skin condition and functional status) from baseline, as compared to the most recent comprehensive assessment, and did not return to baseline within two weeks.This deficient practice had the potential to negatively impact the provision of necessary care and services.During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted Resident 5 on 1/20/2026 and was readmitted on [DATE] with diagnoses that included intervertebral disc degeneration (a condition that occurs when your spinal disks wear down) of the thoracic region (the chest area, located between the neck and the abdomen), Stage 3 (full thickness loss of skin, dead and black tissue may be visible) pressure ulcer/pressure injuries (localized damage to the skin and or underlying tissue usually over bony prominence) to the left buttock, and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by long term high blood sugar causing numbness or weakness in the hands and feet). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 1/23/2026, the MDS indicated Resident 5 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), no pressure ulcer/injuries and that Resident 5 required maximal assistance from staff for toileting hygiene, tub/shower transfers, lower body dressing, sit-to-lying, and lying-to-sitting on the side of bed. During a review of Resident 5's Skin and Body assessment dated [DATE], the Skin and Body Assessment indicated that Resident 5 had a Stage 3 pressure ulcer/injury to the left buttock. During a review of Resident 5's Weekly Pressure Injury Records dated 3/24/2026, 3/31/2026, and 4/7/2026, the Weekly Pressure Injury Record indicated the continued presence of a Stage 3 pressure ulcer/injury to the left buttock. During a review of Resident 5's Occupational Therapy (OT - focuses on helping residents regain independence in daily activities - such as dressing, bathing and eating) Therapy Progress Report, Date of Service 4/1/2026 through 4/7/2026, the OT Therapy Progress Report indicated a decline in functional status for lower body dressing. The OT Therapy Progress Report indicated prior level of function (PLOF) for lower body dressing as Minimal assist, with baseline (3/18/2026), previous (3/31/2026), and current (4/7/2026) status all reflecting Total Dependence with attempts to initiate. During a review of the Resident Assessment Instrument (RAI), Chapter 2, last reviewed on 5/14/2025, the RAI Chapter 2 indicated Significant Change in Status Assessment (SCSA) must be completed when the Interdisciplinary Team (IDT - a collaborative group of professionals who work together to create, manage, and implement a unified, person-centered plan of care for residents) determines that a resident meets the significant change guidelines for either major improvement or decline, an SCSA is required when a significant change (either improvement or decline) in resident's condition from baseline is identified/ has occurred through comparison of the resident's current status with the most recent comprehensive assessment and subsequent quarterly assessments, and the resident condition is not expected to return to baseline within two weeks. During an interview on 4/22/2026 at 10:35 a.m., with MDS Coordinator Nurse (MDSCN), the MDSCN stated that in comparison to Resident 5's most recent MDS admission and 5-Day Assessment (Comprehensive) with an Assessment Reference Date of 1/23/2026, the resident's condition from 3/18/2026 through 4/7/2026 reflected a significant decline. This included a decline in Resident 5's skin condition, evidenced by the development of a Stage 3 pressure ulcer, and a decline in functional status, with the resident becoming totally dependent in lower body dressing with attempts to initiate. The MDSCN stated that the resident's condition did not return to baseline within two weeks (3/18/2026 to 4/7/2026) therefore an SCSA should have been completed. The MDSCN further stated that failure to complete the SCSA and update the care plan delayed the provision of necessary care and services for Resident 5. During an interview on 4/22/2026 at 3:45 p.m., with the Director of Nursing (DON), the DON stated that an SCSA should have been completed by the MDSCN. The DON further stated that failure to complete the SCSA and revise the care plan resulted in a delay in the delivery of care and services needed to meet the resident's needs. During a review of the facility`s policy and procedure (P&P) titled, Resident Assessment Instrument (RAI) Process last reviewed on 5/14/2025, the policy indicated the facility will utilize the Resident Assessment Instrument (RAI) process for the accurate assessment of each resident's functional capacity and health status. During a review of Resident Assessment Instrument (RAI) Chapter 2 (P&P) titled, Significant Change in Status Assessment (SCSA) last reviewed on 5/14/2025, the policy indicated Significant Change in Status Assessment (SCSA) must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline, a SCSA is appropriate when there is a determination that a significant change (either improvement or decline) in resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments, and the resident condition is not expected to return to baseline within two weeks.

Based on interview and record review, the facility failed to ensure accurate documentation in the residents' clinical records for two of five sampled residents (Resident 4 and Resident 5), in accordance with accepted medical and professional standards and consistent with the care provided. This deficient practice had the potential to negatively affect the plan of care and the delivery of necessary care and services for these residents. a. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 3/23/2026 and was readmitted on [DATE] with diagnoses that included radiculopathy (a condition caused by compression or irritation of a nerve root in the lower spine) of the lumbar region (lower back), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and intervertebral disc degeneration (a condition that occurs when your spinal disks wear down) of the lumbar region without mention of lumbar back pain or lower extremity pain. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2026, the MDS indicated that Resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), no pressure ulcer/pressure injuries (localized damage to the skin and or underlying tissue usually over bony prominence) and required maximal staff assistance with toileting hygiene, showering/bathing, sit-to-lying, lying-to-sitting on the side of the bed, and toilet transfers. During a review of Resident 4's CBC with differential (a standard blood test that measures the cells in your blood to evaluate overall health, detect infections, blood and immune system disorder) laboratory result dated 4/15/2026, the CBC with differential laboratory result had a handwritten note indicated seen and reviewed 4/16/2026, awaiting orders. During an interview on 4/22/2026 at 11:25 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that the physician responded the same day to the CBC with differential laboratory results dated [DATE] with no new orders, however, he (LVN 4) did not document the physician's response because it was busy that day. LVN 4 stated that he should have documented it because it could have negatively affected Resident 4's plan of care and delayed the provision of necessary care and services that Resident 4 needs. b. During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted Resident 5 on 1/20/2026 and was readmitted on [DATE] with diagnoses that included intervertebral disc degeneration (a condition that occurs when your spinal disks wear down) of the thoracic region (the chest area, located between the neck and the abdomen), Stage 3 (full thickness loss of skin, dead and black tissue may be visible) pressure ulcer/pressure injuries (localized damage to the skin and or underlying tissue usually over bony prominence) to the left buttock, and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by long term high blood sugar causing numbness or weakness in the hands and feet). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 1/23/2026, the MDS indicated Resident 5 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), no pressure ulcer/injuries and that Resident 5 required maximal assistance from staff for toileting hygiene, tub/shower transfers, lower body dressing, sit-to-lying, and lying-to-sitting on the side of bed. During a review of Resident 5's Skin and Body assessment dated [DATE], the Skin and Body Assessment indicated that Resident 5 had a Stage 3 pressure ulcer/injury to the left buttock. During a review of Resident 5's Weekly Pressure Injury Records dated 3/24/2026, 3/31/2026, and 4/7/2026, the Weekly Pressure Injury Record indicated the continued presence of a Stage 3 pressure ulcer/injury to the left buttock. During a review of Resident 5's Discharge Skin and Body assessment dated [DATE], the Discharge Skin and Body Assessment indicated that Resident 5 had intact skin with no documented pressure ulcers/pressure injuries (localized damage to the skin and or underlying tissue usually over bony prominence). During an interview on 4/22/2026 at 12:39 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that Resident 5 was transferred via 911 (emergency telephone number used to immediately request help from emergency medical services) and she (RN 2) was in a hurry to complete the discharge form and was not able to double check that Resident 5 had a Stage 3 pressure ulcer/injury. RN 2 stated she should have documented accurately, as the omission could have negatively affected Resident 5's plan of care in the general acute care hospital (GACH). During an interview on 4/22/2026 at 3:45 p.m., with the Director of Nursing (DON), the DON stated that nurses are expected to accurately document the care they provide, as incomplete or inaccurate documentation can negatively impact the resident's plan of care. During a review of the facility`s policy and procedure (P&P) titled, Documentation Principles last reviewed on 5/14/2025, the facility policy indicated that resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. Entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received their mail unopened, in accordance with the facility's policy on Resident Rights.This deficient practice resulted in the violation of Resident 1's right to receive mail unopened.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 9/3/2023 and readmitted Resident 1 on 2/4/2024 with diagnoses including idiopathic progressive neuropathy (a condition involving long-term, worsening damage to the nerves outside the brain and spinal cord [a long, thin bundle of nervous tissue and support cells that extends from the brainstem down through the center of the back] where the underlying cause cannot be determined by doctors), heart failure (a condition where the heart muscle becomes too weak or stiff to pump blood efficiently), and leukemia (a cancer of the body's blood-forming tissues).During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 3/5/2026, the MDS indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding through thought experience and senses) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) from staff with toileting hygiene, required supervision or touching assistance from staff with personal hygiene, and was independent with eating and oral hygiene.During an interview on 4/1/2026 at 10:00 a.m. with Resident 1, in Resident 1's room, Resident 1 stated that on 3/8/2026 the Business Office Manager (BOM) came into Resident 1's room and showed Resident 1 her Medi-Cal (a program that provides free or low-cost health coverage to eligible, low-income residents) statement. Resident 1 stated that she was upset because the BOM violated Resident 1's rights by opening her mail without Resident 1's permission.During an interview on 4/1/2016 at 10:34 a.m. with the BOM, the BOM stated that on 3/8/2026, while working as the manager of the day, she opened Resident 1 mail without verifying the intended recipient, as she assumed it was for the business office. The BOM stated she should have verified the intended recipient before opening the mail to ensure the resident's right to receive unopened mail. During an interview on 4/1/2026 at 4:45 p.m., with the Administrator (ADM), the ADM stated that the BOM should not have opened Resident 1's mail. The ADM stated that facility staff should not open mail that is not addressed to them or their department. The ADM stated that the BOM should have apologized to Resident 1 as soon as the event occurred. During a review of the facility's policy and procedure (P&P) titled Resident's Rights, reviewed on 5/14/2025, the P&P indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: Privacy in sending and receiving mail unopened.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) addressing a resident's discharge plan for one of three sampled residents (Resident 2).This deficient practice placed Resident 2 at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/29/2025 with diagnoses that included nontraumatic intracerebral hemorrhage (a medical emergency where bleeding occurs directly into the brain tissue without any external injury to the head) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a neurological condition characterized by weakness or reduced motor function on one side of the body) following cerebral infarction (process that results in an area of necrotic tissue in the brain) affecting left dominant side.During a review of Resident 2's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/4/2026, the MDS indicated Resident 2's cognition (a mental process of acquiring knowledge and understanding through thought experience and senses) was intact. The MDS indicated Resident 2 required supervision or touching assistance from staff with oral hygiene, required partial/moderate assistance from staff with personal hygiene, required substantial/maximal (staff does more than half the effort) assistance with toileting hygiene, and was independent with eating.During a concurrent interview and record review with the Social Services Director (SSD) on 4/1/2026 at 3:01 p.m., reviewed Resident 2's care plans. The SSD stated that the SSD is aware that Resident 2 requested to be transferred to an assisted living facility (ALF- a residential community for seniors or adults who need help with daily tasks) closer to Resident 2's friend. The SSD stated Resident 2 did not have a care plan addressing Resident 2's discharge plan.During a follow-up interview with the SSD on 4/1/2026 at 3:29 p.m., the SSD stated that the SSD is responsible for developing residents' discharge care plans. The SSD stated that Resident 2 should have had a care plan addressing Resident 2's discharge plan to ensure facility staff involve in Resident 2's care were aware of Resident 2's needs and that Resident 2's goals were met. During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Planning, reviewed on 5/14/2025, the P&P indicated that it is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The discharge planning process must be focused on the discharge planning goals prepares each resident to be an active partner in post-discharge care and the transition process to reduce factors that lead to preventable readmission.During a review of the facility's P&P titled Discharge Planning Process, reviewed on 5/14/2025, the P&P indicated the facility should update their residents comprehensive care plan and discharge plan as appropriate in response to information received from referrals to local contact agencies or other appropriate entities.

Based on interview and record review the facility failed to implement the facility's discharge planning process policy by failing to document the resident's discharge needs and discharge plan for one of three sampled residents (Resident 2).This deficient practice had the potential to delay Resident 2's discharge to the community and placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/29/2025 with diagnoses that included nontraumatic intracerebral hemorrhage (a medical emergency where bleeding occurs directly into the brain tissue without any external injury to the head) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a neurological condition characterized by weakness or reduced motor function on one side of the body) following cerebral infarction (process that results in an area of necrotic tissue in the brain) affecting left dominant side.During a review of Resident 2's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/4/2026, the MDS indicated Resident 2's cognition (a mental process of acquiring knowledge and understanding through thought experience and senses) was intact. The MDS indicated Resident 2 required supervision or touching assistance from staff with oral hygiene, required partial/moderate assistance from staff with personal hygiene, required substantial/maximal (staff does more than half the effort) assistance with toileting hygiene, and was independent with eating.During an interview with the Social Services Director (SSD) on 4/1/2026 at 3:01 p.m., the SSD stated that the SSD is aware that Resident 2 requested to be transferred to an assisted living facility (ALF- a residential community for seniors or adults who need help with daily tasks) closer to Resident 2's friend. The SSD stated that it would be difficult to find a placement for Resident 2 due to Resident 2's insurance coverage and income. The SSD stated she is assisting Resident 2 with changing Resident 2's insurance so that Resident 2 can qualify placement to an AFL. The SSD stated that she has not documented any notes in Resident 2's medical records documenting Resident 2's discharge planning process. The SSD stated that she has not documented her efforts in Resident 2's discharge planning process because the SSD has a lot of residents that she is overseeing. The SSD stated that it is important to document Resident 2's discharge planning process so that facility staff involved in Resident 2's care are aware of Resident 2's discharge plan. During a review of the facility's policy and procedure (P&P) titled Discharge Planning Process, reviewed on 5/14/2025, the P&P indicated that it is the policy Of the facility to develop and implement an effective discharge planning process that focuses on the residence discharge goals preparing residents to be active participants and effectively transition them to post discharge care can reduce factors leading to preventable readmissions the discharge planning process should: involve the IDT (Interdisciplinary Team- a group of professionals from different disciplines who work together collaboratively, rather than independently, to achieve a common goal or provide comprehensive care) in this ongoing process of developing the discharge plan; document that the resident has been asked about their interest in receiving information regarding returning to the community; umm if a resident expresses an interest in returning to the community the facility should document any referrals to local contact agencies or other appropriate entities for this purpose; the facility should update their residence comprehensive care plan and discharge plan as appropriate in response to information received from referrals to local contact agencies or other appropriate entities; if discharged to the community is determined to not be feasible the facility will document who made the determination and why this determination was made; Facility we'll document and evaluation of the residents discharge needs and discharge plan based on the residence needs this will be documented timely and the evaluation will be discussed with the resident or their representative all relevant resident information should be incorporated into the residence discharge plan to facilitate its implementation and to avoid unnecessary delays in the residence discharge or transfer.

Based on interview and record review, the facility failed to ensure that pain medication was administered in accordance with the physician's orders based on the documented pain scale for one of three sampled residents (Resident 1). This deficient practice had the potential to result in inadequate pain management for Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/28/2020 with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), muscle weakness, and non-displaced fracture of medial malleolus of right tibia (a crack in the bony bump on the inner side of the right ankle, where the broken pieces remain properly aligned). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance from staff with oral hygiene and required substantial/maximal assistance from staff with toileting hygiene and personal hygiene. During a review of Resident 1's Order Summary Report with order date of 6/29/2025, the Order Summary Report indicated an order for Acetaminophen (known as Tylenol - brand name, a medication used to relieve mild to moderate pain) 325 milligrams (mg- unit of measurement). Give two tablets by mouth every four (4) hours as needed for mild pain (a rating of one to four on a zero [0- no pain] to ten [10- worst pain imaginable numerical pain scale [used to assess a resident's pain intensity]) scale 1 to 4/10. During a review of Resident 1's care plan regarding at risk for chronic pain/discomfort related to chronic physical or psychosocial impairment, reviewed in December 2025, the care plan indicated the following intervention: Provide consistent and sufficient medication for pain relief, tailored to the individual. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation- a structured, four-step communication framework, used by nurses to deliver concise, critical patient information, usually to physicians or during handoffs) Communication Form dated 12/28/2025, timed at 8:45 p.m., the SBAR Communication Form indicated Resident 1 had an unwitnessed fall on 12/28/2025, resulting in a bump to the right forehead and severe forehead pain rated at eight (8) out of ten (10) using a pain rating scale (used to assess a resident's pain intensity from 0 [no pain] to 10 [worst pain imaginable]). The SBAR Communication Form indicated ice pack and Tylenol (dose not specified) were provided. During a review of Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of December 2025, the MAR indicated that Resident 1 was administered Acetaminophen on 12/28/2025 at 8:45 p.m. for forehead pain, with a documented pain level of seven (7). During an interview on 1/14/2026 at 11:47 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that Resident 1 had an unwitnessed fall on 12/28/2025 at around 8:30 p.m. LVN 1 stated that Resident 1 complained of forehead pain rated at 8/10, and LVN 1 administered Acetaminophen for the reported 8/10 pain. LVN 1 further stated that Resident 1's physician was not contacted for stronger pain medication because Resident 1 had only a small bump on the forehead and LVN 1 thought that administering Acetaminophen was appropriate. LVN 1 stated that the pain level documented as seven in the MAR dated 12/28/2025 was incorrect and that the pain level should have been documented as eight, as reported by Resident 1. During an interview and concurrent record review on 1/15/2026 at 10:15 a.m., with the Assistant Director of Nursing (ADON), Resident 1's MAR for the month of December 2025 was reviewed. The ADON stated that on 12/28/2025 at 8:45 p.m., Resident 1 was administered Acetaminophen 325 mg, two (2) tablets, for a reported pain level of 7/10. The ADON stated that Acetaminophen should not have been administered as the order is for pain levels 1-4/10. The ADON further stated that LVN 1 should have contacted Resident 1's physician to request an order for a stronger pain medication appropriate to Resident 1's documented pain level of 8/10. The ADON stated that by not providing appropriate medication, Resident 1's pain may not have been adequately alleviated and may have been prolonged. During a review of the facility's policy and procedure (P&P) titled, Pain Management Protocol, last reviewed on 5/14/2025, the P&P indicated Purpose: 4. Intervening to treat pain before the pain becomes severe. Wherever the presence of pain is indicated, the process of pain assessment and management begins. At the identification of pain, the pain rating should always be included in the documentation. Medical records will monitor the implementation of this policy. During a review of the facility's P&P titled Medication Administration, last reviewed on 5/14/2025, the P&P indicated it is the policy of the facility that medications for residents be administered in a safe and timely manner, and as prescribed. Medications should be administered in accordance with the physician's orders. If the dosage is believed to be inappropriate or excessive for a resident. the licensed nurse administering the medication should contact the resident's attending physician, physician's assistant, nurse practitioner or Medical Director to discuss the concerns

Based on interview and record review the facility failed to provide resident-centered care and services, for one of three sampled residents (Resident 1) by failing to ensure that a required 72-hour neurological assessment (neuro check - an evaluation of neurological [relating to the nerves or the nervous system, which includes the brain, spinal cord, and peripheral nerves that control body functions, movement, and sensation] status) was accurately completed following Resident 1's unwitnessed fall on 12/28/2025. This deficient practice had the potential to cause confusion in the care and services provided to Resident 1 and placed the resident at risk of not receiving appropriate care due to inaccurate or incomplete medical information.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/28/2020 with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), muscle weakness, and non-displaced fracture of medial malleolus of right tibia (a crack in the bony bump on the inner side of the right ankle, where the broken pieces remain properly aligned). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance from staff with oral hygiene and required substantial/maximal assistance from staff with toileting hygiene and personal hygiene. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation- a structured, four-step communication framework, used by nurses to deliver concise, critical patient information, usually to physicians or during handoffs) Communication Form dated 12/28/2025, timed at 8:45 p.m., the SBAR Communication Form indicated Resident 1 had an unwitnessed fall on 12/28/2025, resulting in a bump to the right forehead and severe forehead pain rated at eight (8) out of ten (10) using a pain rating scale (used to assess a resident's pain intensity from 0 [no pain] to 10 [worst pain imaginable]). During an interview and concurrent record review on 1/15/2026 at 10:12 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Neuro Check List with a start date of 12/28/2025 at 8:30 p.m. was reviewed. The ADON stated that a 72-hour neuro check is initiated when a resident experiences an unwitnessed fall. The ADON reviewed Resident 1's 72-hour Neuro Check List dated 12/28/2025 and stated that Resident 1's 72-hour neuro check list was initiated at 8:30 p.m. Upon further review of the 72-hour neuro check documentation, the ADON stated that the assessment intervals were not accurately completed. The ADON stated that the every 30 minute neurological checks (x3) should have been conducted at 9:15 p.m., not 9:00 p.m., and the subsequent 30-minute check should have been completed at 9:45 p.m., not 9:30 p.m. The ADON further stated that 72-hour neurological checks must be accurately assessed and documented because facility staff are required to closely monitor the resident for any acute changes such as alterations in level of consciousness (refers to a person's state of arousal, alertness, and awareness of themselves and their surroundings, ranging from fully awake to unconscious) or pupil (the black, circular opening in the center of the iris that regulates the amount of light entering the eye) size and to immediately report any changes from baseline to the physician for further intervention. The ADON stated reporting any changes from baseline is very important, as such changes may indicate a brain injury related to the fall. The ADON also reviewed Resident 1's Nurse's Note dated 12/28/2025, timed at 9:30 p.m., and stated that Resident 1 was transferred to the General Acute Care Hospital 1 (GACH 1) at 9:30 p.m. During a follow-up concurrent interview and record review on 1/15/2026 at 10:15 a.m., with the ADON, Resident 1's Nurse's Note dated 12/29/2025 was reviewed. The ADON stated that Resident 1 returned to the facility on [DATE] at 5:15 a.m. The ADON reviewed Resident 1's 72-hour neuro check documentation and stated that, because Resident 1's return to the facility was documented at 5:15 a.m. on 12/29/2025, the 72-hour neurological checks should have resumed upon arrival and followed the appropriate assessment intervals as follows: - 12/29/2025 at 5:15 a.m.; 9:15 a.m.; 1:15 p.m.; 5:15 p.m.- 12/30/2025 at 1:15 a.m.; 9:15 a.m.; 5:15 p.m. and- 12/31/2025 at 1:15 a.m.; 9:15 a.m.; 5:15 p.m. The ADON further stated that precise timing of 72-hour neurological checks is critical to ensure staff promptly assess the resident and timely report any changes from baseline to support Resident 1's safety. During a review of the facility's policy and procedure (P&P) titled Neurological Checks, last reviewed on 5/14/2025, the P&P indicated it is the policy of the facility that if a resident sustains a fall and hits his/her head neurological checks will be conducted. The appropriate form will be utilized for proper documentation and timetable for neuro-checks for 72 hours. During a review of the facility's P&P titled Documentation Principles, last reviewed on 5/14/2025, the P&P indicated it is the policy of the facility that resident's clinical record shall be current and kept in detail consistent with good medical and professional practice based on the care provided to each resident. Entries must be accurate, timely, objective, specific, concise, legible, clear, and descriptive.

Based on observation, interview, and record review the facility failed to: Record the medication refrigerator temperatures containing vaccines twice a day from [DATE] to [DATE], in one (1) of three (3) inspected medication rooms (Medication Room Station 2.) 2. Remove and discard from use four (4) expired budesonide (a medication used to treat and prevent shortness of breath wheezing [breathing with a whistling sound in the chest] and Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation solutions inside an open foil pouch (package made of foil protecting the inhalation solution from light and degradation) for Resident 54, in accordance with the manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart Station 2.) These deficient practices increased the potential for Resident 54 to receive suboptimal care resulting in adverse consequences such as exacerbation of COPD leading to breathing difficulty and hospitalization, and for Resident 111 to receive vaccine that was ineffective or toxic due to the inadequate storage monitoring, potentially resulting in negative impact to their health and well-being. Findings: During an observation and concurrent interview on [DATE] at 10:05 a.m., with the Assistant Director of Nursing (ADON), in Medication Room Station 2, the refrigerator contained mResvia (a vaccine used for the prevention of lower respiratory tract disease) vaccine for Resident 111. The refrigerator temperature monitoring log was observed containing documentation for the temperatures once a day [DATE] to [DATE]. The ADON acknowledged the refrigerator contained mResvia vaccine for Resident 111. The ADON noted the refrigerator temperature monitoring form indicated Medication Refrigerator 36-degree Fahrenheit ( F - a unit of measurement) to 46 F. Log Temperature twice daily AM & PM. If the temperature is out of range take corrective action and document. Monitor and maintain temperature per CDC and CDPH guidelines and manufacturer instructions for medication storage requirements for Skilled Nursing Facilities.) The ADON stated between [DATE] to [DATE] the Medication Room Station 2 Medication Refrigerator Temperature Log did not contain documentation for temperature monitoring twice a day. The ADON stated if the temperatures were not documented on the monitoring log, then it was considered that the temperatures were not monitored. ADON stated that several licensed nurses failed to monitor and document the temperature of the refrigerator twice a day between [DATE] to [DATE]. The ADON stated that monitoring the refrigerator temperature was important to ensure medications and vaccines were maintained at the acceptable temperature range (36 and 46 F,) had not gone bad, and their potency (the strength of medication required to produce an effect) was not affected. The ADON stated without monitoring and documenting the temperatures twice a day it was unknown if the refrigerator temperatures were maintained between36 and 46 F, and if the medications and vaccines were negatively impacted during that time. The ADON stated using improperly maintained vaccine can harm Resident 111 by receiving vaccine that was toxic and ineffective. During an observation on [DATE] at 10:55 a.m., with Licensed Vocational Nurse (LVN) 3, in Medication Cart Station 2, the following medications were found stored in a manner contrary to their respective manufacturers' requirements, expired and not discarded, and contrary to facility policies: One (1) open budesonide inhalation solution foil pouch for Resident 54, was found stored at room temperature and labeled with a date indicating the inhalation solution foil pouch was opened on [DATE]. Four (4) inhalation solutions were observed remaining in the foil pouch. According to the manufacturer's product storage and labeling, the budesonide inhalation solutions should be stored in the foil envelope at room temperature between 68 and 77 degrees Fahrenheit. Once the foil envelope is opened, to use within two (2) weeks. During a concurrent interview, LVN 3 stated the budesonide inhalation solution foil pouch for Resident 54 in the Medication Cart Station 2 was opened on [DATE] and four (4) inhalations were remaining in the foil pouch. LVN 3 stated according to manufacturer guidelines printed on the outside of the budesonide medication box, the inhalation solutions needed to be discarded within two (2) weeks of opening the foil pouch. LVN 3 stated expired budesonide inhalation solutions had lost potency (effectiveness) beyond the expiration date. LVN 3 stated the remaining four (4) inhalation solutions expired on [DATE] and needed to be removed from the medication cart to avoid administering expired and ineffective budesonide to Resident 54. Administering expired budesonide to cause harm to Resident 54 by not treating the shortness of breath and COPD leading to difficulty in breathing, requiring immediate treatment and potential hospitalization. LVN 3 stated several licensed nurses failed to remove expired budesonide inhalation solutions from Medication Cart Station 2, and that the four (4) remaining budesonide inhalation solutions for Resident 54 should be immediately discarded from Medication Cart Station 2. During an interview on [DATE] at 11:15 a.m., with the Director of Nursing (DON), the DON stated per facility policy the temperature of the refrigerator in Medication Room Station 2 should be monitored and documented twice a day since vaccines are stored in the refrigerator. The DON stated not knowing the temperature of the refrigerator and if the appropriate temperature range was maintained, the vaccines may have lost efficacy and potency, maybe expired, and need to be disposed of to prevent use. The DON stated using expired vaccines will not be effective in treating Resident 111's condition. The DON stated the facility was not in compliance for the refrigerator monitoring for Medication Room Station 2 from [DATE] and [DATE]. During the same interview, the DON stated that the budesonide inhalation solution for Resident 54 was opened on [DATE] and expired on [DATE]. The DON stated expired inhalation solutions have lost effectiveness and when administered in error will not treat the shortness of breath or COPD further causing respiratory distress and stoppage of breathing for Resident 54 requiring immediate treatment and hospitalization. The DON stated the expired budesonide inhalation solutions needed to be removed from Medication Cart Station 2 on [DATE]. During a review of facility's policy and procedures (P&P,) titled Storage of Medications, last reviewed on [DATE], the P&P indicated that Medications and biologicals are stored safely, and properly, following manufacturer's recommendations or those of the supplier. K. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring. M. Outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from pharmacy if a current order exist. During a review of the facility's P&P, titled Discontinued Medications, last reviewed [DATE], the P&P indicated: When medication are expired, .the medications are marked as discontinued or stored in a separate location and later destroyed. If a medication expires,., the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications are removed from the medication cart or storage area prior to expiration, . During a review of manufacturer's guide Highlights of Prescribing Information for budesonide inhalation dated [DATE], the guide indicated Budesonide inhalation suspension should be stored upright at controlled room temperature 68 to 77 degrees Fahrenheit and protected from light. When an envelope has been opened, the shelf life of the unused ampules is 2 weeks. Any opened ampule must be used promptly.

Based on interview and record review the facility failed to: Reconcile (the process of comparing transactions and activity to supporting documentation) and account for five (5) medication emergency kits (eKITs) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances {CS}) for November and December 2025, in three (3) of three (3) inspected Medication Rooms (Medication Room Station 1, Station 2 and Station 3/4) and one (1) of two (2) inspected medication carts (Medication Cart Station 4.) 2. Account for two (2) doses of lacosamide (a CM used for seizure [bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations, or states of awareness]) for Resident 54 in two (2) of two (2) inspected medication carts (Medication Cart Station 2 and 4.) As a result, control and accountability of medications and CM's did not follow state and federal regulations and facility policy and procedures These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that Resident 54 and other residents in the facility could have accidental overdose (administering more than the prescribed dose causing adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) from exposure to harmful medications, and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. Findings: During an observation on 12/1/2025 at 2 p.m., with Licensed Vocational Nurse (LVN) 5, in Medication Cart Station 4, there was: 1.a discrepancy in the count between the Antibiotic or Controlled Drug Record and the amount of medication remaining in the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for Resident 54. One (1) dose of lacosamide 200 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 54. The Antibiotic or Controlled Drug Record accountability log for lacosamide indicated the medication bubble pack should have contained a total of 17 lacosamide 200 mg tablets, after the last administration of lacosamide 200 mg tablet documented/signed-off on 11/30/2025 at 5 p.m., however the medication bubble pack contained 16 lacosamide 200 mg tablet and contained no other documentation of subsequent administrations. 2.One (1) medication eKIT labeled 125, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for November and December 2025. During a concurrent interview, LVN 5 stated LVN 5 administered 200 mg tablet to Resident 54 earlier that day at 9 a.m. and forgot to sign off the Antibiotic or Controlled Drug Record accountability log. LVN 5 stated LVN 5 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the doses for the residents. LVN 5 stated LVN 5 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 5 stated if documentation was not accurate then it can lead to overdose harming Residents 54 leading to respiratory depression (stoppage of breathing) and potential hospitalization. During the same interview, LVN 5 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. LVN 5 stated the eKIT labeled 125 containing CMs in Medication Cart Station 4 was not reconciled at every shift for November and December, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 12/2/2025 at 9:42 a.m., with Registered Nurse (RN) 2, in Medication Room Station 3/4 there were: -Two (2) medication eKITs stored in the refrigerator and labeled 100 and 601, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for November and December 2025. During a concurrent interview, RN 2 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. RN 2 stated that two (2) eKITs labeled 100 and 601 containing CMs in Medication Room Station 3/4 were not reconciled at every shift in November and December 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 12/2/2025 at 10:05 a.m., with the Assistant Director of Nursing (ADON,) in Medication Room Station 2 there was: -One (1) medication eKIT stored in the refrigerator and labeled 301, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for November and December 2025. During a concurrent interview, ADON stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. ADON stated that eKIT labeled 301 containing CMs in Medication Room Station 2 was not reconciled at every shift in November and December 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 12/2/2025 at 10:10 a.m., with ADON, in Medication Room Station 1 there was: -One (1) medication eKIT stored in the refrigerator and labeled 581, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for November and December 2025. During a concurrent interview, ADON stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. ADON stated that eKIT labeled 581 containing CMs in Medication Room Station 1 was not reconciled at every shift in November and December 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an observation on 12/2/2025 at 10:55 a.m., with LVN 3, in Medication Cart Station 2, there was a discrepancy in the count between the Antibiotic or Controlled Drug Record and the amount of medication remaining in the medication bubble pack for the following resident: 3.One (1) dose of lacosamide 200 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 54. The Antibiotic or Controlled Drug Record accountability log for lacosamide indicated the medication bubble pack should have contained a total of 15 lacosamide 200 mg tablets, after the last administration of lacosamide 200 mg tablet documented/signed-off on 12/1/2025 at 5 p.m., however the medication bubble pack contained 14 lacosamide 200 mg tablet and contained no other documentation of subsequent administrations. During a concurrent interview, LVN 3 stated that LVN 3 administered lacosamide 200 mg tablet to Resident 54 earlier that day at 9 a.m. and forgot to sign off the Antibiotic or Controlled Drug Record accountability log. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the doses for the resident. LVN 3 stated LVN 3 understood the importance of signing each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 3 stated if documentation was not accurate then it can lead to overdose harming Resident 54 leading to respiratory depression and potential hospitalization. During an interview on 12/2/2025 at 11:15 a.m., with the Director of Nursing (DON), the DON stated LVN 3 and 5 failed to follow policy of documenting the preparation of CM immediately on the accountability records for Resident 54. The DON stated not documenting the Antibiotic or Controlled Drug Record accountability log timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. During the same interview, the DON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated five (5) eKits containing CMs in Medication Cart 4, Medication Rooms: Station 1, 2 and 3/4 did not have accountability and reconciliation logs at each shift change for November and December 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of all eKits containing CMs at each shift change in all medication storage areas for compliance. During a review of Resident 54's admission Record (a document containing demographic and diagnostic information,) dated 12/1/2025 the admission Record indicated Resident 54 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including epilepsy (brain disorder characterized by recurrent seizures.) During a review of Resident 54's Order Summary Report (a report listing the physician order for the resident,) dated 12/1/2025, the report indicated Resident 54 was prescribed lacosamide 200 mg one (1) tablet orally twice a day for seizure disorder, starting 10/9/2025. During a review of Resident 54's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for December 2025, the MAR indicated Resident 54 was prescribed lacosamide 200 mg one (1) tablet orally twice a day for seizure disorder, to give at 9 a.m. and 5 p.m. During a review of facility's policy and procedures (P&P), titled Controlled Medication Storage, dated 5/14/2025, the P&P indicated that At each shift change, a physical inventory of all CM, including the emergency supply is conducted by 2 licensed nurses and is documented on the CM accountability record. During a review of facility's P&P, titled Controlled Medications, last reviewed 5/14/2025, the P&P indicated: Medications included in the Drug Enforcement Administration classification as CS are subject to special handling, storage, disposal, and recordkeeping at the facility, in accordance with federal and state laws and regulations. The DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: Date and time of administration Amount administered Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 25 total opportunities contributed to an overall medication error rate of 12% affecting three (3) of five (5) residents observed for medication administration (Resident 37, 70, and 101.) The medication errors were as follows: Resident 37 received aspirin (a medication used for cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood,) prophylaxis ([PPX] - action taken to prevent disease,) at a different time than ordered by Resident 37's physician. 2. Resident 70 received a form of multivitamin (a medication used as dietary supplement to provide vitamins, minerals, and other nutritional elements as tolerated) that was different than the one ordered by Resident 70's physician. 3. Resident 101 received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 101's physician. These failures had the potential to result in Resident 37, 70, and 101 receiving suboptimal (less than standard) care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and resulting in Residents 37, 70, and 101 health and well-being negatively impacted. Findings: During an observation on 12/1/2025 at 9:05 a.m., in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 5 was observed administering carvedilol 6.25 milligram ([mg]-a unit of measure of mass) tablet orally to Resident 101. Resident 101 was observed swallowing the carvedilol tablet with a glass of water. During an observation on 12/1/2025 at 9:30 a.m., in Medication Cart 3, LVN 5 was observed administering aspirin 81 mg chewable tablet to Resident 37. Resident 37 was observed swallowing the aspirin tablet with a glass of juice. During an observation on 12/1/2025 at 10 a.m., in Medication Cart Station 4, Registered Nurse (RN) 4 was observed administering multivitamin with minerals tablet orally to Resident 70. Resident 70 was observed swallowing the multivitamin with mineral tablet with a glass of water. During an interview on 12/1/2025 at 12:05 p.m., with RN 4, RN 4 stated RN 4 administered multivitamin with minerals tablet earlier at 10 a.m. to Resident 70. RN 4 stated RN 4 acknowledged the physician order for Resident 70 indicated to give multivitamin not containing minerals. RN 4 stated RN 4 failed to administer the correct multivitamin as prescribed by Resident 70's physician. RN 4 stated administering multivitamin with minerals to Resident 70 may not be beneficial to their health and may cause adverse effects if unable to process the extra minerals. RN 4 stated this was considered a medication error. During an interview on 12/1/2025 at 12:20 p.m., with LVN 5, LVN 5 stated LVN administered carvedilol 6.25 mg tablet during the morning medication administration at 9:05 a.m. to Resident 101. LVN 5 acknowledged the physician order for Resident 101 specified to administer carvedilol at 7:30 a.m. with breakfast to prevent stomach discomfort. LVN 5 stated Resident 101 had breakfast at 7 a.m. LVN 5 stated per facility policy there was a 60-minute window for medication administration and LVN 5 administered carvedilol later than that timeframe. LVN 5 stated LVN 5 failed to administer carvedilol as prescribed by Resident 101's physician placing Resident 101 at risk of receiving the next dose closer in time and experiencing stomach irritation. LVN 5 stated this was considered a medication error. During the same interview, LVN 5 stated that LVN 5 administered aspirin 81 mg chewable tablet during the morning medication administration at 9:30 a.m. to Resident 37. LVN 5 acknowledged the physician's order to Resident 37 specified to administer aspirin at 7:30 a.m. with food to prevent stomach discomfort. LVN 5 stated Resident 37 had breakfast at 7 a.m. LVN 5 stated that LVN 5 administered the aspirin later than the facility 60-minute window allowance. LVN 5 stated this was also considered a medication error. During an interview 12/2/2025 at 11:15 a.m., with the Director of Nursing (DON), the DON stated LVN 5 failed to administer carvedilol 6.25 mg tablet to Resident 101 and aspirin chewable 81 mg to Resident 37, on 12/1/2025 according to physician orders, at their scheduled time of 7:30 a.m. The DON stated Resident 37 may be at risk for developing stomach irritation from receiving aspirin 81 mg much later , and Resident 101 may be at risk for having the next dose given in a shorter timeframe since it was ordered to be given twice a day, and possible stomach irritation when given much later. The DON stated RN 4 failed to administer multivitamin without minerals to Resident 70, according to physician orders on 12/1/2025. The DON stated Resident 70 may possibly be at risk of not being able to tolerate the additional minerals from the multivitamin with minerals. The DON stated these were considered medication errors. The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered at the right time to residents. During a review of Resident 37's admission Record (a document containing demographic and diagnostic information,) dated 12/1/2025, indicated Resident 37 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including cerebral infarction (where blood flow to a part of the brain gets blocked, starving brain cells of oxygen and nutrients, causing them to die.) During a review of Resident 37's Order Summary Report, dated 12/1/2025, the report indicated Resident 37 was prescribed: Aspirin chewable 81 mg to give one (1) tablet by mouth once a day for CVA prophylaxis with food, starting 8/18/2024. During a review of Resident 37's Medication Administration Record ([MAR] - a record of mediations administered to residents), for December 2025, the MAR indicated Resident 37 was prescribed: Aspirin chewable 81 mg one (1) tablet by mouth once a day for CVA prophylaxis with food, to give at 7:30 a.m. During a review of Resident 70's admission Record dated 12/1/2025, indicated Resident 70 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including muscle weakness, need for assistance with personal care, and absence of kidney (organ responsible for filtering waste materials out of the body and balancing minerals.) During a review of Resident 70's Order Summary Report, dated 5/6/2025, indicated Resident 70 was prescribed: multivitamin to give one (1) tablet by mouth once a day for supplement, starting 10/16/2025 During a review of Resident 70's MAR for December 2025, the MAR indicated Resident 70 was prescribed: multivitamin one (1) tablet by mouth once a day for supplement, to give at 9 a.m. During a review of Resident 101's admission Record dated 12/1/2025, indicated Resident 101 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including HTN. During a review of Resident 101's Order Summary Report, dated 12/1/2025, indicated Resident 101 was prescribed: carvedilol 6.25 mg to give (1) tablet by mouth twice a day for HTN with breakfast and dinner, starting 7/16/2024. During a review of Resident 101's MAR for December2025, the MAR indicated Resident 101 was prescribed: carvedilol 6.25 mg one (1) tablet by mouth twice a day for HTN with breakfast and dinner, to give at 7:30 a.m. and 5:30 p.m. During a review of the facility's policy and procedures (P&P) titled Medication Administration-General Guidelines, last reviewed 5/14/2025, the P&P indicated that Medications are administered as prescribed in accordance with good nursing principles and practices. Preparation 3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Administration Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meals, which are administered based on mealtimes. During a review of the facility's P&P, titled Medication Administration, last reviewed 5/14/2025, the P&P indicated It is the policy of the facility that medications for residents be administered in a safe and timely manner, and as prescribed. Procedure Medications must be administered in accordance with the physician orders, including any required timeframe. Medications must be administered within one (1) hour before or after their prescribed time. The licensed nurse administering the medication must check the label to verify the resident, the right medication, the right dosage, the right time, and route of administration before giving the medication.

Based on observation, interview and record review, the facility failed to provide an environment that is free from accident hazards to four of eight sampled residents (Resident 12, 61, 76 and 85) by failing to: 1. Ensure Resident 12's fall risk assessment was accurate to reflect Resident 12's risk of falling. 2. Ensure disinfectant wipes container was not left open, unattended and within reach at the top of Resident 61's tray table. 3. Ensure Resident 76 and 85 did not possess a lighter and cigarette as indicated in the facility policy titled, Smoking Policy. 4. Ensure Resident 76 and 85's The Safe Smoking Evaluation specify whether both residents were independent smokers or supervised smokers, as indicated in the facility policy titled, Smoking Policy.These deficient practices had the potential to increase Resident 12's risk of falling, potential to result in accidental poisoning if disinfectant wipes were ingested by Resident 61 and potential to result in an accidental fire in the facility that can lead to injury to the residents. Findings: 1. During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted the resident on 9/9/2019 and readmitted the resident on 10/26/2025 with diagnoses including, but not limited to, acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness. During a review of Resident 12's History and Physical (H&P) dated 10/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS – a resident assessment tool), dated 10/30/2025, the MDS indicated the resident was cognitively intact (able to think, learn, and remember clearly) and needed substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 12/3/2025 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 12's MDS, dated [DATE], indicated Resident 12 had one fall since the previous assessment and Resident 12's Fall Risk Evaluation, dated 10/26/2025, indicated the resident had no falls within the past three months. RN 1 stated she could not find information in the resident's current chart about the fall. During a concurrent interview and record review on 12/3/2025 at 3:31 p.m. with the Assistant Director of Nursing (ADON), Resident 12's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 9/10/2025, indicated Resident 12 reported she fell on 9/10/2025 and had new pain to her right foot. Resident 12's Fall Risk Evaluation, dated 10/26/2025, indicated Resident 12 had not fallen in the last three months. The ADON stated the Fall Risk Evaluation should indicate that the resident had a fall. The ADON stated with an accurate Fall Risk Evaluation the staff would know the resident is at a higher risk for falls and they might change what interventions they provide by including her in their Fall Star Program (a patient safety initiative to identify residents who are at a high risk of falls and implement extra precautions). During a concurrent interview and record review on 12/4/2025 at 1:58 p.m. with the Director of Nursing (DON), the DON stated Resident 12's Fall Risk Evaluation, dated 10/26/2025, was incorrect. The DON stated Resident 12's Fall Risk Evaluation should be accurate so that staff is aware Resident 12 is at risk for falling and that she had a previous fall. The DON stated if staff members are not aware of Resident 12's risk for falling it places her at a higher risk for having another fall incident. During a review of the facility's policy and procedure (P&P) titled, Fall Risk & Prevention of Injury to Include Pathological Fractures, last reviewed 5/14/2025, the P&P indicated it is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. During a review of the facility's P&P titled, Falling Star Program, last reviewed 5/14/2025, the P&P indicated the purpose of the policy is to identify residents who are at risk for falls, to try to prevent falls, and to attempt to increase supervision for residents assessed to be at high risk for falls. 2. During a review of Resident 61's, the admission Record indicated the facility originally admitted Resident 61 on 1/20/2022 and readmitted the resident on 3/4/2024 with diagnoses including paroxysmal atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and generalized muscle weakness. During review of Resident 61's MDS, dated [DATE], MDS indicated Resident 61 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly supervision assistance needed from staff for ADLs. During a concurrent observation and interview on 12/1/2025 at 9:58 a.m., with Registered Nurse 2 (RN 2), in Resident 61's room, observed an opened disinfectant wipe container on top of Resident 61's tray table next to the breakfast tray. RN 2 stated Resident 61's tray table has an opened disinfectant wipes container that was left unattended and within reach by Resident 61. RN 2 also stated that it was not safe for Resident 61 to have any type of chemical due to safety concerns. RN 2 also stated that if a resident wanted to clean or disinfect something, the staff should do it for them. During an interview on 12/4/2025 at 8:28 a.m., with the DON, the DON stated that due to resident safety, residents should not be provided with any disinfectant wipes for possible ingestion of the toxic chemicals found in the disinfectant wipes. During a review of facility's P&P, titled, Safety and Supervision of Residents, reviewed on 5/14/2025, the P&P indicated, It is the policy of the facility to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. During a review of facility's P&P, titled, Facility Guidelines, reviewed on 5/14/2025, the P&P indicated, Residents are not permitted to have any flammable or unsafe chemicals at the bedside, i.e., nail polish, air freshener, laundry chemicals, etc. or any items that specifies, 'keep out of the reach of children'. 3a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 4/27/23 with diagnoses including COPD, hypertension (HTN-high blood pressure), and cataract (the clouding of the eye's natural lens, which causes blurry or faded vision). During a review of Resident 76's H&P, dated 11/30/25, the H&P indicated Resident 76 has the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 cognition (refers to mental abilities and processes) was intact. During a review of Resident 76's Smoker's Risk Assessment, dated 10/29/25, the Smoker's Risk Assessment indicated Resident 76 may smoke independently or with set up, must be supervised and may not smoke unsupervised. During a review of Resident 76's Smoking Behavior Contract, dated 10/27/25, the Smoking Behavior Contract indicated that if Resident 76 disregard smoking safety regulations, it will jeopardize his ability to remain at the healthcare residence. During a review of Resident 76's Interdisciplinary Team Conference (IDT - a group of disciplines such as nursing, physician, and social services who meet with a resident or their responsible party to discuss interventions for their medical plan of care) note, dated 10/27/25, the IDT note indicated, residents are not permitted to have cigarettes and lighters, facility shall store smoking materials in locked areas. the resident room will be monitored by a designee to determine that no smoking material are in the possession of the resident or in their room. if residents are found to have any smoking materials, they will remove and interdisciplinary team meeting will be scheduled with the residents. A care plan will be develop based on level of supervisor.resident will be categorized as either safe to smoke without supervisor -no smoking apron needed or require supervisor while smoking safety with or without a smoking apron. During an interview on 12/1/2025 at 3:38 p.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated he observed Resident 76 at around 10 a.m. today (12/1/2025) in possession of a lighter and cigarettes. CNA 7 stated when he tried to collect them from Resident 76, the resident refused and became agitated. CNA 7 stated he reported the incident to the Activity Director (AD). During an interview with the AD on 12/01/2025 at 3:46 PM, the AD stated that based on facility policy residents are not allowed to carry their lighters or cigarettes with them due to fire danger. The AD stated activity staff keep the lighter and cigarettes in a locked cabinet and during designated smoking times, the cigarettes and lighter are handed to the residents and are collected afterward and returned to the locked cabinet. The AD stated it is her responsibility to ensure residents do not carry smoking materials. The AD stated she was not informed that Resident 76 possesses cigarette and a lighter. During an interview on 12/02/2025 at 8:06 A.M., with RN 1, RN 1 stated residents are not allowed to have lighters and cigarettes with them due to safety issues and the potential for accidents and fire hazard. During an interview and record review of Resident 76 Safe smoking evaluation dated 10/29/2025 with RN 1 on 12/02/2025 at 8:10 a.m., RN 1 stated she was the one who completed the safe smoking evaluation/assessment form for Resident 76. RN 1 stated based on facility policy the smoker should be identified as either independent smoker or supervised. However, the smoking assessment indicated Resident 76 may smoke independently, must be supervised and also may not smoke unsupervised. RN 1 stated the evaluation did not specifically indicate if Resident 76 is independent or supervised, and it is confusing. RN 1 stated the potential outcome of not having accurate assessment is staff will not know what interventions Resident 76 needs. 3b. During a review of Resident 85's admission Record, the admission Record indicated the facility initially admitted Resident 85 on 4/10/2024 with diagnoses including hemiplegia (paralysis affecting one side of the body), HTN, and dysphagia (difficulty swallowing). During a review of Resident 85's H&P, dated 9/25/25, the H&P indicated Resident 85 can make needs known but cannot make medical decisions. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognition was intact. During a review of Resident 85's Smoker's Risk Assessment, dated 10/29/25, the Smoker's Risk Assessment indicated Resident 85 may smoke independently or with set up, must be supervised and may not smoke unsupervised.Resident 85 must request smoking material from staff. During a review of Resident 85's Smoking Behavior Contract, dated 10/27/25, the Smoking Behavior Contract indicated, if Resident 85 disregards smoking safety regulations, it will jeopardize his ability to remain at the healthcare residence. During a review of Resident 85's IDT note, dated 10/27/25, the IDT note indicated, residents are not permitted to have cigarettes and lighters.facility shall store smoking materials in locked areas. the Resident room will be monitored by a designee to determine that no smoking material are in the possession of the resident or in their room. if Residents are found to have any smoking materials, they will remove, and interdisciplinary team meeting will be scheduled with the residents. A care plan will be developed based on level of supervision.resident will be categorized as either safe to smoke without supervisor, no smoking apron needed or require supervisor while smoking safety with or without a smoking apron. During a concurrent observation and interview on 12/01/12025 at 3:42 p.m., in the smoking patio, with Resident 85, in the presence of the AD, observed Resident 85 wheeling himself to the smoking patio. Resident 85 removed a lighter and cigarette from his cross-body bag and light his cigarette. Resident 85 stated that the lighter and cigarettes in his possession belong to him and that he has kept them with him at all times for more than two weeks now. During an interview on 12/02/2025 at 8:06 A.M., with RN1, RN 1 stated residents are not allowed to have lighters and cigarettes with them due to their safety issues potential for accident and fire hazard. During a concurrent interview and record review of Resident 85 Safe smoking evaluation dated 10/29/2025 with RN 1 on 12/02/2025 at 8:20 a.m., RN 1 stated she was the one who completed the safe smoking evaluation/assessment form for Resident 85. RN 1 stated based on facility policy the smoker should be identified as either independent smoker or supervised. However, the smoking assessment indicated Resident 85 may smoke independently, must be supervised and also may not smoke unsupervised. RN 1 stated the evaluation did not specifically indicate if Resident 85 is independent or supervised, and it is confusing. RN 1 stated the potential outcome of not having accurate assessment is staff will not know what interventions Resident 85 needs. During an interview on 12/04/2025 at 10:06 A.M. with the Administrator (ADM), the ADM stated based on facility policy, residents are not permitted to carry or possess lighters or cigarettes while in the facility. This rule is in place to ensure the safety of all residents, staff, and the facility, particularly due to the presence of oxygen use, which poses a serious fire and explosion risk when exposed to open flames. The Administrator stated all smoking materials must be stored in a locked cabinet. The ADM stated he collected the lighters and cigarettes from Resident 75 and Resident 85 on 12/01/2025. During an interview on 12/04/2025 at 11:50 A.M. with DON, the DON stated Residents are not permitted to possess lighters or cigarettes while in the facility to ensure the safety of all individuals particularly those who use oxygen, which poses a serious risk of explosion when exposed to open flames. The DON stated all smoking materials must be stored in a locked cabinet and if staff witness a resident carry a lighter or cigarette they should report it to the AD, the ADM or the DON. The DON stated that based on facility smoking policy, residents are categorized as either supervised or independent smokers. However, the smoking assessments for Resident 76 and Resident 85 do not clearly specify their supervision status. The DON stated that this lack of clarity may lead to confusion among staff regarding appropriate safety interventions such as whether a resident requires a smoking apron or is permitted to smoke independently potentially compromising safe smoking practices. During a review of facility P&P, titled Smoking Policy, reviewed May 2025, indicated a smoking policy has been implemented to promote resident safety and protect residents' rights and dignity. All smoking materials such as cigarettes, lighters and smoking aprons will be stored in locked areas. Through the assessments process, smokers are designated as either independent or supervised smokers. -An independent smoker is defined as the one who use all smoking material in a safe and responsible manner. Can state smoking rules and designated smoking area. Observes all smoking rules and adhere to facility policy. -A supervised smoker defines as demonstrate unsafe behavior in the use of smoking and/or lighting materials. Cannot state rules.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) that meets the care/services based on the resident's individual assessed needs for three of 23 sampled residents (Resident 76, 81 and 85) by failing to: 1.Ensure safety and supervision during smoking were addressed in Resident 76's and 85's care plans. This deficient practice had the potential to place the residents at risk for smoking-related injuries. 2. Ensure Resident 81's prescribed Klonopin (an antianxiety medication) black box warning (the strongest safety alert for prescription drugs) was addressed in Resident 81's care plan. This deficient practice had the potential to place Resident 81 at risk for experiencing adverse effects (harmful, undesired reactions) from Klonopin. Findings: 1.a. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 4/27/2023 with diagnoses including chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult due to airflow obstruction, with common symptoms including a chronic cough, wheezing, and shortness of breath), hypertension (HTN-high blood pressure), and cataract (the clouding of the eye's natural lens, which causes blurry or faded vision). During a review of Resident 76's History and Physical (H&P), dated 11/30/2025, the H&P indicated Resident 76 has the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition (the brain's ability to learn, think, understand and solve problems) was intact. During a review of Resident 76's Care Plan (CP) titled Smoking/Tobacco Use, last updated on 11/02/2025, the CP indicated Resident 76 is at risk for injury accident due to smoking with the goal of Resident 76 will remain free of smoking related injuries /accidents. The CP indicated the following interventions: -Assess physical and cognitive abilities to determine the type of assistance to be provided when smoking. -Educate regarding risks of smoking. -Educate regarding alternatives to smoking and refer to support services, as needed. -Educate regarding risks being unsupervised during smoking. -Instruct and encourage compliance with Smoking Schedule. -Educate regarding safe disposal of cigarette butts. -Notify Physician, Family/Responsible party of any injuries resulting from smoking During a concurrent interview and record review of Resident 76's Interdisciplinary Team (IDT - a group of disciplines such as nursing, physician, and social services who meet with a resident or their responsible party to discuss interventions for their medical plan of care) Conference note dated 10/27/2025 with RN 1 on 12/02/2025 at 8:15 A.M., RN 1 stated the IDT note indicated a care plan will be developed based on the level of supervision the resident requires. During a concurrent interview and record review of Resident 76's care plan titled Smoking dated 11/02/2025 with RN 1 on 12/02/2025 at 8:17 A.M., RN 1 stated that Resident 76's care plan is not resident-centered and does not specify the level of supervision the resident requires. RN 1 stated this lack of clarity may result in staff being unaware of the appropriate interventions needed to ensure Resident 85's safety during smoking activities, such as whether the resident requires supervision while smoking, and with or without the use of apron. During an interview on 12/04/2025 at 12:55 P.M. with DON, the DON stated Resident 76's care plan was not resident centered because it lacked interventions addressing the level of supervision the resident requires. The DON stated it is important to address the level of supervision the resident require to ensure staff are aware of the necessary interventions to prevent accidents and hazards during smoking activities. During a review of facility P&P titled Smoking Policy, reviewed on 5/2025, the P&P indicated a plan of care will be developed to addresses each resident's need and level of supervision. A care plan will be developed to address each resident's needs and level of supervision. Based on the safety assessment residents will be categorized as either safe to smoke without supervision (no smoking apron needed) Require supervision while smoking for safety with or without smoking aprons. During a review of facility P&P titled Comprehensive Care Plan, reviewed on 5/2025, the P&P indicated it is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . 1.b. During a review of Resident 85's admission Record, the admission Record indicated the facility admitted Resident 85 on 4/10/2024 with diagnoses including hemiplegia (paralysis affecting one side of the body), HTN, and dysphagia (difficulty swallowing). During a review of Resident 85's H&P, dated 9/25/2025, the H&P indicated Resident 85 can make needs known but cannot make medical decisions. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 cognition was intact. During a review of Resident 85's Care Plan updated on 10/25/2025 titled Smoking/Tobacco Use indicated Resident 85 is at risk for injury accident due to smoking with the goal of Resident 85 will remain free of smoking related injuries /accidents. The CP indicated the following interventions: -Assess physical and cognitive abilities to determine the type of assistance to be provided when smoking -Educate regarding risks of smoking. -Educate regarding alternatives to smoking and refer to support services, as needed. -Educate regarding risks being unsupervised during smoking. - Instruct and encourage compliance with Smoking Schedule. -Educate regarding safe disposal of cigarette butts. -Notify Physician, Family/Responsible party of any injuries resulting from smoking. During a concurrent interview and record review of Resident 85's IDT note dated, 10/27/2025 and care plan titled Smoking/Tobacco use dated 10/29/2025 with RN 1 on 12/02/2025 at 8:25 A.M., RN 1 stated IDT note indicated a care plan will be developed based on the level of supervision the resident requires. During an interview and record review of Resident 85 care plan titled Smoking/Tobacco use dated 10/29/2025 with RN 1 on 12/02/2025 at 8:27 A.M., RN 1 stated that Resident 85's care plan is not resident-centered and does not specify the level of supervision the resident requires. This lack of clarity may result in staff being unaware of the appropriate interventions needed to ensure Resident 85's safety during smoking activities, such as whether the resident requires supervision while smoking, and with or without the use of apron. During an interview on 12/04/2025 at 12:55 P.M. with DON, the DON stated Resident 85's care plan was not resident centered because it lacked interventions addressing the level of supervision the resident requires. The DON stated it is important to address the level of supervision the resident requires to ensure staff are aware of the necessary interventions to prevent accidents and hazards during smoking activities. During a review of facility P&P titled Smoking Policy, reviewed on 5/2025, the P&P indicated a plan of care will be developed to addresses each resident's need and level of supervision. A care plan will be developed to address each resident's needs and level of supervision. Based on the safety assessment residents will be categorized as either safe to smoke without supervision (no smoking apron needed) Require supervision while smoking for safety with or without smoking aprons. During a review of facility P&P titled Comprehensive Care Plan, reviewed on 5/2025, the P&P indicated it is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . 2. During a review of Resident 81's admission Record, the admission Record indicated the facility originally admitted the resident on 5/12/2022 and readmitted the resident on 8/20/2025 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and an anxiety disorder (a mental health condition that causes excessive fear, worry, and feelings of dread and uneasiness). During a review of Resident 81's H&P dated 8/20/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated the resident had severe cognitive impairment (trouble with thinking, learning, and remembering clearly) and was dependent on staff or needed substantial assistance with most ADLs. The MDS further indicated Resident 81 was on an antianxiety medication. During a review of Resident 81's Order Summary Report, the Order Summary Report indicated an order, dated 8/20/2025, to administer one 0.5 milligram tablet of Klonopin two times per day for anxiety. During a concurrent interview and record review on 12/3/2025 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 81's care plan titled Psychotropic Medication Black Box Warning Medications, dated 8/22/2025, and .at risk for adverse reaction related to use of antianxiety medication(s)., dated 8/21/2025, were reviewed. The care plan Psychotropic Medication Black Box Warning Medications did not indicate the resident was on Klonopin or the black box warning for it. The care plan .at risk for adverse reaction related to use of antianxiety medication(s)., did not indicate there was a black box warning for Klonopin. RN 1 stated these care plans were not specific to the black box warnings of Klonopin. RN 1 stated without a care plan for the black box warnings they would be able to monitor for those side effects. During a concurrent interview and record review on 12/4/2025 at 1:58 p.m. with the DON, the black box warning for Klonopin and Resident 81's care plans titled Psychotropic Medication Black Box Warning Medications, dated 8/22/2025, and .at risk for adverse reaction related to use of antianxiety medication(s)., dated 8/21/2025, were reviewed. The DON stated Resident 81's care plan should be updated to include the black box warning for Klonopin. The DON stated the black box warning indicated there is a risk of abuse, addiction, dependence, and withdrawal reactions from Klonopin and these should be included in the care plan so they can monitor for them, and staff will know the dangers of the medication. During a review of the facility's P&P titled, Comprehensive Care Plan, last reviewed 5/14/2025, the P&P indicated it is the facility's policy that a comprehensive resident-centered care plan be developed for each resident which includes measurable objectives and timeframes to meet each resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated a comprehensive care plan will be completed within seven days after the completion of the resident's MDS.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for three of five sampled residents (Residents 61, 17, and 76) when: 1. Resident 61's tray table was not kept clean and free of clutter during mealtime. This deficient practice had the potential to negatively impact Resident 61's quality of life, and placing Resident 61 at risk for not properly eating during mealtimes. 2. An alarm located near Resident 17 and Resident 76s' rooms activated each time a staff member exited and entered through the smoking patio gate. This deficient practice denied Residents 17 and 76 the right to a comfortable, homelike environment and had the potential to negatively impact their quality of life. Findings: 1. During a review of Resident 61's admission Record admission Record indicated the facility originally admitted Resident 61 on 1/20/2022 and readmitted the resident on 3/4/2024 with diagnoses including paroxysmal atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and generalized muscle weakness. During review of Resident 61's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 10/22/2025, the MDS indicated Resident 61 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required supervision assistance needed from staff with most of activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation and interview on 12/1/2025 at 9:58 a.m., with Registered Nurse 2 (RN 2), in Resident 61's room, Resident 61's breakfast meal tray was observed on the tray table, along with other items. RN 2 stated Resident 61's tray table was dirty and cluttered with unnecessary things in it such as an opened disinfectant wipes container, gloves, masks, disposable undergarments and plastic bags. RN 2 stated that resident's tray table should be clean, tidy and uncluttered during mealtimes. During an interview on 12/4/2025 at 8:28 a.m., with the Director of Nursing (DON), the DON stated that residents' rooms should always be clean and clutter free to promote a homelike environment. The DON also stated that the tray table should always be clean and neat with no other things in it except the meal tray during mealtimes. During a review of facility's policy and procedure (P&P), titled, Comfortable Environment, reviewed on 5/14/2025, the P&P indicated, Facility to maintain a safe, clean, comfortable environment for residents. 2. During a review of Resident 17's admission Record, the admission Record indicated the facility originally admitted the resident to the facility on 7/27/2017 and readmitted the resident on 11/10/2025 with diagnoses including, but not limited to, acute pyelonephritis (kidney infection), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty in walking. During a review of Resident 17's History and Physical (H&P) dated 11/13/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident had adequate hearing, was cognitively intact (able to think, learn, and remember clearly), and needed moderate assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident to the facility on 4/27/2023 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), depression, and generalized muscle weakness. During a review of Resident 76's H&P dated 11/30/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated the resident had adequate hearing, was cognitively intact, and required light assistance by setting up or cleaning up with most ADLs. During an observation period of two hours on 12/4/2025 between 7:30 a.m. and 9:30 a.m. the alarm for the smoking patio gate activated inside the facility 34 times at 7:38 a.m., 7:41 a.m., 7:42 a.m., 7:42 a.m. again, 7:44 a.m., 7:56 a.m., 7:57 a.m., 7:59 a.m., 8:01 a.m., 8:03 a.m., 8:09 a.m., 8:15 a.m., 8:16 a.m., 8:18 a.m., 8:23 a.m., 8:23 a.m. again, 8:28 a.m., 8:29 a.m., 8:29 a.m. again, 8:30 a.m., 8:32 a.m., 8:33 a.m., 8:40 a.m., 8:45 a.m., 8:49 a.m., 8:59 a.m., 9:02 a.m., 9:04 a.m., 9:04 a.m. again, 9:06 a.m., 9:07 a.m., 9:15 a.m., 9:19 a.m., and 9:24 a.m. During a concurrent observation and interview on 12/4/2025 at 7:38 a.m. observed the Central Supply (CS) staff open the smoking patio gate setting the alarm off. The CS staff stated the alarm goes off inside often because facility staff only has two seconds to put in the code to deactivate the alarm and it is not long enough. The CS staff stated facility staff has to enter and exit through the gate to go to the laundry and maintenance storage areas and they also use it to get to the parking area behind the facility. During a concurrent observation and interview on 12/4/2025 at 8:16 a.m., observed Janitor (JN) 1 enter the smoking patio gate setting the alarm off. JN 1 stated he had been using the smoking patio gate to retrieve equipment located on the other side of the gate that he needed to clean the patio. During an interview on 12/4/2025 at 8:55 a.m. with Resident 76, Resident 76 stated he can hear the alarm going off frequently while he is in his room. Resident 76 stated it goes off all the time every day, including at night. Resident 76 stated when the alarm first started going off a lot it would bother him, but now he has become used to the noise. Resident 76 stated it is now like background noise to him. During an interview on 12/4/2025 at 12:05 p.m. with Resident 17, Resident 17 stated when the door to his room is open the sound of the alarm bothers him because it is right by him. Resident 17 stated people often forget to close the door to his room and then the alarm sound is very loud. Resident 17 stated he always keeps the door to his room closed because of the noise. During an interview on 12/4/2025 at 1:58 p.m. with the Director of Nursing (DON), the DON stated the facility should have a calm, homelike environment with no excessive noise level so residents can rest comfortably and sleep. The DON stated the smoking patio alarm could disrupt the calm environment and bother the residents especially the ones with rooms near the smoking patio door. During a review of the facility's policy and procedure (P&P) titled, Comfortable Environment, last reviewed 5/14/2025, the P&P indicated it is the policy of the facility to maintain a safe, clean, comfortable environment for the residents.

Based on observation, interview, and record review, the facility failed to maintain residents' privacy of confidential information when Licensed Vocational Nurse 3 (LVN 3) stepped away and left the computer on the medication cart in Station 3 unlocked and unattended. This deficient practice had the potential to violate the right to privacy of all residents in the facility. Findings: During a concurrent observation and interview on 12/03/2025 at 11:37 a.m., with Registered Nurse 5 (RN 5) observed Station 3 Medication Cart with the computer screen open that provided access to resident's electronic health records (EHR- a digital version of a patient's paper chart). RN 5 stated, when a licensed nurse leaves the medication cart, they are to lock the computer so no one will have access to residents' records. RN 5 stated this is important to ensure residents' records are kept private. During a concurrent observation and interview on 12/03/2025 at 11:42 a.m., with Licensed Vocational Nurse 3 (LVN 3) observed the Station 3 medication cart computer screen open. LVN 3 stated she stepped away from the medication cart and should have locked the computer to prevent anyone from having access to residents' records. During an interview with the Director of Nurses (DON) on 12/04/2025 at 1:05 p.m., the DON stated that licensed nurses should lock the computer when leaving the medication cart. The DON stated it is important to maintain residents' privacy. The DON stated leaving a computer open, although not open to a particular residents' record on the computer screen, could potentially allow anyone to access residents' records. The DON stated residents' information must be kept private. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed on 5/14/2025, the P&P indicated residents are to be assured confidential treatment of financial and medical records and to approve or refuse their release, except as authorized by law.

Based on interview and record review, the facility failed to provide in writing the completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a notification to the resident or responsible party [RP] of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services [Medicare that helps pay inpatient care in a hospital, critical access hospital or a skilled nursing facility] with benefit days remaining) for one (Resident 43) of three sampled residents reviewed during the Beneficiary Notification task. This deficient practice had the potential to result in Resident 43 or their representative not being able to exercise their rights to be informed in advance of financial responsibilities, request an expedited review upon appeal, or determine in advance the course of their care. Findings: During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident to the facility on 6/19/2025 with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 43' s Minimum Data Set (MDS, a resident assessment tool), dated 9/22/2025, the MDS indicated Resident 43 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 43 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 43's SNF ABN form, undated, the form indicated Resident 43 no longer met the Medicare part A guidelines for skilled nursing care and rehab services. Resident 43's SNF ABN form indicated Resident 43's last covered day was 8/21/2025 and beginning on 8/22/2025, the resident may have to pay out of pocket for this care if the resident does not have other insurance that may cover these costs. The SNF ABN form was not completed for the selection of the following: Option 1. I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN . Option 2. I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Option 3. I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. The SNF ABN form indicated the facility spoke with Resident 43's Responsible Party (RP 43), where the form indicated Signature of Patient or Authorized Representative on 9/09/2025, 19 days after the last covered day. During a concurrent interview and record review with the Accounts Receivables Supervisor (ARS) on 12/04/2025 at 10 a.m., Resident 43's SNF ABN form was reviewed. The ARS confirmed that Resident 43's responsible party, was notified on 9/09/2025 that Resident 43's last covered day was 8/21/2025. The ARS stated that the form should have been given 72 hours before the last covered day. The ARS stated this is important to ensure that a resident can appeal the decision and possibly have services extended longer than the last covered day. During a concurrent interview and record review with the Director of Nurses (DON) on 12/04/2025 at 1 p.m., reviewed Resident 43's SNF ABN form. The DON stated Resident 43's responsible party should have been notified three days prior to the last covered day. The DON stated this is important to make sure the residents and RPs are aware of the last day of covered services and to ensure they are aware of the right to appeal the decision. During an interview with the ARS on 12/04/2025 at 3:30 p.m., the ARS stated the facility does not have a policy for beneficiary notices but follows the Centers for Medicare and Medicaid Services (CMS, is a federal agency under the U.S. Department of Health and Human Services (HHS) that administers Medicare [insurance program for those greater than [AGE] years old] and Medicaid [a joint federal and state program providing health coverage for low-income individuals] guidelines) guidelines for beneficiary notices. During a review of the CMS Medicare Claims Processing Manual, Chapter 30, Section 70, issued 10/31/2024, the manual indicated prior to the delivery of the SNF ABN a facility needs to provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.

Based on observation, interview, and record review the facility failed to inform a resident's responsible party (one who makes medical decisions for a resident who is unable to make their own decisions), that the resident was place on one-to-one monitoring (when one staff stays with a resident at all times to ensure the safety of the resident), for one (Resident 47) of seven residents reviewed under the care area of accidents. This deficient practice had the potential to violate Resident 47's representative's right to be informed of the treatment and services provided to Resident 47.Findings: During a review of Resident 47's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following stroke (loss of blood flow to a part of the brain) affecting the left side, and aphasia (a disorder that makes it difficult to speak). During a review of Resident 47' s Minimum Data Set (MDS, a resident assessment tool), dated 5/21/2025, the MDS indicated Resident 47 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 47 was able to walk 10 feet in the hallway with partial assistance (helper does less than half the effort). The MDS indicated Resident 47 has not exhibited wandering behavior. During a review of Resident 47's History and Physical (H&P), dated 5/17/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During an observation on 12/01/2025 at 10:02 a.m. observed Resident 47 in his bed sleeping. Certified Nursing Assistant 1 (CNA 1) was standing inside the resident's room. CNA 1 stated she is watching Resident 47 because he tries to go outside of the facility. During a review of Resident 47's most current and past Physician's Orders on 12/1/2025, there was no order for a one-to-one sitter. During a review of Resident 47's Physician's Orders, the orders indicated the following: -May have wander guard (a bracelet that a resident wears that alarms when he attempts to exit the facility) in place, dated 5/15/2025 and discontinued on 12/02/2025. -Monitor blue wearable wander guard in place, dated 5/15/2025 and discontinued on 12/02/2025. During a review of Resident 47's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/24/2025, the SBAR indicated Resident 47 removed both wander guards. During a review of Resident 47's Elopement (the act of leaving a facility unsupervised and without prior authorization) Risk Assessment, dated 5/15/2025, the assessment indicated Resident 47 is assessed to be at risk for elopement; is ambulatory and exhibits wandering behavior; cognitively impaired, and obtained an order for wander guard placement due to elopement risk. During a review of Resident 47's Care Plan for Risk for Elopement, dated 5/15/2025, the care plan indicated a goal that Resident 47 will remain in the facility without episodes of elopement daily for 90 days. The care plan did not indicate an intervention with an order for one-to-one sitter. During a telephone interview with Resident 47's responsible party (RP) on 12/03/2025 at 12:16 p.m., the RP stated that she was told by another family member who was the former responsible party (FRP) that Resident 47 removed his wander guard and refused to have one be reapplied. When asked if she was aware that Resident 47 had a one-to-one sitter, the RP stated neither she nor the FRP has been notified by the facility. During a concurrent interview and record review with the Director of Staff Development (DSD) on 12/03/2024 at 3:25 p.m., reviewed the CNA Assignment Sheets dated 10/28/25 for all three shifts. The DSD stated that Resident 47 was first assigned a one-to-one sitter during the 3 p.m. to 11 p.m. shift on 10/28/2025. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 12/03/2025 at 3:30 p.m., Resident 47's SBAR form, dated 10/24/2025 and CNA assignment sheets dated 10/28/2025 were reviewed. RN 1 stated the SBAR form dated 10/24/2025 indicated Resident 47 removed his wander guards and refused to have them placed back on and that the resident's FRP was notified by phone. RN 1 stated the FRP was not notified Resident 47 was assigned a one-to-one sitter because one had not been assigned to him until 10/28/2025. RN 1 could not find any other documentation that the FRP or the RP was notified of Resident 47 being assigned a one-to-one sitter. RN 1 stated it is important for the resident's responsible party to be notified of the resident requiring a one-to-one sitter because that is a change in condition. During a concurrent interview and record review with the Director of Nurses on 12/04/2025 at 12:36 p.m., Resident 47's SBAR, dated 10/24/2025 and CNA assignment sheets dated 10/28/2025 were reviewed. The DON confirmed that Resident 47's FRP or RP were not notified of the one-to-one sitter assignment to the resident. The DON stated it is important for a responsible party to be notified so they are fully aware of the resident's condition. During a review of the facility's policy and procedure (P&P) titled, Significant Change in Condition, last reviewed on 5/14/2025, the P&P indicated the following: Family members or responsible parties will be notified of a change in condition. Notification of the family or responsible party shall be documented in the nurses' notes including the time and name of person informed. During a review of the facility's P&P titled, Resident Rights, last reviewed on 5/14/2025, the P&P indicated the resident has the right to participate in his/her treatment and support the resident by facilitating the inclusion of the resident or their representative, including an assessment of the resident's strengths and needs and incorporating the resident's personal and cultural preferences in the development of goals.

Based on interview and record review the facility failed to implement the facility's policy and procedure titled Advance Directives, for two of three residents (Resident 3 and Resident 2) reviewed under the Advance Directive Care area by failing to:1.Maintain a copy of Resident 3's Advance Directive in the resident's medical record. 2. Ensure that Resident 1 was provided written information concerning the resident's right to prepare an Advance Directive. These deficient practices had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 3 and 2's wishes regarding their medical care. Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses including Alzheimer's disease (a progressive brain disorder causing nerve cell damage, leading to memory loss, thinking difficulties, and behavioral changes) and hypertension (high blood pressure). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 9/12/2025, the MDS indicated the resident had the ability to usually make self- understood and the ability to usually understand others. The MDS indicated Resident 3 required substantial/maximal assistance with oral hygiene, shower, upper body dressing and dependent on staff for toileting, lower body dressing and putting on and taking off footwear. During a concurrent interview and record review on 12/3/2025 at 8:24 a.m., with Registered Nurse 2 (RN 2), Resident 3's Advance Directive Acknowledgement Form dated 12/13/2023 (ADAF) was reviewed. RN 2 stated that Resident 3's Advance Directive Acknowledgement Form indicated that Resident 3 has executed an advance directive. During review of Resident 3`s electronic medical record and physical chart, RN 2 verified that there was no copy of the advance directive in Resident 3's electronic medical record or physical chart. RN 2 stated that an advance directive would indicate the resident`s healthcare wishes and it is important to have it accessible during an emergency so facility staff can determine whether the resident has chosen full treatment or not. RN 2 stated that it is a violation of the Resident 3's rights if his/her healthcare wishes are not honored. During a review of the facility`s policy and procedure (P&P), titled Advance Directive, last reviewed on 5/14/205, the P&P indicated that It is the policy of the facility that a resident may develop an advance directive relative to his/her refusal of medical or surgical treatment, which will be followed in accordance with this policy and procedure and current State Law.the resident or their responsible party will be asked if the resident has completed an advance directive, and provide a copy of the document for the resident`s clinical record. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 to the facility on 6/12/2024 and readmitted the resident on 11/30/2024 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pyelonephritis (a urinary tract infection [UTI] that occurs when bacteria enter the urinary tract [drainage system to urinate] and travel up to one or both kidneys [body organ that filters and remove waste from the blood]) and lack of coordination. During review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 9/24/2025, the MDS indicated Resident 2 has an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required moderate to maximal assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 12/2/2025 at 9:33 a.m., with the Social Service Director (SSD), Resident 2's electronic and physical chart was reviewed. The SSD stated that she could not locate Resident 2's Advance Directive Acknowledgement form. The SSD stated that upon admission they are supposed to check with the resident or the resident's representative if the resident has an advance directive and if the resident does not have one, they have to offer information on how to formulate one. The SSD stated it is important to check for an advance directive to ensure the facility is aware of the resident or the resident representative's wishes regarding medical care. During an interview on 12/4/2025 at 8:28 a.m., with the Director of Nursing (DON), the DON stated that it is important to check whether or not the resident or resident representative has executed an advance directive and/or provide information on how to formulate one on admission to ensure the facility is aware of the resident's wishes regarding their health care. During a review of facility's policy and procedure (P&P), titled, Advance Directives, reviewed on 5/14/2025, the P&P indicated, Prior to, or upon admission, resident will be provided with written information concerning the resident's rights under the State law to prepare an advance directive.

Based on interview, and record review, the facility failed to ensure the prescribing provider obtained informed consent from a resident's responsible party for the use of a physical restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body i.e. [wander guard], a bracelet that a resident wears that alarms when he attempts to exit the facility) for one of one of one resident investigated for the use of restraints. This deficient practice had the potential for the responsible party to not be informed regarding decisions that may affect Resident 47's health conditions. Findings: During a review of Resident 47's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following stroke (loss of blood flow to a part of the brain) affecting the left side, and aphasia (a disorder that makes it difficult to speak). During a review of Resident 47' s Minimum Data Set (MDS, a resident assessment tool), dated 5/21/2025, the MDS indicated Resident 47 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 47 was able to walk 10 feet in the hallway with partial assistance (helper does less than half the effort). The MDS indicated Resident 47 has not exhibited wandering behavior. During a review of Resident 47's History and Physical (H&P), dated 5/17/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 47's Physician's Orders, the orders indicated the following: May have wander guard in place, dated 5/15/2025 and discontinued on12/02/2025. Monitor blue wearable wander guard in place, dated 5/15/2025 and discontinued on 12/02/2025. During a review of Resident 47's Informed Consent for use of a Wander Guard, dated 5/15/2025, the Informed Consent indicated Resident 47 was self-responsible and unable to sign. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 12/04/2025 at 8:20 a.m., reviewed the policy for physical restraints and Resident 47's medical records including informed consents, H&P dated 5/17/2025, and Interdisciplinary Team (IDT, a group of disciplines such as nursing, physician, and social services who meet with a resident or their responsible party to discuss interventions for their medical plan of care) Care Plan Conference Summary dated 8/25/2025. RN 1 stated that the policy indicated the wander guard is considered a restraint. RN 1 stated that Resident 47's Informed Consent for use of a wander guard indicated Resident 47 was self-responsible and unable to sign because at that time, the facility was unaware Resident 47 had family. RN 1 stated that after the facility was notified Resident 47 had family (unable to state the specific date), they (licensed nurses) should have obtained the resident's responsible party a written consent. RN 1 stated Resident 47's History and Physical indicated the resident does not have the capacity to understand and make decisions and it was important to ensure the resident's responsible party is fully informed of his (Resident 47) care so they would be able to make medical decisions on his behalf. RN 1 stated the IDT Care Plan Conference Summary, dated 8/25/2025 indicated Resident 47's family member was contacted for the IDT meeting but had not returned the phone call and was not at the care plan meeting. RN 1 stated that the facility was aware that Resident 47 had family as of at least 8/25/2025. During a review of the facility's policy and procedure (P&P) titled, Physical Restraints, last reviewed on 5/14/2025, the P&P indicated the informed consent for the physical restraint is required to be obtained from the resident or legal representative. During a review of the facility's P&P titled, Resident Rights, last reviewed on 5/14/2025, the P&P indicated the resident/representative to receive all information, in advance, of risks and benefits of proposed, care, treatment, alternatives, and choose the alternative of choice which includes information for the administration of physical restraints.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when on 4/19/2025, Resident 2 hit Resident 1 ' s face several times with a fist (a person ' s hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained hematoma (a type of discoloration [change in skin color] caused by bleeding under the skin) on the left dorsal (on the back) hand, left eye and left nostril, and skin lacerations (or skin cut, a deep cut or tear in the skin) on the nasal septum (the thin wall that separates the right and left sides of the nose), left eye, left lower lip, and left lower chin requiring transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation and suturing (the process of using stitches [known as sutures - typically made from thread-like materials and are used to bring the edges of a wound together to promote healing] to close as wound). Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on 9/7/2023, with diagnoses that included cerebral infarction (often referred to as a stroke, death of brain tissue caused by a blockage or disruption of blood flow to the brain) with hemiplegia (severe or complete loss of strength leading to paralysis [loss of ability to move] on one side of the body) and hemiparesis (weakness or inability to move one side of the body), dementia (a progressive state of decline in mental abilities), During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/13/2025, the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene and lower body dressing, and required maximum assistance from staff for oral hygiene, upper body dressing, personal hygiene, and mobility [movement]. During a review of Resident 1 ' s Situation- Background- Assessment- Recommendation (SBAR- a form that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form dated 4/19/2025, timed at 6:00 p.m., the SBAR indicated on 4/19/2025 Resident 1 was hit by his roommate (Resident 2) and as a result Resident 1 sustained facial cuts and a cut on his (Resident 1) nose. The SBAR further indicated Resident was observed with a bloody face. The SBAR indicated Resident 1 ' s physician was notified with a new order to transfer Resident 1 to a hospital for further evaluation and treatment. During a review of Resident 1 ' s Physician Order dated 4/19/2025, timed at 11:30 p.m., the Physician Order indicated to transfer Resident 1 to GACH 1 for further evaluation due to cuts on the lip and nose. During a review of Resident 1 ' s Discharge Skin and Body assessment dated [DATE], the Skin and Body Assessment indicated the following skin conditions: 1. Skin cut on left eye area measuring 1.5 centimeters (cm - unit of length) 2. Skin cut on nose area measuring 0.5 cm 3. Skin cut on left side of lip area measuring 0.5 cm 4. Skin cut on left lower chin area measuring 1.5 cm 5. Hematoma on Resident 1 ' s left dorsal hand During a review of Resident 1 ' s Physician Order dated 4/20/2025, timed at 5:24 p.m., the Physician Order indicated to readmit the resident (Resident 1) to the facility. During a review of Resident 1 ' s Skin assessment dated [DATE] (upon Resident 1 ' s return to the facility), the Skin Assessment indicated the following skin conditions: 1. Nasal Septum cut closed with two stitches, measuring 1.5 cm in length and zero cm in width. 2. Left eye cut closed with one stitch, measuring 0.6 cm in length and zero cm in width. 3. Left lower lip cut closed with four stitches, measuring two cm in length and zero cm in width 4. Left lower chin cut closed with two stitches, measuring one cm in length and zero cm in width 5. Left dorsal hand hematoma measuring two cm in length and two cm in width 6. Left eye hematoma measuring three cm in length and five cm in width 7. Left nostril hematoma measuring one cm in length and 0.5 cm in width 8. Left eye bruise (a type of injury where small blood vessels under the skin break, usually due to trauma [serious physical injury] or impact, causing blood to leak into surrounding tissues) with swelling (enlargement or puffiness of a body part due to accumulation of fluid in the tissues that can occur from injury or trauma). During a review of Resident 1 ' s Physician Orders dated 4/20/2025, the Physician Orders indicated the following: 1. Nasal Septum cut with two stitches: Cleanse with normal saline (NS - a saltwater solution used to clean wounds). Pat dry and leave open to air every day shift for laceration for 14 days. 2. Left eye cut with one stitch: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 3. Left lower lip cut with four stitches: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 4. Left lower chin cut with two stitches: Cleanse with NS. Pat dry and leave open to air every day shift for laceration for 14 days. 5. Left dorsal hand hematoma: Monitor left dorsal hand hematoma for signs and symptoms (s/s - signs are objective findings that can be observed or measured by a healthcare professional, symptoms are subjective experiences reported by the resident) of skin breakdown every shift for 30 days. 6. Left eye hematoma: Monitor left eye hematoma for s/s of skin breakdown every shift for 30 days. 7. Left nostril hematoma: Monitor left nostril hematoma for s/s of skin breakdown every day shift for 30 days. During a review of Resident 2 ' s Admission Record, the Admission Record indicated the facility admitted Resident 2 on 4/24/2024 with diagnoses that included age-related cognitive decline (refers to the gradual decline in thinking abilities that can occur as people age) and alcohol dependence (a condition where a person ' s drinking pattern becomes problematic leading to significant health, social or occupational difficulties). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS further indicated that Resident 2 required moderate assistance from staff for personal hygiene and upper and lower body dressing, and supervision with toileting hygiene and mobility. During a review of Resident 2 ' s SBAR dated 4/19/2025, timed at 6:00 p.m., the SBAR indicated that on 4/19/2025, Resident 2 exhibited an aggressive behavior towards his (Resident 2 ' s) roommate and hit his (Resident 2 ' s) roommate (Resident 1) in the face causing skin cuts and bleeding from nose. During a review of Resident 2 ' s Physician Order dated 4/19/2025, timed at 6:30 p.m., the Physician Order indicated to arrange Resident 2 ' s transfer to an inpatient psychiatric care (receiving mental health treatment while staying overnight in a hospital or treatment facility) due to sudden onset of aggressive behavior. During a review of Resident 2 ' s Physician Order dated 4/20/2025, timed at 1:10 a.m., the Physician Order indicated to transfer Resident 2 to GACH 1 (same hospital Resident 1 was transferred) instead for evaluation of sudden behavioral changes. During an interview on 5/2/2025 at 11:20 a.m. with Resident 1 and Admissions Coordinator 1 (AC 1), in Resident 1 ' s room, Resident 1 stated he does not remember the specific date but recalls his (Resident 1 ' s) former roommate (Resident 2) hit him (Resident 1) on the face (while pointing to Resident 1 ' s left eye, nose and left side of chin). Resident 1 stated that at the time of the incident, he (Resident 1) was calling the nurses to obtain assistance however Resident 2 did not like it and started hitting Resident 1 in the face several times with Resident 2 ' s fist. Resident 1 further stated he was very upset following the incident, during which Resident 1 was hit in the face multiple times by Resident 2 with a fist. Resident 1 stated he (Resident 1) could not express with the right words how he (Resident 1) feels but wanted to press charges against Resident 2. During an interview on 5/2/2025 at 4:42 p.m., with the Director of Nursing (DON), the DON stated that Resident 2 hitting Resident 1 in the face several times with a fist is physical abuse. The DON stated the incident on 4/19/2025 (involving Resident 1 and Resident 2) resulted in actual harm to Resident 1. During a phone interview on 5/5/2025 at 12:41 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that he (RN 2) heard screaming and an agitated voice (a voice that is upset or expressing worry, often showing signs of distress [indicates a condition where a person is in extreme danger and needs urgent help]) coming from the shared room of Resident 1 and Resident 2 while RN 2 was walking through the hallway. RN 2 stated he (RN 2) then entered the shared room of Resident 1 and Resident 2 and observed Resident 1 lying in his (Resident 1 ' s) bed with visible facial bleeding. RN 2 stated Resident 2 was unable to provide an explanation of the incident. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention/Investigation/Reporting and Resolution, last reviewed on 2/26/2025, indicated This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, mental abuse .that are necessary to avoid physical harm, and to attain or maintain physical, mental, and psycho-social well-being of the residents.

Based on interview, and record review, facility staff (Registered Nurse 3 [RN 3]) failed to monitor and provide peripheral (away from the center of the body) intravenous (IV- into a vein) line care to one of one sampled resident (Resident 65) on 10/6/2024, when Resident 65 complained of pain to the IV site on the left forearm. This deficient practice resulted in RN 3 continuing to use Resident 65's IV site on the left forearm on 10/6/2024 to administer IV medication further causing Resident 65 to experience untreated pain to the IV site. Findings: During a review of Resident 65's Admission Record, the Admission Record indicated the facility admitted Resident 65 on 9/4/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive group of lung diseases that make it hard to breathe), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), transient ischemic attack (TIA - a temporary disruption in the blood supply to part of the brain) and cerebral infarction (a serious condition when blood flow to the brain is blocked, causing brain tissue to die). During a review of Resident 65's History and Physical (H&P- a comprehensive assessment of a resident's medical history and current condition), dated 9/6/2024, the H&P indicated Resident 65 did not have the capacity to understand and make decisions. The H&P also indicated Resident 65 was admitted to the General Acute Care Hospital (GACH) for cholecystitis (inflammation of the gallbladder [a small digestive organ]) status post (s/p- medical term that refers to a patient's condition after a specific event, treatment, or diagnosis) cholecystectomy (surgical procedure to remove the gallbladder). During a review of Resident 65's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 9/11/2024, the MDS indicated Resident 65 needed substantial assistance from staff for toileting, dressing, showering, and personal hygiene, and some assistance for eating. During a review of Resident 65's physician's orders, the physician orders indicated the following: 1. Zosyn (antibiotic) 3.375 milligrams (mg - unit of measurement) IV every six hours for seven days for wound infection, ordered 10/3/2024. 2. Vancomycin (antibiotic) one (1) gram (gm - unit of measurement) IV every 12 hours for seven days for wound infection, ordered 10/3/2024. During a review of Resident 65's Type of Line form (documentation form for the insertion of IV lines) undated, the Type of Line form indicated that on 10/3/2024 at 6:00 p.m., Resident 65 had a left forearm IV line inserted. During a review of Resident 65's Type of Line form undated, the Type of Line form indicated that on 10/7/2024 at 10:30 a.m., Resident 65's left forearm IV access site was discontinued (removed) due to the IV line being infiltrated (a complication of IV therapy that occurs when IV fluid or medication leaks out of the vein and into the surrounding tissue causing swelling and pain). During a concurrent observation and interview on 10/7/2024 at 12:20 p.m., with Resident 65's wife (RR 1) in Resident 65's room, observed Resident 65's left forearm. RR 1 pointed to Resident 65's left foreman covered with a bandage and stated that the IV that was previously on Resident 65's left forearm was infiltrated from 10/6/2024 and had to be removed. RR 1 stated that RR 1 informed RN 3 on 10/6/2024 about Resident 65's left forearm IV access site having blood and fluid on the outside of the IV insertion site and causing Resident 65 pain, but RN 3 never checked Resident 65's left forearm IV site. RR 1 stated that Registered Nurse 4 (RN 4) removed Resident 65's left forearm IV access on 10/7/2024 because the IV access was causing Resident 65 pain. During an interview on 10/7/2024 at 12:30 p.m., with Resident 65, Resident 65 stated that his (Resident 65) IV access on the left forearm began to cause Resident 65 pain starting on 10/6/2024. Resident 65 stated that he (resident 65) informed RN 3 about the pain to the left forearm IV access site, but RN 3 did not provide any intervention for the pain in Resident 65's left forearm IV access site. Resident 65 stated that RN 3 even continued administering Resident 65's IV antibiotic Zosyn despite the pain at the IV access site on the left forearm. During an interview on 10/7/2024 at 12:35 p.m., with RN 4, RN 4 stated she (RN 4) had to remove the IV access on Resident 65's left forearm on 10/7/2024 during the 7 a.m.-3 p.m. shift because it was painful to Resident 65 and was no longer patent (patency refers to when the IV line is open and not clogged). During an interview on 10/7/2024 at 3:35 p.m., with RN 3, RN 3 stated that on 10/6/2024, Resident 65 complained of pain to the left forearm IV access site. RN 3 stated that he (RN 3) noted that Resident 65's IV access site to the left forearm had blood around the outside of the tubing. RN 3 stated that he (RN 3) did not check the patency of Resident 65's IV access to the left forearm and did not address Resident 65's complaint of pain to the left for arm access site. RN 3 stated that he (RN 3) continued to utilize Resident 65's left forearm IV access on 10/6/2024 at 6 p.m. to infuse the physician ordered antibiotic Zosyn despite Resident 65's complaint of pain; and despite not checking the patency of Resident 65's IV access. RN 3 stated he (RN 3) should have not increased the rate of the Zosyn administration and should have checked for placement and infiltration. During an interview on 10/10/2024 at 11:45 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses must address any pain the residents are experiencing are reporting immediately. During an interview on 10/11/2024 at 2:00 p.m., with the Medical Records Assistant (MRA), the MRA stated they do not have a policy regarding IV medication administration and peripheral IVs.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who has severe impaired cognition (ability to think and make decisions), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician was kept free from accidents and hazards by failing to monitor and provide supervision to Resident 1. This deficient practice resulted in Resident 1 leaving the facility on 2/8/2024 at 2:35 a.m. unnoticed, sustained abrasions (skin scrapes) on the left side above of the eyebrow, left side of the forehead, right side above of the eyebrow, right knee and left posterior (back) forearm, and required transfer to General Acute Care Hospital 1 (GACH 1) where Resident 1 was diagnosed with hypothermia (happens with prolonged exposure to cold weather and a person's body temperature drops dangerously low) and urinary tract infection (UTI - a condition in which bacteria invade and grow in any part of the urinary system). Findings: A review of Resident 1's Admission Record indicated the facility readmitted Resident 1 on 12/28/2023 with diagnoses that included hypertension (elevated blood pressure), type 2 diabetes mellitus (a disease in which your blood glucose [blood sugar] levels are too high), depression (a mood disorder that causes a persistent feeling of sadness, loss of interest and can interfere with daily living), bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs [mania or manic episode] to lows (depression or depressive episode]) and schizophrenia (a mental disorder in which a person interpret reality abnormally). A review of Resident 1's Initial History and Physical Examination Form dated 12/29/2023 indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/5/2024 indicated that Resident 1's cognition was severely impaired. A review of Resident 1's Elopement (leaving the facility without notice or permission) Risk Form dated 12/28/2023 indicated that Resident 1 had one or more predisposing disease present, disoriented all the time, and takes two or more medications that can place resident at risk for elopement. A review of Resident 1's Physician Order with a clarification date of 1/18/2024 (originally ordered 10/7/2023) indicated for licensed nurses to check the presence and placement of Resident 1's wander guard every shift and document one (1) if present and two (2) if absent. A review of Resident 1's Care Plan, titled Wandering (to walk around without any clear purpose or direction) initiated on 11/30/2022, last revised on 2/2024 indicated Resident 1 has sporadic (occurring occasionally or random instances) wandering related to memory or recall deficits, disorientation (condition of having lost one's sense of direction), cognitive impairment, and diagnosis of schizophrenia. The care plan indicated a goal that Resident 1 would be free of injuries and unplanned exits. The care plan interventions included to provide a safe place to wander, away from safety hazards, and use of a wander-guard device. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a tool used to communicate a resident's condition among members of the health care team) Form dated 2/8/2024 indicated that on 2/8/2024 at approximately 2:35 a.m. Resident 1 was observed by Registered Nurse 1 (RN 1) not to be in his bed. A review of Resident 1's Nurses Notes, dated 2/8/2024 timed at 8:00 a.m., indicated that at approximately 8:00 a.m., of 2/8/2024, Emergency Medical Services Worker 1 (EMSW 1) notified the facility that they had found Resident 1 and had taken him to GACH 1. A review of Resident 1's Physician's Orders dated 2/8/2024 at 6:10 p.m. (upon Resident 1's return to the facility) indicated to resume all current orders, and to administer Cefdinir (a medication used to treat bacterial infections) 300 milligrams (mg- unit of measure) one capsule by mouth every 12 hours for UTI to be taken for seven days. Further review of Resident 1's Physician Orders dated 2/8/2024 at 6:10 p.m. indicated to cleanse Resident 1's left side above eyebrow abrasion, left side of forehead abrasion, right side above eyebrow abrasion, right knee abrasion and left posterior forearm abrasion with Normal Saline (a liquid solution used to cleanse wounds), pat dry and leave open to air daily for 14 days. During an interview with the Director of Nursing (DON) on 2/14/2024 at 8:30 a.m., the DON stated that on 2/8/2024 at approximately 2:35 a.m., RN 1 noted Resident 1 to be missing. The DON further stated that at approximately 8:00 a.m. on 2/8/2024, the facility received a call from EMSW 1 who informed that Resident 1 had been found wandering along the street (did not specify) and was transferred to GACH 1. The DON stated that the facility staff did not adequately monitor Resident 1 as evidenced by the fact that the facility staff did not know when or how Resident 1 left the facility. The DON stated that Resident 1's cognition is severely impaired and placed the resident at increased risk for injury when the resident eloped from the facility. The DON stated that Resident 1 could have been hit by a car or fallen and sustained some other injury while outside of the facility without supervision, which could have resulted in Resident 1 suffering pain, hospitalization , and death. The DON stated the facility has a policy for elopement prevention and the facility staff did not follow it. During an interview with Resident 1 on 2/15/2024 at 4:50 p.m., Resident 1 was unable to recall the elopement incident on 2/8/2024. During a follow-up interview with the DON on 2/15/2024 at 4:57 p.m., the DON stated that Resident 1 is mentally impaired (a condition in which a part of a person's mind is damaged or is not working properly) and requires supervision for his safety, but the facility staff failed to supervise Resident 1 on the early morning of 2/8/2024. During a review of Resident 1's GACH Emergency Documentation (ED) Notes dated 2/8/2024 timed at 11:01 a.m. indicated Resident 1 was seen and evaluated at GACH 1 on 2/8/2024 at 9:04 a.m. after Resident 1 was found wandering along the street. Resident 1 was diagnosed with hypothermia and urinary tract infection. Resident 1's rectal (refers to rectum, area where a person holds solid waste [stool] before excreting it from the body) temperature (involves gently inserting a thermometer into the anus [opening in a person's bottom through which solid waste leaves the body] for about one minute) was 34.5 degrees Celsius ( C - unit of measure, normal range 36.6 C to 38 C) low. The GACH ED Notes further indicated Resident 1 was found to be hypothermic (condition of having an abnormally low body temperature) and external warming was initiated. The GACH ED Notes indicated Resident 1 was hydrated with administration of Normal Saline (a fluid and electrolyte [minerals in body that affect how a person's body functions] replenisher used as a source of water and electrolytes) bolus (a single, large dose) intravenously (IV - into a vein) and ceftriaxone (a medication used to treat bacterial infection such as urinary tract infections) (dose not indicated) via IV. During a review of Resident 1's GACH laboratory results dated [DATE] at 1:23 p.m. indicated Resident 1's Blood Urea Nitrogen (BUN - a test that measures how much urea nitrogen [a waste product that kidneys remove from a person's blood] is in a person's blood; elevated BUN level can be due to dehydration [occurs when a person lose more fluid than a person takes in, causing the body not to have enough water and other fluids to carry out its normal functions]) Test Result was high at 39 milligrams per deciliter (mg/dl - unit of measure, normal range six (6) to 24 mg/dl). The GACH Laboratory Results further indicated Resident 1 was noted with leukocytosis (high white blood cell count [WBC- elevated level can indicate infection, inflammation, and injury]), WBC of 16,300 cells per microliter (cells/mcl - unit of measure, normal range 4,500 to 11,000 cells/mcl). A review of the facility's policy and procedure titled, Elopement/Against Medical Advice, with an effective date of 2/15/2018, last reviewed 2/28/2023, indicated .the facility has a responsibility to provide oversight and protect the rights, health and safety of each resident.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 2 for one of five sampled residents (Resident 1); when on 12/21/2023 Resident 2 pulled Resident 1 out of bed causing Resident 1 to fall to the floor. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 2 pulled Resident 1 out of his bed causing Resident 1 to fall onto the floor, to cry, scream, and shake. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1 ' s severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Face Sheet (admission record), dated 3/15/23, indicated the facility admitted Resident 1 on 2/23/23 with a medical history of psychosis (a condition of the mind that results in difficulties determining what is real and what is not real). A review of Resident 1's Minimum Data Set (MDS, a tool for resident assessment), dated 11/2/23, indicated Resident 1 had severe mental confusion. A review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident 's condition), dated 12/21/23, indicated the facility noted Resident 1 to be a victim of aggressive behavior when Resident 2 pulled Resident 1 out of bed. The SBAR further indicated that Resident 1 was crying after being pulled out of the bed by Resident 2. A review of Resident 1's Care Plan for Psychosocial Well Being (an individual's emotional health and overall functioning), dated 12/21/23, indicated that Resident 1 was at risk for alteration in Psychosocial Well-Being as manifested by crying due to Resident 2 pulling Resident 1 out of bed. A review of Resident 2's Face Sheet, dated 7/26/23, indicated the facility admitted Resident 2 on 11/4/20 with a medical history of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2's MDS dated [DATE], indicated Resident 2 had severe mental confusion. A review of Resident 2's SBAR Communication Form, dated 12/21/23, indicated the facility noted Resident 2 to have aggression towards Resident 1. The SBAR indicated that Resident 2 was aggressive towards Resident 1 by pulling Resident 1 out of bed. The SBAR communication form further indicated that Resident 2's physician ordered the facility to transfer Resident 2 to the General Acute Care Hospital (GACH) for evaluation. A review of Resident 2's care plan for Behavioral Problems, dated 12/21/23, indicated that Resident 2 exhibited aggressive behavior towards Resident 1 by pulling Resident 1 out of bed. During an interview on 12/26/23 at 9:20 a.m. with Resident 1, when Resident 1 was asked if he was able to recall the incident that occurred on 12/21/23 where in Resident 2 pulled Resident 1 out of bed onto the floor, Resident 1 did not respond and was noted to be nonverbal. During an interview on 12/26/23, 9:50 a.m., Licensed Vocational Nurse 2 (LVN 2) stated that on 12/21/2023, LVN 2 heard screaming and crying coming out of Resident 1 and Resident 2 ' s room. LVN 2 stated that she ran into Resident 1 and Resident 2 ' s room where she witnessed Resident 2 pull Resident 1 off the resident ' s bed causing Resident 1 to fall to the floor. LVN 2 stated that she witnessed Resident 1 crying and shaking as she assisted Resident 1 back to the resident ' s bed. LVN 2 stated that she had received training in identifying distress in residents. LVN 2 stated that it appeared as though Resident 1 had suffered from psychosocial harm as the resident was crying and shaking as the result of the incident. During an interview on 12/26/2023 at 10:40 a.m., Administrator (ADM) stated that the incident that occurred on 12/21/2023, in which Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful (intentional, purposeful) abuse. The ADM stated that Resident 1 had a right to be free from all forms of abuse, and as a result of the incident, Resident 1 was not kept free from abuse while in the facility. During an interview on 12/26/2023 at 10:44 a.m. with the Director of Nursing (DON), the DON stated that the incident that occurred on 12/21/2023 where in Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful abuse. The DON stated that Resident 1 had the right to be free from all forms of abuse and that the facility was unable to protect Resident 1 from physical abuse. A review of the facility's policy and procedure titled Alleged Abuse Investigation, dated 1/27/11 and re-approved on 2/22/23, indicated that Abuse, is defined as a willful infliction of injury resulting in physical harm or pain or mental anguish. The policy further indicated the facility, will ensure that resident's rights are protected .

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 106) maintained acceptable parameters of nutritional status (desirable body weight) and did not experience unplanned severe weight loss (a body weight loss of greater than five [5] percent [%-unit of measure] of weight in one months' time) by: 1. Failing to ensure Resident 106 received their gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feedings at the rate of 70 milliliters (ml-unit of measure) per hour (hr- unit of time) as ordered by the physician, the g-tube feeding rate was observed set at 60 ml per hour on 10/17/2023. The physician had ordered to increase Resident 106's G-tube feeding rate on 10/14/2023 from 60 ml per hr to 70 ml per hr to meet the recommended daily nutritional intake and prevent severe weight loss. 2. Failing to ensure Resident 106 received the total volume of G-tube feeding volume or Kilocalorie (Kcal- unit of energy where 1 kcal equals 1000 calories) which was equal to 1600 ml or 2400 Kcal, as ordered by the physician to meet the recommended daily nutrition intake on 10/18/2023. 3. Failing to ensure facility staff monitored and documented Resident 106's intake (consumption of food) and output (amount of urine and stool) for four weeks as ordered by the physician on 9/5/2023 and per facility's policy and procedure regarding resident with a G-tube and indwelling urinary catheter (tube inserted into the bladder to allow urine to drain freely). 4. Failing to ensure that Resident 106's significant weight loss of 17 pounds (lbs.- unit of measure). in one months' time was reported to the resident's physician as soon as Licensed Vocational Nurse 1 (LVN 1) was made aware of the weight loss on 10/4/2023. 5. Failing to ensure Resident 106 was immediately seen by Registered Dietitian 1 (RD 1) when the resident was identified as exhibiting severe weight loss of 17 pounds on 10/4/2023; RD 1 did not assess Resident 106 until 10/10/2023 approximately six (6) days later. 6. Failing to ensure Resident 106's G-tube feeding recommendation by RD 1 on 10/10/2023 was carried out and implemented within 24 hours. The recommendations were not started until 10/14/2023, approximately four (4) days later. These deficient practices resulted in Resident 106 experiencing severe weight loss of 17 lbs., which was the equivalent of 13% of the resident's body weight from 9/5/2023 to 10/4/2023 and placed Resident 106 at risk for further weight loss. Findings: 1. A review of Resident 106's Admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including G-tube, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs [arms and legs]). A review of Resident 106's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/12/2023, indicated that Resident 106 had a severely impaired cognition (ability to think and make decisions). The MDS indicated that Resident 106 was totally dependent on staff for eating. The MDS indicated that Resident 106's height was 71 inches (in-unit of measure), and weight was 130 lbs. The MDS indicated that Resident 106 was on a mechanically altered diet (food that can be safely and successfully swallowed) and feeding tube. The MDS further indicated that Resident 106 had an indwelling urinary catheter. The MDS also indicated that Resident 106 was admitted with a stage four (4) pressure ulcer (severe tissue damage caused by injury to skin and underlying tissue resulting from prolonged pressure on the skin; a stage four is the largest and deepest of all pressure ulcer stages). A review of Resident 106's General Acute Care Hospital (GACH) Discharge Summary Record, dated 8/17/2023, indicated Resident 106's diagnoses including, severe sepsis (serious condition in which the body responds improperly to an infection), bacteremia (infection of the blood) and severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The GACH Discharge Summary Record indicated that Resident 106 had a G-tube placed on 8/14/2023. A review of Resident 106's Registered Dietitian Assessment (RDA) Form, dated 9/8/2023, indicated Resident 106's weight was 130 lbs., height was 71 inches and Body Mass Index (BMI- is a tool that healthcare providers use to estimate the amount of body fat by using your height and weight measurements, a BMI of less than 18.5 falls within the underweight range.) was 18.1. It also indicated that the resident Ideal Body Weight (IBW) range was 154 to 172 lbs., and the goal was to gradually gain weight. RD 1 documented that no edema (medical term for swelling) was noted on Resident 106. The RDA Form further indicated that Resident 106 may benefit from additional Kcals, protein (builds, maintains, and replaces the tissues in your body) and supplement (anything that is added to a diet to benefit health) due to wounds and significant weight loss. A review of Resident 106's physician order dated 9/5/2023, indicated Resident 106 had the following orders: a) Isosource 1.5 (a type of feeding formula [nutrition that is delivered through a tube placed in the stomach] dense in calories and protein so that it supplies more of what the body needs in each serving, making it suitable for those with limited fluid tolerance) to provide 1200 ml and 1800 Kcal via G-tube for 20 hours via G-tube pump (a device that delivers the tube feeding formula with the ability to set the rate (speed) at which the formula is administered to a resident). Start infusion at 12:00 p.m. to 1:00 p.m. and continue until the ordered volume is infused (administered). Set pump at 60 ml per hour. b) Flush (water flush- injecting water into a tube to keep it from getting clogged) G-tube feeding with 40 ml of water for 20 hrs continuously to provide 800 ml of water via G-tube pump. c) Monitor intake and output for four weeks then reevaluate. d) Pureed diet (foods that have a soft, pudding like consistency) with thin liquids (watery liquids) as ordered. A review of Resident 106's physician order dated 10/14/2023, indicated an order for the following: a) Discontinue current G-Tube feeding rate and start Isosource 1.5 at 70 ml (one cc is the equivalent of one ml) per hr to run for 20 hours to provide 1400 ml or 2100 Kcal via enteral feeding (tube feeding). Start infusion at 12:00 p.m. to 1:00 p.m. and continue until the ordered volume is infused. A review of Resident 106's Weekly Weights Record were as followed: a) 9/6/2023, Resident 106 weighs 130 lbs. (admission weight) b) 9/13/2023, Resident 106 weighs 126 lbs. (three [3] lbs. of weight loss in seven [7] days) c) 9/20/2023, Resident 106 weighs 123 lbs. (seven lbs. of weight loss in 14 days) d) 9/27/2023, Resident 106 weighs 120 lbs. (10 lbs. of weight loss in 21 days) e) 10/4/2023, Resident 106 weighs 113 lbs. (17 lbs. of total weight loss in 28 days) During a concurrent observation and interview on 10/17/2023 at 8:25 a.m., with Registered Nurse 1 (RN 1), observed Resident 106's G-tube pump inside the resident's room. RN 1 stated that Resident 106's G-tube feeding rate was set at 60 ml per hr (ml/hr) and the feeding was currently ongoing. During a concurrent interview and record review on 10/17/2023 at 8:29 a.m., with RN 1 and LVN 1, Resident 106's Medication Administration Record (MAR- a document that tracks the daily medications administered to a resident by the licensed nurses) for 10/2023 was reviewed. RN 1 stated that according to Resident 106's MAR, the resident's G-tube feeding rate should have been set to 70 ml/hr starting on 10/14/2023 as ordered by Resident 106's physician. RN 1 stated that Resident 106's G-tube feeding rate was set to the wrong rate and amount. LVN 1 stated that Resident 106's was not getting the ordered g-tube feeding rate and amount as per Resident 106's physician's order. During an interview on 10/18/2023 at 1:44 p.m. with RD 1, RD 1 stated that she assessed Resident 106 on 10/10/2023 and recommended to increase the resident's G-tube feeding rate from 60 ml/hr to 70 ml/hr, and the volume from 1200 ml and 1800 Kcal to 1400 ml and 2100 Kcal because of the significant weight loss and multiple wounds the resident had experienced. A review of the facility's policy and procedure titled Enteral Feeding reviewed on 2/22/2023, indicated all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The policy further indicated that the facility would remain current in and follow accepted best practices in enteral nutrition. It indicated to prevent errors in administration: a) Check the enteral nutrition label against the order before administration. Check the following information: i. Resident name, identification, and room number ii. Type of formula iii. Date and time formula was prepared. iv. Route of delivery. v. Access site vi. Rate of administration (ml/hr) 2. A review of Resident 106's physician order dated 10/14/2023, indicated an order for the following: Start Isosource 1.5 at 80 ml/hr to run for 20 hours to provide 1600 ml or 2400 Kcal via enteral feeding (tube feeding). Start infusion at 12:00 p.m. to 1:00 p.m. and continue until the ordered volume is infused. During a concurrent observation and interview on 10/19/2023 at 8:10 a.m., with LVN 1, Resident 106's G-tube feeding pump was observed inside the resident's room. LVN 1 stated that the total volume administered to Resident 1 as calculated by the G-tube pump at the time of observation was 1081 ml. When asked how come the total administered volume was less than the 1600 ml as ordered by the physician, LVN 1 stated that the facility staff (unidentified) likely stopped the feeding pump throughout various times of each shift. During an interview on 10/19/2023 at 11:01 a.m., LVN 1 stated that she turned off Resident 106's G-tube feeding pump at approximately 9:40 a.m. LVN 1 stated that the total volume of G-tube feeding administered to Resident 106 was only 1160 ml. LVN 1 stated that Resident 106 did not receive the full amount of G-tube feeding equaling to 1600 ml or 2400 Kcal as ordered by the physician. LVN 1 stated that when a resident does not receive the entire volume of G-tube feeding equivalent to the ordered Kcal, it places the resident as further risk of weight loss and malnutrition. During an interview on 10/19/2023 at 10:00 a.m., with RD 1, RD 1 stated that G-tube residents should always receive the total volume amount of G-tube feeding ordered by the physician. RD 1 stated for Resident 106, the physician order was for G-tube feeding at 80 ml/hr for 20 hours, will total 1600 ml or 2400 Kcal. RD 1 stated that even if the order was to turn off the feeding at 8:00 a.m., the licensed nurses should check the total G-tube feeding volume administered before turning the G-tube feeding off. RD 1 stated that if the total volume of the tube feeding volume administered did not reach the amount as ordered by the physician, then the tube feeding should still be continued. RD 1 stated that the total volume and the total Kcal ordered is important for residents who are losing weight. A review of the facility's policy and procedure titled Enteral Feeding reviewed on 2/22/2023, indicated all personnel responsible for preparing, storing, and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The policy further indicated that the facility would remain current in and follow accepted best practices in enteral nutrition. 3. A review of Resident 106's physician order dated 9/5/2023, indicated Resident 106 had the following orders: a. Monitor intake and output for four weeks then reevaluate. During a concurrent interview and record review on 10/18/2023 at 9:22 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 106's medical chart was reviewed with no documented evidence found of staff completing any intake and output monitoring sheets from 9/5/2023 to 10/18/2023. LVN 2 stated that Resident 106 had a physician's order to monitor the resident's intake and output starting on 9/5/2023. LVN 2 stated that she was not able to find any documentation evidence of any intake and output sheets from 9/5/2023 to 10/18/2023 in Resident 106's medical chart. LVN 2 stated that it is also the facility's policy and practice that for any newly admitted resident with G-tubes and indwelling catheters, staff is to monitor the resident's intake and output for approximately one month. LVN 2 stated that when there is a physician's order to monitor a resident's intake and output, the nursing staff will have to document the total amount of tube feeding and water flushes provided to a G-tube resident during each shift, the total amount of the resident's oral intake, the total amount of urine output from an indwelling catheter, and the total amount of stool. LVN 2 stated these were not done for Resident 106. During an interview on 10/19/2023 at 11:10 a.m. with Director of Nursing (DON), the DON stated that new admissions, especially residents with a G-tube or an indwelling catheter, intake and output should be monitored according to the facility's policy and procedures. DON stated that there was no intake and output documentation completed for Resident 106 from the time of readmission on 9/5/2023 to present (10/19/2023). DON stated that since admission, resident had been progressively losing weight, approximately three (3) to four (4) lbs. per week. The DON further stated that the intake and output monitoring sheet form would inform the licensed nurses whether a resident was receiving the total volume of the G-tube feeding as ordered by the physician, and if the resident is dehydrated (lack of fluid consumption) or having fluid overload (too much water). A review of the facility's policy and procedure titled Intake and Output reviewed on 2/22/2023, indicated, intake and output monitoring will be initiated by the licensed nurse or as ordered by the physician. Intake and output measurement will be performed on all residents with urinary catheters, enteral feedings, and Intravenous (IV - into a vein) fluid infusion or if potential for dehydration (harmful reduction in the amount of water in the body) exists. The purpose of intake and output records is to evaluate the resident's fluid balance, suggest various diagnoses and influence the physician choice of therapies. It also indicated that the nursing assistant and licensed nurse will document the resident's intake and output on the Intake and Output Form in the resident's medical record. 4. During a concurrent interview and record review on 10/19/2023 at 10:46 a.m., with Restorative Nursing Assistant 1 (RNA 1), Resident 106's Weekly Weight Record from 9/5/2023 to 10/4/2023 was reviewed. RNA 1 stated that when Resident 106 was weighed on 10/4/2023, it was discovered that Resident 1 had lost a total of 17 lbs. and went from 130 lbs. on 9/6/2023 to 113 lbs. on 10/4/2023. RNA 1 stated that on 10/4/2023, she notified LVN 1 of Resident 106's weight loss of 17 lbs. During a concurrent interview and record review on 10/19/2023 at 11:01 a.m., with LVN 1, Resident 106's weekly weight from 9/5/2023 to 10/4/2023 was reviewed. LVN 1 stated that on 10/4/2023, (unable to recall exact time), RNA 1 notified her about Resident 106's weight loss of 17 lbs. LVN 1 stated that she did not notify Resident 106's physician or RD 1 on 10/4/2023. LVN 1 stated that she should have notified Resident 106's physician and RD 1 as soon as possible for any weight loss especially a significant weight loss of 17 lbs. in one month. LVN 1 stated she did not notify Resident 106's physician nor the facility's RD regarding the 17 lbs. weight loss because she forgot about it. LVN 1 stated that she should have notified the RN Supervisor on 10/4/2023 regarding Resident 106's weight loss. LVN 1 stated that because she did not notify Resident 106's physician or the RN Supervisor on 10/4/2023, Resident 106 was placed at risk for further weight loss and possible malnutrition. During an interview on 10/19/2023 at 11:10 a.m., with the DON, the DON stated that Resident 106's physician should have been notified as soon as possible for any weight loss of three (3) % or three lbs. or more each week. When the DON was asked what the risk is of not notifying Resident 106's physician of the resident's weight loss, the DON stated that Resident 106 would not be assessed for possible underlying conditions (issues that may have contributed to the resident's weight loss), interventions to address the weight loss will not be in place and that Resident 106 would lose more weight. A review of the facility's policy and procedure titled Weight Assessment and Interventions reviewed on 2/22/2023, indicated, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for their residents. The policy indicates that any weight change of five % or more since the last weight assessments will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The dietitian will respond within 24 hours of receipt of written notification. The policy indicates that the threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. One month: five % weight loss is significant; greater than five % is severe. The policy further indicated that the physician and the multi-disciplinary team will identify conditions and medications that may be causing weight loss or increase the risk of weight loss. 5. During a concurrent interview and record review on 10/18/2023 at 1:44 p.m. with RD 1, Resident 106's RDA Form from 9/4/2023 to 10/18/2023 was reviewed. RD 1 stated that Resident 106 was assessed on 9/8/2023, but that there were no other RD visits made to Resident 106 until 10/10/2023. RD 1 stated that Resident 106 first was noted with severe weight loss of 17 lbs. or 13 % of body weight on 10/4/2023. RD 1 stated that Resident 106 was not assessed until 10/10/2023, six (6) days after Resident 106's first identified severe weight loss. RD 1 stated that after she had assessed Resident 106 on 10/10/2023, RD 1 recommended to increase Resident 106's tube feeding rate from 60 ml per hr to 70 ml per hr, and to increase the total infused volume to 1400 ml and 2100 Kcal because of the significant weight loss. When asked, if providing dietary recommendations six (6) days after a resident is identified as exhibiting severe weight loss would be considered a delay in treatment, RD 1 was unable to answer. When asked, if providing dietary recommendations six (6) days after a resident is identified as exhibiting severe weight loss could result in further west loss, RD 1 was unable to answer. During an interview on 10/19/2023 at 11:10 a.m., with the DON, the DON stated that there was a delay in treatment for Resident 106 by the RD 1 because the RD 1 did not assess Resident 106 until 10/10/2023 when the resident has exhibited severe weight loss on 10/4/2023. A review of the facility's policy and procedure titled Nutritional Assessment reviewed on 2/22/2023, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. It indicated that the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutrition assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 6. A review of Resident 106's Registered Dietitian (RD) Progress Notes dated 10/10/2023, indicated the following dietary recommendations: a. Add fortified (Food fortification is defined as the practice of adding vitamins and minerals to commonly consumed foods during processing to increase their nutritional value.) to diet order. b. Discontinue Isosource 1.5 at 60 ml/hr for 20 hours. c. Initiate Isosource 1.5 at 70 ml/hr for 20 hours to provide a total of 2100 Kcal. d. Initiate active liquid protein (a ready-to-use protein concentrate) 30 ml twice a day. e. Initiate zinc sulfate (a type of dietary supplement) 50 milligrams (mg- unit of measure) daily for 30 days. A review of Resident 106's physician orders dated 10/14/2023, indicated an order for the following: a. Discontinue current G-Tube feeding rate and start Isosource 1.5 at 70 ml/hr for 20 hours to provide 1400 ml or 2100 Kcal via enteral feeding. b. Discontinue current diet order and start fortified pureed diet with thin liquids. c. Administer 30 ml of active liquid protein via G-tube twice a day d. Zinc sulfate 50 mg daily for 30 days During a concurrent interview and record review on 10/18/2023 at 1:44 p.m. with RD 1, Resident 106's RDA Form from 9/4/2023 to 10/18/2023 were reviewed, and Resident 106's physician orders dated 10/14/2023 were reviewed. When the RD was asked if there was a delay in Resident 106's plan of care because the licensed nursing staff did not obtain physician orders for Resident 106 related to RD 1's dietary recommendations on 10/10/2023 until 10/14/2023, approximately four (4) days later, RD 1 was unable to answer. RD 1 stated that she would expect the licensed nurses to notify Resident 1's physician of the resident's dietary recommendations as soon as possible so that the recommendations can be implemented immediately to help prevent further weight loss and malnutrition. During a concurrent interview and record review on 10/19/2023 at 11:10 a.m., with DON, Resident 106's RDA Form from 9/4/2023 to 10/18/2023 were reviewed, and Resident 106's physician orders dated 10/14/2023 were reviewed. The DON stated that Resident 106 experienced a delay in care of approximately 10 days. The DON stated that the facility was first made aware of Resident 106's severe weight loss on 10/4/2023, but RD 1's dietary recommendations were not ordered for Resident 106 until 10/14/2023. A review of the facility's policy and procedure titled Weight Assessment and Interventions reviewed on 2/22/2023, indicated, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for their residents.

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who exhibited wandering behavior was kept free from accidents and hazards by failing to: 1. Re-evaluate elopement (leaving the facility without prior approval) risk behavior after Resident 1 was found wandering outside of the facility on 6/23/2021. 2. Ensure facility staff conducted hourly monitoring of Resident 1 as indicated in his care plan to provide the necessary supervision to prevent elopement. 3. Ensure the facilities main alarm systems (devices attached throughout the facility that when activated, emits a sound when the gate doors are opened) were in working condition to prevent Resident 1's elopement. These deficient practices resulted in Resident 1 who required close supervision, to be missing as of 6/24/2021, and the facility is still unable to locate Resident 1 as of 7/2/2021. This has the potential to result in harm, injury, or death. On 6/30/2021 at 2:02 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (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) in the presence of the Assistant Administrator (AADM) and Director of Nursing (DON) with regards to the failure of the facility to provide a safe environment for Resident1. On 7/2/2021 at 4:47 p.m., the AADM provided the Department with a Plan of Action (POA) which included the following summarized actions: o The Maintenance Supervisor (MS) checked and repaired the alarm system and made sure that all exit gates/doors alarms are functioning properly, completed on 6/30/2021 o On 6/30/2021, MS ensured that daily checks of all exit door alarms will be completed. A copy of the log will be submitted to the Administrator (ADM) weekly. o On 6/30/2021, the facility started checking the alarm system daily. The MS, Janitors and Registered Nurse Supervisors are the only individuals that can arm and disarm the alarm system for all exit doors. o On 6/30/2021, the Administrator (ADM) and MS started the in-service to all 3-11 staff on the facility's door alarm system and wandering alert system (a device designed to activate alarms when a resident gets closer to entries and exit points). The facility will continue until all staff are given in-service on the Wander Guard system. o On 6/30/2021, the DON started in-service to 3-11 staff Nurses on Elopement: risk factors, assessment, interventions, care planning and communication. The DON will continue in-service until all nursing staff is provided with the education. o On 7/1/2021, the DON provided in-service to Licensed Nurses and Department heads on the facility's protocol on Initiate Situation Background Assessment Recommendation (SBAR - communication form for change of condition progress notes) related to patient trying to leave or any verbalization of wanting to leave the facility. o On 7/1/2021, the facility developed documentation guide for licensed nurses and department heads for any SBAR related to patient trying to leave or any verbalization of wanting to leave the facility including: o SBAR o Update elopement risk assessment o Start every hour monitoring of resident's whereabouts o Assess the need for a 1:1 sitter (one specific person will be assigned to remain at the resident's side to ensure safety) o Change of shift endorsement o On 7/2/2021, the DON provided one on one in service on documentation and assessments regarding Elopement to the Registered Nurse Supervisor and Charge nurse that did the Situation Background Assessment Recommendation (SBAR - communication form for change of condition progress notes) when the resident attempted to get leave the facility on June 23, 2021. o On 7/2/2021, the DON and AADM started competency skills for all Licensed Nurses on documentations and assessments related to elopement. On 7/2/2021 at 5:08 p.m., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM, AADM, and DON. Findings : 1. A review of Resident 1's Admission Record (Face sheet) indicated the facility admitted the resident on 6/20/2021 with diagnosis of alcohol dependence (A chronic disease characterized by uncontrolled drinking and preoccupation with alcohol) in remission. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/24/2021 indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 needed limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for bed mobility, transfer, walk in the room and corridor and toilet use. A review of Resident 1's Psychiatric Examination dated 6/24/2021 indicated that Resident 1 was lacking the capacity to make decision and provide for self. A review of Resident 1's Elopement Risk assessment dated [DATE] indicated the score of seven (score of less than 10 indicates a resident is not at risk for elopement). Resident 1 was assessed on the following criteria. 1. Predisposing diseases- Resident 1 scored zero (0) (nonpresent) 2. Ambulation (moving about or walking )- Resident 1 scored a two (2) (ambulatory or use of wheelchair) 3. Mental Status- Resident 1 scored one (1) (alert) 4. Medications -Resident 1 score two (2) (indicating he takes 2 or more medications) 5. Days of Residence-Resident 1 scored two (2) (meaning new admission) 6. History of elopement-Resident 1 scored zero (0) (no history) A review of Resident 1's Situation Background Assessment Recommendation (SBAR - communication form for change of condition progress notes) dated 6/23/2021 at 9:50 p.m., indicated that the resident attempted to leave the facility. It indicated that Resident 1 was wandering, confused and disoriented. The form indicated that Resident 1 stated I got lost. During a telephone interview with Licensed Vocation Nurse 1 (LVN 1) on 6/28/2021 at 4:41 p.m., LVN 1 stated that on 6/23/2021, after having been informed that the alarm for the rear gate near the parking lot had been activated, Resident 1 was found by the stairs entering the rear parking lot. LVN 1 stated she returned Resident 1 back to the facility. LVN 1 stated that Resident 1 attempted to leave one additional time on 6/23/2021, and again was found by the stairs entering the rear parking lot. LVN 1 stated she again returned Resident 1 to the facility. A record review of Resident 1's skilled nursing facility medical records indicated that there was no updated elopement risk assessment to reflect Resident 1's wandering behavior exhibited on 6/23/2021. The last elopement risk assessment form noted was dated 6/22/2021. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 6/29/2021 at 6:32 p.m., Resident 1's elopement risk assessment dated [DATE] was reviewed. RN 1 verified that the most recent elopement risk assessment for Resident 1 is dated 6/22/2021. RN 1 stated that there was no updated elopement risk assessment done for Resident 1, after the resident had two episodes of wandering behavior, and was found near the back-parking lot of the facility. RN 1 stated that an elopement risk assessment should have been completed to re-evaluate Resident 1's elopement risk on 6/23/2021. RN 1 stated he was the RN supervisor on 6/23/2021 and was informed that Resident 1 had been found outside the facility on two occasions on that day. RN 1 stated he did not complete an updated elopement risk assessment because it slipped my mind During the concurrent interview and record review with AADM on 6/30/2021 at 4:03 p.m., Resident 1's elopement risk assessment dated [DATE] was reviewed. AADM stated that had a reassessment of Resident 1's elopement risk assessment was completed as required by their policy after the resident exhibited wandering behavior on 6/23/2021, Resident 1 would have had an increased score which would then identified him as a high risk for elopement. AADM stated that they could have implemented additional interventions on Resident 1 such as placing a Wander-Guard (a device designed to activate alarms when a resident gets closer to entries and exit points). AADM stated that had Resident 1 been placed on a Wander-Guard, this could have prevented his elopement on 6/24/2021. 2. During a record review of Resident 1's short term care plan titled trying to get out of the facility, dated 6/23/2021, it indicated the goal of Resident 1 was to not go missing, and the resident will remain safe with the following interventions: 1. Monitor Resident every hour 2. Assist with activities of daily living 3. Call light withing reach 4. Reorient resident to his situation 5. Redirect resident to his bedroom During a concurrent interview and record review on 6/30/2021 at 4:50 p.m. with AADM, Resident 1's Resident Monitoring Sheet (form to document the location and of a resident each hour) dated 6/24/2021 was reviewed. It was noted that there was no documentation that hourly monitoring was conducted for Resident 1 on the following dates: 1. For 6/23/2021 No hourly monitoring was documented for 10:00 p.m. and 11:00 p.m. 2. For 6/24/2021 No hourly monitoring was documented for 12:00 a.m., 1:00 a.m. 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m., 6:00 a.m., 7:00 a.m., 4:00 p.m. and 5:00 p.m. During the interview, the AADM confirmed that there was a total of 12 missing entries out of 20 opportunities for hourly monitoring for Resident 1from 6/23/2021 to 6/24/2021.AADM stated that if it was not documented, it means staff did not conduct the hourly monitoring. A review of Resident 1's SBAR dated 6/24/2021 at 5:45 p.m., indicated that the facility staff were unable to locate Resident 1. The form indicated that staff searched around the facility but was still unable to locate Resident 1. 3. During the concurrent observation and interview with MS on 6/30/2021 at 12:12 p.m., MS was asked about the facility's main alarm system. MS stated that when the front and rear gate are opened, the facility alarm system will be activated, and a sound will be emitted to alert staff that a gate has been opened. During an observation of the outside of the facility, the front gate was opened in the presence of MS and the alarm system inside the facility did not activate. During an observation of the outside of the facility, the back gate was opened in the presence of MS, and the alarm system inside the facility did not activate. MS stated that the facility main alarm should have been activated when the rear and or the front gates were opened. MS stated that since the alarm was not activated, the facility's main alarm system was not in working condition. MS stated that it is important to ensure the facility's main alarm system is in working order for resident and staff safety. MS was asked how often the alarm system is checked to ensure working order; MS stated he checks the system monthly. When asked if he felt the frequency of checking the alarm monthly was sufficient to ensure the alarm was in working order, MS stated that he should check the alarm system more frequently. During an interview on 6/30/2021 at 4:03 p.m. with AADM, AADM stated that had the facility's main alarm system been in working order, this could have prevented the elopement of Resident 1 on 6/24/2021. During an interview on 7/2/2021 at 10:27 a.m. with AADM, AADM stated that Resident 1 is still missing and that the facility is making efforts to search for him by contacting the police department and local hospitals. A review of the facility's Policy and Procedures titled, Wandering Resident undated, indicated that the facility will identify residents who walk or wheel about unrestricted and are a threat to leave the facility unattended due to their confusion. A review of the facility's policy and procedure titled Environment of Care dated 1/27/2011 indicated that it is the policy of the facility to maintain a safe, accessible, effective, and efficient environment of care. A review of the facility's policy and procedure titled Interior Maintenance dated 1/27/2011 indicated that maintenance staff are to check door alarms to ensure they are in good working order. A review of the facility's policy and procedures titled Elopement/Missing Resident, dated 8/1/2020 indicated that resident elopement resulting in a missing resident is considered a facility emergency, Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety.

Based on observation, interview, and record review, the facility failed to practice infection control measures by: 1. Failing to ensure three of three sampled residents (Resident 75, 136, and 141) were free from serious risk of bloodborne infections (germs transmitted through human blood and can cause diseases including [CONDITION(S)] and C [a virus affecting the liver] and human immunodeficiency virus [HIV, a virus that attacks the body's immune system]) when licensed nurses failed to disinfect (clean with a chemical, to destroy bacteria) the International Normalized Ratio (INR, used to determine an effective dose of an anticoagulant [blood thinner] medication) testing device (a small portable device to measure the INR by taking a drop of blood from a finger into a test strip (strip of material used to collect blood for analysis of Prothrombin Time [PT, a blood test which measure how long it takes for a clot to form in the blood] /International Normalized Ratio [INR, a blood test used to determine an effective dose of [MEDICATION(S)], a blood thinning medication]) after using the device. 2. Failing to ensure facility staff disinfected the blood pressure cuff (a medical equipment that is wrapped around a patient's arm and then inflated in order to measure their blood pressure) between use for two of two sampled residents (Resident 16 and 37). 3. Failing to ensure facility staff observed hand hygiene prior to administering medications to one of two sampled residents (Resident 37). 4. Failing to screen for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious infection that transmits from person to person and affects the respiratory system) for one of four visitors upon entrance. 5. Failing to ensure facility staff donned (put on) a gown and gloves prior to entering the room of one of three sampled resident (Resident 386) who was on contact isolation (precautions used for residents with known or suspected infections). 6. Failing to ensure facility staff used bleach-based disinfectant wipes to disinfect medical equipment (blood pressure cuff, stethoscope, etc.) for one of three sampled resident (Resident 386) who was on contact isolation for [CONDITION(S)] (C. diff., bacteria that cause severe diarrhea and inflammation of the bowel). These deficient practices placed Residents 75, 136, and 141 at risk for serious potential harm for bloodborne infections due to their use of the shared INR testing device, placed Residents 16, 37, and 386 at increased risk for infection, and the failure of screening visitors placed staff and resident at risk for contracting and spreading COVID-19. Due to the serious potential for harm of infection with bloodborne pathogens (infectious microorganisms in human blood that can cause disease in humans) as a result of failing to disinfect the INR testing device, an Immediate Jeopardy situation (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 called on 4/9/2021 at 2:49 p.m. in the presence of the Administrator (ADM), Assistant Administrator (AADM), and Director of Nursing (DON). On 4/10/2021 at 11:48 a.m., the facility presented the Department with a Plan of Action (POA, a plan to immediately address an issue so that residents are not in danger) which included the following summarized actions: 1. Resident 136 was fully assessed by the Medical Director (MD 2) and DON. 2. Two other residents (Resident 75 and 141) who are currently admitted in the facility were identified as at risk for blood borne pathogen infection. The residents were fully assessed by MD 2 and DON. 3. System measures to prevent recurrence included discontinuing use of the INR testing device and using laboratory blood draws. Staff teaching was conducted on Disinfection of Devices and/or Equipment Use for Nursing Care. The C-diff equipment disinfecting wipes were switched from [MEDICATION(S)] (mild antiseptic [substance that stops or slows down the growth of microorganism) to bleach. 4. System changes will be monitored by DON, Infection Preventionist (IP) and Director of Staff Development (DSD). On 4/10/21 at 1:59 p.m., in a conference meeting with the ADM, the Department informed the facility that the POA was not accepted and the Immediate Jeopardy was still in effect. The Department notified the ADM that the POA needed to specify any labs in addition to the assessments. The Department notified the ADM the facility's implementation of the immediate corrective actions would need to be confirmed. On 4/12/2021 at 8:37 a.m., the facility presented a revised POA which included the following additional summarized actions: The POA included the summarized actions: 1. Resident 136 was fully assessed by the Medical Director (MD 2) and DON. 2. Two other residents at risk for blood borne pathogen infection were identified. The residents were fully assessed by MD 2 and DON. MD 2 ordered an HIV and Hepatic (liver) function lab and were drawn. 3. System measures to prevent recurrence included discontinuing use of the INR testing device and using laboratory blood draws instead. Staff teaching was conducted on Disinfection of Devices and/or Equipment Use for Nursing Care. The C-diff equipment disinfecting wipes were switched from [MEDICATION(S)] to bleach. 4. System changes will be monitored by DON, IP and DSD. On 4/12/21 at 4:54 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the ADM, AADM, and DON. Findings: 1. A review of Resident 136's Admission Record, dated 3/23/2021, indicated the facility admitted Resident 136 on 3/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 136's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/30/2021 indicated Resident 136 had no memory problems, was able to understand and make decisions. Resident 136 required one-person limited assistance with transfer, dressing, and toilet use. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 75's Minimum Data Set, dated dated [DATE] indicated Resident 75 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 75 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in skills required for daily decision making. Resident 75 required one-person limited assistance with bed mobility, transfer, and dressing. A review of Resident 75's January 2020 through April 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 75's PT/INR Testing Record indicated Resident 75's PT/INR was taken from 6/4/20 until 7/13/20 a total of 12 times. A review of Resident 141's March 2021 and April 2021 MARs indicated Resident 141 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 141's March 2021 to April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and concurrent interview with Registered Nurse 2 (RN 2) in the conference room on 4/8/21 at 3:47 p.m., RN 2 was observed demonstrating how to use the INR testing device. Observed was a visible dry brownish-red substance on the exterior of the INR testing device. When asked what the brownish-red substance on the INR testing device was, RN 2 stated that it looked like blood. RN 2 stated the device was last used on 4/8/21 at 6:00 a.m. by Registered Nurse 4 (RN 4) .RN 2 stated that the device was not disinfected after use by RN 4. When asked about disinfecting the device test strip guide (the testing slot for the INR test strip to be placed when calculating the INR value), RN 2 demonstrated the disinfection by placing an alcohol pad in the test strip guide. When asked if there was a user manual for the testing device, RN 2 stated the facility did not have one. On 4/8/2021 at 4:10 p.m., during an interview with RN 2, when asked if the cover of the test strip guide on the INR testing device should be removed prior to disinfecting, , RN 2 stated not knowing the cover could be removed. RN 2 stated he had been using the INR testing device for approximately six years but did not know the recommended procedure to use and disinfect the testing device. On 4/8/2021 at 4:22 p.m., during an interview, DSD stated that the facility uses the same INR testing device for all residents in the facility requiring PT/INR testing. DSD stated that by not disinfecting the INR testing device, it could put residents who use the device at risk of contracting a bloodborne pathogen. A review of the INR testing device User Manual found online, dated August 2016, indicated that medical staff and other persons using the INR testing device to perform tests on more than one patient must be aware that any object encountering human blood is a potential source of infection. The manual indicated that when disinfecting, one is to use a thumbnail to open the cover of the test strip guide by pressing its front edge upward and to move the cover safely away from the testing device. A cotton swab should be used with a cleaning agent to clean the easily accessible areas. A review of the facility's policy and procedure titled, PT/INR Testing, reviewed 1/27/21, the policy did not address the cleaning of the INR testing device. 2. On 4/8/2021 at 9:56 a.m., RN 5 was observed checking Resident 37's blood pressure on the left arm, without first disinfecting the blood pressure cuff. After taking the blood pressure, RN 5 removed the blood pressure cuff from Resident 37's arm, and without disinfecting it, placed it on the medication cart. On 4/8/2021, at 10:09 a.m., RN 5 proceeded to take Resident 16's blood pressure, with the same blood pressure device previously used with Resident 37. RN 5 checked Resident 16's blood pressure without disinfecting the blood pressure cuff. After completing the procedure, during an interview, RN 5 stated he should have disinfected the blood pressure cuff before and after each resident but forgot. A review of the facility's policy and procedure titled, Cleaning and Disinfecting of Blood Pressure Cuffs, dated 1/27/2021, indicated to clean the inside of the blood pressure with Environmental Protection Agency (EPA) approved disinfectant before each use for each resident. On 4/8/2021 at 12:00 p.m., during an interview, the Infection Preventionist (IP) stated that the blood pressure cuff should be disinfected between use of residents to prevent the spread of infection and cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 3. On 4/8/2021 at 10 a.m., during a concurrent observation and interview in Resident 37's room, RN 5 was observed administering medications to Resident 37 without first performing hand hygiene. RN 5 stated he was required to perform hand hygiene before and after administering medications for each resident but forgot to do it. On 4/8/2021 at 12 p.m., during an interview, IP stated licensed nurses are required to perform hand hygiene with hand sanitizer or hand washing before and after medication pass for each resident and confirmed that RN 5 should have performed hand hygiene before administering medications for Resident 37 to prevent the spread of infection and cross contamination. A review of the facility's policy and procedure titled, Hand Hygiene dated 1/27/2021, indicated to perform hand hygiene before handling medication. 4. A review of the facility's COVID-19 screening log for visitors, dated 4/4/2021, indicated one of four visitors was not screened for signs and symptoms of COVID-19. On the form it was noted that the visitor's temperature was checked, but they were no documentation that the visitor was asked if they were or were not experiencing any signs and symptoms of COVID-19 was done. On 4/8/2021 at 12:29 p.m., during a concurrent interview and record review, the IP stated the receptionist checks the temperature and screens all staff and visitors for COVID-19 symptoms and documents on a log. The IP reviewed the screening logs and confirmed that on 4/4/2021, one of four visitors did not have documentation that they were screened for signs and symptoms of COVID-19. A review of the facility's policy and procedures titled, COVID-19 Screening, dated 1/27/2021, indicated all individuals entering the building will be asked the following questions: Have you had any of the following respiratory symptoms? cough, shortness of breath Or any of these symptoms? fever, repeated shaking with chills, headache, new loss of taste or smell, diarrhea, congestion or runny nose, chills, muscle or body aches, sore throat, nausea/vomiting, fatigue. Ask if they have had a known exposure to someone with COVID-19. Check temperature and document results. Ask all healthcare personnel, including staff, if they have had exposure to other facilities with recognized COVID-19 cases. 5. A review of Resident 386's Admission Record (Face Sheet) indicated the facility admitted the resident on 9/2/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 386's MDS dated [DATE] indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired and required total care. A review of Resident 386's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diff. On 4/6/2021 at 10:23 a.m., during a concurrent observation and interview, the Central Supply Supervisor (CSS) entered Resident 386's room without putting on personal protective equipment (PPE, refers to protective clothing, helmets, gloves, face shields, goggles, facemask and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness). Resident 386's room was observed with a cart outside the room with PPEs (isolation cart) and a contact isolation signs outside the room. The CSS was asked what he should wear prior to going into a contact isolation room and he stated, I made a mistake and forgot to put on an isolation gown and gloves. On 4/8/2021 at 12:02 p.m., during an interview, the IP stated CSS should have donned (put on) an isolation gown and gloves prior to entering a contact isolation room to prevent the spread of infection. A review of the facility's policy and procedures titled, Transmission-Based Precaution dated 1/27/2021, indicated for Contact Precautions, use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens (bacterium, virus, or other microorganism that can cause disease). 6. On 4/11/2021 at 1:35 p.m., during an observation and concurrent interview with Registered Nurse 5 (RN 5) of Resident 386's isolation cart, it was noted that there were no disinfectant wipes in the cart. RN 5 was asked what type of disinfectant is to be use for medical equipment (blood pressure cuff, stethoscope, etc.) used by Resident 386 as the resident had C-diff, RN 5 was observed pulling out [MEDICATION(S)] disinfectant wipes from the medication cart. RN 5 stated that he uses the [MEDICATION(S)] disinfectant wipes for all medical equipment shared between residents. On 4/11/2021 at 3:33 p.m., during an interview, IP was asked if [MEDICATION(S)] wipes should be used on medical equipment for residents with C-diff. IP stated that [MEDICATION(S)] should not be used, and that only bleach can kill C. diff. IP stated that staff should only use wipes containing bleach for Resident 386 medical equipment as the resident has an active C. diff. infection. A review of the facility's policy and procedure titled Infection Control: [CONDITION(S)] dated 03/2015 indicated to implement infection control measures to prevent the spread of communicable disease and conditions.

Based on interview, and record review, the facility failed to administer six doses of [MEDICATION(S)] (also known by the brand name, [MEDICATION(S)], an anticoagulant [blood thinner] to prevent blood clot formation [thrombus that partially blocks the vessel] which may detach or break off [embolus] and moves through the blood vessels until it gets stuck in small vessels [embolism], it usually affects the legs, lungs, or heart) from 3/24/2021 until 3/30/2021 for one of three sampled residents (Resident 136) prescribed [MEDICATION(S)]. The deficient practice placed Resident 136 at risk for serious potential harm including [CONDITION(S)] (DVT - blood clot), pulmonary embolism (PE - blockage in a lung due to a blood clot), and stroke due to the lack of administering the anticoagulant medication for six days, in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Because of the serious potential harm of vascular complications (related to blood vessels) as a result of the deficient practice, an Immediate Jeopardy situation (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 identified and called on 4/9/2021 at 2:49 p.m., in the presence of the Administrator, Assistant Administrator, Director of Nursing (DON). On 4/12/2021, at 8:37 a.m., the facility submitted an acceptable POA which included the following summarized actions: - Resident 136 was assessed for complications, laboratory tests done. - The facility identified two other residents on [MEDICATION(S)], which were assessed, laboratory tests done, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The facility's Medical Director (MD 2) evaluated all residents taking [MEDICATION(S)]. - The DON and Director of Staff Development (DSD) conducted in-service training to licensed nurses on medication related topics. - System changes monitored by DON and results communicated to the Quality Assurance and Compliance Committee for their review. The Quality Assurance Compliance will review the results and a Performance Improvement Project (PIP, interventions to address a particular issue) for ensuring residents are free of any medication error On 4/12/2021 at 4:54 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the IJ was lifted in the presence of the Administrator, Assistant Administrator, and DON. Findings: A review of Resident 136's Admission Record, dated 3/23/2021, indicated the facility admitted Resident 136 on 3/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This increases the risk of DVT, PE and history of coronary artery bypass graft (CABG, a form of bypass surgery that can create new routes around narrowed and blocked coronary arteries). A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A typical therapeutic value is between 2 - 3 but can depend on resident-specific factors) on 3/25/2021. A review of Resident 136's MAR for 3/2021 indicated the resident did not receive [MEDICATION(S)] between 3/23/2021 and 3/29/2021. A review of the pharmacy delivery receipts indicated [MEDICATION(S)] was not delivered to the facility on [DATE] along with the other medications ordered on admission. A review of Resident 136's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/30/2021 indicated Resident 136 had no memory problems, was able to understand and make decisions. Required one-person limited assistance with transfer, dressing, and toilet use. Resident 136 used a walker to walk inside his room and hallways. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's MAR for 3/2021 indicated the INR was abnormally low on: 3/24 = 1.1 3/25 = 1.1 3/30 = 1.0 A review of Pharmacy 1's delivery receipts indicated the first delivery of Resident 136's [MEDICATION(S)] to the facility was on 3/30/2021 at 3:16 p.m. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 12 mg one time today and draw a PT/INR on 3/31/2021. A review of Resident 136's MAR for 3/31/2021 indicated the INR was 1.1. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's MAR for 4/1/2021 indicated the INR was 1.2. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's MAR for 4/2/2021 indicated the INR was 1.4. On 4/3/2021, the INR was 1.5. On 4/4/2021 Resident 136's INR was 3.0 (therapeutic range: either the dosage range or blood plasma or serum concentration usually expected to achieve desired therapeutic effects for a safe effective therapy). On 04/06/21 at 10:27 a.m., during an interview, Resident 136 stated he was admitted to the facility on [DATE] and a nurse told him the pharmacy did not deliver his [MEDICATION(S)] from 3/24/2021 until 3/30/2021. Resident 136 stated he was unaware of this since he takes many medications and staff put all his medications together in one cup. Resident 136 stated he trusted that staff were giving him all his medications. On 4/6/2021, at 12 p.m., during a review of the MAR for 03/2021 and concurrent interview, Registered Nurse 1 (RN 1) stated she did not see any initials for the [MEDICATION(S)] on the MAR for the dates 3/23/2021 through 3/29/2021, which means the [MEDICATION(S)] was not given. RN 1 stated on 3/29/2021, she was reviewing Resident 136's INR low results and notified Resident 136's Nurse Practitioner. RN 1 stated was low during the days the [MEDICATION(S)] was not given. On 4/6/2021 at 12:54 p.m., during an interview, the Administrator stated the facility had used only one pharmacy and the licensed nurses did not follow up the [MEDICATION(S)] with the pharmacy. On 4/6/2021, at 3:42 p.m., during a record review and concurrent interview, Infection Preventionist (IP) indicated Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/2021 at 4:16 p.m., during an interview and concurrent review of the MAR for 03/2021, Licensed Vocational Nurse 1 (LVN 1) stated she was Resident 136's medication nurse and worked the 3 p.m. to 11 p.m. from 3/24/2021 to 3/29/2021. LVN 1 stated she administered all of Resident 136's scheduled medications during that timeframe except for [MEDICATION(S)] because she did not see the order for [MEDICATION(S)] in the MAR. LVN 1 stated the DSD notified her of the omission error on 3/30/2021. LVN 1 stated when she checked the medication cart for Resident 136's [MEDICATION(S)] on 3/30/21, it was not present. On 4/9/2021, at 10:24 a.m., during an interview, the pharmacy's vice-president, stated on 3/23/2021, the pharmacy received the order for [MEDICATION(S)] but did not process it as a result of a human error. [MEDICATION(S)] was delivered to the facility on [DATE]. On 4/9/2021 at 10:58 a.m., during a telephone interview, Resident 136's Medical Doctor 1 (MD 1) stated Resident 136's therapeutic INR range was 2 to 3. MD 1 stated he and NP 1 were checking Resident 136's INR every day and adjusting the medication according to the INR result. MD 1 stated he was not aware Resident 136 was not receiving the [MEDICATION(S)] until 3/30/2021. During a phone interview with the facility's Medical Director 2 (MD 2) on 4/13/21 at 12:05 PM, he stated Resident 136 was at risk for developing a DVT and PE. A review of the facility's policy and procedures titled, Medication Ordering and Receiving From Pharmacy, reviewed 1/27/2021, indicated licensed nurses receive medications delivered to the facility and document the delivery was received and was secure (on the medication delivery receipt). Verify medications received and directions for use with the medication order form. Promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. Immediately delivers the medications to the appropriate secure storage area. Assures medications are incorporated into the resident's specific allocation prior to the next medication pass.