Every finding on record at The Earlwood

Based on interview and record review, the facility failed to provide pain medication for one of three sampled residents (Resident 1) who complained of level eight (8) out of 10 pain on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain) multiple times to staff from 5:20 pm on 7/11/2026 until 4:30 am on 7/12/2026 (a total of 6 hours).The facility failed to:1. Fax Resident 1's physician order for Oxycodone (medication used to treat moderate to severe pain) to the pharmacy within one hour of admission for oxycodone was sent six hours after admission.2. Contact the pharmacy to access the facility's emergency kit ([EKit] a sealed supply of urgent, life-saving medications and medical items kept on-site for immediate use when regular pharmacy delivery was unavailable) for pain relief for Resident 1.3. Notify the Medical Director or Director of Nursing (DON) when Resident 1's physician failed to respond to multiple staff messages regarding the resident's complaints of pain.These deficient practices resulted in Resident 1 experiencing severe unmanaged pain from 7/11/2026 at 5:20 p.m., until 7/12/2026 at 4:30 a.m.,( 6 hours) leading to Resident 1's family (FM 1) providing the resident pain medication from home and FM 2 calling emergency services (911) to transfer Resident 1 to the General Acute Care Hospital (GACH) on 7/12/2026. FindingsDuring a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of fracture of right humerus (broken right arm) and fractured right fourth metatarsal (broken right fourth toe).During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 7/12/2026, the MDS indicated Resident 1 was independent in making decisions regarding tasks of daily living. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) from staff to complete activities of daily living ([ADL] such as bathing, dressing and toileting a person performs daily.During a review of Resident 1's Nurses Progress Note dated 7/11/2026 and timed at 5:55 p.m., the Nurses Progress Note indicated Resident 1's orders were reviewed and initiated as appropriate and attending physician was notified of resident 1's admission.During a review of Resident 1's Physician Order dated 7/11/2026, the Physician Order indicated oxycodone 10 milligram ([mg] unit of measurement) tablet by mouth every six hours as needed for moderate to severe pain.During a review of Resident 1's Medication Administration Record (MAR) for 7/2026, the MAR did not indicate Resident 1 was administered oxycodone.During a review of the facility's facsimile report sent to facility's pharmacy, the facsimile report of Resident 1's medication orders indicated the fax was sent on 7/11/2026 at 11:29 p.m.During a review of the facility's Ekit Controlled Medication logbook for the month of 7/2026, there was no documentation of any medication removed for Resident 1.During a review of Resident 1's Nurses Progress Note dated 7/12/2026 and timed at 4:59 a.m., Resident 1's Nurses progress note indicated Resident 1 reported pain and Tylenol ( medication for pain and fever) was offered while awaiting additional medication orders. The nurses progress note indicated authorization to access the Ekit was obtained at 4:10 a.m. and Resident 1 refused the medication and requested transfer to the GACH due to ongoing pain. The nurses progress note indicated 911 was called by Resident 1's family (FM 2) and Resident 1 was transported to the GACH.During a review of Resident 1's Transfer form dated 7/12/2026 timed at 4:07 a.m., the Transfer form indicated Resident 1 requested transfer to the GACH due to pain. The transfer form indicated Resident 1's vital signs were the following: blood pressure (BP) 171/100, heart rate (HR) 96, and pain level was 10/10 on the right shoulder.During a review of Resident 1's Paramedic Report dated 7/12/2026 and timed at 4:22 a.m., the Paramedic Report indicated Resident 1's primary symptom was right extremity pain at 6/10 (moderate pain), Resident 1's vital signs were as follows: BP 172/89 and HR 100. The Paramedic report indicated Resident 1 was in mild level distress, stated she was not being properly cared for by facility staff and not receiving proper pain management.During an interview on 8/18/2026 at 1:57 p.m., Resident 1 stated when she was admitted to the facility on [DATE] around 5:30 p.m., the facility staff asked about her pain while she was still in the gurney, Resident 1 told them she was okay but after she was moved to the bed and the pain was 8/10 on the pain scale indicating severe pain she (Resident 1) asked for pain medication from the staff. The nursing staff, who she cannot remember, told her they were waiting for a response and authorization from the doctor (MD) so they could get the pain medication. Resident 1 stated she was waiting and crying in pain all night, and felt as if no one would help her. Resident 1 stated she called the MD herself and the General Acute Care Hospital (GACH) for additional contact information for the MD. Resident 1 stated around 10 pm on 7/11/2026, she was in so much pain she had her daughter sneak a pill to the facility without the staff's knowledge because she was experiencing 8/10 pain in her right shoulder and it was so overwhelming Resident 1 stated around 3:50 a.m., she woke up in pain 7/10 which crept up to 8/10, and she was moaning in pain. She was already frustrated and she wanted to leave for the GACH so her husband called 911 to transport her to the GACH. Resident 1 stated when the first set of nurses talked to her about missing the MD authorization, they told her that they could not access the Ekit because they were missing the doctor's signature. Resident 1 stated when she was on the gurney after calling 911, the facility staff offered medication from the Ekit, and Resident 1 said it was too late she just wanted to leave.During an interview on 8/19/2026 at 12:20 p.m., the MD stated he received multiple messages via text and voice messages on 7/11/2026 at 6 p.m. Resident 1 experiencing severe pain and needing authorization to release the medication from the pharmacy. The MD stated he did not see the messages until the next morning, 7/12/2026, and he gave authorization to the pharmacy around 7 a.m.During an interview on 8/19/2026 at 1:12 p.m., the Certified Nursing Assistant (CNA 1) stated Resident 1 asked for pain medication and complained of not receiving any medication. CNA 1 stated Resident 1's pain started around 2-3 a.m., and the pain was so strong.During an interview on 8/19/2026 at 4:55 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was 7/11/2026 at 5:55 p.m. to the facility with a lot of pain following a recent surgery to fix her broken arm. LVN 1 stated she offered Resident 1 Tylenol (pain medicine) but Resident 1 did refused. LVN 1 stated there was no paper prescription from the GACH for the oxycodone ordered and she was waiting for a signature from the MD. LVN 1 stated when her shift ended at 11 p.m., the MD had not called back with authorization. LVN 1 stated the licensed nurse did not call the Medical Director since the licensed nurse were waiting for the MD to call back.During an interview on 8/19/2026 at 5:19 p.m., Registered Nurse (RN 1) stated she was busy and might have forgotten to fax Resident 1's medication orders to the pharmacy on 7/11/2026, which is why the orders were faxed six hours after Resident 1 was admitted to the facility. RN 1 stated there was no prescription sent from the GACH for Resident 1's oxycodone medication, so she sent a message to the MD, and endorsed it to the next shift (11 p.m.-7 a.m.).During an interview on 8/19/2026 at 5:51p.m., the Director of Nursing (DON) stated if a resident does not come with a prescription for the narcotic medication from the GACH, the facility staff can call the pharmacy to access the Ekit. The DON states if the facility are waiting to hear back from the MD and there is no response within 30 minutes to one hour, the staff can call the Medical Director or the DON. The DON stated there was no documentation indicating the Medical Director or the DON was called. The DON stated the facility staff should not have waited for six hours to fax the medication orders to the pharmacy, and should have called the MD immediately regarding the pain medication. The DON stated pain management should be a priority, and the medication should have been accessed as soon as possible from the Ekit.During an interview on 8/20/2026 at 1:07 p.m., RN 2 stated on 7/12/2026 at 3:50 a.m., Resident 1 inquired about the status of her pain medication and RN 2 informed Resident 1, staff was still waiting to hear back from the MD. RN 2 stated facility staff were following up throughout the shift (11 p.m.- 7 a.m.) with the MD for the pain medication authorization and did not receive any response from the MD. RN 2 stated LVN 2 received authorization to get the pain medication from the Ekit but Resident 1 did not want the medication and wanted to be transferred to the GACH.During an interview on 8/20/2026 at 1:30 p.m., the Pharmacist (Pharm) stated the pharmacy received a fax for Resident 1's medication on 7/12/2026 at 12:26 a.m. The Pharm stated when a resident is admitted to the facility with a narcotic order, the hospital should send a prescription for the narcotic order because it required a MD signature to release the narcotic to the facility. The Pharm stated without the signature, the facility would need to reach out to the MD for authorization. The Pharm stated while waiting for the MD's authorization, staff could access the Ekit, speak to the pharmacist, for a one time authorization to access the Ekit.During a review of the facility's policy and procedure (P&P) titled, Pain Management dated 8/25/2021, the P&P indicated the purpose of pain management was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of four sampled residents (Resident 1 and Resident 2). The facility failed to:A. Identify and develop individualized care plan interventions addressing a new behavior in which Resident 1 attempted to grab a male staff member's (unknown) private area.B. Develop individualized care plan interventions for Resident 2's recurrent urinary tract infections (UTI- an infection in the bladder/urinary tract).These failures had the potential to result in Resident 1 and 2's needs not being met, affecting the residents' well-being, and poor patient outcomes.Findings:A. 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 initially on [DATE] and had last readmitted the resident on [DATE] with diagnoses included dementia (a progressive state of decline in mental abilities), epilepsy (disorder that causes episodes of seizures or altered consciousness), and diabetes mellitus (a chronic disease that affects how the body processes sugar).During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated 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 [DATE], the MDS indicated that Resident 1 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, moderate assistance (Helper does less than half the effort) from one staff for dressing, bed mobility, 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 oral hygiene, personal hygiene, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating.During a phone interview on [DATE] at 10:26 a.m. with Resident 1's Family Member (FM 1), FM 1 stated the facility's Social Service Director (SSD) informed FM 1 if Resident 1's behavior of attempting to grab male staff member's private area continued, the SSD would initiate a 5150 hold (an involuntary 72 hour psychiatric detention for evaluation). FM 1 stated FM 1 knew Resident 1 had some behavioral issues, but this was the first time they had been informed about this specific behavior. FM 1 stated they had not been notified of this new behavior that allegedly started in [DATE].During a concurrent interview and record review on [DATE] at 3:48 p.m. with the SSD, Resident 1's Social Service Notes (SSN), dated from [DATE] to [DATE], were reviewed. The SSN indicated staff (unknown) reported Resident 1 continued to have episodes of grabbing staff members' private areas on [DATE]. The SSD stated they had not witnessed this behavior and stated SSD spoke to FM 1 a possible 5150 hold for Resident. The SSD stated they mentioned the 5150 hold because there was a possibility Resident 1 might attempt the same behavior with other residents. The SSD stated this new behavior should have been discussed during the interdisciplinary team (IDT - a regular conference where different health experts meet to review a resident's health, update their care plan, and set goals) meeting and included in the care plan.During a concurrent interview and record review on [DATE] at 4:00 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan Report (CPR) titled Resident 1 exhibits or has the potential to exhibit physical behaviors related to dementia, revised on [DATE], was reviewed. The CPR goal indicated Resident 1 would not harm others by the next target date of [DATE]. The CPR interventions indicated staff should assess and document the resident's level of agitation, behavior, triggers, and changes in mental status, and encourage the resident to seek staff support for distressed mood. The MDSC stated the care plan should have addressed this new behavior and the interdisciplinary team (IDT) should have suggested resident specific interventions to prevent repeated episodes of this behavior.During a concurrent interview and record review on [DATE] at 1:21 p.m. with the Assistant Director of Nursing (ADON), Resident 1's IDT Care Conference dated [DATE] was reviewed. The IDT Care Conference indicated there was no discussion or documentation regarding Resident 1's attempt to grab a male staff member's private area. The ADON stated this new behavior should have been discussed during the IDT Care Conference meeting, and recommendations should have been reflected as care plan interventions to prevent future incidents.B. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 initially on [DATE] and last readmitted the resident on [DATE] with diagnoses including Bechet's disease (a rare, chronic disorder that causes inflammation in blood vessels throughout the body), dementia (a progressive state of decline in mental abilities), and function quadriplegia (the complete inability to move the limbs due to severe physical disability, frailty, or end-stage cognitive decline, without direct physical injury or structural damage to the brain or spinal cord).During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 had no capacity (ability) to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated that Resident 2 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, transfer, dressing, shower, hygiene care, and 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 oral hygiene, eating.During a concurrent interview and record review on [DATE] at 1:41p.m., with the ADON, Resident 2's General Acute Care Hospital (GACH) Medical Record, dated [DATE] was reviewed. The GACH Emergency Department (ED) physician note indicated Resident 2's urinalysis (a medical test that checks the look, chemical makeup, and content of the urine) showed positive nitrite results (an indicator of bacterial infection in urine) and many bacteria in the urine on [DATE]. The GACH ED physician note indicated Resident 2 had an altered mental status due to a urinary tract infection (UTI) and had a history of recurrent UTIs. The ADON stated the UTI should have been care planned and discussed in the IDT Care Conference when Resident 2 returned from the GACH.During a concurrent interview and record review on [DATE] at 2:10 p.m., with the MDSC, Resident 2's Care Plan (CP), dated from [DATE] to [DATE] was reviewed. The CP indicated there was no care plan developed for UTI. The MDSC stated the UTI should have been care-planned and interventions should have been implemented to prevent recurrent UTIs.During an interview on [DATE] at 2:24 p.m. with the Director of Nursing (DON), the DON stated the care plan should be resident centered and that interventions had to be implemented to provide proper care to residents. The DON stated the resident's care plan was the resident's specific plan of care and should have been implemented as written. The DON stated care plan interventions should have been implemented and routinely reevaluated. The DON stated the care plan should have been implemented to prevent recurrent events or complications.During a review of facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive, dated [DATE], the P&P indicated, Purpose: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Policy: The facility's Interdisciplinary Team, in coordination with the resident and /or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident .Procedure:1. Eash resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. B. Incorporate risk and contributing factors associated with identified problems. C. Build on the resident's individualized needs, strengths, preferences .4. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes .5. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and systematic clinical decision making .7. Assessments of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident's condition changes .8. The IDT Team is responsible for evaluation and updating of care plans: a. when there has been a significant change in the resident's condition. B. when the desired outcome is not met. c. when the resident has been readmitted to the facility from a hospital stay, and d. at least quarterly.

Based on interview, and record review, the facility failed to complete and follow through with the informed consents (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their authorized responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with Xanax (Alprazolam- a prescription medication used to treat anxiety) for one of three sampled residents (Resident 1).This failure had the potential to result in violating the residents' right to make an informed decision regarding the use of psychoactive (a chemical substance that crosses the blood-brain barrier and acts on the central nervous system, altering brain function to affect perception, mood, consciousness, cognition, and behavior) medication.Findings: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 admitted Resident 1 initially on 6/3/2024 and last readmitted the resident on 6/1/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), epilepsy (disorder that causes episodes of seizures or altered consciousness), and dementia (a progressive state of decline in mental abilities) with mood disturbance (a mental health condition that causes persistent and severe disruptions in a person's emotional state, energy levels, and daily functioning).During a review of Resident 1's History and Physical (H&P), dated 6/16/2026, 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 6/8/2026, the MDS indicated that Resident 1 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, shower, moderate assistance (Helper does less than half the effort) from one staff for dressing, bed mobility, 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 oral hygiene, personal hygiene, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating.During a phone interview on 8/12/2026 at 10:26 a.m. with Resident 1's Family Member (FM 1), FM 1 stated on 8/1/2026 staff called to obtain informed consent to administer Xanax to Resident 1. FM 1 stated FM 1 asked to speak with Resident 1's Primary Care Physician (PCP) because FM 1 wanted information regarding the risks and benefits of taking Xanax. FM 1 stated FM 1 never received a call from the PCP and had to refuse the consent. FM 1 stated FM 1 looked up information regarding Xanax and found possible side effects such as drowsiness, memory problems, constipation, and trouble with coordination. FM 1 stated staff insisted Resident 1's behaviors and anxiety had increased in frequency, and taking Xanax was necessary for Resident 1's safety. FM 1 stated FM 1 could not give consent because FM 1 was concerned Xanax might cause more harm.During a concurrent interview and record review on 8/12/2026 at 2:01 p.m. with the Director of Staff Development (DSD), Resident 1's Nursing Progress Note (NPN) dated 8/10/2026 was reviewed. The NPN indicated Xanax 0.25 milligram (mg) by mouth every eight hours as needed was ordered on 8/10/2026 and discontinued on 8/10/2026 due to refusal from the RP. The NPN indicated there was no documentation regarding the reason for the refusal or notification to the PCP. The DSD stated staff should have documented the reason the RP refused to give consent and should have notified the PCP. The DSD stated that if the RP wanted more information regarding new medications, especially psychoactive medications, staff should have asked the PCP to contact the RP to discuss the treatment plan, the length of treatment, and the risks and benefits but staff did not call the PCP During an interview on 8/13/2026 at 2:24 p.m. with the Director of Nursing (DON), the DON stated the PCP should have discussed and explained the risks and benefits of any medications that required informed consent, such as pain medications and psychoactive medications. The DON stated these medications affected residents' (general) quality of life and the resident or the residents' RP had the right to be fully informed before making decisions. The DON stated not informing the resident or their RP about the medication and risk and benefits delays necessary treatments and care.During a review of Resident 1's Order Summary Report (OSR) dated 8/21/2026, the OSR indicated Xanax 0.25 mg, one tablet by mouth every eight hours as needed for anxiety for 14 days manifested by agitation, was ordered on 8/10/2026 and discontinued on 8/10/2026.During a review of the facility's Policy and Procedures (P&P) titled, Resident Rights, revised 10/2025, the P&P indicated, Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be notified of their medical condition and of any changes in their condition; be informed of, and participate in, their care planning and treatment.During a review of the facility's Policy and Procedures (P&P) titled, Informed Consent, undated, the P&P indicated, Responsibilities: Physician/Healthcare Practitioner- Discuss material information with the resident/RP prior to initiation or dose increase. Provide written information. Document consent in the resident's record, including any refusal or revocation . Facility Role- fully inform residents/RP of health status, including changes affecting well-being. If doubt/confusion arises or consent is withdrawn, contact the prescriber immediately .Procedure: 6. Refusal/Revocation: Honor immediately; notify prescriber; explore alternatives.

Based on interview and record review, the facility failed to thoroughly investigate an alleged sexual abuse allegation for one of three sampled residents (Resident 1). The facility failed to:1.Initiate or complete an investigation after learning that Certified Nursing Assistant (CNA) 1 allegedly made a sexually inappropriate comment to Resident 1 while providing perineal care cleaning of the genital area and anal areas).This deficient practice had the potential to place Resident 1 and other residents at risk for unaddressed abuse, psychological harm, and fear, and it violated Resident 1's right to be free from abuse.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 Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), depression (persistent feelings of sadness, emptiness and a loss of interest) and anxiety (emotion characterized by feelings of tension, worried thoughts ).During a review of Resident 1's History & Physical (H&P) dated 3/25/26, the H&P indicated, Resident 1 was alert and oriented to person, place and time.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 5/5/26, the MDS indicated, Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 1 needed substantial/maximal assistance ( helper does more than half the work), with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 was incontinent (inability to voluntarily control bladder or bowels) of bowel and bladder. During a review of Resident 1's Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 6/3/26 at 5:57 p.m., the COC indicated, Resident claimed CNA 1 told Resident 1 I will clean your vulva(external female genital organ).During an interview on 6/6/26 at 7:28 a.m., with Resident 1, Resident 1 stated on 5/28/26, Resident 1 told CNA 2 she felt CNA 1 behaved in a strange manner when CNA 1 asked Resident 1 if she knew were her vulva was and can he clean it during a previous incontinent brief change. Resident 1 stated she told CNA 2 she no longer wanted CNA 1 to provide her care because the interaction made her uncomfortable. She stated feeling embarrassed sharing the information but stated she was tired of feeling afraid each time CNA 1 changed her incontinent brief. Resident 1 stated she told CNA 1 on 6/1/26, at approximately 2:30 a.m. during the 11p.m., to 7 a.m., shift, she wanted a female staff member to change her incontinent brief. She stated CNA 1 told her no female staff were available to assist her and she would have to wait a long time. Resident 1 stated she waited until she could no longer tolerate the discomfort and ultimately allowed CNA 1 to change her incontinent brief because she felt she had no other option. Resident 1 stated she felt angry and very upset CNA 1 continued to be assigned to her care after she informed CNA 2 on 5/28/26 that CNA 1 was weird and made her feel uncomfortable when CNA 1asked Resident 1 if she knew where her vulva was and could CNA 1 clean it. She stated she now felt a sense of relief because the facility was finally listening to her concerns.During an interview on 6/5/26 at 12:10 p.m., with the DSD, DSD stated CNA 2 informed her on 5/28/26 that Resident 1 no longer wanted CNA 1 to be her caregiver. The DSD stated she did not ask CNA 2 for additional details and simply instructed the SC not to schedule CNA 1 with Resident 1. She stated she did not notify the Director of Nursing (DON) about the report on 5/28/26 because she did not take the concern seriously at that time. The DSD stated she should have spoken with Resident 1 on 5/28/26 when the incident was first reported and the facility should have initiated an investigation on 5/28/2026. She stated there was potential for harm to Resident 1 due to the failure to conduct a proper investigation into the alleged incident involving CNA 1. The DSD stated she would have felt scared if she were Resident 1, wondering whether CNA 1 would return to her room to provide care.During an interview on 6/6/26 at 9:04 a.m., the DON, the DON stated she became aware of the allegation on 6/3/26 after the Social Services Director informed her that Resident 1 felt uncomfortable with CNA 1 after CNA 1 asked Resident 1 do you know where your vulva is and can CNA 1 clean it. The DON stated she was not aware this concern had originally been reported to the DSD on 5/28/26 by CNA 2. She stated the facility dropped the ball and should have reported the allegation and initiated an investigation on 5/28/26 when Resident 1 informed CNA 2 she no longer wants CNA 1 take care of her because she felt uncomfortable. The DON stated there was a potential risk for Resident 1 to experience harm because the investigation was delayed. She stated she would have felt bad and uncomfortable if she were Resident 1 and had continued to receive care from CNA 1 after reporting an allegation of sexual abuse. The DON stated she thought the word vulva could be considered sexual to some people.During an interview on 6/6/26 at 11:15 a.m., with the Administrator (ADM) in training, the ADM stated he became aware of the allegation on 6/3/26. He stated he did not know that Resident 1 had reported the concern to CNA 2 on 5/28/26 or that the DSD had been informed. The ADM in training stated that if he had been notified on 5/28/26, the facility should have initiated its investigation and reported the incident to the appropriate agencies that same day. He stated CNA 1 should have been removed from the schedule on 5/28/26 when the allegation was first reported, and that CNA 1 should not have been assigned to Resident 1 after she expressed, she did not want him to be her caregiver. The ADM in training stated residents needed to feel safe in the facility, as it was their home, and the facility was responsible for ensuring residents felt safe when staff provided care.During a review of the facilities policy and procedure (P&P) titled Abuse Investigation and Reporting dated 2/2017 the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

Based on interview and record review, the facility failed to report allegation of sexual abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH). The facility failed to:1.Implement its policy and procedures (P&P) titled, Abuse Investigation and Reporting dated 2/2017 which indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.This deficient practice resulted in a delay in reporting to CDPH and CDPH's investigation, and a potential risk for continued abuse, or mistreatment of Resident 1 and other residents in the facility.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 Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), depression (persistent feelings of sadness, emptiness and a loss of interest) and anxiety (emotion characterized by feelings of tension, worried thoughts ).During a review of Resident 1's History & Physical (H&P) dated 3/25/26, the H&P indicated, Resident 1 was alert and oriented to person, place and time.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 5/5/26, the MDS indicated, Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 1 needed substantial/maximal assistance ( helper does more than half the work), with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 was incontinent (inability to voluntarily control bladder or bowels) of bowel and bladder. During a review of Resident 1's Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 6/3/26 at 5:57 p.m., the COC indicated, resident claimed CNA 1 told Resident 1 I will clean your vulva(external female genital organ).During a review of Resident 1's care plan titled Resident at risk for emotional distress due to resident allegation dated 6/3/2026, the Care Plan indicated a goal was for resident will not experience untoward (inappropriate, improper or unfavorable) outcomes due to trauma history. The Care Plan indicated interventions including monitor for emotional distress, psychological (emotional state) and psychiatrist ( physician who specializes in mental health) consult and social services (SS) to provide wellness visit.During a review of the facility's SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) form, the SOC 341 indicated the police department was notified by telephone on 6/3/26 at 5:34 p.m. regarding the alleged incident between CNA 1 and Resident 1.During a review of the facility's Transmission (Fax) Verification Report, the report indicated the facility reported the alleged incident that occurred between CNA 1 and Resident 1 to the California Department of Public Health (CDPH) on 6/3/26 at 5:48 p.m.During a review of the facility's Transmission Verification Report, the report indicated the facility reported the alleged incident that occurred between CNA 1 and Resident 1 to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) on 6/3/26 at 5:53 p.m.During an interview on 6/6/26 at 7:28 a.m., with Resident 1, Resident 1 stated on 5/28/26, Resident 1 told CNA 2 she felt CNA 1 behaved in a strange manner when CNA 1 asked Resident 1 if she knew were her vulva was and can he clean it during a previous incontinent brief change. Resident 1 stated she told CNA 2 she no longer wanted CNA 1 to provide her care because the interaction made her uncomfortable. She stated feeling embarrassed sharing the information but stated she was tired of feeling afraid each time CNA 1 changed her incontinent brief. Resident 1 stated she told CNA 1 on 6/1/26, at approximately 2:30 a.m. during the 11p.m., to 7 a.m., shift, she wanted a female staff member to change her incontinent brief. She stated CNA 1 told her no female staff were available to assist her and she would have to wait a long time. Resident 1 stated she waited until she could no longer tolerate the discomfort and ultimately allowed CNA 1 to change her incontinent brief because she felt she had no other option. Resident 1 stated she felt angry and very upset CNA 1 continued to be assigned to her care after she informed CNA 2 on 5/28/26 that CNA 1 was weird and made her feel uncomfortable when CNA 1asked Resident 1 if she knew where her vulva was and could CNA 1 clean it. She stated she now felt a sense of relief because the facility was finally listening to her concerns.During a telephone interview on 6/5/26 at 9:49 a.m., with CNA 2, CNA 2 stated on 5/28/26 around 3:00 p.m., Resident 1 told her CNA 1 had asked Resident 1 if she knew where her vulva was and if he could clean it, which made her feel uncomfortable. Resident 1 told CNA 2 she no longer wanted CNA 1 to be her caregiver because the interaction made her feel uncomfortable. CNA 2 stated she immediately reported the incident to the Director of Staff Development (DSD) because she was a mandated reporter, and based on Resident 1's description, the interaction sounded sexual. She stated she wanted to ensure CNA 1 no longer provided care to Resident 1. CNA 2 stated the DSD told her she would make sure CNA 1 was no longer scheduled with Resident 1. CNA 2 stated when she returned to work on 6/2/26 and visited Resident 1, Resident 1 told her CNA 1 had still been assigned to her on 5/31/26 during the 11-7 shift. CNA 2 stated she then texted the Staffing Coordinator (SC) to ask why CNA 1 had been assigned to Resident 1 despite her report to the DSD on 5/28/26 that Resident 1 did not want CNA 1 assigned because he (CNA 1) made her feel uncomfortable.During an interview on 6/5/26 at 12:10 p.m., with the DSD, DSD stated CNA 2 informed her on 5/28/26 Resident 1 no longer wanted CNA 1 to be her caregiver. The DSD stated she did not ask CNA 2 for additional details and simply instructed the SC not to schedule CNA 1 with Resident 1. She stated she did not notify the Director of Nursing (DON) about the report on 5/28/26 because she did not take the concern seriously at that time. The DSD stated she should have spoken with Resident 1 on 5/28/26 when the incident was first reported and the facility should have initiated an investigation on 5/28/2026. She stated there was potential for harm to Resident 1 due to the failure to conduct a proper investigation into the alleged incident involving CNA 1. The DSD stated she would have felt scared if she were Resident 1, wondering whether CNA 1 would return to her room to provide care.During an interview on 6/6/26 at 9:04 a.m., the DON, the DON stated she became aware of the allegation on 6/3/26 after the Social Services Director informed her that Resident 1 felt uncomfortable with CNA 1 after CNA 1 asked Resident 1 do you know where your vulva is and can CNA 1 clean it. The DON stated she was not aware this concern had originally been reported to the DSD on 5/28/26 by CNA 2. She stated the facility dropped the ball and should have reported the allegation and initiated an investigation on 5/28/26 when Resident 1 informed CNA 2 she no longer wants CNA 1 take care of her because she felt uncomfortable. The DON stated there was a potential risk for Resident 1 to experience harm because the reporting and investigation was delayed. She stated she would have felt bad and uncomfortable if she were Resident 1 and had continued to receive care from CNA 1 after reporting an allegation of sexual abuse. The DON stated she thought the word vulva could be considered sexual to some people.During an interview on 6/6/26 at 11:15 a.m., with the Administrator (ADM) in training, the ADM stated he became aware of the allegation on 6/3/26. He stated he did not know that Resident 1 had reported the concern to CNA 2 on 5/28/26 or that the DSD had been informed. The ADM in training stated that if he had been notified on 5/28/26, the facility should have initiated its investigation and reported the incident to the appropriate agencies that same day. He stated CNA 1 should have been removed from the schedule on 5/28/26 when the allegation was first reported, and that CNA 1 should not have been assigned to Resident 1 after she expressed, she did not want him to be her caregiver. The ADM in training stated residents needed to feel safe in the facility, as it was their home, and the facility was responsible for ensuring residents felt safe when staff provided care.During a review of the facilities policy and procedure (P&P) titled Abuse Investigation and Reporting dated 2/2017 the P&P indicated, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The P&P indicated An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious. bodily injury: or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record review the facility failed to protect the residents' right to be free from sexual abuse for one of three sampled residents (Resident 1) after she reported an allegation involving Certified Nursing Assistant 1 (CNA 1) to CNA 2 on 5/28/2026. The facility failed to:1.Ensure CNA 1 was removed from providing care to Resident 1, after Resident 1 verbalized she does not want CNA 1 to take care of her on 5/28/2026 to CNA 2.These failures resulted in Resident 1 experiencing emotional distress and feeling unsafe in the facility.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), depression (persistent feelings of sadness, emptiness and a loss of interest) and anxiety (emotion characterized by feelings of tension, worried thoughts ).During a review of Resident 1's History & Physical (H&P) dated 3/25/26, the H&P indicated, Resident 1 was alert and oriented to person, place and time.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 5/5/26, the MDS indicated, Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 1 needed substantial/maximal assistance ( helper does more than half the work), with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 was incontinent (inability to voluntarily control bladder or bowels) of bowel and bladderDuring a review of Resident 1's Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 6/3/26 at 5:57 p.m., the COC indicated, Resident claimed CNA 1 told Resident 1 I will clean your vulva(external female genital organ).During a review of Resident 1's care plan titled Resident at risk for emotional distress due to resident allegation dated 6/3/2026, the Care Plan indicated a goal was for resident will not experience untoward (inappropriate, improper or unfavorable) outcomes due to trauma history. The Care Plan indicated interventions including monitor for emotional distress, psychological (emotional state) and psychiatrist (specializes in mental health) consult and social services (SS) to provide wellness visit.During a review of CNA 1's time card for the period of 5 /1/2026, through 5/31/2026, the record indicated on 5/31/26, CNA 1 clocked in at 3:01 p.m. and clocked out at 11:00 p.m. The time card indicated CNA 1 clocked back in on 5/31/26 at 11:30 p.m. and clocked out on 6/1/26 at 7:21 a.m., working a total of 14.80 hours.During a review of the Nursing Staffing Assignment and Sign In Sheet dated 5/31/26, the document indicated the shift was from 3:00 p.m. to 11:00 p.m. The assignment showed that CNA 1 was assigned to and provided care for Resident 1.During a review of Resident 1's Toileting Log record dated 5/31/26, the record indicated resident was incontinent of urine. The log indicated resident received an incontinent brief (diaper) change at 2:59 p.m. for urinary incontinence, and CNA 1 performed the incontinent brief change.During a review of Resident 1's Toileting Log record dated 6/01/26, the record indicated resident had a bowel movement and urinary incontinence at 3:53 a.m., and that CNA 1 performed the incontinent brief change.During an interview on 6/6/26 at 7:28 a.m., with Resident 1, Resident 1 stated on 5/28/26, Resident 1 told CNA 2 she felt CNA 1 behaved in a strange manner when CNA 1 asked Resident 1 if she knew were her vulva was and can he clean it during a previous incontinent brief change. Resident 1 stated she told CNA 2 she no longer wanted CNA 1 to provide her care because the interaction made her uncomfortable. She stated feeling embarrassed sharing the information but stated she was tired of feeling afraid each time CNA 1 changed her incontinent brief. Resident 1 stated she told CNA 1 on 6/1/26, at approximately 2:30 a.m. during the 11p.m., to 7 a.m., shift, she wanted a female staff member to change her incontinent brief. She stated CNA 1 told her no female staff were available to assist her and she would have to wait a long time. Resident 1 stated she waited until she could no longer tolerate the discomfort and ultimately allowed CNA 1 to change her incontinent brief because she felt she had no other option. Resident 1 stated she felt angry and very upset CNA 1 continued to be assigned to her care after she informed CNA 2 on 5/28/26 that CNA 1 was weird and made her feel uncomfortable when CNA 1asked Resident 1 if she knew where her vulva was and could CNA 1 clean it. She stated she now felt a sense of relief because the facility was finally listening to her concerns.During a telephone interview on 6/5/26 at 9:49 a.m., with CNA 2, CNA 2 stated on 5/28/26 around 3:00 p.m., Resident 1 told her (CNA 2) CNA 1 had asked Resident 1 if she knew were her vulva was and could he clean it, which made her feel uncomfortable. Resident 1 told CNA 2 she no longer wanted CNA 1 to be her caregiver because of how the interaction made her feel. CNA 2 stated she immediately went to the Director of Staff Development (DSD) to report the incident because, based on Resident 1's description, it sounded sexual and she wanted to ensure CNA 1 no longer provided care to Resident 1.The DSD told her she would ensure CNA 1 was no longer scheduled with Resident 1. CNA 2 stated when she returned to work on 6/2/26 and visited Resident 1, Resident 1 told her CNA 1 had still been assigned to her on 5/31/2026 during the 11 p.m., to 7 a.m., shift. CNA 2 stated she then texted the Staffing Coordinator (SC) to ask why CNA 1 had been assigned to Resident 1 despite her report to the DSD on 5/28/2026 regarding Resident 1 did not want CNA 1 to be assigned to the resident as CNA 1 makes her feel uncomfortable.During an interview on 6/5/26 at 12:40 p.m., with the SC, SC stated the DSD told her on 5/28/26 not to schedule CNA 1 with Resident 1. The SC stated she forgot to inform the Registered Nurse Supervisor (RNS) of this instruction, which resulted in CNA 1 being assigned to Resident 1 on 5/31/26 and 6/1/26. She stated she dropped the ball and should have spoken with Resident 1 when the DSD informed her on 5/28/26 that Resident 1 no longer wanted CNA 1 as her caregiver. The SC stated the situation should not have occurred and that the facility should have looked deeper into the matter and initiated an investigation on 5/28/26 when the incident was first reported. She stated she would have been upset if she were Resident 1.During an interview on 6/5/26 at 12:10 p.m., with the DSD, DSD stated CNA 2 informed her on 5/28/26 that Resident 1 no longer wanted CNA 1 to be her caregiver. The DSD stated she did not ask CNA 2 for additional details and simply instructed the SC not to schedule CNA 1 with Resident 1. She stated she did not notify the Director of Nursing (DON) about the report on 5/28/26 because she did not take the concern seriously at that time. The DSD stated she should have spoken with Resident 1 on 5/28/26 when the incident was first reported and the facility should have initiated an investigation on 5/28/2026. She stated there was potential for harm to Resident 1 due to the failure to conduct a proper investigation into the alleged incident involving CNA 1. The DSD stated she would have felt scared if she were Resident 1, wondering whether CNA 1 would return to her room to provide care.During an interview on 6/6/26 at 10:23 a.m., with the Registered Nurse Supervisor (RNS), RNS stated she was responsible for creating the CNA schedule on 5/31/2026 for the 3-11 p.m. shift. RNS stated no one in the facility informed her that CNA 1 should not be scheduled to care for Resident 1; therefore, she assigned CNA 1 to the resident. The RNS stated she was unaware of the alleged incident involving Resident 1 and CNA 1. She stated had she known, she would not have scheduled CNA 1 to care for Resident 1 on the 3-11 p.m. shift on 5/31/26. The RNS stated she later learned CNA 1 told Resident 1 he wanted to clean her vulva. RNS stated word vulva sounds sexual and was offensive. RNS stated CNA 1 could have used a different word.During an interview on 6/6/26 at 9:04 a.m., the DON, the DON stated she became aware of the allegation on 6/3/26 after the Social Services Director informed her that Resident 1 felt uncomfortable with CNA 1 after CNA 1 asked Resident 1 do you know where your vulva is and can CNA 1 clean it. The DON stated she was not aware this concern had originally been reported to the DSD on 5/28/26 by CNA 2. She stated the facility dropped the ball and should have reported the allegation and initiated an investigation on 5/28/26 when Resident 1 informed CNA 2 she no longer wants CNA 1 take care of her because she felt uncomfortable. The DON stated there was a potential risk for Resident 1 to experience harm because the investigation was delayed. She stated she would have felt bad and uncomfortable if she were Resident 1 and had continued to receive care from CNA 1 after reporting an allegation of sexual abuse. The DON stated she thought the word vulva could be considered sexual to some people.During an interview on 6/6/26 at 11:15 a.m., with the Administrator (ADM) in training, the ADM stated he became aware of the allegation on 6/3/26. He stated he did not know that Resident 1 had reported the concern to CNA 2 on 5/28/26 or that the DSD had been informed. The ADM in training stated that if he had been notified on 5/28/26, the facility should have initiated its investigation and reported the incident to the appropriate agencies that same day. He stated CNA 1 should have been removed from the schedule on 5/28/26 when the allegation was first reported, and that CNA 1 should not have been assigned to Resident 1 after she expressed, she did not want him to be her caregiver. The ADM in training stated residents needed to feel safe in the facility, as it was their home, and the facility was responsible for ensuring residents felt safe when staff provided care.During a review of the facilities Policy and Procedure (P&P) titled Abuse Investigation and Reporting dated 2/2017 the P&P indicated, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source {abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.During a review of the facilities Policy and Procedure (P&P) titled Residents rights dated 10/2025 the P&P indicated, federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to, a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review the facility failed to ensure one of seven sampled residents (Resident 88), who was at risk for falls, had fall precautions in place to prevent the resident from falling on 10/13/2025 at 9 p.m., and 10/14/25 at approximately 1 a.m. (approximately 4 hours apart).The facility failed to:1.Update Resident 88's care plan titled Unwitnessed Fall to include interventions such as a bed alarm (fall prevention device that alerts caregivers when a patient attempts to get out of bed), landing pads (foam pads placed on the floor alongside a bed to cushion the impact of a person falling), and maintaining the resident's bed in the lowest position after Resident 88's first fall on 10/13/2025 at 9:00 p.m. 2. Ensure Resident 88 was monitored every hour following a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status without which immediate intervention, may result in complications or death) on 10/13/2025. 3.Implement additional safety measures such as one-on-one supervision or move Resident 11 to a room closer to the nurses' station, despite multiple falls and high-fall risk status. 4. Follow its policy and procedure (P&P), titled Accidents and Incidents-Investigating and Reporting, which indicated the facility will collect and evaluate information to determine the cause of a fall and identify pertinent interventions to prevent subsequent falls. These failures resulted in Resident 88 experiencing two falls four hours apart on 10/13/2025, sustaining a laceration (a deep cut, tear, or rip in the skin) to the left forehead, generalized body bruises, and skin tears on both hands and left arm. Resident 88 was transferred to a general acute care hospital (GACH) on 10/14/2025, where treatment included closure of the forehead laceration with steri-strips (sterile noninvasive adhesive strips used to close and support minor, shallow cuts and surgical incisions).5. The facility failed to ensure that the front door was equipped with an active alarm on the inside and alarms on three of four emergency exit doors were activated. This failure had the potential to compromise resident safety by not alerting staff when doors were accessed from the inside.Findings: During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 88's diagnoses included history of falling, cardiac pacemaker (medical device designed to regulate or maintain the heart's rhythm), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis ), and difficulty walking. During a review of Resident 88's Nursing Documentations Evaluation dated 12/3/24 at 11:49 p.m., the evaluation indicated fall risk factors included history of falls, poor safety judgment, impaired balance and unsteady gait (walking). During a review of Resident 88's care plan, titled Resident is at risk for falls, dated 2/2/2025, the care plan goal indicated Resident 88 will be free from serious injury. The care plan interventions included to maintain a clutter-free environment in the resident's room and consistent furniture, place the call light in reach while the resident was in bed or close in proximity to the bed, remind the resident to use the call light when attempting to ambulate or transfer and to place all necessary personal items within reach. During a review of Resident 88's History and Physical (H&P), dated 9/24/2025, the H&P indicated Resident 88 had fluctuating capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, the MDS indicated Resident 88 had the ability to express ideas and wants. The MDS indicated Resident 88 had the ability to understand others. Resident 88 was dependent (helper does all of the effort) on staff for help with toileting, showering, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 88 needed substantial to maximal assistance (helper does more than half the effort) from nursing staff with walking, upper body dressing, sitting, lying down, standing, and transferring. The MDS indicated Resident 88 did not use any assistive device (a mobility aid that provides support, stability, and balance for people with walking difficulties). During a review of Resident 88's care plan, titled Resident is at risk for falls: history of repeated falls dated 6/12/2025 revised 1/7/2026, the care plan interventions indicated to place the call light within reach, maintain a clutter free environment and close monitoring throughout the shift. During a review of Resident 88's care plan titled Resident was observed on the floor on the left side of the bed dated 9/9/25 revised on 1/7/2026, the care plan interventions included neuro checks ( assessments to evaluate the mental status) for 72 hours, educate the resident on the importance of not ambulating without assistance, using the call light for assistance, engaging in independent activities, and toilet resident before and after meals, and at bedtime. During a review of Resident 88's care plan titled Unwitnessed fall dated 10/13/2025 revised 1/7/2026, the care plan interventions indicated assess vital signs and level of consciousness, check for pain, perform a head to toe assessment for any signs of injury. During a review of Resident 88's COC Evaluation dated 10/13/2025 at 9:48 p.m., the COC indicated Resident 88 had an unwitnessed fall. The COC indicated on 10/13/2025 at 3:00 p.m., Resident 88 was observed in bed, alert and verbally responsive. At approximately 9 p.m., Certified Nursing Assistant (CNA) notified Licensed Vocational Nurse (LVN 4) that Resident 88 was found on the floor. The note indicated Resident 88 had no apparent injuries and was unable to verbalize what happened when asked. During a review of Resident 88's COC Evaluation dated 10/14/2025 at 12:55 a.m., the COC indicated Resident 88 was found laying on the floor on his left side facing the door. The COC indicated resident sustained a one inch laceration to the left side of the forehead. Resident 88 verbalized that he wanted to go to the washroom when he fell. During a review of Resident 88's Emergency Department Hospital Admission report dated 10/14/2025, the report indicated Resident 88 presented to the GACH with a left forehead laceration that required stitches (medical threads used to hold skin and tissue together while the body heals) with steri-strips. The report indicated Resident 88 had skin tears to the left elbow, left forearm, and hands covered with gauze (wound dressing). The report indicated Resident 88 had generalized bruising and scabs (protective crust over a wound) to his body (sites not indicated). During an interview on 1/07/2026 at 9:19 a.m. with CNA 6, CNA 6 stated Resident 88 was confused and required constant assistance with toileting. CNA 6 stated on 10/14/2025, Resident 88 fell while attempting to walk to the bathroom. CNA 6 stated resident was assessed as high risk for falls and should have been monitored or supervised every two hours. During a concurrent interview and record review on 1/07/2026 at 9:36 a.m. with LVN 2, Resident 88's COCs dated 10/13/2025 and 10/14/2025, and care plan titled Resident is at High Risk for Falls dated 6/12/2025 were reviewed. LVN 2 stated the COC indicated Resident 88 fell on [DATE] at 9:00 p.m., and had a second fall at approximately 1:00 a.m., on 10/14/2025 (4 hours apart). LVN 2 stated on 10/13/2025 at 9:00 p.m., Resident 88 was found lying on the floor after attempting to go to the bathroom. LVN 2 stated Resident 88 required assistance with ambulation, had a second fall on 10/14/2025 which resulted in a one-inch laceration on the forehead after the second fall. LVN 2 stated Resident 88 was assessed at high risk for falls, had a history of falls but did not have interventions in place such as a bed alarm and frequent rounding to prevent further falls. During an interview on 1/07/2026 at 10:19 a.m. with CNA 7, CNA 7 stated she was assigned to Resident 88 on 10/13/2025. CNA 7 stated at 5:30 p.m., she assisted Resident 88 with dinner in his room. CNA 7 stated at 6:30 p.m., while collecting trays, she observed Resident 88 again. CNA 7 stated the next time she saw Resident 88 was after the fall at 9:00 p.m. on 10/13/25. CNA 7 stated Resident 88 frequently attempted to get up without assistance. During a concurrent interview and record review on 1/07/2026 at 3:30 p.m., with LVN 4, Resident 88's care plan titled Unwitnessed Fall dated 10/13/2025 was reviewed. LVN 4 stated the care plan did not include interventions such as bed alarms or landing pads after Resident 88's fall on 10/13/2025 at 9:00 p.m. LVN 4 stated Resident 88 experienced two falls: the first on 10/13/2025 at 9:00 p.m., when the resident was found sitting next to the closet, and the second fall on 10/14/2025 at 1 a.m. He stated fall prevention measures such as landing pads and bed alarms should have been included in Resident 88's care plan but they were not. During an interview on 1/08/2026 at 1:15 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated Resident 88 fell on [DATE] at 9:00 p.m. and Resident 88's fall care plan updated on 10/13/2025 did not include new safety measures such as bed alarm or any new fall precaution measures to prevent further falls. RNS 3 stated Resident 88 fell again on 10/14/2025 at 1 a.m. RNS 3 stated the falls could have been prevented with more frequent rounding (at least every one to two hours), moving Resident 88 to a room closer to the nurses' station, and implementing a bed alarm. During a concurrent interview and record review on 1/08/2026 at 6:54 p.m. with the Director of Nursing (DON), Resident 88's care plan titled Unwitnessed Fall dated 10/13/2025 was reviewed. The DON stated the care plan did not include interventions such as landing pads or a bed alarm following the fall on 10/13/2025 at 9:00 p.m. The DON stated Resident 88 fell again on 10/14/2025 and sustained a laceration on the forehead. The DON stated Resident 88 was at high risk for falls and required supervision and assistance. She stated interventions such as a bed alarm, one-on-one supervision, and landing pads should have been implemented but were not. The DON stated the interventions in Resident 88's care plan were insufficient to prevent additional falls. The DON stated Resident 88 sustained an injury after the second fall on 10/14/2025 which required evaluation and treatment at a GACH. During a review of the facility's Policy and Procedure (P&P), titled Accidents and Incidents-Investigating and Reporting, date revised 3/2018, the P&P indicated The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form . any corrective action taken . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) . During a review of the facility's P&P, titled Accidents and Incidents-Investigating and Reporting, date revised 3/2018, the P&P indicated The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 5. During a concurrent observation and interview on 1/7/2026 at 6:00 a.m. with the Registered Nurse Supervisor 1 (RNS 1), observed the front door and four exit doors were accessed from inside the building. The alarms on three exit doors were not activated. RNS 1 stated the front door does not have an alarm and can simply be pushed open. She stated the doors were not alarmed because staff frequently use them to enter and exit the building, and a key was required to turn the alarms on and off, only supervisors have these keys. RNS 1 stated exit doors should always remain alarmed and the front door should be alarmed when the front lobby was closed to help ensure resident safety. RNS 1 stated the alarms were intended to alert staff of a possible elopement (leaving the facility unsupervised and without authorization). During an observation and interview on 1/7/2026 at 6:45 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 was observed opening the exit door and the alarm did not activate. CNA 1 stated that this door was used by staff to take linen barrels to the laundry. CNA 1 stated the door should have been alarmed from the inside to alert staff when it was opened. CNA 1 stated that the lack of an active alarm posed a risk for resident to elope, as staff would not be aware if a resident exited through the door. During an interview on 1/7/2026 at 7:35 a.m. with the Administrator (ADM), the ADM stated she was made aware alarms on three of the four exit doors were not activated from the inside and the front door did not have an alarm to alert staff when opened. The ADM stated this posed a safety risk, as residents could elope without staff being aware if the doors were not alarmed. During a review of the policy and procedure (P&P) titled Security Plan (undated) the P&P indicated the facility has established a security plan to help protect the safety of residents/patients, staff and visitors. Exterior building security: a. This center has a schedule for locking/unlocking of exterior doors during night time hours, including persons responsible. b. This center follows a schedule to inspect outdoor lighting adequacy Interior building security: a. This center's security plan includes, if applicable, a plan for stairwell protection. The plan may include descriptions of door security alarms/keypads and titles of persons responsible for updating/changing entry codes, use of cameras and camera monitoring protocols, or other processes used for stairwell protection. b. This center's security plan includes a schedule to inspect indoor lighting adequacy. c. The center's plan also contemplates resident-specific security needs, including: 1.Security measures for special units. 2. Risk for resident elopement. 3. Use of electronic alarms systems and communication call bells.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 11), was provided needed care and services when the resident had a change of condition ([COC] a sudden, clinically important deviation from a person's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) on 11/21/25. The facility failed to: 1. Follow Resident 11's Nurse Practitioner's ( NP) order from a text message communication to Registered Nurse Supervisor (RNS 3) dated 11/22/25 at 1:35 p.m., which indicated to transfer Resident 11 to the general acute care hospital (GACH) immediately for magnetic resonance imaging ( MRI- process of taking pictures of organs and tissues inside the body to dictate or diagnosis diseases, and monitor treatment) and further evaluation due to Resident 11 having symptoms of abdominal and arm pain rated at 10 out of 10 on a pain scale rating (where 0 to 3= mild pain, 4 to 7 =moderate pain, 8 to 10 = severe pain, and 10 = worse pain possible), concern of dehydration and esophageal varices (swollen enlarged, veins in the lining of the esophagus [food pipe], that can become weaken, rupture, and cause sudden, severe, and life-threatening internal bleeding).2. Document Resident 11's NP's text message orders dated 11/22/25, which indicated to transfer Resident 11 to a GACH in the resident's medical record for care continuity.3. Follow Resident 11's NP's text message orders dated 11/21/25, which indicated to give Resident 11 Tylenol (pain medication) suppository (inserted into anus), use warm compress to the abdomen for comfort and reposition to reduce discomfort when Resident 11 complained of a sharp stubbing pain rated at 10/10 to her abdomen and had been vomiting (throw up) for three days4. Follow NP's orders to transfer Resident 11 to the GACH on 11/22/25 instead of the Director of Nursing ( DON)'s order which indicated not to transfer the resident to the GACH per progress notes dated 11/23/25 at 5:50pm.5. Ensure timely completion of STAT (immediately) laboratory tests as ordered by the NP on 11/22/25 at 7:13 p.m., without waiting until 11/23/25 at 8:00 a.m., (approximately 13 hours) after the orders were received. 6. Ensure a person-centered care plan with measurable interventions was created and implemented for Resident 11, when on 11/20/2025, the resident started vomiting and complained of generalized pain of 10/10. 7. Follow its policy and procedures (P/P) titled Transfer or discharge dated 8/2018, which indicated to transfer residents as necessary for the resident's welfare and if the resident's needs could not be met in the facility These failures resulted in 30 hours delay in transferring Resident 11 to the GACH from the time the NP gave the transfer order on 11/22/2025 at 1:35 p.m. On 11/23/2025, Resident 11 was transferred to GACH after the resident started vomiting blood, received one unit of blood transfusion (replacement of loss blood) and underwent a therapeutic paracentesis ( medical procedure performed to remove excess fluid from the abdomen for symptom relief).Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen), secondary esophageal varices without bleeding , quadriplegia, (paralysis of both arms, and both legs), contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and cervical disc disorder (condition affecting the intervertebral discs (spine) in the cervical spine (neck region) with myelopathy (disorder or injury affecting the spinal cord) and spinal stenosis (condition where the spaces within a person's spine narrow). During a review of Resident 11's Minimum Data Set (MDS- a resident's assessment tool) dated 6/14/2025, the MDS indicated Resident 11 had intact cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort and the resident makes none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 11's Nurse's Progress Notes dated 11/21/25 at 3:27 p.m., the Nurse's Progress Notes indicated Resident 11 refused gabapentin (medication used to treat pain) 300 milligram (mg-unit of measurement). The Nurse's Progress Note indicated Resident 11 stated she did not want to take the medication as she did not want to throw up. During a review of Resident 11's Nurse's Progress Notes dated 11/21/25 at 3:33 p.m., the Nurse's Progress Notes indicated Resident 11 refused lactulose (medication used to treat constipation) due to recurrent vomiting. The Nurse's Progress Notes indicated Resident 11 stated she did not want to vomit and felt the medication did not work for her. During a review of Resident 11's Nurse's Progress Note dated 11/21/25 at 4:22 p.m., the Nurse's Progress Notes indicated Resident 11 had been vomiting for three days. Resident 11's vital signs (VS-measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) were taken, the abdomen was firm, and bowel sounds were active in all quadrants (areas). The notes indicated Resident 11 was placed on nothing by mouth (NPO) status, except for sips of water. During a review of Nurse's Progress Note dated 11/21/25 at 7:20 p.m., the note indicated Resident 11 had been vomiting throughout the day. During a review of text message exchanges between RNS 3 and the NP dated 11/21/25 (unknown time), the text message indicated RNS 3 reported that Resident 11 had been vomiting for three days, complained of a sharp stabbing pain rated at 10/10 to her abdomen and arm. RNS 3 asked for options for Resident 1's pain of 10/10. The NP responded indicating for pain control use Tylenol suppository (if available), warm compress to the abdomen for comfort and reposition to reduce discomfort. During a review of text message exchanges between RNS 3 and the NP dated 11/22/25 at 1:35 p.m., the text messages indicated instructions from the NP to transfer Resident 11 to the GACH immediately due to vomiting for three days, abdominal and arm pain rated 10/10, concerns for dehydration (body loses more fluid than it takes in) and possible esophageal varices. The NP indicated Resident 11 must be sent out to a GACH immediately for magnetic resonance imaging (MRI-a test that creates clear images of structures inside the body) and further evaluation. During a review of Resident 11 s COC Evaluation dated 11/22/25 timed at 3:37 p.m., the COC indicated Resident 11 was unable to eat, or drink, and eat adequate amount of food and fluid, nausea (unpleasant sensation or discomfort in the stomach) and vomiting started 11/20/25. The COC indicated Resident 11's primary care physician was notified (date/time and recommendation not indicated). The COC indicated decreased appetite/fluid intake and unable to keep food down. During a review of text message exchanges between RNS 3 and the NP dated 11/22/25 at 6:06 p.m., NP asked RNS 3 if Resident 11 was transferred to GACH. RNS 3 responded that the RN Supervisor (name unknown) from 7 a.m. to 3 p.m., shift told her the Director of Nursing (DON ) advised not to take Resident 11 to the GACH, to start intravenous (IV-through the vein) fluids and STAT (immediately) labs. RNS 3's text message also indicated Resident 11 had vomiting with pain and abdominal discomfort. NP responded If the DON is taking over this case, please follow her direction for now, continue IV hydration and complete the STAT Complete Blood Count (CBC) - blood test that measures several components of the resident's blood) , Comprehensive Metabolic Profile ([CMP] - blood test that measures 14 different substances to evaluate the body's chemical balance, Lipase (blood test) and Lactate (blood test) as ordered. Monitor the resident closely and notify me immediately of any worsening abdominal pain, vomiting, changes in vital signs, or signs of dehydration.During a review of Nurse's Progress Note dated 11/23/25 at 5:50 p.m.,the note indicated Resident 11 was transferred to GACH due to esophageal (throat) pain rated at 10/10. The note indicated Resident 11 had nausea and red-colored vomitus (contents of the stomach that have come up through the mouth) and refused all medications because of their taste and smell. The Nurse's Progress Note indicated Resident 11 was scheduled to be transferred to the GACH for further evaluation on 11/22/25, during the 7:00 a.m. to 3:00 p.m. shift per physician's order. The note indicated according to the DON Resident 11 was already given IV hydration and STAT CBC tests done. The NP was informed and instructed staff to follow the DON's orders and notify her if symptoms worsened. During a review of Resident 11's GACH's History and Physical (H&P) dated 11/23/25 at 11:42 p.m., the H&P indicated Resident 11 arrived for hematemesis (blood in vomitus) and reported severe pain. The H&P indicated Resident 11 reported vomiting blood that began approximately two weeks ago and on 11/23/2025 characterized by a copper (metallic) taste and a small amount of visible blood. During a review of Resident 11's GACH's Discharge summary dated [DATE], the report indicated Resident 11 was admitted to the GACH on 11/23/25 and discharged on 11/26/25 (a total of 3 days). The report indicated Resident 11 presented to the emergency room (ER) with hematemesis (blood in the vomit) and severe pain, which the resident reported started 2 weeks prior. The report indicated Resident 11 underwent Esophagogastroduodenoscopy (EGD diagnostic procedure where a flexible tube with a camera (endoscope) is inserted through the mouth to examine the esophagus, stomach, and the first part of the small intestine) on 11/25/25 with minimal esophageal varices and gastritis (inflammation of the stomach's inner lining). Resident 11 started on Proton Pump Inhibitor (PPI - medications to reduce stomach acid production) IV (drip.(infusion) Resident 11 underwent therapeutic paracentesis on 11/26/25 with 3.6 liters of fluid removed. Resident 11 received one unit of packed red blood cells ( PRBC- blood) transfusion. During an interview on 1/5/2026 at 10:45 a.m., Resident 11 stated she was hospitalized on 11/2025 and returned to the facility after two days. Resident 11 stated she had severe abdominal pain with nausea, vomiting and vomiting with blood that started on 11/20/2025. Resident 11 stated she was transferred to the GACH the evening of 11/23/2025. During an interview on 1/8/2026 at 11:26 a.m. with Certified Nurse Assistant (CNA 3), CNA 3 stated on 11/22/25 (unknown time) she observed Resident 11 vomit twice while she was in the resident's room. CNA 3 stated she notified the Licensed Vocational Nurse (LVN) (name unknown ) and the LVN assessed Resident 11. CNA 3 stated Resident 11 told the LVN that she was nauseous, and her abdominal pain was more severe than usual. CNA 3 stated the LVN offered Resident 11 medication to stop her from vomiting but Resident 11 refused stating she did not want to take it because she was afraid it would make her vomit During an interview on 1/8/26 at 11:37 a.m. with CNA 4, CNA 4 stated on 11/22/25 at 12:30 p.m., she informed the charge nurse Resident 11 was complaining of feeling sick and nauseous. During a telephone interview on 1/8/2026 at 12:03 p.m., with the NP, the NP stated on 11/21/25 RNS 3 notified her that Resident 11 was vomiting. The NP advised RNS 3 to monitor Resident 11 and inform her of any changes. On 11/22/25 the NP ordered lab test, and IV fluids. The NP stated RNS 3 did not notify her that Resident 11 vomited blood. The NP stated she ordered NPO and notified Resident 11's primary doctor that the resident was vomiting blood. The NP stated RNS 3 sent a text message on 11/22/25 reporting Resident 11 was vomiting. The NP responded with a text message asking if Resident 11 was vomiting blood, and RNS 3 reported on 11/22/25 the resident consumed Jello despite being NPO at 12:00pm. The NP stated that around midnight on 11/22/25, the RNS 4 texted her stating Resident 11 was vomiting and the vomitus appeared reddish. The NP stated on 11/23/25 at 6:00 p.m., she determined Resident 11 needed to be transferred to the GACH due to inability to maintain adequate oral intake, blood in the vomit, and abdominal cramping. The NP stated Resident 11's primary care physician was informed, as he was included in the text messages. During a concurrent interview and record review on 1/8/2026, at 3:11 p.m. with LVN 3, Resident 11's Progress Notes dated 11/21/25, Weights and Vital Summary dated 11/25 were reviewed. LVN 3 stated on 11/21/2025, Resident 11 vomited twice during his shift (3:00 p.m. to 11:00 p.m.) LVN 3 stated the first vomitus consisted of food the resident had eaten. He did not observe the second episode, as the RN Supervisor (RNS) 2 assessed Resident 11 at that time. LVN 3 stated there was no documentation of Resident 11's assessment to include color, and smell of vomitus, abdominal assessment and VS. LVN 3 stated a COC report and care plan were not initiated and Resident 11 was not closely monitored. LVN 3 stated a proper assessment should include evaluating the color and smell of vomitus, recent intake, and the resident's physical state. He stated no assessment was documented, and that meant the assessment was not done. LVN 3 stated residents should be monitored closely at least every one to two hours. During a concurrent interview and record review on 1/8/26 at 4:15 p.m., with RNS 3, Resident 11's Progress Notes dated 11/20/25 to 11/23/25, COC Evaluation dated 11/22/25, Weights and Vital Summary dated 11/25, Physician Orders, Medication Administration Record (MAR) dated 11/2025, and Pain assessment dated 11/2025 were reviewed. RNS 3 stated Resident 11 began vomiting on 11/20/25 and the COC was not initiated until 11/22/25 (2 days later). RNS 3 stated Resident 11 had been refusing to take medications since 11/21/25 due to fear of vomiting. RNS 3 stated on 11/21/25, the NP was notified about Resident 11's vomiting and the NP ordered the resident to be placed on NPO. RNS 3 stated on 11/22/25 at 5:00 p.m., Resident 11's family member (FM 1) requested to see the resident's doctor and RNS 3 contacted the NP, at 7:13 p.m., and the NP ordered STAT lab tests, and IV fluids. RNS 3 stated Resident 11 was started on IV fluids at 8:00 p.m. She further stated lab tests were not performed until 11/23/25 at 8:00 a.m. (13 hours after the orders received ). RNS 3 stated STAT lab orders were supposed to be completed within four hours, RNS 3 stated she was unsure why Resident 11's care was delayed. RNS 3 stated given Resident 11 had been vomiting since 11/20/25, complained of pain at 10/10 on 11/21/25, and was refusing medications due to fear of vomiting, Resident should have been transferred to a GACH when the NP gave the order on 11/22/25. RNS 3 stated she did not know why the order was not entered on Resident 11's electronic health record (EHR), and why Resident 11 was not transferred to the GACH on 11/22/25. RNS 3 stated the delay in providing needed care and services to Resident 11 and per the NP's orders placed Resident 11 at risk for harm. During a concurrent interview and record review on 1/8/26 at 6:54 p.m., with the Director of Nursing (DON), Resident 11's Progress Note dated 11/23/25 at 5:50 p.m., was reviewed. The DON stated she did not give any instructions to LVN 6 not to transfer Resident 11 to the GACH on 11/22/25 and did not know why LVN 6 documented such. The DON did not respond when told there was a text message conversation from the NP and RNS 3 on 11/22/25 to transfer Resident 11 to GACH. The DON stated when a resident had a COC, the resident should be monitored every hour, vital signs taken, and assessments documented. She stated there was no COC initiated for Resident 11's vomiting until 11/22/25, no COC for Resident 11's complaint of pain rated 10/10 on 11/21/25, and no care plan initiated to address Resident 1's vomiting and pain. The DON stated the importance of having a care plan was for staff to know interventions needed for Resident 11. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or status dated 2/2021, the P&P indicated the facility promptly notified the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition.The nurse will notify residents attending physicians on call when there had been a/ an:An accident or incident involving the residentDiscovery of injuries of an unknown sourceSignificant change in the residents' physical/emotional/ mental conditionNeed to transfer the resident to a hospital/treatment centerSpecific instructions to notify the physician of changes in resident's condition. In addition to notifying the residents and /or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition or status. During a review of the facility's P&P titled, Transfer or discharge dated 8/2018, indicated transfers or discharges may be necessary to protect the health and well-being of the residents:If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The facility will notify the resident's attending physician for transfer to the hospital for treatmentNotify the receiving facility that the transfer is being madeNotify the representative or family member. Cross reference to F697

Based on observations, interviews, and record reviews, the facility failed to follow its policy on food handling and storage by not discarding expired crackers used for food preparation, which were 60 days past their expiration date. These deficient practices had the potential to cause foodborne illness (an illness resulting from consuming food contaminated with harmful microorganisms) among residents who rely on facility-prepared meals for their daily nutrition and well-being. During a concurrent observation and interview on 1/5/26 at 11:44 a.m. with Dietary Aid (DA 1) and Dietary Supervisor (DS) in the kitchen dry storage room, an open container of ground cracker crumbs was observed with an opened date of 10/11/2025, and a 'use by' date of 11/12/2025. The crackers remained available for use in food preparation. DA 1 stated open ground crackers can only be used for one month after the opened date and stated the crackers should have been removed and discarded after the expiration date but were not. During an interview on 1/6/26 at 12:44p.m. with the DS, the DS stated the expired ground cracker crumbs should have been discarded. The DS stated it is his responsibility to check the storage area daily ( Monday through Friday) to ensure that no expired items remain and all expired products were discarded. The DS stated if expired ground crackers were used, residents could become ill, experience diarrhea (loose stools), and in severe cases, the situation could be life-threatening. The DS stated he plans to ensure all stored food items were used by their designated dates and discarded if expired. During a review of the facility's policy and procedure (P&P) titled Food Life Reference sheet dated 12/2/22, the P&P indicated Food items like crackers, saltine/graham has duration usability of 60 days. During a review of the facility's P&P titled Food storage Dry Goods dated 2/2023, the P&P indicated Storage areas will be neat, arranged for easy identification, and date marked as appropriate.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection prevention and control practices for six out of six sampled residents ( Resident 11,2,15, 1, 82 and 45) The facility failed to: 1. Ensure Resident 11's foley catheter (a soft flexible tube used to drain urine directly from the bladder) bag was not placed on the floor. 2. Failed to ensure Resident 2's water bag hydration was labeled with date and time when hung. 3.Ensure Resident 15's nasal canula (medical device use to give extra oxygen) and humidifier ( a household device that add extra moisture to prevent the air from dryness) were labeled with the date and time. 4. Disinfect Resident 1's and Resident 82's medication tray prior to using it to pass medications. 5. Disinfect a blood pressure cuff (B/P-inflatable band that wraps around the arm) and stethoscope (a medical instrument used for listening to sounds produced by the body) prior to taking the blood pressure (the force off blood against your artery walls) for Residents' 45 and Resident 82. These failures placed residents at risk for cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and infection. Findings: 1.During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen), secondary esophageal varices without bleeding , quadriplegia, (paralysis of both arms, and both legs), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). During a review of Resident 11's Minimum Data Set (MDS- a resident's assessment tool) dated 6/14/2025, the MDS indicated Resident 11 had intact cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort and the resident makes none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 2's diagnoses included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) contractures of muscles of both lower extremities. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive skills for daily decision making. The MDS indicated Resident 2 was with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnoses included dysphagia (difficulty swallowing), Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform simple daily tasks) During an observation on 1/5/26 at 10:20 a.m. in Resident 11's room, observed Resident 11's foley catheter bag was on the floor. During a concurrent observation and interview on 1/5/26 at 10:25 a.m. with Certified Nurse Assistant (CNA) 2 in Resident 11's room, CNA 2 stated the foley catheter bag should not be placed on the floor because this could lead to a bladder infection (an infection of the organ that stores urine) and cause urine flow obstruction. CNA 2 lifted the foley catheter bag off the floor and secured it to the bed rail. 2.During a concurrent observation and interview on 1/5/26 at 9:23 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 2's room, a water bag for hydration was observed hung in an infusion pump (a device used to deliver fluids intravenously). The water bag was not labeled with the date and time it was hung. LVN 2 stated the water bag should be dated and runs for 24 hours. LVN 2 stated labeling and dating the water bag ensures other nurses know when to replace it, prevents contamination, and reduces the risk of stomach upset for Resident 2 while maintaining continuous hydration (the process of providing the body with adequate water to function properly). 3.During a concurrent observation and interview on 1/5/26 at 10:41 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 15's room, Resident 15 was receiving oxygen through a nasal cannula that was positioned in the mouth instead of the nostrils. The tubing and humidifier were not labeled with the date and time of setup. LVN 2 stated the nasal cannula tubing and humidifier should be dated and that the nasal cannula should be correctly placed in the nostrils. LVN 2 stated the oxygen tubing was scheduled to be changed every Sunday during the 11:00 p.m. to 7:00 a.m. shift. During an interview on 1/6/26 at 9;58 a.m. with Infection Prevention Nurse (IP), IP stated foley catheter bag should not touch the floor. IP stated foley catheter must be kept six inches away from the floor to prevent any infection, and cross contamination. IP stated foley catheter bags should not be placed on the floor because this place residents at risk of urinary tract infection (infection of the bladder). CNAs and license nurses were responsible for monitoring foley catheters in the facility. During an interview on 1/6/26 at 10:17 a.m. with the IP, the IP stated the facility must ensure the feeding source and water bag have the same date of change and should be replaced within 20 hours. The IP stated licensed nurses would not know when the bags were changed if the date and time were not documented. IP stated failure to change and label these items could result in contamination and stomach upset, placing Resident 2 at risk of infection. The IP stated the feeding source and hydration bag should be monitored by licensed nurses every shift. During an interview on 1/7/26 at 10:23 a.m. with the IP, the IP stated oxygen tubing should be changed every Sunday during the 11:00 p.m. to 7:00 a.m. shift and must be dated to verify when it was last changed. The IP stated if not dated, it cannot be confirmed that the tubing was replaced. The IP stated both the humidifier and oxygen tubing should be labeled with the date and time of change, as failure to do so could result in infection. During a review of the facility's policy and procedure titled Oxygen Administration dated 1/31/23, indicated Nasal catheter tubing is changed and dated every 7 days/PRN (whenever necessary). Oxygen humidifier will be changed and dated every 7 days/PRN or when the water level reaches the bottom line of the humidifier container. 4. During an observation on 1/6/2026 at 9:02 a.m. in Resident 1's room, Licensed Vocational Nurse (LVN) 1 was observed giving Resident 1 her morning medications on a medication tray that was taken out of her medication cart. LVN 1 did not disinfect it prior to placing Resident 1's medications on the tray. During a review of Resident 1's admission Record (face sheet) dated 1/8/2026, the admission record indicated Resident 1 was admitted on [DATE] with diagnosis including hypertension (HTN-high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set([MDS]) a standardized assessment and care screening tool) dated 12/8/2025, the MDS indicated Resident 1's cognition was intact. The MDS indicated Resident 1 needed partial assistance (helper does less than half the work) with Activities of Daily Living (ADLs- routine tasks/activities such as dressing and hygiene a person performs daily to care for themselves). During a review of Resident 1's Order Summary Report dated 1/8/2026, the order summary report indicated Resident 1 had an order for Vitamin C (organic compound essential for normal growth 500 milligrams (mgs-unit of measure) one time a day and Acetaminophen (pain medication) 500 mgs one time a day for pain management. 5. During an observation on 1/6/2026 at 9:46 a.m. Resident 45's room LVN 1 was observed taking Resident 45's blood pressure on her right upper arm using a B/P cuff and a stethoscope. LVN1 did not disinfect the B/P cuff or stethoscope prior to taking Resident 48's blood pressure. During a review of Resident 45's admission Record dated 1/8/2026, the admission record indicated Resident 45 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) atrial fibrillation (irregular heart beat), and chronic kidney disease (kidneys are not filtering waste properly). During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45's cognition was intact. The MDS also indicated Resident 45 needed partial / moderate assistance (helper does less than half the work) with ADLs. During a review of Resident 45's Order Summary Report dated 1/8/2026 the order summary report indicated Resident 45 had an order for Carvedilol (blood pressure medication) 3.125 mg one tablet by mouth two times a day with meals. The order summary report indicated to hold. C. During an observation on 1/6/2026 at 9:22 a.m. in Resident 82 room, LVN1 was observed taking Resident 82's blood pressure on her right upper arm using a B/P cuff and a stethoscope. LVN1 did not disinfect the BP cuff or stethoscope prior to taking Resident 82's blood pressure. During an observation on 1/6/2026 at 9:38 a.m. in Resident 82's room LVN1 was observed giving Resident 82 her morning medications on a medication tray that was not disinfected prior to placing Resident 82's medication on the tray. During a review of Resident 82's admission Record dated 1/8/2026, the admission record indicated Resident 82 was admitted on [DATE] and readmitted [DATE] with diagnosis including heart failure, anxiety (an emotion characterized by feelings of tension, worried thoughts) and dementia. During a review of Resident 82's MDS dated [DATE], the MDS indicated Resident 82's cognition was intact. The MDS also indicated Resident 82 needs substantial/ maximal assistance (helper does more than half the work) with ADLs. During a review of Resident 82's Order Summary Report dated 1/8/2026, the order summary report indicated Resident 82 had an order for Amlodipine Besylate 5mgs one tablet by mouth one time a day and to hold if SBP is less than 110. During an interview on 1/6/2024 at 12:14 p.m. with LVN 1, LVN1 stated she did not disinfect the medication tray prior to using it for Resident 1 or Resident 82's medications. LVN 1 stated she did not disinfect the B/P cuff or stethoscope prior to using it on Resident 45 or Resident 82 but she should have, to prevent the spread of infection. During an interview on 1/06/2026 at 12:36 p.m. with the Director of Nurses (DON), the DON stated she was made aware LVN 1 did not disinfect her medication tray, B/P cuff or stethoscope before using them for Resident 1, Resident 45 and Resident 82. The DON stated that any time the staff use any medical equipment on residents it should be disinfected before and after it is used to prevent the spread of infection through cross contamination. During a review of the facility's policy and procedure (P&P) titled cleaning and disinfection of Resident- Care Items and Equipment dated 8/2022. The P&P indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The P&P indicated reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based on interview and record review the facility failed to ensure timely completion of STAT (immediately) laboratory tests for one of two sampled residents (Resident 11) as ordered by the Nurse Practitioner on 11/22/25 at 7:13 p.m., without waiting until 11/23/25 at 8:00 a.m., (approximately 13 hours) after the orders were received. This failure had the potential to negatively impact Resident 11's health by delaying critical diagnostic information necessary for timely treatment decisions, increasing the risk of the resident's condition worsening, leading to complications, and compromising the overall quality of care.Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen), secondary esophageal varices without bleeding , quadriplegia, (paralysis of both arms, and both legs), contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and cervical disc disorder (condition affecting the intervertebral discs in the cervical spine (neck region) with myelopathy (disorder or injury affecting the spinal cord) and spinal stenosis (condition where the spaces within a person's spine narrow). During a review of Resident 11's Minimum Data Set (MDS- a resident's assessment tool) dated 6/14/2025, the MDS indicated Resident 11 had intact cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort and the resident makes none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 11's Physician Order dated 11/22/25 at 5:40 p.m., the Physician Order indicated a STATE order for Complete Blood Count (CBC) - blood test that measures several components of the resident's blood) , Comprehensive Metabolic Profile ([CMP] - blood test that measures 14 different substances to evaluate the body's chemical balance, Lipase (blood test) and Lactate (blood test) as ordered. During a review of text message exchanges between RNS 3 and the NP dated 11/22/25 at 6:06 p.m., Nurse Practitioner (NP) asked Registered Nurse Supervisor (RNS) 3 if Resident 11 was transferred to general acute care hospital (GACH). RNS 3 responded that the RN Supervisor (name unknown) from 7 a.m. to 3 p.m., shift told her the Director of Nursing (DON ) advised not to take Resident 11 to the GACH, to start intravenous (IV-through the vein) fluids and STAT (immediately) labs. RNS 3's text message also indicated Resident 11 had vomiting with pain and abdominal discomfort. NP responded to continue IV hydration and complete the STAT Complete Blood Count (CBC) - blood test that measures several components of the resident's blood) , Comprehensive Metabolic Profile ([CMP] - blood test that measures 14 different substances to evaluate the body's chemical balance, Lipase (blood test) and Lactate (blood test) as ordered. During a concurrent interview and record review on 11/8/26 at 4:15 p.m., with RNS 3, Resident 11's Physician Orders dated 11/22/25 and lab results dated 11/23/25 were reviewed. RNS 3 stated lab tests were not performed until 11/23/25 at 8:00 a.m. (13 hours after the orders received ). RNS 3 stated STAT lab orders were supposed to be completed within four hours, RNS 3 stated she was unsure why Resident 11's lab draw was delayed. During a review of Resident 11's lab result dated 11/23/25, the lab result indicated collection date of 11/23/25 at 8:00 a.m., received 11/23/25 at 10:35a.m., and reported 11/23/25 at 12:50 p.m.During a review of the facility's policy and procedure (P&P) titled Laboratory Services undated, the P&P indicated When there is a STAT order for laboratory testing, facility must call in the order to the laboratory immediately, upon getting the order from the physician. Please identify the order as a STAT order. The facility will make its best efforts to limit STAT orders for critical conditions, as deemed absolutely necessary by the physician.The nursing staff must completely fill out a requisition and place it in the laboratory binder. Nurse must clearly mark STAT on the requisition form for expedited processing. Laboratory will send a phlebotomist to collect specimens, arrange for transportation to a laboratory for testing and results.Laboratory will prioritize and expedite all qualified stat orders. It is our goal to complete STAT orders promptly within a 4-to-6-hour timeframe. Results are automatically faxed to the facility fax number and uploaded in EMR (electronic medical record) as appropriate. Cross reference F684

Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 33 and 79) were provided with food that was appetizing, pleasing, and palatable. This failure had the potential to result in missed meals and subsequent weight loss. Findings: During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to the brain ) affecting the left non-dominant side, contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on the left and right legs, end stage renal disease (ESRD- irreversible kidney failure), muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (the wasting or thinning of muscle mass). During a review of Resident 33's Physician Progress Notes, dated 10/9/2025, the Physician Progress Notes indicated Resident 33 was self-responsible. During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 33 had the ability to express wants and ideas. The MDS indicated Resident 33 had the ability to understand verbal content. The MDS indicated Resident 33 was dependent on nursing staff for toileting hygiene, lower body dressing, putting and taking off shoes, sitting, lying down, standing and transferring. The MDS indicated Resident 33's prior ability with everyday activities needed partial assistance from nursing staff with bathing, dressing, using the toilet, or eating. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 79's Physician Progress Notes, dated 6/12/2025, the Physician Progress Notes indicated Resident 79 had the capacity to understand and make decisions.During a review of Resident 79's MDS, dated [DATE], the MDS indicated Resident 79 was dependent on nursing staff for toileting, and putting on and taking off shoe. The MDS indicated Resident 79 needed substantial to maximal assistance with dressing, sitting, lying down and standing. The MDS indicated Resident 79 needed partial to moderate assistance with oral hygiene, showering, and personal hygiene. The MDS indicated Resident 79 needed supervision or touching assistance with eating. During an interview on 1/5/2026 at 2:01 p.m. with Resident 33, Resident 33 stated the food has no flavor. During an interview on 1/5/2026 at 2:02 p.m. with Resident 79, Resident 79 stated that the meat was always dry and the food almost made her vomit. (throw up) During a concurrent observation and interview on 1/6/2026 at 12:20 p.m. with the Dietary Supervisor (DS), the DS presented a test tray consisting of herbed meatloaf with a ketchup glaze, au gratin potatoes, a biscuit, and oven-baked cauliflower. Observed the cauliflower was overcooked and mushy, and the biscuit was hard. The entire meal had a strong, overpowering onion odor. The DS stated receiving complaints about food being served too cold and stated that an in-service had been provided to dietary staff to ensure proper cooking. The DS stated when food was not appetizing, pleasing, or palatable, residents may experience weight loss and inadequate meal intake. During an interview on 1/8/2026 at 6:37 p.m. with the Director of Nursing (DON), the DON stated she was disappointed as the facility's food service was outsourced to a third-party contractor. The DON stated there had been no communication regarding issues with the food. The DON stated poorly cooked, unappealing, or overcooked food could lead to residents losing weight, developing pressure ulcers (injury to the skin and underlying tissue caused by prolonged pressure on the skin) and experiencing depression (persistent feelings of sadness, hopelessness, and a lack of interest). During a record review of the facility's policy and procedures (P&P), titled Food: Quality and Palatability, date revised 2/2023, the P&P indicated, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature.

Based on interview and record review the facility failed to ensure call lights were answered in a timely manner for two of two sampled residents (Resident 28 and Resident 61).This failure had the potential to delay care and prevent residents from receiving assistance with activities of daily living (ADLs). Findings:During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses of repeated falls, vertigo (the sensation of spinning or imbalance) muscle wasting (the weakening, shrinking, and loss of muscle tissue) and atrophy (the wasting or shrinking of body tissue due to lack of use) During a review of Resident 28's Minimum data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 28 had the ability to express ideas and wants. The MDS indicated Resident 28 had the ability to understand others. The MDS indicated Resident 28 was dependent on nursing staff for showering, dressing, putting on and taking off shoes, sitting and lying down. The MDS indicate Resident 28 needed supervision or touching assistance with eating, oral hygiene, bathing, and personal hygiene. During a review of Resident 28's Care Plan, titled The Resident has an Activities of daily living self-care deficit related to disease process., dated 12/9/2025, the Care Plan indicated to encourage the resident to use call light to call for assistance. During review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses of but not limited to broken left leg, urinary incontinence (loss of bladder), emphysema (a lung disease causing shortness of breath due to damage to the air sacs in the lungs), and dependence on supplemental oxygen. During a review of Resident 61's MDS dated [DATE], the MDS indicated Resident 61 had the ability to express ideas and wants. The MDS indicated Resident 61 had the ability to understand others. The MDS indicated Resident 61 was dependent on nursing staff for dressing and putting on and taking off shoes. The MDS indicated Resident 61 needed substantial to maximal assistance with sitting, standing and lying down and transferring. The MDS indicated Resident 61 needed setup or clean-up assistance eating oral hygiene, and personal hygiene. During a review of Resident 61's Care Plan, titled The Resident has an ADL Self Care Performance Deficit related to Limited Mobility, Recent hospitalization, Recent Surgery for Left Hip Fracture (broken bone), dated 12/1/2025, the Care Plan indicated to encourage the resident to use call light to call for assistance. During an interview on 1/5/2026 at 1:17 p.m. with Resident 28, Resident 28 stated that he has to wait a long time at night for assistance. Resident 28 stated sometimes he resorts to calling the nurses' station on his cellphone to get help when his call light was not answered. During an interview on 1/5/2026 at 2:19 p.m. with Resident 61, Resident 61 stated the nurses take a long time to answer his call light. During an interview on 1/8/2026 at 10:59 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated that CNAs on the night shift do not answer call lights. CNA 9 stated the facility conducted an in-service training on call lights approximately two weeks ago to ensure call lights were within residents' reach. CNA 9 stated call lights should be answered promptly when observed, so residents can receive assistance for needs such as pain management, water, or incontinent pad (diaper) changes. During an interview on 1/8/2026 at 11:40 a.m. with the Director of Staff Development (DSD), the DSD stated the facility continues to receive reports and concerns regarding call lights not being answered during the evening and night shifts. The DSD stated in-service training was being conducted to address this issue. The DSD stated all staff members were responsible for answering call lights. The DSD further stated that when residents were in need, staff must assist them because residents were unable to perform tasks independently. During an interview on 1/8/2026 at 11:56 a.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she has heard complaints about call lights not being answered promptly. LVN 7 stated Resident 28 had to call the nurses' station for assistance because the call light was not answered, which occurred approximately one month ago. LVN 7 stated call lights should be answered within minutes to determine if the resident was experiencing pain or has breathing difficulties. LVN 7 further stated that if a call light goes unanswered, the resident could be at risk of falling. During a review of the facility's policy and procedure (P&P), titled Answering the Call Light, date revised 10/24/2024, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 11) who complained of stomach and arm pain rated at 10/10, on a pain scale rating of 0-10 (where 0 to 3= mild pain, 4 to 7 =moderate pain, 8 to 10 = severe pain, and 10 = the worse pain possible) was assessed, medicated and monitored. The facility failed to: 1. Ensure Registered Nurse Supervisor (RNS) 3 assessed and monitored Resident 11's pain after Resident 11 complained of severe pain of 10/10 on 11/21/25. 2. Ensure RNS 3 administered pain medication to Resident 11 when on 11/21/25 at 2:59 p.m., Resident 11 complained of severe pain rated at 10/10, as documented in the Nurses Progress notes on 11/21/25 at 2:59 p.m.3. Develop an individualized care plan for Resident 11 with interventions to monitor, prevent or manage Resident 11's pain. 4. Offer Resident 11, non-pharmacologic interventions (approaches that do not involve medications including heat, repositioning, relaxation, massage, exercise) per the Physician's order on 6/9/25 and the Nurse Practitioner's (NP) text message order on 11/21/25, which indicated to use warm compresses to the abdomen for comfort, relaxation breathing, and repositioning to reduce discomfort. 5. Document the NP's text message orders dated 11/21/25 which indicated staff should provide non-pharmacological pain interventions to Resident 11.6. Follow the facility's policy and procedures (P&P) titled Pain Management dated 8/25/21, which indicated the facility will maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain. These deficient practices resulted in Resident 11 experiencing severe sharp, stabbing pain in the arm and abdomen rated at 10/10 (approximately 48 hours), which required evaluation and treatment at a general acute care hospital (GACH). It also resulted in Resident 11 feeling very stressed, frustrated, and she described the pain as the worst pain she ever experienced.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen), secondary esophageal varices (enlarged, fragile veins in the lower part of the throat at risk of bleeding) without bleeding , quadriplegia, (paralysis of both arms, and both legs), contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and cervical disc disorder (condition affecting the intervertebral discs in the cervical spine (neck region) with myelopathy (disorder or injury affecting the spinal cord) and spinal stenosis (condition where the spaces within a person's spine narrow).During a review of the Resident 11's Order Summary Report dated 6/9/25, the order indicated:-Monitor Resident 11 for pain (mild pain 1-4, moderate pain 5-7, severe pain 8-10) every shift-Acetaminophen oral tablet 325 milligrams (mg-unit of measurement), give two tablets by mouth every 6 hours as needed for mild pain of 1-4.-Document non-pharmacological interventions (repositioning, relaxation breathing, and massage) as needed and document results in the progress notes. During a review of Resident 11's Minimum Data Set (MDS- a resident's assessment tool) dated 6/14/2025, the MDS indicated Resident 11 had intact cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort. The resident makes no effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident11's Order Summary Report dated 11/14/25, the order indicated suboxone (medication used to control pain) sublingual ( SL- under the tongue) film 2-0.5 mg, give one film SL one time a day for pain management. During a review of Resident 11's Pain Assessment, the record indicated:On 11/19/25 at 11:15p.m Resident 11's pain level was 7/10. On 11/21/25 at 4:42 a.m., Resident 11's pain level was 0/10. On 11/22/25 at 3:47 a.m., Resident 11's pain level was 0/10On 11/23/25 at 4:15 a.m. Resident 11's pain level was 0/10. On 11/23/25 at 7:35 p.m. Resident 11's pain level was 8/10. During a review of Resident 11's Pain Assessment the record indicated Resident 11's pain was not assessed on 11/21/25, after she complained of pain rated at 10/10 at 2:59 p.m., per RNS 3's progress notes.During a review of Resident11's Medication Administration Record (MAR) dated 11/19/2025, the MAR indicated Resident 11 received acetaminophen ([Tylenol] -pain relieving medication) oral tablet 325 mg, two tablets for a pain level of 7/10. During a review of Resident11's MAR dated 11/21/25 to 11/22/25, the MAR indicated Resident 11 did not receive suboxone, as ordered for pain management. During a review of Resident 11's Nurses Progress Note dated 11/21/25 at 2:59 p.m., the Nurses Progress Note indicated Resident 11 complained of severe pain 10/10 and had been vomiting for the last three days. During a review of Resident 11's Nurses Progress Note dated 11/21/25 at 4:59 p.m., the Nurses Progress Note indicated Resident 11 reported only her sublingual pain medication (unable to state the name) helped relief her pain. During a review of text message exchanges between RNS 3 and the NP dated 11/21/25 (unknown time), the text message indicated RNS 3 reported that Resident 11 had been vomiting for three days, complained of a sharp stubbing pain rated at 10/10 to her abdomen and arm. RNS 3 asked for options for Resident 1's pain of 10/10. The NP responded indicating for pain control use Tylenol suppository (medications you insert into patient's rectum [anal]) (if available), warm compress to the abdomen for comfort and reposition to reduce discomfort. During a review of text message exchanges between RNS 3 and the NP dated 11/22/25 at 1:35 p.m., the text messages indicated instructions from NP to transfer Resident 11 to the GACH immediately due to vomiting for three days, abdominal and arm pain rated 10/10, concerns for dehydration (body loses more fluid than it takes in) and possible esophageal varices. The NP indicated Resident 11 must be sent out to a GACH immediately for magnetic resonance imaging (MRI-a test that creates clear images of structures inside the body) and further evaluation. During a review of Nurse's Progress Note dated 11/23/25 at 5:50 p.m.,the Nurse's Progress Note indicated Resident 11 was transferred to a GACH due to esophageal pain rated at 10/10.During an interview on 11/5/2026 at 10:45 a.m., with Resident 11, Resident 11 stated, she was hospitalized on [DATE] for severe abdominal pain vomiting with blood that started on11/20/25. Resident 11 stated the pain was horrible, and nurses (unnamed) only gave her the lowest dose of Tylenol which could not help relieving her pain. Resident 11 stated she was very stressed, frustrated and had the worse abdominal pain. Resident 11 stated the SL medication was the only medication that relieved her pain, but nurses refused to give her for several days (11/14/25 to 11/16/25 and, 11/20/25 to 11/21/25). During an interview on 1/8/26 at 11:26 a.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated on 11/22/25 Resident 11 complained of severe pain in her abdomen and she notified a licensed nurse (name unknown).During a telephone interview on 1/8/25, at 12:03 p.m. with the NP, the NP stated on 11/21/25, staff were informed to monitor Resident 11's pain. The NP stated on 11/23/25, when Resident 11 complained of abdominal pain she decided it was no longer safe to keep Resident 11 in the facility, so she advised staff to send Resident 11 to the GACH for a Computed Tomography ([CT] process of taking pictures of the body, to diagnose diseases) scan for further evaluation. During an interview on 1/8/26 at 3:11p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, on 11/21/25, (unknown time) Resident 11 complained of abdominal pain, but he (LVN 3) did not assess the resident's pain location, level, or characteristic. LVN 3 stated he should have assessed Resident 11 for pain. LVN 3 stated he did not assess or record Resident 11's vital signs (VS-measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) and pain scales were not recorded despite Resident 11 change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status which without immediate intervention, may result in complications or death). LVN 3 stated Resident 11 should have been monitored at least every one to two hours after a COC. LVN 3 stated he notified RNS 2 that Resident 11 had severe abdominal pain, and the RNS 2 stated, what can we do. LVN 3 stated he did not document Resident 11's complaints of pain. During a concurrent interview and record review on 1/8/26 at 4:15 p.m., with RNS 3, Resident 11's Nurses Progress Notes 11/20/25 to 11/23/25, Pain Assessment for the month of 11/25, and MAR for the month 11/25, were reviewed. RNS 3 stated there was no documentation that Resident 11's pain assessment was done after the resident first complained of abdominal pain on 11/21/2025. RNS 3 stated Resident 11 was not provided pharmacological (medication) or non-pharmacological pain interventions on 11/21/25. RNS 3 stated on 11/21/25, Resident 11 complained of severe generalized pain rated at 10/10. RNS 3 stated she did not initiate a COC, administer any pain medication, provide non-pharmacological measures, assess or monitor Resident 11's pain when the resident complained. RNS 3 stated Resident 11 was not offered suboxone for pain relief because the medication was not available. RNS 3 stated she did not document the NP's text message order 11/21/25 to provide non-pharmacological interventions to the resident, in progress notes, or create a care plan to address Resident 11's pain, for continuity of care. RNS 3 stated failure to address Resident 11's pain could affect the resident mentally, physically, and potentially elevate the resident's blood pressure. During a review of the facility's P&P titled Pain Management dated 8/25/21, the P&P indicated To maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain. The P&P indicated If the nursing assessment indicates pain: 1. Review care plan triggers.2. The nurse will notify the physician/advance practice provider as appropriate and obtain treatment orders as indicated.3. An individualized, interdisciplinary (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) care plan will be developed.4. Resident receiving interventions for pain will be monitor for the effectiveness and side effects.in providing pain relief. Document non-pharmacological interventions and effectiveness, effectiveness of as needed medications (PRN), ineffectiveness of routine or PRN medications including interventions, follow up, and physician notification. During a review of the facility's P&P titled, Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated the following information should be documented in the resident's medical record: a. Objective observationsb. Medications administeredc. Treatments or services performedd. Changes in the residents' conditione. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.

Based on interview and record review, the facility failed to ensure a person-centered care plan with measurable interventions was created and implemented for one of two sampled residents (Resident 11), when on 11/20/2025, the resident started vomiting and complained of generalized pain of 10/10. This deficient practice had the potential to negatively impact the delivery of necessary care and services for Resident 11.Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included irritable bowel syndrome (a condition that affects a person's stomach and intestines and can cause abdominal cramping, bloating [uncomfortable feeling of fullness, tightness, or swelling in the abdomen] and change in bowel habits) alcoholic cirrhosis of liver (when long term alcohol use severely damage the liver causing it to harden) with ascites (accumulation of fluid in the abdomen), secondary esophageal varices without bleeding , quadriplegia, (paralysis of both arms, and both legs), contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and cervical disc disorder (condition affecting the intervertebral discs in the cervical spine (neck region) with myelopathy (disorder or injury affecting the spinal cord) and spinal stenosis (condition where the spaces within a person's spine narrow). During a review of Resident 11's Minimum Data Set (MDS- a resident's assessment tool) dated 6/14/2025, the MDS indicated Resident 11 had intact cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 11 was dependent (helper does all the effort and the resident makes none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 11's Nurse's Progress Note dated 11/21/25 at 4:22 p.m., the Nurse's Progress Notes indicated Resident 11 had been vomiting for three days. Resident 11's vital signs (VS-measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) were taken, the abdomen was firm, and bowel sounds were active in all quadrants (areas). The notes indicated Resident 11 was placed on nothing by mouth (NPO) status, except for sips of water. During a review of Nurse's Progress Note dated 11/21/25 at 7:20 p.m., the note indicated Resident 11 had been vomiting throughout the day. During a review of Resident 11' s change of condition ([COC] a sudden, clinically important deviation from a person's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 11/22/25 timed at 3:37 p.m., the COC indicated Resident 11 was unable to eat, or drink, and eat adequate amount of food and fluid, nausea (unpleasant sensation or discomfort in the stomach) and vomiting started 11/20/25. The COC indicated Resident 11's primary care physician was notified (date/time and recommendation not indicated). The COC indicated decreased appetite/fluid intake and unable to keep food down. During a concurrent interview and record review on 1/8/2026, at 3:11 p.m. with LVN 3, Resident 11's Progress Notes dated 11/21/25, Weights and Vital Summary dated 11/25 were reviewed. LVN 3 stated on 11/21/2025, Resident 11 vomited twice during his shift (3:00 p.m. to 11:00 p.m.) LVN 3 stated the first vomitus consisted of food the resident had eaten. He did not observe the second episode, as the RN Supervisor (RNS) 2 assessed Resident 11 at that time. LVN 3 stated there was no documentation of Resident 11's assessment to include color, and smell of vomitus, abdominal assessment and VS. LVN 3 stated a COC report and care plan were not initiated and Resident 11 was not closely monitored. LVN 3 stated a proper assessment should include evaluating the color and smell of vomitus, recent intake, and the resident's physical state. He stated no assessment was documented, and that meant the assessment was not done. LVN 3 stated residents should be monitored closely at least every one to two hours. During a concurrent interview and record review on 11/8/26 at 4:15 p.m., with Registered Nurse Supervisor (RNS) 3, Resident 11's Progress Notes dated 11/20/25 to 11/23/25, COC Evaluation dated 11/22/25, Weights and Vital Summary dated 11/25, Physician Orders, Medication Administration Record (MAR) dated 11/25, and Pain Assessment were reviewed. RNS 3 stated Resident 11 began vomiting on 11/20/25 and the COC was not initiated until 11/22/25 (2 days later). RNS 3 stated Resident 11's complained of pain and vomiting was not care planned RNS 3 stated a person-centered care plan with measurable interventions should have been created and implemented for Resident 11, when on 11/20/2025, the resident started vomiting and complained of generalized pain of 10/10. RNS 3 stated a care plan serves as a guide for licensed nurses to provide treatment and care tailored to each resident's individual needs.During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team dated 8/25/21, the P&P indicated The facility's interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven (7) days of completion of the comprehensive assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by an interdisciplinary Team which includes but is not necessarily limited to the following: The residents' attending PhysicianA registered nurse with responsibility for the residentThe charge nurse responsible for resident careThe dietary manager/dieticianNursing assistants with responsibility for the residents etc. Cross Reference F697 and F684

During an interview and record review the facility failed to ensure one of two sampled resident (Resident 7) had a Level II preadmission screening and resident review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services). This failure had the potential to place Resident 7 at risk of inappropriate placement, not receiving necessary care, and unidentified specialized services.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the hospital on [DATE] with diagnoses of but not limited to bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and paraplegia (loss of movement and/or sensation, to some degree, of the legs) . During a review of the Physician Progress Notes, dated 11/25/2025, the Physician Progress Notes indicated Resident 7 had the capacity to make medical decisions. During a review of the Minimum Data Set (MDS-a resident assessment tool), dated 11/27/2025, the MDS indicated Resident 7 had the ability to express ideas and wants. The MDS indicated Resident 7 had the ability to understand others. The MDS indicated Resident 7 needed nursing supervision or touching assistance when transferring to the shower. The MDS indicated Resident 7 needed setup or clean-up assistance with toileting, showering, dressing and putting on and taking off shoes. The MDS indicated Resident 7 had a diagnosis of bipolar disorder. During a concurrent interview and record review on 1/8/2026 at 3:11 p.m., with the Minimum Data Set Nurse (MDSN), Resident 7's Notice of PASARR Level I Screening Results, dated 11/21/2025 was reviewed. The Notice of PASARR Level I Screening Results indicated a Level II Mental Health evaluation was not required for serious mental illness (SMI). The MDSN stated she reviewed the PASARR and medical records for any inaccuracy and reviewed the residents' medication list and diagnoses. The MDSN stated she missed Resident 7's diagnosis of bipolar. The MDSN stated appropriate services for mental illness and recommendations from the PASARR could be missed. During an interview on 1/8/2026 at 6:37 p.m. with the Director of Nursing (DON), the DON stated the pre-screening process functions similarly to a care plan. The DON stated that if the pre-screening was not documented accurately, the resident may not receive appropriate care for behaviors and necessary services. During a review of the policy and procedure (P&P), titled PASRR Completion Policy, date revised 9/30/2024, the P&P indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASARR) completed.

Based on interview and record review, the facility failed to provide a written notice of bed hold (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) for one of four sampled residents (Resident 13) or resident 's representative ([RP] resident's representative-individual acting on behalf of the resident) at the time of transfer to a General Acute Care Hospital(GACH).This failure had the potential to result in an inappropriate discharge by not informing Resident 13 and / or their RP of the right to receive a bed hold and to return to the facility after hospitalization.Findings:During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted to the facility with diagnoses including intrahepatic bile duct carcinoma ( rare cancer that starts in the tiny tubes inside the liver that carry digestive fluid out of the liver to the small intestine) and mechanical complication of bile duct prosthesis(when the tube used to keep the bile duct[small tube that carries digestive fluid from the liver and gallbladder to the small intestine to help digest fats and remove waste] open breaks, gets blocked by sludge or stones , moves out of place or causes tissue irritation or damage).During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 11/14/2025, the MDS indicated the Resident 13 had moderately impaired cognitive skills(thinking, learning, remembering and problem solving is noticeably harder affecting daily tasks of life) and required partial/moderate assistance ( helper does less than half the effort) bed mobility , transfer to and from a bed to chair and dressing.During a concurrent interview and record review on 1/7/2026 at 4:26 p.m. with RN Supervisor (RNS) 2, Resident 13's Transfer Form, dated 11/6/2025 was reviewed. The Transfer Form indicated, Resident 13 was transferred to the GACH due to the biliary drain ( thin , flexible tube into a blocked bile duct to let backed up digestive fluid flow out either into a bag outside the body or internally, relieving symptoms like pain or jaundice[ condition where the skin and the whites of the eyes turn yellow due to a buildup of bilirubin] malfunctioning.During an interview on 1/8/2026 at 3:35 p.m. with RNS 3, RNS 3 stated a Bed Hold Notice is provided to the resident and ordered by a physician when a resident is transferred to GACH to ensure the resident's bed is still available when he or she returns to the facility. RNS 3 stated a Bed Hold Notice is Resident 13's right to have her bed when returning to the facility. RNS 3 stated not providing a written Bed Hold Notice would upset Resident13 if a bed was available from the GACH.During an interview on 1/8/2026 at 5:28 p.m. with the Director of Nursing (DON), the DON stated there was no written bed hold notice provided to Resident 13 before transferring or discharging to GACH. The DON stated the licensed nurses can obtain a verbal order from the physician for a 7-day bed hold and will give the written notice of bed hold to Resident 13 or the RP. The DON stated not providing the Resident 13 or the RP with a written bed hold notice would violate their right to be informed that the bed is going to be held while Resident 13 was not in the facility.During a review of facility's policy and procedure(P&P) titled, Bed-Holds and Returns, revised 10/2022, the P&P indicated all residents/representatives are provided with a written information regarding state bed-hold policies which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave) at the time of transfer or within 24 hours if the transfer was an emergency.

Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 33 and Resident 44) discharged to a general acute care hospital (GACH) had a necessary and appropriate transfer and failed to complete assessment or document attempts to meet resident needs. The facility failed to: 1. Ensure a medical necessity for Resident 33's transfer to a GACH 33's the General Acute Care Hospital (GACH) on 12/11/2025 to 12/14/2025 for decreased participation in Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), when evidence in the medical record indicated Resident 33 received physical therapy (PT-the treatment of disease, injury, or physical conditions by methods such as massage, heat treatment, and exercise) and occupational therapy (OT-the therapeutic use of self-care, work and play activities to increase independent function, enhance development, and prevent disability) on 10/1/2025 to 12/10/2025 and had improved and exceeded goals in PT and OT 2. Ensure Resident 44's change of condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) on 8/27/2025 was addressed properly through monitoring, reassessing and documenting identified problems in resident's medical records before transferring or discharging the resident to a GACH. Resident 44 was transferred two days later on 8/29/2025. 3.Document the reason for transfer including symptoms, and interventions attempted for Resident 33 and Resident 44 prior to transfer to GACH. These failures resulted in residents being transferred to a GACH without evidence that the facility assessed their needs or attempted to meet those needs prior to discharge. This lack of assessment and planning placed residents at risk for unmet care needs, compromised continuity of care, and potential adverse health outcomes during hospitalization and upon return. Findings: 1.During a review of Resident 33's admission Record , the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to , hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to the brain ) affecting the left non-dominant side, contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on the left and right legs, end stage renal disease (ESRD-End Stage Renal Disease-irreversible kidney failure), muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (the wasting or thinning of muscle mass). During a review of Resident 33's Care Plan, date revised 12/8/2023, the Care Plan indicated the focus was Resident/Patient requires assistance and is dependent for Activities of Daily Living with care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion (movement or the ability to move from one place to another), toileting related to.hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. The goal of the Care Plan indicated Resident ADL care needs will be anticipated and met throughout the next review period. The Care Plan interventions indicated to monitor conditions that may contribute to ADL decline and refer to rehabilitation therapy if a decline in ADLs was noted. During a review of Resident 33's Physician Progress Notes, dated 10/9/2025, the Physician Progress Notes indicated Resident 33 was self responsible. The Physician Progress Notes indicated there was no reported decline in responsiveness or new confusion. The Physician Progress Notes indicated Resident 33 had limited mobility and is likely dependent on assistive devices. The Physician Progress Notes indicated when confronted with acute medical symptoms or conditions necessitating immediate attention for Resident 33 the staff has received explicit instructions to promptly trigger emergency medical services (EMS) via 911 and direct patients to the emergency department. During a review of Resident 33's Nursing Progress Notes, dated 12/8/2025, the Nursing Progress Notes indicated, Resident 33 was alert and oriented times three, able to make needs known. Resident made aware regarding doctor order to transfer to GACH for further evaluation related to decrease in participation in ADLs. Resident refused to be transferred to the hospital. Risk and benefit explained to Resident 33, Resident 33 verbalized good understanding and continued to refuse. During a review of Resident 33's Nursing Progress Notes, dated 12/10/2025, the Nursing Progress Notes indicated, the nurse talked with the resident regarding the change of time of transportation arrival.due to emergency room saturation situation the transportation will be moved to 6 pm, but if not, transportation will be tomorrow morning.Resident disappointed with the situation. During a review of Resident 33's Occupational Therapy Discharge summary, dated [DATE] to 12/10/2025, the Occupational Therapy Discharge Summary indicated Resident 33 met the goals for safely washing the face while with setup and clean up assistance on 10/20/2025. The Occupational Therapy Discharge Summary indicated Resident 33 met the goals for safely washing the face while with contact and guarded assistance on 10/30/2025. The Occupational Therapy Discharge Summary indicated Resident 33's Modified Barthel Index (MBI- gives clinicians a quick validating way to measure independence with Activities of Daily Living) Current Level of Functioning (CLOF) Score equaled 19. The Occupational Therapy Discharge Summary indicated Resident 33's Target MBI equaled 18. The Occupational Therapy Discharge Summary indicated Resident 33 was discharged from OT on 12/10/2025. The Occupational Therapy Discharge Summary indicated Resident 33 made gains in skilled OT. During a review of Resident 33's Physical Therapy Encounter Note, dated 12/10/2025, the Physical Therapy Treatment Encounter Note indicated Resident 33 improved on the right knee extension from -40 degrees to -50 degrees. The Physical Therapy Treatment Encounter Note indicated Resident 33 improved on the left knee extension from -30 degrees to -35 degrees. The Physical Therapy Treatment Encounter Note indicated Resident 33 participated in therapeutic exercises with a focus on balance, strength, and functional activity tolerance to enhance muscle strength, improve balance and improve functional performance in order to improve balance for safe functional mobility and increase independence with functional tasks. The Physical Therapy Treatment Encounter Note indicated Resident 33 actively participates with skilled interventions. During a review of Resident 33's Physical Therapy Discharge summary, dated [DATE] to 12/10/2025 indicated Resident 33 was discharged from PT on 12/10/2025. During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 33 had the ability to express wants and ideas. The MDS indicated Resident 33 had the ability to understand verbal content. The MDS indicated Resident 33 was dependent on nursing staff for toileting hygiene, lower body dressing, putting and taking off shoes, sitting, lying down, standing and transferring. The MDS indicated Resident 33 used a wheelchair. The MDS indicated Resident 33's prior ability with everyday activities needed partial assistance from nursing staff with bathing, dressing, using the toilet, or eating. The MDS indicated Resident 33 had occupational and physical therapy administered for at least 15 minutes a day or on one or more days in the last seven days. The MDS indicated Resident 33 had zero days of the restorative nursing program (RNA-nursing aide program that helps residents to maintain their function and joint mobility) During an interview on 1/5/2026 at 2:01 p.m. with Resident 33, Resident 33 stated that she was transferred to the hospital on 12/11/ 2025, for three days with the expectation of receiving therapy, but has not received any therapy since returning. Resident 33 stated upon arrival at the hospital, she repeatedly asked, Why am I here? Resident 33 stated that while at the hospital, she underwent dialysis (a treatment that cleanses the blood of waste and excess fluids through a machine when the kidneys have failed). During an interview on 1/7/2026 at 1:01 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 33 transferred to the GACH on 12/11/2025 for an evaluation. CNA 8 stated there was no changes with Resident 33 participation with ADL. During an interview on 1/7/2026 at 1:32 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated on 12/11/2025 stated Resident 33 was transferred to the GACH for decrease in participation in activities of daily living. Resident 33 stated she did not see any documentation of a change of condition for a decrease in ADLs. LVN 5 stated there was no documentation in the Nursing Progress Notes regarding a decrease in ADLs prior to Resident 33's transfer to the GACH. LVN 5 stated she does not know if anything was done to prevent Resident 33's hospitalization. LVN 5 stated a COC was dated 12/11/2025 but the COC was blank with no documentation. LVN 5 stated she does not know if Resident 33's ADLs have improved or declined. During an interview on 1/8/2026 at 1:44 p.m. with Registered Nurse Supervisor (RNS) 3, RNS 3 stated Resident 33 was a dialysis resident and was transferred to the GACH for an evaluation of a decreased participation in ADLs. RNS 3 stated Resident 33 was on RNA. During an interview on 1/8/2026 at 2:03 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 33 received PT and PT services from 9/29/2025 to 12/10/2025. The DOR stated on 12/10/2025 Resident 33 was discharged from PT and OT. DOR stated Resident 33 did not have a decline. DOR stated Resident 33 improved and exceeded goals for dressing and personal hygiene. The DOR stated on 12/11/2025 Resident 33 returned to custodial care. The DOR stated on 12/11/2025 she was notified Resident 33 transferred to the GACH for a change of condition. The DOR stated a decrease in ADLs is not a hospital diagnosis. During an interview on 1/8/2026 at 7:12 p.m. with the Director of Nursing (DON), the DON stated on 12/8/2025 Resident 33 had a decrease participation in ADLs. The DON stated there was no documentation from the licensed nurses regarding a decreased participation in ADLs. The DON stated there was no documentation of a change of condition. The DON stated when Resident 33 was discharged from PT and OT, Resident 33 went to custodial care. The DON stated there was no medical necessity and no reason for Resident 33's transfer to the GACH. The DON stated when Resident 33 returned from the GACH Resident 33 was recalculated for new services and was now on skilled services. During an interview on 1/8/2026 at 7:28 p.m. with the DOR, the DOR stated Resident 33 was re-admitted to the facility back on PT and OT. The DOR stated the PT and OT therapy was reset after three days in the hospital and Resident 33 was admitted again for PT and OT therapy. The DOR stated Resident 33 went to the hospital without a medical necessity. The DOR stated Resident 33 met the goals for PT and OT on 12/10/2025. During a review of Resident 33's GACH Face Sheet, the GACH Face Sheet indicated Resident 33 was admitted go facility on 12/11/2025 at 5:15 p.m. The GACH Face Sheet indicated Resident 33 was admitted to the GACH with a chief complaint of end stage renal disease and elevated lipase (a protein enzyme that breaks down fat and oils into fatty acids and glycerol). During a review of Resident 33's GACH records, titled Physician Progress Notes, dated 12/12/2025, the Physician Progress Notes indicated Resident 33 presented with intermittent abdominal pain. The Physician Progress Notes indicated Resident 33's right upper and lower extremity strength was 5/5, left hemiplegia.sensation is intact with pinprick and light touch stimulation to all extremities. During a review of Resident 33's GACH record, titled General Radiology, dated 12/12/2025, the General Radiology record indicated Resident 33 had a Kidneys Ureters and Bladder (KUB- an x-ray to assess the abdominal pain or to assess kidneys, ureter and bladder). The KUB findings indicated Resident 33 had nonspecific bowel gas. During a review of resident 33's GACH records, titled Physician Progress Notes, dated 12/13/2025, the Physician Progress Notes indicated Resident 33 was very stable from a neurological (problems affecting the nervous system) perspective. The Physician Progress Notes indicated no new recommendation at this time. During a review of Resident 33's Nursing Progress Notes, dated 12/14/2026, the Nursing Progress Notes indicated Resident 33 was readmitted to the facility on [DATE], alert and oriented to name, place, time and situation, stable condition.Per nursing report from the GACH Resident 33 was admitted for abdominal pain, was diagnosed with end stage renal disease and elevated lipase. The Nursing Notes indicated Resident 33 received dialysis at the GACH with two liters of fluid removed. 2. During a review of Resident 44's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] and 9/2/2025 to the facility with diagnoses including dementia ( a progressive state of decline in mental abilities), congestive heart failure( CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), generalized muscle weakness and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 44's MDS dated [DATE], the MDS indicated the resident had an intact cognition (ability to think and make decisions) and required partial/moderate assistance (helper does less than half the effort) with bed mobility, and lower body dressing. During a review of Resident 44's Transfer Form dated 8/29/2025, the Transfer Form indicated the resident was transferred to GACH on 8/29/2025 at 3:38 p.m. due to decline in ADL status. During a concurrent interview and record review on 1/8/2026 at 12;14 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 44's Transfer Form dated 8/29/2025, COC Form dated 8/27/2025, and all laboratory results and radiology results done on 8/2025 were reviewed. LVN 1 stated the resident had a COC on 8/27/2025 due to a decline in ADL and the Transfer Form indicated the resident had postural imbalance( body is not aligned correctly) with right sided leaning which raised concerns for musculoskeletal( having to with muscles, bones, tendons, ligaments and joints) weakness or neurological involvement( problems with the brain, spinal cord or nerves that disrupt how a person think, move, feel or control basic functions like breathing or balance). LVN 1 stated the resident came back to the facility on 9/2/2025. LVN 1 stated there were no laboratory tests or diagnostic test ordered by the physician when the resident had a change of condition and before discharging to the GACH two days later. During a review of Resident 44's COC dated 8/27/2025 timed at 2:01 p.m., the COC indicated a decline in ADL status started on 8/27/2025. The COC indicated the resident had noticeable regression in physical and postural control. The COC indicated the physician was notified. During a review of Resident 44's OT Treatment Encounter Note dated 8/26 /2025 and 8/27/2025, the Occupational Therapy Treatment Encounter Note indicated the resident actively participate and compliant with skilled interventions (goal directed treatments requiring a therapist's specialized knowledge, judgement, and skill to help clients regain or improve their ability to perform daily activities). During a review of Resident 44's PT Treatment Encounter Note dated 8/26/2025 and 8/28/2025, the Physical Therapy Treatment Encounter Note indicated the following on; 8/26/2025 bed mobility Resident 44 required 26 to 50 percent assistance. 8/28/2025 bed mobility Resident 44 required 26 to 50 percent assistance. 8/26/2025 transfer from sit to stand Resident 44 required 51 to 75 percent assistance. 8/28/2025 transfer from sit to stand the Resident 44 required 51 to 75 percent assistance. 8/26/2025 for ambulation (act of walking), Resident 44 walked five feet with two wheeled walker and required 51 to 75 percent assistance. 8/28/2025 for ambulation, Resident 44 walked five feet with two wheeled walker and required 51 to 75 percent assistance. The Physical Therapy Encounter Notes indicated the resident actively participated with skilled interventions on 8/26/2025 and 8/28/2025. During a review of Resident 44's GACH's Records titled, Physician H&P, dated 8/30/2025 timed at 10:36 a.m., the H&P indicated the resident's chief complaint (main reason the patient sees a physician) was declining ADL. The H&P indicated the resident received 500 milliliters (ml- unit of volume) Normal Saline (sterile solution of salt in sterile water) intravenously (directly into a vein) and resident's serum sodium was 134 milliequivalents per liter (mEq/L- unit of measurement and normal levels of Sodium is between 135-145 milliequivalents per liter). During a concurrent interview and record review on 1/8/2026 at 2:18 p.m. with the Director of Rehabilitation (DOR), Resident 44's Occupational Therapy Treatment Encounter Note dated 8/26/2025, and 8/27/2025 were reviewed. DOR stated the resident actively participated in ADL and based on the OT Treatment Notes on 8/27/2025 the resident had improved and indicated no ADL decline. During a concurrent interview and record review on 1/8/2026 at 2:18 p.m. with DOR, Resident 44's Physical Therapy Encounter Note dated 8/26/2025 and 8/28/2025 were reviewed. DOR stated PT Treatment Encounter Note dated 8/26/2025 and 8/28/2025 indicated no decline in mobility and no decline in ADL. DOR stated the resident had improved in terms of ADL before the resident was discharged to GACH. During a concurrent interview and record review on 1/8/2026 at 4:37 p.m. with Director of Nursing (DOR) and Minimum Data Set Nurse (MDSN), Resident 44's electronic chart was reviewed. [NAME] stated the resident had a COC on 8/27/2025 for inability to participate in ADL. MDSN stated there were no laboratory tests or diagnostic tests ordered related to the COC on 8/27/2025. MDSN stated there was no documentation indicating the resident was monitored or the resident was not doing well due to decline in ADL after the COC on 8/27/2025 and to the day the resident was transferred to GACH on 8/29/2025. MDSN stated there was no documentation the resident required to be transferred or discharged to GACH. DON stated she could not recall why the resident was being discharged to the hospital. MDSN stated the physician order for transfer to GACH was ordered on 8/29/2025 and timed at 3:54 p.m. DON stated not monitoring, reassessing the resident after a COC and documenting the necessity of transfer had the potential to result in an inappropriate discharge to the hospital. During a review of the facility's policy and procedure (P&P), titled Transfer or Discharge, undated, the P&P indicated, If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents the specific resident needs that cannot be met, this facility's attempt to meet those need, and the receiving facility's service(s) that are available to meet those needs.

Based on interview and record review, the facility failed to inform and provide evidence that a resident's representative was informed of the right to formulate an Advance Directive(a legal document indicating resident preference on end-of-life treatment decisions) for one of six sampled residents (Resident 24) who was diagnosed with dementia (a progressive state of decline in mental abilities) and lacked the capacity to understand and make decisions.This failure had the potential to cause conflict with the resident or responsible party regarding alternatives in the provision of health care. Findings:During a review of Resident 24's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke-blood flow to a part of the brain is blocked or a blood vessel burst) affecting the left non-dominant side and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 24's History and Physical (H&P-medical document summarizing a patient's health, combining a narrative medical history with a hands-on physical examination by a healthcare provider) dated 1/17/2025, the H&P indicated Resident 24 did not have the capacity to understand and make decisions.During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 24 had severely impaired cognition (a person has significant trouble with thinking, remembering, focusing, and making decisions to the point that it affected daily life) and was dependent (helper does all the effort to complete the activity) on the staff in eating, oral hygiene, toileting hygiene, dressing, and personal hygiene.During a concurrent interview and record review on 1/7/2026 at 9:57 a.m. with the Minimum Data Set Nurse (MDSN), Resident 24's Advance Directive Acknowledgement Form dated 12/23/2025 was reviewed. The MDSN stated the Advance Directive Acknowledgement Form indicated the resident refused to sign. The MDSN stated the resident did not have the capacity to sign the form and understand what she was signing due to cognitive impairment. The MDSN stated the staff should have documented that Resident 24 had impaired cognition and the advance directive should have been offered to the responsible party. The MDSN stated an Advance Directive should be offered to residents and responsible parties because it is their right to know what to do involving their care especially during end-of-life care.During a concurrent interview and record review on 1/7/2026 at 10:05 a.m. with the Social Worker (SW), Resident 24's Social Services Quarterly assessment dated [DATE] and Advance Directive Acknowledgement Form dated 12/23/2025 were reviewed. The SW stated there was no documentation that it was offered to the responsible party in the Social Service Quarterly Assessment. The SW stated Resident 24 did not have the capacity to sign the form and the ability to understand what she was signing. The SW stated the Social Worker is responsible for offering and following up regarding the advance directive to the residents and the responsible party. The SW stated an Advance Directive is important because it is Resident 24's right to choose what they want in their health care, and should be offered to the residents, to ensure the facility will know what kind of care can be provided to the residents during a change of condition or for end-of-life care.During a review of facility's policy and procedure (P&P) titled, Advance Directive, dated 3/23/2022, the P&P indicated the facility will provide residents the opportunity to make decisions regarding their health care and the choice not to complete the Advance Directive form is recorded in the resident's medical record. The P&P indicated the Advance Directive is reviewed as needed with the resident to ensure the selections still reflect the wishes of the resident.

Based on interview and record review, the facility failed to revise, review and update the care plan for one of two sampled Residents (Resident 13) addressing Resident 13's risk for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence).This failure had the potential to result in a recurrence of Resident 13's pressure injury in the coccyx (tailbone).Findings:During a review of Resident 13's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted to the facility with diagnoses including intrahepatic bile duct carcinoma (rare cancer that starts in the tiny tubes inside the liver that carry digestive fluid out of the liver to the small intestine) and mechanical complication of the bile duct prosthesis (when the tube used to keep the bile duct [small tube that carries digestive fluid from the liver and gallbladder to the small intestine to help digest fats and remove waste] open breaks, gets blocked by sludge or stones, moves out of place or causes tissue irritation or damage).During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 11/14/2025, the MDS indicated Resident 13 had moderately impaired cognitive skills (thinking, learning, remembering and problem solving is noticeably harder affecting daily tasks of life) and required partial/moderate assistance (helper does less than half the effort) in bed mobility, transfers to and from a bed to chair and dressing. The MDS indicated that the resident is at risk of developing pressure injuries and required substantial/maximal assistance (helper does more than half the effort) with toilet hygiene and bathing.During a concurrent interview and record review on 1/7/2026 at 11:10 a.m. with Treatment Nurse (TN) 1, Resident 13's Care Plan was reviewed. TN1 stated the care plan was not created or changed when the physician order for treatment of the pressure injury on the coccyx was changed to skin maintenance (keeping skin clean, dry and protected to prevent skin breakdown) due to resolved pressure injury. TN 1 stated Resident 13's pressure injury of the coccyx developed in the facility and the current treatment order indicated to apply an application of zinc oxide (topical skin protectant that creates a barrier and prevents minor skin irritations by blocking moisture and external irritants) ointment to the coccyx for skin maintenance. TN 1 stated updating and developing a care plan addressing the resolved pressure injury on Resident 13's coccyx is important to ensure proper treatment is followed.During a concurrent interview and record review on 1/7/2026 at 10:50 a.m. with the Infection Preventionist Nurse (IPN), Resident 13's Care Plan was reviewed. The IPN stated the Care Plan for pressure injury was resolved on 12/30/2025 and there was no care plan created for skin maintenance for the coccyx. The IPN stated revising and developing a care plan for resolved pressure injury was important to ensure any skin breakdown on the coccyx area is monitored and proper interventions are implemented.During an interview on 1/8/2026 at 5:26 p.m. with the Director of Nursing (DON), the DON stated TN1 should have developed a care plan for Resident 13 addressing skin maintenance for the coccyx, so that the care plan will be known to all the staff who are taking care of the residents.During a review of facility's policy and procedure (P&P) titled, Care Plan Comprehensive, revised 8/5/2021, the P&P indicated assessments of residents are ongoing, care plans are reviewed and revised as information about the resident and the resident's condition change.

Based on observation, interview, and record review, the facility failed to ensure a resident, who refused to be placed back to bed, did not sustain an injury, when a Certified Nursing Assistant (CNA 1) picked her up and placed her in bed against the resident wishes, for one of four sampled residents (Resident 2). The facility failed to: 1. Ensure CNA 1 honored Resident 1's decision not to go back to bed and did not force the resident against her wishes back to bed by holding her tightly, which resulted in Resident 1 becoming combative as she resisted CNA 1's attempt to place her back to bed. 2. Ensure CNA 1 and Registered Nurse Supervisor 1 (RNS 1) followed the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, which indicated if a resident resist or refuses care, staff will consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. 3. Ensure CNA 1 and RNS 1 followed the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, which indicated residents have the right to refuse and/or discontinue treatment and is not forced to accept any care or treatment. These failures resulted in Resident 2 becoming combative, when she was forced into bed against her wishes, while being held tightly by CNA 1, and sustaining bruises on her mid right forearm and right hand, and a skin tear on her right hand by the thumb, that measured approximately 2.0 centimeters ([cm] a unit of measurement) long. Findings: During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability but without injury to the brain or spial cord), spinal stenosis (a narrowing of the spinal canal in the lower back that can put pressure on the spinal cord and nerves) of the lumbar region, a displaced traverse fracture of the shaft of the right tibia (a break in the shinbone where the bone pieces moved out of alignment, creating a gap), a displaced fracture of the lateral condyle of the left tibia (a break in the bone on the outside of the shin near the knee), and neuromuscular dysfunction of the bladder (when a problem in your brain, spinal cord, or central nervous system causes loss of bladder control). During a review of Resident 2's Minimum Data Set ([MDS] a Federal mandated assessment tool), dated 7/18/2024, the MDS indicated Resident 2's cognition (thinking) was intact, she had the ability to understand others, and could make herself understood. The MDS indicated Resident 2 required substantial maximum assistance rolling left to right, sitting to lying down, lying down to sitting and lying down to sitting on the side of the bed. During a review of Resident 2's History and Physical (H&P), dated 9/6/2024, the H&P indicated Resident 2 had a fluctuating capacity to make decisions. During a review of Resident 2's Progress Notes, dated 9/10/2024, the Progress Notes indicated, at 9:25 p.m., CNA 1 attempted to put Resident 2 into bed several times because it was getting late but Resident 2 refused to go to bed. The Progress Notes indicated Resident 2 did not want CNA 1 to use a sling (a device that is attached to a mechanical lift [a device operated by a motor used to move a client from one position or place to another] used to move a patient from one surface to another) to assist with putting her in bed. The Progress Notes indicated when CNA 1 carried Resident 2 to the bed, Resident 2 suddenly bit CNA 1 on his arm, yelled, pulled on her indwelling urinary catheter (a thin hollow tube that is inserted into the bladder to drain urine), and struggled not to go to bed, which was when a skin tear was found on Resident 2's right wrist. During an interview on 9/24/2024, at 3:50 p.m., CNA 1 stated Resident 2 was usually transferred to bed via a mechanical lift, and she had a behavior of screaming. CNA 1 stated on 9/10/2024 around 10:30 p.m., Resident 2 was soiled, she did not want to go to bed, and she did not want the mechanical lift used to put her in bed. CNA 1 stated, he picked up Resident 2 to put her into bed but acknowledges he could have left Resident 2 in the geriatric chair ([Geri chair] a large, padded reclining chair that provides support and comfort for people with limited mobility) she was sitting in, but his shift was almost over and he did not want to leave Resident 2 wet and sitting in the Geri chair, which would have made Resident 2's family upset. During an interview on 9/24/2024, at 4:32 p.m., RNS 1 stated after dinner, around 7 p.m., (9/10/2024) she told CNA 1 to put Resident 2 back to bed and Resident 2 yelled No, I don't want to go to bed. RNS 1 stated she again asked Resident 2 to go to bed at 8 p.m., 9 p.m., and 10 p.m., but Resident 2 yelled and screamed because she did not want CNA 1 to use the mechanical lift to transfer her to the bed. RNS 1 stated CNA 1 stood in front of Resident 2, who was sitting in a Geri chair, and picked her up to place her into bed, that was when Resident 2 bit CNA 1 on his arm. RNS 1 stated, she observed Resident 2 with a skin tear on her right hand by the thumb, that measured approximately 2.0 cm long, and bled a little bit. RNS 1 stated they should have left Resident 2 in the Geri chair and called Resident 2's family member (FM 1), who could have spoken to Resident 2 to convince her to go to bed, or they could have come back later to try again and documented Resident 2's refusal of care in the resident's Progress Notes and care plan. During an observation and concurrent interview on 9/25/2024, at 10:50 a.m., at the GACH where Resident 2 was transferred on 9/20/2024 for an unrelated event, Resident 2 was observed with a purple discoloration on her right hand and mid right forearm. Resident 2 stated, on 9/10/2024 CNA 1 lifted her from the Geri chair she was sitting in to put her in bed even though she did not want to go to bed. Resident 2 stated she kept telling CNA 1 No!! No!! Resident 2 stated she wanted CNA 1 to use the mechanical lift to transfer her back to bed. Resident 2 stated, CNA 1 would not listen to her and kept coming towards her. Resident 2 stated, she yelled at him, saying she did not want to go to bed, and finally she just gave up. Resident 1 stated when CNA 1 lifted her from the Geri chair he squeezed her arms really hard. Resident 2 stated RNS 1 was there and told CNA 1 to put her (Resident 2) into bed. Resident 2 stated she felt no protection from RNS 1 and could see people in the hallway pass by as she yelled for help, and no one stopped to see if she was ok or ask CNA 1 what was he doing? Resident 2 stated this went on for about 20 to 30 minutes, she stated she was afraid of CNA 1, she no longer felt safe at the facility, and did not want to return there because it was the worst thing that ever happened to her. During an interview on 9/25/2024, at 3:34 p.m., the Director of Staff Development (DSD) stated if a resident refused to use a mechanical lift or refused any care, the CNAs (in general) were expected to stop, explain to the resident the reason care was needed and if the resident still refused, CNAs were instructed to report the refusal of care to the charge nurse, come back later and try again. The DSD stated the nurses could have called the family member to ask them to talk to the resident. During an interview on 9/25/2024, at 4:54 p.m., the Director of Nursing (DON) stated, on 9/10/2024 at around 9 a.m., she checked on Resident 2 and saw that Resident 2 had discoloration on both of her hands, the discoloration had had always been there but stated it seemed more pronounced than usual, but stated there was no swelling, or complaints of pain, and Resident 2 had full range of motion (the amount of movement a joint can make when its flexed, extended, and rotated) to both of her wrist and hands. The DON stated, there was a dressing around Resident 2's right wrist that was not there before the skin tear that Resident 2 sustained. The DON stated, she was told that Resident 2 did not want to go to bed, and she (Resident 2) did not want to be transferred without the mechanical lift, and staff should have let Resident 2 remain in her Geri chair, come back later, call Resident 2's family and/or Resident 2's physician if she (Resident 2) continued to refuse care. During a review of the facility's P&P, titled, Activities of Daily Living (ADLs), Supporting, dated 3/2018, the P&P indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). If a resident resist or refuses care, staff will attempt to identify the underlying cause of the behavior and consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. The resident's response to interventions will be monitored, evaluated, and revised as appropriate During a review of the facility's P&P, titled Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated, residents and resident representatives have the right to refuse and/or discontinue treatment. The resident is not forced to accept any care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously, and/or care or treatment that the resident previously agreed to but has not yet been administered. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following, the date and time the care or treatment was attempted, the type of care or treatment, the resident's response and stated reasons for request, discontinuation or refusal, and that the resident is informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/ treatment.

Based on observation, interview, and record review, the facility failed to ensure the licensed vocational nurse (LVN) 1was trained and had knowledge on how to operate an automated medication machine (AMM) Emergency Kit (E-KIT) during emergencies to retrieve emergency medication for 1 of 6 sampled residents (Resident) 1. The facility failed to: 1. Ensure LVN 1 was able to retrieve Glucagon (medication to reverse low blood sugar levels) from the AMM E-KIT, to administer to Resident 1 when the resident was found unresponsive with a blood sugar (BS) of 59 milligrams per deciliter [(mg/dl) - a unit of measurement]. The BS reference range is 80 mg/dl to 130 mg/dl). This deficient practice resulted in Resident 1's blood sugar level dropping to 25 mg/dl upon paramedic's arrival to the facility, who administered needed Glucagon to increase Resident 1's blood sugar level to prevent the resident from having seizures (uncontrolled, abnormal electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory, or feelings), going into a coma (a state of unconsciousness where a person is unresponsive and cannot be woken), and possible death. Paramedics transferred Resident 1 to a general acute care hospital (GACH) for an acute (severe and sudden onset) hypoglycemic episode. On 07/28/2023 at 3:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADMIN) and the Director of Nursing (DON) due to LVN 1's lack of knowledge and ability to operate the AMM to get an access to emergency medication to administer in case of emergencies The facility submitted an acceptable IJ removal plan [(IJRP) an interventions to immediately correct the deficient practices). After verification of the IJRP implementation through observation, interviews, and record review, the IJ was removed on 7/29/2023 at 3:36 p.m., in the presence of the ADMIN, Regional [NAME] President of Operations (VP) and the Regional Quality Assurance Registered Nurse (QA RN). The IJRP included the following immediate actions: 1. On 7/29/2023, the ADMIN and DON followed up with the Facility pharmacist to schedule a Train-the-trainer in-service (staff education on a specific subject) to make the DON and Director of Staff Development (DSD) the facility superusers. As superusers, the DON and DSD can enroll new licensed nurses, reset passwords, and train licensed nurses on AMM functionality and usage. 2. The DON and/or Designee will review Electronic Medication Administration Records (EMAR) of diabetic (a condition where the body is not able to process and use sugar for functioning without medication) residents, including new admissions, five times a week. On Saturdays and Sundays Registered Nurse (RN) supervisor will review EMAR of new diabetic residents admitted to the facility to verify that Physician Orders are correct, and the facility has medications in stock to be provide to residents according to Physician's Orders. 3. Newly hired licensed nurses will be in-serviced by the DON and/or designee during initial orientation; 1) To understand the significance of correctly accessing medication from the AMM and 2) To Demonstrate the proper steps to access medication safely and efficiently, including emergency medications such as glucagon. 4. Return demonstration of knowledge and competency will be assessed on five facility licensed nurses each week by the DON and/or designee for the next eight weeks. All new hires (licensed nurses) will be assessed for knowledge and competency by the DON and/or Designee on a weekly basis for a period of eight weeks. Each licensed nurse assessed must achieve a competency score of 100 percent (%). 5. During an emergency such as when a resident experiences a hypoglycemic event, licensed nurses can access emergency glucagon injections and other emergency medications such as Epinephrine (medication to treat many sudden life-threatening conditions) and Narcan (medication to treat a drug overdose) at these locations. Locations were discussed with facility pharmacist on 07/29/2023. DON and/or Designee will keep inventory of these medications and will order from Pharmacy if/when used, to maintain supply stock in: a. Nurse Medication Carts (two in each cart for a total of six). b. Crash Cart (an organized mobile container of medications for life threatening conditions) (two total). c. Medication Room (two total). d. AMM E-Kit. e. For non-emergent medications, licensed nurses will notify the assigned physician and will order required medications from the Facility Pharmacy. f. Facility will initiate huddles (a short, stand-up meeting) at the start of each shift to routinely check emergency medication supplies such as glucagon and contact AMM agency to replenish emergency medication supplies after each use. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease to filter out toxins from the blood, leading to the need for a regular course of long-term mechanical filtering or a kidney transplant to maintain life), hypoglycemia, seizures, diabetes mellitus, and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool] dated 5/17/2023, indicated Resident 1's cognitive (process of thinking) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required extensive assistance with bed mobility, toilet use, bathing, personal hygiene, and eating. The MDS indicated that Resident 1 was usually understood and was able to understand others. A review of Resident 1's physician's orders (PO) dated 7/14/2023, indicated the following: 1. Administer Glucagon 1 milligram [(mg) unit of measurement] from Emergency Kit intramuscular [(IM) a technique used to deliver a medication deep into the muscles] every 15 minutes as needed for hypoglycemic symptoms, difficult to arouse or unconsciousness. Administer immediately, repeat BS in 15 minutes, if no response to first dose administrated, repeat Glucagon 1 mg, if no response to second dose administered in 15 min repeat blood glucose test and start intravenous [(IV) method of delivering medications and fluids through a vein) access, if not presently established, and go to the next step based on BS results. 2. Insulin Glargine (a long-acting medication used to control blood sugars that lasts in the body for 24 hours) subcutaneous [(SQ) beneath all the layers of the skin] solution with concentration of 100 units per milliliter [(u/ml) medication concentration], inject 20 units SQ at bedtime for diabetes mellitus (DM). 3. Insulin Lispro (a fast-acting medication used to control blood sugars) injection solution 100 u/ml, inject SQ before meals and at bedtime based on a sliding scale (amount of medication depends on results of BS) as follows: A. For blood sugar level 70-150 mg/dl-administer zero units. B. For blood sugar level 151-200 mg/dl- administer three units. C. For blood sugar level 201-250 mg/dl-administer six units. D. For blood sugar level 251-300 mg/dl-administer nine units. E. For blood sugar level 301-350 mg/dl-administer 12 units. F. For blood sugar level 351-400 mg/dl-administer 15 units. G. For blood sugar level >401 18 units and call Medical Doctor (MD) During a review of the facility's AMM inventory list dated 7/22/2023 and timed at 8:22 a.m., the inventory list indicated the AMM had four Glucagon medication pens in stock. A review or Resident 1's electronic medical record (eMAR), dated 7/21/2023 indicated Resident 1 received 3.0 units of Insulin Lispro and 24 units of Insulin Glargine at 9:00 p.m. A review of Resident 1's change of condition (COC - a documentation of vital medical information of a resident's sudden change of condition from baseline) report dated 7/22/2023 at 5:00 a.m., indicated Resident 1 was found unresponsive with a BS of 59 mg/dl. A review of Resident 1's PO dated 7/22/2023, timed at 5:09 a.m., indicated to transfer Resident 1 to emergency room (ER) for further evaluation due to Resident 1 unresponsiveness and low blood sugar. A review of Resident 1's Transfer Form (TF) dated 7/22/2023 and timed at 5:15 a.m., indicated that Resident 1 was transferred to the GACH via ambulance. A review of Resident 1's GACH's History of Present Illness (HPI) dated 7/22/20223 and timed at 5:18 a.m., indicated Resident 1's BS was 25, and Resident 1's Glasgow Coma Scale ([GCS] a clinical scale used to reliably measure a person's level of consciousness after a brain injury, severe=8 or less, moderate=9-12, mild=13-15) was a 3. According to the HPI paramedic administered Glucagon 1 mg IM to Resident 1 at the skilled nursing facility and upon Resident 1's arrival to GACH the resident returned to the baseline (normal state of being). During a concurrent observation and interview with Registered Nurse (RN) 1 on 7/26/2023 at 2:43 p.m., RN 1 stated that the AMM is the facility's 'E-kit and it is where staff can obtain the necessary medications that they need during an emergency. RN 1 stated that all residents with diagnosis of diabetes have a standing order (permanent physician's orders in place, to avoid a delay in care during emergencies) for Glucagon and can get the medication by either going into the resident's profile (information stored in the AMM about a resident's medication, dosage and frequency) or overriding (taking manual control of the AMM to access medication) the system in the event of an emergency. During an interview with LVN 4 on 7/26/2023 at 2:56 p.m., LVN 4 stated if a resident had a hypoglycemic episode, first he would check the resident's blood sugar, see if there is a Glucagon order, then go to the AMM to retrieve it, administer Glucagon to a resident and follow the physician's order. The physician's order might indicate to repeat the process if the resident did not respond to the first dose of Glucagon, just depends on what the order states. During an interview with LVN 1 on 7/27/2023 at 6:24 a.m., LVN 1 stated that when Resident 1 was found unresponsive and had a low blood sugar, he came to the AMM to retrieve Glucagon, while LVN 2 was calling 911. LVN 1 stated that he was not able to retrieve the medication because the medication indicated it was out of stock. LVN 1 stated that he did not know about the 'override' function at that time, that would have allowed him to access the emergency Glucagon. During an interview with LVN 2 on 7/27/2023 at 7:10 a.m., LVN 2 stated that LVN 1 asked her to call 911 while he (LVN 1) was retrieving the Glucagon from AMM. LVN 2 stated that LVN 1 was struggling to retrieve the Glucagon and that he (LVN 1) went back to Resident 1 without the medication. LVN 2 stated she was aware of the override function but did not help LVN 1 because, I was gathering documents so it can be ready for the paramedics. During a concurrent observation and interview with LVN 3 on 7/27/2023 at 7:28 a.m., LVN 3 was able to demonstrate the AMM override function. LVN 3 stated that before working on the floor licensed staff usually get training on how to use the AMM and the override function. During an interview with DON on 7/27/2023 at 9:20 a.m., the DON stated that LVN 1 should have accessed stock medications to retrieve the emergency Glucagon. The DON stated that LVN 1 panicked, and his main concern was being with Resident 1 at that time. The DON stated LVN 1 was trained on how to use the AMM and the override function right after the incident. The DON stated that if the resident does not receive the Glucagon in a timely matter, the outcome could be fatal. A review of the facility's document titled LVN Job Description, revised May 2022, indicated the LVN must attend and participate in continuing education programs. The document also indicated that LVNs must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents serve and the LVN must be able to cope with mental and emotional stress of the position. A record review of the facility's undated document titled Facility Assessment Tool (a tool for the facility to evaluate its resident population and identify the resources needed to provide necessary person-centered care and services the facility residents require), indicated that nursing staff are checked for competency skills and if they are deemed competent then they are assigned to the unit that they meet qualifications for. The document also indicated that competency skills evaluations are checked upon hiring and annually thereafter. Performance evaluations are performed annually to ensure staff is meeting the facility's standards of performance and conduct.

Based on observation, interview and record review, the facility failed to follow its policies on pain management and physician notification for one of three sampled residents (Resident 1), who was experiencing severe back pain by not: 1. Notifying the facility's Medical Director, once Resident 1's primary physician was not responding for pain management for Resident 1, as per the facility's policy. 2. Medicating Resident 1 for severe back pain once the resident requested for pain medication as prescribed by the physician on 5/31/19. These deficient practices resulted in Resident 1 having uncontrolled pain of ten (10) on a pain scale one (1) to 10 (10 being the worse pain) from 6 p.m., till 11:33 p.m., a total of five and a half (5 1/2) hours. As a result, Resident 1 had to be transferred back to the general acute care hospital (GACH) for pain management only. Resident 1 stated he felt helpless as the licensed nurses would not help to ease his pain. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED].), stimulant dependence (continuous use of drugs such as cocaine that can cause mental discomfort ), [MEDICAL CONDITION] (paralysis (inability to move) of the legs and lower body), intra-spinal abscess (a collection of pus that has built up within the tissue of the body) and [DIAGNOSES REDACTED] (a small area of inflammation (a part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants)). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Progress Note, dated 5/31/19 and timed at 6 p.m., indicated Resident 1 was admitted to the facility, unable to reposition in bed and/or transfer himself to and from the bed. According to the progress note, Resident 1 complained of severe back pain of 10 on a pain scale of 1-10 and 10 being the worse pain. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 5/31/19, indicated Resident 1 had uncontrolled pain and was transferred, per the nurse's judgement and the facility's policy, to a GACH on 5/31/19 at 11:40 p.m. A review of a Prehospital Care Report Summary, from an Ambulance Service, dated 5/31/19 and timed at 11:33 p.m., indicated Resident 1 was alert and experiencing severe back pain of 10 on a pain scale (0-10), as per the emergency medical technicians ((EMTs) a person who is specially trained and certified to administer basic emergency services) assessment. Resident 1 was transferred to the GACH by the EMTs. A review of an Emergency Department (ED) Arrival Information form, dated 6/1/19, indicated Resident 1 arrived at the ED at 11:57 p.m. on 5/31/19 to receive medication for the uncontrolled back pain. The form indicated Resident 1 had a laminectomy (surgical operation to remove one or more small bones in the back to relieve pressure on the nerves or spinal cord) on 5/16/19. The ED Information form indicated Resident 1 did not receive pain medications at the facility because the resident's pain prescriptions was not filled. According to this form, Resident 1 was treated and medicated for pain in the ED and sent back to the facility on [DATE]. According to the ED note, Resident 1 received [MEDICATION NAME] one 4 mg tablet by mouth with decreased pain. A review of Resident 1's facility Nurse's Progress Note, dated 6/1/19 and timed at 1:32 a.m., indicated Resident 1 was readmitted to the facility from the GACH in severe pain. The nurse's progress note indicated Resident 1 refused to take Tylenol while the nurse waited for the other stronger pain medications to be approved by the resident's primary physician. The nurse's progress note indicated the pharmacist (a person who is professionally qualified to prepare and dispense medication) was made aware and stated that due to high volume of calls, the attending physician had not yet approved for the nurses to get narcotic medications from the facility's automated medications dispensing unit (Omnicell). According to the nurse's note, Resident 1's family member (FM 1) was very upset and requested for Resident 1 to be transferred back to the GACH for pain management. Resident 1 was transferred to the GACH per FM 1's request. On 6/14/19 at 3:10 p.m., during an interview, FM 1 stated Resident 1 was admitted to the facility on [DATE] at 6:30 p.m. and had to be transferred to an ED at 12 a.m., which was approximately five hours after being transferred to the facility from the GACH. FM 1 stated Resident 1 was crying in much pain and the facility did not have any pain medications to give the resident. FM 1 stated that she asked the nurse to send Resident 1 back to the GACH for prompt treatment because the resident had just had back surgery and needed pain medications. On 6/18/19 at 8:44 a.m., during a concurrent observation and interview, Resident 1 was observed in bed complaining of pain. Resident 1 stated that a Licensed Vocational Nurse (LVN 2) was notified at 7 a.m., that he was in pain, but no one has come to medicate him as usual. Resident 1 stated he decided not to bother them anymore, because the nurses would do what they wanted regardless. Resident 1 stated that he felt helpless, especially since he could not walk and the nurses would not help to ease his pain. On 6/18/19 at 8:58 a.m., during an interview, LVN 2 stated that Resident 1's pain medication was due at 8:30 a.m. (on the same day), but she did not medicate Resident 1 because the treatment nurse asked her to wait and medicate Resident 1 just before the wound care treatment. LVN 2 stated that she should have given Resident 1 his pain medications as prescribed to decrease the resident's pain and make him comfortable, as well to prevent the resident's pain from getting worse. On 6/18/19 at 9:05 a.m., during a concurrent interview and record review of Resident 1's clinical record nursing progress notes, Registered Nurse 1 (RN 1) stated that there was no documentation indicating the facility's Medical Director (a physician who provides guidance and leadership on the use of medicine in a healthcare organization) was called regarding the nurse's inability to reach Resident 1's primary physician for Resident 1's pain medication order. RN 1 stated that upon admission, residents are assessed by an RN and the physician was called within an hour for medication orders to be verified. RN 1 stated that if the physician did not respond to telephone calls within two (2) hours, the facility's Medical Director or the GACH's transferring physician should be called for resident's admitting orders. RN 1 stated after a physician prescribes narcotic medications it still had to be authorize by the pharmacist before the narcotics (strong pain medicines) could be provided to the residents. On 6/18/19 at 9:39 a.m., during an interview, the facility's pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs) stated that Resident 1's physician was paged on 5/31/19 at 11 p.m., to authorize the narcotic orders for Resident 1, but the physician never returned the pharmacist's call. The pharmacist stated that Resident 1's narcotics could not be filled until the physician gave an approval. On 6/18/19 at 9:57 a.m., during an interview, LVN 1 stated on 5/31/19, as soon as Resident 1 was admitted to the facility, the physician gave written orders to continue with the GACH's medication orders. LVN 1 stated that the orders were sent to the pharmacy to be filled immediately because Resident 1 had a lot of pain to the back of 9 out of 10 upon admission. LVN 1 stated that the Omnicell could not be opened because the pharmacist was waiting for the physician's approval. According to LVN 1, Resident 1 was prescribed 8 mg of [MEDICATION NAME], but the pharmacist refused to send the medication because the physician did not provide an actual written order. LVN 1 stated that the facility's Medical Director was not called, because she did not control the doctor. A review of the facility's policy with a revision date of 12/1/18 and titled, Physician/Advanced Practice Provider Notification, indicated if a patient had a change of condition, the licensed nurse would assess the resident, and notify to the physician or advanced practice provider. The policy also indicated if the staff were unable to reach the attending physician, the facility's medical director would be contacted, and interventions initiated as needed. On 6/18/19 at 10:54 a.m., during an interview, the Director of Nursing (DON) stated that upon admission, a licensed nurse should fax the resident's physician orders [REDACTED]. The DON stated the pharmacist have to authorize for the nurse to get pain medications from the Omnicell to give to the resident. The DON stated that if Resident 1's physician did not respond to telephone calls for admitting orders within an hour the Medical Director should have been called for immediate pain medication orders. The DON stated the licensed nurse should have transferred Resident 1 to the ED upon admission because the resident's pain could have been be a complication from the surgery. A review of the facility's undated policy titled, After Hour, Weekend and Holiday Calls to Physicians/Advanced Practice Providers Process Guidelines, indicated if a resident had a change of condition between the hours of 5 p.m., and 7 a.m., on the weekends or holidays, the supervisor would call the physician with the identified problems and document the notification in a change in condition follow- up note and then follow-up as indicated. A review of another policy, with a revision date of 3/1/18 and titled, Pain Management, indicated the purpose of the policy was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain. A review of a policy, dated 1/15/18 and titled, Automated Medication Dispensing System for Interim (temporary)/Stat/Emergency Supply (Omnicell, Pyxis) indicated the purpose of the policy was to ensure access to medically necessary medications and to facilitate administration of STAT (immediately) and FIRST DOSES by authorized center staff. A review of a policy titled, Physician Notification, dated 12/1/06 indicated a change in a resident's condition would be communicated to the physician and interventions initiated as needed. According to this policy, if the resident's condition was life threatening or an emergency, the staff would call 911 and notify the physician immediately.

Based on observation, interview and record reviews, the facility failed to ensure Resident A, who had a history of [REDACTED]. (Spanish), was kept safe and free from injury by failing to: 1. Closely monitor Resident A's whereabouts during a fire drill. 2. Conduct an elopement risk assessment upon admission and after Resident A had an elopement attempt, in accordance to the facility's policy and procedure. 3. Ensure Residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury and to complete the Elopement Evaluation when Resident A exhibited signs of elopement risk between assessments. Consequently, Resident A left the facility unnoticed and was found missing after a fire drill (a practice of the emergency procedures to be used in case of fire). The resident was found outside the facility and transported by emergency services (911) to a general acute care hospital (GACH) with multiple abrasions (superficial damage to the skin) to the face and lower extremities (body) and a fracture (broken bone) to the right arm. Findings: A review of Resident A's admission records indicated she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Care Plan, dated December 12, 2015 revealed Resident A was at risk for further falls due to; impaired mobility, cognitive loss, dementia and having poor regards for safety. The interventions includes to assist the resident in and out of the bed with extensive assistance, assist with ambulation, provide verbal cues for safety when needed, provide the resident/care giver with safe techniques and to provide a Spanish interpreter for needs and wants as needed. However, the Care Plan did not address the resident's risk factors of packing her things, roaming around the facility and sitting near exit door. The Minimum Data Set (MDS), an standardized assessment and care screening tool, dated March 2, 2017 indicated Resident A was able to understand and answered five of 15 questions from the brief interview for mental status. The MDS assessment further indicated the resident had no behaviors of wandering and required limited one-person physical assistance for bed mobility, transfers, walking in the room and locomotion on the unit. The resident had no functional limitation in range of motion (the distance and direction a joint can move to its full potential) and used a walker and wheelchair for mobility. A review of the Progress Notes, dated March 13, 2017 at 9:20 p.m., indicated Resident A was noted to be missing. The facility activated a code pink (missing person) where the staff checked for the resident inside and outside of the building. According to the notes, the assisted living center next to the facility as well as the GACH across the street from the facility was checked. At 9:40 p.m., the police was notified. At 9:50 p.m., the police called the facility stating the resident was found on the corner just past the facility and was taken via ambulance to a GACH. A review of handwritten investigation notes, dated March 14, 2017, revealed CNA 2 was asked if he/she saw Resident A. CNA 2 stated the resident was seen by the back door at around 6 p.m., to 6:30 p.m., with her clothes on the wheelchair. The notes indicated the resident was brought back to the nursing station. When asked if the resident said anything, CNA 2 stated Resident A speaks Spanish, and he could not understand her. A Situation Background Assessment Recommendation (SBAR) form, dated March 13, 2017, indicated Resident A eloped from the facility and was last seen by a certified nursing assistant (CNA) at 9 p.m., (which C.n.a) during a fire drill. On March 16, 2017, at 10:45 a.m., during an interview the administrator stated Resident A was alert with confusion and only spoke Spanish. She stated she believed Resident A used the back door to leave the facility since her bedroom was near the back door and she was last seen in that vicinity. On the day she eloped from the facility, the resident had an abnormally large amount of family visiting her. The Administrator stated she believed the resident may have been looking for her family after they left. The administrator further stated it was reported to her the resident was seen by multiple staff around 8 p.m., in the hallway sitting with other residents. When her assigned CNA could not locate her, they initiated a code pink and searched inside and outside of the building, called the GACH across the street and notified the local police department. Approximately 10 minutes after speaking to the police, the local police called back to say the resident was at a GACH located in another part of city. The administrator stated apparently the resident had fallen from her wheelchair and was found on the ground on the corner down the street from the facility by someone who called 911. The administrator stated Resident A had never exhibited indicators that would make her an elopement risk, nor had she ever attempted to leave the facility. She stated they only assess residents for elopement risk for the following reasons: 1. On admission, 2. If there was a report of a history and/or attempts of elopement, 3. Once the resident had indicators that would alert the staff about attempts or actually leaving the facility. The Administrator stated they do not have a wander guard system (an system that alarms when a resident is close to doors) but there are alarms on all of the doors. She stated the receptionist is present Monday thru Thursday from 8 a.m., until 7:30 p.m., Friday from 8 a.m., until 9:30 p.m., and Saturday thru Sunday from 8 a.m., until 4 p.m. She acknowledged the doors did not have a continuous sounding alarm making it unnoticeable since it was frequently used by staff, residents and visitors. She stated she believes Resident A used the back door to leave the facility since her bedroom is near the back and she was last seen in that vicinity. On March 16, 2017 at 11:15 a.m., during a tour of the facility it was confirmed when the front and back doors were opened, the alarm sounded loudly, only once, for approximately 2 seconds and then it stopped. The tour continued through the door to where the resident was thought to have eloped from. It was found the resident propelled herself through a parking lot, made a left and continued down a drive way that was approximately 30 yards in length, made a right at the end of the driveway and continued down the sidewalk for approximately 30 more yards when she most likely fell from her wheelchair when she attempted to cross at the corner. On March 16, 2017 at 11:30 a.m., Resident A was observed lying in bed on her back sleeping. There was an abrasion/bruise (forms because the soft tissues of your body have been bumped) to her forehead and to the left side of her nose. A sling was noted on her right upper extremity, the rest of her body was covered by a blanket and not visible for observation. On March 16, 2017, at 11:54 a.m., during a subsequent interview, the Administrator stated they contract with an independent company unannounced to conduct the facility's fire drills. She stated that evening the fire consultant conducted a fire drill at the facility. The consultant was still in the facility during the time Resident A eloped. The administrator, acknowledged, but could not say with certainty the staff may have been preoccupied with the fire drill, which possibly allowed the resident to leave the facility unnoticed as she eloped from the facility. She stated the staff were responsible for monitoring the resident's whereabouts. On March 16, 2017, at 12:35 p.m., during an interview Registered Nurse (RN 1), the Director of Staff Development (DSD) stated she gave a recent elopement in-service that included the types of indicators to look for in residents who may be trying to leave the facility. The DSD stated some of the indicators include statements from the residents saying they want to and/or are going home, moving toward and always congregating around the doors and packing their things. She stated the in-service only documented the elopement drill, but as far as a resident's risk indicators they were only talked about. When those indicators occurred the staff were instructed to report to their charge nurse and be more observant of the resident's behavior and whereabouts. A review of the Elopement Drill Documentation Form indicated an elopement drill was conducted on February 28, 2017. However, there was no documentation reflecting the elopement risk indicators were addressed. Additionally, CNA1 was not on the list of staff who attended the In-service. On March 16, 2017 at 12:55 p.m., during an interview, the MDS nurse stated she was at the facility when Resident A eloped. She stated she was walking out the front door about 8:45 p.m., when the fire consultant came to the facility. She walked back into the facility with him and assisted with the fire drill by activating the fire alarm. She stated most of the staff were present at the fire drill, which lasted approximately 15 minutes. She then walked out of the building with the fire consultant around 9:05 p.m. When she returned at approximately 9:25 p.m., staff reported to her the resident was missing. She stated it was a definite possibility the resident eloped from the facility when staff was distracted with the fire drill. 0 On March 16, 2017, at 4:25 p.m., during an interview CNA 1 stated he brought Resident A to the dining room at approximately 5 p.m., for dinner. The next time he saw her was at approximately 7:30 p.m. At that time she had all of her things from her drawers and closet including her diapers packed and sitting in the seat of her wheelchair. She was behind the wheelchair pushing it walking back and forth in front of her bedroom which made him think she was planning on leaving. He redirected her back to her room at around 8 p.m., then placed her clothing in the closet and left her sitting on her bed. He stated the resident was speaking in Spanish but he could not understand what she was saying. He then went on his break from 8 p.m., - 8:30 p.m., and when back the resident was in the hallway sitting in her wheelchair near the nursing station. When he got to Resident A's room at approximately 9:20 p.m., she was not there. He looked around the immediate area and asked if anyone had seen her, they had not. A code pink was called and everyone began looking for her. On March 21, 2017, at 9:28 a.m., during a telephone interview with the Licensed Vocational Nurse ( LVN 1) stated CNA 1 reported to her Resident A had packed all of her belongings and put them in her wheelchair but thought this was her normal behavior but the staff usually watched to make sure she did not leave the facility. LVN 1 stated the resident had previously left the building on the same night at approximately 6 p.m., but was found in the back parking lot and a CNA brought her back into the building. That night there was a fire drill at approximately 9 p.m., where most of the staff attended and believed that was how the resident was able to get out of the building without anyone noticing her. There was no documented evidence the facility developed a plan of care to address Resident A's earlier elopement form the facility to ensure supervision and prevent further elopements. A review of the Facility's Floor Plan indicated Resident A's room (Room 20) was in close proximity to the facility's back door. There were two resident rooms, DON's office, a restroom and another office that separated the resident's room from the back door. A review of the Emergency Documentation from the GACH where Resident A was transferred after the elopement and fall incident, dated March 13, 2017 indicated the resident was alert, awake and oriented to person. She was brought in by an ambulance after a fall out of her wheelchair while going down a driveway in the street. She had a laceration to her forehead with pain to her right shoulder and ankles. An X-ray report (used to take images of the human body), dated March 13, 2017 revealed a comminuted fracture (when a bone is broken into several parts) through the right humeral neck (the bone of the upper arm, extending from shoulder to elbow) with medial displacement (fractures resulting in abnormal positions of the bone). A review of the readmission Nursing Assessment form, dated March 15, 2017 showed the following: 1. Abrasions to nasal area 2. Abrasions to the right and left knees 3. Discoloration to right peri orbital (the bony part of the skull that houses and protects the eyeball, the eye socket) extending to her nasal area and cheeks 4. Discoloration to left shin (the front of the leg below the knee) and left hand 5. Swollen and bruised right arm extending to the back, elbow and armpit. A review of the facility's policy and procedures titled Elopement of Patient, dated May 15, 2014 indicated patients will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. To complete the Elopement Evaluation (both electronic and non-electronic) if a patient exhibits signs of elopement risk between routine assessment/evaluation. There was no documented evidence the facility conducted an elopement risk assessment upon admission and when Resident A exhibited elopement behaviors.

Based on interview, and record review, the facility staff failed to immeidately consult with the physician and notify the responsible party (FM 1) of one of one sampled residents (Resident 1), after the resident had a fall, which resulted in a bruised, swollen and painful left leg and knee. The physician was not noitfied until six hours later, after Resident 1 told FM 1 about the fall, and discovered Resident 1's left leg and knee were bruised, swollen and painful. This resulted in a delay in services and treatment for [REDACTED]. Consequently, Resident 1 had an open reduction internal fixation (ORIF-surgery to repair the femur fracture), remained in the acute hospital for 14 days. Findings: A review of Resident 1's admission record indicated she was admitted to the facility on (MONTH) 8, 2013, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) a resident assessment tool, dated (MONTH) 1, 2013, indicated Resident 1 was severely impaired cognitively, had short and long term memory problems, was sometimes self-understood and at times able to understand others. The MDS further indicated Resident 1 was visually severely impaired and required extensive assistance with one person physical assistance with bed mobility, transfers, ambulation in room, dressing, eating, toilet use, bathing and personal hygiene. The resident spoke Russian. During a telephone interview on (MONTH) 16, 2014 at 1:00 p.m., with family member 1 (FM1), she stated on (MONTH) 26, 2014 at 3:30 p.m., Resident 1 told FM 1 she fell and had pain. FM1 rolled up the resident's pants leg and observed her left leg was swollen with a large bruise to the knee. Facility staff told FM1 they were not aware of the resident's leg bruising. During an interview with Licensed Vocational Nurse 1( LVN 1), on (MONTH) 4, (YEAR) at 11:40 a.m., stated Certified Nursing Assistant 1 (CNA 1), called her to Resident 1's bedside because the resident was saying, ouch, ouch, Resident 1 spoke little English. LVN 1 stated she was not notified of Resident 1's fall. LVN 1 stated Resident 1 was wearing pants and she did not take the resident's pants off or rolled up the pants to assess under the resident's garment. LVN 1 checked if the resident was wet by touching her diaper. LVN 1 stated CNA 1 changed the resident's pants after lunch and did not report any change in Resident 1. A review of the Daily and Q (every) Shift Charting, dated (MONTH) 26, 2014 at 4 p.m., indicated staff was notified by FM1 that Resident 1 was having pain. An assessment by the licensed nurse indicated the resident's left shin was bruised, swollen, skin was dry, warm, and tender to touch. Resident 1 complained of pain 7 out of 10, 10 being the highest. Tylenol 325 milligrams (mg) two tablets were given and the supervisor was notified to further assess Resident 1. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014 at 5 pm, indicated LVN 1 (7 am to 3 pm shift), was called by LVN 10 to Resident 1's room, and saw the resident's left leg was discolored. The resident's FM 1 translated and stated the resident stated she fell . There was no fall incident reported by CNA 1. CNA 1 indicated the resident was saying oy oy oy. LVN 1 went to Resident 1's room and she pointed to her stomach and repeated oy oy oy. I checked her diaper it was wet and asked the CNA to change her. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014 at 5 pm, indicated FM1 reported to LVN 10, Resident 1 told FM1 she had a fall. LVN 10 and LVN 11 pulled up the resident's pant leg and noted a purplish skin discoloration on the left leg, swelling from the mid thigh to the foot, the pedal pulse was diminished, and a pain assessment indicated the resident had facial grimacing, and moaning. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014 at 10:10 am, indicated when LVN 11 assessed Resident 1's left leg there was discoloration, tender, and warm to touch. The resident was grimacing and kept saying in Russian, I am in pain, was translated by the daughter (FM1). Two tablets of Tylenol 325 mg were given to the resident and the supervisor was notified. LVN 11indicated she had worked on Sunday 3 pm-11 pm, shift and did not recall a fall incident being reported. A review of the SBAR(Situation Background Assessment Recommendation) Communication Form, dated (MONTH) 26, 2014 at 4:08 pm, indicated the charge nurse reported Resident 1 was in pain and needed further assessment. At 4:10 p.m., during an assessment the resident's left knee was swollen and tender to touch, physician was paged awaiting call back. At 4:20 pm, the physician was paged again, Resident 1's pain was getting worst. At 4:35 p.m., while attempting to call medical director for stat (immediate), transfer a call was received to transfer the resident to the GACH. At 5:20 p.m., Resident 1 was transferred to the GACH. A review of the, Final Licensed Nurses Progress Notes, dated (MONTH) 26, 2014 at 5:20 pm, indicated Resident 1 was transferred to the GACH. The condition of the resident at time of discharge was bluish discoloration, swollen left thigh and swollen left knee with a pain scale of 9, on a scale from 0 to 10, 10 the highest. A review of the facility's document titled, Statement, dated (MONTH) 30, 2014, CNA 1 indicated on the morning of (MONTH) 26, 2014, around 10 a.m., on the way to the bathroom Resident 1 stumbled and was lowered down to the floor by CNA 1. Resident 1 was put back to bed with assistance from CNA 3. The statement indicated Resident 1 was combative. A review of clinical records there was no documentation that a fall was reported for Resident 1. A review of the Report of Alleged Incident /Accident, dated (MONTH) 26, 2014, indicated the time of the incident was unknown. Notification of the administrator indicated (MONTH) 26, 2014, at 9:30 a.m., the director of nursing (DON) was at 10 a.m., physician was notified at 4:35 p.m., and FM1 at 4:20 p.m. Pain was assessed at a scale of eight indicating severe pain (on scale of 1 to 10, 10 the highest). The incident was unwitnessed, a suspected fall in Resident 1's room. A review of Resident 1's, Fall Risk Evaluation, dated (MONTH) 9, 2014, indicated a total score of 27 (a score of 10 or above represented a high risk). A review of the Restorative Feeding Program, dated (MONTH) 26, 2014, the Restorative Nurse Assistant 1 (RNA 1), indicated Resident 1 was unable to attend her lunch was very agitated, and disoriented at this time, and documented the CNA will assist with the resident's lunch in her room, CNA made aware. A review of the Nursing Home to Hospital Transfer Form, dated (MONTH) 26, 2014 at 5:30 p.m., indicated the reason for Residenty 1's transfer was left leg pain, and additional clinical information included the SBAR acute change in condition. A review of the facility's report to the Department of Public Health, dated (MONTH) 30, 2014, indicated a follow up investigation clarification with staff determined Resident 1 was ambulating towards the bathroom, began to stumble and fell . CNA 1 lowered Resident1 to the floor attempting to prevent further injury. A Nursing assessment indicated a swollen leg, discoloration, and upon notification of the physician ordered acute transfer for further evaluation. Corrective actions taken were: RN assessment, physician notified, responsible party aware, transferred to the general acute care hospital(GACH). This correction action occurred after FM 1 visited Resident 1 and discovered the painful, discolored, swollen left leg. CNA 1 reported to LVN 1 the resident was repeating, ouch, ouch. There was no assessment done for five hours after Resident 1 was assisted to the ground by CNA 1. A review of the general acute care hospital (GACH), History and Physical, dated (MONTH) 26, 2014, indicated Resident 1 was transferred to the emergency room (ER) and was diagnosed with [REDACTED]. The left lower extremity had significant [MEDICAL CONDITION] around the knee distal and proximal, A large bruise on the same area, and the resident was unable to move her leg. An open reduction internal fixation (ORIF)(surgery to repair a femur fracture,), was done on (MONTH) 28, 2014, and Resident 1 remained in the GACH for 14 days. Resident 1 returned to the facility on (MONTH) 10, 2014, and was placed on Hospice. A review of the care plan for history of falls, dated (MONTH) 6, 2013, indicated Resident 1 had falls prior to admission, and had impaired balance, approaches included to use one or two staff to help with transfer/ADL(activities of daily living) if needed, and to keep resident's family informed. A review of the care plan for activities of daily living (ADL), function, impaired physical mobility, dated (MONTH) 5, 2013, indicated the resident required extensive assistance for bed mobility, transfers, walk in room, corridor, and toilet use. A review of the facility's policy and procedure titled, Physician Notification of Change in Resident Condition, dated (MONTH) 2005, indicated the policy of the center was to notify the physician and resident's responsible party of a significant change in the resident's physical, mental, psychosocial status, including accidents and when there is a need to alter treatments significantly. The policy was to provide emergency health care as needed, providing first aid, arranging for the resident to be taken by ambulance to an acute care hospital. A review of the facility's policy and procedure titled, Incident/Accident Reporting, dated (MONTH) 2004, indicated the purpose of the policy was to ensure safety to our residents, staff, and visitors, as well as to meet the requirements of both state and federal law that all incidents are investigated, documented and reported as mandated. Upon notification of an incident by staff member, family or visitor, the Administrator or designee will be notified. Reports of the following will be given to the Administrator or his/her designee in person or by phone immediately, serious accidental injuries, fracture of unknown origin.

Based on interview and record review the facility failed to provide the necessary care and services to one of one sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 and CNA 3 immediately reported Resident 1's fall to the charge nurse. 2. Ensure LVN 1 reported to the RN supervsior Resident 1's pain and fall incident. 3. Conduct a timely assessment of Resident 1 after she had a fall. 4. Ensure Tylenol 650 milligrams, which is indicated for mild pain, was not administered to Resident 1 who had a swollen and bruised left leg and complained of severe pain. This resulted in continuos pain and suffering for Resident 1 and caused a delay in services and treatment. Resdent 1 was ultimately transferred to the acute hospital for evaluation and was diagnosed with [REDACTED]. Consequently, Resident 1 had an open reduction internal fixation (ORIF-surgery to repair the femur fracture), and remained in the acute hospital for 14 days. Findings: A review of a report from the facility to the Department of Public Health, dated (MONTH) 30, 2014, indicated Resident 1 was ambulating towards the bathroom, (Was she ambulating In her room?) began to stumble and fell . CNA 1 lowered her to the floor attempting to prevent further injury. (What does further injury mean?) The Nursing assessment indicated Resident 1 had a swollen leg, with discoloration. The physician was notified and ordered to transfer the resident to the acute hospital for further evaluation. The following corrective actions taken included an RN assessment, physician notified and the responsible party aware, and the resident was transferred to the general acute care hospital(GACH). A review of the facility's investigative form titled Statement, dated on (MONTH) 30, 2014, indicated CNA 1 stated on the morning of (MONTH) 26, 2014, around 10 a.m., Resident 1 stumbled, and was lowered down to the floor and was put back to bed with assistance from CNA 3. The statement indicated Resident 1 was combative. A review of clinical records indicated there was no documentation that a fall was reported for Resident 1 or a post fall investigation assessment. A review of Resident 1's admission records indicated she was admitted to the facility on (MONTH) 8, 2013, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) a resident assessment tool, dated (MONTH) 1, 2013, indicated Resident 1's cognition was severely impaired and had short and long term memory problems. The resident was sometimes self-understood and at times able to understand others. The MDS further indicated Resident 1's vision was severely impaired and required extensive assistance with one person assist with bed mobility, transfers, ambulation in room, dressing, eating, toilet use, bathing and personal hygiene. The resident spoke Russian. A review of the care plan for activities of daily living (ADL), dated (MONTH) 5, 2013, indicated Resident 1 required extensive assistance with bed mobility, transfers, walking in the room and corridor, and toilet use. A review of physicians orders dated (MONTH) 5, 2013, indicated to administer Tylenol 650 milligrams (mg) orally every four hours as needed (PRN) for mild pain (pain scale from 1 to 3). A review of Resident 1's, Fall Risk Evaluation, dated (MONTH) 9, 2014, indicated Resident 1 had a total score of 27, which indicated the resident was a high risk for falls. A score of 10 or above represented a high risk. A review of the care plan for ADL Functional/Rehab Potential, updated (MONTH) 2014, indicated Resident 1 had impaired physical mobility manifested by extensive assistance required for bed mobility, transfers, walking in room, toilet use, had altered gait and balance, decreased range of motion, impaired cognitive function. The listed interventions included to ambulate with an assistive device and to provide assistance as needed; use one or two staff during transfer and ADL care as needed, and to implement safety measures as appropriate. During a telephone interview on (MONTH) 16, 2014, at 1:00 p.m., with Resident 1's family member 1 (FM1), she stated on (MONTH) 26, 2014, at 3:30 p.m., she observed Resident 1 laying in bed fully dressed, and complaining of leg pain. Resident 1told FM 1 she fell . FM 1 rolled up the resident's pants leg and noticed the resident's left knee cap was bruised and her left leg was swollen. FM 1 then notified the licensed staff immediately of the resident's complaint of pain, bruising and swelling to her left leg and knee. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014 at 5 pm, indicated FM1 reported to LVN 10, Resident 1 told FM1 she had a fall. LVN 10 and LVN 11 pulled up the resident's pant leg and noted a purplish skin discoloration on the left leg, swelling from the mid thigh to the foot, the pedal pulse was diminished, and a pain assessment indicated the resident had facial grimacing, and moaning. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014 at 10:10 am, indicated when LVN 11 assessed Resident 1's left leg there was discoloration, tender, and warm to touch. The resident was grimacing and kept saying in Russian, I am in pain, was translated by the daughter (FM1). Two tablets of Tylenol 325 mg were given to the resident and the supervisor was notified. A review of the Incident/Accident Investigation Interview, dated (MONTH) 27, 2014, at 5 pm, indicated LVN 1 (7 am to 3 pm shift), was called by LVN 10 to Resident 1's room, and saw the resident's left leg was discolored. The resident's FM 1 translated and stated the resident stated she fell . There was no fall incident reported by CNA 1. CNA 1 indicated the resident was saying oy oy oy. LVN 1 went to Resident 1's room and she pointed to her stomach and repeated oy oy oy. I checked her diaper it was wet and asked the CNA to change her. During an interview on (MONTH) 4, (YEAR), at 11:40 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Certified Nursing Assistant 1 (CNA 1) called her to Resident 1's bedside because the resident was stating ouch, ouch, and the resident spoke simple English terms. LVN 1 stated Resident 1 was wearing pants and she did not take the resident's pants off or roll up the pants to assess under the resident's garment. LVN 1 further stated she touched Resident's 1 diaper to verify if the resident was wet and informed CNA 1 to change the residents pants after lunch. LVN 1 stated she was not told Resident 1 had a fall. A review of the Daily and Q (every) Shift Charting, dated (MONTH) 26, 2014, timed at 4 p.m., indicated (FM 1) had notified the staff that Resident 1 was having left leg pain. An assessment by the licensed staff indicated the resident's left shin was bruised, and the nursing supervisor was notified to further assess Resident 1. A review of Resident 1's Medication Administration Sheet (MAR), dated (MONTH) 26, 2014 at 4 p.m., indicated Tylenol 650 mg orally was administered five hours after Resident 1's fall. A review of the SBAR (Situation Background Assessment Recommendation-(a nursing staff communication tool), dated (MONTH) 26, 2014, indicated the following: At 4:08 p.m., the charge nurse had reported that Resident 1 was in pain and needed further assessment. At 4:10 p.m., Resident 1 was assessed and had a swollen left knee and was tender to touch, the physician was paged and was awaiting a call back. At 4:20 p.m., paged physician regarding concerns Resident 1's pain was getting worse. At 5:20 p.m., Resident 1 was transferred to the GACH. A review of the, Final Licensed Nurses Progress Notes, dated (MONTH) 26, 2014 at 5:20 pm, indicated Resident 1 was transferred to the GACH. The condition of the resident at time of discharge was bluish discoloration, swollen left thigh and swollen left knee with a pain scale of 9, on a scale from 0 to 10, 10 the highest. A review of the Report of Alleged Incident /Accident, dated (MONTH) 26, 2014, indicated the time of the incident was unknown and there was notification made to the administrator on (MONTH) 26, 2014, at 9:30 a.m. and to the director of nursing (DON) was at 10 a.m. It futher indicated the physician was notified at 4:35 p.m., and FM1 at 4:20 p.m. The resident's pain was assessed to be an eight indicating severe pain (on scale of 1 to 10, 10 the highest). The incident was unwitnessed, and a suspected fall in Resident 1's room. A review of the Comprehensive Pain Assessment, dated (MONTH) 26, 2014, indicated Resident 1 complained of aching left knee pain. Her pain was assessed as an eight (8) out of 10 (7 to 9 indicated severe pain). According to the Comprehensive Pain Assessment, Resident 1 was unable to move and was administered Tylenol 650 milligrams (mg) orally. A review of the physicians orders dated (MONTH) 5, 2013, indicated to administer Tylenol 650 milligrams (mg) orally every four hours as needed (PRN) for mild pain (pain scale from 1 to 3). A review of the physicians orders, dated (MONTH) 26, 2014 at 4:48 p.m., indicated to transfer Resident 1 to the GACH for further evaluation. A review of the general acute care hospital (GACH), History and Physical, dated (MONTH) 26, 2014, indicated Resident 1 was transferred to the emergency room (ER) and was diagnosed with [REDACTED]. The left lower extremity had significant edema around the knee distal and proximal, A large bruise on the same area, and the resident was unable to move her leg. A review of the facility's policy and procedure titled, Fall Management, dated (MONTH) 2013, indicated the policy of the center was to assess residents for risk of falls, to follow up and evaluate falls of residents in order to assess the resident's condition; to identify the reason for the fall and prepare a plan of care to reduce the potential for future falls. The purpose was to outline the process for assessment , monitoring and post fall interventions to prevent and/or reduce future fall occurrence. To provide a process for prompt assessment and treatment following any fall or injury by the appropriate health professional. Following a resident's fall, the licensed nurse will assess the resident for injury and necessary treatment/interventions including neurological evaluation for unwitnessed falls of falls with head injuries (Neurological Evaluation Flow Sheet), documented in the medical record. The licensed nurse will initiate interviews with staff, resident and/or visitor who may know information related to the fall. The licensed nurse will notify the physician, responsible party, and DON/designee. The facility's policy notes following a resident's fall, the licensed nurse will assess the resident for injury and necessary treatment/interventions including neurological evaluation for unwitnessed falls of falls with head injuries (Neurological Evaluation Flow Sheet), documented in the medical record. The licensed nurse will initiate interviews with staff, resident and/or visitor who may know information related to the fall. The licensed nurse will notify the physician, responsible party, and DON/designee.

Based on observation, interview and record review the facility failed to maintain a hazard free environment for the resident, who had a muscle weakness and [DIAGNOSES REDACTED] (paralysis of one side of the body that results from disease or injury) and was unable to bear weight for one out of one sample resident (1). The facility failed to: 1. Provide two-person physical assistance during Resident 1's transfer from a wheelchair to a bed by using a Sabrina II EE mechanical lift (a mechanical device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually). 2. Assess Resident 1 to determine lifting equipment and transfer needs for Resident 1 in accordance with the facility's policy and procedure. 3. Follow the facility's policy and procedure on use of mechanical lifts which required at least two persons to be present while a resident was transferred with the mechanical lift. 4. To train licensed nurses and a certified nursing assistants (CNAs) on use of Sabina II EE mechanical lift and selection of lifting accessories to ensure safe transfer. This deficient practice resulted in Resident 1 sustaining a fracture of the left humerous (upper arm) and left forearm with a soft tissue swelling, experience unbearable pain and to be admitted to a general acute care hospital (GACH) for two days. The deficient practice also placed other residents in the facility at risk for falls and injuries. On January 22, 2015 at 2:30 p.m., an unannounced visit was conducted to investigate an Entity Reported Incident (ERI) about Resident 1 felt during the process of transfer from a wheelchair to a bed with mechanical lift on January 9, 2015. The resident slipped from the Support Vest sling with the lower half of the body on the floor and the resident's left arm was caught in the sling while being lifted with a mechanical lift by a certified nurse assistant 1 (CNA 1) alone without additional help. According to Resident 1's admission record the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. system mistakenly attacks health tissue. It can affect the skin, joints, kidneys, brain, and other organs) and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 22, 2014, indicated Resident 1 had severely impaired cognitive skills for daily decision making and required extensive assistance with bed mobility, dressing, eating, toilet use, personal hygiene and transfer between surfaces including to or from bed, chair, wheelchair and standing position. According to the MDS Resident 1 required two plus persons physical assistance with aforementioned activities of daily living (ADL) and was totally dependent on staff for locomotion on and off unit and bathing. Also, MDS indicated Resident 1 had a functional impairment of a left upper and lower extremity. During an interview conducted on January 22, 2015, at 2:30 p.m., with the facility's Administrator, Director of Nurses (DON) and the Director of Physical Therapy (PT), they stated CNA 1 was terminated on January 14, 2015, and was not available for interview. A review of the facility's post fall investigative report dated January 9, 2015, indicated that on January 9, 2015, CNA 1 at approximately 2 p.m., went to Resident 1's room where the resident was sitting in a wheelchair. CNA 1 left the room to bring the Sabina II EE lift (a mechanical device used to lift and transfer residents from a seated position to the bed) to transfer Resident 1 from the wheelchair to the bed. In the process of transferring Resident 1 began to fall through the sling. CNA 1 then stopped the operation of the Sabina II EE lift; however, Resident 1 continue to fall and ended up sitting on the floor while the resident's left arm was caught in the sling bearing the resident's weight. CNA 1 immediately grab Resident 1, lifted the resident up and put the resident on the bed. CNA 1 went out of the room and notified the licensed vocation nurse 1 (LVN 1), who was a charge nurse. According to Situation Background Assessment Request (SBAR)dated January 9, 2015, the LVN 1 found Resident 1 groaning and lying in bed with the head of the bed elevated. The LVN 1 documented Resident 1 had a swelling on the left shoulder and groaned louder upon touch of the shoulder. LVN 1 asked Resident 1 where the pain was and the resident pointed to her left shoulder and left hand. Resident 1 indicated pain to the left shoulder as ten on scale from zero to ten, where a zero was no pain and a ten was the most unbearable pain. According to Resident 1's Post Fall Report dated January 9, 2015, Resident 1 confirmed she had a fall. In the report was documented the physician was notified of the fall on January 9, 2015, at 2:20 p.m., and the resident was medicated with Vicodin 500 milligrams (a narcotic analgesic medication) for pain in her left arm. Resident 1 was then transferred by ambulance to the acute care hospital emergency room . A review of the acute hospital's physician progress notes [REDACTED]. According to the resident's History of a Present Illness documented in the hospital's record and dated January 9, 2015, Resident 1 was on a mechanical lift during, slipped and fell on her left functionally impaired side of her body. According to the documented hospital's Review of the Systems dated January 9, 2015, Resident 1's left shoulder was tender and deformed. According to the hospital physician's note dated January 11, 2015, the recommendation was to apply sling for immobilization without operative treatment, repeat an x-ray in the next one to two weeks and resident should remain non-weight bearing on the left arm. During an interview with the PT on January 28, 2015 at 3:15 p.m., stated that Resident 1 was totally dependent on facility's staff for transfer, including a transfer from a wheelchair to a bed. The PT additionally indicated the word "totally dependent" meant the resident required two or more persons physical assistance when transferred. PT stated whenever a resident requires two plus persons physical assistance in transferring a Hoyer lift (a manual mechanical device that uses hydraulics to enable to lift/transfer a person between surfaces) is used. The PT was asked if he was aware that during the time of Resident 1's fall a Hoyer lift was not used to transfer Resident 1 from a wheelchair to a bed. The PT stated that he was aware that a Sabina II EE lift was used during Resident 1's fall on January 9, 2015, and added that the Sabina II EE lift is only used for partially dependent residents for transfer. The PT stated that at the completion of physical therapy treatment provided from May 21, 2014, to June 17, 2014, licensed nurses were provided with an assessment of Resident 1's functional abilities. A review of the PT's Evaluation and Plan of Treatment dated June 23, 2014, for the time period of May 21, 2014, to June 16, 2014, indicated Resident 1 was totally dependent in bed mobility, transfers, had impaired range of motion (ROM) for left lower extremity (LLE) and poor balance with support while sitting. A review of the facility's policy titled "Mechanical Lift" (not dated) indicated at least two people had to be present while the resident is being transferred with the mechanical lift. According to the facility's policy and procedure titled "Lifting and Transferring of Resident", (not dated) the licensed nurses had to assess and determine lifting and transfer requirement for each resident by assessing the resident for: a) Physical limitations. b) Equipment that must be moved. c) Ability of resident to follow directions. According to the policy all residents should be lifted or transferred according to the assessment. All members of the nursing staff, licensed nurses and nursing assistants were responsible for knowing the procedures and operating assistive devices. Mechanical lift procedures had to be used on any resident unable to independently pivot or transfer. A review of the resident's clinical record indicated there was a plan of care dated May 20, 2014, for impaired physical mobility manifested by total assistance with transferring. The intervention was to evaluate and provide appropriate devices and assistance. During a phone interview with the director of staff developer (DSD) on March 25, 2105, at 1:40 p.m., DSD stated that the assessment is being done by the rehabilitation department including the assessment and determination of the physical limitations and selection of a proper mechanical lift that must be used to move the resident safely. The DSD confirmed there was no documented evidence in Resident 1's record to indicate the evaluation, determination, and mechanical lift selection was done as stated in the facility's policy and procedure. The DSD did not provide with a clear answer how it is determine what mechanical lift is selected for residents who required physical assistance with transfer and mobility between surfaces. On January 27, 2015, at 2:30 p.m., in the presence of administrator, observation occurred that the Sabina II EE mechanical lift used to lift Resident 1 had a "Narrow Sling Bar" with a Support Vest. Based on the nursing and PT's assessment as well as the manufacturer's recommendation, the Comfort Sling bar in combination with the Comfort Vest were for residents who were paralyzed on one side ([DIAGNOSES REDACTED]s). A review of manufacturer's instruction guide dated April 17, 2012, for the Sabina II EE lift indicated the Comfort Vest with a Comfort Sling bar were for someone who was paralyzed on one side and the Support Vest with the Narrow Sling bar were for the residents who were able to stand steadily. Personnel who were using the lift required to be trained on the correct operation and use of the lift. The lifting accessory had to be selected appropriately in terms of type, size, material and design with regard to the resident's needs. The lifting accessory had to be correctly and safely applied on the resident in order to avoid bodily injury. A caregiver need to assure that the resident was not at risk of falling forward or to any side during lifting. A review of Resident 1's care plan dated May 20, 2014, for impaired physical mobility, indicated there was no documentation what mechanical lift and what lifting accessory would be used for Resident 1's transfer with the mechanical lift. According to the Sabina II EE lift manufacturer's product description dated April 17, 2012, a resident must be able to actively participate in the rising motion. The resident's overall mobility determines the choice of a sling bar and a sit-to-stand vest utilized during transfer. A review of the facility's policy and procedure titled "Lifting and Transferring of Resident" indicated there was no documented evidence that would distinguish when a Hoyer lift is used or when the Sabina II EE lift is used. During an interview with the Administrator, DON and PT on January 28, 2015, at 3:40 p.m., they stated that manufacturer's recommendation for the use of the Sabina II EE lift were unfamiliar to the facility staff. They were unable to provide evidence that indicated in-service training was provided to direct care staff and licensed nurses on selection and use of mechanical lifts and their lifting accessories in accordance with manufacturer's recommendations. During an interview with the administrator, DON and PT on January 28, 2015, at 4 p.m., they stated that the facility had no policy and procedure for the use and application of the Support vest and Comfort vest. In addition, they stated the facility had not adopted the manufacturer's requirements for the use of the vests.