Every finding on record at The Beach Post-Acute

Based on observation, interviews, and record review, the facility failed to ensure that residents were provided with a homelike environment, as evidenced by:A. Failing to perform and document the calibration (the process of comparing a measuring instrument's readings against a known, accurate standard to check for errors) of Infrared Thermometer (IR thermometer- a thermometer that measures the surface temperature of an object from a distance without touching it) guns.B. Failing to maintain the required temperature range of 71 F (degree Fahrenheit) to 81 F in the dining room for Resident 1.C. Failing to maintain the required room temperature range of 71 F to 81 F for Resident 2.D. Failing to maintain the required temperature range of 71 F to 81 F in the hallways and in two additional residents' rooms.These failures resulted in increased discomfort for residents and could have led to dehydration (a condition in which the body loses more fluid through sweat than it replaces) and heat stroke (a life threatening emergency that occurs when the body overheats and can no longer regulate its temperature).Findings:A. During a concurrent observation and interview on 8/28/2026 at 1:47 p.m., the Maintenance Supervisor (MS) checked the conference room temperature using three IR thermometer guns. The temperature readings were as follows: IR thermometer gun #1 measured 83 F, gun #2 measured 76 F, and gun #3 measured 82.5 F. The MS stated that the reading from IR thermometer gun #2 was significantly inaccurate and was most likely not functioning properly. The MS also stated that he had not performed or documented calibration for the IR thermometer guns and explained that calibration should have been performed to ensure accurate temperature measurements.B. During a review of Resident 1's admission Record (face sheet-the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility had admitted Resident 1 on 6/18/2026 with diagnoses included dementia (a progressive state of decline in mental abilities), transient ischemic attack (a temporary blockage of blood flow to the brain), myocardial infarction (MI-heart attack), and dysphagia (difficulty swallowing).During a review of Resident 1's History and Physical (H&P), dated 6/21/2026, the H&P indicated that Resident 1 had no capacity (ability) to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 6/20/2026, the MDS indicated that Resident 1 required dependent assistance (Helper does ALL of the effort) from two or more staff for transfer, toileting hygiene, shower, dressing, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, eating.During a concurrent observation and interview on 8/28/2026 at 1:55 p.m., Resident 1 was seated in a wheelchair near a table in the dining room, and her forehead was visibly sweating. Resident 1 stated she did not want to stay in the hallway near her room because it was hotter there than in the dining room. Resident 1 stated it had been very hot since last week because the air conditioning (AC) was broken. Resident 1 stated she felt constantly thirsty because she was sweating continuously due to the heat.During a concurrent observation and interview on 8/28/2026 at 1:59 p.m., with the MS in dining room, the MS checked the temperature, and IR thermometer gun #1 measured 82.3 F, while gun #3 measured 83.2 F. The MS stated that the temperature should have been maintained between 71 F and 81 F and stated that the readings were above the required temperature range.C. During a review of Resident 2's admission Record, the admission Record indicated the facility had admitted Resident 2 on 5/27/2015 with diagnoses included dysphagia (difficulty swallowing), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), left side breast cancer, and Central pontine myelinolysis (a serious brain condition where the protective insulation around nerve cells in a specific part of the brainstem is damaged).During a review of Resident 2's History and Physical (H&P), dated 5/24/2026, the H&P indicated that Resident 2 had the capacity (ability) to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated that Resident 2 required moderate assistance (Helper does less than half the effort) from one staff for hygiene, shower, toilet transfer, shower transfer, supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for chair to bed transfer, and independent bed mobility.During a concurrent observation and interview on 8/28/2026 at 2:10 p.m., Resident 2 was in her room, seated in a wheelchair in front of a fan that was positioned on the bedside table. Resident 2's lips appeared dry and chapped. Resident 2 stated that her room had been very hot since the AC was broken. Resident 2 stated she could not drink water because she had swallowing problems and received hydration through a gastrostomy tube (G tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). Resident 2 stated she had not been able to sleep well due to the heat.During a concurrent observation and interview on 8/28/2026 at 2:15 p.m., with the MS in Resident 2's room, the MS checked the temperature. IR thermometer gun #1 measured 84 F, and gun #3 measured 85.1 F. The MS stated that the temperature should have been maintained between 71 F and 81 F and stated that the readings were above the required temperature range.D. During a concurrent observation and interview on 8/28/2026 at 2:25 p.m., the MS obtained additional temperature readings from two more residents' rooms and five hallways. The results were as follows:a. Hallway #1: IR gun #1 measured 84.2 F, and gun #3 measured 84.3 F.b. Hallway #2: IR gun #1 measured 81.5 F, and gun #3 measured 82.5 F.c. Hallway #3: IR gun #1 measured 81.5 F, and gun #3 measured 81.7 F.d. Hallway #4: IR gun #1 measured 83.9 F, and gun #3 measured 84.9 F.e. Hallway #5: IR gun #1 measured 84 F, and gun #3 measured 85 F.f. Resident room [ROOM NUMBER]: IR gun #1 measured 85 F, and gun #3 measured 85.1 F.g. Resident room [ROOM NUMBER]: IR gun #1 measured 84 F, and gun #3 measured 85.2 F.The MS stated that two additional residents' rooms and all five hallways were above the required temperature range. The MS stated this temperature readings were concerning because they would greatly affect the residents' comfort level.During an interview on 8/28/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated that residents' room and building temperatures should be maintained between 71 F and 81 F according to the facility's policy and Federal regulation to keep residents comfortable and safe. The DON stated that if the temperature rose above the required range, residents might become dehydrated and suffer heat stroke. The DON stated that the facility was in the process of repairing the AC to prevent these outcomes.During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life - Homelike Environment, revised 5/2017, the P&P indicated, Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: h. Comfortable and safe temperatures (71 f - 81 f).

Based on interview and record review the facility failed to ensure one of five sampled residents, Resident (5) was permitted to return to the facility. The facility failed to:1.Readmit Resident 1 to the facility after Resident 5 was evaluated and cleared by general acute care hospital (IGACH) to return to the facility on [DATE].2.Implement facility's policy and procedure (P&P) titled, Bed-Holds (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) and Returns, dated 10/2022, which indicated residents who seek to return to the facility after the state bed-hold period has expired are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room.3. Ensure Resident 5 received the required bed hold policy and notification form at the time of his transfer on [DATE] to general acute care hospital (GACH).These deficient practices resulted in Resident 5 being denied the opportunity to return to the facility he had called home for four years and placed him at risk for emotional distress, disrupted continuity of care, delayed treatment and services, unsafe discharge placement, decline in physical and psychosocial well being, and potential homelessness. Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 with diagnoses including paraplegia (paralysis of two limbs), and depression (persistent feelings of sadness, emptiness, and a loss of interest in activities).During a review of Resident 5's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set ([MDS], resident assessment tool), dated [DATE], the MDS indicated, Resident 5 was dependent (helper does all of the effort) for toileting and lower body dressing.During a review of Resident 5's Physician Order, dated [DATE], the Physician Order indicated, transfer Resident 5 to the hospital due to resistance while re-inserting foley catheter (medical device that helps drain urine from the bladder).During a telephone interview on [DATE] at 9:30 a.m., with the Director of Marketing and admission (DMA), the DMA stated she oversees readmissions at the facility. The DMA stated the GACH did not directly inform her that Resident 5 was cleared for discharge, and communication occurred instead between the GACH and the facility Admissions Coordinator. The DMA stated she met Resident 5 at his bedside at the GACH on [DATE]. She informed him that his bed hold had ended and that, if he returned to the facility, he would need to be readmitted to another room because the Maintenance Supervisor (MS) was performing repairs in his original room. She also told Resident 5 he would need a roommate if he returned. The DMA stated, Resident 5 became upset and began verbally threatening her. The DMA stated she explained the resident's admission rights to him, including his right to be readmitted to the facility and to his original room or the first available room, as the facility was considered his home. She stated there were available beds but not the resident's original room. The DMA stated the facility did not routinely review the census or bed availability at the time of readmissions. The DMA stated the facility did not assist Resident 5 with returning to the facility or locating another facility. She also stated she did not know the facility's responsibilities regarding a hospitalized resident's return once medically cleared. The DMA stated she did not have an opinion about the potential effects on a resident when readmission was delayed or denied.During a concurrent interview and record review on [DATE] at 9:55 a.m., with the Maintenance Supervisor (MS), reviewed MS facility text messages from April and [DATE]. The text messages did not show any repair requests for Resident 5's room. The MS stated he handles all building repairs and the facility notifies him of needed repairs by text messages. The MS stated he does not keep a log, as all requests come through text. The MS stated he repaired the television and call light in Resident 5's room approximately three weeks ago and completed the repairs on the same day.During a concurrent interview and record review on [DATE] at 10:40 a.m., with the Director of Nursing (DON), reviewed the Facility Census dated [DATE], [DATE], and [DATE]. The census indicated Resident 5's room was available. The DON stated that room availability existed when Resident 5 was cleared for discharge from the GACH on [DATE]. The DON stated Resident 5 did not have a roommate before his transfer to the GACH due to prior incompatibility concerns. She reported Resident 5 had a previous altercation with a former roommate, which occurred approximately two years ago. The DON stated Resident 5 had also exhibited aggressive behaviors toward other residents in the past. The DON stated Resident 5 was transferred to the GACH on [DATE] because his foley catheter was dislodged and staff were unable to reinsert it. The DON stated when a resident was transferred to the GACH, the facility initiates the bed hold process and provides the resident and/or resident representative with the required transfer and bed hold documentation. She stated that the resident or representative is asked to sign forms acknowledging the transfer, bed hold status, and readmission rights. She also stated once the bed hold period expires, the resident may return to the next available appropriate bed, which may not be the original room. The DON stated there were no male/female bed restrictions, isolation requirements, or other barriers that would have affected Resident 5's readmission. She stated that the attending physician and Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) were not involved in the decision regarding Resident 5's readmission. The DON stated the facility did not issue Resident 5 the required bed hold policy and notification form at the time of transfer and was unable to explain why the documentation was not provided. She stated if a resident was unable to return to the facility after hospitalization, the resident could experience emotional distress, confusion, and disruption in continuity of care, which could lead to a decline in physical and psychosocial well being.During a review of the facility's P&P titled, Bed-Holds and Returns, dated 10/2022, the P&P indicated, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provide that the resident: a. still requires the services provided by the facility; and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services.

Based on interview and record review, the facility failed to provide supervision and assistance to prevent accidents for one of one residents reviewed for falls (Resident 1). The facility failed to:1. Ensure Resident 1 who was assessed as high fall risk and needs substantial/ maximal assistance with ambulation received assistance during ambulation on 3/19/2026 and 3/21/2026.This failure resulted in two unwitnessed falls in the hallway, including one fall causing a right elbow laceration, and placed Resident 1 at further risk for injury.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated Resident 1 with diagnoses of but not limited to abnormalities of the gait, and mobility, abnormal posture, end stage renal disease, (ESRD-irreversible kidney failure) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Morse Fall Assessment (a tool used for healthcare professionals to assess a patient's risk of falling) dated 3/6/2026, the Morse Fall Assessment indicated Resident 1 had a prior history of falls, used a walker a assistive device), and was unable to ambulate without assistance. Resident 1's Fall Score was 85 ( a score greater than of 45 indicating a high risk for falls).During a review of Resident 1's History and Physical (H&P), dated 3/09/2026, the H&P indicated Resident 1 had the capacity to make decisions for herself. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 1 needed substantial to maximal assistance (helper does more than half the effort) with walking at least 10 feet in a room, corridor or small space, transferring, sitting, and standing. During a review of Resident 1's Care Plan, dated 3/7/2026, the Care Plan titled Resident 1's physical mobility related to unsteady gait and use of a rollator walker (a four-wheeled mobility aid designed to help users walk safely while offering resting options)indicated a focus for Resident 1's physical mobility related to unsteady gait and use of a rollator walker (a four-wheeled mobility aid with handlebars, brakes, and a seat, designed to help users walk safely while offering resting options). The Care plan indicated interventions to provide supportive care, assistance with mobility as needed. The Care Plan indicated a goal for Resident 1 was to remain free of complications related to immobility, including contractures (a stiffening/shortening at any joint), thrombus formation (the creation of a blood clot), skin breakdown, fall related injury through next review date (6/5/2026).During a review of Resident 1's Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Fall Progress Notes, dated 3/20/2026, the IDT-Fall Progress Notes indicated Resident 1 had a witnessed fall in Station 2's hallway. The IDT-Fall Progress Notes indicated Resident 1 was seen ambulating with her rollator-walker in the hallway, lost her balance and fell on the ground on her right side. The IDT-Fall Progress Notes indicated Resident 1 sustained a right inner elbow superficial laceration measures 0.1 centimeters by 1.1 centimeters with minimal bleeding. The IDT-Fall Progress Notes indicated Resident 1 complained of right arm pain. The IDT-Fall Progress Notes indicated Resident 1 refused pain management, appeared confused and stated a desire to go home. The Notes indicated Resident 1 was left untouched on the ground until paramedics arrived. The IDT-Fall Progress Notes indicated due to Resident 1 increased confusion and attempt to exit in haste caused Resident 1 to lose balance and fall on her right side. The IDT-Fall Progress Notes indicated Resident 1 had a history of falls and gait and balance deficits. The Notes indicated Resident 1 had immediate interventions for the Falling Star Program (immediate identification and heightened monitoring for residents at the highest risk for falls), fall risk identifiers on the door and above the bed, referral to physical therapy (PT- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) for fall management, continued physical therapy and occupational therapy (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) with a focus on fall management.During an interview on 4/2/2026 at 2:09 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 experienced periods of confusion, needed assistance with walking, had weakness, and was a high fall risk. LVN 1 stated Resident 1 had an unwitnessed fall in the hallway on 3/19/2026 and a second unwitnessed fall in the hallway on 3/21/2026. LVN 1 stated Resident 1 could ambulate with a walker only when staff provided supervision. LVN 1 stated Resident 1's falls could have been avoided with proper supervision and a one-on-one sitter (continuous supervision for a resident to prevent falls, self harm, or disruption of medical devices).During an interview on 4/6/2026 at 11:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1 on 3/21/2026. CNA 1 stated Resident 1 fell while using her walker and was found on the floor. CNA 1 stated the last time she saw Resident 1 on 3/21/2026 was at 9:00 p.m., when Resident 1 was walking in the hallway with her walker unassisted. CNA 1 stated Resident 1 was a high fall risk but did not assist her because she believed Resident 1 was fine walking without any help. CNA 1 stated Resident 1 remained at high risk for falls and injury, had been injured in a previous fall, Resident 1 should have assistance with walking.During an interview on 4/6/2026 at 11:33 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 1 fell in the hallway on 3/19/2026 and sustained a right elbow laceration. RNS 1 stated Resident 1 had a history of falls, used a walker, and had a weak gait. RNS 1 stated Resident 1's fall assessment score was 85 ( a score greater than of 45 indicating a high risk for falls) and the facility initiated the falling star program and visual checks to ensure Resident 1 was in bed. RNS 1 stated when staff saw Resident 1 ambulating in the hallway, they were expected to ask what she needed and encourage her to return to her room for safety and to avoid walking without assistance. RNS 1 stated CNA 1 should have assisted Resident 1 with walking on 3/21/2026 and that the fall could have been avoided.During an interview on 4/6/2026 at 12:06 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had impaired mobility and fell walking alone in the hallway. The DON stated the fall was avoidable and CNA 1 should have been watching Resident 1 while walking in the hallway. The DON stated CNA 1 should have notified the licensed nurses' that Resident 1 was walking in the hallway alone.During a review of the facility's policy and Procedure (P&P), titled Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) did not miss her hemodialysis ([HD] a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatments as ordered and failed to implement Resident 1's care plan which included monitoring Resident 1 for changes in level of consciousness, abnormal vital signs (essential measurements taken by the healthcare team providers to check the body's most basic and life sustaining functions), heart and lung sounds, edema (swelling caused by excess fluid building up in the body's tissues). These failures resulted in Resident 1 presenting to the dialysis center on 2/16/2026 with facial and generalized body edema. Resident 1 was above the prescribed target weight of 63 kilograms ([kg] metric unit of measurement for mass/weight), weighing 74 kilograms. These failures had the potential for Resident 1 to have pulmonary edema (excess fluid buildup in the lungs, making it difficult to breathe), hypertension ([HTN] high blood pressure, hyperkalemia (a condition in which the level of potassium in the blood is higher than normal), irregular heartbeat, and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including joint (where to or more bones meet) replacement surgery (a procedure in which a surgeon removes the damaged parts of a joint and replaces them with an artificial joint) and end stage renal disease ([ESRD] irreversible kidney failure) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/kidneys have failed).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/25/2026, the MDS indicated Resident 1 was able make decisions that were reasonable and consistent and required partial/moderate assistance (helper does less than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance) for her Activities of Daily Living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's Order Summary Report (Physician's Orders) dated 3/9/2026, the Physician's Orders indicated an order was placed for Resident 1 to receive hemodialysis on Monday, Wednesday and Friday scheduled at 7:40 a.m. with a transportation pick up at 7:30 a.m., ordered on 2/12/2026.During a review of Resident 1's untiled Care Plan dated 2/13/2026, the Care Plan indicated Resident 1 needed dialysis related to ESRD with goals including Resident 1 will have no signs and symptoms of complications related to fluid overload and will maintain a normal weight. The Care Plan's interventions included Resident 1 was to receive HD every Monday, Wednesday, and Friday and monitor Resident 1 for change of condition including changes in level of consciousness, vital signs, heart and lung sounds, edema (swelling caused by excess fluid trapped in the body's tissues) and reporting to the primary care physician.During a review of Resident 1's Clinical Records for 2/2026, there was no documentation indicating Resident 1 was dialyzed on 2/13/2026 and 2/14/2026. There was no documentation indicating License Nurses identified, monitored, and/or assessed Resident 1 for complications related to missed HD treatments on 2/13/2026 and 2/14/2026. During a telephone interview on 3/4/2026 at 9:55 a.m., Resident 1's Emergency Contact (EC) 1 stated Resident 1 was scheduled for HD on 2/13/2026 but missed the treatment because transportation did not pick her up. EC 1 stated the dialysis center scheduled an additional treatment 2/14/2026, which was also missed due to the same transportation issue. EC 1 stated she was concerned Resident 1 would retain excess fluids because Resident 1's kidneys were no longer functioning on their own.During an interview and concurrent record review on 3/6/2026 at 3:25 p.m., Registered Nurse Supervisor (RNS) 1 stated when Resident 1 was admitted on [DATE], the Admissions Coordinator (AC) informed her that Resident 1's HD appointment and transportation had been arranged. RNS 1 stated on 2/13/2026 during the 7a.m. to 3 p.m. shift, Resident 1 informed her that she missed her HD appointment because transportation had not been arranged. RNS 1 confirmed she did not assess or monitor Resident 1 for a change of condition after the missed treatment. RNS 1 stated she should have assessed Resident 1, notified the primary physician, and initiated monitoring Resident 1 to identify any worsening condition or potential complications related to the missed HD. RNS 1 stated she could not remember whether another HD treatment had been scheduled for that day or the following day.During an interview on 3/6/2026 at 4:05 p.m., the Dialysis Clinical Coordinator (DCC) stated Resident 1 missed the HD treatment on 2/13/2026 and extra day of treatment on 2/14/2026. The DCC stated on 2/16/2026, during a pre-dialysis assessment, Resident 1 was assessed with facial and generalized body edema and was over her target weight of 63 kg. The DCC stated Resident 1 weighed 74 kg (11 kg over her target weight). During an interview on 3/6/2026 at 4:44 p.m., the Admissions Coordinator (AC) stated prior to admitting Resident 1 to the facility she was informed by Resident 1's insurance case manager that Resident 1's HD and transportation were approved and arranged. The AC stated she should have confirmed Resident 1's pick up time with the transportation company to prevent Resident 1 from missing HD treatment.During an interview on 3/9/2026 at 9:30 a.m., the Case Manager (CM) stated she was able to confirm Resident 1's transportation on 2/13/2026 and had arranged an extra day of HD treatment for Resident 1 on 2/14/2026 at 1:45 p.m. with transportation pick up time at 12:30 p.m. The CM stated she informed RNS 1 of the HD and pick up time. The CM stated she documented it on the facility's communication board, so all staff were informed of Resident 1's HD appointment.During a telephone interview on 3/9/2026 at 10:42 a.m. RNS 4 stated she worked on 2/14/2026 at 7 a.m. to 3 p.m. shift but did not receive an endorsement from the outgoing shift on 2/13/2026 11 p.m. to 7 a.m. shift nor saw any notes on the communication board indicating Resident 1 had an appointment for HD that day. During an interview and concurrent record review on 3/9/2026 at 12:27 p.m., RNS 2 stated she worked on 2/13/2026 at 3 p.m. to 11 p.m. shift and was aware of Resident 1's extra HD treatment on 2/14/2026 and she endorsed this information to the licensed nurse assigned to Resident 1 on 2/13/2026 at 11p.m. to 7 a.m. shift. RNS 2 stated on 2/14/2026 at 3 p.m. to 11 p.m. shift, the family of Resident 1 (EC1) informed her that Resident 1 missed HD that day due to transportation not being available. RNS 2 stated and confirmed Resident 2 was not on any monitoring despite missing two hemodialysis appointments, no specific plan of care formulated for the missed hemodialysis nor was the primary physician notified. RNS 2 stated it was the responsibility of the licensed nurses to inform the primary physician and monitor Resident 1 for worsening of her condition. During an interview on 3/9/2026 at 1:19 p.m., the Director of Nursing (DON) stated Resident 1's HD schedule and transportation should have been confirmed and followed up by the AC and the CM to ensure smooth transition from the hospital to the facility to prevent missed opportunities for hemodialysis treatment. The DON stated the licensed nurses assigned to Resident 1's care should have initiated a change of condition and/or monitoring for Resident 1 when she initially missed her hemodialysis appointment on 2/13/2026 and continue monitoring, documenting Resident 1's progress for 72 hours and formulate a plan of care. The DON stated the licensed nurse should have called Resident 1's primary care physician when she missed her hemodialysis appointments to prevent delay of her care needs, should any complications arise.During a review of the facility's policy and procedure (P&P) titled, Transportation, Social Services, revised 12/2008, the P&P indicated the facility shall help arrange the residents' transportation as needed.During a review of the facility's P&P titled, End-Stage Renal Disease, Care of a Resident with, revised 9/2010, the P&P indicated the residents of the facility with ESRD shall be cared for according to the recognized standards of care. The P&P indicated the licensed nursing staff of the facility shall be trained to care for residents with ESRD and shall be able to recognize signs and symptoms of worsening condition and/or complications of ESRD.During a review of the facility's P&P titled, Change in a Resident's Condition or Status revised 5/2017, the P&P indicated the facility licensed nursing staff shall make detailed observation and gather relevant and pertinent information including information prompted by the Interact SBAR Communication and shall promptly notify the attending physician of any changes in the residents' medical and mental condition and/or status and any changes in their medical care or nursing treatments. The P&P indicated the licensed nurses of the facility shall record in the residents' medical record information relative to changes in the residents' medical/mental condition and such documentation of the change of condition shall include the following, but not limited to:a. documenting for at least 72 hours or longer if change of condition warrantsb. documenting of vital signs each shiftc. evident care pland. interdisciplinary meeting as needede. reassessment of the resident condition as neededf. COC and/ or SBAR will be completed as indicated.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was experiencing pain, pain level (an eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) was accurately documented by Licensed Vocational Nurse (LVN) 1. This deficient practice resulted in Resident 1's pain level not being identified and had the potential for delayed pain relief and impaired communication among facility staff.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including joint (where to or more bones meet) replacement surgery (a procedure in which a surgeon removes the damaged parts of a joint and replaces them with an artificial joint) and end stage renal disease ([ESRD] irreversible kidney failure) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/kidneys have failed).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/25/2026, the MDS indicated Resident 1 was able make decisions that were reasonable and consistent and required partial/moderate assistance (helper does less than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance) for her Activities of Daily Living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's Order Summary Report (Physician's Orders) dated 3/9/2026, indicated Resident 1 had the following orders:1. Assess Resident 1's pain level every shift, ordered on 2/12/2026.2. Hydrocodone-Acetaminophen (an opioid prescribed and used to relieve moderate to severe pain) 5/325 milligrams ([mg]a unit of mass of one thousandth of a gram, used in medicine) one tablet by mouth every four hours as needed for moderate pain (pain level from 4 to 6) and severe pain (pain level from 7 to 10), ordered on 2/13/2026.During a review of Resident 1's untitled Care Plan dated 2/13/2026, the Care Plan indicated Resident 1 was at risk for adverse consequences related to use of opioids (strong pain-relief medications that work by blocking pain signals in the brain and body) related to left hip hemiarthroplasty (a surgery where only one part of a joint, usually the ball of the hip is replaced with an artificial implant) with goals including Resident 1's pain will be managed. The Care Plan's interventions indicated assessing and monitoring Resident 1's pain level every shift and addressing Resident 1's choices in managing her pain.During a review of Resident 1's Weights and Vitals Summary ([vital signs] basic measurements that show how well the body is working, such as temperature, pulse, breathing rate, and blood pressure) dated 2/15/2026 and timed at 9:19 a.m., the Weight and Vitals Summary indicated Resident 1's blood pressure (a measure of the force that your heart uses to pump blood around your body) was 94/60 millimeters of mercury ([mmHg] a standard unit of measurement for pressure specifically for blood pressure) and a heart rate (the number of times the heart beats per minute to pump blood throughout the body) of 70 beats per minute.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) dated 2/2026, the MAR indicated Resident 1's pain level was to be monitored every shift. The MAR indicated Resident 1 had a recorded pain level of 3 on 2/15/2026 during the day shift.During a review of Resident 1's MAR dated 2/2026, the MAR indicated Resident 1 was to receive Hydrocodone-Acetaminophen 5/325 mg one tablet by mouth every four hours as needed for moderate pain (pain level 4-6) and severe pain (pain level 7-10). The MAR indicated Resident 1 received one tablet of Hydrocodone-Acetaminophen 5/325 on 2/15/2026 at 11:01 a.m.During a telephone interview on 3/4/2026 at 10:35 a.m., Resident 1 stated one morning, a few hours after breakfast (unable to specify the date and time) she informed LVN 1 that her pain was getting worse, but LVN 1 did not pay attention to her. Resident 1 stated LVN 1 was standing by her door and did not ask any questions about her pain, so she decided to call her family member because the pain was starting to make her anxious. During a concurrent interview and record review on 3/6/2026 at 1:20 p.m., LVN 1 stated and confirmed she checked Resident 1's vital signs at the start of the shift (7 a.m. to 3 p.m.) on 2/15/2026 at 9:17 a.m. but she did not document Resident 1's pain level with the vital signs. LVN 1 stated she identified Resident 1's pain level at a 6 at around 11 a.m. on 2/15/2026 but she did not document Resident 1's pain level in the medical records at that time. LVN 1 stated she administered Hydrocodone-Acetaminophen 5/325 mg one tablet by mouth to Resident 1 on 2/15/2026 at 11:01 a.m. LVN 1 stated should have documented Resident 1's complete and accurate vital signs in the medical record and should have documented Resident 1's accurate/updated/latest pain level during the shift to depict and/or track Resident 1's condition and well-being.During a concurrent interview and record review on 3/9/2026 at 1:19 p.m., the Director of Nursing (DON) stated LVN 1 should have documented the complete vital signs for Resident 1 in the medical record and should have updated and recorded Resident 1's accurate pain level during the shift to reflect the accurate condition of Resident 1 and to ensure continuity of her care. The DON stated it was the responsibility of all licensed nurses to accurately identify the residents' pain level before administering pain medication to ensure provision of the appropriate medication with a goal to relieve the residents from pain and prevent delay of care and services.During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 3/2020, the P&P indicated the facility, and its staff shall identify pain in the residents by the following, but not limited to:a. assessing the potential for painb. recognizing the presence of painc. identifying the characteristics of paind. addressing the underlying causes of [NAME]. identifying and using specific strategies for different levels and sources of painf. monitoring the effectiveness of interventions and modifying as necessary, andg. documenting the residents' reported level of pain with adequate detail to gauge the status of pain and the effectiveness of intervention for pain as necessary and in accordance with the pain management.

Based on observation, interview, and record review, the facility failed to ensure they were free from roaches. This deficient practice resulted in a report of roaches in one of three sampled residents' (Resident 1) room, and observations of live and dead roaches in the facility's staff breakroom. This deficient practice had the potential for a roach infestation to occur affecting residents' health and wellbeing.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had a diagnosis of anoxic brain damage (when the brain is completely deprived of oxygen causing cell death). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/16/2025 the MDS indicated Resident 1's cognition was moderately impaired. Resident 1 was dependent (helper does all the effort) on staff for toilet hygiene, shower/bath, lower body dressing and needed partial/moderate assistance with eating and oral hygiene. During a tour of the facility on 2/20/2026 at 2 p.m., two large dead roaches were observed on the floor behind the facility's water dispenser, and a live cockroach was observed crawling from under the water machine in the nurse's breakroom. Certified Nursing Assistant (CNA) 4, who was present in the breakroom when the roaches were observed, stated we've had an ongoing problem with roaches for a while. During an observation on 2/20/2026 at 2:05 p.m., in the staff's breakroom, a roach was observed crawling from underneath the refrigerator and Housekeeper (HS) 1, who was present in the breakroom, stepped on the roach. HS 1 stated when she sees a roach, she steps on it, reports it to her supervisor, who gives her a pesticide (a chemical or biological substance designed to prevent, destroy, repel, or mitigate [make less severe] pest) spray to use on the roach. HS 1 stated roaches carry germs, and they should not be in the breakroom because they can spread to the resident's room. During an interview on 2/20/2026 at 1:07 p.m., Resident 1 stated three weeks ago (exact day unknown) he saw a couple of big roaches crawling across the wall in his room. Resident 1 stated he told the Maintenance Supervisor (MS) who sprayed his room. Resident 1 stated cockroaches were nasty, and he did not want them in his room. During an interview on 2/20/2026 at 2:15 p.m., CNA 1 stated she sees roaches daily while she is eating lunch and has reported this to the MS. During an interview on 2/20/2026 at 3 p.m., HS 2 stated the nurses told her about the roaches in the breakroom, she stated, she reported it the MS and was instructed by him to clean the breakroom and spray insecticide (a substance used to kill insects). During an interview on 2/20/2026 at 3:30 p.m., the MS stated the nurses reported to him there were roaches in the breakroom two weeks ago (exact date unknown) and he sprayed the breakroom with an insecticide until he could call the pest control company (2/13/2026), that services the facility monthly and more frequently if needed. The MS stated he did not see any evidence of roaches in resident's rooms but knew there was a problem in the nurses' breakroom. The MS stated when the Pest Control Company came to the facility, their report indicated there was no pest activity found. The MS stated it was important to call the Pest Control Company when there was a report of pest because if there were roaches in one area of the facility, they could spread to the kitchen and residents' room and roaches carry germs. During an interview on 2/20/026 at 4:15 p.m., the Administrator (ADM) stated he was not aware there were roaches in the breakroom, but it was important to eliminate roaches from the facility due to germs they carry that could affect the residents health. During a review of the facility's Policy and Procedures (P&P) titled Pest Control dated 5/2008, the P&P indicated, the facility maintains an ongoing pest control program to ensure the building is free of insects and rodents.

Based on observation and interview, the facility failed to maintain and observe infection control practices by failing to:1.Ensure Certified Nurse Assistant (CNA) 2 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with fixing linens for Resident 41 which required direct contact with Resident 41 who was on Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one of more classes of antimicrobial agents}).2.Ensure the oxygen tubing was changed and dated for Resident 42.3.Ensure the intravenous (IV- administering fluids, medications, or nutrients directly into a vein using a needle or tube) site was changed and dated for Resident 47.4.Ensure CNA 2 performed hand hygiene when passing meal trays.These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.Findings:1.During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cerebral infarction (loss of blood flow to a part of the brain).During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 41's cognition (ability to think, understand, learn, and remember) was severely impaired and required maximal assistance (helper does more than half the effort with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a concurrent observation and interview on 2/10/2026 at 11:48 a.m., with CNA 2, CNA 2 was observed entering Resident 41's room who was on EBP, to fix her linens but did not put on a gown or gloves. CNA 2 stated she should have put on a gown and gloves to prevent the spread of infection. 2.During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure (CHF- a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42's cognition was intact and required moderate assistance (helper does less than half the effort) with ADLs.During an observation and interview on 2/10/2026 at 9:52 a.m., with Licensed Vocational Nurse (LVN) 1, it was observed Resident 42's oxygen tubing was not labeled or dated. LVN 1 stated there was no way of telling when the tubing was changed and it should have been labeled so the staff were aware of when it needed to be changed. LVN 1 stated it was important to label and date the tubing for infection control and prevent the resident from getting sick.3.During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscle rigidity, and slow, imprecise movement) and rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility).During a review of Resident 47's MDS dated [DATE], the MDS indicated Resident 47's cognition was intact and required maximal assistance with ADLs.During a concurrent observation and interview on 2/10/2026 at 10:09 a.m., with Registered Nurse Supervisor (RNS) 1, observed Resident 47's IV site was dated 1/9/2026. RNS 1 stated he changed it the day before and put the wrong date. When asked if he could show me the documentation that the IV site was changed, RNS 1 stated he did not document that he changed Resident 47's IV site but should have. RNS 1 stated it was important to document and change the IV site every three days to prevent an infection from developing.4.During an observation and interview on 2/10/2026 at 11:48 a.m., with CNA 2, CNA 2 was observed passing out lunch trays to the residents without performing hand hygiene in between residents. CNA 2 stated she should have performed hand hygiene to prevent the residents from getting sick, prevent the spread of germs to the residents, and for infection control.During an interview on 2/11/2026 at 11:20 a.m., with the Infection Prevention Nurse (IPN), the IPN stated gown and gloves should be worn when fixing linens for residents on EBP to prevent the spread of infection because the resident may have an open wound or an indwelling device (an object that is inserted and left inside the body for a period of time). The IPN stated hand hygiene should be performed between residents when passing meal trays to prevent the spread of infection. The IPN stated oxygen tubing should be change weekly with a label and date, so the staff are aware of when it was changed and to prevent the residents from developing an infection.During an interview on 2/12/2026 at 1:23 p.m., with the Director of Nursing (DON), the DON stated hand hygiene should be performed between residents when passing meal trays for the safety of the residents, for the prevention of spreading germs, and for infection control. The DON stated IV sites should be documented, labeled, and dated because the IV goes directly into the resident and could cause an infection if not changed. The DON stated when a resident was on EBP and staff were going in to fix their linens, gown and gloves must be worn for infection control. The DON stated oxygen tubing should be changed weekly and must be labeled and dated, not doing so endanger the resident if the tubing was used for too long.During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and gloves use during high contact resident care activity. Examples of high-contact resident care activities include changing linens.During a review of the facility's P&P titled, Departmental (Respiratory Therapy)- Prevention of Infection, dated 11/2011, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks. [NAME] water bottle with date and initials upon opening.During a review of the facility's P&P titled, Peripheral and Midline IV Catheter Flushing and Locking, dated 6/2025, the P&P indicated, Document procedure in treatment and administration record. Note location of the catheter, condition of the insertion site, and dressing in nurse's notes.During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of infection. Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: before and after eating or handling food and before and after assisting a resident with meals.

Based on interview and record review, the facility failed to ensure an annual competency assessment (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks for one of three employees (Registered Nurse Supervisor) were performed every year.This deficient practice had the potential for the facility not able to assess the skills, knowledge, training, and certification necessary to provide nursing services to assure resident safety and adequate resident care.Findings:During a record review on 02/11/2026 at 1:38 p.m. with the Director of Staff Development (DSD), there were no records of annual competency training that was done in employee file for RNS 1 for 2025. RNS1 was hired in 2022 as an Licensed Vocational Nurse (LVN) and was hired as RN in 2024 working day shift.During a follow up interview on 02/11/2026 at 3:27 pm with the DSD, The DSD stated it was very important to perform competency evaluation annually to know if staff are competent enough to perform their duties to help the residents. The DSD stated she will make sure employee files were updated, and track training hours needed to be completed. The DSD stated she was still working on developing a process to audit the files and catch up on required reviews because she had only begun working as the DSD in April 2025.During an interview on 2/12/26 at 12:36 p.m. with RNS 1, RNS 1 stated it was important to perform competency training to ensure staff understand their duties. RNS 1 stated she was supposed to be evaluated annually to determine if she remained competent and to receive refresher training to support resident care. RNS 1 stated that performance evaluations help improve staff skills and promote resident safety.During an interview on 02/13/26 at 8:52 a.m. with the Director of Nursing (DON), the DON stated she recognized she had not completed all required competencies and was currently working on updating all licensed staff competency evaluations. The DON stated she had not yet reached RNS 1's file. The DON stated annual skills competency evaluations and all required training must be completed for RNS 1 and all staff. The DON stated staff competency was very important to ensure staff skills were improved, residents remain safe, and staff understand how to properly perform their duties.During a review of the facility's policy and procedure (P&P), titled Staffing, Sufficient and Competent Nursing revised 08/2022, the P&P indicated Facility provides staff with the appropriate skills and competency necessary to provide nursing and related care and service for all residents.

Based on interview and record review the facility failed to ensure that a binding arbitration agreement (out-of-court process where a neutral third party hears a dispute and makes a final, legally binding decision) was explained in a form and manner that the resident's representative ([RR]- an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident) could understand prior to obtaining a signature for one of three resident's (Resident 15).This failure had the potential to result in the resident or resident representative unknowingly waiving the right to pursue disputes through the judicial system, thereby limiting legal rights and protections.Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).During a review of Resident 15's Minimum Data Set (MDS a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 15's cognition (ability to think, understand, learn, and remember) was severely impaired and required substantial/maximal assistance (helper does more than half the effort) with toileting, bathing, and dressing.During a review of Resident 15's Care Plan dated 12/2025, the Care Plan indicated, Resident has impaired cognitive function/dementia or impaired thought processes related to dementia, psychotropic drug use.During an interview on 2/12/2026 at 9:18 a.m. with Resident 15, Resident 15 was alert, and was able to state his name. Resident 15 was unable to state the month, day, or year. Resident 15 stated that he does not recall being informed upon admission that he was required to sign any documents related to legal disputes or arbitration. Resident 15 stated that he does not know what a binding arbitration agreement was.During a review of Resident 15's Arbitration Agreement, dated December 2025, the Arbitration Agreement indicated, an electronic signature by the resident representative. During an interview on 2/12/2026 at 10:20 a.m. with the Resident Representative (RR), the RR stated she was never informed about any binding arbitration agreement. The RR stated she did not know what a binding arbitration agreement was. She stated at the time of admission, she signed multiple admission documents but does not recall any explanation regarding arbitration or being informed that signing such an agreement was optional. The RR denied being told that the agreement involved waiving the right to pursue legal action in court. RR also stated she did not recall being given an opportunity to decline or rescind the agreement.During a concurrent interview and record review on 2/13/2026 at 8:13 a.m. with the Admissions Director (ADMD), the ADMD stated that the binding arbitration agreement was included in the admission packet. The ADMD stated she goes through the paperwork with the residents or the resident representatives and explains that it relates to how legal disputes would be handled. The ADMD stated that signing the agreement was not required for admission to the facility. The ADMD stated that the residents/resident representative sign many papers, and sometimes they don't remember if they signed the arbitration agreement. The ADMD was unable to identify documentation in the resident's medical record reflecting that the arbitration agreement was explained to the resident representative at the time of signing it. The ADMD stated that the facility ensures the residents or resident representative understands the agreement by going through the paperwork and answering any questions that they may have. ADMD stated that binding arbitration agreements waive significant legal rights, including the right to pursue disputes in a court of law and the right to a jury trial. ADMD stated that if a resident or representative does not understand the agreement, the voluntariness and informed consent requirements may not be met.During a review of the facility's policy and procedure (P&P) titled, Arbitration Agreement, dated 2022, the P&P indicated, The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. The resident or his or her representative acknowledges that he or she understands the agreement.

Based on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term) for one of three residents (Resident 63).This failure had the potential to result in an inappropriate placement and delay of services needed for Resident 63.Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and colitis (inflammation in your colon).During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 63's cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting, showering, and dressing.During a review of Resident 63's PASARR I dated 12/18/2026, the PASARR I indicated a negative Level I screening. The PASAAR I indicated Resident 63 did not have a diagnosis of a serious mental disorder (conditions that affect your thinking, feeling, mood, and behavior). During a concurrent interview and record review on 2/11/2026 at 1:12 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN indicated Resident 63 was admitted to the facility with a diagnosis of schizoaffective disorder. The MDSN stated the PASARR Level I completed prior to admission was negative but should have been positive so Resident 63 could receive additional mental health referrals and resources.During an interview on 2/12/2026 at 1:23 p.m., with the Director of Nursing (DON), the DON stated she was responsible for ensuring the PASARR was completed and accurate which was important, so the facility was aware of the residents' behaviors and needs and so the resident receives the mental health resources they may need.During a review of the facility's policy and procedure (P&P) titled, admission Criteria, 3/2019, the P&P indicated, The facility verifies that the PASARR was completed for all potential admissions, to determine if the individual meets the criteria for mental disorder.

Based on observations, interviews and record review, the facility failed to ensure medications removed from the emergency kit (E Kit-collection of different types of medications in a small box for emergency use supplied by pharmacy to health care organizations) were entered in the communication form and promptly replaced.Augmentin ( a combination of antibiotic that contains two active ingredients: amoxicillin (the primary germ-fighter) and clavulanic acid 125 milligram (mg-unit of measurement) removed from the E-kit (date and time unknown) and Keflex 250 mg (antibiotic use to kill a wide range of bacteria), medications removed from the emergency kit (E Kit-collection of different types of medications in a small box for emergency use supplied by pharmacy to health care organizations) on [DATE] at 1:30 p.m.This failure had the potential to leave the facility without STAT (immediately) Augmentin 125 mg and Keflex 250 mg in the E Kit if another resident required these antibiotics urgently as prescribed by a physician. Findings:During an observation on [DATE] at 10:16 a.m. in Medication Storage room [ROOM NUMBER], one E Kit was found open and missing one Augmentin 125 mg tablet. The E Kit was required to contain four tablets, but only three remained, and there was no record of replacement. Facility staff were unable to determine when the Augmentin had been used. The E Kit was required to contain eight capsules of Keflex 250 mg; two capsules had been removed on [DATE] at 1:30 p.m.During an interview on [DATE] at 10:20 a.m., Licensed Vocational Nurses (LVN) 2, LVN 2 stated when licensed staff open an E Kit and remove medications, they should document the removal on the communication form inside the kit and endorse the information to the next shift. LVN 2 stated this process should occur each shift to ensure removed medications were replaced immediately after the pharmacy was notified. LVN 2 stated she did not know who removed the Augmentin 125 mg but acknowledged removing the Keflex 250 mg during the [DATE] 7 am -3 pm shift. LVN 2 stated the E Kit should have been replaced on [DATE] when it was opened. She stated that failure to replace medications may result in the medications being unavailable in an emergency. LVN 2 stated all licensed nurses were responsible for ensuring that E Kit medications were replaced once removed.During an interview on [DATE] at 2:45 p.m., with Registered Nurse (RN) 1, RN1 stated when licensed nurses receive a physician's order, they enter it into the computer and notify the pharmacy. If the medication was not available in the facility, the pharmacy authorizes staff to obtain it from the E Kit. RN 1 stated each shift must follow up to ensure the E Kit was replaced as soon as possible; however, RN 1 did not provide a specific turnaround time for replacement. RN 1 stated the licensed nurse removing medication must complete a form but does not need to send the form to the pharmacy. The pharmacy must be notified before the E Kit was opened.During an interview on [DATE] at 10:10 a.m., with LVN 2, LVN 2 stated that staff are required to complete a pharmacy form indicating the resident's name and the medication removed from the E Kit. The form has two copies: the white copy should be sent to the pharmacy, and the yellow copy was kept in the facility. LVN 2 stated the pharmacy retrieves and replaces the E Kit when medications were removed. If an opened E Kit remains in the facility, it indicates the pharmacy has not replaced the removed medication. LVN 2 stated medications removed from the E Kit must be replaced immediately because another resident may require them urgently.During a review of the facility's policy and procedure (P&P) titled, E: Emergency Supply Replacement dated 7/2023, the P&P indicated in order to assure that emergency supplies of certain infusion medications and supplies are maintained for STAT use within nursing facilities, the pharmacy will provide sealed supplies of these medications and solutions for the purpose of assuring their prompt administration. The nursing facility must notify the pharmacy so that these emergency supplies can be promptly replenished and the appropriate resident account is invoiced.The pharmacy will provide emergency supplies to be maintained within the medication room(s) or in location designated by the policy of the nursing facility.The expired product will be replaced by the expiration dates according to pharmacy policy.Verify STAT physician orders and process per facility policy. Notify the pharmacy to replace emergency doses per protocol.Obtain necessary supplies and communicate with the pharmacy for replacement per protocol.Emergency drug supply replacement will be documented per protocol.

Based on observation, interview, and record review, facility staff failed to provide implement post fall interventions for one of three sample residents (Resident 1). Facility failed to: 1. Ensure Resident 1's bed was maintained in the lowest position to help prevent additional falls. This deficient practice placed Resident 1, identified as a fall risk, at increased risk for further falls and potential injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis ( a condition that causes partial paralysis or weakness on one side of the body) following intracranial hemorrhage (a bleeding inside the skull from a ruptured blood vessel ) affecting left dominant side. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's had severe cognitive impairment for daily decision-making. The MDS indicated Resident 1 was dependent (helper does all of the efforts, resident does none of the efforts to complete the activity) with transfers between surfaces, including from bed to chair and from chair to bed (or wheelchair). During a concurrent observation and interview on 12/26/2025 at 2:00 pm with Resident 1, Resident 1 was observed in bed, alert but confused. At the time of observation, the bed was in the highest position. Resident 1 stated that she remembered falling on the floor while trying to clean the carpet and move items around. She told staff not to do that again and called for help. Resident 1 was unable to recall the exact date or location of the fall. During the observation and interview, Certified Nursing Assistant (CNA) 1 was present in Resident 1's room and assisted resident with personal care. After completing care, CNA 1 left the room without lowering the bed to the lowest position for safety. CNA 1 did not return to Resident 1's room to place the bed in lowest position for safety. The bed remained in the highest position until the surveyor exited the room. During an interview on 12/26/2025 at 2:13 pm with CNA 2, CNA 2 stated she was assigned to Resident 1 on 12/11/2025, the day the resident fell. CNA 2 reported that she did not witness the fall but found Resident 1 lying sideways on the floor in her room. CNA 2 reported Resident 1 stated she fell from her wheelchair while trying to turn off the television. CNA 2 noted that Resident 1 experiences intermittent confusion but was able to communicate and follow instructions well prior to the fall on 12/11/2025. During a concurrent observation and interview on 12/26/2025 at 2:45 pm with the Registered Nurse Supervisor (RNS) in Resident 1's room, the bed was observed in the highest position. The RNS stated that he was aware of Resident 1's fall incident and that the intervention implemented after the fall was to keep the bed in the lowest position and relocate Resident 1 near the nursing station. The RNS acknowledged that the bed should remain in the lowest position for safety, even though the residents require assistance with turning and repositioning. He stated while they did not expect the resident to attempt getting out of bed, leaving the bed in the highest position could lead to another fall. The RNS stated that staff will be re-educated through in-service training to always keep beds in the lowest position. During a follow-up phone interview on 12/26/2025 at 3:38 pm with CNA 1, CNA 1 stated that when she last saw Resident 1, the bed was in the lowest position, and she did not know who left the bed in the highest position. When asked why she left the bed in the highest position after assisting the resident in the surveyor's presence, CNA 1 explained that she was rushing to attend to another resident. CNA 1 suggested that licensed staff might have raised the bed for medication administration or treatment. CNA 1 stated it was important to always keep the bed in the lowest position for safety and to prevent another fall. During an interview on 12/26/2025 at 4:20 pm with the Director of Nursing (DON), the DON stated that fall prevention in-service training has been conducted with all staff and was ongoing. The DON stated she was surprised that Resident 1's bed was found in the highest position, given that the resident was identified as a fall risk. The DON stated that keeping the bed in the lowest position was one of the interventions in place. She stated that she will monitor staff compliance and continue reinforcing in-service education to ensure adherence to safety measures. During a review of the facility policy and procedure (P&P) revised on 3/1/ 2018, titled Falls and Falls Risk, managing the P&P indicated The staff will monitor and document each resident's response to intervention intended to reduce falling or the risks of falling

Based on interviews and record reviews, the facility failed to ensure that one of three sampled residents (Resident 1) was treated with dignity and respect during personal care. Certified Nursing Assistant (CNA 1) used derogatory and offensive language toward Resident 1, including statements such as It smells bad and stinkyThis failure resulted in Resident 1 feeling humiliated, insulted, and emotionally distressed. The resident reported staying awake all night due to the incident on 11/29/2025.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including broken left leg, broken left wrist and generalized muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 11/21/2025, the H&P indicated Resident 1 had the capacity to make decisions for herself. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 1 understood clear comprehension. The MDS indicated Resident 1 was dependent on nursing staff for toileting, showering, sitting, standing and transferring. During a review of Resident 1's Grievance Resolution Report dated 11/30/2025 at 5:57 p.m., the Grievance Resolution Report indicated that Resident 1 was interviewed regarding the incident on 11/29/2025. Resident 1 stated that CNA 1, who was assigned to her, said, It smells bad and stinky. The Grievance Resolution Report also indicated that Resident 1 felt CNA 1 and CNA 2 were in a hurry while providing personal care. The report indicated that Resident 1 was satisfied with the outcome of the investigation and with her current care. During an interview on 12/13/2025 at 12:05 p.m. with Resident 1, Resident 1 stated that on 11/29/2025, Certified Nursing Assistant (CNA 1) entered her room between 11:30 p.m. to 12:30 a.m., without saying much, then removed her soiled incontinent briefs ( a disposable absorbent garment for managing bladder or bowel leakage) and began yelling, You are trash, messy, and stinky. Resident 1 stated she had never experienced such treatment before and was shocked. Resident 1 stated CNA 1 continued making comments such as This is smelly and disgusting while cleaning her with a dry terry cloth inside her legs and genital area. Resident 1 stated she began to cry and felt humiliated, insulted, and shocked. After CNA 1 left, Resident 1 stated she stayed awake all night crying. Resident 1 stated on 11/30/2025 (the next day), CNA 2 entered her room and asked why she told CNA 1 that she had not cleaned her, which made Resident 1 cry again because she had not said anything to CNA 1. Resident 1 reported that CNA 1 later returned, apologized, and told her to forget about what happened and move on. Resident 1 stated she did not forget and reported the incident to a nurse (unknown) and the Social Worker (SW 1). Resident 1 stated SW 1 told her the facility would investigate and follow up. She stated no one ever got back to her. She stated someone later told her the investigation was final and asked her to sign a document related to the incident, which she did without reading and did not receive a copy. Resident 1 stated she also reported the incident to the Administrator and SW 1 on 12/1/2025. Resident 1 stated she filed a grievance indicating on 11/30/2025 at 5:57 p.m., the incident was reported to the charge nurse and RN supervisor. During an interview on 12/14/2025 at 12:16 p.m. with CNA 1, CNA 1 stated when he entered Resident 1's room, it smelled unpleasant. CNA 1 reported checking the resident's diaper and noted a strong odor, then told Resident 1 that she needed to be cleaned and mentioned that she smelled stinky. CNA 1 stated that Resident 1 began to cry but said she was okay. CNA 1 stated Resident 1 appeared offended by the word stinky, and he apologized for using it. CNA 1 stated he informed Licensed Vocational Nurse (LVN 1) on 11/30/2025 at 1 a.m., about the incident with Resident 1 . CNA 1 stated it was inappropriate to say Resident 1 was stinky. CNA 1 stated upon his return to work on 12/1/2025 he was told by Registered Nurse Supervisor (RNS 1) he could no longer take care of Resident 1. CNA 1 stated he was sorry for hurting Resident 1's feelings and recognized that his words caused Resident 1 distress. CNA 1 stated he offended, hurt and made Resident 1 cry with his words used and apologized. CNA 1 stated when he walked into the room the resident smelled awful, stinky and had dry poop on her. CNA 1 stated his words were inappropriate to Resident 1. During an interview conducted on 12/15/2025 at 7:21 a.m. with LVN 1, LVN 1 stated Registered Nurse Supervisor (RNS 1) informed him om 11/30/2025 at 3 p.m., that CNA 1 had commented that Resident 1 was smelly. LVN 1 stated the CNAs were advised to exercise greater caution when using language related to patients and their care. RNS 1 explained that verbal abuse occurs when hurtful or derogatory words are directed toward a resident.During an interview on 12/15/2025 at 8:07 a.m. with RNS 1, RNS 1 stated verbal abuse consists of words that can offend a resident, cause them to become upset, or lead them to think negatively.During an interview on 12/15/2025 at 8:39 a.m. with the Administrator ( ADM) the ADM stated verbal abuse consists of words that cause mental anguish or hurt the residents' feelings.

Based on interview and record review, the facility failed to ensure the following for two of five sampled residents (Resident 1 and Resident 5): 1. Failed to ensure Resident 1 did not develop a Moisture Associated Skin Damage (MASD: skin inflammation caused by prolonged exposure to various sources of moisture such as urine and stool) to her peri-area (region between the buttocks and female reproductive area). 2. Failed to ensure Resident 1's family was able to contact Resident 1 via telephone while residing in the facility. 3. Failed to address ongoing concerns expressed in written grievances for answering call lights for Resident 1 and Resident 5. A. During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility 5/9/2025 with diagnoses including dislocation of right shoulder joint (two or more bones connect), injury of axillary (armpit) artery (major blood vessel in the upper limb that supplies blood to shoulder and arm put) on right side, and generalized muscle weakness. During a review of Resident 1's history and physical (H&P) dated 5/12/2025, the H&P indicated Resident 1 has the capacity to make decisions for herself. During a review of Resident 1's Minimum Data Set (MDS: a resident assessment tool) dated 5/16/2025, the MDS indicated Resident 1 was cognitively (having problems remembering things, concentrating, making decisions and solving problems) intact. The MDS indicated Resident 1 is dependent on chair/bed-to-chair transfer, toilet transfer, roll left and right, putting on footwear, required maximal assistance (provides more than half the effort) for toileting hygiene, bathing, upper (above waist) and lower body (waist below) dressing, personal hygiene, and required supervision for eating and oral hygiene. The MDS indicated Resident 1 is frequently incontinent (having no control) for both urine and bowel. 1. During a review of Resident 1's Treatment Administration Record (TAR: document that tracks the administration of medications and other treatments to residents) dated 5/1/2025-5/31/2025, the TAR indicated Resident 2 received treatment of Nystatin Powder (antifungal medication) 100,000 unit (system used to measure weight, distance, volume)/gram (gm: unit of mass) to apply to peri area every shift for MASD. During a review of Resident 1's progress note dated 5/22/2025 at 3:50 a.m., the progress note indicated Resident 1 was evaluated due to reported discomfort and visible irritation in the peri-area. The progress note indicated Resident 1's skin was erythematous, warm to touch, and shows signs of early maceration (the softening and breakdown of skin due to prolonged exposure to moisture). Resident 1 expressed pain during hygiene care related to prolonged exposure to urine. During a review of Resident 1's Change of Condition (COC) dated 5/22/2025 at 3:57a.m., the COC indicated Resident 1's groin area appeared to be inflamed, with moist erythematous (abnormally red) regions and visible signs of irritation in peri-genital area. The COC indicated to notify the doctor for topical treatment orders, implement more frequent incontinence checks and do prompt cleansing. During a review of the grievance/complaint resolution report dated 5/22/2025 at 10:25a.m., Resident 1's Family Member 1 (FM 1) filed a grievance report with an initial allegation date of 5/21/2025 during the 11:00p.m. to 7:00a.m. shift. The grievance report indicated FM G stated her concerns as Resident 1 had verbalized the CNAs during the 11:00p.m. to 7:00a.m. shift did not change her for the whole night. During a review of the grievance/complaint resolution report dated 6/2/2025 at 1:50p.m. was filed by FM 1 indicated Resident 1 stated it takes too long for the CNAs to change her. During an interview on 6/23/2025 at 9:29a.m. with FM 1, FM 1 stated Resident 1 had complained about not getting changed frequently. During an interview on 6/23/2025 at 2:43p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated they have used sheets to cover Resident 1 as a diaper and has reported that she has not been cleaned all night. CNA 2 stated she has received in service for perineal care as no residents should be left like that. CNA 2 stated everyone should be able to answer the call lights to assist residents so see what they need to fulfill their needs. CNA 2 stated if no one responded to call lights, the residents could fall and hurt themselves. 2. During a review of the grievance/complaint resolution report dated 5/22/2025 at 11a.m., Resident 1's FM 1 filed a grievance report with an initial allegation date of 5/13/2025 during 5:00p.m. to 5:10p.m. The grievance indicated FM 1 complained on 5/13/2025, she called the facility multiple times around 5:00p.m. with no answer. The front desk phone log history indicated some calls were not being answered. During a record review on 5/30/2025 at 11:28a.m., an email was received from IT indicated the phone rings, but no one picked up on some calls. During a review of the grievance/complaint resolution report dated 6/2/2025 at 12:42p.m., Resident 1's FM 1 filed a grievance report with an initial allegation date of 5/31/2025 during 3:00 p.m. to 11:00 p.m., FM 1 expressed concerns again stating on 5/31/2025 at 10:21p.m., she called numerous times, however no one answered in the facility. The grievance report indicated the receptionist inspected the nursing station call log and front desk and identified that calls are not being transferred automatically to the nursing station after receptionist hours. During an interview on 6/23/2025 at 9:29a.m. with FM 1, FM 1 stated she has called the facility about 30 times, and they did not answer the phone calls. FM 1 stated she has been unable to get a hold of the facility ever since Resident 1 was admitted to the facility. During an interview on 6/23/2025 at 1:41p.m. with the Social Service Director (SSD), the SSD stated there were 4 grievances filed for Resident 1. SSD stated there is a receptionist from 7:00a.m. to 9:00p.m. every day and on the weekends, and after 9:00p.m., the calls go directly to the nursing station. The SSD stated there was an incident regarding the night shift (11:00p.m. to 7:00a.m.) not assisting Resident 1 and the phone calls not being answered. The SSD stated another issue about the phone not being answered after 9:00p.m. was brought to their attention two weeks later. The SSD stated the phone calls are supposed to go to the nursing station, however the phone was not getting transferred automatically after 9:00p.m. The SSD stated the family will feel worried if they cannot get a hold of the facility and indicated their phone system changed about 6 months ago. During a concurrent interview and record review on 6/24/2025 at 3:14p.m. with the Receptionist (RECPST), the RECPST stated during the first incident on the grievance dated 5/22/2025, some of the calls were not picked up because they were on the line with someone. RECPST stated she was not sure if someone just neglected the calls. The RECPST stated she saw a number that was called multiple times and indicated this was a technical issue and should have been set for all calls to be transferred automatically to the nursing station after hours. The RECPST stated if they had full control over their phone system, this could have been avoided. B. During a review of Resident 5's Face Sheet, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including fracture of unspecified part of right clavicle (collarbone: long curved bone that connects arm to body), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and systemic lupus erythematosus (chronic autoimmune disease where the body immune system attacks health tissues and organs). During a review of Resident 5's H&P dated 3/1/2025, the H&P indicated Resident 5 has the capacity to make her own medical decisions at this time. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 was cognitively intact. The MDS indicated Resident 5 required maximal assistance for toileting hygiene, bathing, lower body dressing, chair/bed-to-chair transfer, toilet transfer, and required moderate assistance (provides less than half the effort) for eating, oral hygiene, upper body dressing, and personal hygiene. 3.During a review of the Resident Council Meeting Minutes dated 3/27/2025, the Resident Council Minutes indicated a resident (un-named) had noticed their roommates call light is always disconnected and is worried if she needs the call light, no one will get her attention. During a review of the Resident Council Meeting Minutes dated 5/15/2025, the Resident Council Meeting Minutes indicated on 5/14/2025 during the 3:00p.m. to 11:00p.m. shift, a resident has waited almost 2 hours for her call light to be answered. During a review of the Resident Council Meeting Minutes dated 6/19/2025, the Resident Council Meeting Minutes indicated call lights were not being answered in a timely manner and licensed staff need to help out when Certified Nurse Assistants (CNA) are not available. During an interview on 6/24/2025 at 3:31p.m. with the Director of Nursing (DON), the DON stated an in service regarding the family member not being able to reach the facility was done and indicated this incident could have been avoided if there was an open and proper communication. The DON stated from the first grievance that was filed, the second incident of the family not being able to get a hold of the facility should have been avoided. The DON stated everyone answers call lights and should be answered in a timely manner. The DON stated if no one answered call lights, the residents could develop skin issues. During a review of the facility's policy and procedure (P&P) titled, Resident Rights dated 10/2022, the P&P indicated the facility will ensure that all direct and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. The resident has the right to be informed of, and participate in, his or her treatment, including the right to receive the services and/or items included in the plan of care. The resident has the right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. During a review of the facility's P&P titled, Call Lights: Accessibility and Timely Response dated 10/28/2023, the P&P indicated all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. During a review of the facility's policy and procedure (P&P) titled, Dignity-Promoting/Maintaining Dignity dated 10/2022, the P&P indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Staff members involved in providing care or interacting with residents must promote and maintain resident dignity and respect's Resident Rights. Respond to requests for assistance in a timely and courteous manner.

Based on interview and record review the facility failed to ensure one out of four sampled residents (Resident 2) received care and services to promote wound healing and to prevent worsening pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from occurring by failing to implement interventions such as a special low air-loss mattress (designed to prevent pressure injuries, treat pressure injuries) and vitamin supplements such as zinc (mineral that plays a crucial role in numerous bodily functions, including immune system support and wound healing), vitamin C (form protein called collagen to make skin and blood vessels), and a multivitamin (dietary supplement that provides foundational support for daily nutritional needs that is not taken through diet) to promote wound healing for Resident 2. This deficient practice resulted in Resident 2's sacrococcyx (fused bone structure that consist of the sacrum [triangular bone at the base of the spine] and coccyx [tail bone]) wound progressing from a stage I (non-blanchable redness of intact skin indicating localized damage due to pressure) to a stage 2 (skin loss appearing as a shallow open ulcer with a red or pink wound bed) with a deep tissue pressure injury (DTI: a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact leading to decreased blood flow and dead tissue). During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted to the facility 5/19/2025 with diagnoses including radiculopathy (condition caused by pinched nerve in your spine that leads to pain, numbness, and weakness), vertebrogenic low back pain (low chronic back pain caused by layers of bone and cartilage at the top and bottom of each back bone become damaged), fusion of spine (surgical procedure that connects two or more bones in the spine to alleviate pain and restore stability), and Type II Diabetes Mellitus ( a chronic disease that affects how the body processes sugar). During a review of Resident 2's history and physical (H&P: initial visit and evaluation) dated 5/21/2025, the H&P indicated Resident 2 does not have the capacity to make decisions for himself but can make needs known. During a review of Resident 2's minimum data set (MDS: a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 2 was cognitively (mental action or process of acquiring knowledge and understanding ability) intact. The MDS indicated Resident 2 is dependent on chair/bed-to-chair transfer, shower transfer, required maximal assistance (provides more than half the effort) for toileting hygiene, bathing, lower body (waist below) dressing, sit to lying, lying to sitting on side of bed, required supervision for rolling left to right), and required set up for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 2 was frequently incontinent for both bowl and bladder. During a review of Resident 2's CP untitled, dated 5/20/2025, the CP indicated actual pressure ulcer; sacrococcyx pressure injury stage 1. The CP interventions included to notify MD as needed if ulcer fails to show progress in healing and provide offloading of ulcer site. During a review of Resident 2's Order Summary Report dated 6/23/2025, the report indicated Resident 2 had the following wound care orders placed: 1.Sacrococcyx pressure injury stage 1: cleanse with normal saline station (NSS: a mixture of salt and water used to clean wounds, hydration), pat dry. Apply zinc oxide (medication applied to specific area of the body to aid in wound healing and act as a skin protectant) and leave open to air (LOA) every shift ordered 5/20/2025. 2. Sacrococcyx with non-blanchable redness moist: cleanse with NSS, pat dry. Apply zinc oxide and leave open to air every shift ordered 5/20/2025. During a review of Resident 2's Skin Inspection assessment dated [DATE] at 9:08 a.m., the skin inspection assessment indicated Resident 2 had a sacrococcyx area pressure injury stage I. During a review of Resident 2's Skin Inspection assessment dated [DATE] at 9:57a.m., the skin inspection assessment indicated Resident 2 had a sacrococcyx pressure injury stage II with surrounding area DTI measuring size 6cm x 5cm x 0.1cm, eight days later. During a review of the Braden Scale (assessment tool used to predict a resident's risk of developing pressure injuries) dated 5/19/2025 at 7:28p.m., the Braden Scale indicated Resident 2 was at moderate risk (score range 13-14) with a score of 13. During a review of the Braden Scale dated 5/26/2025 at 12:54p.m., the Braden Scale indicated Resident 2 was at risk (score range 15-18) with a score of 18. During an interview on 6/23/2025 at 11:39 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated residents who are bed bound or residents who have a stage II to stage IV (deep wounds that may impact muscle, tendons, ligaments, and bone) need a low air mattress. During a concurrent interview and record review on 6/24/2025 at 2:09 p.m. with the Treatment Nurse (TXN), the TXN stated the primary physician (MD 1) will give an order for a wound consult and indicated if she notices a stage II (open) pressure ulcer during the wound assessment, she will request a wound consult from the MD 1. The TXN 1 stated Resident 2's sacrococcyx wound was getting worse because he only had a stage I on 5/20/2025, but on the day of discharge (5/28/2025), when she checked his skin, it got worse. The TXN stated if a resident has a stage II or if a wound became worse, she would request supplements or nourishments from the MD. The TXN stated Resident 2's did not have any vitamins ordered by the MD. During an interview on 6/24/2025 at 2:50p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the day she noticed any changes to Resident 2's skin was on the day of his discharge on [DATE]. During an interview on 6/24/2025 at 6:22p.m. with Family Member 2 (FM 2), FM 2 stated Resident 2's wound was getting worse, and he should not go home. FM 2 stated she believes Resident 2 was not getting turned at the facility. During a concurrent interview and record review on 6/25/2025 at 3:47p.m. with Dietary Assistant Manager (DAM), the DAM stated if a resident has altered nutrition with a wound, she will inform the dietitian, review the resident, and would order vitamins, zinc with the treatment nurse and provide protein. The DAM stated she did not see any vitamin C or zinc orders for Resident 2 and indicated they should have been recommended. The DAM stated it is important for residents to receive adequate nutrition and hydration to promote wound healing. During an interview on 6/25/2025 at 4:50p.m. with MD 1, MD 1 stated he was aware of Resident 2's stage I pressure injury upon admission MD 1 stated ordering vitamin supplements for Resident 2 would have been beneficial since Resident 1 came to the facility with a wound and the supplements (Vitamin C, Multivitamins) would aid in wound healing. During a concurrent interview and record review on 6/25/2026 at 5:10p.m. with the DON, the DON stated if Resident 2's stay at the facility was short, it might have been preventable. The DON stated on the IDT initial assessment date 5/19/2025, the skin integrity is assessed by the RD, DON, and TXN. The DON stated the RD was not present during the initial assessment for the IDT to give recommendations. During a review of the facility's policy and procedure (P&P) titled, Resident Rights dated 10/2022, the P&P indicated the facility will ensure that all direct and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. The resident has the right to be informed of, and participate in, his or her treatment, including the right to receive the services and/or items included in the plan of care. The resident has the right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. During a review of the facility's P&P titled, Title: Nutrition Assessment, dated 2/09, the P&P indicated each resident receives a comprehensive nutritional assessment upon admission and annually and whenever a resident is identified as having a significant change in status. The Nutritional Screening and Assessment includes the information noted on the form as well as additional pertinent information with may include: a. Physical appearance, noting any signs of malnutrition or dehydration b. Vitamin and mineral supplements c. Condition of the skin, noting any pressure ulcers or wounds d. Identification of medical nutritional therapy needs goals and approaches that will be addressed on the interdisciplinary plan of care During a review of the facility's P&P titled, Title: Nutritional Wound Therapy, dated 2/09, the P&P indicated purpose: to provide appropriate nutrition to prevent development of wounds. To facilitate healing of wounds while considering resident's individual preferences and needs. All residents with wounds will be assessed and documented upon by nursing and a Registered Dietitian. Based on a review of the medical record, interviews with the resident and caregivers, and observation of the resident at meals, a Registered Dietitian should evaluate the resident's nutritional status, write a nutritional assessment, and make recommendations for medical nutrition therapy in conjunction with nursing. The assessment of residents should include: 1. Diagnosis and recent changes in condition. 2. Risk factors for pressure ulcer development: immobility 3. Below 18 score on a Braden Skin Risk Assessment (identify current skin condition). 4. Food and fluid intake adequacy compared to calculated nutritional needs (calories, protein, Vitamin C, Zinc, fluids). 5. Nutrition-related lab values (albumin, hemoglobin, serum transferrin, additional indicators: pre-albumin, cholesterol, hematocrit, and serum cholesterol). During a review of the facility's P&P titled, Registered Dietitian, undated, the P&P indicated: evaluate the nutrition care of residents and document in the medical record, using the Company formulary, recommends dietary interventions according to the status of the resident, provide high quality service to everyone, as though they are your 'family,' and takes the initiative whenever they can to identify clinical or service problems, identify solutions, and works with our fellow employees and managers to implement them.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum), anemia (when the blood doesn ' t have enough healthy red blood cells and hemoglobin [a protein in the red blood cells that carries oxygen to carry oxygen all through the body), and a low hemoglobin, their Stat (immediate) laboratory (lab) order for a Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body ' s immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when a blood vessel is damaged}, hemoglobin and hematocrit}a measure of the proportion of red blood cells in the total volume of blood}, was carried out, per the physician ' s order, and followed up to ensure lab results were obtained promptly (within two to six hours). These deficient practices resulted in a delay in obtaining Resident 1 ' s blood specimen in order to obtain a STAT CBC causing a delay in the CBC test results. Resident 1 ' s hemoglobin was critically (a laboratory test result that indicates a life-threatening condition and requires immediate medical attention) low, which resulted in Resident 1 ' s admission to a General Acute Care Hospital (GACH), where he received one unit of blood and was subsequently admitted to the GACH ' s Telemetry unit because his condition was unstable. This deficient practice had the potential for Resident 1 to suffer severe complications such as heart failure, organ damage, and death. On 3/27/2025 at 3:23 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility ' s Regional Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s inability to provide laboratory services to Resident 1 as ordered by his physician. On 3/28/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After an onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the IJ was removed on 3/28/2025 at 4:45 p.m., in the presence of the facility ' s Designated ADM, the ADM in Training (A.I.T.), and the DON. The facility ' s IJRP included the following immediate actions: How the correction(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 1 was readmitted to facility on 3/11/2025. No new STAT lab orders have been ordered since his readmission. Resident 1 has not refused any labs since readmission. Resident 1 ' s Alteration for Hematological care plan for lab orders and nursing interventions was updated on 3/27/2025 to include observing, reporting, and documenting signs and symptoms of anemia, monitoring vital signs every day and as needed (PRN) and notifying the Medical Doctor (MD) via phone of abnormalities. If abnormal labs are reported or the patient refuses lab work, the MD will be notified via phone and the MD will respond in like manner. The lab report and orders will be documented in the patient ' s chart under progress notes. The pending labs and results will be tracked via the communications tab in Point Click Care ([PCC] a software platform used for electronic health records), verbal reports from nurse to nurse and progress notes documented in PCC. If the results are late (2-6 hours for STAT labs), the nurse will call the lab to follow up, and if no result are available, the MD will be notified for further orders. If the patient ' s MD doesn ' t respond timely the Medical Director will be notified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/25/2025, DON and Medical Records Director (MRD) audited and reviewed 16 residents with STAT lab orders from the prior three months for residents with diagnoses of Anemia, GI bleeding and low hemoglobin. The audit showed no other STAT lab orders were given in last three months, all other labs were done as ordered and reported timely. On 3/27/2025, the DON and MRD audited and reviewed 14 residents who had diagnoses of Anemia, GI bleeding and low hemoglobin care plans, for lab orders and nursing interventions. The care plans were reviewed and updated to reflect lab orders and nursing interventions including observing, reporting, documenting signs and symptoms of anemia, and monitoring vital signs every day and PRN, and notifying the MD via phone for abnormalities. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The DON and Registered Nurse Supervisors (RNS) provided all licensed nurses (LN) in-service training beginning 3/20/2025 through 3/27/2025 and will continue until all active LNs have been in-serviced. In-services included Stat Lab orders included policy and procedures (P/P), timely reporting of labs, timely reporting of Change of Conditions (COC) and resident refusals to physicians. How to correctly communicate accurate orders to the lab to obtain STAT lab blood draws timely, following care plans for residents, follow up procedure for all stat lab orders, facility P/P for lab results, physician orders and COC and how to properly endorse resident status to oncoming shifts. Nursing staff are to use verbal endorsements and a written endorsement log between shifts to communicate pending labs/orders. Who will monitor to ensure compliance? 1. The MRD, weekend RNS or designee will complete the audit of the endorsement log and PCC communications of all new STAT lab orders daily to ensure orders are completed, and results are obtained in a timely manner. 2. The DON or designee will review prior to daily stand up meeting any COC and/or refusal of the resident using the endorsement log and PCC to ensure staff communicate with the physician to allow the physician to assess the resident ' s care needs and give instructions for treatment. 3. The MRD, weekend RNS or designee will complete an audit of all STAT lab orders daily using the endorsement log and PCC to ensure that orders are followed up and results obtained in a timely manner. 4.The MRD, weekend RNS or designee will complete audit of new STAT lab orders daily using PCC to verify the communication between the lab and the nurse matches the physician ' s order. This is to ensure orders are communicated accurately to the lab to obtain STAT lab blood draws, and results are obtained in a timely manner. 5. The DON or designee will audit residents ' new or changed care plans pertaining to lab work or COCs during daily stand-up meetings. The Interdisciplinary Team (IDT) will review, and update care plans as needed to ensure they follow lab orders and that nursing interventions are measurable. 6. The MRD, weekend RNS or designee will complete an audit of all STAT lab orders daily to ensure orders are followed up on, and results are obtained in a timely manner. 7. The MRD, weekend RNS or designee will complete an audit of all STAT lab orders daily to ensure lab test results are completed and results are obtained and reported in a timely manner. The MRD or designee will audit any COCs and new physician orders prior to daily stand-up meetings to ensure physician orders and COC P/P are followed correctly. 8. The DON or designee will audit the shift endorsement log and PCC communications daily to ensure that facility staff are endorsing resident status and COCs to oncoming shifts for continuity of care. Facility plan to monitor the process and sustain compliance/Integrate into the Quality Assurance System. The DON or Administrator will report the findings of the audits to the Quality Assurance meeting monthly until sustained compliance is achieved for at least one month, then quarterly for 6 months or according to the Quality Assessment and Assurance (QAA) committee to ensure STAT lab orders are completed and results obtained and reported in a timely manner. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including GI bleed and anemia. During a review Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 1 was unable to make decisions for himself that were consistent and reasonable. During a review of Resident 1 ' s Care Plan on anemia dated 2/18/2025, the Care Plan indicated a goal for Resident 1 was to maintain his laboratory values within acceptable parameters and to be free from signs/symptom (s/s), and complications of anemia with interventions that included observing, documenting, and reporting to Resident 1 ' s physician any s/s of fatigue, dizziness, change in cognition, paleness, low hemoglobin, obtain and monitor laboratory work as ordered, report the results to Resident 1 ' s physician and follow up as indicated. During a review of Resident 1 ' s COC dated 3/5/2025 and timed at 5:37 a.m., the COC indicated Resident 1 had increased confusion, hit his right leg on the bed frame and was bleeding from a skin tear on his right lower leg. During a review Resident 1 ' s COC dated 3/5/2025 and timed at 6:01 a.m., the COC indicated Resident 1 was tired, more confused and drowsier after an incident of a bleeding from his right leg skin tear and swelling on his right lower leg. During a review of Resident 1 ' s Fall Incident Report dated 3/5/2025 and timed at 11:27 a.m., the Fall Incident Report indicated Resident 1 had an unwitnessed fall and was found on the floor near his bathroom with more confusion. During A review of Resident 1 ' s COC dated 3/6/2025 and timed at 2:09 p.m., the COC indicated Resident 1 had a small amount of black tarry stool (occurs when there is bleeding in the upper digestive system, black or brown in color, with a sticky consistency and may have an unpleasant odor), Resident 1 ' s physician ordered a STAT CBC. During a review of Resident 1 ' s Lab Results Report dated 3/6/2025 and timed at 8:05 p.m., the Lab Results Report indicated Resident 1 ' s hemoglobin result was 7.0 grams per deciliter ([g/dl] a unit of measurement; reference range is 13.5 g/dl to 16.9 g/dl). During a review of Resident 1 ' s Nursing Progress Notes dated 3/6/2025 and timed at 11:31 p.m., the Nursing Progress Notes indicated Resident 1 ' s physician was notified of Resident 1 ' s hemoglobin result, pending a response (order). During a review of Resident 1 ' s Nursing Progress Notes dated 3/7/2025 and timed at 8:12 a.m., the Nursing Progress Notes indicated Resident 1 was hypotensive (low blood pressure [BP]) with a BP of 86/48 millimeters of mercury (mm/Hg). (reference range 120/80 mm/Hg). The Nursing Progress Notes indicated the paramedics were called but Resident 1 ' s Responsible Party (RP) refused to transfer Resident 1 to a GACH due to a paracentesis (a medical procedure that removes fluid from the abdominal cavity) appointment that was scheduled for that day (3/7/2025). The Nursing Progress Notes indicated Resident 1 ' s physician was aware and ordered a STAT CBC to be completed when Resident 1 returned from his appointment. During a review of Resident 1 ' s Order Summary Report (Physician ' s Order) dated 3/24/2025, the Physician ' s Order indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m. and reordered at 2:20 p.m. upon Resident 1 ' s return to the facility from paracentesis appointment. During a review of Resident 1 ' s Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., the Nursing Progress Notes indicated Resident 1 returned to the facility after his paracentesis appointment and the lab was called to confirm Resident 1 ' s lab order for a STAT CBC. During a review of the Laboratory Call Log Recording on 3/7/2025 at 2:20 p.m., the Laboratory Call Log Recording indicated Licensed Vocational Nurse (LVN) 1 spoke to laboratory personnel indicating she was following up on an order for a CBC for Resident 1. The Laboratory Call Log Recording did not indicate that LVN 1 said the lab order was STAT. During a review of the laboratory ' s Dispatch Log dated 3/7/2025, the Dispatch Log indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1 ' s blood on 3/7/2025 at 10:09 p.m. (approximately eight hours after the order was placed on 3/7/2025 at 2:20 p.m.) but Resident 1 refused. During a review of Resident 1 ' s untimed Nursing Progress Note dated 3/7/2025, the Nursing Progress Note indicated there was no documentation that Resident 1 ' s physician or RP were notified when Resident 1 refused to have his blood drawn. During a review of Resident 1 ' s Physician ' s order dated 3/7/2025, and timed at 11:59 p.m., the Physician ' s Order indicated a STAT CBC for Resident 1. During a review of Resident 1 ' s Lab Results Report dated 3/8/2025, the Lab Results Report indicated Resident 1 ' s labs were drawn on 3/8/2025, at 9:44 a.m., (almost 10 hours after the order was made on 3/7/2025 at 11:59 p.m.). The Lab Results Report indicated Resident 1 ' s hemoglobin result was critical at 6.7 g/dl, his hematocrit count was 21.5%, (reference range is 39.5% to 50.0% ) and his platelet count was 52,000 platelets per microliter ([mcl] with a reference range of 150, 000 to 400,000 platelets per mcl). The Lab Results Report indicated Resident 1 ' s lab results were available at 11 a.m., on 3/8/2025, and the lab attempted several times to notify the facility of Resident 1 ' s critical lab value but was unable to reach the facility until 3/8/2025 at 1:31 p.m., because no one at the facility picked up the phone. During a review of the Laboratory Call Log dated 3/8/2025, the Laboratory Call Log indicated lab personnel attempted to report Resident 1 ' s critical hemoglobin result to the facility at 11 a.m., 11:54 a.m., 12:19 p.m., 12:53 p.m., and 1:14 p.m. The Laboratory Call Log indicated Resident 1 ' s critical laboratory result (hemoglobin) was finally reported to the facility on [DATE] at 1:31 p.m. During a review of Resident 1 ' s Transfer Form dated 3/8/2025 and timed at 2:17 p.m., the Transfer Form indicated Resident 1 was transferred to a GACH at 3:30 p.m., due to black tarry stools, a decreased hemoglobin, a low hematocrit and a low platelet count. During a review of the GACH ' s Emergency Department (ED) Note dated 3/8/2025 and timed at 4:10 p.m., the ED Note indicated Resident 1 was admitted to the ED with a chief complaint of three episodes of black tarry stools within two days, a hemoglobin of 6.7 g/dl, and a chronic (last for an extended period, typically, for three months or more) hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to Resident 1 ' s lower extremities (legs). The ED Note indicated Resident 1 received 1 unit of packed red blood cells ([PRBC] a concentrated preparation of red blood cells [specialized cells that circulate in the blood steam] obtained from whole blood after the plasma {the liquid component of whole blood}is removed) and was admitted to the GACH ' s telemetry unit (a specialized ward where patients requiring continuous cardiac monitoring receive care) because his condition was unstable. During an interview on 3/20/2025 at 1:20 p.m., Registered Nurse Supervisor (RNS) 1 stated a STAT lab order should be completed within four hours and the lab result should be reported to the facility within two hours. During a subsequent interview on the same day at 2:05 p.m., RNS 1 stated Resident 1 had an order for a STAT CBC on 3/7/2025 at 8:28 a.m., but Resident 1 ' s blood was not drawn until 3/8/2024 at 9:44 a.m. RNS 1 stated there was a miscommunication between the licensed nursing staff on 3/7/2024 on all shifts which delayed Resident 1 ' s STAT lab order. RNS 1 stated there was no follow up on Resident 1 ' s lab order to ensure his labs were completed and results obtained. During an interview on 3/20/2025 at 3:31 p.m., RNS 2 stated she worked on the 3 p.m., to 11 p.m., shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m., to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order but when the lab technician came to the facility (3/8/2025) Resident 1 refused to have his blood drawn. During a subsequent interview on 3/24/2025 at 6:24 p.m., RNS 2 stated she reordered another STAT CBC for Resident 1 on 3/7/2025 11:59 p.m., and verbally endorsed the order to the 11 p.m. to 7 a.m. shift and documented the endorsement in the facility ' s communication board through their electronic medical record system. RNS 2 stated she did not call Resident 1 ' s physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1 ' s RP to notify them of Resident 1 ' s refusal and to allow Resident 1 ' s physician to give instructions for Resident 1 ' s care. During an interview on 3/20/2025 at 3:50 p.m., RNS 3, who worked from 7 a.m., to 3 p.m., on 3/8/2025, stated he did receive an endorsement from the 11 p.m., to 7 a.m. shift regarding a STAT CBC for Resident 1. RNS 3 stated he checked the facility ' s Electronic Communication Board after conducting resident rounds and saw an order for a STAT lab for Resident 1. RNS 3 stated the STAT lab order had not been completed and there was no documentation in Resident 1 ' s Progress Notes, why it had not been done. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1 ' s Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1 ' s refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated, instead of waiting. During an interview on 3/25/2025 at 2 p.m., the ADM acknowledged and stated there was a gap of time between Resident 1 ' s lab order and results of his labs caused by the licensed nursing staff. During an interview on 3/25/2025 at 5 p.m., after listening to the Laboratory Audio Call Log, LVN 1 stated she did not tell the lab that Resident 1 ' s lab order was STAT. LVN 1 stated she should have communicated with the lab that Resident 1 ' s lab order was STAT to ensure the labs were done based on the doctor ' s order and to prevent a delay in obtaining the blood sample and results. During an interview on 3/26/2025 at 5:13 p.m., the DON stated there was a lack of communication amongst the licensed nurses and because of that they did not ensure Resident 1 ' s lab were completed, and results obtained. The DON stated staff should have notified Resident 1 ' s physician as well as Resident 1 ' s RP when Resident 1 refused to have his blood drawn to prevent a delay in the care of Resident 1. During a review of the facility ' s P/P titled Processing Physician Orders dated 8/2017, the P/P indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patients/residents ' risks. During a review of the facility ' s undated P/P titled Reporting Laboratory Test Results the P/P indicated the facility shall ensure all emergency laboratory draws should have results in two to six hours.

Based on interview and record review, the facility failed to ensure the physician and Responsible Party (RP) for one of four sampled residents (Resident 1), who had a history of gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum), anemia (when the blood doesn ' t have enough healthy red blood cells and hemoglobin [a protein in the red blood cells that carries oxygen) to carry oxygen all through the body], and a low hemoglobin, were notified when Resident 1 refused to have his blood drawn in order to obtain a Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body ' s immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when a blood vessel is damaged}, hemoglobin and hematocrit} a measure of the proportion of red blood cells in the total volume of blood}, per the physician ' s order. This deficient Practice resulted in a delay Resident 1 ' s critical hemoglobin results of 6.7 grams per deciliter ([g/dl] a unit of measurement; reference range is 13.5 g/dl to 16.9 g/dl), abnormal hematocrit results of 21.5%, (reference range is 39.5% to 50.0% ), and abnormal platelet count results of 52,000 platelets per microliter ([mcl] with a reference range of 150, 000 to 400,000 platelets per mcl), due to Resident 1 ' s blood sample not being obtained. This deficient practice had the potential for Resident 1 to suffer severe complications such as heart failure, organ damage, and death. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including GI bleed and anemia. During a review Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 1 was unable to make decisions for himself that were consistent and reasonable. During a review of Resident 1 ' s Nursing Progress Notes dated 3/7/2025 and timed at 8:12 a.m., the Nursing Progress Notes indicated Resident 1 was hypotensive (low blood pressure [BP]) with a BP of 86/48 millimeters of mercury (mm/Hg). (reference range 120/80 mm/Hg). The Nursing Progress Notes indicated the paramedics were called but Resident 1 ' s Responsible Party (RP) refused to transfer Resident 1 to a GACH due to a paracentesis (a medical procedure that removes fluid from the abdominal cavity) appointment that was scheduled for that day (3/7/2025). The Nursing Progress Notes indicated Resident 1 ' s physician was aware and ordered a STAT CBC to be completed when Resident 1 returned from his appointment. During a review of Resident 1 ' s Order Summary Report (Physician ' s Order) dated 3/24/2025, the Physician ' s Order indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m. and reordered at 2:20 p.m. upon Resident 1 ' s return to the facility from paracentesis appointment. During a review of Resident 1 ' s Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., the Nursing Progress Notes indicated Resident 1 returned to the facility after his paracentesis appointment and the lab was called to confirm Resident 1 ' s lab order for a STAT CBC. During a review of the laboratory ' s Dispatch Log dated 3/7/2025, the Dispatch log indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1 ' s blood on 3/7/2025 at 10:09 p.m. but Resident 1 refused. During a review of Resident 1 ' s Nursing Progress Note dated 3/7/2025 on the 3 p.m. to 11 p.m. shift, the Nursing Progress Note indicated there was no documentation that Resident 1 ' s physician or RP were notified when Resident 1 refused to have his blood drawn. During a telephone interview on 3/25/2025 at 11:25 a.m., RP 1 stated she was not notified on 3/7/2025 during the 3 p.m. to 11 p.m. shift when Resident 1 refused to have his blood drawn and stated she should have been notified and allowed to make medical decision for Resident 1. During an interview on 3/20/2025 at 3:31 p.m., Registered Nurse Supervisor (RNS) 2 stated she worked on the 3 p.m., to 11 p.m., shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m., to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order but when the lab technician came to the facility (3/8/2025) Resident 1 refused to have his blood drawn. RNS 2 stated she did not call Resident 1 ' s physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1 ' s RP to notify them of Resident 1 ' s refusal and to allow Resident 1 ' s physician to give instructions for Resident 1 ' s care. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1 ' s Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1 ' s refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated, instead of waiting. During an interview on 3/26/2025 at 5:13 p.m., the Director of Nursing Services (DON) stated the licensed nursing staff are expected to call the primary physician and the RP to notify them when there is a COC and/or difficulty in completing an order. The DON stated staff should have notified Resident 1 ' s physician as well as his RP when Resident 1 refused to have his blood drawn to prevent a delay in the care of Resident 1. During a review of the facility ' s Policy and Procedure (P/P) titled Resident Rights dated 10/2022, the P/P indicated the facility shall have the residents and their responsible parties be informed of, in advance and participate in, their treatment including changes of plan of care. During a review of the facility ' s P/P titled Change of Condition dated 2016, the P/P indicated the facility shall provide treatment and services to address changes in accordance with the residents ' needs by notifying the physician of the residents ' current status, assessment findings and subsequent actions. The P/P indicated the facility shall notify the resident and /or responsible party of the resident ' s current status and subsequent actions/orders

Based on interview and record review, the facility failed to promptly identify and intervene to ensure Resident 1 received treatment and care in accordance with professional standards and their comprehensive person-centered care plan when two physician's orders for Stat (immediately) laboratory (lab) tests were not completed within the required time frame for one of four sampled residents (Resident 1), reviewed for gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum). The physician placed a STAT order for Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body's immune system}, platelets {a tiny disc shaped pieces of cells in the blood that help stop bleeding by forming clots [a mass of blood that forms when clot platelets, proteins, and cells stick together] when a blood vessel is damaged}, hemoglobin and hematocrit}a measure of the proportion of red blood cells in the total volume of blood}to assess and treat Resident 1's anemia and history of GI bleeding. The first STAT CBC order was completed in 7 hours 49 minutes, which is outside the 4-hour time requirement. The second STAT CBC order was completed in 9 hours and 45 minutes, which is outside the 4-hour time requirement with the results communicated in 12 hours and 32 minutes, which is outside the 6-hour time requirement.The facility failed to: 1. Ensure when Resident 1 refused to have his blood drawn for a laboratory analysis/test (CBC), his physician was notified in order to obtain instructions for Resident 1's care. 2. Ensure the laboratory was provided with an accurate order indicating a STAT priority to prevent a delay in processing of the order and obtaining Resident 1's blood and test results promptly. 3. Ensure staff followed Resident 1's Care Plan that indicated obtain and monitor Resident 1's laboratory test as ordered. 4. Ensure the facility had a system in place to follow up on Resident 1's STAT lab order, in order to obtain STAT lab results promptly, within two to six hours. 5. Ensure staff followed the facility's undated Policy and Procedure (P/P) titled Reporting Laboratory Test Results that indicated emergency STAT lab work should have results in two to six hours 6. Ensure staff followed the facility's P/P titled, Processing Physician Orders dated 8/2017 that indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patient/residents' risks. 7. Ensure staff followed the facility's P/P titled Change of Condition dated 2016 that indicated the facility shall provide treatment and services to address changes in accordance with the residents' needs These deficient practices had the potential for hemorrhage, hypovolemic shock, and death from blood loss. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including GI bleed and anemia. During a review Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 1 was unable to make decisions for himself that were consistent and reasonable. During a review of Resident 1's Care Plan on anemia dated 2/18/2025, the Care Plan indicated a goal for Resident 1 was to maintain his laboratory values within acceptable parameters and to be free from signs/symptom (s/s), and complications of anemia with interventions that included observing, documenting, and reporting to Resident 1's physician any s/s of fatigue, dizziness, change in cognition, paleness, low hemoglobin, obtain and monitor laboratory work as ordered, report the results to Resident 1's physician and follow up as indicated. During a review of Resident 1's COC dated 3/5/2025 and timed at 5:37 a.m., the COC indicated Resident 1 had increased confusion, hit his right leg on the bed frame and was bleeding from a skin tear on his right lower leg. During a review Resident 1's COC dated 3/5/2025 and timed at 6:01 a.m., the COC indicated Resident 1 was tired, more confused and drowsier after an incident of a bleeding from his right leg skin tear and swelling on his right lower leg. During a review of Resident 1's Fall Incident Report dated 3/5/2025 and timed at 11:27 a.m., the Fall Incident Report indicated Resident 1 had an unwitnessed fall and was found on the floor near his bathroom with more confusion. (GI bleeding can lead to confusion, fatigue, tiredness, weakness, dizziness, and falls). During a review of Resident 1's COC dated 3/6/2025 and timed at 2:09 p.m., the COC indicated Resident 1 had a small amount of black tarry stool (occurs when there is bleeding in the upper digestive system, black or brown in color, with a sticky consistency and may have an unpleasant odor), Resident 1's physician ordered a STAT CBC. During a review of Resident 1's Lab Results Report dated 3/6/2025 and timed at 8:05 p.m., the Lab Results Report indicated Resident 1's hemoglobin result was 7.0 grams per deciliter ([g/dl] a unit of measurement; reference range is 13.5 g/dl to 16.9 g/dl). Review of Resident 1's Lab Results Report for the previous day, 3/5/2025 and timed at 12:09 AM, documented Resident 1's hemoglobin was 8.5 g/dl, a significant decrease. During a review of Resident 1's Nursing Progress Notes dated 3/6/2025 and timed at 11:31 p.m., the Nursing Progress Notes indicated Resident 1's physician was notified of Resident 1's hemoglobin result, pending a response (order). During a review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 8:12 a.m., the Nursing Progress Notes indicated Resident 1 was hypotensive (low blood pressure [BP]) with a BP of 86/48 millimeters of mercury (mm/Hg). (reference range 120/80 mm/Hg). The Nursing Progress Notes indicated the paramedics were called but Resident 1's Responsible Party (RP) refused to transfer Resident 1 to a GACH due to a paracentesis (a medical procedure that removes fluid from the abdominal cavity) appointment that was scheduled for that day (3/7/2025). The Nursing Progress Notes indicated Resident 1's physician was aware and ordered a STAT CBC to be completed when Resident 1 returned from his appointment. Review of Resident 1's previous BP and Heart Rate (HR) measurements documented: 3/4/25 at 3:51 PM with BP of 130/84 and HR of 80, 3/5/25 at 5:44 AM with BP of 128/68 and HR of 68 at 9:40 PM with BP of 114/67 and HR of 80, 3/6/25 at 1:38 with BO of 114/67 and HR of 80, at 2:15 PM with BP of 121/62 and HR of 77. During a review of Resident 1's Order Summary Report (Physician's Order) dated 3/24/2025, the Physician's Order indicated a STAT CBC was ordered on 3/7/2025 at 8:28 a.m. and reordered at 2:20 p.m. upon Resident 1's return to the facility from paracentesis appointment. During a review of Resident 1's Nursing Progress Notes dated 3/7/2025 and timed at 2:20 p.m., the Nursing Progress Notes indicated Resident 1 returned to the facility after his paracentesis appointment and the lab was called to confirm Resident 1's lab order for a STAT CBC.During a review of the Laboratory Call Log Recording on 3/7/2025 at 2:20 p.m., the Laboratory Call Log Recording indicated Licensed Vocational Nurse (LVN) 1 spoke to laboratory personnel indicating she was following up on an order for a CBC for Resident 1. The Laboratory Call Log Recording did not indicate that LVN 1 said the lab order was STAT. During a review of the laboratory's Dispatch Log dated 3/7/2025, the Dispatch Log indicated a phlebotomist (a healthcare professional trained to collect blood samples from patients) attempted to draw Resident 1's blood on 3/7/2025 at 10:09 p.m. (approximately eight hours after the order was placed on 3/7/2025 at 2:20 p.m.) but Resident 1 refused. A review of Resident 1's untimed Nursing Progress Note dated 3/7/2025, the Nursing Progress Note indicated there was no documentation that Resident 1's physician or RP were notified when Resident 1 refused to have his blood drawn. During a review of Resident 1's Physician's order dated 3/7/2025, and timed at 11:59 p.m., the Physician's Order indicated a STAT CBC for Resident 1. During a review of Resident 1's Lab Results Report dated 3/8/2025, the Lab Results Report indicated Resident 1's labs were drawn on 3/8/2025, at 9:44 a.m., (almost 10 hours after the order was made on 3/7/2025 at 11:59 p.m.). The Lab Results Report indicated Resident 1's hemoglobin result was critical at 6.7 g/dl, his hematocrit count was 21.5%, (reference range is 39.5% to 50.0%) and his platelet count was 52,000 platelets per microliter ([mcl] with a reference range of 150, 000 to 400,000 platelets per mcl). The Lab Results Report indicated Resident 1's lab results were available at 11 a.m., on 3/8/2025, and the lab attempted several times to notify the facility of Resident 1's critical lab value but was unable to reach the facility until 3/8/2025 at 1:31 p.m., because no one at the facility picked up the phone. Review of The National Cancer Institute (NCI) grading of anemia documented Mild anemia is defined as Hemoglobin levels between 10.0 g/dL and the lower limit of normal. Moderate anemia is defined as Hemoglobin levels between 8.0 and 10.0 g/dL. Severe anemia is defined as Hemoglobin levels below 8.0 g/dL, and Life-threatening anemia is defined as Hemoglobin levels below 6.5 g/dL. During a review of the Laboratory Call Log dated 3/8/2025, the Laboratory Call Log indicated lab personnel attempted to report Resident 1's critical hemoglobin result to the facility at 11 a.m., 11:54 a.m., 12:19 p.m., 12:53 p.m., and 1:14 p.m. The Laboratory Call Log indicated Resident 1's critical laboratory result (hemoglobin) was finally reported to the facility on 3/8/2025 at 1:31 p.m. (more than 12 hours after the order was made on 3/7/2025 at 11:59 p.m.). During a review of Resident 1's Transfer Form dated 3/8/2025 and timed at 2:17 p.m., the Transfer Form indicated Resident 1 was transferred to a GACH at 3:30 p.m., due to black tarry stools, a decreased hemoglobin, a low hematocrit and a low platelet count. During a review of the GACH's Emergency Department (ED) Note dated 3/8/2025 and timed at 4:10 p.m., the ED Note indicated Resident 1 was admitted to the ED with a chief complaint of three episodes of black tarry stools within two days, a hemoglobin of 6.7 g/dl, and a chronic (last for an extended period, typically, for three months or more) hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to Resident 1's lower extremities (legs). The ED Note indicated Resident 1 received 1 unit of packed red blood cells ([PRBC] a concentrated preparation of red blood cells [specialized cells that circulate in the blood steam] obtained from whole blood after the plasma {the liquid component of whole blood}is removed) and was admitted to the GACH's telemetry unit (a specialized ward where patients requiring continuous cardiac monitoring receive care) because his condition was unstable. During an interview on 3/20/2025 at 1:20 p.m., Registered Nurse Supervisor (RNS) 1 stated a STAT lab order should be completed within four hours, and the lab result should be reported to the facility within two hours. During a subsequent interview on the same day at 2:05 p.m., RNS 1 stated Resident 1 had an order for a STAT CBC on 3/7/2025 at 8:28 a.m., but Resident 1's blood was not drawn until 3/8/2024 at 9:44 a.m. RNS 1 stated there was miscommunication between the licensed nursing staff on 3/7/2024 on all shifts which delayed Resident 1's STAT lab order. RNS 1 stated there was no follow up on Resident 1's lab order to ensure his labs were completed and results obtained. During an interview on 3/20/2025 at 3:31 p.m., RNS 2 stated she worked on the 3 p.m., to 11 p.m., shift on 3/7/2025 and received a report from RNS 1, who worked the 7 a.m., to 3 p.m. shift (3/7/2025), that Resident 1 had an order for a STAT CBC. RNS 2 stated she processed the lab order but when the lab technician came to the facility (3/8/2025) Resident 1 refused to have his blood drawn. During a subsequent interview on 3/24/2025 at 6:24 p.m., RNS 2 stated she reordered another STAT CBC for Resident 1 on 3/7/2025 11:59 p.m. and verbally endorsed the order to the 11 p.m. to 7 a.m. shift and documented the endorsement in the facility's communication board through their electronic medical record system. RNS 2 stated she did not call Resident 1's physician to notify him that Resident 1 refused to have his blood drawn. RNS 2 stated she should have called the physician and Resident 1's RP to notify them of Resident 1's refusal and to allow Resident 1's physician to give instructions for Resident 1's care. During an interview on 3/20/2025 at 3:50 p.m., RNS 3, who worked from 7 a.m. to 3 p.m., on 3/8/2025, stated he did receive an endorsement from the 11 p.m., to 7 a.m. shift regarding a STAT CBC for Resident 1. RNS 3 stated he checked the facility's Electronic Communication Board after conducting resident rounds and saw an order for a STAT lab for Resident 1. RNS 3 stated the STAT lab order had not been completed and there was no documentation in Resident 1's Progress Notes, why it had not been done. During an interview on 3/25/2025 at 5 p.m., after listening to the Laboratory Audio Call Log, LVN 1 stated she did not tell the lab that Resident 1's lab order was STAT. LVN 1 stated she should have communicated with the lab that Resident 1's lab order was STAT to ensure the labs were done based on the doctor's order and to prevent a delay in obtaining the blood sample and results. During a telephone interview on 3/25/2025 at 1:24 p.m., Resident 1's Physician stated Resident 1 had a GI bleed and had he been notified of Resident 1's refusal to have his blood drawn, he could have reordered another lab or sent Resident 1 to the GACH to be evaluated, instead of waiting. During an interview on 3/25/2025 at 2 p.m., the ADM acknowledged and stated there was a gap of time between Resident 1's lab order and results of his labs caused by the licensed nursing staff. During an interview on 3/26/2025 at 5:13 p.m., the DON stated there was a lack of communication amongst the licensed nurses and because of that they did not ensure Resident 1's lab was completed, and results obtained. The DON stated staff should have notified Resident 1's physician as well as Resident 1's RP when Resident 1 refused to have his blood drawn to prevent a delay in the care of Resident 1. During a review of the facility's P/P titled Processing Physician Orders dated 8/2017, the P/P indicated the facility shall maintain accuracy of physician orders to provide appropriate care and services related to patients/residents' risks. During a review of the facility's undated P/P titled Reporting Laboratory Test Results the P/P indicated the facility shall ensure all emergency laboratory draws should have results in two to six hours but did not specify the timeliness standards for physician order and blood collection. During a review of the facility's Laboratory Services Agreement, dated 7/22/2019, the agreement did not outline the time expectations for emergency laboratory orders; including both laboratory drawings and results. Please also see F580.

Based on observation, interview, and record review, the facility failed to ensure three out of three sampled residents, Residents 26,31 and 61 who were receiving hemodialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatments had an emergency dialysis kits (supplies needed to use in an emergency) at bedside, to respond to a potential medical complication, such as bleeding. This failure had the potential to cause a delay in treatment in case of an emergency. Findings: During a review of Resident 61s Admission Record, dated 1/10/2025, the admission record indicated, Resident 61 was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), dependence on renal dialysis and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2025 the MDS indicated Resident 61 has moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS also indicated, Resident 61 needs substantial assistance (helper does more than half the work) with activities of daily living (ADL- activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated that Resident 61 was receiving hemodialysis. During a review of Resident 61s History and Physical (H&P), dated 1/2/2025, the H&P indicated, Resident 61 does have the capacity to understand and make decisions. During a review of Resident 61's Order Summary Report dated 1/10/2025, the order summary report indicated, Resident 61 has orders to go to the dialysis center three times a week on Monday, Wednesday, and Friday, dialysis access site left femoral (groin) artery (main blood vessel supplying blood to the lower body). During an observation on 1/7/2025 at 9:00 a.m. in Resident 61's room there was no emergency dialysis kit at the bedside. During a review of Resident 31's Admission Record, dated 1/10/2025, the admission record indicated, that Resident 31 was admitted to the facility on [DATE] with diagnoses including ESRD, dependence on renal dialysis, and type 2 DM. During a review of Resident 31's MDS dated [DATE] the MDS indicated Resident 31 has moderate cognitive impairment. The MDS also indicated Resident 31 needs substantial assistance (helper does more than half the work) with her ADL's. The MDS indicated, Resident 31 was receiving hemodialysis. During a review of Resident 31's H&P, dated 7/2/2024, the H&P indicated, Resident 31 does have the capacity to understand and make decisions. During a review of Resident 31's Order Summary Report dated 1/10/2025, the order summary report indicated, Resident 31 has orders to go to the dialysis center three times a week on Monday, Wednesday, and Friday. The order summary report also indicated to check arteriovenous access site (AV-surgical connection between artery and a vein that allows for blood access during hemodialysis) to left upper arm every shift. During an observation on 1/10/2025 at 8:45 a.m. in Resident 31's room there was no emergency dialysis kit at bedside. During a review of Resident 26's Admission Record, dated 1/10/25 the Admission Record indicated, Resident 26 was admitted to the facility on [DATE] with diagnoses including ESRD, dependence on renal dialysis, and type 2 DM. During a review of Resident 26's MDS dated [DATE] the MDS indicated Resident 26 has severe cognitive impairment. The MDS indicated Resident 31 was dependent (helper does all the work) with ADL's. The MDS indicated Resident 26 was receiving hemodialysis. During a review of Resident 26 H&P, dated 7/22/24, the H&P indicated, Resident 26 does not have the capacity to understand and make decisions. During a review of Resident 26's Order Summary Report dated 1/10/2025, the order summary report indicated, Resident 26 had orders to go to the dialysis center three times a week on Tuesday, Thursday, and Saturday. The order summary report also indicated to check dressing to left upper AV fistula and remove if no signs and symptoms of bleeding after dialysis visits in the evening. During an observation on 1/10/2025 at 9:03 a.m. in Resident 26's room there was no emergency dialysis kit at the bedside. During a concurrent observation and interview on 1/10/2025 at 8:45 a.m. with Certified Nursing Assistant (CNA)1, CNA1 stated that if the resident's dialysis access site was to start bleeding, she would apply pressure to the site and call the licensed nurse. CNA1 stated she believes she has seen an emergency dialysis kit in the resident's bedside drawer. Walking rounds done with CNA 1 for Residents 26,31, and 61, observed no emergency dialysis kits were found at the bedside. During a concurrent observation and interview on 1/10/2025 at 9:03 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated that there should be an emergency dialysis kit with a dressing, clamp, and tape at the bedside of residents who are receiving hemodialysis. Walking rounds done with LVN 1 for Residents 26,31, and 61, observed no emergency dialysis kits were found at the bedside. LVN 1 stated if there was emergency bleeding we could stop it right away with an emergency dialysis kit. LVN 1 stated there was a risk for residents on hemodialysis to have a severe hemorrhage (bleeding). During an interview on 1/10/2025 at 2:34 p.m. with the Director of Nursing (DON), the DON stated she was made aware that there were no emergency dialysis kits at Resident 26,31, and 61's bedside and that they were in central supply. The DON stated, there should be an emergency dialysis kit at the bedside for all residents on hemodialysis. The DON stated there was a safety concern with residents who are receiving hemodialysis these residents could get hypotension (low blood pressure) and bleed out. During a review of the facility's policy and procedure (P&P) titled Hemodialysis Care dated Sept. 2007 indicated if bleeding is apparent, apply direct pressure direct pressure over the shunt site or graft site for 10-12 minutes. If bleeding is persistent or severe call physician immediately and notify dialysis center.

Based on observation interview and record review the facility failed to ensure a label of open date and use by dates were placed on an open bag of frozen pancakes and cinnamon rolls. This failure had the potential to expose residents to a food-borne illnesses (any illness resulting from eating contaminated/spoiled foods). Findings: During an observation [DATE] at 8:10 a.m. in the kitchen freezer an open bag of pancakes and cinnamon rolls did not have a label of open date or use by date on the bag. During an interview on [DATE] at 8:10 a.m., with the Dietary Supervisor (DS), the DS stated that there was not a label of open date or use by date on the open bag of pancakes or cinnamon rolls. DS stated there always needs to be label of open date and use by date on food after it has been opened to ensure the quality of the food was good and palatable for the residents. During an interview on [DATE] at 2:34 p.m. with the Director of Nursing (DON), the DON stated all open food needs to have a label of open date and best by date to ensure the food was fresh. The DON stated there was a possibility for gastrointestinal (GI) illness if residents were served food that was expired. During a review of the facility's policy and procedure (P&P) titled Food Receiving dated February 2009, the P&P indicated, Upon delivery and/ or opening / using a food item's, label and date the food items at the time they are opened, follow the used- by- dates and expiration date on the product.

Based on interview and record review, the facility failed to ensure a resident, who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor or incapacitated person) with a history of elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision), and assessed as high risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 did not elope from the facility twice, the first time on 1/19/2024 and again 4/13/2024. 2. Ensure Resident 1 was not placed in a room with access to an outside patio with a door that opened to an alley. The door's alarm, when sounded, was faint and could be heard only when in close proximity to it and would shut off within five seconds after activation. 3. Have a system in place to alert staff when the facility's front entrance/exit door as well as the rehabilitation patio door was opened, to prevent residents from leaving the facility without staff knowledge. 4. Develop and implement a care plan for Resident 1 when Resident 1 was identified as a risk for elopement on 12/29/2023. 5. Ensure a care plan was developed to address Resident 1's risk for elopement with appropriate time sensitive interventions that defined frequent visual checks and documentation of times when Resident 1 was monitored. 6. Develop and implement a care plan for Resident 1's refusal to wear and taking off his wander guard bracelet (a device placed on a resident that triggers an alarm alerting staff that a resident is close to a door to prevent the resident from leaving unattended). As a result of these deficient practices, Resident 1 eloped from the facility and was missing for 11 hours on 1/19/2024 and eloped from the facility again on 4/13/2024. These deficient practices placed Resident 1 at risk for exposure to harsh environmental conditions (rain and/or cold), hypothermia (a dangerously low body temperature), injury from motor vehicle accidents, medical complications related to his diagnosis of paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia (a serious mental disorder in which people interpret reality abnormally) and psychosis (when a person has trouble telling the difference between what's real and what's not) without receiving prescribed medication, lack of food with the risk of malnutrition (health problems that may arise due to lack of nutrients), dehydration (abnormally low fluid levels in the body), and possible death. On 4/18/2024 at 4:38 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider'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 in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent his elopement from the facility on 4/13/2024. On 4/22/2024 at 3:53 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 4/22/2024 at 5:52 p.m., in the presence of the facility's ADM and DON. The facility's IJRP included the following immediate actions: 1. The facility will follow residents' care plan interventions that requires frequent visual checks every hour, every 30 minutes, or every 15 minutes depending on the patient's needs and document monitoring of the resident on the facility's Frequent Observation Flow sheet. 2. The facility staff were reeducated on 4/1/4/2024 on the facility's elopement policy and procedure (P&P) with an emphasis on monitoring and providing supervision to residents who are at risk for elopement according to their plan of care. The ADM, DON and Department heads were in-serviced on 4/18/2024 on the same. 3. An Elopement binder was created and will be placed at nursing station one. The Elopement binder will include resident's face sheets, photos, interventions specific to elopement, and wander guard manufacturing guidelines. 4. On 4/18/2024 all licensed staff will receive an in-service on the development, evaluation, and revision of a care plan as needed to ensure care plans identify the residents' needs in order to prevent elopement including goals, interventions, and implementation with documentation of interventions. 5. The licensed nurses will check residents' Wander Guard placement every shift and check the function of the Wander Guard with the manufacturer recommended tester once a week for all residents assessed with risk of elopement. The findings will be documented in the electronic Medication Administration Record (eMAR). The Director of Staff Development (DSD) or designee will monitor for compliance with elopement risk care plan interventions including validation of Wander Guard placement and alarm function three times a week. 6. On 4/19/2024 the ADM in collaboration with the Maintenance Supervisor (MS) placed an audible alarm on the facility's front entry/exit door and the kitchen exit door. A lock was placed on the patio exterior exit gate preventing further use of the door for entering and exiting. 7. The MS or designee will monitor the alarm function daily and report any findings to the Administrator for appropriate corrective actions. 8. The licensed nurses will check all exit door alarms every shift and document the results on the Exit Door Alarms Check Log. 9. The facility front doors will be unlocked and unarmed each day at 9 a.m., and armed at 5 p.m. During the time when the front doors are open, a receptionist will be present in the front lobby. If there is no receptionist present, then front entry doors will stay locked from outside entry the alarm will be armed. 10. On 4/18/2024, the facility staff were educated on the facility's elopement P&P with an emphasis on residents who are identified as elopement risk and are seen outside of the facility The facility staff will intercept the resident to ensure the resident safety and to encourage and assist the resident to return to the facility. The staff will not leave the resident unattended until help is secured. 11. On 4/19/2024, the ADM and DON were reeducated on the facility's elopement P&P with an emphasis on reporting elopement within 24 hours to all appropriate entities. The facility will report all elopements within 24 hours according to Federal and Title 22 regulations. Findings: During a review of Resident 1's General Acute Care Hospital (GACH) Face Sheet, the Face Sheet indicated Resident 1 was brought to the GACH for a mental health evaluation, after being taken into custody and arrested breaking into a car. Resident 1 was admitted to the GACH on 5/17/2023 with a diagnosis of psychosis. Resident 1 was subsequently placed on a 5150 72-hour hold (an involuntary detention of an adult who is experiencing a mental health crisis) due to Resident 1's incoherent statements, Resident 1's inability to explain a safety plan and being found inappropriate for voluntary hospitalization . During a review of Resident 1's Psychiatric Evaluation from the GACH, dated 5/18/2023, the Psychiatric Evaluation indicated Resident 1 made bizarre statements including hearing demons and angels fighting and hearing voices tormenting him, telling him to walk into traffic, or overdose (taking more than the usual recommended amount of something, often medicine or drugs). The Psychiatric Evaluation indicated Resident 1 stated, I just feel like dying. During a review of the GACH's Discharge Summary, dated 11/17/2024 and timed at 7:33 p.m., the Discharge Summary indicated Resident 1's chief complaint was wanting to harm himself. The Discharge Summary indicated Resident 1's baseline level (an initial measurement of a condition taken at an early point in time that is used for comparison over time to look for changes) was disorganized (odd, bizarre behavior such as smiling, laughing, or talking to oneself or being preoccupied/responding to internal stimuli). During a review of Resident 1's facility's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, psychosis, and absence of his right leg above the knee. During a review of Resident 1's Conservatorship documents dated 11/22/2023, the Conservatorship documents indicated Resident 1 was gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) as a result of a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior). During a review of Resident 1's Elopement Evaluation dated 12/29/2023, the Elopement Evaluation indicated Resident 1 scored one (a score of one or higher indicates a risk of elopement). During a review of Resident 1's clinical record, the Care Plan section, indicated there was no care plan in place addressing Resident 1's history of elopement or his elopement risk, as assessed on 12/29/2023. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 2/20/2024, the MDS indicated Resident 1 was cognitively intact (a person who can follow two simple commands). The MDS indicated Resident 1 received antipsychotic (medication used to treat hallucinations [sights, sounds, smells, tastes, or touches that a person believes to be real but are not real] and delusions [false beliefs]) and antianxiety (medication used to treat symptoms of anxiety [feelings of fear, dread, uneasiness]) medication. During a review of Resident 1's Order Summary Report (Physician's Orders), the Physician's Orders indicated Resident 1 was receiving the following medications as ordered: 1. On 11/17/2023 - Divalproex Sodium 250 milligrams ([mg] a unit of measurement), once a day for seizures. 2. On 11/20/2023 - Risperidone 2 mg, twice a day for psychosis as manifested by visual hallucinations. 3. On 11/29/2024 - Invega 6 mg once a day for psychosis manifested by sudden angry outbursts. During a review of the facility's undated floor plan, the floor plan indicated Resident 1's room had access to an outside patio which had direct access to an alley. During a review of Resident 1's Situation Background, Assessment, and Recommendation ([SBAR] a communication tool between members of the health care team about a patient's condition) Elopement Report of Incident, dated 1/20/2024 and timed at 12:12 a.m., the SBAR indicated Resident 1 left the building (1/19/2024) without informing the staff. During a review of Resident 1's Nurses Notes dated 1/20/2024 and timed at 1:30 a.m., the Nurses Notes indicated on 1/19/2024 at 10:40 p.m., Resident 1 was seen sitting at the nurses' station. The Nursing Notes indicated at around 11:30 p.m., Resident 1 was not in his room nor in the building. The Nursing Notes indicated the surrounding area was searched and the resident was not located. During a review of Resident 1's Nurses Notes dated 1/20/2024 and timed at 11:20 a.m., the Nursing Notes indicated Resident 1 was accompanied back to the facility on [DATE] around 11 a.m., after being found at a laundromat, 0.4 miles away from the facility (approximately 11.5 hours after Resident 1 went missing). A physician's order was obtained to place a wander guard on Resident 1 for monitoring. During a review of Resident 1's Physician's Order dated 1/20/2024, the Physician's Order indicated to check placement of the wander guard bracelet every shift and check its function every week. During a review of Resident 1's Elopement Evaluation dated 1/20/2024, the Elopement Evaluation indicated Resident 1 scored six (a score of 6 indicated Resident 1 was a high elopement risk). During a review of Resident 1's Care Plan, dated 1/20/2024, the Care Plan indicated Resident 1 was identified as a high risk for elopement related to a history of elopement and irritable behaviors as evidenced by excessive pacing for no apparent reason. The Care Plan's goal indicated Resident 1 would be safe while at the facility through a review date of 5/14/2024. The Care Plan's interventions included relocating Resident 1 closer to the nursing station for better monitoring and visual checks as needed, and to check Resident 1's wander guard placement and functioning. During a review of Resident 1's Social Service Notes dated 1/26/2024 and timed at 12:53 p.m., the Social Service Notes indicated Resident 1 verbalized to his Conservator that he had a plan to leave the facility when staff was not around. During a review of Resident 1's Social Service Notes dated 1/26/2024 and timed at 3:59 p.m., the Social Service Notes indicated Resident 1 verbalized he would escape if nobody was looking. During a review of Resident 1's Nursing Note, dated 1/31/2024 and timed at 6:30 p.m., the Nursing Note indicated Resident 1's wander guard was found on Resident 1's dresser. The Nursing Note indicated Resident stated the wander guard drove him crazy when he wore it, especially when the alarm went off when he went outside to smoke. During a review of Resident 1's Medication Administration Record (MAR) Note, dated 1/31/2024 and timed at 8:05 p.m., the MAR Administration Note indicated Resident 1 refused to wear the wander guard. During a review of Resident 1's clinical record, the Care Plan section indicated there was no Care Plan in place addressing Resident 1's behavior of taking his wander guard off or refusing to wear his wander guard. During a review of Resident 1's Physician's Order dated 3/30/2024, the Physician's Order indicated to administer Ativan 1 mg every 12 hours as needed for irritability as evidenced by excessive pacing for no apparent reason. During a review of Resident 1's MAR dated 4/2024, the MAR indicated Resident 1 received Ativan for irritability as evidenced by pacing for no apparent reason on the following dates and times: 1. On 4/1/2024, at 2:45 p.m. 2. On 4/2/2024, at 3 a.m. 3. On 4/3/2024, at 4:02 a.m. 4. On 4/5/2024, at 4:06 a.m. 5. On 4/6/2024, at 7:48 p.m. 6. On 4/8/2024, at 7:38 p.m. 7. On 4/9/2024, at 9:50 a.m. 8. On 4/10/2024, at 8:10 a.m. 9. On 4/12/2024, at 7:57 p.m. During a review of Resident 1's Progress Notes dated 4/10/2024, the Progress Notes indicated at 11:52 a.m., Resident 1 went out on pass for a court appointment. During a review of Resident 1's Court Minutes dated 4/10/2024 and timed at 1:30 p.m., the Court Minutes indicated Resident 1 remained gravely disabled as a result of a mental disorder and Resident 1's Conservator was reappointed over Resident 1 and his estate. During a review of Resident 1's SBAR Elopement Report of Incident, dated 4/13/2024 and timed at 7:45 p.m., the SBAR indicated Resident was previously seen by staff at approximately 7:25 p.m. During a review of Resident 1's Nursing Note dated 4/13/2024 and timed at 7:45 p.m., the Nursing Note indicated on 4/13/2024 at around 7:30 p.m., Resident 1 was noted by staff outside of the facility wheeling himself across the street. The Nursing Note indicated Resident 1's wander guard was discovered ripped and lying on top of Resident 1's side table. The Nursing Note indicated a search for Resident 1 was initiated outside of the facility and Resident 1 was not found. During a tour of the facility on 4/16/2024 at 3:27 p.m., a total of seven doors were observed. Four of the seven doors were observed with alarms as well as a wander guard system. One door that lead to the rehabilitation patio was observed with an alarm and no wander guard system. One door at the front of the facility, that was used as the primary entrance into the facility and exit out of the facility was observed with a wander guard system but did not have an audible alarm in place. One door was observed in the kitchen that lead to an alley without an or wander guard system. During a concurrent tour of the facility's outside patio and interview with the MS on 4/16/2024 at 3:53 p.m., the facility's outside patio door was observed with access to the alley. The door's alarm, when sounded, was faint and could be heard only when in close proximity to it, and the alarm once activated would shut off within five seconds. The MS stated the alarm was not loud enough to be heard at a distance and didn't stay on long enough for anyone to hear it. During an interview on 4/16/2024 at 5:32 p.m., a certified nursing assistant (CNA 1) stated on 4/13/2024 around 7:30 p.m., she was sitting in her car and saw a man approximately 300 feet away from the facility in a wheelchair crossing the street and blocking oncoming traffic. CNA 1 stated it was difficult to see initially if it was Resident 1 because it was raining really hard. CNA 1 stated once she realized it was Resident 1 crossing the street, she immediately went inside the facility and notified the registered nurse (RN 1) that Resident 1 was outside of the facility crossing the street. CNA 1 stated the facility's front door was locked and she had to ring the doorbell and wait for someone to open the door (not sure of how much time lapsed from identifying Resident 1 outside the facility and obtaining help). CNA 1 stated she did not immediately chase after Resident 1 or yell for him to come back because she was in shock and her first thought was to get help. During an interview on 4/16/2024 at 6:27 p.m., the licensed vocational nurse (LVN 1) stated on 1/20/2024 Resident 1 eloped from the facility around 11:30 p.m. LVN 1 stated the facility staff did not know how Resident 1 eloped from the facility. LVN 1 stated on 4/13/2024 around 7:30 p.m., she heard CNA 1 yelling that Resident 1 was outside of the facility crossing the street. LVN 1 stated she did not recall hearing an alarm sound during her shift, but she did see Resident 1's wander guard lying on his bedside table, and it looked as if Resident 1 had ripped it off. During an interview on 4/17/2024 at 10:25 a.m., the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents) after reviewing Resident 1's Elopement Evaluation dated 12/29/2023 and Nursing Notes dated 1/31/2024, stated a care plan related to Resident 1's elopement risk should have been created as well as a care plan addressing Resident 1's behavior of refusing to wear his wander guard bracelet and taking it off. During an interview on 4/17/2023 at 12:02 p.m., the DON stated all staff are responsible for the safety of the residents, and anything could happen to a resident when they elope from the facility. The DON stated she was aware Resident 1 had a history of elopement, but they could not hold a resident against their will. During an interview on 4/18/2024 at 2:28 p.m., Resident 5 stated on 4/10/2024, Resident 1 had a court hearing to determine if he (Resident 1) could leave the facility. Resident 5 stated when Resident 1 returned from his court hearing, he was upset because he wanted to leave the facility and the court would not let him leave. Resident 5 stated Resident 1 carried a backpack which looked full and told him (Resident 5) I always gotta be ready to leave at any time. During an interview on 4/18/2024 at 4:21 p.m., with the ADM and the DON, the ADM stated, there was a potential for Resident 1 to be injured and/or killed since his whereabouts and health status were unknown. The DON stated, Resident 1 was not taking his psychiatric medications, and there was a potential for him to harm others and/or himself. During a telephone interview on 4/25/2024 at 1:53 p.m., Resident 1's Conservator stated Resident 1 was appointed a psychiatric conservatorship 12/2021 because of Resident 1's mental health disorder and being gravely disabled. The Conservator stated Resident 1 had no plan for self-care and could be a danger to himself and/or other's if he did not continue his medication regimen. The Conservator stated Resident 1 had a history of elopement which was discussed with the facility prior to his admission on 11/17/2023. The Conservator stated Resident 1 also had a history of alcohol and illegal drug abuse which placed Resident 1 at further risk of harming himself and/or others because he could consume substances not prescribed to him and he was not taking his prescribed medications. During a review of the facility's P&P titled, Incident & Accident Management Policy, revised 10/2011, the P&P indicated the purpose is to promptly acknowledge and manage facility incidents and accidents to ensure the medical needs of affected individuals are identified and addressed; to analyze contributing factors and environmental conditions that may be modified in order to provide a safe environment and reduce incidents of reoccurrence; to provide a process for tracking and trending incident data for improved quality of care and facility safety, as well as reduce legal risk to the facility. The P&P indicated an incident is defined as any event in which an injury was sustained by a resident .or may have the potential to cause injury. During a review of the facility's P&P titled, Elopement and Missing Resident, dated 12/2027, the P&P indicated to monitor and evaluate residents at risk for wandering and elopement. The Interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs. The P&P indicated an elopement occurs when a resident leaves the premises or a safe area without authorization or staff notification and/or any necessary supervision to do so. The P&P indicated to initiate interventions to address resident's elopement risk.

Based on interview and record review, the facility failed to ensure a resident, who was admitted to the facility for pain management, from a General Acute Care Hospital (GACH) following two spinal fusion (a surgical procedure to connect two or more bones in the lower part of the spine) surgeries, was medicated to control the pain for one of five sampled residents (Resident 1). The facility failed to: 1. Provide Dilaudid (a narcotic medication used to treat moderate to severe pain), for approximately six hours, to Resident 1 who complained of a pain level of 10 out 10 on a 0-10 pain rating scale (where zero= no pain and 10= is the worst pain possible). 2. Follow up with the pharmacy to confirm the pharmacy received the fax order for Dilaudid. 3. Contact Resident 1's physician and/or the facility's pharmacy to request access to the facility's Emergency Kit ([E-Kit] a kit containing a small supply of medication that can be dispensed when the medication is not available from the pharmacy) in order to obtain Dilaudid to administer to Resident 1 for a pain level of 10 out of 10. 4. Ensure Licensed Vocational Nurse (LVN 1) was knowledgeable regarding the purpose of the E-Kit, was trained/instructed when the E-Kit should be used and, on the protocol/procedure necessary to access the medications that were in the E-Kit. 5. Ensure LVN 1, when she was made aware of Resident 1's pain level of 10 out of 10, continued to assess and monitor Resident 1's status and documented care provided to Resident 1 to relieve her pain. These deficient practices resulted in Resident 1 experiencing increased, unrelieved severe intense pain for approximately six hours and had the potential to affect Resident 1's sleep, appetite, mental health and delay her recovery. On 2/20/2024 at 1:03 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider'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 in the presence of the facility's Administrator (ADM) and the Regional Director of Clinical Operations (RDCO) due to the facility's failure to obtain and administer pain medication to Resident 1 to relieve her severe pain. On 2/21/2024 the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/21/2024 at 5:20 p.m., in the presence of the facility's ADM and RDCO. The facility's IJPR included the following immediate actions: 1. The RDCO, Director of Nursing Services (DNS), Infection Preventionist (IP) and or Director of Staff Development (DSD) will re-educate licensed nurses on the facility's pain management policy and procedures emphasizing how to assess and recognize pain to ensure residents' safety and comfort, who to contact for assistance as needed, such as the resident's physician and/or the Director of Nursing Service (DNS). This education was initiated on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 2. The Pharmacist, Pharmacy Nurse, RDCO, DNS, IP, and/or DSD will re-educate licensed nurses on the facility's policy and procedure on how to obtain pain medication (narcotics) from the facility's Emergency Kit (E Kit) and to follow up with the pharmacy on transmitted orders to ensure the pharmacy is aware of the order to ensure the medication is available to residents. This education was initiated by RDCO on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21 /24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 3. The Pharmacist, Pharmacy Nurse, RDCO, DNS, IP and/or (DSD will reeducate licensed nurses on the facility's E-Kit use and policy and procedures emphasizing the necessary steps needed to access the E-Kit to obtain medication from the E-Kit. This education was initiated by RDCO on 2/21/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 4. The RDCO, DNS, IP, and/or DSD will reeducate licensed nurses on facility's pain management policy and procedures emphasizing when and how to assess residents for pain, continue to monitor residents for pain and document care provided to residents. This education was initiated by RDCO on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 5. On 2/15/24 at 5:40 p.m., the RDCO provided 1:1 in-service to L VN 1 over the phone on Medication Administration, Pain Assessment, Documentation of non-pharmacological intervention, utilization of the E-kit, following up with pharmacy, primary care physician, and the medical director, to facilitate controlled pain medication orders, and the importance of calling the DNS for further direction. The RDCO, DNS or designee will provide in-person re-education to L VN 1, who was in charge during the nightshift, prior to her next scheduled shift. LVN 1 will be re-educated on the following: a. The facility's pain management policy and procedures emphasizing how to assess and recognize pain. b. The facility's policy and procedure on how to obtain pain medication (narcotics) from the facility's E-Kit and to follow up with the pharmacy on transmitted orders to ensure the pharmacy is aware of the order to ensure medication is available to residents. c. The facility's E-Kit use policy and procedures emphasizing the necessary steps to access the E-Kit in order to obtain medication from the E-Kit. e. The facility's pain management policy and procedures emphasizing when and how to assess residents for pain, continue to monitor residents for pain and document the care provided to a resident. f. The facility's pain management policy and procedures emphasizing residents' safety and comfort and who to contact for assistance as needed, such as the resident's physician and/or the Director of Nursing. 6. Have a system in place for residents who are admitted to the facility with indications of pain to assess, report, monitor, treat pain, to get pain under control. 7. The facility Administrator hired a DSD on 1/2/24 who resigned on 1/9/24 to return to their previous employer. The Facility Administrator hired another DSD on 2/5/24 who resigned on 2/9/24 to obtain her Administrator in Training license. On 2/21/24, the Administrator hired a new DSD who will begin working at the facility on 3/6/24. The DNS, DSD and/or RDCO will provide instruction to new licensed nurses on the corrective action/plan for F697- Pain Management. Effective 2/22/24, Covenant Care Clinical Resources will provide a designee, Covenant Care employee or DSD from a sister facility who will act as an interim DSD to provide new hire training, until the new DSD is officially onboarded. 8. Licensed Nurses will be in-serviced by the DNS, RDCO, DSD, and/or the Pharmacy representative on pain management and the E-Kit every quarter x four quarters, and on an as needed basis to be provided. For What 9. On the evening shift, there will be at least 3 licensed nurses. On the night shift there will be at least 2 licensed nurses. DNS or designee will be available on call to support and provide guidance in an urgent/emergent situation, such as pain management. 10. Licensed Nurses have been provided an in-service on contacting the Medical Director when Primary Care Physician is not available. The Administrator will hire a Quality Assurance (QA) Physician to be the alternate physician if the Medical Director is not available. 11. The licensed nurses will assess newly admitted residents for pain upon admission, utilizing the admission pain assessment and will develop a plan of care according to the pain assessment. 12. The Interdisciplinary (IDT) members will review the newly admitted /readmitted residents the following business day to ensure residents' pain is assessed, interventions developed and implemented to help manage pain. The findings will be communicated to the DNS and Charge Nurse to ensure that this is communicated to the resident and/or resident's responsible party and physician for medication adjustment as necessary. The findings and resolution will be communicated to the facility Administrator for further recommendations. 13. The Medical Records Director (MRD) will conduct a weekly QA audit for newly admitted residents within 72 hours of admission for pain assessment completion. The findings will be reported to the DNS. The DNS will designate a licensed nurse to complete pain assessment within 24 hours. The involved Licensed Nurse will be re-trained by the DNS or designee on completion of the pain assessment. 14. The Social Service Designee and or Designee on a weekly basis will conduct 5 random residents' interview to determine their satisfaction with pain management. The findings will be reported to the DNS or RN supervisor for pain re-evaluation and communicated to the primary care physician. 15. The DNS will provide a summary trend analysis of IDT, MRD, DNS, and Social Service reviews, for further review and recommendations to the facility's quarterly QAPI meeting, beginning March 2024, x 4 quarters or until substantial compliance is achieved. Findings: During a review of Resident 1's GACH's Admission Record, the Admission Record indicated Resident 1 was admitted to the GACH on 2/2/2024. During a review of Resident 1's Neurosurgery Operative report, from the GACH, dated 2/2/2024, the Operative Report indicated Resident 1 had a lumbar (lower part of the back) two to lumbar three lateral retroperitoneal approach (surgery performed through an incision over the patient's side) surgery with discectomy (surgical removal of the damaged portion of the disk in the spine) and insertion of a biomechanical device (spine surgery to connect two or more bones with screws in the lower part of the spine). During a review of Resident 1's Neurosurgery Operative report dated 2/6/2024, the Operative Report indicated Resident 1 had a lumbar one to lumbar three intertransverse (between the bones of the spine) and posterolateral (on the side and toward the back of the body) lumbar fusion (back surgery where the spine is fused together to treat pain) surgery. During a review of Resident 1's GACH Medication Administration Record (MAR) dated 2/10/2024, the MAR indicated Resident 1 received Dilaudid 1 mg at 2:24 a.m., 5:38 a.m., 8:58 a.m., 12:26 p.m., 3:30 p.m., and 6:35 p.m. During a review of Resident 1's GACH Discharge Summary Note dated 2/10/2024, the Discharge Summary Note indicated Resident 1's pain was managed well with a Fentanyl patch (medication used to treat moderate to severe patch in the form of a patch placed on the skin of a patient) and Dilaudid medication. During a review of Resident 1's Admission Record (Face Sheet) for the facility, the Face Sheet indicated Resident 1 was admitted on [DATE] with the diagnosis of fusion of the lumbar region of the spine (a surgical procedure to permanently join two or more bones in the spine so there is no movement between them). During a review of Resident 1's History and Physical (H&P) dated 2/12/2024, the H&P indicated Resident 1 had the mental capacity to make decisions. The H&P indicated the plan for Resident 1 was for pain management. During a review of Resident 1's Physician's Orders dated 2/10/2024, the following medications were prescribed to Resident 1 for pain: 1. Dilaudid 1 milligram ([mg] a unit of measurement) tablet every three hours as needed for moderate pain (4-6) and severe pain (7-10). 2. Tylenol (a medication used to treat minor aches, pains, and fever) 650 mg tablet every four hours as needed for mild pain (1-3). During a review of Resident 1's Care Plan for Acute/Chronic Pain dated 2/10/2024, the Care plan indicated Resident 1 had acute/chronic pain and the goal was for Resident 1 to report satisfactory pain control. The Care Plan's interventions included evaluating Resident 1's pain, medicating Resident 1 with pain medication as needed and evaluating the effectiveness of the pain medication. During a review of Resident 1's MAR dated 2/11/2024, the MAR indicated Tylenol 650 mg was administered to Resident 1 on 2/11/2024 at 2:36 a.m., for a pain level of 10 out of 10. During a review of the facility's Narcotic Emergency Box (E-Kit), the list of contents dated 12/31/2024 included four tablets of Dilaudid 2 mg per tablet. During an interview on 2/13/2024 at 11:46 a.m., and a subsequent interview on 2/16/2024 at 10:35 a.m., Resident 1 stated she was given pain medication at the GACH at approximately 6:40 p.m., on 2/10/2024, before she was transferred to the facility and her pain was under control when she arrived at the facility. Resident 1 stated she began asking about the status of the Dilaudid delivery at approximately 11 p.m., on 2/10/2024 because she did not want to wait until the pain was unmanageable and she was given different reasons why the Dilaudid was not available. Resident 1 stated the next time she received Dilaudid at the facility was 8:30 a.m., on 2/11/2024 and by that time she was delirious (a disturbed state of mind resulting from illness, characterized by restlessness and the inability to think or speak in a sensible and reasonable way) with pain. Resident 1 stated her pain was an 18 out of 10 (indicating it was worse than a 10 on the pain scale). Resident 1 stated on 2/11/2024 at 2:30 a.m., she was in the bed hollering, screaming in pain and crying for someone to help her. Resident 1 stated she experienced a burning sensation which extended from her lower back to her upper thighs. Resident 1 stated the pain continued to get worse, she reported it to the staff, they offered her Tylenol, and she took the Tylenol knowing it would not help stop the pain. During a telephone interview on 2/13/2024 at 3:35 p.m., Resident 1's Family Member (FM) stated when she spoke to the facility's staff on 2/10/2024 she was told the facility did not have Resident 1's Dilaudid pain medication and she (FM) even offered to pick it up. Resident 1's FM stated she spoke to the morning charge nurse on 2/11/2024 and was told the Dilaudid was available in the facility's E-kit. Resident 1's FM stated it was so hard to hear her sister in tears because of the pain she (Resident 1) experienced throughout the night. During an interview on 2/14/2024 at 11:46 p.m., Registered Nurse Supervisor 1 (RNS 1) stated he admitted Resident 1 to the facility on [DATE] at approximately 8 p.m., and he faxed Resident 1's medication orders to the pharmacy but the medications were not delivered before the end of his shift (3 p.m. - 11 p.m.). RNS 1 stated Resident 1's FM came to the facility on [DATE] around 7 a.m., upset because Resident 1 had not received any pain medication throughout the night. RNS 1 stated he refaxed the medication orders to the pharmacy on 2/11/2024 and received authorization from the pharmacy to access the E-kit to obtain the Dilaudid. RNS 1 stated the purpose of the E kit was to have medication available if the pharmacy was not able to deliver it, if medications were missing, or if the resident was newly admitted and needed medication immediately. During an interview on 2/14/2024 at 12:18 p.m., the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) stated if medication was not delivered by the pharmacy, licensed nurses could contact the physician to obtain authorization to get medication from the E kit and administer a onetime dose to a resident. The MDS Nurse stated Resident 1 received Tylenol 650 mg on 2/11/2024 at 2:36 a.m., for a pain level of 10 out of 10, but it was indicated for mild pain (1-3). The MDS Nurse stated there was no documentation to indicate if the Tylenol was effective in relieving Resident 1's pain. The MDS Nurse stated pain medication effectiveness should be reassessed 30 minutes to one hour after administration of pain medications. The MDS Nurse stated if the pain medication was not effective the resident's physician should be contacted for additional instructions or to authorize access to the E-Kit, if the resident's physician could not be reached, the medical director should be called. During an interview on 2/14/2024 at 1:13 p.m., and subsequent interviews on 2/16/2024 at 10:04 a.m., and at 4:01 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was admitted to the facility on [DATE] and her pain began that night between 11 p.m., and 12:30 a.m. LVN 1 stated Resident 1's FM called the facility around midnight asking what could be done for Resident 1 to relieve her pain. LVN 1 stated she explained to Resident 1's FM that Resident 1 would have to wait for the pain medication to be delivered. LVN 1 stated she did not contact Resident 1's physician or the pharmacy because the pain medication had already been ordered and she thought it would arrive during the first delivery (1 a.m. - 2 a.m.). LVN 1 stated she administered Tylenol 650 mg to Resident 1 because that, was the only pain medication available. LVN 1 stated Resident 1 agreed to take Tylenol even though she (Resident 1) knew it would not relieve her pain. LVN 1 stated she checked on Resident 1 after the Tylenol was given to her and Resident 1 was still in pain. LVN 1 stated she did not notify of Resident 1's physician of Resident 1's unrelieved pain. LVN 1 stated she was expecting and hoping Resident 1's pain medication would be delivered from the pharmacy during her shift (11 p.m. to 7 a.m.) but it was not delivered. LVN 1 stated when RNS 1 arrived the next morning (2/11/2024), her and RNS 1 called the pharmacy to obtain authorization to access the E-Kit and administered Dilaudid 1 mg to Resident 1. LVN 1 stated she thought the E kit was for specific residents and not intended for Resident 1's use, she did not know how to access the medications in the E kit, and she did not understand the medication in the E-Kit were for any resident that needed them. LVN 1 stated she was not provided training on the E kit during her orientation. During a review of the facility's Emergency Kit Pharmacy Log, the log indicated Resident 1 received Dilaudid 0.5 mg tablet on 2/11/2024 at 7:45 a.m. During an interview on 2/15/2024 at 2:30 p.m., the Pharmacy Nurse Executive stated when the facility gets a new admission, the facility's licensed nurses should fax the medication order to the pharmacy and follow up with a phone call in 20 minutes to ensure the pharmacy received the fax. During an interview on 2/15/2024 at 3:11 p.m., the Director of Pharmacy Operations stated if a resident was experiencing pain and the resident's physician was unavailable, the pharmacist could assess the resident's profile to give a onetime authorization for the resident to receive pain medication. During an interview on 2/15/2024 at 3:45 p.m., and a subsequent interview on 2/16/2024 at 12:07 p.m., the RDCO stated if medication had not arrived from the pharmacy, the licensed nurses should follow up with the pharmacy, the resident's physician and if the resident's physician was not available, the licensed nurses should call the medical director. The RDCO stated the purpose of the E-Kit was to provide medication to residents when medication was not available from the pharmacy or if there was an emergency situation. The RDCO stated if the resident does not receive pain medication, they could experience continued pain or an increased intensity in pain. During a review of the facility's policy and procedure (P/P), titled Medication Administration, dated 10/2022, the P/P indicated medications should be administered by the licensed nurse as ordered by the physician and in accordance with professional standards of practice. During a review of the facility's P/P titled Pain Management, dated 10/2022, the P/P indicated the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. During a review of the facility's P/P titled Emergency Pharmacy Service and Emergency Kits, dated 2/2020, the P/P indicated emergency needs for medication are met by using the facility's approved emergency medication supply. When there is an emergency, the charge nurse should determine if the order is a true emergency, if the order cannot wait until the next scheduled pharmacy delivery and ascertain whether the ordered medication is contained in the emergency kit by referring to the list of contents posted at the nursing station or on the box. During a review of the facility's Job Description for an LVN the Job Description indicated the key job functions for a LVN included: accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition, respond promptly to evaluate and remedy patient concerns and complaints, maintains familiarity with use of emergency medical supplies, and facilitates the availability of medications to comply with physician orders and invokes STAT procedure when needed, and appropriately monitors, assesses, documents, and medicates pain throughout the shift. Based on interview and record review, the facility failed to ensure a resident, who was admitted to the facility for pain management, from a General Acute Care Hospital (GACH) following two spinal fusion (a surgical procedure to connect two or more bones in the lower part of the spine) surgeries, was medicated to control the pain for one of five sampled residents (Resident 1). The facility failed to: 1. Provide Dilaudid (a narcotic medication used to treat moderate to severe pain), for approximately six hours, to Resident 1 who complained of a pain level of 10 out 10 on a 0-10 pain rating scale (where zero= no pain and 10= is the worst pain possible). 2. Follow up with the pharmacy to confirm the pharmacy received the fax order for Dilaudid. 3. Contact Resident 1's physician and/or the facility's pharmacy to request access to the facility's Emergency Kit ([E-Kit] a kit containing a small supply of medication that can be dispensed when the medication is not available from the pharmacy) in order to obtain Dilaudid to administer to Resident 1 for a pain level of 10 out of 10. 4. Ensure Licensed Vocational Nurse (LVN 1) was knowledgeable regarding the purpose of the E-Kit, was trained/instructed when the E-Kit should be used and, on the protocol/procedure necessary to access the medications that were in the E-Kit. 5. Ensure LVN 1, when she was made aware of Resident 1's pain level of 10 out of 10, continued to assess and monitor Resident 1's status and documented care provided to Resident 1 to relieve her pain. These deficient practices resulted in Resident 1 experiencing increased, unrelieved severe intense pain for approximately six hours and had the potential to affect Resident 1's sleep, appetite, mental health and delay her recovery. On 2/20/2024 at 1:03 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider'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 in the presence of the facility's Administrator (ADM) and the Regional Director of Clinical Operations (RDCO) due to the facility's failure to obtain and administer pain medication to Resident 1 to relieve her severe pain. On 2/21/2024 the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/21/2024 at 5:20 p.m., in the presence of the facility's ADM and RDCO. The facility's IJPR included the following immediate actions: 1. The RDCO, Director of Nursing Services (DNS), Infection Preventionist (IP) and or Director of Staff Development (DSD) will re-educate licensed nurses on the facility's pain management policy and procedures emphasizing how to assess and recognize pain to ensure residents' safety and comfort, who to contact for assistance as needed, such as the resident's physician and/or the Director of Nursing Service (DNS). This education was initiated on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 2. The Pharmacist, Pharmacy Nurse, RDCO, DNS, IP, and/or DSD will re-educate licensed nurses on the facility's policy and procedure on how to obtain pain medication (narcotics) from the facility's Emergency Kit (E Kit) and to follow up with the pharmacy on transmitted orders to ensure the pharmacy is aware of the order to ensure the medication is available to residents. This education was initiated by RDCO on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21 /24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 3. The Pharmacist, Pharmacy Nurse, RDCO, DNS, IP and/or (DSD will reeducate licensed nurses on the facility's E-Kit use and policy and procedures emphasizing the necessary steps needed to access the E-Kit to obtain medication from the E-Kit. This education was initiated by RDCO on 2/21/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 4. The RDCO, DNS, IP, and/or DSD will reeducate licensed nurses on facility's pain management policy and procedures emphasizing when and how to assess residents for pain, continue to monitor residents for pain and document care provided to residents. This education was initiated by RDCO on 2/15/24 for in house staff, in-services to all licensed nurses will be completed by 2/21/24. Licensed staff who were not able to attend the training will be educated prior to the start of their shift. 5. On 2/15/24 at 5:40 p.m., the RDCO provided 1:1 in-service to L VN 1 over the phone on Medication Administration, Pain Assessment, Documentation of non-pharmacological intervention, utilization of the E-kit, following up with pharmacy, primary care physician, and the medical director, to facilitate controlled pain medication orders, and the importance of calling the DNS for further direction. The RDCO, DNS or designee will provide in-person re-education to L VN 1, who was in charge during the nightshift, prior to her next scheduled shift. LVN 1 will be re-educated on the following: a. The facility's pain management policy and procedures emphasizing how to assess and recognize pain. b. The facility's policy and procedure on how to obtain pain medication (narcotics) from the facility's E-Kit and to follow up with the pharmacy on transmitted orders to ensure the pharmacy is aware of the order to ensure medication is available to residents. c. The facility's E-Kit use policy and procedures emphasizing the necessary steps to access the E-Kit in order to obtain medication from the E-Kit. e. The facility's pain management policy and procedures emphasizing when and how to assess residents for pain, continue to monitor residents for pain and document the care provided to a resident. f. The facility's pain management policy and procedures emphasizing residents' safety and comfort and who to contact for assistance as needed, such as the resident's physician and/or the Director of Nursing. 6. Have a system in place for residents who are admitted to the facility with indications of pain to assess, report, monitor, treat pain, to get pain under control. 7. The facility Administrator hired a DSD on 1/2/24 who resigned on 1/9/24 to return to their previous employer. The Facility Administrator hired another DSD on 2/5/24 who resigned on 2/9/24 to obtain her Administrator in Training license. On 2/21/24, the Administrator hired a new DSD who will begin working at the facility on 3/6/24. The DNS, DSD and/or RDCO will provide instruction to new licensed nurses on the corrective action/plan for F697- Pain Management. Effective 2/22/24, Covenant Care Clinical Resources will provide a designee, Covenant Care employee or DSD from a sister facility who will act as an interim DSD to provide new hire training, until the new DSD is officially onboarded. 8. Licensed Nurses will be in-serviced by the DNS, RDCO, DSD, and/or the Pharmacy representative on pain management and the E-Kit every quarter x four quarters, and on an as needed basis to be provided. For What 9. On the evening shift, there will be at least 3 licensed nurses. On the night shift there will be at least 2 licensed nurses. DNS or designee will be available on call to support and provide guidance in an urgent/emergent situation, such as pain management. 10. Licensed Nurses have been provided an in-service on contacting the Medical Director when Primary Care Physician is not available. The Administrator will hire a Quality Assurance (QA) Physician to be the alternate physician if the Medical Director is not available. 11. The licensed nurses will assess newly admitted residents for pain upon admission, utilizing the admission pain assessment and will develop a plan of care according to the pain assessment. 12. The Interdisciplinary (IDT) members will review the newly admitted /readmitted residents the following business day to ensure residents' pain is assessed, interventions developed and implemented to help manage pain. The findings will be communicated to the DNS and Charge Nurse to ensure that this is communicated to the resident and/or resident's responsible party and physician for medication adjustment as necessary. The findings and resolution will be communicated to the facility Administrator for further recommendations. 13. The Medical Records Director (MRD) will conduct a weekly QA audit for newly admitted residents within 72 hours of admission for pain assessment completion. The findings will be reported to the DNS. The DNS will designate a licensed nurse to complete pain assessment within 24 hours. The involved Licensed Nurse will be re-trained by the DNS or designee on completion of the pain assessment. 14. The Social Service Designee and or Designee on a weekly basis will conduct 5 random residents' interview to determine their satisfaction with pain management. The findings will be reported to the DNS or RN supervisor for pain re-evaluation and communicated to the primary care physician. 15. The DNS will provide a summary trend analysis of IDT, MRD, DNS, and Social Service reviews, for further review and recommendations to the facility's quarterly QAPI meeting, beginning March 2024, x 4 quarters or until substantial compliance is achieved. Findings: During a review of Resident 1's GACH's Admission Record, the Admission Record indicated Resident 1 was admitted to the GACH on 2/2/2024. During a review of Resident 1's Neurosurgery Operative report, from the GACH, dated 2/2/2024, the Operative Report indicated Resident 1 had a lumbar (lower part of the back) two to lumbar three lateral retroperitoneal approach (surgery performed through an incision over the patient's side) surgery with discectomy (surgical removal of the damaged portion of the disk in the spine) and insertion of a biomechanical device (spine surgery to connect two or more bones with screws in the lower part of the spine). During a review of Resident 1's

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who tested positive for COVID-19 (Coronavirus disease -a contagious respiratory infectious illness) on 11/2/2023 and had a change of condition (COC) of shortness of breath and lethargy (condition of deep and lasting drowsiness from which the person can be aroused only with difficulty and temporarily) on 11/6/2023, was provided care. The facility failed to: 1. Ensure Resident 1 was assessed, monitored, and had vital signs (VS- measurements of the body's most basic functions temperature, pulse rate, respiration rate [rate of breathing] and blood pressure)including oxygen saturation ([O2 sat] blood oxygen level) checked every shift as ordered by the physician. 2. Ensure Resident 1 ' s physician was informed of the continuous shortness of breath after Resident 1 was seen by the medical doctor (MD) on 11/7/2023. 3. Ensure staff followed the facility ' s policy and procedure (P&P) titled, Change of Condition To appropriately assess, document, and communicate change of condition .to provide treatment and services to address changes in accordance with resident needs . 4. Ensure staff followed the facility ' s P&P titled, Covid-19 Management & Mitigation Policy. Monitor vital signs and symptoms each shift (minimally) to promptly identify conditions changes and quickly identify residents who require a higher level of care. These failures resulted in a delay of identification of abnormal changes in Resident 1 ' s status on 11/6/2023. Resident 1 had low oxygen saturation of 70 percent ([%] normal oxygen saturation was 95 %-100%), with shortness of breath, congestion (accumulation of mucus in the lungs), and change in mental status (lethargic). Resident 1 was transferred to a General Acute Care Hospital (GACH) for an oxygen saturation of 70 % and admitted with acute respiratory failure (results from acute or chronic impairment of gas exchange [occurs in the lungs and the blood] with hypoxemia (an abnormally low level of oxygen in the blood), and consequently was placed on a Bipap machine (a device that helps with breathing) to assist with Resident 1 ' s breathing. Findings: During a review of Resident 1 ' s Admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), congested heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and failure to thrive (a term used to describe inadequate weight, appetite, nutrition, mood, and physical activity). During a review of Resident 1 ' s History and Physical (H&P), dated 11/7/23, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool), dated 11/3/23, the MDS indicated Resident 1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. The MDS indicated Resident 1 was dependent (relies on support from another individual) with sit to lying, oral hygiene, toileting hygiene, showering, and dressing. During an interview on 11/9/23 at 9:52 am with Resident 1 ' s Representative (RR), RR stated, she visited Resident 1 at the facility on Monday 11/6/23 approximately 1:00 pm. RR stated Resident 1 was having shortness of breath (SOB) and was lethargic. RR reported to licensed vocational nurse (LVN) 1 regarding Resident 1 ' s condition (SOB and lethargy). RR stated LVN 1 administered a breathing treatment (procedure that delivers medication directly to the lungs) to Resident 1. RR stated after the breathing treatment was given Resident 1 continued to have SOB. RR stated LVN 1 did not check Resident 1 ' s VS and oxygen level at the time she reported Resident 1 having shortness of breath. RR stated Resident 1 would not respond to her verbally and had a lot of mucous (slimy substance that is produced by the body) in his mouth. RR stated Resident 1 ' s was able to respond to her verbally prior to 11/6/2023. RR stated she was notified on 11/7/23 at 11:30 pm that Resident 1 was being transferred to the hospital. During a concurrent interview and record review on 11/9/23 at 12:46 pm, with Registered Nurse (RN) 1, RN 1 stated Resident 1 was verbal, Spanish speaking, alert, and oriented. RN 1 stated Resident 1 was on continuous oxygen via nasal cannula (a device that delivers oxygen through a tube and into the nose) and due to congestion, needed frequent oral suctioning (inserting a small plastic tube into the mouth or nose that is attached to a suction machine to remove saliva or mucus). Resident 1 ' s Nurses Progress Notes dated 11/7/2023 timed at 7:13 pm was reviewed and indicated Resident 1 had difficulty breathing, labored breathing and shortness of breath, upon exertion and mental status was lethargic. RN 1 stated if staff knew that Resident 1 was having difficulty breathing, Resident 1 ' s physician should be notified about his condition so the resident could be transferred to a higher level of care (GACH). RN 1 stated when Resident 1 had an oxygen saturation of 70 % (normal oxygen saturation was 95 %-100%) that would be considered a significant change of condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain). During a concurrent interview and record review on 11/9/23 at 1:00 pm, with Director of Nursing (DON), the DON stated an oxygen saturation of 70% would be considered a change of condition and should be reported immediately to the physician. The DON stated when a resident has a change of condition (SOB, congestion, and Oxygen saturation of 70%) an assessment including VS and oxygen saturation should be done every 4 hours. The DON stated when a resident has low oxygen saturations the resident could go into respiratory failure, or cardiac arrest. The DON stated, LVN 2 informed her on 11/8/23 at 12:00 am, via text message, that Resident 1 ' s oxygen saturation was low, and she instructed LVN 2 to call 911 immediately. The DON stated, vital signs should be done at the beginning of each shift and documented in Resident 1 ' s medical record, to have a baseline of Resident 1 ' s condition, because vital signs could be abnormal and appropriate interventions could be done if needed. The DON reviewed the Weights and Vitals Summary dated 11/7/23 that indicated Resident 1 ' s oxygen saturation was checked at 11:15 pm and was 70 percent and no other documentation for vital signs were noted for the shift by LVN 2. The DON stated if Resident 1 was having difficulty breathing at the beginning of the shift (3-11 shift) vital signs including oxygen saturation should have been obtained to prevent a delay in Resident 1 ' s care and the need to be transferred to a higher level of care. During an interview on 11/9/23 at 2:34 pm with LVN 2, LVN 2 stated Resident 1 was having difficulty breathing on 11/7/2023 at the beginning of 3 pm to 11 pm shift, but Resident 1 was not gasping for air. LVN 2 stated, Resident 1 had labored breathing on two liters (the flow of oxygen you receive from your oxygen delivery device) of oxygen as ordered. LVN 2 stated Resident 1 was observed trying hard to breath. LVN 2 stated she administered a breathing treatment on 11/7/2023 at 5:00 pm. LVN 2 stated she did not obtain VS and oxygen saturation before or after administering the breathing treatment. LVN 2 stated VS and oxygen saturation should be checked before and after a breathing treatment, to know if the treatment was effective. LVN 2 stated she did not take Resident 1 ' s VS at the start of her shift. LVN 2 stated she only took Resident 1 ' s VS and oxygen saturation at 11:00 pm before transferring the resident to the GACH. LVN 2 stated Resident 1 ' s condition declined rapidly by the end of her shift. During an interview on 11/10/23 at 9:22 am with LVN 1, LVN 1 stated, Resident 1 ' s representative informed him that Resident 1 was having difficulty breathing when she visited on 11/6/23 at approximately 1 pm to 2 pm. LVN 1 stated upon his assessment Resident 1 was having difficulty breathing and he (LVN 1) gave Resident 1 a breathing treatment. LVN 1 stated, Resident 1 ' s vital signs including oxygen saturation were not checked before or after the breathing treatment, so he did not know Resident 1 ' s oxygen saturation. LVN 1 stated VS including oxygen saturation should have been checked when Resident 1 was assessed of having difficulty breathing, lethargy and before and after a breathing treatment to get a baseline of the Resident 1 ' s condition. LVN 1 stated the MD came on 11/7/2023 at 5 pm and examined the resident and informed LVN1 the resident had chest congestion and a chest x-ray (pictures of the inside of your body) was ordered (the resident continued to have SOB). LVN 1 stated, when a Resident 1 had a change of condition the process was to do a COC, inform the MD, and resident representatives. During an interview on 11/10/23 at 9:55 am, with Certified Nursing Assistant (CNA) 4, CNA 4 stated she informed LVN 2 that Resident 1 was having difficulty breathing on 11/7/23 at 3:00 pm, the beginning of the shift and LVN 2 stated she would check on Resident 1. CNA 4 stated she does not know if LVN 2 checked on Resident 1 at that time. CNA 4 stated, Resident 1 ' s breathing got worse by the end of the shift (3-11 shift). During a review of Resident 1 ' s Nurses Progress Notes dated 11/7/23 at 7:13 pm, the progress notes indicated Resident 1 was having difficulty breathing, labored breathing and shortness of breath, noted upon exertion. The Nurses Progress Notes indicated Resident 1 ' s mental status was lethargic. During a review of Resident 1 ' s Weights and Vitals Summary dated 11/7/23 at 11:15 pm indicated, Resident 1 ' s oxygen saturation with two liters oxygen via nasal cannula was 70 percent (normal range is ninety-five [95] to one hundred [100] percent [%]). During a review of Resident 1 ' s Care Plan dated 11/2023 titled, Potential for severe illness or complications related to symptoms of COVID-19, the Care Plan indicated to monitor respiratory status and lung sounds for oxygenation and perfusion issues, report to MD as needed (PRN). During a review of Resident 1 ' s Care Plan dated 11/2023 and titled, The Resident has Congestive Heart Failure upon admission, the care plan indicated to monitor/document/report prn any signs/symptoms of congestive heart failure .shortness of breath (SOB) upon exertion .lethargy and disorientation. During a review of Resident 1 ' s Care Plan dated 10/2023 and titled Bilateral Hands Non-Pitting Edema +3 (occurs when excess fluid builds up in the body, causing swelling), indicated notify MD promptly of acute mental status changes .breathing difficulties. During a review of Resident 1 ' s Paramedic Run Sheet, (run sheet- a standard document used by first responders and other emergency medical service care providers that documents the patient's chief complaint, and history), dated 11/7/23 at 11:27 pm, the run sheet indicated, Resident 1 was found supine (lying face upward) in bed at the facility, conscious but altered level of consciousness (ALOC- refers to a change in a patient's state of awareness ability to relate to self and the environment and arousal alertness) and shortness of breath (SOB-difficulty breathing). Per facility staff symptoms began yesterday (11/6/2023) with ALOC tonight (11/7/2023). During a review of Resident 1 ' s GACH H&P dated 11/8/2023 at 7:29 pm, the H&P indicated Resident 1 with complaint of SOB and altered mental status (baseline was alert oriented), lethargic and oxygen saturation of 71 %. The H&P indicated Resident 1 with acute respiratory failure with hypoxemia, and consequently was placed on a Bipap machine to assist with his breathing. During a review of Resident 1 ' s GACH diagnostic radiology chest x-ray report, dated 11/8/23, the chest x-ray report indicated, impression of bilateral infiltrates (an abnormal substance that accumulates gradually within cells or body tissues) could be due to pneumonia or edema. During a review of the facility ' s P&P titled, Notification of Changes, dated 2022, the P&P indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident ' s physician: and notifies, consistent with his or her authority, the resident ' s representative when there is a change requiring notification. During a review of the facility ' s LVN Job Description/Performance Evaluation, dated 2017, the LVN job description indicated, Key job functions: Provides accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition. During a review of facility ' s P&P titled Covid-19 Management & Mitigation Policy dated 2023, the P&P indicated Actions for Covid-19 Positive Test Results in Residents .Monitor vital signs and symptoms each shift (minimally) to promptly identify condition changes and quickly identify residents who require a higher level of care. During a review of facility ' s P&P titled Covid-19 Prevention, Response and Reporting Policy, dated 2023, the P&P indicated Staff will be alert to signs of Covid-19 and notify the resident ' s physician/practitioner if evident: shortness of breath or difficulty breathing.

Based on interview and record review, the facility failed to implement safety measures as per its policy and procedure, which included sensor mats, floor pads, non-skid mats and other equipment to prevent falls and injury for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls with a history of falls and an impulsive behavior of ambulating without assistance, was not provided with adequate supervision and assistance devices to prevent further falls. This deficient practice resulted in Resident 1 falling three (3) times within six days, and the last fall required a transfer to the GACH. Resident 1's condition was so severe the resident had to be transferred from GACH 1 to GACH 2 and an admission into the intensive care unit ((ICU) a higher level of care), with a [MEDICAL CONDITION] (deep cut), traumatic subdural hematoma (a collection of blood outside the brain), and a left rib fractures ((bones on both sides of the chest) broken bone) with a [MEDICAL CONDITION] contusion (a bruise on the lung). Findings: A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 2/27/2020 indicated Resident 1 had no cognitive impairment (thought process). The MDS, under Section G110, Resident 1 was assessed requiring a one-person physical assist during bed mobility, toilet use, transferring, locomotion on and off the unit, personal hygiene and dressing. The MDS indicated Resident 1 required an extensive assistance with walking in room and corridor, as well as eating. According to the MDS, Resident 1 used a walker and wheelchair for mobility and was assessed as having an abnormal gait (manner of walking) and mobility. A review of Resident 1's Initial Fall Risk Screen, dated 2/21/2020 indicated Resident 1 had a score of 36 (total score of 25 to 44 indicated moderate risk for falls). According to the Initial Fall Risk Screen, Resident 1 had an impaired gait and required the use of an assistive device, such as a wheelchair. A review of Resident 1's care plan, initiated on 2/24/2020, identified a problem for risk for falls and injuries. The goal indicated Resident 1 would have decreased risk of falls and/or injuries for 90 days. The staff's interventions included to keep the call light in reach and keep the environment clutter free. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication form), dated 3/7/2020 and timed at 9:45 a.m. indicated a fall report for Resident 1. The SBAR indicated Resident 1 was found by an unspecified staff member sitting on the floor near the bathroom in the room. The SBAR indicated a bed alarm was in place for Resident 1 and the bed was in the lowest position. Neurological checks (an examination of the motor responses to determine [MEDICAL CONDITION] or impairment) done and safety protocol in place. Will continue to monitor the resident's (Resident 1) whereabouts at all times. A review of Resident 1's plan of care (2/24/2020) for falls and injury indicated it was not revised nor updated after the resident fell to prevent Resident 1 from further falls. A review of an SBAR, dated 3/9/2020 and timed at 4:02 p.m., indicated Resident 1 had a second fall. The SBAR indicated Resident 1 was found on the floor lying on his left side with no injury noted. According to the SBAR, Resident 1 was able to move the upper and lower extremities. Resident 1 was observed with a bump and bruising to left side of the head. The SBAR indicated a skull x-ray was ordered and done without indication of the results. A review of a SBAR written by Licensed Vocational Nurse 1 (LVN 1), dated 3/13/2020 and timed at 10:35 a.m. indicated a Fall report incident. The SBAR indicated Resident 1 was found on the floor, with a laceration (deep cut) on the forehead. The SBAR indicated a possible contributing factor to Resident 1's falls was Resident 1 did not ask for help or the used the call light. A review of Resident 1's GACH 1 Emergency Department (ED) report, dated 3/13/2020 and timed at 11:40 a.m. indicated Resident 1 arrived to the ED with a 4 centimeters ((4 cm) unit of measurement) in size right eyebrow laceration after a fall with a pressure gauze dressing in place. A review of GACH 1's ED report, dated 3/13/2020 and timed at 12 p.m. indicated Resident 1 was transported immediately for a computed tomography ((CT Scan) an imagery that reveals anatomic details of internal organs that cannot be seen on conventional x-rays) of the head. The report dated 3/13/2020 and timed at 12:47 p.m. indicated the ED was contacted to transfer Resident 1 to GACH 2 for a higher level of care. GACH 1's ED documentation indicated the paramedics were at the bedside to transport Resident 1 via 911 to GACH 2 due to a brain bleed. Resident 1's Blood pressure was elevated at 149/129 (normal reference range (NRR) is 90/60-139/79). A review of GACH 2's ED report, dated 3/13/2020 and timed at 1:10 p.m. indicated Resident 1 arrived from GACH 1 with a [DIAGNOSES REDACTED]. GACH 2's ED report indicated Resident 1 had an altered level of consciousness ((ALOC) lack of responsiveness to stimuli) with a hematoma and laceration near the right eye. A review of GACH 2's ED report, dated 3/13/2020 and timed at 1:47 p.m. indicated Resident 1 sustained a confirmed holohemispheric subdural hematoma (a type of bleeding in which there is a collection of blood associated with a [MEDICAL CONDITION] gathers between the inner layers of the brain), left chest ecchymosis (bruising) with a left [MEDICAL CONDITION] contusion (a bruise on the left lung caused by chest trauma), left flank (side of the body between the ribs and the hip) ecchymosis (a hemorrhagic spot in the skin or mucous membrane, forming a flat, rounded or irregular, blue or purplish patch), a left nondisplaced fracture (broken bone) of the left seventh rib and with closure of the [MEDICAL CONDITION]. Resident 1 was admitted into the ICU. GACH 2's ED report indicated Resident 1's medical condition placed him at an increased risk of decompensation (showing signs of deterioration regarding daily functioning) and death. On 4/9/2020 at 7:42 a.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated she was providing care for another resident and stated she was called by LVN 1 for an emergency to assist with Resident 1. CNA 1 stated she saw Resident 1 on the floor and LVN 2 was applying pressure to Resident 1's forehead. CNA 1 stated Resident 1 had a [MEDICAL CONDITION] after falling in his room. CNA 1 stated Resident 1 always tried to get out of his bed and wheelchair without assistance from the staff. On 4/9/2020 at 8:03 a.m., during a telephone interview, LVN 1 stated Resident 1 was offered his morning medications on 3/13/2020 but refused. LVN 1 stated about five minutes later Resident 1's roommate called the staff to report Resident 1 had fallen two times in the room. LVN 1 stated she heard Resident 1 fall again from the hallway and she responded right away. LVN 1 stated upon entering the room she observed Resident 1 on the floor laying on his side, with a laceration on his forehead above the right eyebrow. LVN 1 stated she called for help and the treatment nurse (LVN 2) responded. LVN 1 stated Resident 1 sustained a bleeding laceration and LVN 2 applied a gauze and an ice pack to the site. LVN 1 stated Resident 1's physician was called and gave an order to transfer the resident out to GACH 1. On 4/9/2020 at 8:22 a.m., during a telephone interview, LVN 2 stated Resident 1 sustained a laceration of the forehead after a fall but was stable. According to LVN 2, Resident 1 was at risk for falls due to a history of getting up from his wheelchair unassisted and unsupervised. LVN 2 stated an Interdisciplinary Team ((IDT) a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a resident) Meeting was held with the Administrator (ADM) and staff regarding Resident 1's fall. According to LVN 2, the ADM was aware of Resident 1's fall because she documented about the fall on the facility's communication board. On 4/9/2020 at 8:39 a.m., during a telephone interview, the ADM stated he was made aware of Resident 1's fall with laceration by the staff during the morning huddle (rounds). The ADM stated he was not aware of the extent of Resident 1's injuries, which included a rib fracture and subdural hematoma. A review of the facility's policy and procedure (P/P) titled, Fall Management, dated 8/2014, indicated the purpose of the P/P was to evaluate risk factors and provide interventions to minimize risk, injury and occurrences. The P/P indicated fall prevention may include but is not limited to alarms, sensor mats, transfer poles, floor pads, non-skid mats, handrails, grab bars, trapeze, adaptive equipment, transfer lifts etc.

Based on interview and record review, the facility failed to ensure that one of two residents (Resident 1) was free from neglect by failing to: 1. Promptly report to the facility Administrator and investigate the incident whereby, Resident 1 (female resident) wandered inside Resident 2's room (male resident). The incident which occurred a couple of months prior to 1/9/17 (the date when the incident report was made), was reported by Certified Nursing Assistant (CNA 1) to a charge nurse. The abuse report was not in accordance with the facility's abuse policy and procedures. 2. Monitor Resident 1's location every 30 minutes as indicated in the plan of care initiated on 4/21/16 for resident's wandering behavior. 3. Change Resident 1's or Resident 2's room to prevent reoccurrence, since the residents' rooms were one room apart from each other, and Resident 1 could easily wander to Resident 2's room. As a result, Resident 1, the female wandered again into Resident 2's room on 1/9/17, and was observed performing oral (mouth) sex with Resident 2 the male resident. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/17/16, indicated that the resident's cognitive (thinking, reasoning, or remembering) skills for daily decision-making were severely impaired. The MDS indicated that the resident required extensive assistance from the staff with transfer, locomotion on and off the unit, dressing, toilet use and personal hygiene. The resident used walker and wheelchair as mobility devices. A review of Resident 1's care plan for the resident's wandering behavior (The resident is a wanderer) because the resident wanders aimlessly, significantly intrudes on others privacy and activities, was initiated on 4/24/16, reviewed on 9/22/16 and had a target goal date of 2/15/17. One of the goal indicated that resident's safety will be maintained through the review date. The interventions included to monitor the resident's location every 30 minutes, document wandering behavior, and attempted diversional interventions in a behavior log. A review of Resident 1's Situation, Background, Assessment or Appearance and Request Form (SBAR, a framework for communication between members of the health care team about a resident's condition) dated 4/21/16 in the afternoon, and without a specific time, indicated that the resident had a wandering behavior. There was no specific description of where the resident wandered. A review of Resident 1's Progress Notes dated 4/23/16, 4/24/16, 4/25/16, 4/26/16, and 4/27/16, 4/30/16 indicated that Resident 1 was being monitored for wandering behavior and had episodes of wandering. The Progress Notes, dated 4/30/16 at 10:05 p.m., indicated that the resident had two (2) episodes of wandering into other residents' room. During an interview on 1/11/17 at 3:34 p.m., Certified Nursing Assistant (CNA 1) stated that Resident 1 wandered in Resident 2's room couple months ago. CNA 1 stated that she removed Resident 1 from Resident 2's room and reported the incident to the charge nurse. A review of Resident 1's Neuropsychological Evaluation (tests to examine a variety of cognitive abilities, including speed of information processing, attention, memory, language, and functions, which are necessary for goal-directed behavior) dated 1/19/17 indicated that Resident 1 advance dementia syndrome (a group of symptoms that consistently occur together) renders her more vulnerable to the possibility of coercion or abuse, hence behavior and activities should be closely monitored to prevent future involvement in compromising situation. During an interview with the Administrator on 1/11/17 at 5:52 p.m., with concurrent review of Resident 1's medical record from 4/2016 to 1/9/17, the Administrator indicated that he was unable to provide the documented evidence that Resident 1's location was being monitored every 30 minutes as indicated in the plan of care that indicated that The resident is a wanderer .wanders aimlessly, significantly intrudes on the privacy of others or activities, initiated on 4/24/16, and reviewed on 9/22/16, with a target goal date of 2/15/17. During an interview with registered nurse supervisor (RNS 1) on 1/12/17 at 11:10 a.m., RNS 1 stated she was the RNS on 1/9/17, for the 3 p.m. to 11 p.m. shift. RNS 1 stated at 3:45 p.m., while doing her rounds, she entered Resident 2's room and talked to residents on bed 1 and bed 2. RNS 1 stated that she proceeded to bed 3 (Resident 2's bed) and saw Resident 1 performing oral sex to Resident 2. RNS 1 stated that she took Resident 1 out of the room and placed her on 1:1 monitoring. During an interview with the Director of Nurses (DON), on 3/20/17, at 3:35 p.m., the DON stated that she was not aware that Resident 1 was found inside Resident 2's room by CNA 1 couple of months ago. The DON stated that there was no investigation done about this incident. The DON was unable to explain the reason why either Resident room was not changed after the incident, since both rooms were one room apart from each other, and it was quite conceivable that Resident 1 could easily wander into Resident 2's room. During an interview on 1/11/17 at 3:30 p.m., Resident 2 stated that Resident 1 just comes into his room. Resident 2 declined to answer any further question about the incident. A review of Resident 2's Admission Record indicated that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/16 indicated that the resident was capable of daily decision-making. A review of the facility's 12/2012 revised policy and procedures titled Abuse prevention, Intervention, Investigation and Crime reporting policy, indicated that it is the responsibility of employees to promptly report to the facility Administrator, local ombudsman, and Sate Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse from other residents .Reports shall be thoroughly investigated in a timely manner. The policy and procedures under Identification indicated that the facility will monitor the adequacy of assessment, care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as: socially inappropriate or disruptive behaviors .wandering into the rooms or personal space of other residents.