Every finding on record at The Ellison John Transitional Care Center

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 3). The facility failed to:Reassess the need for the continuation of the wound care for Resident 3 who had an actively draining and worsening surgical wound/incision on the right side of head status post right side craniotomy (a surgical procedure where a surgeon temporarily removes a section of bone from the right side of the skull [the protective bone shell that forms the shape of the head] to access the brain).This deficient practice has the potential for delayed wound healing and an increased risk for surgical wound/incision infection. On 6/20/2026, Resident 3 observed with myiasis (a parasitic infection caused by fly larvae [maggots] infesting live human or animal tissue) infestation on his (Resident 3) surgical wound on his right side of the head and his (Resident 3) ear requiring a transfer to General Acute Care Hospital (GACH) 1 on 6/20/2026. Findings:During a review of Resident 3's undated admission Record (AR), the AR indicated the facility admitted Resident 3 on 5/15/2026 with diagnoses that included hemiplegia (a severe or complete loss of motor function [the body's ability to control voluntary muscle movement to perform physical tasks] or paralysis [the complete or partial loss of voluntary muscle function in one or more muscles in the body] one side of the body) and hemiparesis (a mild to moderate weakness affecting one side of your body), following cerebral infarction (a brain tissue death caused by a lack of blood flow to a specific region of the brain) affecting left non-dominant side, acute respiratory failure (when lungs cannot get enough oxygen into the blood, or they cannot remove enough waste gas out) with hypoxia (a medical condition when body's tissues and organs do not get enough oxygen to function properly), encounter for attention to tracheostomy (a surgically created opening made directly into the front of the neck and into the windpipe), and dependence on respiratory ventilator (a person cannot breathe adequately on their own and relies on a mechanical breathing machine to stay alive).During a review of Resident 3's Admit/Readmit (Admission/Readmission) Evaluation (ARE), dated 5/15/2026 at 12:18 p.m., the ARE indicated Resident 3 was admitted with an admitting diagnoses of right side craniotomy, acute encephalopathy (a sudden, widespread brain dysfunction), and right Middle Cerebral Artery (MCA, one of the three major arteries supplying blood to the brain) stroke (a stroke [a blood supply to the part of the brain is suddenly interrupted or reduced] that happens when the MCA on the right side of the brain becomes blocked by a blood clot or bursts). The ARE's Skin Integrity indicated Resident 3 had craniotomy on the right side of the head.During a review of Resident 3's History of Present Illness and Physical Exam (H&P - a medical report that summarizes a resident's complete medical past and current physical health), dated 5/17/2026, the H&P indicated Resident 3 did not have the capacity to make decisions for himself.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 3 was rarely/never able to understand others and was rarely/never able to make self-understood. The MDS indicated Resident 3's cognitive skills for daily decision making were severely impaired (a person completely or near completely lost the ability to make safe, logical, and correct decisions for their own day-to-day survival). The MDS indicated Resident was dependent (helper does all the effort) with oral hygiene, showering, upper and lower body dressing, and personal hygiene.During a review of Resident 3's undated Order Summary Report (OSR, a vital medical document that lists every active treatment, medication, and care instruction by a physician for a resident), the OSR indicated the following physician orders:Right side of head craniotomy, cleanse with Normal Saline (NS - a simple, sterile mixture of water and salt), pat dry (to dry a surface by gently pressing a clean cloth against it, without rubbing or wiping), apply betadine (an antiseptic [germ-killing] medicine called povidone-iodine, a liquid used to kill germs) and leave open to air as needed for skin maintenance for 14 days. The OSR indicated an order start date of 5/16/2026 and order end date of 5/30/2026.Right side of head craniotomy, cleanse with NS, pat dry, apply betadine, and leave open to air every day shift for skin maintenance for 14 days. The OSR indicated an order start date of 5/17/2026 and order end date of 5/31/2026.Cadexomer Iodine External Gell (a topical [applied directly on the surface of the body] antimicrobial medication used primarily in professional wound care to treat chronic, highly draining [wet] wounds) 0/9 percent (%, a ratio by the hundreds), apply to surgical head wound topically every day shift for wound for 14 days. The OSR indicated an order start date of 6/4/2026 and order end date of 6/19/2026.Cadexomer Iodine External Gell 0/9 %, apply to surgical head wound topically one time a day for wound management for 14 days. The OSR indicated an order start date of 6/2/2026 and order end date of 6/16/2026.Providone-iodine solution (a highly effective, broad-spectrum [a treatment or chemical that is highly effective against a wide variety of germs] antiseptic chemical compound (a chemical substance applied directly to the wound to kill or stop the growth of microorganisms [germs], used to kill a wide array of bacteria, viruses, fungi, and parasites) 10 %, apply to the right side of head surgical incision topically every day shift for wound management for 14 days, with NS, pat dry, apply and cover with dry dressing. The OSR indicated an order start date of 6/3/2026 and order end date of 6/17/2026.During a review of Resident 3's Treatment Administration Record (TAR, a formal document used to track non-medication clinical treatments provided to a resident) from 5/1/2026 to 5/31/2026, the TAR indicated:Right side of head craniotomy, cleanse with NS, pat dry, apply betadine and leave open to air as needed for skin maintenance for 14 days. The TAR indicated the treatment was not administered in May 2026.Right side of head craniotomy, cleanse with NS, pat dry, apply betadine and leave open to air every day shift for skin maintenance for 14 days. The TAR indicated the treatment was started on 5/17/2026 and the last treatment was done on 5/27/2026.During a review of Resident 3's Medication Administration Audit Report for the schedule dates from 6/1/2026 to 6/30/2026, the Medication Administration Audit Report indicated: Povidone-Iodine Solution 10%, apply to right side of head surgical incision topically every day shift for wound management for 14 days. Cleanse with NS, pat dry, and cover with dry dressing. Medication Administration Audit Report indicated the treatment was started on 6/3/2026 and the last treatment was administered on 6/16/2026 at 12:52 p.m. Medication Administration Audit Report did not indicate if the treatment was administered on 6/17/2026.Cadexomer Iodine External Gel 0.9%, apply to surgical head wound topically every day shift for wound management for 14 days. Medication Administration Audit Report indicated the treatment was started on 6/5/2026 and the last treatment was administered on 6/18/2026 at 10:21 a.m. Medication Administration Audit Report did not indicate if the treatment was administered on 6/19/2026.Cadexomer Iodine External Gel 0.9%, apply to surgical head wound topically one time a day for wound management for 14 days. Medication Administration Audit Report indicated the treatment was started on 6/2/2026 and the last treatment was administered on 6/4/2026 at 9 a.m. During a review of Resident 3's Wound Weekly Monitoring Assessment - Non-Pressure, dated 5/16/2026, the Wound Weekly Monitoring Assessment - Non-Pressure indicated Resident 3 was admitted with right side of head craniotomy, with 100 % dry scab (a hard, protective crust that forms over a wound) and no drainage (a fluid that leaks out of wound or surgical incision).During a review of Resident 3's Situational Background Assessment and Request (SBAR - a tool used to clearly share important information with others): Change of Condition (COC - a noticeable shift in a resident's baseline health status), dated 5/28/2026 at 12:33 a.m. the SBAR:COC indicated swelling to the right side of head and leaking of clear fluid from craniectomy (a surgical procedure where a surgeon removes a section of the skull bone [bone flap] and does not immediately replace it) incision. The SBAR:COC indicated Resident 3 had clear liquid pooling in his right ear and a trail of clear liquid running from the edge of the craniectomy incision. The SBAR:COC indicated that upon assessment right side of Resident 3's head was swollen. The SBAR:COC indicated 911 (the universal emergency telephone number) was called on 5/28/2026 at 12:34 a.m. and Resident 3 left the facility at 12:50 a.m.During a review of Resident 3's undated OSR, the OSR indicated a physician order send Resident 3 to emergency room (ER - a hospital department equipped and staffed to treat people with sudden, severe illnesses or injuries) via 911 for further evaluation of swelling to right side of head and leaking of clear liquid from craniectomy incision one time only for one day. The OSR indicated order date of 5/28/2026.During a review of Resident 3's General Acute Care Hospital (GACH) 1 Discharge summary, dated [DATE] at 3:45 p.m., the GACH 1 Discharge Summary indicated Resident 3 developed increasing drainage and wound dehiscence (to burst, split, or pop open along a natural line or seam) from the craniotomy site with associated purulent (a thick, cloudy, and milky fluid that oozes from a wound, usually signaling that the body is actively fighting an infection) drainage from the ear, prompting transfer back to the hospital for neurosurgical evaluation. The Discharge Summary indicated neurosurgery evaluated Resident 3 and determined no indication for operative interventions. The Discharge Summary indicated the drainage from the inferior porthole (a wound or a packet of skin breakdown located on the lower part of the resident's body) of the craniectomy incision was felt to represent a cerebrospinal fluid (a clear, colorless, and watery liquid that continuously circulates through and around the brain and spinal cord [connects brain to the rest of the body]) leak rather than a drainable infection, a suture (a [NAME] used by doctors to hold the skin together after surgery) was placed with successful cessation (stopped) of drainage.During a review of Resident 3's Wound Weekly Monitoring Assessment - Non-Pressure, dated 6/2/2026, the Wound Weekly Monitoring Assessment Non-Pressure indicated a right side of head surgical incision measuring 12 centimeters (cm - a unit of measurement), scattered scabs along surgical site, site above the ear is leaking fluid clear and white, surrounding tissue is blanchable (a red area of the skin that turns white or pale when pressed with a finger, then turns red again when released) redness.During a review of Resident 3's Wound Weekly Monitoring Assessment - Non-Pressure, dated 6/16/2026, the Wound Weekly Monitoring Assessment - Non-Pressure indicated right side of head surgical site with drainage noted seeping from the wound site, moderate (more than 25% and less than 75%) serous (clear, watery) drainage with surrounding tissue blanchable redness.During a review of Resident 3's SBAR:COC, dated 6/19/2026 at 12:49 a.m., the SBAR:COC indicated Resident 3 was noted with purulent drainage from right side of craniectomy incision. Resident 3 noted with purulent (pus or fluid that contains pus) drainage leaking from his (Resident 3) right side craniectomy incision in two different areas, one anterior (toward the front) to his ear and one superior (above or higher) to his ear. The SBAR:COC indicated area superior to ear is still swollen and some redness noted around incision. The SBAR:COC indicated Resident 3 pushed nurse's (RN 2's) arm away while attempting to clean the drainage that had pooled in his (Resident 3) ear. Resident 3 repeatedly puts his right hand on the area of his head where the bone flap was removed on the right side.During a review of Resident 3's Wound Weekly Monitoring Assessment - Non-Pressure, dated 6/20/2026, the Wound Weekly Monitoring Assessment - Non-Pressure indicated right side of head surgical site measuring 30 cm in length and 0.1 cm in width, surgical site has 0.3 cm length dehisce (a clinical measurement indicating how long the open, separated section of a surgical incision is) with purulent drainage seeping from the wound site, no redness, mild swelling, and maggots coming out of ear canal. Additional information indicated the surgical site was cleaned with NS, and pat dry, ear canal was cleansed with four-by-four sterile gauze and NS.During a review of Resident 3's SBAR:COC, dated 6/20/2026 at 9:24 a.m., the SBAR:COC indicated worsening right ear infection with increased purulent drainage and small maggots crawling from right ear and right craniectomy site. The SBAR:COC indicated upon rounding with Nurse Practitioner (NP - a registered nurse with extra education, like a master's or doctorate degree), (unspecified), noted Resident 3 with worsening right ear infection, increased purulent drainage, and small maggots crawling out from right ear canal and right craniectomy site. NP (unspecified) and Medical Doctor (MD)1 ordered to transfer Resident 3 via non emergent transportation to General Acute Care Hospital (GACH) 1.During a review of Resident 2's undated admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/21/2026 with diagnoses that included muscle weakness and depressive episodes (a specific period of time during which a person experiences a persistent, overwhelming feeling of sadness or a complete loss of interest in activities they normally enjoy).During a review of Resident 2's History of Present Examination (H&P), dated 6/24/2026, the H&P indicated Resident 2 had the capacity to make to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition.During an interview on 7/7/2026 at 1 p.m. with Resident 2 in the resident's room, Resident 2 stated facility had flies but not all the time, only when they open the window. Resident 2 stated even the nurses (unable to recall the names) have seen the flies. Resident 2 stated that there was a time when a nurse (Resident 2 was not able to recall nurses' name and the time) came in and told Resident 2 to cover up because there was a fly on his open wound in his (Resident 2) left knee. Resident 2 stated the nurses try to get rid of them.During a concurrent interview and record review on 7/7/2026 at 1:56 p.m. of Resident 3's June 2026 TAR with Treatment Nurse (TN) 1, TN 1 stated that she worked with Resident 3 on 6/19/2026. TN1 reviewed Resident 3's June 2026 TAR and stated that for the povidone-iodine she (TN 1) did not sign off that the treatment was done. TN 1 stated since it was not signed off, she (TN 1) cannot say Resident 3 received the treatment on 6/19/26. TN 1 stated if residents are not given wound treatment can be a potential for infection. During a concurrent interview and record review on 7/7/2026 at 2:23 p.m. of Resident 3's June 2026 TAR with TN 2, TN 2 stated she (TN 2) worked on 6/20/2026. TN 2 stated Resident 3 had a surgical site on his right side of scalp; craniotomy closed with sutures. TN 2 stated craniotomy surgical site was initially dry without swelling then it got softer, it was boggy (a wound or the skin around it that feels abnormally soft, spongy, or mushy to the touch), it started to drain and it felt like there was drainage under the skin. TN 2 stated on 6/20/2026, Resident 3 was laying on his back, had a chuck pad (disposable, waterproof, absorbent pad) behind his (Resident 3) head and she (TN 2) noticed small maggots, the maggots were crawling out of Resident 3's ear canal, mostly ear, and surrounding cheek and going back of the ear. TN 2 stated there were a handful of maggots. TN 2 stated she tried to clean and noticed in the ear canal the maggots were pocketed in Resident 3's ear. TN 2 stated she noted a small amount of drainage from the surgical site draining into Resident 3's ear. TN 2 reviewed Resident 3's June 2026 TAR and stated she (TN 2) was not sure why Resident 3 did not get treatment on 6/19/2026, the order may have fallen off, and they (nurses) did not verify with the doctor if they wanted to continue with the wound care. TN 2 stated on 6/20/2026 she (TN 2) did not put iodine or cover the site but did cleanse the site with NS. TN 2 stated she (TN 2) was not sure of the incubation period for maggots and was not sure if two days of missed treatment would affect Resident 3. TN 2 stated:Cadexomer Iodine External Gel 0.9%, apply to surgical head wound topically every day shift for wound management for 14 days with the start date of 6/5,2026. The TN 2 stated it was signed off as done from 6/5/2026 to 6/18/2026.Povidone-Iodine Solution 10%, apply to right side of head surgical incision topically every day shift for wound management for 14 days, cleanse with NS, pat dry, apply and cover with dry dressing started on 6/3/2026 and discontinued on 6/21/2026. The TN 2 stated it was signed off from 6/3/2026 to 6/16/2026.During an interview on 7/7/2026 at 3:58 p.m. with the Director of Nursing (DON), the DON stated for wound treatment they use whatever the doctor orders. The DON stated there was no treatment for Resident 3 on 6/19/2026 and Resident was still having drainage. DON stated on 6/20/2026 there was significant drainage and there was swelling. The DON stated staff should call the doctor and verify the need to continue the treatment. The DON stated there is a potential if they do not continue with treatment, there will be lapse in the healing process. The DON stated she (DON) is unsure of the incubation period for maggots.During an interview on 7/8/2026 at 1 p.m. with Certified Nursing Assistant (CNA) 3, CNA3 stated on 6/20/2026, he worked with Resident 3 in the morning shift (started around 7 a.m.). CNA 3 stated he (CNA 3) did not see any maggots during his initial rounds and care of Resident 3. CNA 3 stated Resident 3 had maggots in his ear and outside of his ear. CNA 3 stated there were a lot of maggots, more than 10 maggots.During an interview on 7/8/2026 at 1:21 p.m. with Registered Nurse (RN) 1, RN 1 stated on 6/20/2026, she (RN 1) worked in the morning shift. RN 1 stated Nurse Practitioner (NP) came in (unspecified) and asked RN 1 to go with NP to see Resident 3 because NP stated she (NP) thought she had seen mites (tiny bugs). RN 1 stated when she (RN 1) went to see Resident 3, she (RN 1) saw small maggots coming out of Resident 3's right ear canal. RN 1 stated she (RN 1) could not count how many maggots, but there were more than 10 maggots. RN 1 stated Resident 3 was lying on his back, and his head was slightly turned to the right side, and the surgical wound on his right side of the head looked moist. RN 1 stated drainage from the surgical wound on the right side of the head was draining and would pool in Resident 3's ear canal. RN 1 stated she (RN 1) cleaned the maggots; it took her about 10 minutes to clean and remove the maggots.During an interview on 7/8/2026 at 3:15 p.m. with the Director of Infection Prevention (DIP), the DIP stated when a resident has active drainage, the wound care with pending doctors' recommendations the doctor must decide. The DIP stated the nurse will follow up with the doctor to see if there is a new recommendation or change in treatment. The DIP stated if there was no documentation, she (DIP) cannot say if the doctor was made aware of no treatment done for Resident 3. The DIP stated if there is purulent drainage, they should be doing something to keep the site clean and dry, but that is based on doctor's order. The DIP stated for treatment, it would be wound care nurse and/or RN supervisor that would ensure the doctor is aware that the treatment is completed and if there is a need for new order or for continuing of the treatment.During an interview with Medical Doctor (MD) 1 on 7/9/2026 at 12:41 p.m. the MD 1 stated he (MD 1) was informed of day of transfer (6/20/2026) regarding Resident 3's maggots. MD 1 stated that NP (unspecified) was onsite when the maggots were noted. MD 1 stated he was not aware that there was no wound care for Resident 3. MD 1 stated if he (MD 1) was aware that Resident 3 did not have wound treatment, he would have asked staff to refer to the wound doctor. During a review of the facility provided Policies and Procedures (P&P) titled, Myiasis, last revised on 12/10/2025, the P&P indicated facility will provide timely assessment, treatment, and investigation of residents with suspected or confirmed myiasis (larval infestation).During a review of the facility provided P&P titled, Skin Assessment, last revised on 12/10/2025, the P&P indicated to provide guidelines for routine assessment of residents' skin to maintain skin integrity and promote healing in accordance with standard of care practice guidelines.During a review of the facility provided P&P titled, Wound management, last revised on 12/10/2025, the P&P indicated the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The Reporting indicated to report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 14) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale documented for continuing Zoloft (a psychotropic medication used to treat depression) as originally prescribed on 8/29/2024 without attempting Gradual Dose Reduction ([GDR] - stepwise tapering of a medication dose to determine if symptoms or conditions can be managed by a lower dose, or if the drug can be safely discontinued). This deficient practice had the potential to place Resident 14 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, resulting in impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 14's admission Record (a document containing demographic and diagnostic information,) dated 6/16/2026, the admission Record indicated the facility originally admitted Resident 14 on 4/21/2024, and re-admitted on [DATE], with a diagnosis including depression (a condition where one has constant feelings of sadness and loss of interest). During a review of Resident 14's Order Summary Report, dated 6/16/2026, indicated Resident 14 was prescribed Zoloft 50 milligram (mg- a unit of measure of mass) one (1) tablet once a day for depression manifested by verbalization of sadness, starting 9/4/2025. During a review of Resident 14's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) initiated 9/4/2025, the Care Plan indicated Resident 14 was on antidepressant medication Zoloft for depression manifested by verbalization of sadness with a goal of decreased episodes of sign and symptoms of depression. During a review of Resident 14's Minimum Data Set (MDS-a resident assessment tool), dated 10/14/2025, indicated Resident 14 did not have symptoms of feeling down, depressed, or hopeless. The MDS indicated Resident 14 diagnosis included depression. Resident 14's MDS indicated Resident 14 received antidepressants on a routine basis. During a review of Resident 14's MDS, dated [DATE], indicated Resident 14 did not have symptoms of feeling down, depressed, or hopeless. The MDS indicated Resident 14 diagnosis included depression. Resident 14's MDS indicated Resident 14 received antidepressants on a routine basis. During a review of Resident 14's MDS, dated [DATE], indicated Resident 14 did not have symptoms of feeling down, depressed, or hopeless. The MDS indicated Resident 14 diagnosis included depression. Resident 14's MDS indicated Resident 14 was not marked for receiving antidepressants on a routine basis. During a review of Resident 14's Medication Administration Record (MAR-a record of mediations administered to residents), for June 2026, the MAR indicated Resident 14 was prescribed Zoloft 50 mg one (1) tablet once a day for depression manifested by verbalization of sadness, to give at 9 a.m. During a review of Resident 14's MARs between January to June 2026, the MARs indicated: 1.Resident 14 received Zoloft 50 mg daily at 9 a.m. between 1/1/2026 and 6/15/2026 2.Resident 14 had zero (0) documented behaviors of depression manifested by verbalization of sadness between 1/1/2026 and 1/31/2026 3.Resident 14 had zero (0) documented behaviors of depression manifested by verbalization of sadness between 2/1/2026 and 2/28/2026 4.Resident 14 had one (1) documented behaviors of depression manifested by verbalization of sadness between 3/1/2026 and 3/31/2026 on 3/26/2026 5.Resident 14 had zero (0) documented behaviors of depression manifested by verbalization of sadness in between 4/1/2026 and 4/30/2026 6.Resident 14 had zero (0) documented behaviors of depression manifested by verbalization of sadness between 5/1/2026 and 5/31/2026 7.Resident 14 had zero (0) documented behaviors of depression manifested by verbalization of sadness in between 6/1/2026 and 6/15/2026. During a review of Resident 14's Psychiatric Progress Notes by MD 1, dated 4/14/2026, the Progress Note indicated per nursing staff, no recent behavior disturbances manifested by verbalization of sadness have been observed. The Progress Note indicated GDR not indicated at this time as benefits of current treatment outweigh risks of dose reduction. During an interview and concurrent record review on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 14's MARs between January and June 2026, Care plan, psychiatric note, and MDS dated [DATE], 1/12/2026 and 4/9/2026. The DON acknowledged the documentation indicated that Resident 14 had almost no documented behaviors of depression manifested by verbalization of sadness since January 2026 on the MARs, and no documented symptoms of depression on MDSs since October 2025. The DON acknowledged the care plan goals set in September 2025 for decreased episodes of sign and symptoms of depression were met. The DON acknowledged Resident 14 continued to receive Zoloft 50 mg daily as originally prescribed since 8/29/2024. The DON stated the psychiatric note dated 4/14/2026 did not indicate a specific clinical rationale for continuing Zoloft as originally prescribed or a clinical contraindication or risk for GDR. The DON stated it was important to identify the absence of behaviors and when individual resident goals were met and consider GDR for psychotropic medications to ensure residents receive treatment optimal for their condition while maintaining their highest level of well-being. The DON stated that the facility should have attempted a GDR for Zoloft 50 mg daily or provided documentation indicating a clinical rationale for continuing Zoloft 50 mg daily or what specific contraindications prevented the GDR for Resident 14. The DON stated the facility failed to attempt a GDR in two (2) separate quarters within the first year of starting Zoloft and/or to indicate a clinical rationale for continuing Zoloft or what clinical contraindications prevented a GDR. The DON stated as a result, Resident 14 was placed at risk of continuing unnecessary psychotropic medication that could result in adverse consequences and side effects, negatively impacting Resident 14's well-being. During a phone interview on 6/18/2026 at 12:06 p.m., with the Consultant Pharmacist (CP,) the CP stated that federal regulations require that a GDR be attempted in two (2) separate quarters within the first year of starting psychotropic medications, unless there's specific clinical contraindications. The CP stated the goal for GDRs was to provide behavior management at the lowest possible dose with the least number of adverse consequences for residents. The CP stated when GDRs were not attempted due to clinical contraindications, the contraindications must be thoroughly documented in the resident's clinical record. During a review of the facility's Policy and Procedures (P&P) titled Dignity and Respect Psychoactive Medications, last reviewed 12/10/2025, the P&P indicated: must only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. Psychotropic drug: Any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (ii) anti-depressant Unnecessary drugs: Any drug when used: 3.without adequate indications for its use Gradual Dose Reduction (GDR): stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed at a lower dose or if the dose or medication can be discontinued. 2.Residents who use psychotropic drugs shall receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 14.The medical record must include documentation of the adequate clinical indication and necessity for prescribed psychotropic medication. 36.During the first year.the interdisciplinary team shall attempt to perform a GDR, in two separate quarters, unless clinically contraindicated. 38.A GDR may be considered clinically contraindicated for reasons including, but not limited to, the following: The physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function of exacerbate an underlying medical or psychiatric disorder. The residents target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why resident's function, exacerbate an underlying medical or psychiatric disorder. 40.Physician documentation should contain the rationale for why GDR attempts are clinically contraindicated for the resident.

Based on observation, interview, and record review, the facility failed to ensure residents with urinary incontinence received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 183 and Resident 5) reviewed under the Urinary Catheters (indwelling catheter -a hollow tube inserted into the bladder to drain or collect urine) care area by failing to: 1. Ensure the facility's policy and procedure (P&P) was followed for Resident 183, when there was no documentation of measured indwelling catheter output on multiple shifts since resident admission on [DATE]. 2. Ensure notification for an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [SBAR] among the residents) for Resident 183, when the indwelling catheter was bypassing (urine leaking around the outside of an indwelling catheter instead of flowing through the tube) and the indwelling catheter could not be changed by staff. These deficient practices had the potential for residents to develop catheter associated urinary tract infections (CAUTI, an infection of the urinary tract caused by an indwelling catheter) and potentially contributed to the resident's hospitalization on 6/16/2026 for urinary retention and abdominal discomfort. 3. Ensure Resident 5 received appropriate treatment and services to prevent urinary tract infection (UTI - an infection in the bladder/urinary tract) by failing to maintain Resident 5's urinary catheter (a hallow tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. This deficient practice had the increased potential for Resident 5 to develop catheter associated urinary tract infection (CAUTI - UTI developed in a resident with an indwelling catheter). Cross-reference F580.Findings: 1. During a review of Resident 183's admission Record, the admission Record indicated the facility admitted the resident on 6/7/2026 with diagnoses that included encounter for surgical aftercare following surgery on the genitourinary system (organs involved in both urinary and reproductive functions), abscess (a collection of pus that has built up within the tissue of the body) of corpus cavernosum (spongy tissue) and penis, Fournier gangrene (a rapidly progressive, life-threatening infection of the genitals), and other abnormal findings in urine. During a review of Resident 183's Admit/Readmit Evaluation, dated 6/7/2026, the Admit/Readmit Evaluation indicated the resident was alert and oriented to name, place, date, and time. The Admit/Readmit Evaluation further indicated Resident 183 had an indwelling catheter. During a review of Resident 183's History and Physical (H&P), dated 6/16/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 183's Physician Orders Summary Report, the Physician Orders Summary Report indicated orders for the following: -Indwelling Catheter: French number 16 (the diameter of the catheter) to drainage bag due to diagnosis of iatrogenic bladder (bladder injury), dated 6/7/2026. -Indwelling Catheter: change catheter (if blockage / leakage / removal / dislodge) as needed, dated 6/7/2026. During a review of Resident 183's Care Plan (CP) titled, (Resident 183) has an indwelling catheter, initiated 6/9/2026, the CP indicated a goal that the resident would remain free from catheter related trauma and would show no signs and symptoms of UTI with interventions that included to change the catheter for leaking and to monitor / document / report to the physician for signs and symptoms of UTI including no urine output. During a review of Resident 183's SBAR form, dated 6/16/2026 at 5:12 p.m., the SBAR form indicated the resident complained of discomfort on the pelvic area and reported that he felt his urine was going to his scrotum area, the physician was made aware with orders to transport the resident to the hospital via non-emergent transport. During an observation and interview on 6/15/2026 at 9:48 a.m., in Resident 183's room, observed Resident 183 lying in bed with an indwelling catheter. Resident 183 stated his catheter had been leaking urine for about a week and all the staff were aware, but they told him they could not do anything about it because the resident needed to see the urologist (physician that specialized in the urinary tract system) to have the catheter changed. Resident 183 stated he felt uncomfortable because he was not used to being wet. During an interview on 6/16/2026 at 2:15 p.m., in the hallway outside Resident 183's room, with Family Member (FM) 1, FM 1 stated Resident 183 had been complaining since the prior week that his catheter was leaking, and she (FM 1) told the nurse. FM 1 stated she could not remember the nurse's name, but the nurse said they could not change the catheter and the resident needed to see the urologist. FM 1 stated Resident 183's catheter was still leaking urine. During an interview on 6/16/2026 at 2:28 p.m., in the hallway, with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 183's catheter had been leaking for the past two days that she had cared for him. CNA 4 stated on 6/15/2026 day shift (a standard period of time worked between 7 a.m. to 4 p.m.), she reported to Licensed Vocational Nurse (LVN) 1 that Resident 183's catheter drainage bag had zero urine output for the entire shift and all the urine had leaked into the resident's brief. CNA 4 stated Resident 183's catheter was still leaking and his brief was wet. During an interview on 6/16/2026 at 2:36 p.m. with LVN 1, at Nursing Station 1, LVN 1 stated she had been caring for Resident 183 for the past few days and was not aware of any issues reported by the family or staff regarding Resident 183's indwelling catheter. LVN 1 stated she was not aware that Resident 183's catheter was leaking. During an interview on 6/16/2026 at 2:39 p.m. with Treatment Nurse (TN) 1, TN 1 stated Resident 183 had an indwelling catheter to keep the area at the penile abscess clean and dry. TN 1 stated the indwelling catheter had bypassing issues (urine leaking around the outside of the catheter tube instead of draining properly through it) and the resident needed to follow up with the urologist. TN 1 stated only the urologist can change the resident's catheter. During a concurrent interview and record review on 6/17/2026 at 2:19 p.m., with MDS Nurse (MDSN) 1, in the conference room, reviewed Resident 183's SBAR forms and Progress Notes for 6/2026. MDSN 1 stated bypassing indicates an indwelling catheter is not functioning properly and could indicate the tubing is blocked or not inserted correctly and needs to be changed. MDSN 1 stated a change of condition is any change from the resident's baseline. MDSN 1 stated resident changes of conditions are reported by the CNAs or LNs to the supervising nurse and to the physician to determine any necessary treatments. MDSN 1 stated if a resident's catheter was bypassing, there was no urine in the drainage bag for an entire shift, and nursing staff cannot change the catheter; it would be considered an SBAR and should be reported to the physician. MDSN 1 stated between Resident 183's admission and the evening shift (3 p.m. to 11 p.m.) on 6/16/2026 there was no documented evidence that it was reported to the physician that Resident 183's catheter was bypassing and needed to be changed. During a follow up interview on 6/17/2026 at 4:06 p.m. with TN 1, in the conference room, TN 1 stated when Resident 183's indwelling catheter was bypassing and there was no urine in the drainage bag for the day shift on 6/15/2026 it was considered a change of condition, and CNA 4 should have reported to LVN 1 to evaluate the catheter. TN 1 stated on the evening shift of 6/16/2026 Resident 183's abdomen was distended and he was found to be retaining 600 milliliters (mL, a unit of liquid measurement) of urine and was sent to the hospital for further evaluation. During a concurrent interview and record review on 6/18/2026 at 1 p.m. with the Director of Nursing (DON), in the conference room, reviewed the P&P regarding SBAR and indwelling catheters. The DON stated Resident 183 was newly admitted and has urological issues that require an indwelling catheter that should only be changed by the urologist. The DON stated Resident 183 had a physician's order that indicated to change the catheter if there was leaking. The DON stated bypassing could indicate that an indwelling catheter has a blockage and urine is not flowing and needs to be changed. The DON stated when an indwelling catheter bypasses and is not changed there is the potential that the resident would develop a UTI. The DON stated when Resident 183's catheter was bypassing with no urine collection in the drainage bag for an entire shift it was considered a resident change of condition that the CNA should report to the LN by completing a Stop and Watch form. The DON stated CNA 4 did not complete a Stop and Watch form on 6/15/2026 and the LN did not address Resident 183's change in condition regarding the catheter bypassing with the need to be changed. The DON stated on 6/15/2026, the physician should have been notified of Resident 183's SBAR to determine the necessary treatment but was not. The DON stated the facility P&P was not followed for SBAR potentially contributing to indwelling catheter complications resulting in hospitalization of Resident 183 on 6/16/2026. During a review of the facility P&P titled, Bowel and Bladder Retraining, last reviewed 12/10/2025, the P&P indicated, INTENT . To ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. GUIDELINES. 1. The interdisciplinary team provide appropriate and sufficient services and assistance to:. c. Prevent urinary tract infections to the extent possible. During a review of the facility P&P titled, Notification of Changes, last reviewed 12/10/2025, the P&P indicated, DEFINITIONS. A need to alter treatment significantly: . commence a new form of treatment to deal with a problem. GUIDELINES: . 1. The facility shall immediately or as soon as practicable inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is: . b. A significant change in the resident's physical, mental, or psychosocial status. c. A need to alter treatment significantly; . Licensed personnel will provide timely, accurate, and standardized communication with the physician or licensed practitioner when a resident experiences a significant change in condition using the SBAR (Situation Background Assessment Recommendation) communication tool or documented equivalent in the nursing progress notes. The form is used for a resident change in condition resulting in a need to significantly alter the resident's treatment plan. 2. During a review of Resident 183's CP titled, UTI: The resident has UTI (with catheter), initiated 6/7/2026, the CP indicated the resident had a UTI with a goal to resolve without complications by implementing interventions that included monitor intake and output (I/O - the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]), and report to the physician as needed for signs and symptoms of UTI. During a concurrent interview and record review on 6/17/2026 at 2:19 p.m., with MDSN 1, in the conference room, reviewed Resident 183's Medication and Treatment Administration Records (MAR and TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident and Progress Notes for 6/2026. MDSN 1 stated the facility process for all residents newly admitted with an indwelling catheter was to monitor the catheter to ensure it was functioning properly, including measuring and documenting the urine output from the catheter. MDSN 1 stated urine output is measured by the CNA and reported to the licensed nurse (LN) who monitors and documents the output amount in the MAR/TAR. MDSN 1 stated Resident 183 did not have an order to monitor I/O and there was no documented evidence that the LNs followed the facility process to monitor and document Resident 183's catheter output. During a concurrent interview and record review on 6/17/2026 at 2:35 p.m., with LVN 1, in Nursing Station 1, reviewed Resident 183's MAR/TAR. LVN 1 stated the facility process is all residents with indwelling catheters have urine output monitored and documented every shift by the LN in the MAR. LVN 1 stated the CNA's report the measured amount to the LN and then the LN documents in the MAR. LVN 1 then reviewed Resident 183's MAR/TAR and stated there was no documented evidence that Resident 183's urine output was monitored and documented by the LN since admission, but there should have been. LVN 1 stated she did not monitor and document Resident 183's indwelling catheter's measured output because she missed it. During a follow-up concurrent interview and record review on 6/17/2026 at 2:50 p.m., with CNA 4 and MDSN 1, reviewed Resident 183's POC Response History form dated 6/11/2026 to 6/16/2026. CNA 4 stated Resident 183's indwelling catheter was working fine when he was admitted , but then it started leaking. CNA 4 stated the CNA documents indwelling catheter urine output on the POC Response History form. MDSN 1 stated it was important for CNAs to measure catheter output every shift and report to the LN to monitor I/Os. MDSN 1 stated on the following dates and times there was no measured urine output documented for Resident 183 by the CNAs: -On 6/11/2026 for the evening shift and night shift (11 p.m. to 7 a.m.). -On 6/13/2026 for the evening shift. -On 6/14/2026 for the day and evening shift. -On 6/15/2026 for the day shift and night shift. -On 6/16/2026 for the day shift. MDSN 1 stated when there was no documented output by the CNAs and no monitoring of I/Os by the LNs, there was the potential for a delay in treatment when the catheter was not functioning correctly. During a concurrent interview and record review on 6/17/2026 at 4:17 p.m., in the conference room, MDSN 1 reviewed the facility P&P regarding I/Os and indwelling catheters. MDSN 1 stated the P&P indicates residents with indwelling catheters have urine output measurements documented every shift. MDSN 1 stated the facility P&P was not followed for Resident 183's indwelling catheter when there was no CNA documentation of urine output on multiple shifts and the LN did not monitor and document I/Os since admission. During a concurrent interview and record review on 6/18/2026 at 1 p.m. with the DON, in the conference room, reviewed the P&P regarding indwelling catheters and I/O. The DON stated the way to ensure that an indwelling catheter is functioning properly is to measure and monitor the urine output in the drainage bag. The DON stated the facility process is catheter urine is measured by the CNA, then monitored and documented in the MAR by the LN every shift. The DON stated the facility P&P was not followed when the facility process for indwelling catheter I/Os was not followed for Resident 183 potentially resulting in delay of treatment and hospitalization of the resident. During a review of the facility P&P titled, Intake and Output Monitoring, last reviewed 12/10/2025, the P&P indicated, Purpose Statement. The facility provides care and services for residents who require monitoring of their intake and or output consistent with the standard of practice. INTENT. To provide guidelines for maintaining a measurement of resident's intake and output and to assess fluid balance. GUIDELINES. 2. Fluid intake and output shall be recorded for each patient: . b. For each patient with an indwelling catheter. c. Intake and output records shall be evaluated and documented weekly by a licensed nurse. PROCEDURE. 1. Measure and record all liquids ingested . 2.Measure urine. 5. Complete the intake and output record for the appropriate parameters. 3. During a review of Resident 5's admission Record (AR), the facility admitted resident originally on 1/27/2020 and readmitted on [DATE] with diagnoses including acute respiratory failure (occurs when lungs suddenly cannot get enough oxygen into the blood), neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder are not communicating properly), and muscle weakness. During a review of Resident 5's History and Physical (H&P – a document with patient's medical history and physical examination done by a physician) dated 11/01/2025, the H&P indicated that Resident 5 did not have the capacity to make decisions. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 5 was dependent (helper does all the effort) with eating, personal and toileting hygiene, shower, dressing, and transfers. During a review of Resident 5's Care Plan titled, Resident 5 has an indwelling catheter due to neurogenic bladder with a goal indicating that Resident 5 will have minimized risk for complications from indwelling catheter and interventions including anchor catheter to prevent tension, observe urine odor, color clarity and amount as needed, secure catheter to facilitate urine flow, and check tubing for kinks each shift. During a concurrent observation and interview on 6/15/2026 at 10:56 a.m. with Licensed Vocational Nurse 4 (LVN 4) inside Resident 5's room, indwelling catheter was observed in a dependent loop wherein urine was observed stagnant and partially cloudy and the lower part of the bed was elevated in an angle where the catheter tubing was positioned above resident's bladder. LVN 4 stated that the tubing seemed like coiling and should drain by gravity. LVN 4 stated indwelling catheter tubing must flow by gravity and tubing should not be coiling to prevent resident from developing urinary tract infection. During an interview on 6/17/2026 at 1:15 a.m. with the Director of Nursing (DON), the DON stated that indwelling catheters must be checked every time a care is rendered to the resident including the color and output. The DON stated that the catheter must be positioned below the bladder to prevent backflow of the urine which could potentially lead to an infection specifically CAUTI. During a review of the facility's Policy and Procedures titled, Indwelling Catheter Use, revised on 1/2025 indicated A resident who enters the facility with an indwelling catheter or subsequently received one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is clinically necessary. (1) The facility provides the necessary treatment and services to achieve or maintain as much normal urinary function as possible for residents identified with incontinence. (6) The facility monitors residents with catheters for changes in skin integrity, skin irritation or breakdown, and signs and symptoms of urinary tract infection. (10) Catheter tubing should be positioned lower than the resident's body to facilitate drainage.

Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication emergency kits ([eKIT] - kit containing medications needed to be used during emergencies) containing ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics, drugs or controlled medication) for June 2026, in two (2) of two (2) inspected Medication Rooms (Medication Room Station 1 and 2). 2.Account for two (2) doses of CS for Resident 19 and 74 in one (1) of five (5) inspected medication carts (Medication Cart 2 Station 2). These deficient practices increased the opportunity for CS diversion (the transfer of a CS from a lawful to an unlawful channel of distribution or use,) and exposure of harmful medications to residents in the facility, and that Residents 19 and 74 could have accidental overdose (administration of more than the prescribed dose) to CS possibly leading to physical and psychosocial harm, hospitalization and death and the potential to result in their health and well-being to be negatively impacted. Findings: During an observation and concurrent interview on 6/15/2026 at 12:15 p.m., with Licensed Vocational Nurse (LVN) 6, in Medication Room Station 2, there was: 1. One (1) medication eKIT stored in the refrigerator and labeled 35, containing lorazepam (a CS) without an accountability log for the reconciliation of CS inventory at every shift change for June 2026. Duri ng a concurrent interview, LVN 6 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 6 stated the eKIT labeled 35 containing CSs in Medication Room Station 2 was not reconciled at every shift in June 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an observation and concurrent interview on 6/15/2026 at 12:35 p.m., with LVN 7, in Medication Room Station 1, there was: 1. One (1) medication eKIT stored in the refrigerator and labeled 69, containing lorazepam without an accountability log for the reconciliation of CS inventory at every shift change for June 2026. During a concurrent interview, LVN 7 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 7 stated the eKIT labeled 69 containing CSs in Medication Room Station 1 was not reconciled at every shift in June 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an observation on 6/15/2026 at 1:14 p.m., with LVN 3, in Medication Cart 2 Station 2, there was a discrepancy in the count between the Drug Control Receipt Record/Disposition Form accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: 1. One (1) dose of pregabalin (a CS used for neuropathic [related to nerves] pain) 75 milligram ([mg] - a unit of measure of mass) tablet was extra in the bubble pack compared to the count indicated on the Drug Control Receipt Record/Disposition Form accountability log for Resident 19. The Drug Control Receipt Record/Disposition Form accountability log for pregabalin indicated the bubble pack should have contained a total of 11 pregabalin 75 mg tablets; however the bubble pack contained 12 pregabalin 75 mg tablets and no documentation of additional administrations after 6/15/2026 at 2:07 p.m. 2. One (1) dose of lacosamide (a CS used for seizure [bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations or states of awareness] pain) 100 mg tablet was missing from the bubble pack compared to the count indicated on the Drug Control Receipt Record/Disposition Form accountability log for Resident 74. The Drug Control Receipt Record/Disposition Form accountability log for lacosamide indicated the bubble pack should have contained a total of 48 lacosamide 100 mg tablets, however the bubble pack contained 47 lacosamide 100 mg tablets and no documentation of additional administrations after 6/14/2026 at 5:36 p.m. During a concurrent interview, LVN 3 stated LVN 3 was about to prepare one (1) pregabalin 75 mg tablet for administration at 2 p.m. to Resident 19 and had signed the Drug Control Receipt Record/Disposition Form accountability log in advance of the preparation. LVN 3 also stated that LVN 3 administered one (1) lacosamide 100 mg tablet to Resident 74 that morning (6/15/2026) at 10:01 a.m. and forgot to sign the Drug Control Receipt Record/Disposition Form accountability log. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CS dose on the Drug Control Receipt Record/Disposition Form accountability log after preparing the doses for Resident 19 and 74. LVN 3 stated LVN 3 understood it was important to document/sign each dose once prepared to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 3 stated if documentation was not accurate then it can lead to medication error if overdosed leading to stoppage of breathing, hospitalization and possibly death for Residents 19 and 74. During an interview on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON,) the DON stated that medication eKITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated the eKITs labeled 35 and 69 containing CSs in Medication Room Station 1 and 2 were not reconciled at every shift in June 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During the same interview, the DON stated that LVN 3 failed to follow facility policy of documenting the preparation of CS immediately on the Drug Control Receipt Record/Disposition Form accountability log for Resident 19 and 74. The DON stated not documenting the Drug Control Receipt Record/Disposition Form timely can lead to accountability failures, CS diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. During a review of Resident 19's admission Record (a document containing demographic and diagnostic information,) dated 6/16/2026, the admission Record indicated the facility originally admitted Resident 19 on 5/5/2026, with diagnoses including polyneuropathy (a condition where multiple nerves are damaged). During a review of Resident 19's Medication Administration Record (MAR- record of medications administered to a resident) for June 2026, the MAR indicated Resident 19 was prescribed pregabalin 75 mg for neuropathic pain, starting 5/18/2026, to be given every eight (8) hours at 6.a.m., 2 p.m. and 10 p.m. During a review of Resident 74's admission Record dated 6/16/2026, the admission Record indicated the facility originally admitted Resident 74 on 6/5/2019, and re-admitted on [DATE], with diagnoses including seizures. During a review of Resident 74's MAR for June 2026, the MAR indicated Resident 74 was prescribed lacosamide 100 mg for seizure disorder, starting 11/18/2023, to be given twice a day at 9.a.m. and 5 p.m. During a review of the Policy and Procedures (P&P) titled Controlled Medications, last reviewed 12/10/2025, the P&P indicated:D. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) Date and time of administration. (MAR, Accountability Record). 2) Amount administered. (Accountability Record). 3) Remaining quantity. (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered. (MAR, Accountability Record). During a review of the P&P, titled Controlled Substance Storage, last reviewed 12/10/2025, the P&P indicated: E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two (2) licensed nurses and is documented. During a review of the P&P, titled Safeguarding Controlled Substances, last reviewed 12/10/2025, the P&P indicated: The facility has established guidelines for safe handling receiving, storing, administering, reconciling, and safeguarding controlled substances. To minimize the time between identification and actual loss or diversion of medications or suspected controlled substance diversion involving any employee, determination of the extent of loss or diversion and to safeguard patients and their property. 13. Controlled substances will be counted at the onset and completion of each shift by two nurses and verified accurately through each nurses' signature on the reconciliation log. 1. The Licensed Nurse will enter the following information immediately upon removing dose(s) from the controlled storage on the resident's individual controlled substance accountability reconciliation log. a. Date of medication removal. b. Time of medication removal. c. Amount of medication removed.d. Amount of medication remaining. e. Signature of nurse removing the medication. 1.Each individual controlled substance must be counted when there is a change in shift nurse. 4.Narcotic e-kits should be checked & verified as present/sealed or reconciled as indicated.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1.Not administer two (2) doses of expired insulin (a medication used to control high blood sugar levels) Novolog (a brand name insulin for Aspart that is rapid-acting) Flexpen (an injection device containing insulin) by two (2) different licensed nursing staff to Resident 123 in one (1) of five (5) inspected medication carts (Medication Cart 2 Subacute.) As a result, Resident 123 received a total of two (2) doses of expired insulin from 6/11/2026 to 6/15/2026, not in accordance with manufacturer guidelines, standards of practice and facility policy and procedures. 2.Ensure amiodarone (medication to treat life-threatening, irregular heartbeats) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than (<) 110 millimeters of mercury (mmHg, a unit of measurement) for one (1) of one (1) sampled resident (Residents 153) reviewed during the hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care area.These deficient practices had the potential to cause Resident 123 and 153 to experience adverse effects (unwanted, unintended results) and serious health complications due to improper management of blood sugar and from unnecessary medications including cardiovascular issues, hypotension (abnormally low blood pressure [BP]) and possible coma (a state of deep unconsciousness caused by injury or illness,) resulting in hospitalization and/or death. Findings: 1. During a review of Resident 123's admission Record (a document containing demographic and diagnostic information,) dated 6/16/2026, the admission Record indicated the facility originally admitted Resident 123 on 9/24/2021 and re-admitted on [DATE] with diagnosis including Type two Diabetes Mellitus (DM2– a condition where there is high blood sugar levels.) During a review of Resident 123's Order Summary Report (a report listing the physician order for the resident), dated 6/16/2026, the report indicated Resident 123 was prescribed insulin Aspart (generic name for Novolog) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) subcutaneous ([SQ] – under the skin) every eight (8) hours for Diabetes, starting 1/24/2024. During a review of Resident 123's Medication Administration Record (MAR - a document of the medications administered to a resident that is part of the resident's permanent medical record), for June 2026, the MAR indicated Resident 123 was prescribed insulin Aspart per sliding scale SQ every eight (8) hours for Diabetes, to inject at 6 a.m., 2 p.m. and 10 p.m., and that Resident 123 received two (2) doses of expired insulin Novolog Flexpen from the following nurses on the following dates and times: -LVN 4 – 1 dose at 2 p.m. on 6/14/2026, -LVN 8 - 1 dose at 6 a.m. on 6/14/2026. During an observation on 6/15/2026 at 1:35 p.m., in the presence of Licensed Vocational Nurse (LVN) 4, in Medication Cart 2 Subacute, the following medications were found either expired and not discarded, or stored contrary to their respective manufacturer's specifications and facility policies and procedures: 1.One (1) open insulin Novolog Flexpen for Resident 123 was found stored at room temperature with a handwritten label indicating that use at room temperature began on 5/13/2026, and to discard in 28 days. According to the manufacturer's product labeling, open Novolog Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening the pen. During a concurrent interview, LVN 4 stated according to the handwritten date Resident 123's Novolog Flexpen was opened on 5/13/2026 and considered expired on 6/10/2026. LVN 4 stated the pen was not removed and continued to be stored and used in Medication Cart 2 Subacute for Resident 123. LVN 4 stated expired medications needed to be removed from the cart and placed in the expired medication bin to be disposed of and not accidentally used for residents. LVN 4 stated that expired insulin has lost its potency (strength) and administering expired insulin Novolog after 6/10/2026 will not be effective in controlling blood sugar levels and can harm Resident 123 by causing hyperglycemia (high blood sugar levels) and coma, leading to hospitalization and death. LVN 4 stated the pen needed to be discarded and replaced with a new one from pharmacy before it expired on 6/10/2026. LVN 4 stated that LVN 8 and herself administered two (2) doses of expired Novolog Flexpen to Resident 123 on 6/14/2026, and these were considered significant medication errors. During an interview, on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON,) the DON acknowledged several LVN's failed to remove the expired Novolog Flexpen from Medication Cart 2 Subacute leading to the administration of two (2) expired doses of insulin to Resident 123 resulting in significant medication error. The DON stated that expired insulins have lost potency and effectiveness and when administered expired insulin will not be effective in controlling blood sugar levels leading to hyperglycemia and adverse effects for Resident 123, potentially resulting in coma, hospitalization and/or death. During a review of the facility's Policy and Procedures (P&P,) titled Administration Procedure for All Medications, last reviewed 12/10/2025, the P&P indicated: To administer medications in a safe and effective manner. D. Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. During a review of the facility's P&P titled Administering Medications, last reviewed 12/10/2025, the P&P indicated: The expiration/beyond use date on the medication label must be checked prior to administering. During a review of the facility's P&P titled Labeling of Biologicals and Storage of Biologicals, last reviewed 12/10/2025, the P&P indicated: The facility, in coordination with the licensed pharmacist, provides accurate labeling to facilitate precautions and safe administration of medications, and safe and secure storage. 1.The Facility shall maintain a current medication dating reference guide based on manufacturer instructions for medications that have shortened expiration periods after opening, puncture, reconstitution, activation, or removal from original packaging. 2.See Attachment A – Novolog Flexpen – 28 days. During a review of manufacturer guideline, titled Highlights of Prescribing Information for Novolog, dated 2/2025, the guide listed the following:Once a cartridge or NovoLog FlexPen or NovoLog FlexTouch is punctured, it should be kept at temperatures below 86 degrees Fahrenheit for up to 28 days. 2.During a review of Resident 153's admission Record (AR), the AR indicated the facility admitted the resident on 5/22/2026, with diagnoses that included End Stage Renal Disease (ESRD -irreversible kidney failure), dependence on HD, hypertensive heart disease (refers to heart problems that occur because of high BP that is present over a long time), atrial fibrillation (A-fib - an irregular and often very rapid heart rhythm that can lead to blood clots [clumps that occur when blood hardens from a liquid to a solid] in the heart), and hypotension. During a review of Resident 153's Minimum Data Set (MDS – resident assessment tool) dated 5/29/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for toileting, bathing, lower body dressing, personal and oral hygiene, and mobility. During a review of Resident 153's Physician Order Summary, the Physician Order Summary indicated an order for amiodarone HCL Oral Tablet 200 milligram (mg – a unit of measurement) give two (2) tablets by mouth in the morning for A-fib. Hold if SBP < 110 or heart rate (HR) < 60 beats per minute. Call physician if SBP <90 or HR <60. Call physician if BP medications are held for one (1) week due to low parameters, dated 5/22/2026. During a concurrent interview and record review on 6/16/2026 at 11:45 a.m. with MDS Nurse (MDSN) 1, in the conference room Resident 153's physician orders and MAR for 6/2026 were reviewed. The MDSN 1 stated the facility process is to document in the MAR immediately after administering medication. The MDSN 1 stated a check mark in the MAR indicates that a medication was administered. The MDSN 1 stated Resident 153 is administered amiodarone for A-fib and the medication should not be given if the resident's SBP <110 or HR <60. The MDSN 1 reviewed Resident 153's MAR for 6/2026 and noted amiodarone was not administered per the physician's orders when: -On 6/5/2026 at 9 a.m., amiodarone was administered with an SBP of 102. -On 6/12/2026 at 9 a.m., amiodarone was administered with an SBP of 108. The MDSN 1 stated when Resident 153 was administered amiodarone with a SBP <110, the resident's BP could have gone down even lower causing the resident to have cardiac issues. During an interview on 6/17/2026 at 4:40 p.m. with RN 1, RN 1 reviewed Resident 153's MAR and physician orders. RN 1 stated the MAR documentation is completed right after medication is administered and is accurate. RN 1 stated if she documented medication was administered in the MAR then the medication was administered. RN 1 stated on 6/5/2026 she cared for Resident 153 and administered his medications. RN 1 stated she does not remember holding any of Resident 153's medications on 6/5/2026. RN 1 stated when the MAR indicated Resident 153's amiodarone as administered, then she administered the medication. RN 1 stated on 6/5/2026 amiodarone was not administered to Resident 153 per the physician's order because there was a hold parameter for SBP <110, the SBP was 102, and the medication was not held. During a concurrent interview and record review on 6/18/2026 at 1 p.m., with the Director of Nursing (DON), reviewed the facility policy and procedure (P&P) regarding medication administration and manufacture guidelines for amiodarone. The DON stated the medication administration process is to check the physician's orders, including the hold parameters, and administer medication per the orders. The DON stated the MAR documentation is considered accurate and if medication was administered as documented then it happened. The DON confirmed the amiodarone manufacture guidelines indicated a potential cardiac side effect of the medication was hypotension that is sometimes fatal. The DON stated Resident 153 was medically complex, and amiodarone was not administered per the physician's orders or P&P and placed the resident at risk for cardiovascular adverse effects including hypotension. During a review of the facility provided Medication Guide for amiodarone, last reviewed 10/2028, the Medication Guide indicated, At the usual maintenance dose (400 mg/day) and above, (amiodarone) causes adverse reactions in about three-fourths of all patients. The following side-effect rates are based on a retrospective study of 241 patients treated for 2 to 1,515 days:. hypotension. The following adverse reactions have been identified during post-approval use . Cardiac: hypotension (sometimes fatal). During a review of the facility P&P titled, Administering Medication, last reviewed 12/10/2025, the P&P indicated, PURPOSE STATEMENT: To provide employees with guidelines for the safe and timely administration of medications per physician order. INTENT: To ensure medications are prepared, administered, stored, documented and monitored in a safe and accurate manner by authorized personnel in accordance with physician orders. GUIDELINES: . 3. Medications must be administered in accordance with the orders. Vital signs and other clinical parameters shall be assessed and evaluated in accordance with physician orders and the resident's individualized clinical condition, diagnoses, goals of care, and the intended therapeutic use of the medication. During a review of the facility P&P titled, Unnecessary Drugs, last reviewed 12/10/2025, the P&P indicated, Each resident's drug regimen shall be free from unnecessary drugs The facility is cautious in determining the necessity of proper medication selection and prescribing (including dose, duration, and type of medication(s)) which may help stabilize or improve a resident's outcome, quality of life and functional capacity Any medication or combination of medications-or the use of a medication without adequate indications, in excessive dose, for an excessive duration, or without adequate monitoring-may have serious side effects, such as changes in vital signs/lab values, confusion, immobility, falls, and hip fractures, which can be especially dangerous for elderly residents, in addition to an increased risk of death Unnecessary drugs include .: in excessive dose . without adequate indications for its use Documentation is necessary to clarify the rationale for each medication and the approach to monitor the benefits and any adverse consequences

Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use one (1) expired insulin (medication used to regulate blood sugar levels) Lispro (rapid-acting insulin) Kwikpen (an injection device containing insulin) for Resident 44, in accordance with manufacturer's requirements and facility policy and procedures (P&P) in one (1) of five (5) inspected medication carts (Medication Cart 2 Station 1).2. Remove and discard from use one (1) expired insulin Novolog (rapid-acting insulin) Flexpen (an injection device containing insulin) for Resident 123, in accordance with manufacturer's requirements and facility P&P in one (1) of five (5) inspected medication carts (Medication Cart 2 Subacute).3. Label and store one (1) levalbuterol (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (a package made of foil protecting the inhalation solution from light and degradation) and dorzolamide with timolol (a combination medication used to decrease pressure in the eye) ophthalmic (related to the eye) solution foil pouch for Resident 57 at room temperature in accordance with the manufacturer's requirements and facility P&P in one (1) of five (5) inspected Medication Carts (Medication Cart 2 Station 1). 4. Label one (1) open epogen (medication used to treat anemia [having low red blood cells) vial with date open for Resident 80 in accordance with manufacturer's requirements and facility P&P in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1). These deficient practices increased the risk that Residents 44, 57, 80 and 123 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on 6/15/2026 at 12:35 p.m., inside Medication Room Station 1, in the presence of Registered Nurse (RN) 4, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) open and used multi dose (containing more than one dose) vial of epogen for Resident 80 was found stored in the refrigerator containing unused volume of medication, without a label indicating when the vial was first used/punctured. According to manufacturer's product storage and labeling, epogen multi-dose vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and to throw away multiple-dose vials no later than 21 days from the first day vial was punctured. During a concurrent interview with RN 4, RN 4 stated the epogen vial for Resident 80 was open and used with some volume of medication remining in the vial and was not labeled with a date when the vial was opened. RN 4 stated the epogen vial for Resident 80 was considered expired since it was unknown when the vial was opened. RN 4 stated expired epogen vial has decreased potency (effectiveness) and since it was stored in the refrigerator could be used in error resulting in not treating or controlling Resident 80's anemia. RN 4 stated the epogen vial for Resident 80 needed to be removed from the refrigerator and disposed of to prevent accidental use. During an observation on 6/15/2026 at 12:50 p.m., in Medication Cart 2 Station 1, in the presence of Licensed Vocational Nurse (LVN) 9, the following medications were found either expired or stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) open insulin Lispro Kwikpen for Resident 44 was found stored in the refrigerator with a label indicating that use began on 5/16/2026, and an additional label indicating to discard 28 days after opening. According to the manufacturer's product labeling, opened Lispro Kwikpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening. 2. One (1) open levalbuterol inhalation solution foil pouch for Resident 57, was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. According to the manufacturer's product storage and labeling, opened foil pouch of levalbuterol inhalation solutions should be stored between 68 to 77 degrees Fahrenheit and once the foil pouch is opened to be used within two (2) weeks. 3. One (1) open dorzolamide with timolol ophthalmic solution foil pouch for Resident 57, was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. According to the manufacturer's product storage and labeling, opened foil pouch of dorzolamide with timolol ophthalmic solutions should be stored between 68 to 77 degrees Fahrenheit and to throw away unused solutions 15 days after first opening the pouch. During a concurrent interview with LVN 9, LVN 9 stated the insulin Lispro Kwikpen for Resident 44 was opened on 5/16/2026 and expired on 6/13/2026 and continued to be stored in the refrigerator. LVN 9 stated expired insulin has lost its potency and administering expired insulin Lispro to Resident 44 will not be effective in keeping the blood sugar stable and can harm Resident 44 by causing high blood sugar levels leading to coma (a state of deep unconsciousness caused by severe injury or illness) and potential hospitalization. LVN 9 stated the Lispro Kwikpen needed to be removed from the refrigerator on 6/13/2026 and replaced with a new pen from pharmacy to prevent accidental use. During the same interview, LVN 9 stated the levalbuterol inhalation solution foil pouch and dorzolamide with timolol ophthalmic solution foil pouch for Resident 57 was not labeled with a date indicating when the foil pouches were opened. LVN 9 stated that per facility policy multi-dose products such as inhalation solutions should be labeled with the date when first opened to know when they expire. LVN 9 stated that expired medications have lost potency and will not be effective in treating residents' condition. LVN 9 stated according to the manufacturer guidelines, the levalbuterol inhalation solution should be used within two (2) weeks of opening the pouch and dorzolamide with timolol ophthalmic solution within 15 days. LVN 9 stated failing to record the date of first use could lead to Resident 57 receiving potentially expired and ineffective levalbuterol and dorzolamide with timolol. LVN 9 stated this could cause Resident 57 harm by not treating or preventing the shortness of breath, making breathing more difficult, keeping the pressure high in the eye, requiring immediate treatment and potential hospitalization. During an observation on 6/15/2026 at 1:35 p.m., in the presence of Licensed Vocational Nurse (LVN) 4, in Medication Cart 2 Subacute, the following medications were found either expired and not discarded, or stored contrary to their respective manufacturer's specifications and facility policies and procedures: 1. One (1) open insulin Novolog Flexpen for Resident 123 was found stored at room temperature with a handwritten label indicating that use at room temperature began on 5/13/2026, and to discard in 28 days. According to the manufacturer's product labeling, open Novolog Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening the pen. During a concurrent interview, LVN 4 stated according to the handwritten date Resident 123's Novolog Flexpen was opened on 5/13/2026 and considered expired on 6/10/2026. LVN 4 stated the pen was not removed and continued to be stored and used in Medication Cart 2 Subacute for Resident 123. LVN 4 stated expired medications needed to be removed from the cart and placed in the expired medication bin to be disposed of and not accidentally used for residents. LVN 4 stated that expired insulin has lost its potency and administering expired insulin Novolog after 6/10/2026 will not be effective in controlling blood sugar levels and can harm Resident 123 by causing hyperglycemia (high blood sugar levels) and coma, leading to hospitalization and death. LVN 4 stated the pen needed to be discarded and replaced with a new one from pharmacy before it expired on 6/10/2026. During an interview, on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON,) the DON acknowledged that expired medications should be removed from medication carts and rooms to prevent accidental use and that multi-dose medications such as insulin pens and epogen vials should be labeled with a date indicating when use first began to know when they expire. The DON acknowledged that several LVN's failed to remove the expired Lispro Kwikpen from Medication Cart 2 Station 1 and Novolog Flexpen from Medication Cart 2 Subacute. The DON stated that expired insulins have lost potency and effectiveness and when administered expired insulin will not be effective in controlling blood sugar levels leading to hyperglycemia and adverse effects for Resident 44 and 123, potentially resulting in coma, hospitalization and/or death. During the same interview, the DON stated that the levalbuterol and dorzolamide with timolol foil pouches for Resident 57 were not labeled with a date when the pouch was opened to know when the expire. The DON stated that expired inhalation and ophthalmic solutions have lost effectiveness and when administered in error will not treat the shortness of breath or increased eye pressure further causing respiratory distress and stoppage of breathing and possible eye blindness from elevated pressure for Resident 57 requiring immediate treatment and hospitalization. During the same interview, the DON further stated the epogen vial for Resident 80 was not labeled with a date indicating when the vial was punctured and needed to be removed from the medication room and discarded to prevent accidental use. The DON stated that administering expired epogen in error will not be effective and can harm Resident 80 by not treating the anemia. During a review of facility's P&P titled Administration Procedure for all Medications, last reviewed on 12/10/2025, the P&P indicated: When opening a multidose container, place the date on the container. During a review of facility's P&P titled Storage of Medications, last reviewed on 12/10/2025, the P&P indicated: B. Certain medications or package types, such as IV sol tions, multiple dose injectable vials, ophthalmics, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview, and record review, the facility failed to immediately notify the primary care physician of a significant change in condition for one of one sampled resident (Resident 183) reviewed under the Urinary Catheters (indwelling catheter -a hollow tube inserted into the bladder to drain or collect urine) care area by failing to ensure notification for an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [SBAR] among the residents) when the indwelling catheter was bypassing (urine leaking around the outside of an indwelling catheter instead of flowing through the tube) with no urine output collected in the drainage bag for the day shift (7 a.m. to 3 p.m.) on 6/15/2026. This deficient practice had the potential for the resident to develop catheter associated urinary tract infections (CAUTI, an infection of the urinary tract caused by an indwelling catheter) and potentially contributed to the resident's hospitalization on 6/16/2026 for urinary retention (inability to completely empty your bladder) and abdominal discomfort. Cross-Reference F690. Findings: During a review of Resident 183's admission Record, the admission Record indicated the facility admitted the resident on 6/7/2026, with diagnoses including encounter for surgical aftercare following surgery on the genitourinary system (organs involved in both urinary and reproductive functions), abscess (a collection of pus that has built up within the tissue of the body) of corpus cavernosum (spongy tissue) and penis, Fournier gangrene (a rapidly progressive, life-threatening infection of the genitals), and other abnormal findings in urine. During a review of Resident 183's Admit/Readmit Evaluation, dated 6/7/2026, the Admit/Readmit Evaluation indicated the resident was alert and oriented to name, place, date, and time. The Admit/Readmit Evaluation further indicated the resident had an indwelling catheter. During a review of Resident 183's History and Physical (H&P), dated 6/16/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 183's Physician Orders Summary Report, the Physician Orders Summary Report indicated orders for the following: -Indwelling Catheter: French number 16 (the diameter of the catheter) to drainage bag due to diagnosis of iatrogenic bladder (bladder injury), dated 6/7/2026. -Indwelling Catheter: change catheter (if blockage / leakage / removal / dislodge) as needed, dated 6/7/2026. During a review of Resident 183's Care Plan (CP) titled, (Resident 183) has an indwelling catheter, initiated 6/9/2026, the CP indicated a goal that the resident would remain free from catheter related trauma and would show no signs and symptoms of UTI with interventions that included to change the catheter for leaking and to monitor / document / report to the physician for signs and symptoms of UTI including no urine output. During a review of Resident 183's SBAR form, dated 6/16/2026 at 5:12 p.m., the SBAR form indicated the resident complained of discomfort on the pelvic area and reported that he (Resident 183) felt his urine was going to his scrotum area, the physician was made aware with orders to transport the resident to the hospital via non-emergent transport. During an observation and interview on 6/15/2026 at 9:48 a.m., inside Resident 183's room, observed Resident 183 lying in bed with an indwelling catheter. Resident 183 stated his catheter had been leaking urine for about a week and all the staff were aware, but they told him they could not do anything about it because the resident needed to see the urologist (physician that specialized in the urinary tract system) to have the catheter changed. Resident 183 stated he (Resident 183) felt uncomfortable because he (Resident 183) was not used to being wet. During an interview on 6/16/2026 at 2:15 p.m., in the hallway outside Resident 183's room, with Family Member (FM) 1, FM 1 stated Resident 183 had been complaining since the prior week that his catheter was leaking, and she (FM 1) told the nurse. FM 1 stated she (FM 1) could not remember the nurse's name, but the nurse said they could not change the catheter and the resident needed to see the urologist. FM 1 stated Resident 183's catheter was still leaking urine. During an interview on 6/16/2026 at 2:28 p.m., in the hallway, with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 183's catheter had been leaking for the past two days that she (CNA 4) had cared for him. CNA 4 stated on 6/15/2026 day shift (a standard period of time worked between 7 a.m. to 4 p.m.), she (CNA 4) reported to Licensed Vocational Nurse (LVN) 1 that Resident 183's catheter drainage bag had zero urine output for the entire shift and all the urine had leaked into the resident's brief. CNA 4 stated Resident 183's catheter was still leaking and his brief was wet. During an interview on 6/16/2026 at 2:36 p.m. with LVN 1, at Nursing Station 1, LVN 1 stated she (LVN 1) had been caring for Resident 183 for the past few days and was not aware of any issues reported by the family or staff regarding Resident 183's indwelling catheter. LVN 1 stated she (LVN 1) was not aware that Resident 183's catheter was leaking. During an interview on 6/16/2026 at 2:39 p.m. with Treatment Nurse (TN) 1, TN 1 stated Resident 183 had an indwelling catheter to keep the area at the penile abscess clean and dry. TN 1 stated the indwelling catheter had bypassing issues and the resident needed to follow up with the urologist. TN 1 stated only the urologist can change the resident's catheter. During a concurrent interview and record review on 6/17/2026 at 2:19 p.m., with MDS Nurse (MDSN) 1, in the conference room, Resident 183's SBAR forms and Progress Notes for 6/2026 were reviewed. The MDSN 1 stated bypassing indicates an indwelling catheter is not functioning properly and could indicate the tubing is blocked or not inserted correctly and needs to be changed. The MDSN 1 stated a change of condition is any change from the resident's baseline. The MDSN 1 stated resident changes of conditions are reported by the CNAs or LNs to the supervising nurse and to the physician to determine any necessary treatments. The MDSN 1 stated if a resident's catheter was bypassing, there was no urine in the drainage bag for an entire shift, and nursing staff cannot change the catheter; it would be considered an SBAR and should be reported to the physician. The MDSN 1 stated between Resident 183's admission and the evening shift (3 p.m. to 11 p.m.) on 6/16/2026 there was no documented evidence that it was reported to the physician that Resident 183's catheter was bypassing and needed to be changed. During a follow up interview on 6/17/2026 at 4:06 p.m. with TN 1, in the conference room, TN 1 stated when Resident 183's indwelling catheter was bypassing and there was no urine in the drainage bag for the day shift on 6/15/2026 it was considered a change of condition, and CNA 4 should have reported to LVN 1 to evaluate the catheter. TN 1 stated on the evening shift of 6/16/2026 Resident 183's abdomen was distended and he was found to be retaining 600 milliliters (mL, a unit of liquid measurement) of urine and was sent to the hospital for further evaluation. During a concurrent interview and record review on 6/18/2026 at 1 p.m. with the Director of Nursing (DON), in the conference room, reviewed the P&P regarding SBAR and indwelling catheters. The DON stated Resident 183 was newly admitted and has urological issues that require an indwelling catheter that should only be changed by the urologist. The DON stated Resident 183 had a physician's order that indicated to change the catheter if there was leaking. The DON stated bypassing could indicate that an indwelling catheter has a blockage and urine is not flowing and needs to be changed. The DON stated when an indwelling catheter bypasses and is not changed there is the potential that the resident would develop a UTI. The DON stated when Resident 183's catheter was bypassing with no urine collection in the drainage bag for an entire shift it was considered a resident change of condition that the CNA should report to the LN by completing a Stop and Watch form. The DON stated CNA 4 did not complete a Stop and Watch form on 6/15/2026 and the LN did not address Resident 183's change in condition regarding the catheter bypassing with the need to be changed. The DON stated on 6/15/2026, the physician should have been notified of Resident 183's SBAR to determine the necessary treatment but was not. The DON stated the facility P&P was not followed for SBAR potentially contributing to indwelling catheter complications resulting in hospitalization of Resident 183 on 6/16/2026. During a review of the facility P&P titled, Bowel and Bladder Retraining, last reviewed 12/10/2025, the P&P indicated, INTENT . To ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. GUIDELINES. 1. The interdisciplinary team provide appropriate and sufficient services and assistance to:. c. Prevent urinary tract infections to the extent possible. During a review of the facility P&P titled, Notification of Changes, last reviewed 12/10/2025, the P&P indicated, DEFINITIONS. A need to alter treatment significantly: . commence a new form of treatment to deal with a problem. GUIDELINES: . 1. The facility shall immediately or as soon as practicable inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is: . b. A significant change in the resident's physical, mental, or psychosocial status. c. A need to alter treatment significantly; . Licensed personnel will provide timely, accurate, and standardized communication with the physician or licensed practitioner when a resident experiences a significant change in condition using the SBAR (Situation Background Assessment Recommendation) communication tool or documented equivalent in the nursing progress notes. The form is used for a resident change in condition resulting in a need to significantly alter the resident's treatment plan.

Based on observation, interview, and record review, the facility failed to ensure that the respiratory care provided to residents was consistent with professional standards of practice for two (2) of three (3) sampled resident (Resident 30, 184) reviewed for respiratory care by failing to ensure Resident 30, and Resident 184's oxygen via nasal cannula (N/C a flexible plastic tube with two tips that go into the nose to give a person extra oxygen and help them breathe easier) tubing was labeled with the date it was last changed. This deficient practice had the potential to result in placing Residents 30 and 184 at risk for infection. Findings: 1. During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted the resident on 5/20/2026, with diagnoses including acute respiratory failure with hypoxia (a sudden condition in which the lungs cannot get enough oxygen into the blood, causing low oxygen levels in the body); type two (2) diabetes mellitus with hyperglycemia (a disorder characterized by difficulty in blood sugar control there is too much sugar in the blood); muscle weakness (Generalized) (weakness in many muscles throughout the body). During a review of Resident 30's History and Physical (H&P), dated 5/29/2026, the H&P indicated the resident had the capacity to make decisions for herself. During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 5/27/2026, the MDS indicated, Resident 30 was able to make self- understood and has the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated that the resident required maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 6/15/2026, at 12:42 p.m., with Licensed Vocational Nurse (LVN)3, inside resident's room, observed Resident 30's NC was not labeled with the date it was started or last changed. LVN 3 stated the NC needs to be labeled with the date it was started or changed for infection control precautions. LVN 3 stated that the NC tubing is changed once a week, it is done every Tuesday at night or changed as needed. LVN 3 stated if the NC is not labeled, they would not know when it was changed and resident is at risk for developing respiratory infection. During an interview on 6/18/2026 at 1:47p.m., with the Director of Nursing (DON), the DON stated that if the NC is not labeled with the date it was started, staff are unable to determine when it is due for replacement. The DON stated this prevents staff from monitoring timely tubing changes in accordance with the facility's infection prevention practice and places the resident at risk of respiratory infection. 2. During a review of Resident 184's AR, the AR indicated the facility admitted the resident on 6/8/2026, with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (COPD- a chronic lung disease causing difficulty in breathing and has suddenly worsen); muscle weakness (Generalized) (weakness in many muscles throughout the body); history of falling. During a review of Resident 184's H&P, dated 6/9/2026, the H&P indicated the resident had the capacity to understand and make decisions for herself. During a concurrent observation and interview on 6/15/2026, at 12:50 p.m., with LVN 3, inside Resident 184`s room observed the resident`s NC was not labeled with date it was started or changed. LVN 3 stated the NC needs to be labeled with the date it was started or changed for infection control precautions. LVN 3 stated that the NC tubing is changed once a week, it is done every Tuesday at night or changed as needed. LVN 3 stated if the NC is not labeled, they would not know when it was changed and resident is at risk for developing respiratory infection. During an interview on 6/18/2026 at 1:47p.m., with the DON, the DON stated that if the NC is not labeled with the date it was started, staff are unable to determine when it is due for replacement. The DON stated this prevents staff from monitoring timely tubing changes in accordance with the facility's infection prevention practice and places the resident at risk of respiratory infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, last reviewed on 12/10/2025, the P&P indicated the purpose of this procedure is to provide guidelines for the administration of oxygen. Guidelines: 8. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are for single resident use only, will be changed weekly and when visibly soiled, and will be stored in a plastic bag at the resident's bedside to protect the equipment from dust or dirt when not in use.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 followed Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) while administering medications to a resident with wounds) for one of three observed residents (Resident 93) for medication administration. This deficient practice had the potential to place Resident 93 at risk for infections, which could result in impairment or decline in the residents' health and well-being. Findings: During an observation on 6/15/2026 at 9:15 a.m., observed an EBP sign posted at the entry to Resident 93's room. At 9:35 a.m., LVN 3 was observed sanitizing her hands and entering Resident 93's room and administering 14 medications to Resident 93. LVN 3 was not observed wearing gloves and gown while administering Resident 93's medications. During an interview on 6/15/2026 at 12 p.m., with LVN 3, LVN 3 stated Resident 93 had an EBP sign at the entry to his room to reduce the transmission of infectious organisms to the resident because the resident had wounds. LVN 3 stated gloves and a gown should be worn when giving medical treatments to Resident 93. LVN 3 stated she failed to wear gloves and gown earlier that day (6/15/2026) when administering medications to Resident 93. During an interview on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON,) the DON acknowledged Resident 93 was placed on EBP due to wounds. The DON stated residents with wounds are at increased risk of infections. The DON stated wearing gloves and gown during medication administration helps prevent the transfer of infectious organisms from staff to the resident. The DON stated LVN 3 failed to follow facility's policy and procedures (P&P) for EBP and infection control by failing to wear gloves and gown while administering medications to Resident 93, placing the resident at risk of infections. During a review of Resident 93's admission Record (a document containing demographic and diagnostic information,) dated 6/16/2026, the admission Record indicated Resident 93 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including malignant (harmful, dangerous) neoplasm (abnormal, excessive growth) of skin. During a review of Resident 75's Order Summary Report, dated 6/14/2026, the report indicated Resident 93 was placed on EBP due to wounds, starting 5/21/2024. During a review of the facility P&P titled, Enhanced Barrier Precautions, last reviewed 12/10/2025, the P&P indicated: The facility has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. EBP is an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: 3. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 6. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. During a review of the EBP sign posted on Resident 93's doorstep, the sign indicated: Providers and staff must also wear gloves and a gown for the high contact resident care activities below: 3. Caring for devices & giving medical treatments.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 12) received a suitable meal when Resident 12 had a scheduled appointment at lunchtime. This failure had the potential for Resident 12 to have weight loss and dehydration due to missing a meal. Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 4/23/24 with diagnoses including cerebral infarction (irreversible damage to the brain due to lack of blood flow), diabetes (a condition where the body cannot effectively produce or use insulin, a hormone that manages blood sugar in the body), and muscle weakness. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2026, the MDS indicated that Resident 12 does not have visual or hearing difficulties. The record indicated that Resident 12 has significant memory loss, uses a wheelchair, and has impairment (diminished or weakened) in both arms and legs. The record also indicated that Resident 12 is dependent on caregivers for all daily activities, including feeding assistance. During a review of Resident 12's care plan for Nutrition Risk, dated 4/23/24, the care plan indicated that Resident 12 should receive diet as ordered. During a review of Resident 12's SBAR (Situation Background Assessment Recommendation - a standardized communication framework that helps professionals share essential, concise information quickly and accurately): Change of Condition, dated 5/20/26, the record indicated that Resident 12 had a weight loss of sixteen pounds in six months. During a concurrent observation and interview on 6/15/2026 at 12:52 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 12's room, medical transport had arrived with a gurney and began taking vital signs on Resident 12. Resident 12's meal tray arrived at 12:55 p.m. LVN 2 stated that Resident 12 had an appointment and required medical transport. LVN 2 stated that due to the appointment, Resident 12 was unable to be fed a meal and was instead given an Ensure (supplemental drink). During an interview on 6/17/2026 at 12:52 p.m. with LVN 2, LVN 2 stated that Resident 12 is being monitored for weight loss. LVN 2 stated that the appointment should have been communicated to the kitchen to ensure that Resident 12 received a 'snack pack before appointment. During an interview on 6/17/2026 at 1:58 p.m. with the Registered Dietician (RD), the RD stated that Ensure should not replace a meal, as it is meant to supplement a meal. During an interview on 6/18/2026 at 9:57 p.m. with the Director of Dietary (DD), the DD stated that if a resident has an appointment at a mealtime, it must be communicated to the kitchen so that a sack lunch or alternative arrangement can be made prior to the appointment. The DD stated that the kitchen was not aware of Resident 12's appointment on 6/15/2026 and confirmed that a sack lunch was not prepared for Resident 12. The DD stated that Resident 12 should have received a sack lunch. During an interview on 6/18/2026 at 1:08 p.m. with the Director of Nursing (DON), the DON stated that the policy for Meals Packed to Go was not followed and that Ensure is not an appropriate replacement for a meal. The DON stated that if a resident with weight loss does not receive a therapeutic diet (a diet ordered by a physician as treatment for a condition), it could potentially lead to a failure of the interventions to combat weight loss. During a review of the facility's Policy and Procedure (P&P) titled, Therapeutic Diet, dated January 2026, the P&P indicated, The facility ensures residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. During a review of the facility's P&P titled, Meals Packed to Go, dated 2020, the P&P indicated, Residents in need of a meal while away from the facility will be provided with a packed meal to take with them. The P&P indicated, A member of the nursing staff will notify Dining Services prior to the time packed meal is needed.

Based on observation, interview, and record review, the facility failed to ensure that residents' drug regimen included adequate (acceptable) monitoring for HgA1c ([A1C] -a test that measures average blood sugar (BS) levels over a three-month period) levels for one (1) of five (5) sampled residents investigated for unnecessary medications (Resident 7) between 7/13/2025 and 6/16/2026. This deficient practice had the potential to cause Resident 7 to receive suboptimal (less than the highest standard or quality) care by not providing the appropriate care for Diabetes Mellitus two (2) (DM2- a condition characterized by high or uncontrolled levels of BS which can lead to serious damage to the heart, eyes and kidneys [pair of organs responsible for filtering waste materials out of the blood and passing them out of the body as urine, and regulating blood pressure of the body) resulting in poorly managed BS levels leading to long term health complications and in Resident 7's health and well-being to be negatively impacted.Findings:During a review of Resident 7's admission Record (a document containing demographic and diagnostic information) dated 6/16/2026, the admission Record indicated the facility originally admitted Resident 7 on 6/6/2024, and re-admitted on [DATE],5 with diagnosis including DM2. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 3/11/2026, the MDS indicated Resident 7 had Diabetes Mellitus and was using insulin. During a review of Resident 7's Order Summary Report (a report listing the physician order for the resident,) dated 6/16/2026, the Order Summary Report indicated Resident 7 was prescribed Insulin (a medication used to treat high BS levels) Regular (short-acting insulin) to inject per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) subcutaneous (SQ- under the skin) every six (6) hours for DM2, starting 7/13/2025. During a review of Resident 7's medication administration records (MAR- a document of the medications administered to a resident that is part of the resident's permanent medical record), for June 2026, the MAR indicated Resident 7 was prescribed Insulin Regular per sliding scale SQ every six (6) hours for DM2, to be given at 12 a.m., 6 a.m., 12 p.m. and 6 p.m. During a review of Resident 7's clinical record on 6/16/2026 at 12:45 p.m., the clinical record did not include laboratory (tests that analyze certain health status) tests or results for HbA1C since 7/13/2025. During an interview and record review on 6/16/2026 at 3:05 p.m., with the Director of Nursing (DON), the DON reviewed Resident 7's clinical record. The DON acknowledged Resident 7 had a diagnosis of DM2 and was prescribed insulin Regular per sliding scale, starting 7/13/2025. The DON stated that the DON needed time to review the laboratory tests and results. During a phone interview on 6/17/2026 at 2:24 p.m., with the DON, the DON stated after a thorough search of Resident 7's clinical record, the record did not contain baseline (initial) or subsequent (following) HgA1c level monitories since admission. The DON stated that monitoring HgA1c level was important to know if the insulin therapy was effective for the residents and if any changes to medications were needed based on the level. The DON stated that residents with DM2 and insulin should have baseline HgA1c levels when admitted and monitored every three (3) to six (6) months to ensure residents were on the right medications and DM2 was managed without long term uncontrolled blood sugar levels and health complications. The DON stated that the facility failed to monitor baseline and subsequent HgA1c levels for Resident 7, since 7/13/2025. During a phone interview on 6/18/2026 at 12:06 p.m., with the Consultant Pharmacist (CP), the CP stated for residents with DM2 that HgA1c levels should be monitored every three (3) months and for stable residents every six (6) to twelve months. The CP stated that BS level monitoring was not enough to determine effectiveness of medications, such as insulin. The CP stated that monitoring HgA1c levels every three (3) to six (6) months was a diagnostic tool to evaluate the effectiveness of therapy for residents to determine if changes in medication therapy were necessary. During a review of the facility's policy and procedure (P&P) titled Unnecessary Drugs, last revised on 12/10/2025, the P&P indicated that Each resident's drug regimen shall be free from unnecessary drugs. The intent of these requirements is to ensure each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Any medication or combination of medications-or the use of a medication without adequate indications, in excessive dose, for an excessive duration, or without adequate monitoring-may have serious side effects, such as changes in vital signs/lab values, confusion, immobility, falls, and hip fractures, which can be especially dangerous for elderly residents, in addition to an increased risk of death. 2. The facility does not promote the use of unnecessary drugs. 3. Unnecessary drugs include but may not be limited to medications used: c. Without adequate monitoring 16. Examples of inappropriate duration that should be cited for noncompliance may include: 1. The facility is responsible for the resident's medication management including but not limited to:d. Monitoring 2. The interdisciplinary team are responsible for documenting medication management steps including monitoring and documenting the resident's response to any treatment such as lab results.

Based on observation, interview, and record review, the facility failed to provide appropriate care for one of one sample resident (Resident 75) receiving enteral feeding (is a feeding tube that provides liquid nutrition directly into the stomach) by failing to label the flushing bag (a bag filled with water that's connected to an enteral feeding pump system) with the name of the correct solution. This deficient practice had the potential for placing Resident 75 at risk for harm when using wrong type or old fluid in the enteral flush bag. Findings: During a review of Resident 75's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/28/2026, and readmitted on [DATE], with diagnoses including of hemiplegia (the severe or complete loss of motor function on one side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following cerebral infarction (supply of blood to the brain becomes blocked, cutting off oxygen and vital nutrients) affecting left non-dominant side; muscle weakness (Generalized) (weakness in many muscles throughout the body); encounter for attention to gastrostomy (a routine medical visit for the routine care, cleaning, or changing of a feeding tube). During a review of Resident 75's History and Physical (H&P), dated 5/19/2026, the H&P indicated that the resident could make needs known but cannot make decisions. During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2026, the MDS indicated Resident 75 was able to make self- understood and has the ability to understand others and had severe cognitive impairment (has major problems with thinking, memory, understanding, and may need significant assistance with daily activities and supervision for safety). The MDS indicated that the resident was dependent to staff or required maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 75's Order Summary Report (OSR), dated 6/3/2026, the OSR indicated an order for enteral feed order every shift Diabetisource AC (a type of tube feeding): set pump @55 ml/hr (milliliters per hour) for 20 hrs., to provide 1100ml/1320KCAL (kilocalorie is a unit used to measure the amount of energy in food and tube feeding). Start infusion @1200 and continue for 20 hrs. or until total volume is complete. During a review of Resident 75's Order Summary Report (OSR), dated 6/3/2026, the OSR indicated an order for enteral feed order during every shift, flush feeding tube with water at 35ml/hr x20 hrs. via kangaroo pump (a tube feeding pump used to deliver liquid nutrition and water through feeding tube) to provide 700ml/day. During an observation on 6/15/2026 at 9:50 a.m. inside Resident 75's room, the Diabetisource bag and flush bag were hanging from the kangaroo pump pole. The flush bag had clear liquid and had a label that indicated the bag was filled with Diabetisource at 35ml/hr. During a concurrent observation and interview on 6/15/2026, at 12:55 p.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 75`s room, LVN 3 observed the flush bag that had a label with the solution name Diabetisource. LVN 3 stated the flush bag was labeled incorrectly and should include the rate, time, and date, and the correct solution name in this situation water instead of Diabetisource. LVN 3 stated labeling Diabetisource on the water bag instead of water is incorrect and confusing and may lead to errors. During an interview for on 6/18/2026 1:47 p.m. with the Director of Nursing (DON), the DON stated that prior to hanging the enteral feeding bag and flush bag, they are labeled with the name, rate, time, and solution name. The DON stated the flush bag was incorrectly labeled as Diabetisource instead of water, which could cause confusion with the delivery of the feeding and can potentially lead to an error. During a review of the facility's policy and procedure (P&P) titled, Assisted Nutrition and Hydration, last reviewed on 12/10/2025, the P&P indicated to provide facility personnel with guidelines to ensure that a resident maintains acceptable parameters of nutritional status; is offered sufficient fluid intake to maintain proper hydration and health; and is offered a therapeutic diet when ordered.

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for patients to call a nursing personnel to assist them when needed) within reach of residents for two (2) of two (2) sampled residents (Residents 39, 110) reviewed under environment task. The deficient practice had the potential to place the residents at risk for delayed assistance, potentially affecting safety and timely care. Findings: 1. During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 2/17/2026, with diagnoses including type two (2) diabetes mellitus with hyperglycemia (a disorder characterized by difficulty in blood sugar control there is too much sugar in the blood); muscle weakness (Generalized) (weakness in many muscles throughout the body); cognitive communication deficit ( a person has difficulty thinking, remembering things, understanding, or organizing information, which affects their ability to communicate effectively). During a review of Resident 39's History and Physical (H&P), dated 2/18/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2026, the MDS indicated Resident 39 had severe cognitive impairment (has major problems with thinking, memory, understanding, and may need significant assistance with daily activities and supervision for safety). The MDS indicated that the resident was dependent or required maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 39's Fall Risk Evaluation (FRE), dated 5/19/2026, the FRE indicated the resident was at high risk for falls. During a review of Resident 39's Care Plan (CP) Report, titled Risk for falls: Resident 39 is at risk for recurrent falls and spontaneous injuries r/t gait (the way a person walks)/balance problems, incontinence (a person is unable to fully control urine or bowel movement resulting in accidents) dated 2/23/2026, the CP indicated a goal to minimize the risk of injury from falls until the next review date. The CP intervention was to keep the call light within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 6/15/2026, at 1:08 p.m., with Certified Nursing Assistant (CNA) 5 inside Resident 39's room, CNA 5 observed call light on the bottom part of the bed in between side rail and mattress. CNA 5 stated Resident 39 would not have been able to call; it would have been difficult for Resident 39 to get help, and resident could potentially fall trying to reach for the call light. During a concurrent interview and record review on 6/17/2026, at 10:20 a.m., with Licensed Vocational Nurse (LVN) 5, Resident 39`s FRE dated 5/19/2026 and CP dated 2/23/2026 were reviewed. LVN 5 stated Resident 39 was at high risk for falls. LVN 5 stated the purpose of the call light is for residents to utilize it when they need assistance. LVN 5 stated Resident 39 would not have been able to reach the call light, and the resident could have potentially fallen. LVN 5 stated the care plan and policy titled, Resident Call System were not followed. During an interview on 6/18/2026 at 1:47p.m., with the Director of Nursing (DON), the DON stated the purpose of the call light is for the residents to call when they need assistance is a way to communicate with staff. The DON stated if the call light is not within reach, then there will be a delay in care. The DON stated that Resident 39 would not have been able to call for assistance because the call light was stuck between side rail and mattress and it could have been an emergency, by not having call light within reach would also delay assistance. The DON stated Resident 39 could potentially fall if resident was not able to call for assistance. The DON stated the policy and procedure (P&P) titled, Resident Call System was not followed. 2. During a review of Resident 110's AR, the AR indicated the facility originally admitted the resident on 1/16/2024 and readmitted on [DATE], with diagnoses including spinal stenosis, cervical region (a condition where the neck part of the spine becomes narrow and presses on the nerves); muscle weakness (Generalized) (weakness in many muscles throughout the body); history of falling. During a review of Resident 110's H&P, dated 11/24/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 110's MDS, dated [DATE], the MDS indicated that Resident 110 was able to make self- understood and had the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated the resident required partial/moderate assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 110's FRE, dated 5/8/2026, the FRE indicated the resident was at risk for falls. During a review of Resident 110's CP Report, titled Resident 110 is at risk for recurrent falls and spontaneous injuries r/t muscle weakness, deconditioning, spinal stenosis of cervical region, and history of falling, dated 11/19/2024, the CP indicated a goal to minimize the risk of injury from falls until the next review date. The CP intervention was to keep the call light within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 6/15/2026, at 1:15 p.m., with CNA 5 inside Resident 110's room, CNA 5 observed the resident`s call light and bed remote control hanging down below and between left side bed rail and mattress. CNA 5 stated Resident 110 would not have been able to call for assistance and resident could have potentially fallen trying to reach for the call light. During a concurrent interview and record review on 6/17/2026, at 10:20 a.m., with LVN 5, Resident 110`s FRE dated 5/8/2026 and CP dated 11/19/2024 were reviewed. LVN 5 stated Resident 110 was at risk for falls. LVN 5 stated the purpose of the call light is for residents to utilize it when they need assistance. LVN 5 stated Resident 110 could have potentially fallen trying to reach for the call light. LVN 5 stated the CP and policy titled, Resident Call System were not followed. During an interview on 6/18/2026 at 1:47p.m., with the DON, the DON stated that Resident 110 would not have been able to call for assistance because the call light was not within reach and could have potentially fallen trying to reach for the call light. The DON stated the P&P titled, Resident Call System was not followed. During a review of the facility's P&P titled, Resident Call System, last reviewed on 12/10/2025, the P&P indicated the facility is adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the residents' bedside, floor, or toileting facilities. Procedure: 5. When the resident is sitting in his/her chair or confined to his/her bed, be sure to provide resident with call light access. 8. Resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the residents' room.

Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for two of three sampled residents (Resident 96 and 188) reviewed for accidents by failing to: 1. Ensure Resident 96's room was free from liquid spills while the resident was left unattended by staff. 2. Ensure Resident 188 did not have a chair and trash bin placed on top of the floor mat (a thick, soft pad placed on the floor beside a resident's bed to cushion them if they fall) on the resident's left side of the bed. These deficient practices had the potential to result in resident falls resulting in injuries like fractures (broken bones) and lacerations. Findings: a. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 12/22/2025 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), muscle weakness, and history of falling. During a review of Resident 96's Minimum Data Set (MDS – resident assessment tool), dated 5/27/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated Resident 96 required substantial/maximal assistance from staff for toileting, bathing, and personal hygiene; and was dependent on staff for eating, oral hygiene, and mobility. During a review of Resident 96's History and Physical (H&P), dated 2/19/2026, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 96's Fall Risk Evaluation (FRE), dated 6/11/2026, the FRE indicated the resident was disoriented, had a history of one to two falls in the past three months, had balance problems while standing/walking, and was a high risk for falls. During a review of Resident 96's Post Fall Evaluation (PFE), the PFE indicated on 6/11/2026 the resident had an unwitnessed fall that resulted in redness to the face, bruising to the nose, bleeding lips and gums and with the upper three front teeth dislodged, abrasion with bleeding and swelling to the arm, immobility of the left elbow, and mild swelling to the left knee. The PFE indicated Resident 96 had seven falls in the last 180 days. During a review of Resident 96's Care Plan (CP) titled, Actual Fall: The resident had an actual fall from bed. initiated 6/11/2026, the CP indicated a goal that the resident would resume usual activities minimizing risk of injury with interventions that included to transfer the resident to the emergency room. During a review of Resident 96's Care Plan (CP) titled, Risk for Fall, (Resident 96) was a high risk for falls. initiated 2/18/2026, the CP indicated interventions that included to promote a safe environment with even floors that are free from spills. During a concurrent observation and interview on 6/15/2026 at 12:15 p.m., observed Resident 96 lying in bed, observed the resident was missing three front teeth. Resident 96 stated that he recently had a fall when he was trying to get up without calling for help. Resident 96 stated he lost his front teeth and hurt his shoulder and leg. During an observation on 6/16/2026 at 1:20 p.m., observed Resident 96 sitting up at the left side of the bed and eating. Observed the resident was unattended by staff and there was a puddle of clear liquid between the foot of the bed and the wall that was visible from the hallway. During an observation on 6/16/2026 at 1:23 p.m., observed Licensed Vocational Nurse (LVN) 1 entered the resident's room, spoke with the resident, and exited the room while the puddle of liquid remained on the floor. During an observation and interview on 6/16/2026 at 1:50 p.m. with LVN 1, at Nursing Station 1, LVN 1 stated Certified Nursing Assistant (CNA) 3 was in Resident 96's room assisting the resident, observed CNA 3 exit the room and left the resident unattended and walked down the hall. Observed the puddle of clear liquid remained on the floor between the foot of the bed and wall. LVN 1 stated Resident 96 had a recent fall with injury. Upon the surveyor's request, observed LVN 1 then entered Resident 96's room and stated there was possibly water spilled on the floor between the foot of the bed and the wall. LVN 1 stated CNA 3 should have identified and cleaned the spill and did not. LVN 1 stated when she (LVN 1) was in the room earlier, LVN 1 did not see the liquid on the floor, but she should have. LVN 1 stated spills should be cleaned right away because they create a fall hazard for the resident. During an interview on 6/17/2026 at 10:41 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 96 had a recent fall with major injuries and was considered a high risk for falls. The ADON stated a wet floor would be considered a risk for the resident slipping and falling. The ADON stated all the staff are responsible to ensure that the resident's environment is clean and the floor is dry every time they enter the resident's room. The ADON stated when the staff left a spill in Resident 96's room, the resident could have potentially stood up and slipped on the spill resulting in further injuries like broken bones. During a concurrent interview and record review on 6/18/2026 at 1 p.m. with the Director of Nursing (DON), in the conference room, the DON reviewed the facility policy and procedures (P&P) regarding fall management and accident prevention. The DON stated staff should immediately clean liquid spills and not wait for housekeeping to clean them. The DON stated when staff does not clean a spill it is an environmental risk that could result in a resident falling. The DON stated when Resident 96 had a spill in his room that was not cleaned the facility P&P was not followed potentially resulting in further injuries in the resident. During a review of the facility P&P titled, Free of Accident Hazards / Supervision / Devices, last reviewed 12/10/2025, the P&P indicated, The facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision to prevent avoidable accidents. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety: . acknowledges the high-risk nature of its population and setting . Demonstrates a commitment to safety at all levels of the organization. Processes in a facility's interdisciplinary systematic approach may include: . Identification of hazards, including inadequate supervision, and a resident's risks of potentially avoidable accidents in the resident environment. All staff is involved in observing and identifying potential hazards in the environment. Factors that may result in resident falls include, but are not limited to, . environmental hazards. wet floors. During a review of the facility P&P titled, Fall Management Program, last reviewed 12/10/2025, the P&P indicated, The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. Accident: Any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable Accident: An accident which occurred because the facility failed to:. Identify environmental hazards. Evaluate and analyze the hazards and risks and eliminate them. b. During a review of Resident 188's AR, the AR indicated the facility initially admitted the resident on 6/4/2026, and readmitted on [DATE], with diagnoses including unspecified dementia, contusion of the head (a bruise caused by direct blow or jolt), dysphagia (difficulty swallowing), muscle weakness, alcohol dependence (a person's body and mind rely on alcohol to function), and history of falling. During a review of Resident 188's History and Physical (H&P), dated 6/9/2026 indicated that the resident had fluctuating capacity to understand and make decisions. The H&P also indicated the prior level of function as independent on ambulation, bathing, grooming, toileting and transfers and does not use any assistive devices. During a review of Resident 188's CP titled, Risk for Fall: The resident is at risk for recurrent falls related to contusion, gait/balance problems, impaired mobility, poor communication/comprehension, unaware of safety needs, history of fall . initiated on 6/08/2026, the CP indicated a goal that will minimize risk of injury from falls . with interventions that included bilateral floor mat/landing mat to minimize injury, and promote safe environment with (example: even floors free from spills and/or clutter, glare-free light; a working and reachable call light, personal items within reach). During a review of Resident 188's CP titled, Bilateral floor mat/landing mat: Resident utilizes floor mat/landing mat as a preventative measure to cushion the fall impact and decrease the likelihood of injury, the CP indicated a goal that resident will have reduced risks of injury from falls due to the placement of landing mats with interventions that indicated to regularly check the floor mats for any signs of wear or damage, ensuring they remain in good condition. During a concurrent observation and interview on 6/15/2026 at 11:06 a.m. with 1:1 sitter (S1 – a dedicated staff member often a nursing assistant, patient observer, or trained volunteer assigned to stay in the room and continuously monitor exactly one patient to ensure their physical safety and mental well-being), S1 stated that Resident 188 had bilateral floor mats and to the resident's left side of the bed the floor mat had a chair and trash bin on top of the mat. S1 stated that it is okay to have a chair and a trash bin on top of the floor mat and further stated that the objects were already on top of the floor mat at the start of her shift. During an observation and interview on 6/15/2026 at 11:22 a.m. with LVN 5, the LVN 5 stated that floor mat is used to assist when there is a fall for injury prevention. LVN 5 stated that it is not okay to place any objects on top of the floor mat. LVN 5 stated the chair and trash bin should not have been placed on the top the floor mat and further stated that instead of protecting the resident with the cushioned floor mat, any objects placed on top of the mat could cause injury to the resident. During an interview on 6/17/2026 at 2:08 p.m. with DON, the DON stated that the purpose of floor mats are used to prevent injury in case of fall. The DON stated that floor mats should be free from any objects. The DON further stated that the resident can land on the object which can lead to injuries. During a review of the facility's P&P titled, Free of Accident Hazards/Supervision/Devices, revised on 1/2025, the P&P indicated, The facility provides and environment that is free from accidental hazards over which the facility has control, and each resident received adequate supervision and assistive devices for each resident to prevent avoidable accidents. Guidelines: (2) An effective way for the facility to avoid accidents or to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A Systems Approach: (1-a) Identification of hazards, including inadequate supervision, and a resident's risks of potentially avoidable accidents in the resident environment. (5) Effective Accident Management identifies environmental hazards, the resident's risk for an avoidable accident, and evaluates the resident's need for supervision. (6) identifying and addressing risks, including the potential for accidents, includes consideration of the environment, the residents' risk factors, and the need for supervision, care, and assistive devices.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for three of three sampled residents (Resident 5, Resident 6, and Resident 7) by failing to: 1. Ensure licensed nurses appropriately assessed and monitored Resident 5's medical status following the resident's Change of Condition (COC - any sudden or major shift in a person's physical, mental, or behavioral health compared to their normal baseline) on 6/7/2026 related to the alleged physical aggression with Resident 6.2. Ensure licensed nurses appropriately assessed and monitored Resident 6's medical status following the resident's Change of Condition (COC) on 6/7/2026 related to the alleged physical aggression with Resident 5.3. Ensure licensed nurses appropriately assessed Resident 7's mental status (the brain's ability to clearly think) following the resident's admission on [DATE].These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration thereby placing Resident 5, 6, and 7 at risk for adverse health outcomes and compromised safety.Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 5/19/2026 with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), muscle weakness, and depression (serious mood disorder characterized by persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 5's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired.During a review of Resident 5's COC form, dated 6/7/2026, the COC form indicated on 6/7/2026 at 11:13 a.m., Resident 5 was heard yelling in the station A hallway. The COC form indicated that Resident 5 allegedly reported getting hit on the arm by Resident 6.During a concurrent interview and record review on 6/10/2026 at 4:30 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Progress Notes, dated 6/7/2026 to 6/10/2026 were reviewed. The ADON stated residents should be monitored every shift for 72 hours after a change of condition. The ADON stated Resident 5's Progress Notes indicated there was no documented evidence that the resident was monitored on the following shifts:a. On 6/7/2026 (11 p.m. to 7 a.m. shift),b. On 6/8/2026 (3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift), andc. On 6/9/2026 (11 p.m. to 7 a.m. shift).The ADON stated care not documented was considered not provided. The ADON stated that failure to document Resident 5's medical status monitoring following a change of condition could put Resident 5's safety at risk.2. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2022 with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (inability to move one side of the body), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact.During a review of Resident 6's COC form, dated 6/7/2026, the COC form indicated on 6/7/2026 at 11:13 a.m., Resident 6 was heard yelling in the station A hallway. The COC form indicated that Resident 6 allegedly hit Resident 5 on the right arm.During a concurrent interview and record review on 6/10/2026 at 4:30 p.m. with the ADON, Resident 6's Progress Notes, dated 6/7/2026 to 6/10/2026 were reviewed. The ADON stated residents should be monitored every shift for 72 hours after a change of condition. The ADON stated Resident 6's Progress Notes indicated there was no documented evidence that the resident was monitored on 6/8/2026 (3 p.m. to 11 p.m. shift). The ADON stated care not documented was considered not provided. The ADON stated that failure to document Resident 6's medical status monitoring following a change of condition could put Resident 6's safety at risk.During an interview on 6/10/2026 at 5:33 p.m. with the Director of Nursing (DON), the DON stated Resident 5 and Resident 6 should be monitored every shift for 72 hours after a change of condition. The DON stated there was no confirmed documented evidence of monitoring on the identified shifts for Resident 5 and 6. The DON stated failure to monitor Resident 5 and 6 every shift after a COC could result in the resident's missed signs of aggression, altercation with other residents, and compromised resident safety. The DON stated that care not documented was considered not provided. The DON acknowledged and stated the facility failed to monitor and document Resident 5 following a change of condition.During a review of the facility's policy and procedures (PnP) titled, Documentation Policy, last reviewed on 12/10/2025, the PnP indicated it is the policy of this facility to document relevant findings in the clinical record. The PNP indicated 72-hour charting shall be initiated at the following times. a significant change in physical, mental, or psychosocial status of the resident (progression, regression, new problems).3. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 6/4/2026 with diagnoses including urinary tract infection (an infection caused by bacteria entering the urinary system), sepsis (the body's life-threatening reaction to an infection), and muscle weakness.During a review of Resident 7's General Acute Care Hospital (GACH) 1 Discharge summary, dated [DATE], GACH 1 Discharge Summary indicated Resident 7 had diagnoses that included dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life), cognitive impairment, and altered mental status.During a review of Resident 7's Progress Notes, dated 6/4/2026, the Progress Notes indicated the resident alert and oriented times one (a medical phrase used to describe a person's mental status indicating the person only know their own identity and recognize themselves).During a concurrent interview and record review on 6/10/2026 at 4:02 p.m. with Registered Nurse (RN) 1, Resident 7's Admit/Readmit Evaluation, dated 6/4/2026, was reviewed. RN 1 stated Resident 1 was only responsive to his name. RN 1 stated Resident 7's Admit/Readmit Evaluation indicated the resident was alert, oriented to person, place, time, situation, and was verbally appropriate. RN 1 stated Resident 7's documented assessment on the Admit/Readmit Evaluation was not accurate. RN 1 stated inaccurate assessments could result in miscommunication amongst the healthcare team. RN 1 further stated inaccurate assessments could negatively affect Resident 7's safety. RN 1 acknowledged and stated the facility failed to accurately assess and document Resident 7's mental status on admission.During an interview on 6/10/2026 at 5:33 p.m. with the DON, the DON stated Resident 7's documented admission assessment was inaccurate. The DON stated inaccurate assessment could result in inappropriate and incomplete plan of care for Resident 7. The DON acknowledged and stated the facility failed to ensure accurate resident assessment was performed on admission and documented in the resident's medical records.During a review of the PnP titled, Accuracy of Assessments, last reviewed on 12/10/2026, the PnP indicated the intent to ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline.During a review of the facility's PnP titled, Documentation Policy, last reviewed on 12/10/2025, the PnP indicated it is the policy of this facility to document relevant findings in the clinical record. The PNP indicated 72-hour charting shall be initiated at the following times. a significant change in physical, mental, or psychosocial status of the resident (progression, regression, new problems).

Based on interview and record review, facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 1) when Resident 1 did not have an accurate assessment of the skin conditions that was conducted on 5/25/2026.This deficient practice has the potential to result in Resident 1's delay in necessary care and treatment.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 5/15/2026 with diagnoses including hemiplegia (paralysis of one entire side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness.During a review of Resident 1's Admit/Readmit Evaluation, dated 5/15/2026, the Admit/Readmit Evaluation did not indicate that Resident 1 had a deep tissue injury (DTI - a non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue caused by prolonged pressure or friction where the true depth and severity of the wound cannot be seen).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent on facility staff on rolling to the left and right sides. The MDS indicated sitting to lying and lying to sitting actions were not attempted due to medical conditions or safety concerns. The Skin Conditions section of the MDS indicated Resident 1 had one unstageable DTI that was present on admission.During a concurrent interview and record review on 6/9/2026 at 2:37 p.m. with MDS Nurse (MDSN) 1, Resident 1's Change of Condition form, dated 5/25/2026, was reviewed. MDSN 1 stated Resident 1's DTI developed at the facility. MDSN 1 stated Resident 1's MDS assessment on skin condition was inaccurate. MDSN 1 stated that failure to accurately document Resident 1's skin condition in the MDS could negatively affect the resident's plan of care.During an interview on 6/9/2026 at 3:57 p.m. with the Director of Nursing (DON), the DON stated Resident 1's MDS was one of the tools used to the Resident 1's care plan. The DON stated failure to accurately assess and document Resident 1's skin condition in the MDS could result in an inaccurate resident care plan. The DON acknowledged and stated the facility failed to accurately document Resident 1's skin conditions on the MDS assessment following the resident's admission.During a review of the facility's policy and procedure (PnP) titled, Accuracy of Assessments, last reviewed on 12/10/2025, the PnP indicated the MDS assessment must accurately reflect the residents' status. The PnP indicated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. The PnP further indicated the initial comprehensive assessment provides starting point data for ongoing assessment of resident progress.

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 5) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented Resident 5's assessment timely.This deficient practice resulted in inaccurate information on Residents 5's medical records and had the potential for delayed and inaccurate medical interventions.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 5/19/2026 with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), muscle weakness, and depression (a common, serious mood disorder characterized by persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 5's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired.During a review of Resident 5's Change of Condition (COC - any sudden or major shift in a person's physical, mental, or behavioral health compared to their normal baseline) form, dated 6/7/2026, the COC form indicated on 6/7/2026 at 11:13 a.m., Resident 5 was heard yelling in station A hallway. The COC form indicated that Resident 5 allegedly reported getting hit on the arm by Resident 6.During a concurrent interview and record review on 6/10/2026 at 4:30 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Progress Notes, dated 6/7/2026 to 6/10/2026, were reviewed. The ADON stated should be monitored every shift for 72 hours after a change of condition. The ADON stated Resident 5's Progress Notes indicated he (ADON) assessed Resident 5 on 6/8/2026 at 6:33 a.m. and documented the assessment on 6/10/2026 at 3:34 p.m., two days, nine hours, and one minute after. The ADON stated on 6/9/2026 at 6:39 a.m., he assessed Resident 5 and documented the assessment on 6/10/2026 at 3:37 p.m., 32 hours and 58 minutes after. The ADON stated his documented assessment of Resident 5 was not documented timely and did not indicate that the documentation was a late entry. During an interview on 6/10/2026 at 5:33 p.m. with the Director of Nursing (DON), the DON stated the assessment on Resident 5 was not documented timely and did not indicate that the documentation was a late entry. The DON acknowledged and stated the facility failed to timely document the assessment on Resident 5 and failed to indicate the documentation as a late entry.During a review of the facility's policy and procedures (PnP) titled, Documentation Policy, last reviewed on 12/10/2025, the PnP indicated late entries in the clinical record are dated for the day of entry. These entries are to be made to the record in a timely manner. late entries are to include the date and time the late entry was made and the date for the late entry. Example: 05/05/02 1400 entry for 05/03/02 1000.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of three sampled residents (Resident 1), when on 5/15/2026, Resident 1 was transferred to the general acute care hospital (GACH) for gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dislodgement (gastrostomy tube has been partially or completely pulled out of the stomach).This deficient practice had the potential to delay provision of care and services for Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 11/16/2023 and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and diabetes mellitus type 2 (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff with eating and showers. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff with oral hygiene and personal hygiene. During a review of Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 5/15/2026, the COC form indicated that on 5/15/2026, Resident 1's G-tube was in the process of dislodgement. The COC form indicated Resident 1's G-tube stoma site had redness and drainage. The COC form indicated that on 5/15/2026 at 10:06 p.m., Resident 1 was transferred to the GACH. During a concurrent interview and record review on 5/27/2026 at 3:22 p.m. with the MDS Coordinator, Resident 1's Care Plan was reviewed. The MDS Coordinator stated Resident 1's Care Plan was not revised to reflect Resident 1's G-tube dislodgement. The MDS Coordinator stated that care plans provide guidance and steps to provide necessary services for Resident 1's G-tube care. The MDS Coordinator stated that the failure to revise Resident 1's Care Plan could delay care and potentially cause complications for Resident 1. During an interview on 5/28/2026 at 11:46 a.m. with the Director of Nursing (DON), the DON stated that Resident 1's Care Plan should have been revised after Resident 1's G-tube dislodgement and GACH transfer. The DON stated Resident 1's care plan should have been reviewed and revised to reflect services necessary to care for Resident 1's G-tube and prevent accidents. The DON stated the failure to revise Resident 1's Care Plan had the potential to lead to disruption of feeding and care of the stoma site, negatively affecting Resident 1's comfort. During a review of the facility provided policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, last reviewed on 1/2026, the P&P indicated, The facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Guidelines: 1. The comprehensive care plan describes: a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.During a review of the facility provided P&P titled, Comprehensive Care Plans-Timing, last reviewed on 1/2026, the P&P indicated, Each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1 and Resident 2) by failing to:1. Ensure Licensed Vocational Nurse (LVN) 1 created Resident 1's Change of Condition (COC) Evaluation form. Resident 1 was reported wandering in another resident's room on 3/13/2026. Resident 1's Attending physician (MD) 1 and Family Member (FM) 1 were not notified. 2. Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's COC on 3/13/2026 related to the resident's new wandering behavior. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety. During a review of Resident 1's undated admission Record, the admission Record indicated on the facility admitted the resident 12/22/2025 and readmitted the resident on 2/27/2026 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), chronic obstructive pulmonary disease (COPD - a progressive, long-term disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During a review of Resident 1's Wandering/Elopement Risk Evaluation, dated 2/18/2026, the Wandering/Elopement Risk Evaluation indicated the resident was not at risk for wandering and elopement. During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/19/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. During an interview on 3/25/2026 at 1:39 p.m. with Resident 2, who was cognitively intact, Resident 2 stated Resident 1 went inside her room three times on 3/13/2026. Resident 2 stated Resident 3, who was also cognitively intact, reported the incidents to a licensed nurse. Resident 2 stated Resident 1 continued going in her room on 3/14/2026 and 3/15/2026. During an interview on 3/25/2026 at 3:45 p.m. with LVN 1, LVN 1 stated Resident 3 reported to her that Resident 1 was inside Resident 2 and 3's room. LVN 1 stated Resident 1's wandering behavior was new to the resident. LVN 1 stated that she reported the incident to the licensed nurse in charge of Resident 1 at the 11 p.m. to 7 a.m. shift. During an interview on 3/25/2026 at 1:01 p.m. and a concurrent record review of Resident 1's medical records, reviewed with LVN 3, LVN 3 stated Resident 1's wandering behavior was a change in the resident's condition. LVN 3 stated there was no documented COC for Resident 1 on 3/13/2026. LVN 3 further stated there was no documented evidence that MD 1 and FM 1 were notified about Resident 1's wandering behavior on 3/13/2026. LVN 3 stated Resident 1 should be monitored every shift for 72 hours. RN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that the resident was monitored on the following shifts:a. On 3/14/2026 (7 a.m. to 3 p.m. shift and 3 p.m. to 11 p.m. shift),b. On 3/15/2026 (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift), andc. On 3/16/2026 (7 a.m. to 3 p.m. shift). LVN 3 stated that care not documented was considered not provided. LVN 3 further stated that failure to document Resident 1's change of condition and the monitoring provided for the resident's wandering behavior could put Resident 1 and other residents' safety at risk. During an interview on 3/25/2026 at 2:05 p.m. with the Director of Nursing (DON), the DON stated Resident 1's wandering behavior was new to the resident and should be documented as a change of condition. The DON stated Resident 1 should be monitored every shift for at least 72 hours following COC. The DON stated there was no confirmed documented evidence of monitoring on the identified shifts. The DON stated failure to monitor Resident 1 every shift after a COC could result in missed signs of aggression, altercation with other residents, and compromised resident safety. The DON acknowledged and stated the facility failed to identify, document, and monitor Resident 1's change of condition. During a review of the facility's policy and procedure (PnP) titled, Notification of Changes, last reviewed on 12/10/2025, the PnP indicated the facility shall immediately. consult with the resident's physician and notify.the resident representative(s) when there is. a significant change in the resident's physical, mental, or psychosocial status. The PnP indicated the SBAR (Situation-Background-Assessment-Recommendation) charting form is designed to make the charting process more efficient and serves as the actual documentation of a resident change in condition. The PnP indicated the licensed nurse acting within his/her scope of practice will collect patient data and complete the Situation, Background, Appearance, and Request sections that are applicable. During a review of the facility's PnP titled, Documentation Policy, last reviewed on 12/10/2025, the PnP indicated it is the policy of this facility to document relevant findings in the clinical record. The PNP indicated 72-hour charting shall be initiated at the following times. a significant change in physical, mental, or psychosocial status of the resident (progression, regression, new problems).

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to:1. Develop a care plan to address Resident 1's need for maximum assistance from staff for eating as indicated in Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/11/1025. 2. Implement the care plan regarding Resident 1's risk of constipation (when your bowel movements become less frequent and stools become difficult to pass).3. Develop a care plan to address Resident 1's refusal of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) glargine (medication that is a long-acting type of insulin that works slowly, over about 24 hours). These failures had the potential to result in a delay in the delivery of necessary care and services and had the potential to result in weight loss, constipation and hyperglycemia (elevated blood sugar).a. During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses that included other sequelae of nontraumatic intracerebral hemorrhage (long-term, lasting complications or physical/cognitive deficits remaining after the initial brain bleed has stabilized), diabetes mellitus, (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized weakness. The admission record indicated Family Member 1 (FM 1) and FM 2 were Resident 1's power of attorney (POA- is a legal document that authorizes a chosen person to act on behalf of another person regarding financial, legal, or medical affairs. It is used to ensure decisions can be made if the principal is unable to do so due to illness, incapacity, or absence).During a review of Resident 1's Order Summary Report, dated 11/4/2025, the Order Summary Report indicated Resident 1 was on a Controlled Carbohydrate Diet (diet regulates the timing and amount of carbohydrate intake throughout the day to prevent blood sugar spikes), with no added salt, regular texture with thin liquids consistency.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/6/2025, the H&P indicated Resident 1 had glaucoma (an eye condition that damages the optic nerve. This damage can lead to vision loss or blindness) with poor vision. The H&P indicated Resident 1 was alert and oriented to person, place and time.During a review of Resident 1's Care Plan, dated 11/10/2025, the Care Plan for activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) indicated Resident 1 required assistance with eating. The Care Plan indicated no intervention of what kind of assistance would be provided to Resident 1.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximum assistance from staff for all ADL's. The MDS indicated Resident 1 was frequently incontinent (unable to control) of bowel and bladder functions.During an interview on 3/17/2026, at 9:39 a.m., with FM 1, FM 1 stated Resident 1 was visually impaired (having restricted vision, or no usable vision; partially or completely blind), and the facility would deliver her (Resident 1) food tray, inform her (Resident 1) of what was on the tray and leave her (Resident 1) to eat on her (Resident 1) own. FM 1 stated the food that she (Resident 1) was informed to be on the tray were not on her (Resident 1) the tray.During a concurrent interview and record review on 3/20/2026, at 10:51 a.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 1's admission record, and MDS, dated [DATE], were reviewed. LVN 1 stated Resident 1 had a diagnosis of glaucoma and the MDS indicated Resident 1 required maximum assistance with eating.During an interview on 3/20/2026, at 1:03 p.m., with the MDS Nurse (MDSN), Resident 1's MDS, dated [DATE], and Care Plan for Glaucoma, dated 11/4/2025 and the Care Plan on the ADL, dated 11/10/2025, were reviewed. The Care Plan titled glaucoma due to impaired visual functioning indicated an intervention to encourage independence with ADLs, and assist as needed. The MDSN stated Resident 1 had impaired vision and required maximum assistance from staff for eating. The MDSN stated the Care Plan for ADL's indicated no intervention of what kind of assistance would be provided to Resident 1 while eating. The MDSN stated the Care Plan should have indicated that Resident 1 required maximum assistance with eating from staff. The MDSN stated the interventions included in Resident 1's Care Plan are important to plan the type of care that will be provided to Resident 1.During an interview on 3/202/2026, at 1:56 p.m., with the Director of Nursing (DON), the DON stated the care plan for glaucoma and ADL's should have indicated an intervention that Resident 1 required maximum assistance for eating from staff. The DON stated the care plan for Resident 1 should be individualized to provide specific care and assistance to Resident 1 to prevent potential weight loss.b. During a review of Resident 1's Order Summary Report, dated 11/4/2025, the following orders indicated to administer the following medications as ordered;1. Bisacodyl (medication used to treat constipation) rectal suppository (a medication designed to be inserted into the anus) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), insert one suppository rectally every 12 hours as needed for constipation.2. Milk of magnesia (MOM- medication that relieves constipation in 30 minutes to 6 hours and treats heartburn [a painful burning sensation in the chest or throat caused by stomach acid flowing back into the esophagus]/indigestion [discomfort after eating]) suspension (a liquid mixture where solid drug particles are dispersed throughout a liquid but not dissolved in it) 400 mg/5 milliliter (ml-unit of measurement), give 30 ml by mouth every 24 hours as needed for constipation if no bowel movement in three days.During a review of Resident 1's Point of Care (POC)-Response History for Bowel Movements, dated 11/4/2025, to 11/17/2025, the POC-Response History for Bowel Movements indicated Resident 1 did not have bowel movements on 11/7/2025, 11/8/2025, 11/9/2025, 11/11/2025 and 11/15/2025.During a review of Resident 1's Care Plan, dated 11/4/2025, the Care Plan titled ''at risk for constipation'' indicated an intervention to administer medications as ordered, monitor for the effectiveness/side effects (unwanted symptoms caused by medical treatment) and notify the physician as needed.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2025, the MAR indicated the nurses did not administer bisacodyl and MOM to Resident 1 on 11/7/2025, 11/8/2025, 11/9/2025, 11/11/2025 and 11/15/2025.During a concurrent interview and record review on 3/20/2026, at 10:51 a.m. with LVN 1, Resident 1's Care Plan for constipation, dated 11/4/2025, POC-Response History for Bowel Movements, dated 11/4/2025 to 11/17/2025, and MAR, dated 11/2025, were reviewed. LVN 1 stated Resident 1 did not have bowel movements on 11/7/2025, 11/8/2025, 11/9/2025, 11/11/2025 and 11/15/2025. LVN 1 stated the nurses did not administer bisacodyl to Resident 1 on 11/7/2025, 11/8/2025, 11/9/2025, 11/11/2025 and 11/15/2025. LVN 1 stated the nurses did not administer MOM to Resident 1 on 11/9/2025 (third day of having no bowel movement). LVN 1 stated the nurses should have administered the bisacodyl as ordered by the physician and as indicated in Resident 1's Care Plan to prevent constipation. LVN 1 stated the nurses should have administered the MOM on 11/9/2025, as ordered by the physician and as indicated in Resident 1's Care Plan to prevent constipation and impaction. LVN 1 stated Resident 1's care plan was not followed. LVN 1 stated the Care Plan is developed and implemented to ensure each residents' problems have interventions. LVN 1 stated if care plan was not implemented Resident 1 could have pain, nausea and vomiting from constipation.During a concurrent interview and record review on 3/20/2026, at 1:03 p.m., with the MDSN, Resident 1's Care Plan, dated 11/4/2025, was reviewed. The MDSN stated Resident 1's Care Plan for at risk for constipation indicated an intervention to administer medication as ordered.During an interview on 3/20/2026, at 1:56 p.m., with the DON, the DON stated the nurses should have followed the care plan to prevent constipation by administering the medication ordered by the physician. The DON stated if medication was not administered and the care plan not followed, Resident 1 could have developed further constipation that could potentially cause abdominal discomfort and abdominal pain.c. During a review of Resident 1's Order Summary Report, dated 11/4/2025, the Order Summary Report indicated, an order for insulin glargine subcutaneous (under the skin) solution 100 units per ml, inject 20 units subcutaneously one time a day for DM, rotate injection sites, hold (temporarily stop) for blood sugar less than 100 mg per deciliter (dl-unit of measurement).During a review of Resident 1's MAR, dated 11/2025, the MAR indicated on 11/15/2025, and 11/16/2025, Resident 1 refused glargine.During a concurrent interview, and record review on 3/20/2026, at 10:51 a.m. with LVN 1, Resident 1's, Order Summary Report, dated 11/4/2025, and MAR, dated 11/2025, were reviewed. LVN 1 stated the MAR dated 11/15/2025, and 11/16/2025, indicated at 9 a.m., Resident 1 refused glargine. LVN 1 stated a care plan should be developed regarding Resident 1's refusal of glargine.During a concurrent interview, and record review on 3/20/2026, at 1:03 p.m., with the MDSN, Resident 1's Care Plans were reviewed. The MDSN stated there was no care plan developed for Resident 1's refusal of insulin glargine.During an interview on 3/20/2026, at 1:56 p.m., with the DON, the DON stated there was no care plan developed for Resident 1's refusal of insulin glargine. The DON stated Resident 1's refusal of insulin should have been care planned to prevent further risk for hyperglycemia.During a review of facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 1/2026, was reviewed. The P&P indicated, The facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.1. The comprehensive care plan describes: a. The services that are to be furnished are to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. b. Any services that are not provided due to the resident's exercise of right to refuse treatment.2. Care plans must be person-centered and reflect the residents' goals for admission and desired outcomes, interventions that reflect the resident's cultural preferences, values, and practices.5. Facility staff shall work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices, and goals during their stay at the facility.6. The facility establishes, documents, and implements the care and services provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.Refusal of Treatment1. A resident may choose to refuse services or treatments that staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being or to keep the resident safe.2. When a resident's choice to decline care or treatment poses a risk to the resident's health or safety, the comprehensive care plan must. a. Identify the care or service being declined. b. The risk the decline poses to the resident. c. Efforts by the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) to educate the resident and the representative, as appropriate; and d. Attempts to find alternative means to address the identified risk.

Based on observation, interview and record review, the facility failed to: 1. Ensure the resident who was repeatedly attempting to get out of bed unassisted, did not fall out of bed and sustained injury for one of four sampled residents (Resident 1). The facility failed to: 1a. Ensure Licensed Vocational Nurse (LVN) 3 responded to Resident 1's family provided caregiver (Companion) 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1b. Ensure LVN 3 notified Registered Nurse (RN) 2 regarding Companion 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1c. Ensure Resident 1's bed's pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was plugged-in and functioning when Resident 1 was attempting to get out of bed unassisted on 8/26/2025. 1d. Ensure LVN 3 and Certified Nursing Assistant (CNA) 3 did not move Resident 1 back to bed without a registered nurse (RN) assessing the resident for safe transfer to bed after Resident 1's fall on 8/26/2025. These deficient practices resulted in Resident 1 having an unwitnessed fall on 8/26/2025 at 9:21 p.m. and was transferred to the General Acute Care Hospital (GACH) for possible fracture (broken bone). At the GACH, Resident 1 was diagnosed with a right angulated (bent), displaced (the bone cracks or breaks and does not retain proper alignment) oblique (slanting or diagonal) fracture of the distal (away from the center of the body) humerus (a severe elbow fracture where the broken bone fragments have shifted out of alignment and are angled) requiring surgery with the placement of metallic hardware (device implanted into the body to provide support), blunt head trauma (injury caused by a sudden impact), and mild left frontal scalp (the skin covering the head) and periorbital (around the eye) soft tissue swelling / hematoma (bruise). 2. Ensure Resident 2's pad alarm was plugged in and functioning. This deficient practice had the potential to result in falls with injury to Resident 2. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric (a hip fracture that occurs between the greater [large bony prominence on the outer side of the femur {thighbone} and lesser trochanters {smaller projection on the inner side of the femur}, which are bony protrusions {sticks out} on the upper part of the femur) fracture of the left femur, pain, bacterial pneumonia (an infection/inflammation in the lungs), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life) of unspecified severity, age-related osteoporosis (weak and brittle bones), muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/26/2025, the MDS indicated Resident 1 was able to understand others and able to make herself understood. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene and upper body dressing; and substantial/maximal assistance (helper does more than half the effort) with bathing, lower body dressing, toileting, rolling left to right, moving from sitting to lying, and moving lying to sitting on the side of the bed. During a review of Resident 1's Fall Risk Evaluation (FRE), dated 8/19/2025, the FRE indicated the resident had a history of one to two falls in the past three months, had balance problems while standing / walking, was regularly incontinent (having no or insufficient voluntary control over urination or defecation [the discharge of feces from the body]) of unspecified bladder or bowel, and was a high risk for falls. During a review of Resident 1's care plan (CP) titled Risk for fall: Resident is at risk for recurrent falls and spontaneous injuries related to history of falling, muscle weakness, left intertrochanteric fracture due to fall., initiated 8/20/2025, the CP indicated a goal for the resident was to minimize risk of injury from falls. The CP interventions included anticipating and meeting the resident's needs, promoting a safe environment, and that the resident needs activities that minimize the potential for falls while providing diversion and distraction. During a review of Resident 1's CP titled Bed Alarm: Resident is at risk for recurrent fall and spontaneous injury due to impaired safety awareness, cognitive impairment and getting out of bed unassisted, history of fall and poor follow through, initiated 8/19/2025, the CP indicated a goal for Resident 1 was to maintain optimal safety by ensuring the bed alarm is used consistently, and that staff respond appropriately to prevent falls. The CP indicated interventions included to place a functioning bed alarm on Resident 1's bed, ensure the bed alarm was securely attached, and training staff how to properly use the bed alarm. During a review of Resident 1's Physician Orders, the Physician Orders indicated the following: -Place a pad alarm in bed, monitor for placement and function every shift, dated 8/19/2025. - Transfer Resident 1 out via 911 (phone number used to contact the emergency services) due to possible fracture status post fall, dated 8/26/2025. During a review of Resident 1's Post Fall Evaluation / Interdisciplinary Team (IDT- a group of healthcare professionals with various areas of expertise who work together toward the goals of their residents), dated 8/27/2025, the Post Fall Evaluation/IDT document indicated Resident 1 had a previous fall on 8/12/2025, prior to admission to the facility. The Post Fall Evaluation /IDT document indicated on 8/26/2025 at 9:20 p.m. the family-provided companion (Companion 1) exited Resident 1's room to make a phone call. The Post Fall Evaluation/IDT indicated at 9:21 p.m. on 8/26/2025, Resident 1 had an unwitnessed fall inside the resident's room that resulted in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status (did not specify the location). During a review of Family Member (FM) 1's provided Incident Statement - Caregiver Report, dated 8/26/2025, the report indicated on the evening of 8/26/2025 Companion 1 notified facility staff multiple times (did not indicate the exact times) that Resident 1 was repeatedly attempting to get out of bed without assistance. The report indicated Companion 1 called the assigned nurse who confirmed assistance would be sent, but no staff arrived. The report indicated Companion 1 exited the room to call Companion 1's Home Health Care Agency (HHCA) Supervisor (on 8/26/2025) then heard a loud noise from Resident 1's room and discovered Resident 1 had fallen from the bed. During a review of Resident 1's GACH 1's Records, dated 11/18/2025, the GACH 1 Records indicated Resident 1 was admitted to the emergency department on 8/26/2025 at approximately 11 p.m. after a fall with blunt head trauma. Resident 1's diagnostic radiology (x-ray - a medical imaging test that produces images of the structures inside the body) indicated the resident sustained a right angulated, displaced oblique fracture of the distal humerus requiring surgery with the placement of metallic hardware. Resident 1's Computed Tomography (CT - imaging procedure that uses x-rays and digital computer technology to create detailed pictures of the body) indicated the resident sustained a mild left frontal scalp and periorbital soft tissue swelling / hematoma. During an interview on 11/5/2025 at 3:15 p.m. with CNA 3, CNA 3 stated he (CNA 3) was assigned to care for Resident 1 on 8/26/2025 for the evening shift (3 to 11 p.m.) and Resident 1 had a family-provided caregiver at bedside. CNA 3 stated the family-provided caregivers do not provide hands-on care in the facility because the caregivers say it is not their job. CNA 3 stated he (CNA 3) did not know Resident 1 was trying to get out of bed unassisted on 8/26/2025. CNA 3 stated sometime after his (CNA 3) break, the caregiver reported that Resident 1 had a fall and CNA 3 notified LVN 3 and the RN supervisor. CNA 3 stated Resident 1 was found lying face down near the window and there was no bed pad alarm sounding. CNA 3 stated he (CNA 3) assisted with placing Resident 1 back in bed after the fall. CNA 3 stated Resident 1 complained of arm pain when Resident 1 was moved to the bed. During an interview on 11/6/2025 at 1:02 p.m. with LVN 3, LVN 3 stated he (LVN 3) was assigned to care for Resident 1 on 8/26/2025 during the evening shift. LVN 3 stated prior to admission, Resident 1 had a history of getting up unassisted resulting in a fall with injury. LVN 3 stated Resident 1's family provided Companion 1 to sit with and verbally re-direct the resident and there was a physician's order for a pad (bed) alarm to prevent the resident from getting up unassisted. LVN 3 stated Resident 1 was a little more confused and less redirectable on 8/26/2025. LVN 3 stated at approximately 9 p.m., during Resident 1's medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), he (LVN 3) observed Resident 1 was trying to get out of bed. LVN 3 stated Companion 1 told him (LVN 3) that Resident 1 kept trying to get up unassisted. LVN 3 stated he (LVN 3) told Companion 1 to watch Resident 1 and keep the resident safe. LVN 3 stated that he (LVN 3) also told Companion 1 that he (LVN 3) would provide help to redirect the resident so the resident would not fall. LVN 3 stated he (LVN 3) did not check whether Resident 1's pad alarm was functional during the medication pass but should have because Resident 1 tried to get up unassisted. LVN 3 stated he (LVN 3) then exited Resident 1's room and continued the medication pass for other residents because there was a time deadline to complete the medication pass. LVN 3 stated he (LVN 3) did not notify any staff to assist Companion 1 or that Resident 1 was repeatedly trying to get out of bed unassisted. LVN 3 stated he (LVN 3) should have immediately told the RN on duty that Resident 1 was more agitated and was trying to get up unassisted, but he (LVN 3) did not. LVN 3 stated approximately ten minutes later, when he (LVN 3) was in the hallway, he (LVN 3) observed Companion 1 exited Resident 1's room with a phone and stated Companion 1 was calling Companion 1's HHCA Supervisor because Resident 1 was trying to get up. LVN 3 stated he (LVN 3) did not go to Resident 1's room. LVN 3 stated he (LVN 3) then observed Companion 1 entered and exited Resident 1's room and stated to him (LVN 3) that Resident 1 had fallen. LVN 3 stated he (LVN 3) entered Resident 1's room and observed Resident 1 was on the floor and the bed pad alarm was disconnected (unplugged) and not alarming. LVN 3 stated if the bed pad alarm had been connected and functioning, it may have stopped Resident 1 from getting up and alerted staff to immediately respond to Resident 1's attempt to get out of bed. LVN 3 stated Resident 1's fall was preventable to a certain extent because he (LVN 3) should have checked the pad alarm during the medication pass, immediately notified the assigned CNA (CNA 3) to assist Companion 1, and immediately notified the RN on duty to assess Resident 1. LVN 3 stated that preventing resident falls was the responsibility of facility staff, not family caregivers. During an interview on 11/6/2025 at 3:46 p.m. with HHCA Administrator (Adm), the HHCA Adm stated Resident 1's family hired the HHCA to provide companions to Resident 1. The HHCA Adm stated companions provide conversation with the resident, oversee how the residents are doing and make sure they are getting therapy, and are not medically trained. During an interview on 11/7/2025 at 11 a.m. with the HHCA Supervisor, the HHCA Supervisor stated she (HHCA Supervisor) was Companion 1's Supervisor on 8/26/2025. The HHCA Supervisor stated Companion 1 called her (HHCA Supervisor) three times on 8/26/2025 to notify that Resident 1 was agitated, restless, attempting to get out of bed, and that the facility staff were notified but they were not helping. During an interview on 11/7/2025 at 2 p.m. with RN 2, RN 2 stated when a nurse is made aware that a resident is confused and attempting to get out of bed, the nurse should act right away. RN 2 stated on 8/26/2025 when LVN 3 observed, and was notified by Companion, that Resident 1 was repeatedly trying to get out of bed, LVN 3 should have checked the bed alarm and notified RN 2. RN 2 stated she (RN 2) was not notified that Resident 1 was attempting to get out of bed. During a follow-up interview on 11/7/2025 at 3:11 p.m. with RN 2, RN 2 stated that when a resident has a family-provided companion while in the facility, it is still the facility's responsibility to take care of the residents and provide fall interventions. RN 2 stated the pad alarm alerts staff when the resident moves and also reminds the confused resident to call for help. RN 2 stated a pad alarm should be on when the resident is in bed and should be checked when staff enter the room. RN 2 stated when LVN 3 was aware Resident 1 was attempting to get out of bed, LVN 3 should have checked the pad alarm, but the pad alarm was not sounding when RN 2 entered Resident 1's room after the fall. RN 2 stated when LVN 3 did not check the bed pad alarm, he (LVN 3) did not notify her (RN 2) that Resident 1 was confused and attempted to get out of bed and did not provide further assistance to Companion 1. RN 2 stated Resident 1 had a preventable fall that resulted in injury. RN 2 stated that the facility's procedure for a resident who has experienced a fall is to keep the resident in the same location and position until the registered nurse evaluates the situation and determines it is safe to move the resident. RN 2 stated, on 8/26/2025, she (RN 2) entered Resident 1's room and was upset that Resident 1 was placed in bed without a registered nurse assessment. RN 2 stated when she (RN 2) assessed Resident 1 in bed, Resident 1 could not move the right arm and had swelling on the left side of the head. RN 2 stated that she (RN 2) could not rule out the possibility that moving Resident 1 back to bed before a registered nurse assessment might have contributed to further injury to Resident 1. During an interview on 11/7/2025, at 4 p.m., LVN 3 stated that the facility's procedure following a resident fall is to refrain from moving the resident until a registered nurse conducts an assessment. LVN 3 stated the registered nurses (RN) assessment determines if there are other injuries, determines if it is safe to transfer a resident after a fall, and the RN assures safety of the resident during the transfer. LVN 3 stated on 8/26/2025, he (LVN 3) and Companion 1 entered Resident 1's room and found Resident 1 on the floor, face down next to the window. LVN 3 stated he (LVN 3), CNA 3, and another CNA (unidentified) moved Resident 1 from the floor to the bed before RN 2 entered the room and assessed Resident 1. LVN 3 stated RN 2 was upset that LVN 3 moved Resident 1 before RN 2 assessed Resident 1. LVN 3 stated LVN 3 and the CNAs should not have placed Resident 1 in bed without an RN assessment, but they did. During an interview on 11/12/2025 at 8:52 a.m. with FM 1, FM 1 stated, on 8/26/2025, Resident 1 had a fall in the facility resulting in a broken right arm that required surgery. FM 1 stated the physical trauma has left Resident 1 unable to hold the right wrist upright. FM 1 stated Companion 1 was hired to provide companionship for Resident 1 and not to provide care to the resident. During a concurrent interview and record review on 11/12/2025 at 9:23 a.m. with the Director of Nursing (DON), the facility Policies and Procedures (P&Ps) regarding fall prevention, accident / hazard prevention, resident supervision, and licensed nurse's job descriptions were reviewed. The DON stated a family-provided companion is treated more like a visitor in the facility and the facility does not give instructions for resident care to a companion. The DON stated that when a resident has a companion the facility is still responsible for providing all the care, supervision, and interventions to prevent falls. The DON stated when a confused resident is reported or observed repeatedly attempting to get out of bed unassisted, the facility process is to re-orient the resident, the LVN can observe the resident, and then the LVN reports to the RN to further assess the resident. The DON stated when Companion 1 stated to LVN 3 that Resident 1 was getting out of bed, LVN 3 was responsible for providing an intervention. The DON stated LVN 3 should not have just relied on Companion 1 to keep the resident safe. The DON further stated when LVN 3 observed Companion 1 in the hallway on the phone, LVN 3 should have immediately gone to Resident 1, but LVN 3 did not. The DON then stated that the pad alarm prevents falls by alerting staff when a resident shifts weight in the bed. The DON stated the pad alarm can also irritate the resident which may stop them from getting up. The DON stated Resident 1 was a high risk for falls and had a physician's order for a pad alarm. The DON stated the pad alarm should have been turned on and functioning while the resident was in bed even when the companion was at bedside. The DON stated LVN 3, CNA 3, and RN 2 stated the alarm was not functioning at the time of Resident 1's fall. The DON further stated that CNA 3 stated on 8/26/2025 that he (CNA 3) left the bed pad alarm off before the fall and after providing care to Resident 1. The DON stated as a result the bed pad alarm was not functioning when Companion 1 left Resident 1's room. The DON stated the facility P&Ps were not followed when Resident 1's bed pad alarm was not functioning and when LVN 3 did not provide interventions to prevent Resident 1 from falling. The DON stated Resident 1 had an avoidable fall that was the direct cause of Resident 1's injuries. The DON then stated that when a resident falls the RN immediately assesses the resident and the RN decides what interventions are necessary and if the resident can be safely transferred to the bed. The DON stated for example, if there is a possible neck injury, the resident should not be moved. The DON stated it was not within LVN 3's job description and scope of practice to assess Resident 1 and make the decision to move Resident 1 to the bed. The DON stated when LVN 3 did not follow their job description there was the potential to worsen Resident 1's injuries. During a review of the facility P&P titled, Fall Management Program, last reviewed 12/3/2024, the P&P indicated, The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices (external devices that are designed, made, or adapted to assist a person to perform a particular task) to each resident to prevent avoidable accidents. DEFINITIONS. Accident: Any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable Accident: An accident which occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Position change alarms: Alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads. Supervision/Adequate Supervision: An intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident During a review of the facility P&P titled, Free of Accident Hazards / Supervision / Devices, last reviewed 12/3/2024, the P&P indicated, The facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. GUIDELINES . 2. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A SYSTEMS APPROACH . 1. Processes in a facility's interdisciplinary systematic approach may include:a. Identification of hazards, including inadequate supervision, and a resident's risks of potentially avoidable accidents in the resident environment;b. Evaluation and analysis of hazards and risks;c. Implementation of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment; andd. Monitoring for effectiveness and modification of interventions when necessary.5. Effective Accident Management identifies environmental hazards, the resident's risk for an avoidable accident, and evaluates the resident's need for supervision. 6. Identifying and addressing risks, including the potential for accidents, includes consideration of the environment, the resident's risk factors, and the need for supervision, care, and assistive devices. Implementation of Interventions .Implementation refers to using specific interventions to try to reduce a resident's risks from hazards in the environment . 1. The process includes communicating the interventions to all relevant staff, assigning responsibility, . documenting interventions, . and ensuring that the interventions are put into action. Supervision . 3. Devices such as position change alarms may help to monitor a resident's movement temporarily, but do not eliminate the need for adequate supervision. Adequate supervision to prevent accidents is enhanced when the facility: l. Accurately assesses a resident and/or the resident environment to determine whether supervision to avoid an accident is necessary; and/or 2. Determines that supervision of the resident was necessary and provides supervision based on the individual resident's assessed needs and the risks identified in the environment. 3. Some factors that may result in resident falls include, but are not limited to: . g. Acute change in condition such as fever, infection, delirium; . h: Medication side effects: . m. functional impairments (difficulty rising from a chair, getting on or off toilet, etc.): . o. Cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decision): . q. Pain; and r. Incontinence. During a review of the facility provided RN Job Description, dated 10/2016, The Job Description indicated the RN Assesses and evaluates the health status of resident / patient and provides care and treatment in accordance with physician orders and standards of practice. Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Supervises LVNs and nursing assistants During a review of the facility provided LVN Job Description, dated 10/2016, The Job Description indicated, The Licensed Vocational Nurse (LVN) is responsible for managing the residents' care plans and supervising resident care activities. Both care management and supervisory responsibilities must be executed in accordance with state and federal regulations and facility policies and procedures. Roles and Responsibilities: . Make daily resident rounds to observe and evaluate the resident's physical and emotional status. Notify attending physician, family, and members of interdisciplinary team when . there is a change in condition. Participate in procedures for reporting hazardous conditions. b. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included traumatic hemorrhage (bleeding caused from sudden injury) of right cerebrum (a part of the brain) without loss of consciousness, Colles' fracture of the right radius (break in the larger bone in the forearm near the wrist, caused by a fall on an outstretched hand), zygomatic (cheekbone) fracture, cognitive communication deficit (communication difficulties caused by underlying impairments such as attention, memory, and problem-solving), and history of falls. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand others and able to make themselves understood. The MDS further indicated the resident required substantial/maximal assistance with upper and lower body dressing, toileting, with bathing, moving from sitting to standing, and chair to bed transfers. The MDS indicated the resident used a bed alarm to monitor resident movement and alert staff when movement was detected. During a review of Resident 2's FRE, dated 10/24/2025, the FRE indicated the resident had a history of one to two falls in the past three months, had balance problems while standing / walking, was regularly incontinent, and was a high risk for falls. During a review of Resident 2's CP titled Bed Alarm: (Resident 2) is at risk for fall and requires the use of a bed alarm due to impaired safety awareness, cognitive impairment and getting out of bed unassisted., initiated 10/25/2025, the CP indicated a goal that the resident would maintain optimal safety by ensuring the bed alarm is used consistently, and that staff respond appropriately to prevent falls. The care plan indicated interventions that included placing a functioning bed alarm on the resident's bed, ensuring it is securely attached and training staff how to properly use the bed alarm. During a review of Resident 2's Physician Orders, the Physician Orders indicated an order to place a pad alarm in bed, monitor for placement and function every shift, dated 10/24/2025. During a concurrent observation and interview on 11/5/2025 at 9:35 a.m., observed Resident 2 lying in bed. Observed the resident with the right arm in a bandage. Resident 2 stated Resident 2 had a fall before coming to the facility. Observe hanging from the right side of the bed, a bed alarm control unit with the cord dangling toward the floor and not connected to the bed alarm pad sensor. Resident 2 then stated Resident 2 had pain. During an observation on 11/5/2025 at 9:37 a.m., observed LVN 4 entered Resident 2's room, stated to Resident 2 that LVN 4 would provide help with the resident's pain, and then exited the room. Observed the pad alarm remained disconnected. During a concurrent observation and interview on 11/5/2025 at 9:39 a.m., LVN 4 and LVN 5 entered Resident 2's room. Resident 2 stated Resident 2 felt a little confused and wanted to speak with FM 2. LVN 4 placed a call to FM 2. LVN 5 then walked to the right side of Resident 2's bed and stated the pad alarm was disconnected. LVN 5 stated the pad alarm should always be connected, and it was not. Observed LVN 5 connected the pad sensor to the cord and heard a loud beep. During a follow-up interview and record review on 11/5/2025 at 9:41 a.m. with LVN 5, LVN 5 reviewed Resident 2's physician orders. LVN 5 stated Resident 2 had a recent history of falls and was a high risk for falls while in the facility. LVN 5 stated Resident 2 had a physician's order for a pad alarm. LVN 5 stated when Resident 2's pad sensor was not connected, the pad alarm was not functioning. LVN 5 stated Resident 2's pad alarm should be checked for functionality every time a staff member enters the room. LVN 5 stated LVN 5 had been in Resident 2's room a couple of times that morning and LVN 5 did not check Resident 2's pad alarm. LVN 5 stated it was LVN 5's mistake for not checking Resident 2's pad alarm. During a concurrent interview and record review on 11/13/2025 at 11:11 a.m. with the DON, the DON reviewed the facility P&Ps regarding fall prevention and accident / hazard prevention. The DON stated Resident 2 is at risk for falls and rounds are completed by staff that include checking the functionality of the pad alarm. The DON stated every time staff enter a resident's room they check the environment for safety. The DON stated a staff member may not know a resident has a pad alarm, so they should assess the environment and check the functionality of the pad alarm when they see it. The DON stated Resident 2's plan of care was not implemented when the pad alarm was not plugged in potentially resulting in an accidental fall resulting in injury to the resident. During a review of the facility P&P titled, Fall Management Program, last reviewed 12/3/2024, The P&P indicated, The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible.The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. DEFINITIONS. Accident: Any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Avoidable Accident: An accident which occurred because the facility failed to:. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Position change alarms: Alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads . During a review of the facility P&P titled, Free of Accident Hazards / Supervision / Devices, last reviewed 12/3/2024, the P&P indicated, The facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision and assistive devices for eachresident to prevent avoidable accidents. GUIDELINES.2. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents.A SYSTEMS APPROACH.1. Processes in a facility's interdisciplinary systematic approach may include: . c. Implementation of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment; . Implementation of Interventions.Implementation refers to using specific interventions to try to reduce a resident's risks from hazards in the environment. 1. The process includes communicating the interventions to all relevant staff, assigning responsibility, . documenting interventions, . and ensuring that the interventions are put into action.

Based on interview and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) physician, when on [DATE], Resident 1's blood pressure (BP - the measurement of the pressure or force of blood inside your arteries [muscular walled tubes that carries blood from the heart to tissues and organs in the body], normal range less than ,d+[DATE] millimeters of mercury [mmHg - unit of pressure measure]) dropped from ,d+[DATE] mmHg on [DATE] at 7:03 p.m. to ,d+[DATE] mmHg on [DATE] at 1:00 a.m. As a result, Resident 1's BP continued to drop on [DATE] with observations of coffee ground discharge (appears dark brown in color, fluid that comes out of the body) upon tracheal suctioning (a procedure that uses a suction catheter [a flexible, hollow tube used to remove fluids or secretions from a resident's airway] to remove mucus [a slimy, sticky, gelatinous substance produced normally in the body] and other secretions from the airway through a tracheostomy tube [trach tube - a curved tube made of metal or plastic that is inserted into the trachea or windpipe through a surgically created opening in the neck]) and blood in the stool (material in a bowel movement). On [DATE] at 10:20 a.m., Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation and treatment. Resident 1 died in the GACH on [DATE] (time not indicated). On [DATE] at 5:13 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to notify Resident 1's physician when Resident 1 had a change in condition (COC - when there is a sudden and significant change from a resident's health) on [DATE] at 1:00 a.m. and not determining if there was a need to alter treatment significantly by starting a new form of treatment to address the BP drop. On [DATE] at 4:26 p.m., the ADM submitted an IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On [DATE] at 10:36 a.m., while onsite at the facility, after verifying and confirming the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following summarized actions: 1. The DON will re-educate each licensed nurse starting on [DATE], before the start of the shift. This re-education will continue daily until all nurses understand how to complete change-in-condition documentation for blood pressure readings outside the resident's usual low parameters (specific measurements or factors used). 2. On [DATE], the Assistant DON (ADON) trained the Registered Nurse (RN) Supervisor assigned to Resident 1 on [DATE]. This training covered the facility's policies and procedures regarding changes in a resident's condition. The ADON emphasized the importance of promptly recognizing these changes, immediately notifying the resident's physician, providing ongoing monitoring and appropriate nursing interventions, and accurately documenting all actions taken. The training also reinforced the necessity of communicating with both the physician and the resident representative throughout the process. 3. On [DATE], before returning to work, Licensed Vocational Nurse 1 (LVN 1) who cared for Resident 1 on [DATE] will receive re-education on the facility's policies and procedures regarding changes in a resident's condition. This re-education will emphasize the importance of promptly recognizing these changes, immediately notifying the resident's physician, providing ongoing monitoring, and implementing appropriate nursing interventions, and accurately documenting all actions taken, including follow-up vital signs. The training will also reinforce the necessity of communicating with both the physician and the resident representative throughout the process. 4. On [DATE], the Director of Staff Development (DSD)/designee began training Certified Nursing Assistants (CNAs) on how to use the stop and watch form. This form allows CNAs to quickly alert licensed nurses (LVNs/RNs) about potential changes in a resident's condition. After completing the form, CNAs will submit it to a licensed nurse, who will then assess the resident to verify the potential change and report their findings to the supervising RN. 5. On [DATE], the ADON/designee began immediately training all available licensed staff (RN Supervisors and LVNs) on the facility's policies and procedures regarding changes in a resident's condition. This training included when to notify the physician and resident representative, such as when there's a significant change in the resident's physical, mental, or psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) status, a need to alter treatment significantly, or a decision to transfer or discharge the resident. 6. The training emphasized providing detailed information to the physician, especially for chest pain, loss of consciousness, or signs of a heart attack or stroke. Staff also received instruction on proper documentation, monitoring procedures, and when to contact the on-call physician. Furthermore, the facility's policy and procedure on change of condition will be added to the new hire orientation materials (effective [DATE]) and the annual competency program. Any remaining licensed nurses will complete this training before their next shift. 7. All residents experiencing significant changes in their condition, such as changes in baseline vital signs (clinical measurements, specifically pulse rate [PR- number of times the heart beats per minute], temperature [a measure of the degree of hotness or coldness of the body], respiration rate [the number of breaths a person takes per minute] and blood pressure, that indicate the state of a resident's essential body functions), respiratory (relating to breathing) conditions, or cardiac (relating to the heart) function, are potentially affected and may require transfer to the GACH. 8. On [DATE], the DON conducted an audit of the facility's 143 residents to assess for changes in their condition. The audit revealed that eight residents were currently being monitored for changes related to cardiovascular (related to or involving the heart and blood vessels) issues or conditions that could require 911 (telephone number to call for emergency services) intervention. 9. Starting on [DATE], the RN Supervisor for each shift will closely monitor the eight residents identified with changes in condition for at least 72 hours, or until their conditions stabilize, focusing on addressing both actual and potential declines in their physical, mental, and psychosocial well-being. To ensure the best outcomes, the RN Supervisors will collaborate closely with each resident's primary care physician to implement care and treatment interventions, ensuring that care aligns with each resident's individual goals and preferences, and continuously monitor the effectiveness of physician-guided interventions, making revisions as needed. In addition, the DON and RN Supervisors have already reviewed and revised the care plans of these eight residents to address their specific needs and ensure they receive the necessary care and services to maintain the best possible health outcomes. 10. Starting on [DATE], the Interdisciplinary Team (a group of professionals from different field or disciplines who work together collaboratively to achieve a common goal to manage and treat resident's needs) will conduct daily reviews of the eight residents with cardiovascular-related changes in condition or those requiring 911 intervention. These reviews will continue until each resident's condition is resolved, ensuring prompt notifications, appropriate interventions, effective care planning, and timely action to minimize further decline. Following the completion of change-in-condition education on [DATE], the DON will validate the competencies of licensed nurses (RN Supervisors and LVNs) through verbalization. This will confirm their understanding of what constitutes a change in condition, how to communicate effectively with the physician, how to complete assessments and notifications, how to contact the on-call physician, how to communicate pertinent information, how to effectively convey assessment findings (including vital signs, level of consciousness, and relevant laboratory results), how to make decisions about resident transfers, and how to notify the resident and responsible party. 11. Effective [DATE], the facility's policy and procedure on change of condition will be included in the new hire orientation checklist and incorporated into the annual competency program for all staff. 12. The DON and her designee will monitor staff to ensure they are aware of and educated on changes in condition, emphasizing immediate assessment, physician notification, and continuous monitoring until the resident's condition is resolved or they are transferred to the hospital. Additionally, the Weekend RN Supervisor will confirm licensed staff's knowledge of residents being monitored for changes in condition and when to initiate a change-in-condition evaluation and report during the clinical report at the beginning of their shift. 13. The RN Supervisor for each shift is responsible for informing the resident, their physician, and their representative of any changes in condition that involve life-threatening concerns. This ensures that residents receive the necessary resources, including staff, supplies, services, policies, training, and supervision, to meet their needs. Additionally, RN Supervisors and licensed staff caring for residents with changes in condition will verify the resident's code status and report it to the physician when notifying them of the change. 14. Any staff member identified as needing further training on recognizing and responding to resident changes in condition will receive one-on-one (two people talking directly, usually with one teaching or giving information to the other) training and testing by the DON or a designee. This individualized instruction will ensure that all staff members understand and follow the proper protocols for managing changes in resident conditions. 15. The DON or a designee will discuss residents with new or ongoing changes in condition during morning clinical meetings (on Monday to Friday) and pre-shift huddles (a short meeting where a team discusses residents to improve safety and quality of care) on weekends to ensure their (residents') needs are met. 16. To ensure compliance with change-of-condition protocols, the DON, DSD, ADON, or a designee (including RN supervisors from the Skilled Nursing Facility and Subacute units) will provide clinical oversight, evaluating and supervising all staff through clinical rounds conducted every shift. 17. The ADM and DON will analyze concerns related to resident care and report their findings to the Quality Assurance and Assessment (QAA) committee for three months. This ongoing analysis will support continuous quality improvement initiatives within the facility. 18. The QAA committee will determine and implement any necessary actions to address issues or concerns identified during their monthly reviews. This may include further investigation, policy revisions, staff training, or other interventions to ensure resident safety and well-being. 19. This plan to address the IJ situation will remain in effect until all licensed nursing staff have completed the required re-education and the plan is fully implemented. This includes validation by the DON that licensed nurses understand the entire process for addressing resident changes in condition. They must be able to recognize and respond to changes, determine resident code status, notify primary care physicians, follow the escalation plan to notify the facility Medical Director if needed, and transfer unstable residents to the GACH for further evaluation and treatment if the physician cannot be reached. Findings: During a review of Resident 1's Record of Admission, the Record of Admission indicated the facility initially admitted the resident on [DATE] and readmitted on [DATE], with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it) with loss of consciousness (the state of being awake, alert, aware and responsive) and hypotension (low blood pressure wherein the force of blood pushing against your artery walls is lower than normal). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 required an oxygen therapy (a treatment that provides extra oxygen to residents with breathing problems or lung diseases), suctioning, tracheostomy (surgical procedure that creates an opening in the neck to insert a tube into the windpipe) care, and invasive mechanical ventilator (a method of respiratory support that involves a tube inserted into the resident's airway and connected to a machine called a ventilator to deliver air into the lungs). The MDS indicated Resident 1 required a feeding tube (G-tube - medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) while residing in the facility. During a review of Resident 1's History & Physical (H&P), dated [DATE], the H&P indicated the resident did not have the capacity to understand and make decisions due to traumatic brain injury (a brain injury that occurs when the brain is damaged by a sudden external force). During a review of Resident 1's physician's telephone order, dated [DATE] at 7:29 a.m., the order indicated the physician ordered one (1) liter (L - unit of measurement) sodium chloride solution 0.9 (normal saline - a solution of water and salt) percent (% - per one hundred) 75 millimeters (ml - unit of measurement) per hour (hr.) intravenously (IV - refers to administering a substance, such as a drug or fluid, into a vein using a needle or tube) every shift for low BP for one day only. During a review of Resident 1's physician's telephone order, dated [DATE] at 8:00 a.m., the order indicated the physician ordered 1 L sodium chloride solution 0.9 % 250 ml/hr. intravenously every shift for low BP for one day only. During a review of Resident 1's physician's telephone order, dated [DATE] at 8:31 a.m., the order indicated the physician ordered Midodrine hydrochloride (a medication used to treat low BP) oral (by mouth) tablet 10 milligrams (mg - unit of measurement) to be given through G-tube every eight hours as needed for systolic BP (pressure in your arteries when your heart beats and pumps blood out, essentially the top number in a BP reading) of less than 90 mmHg. During a review of Resident 1's physician's telephone order, dated [DATE] at 9:55 a.m., the order indicated the physician ordered to transfer Resident 1 to the GACH via 911 transfer due to tracheal blood, blood in stool, and hypotension with ,d+[DATE] mmHg BP reading (time not indicated in the order). During a review of Resident 1's Los Angeles Fire Department (LAFD) paramedics (health professionals certified to perform advanced life support procedures) report, dated [DATE] timed at 10:00 a.m., the report indicated that the paramedics were notified at 10:00 a.m. on [DATE]. The paramedics report indicated that Resident 1 at 10:12 a.m. (on [DATE]) had a BP of ,d+[DATE] mmHg and PR of 102 beats per minute (bpm), and at 10:25 a.m. (on [DATE]) had a BP of ,d+[DATE] mmHg and PR of 112 bpm. The report indicated the paramedics arrived to find Resident 1 with hypotension, shortness of breath (the uncomfortable feeling of being unable to breathe deeply enough or getting enough air), bradycardia (a condition where the heart beats slower than normal, or less than 60 beats per minute, while at rest), complaints of pain, and resident on ventilator. The report indicated the paramedics transferred Resident 1 to the GACH. During a concurrent interview and record review on [DATE] at 11:40 a.m., with Registered Nurse 1 (RN 1), Resident 1's Weights and Vitals Summary report, dated [DATE] to [DATE] was reviewed. RN 1 stated Resident 1's BP of ,d+[DATE] mmHg on [DATE] at 1:00 a.m. was not reported to her (RN 1). RN 1 further stated had LVN 1 reported this to her (RN 1), she would immediately notify the physician. RN 1 stated the next vital signs check done for Resident 1 was around 6:17 a.m. (on [DATE]) after the Respiratory Therapist 1 (RT 1) reported that Resident 1 had coffee ground discharge during suction. The report indicated Resident 1's BP on [DATE] at 7:03 p.m. was ,d+[DATE] mmHg and on [DATE] at 7:34 a.m. was ,d+[DATE] mmHg. During a concurrent interview and record review on [DATE] at 12:13 p.m., with RN 2, Resident 1's COC form dated [DATE], timed at 10:00 a.m. was reviewed. RN 2 stated Resident 1 had a BP of ,d+[DATE] mmHg (at 10:15 a.m.), with tracheal bleeding, blood in stool with dark brown in color, loose stool with foul (smelly) odor, and with distended (enlarged or stretched out) and rigid (stiff) abdomen. RN 2 stated around 8:00 a.m. ([DATE]), RN 2 reported to MD 1 that Resident 1's BP was ,d+[DATE] mmHg and received an order to give IV fluids of normal saline 250 ml/hr. and Midodrine hydrochloride 10 mg via G-Tube. During a telephone interview on [DATE], at 8:09 a.m., LVN 1 stated she (LVN 1) received a low BP reading from Certified Nursing Assistant 1 (CNA 1) for Resident 1 at 1:00 a.m. (on [DATE]). LVN 1 stated she could not recall the exact BP reading. LVN 1 stated she (LVN 1) elevated Resident 1's feet, rechecked Resident 1's blood pressure after 15 minutes, and was able to obtain a normal reading (,d+[DATE] mmHg). LVN 1 stated she (LVN 1) did not complete a COC about Resident 1's low BP. LVN 1 stated she (LVN 1) did not inform the attending physician and the RN Supervisor about Resident 1's low BP. LVN 1 stated she did not monitor Resident 1's blood pressure again until the end of her shift. During a concurrent interview and record review on [DATE] at 3:43 p.m., with RN 1, Resident 1's COC form dated [DATE], timed at 6:17 a.m. was reviewed. RN 1 stated at 6:17 a.m. (on [DATE]) RT 1 reported that Resident 1 had a coffee ground discharge during suctioning Resident 1. RN 1 stated Resident 1's BP was ,d+[DATE] mmHg (at 6:17 a.m.) and after inserting and administration of an IV fluid (normal saline) BP was rechecked after 15 minutes and Resident 1's BP was ,d+[DATE] mmHg around 6:30 a.m. ([DATE]). During a telephone interview on [DATE] at 2:09 p.m., with MD 2, MD 2 stated he was not notified regarding Resident 1's change of condition and low BP at 1:00 a.m. (on [DATE]). MD 2 further stated had he been informed of Resident 1's BP drop, he (MD 2) would have ordered a normal saline bolus (a single, large dose of medicine or fluid such as normal saline) and if not effective he (MD 2) will order to transfer Resident 1 to the GACH right away. During a telephone interview on [DATE] at 3:23 p.m., with MD 1, MD 1 stated he was not made aware of Resident 1's low BP at 1 a.m. ([DATE]). MD 1 stated he received a call around 6:00 a.m. on [DATE]. MD 1 stated Resident 1's vital signs should have been monitored closely every 15 to 30 minutes after the BP dropped at 1:00 a.m. (on [DATE]). During an interview on [DATE] at 4:41 p.m., the DON stated LVN 1 should have reported Resident 1's low blood pressure to RN 1 and should have notified Resident 1's physician to obtain further orders. This would have allowed Resident 1 to receive necessary interventions sooner. The DON also stated LVN 1 failed to monitor Resident 1's blood pressure as frequently as required. During a review of the current facility-provided policy and procedure (P&P) titled, Notification of Changes, with last reviewed date of [DATE], the P&P indicated the facility informs the resident physician when there are changes involving life threatening conditions. The P&P indicated. The facility notifies the physician and resident representative of: . b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse (harmful) consequences, or to commence a new form of treatment The P&P indicated, Facility staff shall notify the resident's physician when a resident experiences symptom such as chest pain, loss of consciousness, or the other signs or symptoms of heart attack or stroke that may signify a significant change.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from sexual abuse (non-consensual [not agreed by the people involved] sexual contact of any type with a resident) on 12/4/2023 at 8:10 a.m. when Resident 1 sat on Resident 2 ' s bed and touched Resident 2 ' s genitals (the sexual organs; the testicles and penis of a male) while Resident 2 laid in bed as observed by Certified Nursing Assistant 1 (CNA 1) and as communicated by Resident 2. This deficient practice resulted in Resident 2 experiencing non-consensual sexual contact from Resident 1 while under the care of the facility. Resident 2 conveyed he felt sexually assaulted, violated, and humiliated. On 12/15/2023 at 5:28 p.m., the California Department of Public Health (CDPH), while conducting the investigation of a facility-reported incident (FRI) regarding resident abuse, identified an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42CFR S483.12 Freedom from Abuse, Neglect, and Exploitation. On 12/15/2023 at 5:28 p.m., the Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ situation from the facility ' s failure to ensure Resident 2 was free from sexual abuse inflicted by Resident 1. On 12/17/2023 at 2:56 p.m., the IJ situation was removed in the presence of the ADM and the DON, while on site, after verifying and confirming the implementation of the facility ' s submitted IJ Removal Plan (a detailed plan to address the IJ findings) through observation, interview, and record review. The acceptable IJ Removal Plan included the following summarized actions: Resident 1 was discharged as planned per physician order on 12/15/2023. Resident 2 remained in the facility and was assessed after the incident. On 12/15/2023, all 115 alert residents, including Resident 2, were interviewed, and reported they felt safe in the facility. All residents (except Resident 2) stated they have not experienced any sexual abuse while at the facility. On 12/15/2023, all 32 residents who were not able to participate in an interview were assessed by the licensed nurses through comprehensive skin assessments to identify any signs of sexual abuse, with no findings. The Director of Staff Development (DSD)/ DSD Designee re-educated all staff on the Abuse Prevention Policy and will continue until the facility had 100% compliance by 12/20/23. Department heads will do weekly audits to ensure that residents assigned to their room rounds feel safe in the facility and free from any type of abuse. Any resident that reports feeling unsafe or abused, the allegation will immediately be relayed to the Abuse Coordinator for follow-up action. Prior to approving on admitting residents, residents will be screened through [NAME] ' s Law (is the name for a federal law in the United States requiring law enforcement authorities to make information available to the public regarding registered sex offenders) by Admissions Assistant to identify residents that have the ability for sexual abuse. The Director of Nursing screens referral forms prior to admission to identify a resident that could have the potential for sexual-seeking behaviors. Residents that are identified within the facility for having the potential for sexual-seeking behaviors will have a psychiatric (medical specialty that helps people with emotional or mental disorders) evaluation and their care plans will be updated to prevent a behavior from occurring that would cause sexual abuse. All residents who have been identified either before admission or while at the facility as having behaviors that could lead to high potential for sexual-seeking behavior will have their locations documented every two hours using the Resident Whereabouts Rounding Tool. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 9/9/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 11/9/2023, indicated Resident 1 could understand and be understood and had some memory problem. The MDS indicated Resident 1 required partial assistance with sit to stand, chair to chair transfer, and walking. A review of Resident 1 ' s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his / her condition) Change of Condition (COC, a sudden clinically important deviation from a patient's baseline status), dated 12/4/2023, indicated CNA 1 reported that around 8:10 a.m., he witnessed Resident 1 sitting on Resident 2 ' s bed and inappropriately touching the top area of Resident 2 ' s incontinent brief. A review of Resident 1 ' s Care Plan, developed on 12/4/2023 for Resident 1 ' s involvement in a resident-to-resident inappropriate touching, indicated interventions including informing local law enforcement, monitoring for any signs of emotional distress, and offering a room change. A review of Resident 2 ' s Admission Records indicated the facility admitted the resident on 10/15/2021 with diagnoses including cerebral infarction (occurs because of disrupted blood flow to the brain which can cause parts of the brain to die off), dysarthria (difficulty speaking because the muscles for speech are weak), dysphagia (swallowing difficulties), and muscle weakness. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had memory problems and had the ability to understand and be understood. The MDS indicated Resident 2 required two-person assist with bed mobility and transfers and was unable to walk. A review of Resident 2 ' s SBAR COC form, dated 12/4/2023, Registered Nurse 1 (RN 1) documented CNA 1 reported that at around 8:10 a.m. he (CNA 1) witnessed Resident 1 sitting on Resident 2 ' s bed and inappropriately touching Resident 2 ' s incontinent brief area. The SBAR indicated RN 1 documented that when RN 1 attempted to interview Resident 2, Resident 2 did not want to talk. A review of Resident 2 ' s Care plan, developed on 12/4/2023 for Resident 2 ' s involvement in a resident-to-resident inappropriate touching, indicated interventions including monitoring Resident 2 for any signs of emotional distress, psychiatric consult (evaluation of the causes of emotional distress [highly unpleasant reaction]) and for Social Services (SS) staff to provide emotional and psychosocial support (interventions that relieve stress and can help prevent mental conditions). A review of Resident 2 ' s SS Progress Notes, dated 12/4/2023 timed at 8:47 a.m., indicated the Social Services Coordinator (SSC) completed an interview with Resident 2 with yes or no questions. The SS Progress Notes indicated Resident 2 was shaking at the start of the interview, but the shaking decreased as the interview progressed. Resident 2 was able to gesture he was touched over the incontinent brief. During an interview on 12/5/2023 at 10:33 a.m., Resident 1 stated that when (no date or time was specified) he was talking to his roommate (Resident 2), who did not speak but used his hands and gestures to communicate, he was accused of touching Resident 2 inappropriately. Resident 1 stated he only touched Resident 2 ' s leg and did not touch him inappropriately. On 12/5/2023 at 11:11 a.m., a concurrent observation and interview was conducted with Resident 2, who could only communicate with hand gestures and by nodding to indicate Yes and head shaking to indicate No. When asked about the incident with Resident 1 that occurred on 12/4/2023 at around 8:10 a.m., Resident 2 was observed pointing to the bed next to his (previously occupied by Resident 1) and to his own bed to indicate Resident 1 came to his bed. When asked if Resident 1 sat on his bed, Resident 2 nodded Yes. Resident 2 nodded Yes to the question of being touched inappropriately. Resident 2 proceeded to remove his blankets and demonstrated by placing his hand on top of his incontinent brief and motioning up and down, showing the Evaluator what Resident 1 did to him. Resident 2 gestured Resident 1 ' s hand was inside of his incontinent brief (directly over his genitals) when touching him. When asked if that was what Resident 1 had done to him, Resident 2 nodded Yes. When asked if he felt Resident 1 sexually assaulted him, Resident 2 nodded Yes. Resident 2 gestured CNA 1 came in the room and made Resident 1 go back to his bed. During an interview on 12/5/2023 at 12:14 p.m., CNA 1 stated that on 12/4/2023 at around 8 a.m. he was entering Residents 1 and 2 ' s room and observed Resident 1 sitting on Resident 2 ' s bed facing Resident 2. Resident 2 was lying down in bed facing up. CNA 1 stated Resident 2 ' s blanket was removed (was to the side), his gown was pulled up exposing his (Resident 22 ' s) abdomen, his incontinent brief was on, and Resident 1 was massaging Resident 2 over the private area on top of the incontinent brief. CNA 1 stated he did not observe skin-to-skin contact (hand directly touching Resident 2 ' s genitals). CNA 1 stated Resident 2 appeared upset, shaking his hands in attempts to push Resident 1 away. On 12/5/2023 at 1:06 p.m., during an interview, Resident 2 nodded Yes to feeling violated and humiliated. On 12/5/2023 at 1:15p.m., during an interview, with Social Services Coordinator (SSC) stated that on 12/4/2023 after she was informed of the sexual abuse allegation, she went to speak to Resident 2 and observed Resident 2 to be excessively shaking but as the interview progressed, Resident 2 ' s shaking subsided. The SSC stated Resident 2 was shaky due to the alleged sexual abuse. The SSC stated she asked Resident 2 if he could confirm the incident of sexual abuse and Resident 2 nodded Yes and pointed to Resident 1 as the abuser. The SSC stated Resident 2 nodded Yes about Resident 1 touching him over the incontinent brief. On 12/5/2023 at 1:41 p.m., during an interview, RN 1 stated that on 12/4/2023 at 8:20 a.m. Licensed Vocational Nurse 1 (LVN 1) notified her about CNA 1 ' s report of sexual abuse from Resident 1 on Resident 2. RN 1 stated she went to speak to Resident 2 who confirmed Resident 1 touched him over his incontinent brief. During an interview on 12/5/2023 at 3:01 p.m., the DON stated Resident 1 ' s interaction with Resident 2 was inappropriate. A review of the current facility provided policy and procedure (P&P) titled, Abuse Prohibition and Prevention Program, revised 3/2023, indicated the facility has policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting abuse. To ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse. A review of the current facility provided P&P titled, Sexual Abuse, revised 3/2023, indicated the facility conducts investigation and protects a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Sexual abuse: Non-consensual sexual contact of any type with a resident. Unwanted intimate touching of any kind especially of breast or perineal (the area of the genitals) area.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 11), who was not prescribed (ordered) an intravenous (IV, given through the vein [blood vessels forming part of the blood circulation system]) medication, was on hospice care (focuses on comfort care when the person is approaching the end of life), and was not wearing an identification (ID) wristband (a band worn by residents that contains important resident data [such as name, date of birth, medical record number, and facility name], allowing residents to be identified). In addition, the facility failed to ensure Resident 11 was not administered in error the IV antibiotic (medicine that fight infections caused by bacteria delivered directly into the bloodstream) ceftriaxone sodium ordered to Resident 12 (Resident 11 ' s former roommate). On [DATE] at around 10 a.m., Registered Nurse 3 (RN 3), without positively identifying Resident 11, inserted a peripheral (away from the center of the body, on the arms or legs) IV catheter (PIVC or IV line is a thin plastic tube placed into a vein using a needle) to Resident 11 ' s left arm and initiated the IV administration of the antibiotic that was intended for Resident 12, who had been discharged the previous day. The significant (which causes the resident discomfort or jeopardizes his or her health and safety) medication error (administration of medication not in accordance with the physician ' s order) was identified by the visiting Hospice Nurse (HN), who arrived at Resident 11 ' s room when RN 3 was leaving and immediately asked RN 3 about the IV. The HS checked the IV antibiotic bag and noticed the name on the bag was not Resident 11 ' s name. This failure resulted in Resident 11 receiving IV ceftriaxone sodium without a physician ' s order placing Resident 11 at risk of life-threatening complications including an anaphylactic reaction (a severe, life-threatening allergic reaction) or a drug adverse reaction (or side effects, are unwanted undesirable effects that are possibly related to a medication [ceftriaxone common side effects include black, tarry stools, chest pain, chills, fever, cough, and painful or difficult urination]). In addition, Resident 11 underwent an IV insertion which could be painful and contrary to the comfort treatment plan of care. On [DATE] at 5:28 p.m., the California Department of Public Health (CDPH), while conducting the investigation of a complaint regarding quality of care, identified an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.45(f)(2) Residents are free of any significant medication errors. The Administrator (ADM) and the Director of Nursing (DON) were notified on [DATE] at 5:28 p.m. of the IJ situation from the facility ' s failure to ensure Resident 11 was free from any significant medication error. On [DATE] at 2:56 p.m., the IJ situation was removed in the presence of the ADM and the DON, while on site, after verifying and confirming the implementation of the facility ' s submitted IJ Removal Plan (a detailed plan to address the IJ findings) through observation, interview, and record review. The acceptable IJ Removal Plan included the following summarized actions: Resident 11 was discharged as planned on [DATE] without complications. On [DATE], the facility had six residents receiving IV antibiotics and the DON assessed them and audited their medication and their physician ' s orders. No medication errors or adverse effects were found. Other residents given IVs by RN 3 prior to [DATE] were evaluated. Admissions Assistant confirmed on [DATE] the six residents with IV and all residents in the facility had ID wristbands. Re-education on medication administration and IV medication administration, including identification of the resident, to all RNs will continue until 100% of the RNs have been in-serviced by [DATE]. All residents will have wristbands or some other obvious alternative means for identifying them. Two licensed nurses will be required to check the resident ' s ID wristband, the IV medication order, and the IV medication itself. The same two licensed nurses will document they visually verified the right resident, the right medication order, and the right IV medication in the resident ' s medical records. The Reception Team and all licensed nurses will be trained on how to create an ID wristband by [DATE] (or prior to their next shift, whichever is sooner) in the case a resident is missing their ID wristband. All RNs authorized to give IV medications will be trained to check wristbands before giving IV medications. Any resident without a wristband will have one printed or manually made for them immediately. Residents that refuse to wear a wristband will have a color picture taken and printed and kept in their medical records such that all RNs who administer IV medications to those residents will have a large visual way of confirming the identity of the resident prior to giving them medications. The DON and / or the Assistant DON (ADON) will assess the IV medication competency of each RN using the Intravenous Medication Competency Tool, upon hire, biannually (twice a year), and when a variance to standard is identified. Only RNs with a 100% score on their audit will be allowed to give IV medications. The DON and / or the ADON will use the Registered Nurses High Risk Medication Competency Checklist, to confirm all registered nurses who give IV medications know the correct procedure for doing so, upon hire, and biannually. A score of 100% is required to receive authorization to give high risk medications at this facility. If the registered nurse receives a score of 100%, they will be authorized to give high risk medications at this facility. If a RN does not receive a passing score of 100%, he or she will be required to complete a High-Risk Medication in-service, prior to being tested again, and prior to being authorized to give high risk medications. The Quality Assessment and Assurance (QAA) committee will review and discuss medication administration protocols for all residents during the monthly QAA meetings. Findings: A review of Resident 11 ' s Admission Record indicated the facility admitted Resident 11 on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), history of sudden cardiac arrest (when the heart stops beating suddenly), and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 11 ' s Physician Orders for Life-Sustaining Treatment (POLST) form brought upon admission by the caregiver signed and prepared on [DATE], indicated Comfort-Focus Treatment - primary goal of maximizing comfort. Do not use treatment listed in Full and Selective Treatment (sections) unless consistent with comfort goals. The section for Selective Treatment included IV antibiotics, indicating one of Resident 11 ' s wishes was not to give him IV antibiotics. A review of Resident 11 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 11 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 11 was dependent on staff for oral hygiene, toilet hygiene, shower and or bathing, upper and lower body dressing, and personal hygiene. A review of the Physician ' s Orders for Resident 11, dated [DATE], indicated the stay at the facility was for Respite Care (provides short-term relief for in-home hospice caregiver). A review of Resident 11 ' s Situational-Background-Assessment-Recommendation (SBAR - a technique to aid in facilitating and strengthening communication between health care staff), dated [DATE], and timed at 10:57 a.m., indicated a medication error occurred to Resident 11 with no adverse effects. The time of the medication error was not documented. Resident 11 received IV ceftriaxone sodium IV solution 2 grams (gm - unit of measurement) hanging (IV fluids are packaged in bags which need to be hung in a pole above the patient's heart to have enough pressure for the IV fluid to infuse) approximately five (5) minutes. The SBAR indicated that upon arrival of the HN, RN 3 discontinued IV line and the medication right away. A review of Resident 11 ' s Care Plan developed on [DATE], indicated Resident 11 had the potential for complications and adverse effects related to IV therapy due to medication error. The interventions included to assess, record, and report to the physician any complications related to IV medication. A review of the Medication Error Report Form for Resident 11, dated [DATE] with no time specified, indicated the reason for the administration of ceftriaxone 2 gm IV to the wrong resident (Resident 11) was because the nurse (RN 3) did not identify Resident 11. A review of Resident 12 ' s Admission Record indicated the facility admitted Resident 12 on [DATE] with diagnoses including end stage renal disease (the kidneys cease functioning on a permanent basis) and osteomyelitis (infection of the bone) on the right ankle and foot. A review of the Physician ' s Orders for Resident 12, dated [DATE], indicated to administer ceftriaxone sodium IV solution 2 gm once a day for 13 days for osteomyelitis. A review of Resident 12 ' s Nursing Progress Notes, dated [DATE], timed at 4:40 p.m., indicated Resident 12 was transferred to a hospital via emergency ambulance. During an interview on [DATE] at 11:44 a.m., RN 3 stated that on [DATE] she was assigned to the Subacute Care Unit (for residents needing services that are more intensive than those typically received in skilled nursing facilities [SNF] but less intensive than acute care) and there was only one RN in the regular SNF side of the facility when there should have been two RNs. RN 3 stated that around 10 a.m., the DON asked her to help with hanging an IV antibiotic for a resident (Resident 12) in the regular SNF side and gave her (RN 3) the resident ' s room number. RN 3 stated that when she went inside the room there was only one resident, Resident 11, who had no ID wristband and she (RN 3) assumed that he (Resident 11) was the resident (Resident 12) needing the IV medication. RN 3 stated Resident 11 did not have an IV line and she performed a PIVC on Resident 11, connected the IV antibiotic, and started its infusion. RN 3 stated she then exited Resident 11 ' s room and passed the HN in the doorway. RN 3 stated the HN asked who ordered the IV antibiotic and when RN 3 mentioned the name of the doctor and Residents 12 ' s name, the HN told RN 3 she had the wrong resident. RN 3 stated she removed the IV line and reported the error to RN 4. RN 3 stated she should have checked the picture in the Medication Administration Record (MAR) before administering the medication. RN 3 stated Resident 11 could have suffered adverse or allergic reactions to the antibiotic and Resident 11 could have died . During an interview on [DATE] at 12:23 p.m., the HN stated that on [DATE] around 9 a.m., he went to the SNF where Resident 11 was admitted for Respite Care and observed an IV bag hanging and being administered to Resident 11. The HN stated he was not aware of an IV order and asked RN 3 who ordered the IV medication. The HN stated he observed the IV bag with the name of the antibiotic and another resident ' s name (Resident 12). The HN stated he clamped the IV tubing to turn off the infusion. The HN stated he then informed RN 3 that she (RN 3) had made a medication error and reported it to the DON, Family Member 1 (FM 1), and notified all the Hospice interdisciplinary team (IDT - professionals from various disciplines who work in collaboration to manage the care of a patient). On [DATE] at 3 p.m., during an interview, RN 4 stated on [DATE] she was aware Resident 12 had an IV due at 9 a.m. but did not know Resident 12 had been discharged . RN 4 stated she did the incident report, removed IV line, and the HN told her (RN 4) he would notify the physician and FM 1. On [DATE] at 4:10 p.m., during an interview, the Admissions Assistant 1 (AA 1) stated when an admission medical record is created, an ID wristband would also be made. The ID wristband indicates the resident ' s first and last name, date of birth, the doctors name, and facility address. AA 1 stated she worked on [DATE] when Resident 11 was admitted but could not recall if she (AA 1) created the medical record and the wristband for Resident 11. On [DATE] at 2 p.m., during an interview, the DON stated that on [DATE] around 9 a.m. the HN informed her (DON) Resident 11 was given the wrong medication. The DON stated RN 3 failed to look at the physician ' s order in the medical record, the MAR, follow the Nursing Rights of Medication Administration (right patient, right medication, right dose, right time, right route, right reason, right position, and right documentation), and failed to follow the facility ' s policies and procedures (P&Ps) on medication administration. The DON stated RN 3 should have done a two-method resident verification, by checking face / arm band with MAR, or a two-person verification. The DON stated Resident 11 had no reactions from the medication error but there was a potential for an allergic reaction like anaphylactic reaction. On [DATE] at 5:01 p.m., during an interview, the DON stated the Admissions Department would prepare the admission chart (medical record) and the ID wristband and the admitting nurse would place the band on the resident as soon as the resident arrives at the facility. On [DATE] at 5:12 p.m., during an interview, the Medical Director (MD) stated he did not recall being informed about a medication error. MD 1 stated if a resident is administered an antibiotic that was not prescribed and the resident is allergic to it, the resident can have an anaphylactic reaction, a skin reaction, or breathing problems. A review of the current facility provided P&P titled, Infusion Therapy Products-General Information, last revised on ,d+[DATE], indicated the resident ' s medical record is checked for known allergies, and the resident is monitored closely for any signs of adverse reactions after each dose of the medication. A review of the current facility provided P&P titled, Medication Administration-General Guidelines, last revised on ,d+[DATE], indicated medications are administered as prescribed in accordance with good nursing principles and practices. Prior to administration, the medication and dosage schedule on the resident ' s MAR is compared with the medication label. Medications are administered in accordance with written orders of the attending physician. Residents ae identified before medication is administered using (two) methods of identification. Methods of identification include: a. Checking identification band. b. Checking photograph attached to medical record. c. Verifying resident identification with another nurse. A review of the facility ' s provided P&P titled, Medication Errors, last revised on ,d+[DATE] indicated the purpose of the policy is to ensure the prompt reporting of errors in the administration of medications and treatments to residents. The preparation or administration of medication or biologicals which is not in accordance with: a. The prescriber ' s order. b. Manufacturers specification (not recommendations) regarding the preparation and administration of the medication or biological. c. Accepted professional standards and principles which apply to professionals providing services. d. A medication error may be the administration or omission of medications: i. To the wrong resident; ii. At the wrong time; iii. At the wrong dose; iv. Via the wrong route; or v. Which is not currently prescribed.

Based on interview and record review, the facility failed to provide the necessary treatment and services to prevent formation and progression of a pressure injury (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to the sacrococcyx (pertaining to the sacrum [large, curved, triangular-shaped bone at the base of the spine] and coccyx [tailbone]) for three of five sampled residents (Residents 93, 104, and 121) by failing the following: 1. For Resident 93: a. Failed to ensure wound weekly monitoring assessments were completed to determine the healing status of Resident 93's sacroccoccyx pressure injury. b. Failed to notify the physician on 12/27/2022 when Resident 93's wound treatment order came to an end which resulted in Resident 93 not receiving wound treatments since the last treatment was provided on 12/27/2022 and until a new treatment was ordered on 1/2/2023. c. Failed to notify the Registered Dietitian (RD) to provide nutritional recommendations to promote healing of pressure injury when Resident 93's sacrococcyx wound worsened from stage three pressure injury (full-thickness loss of skin, in which subcutaneous [beneath the skin] fat may be visible in the injury) to stage four pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia [is a thin casing of connective tissue that surrounds every structure in the body], muscle, tendon, ligament, cartilage or bone in the injury). d. Failed to ensure Resident 93's skin checks were conducted by the Certified Nursing Assistants (CNAs) during shower days (12/23/2022, 12/26/2023, 12/30/2023, and 1/6/2023). These deficient practices resulted in Resident 93 developing a facility-acquired (developed after admission to the facility) stage three sacrococcyx pressure injury that progressed to a stage four pressure wound while in the facility. 2. Failed to document a new wound on the right buttock for Resident 104. This had the potential to result in the development of worsening and newly acquired pressure injury for Resident 104. 3. Failed to adjust the low air loss mattress based on the weight distribution for Resident 121 who had a stage three pressure injury at the sacrococcyx area. This deficient practice had the potential to cause worsening of the pressure injury on the sacrococcyx of Resident 121. Findings: 1. A review of Resident 93's Admission Record indicated the facility admitted the resident on 5/27/2021 with diagnoses of diffuse traumatic brain injury (a sudden, violent blow or jolt to the head that causes damage to the brain) with loss of consciousness of unspecified duration, generalized muscle weakness, and diabetes mellitus type two (a chronic disease characterized by high levels of sugar in the blood due to impairment in the way the body regulates and uses sugar for fuel). A review of Resident 93's Wound Weekly Monitoring Assessment - Pressure, dated 5/28/2021, indicated Resident 93 did not have a sacrococcyx wound upon admission. A review of Resident 93's Situation-Background-Assessment-Recommendation: Change of Condition (COC - system for identifying, evaluating, and reporting deterioration in resident's condition) form, dated 9/23/2022, indicated a reopened wound to sacral area. A review of Resident 93's Wound Weekly Monitoring Assessment, dated 9/24/2022, indicated a stage three sacrococcyx wound measuring 1 centimeter (cm - unit of measure) in length by 1 cm in width by 0.2 cm in depth with no undermining (erosion under the wound edges resulting in a large wound with a small opening) or tunneling (wound that has progressed to form passageways underneath the surface of the skin). A review of Resident 93's Braden Scale for Predicting Pressure Sore Risk form (Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries), dated 11/30/2022, indicated the resident was a high risk for developing pressure injuries. A review of Resident 93's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/30/2022, indicated Resident 93's cognitive skills (the act or process of knowing and perceiving) for daily decision making were severely impaired and was totally dependent on staff with two people assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from bed, chair, wheelchair, standing position), dressing, and toilet use. A review of Resident 93's Wound Consultation Notes by Wound, Ostomy (an artificial opening in an organ of the body created during an operation) and Continence Nurse 1 (WOCN 1), dated 12/16/2022, indicated a stage 3 pressure injury described as crater-like injury extending through dermis to subcutaneous tissue but not through fascia. A review of Resident 93's Wound Weekly Monitoring Assessment, dated 1/13/2023, indicated an unstageable (full thickness tissue loss in which the base of the injury is covered by slough [yellow, tan, gray, green, or brown colored dead tissue separating from living tissue] and/or eschar [collection of dry, dead tissue within a wound that appears tan, brown, or black] in the wound bed) sacrococcyx wound measuring 6 cm in length by 6 cm in width with 80% slough, 10% granulation (pink lumpy tissue that forms during wound healing), and 10% epithelialization (formation of new tissue covering the wound surface). A review of Resident 93's COC, dated 1/16/2023, indicated the resident's pressure injury had deteriorated as evidenced by increase in size and depth and that the MD had reclassified the sacrococcyx wound from stage three pressure injury to stage four pressure injury. A review of Resident 93's Wound Weekly Monitoring Assessment - Pressure, dated 1/16/2023, indicated a stage four sacrococcyx wound measuring 8.5 cm in length by 8.5 cm in width by 4 cm in depth with undermining of 4 cm noted at 9 a.m. to 4 p.m. The assessment further indicated muscle and tendon were exposed with 30% slough, 60% granulation, and 10% epithelialization. A review of Resident 93's Care Plan, dated 1/16/2023, indicated the resident was at risk for further deterioration of stage four sacrococcyx pressure wound and indicated interventions that included monitoring and reassessing pressure injury for healing weekly, providing treatment as ordered and changing treatment when signs of healing are not noted, RD evaluation as ordered, and notifying MD for changes. A review of Resident 93's Wound Consultation Notes by WOCN 1, dated 1/17/2023, indicated the sacrococcyx wound deteriorated to stage 4 with visible muscle and bone and malodor (a very unpleasant smell) noted. The wound consultation note indicated Resident 93 was noted with slight fever of 100.4 degrees Fahrenheit (unit of measure) and signs and symptoms of infection were noted that included increased pain, increased drainage, and increased wound size. Medical Doctor 1 (MD 1) was notified of the changes. During a concurrent interview and record review, on 2/1/2023 at 10:45 a.m., Treatment Nurse 1 (TN 1) stated Resident 93 developed a stage three pressure injury on the sacrococcyx that had reopened on 9/23/2022 at the facility. TN 1 reviewed Resident 93's Wound Weekly Monitoring Assessment, dated 9/24/2022 to 1/27/2023, and stated that weekly assessments of Resident 93's sacrococcyx pressure injury were not done on 12/30/2022 and 1/6/2023. TN 1 stated she was not aware the weekly assessments were not completed until 1/13/2023 when the next weekly wound assessment was due since she was not working from 12/24/2022 to 1/2/2023 and TN 1 was not assigned to Resident 93 on 1/6/2023. TN 1 stated the treatment nurse assigned to Resident 93 on 12/30/2022 and 1/6/2023 should have assessed the wound and documented on the Wound Weekly Monitoring Assessment form. TN 1 further reviewed Resident 93's physician's order and stated the following order: Cleanse with half-strength Dakin's (solution is used to prevent and treat skin and tissue infections), pat dry, apply gentamycin (antibiotic) ointment on wound bed first, then apply thin layer of triad paste (topical wound dressing), apply skin prep to periwound (tissue surrounding a wound), and cover with foam dressing every day shift every other day for wound management for 14 days, ordered on 12/17/2022. TN 1 reviewed Resident 93's Treatment Administration Record (TAR) for December 2022 and January 2022 and stated a wound treatment was missed on 12/29/2022 which should have been the last treatment date for the specified order. TN 1 stated that no wound treatments were provided for Resident 93's sacrococcyx pressure injury since 12/27/2022 until a new treatment order was obtained from the physician on 1/2/2023, with instructions to cleanse with normal saline, pat dry, apply Medihoney (is a brand name wound and burn gel made from 100% Leptospermum [Manuka] honey), followed by calcium alginate (dressing used for moderate to heavily draining wounds), apply skin prep to periwound, and cover with foam dressing every day shift. TN 1 stated there is potential outcome for the wound to deteriorate further if treatments are missed. TN 1 stated Resident 93's sacrococcyx wound had deteriorated to a stage four pressure injury with exposed muscle and tendon when she reassessed the wound on 1/16/2023 and verified the wound had grown larger measuring 8.5 cm in length by 8.5 cm in width by 4 cm in depth with undermining of 4 cm noted. During an interview on 2/1/2023 at 2:08 p.m., the Assistant Director of Nursing (ADON) confirmed she worked on 12/30/2022 and was assigned to Resident 93. The ADON stated she typically does not provide wound treatments but would fill in as wound treatment nurse when needed. The ADON stated she was not aware Resident 93 had a sacrococcyx wound and stated she did not complete the weekly wound assessment for Resident 39 on 12/30/2022 since she was not aware Resident 93 was due for one. During a concurrent record review of Resident 93's TAR, the ADON stated that the facility did not provide any wound treatment to Resident 93 on 12/30/2022. The ADON stated that she was unaware at that time (12/30/2022) that Resident 93's wound treatment had been completed and that a new order had to be obtained to continue treatment for Resident 93's sacrococcyx wound. The ADON stated that had she known at that time (12/30/2022) that Resident 93 had no further wound treatments ordered for her unhealed sacrococcyx pressure injury, she would have called the registered nurse (RN) to assess and evaluate the wound with her and contact the physician to determine if any changes would need to be made to continue or order a new treatment. The ADON stated there was a potential for Resident 93's sacrococcyx wound to deteriorate further due to wound treatments not being continued and missed opportunities for assessments to monitor the progress of the wound. During a concurrent interview and record review, on 2/1/2023 at 2:28 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she worked on 1/6/2023 and was assigned to residents in station 2 including Resident 93. LVN 3 reviewed Resident 93's TAR and stated the wound treatment was provided for Resident 93 on 1/6/2023. However, LVN 3 stated she did not get a chance to observe the Resident 93's sacrococcyx wound since the treatment was provided by another LVN who offered to assist her that day. LVN 3 stated that a wound assessment was not completed on 1/6/2023 and only the ordered wound treatment was done. LVN 3 stated the weekly wound assessment should have been completed to measure the wound and monitor for any changes and abnormalities that needed to be communicated to the physician promptly. LVN 3 stated there is potential for further skin issues and worsening of existing pressure injuries if skin is not assessed weekly. During a concurrent interview and record review, on 2/2/2023 at 8:50 a.m., the Registered Dietitian (RD) stated she was unaware Resident 93's sacrococcyx wound had deteriorated to a stage 4 pressure injury and confirmed that she was not notified, stating that she would have documented in the dietary/nutritional progress notes addressing the wound. The RD stated she did not receive a call from the treatment nurse and that she did not receive an autopopulated (to automatically fill a form) alert via email which should have been triggered if a resident develops a wound or has wound that has worsened. The RD reviewed Resident 93's dietary progress note, dated 1/29/2023, and stated she did not make any changes or provide new recommendations for wound management since Resident 93's most recent weekly wound assessment, dated 1/27/2023, that she reviewed indicated the sacrococcyx wound had decreased in size. The RD further stated the treatment nurse should have notified her immediately for timely interventions and recommendations for wound management since wound healing can be inhibited if interventions are not implemented promptly. The RD stated that if she had been notified, she would have made recommendations to check laboratory results for complete blood count (CBC, blood test used to look at overall health and help diagnose a medical condition), basic metabolic panel (BMP, blood test that measures the body's fluid and electrolyte balance), albumin (is a protein made by the liver), and prealbumin and reevaluated the need for zinc (essential mineral) and arginaid (a supplement) to promote wound healing. During a concurrent interview and record review, on 2/2/2023 at 10:19 a.m., Treatment Nurse 2 (TN 2) stated she worked on 12/29/2022 and stated she was the only treatment nurse available during the day shift. TN 2 reviewed Resident 93's TAR for December 2022 and stated there was no documented evidence wound treatment was provided for Resident 93's sacrococcyx pressure injury on 12/29/2022. TN 2 stated she did not provide wound care for Resident 93 on that day. TN 2 further stated she did not call the doctor for a new wound treatment order and stated she was unaware the wound treatment for 12/29/2022 was the last scheduled treatment. TN 2 stated WOCN 1 should have been notified to ensure Resident 93 continued to receive wound treatments for her sacrococcyx pressure injury. TN 2 further stated it is important that treatments are not missed to prevent Resident 93's wound from deteriorating and prevent wound infections. During an interview, on 2/2/2023 at 10:28 a.m., LVN 8 stated she worked on 12/29/2022 and stated she did not remember providing a wound treatment for Resident 93. LVN 8 stated that Resident 93's TAR for December 2022 indicated that a wound treatment was not provided on 12/29/2022. During an interview, on 2/2/2023 at 3:45 p.m., WOCN 1 stated Resident 93's sacrococcyx pressure injury was a stage 3 and was stable and small in size when she had visited the resident on 12/16/2022. WOCN 1 stated she was on vacation starting 12/22/2022 and stated her next visit to see Resident 93 was on 1/17/2023 when she noticed Resident 93's sacrococcyx wound had suddenly worsened and deteriorated very fast. WOCN 1 stated she also found Resident 93 to have a fever of 100.4 degrees Fahrenheit and there was foul odor coming from the sacrococcyx wound. WOCN 1 confirmed Resident 93's sacrococcyx wound had increased in size with visible muscle and bone and stated the wound had progressed to a stage 4 pressure injury. WOCN 1 stated she notified Medical Doctor 1 (MD 1) and ordered a wound treatment on 1/17/2023. WOCN 1 stated since she was not available, the treatment nurse should have called MD 1 prior to when the last treatment was provided on 12/29/2022 so there is no lapse in wound treatment. During an interview, on 2/2/2023 at 5:16 p.m., the Director of Nursing (DON) stated Resident 93 did not receive wound care for her sacrococcyx pressure injury when the ordered treatment ended on 12/29/2022 until a new treatment order was obtained on 1/2/2023 upon reviewing Resident 93's TAR. During a concurrent record review of Resident 93's Wound Weekly Monitoring Assessment, dated 12/23/2022 to 1/16/2023, the DON stated there were missing assessments on 12/30/2022 and 1/6/2023. The DON stated the treatment nurses should have assessed Resident 93's sacrococcyx pressure injury and documented on the Wound Weekly Monitoring Assessment every week. The DON stated Resident 93's sacrococcyx wound was assessed to be a stage 3 pressure injury measuring 3.8 cm in length by 2.9 cm in width and 0.1 cm in depth om 12/23/2022 and that the wound had worsened to unstageable pressure injury when assessed on 1/13/2023 and further deteriorated to stage 4 pressure injury measuring 8.5 cm in length by 8.5 cm in width by 4 cm in depth when reassessed on 1/16/2023. During an interview, on 2/3/2023 at 1:19 p.m., MD 1 stated the facility did not call her to reorder wound treatment for Resident 93 between 12/27/2022 and 1/1/2023. MD 1 checked the message system and verified there were no calls received from the facility. MD 1 stated if she had been called, she would have ordered a treatment and not allowed the treatment to come to a stop or be discontinued. MD 1 stated Resident 93 has a deep stage 3 pressure injury on the sacrococcyx that requires continued treatment for wound healing. MD 1 further stated she would have consulted with WOCN 1 for treatment recommendations and would have adjusted the treatment order depending on if the wound was getting better or worse. During an interview, on 2/3/2023 at 2:55 p.m., the DON stated no one had been auditing the weekly wound assessments and therefore were missed. During a concurrent interview and record review, on 2/3/2023 at 3:07 p.m., the Director of Staff Development (DSD) stated the following: Certified Nursing Assistant 6 (CNA 6) did not complete the weekly skin check for Resident 93 during shower day on 12/23/2022. CNA 4 did not complete the weekly skin check for Resident 93 when shower was provided on 12/30/2022. Certified Nursing Assistant 5 (CNA 5) did not complete weekly skin checks during shower days for Resident 93 on 12/26/2022 and 1/6/2022. A review of the facility's current policy and procedure titled, Wound Management, last reviewed on 11/28/2022, indicated a resident who has a wound will receive the necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing. The policy and procedure further indicated the following: A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. Implement a wound treatment per physician's order. The attending physician will be notified to advise on appropriate treatment promptly. Dietary contact will be made for nutritional assessment for wound management. CNAs will complete body checks on resident's shower days and report unusual findings to the licensed nurse. Wound documentation will occur at a minimum of weekly until the wound is healed. Documentation will include: o Location of wound o Length, width, and depth measurements recorded in centimeters o Direction and length of tunneling and undermining if applicable o Appearance of wound base o Drainage amount and characteristics including color, consistency, and odor o Appearance of wound edges o Description of the peri-wound condition or evaluation of the skin adjacent to the wound o Presence or absence of new epithelium at wound rim o Presence of pain 44376 2. A review of Resident 104's Admission Record indicated the facility originally admitted the resident on 3/22/2022 with diagnoses that included acute respiratory failure with hypoxia (a condition that occurs when the respiratory system cannot adequately provide oxygen to the body), stroke, and quadriplegia (paralysis of all four limbs). A review of Resident 104's MDS, dated [DATE], indicated Resident 104 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 104 required total dependence (full staff performance every time during the entire seven-day assessment period) from two-person staff assistance for bed mobility, and transfer. The MDS indicated Resident 104 had a stage III (three) pressure ulcer (a full thickness tissue loss pressure ulcer in which subcutaneous fat [fat underneath the skin that can be grabbed and pinched between the fingers] may be visible, but bone, tendon [tissue attaching a muscle to a bone], or muscle is not exposed). A review of the Resident 104's SBAR: Change of Condition Form, dated 8/06/2022, indicated Resident 104 had a new open wound to the sacrococcyx area. A review of Resident 104's Braden Scale for Predicting Pressure Sore Risk, dated 12/16/2022, indicated a score of 12 (high risk for pressure injuries). A review of Resident 104's current Care Plan for Pressure Ulcer Stage III, initiated on 9/14/2022, indicated a goal that Resident 104 will show signs of pressure ulcer healing. The care plan indicated an intervention that licensed staff will conduct treatment as ordered and change when signs of healing are not noted. The care plan indicated an intervention that licensed staff will notify the resident's physician and family for changes. A review of Resident 104's Physician's Orders indicated an order, dated 2/1/2023, to cleanse the sacrococcyx pressure sore with normal saline (a salty solution to cleanse wounds), pat dry, apply collagen (a treatment medication to stimulate wound healing) to wound bed, followed by Dermaseptin ( brand name for a skin preparation, an ointment that provides a barrier to prevent irritation from moisture and to promote healing) to peri wound (tissue surrounding the wound), then apply a Duoderm (brand name for a commonly used hydrocolloid dressing [dressing to provide a moist and insulating environment to promote wound healing]) dressing, hold for 30 seconds, every day shift for wound management for 14 days. During a concurrent interview and wound observation with Licensed Vocational Nurse 1 (LVN 6) on 2/01/2023 at 9:02 a.m., observed LVN 6 change Resident 104's sacrococcyx dressing. Observed the stage III pressure ulcer which measured 1.5 centimeters (cm, a unit of measure in length) by 1.7 cm. LVN 6 did not measure the depth. Observed a dime shaped circular area of broken skin with red base beside the stage III wound on the upper right side. LVN 6 applied the collagen as ordered to the wound and the skin prep to the surrounding skin which covered the dime shaped reddened open area. When asked what the reddened area was, LVN 6 stated the dime-shaped circular area observed in the wound treatment observation was granulated (that part of the healing process in which lumpy, pink tissue containing new connective tissue forms around the edges of a wound) and not 100% closed skin, but the first layer of the skin was removed. When asked how long circular area had been present, LVN 6 stated she did not know since there was no documentation specifically for that area of reddened area. When asked if the broken skin area was getting larger, treatment nurse stated she did not know. LVN 6 stated she had observed the broken skin before but has not measured it. LVN 6 stated she would describe the dime-shaped, red, circular broken skin as the peri-wound which was red and granulated. LVN 6 stated the wound description needed more clarification since the red, circular, dime-shaped area looks different than the skin touching and surrounding the stage III ulcer. LVN 6 stated documenting accurately is important so it can be monitored and will not increase in size. During a concurrent record review and interview with LVN 6 on 2/02/2023 at 9:45 a.m., reviewed Resident 104's August 2022 Treatment Administration Record (TAR, the form in which treatments such as dressing changes are documented after completing for that day). The TAR indicated there were blank spaces on 8/15/2022, 8/20/2022, and 8/22/2022 for Resident 104's wound treatment. When asked about those blank spaces for Resident 104's August 2022 TAR, LVN 6 stated she did not know what they indicated since she did not conduct Resident 104's wound treatments in August 2022. During an interview on 02/02/23 10:09 a.m., and concurrent record review of the facility's policy and procedure titled, Change of Condition Notification, reviewed 11/28/2022, the DON stated the part of the policy and procedure that indicated a significant change in the resident's physical status referred to development of new breakdown in skin. The DON stated, although not specifically indicated, skin breakdown is considered a significant change in condition. The policy and procedure indicated the attending physician will be notified timely with a resident's change in condition. The DON stated there should have been a change in condition form completed when the broken skin was first observed. The DON stated the resident's physician should have been notified. The DON stated it was important for the resident's physician to be aware so they can order treatment to prevent the wound from getting larger. The DON stated this open area might require different treatment than the ordered skin preparation ointment since there is open skin and is different in appearance from the rest of the skin surrounding the stage III pressure ulcer. When asked about the blank spaces on Resident 104's August 2022 TAR, she stated she could not verify the treatments were done on those dates. The DON stated if there is no documentation then there was the possibility that the treatments were not done on those days. A review of the facility's policy and procedure titled, Pressure Ulcer Prevention, reviewed 11/28/2022, indicated if a resident is identified as having a wound at any time other than admission, the Wound Monitoring Record will be implemented. The policy and procedure indicated a Wound Monitoring Record will be implemented for each identified wound. 34659 3. A review of Resident 121's Admission Record indicated the facility admitted the resident on 10/10/2022 and was readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), diabetes type II (an impairment in the way the body regulates and uses sugar as fuel), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 121's History & Physical (H&P), dated 11/10/2022, indicated that the resident had the capacity to understand and make decisions. A review of Resident 121's MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. The MDS indicated that the resident required total dependence on bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The MDS also indicated, that the resident required one to two persons' physical assist. The MDS further indicated that the resident was always incontinent of stool (feces) and the resident had an unstageable deep tissue injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed). The MDS indicated that the resident's weight was 143 pounds (lbs., a unit of weight). A review of the Braden Scale for Predicting Pressure Sore Risk, dated 10/10/2022, indicated that Resident 121 was at high risk for developing pressure injury. A review of Resident 121's Order Summary Report, dated 11/20/2022, indicated an order for low air loss mattress (a mattress designed to prevent and treat pressure injuries) every shift for wound management/skin management. A review of Resident 121's Wound Weekly Monitoring Assessment- Pressure, dated 1/17/2023, indicated a sacrococcyx extending to the right and left measuring 2.3 centimeters by 2.1 cm by 0.2 cm, stage III. A review of Resident 121's Care Plan, revised date 1/28/2023, indicated a care plan for pressure injury stage 3 skin integrity impaired: sacrococcyx extending to the right and left buttock. During a concurrent observation and interview on 1/30/2023, at 10:40 a.m., with Registered Nurse 3 (RN 3), observed the bed setting of the low air loss mattress of Resident 121 was maximum inflated at 250. RN 3 stated that the setting should be at 120. RN 3 further stated that the setting was probably changed when the staff changed Resident 121's incontinence pad, she was not sure how long the mattress was maximum inflated. RN 3 stated that it is not appropriate for Resident 121's weight which was only 120 to 150 lbs. If the resident had a bedsore, it would make it worse. A review of the facility's recent policy and procedure titled Pressure Ulcer Prevention, dated 11/28/2022, indicated that the purpose of the policy was to identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. A review of the facility's recent policy and procedure titled Wound Management, dated 11/29/2022, indicated that an assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to mechanical offloading and pressure reducing devices. A review of the Manufacturer's Guideline on the use of Alta [NAME] Plus 760000 Alternating Pressure/Low Air Loss Mattress System, dated 2011, indicated on pressure adjustment, generally, a lighter patient will need a lower (softer) setting while a heavier patient will need a higher (firmer) setting, but pressure adjustment must ultimately be based on the patient's weight distribution.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was unable to walk, was incontinent (unable to voluntarily control) of bowel and bladder functions, and was dependent on staff for activities of daily living (ADLs, such as bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). On 4/27/22, around 5 pm, after returning to the facility from conducting personal business at the Department of Motor Vehicles (DMV) and without prior notice and preparation, Resident 1 was discharged against medical advice (AMA) because the resident left with a friend to the DMV and the physician (MD 2) had cancelled (discontinued) the order given earlier the same day to go out on pass (OOP, being temporarily absent from the facility). As a result, Resident 1 spent the night alone at an empty apartment without food, air conditioning, and telephone to call for help, sitting in his wheelchair soaked in urine and feces (bowel movements or stool), and was found by a friend and Family Member 1 (FM 1) on the floor the following day (4/28/22) around 1 pm, crying, hungry, thirsty, soiled, scared, embarrassed, in pain, helpless, and was traumatized. On 7/15/22 at 12:06 pm, the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation under 42CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator (ADM), the Assistant Director of Nursing (ADON), and the Social Services Director (SSD) were notified of the IJ situation from the facility ' s failure to ensure Resident 1 was free from neglect. On 7/16/22 at 12:00 pm, the IJ situation was removed in the presence of the ADM, while onsite, after verifying the implementation of the facility ' s submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions: 1. The facility attempted to contact Resident 1 and their representative to invite him to return to the facility or to assist Resident 1 with being admitted to another facility. 2. The SSD, ADM, and ADON reviewed all residents ' records with planned discharge/transfer to ensure compliance with regulatory requirements. 3. The SSD provided training to the ADM, the ADON, and three physicians on the facility ' s policies and procedures pertaining to discharging residents, resident rights, and resident neglect. 4. The facility created a discharge procedure checklist and discharge documentation auditing program to ensure all discharge planning is completed before a resident is discharged from the facility. 5. Training to all social services and nursing staff regarding the facility ' s discharge documentation auditing program, discharge procedures, resident rights, and resident neglect. Cross-reference F622, F623, and F624. Findings: A review of Resident 1 ' s Admission Record (Face Sheet), dated 6/24/22, indicated the facility admitted Resident 1, a [AGE] year-old male, on 11/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/26/21 and 2/26/22, indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 1 was incontinent (unable to voluntarily control) of bowel and bladder functions, was totally dependent on staff for transferring in and out of his bed, with toilet use, personal hygiene, dressing, and bathing/showering. Resident 1 was unable to walk and required a wheelchair for mobility. A review of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same day the order was discontinued. A review of Resident 1's Health Status Note, written by Licensed Vocational Nurse 9 (LVN 9), dated 4/27/22, indicated Resident 1 returned to facility asking for medication to be sent with him for AMA discharge. The physician (MD 3) was contacted to notify of resident's discharge AMA and to obtain authorization to give the resident his medications upon discharge. MD 3 gave the okay to discharge Resident 1 AMA with all remaining medication. Resident 1 was discharged AMA, via wheelchair, accompanied by family, and with all remaining medications. On 7/8/22, at 2:37 pm, during an interview with MD 2 and concurrent review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated he did not personally give or discontinue Resident 1 ' s order to go OOP on 4/27/22 to the DMV. MD 2 stated a resident must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated MDs 1 and 3 suspected Resident 1 was doing drug-related activities and that was the reason the why they canceled Resident 1 ' s OOP order. MD 2 stated that to his knowledge, Resident 1 did not have a drug test confirming the suspected drug-related activities and did not have documented safety concerns for Resident 1 go OOP. MD 2 stated he did not give a discharge order. MD 2 stated there was no immediate plan to discharge Resident 1. On 7/12/22 at 10:40 am, during an interview, Resident 1 stated that on 4/27/22, he and a family friend (FF 1) went to the DMV and returned to the facility around 4 pm. After the staff assisted him with incontinent care, a staff told him he had to leave the facility immediately because he went to the DMV without permission from a physician. Resident 1 stated FF 1 wheeled him out at 5 pm. Resident 1 stated he felt messed up, it's like I knew I wasn't ready to leave the facility for good. They knew I had nowhere to go at the time, but they didn't care what was going to happen to me. Resident 1 stated Resident 2 offered him to stay at his place and FF 1 and another friend brought him to the apartment, located on a second floor. Thefriends were not able to put him in bed because the hospital bed in the apartment was too high. The friends left to go to work, and he stayed alone. Resident 1 stated he could not reach cups to serve water from the faucet to drink from because they were in high cabinets, and he had to drink from a faucet in the bathroom using his hand. Resident 1 stated his cellphone was broken and he could not call anybody for help, he was scared and helpless. There was no food or air conditioning in the apartment. Resident 1 said he had nothing to eat the evening of 4/27/22 and spent the entire night in his wheelchair soiled and wet. Resident 1 stated that Resident 2 informed Family Member 1 (FM 1) where he was. The following day, 4/28/22, at 1 pm, FM 1 and a friend came to rescue him. Resident 1 stated he was embarrassed, afraid, hungry, thirsty, in pain, and traumatized. On 7/12/22, at 11:35 am, during an interview, Resident 2 (Resident 1 ' s roommate) stated that on 4/27/22, after the facility did not allow Resident 1 to return, he gave him permission to stay in his vacant apartment which had a hospital bed. The following day after not being able to contact Resident 1 by phone, he called FM 1. On 7/12/22, at 3:30 pm, during an interview, Case Manager (CM) stated on 4/27/22 she became aware that Resident 1 had a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 told her to cancel the order which she did and notified the ADM. CM stated she did not know what the safety concerns were. CM 1 stated she did not provide Resident 1 with a discharge assessment, a notice of discharge, or a discharge care plan. On 7/12/22, at 3:40 pm, during an interview, the ADM stated on 4/27/22, CM informed him that a physician had canceled Resident 1 ' s order to go OOP to the DMV due to safety concerns. On 7/13/22, at 12:40 pm, during an interview, FM 1 stated the facility did not inform her they were discharging Resident 1 on 4/27/22. FM 1 learned the following day (4/28/2022) about the discharge of Resident 1 after she called the facility, and the nurse told her Resident 1 was gone and did not know where he went. FM 1 stated she felt upset and scared not knowing where Resident 1 was, and then Resident 2 called her and informed her Resident 1 was in his apartment. FM 1 stated she did not have a car and so she asked a friend of hers to go check on Resident 1. FM 1 stated the friend found Resident 1 in Resident 2 ' s apartment but Resident 1 could not get to the door because he had fallen and was crying. FM 1 stated the friend went to pick her up and both returned to Resident 2 ' s apartment where Resident 1 was on the floor, crying, wet with urine and soiled with feces. FM 1 crying stated she felt awful seeing Resident 1 soaking wet and with feces all over his back. FM 1 stated Resident 1 was too traumatized to go back to a facility. He (Resident 1) won ' t even go to a hospital because he thinks they'll make him go to another place like that (the facility) and he ' s (Resident 1) too scared. On 7/13/22, at 5 pm, during an interview, MD 1 stated residents require a physician's permission to leave the facility. MD 1 stated discharge AMA applied to residents leaving OOP without a physician's permission and was a justification for immediate discharge from the facility. MD 1 stated MD 2 ordered the discharge AMA. On 7/15/22, at 12:30 pm, during an interview, the SSD stated the facility did not provide a safe discharge to Resident 1. On 7/15/22, at 1 pm, during an interview, SSD stated the facility did not ask Resident 1 to sign the form for Discharge AMA as per policy. SSD stated Resident 1 did not request to be discharged AMA. On 4/27/22, Resident 1 went to the DMV and when he returned to the facility staff told him he had to leave immediately. On 7/15/22, at 2:50 pm, during an interview with the ADM and concurrent review of the facility ' s policy on Discharge AMA, the ADM stated Resident 1 was not provided with the Form A - Discharge Against Medical Advice for him to sign. A review of the facility ' s policy titled, Abuse Prevention and Prohibition Program, dated 6/1/21, indicated, Purpose to establish, operationalize, and maintain an Abuse Prevention and Prohibition Program designed to ensure . the prevention . of . neglect, mistreatment . in accordance with federal and state requirements . Policy I. Each resident has the right to be free from mistreatment, neglect . V. Identification A. The Facility provides Facility Staff with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect: .f. inadequate provision of care g. Caregiver indifference to resident ' s personal care and needs . i. Leaving someone unattended who needs supervision

Based on interview and record review the facility failed to permit one of five sampled (Resident 1) to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary and appropriate (needs could not be met at the facility, for safety of the resident or others, the resident no longer needs the services provided by the facility, or lack of payment) and failed to ensure the physician documented in Resident 1 ' s clinical record the basis of the transfer as per facility ' s policy on Transfer and Discharge. On 4/27/22, around 5 pm, after returning to the facility from conducting personal business at the Department of Motor Vehicles (DMV) and without prior notice, Resident 1 was discharged against medical advice (AMA) because the resident left with a friend to the DMV and the physician (MD 2) had cancelled (discontinued) the order given earlier the same day to go out on pass (OOP, being temporarily absent from the facility). As a result, Resident 1 spent the night alone at an empty apartment without food, air conditioning, and telephone to call for help, sitting in his wheelchair soaked in urine and feces (bowel movements or stools), and was found by a friend and Family Member 1 (FM 1) on the floor the following day (4/28/22) around 1 pm, crying, hungry, thirsty, soiled, in pain, scared, embarrassed, helpless, and was traumatized. On 7/15/22 at 12:06 pm, the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation under 42CFR §483.15(c) Transfer and discharge. The Administrator (ADM), the Assistant Director of Nursing (ADON), and the Social Services Director (SSD) were notified of the IJ situation from the facility ' s failure to ensure Resident 1 was permitted to remain in the facility. On 7/16/22 at 12:00 pm, the IJ situation was removed in the presence of the ADM, while onsite, and after verifying the implementation of the facility ' s submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions: 1. The facility attempted to contact Resident 1 and their representative to invite him to return to the facility or to assist Resident 1 with being admitted to another facility. 2. The SSD, ADM, and ADON reviewed all residents ' records with planned discharge/transfer to ensure compliance with regulatory requirements. 3. The SSD provided training to the ADM, the ADON, and three physicians on the facility ' s policies and procedures pertaining to discharging residents, resident rights, and resident neglect. 4. The facility created a discharge procedure checklist and discharge documentation auditing program to ensure all discharge planning is completed before a resident is discharged from the facility. 5. Training to all social services and nursing staff regarding the facility ' s discharge documentation auditing program, discharge procedures, resident rights, and resident neglect. Cross-reference F600, F623, and F624. Findings: A review of Resident 1 ' s Admission Record (Face Sheet), dated 6/24/22, indicated the facility admitted Resident 1, a [AGE] year-old male, on 11/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/26/21 and 2/26/22, indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 1 was incontinent (unable to voluntarily control) of bowel and bladder functions, was totally dependent on staff for transferring in and out of his bed, with toilet use, personal hygiene, dressing, and bathing/showering. Resident 1 was unable to walk and required a wheelchair for mobility. A review of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same day the order was discontinued. A review of Resident 1's Health Status Note, written by Licensed Vocational Nurse 9 (LVN 9), dated 4/27/22, indicated Resident 1 returned to facility (form OOP) asking for medication to be sent with him for AMA discharge. The physician (MD 3) was contacted to notify of resident's discharge AMA and to obtain authorization to give the resident his medications upon discharge. MD 3 gave the okay to discharge Resident 1 AMA with all remaining medication. Resident 1 was discharged AMA, via wheelchair, accompanied by family, and with all remaining medications. On 7/8/22, at 2:37 pm, during an interview with MD 2 and concurrent review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated he did not personally give or discontinue Resident 1 ' s order to go OOP on 4/27/22 to the DMV. MD 2 stated a resident must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated MDs 1 and 3 suspected Resident 1 was doing drug-related activities and that was the reason the why they canceled Resident 1 ' s OOP order. MD 2 stated that to his knowledge, Resident 1 did not have a drug test confirming the suspected drug-related activities and did not have documented safety concerns for Resident 1 go OOP. MD 2 stated he did not give a discharge order, did not conduct a physician ' s discharge medical evaluation, did not do a medication reconciliation, did not complete a discharge summary, and did not provide a written 30-day discharge notice of impending discharge. MD 2 stated there was no immediate plan to discharge Resident 1. On 7/12/22 at 10:40 am, during an interview, Resident 1 stated that on 4/27/22, he and a family friend (FF 1) went to the DMV and returned to the facility around 4 pm. After the staff assisted him with incontinent care, a staff told him he had to leave the facility immediately because he went to the DMV without permission from a physician. Resident 1 stated FF 1 wheeled him out at 5 pm. Resident 1 stated he felt messed up, it's like I knew I wasn't ready to leave the facility for good. They knew I had nowhere to go at the time, but they didn't care what was going to happen to me. Resident 1 stated Resident 2 offered him to stay at his place and FF 1 and another friend brought him to the apartment, located on a second floor. Thefriends were not able to put him in bed because the hospital bed in the apartment was too high. The friends left to go to work, and he stayed alone. Resident 1 stated he could not reach cups to serve water from the faucet to drink from because they were in high cabinets, and he had to drink from a faucet in the bathroom using his hand. Resident 1 stated his cellphone was broken and he could not call anybody for help, he was scared and helpless. There was no food or air conditioning in the apartment. Resident 1 said he had nothing to eat the evening of 4/27/22 and spent the entire night in his wheelchair soiled and wet. Resident 1 stated that Resident 2 informed Family Member 1 (FM 1) where he was. The following day, 4/28/22, at 1 pm, FM 1 and a friend came to rescue him. Resident 1 stated he was embarrassed, afraid, hungry, thirsty, in pain, and was traumatized. On 7/12/22, at 11:35 am, during an interview, Resident 2 (Resident 1 ' s roommate) stated that on 4/27/22, after the facility did not allow Resident 1 to return, he gave him permission to stay in his vacant apartment which had a hospital bed. Resident 2 stated that since he was unable to contact Resident 1 by phone, he called FM 1. On 7/12/22, at 3:30 pm, during an interview, Case Manager (CM) stated on 4/27/22 she became aware that Resident 1 had a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 told her to cancel the order which she did and notified the ADM. CM stated she did not know what the safety concerns were. CM 1 stated she did not provide Resident 1 with a discharge assessment, a notice of discharge, or a discharge care plan. On 7/12/22, at 3:40 pm, during an interview, the ADM stated on 4/27/22, CM informed him that a physician had canceled Resident 1 ' s order to go OOP to the DMV due to safety concerns. On 7/12/22, at 4 pm, during an interview, the Director of Medical Records (DMR), after reviewing Resident 1 ' s medical record, stated the resident ' s record did not contain: a physician ' s documentation of the basis of discharge; a physician ' s discharge evaluation; a physician ' s discharge summary; a nurse ' s discharge assessment; a 30-day written notice of discharge; a nursing discharge care plan; a medication list provided to Resident 1 with the necessary education about the medications; and an inventory list of belongings and equipment Resident 1 took with him when he was discharged on [DATE] at 5 pm. On 7/13/22, at 12:40 pm, during an interview, FM 1 stated the facility did not inform her they were discharging Resident 1 on 4/27/22. FM 1 learned the following day (4/28/2022) about the discharge of Resident 1 after she called the facility, and the nurse told her Resident 1 was gone and did not know where he went. FM 1 stated she felt upset and scared not knowing where Resident 1 was, and then Resident 2 called her and informed her Resident 1 was in his apartment. FM 1 stated she did not have a car and so she asked a friend of hers to go check on Resident 1. FM 1 stated the friend found Resident 1 in Resident 2 ' s apartment but Resident 1 could not get to the door because he had fallen and was crying. FM 1 stated the friend went to pick her up and both returned to Resident 2 ' s apartment where Resident 1 was on the floor, crying, wet with urine and soiled with feces. FM 1 crying stated she felt awful seeing Resident 1 soaking wet and with feces all over his back. FM 1 stated Resident 1 was too traumatized to go back to a facility. He (Resident 1) won ' t even go to a hospital because he thinks they'll make him go to another place like that (the facility) and he ' s (Resident 1) too scared. On 7/13/22, at 5 pm, during an interview, MD 1 stated residents require a physician's permission to leave the facility. MD 1 stated discharge AMA applied to residents leaving OOP without a physician's permission and was a justification for immediate discharge from the facility. MD 1 stated MD 2 ordered the facility to discharge Resident 1 AMA. MD 1 confirmed there was no planned discharge, physician ' s documentation of the basis for discharging Resident 1 and there was no discharge summary. On 7/15/22, at 12:30 pm, during an interview, the SSD stated the facility did not provide a safe discharge to Resident 1. On 7/15/22, at 1 pm, during an interview, SSD stated the facility did not ask Resident 1 to sign the form for Discharge AMA as per policy. SSD stated Resident 1 did not request to be discharged AMA. On 4/27/22, Resident 1 went to the DMV and when he returned to the facility staff told him he had to leave immediately. On 7/15/22, at 2:45 pm, during an interview, the ADM acknowledged the policy on Transfer and Discharge was not implemented when Resident 1 was discharged on [DATE]. On 7/15/22, at 3:10 pm, during an interview, the ADON stated Resident 1 ' s discharge was not planned or necessary based on the facility ' s policy on Transfer and Discharge. A review of the facility's policy titled, Transfer and Discharge, dated 6/1/21. The policy indicated, the facility will only transfer or discharge residents if: - The facility closes; - The resident fails to pay for their admission; - A physician determines and documents that the resident's needs cannot be met by the facility, - A physician determines and documents that the resident no longer needs the services of the facility; and - A physician determines and documents that the resident poses a threat to their own safety or the safety of others in the facility. The facility will provide and document the following discharge services: - A 30-day-written-notice of discharge; - A physician's evaluation of the resident ' s medical needs; - A physician ' s medication reconciliation; - A physician's discharge summary; - A nursing discharge assessment; - A nursing discharge nursing care plan; - A list of the resident ' s medications upon discharge; - Education regarding how a resident should take their medications; - A safe location to go the resident to go to; and - Arrange for another physician to take over the resident's care after they leave the facility. A review of the facility's policy titled, Discharge Against Medical Advice, dated 6/1/21, indicated the purpose of the policy was to respect the right of a resident or resident ' s representative to make informed decisions that are against medical advice and to inform them of the potential risks and consequences of their actions. If a resident desires to leave the facility against medical advice, a licensed nurse will ask the resident or the resident ' s representative to sign (the form) AD - 05 - Form A - Discharge Against Medical Advice . VIII. Nursing staff will document in the progress notes all pertinent information concerning the resident ' s actions, including the resident ' s stated reasons for his/her desire to leave the facility.

Based on interview and record review the facility failed provide one of five sampled (Resident 1) with a written notice of discharge at least 30 days in advance with the reason for the discharge, the effective date of discharge, the location to which the resident is discharged , and the information about the resident ' s appeal rights, as indicated in the facility ' s policy on Transfer and Discharge. On 4/27/22, around 5 pm, after returning to the facility from conducting personal business and without prior notice, Resident 1 was discharged against medical advice (AMA) because the resident left and the physician (MD 2) had cancelled (discontinued) the order given earlier the same day to go out on pass (OOP, being temporarily absent from the facility). As a result, Resident 1 spent the night alone at an empty apartment without food, air conditioning, and telephone to call for help, sitting in his wheelchair soaked in urine and feces (bowel movements or stool), and was found by a friend and Family Member 1 (FM 1) on the floor the following day (4/28/22) around 1 pm, crying, hungry, thirsty, soiled, scared, in pain, embarrassed, helpless, and was traumatized. On 7/15/22 at 12:06 pm, the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation under 42CFR §483.15(c)(3) Notice before transfer. The Administrator (ADM), the Assistant Director of Nursing (ADON), and the Social Services Director (SSD) were notified of the IJ situation from the facility ' s failure to ensure Resident 1 was afforded a written notice of discharge at least 30 days in advance. On 7/16/22 at 12:00 pm, the IJ situation was removed in the presence of the ADM, while onsite, after verifying the implementation of the facility ' s submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions: 1. The facility attempted to contact Resident 1 and their representative to invite him to return to the facility or to assist Resident 1 with being admitted to another facility. 2. The SSD, ADM, and ADON reviewed all residents ' records with planned discharge/transfer to ensure compliance with regulatory requirements. 3. The SSD provided training to the ADM, the ADON, and three physicians on the facility ' s policies and procedures pertaining to discharging residents, resident rights, and resident neglect. 4. The facility created a discharge procedure checklist and discharge documentation auditing program to ensure all discharge planning is completed before a resident is discharged from the facility. 5. Training to all social services and nursing staff regarding the facility ' s discharge documentation auditing program, discharge procedures, resident rights, and resident neglect. Cross-reference F600, F622, and F624. Findings: A review of Resident 1 ' s Admission Record (Face Sheet), dated 6/24/22, indicated the facility admitted Resident 1, a [AGE] year-old male, on 11/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/26/21 and 2/26/22, indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 1 was incontinent (unable to voluntarily control) of bowel and bladder functions, was totally dependent on staff for transferring in and out of his bed, with toilet use, personal hygiene, dressing, and bathing/showering. Resident 1 was unable to walk and required a wheelchair for mobility. A review of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same day the order was discontinued. A review of Resident 1's Health Status Note, written by Licensed Vocational Nurse 9 (LVN 9), dated 4/27/22, indicated Resident 1 returned to facility (from OOP) asking for medication to be sent with him for AMA discharge. The physician (MD 3) was contacted about Resident 1's discharge AMA and to obtain authorization to give the resident his medications upon discharge. MD 3 gave the okay to discharge Resident 1 AMA with all remaining medication. Resident 1 was discharged AMA, via wheelchair, accompanied by family, and with all remaining medications. On 7/8/22, at 2:37 pm, during an interview with MD 2 and concurrent review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated he did not personally give or discontinue Resident 1 ' s order to go OOP on 4/27/22 to the DMV. MD 2 stated a resident must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated MDs 1 and 3 suspected Resident 1 was doing drug-related activities and that was the reason the why they canceled Resident 1 ' s OOP order. MD 2 stated that to his knowledge, Resident 1 did not have a drug test confirming the suspected drug-related activities and did not have documented safety concerns for Resident 1 go OOP. MD 2 stated he did not give a discharge order, did not conduct a physician ' s discharge medical evaluation, did not do a medication reconciliation, did not complete a discharge summary, and did not provide a written 30-day discharge notice of impending discharge. MD 2 stated there was no immediate plan to discharge Resident 1. On 7/12/22 at 10:40 am, during an interview, Resident 1 stated that on 4/27/22, he and a family friend (FF 1) went to the DMV and returned to the facility around 4 pm. After the staff assisted him with incontinent care, a staff told him he had to leave the facility immediately because he went to the DMV without permission from a physician. Resident 1 stated FF 1 wheeled him out at 5 pm. Resident 1 stated he felt messed up, it's like I knew I wasn't ready to leave the facility for good. They knew I had nowhere to go at the time, but they didn't care what was going to happen to me. Resident 1 stated Resident 2 offered him to stay at his place and FF 1 and another friend brought him to the apartment, located on a second floor. Thefriends were not able to put him in bed because the hospital bed in the apartment was too high. The friends left to go to work, and he stayed alone. Resident 1 stated he could not reach cups to serve water from the faucet to drink from because they were in high cabinets, and he had to drink from a faucet in the bathroom using his hand. Resident 1 stated his cellphone was broken and he could not call anybody for help, he was scared and helpless. There was no food or air conditioning in the apartment. Resident 1 said he had nothing to eat the evening of 4/27/22 and spent the entire night in his wheelchair soiled and wet. Resident 1 stated that on 4/28/22, Resident 2 informed Family Member 1 (FM 1) where he was. On 4/28/22, at 1 pm, FM 1 and a friend came to rescue him. Resident 1 stated he was embarrassed, afraid, hungry, thirsty, in pain, and was traumatized. On 7/12/22, at 11:35 am, during an interview, Resident 2 (Resident 1 ' s roommate) stated that on 4/27/22, after the facility did not allow Resident 1 to return, he gave him permission to stay in his vacant apartment which had a hospital bed. Resident 2 stated since he was unable to contact Resident 1 by phone, he called FM 1 and told her where Resident 1 was. On 7/12/22, at 3:30 pm, during an interview, Case Manager (CM) stated on 4/27/22 she became aware that Resident 1 had a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 told her to cancel the order which she did and notified the ADM. CM stated she did not know what the safety concerns were. CM 1 stated she did not provide Resident 1 with a discharge assessment, a notice of discharge, or a discharge care plan. On 7/12/22, at 3:40 pm, during an interview, the ADM stated on 4/27/22, CM informed him that a physician had canceled Resident 1 ' s order to go OOP to the DMV due to safety concerns. On 7/12/22, at 4 pm, during an interview, the Director of Medical Records (DMR), after reviewing Resident 1 ' s medical record, stated the resident ' s record did not contain: a physician ' s documentation of the basis of discharge; a physician ' s discharge evaluation; a physician ' s discharge summary; a nurse ' s discharge assessment; a 30-day written notice of discharge; a nursing discharge care plan; a medication list provided to Resident 1 with the necessary education about the medications; and an inventory list of belongings and equipment Resident 1 took with him when he was discharged on [DATE] at 5 pm. On 7/13/22, at 12:40 pm, during an interview, FM 1 stated the facility did not inform her they were discharging Resident 1 on 4/27/22. FM 1 learned the following day (4/28/2022) about the discharge of Resident 1 after she called the facility, and the nurse told her Resident 1 was gone and did not know where he went. FM 1 stated she felt upset and scared not knowing where Resident 1 was, and then Resident 2 called her and informed her Resident 1 was in his apartment. FM 1 stated she did not have a car and so she asked a friend of hers to go check on Resident 1. FM 1 stated the friend found Resident 1 in Resident 2 ' s apartment but Resident 1 could not get to the door because he had fallen and was crying. FM 1 stated the friend went to pick her up and both returned to Resident 2 ' s apartment where Resident 1 was on the floor, crying, wet with urine and soiled with feces. FM 1 crying stated she felt awful seeing Resident 1 soaking wet and with feces all over his back. FM 1 stated Resident 1 was too traumatized to go back to a facility. He (Resident 1) won ' t even go to a hospital because he thinks they'll make him go to another place like that (the facility) and he ' s (Resident 1) too scared. On 7/13/22, at 5 pm, during an interview, MD 1 stated residents require a physician's permission to leave the facility. MD 1 stated discharge AMA applied to residents leaving OOP without a physician's permission and was a justification for immediate discharge from the facility. MD 1 stated MD 2 ordered the facility to discharge Resident 1 AMA. MD 1 confirmed there was no planned discharge, physician ' s documentation of the basis for discharging Resident 1 and there was no discharge summary. On 7/15/22, at 12:30 pm, during an interview, the SSD stated the facility did not provide a safe discharge to Resident 1. On 7/15/22, at 12:50 pm, during an interview, SSD stated the resident was not given a written notice of discharge at least 30 days in advance with the reason for discharge, the effective date and the appeals rights. SSD stated Resident 1 ' s discharge was not planned. On 7/15/22, at 1 pm, during an interview, SSD stated the facility did not ask Resident 1 to sign the form for Discharge AMA as per policy. SSD stated Resident 1 did not request to be discharged AMA. On 4/27/22, Resident 1 went to the DMV and when he returned to the facility staff told him he had to leave immediately. On 7/15/22, at 2:45 pm, during an interview, the ADM stated Resident 1 was not given a written notice of discharge 30 days prior to discharge on 4/27/22. On 7/15/22, at 3:10 pm, during an interview, the ADON stated Resident 1 ' s discharge was not planned, and a notice of discharge was not given to Resident 1 at least 30 days in advance. A review of the facility's policy titled, Transfer and Discharge, dated 6/1/21. The policy indicated the facility will provide a 30-day written notice of discharge.

Based on interview and record review the facility failed to provide sufficient preparation to ensure a safe discharge for one of five sampled residents (Resident 1). On 4/27/22, around 5 pm, after returning to the facility from conducting personal business at the Department of Motor Vehicles (DMV) and without prior notice, preparation and orientation, Resident 1 was discharged against medical advice (AMA) because the resident left with a friend to the DMV and the physician (MD 2) had cancelled (discontinued) the order given earlier, on the same day, to go out on pass (OOP, being temporarily absent from the facility). Resident 1 did not have a place where to go and was not given time to make living arrangements. As a result, Resident 1 spent the night alone at an empty apartment without food, air conditioning, and telephone to call for help, sitting in his wheelchair soaked in urine and feces (bowel movements or stool), and was found by a friend and Family Member 1 (FM 1) on the floor the following day (4/28/22) around 1 pm, crying, hungry, thirsty, soiled, scared, in pain, embarrassed, helpless, and was traumatized. On 7/15/22 at 12:06 pm, the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation under 42CFR §483.15(c)(7) Orientation for transfer or discharge. The Administrator (ADM), the Assistant Director of Nursing (ADON), and the Social Services Director (SSD) were notified of the IJ situation from the facility ' s failure to ensure Resident 1 was provided sufficient preparation and orientation to ensure safe and orderly discharge from the facility. On 7/16/22 at 12:00 pm, the IJ situation was removed in the presence of the ADM, while onsite, and after verifying the implementation of the facility ' s submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions: 1. The facility attempted to contact Resident 1 and their representative to invite him to return to the facility or to assist Resident 1 with being admitted to another facility. 2. The SSD, ADM, and ADON reviewed all residents ' records with planned discharge/transfer to ensure compliance with regulatory requirements. 3. The SSD provided training to the ADM, the ADON, and three physicians on the facility ' s policies and procedures pertaining to discharging residents, resident rights, and resident neglect. 4. The facility created a discharge procedure checklist and discharge documentation auditing program to ensure all discharge planning is completed before a resident is discharged from the facility. 5. Training to all social services and nursing staff regarding the facility ' s discharge documentation auditing program, discharge procedures, resident rights, and resident neglect. Cross-reference F600, F622, and F623. Findings: A review of Resident 1 ' s Admission Record (Face Sheet), dated 6/24/22, indicated the facility admitted Resident 1, a [AGE] year-old male, on 11/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/26/21 and 2/26/22, indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 1 was incontinent (unable to voluntarily control) of bowel and bladder functions, was totally dependent on staff for transferring in and out of his bed, with toilet use, personal hygiene, dressing, and bathing/showering. Resident 1 was unable to walk and required a wheelchair for mobility. A review of physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same day the order was discontinued. A review of Resident 1's Health Status Note, written by Licensed Vocational Nurse 9 (LVN 9), dated 4/27/22, indicated Resident 1 returned to facility asking for medication to be sent with him for AMA discharge. The physician (MD 3) was contacted about Resident 1's discharge AMA and to obtain authorization to give the resident his medications upon discharge. MD 3 gave the okay to discharge Resident 1 AMA with all remaining medication. Resident 1 was discharged AMA, via wheelchair, accompanied by family, and with all remaining medications. On 7/8/22, at 2:37 pm, during an interview with MD 2 and concurrent review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated he did not personally give or discontinue Resident 1 ' s order to go OOP on 4/27/22 to the DMV. MD 2 stated a resident must have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 2 stated MDs 1 and 3 suspected Resident 1 was doing drug-related activities and that was the reason the why they canceled Resident 1 ' s OOP order. MD 2 stated that to his knowledge, Resident 1 did not have a drug test confirming the suspected drug-related activities and did not have documented safety concerns for Resident 1 go OOP. MD 2 stated he did not give a discharge order, did not conduct a physician ' s discharge medical evaluation, did not do a medication reconciliation, did not complete a discharge summary, and did not provide a written 30-day discharge notice of impending discharge. MD 2 stated there was no immediate plan to discharge Resident 1. On 7/12/22 at 10:40 am, during an interview, Resident 1 stated that on 4/27/22, he and a family friend (FF 1) went to the DMV and returned to the facility around 4 pm. After the staff assisted him with incontinent care, a staff told him he had to leave the facility immediately because he went to the DMV without permission from a physician. Resident 1 stated FF 1 wheeled him out at 5 pm. Resident 1 stated he felt messed up, it's like I knew I wasn't ready to leave the facility for good. They knew I had nowhere to go at the time, but they didn't care what was going to happen to me. Resident 1 stated Resident 2 offered him to stay at his place and FF 1 and another friend brought him to the apartment, located on a second floor. The friends were not able to put him in bed because the hospital bed in the apartment was too high. The friends left to go to work, and he stayed alone. Resident 1 stated he could not reach cups to serve water from the faucet to drink from because they were in high cabinets, and he had to drink from a faucet in the bathroom using his hand. Resident 1 stated his cellphone was broken and he could not call anybody for help, he was scared and helpless. There was no food or air conditioning in the apartment. Resident 1 said he had nothing to eat the evening of 4/27/22 and spent the entire night in his wheelchair soiled and wet. Resident 1 stated that the following day, 4/28/22, Resident 2 informed Family Member 1 (FM 1) where he was. On 4/28/22 at 1 pm, FM 1 and a friend came to rescue him. Resident 1 stated he was embarrassed, afraid, hungry, thirsty, in pain, and was traumatized. On 7/12/22, at 11:35 am, during an interview, Resident 2 (Resident 1 ' s roommate) stated that on 4/27/22, after the facility did not allow Resident 1 to return, he gave him permission to stay in his vacant apartment which had a hospital bed. On 7/12/22, at 3:30 pm, during an interview, Case Manager (CM) stated on 4/27/22 she became aware that Resident 1 had a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 3 told her to cancel the order which she did and notified the ADM. CM stated she did not know what the safety concerns were. CM 1 stated she did not provide Resident 1 with a discharge assessment, a notice of discharge, or a discharge care plan. On 7/12/22, at 3:40 pm, during an interview, the ADM stated on 4/27/22, CM informed him that a physician had canceled Resident 1 ' s order to go OOP to the DMV due to safety concerns. On 7/12/22, at 4 pm, during an interview, the Director of Medical Records (DMR), after reviewing Resident 1 ' s medical record, stated the resident ' s record did not contain: a physician ' s documentation of the basis of discharge; a physician ' s discharge evaluation; a physician ' s discharge summary; a nurse ' s discharge assessment; a 30-day written notice of discharge; a nursing discharge care plan; a medication list provided to Resident 1 with the necessary education about the medications; and an inventory list of belongings and equipment Resident 1 took with him when he was discharged on [DATE] at 5 pm. On 7/13/22, at 12:40 pm, during an interview, FM 1 stated the facility did not inform her they were discharging Resident 1 on 4/27/22. FM 1 learned the following day (4/28/2022) about the discharge of Resident 1 after she called the facility, and the nurse told her Resident 1 was gone and did not know where he went. FM 1 stated she felt upset and scared not knowing where Resident 1 was, and then Resident 2 called her and informed her Resident 1 was in his apartment. FM 1 stated she did not have a car and so she asked a friend of hers to go check on Resident 1. FM 1 stated the friend found Resident 1 in Resident 2 ' s apartment but Resident 1 could not get to the door because he had fallen and was crying. FM 1 stated the friend went to pick her up and both returned to Resident 2 ' s apartment where Resident 1 was on the floor, crying, wet with urine and soiled with feces. FM 1 crying stated she felt awful seeing Resident 1 soaking wet and with feces all over his back. FM 1 stated Resident 1 was too traumatized to go back to a facility. He (Resident 1) won ' t even go to a hospital because he thinks they'll make him go to another place like that (the facility) and he ' s (Resident 1) too scared. On 7/13/22, at 5 pm, during an interview, MD 1 stated residents require a physician's permission to leave the facility. MD 1 stated discharge AMA applied to residents leaving OOP without a physician's permission and was a justification for immediate discharge from the facility. MD 1 stated MD 2 ordered the facility to discharge Resident 1 AMA. MD 1 confirmed there was no planned discharge, physician ' s documentation of the basis for discharging Resident 1 and there was no discharge summary. On 7/15/22, at 12:30 pm, during an interview, the SSD stated the facility did not provide a safe discharge to Resident 1. On 7/15/22, at 1 pm, during an interview, SSD stated the facility did not ask Resident 1 to sign the form for Discharge AMA as per policy. SSD stated Resident 1 did not request to be discharged AMA. On 4/27/22, Resident 1 went to the DMV and when he returned to the facility staff told him he had to leave immediately. On 7/15/22, at 2:45 pm, during an interview, the ADM acknowledged the policy on Transfer and Discharge was not implemented when Resident 1 was discharged on [DATE]. On 7/15/22, at 3:10 pm, during an interview, the ADON stated Resident 1 ' s discharge was not planned or necessary based on the facility ' s policy on Transfer and Discharge. A review of the facility's policy titled, Transfer and Discharge, dated 6/1/21. The policy indicated, the facility will only transfer or discharge residents if: - The facility closes; - The resident fails to pay for their admission; - A physician determines and documents that the resident's needs cannot be met by the facility, - A physician determines and documents that the resident no longer needs the services of the facility; and - A physician determines and documents that the resident poses a threat to their own safety or the safety of others in the facility. The facility will provide and document the following discharge services: - A 30-day-written-notice of discharge; - A physician's evaluation of the resident ' s medical needs; - A physician ' s medication reconciliation; - A physician's discharge summary; - A nursing discharge assessment; - A nursing discharge nursing care plan; - A list of the resident ' s medications upon discharge; - Education regarding how a resident should take their medications; - A safe location to go the resident to go to; and - Arrange for another physician to take over the resident's care after they leave the facility. A review of the facility's policy titled, Discharge Against Medical Advice, dated 6/1/21, indicated the purpose of the policy was to respect the right of a resident or resident ' s representative to make informed decisions that are against medical advice and to inform them of the potential risks and consequences of their actions. If a resident desires to leave the facility against medical advice, a licensed nurse will ask the resident or the resident ' s representative to sign (the form) AD - 05 - Form A - Discharge Against Medical Advice . VIII. Nursing staff will document in the progress notes all pertinent information concerning the resident ' s actions, including the resident ' s stated reasons for his/her desire to leave the facility.

Based on interview and record review, the licensed nursing staff failed to meet professional standards of quality care for one of three sampled residents (Resident 1) by: 1. Failing to notify Resident 1's physician of abnormal labs of elevated blood sugar level, elevated sodium (an electrolyte and mineral, it is also important in how nerves and muscles work) level, and elevated levels of both Blood Urea [MEDICATION(S)] (BUN- measures the amount of [MEDICATION(S)] in the blood that comes from the waste product) and Creatinine (blood test that measure of how well the kidneys are performing their job of filtering waste from the blood). 2. Failing to monitor Resident 1's blood pressure a total of seven occurrences out of 30 for April 2020 as required prior to the administration of blood pressure medication. 3. Failing to notify Resident 1's physician of the resident's refusal of blood pressure medication and hypoglycemic (low blood sugar) medication. These deficient practices resulted in a delay of care and services for Resident 1. The resident was admitted to the General Acute Care Hospital (GACH) for Diabetic Ketoacidosis (serious complication of diabetes that occurs when your body produces high levels of ketones [blood acids]), severe [CONDITION(S)] (very high blood sodium level and associated with high mortality rate), [CONDITION(S)] (a condition in which kidneys can't filter waste from the blood), and placed the resident at risk for death. Findings: 1. A review of the Admission Record indicated the facility originally admitted Resident 1 on 4/15/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 1/22/2020 indicated the resident has moderately impaired cognition (mental action of acquiring knowledge and understanding through thought and the senses). Resident 1 needed extensive assistance with one-person physical assist for bed mobility, toilet use, and personal hygiene. A review of Resident 1's Laboratory Report dated 4/9/2020 indicated the following: 1. Blood glucose level of 395 milligrams per deciliter (mg/dL-unit of measure) (normal blood sugar levels are between 60-110 mg/dL ) 2. Sodium level of 157 Milliequivalents per liter (mEq/L-unit of measure) (normal blood sodium level is between 135 and 145 mEq/L) 3. BUN level of 49 mg/dL (normal BUN levels are between 7 to 20 mg/dL) 4. Creatinine of 2.3 mg/dL . (normal levels of creatinine in the blood is0.6 to 1.2 mg/dL). During a concurrent interview and record review on 6/10/2021 at 11:22 a.m. with the Director of Nursing (DON), Resident 1's skilled nursing facility medical record was reviewed. After reviewing Resident 1's medical record, DON stated that she could not find documented evidence that Resident 1's laboratory report from 4/9/2020 was reported to the physician. DON stated that licensed nurses should have documented in the progress notes or on the actual laboratory result that the physician was notified. DON stated that failure to report abnormal lab values such as a blood glucose level of 395 mg/dl places the resident at risk for Diabetic Ketoacidosis. During a telephone interview on 6/21/2021 at 12:45 p.m., the Attending Physician (MD 1) stated that if there were no documented evidence in Resident 1's medical record indicating that the physician was made aware of the abnormal lab report dated 4/9/2020, that means he was not notified. MD 1 stated that if he had been notified of Resident 1's lab report which indicated a blood sugar of 357 mg/dl, sodium level of 157 mEq/L, BUN level of 49mg/dl, and a creatinine level of 2.3 mg/dl, he would have ordered to have licensed nurses conduct blood sugar checks (a procedure that measures the amount of sugar, or glucose in your blood ) four times per day. MD 1 also stated that he would have ordered for intravenous fluid (liquids given to replace water, sugar, and salt that you might need) and reorder laboratory test to ensure its effectiveness. MD 1 stated that by not informing him about these results, this placed the Resident at risk for dehydration and Diabetic ketoacidosis. A review of Resident 1's Change of condition form dated 4/16/2020 indicated that Resident 1 was transferred to the General Acute Care Hospital (GACH). Resident 1 was having altered level of consciousness (state of being awake), decreased consciousness, and needed more assistance with Activities of Daily Living (ADLs- a term used to collectively describe fundamental skills that are required to independently care for oneself). A review of Resident 1's GACH emergency room Documentation dated 4/16/2020, indicated that Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's blood sugar level was 469 mg/dl. A review of the facility's policy and procedure titled Blood Glucose Monitoring with revised date of 11/1/2017, indicated that the attending physician will be notified of blood sugar levels lower than 70 or higher than 350, unless otherwise indicated in the plan of care. A review of the facility's policy and procedure titled Laboratory, Diagnostic and Radiology Services with revised date of 1/1/2017, indicated that the ordering practitioner will be notified of results that fall outside of clinical reference or expected normal ranges per the ordering practitioner's order. It also indicated that the licensed nurse would document the time when results were reported to the ordering practitioner and the ordering practitioner's response or additional orders, if any. 2. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. April 1, 2020 09:00 165/83 millimeters of mercury (mmHg-unit of measure) 5:00 p.m. 166/89 mmHg 2. April 2, 2020 09:00 155/68 5:00 mmHg p.m. 160/73 mmHg 3. April 3, 2020 09:00 a.m. 156/65 mmHg 5:00 p.m.161/63 mmHg 4. April 4, 2020 09:00 a.m. 166/84 mmHg 5:00 p.m.165/73 mmHg 5. April 5, 2020 09:00 a.m. 159/83 mmHg -5:00 p.m. 152/69 mmHg 6. April 6, 2020 09:00 a.m. 157/88 mmHg 5:00 p.m.124/58 mmHg 7. April 7, 2020 09:00 a.m. 161/77 mmHg 5:00 p.m.161/83 mmHg 8. April 8, 2020 09:00 a.m. 159/79 mmHg 5:00 p.m. 161/88 mmHg 9. April 9, 2020 09:00 a.m. 154/72 mmHg 5:00 p.m. none documented 10. April 10, 2020 09:00 a.m. none documented 5:00 p.m. none documented 11. April 11, 2020 09:00 a.m. 132/68 mmHg 5:00 p.m. 152/72 mmHg 12. April 12, 2020 09:00 a.m. 178/70 mmHg -5:00 p.m. none documented 13. April 13, 2020 09:00 a.m. 154/78 mmHg 5:00 p.m. none documented 14. April 14, 2020 09:00 a.m. none documented 5:00 p.m. 158/75 mmHg 15. April 15, 2020 09:00 a.m. 145/79 mmHg 5:00 p.m. none documented During a concurrent interview and record review on 6/10/2021 at 12:25 p.m. with the DON, Resident 1's medical record was reviewed. DON reviewed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedure titled Medication Administration dated 5/1/2021, indicated that when administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e., blood pressure). A review of the facility's policy and procedure titled Change of Condition Notification with revised date of 1/1/2017, indicated that an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, of functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. It also indicated that members of the Interdisciplinary team are expected to report and document signs and symptoms that might represent an ACOC. The facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in their condition, caused by, but not limited to a significant change in resident's physical, cognitive, behavioral or functional status. The attending physician will be notified timely with a resident's change in condition. 3. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to hold the medication if systolic blood pressure is less than 110 mmHg and heart rate less than 65 beats per minute (BPM). A review of Resident 1's MAR for month of April 2020 indicated that Resident 1 refused the blood pressure medication [MEDICATION(S)] scheduled for 9:00 a.m. on the following dates: 4/10/2020 and 4/14/2020. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to hold the medication if systolic blood pressure (SBP- the top number of a blood pressure reading referring to the pressure in your arteries [tubes that circulate blood] when your heart beats) is less than 110 and heart rate less than 60. A review of Resident 1's MAR for month of April 2020 indicated that Resident 1 refused the blood pressure medication [MEDICATION(S)] scheduled for 9:00 a.m. on the following days: 4/9/2020, 4/10/2020, 4/12/2020, 4/13/2020, 4/15/2020 and 4/16/2020. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR for the month of April 2020, indicated that Resident 1 refused his ordered medication of [MEDICATION(S)] scheduled for 5:00 p.m. on the following dates: 4/9/2020, 4/10/2020, 4/12/2020, 4/13/2020 and 4/15/2020. During an interview on 6/10/2021 at 12:25 p.m. with the DON, DON stated that when a resident refuses medication such as hypoglycemic (medications that lower blood sugar) medications, the physician should be made aware. A review of Resident 1's Care plan titled Resident 1 has hypertension dated 4/17/2019, indicated that resident has hypertension and one of the interventions were to give anti-hypertensive medication as ordered and monitor for side effects and effectiveness of the medication. During a concurrent interview and record review on 6/10/2021 at 12:25 p.m. with the DON, Resident 1's skilled nursing facility medical record was reviewed. DON verified that there was no documentation that the physician was made aware of the resident's refusal of [MEDICATION(S)] , [MEDICATION(S)] and [MEDICATION(S)]. DON stated that when a resident refuses medication such as blood pressure medications or hypoglycemic medication, the physician should be notified. A review of the facility's policy and procedure titled Medication Administration-General guidelines with updated date of 10/2019 indicated that if two consecutive doses of a vital medication are withheld, refused, or not available, the physician is notified.

Based on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents, (Resident 29), who was assessed at risk for falls and identified as a good candidate for toileting program, received care and services to prevent accidents, including: 1. Failure to ensure Resident 29's call light was within reach as indicated in the plan of care. 2. Failure to implement the Fall care plan to anticipate and meet the resident's need for toileting. 3. Failure to follow the facility's Fall Management Program to do root cause analysis and intervention to prevent future falls. Resident 29 fell on [DATE] trying to go the bathroom. The facility had no intervention to address the reason of the fall incident that the resident was trying to go to the bathroom. On May 15, 2018, Resident 29 fell and sustained forearm fracture (broken bone), trying to go the bathroom. These deficient practices had resulted in Resident 29 having four-fall incident including a fall with fracture on May 15, 2018. Resident 29 was transferred to General Acute Care Hospital (GACH) on May 16, 2018, and diagnosed with forearm fracture (broken bone) on the left wrist and returned to the facility with left arm splint. Findings: On September 6, 2018, at 7:35 a.m., during an observation, Resident 29 was observed in bed eating his breakfast. The resident's call light was observed on the left side of the bed, on the floor. During an interview with the resident, the resident stated he was not able to call for help when he needed to go to the bathroom because he did not know where the call light was. Resident 29 further stated that he remembered falling while trying to go to the bathroom by himself and injured his left wrist, but resident could not recall the date of his fall. Certified Nursing Assistant 3 (CNA 3) stated that she did not check the resident's call light was within when started her shift (7 a.m. to 3 p.m. shift) A review of Resident 29's Admission Record (Face Sheet), indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 29 diagnoses included [CONDITION(S)] (an illness that affects the part of the brain that controls how the body move); wedge compression fracture of first lumbar vertebra (when the bone collapses in the spine), difficulty in walking, and generalized muscle weakness. A review of Resident 29's History and Physical examination, dated December 14, 2017, indicated that resident had the capacity to understand and make decisions. A review of Resident 29's Admission Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated December 19, 2017, indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired, able to make self-understood and is able to understand others. The MDS indicated that Resident 29 required extensive assistance from staff for moving in bed, transferring from bed to wheelchair, dressing, toilet use, and limited assistance from staff for personal hygiene. The MDS also indicated no fall history any time in the last month, 2-6 months, or any fracture related to a fall in the 6 months prior to admission or entry to the facility. A review of Resident 29's Care Area Assessment Worksheet (CAA WS), dated January 6, 2018, indicated the resident was potential for falls were triggered by difficulty maintaining balance problems during transition. A review of Resident 29's Fall Risk Assessment, dated December 12, 2017, indicated the resident was a high risk for fall with a score of 20. A review of Resident 29's Fall Care Plan, initiated on January 5, 2018, indicated the resident to have an alarm on bed, due to resident trying to get out of bed by himself and at risk for falls. The goal was for resident to be free of falls and use call light to get out of bed. The interventions included for the resident to have bed alarm while in bed, bed to be in low position, while in bed, and frequent checks. The care plan was revised on February 19, 2018, with an intervention to anticipate and meet the resident needs, and call light within reach of the resident. A review of Resident 29's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form-Change of Condition Progress Note and Investigation Report indicated the following: 1. On February 18, 2018, at 12:15 p.m., indicated the resident was found lying on the floor on his left side. The Interdisciplinary Team (IDT) Progress Notes- Incident/Accident, dated February 19, 2018, indicated the resident had an actual fall on February 18, 2018. The resident was found lying on the floor on his left side, no injury. A review of the facility's Investigation Report titled, Fall dated February 18, 2018, indicated Resident 29 was last seen with Occupational Therapist (OT) on February 18, 2018 at 12:00 p.m. The noted indicated the OT turned off the resident's alarm on his wheelchair due to repetitive movement of sit to stand and the OT did not reconnect wheelchair alarm after treatment. 2. On April 17, 2018, at 6 p.m., indicated that Resident 29 fell attempting to get out of bed unassisted without calling for assistance. The resident was found sitting on the floor next to his bed, no injury. The IDT indicated that resident would benefit for a room change closer to nursing station for close monitoring. A review of the facility's Investigation Report dated April 17, 2018, indicated the resident stated that he was trying to get up to go to the bathroom. 3. On May 16, 2018, at 5:37 p.m., indicated that the resident had a fall dated May 15, 2018, at 5 p.m. The SBAR indicated the resident left wrist was swollen and the resident complaint of pain. The physician was notified and ordered an X-ray. A review of Resident 29's left hand X-ray indicated relatively acute (abrupt onset) appearing fracture (when the continuity of a bone is broken) of the distal radius (a break of the part of the bone which is close to the wrist). The resident was transferred to General Acute Care Hospital (GACH) for further evaluation and readmitted back to the facility on the same date, May 16, 2018. A review of the facility's Investigation Report titled, Fall dated May 15, 2018, indicated that resident was found on the floor on his left side facing the bed and was trying to go to the bathroom. The IDT agreed the resident fall was unavoidable due to resident non-complaint behavior. A review of Resident 29's GACH Discharge Instructions dated May 16, 2018, indicated that resident have been diagnosed with a forearm fracture. A splint (a brace to support and protect broken bones by restricting motion to allow the injured area to heal and prevent further injury) was applied. Resident 29 was also diagnosed with a minor head injury and was prescribed [MEDICATION(S)] tablet (a narcotic pain medication) 5 milligram (mg)/325 mg every 4 to 6 hours around the clock (ATC) and needed (PRN). 4. On July 31, 2018, at 6 a.m., indicated Resident 29 had an unwitnessed fall. The resident was found in a sitting position left leg extended straight and right leg bent with splint to the left arm due to a past fall with fracture. No injury. A review of the facility's Investigation Report, dated July 31, 2018 indicated Resident 29 fell as he was getting up to go to the bathroom. The note indicated that resident is frequently incontinent (no control) and will benefit from toileting schedule. On September 6, 2018 at 12:35 p.m., during an interview with Minimum Data Set / Licensed Vocational Nurse 1 (MDS LVN 1), MDS/LVN 1 stated that the resident was already a candidate for toileting schedule based on admission MDS dated [DATE]. MDS/LVN 1 stated that the resident was not placed on a toileting schedule until August 3, 2018, after fourth fall incident on July 31, 2018. MDS/LVN 1 stated that the facility IDT team missed addressing the reason of fall dated April 17, 2018, that the resident got up because the resident wanted to use the bathroom. On September 6, 2018 at 9:51 a.m., during an interview and concurrent record review of Resident 29's medical record with the Director of Nursing (DON), DON stated Resident 29's fall care plan was not implemented because the resident's call light was not within reach as observed on September 6, 2018 at 7:35 a.m. DON stated that the resident need for toileting was not addressed during the IDT post-fall investigation until August 3, 2018. On September 7, 2018 at 10:00 a.m., during a concurrent interview and record review, the DON was unable to provide documentation regarding resident's non-compliant behavior and no plan of care for this behavior. A review of Facility policy's Fall Management Program, revised on February 25, 2018, indicated that the IDT will meet within 72-hours of a fall and will review, document interventions to prevent future falls, and will document findings and recommendations in the resident's medical record. Following the resident's fall, the licensed nurse will complete an incident report and a Fall Risk Assessment as soon as practicable, the licensed nurse will review the circumstances of the fall, review the plan of care, implement new intervention as appropriate. The IDT will meet within 72 hours of a fall. The IDT will review and document the following: i. Summary of event following a fall; ii. Root cause analysis; iii. Referrals, as necessary; and iv. Interventions to prevent future falls