Every finding on record at Torrance Care Center West, Inc

Based on observation, interview, and record review, the facility failed to ensure staff documented personal belongings on the inventory list for one of three sampled residents (Resident 1). This failure has the potential to result in the inability to track Resident 1's personal belongings, verify reports of missing items, and ensure accountability for residents' personal property.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History and Physical, (H&P), dated 12/14/2025, the H&P indicated Resident 1 had the ability to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set up assistance (helper sets up or cleans up: resident completes activity) from staff with eating, oral hygiene, and supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) from staff with toileting hygiene, showering, and personal hygiene. During a review of Resident 1's Inventory Lists, dated 10/16/2025 and 12/12/2025, the Inventory Lists indicated Resident 1's personal inventory included one housecoat (robe) and one dress. During a concurrent observation and interview on 6/24/2026 at 11:20 a.m. with Resident 1 in Resident 1's room, 12 clothing items were observed in the closet. Resident 1 stated a pair of black pants had recently gone missing.During an interview on 6/25/2026 at 11:20 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, although Resident 1 had numerous clothing items in the closet, the only items were listed on the inventory list are the resident's and the rest of them were donated by the facility to Resident 1. LVN 1 stated the donated clothing is not considered residents' personal property hence why it is not documented on the resident inventory list. During an interview on 6/25/2026 at 11:50 a.m. with the Social Service Director (SSD), the SSD stated once the facility donates an item to a resident, the item becomes the president's personal property and staff should add it to the resident's inventory list and label it with the resident's name.During a concurrent observation and interview on 6/25/2026 at 12:29 p.m. in Resident 1's room, the SSD was observed inspecting Resident 1's closet and stated there were numerous items not listed on Resident 1's inventory list.During a concurrent interview and record review on 6/25/2026 at 12:35 p.m. with the SSD, Resident 1's Inventory Lists, dated 10/16/2025 and 12/12/2025 were reviewed. The SSD stated Resident 1's Inventory List did not accurately reflect the clothing currently in the closet and documented a limited number of clothing items. The SSD stated staff could not determine where the clothing currently in the closet came from. The SSD stated because the pair of black pants the resident reported missing was not documented on the inventory list, staff had no way to verify to track the missing item. The SSD stated all residents' personal belongings should be accounted for and inventoried upon admission and whenever additional items are received.During an interview on 6/25/2026 at 3:20 p.m. with the Director of Nursing (DON), the DON stated when residents received items including the donation, staff should add any items to the personal belongings inventory list to maintain an accurate record to track and prevent mix-ups.During the facility's undated policy and procedure (P&P) titled Resident Personal Belongings and Donations Policy, the P&P indicated the resident's belongings inventory shall be updated whenever significant personal belongings are added or removed. Once a donated item is assigned to a resident, it becomes that resident's personal property. The assigned item shall be documented on the resident's personal belongings inventory, including an appropriate description of the item. Any additional donated items assigned after admission shall also be added to the inventory to maintain an accurate record of the resident's belongings. Staff shall accurately document inventories, promptly report missing or damaged property, update inventories when belongings change, and ensure donated items assigned to residents are added to the resident's belongings inventory.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect by providing attentive, courteous, and respectful interactions during resident communication for one of three sampled residents (Resident 2) when Licensed Vocational Nurse (LVN) 1 engaged in personal activity on a cell phone while interacting with Resident 2. This failure resulted in Resident 2 not being treated with dignity and respect and had the potential for Resident 2 to feel ignored, dismissed, disrespected, unimportant and/or devalued.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/20/2019 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease ([CKD] a progressive loss in kidney function over a period of months or years), and epilepsy (a brain disorder in which a person has repeated seizures [uncontrolled movement]).During a review of Resident 2's History and Physical (H&P), dated 8/21/2025, the H&P indicated, Resident 2 had the ability to understand and make decisions.During a review of Resident 2's Minimum Data Set ([MDS]a resident assessment tool), dated 4/15/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 2 required set up assistance (helper sets up or cleans up and resident completes activity) from staff with eating, oral hygiene, and required supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard) from staff with toileting hygiene, personal hygiene).During an observation on 6/24/2026 at 10:07 a.m. at the facilities Nursing Station A, LVN 1 was observed sitting at the station with a cell phone in his hand and playing a game on the cell phone. Resident 2 was observed standing nearby the station and was repeatedly asking LVN 1 for an extra smoking ticket. LVN 1 repeatedly responded No without making eye contact with Resident 2 throughout the interaction, remained focused on the cell phone and continued playing the game.During an interview on 6/24/2026 at 10:11 a.m. with LVN 1, LVN 1 acknowledged he was playing a game on his cellphone, while interacting with Resident 2. LVN 1 stated he should have maintained eye contact with Resident 2 to demonstrate dignity and respect. LVN 1 admitted that his interaction was not respectful and that he should have shown more courtesy to Resident 2. LVN 1 explained that he knew Resident 2 well and believed he already knew what the resident wanted.During an interview on 6/25/2026 at 1:24 p.m. with Resident 2, Resident 2 stated on 6/24/2026 he was requesting an extra smoking ticket and LVN 1 did not make eye contact during the interaction. Resident 2 stated because LVN 1 did not make eye contact or otherwise acknowledge him and assumed LVN 1 was busy. During an interview on 6/25/26 at 3:20 p.m. with the Director of Nursing (DON), the DON stated staff should respect residents' dignity by giving residents their full attention during interactions and should not engage in personal activities, such as playing games on a cell phone.During a review of the facility's undated policy and procedure (P&P) titled Promoting/ Maintaining Resident Dignity, the P&P indicated, staff should treat each resident with respect and dignity as well as care for each resident in a manner, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The P&P indicated when interacting with a resident, pay attention to the resident as an individual.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic pain (pain that lasts longer than three months) and who had an order for a Transcutaneous Electrical Nerve Stimulation ([TENS] a non-invasive pain relief therapy that uses a compact, battery-powered device to send mild, low-voltage electrical currents through the skin), had the order clarified. This failure resulted in an eight day delay in clarifying information and implementing a physician ordered pain management intervention for Resident 1. This failure had the potential for Resident 1 to experience increased pain or discomfort, decreased mobility, sleep disturbances from uncontrolled pain, increased use of pain medications, and a decline in quality of life and emotional well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 was admitted with diagnoses including intervertebral disc disorders with radiculopathy, lumbar region (a worn or damaged disc, pressing on a nerve causing sharp pain, tingling, numbness or weakness to the lower back), spondylosis (inflammation of the joints between the bones of the spine), myalgia (muscle pain), and muscle spasms (an involuntary muscle contraction; can sometimes be powerful and painful).During a review of Resident 1's History and Physical (H&P) dated 4/29/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and supervision (helper provides verbal cues and/or touching/steadying assistance) from staff for toileting, dressing, shower/bathing and personal hygiene. The MDS indicated Resident 1 received scheduled pain medications regiment and received non-medication intervention for pain. During a review of Resident 1's Pain and Rehabilitation Medical Group Progress Note dated 5/12/2026, the Progress Note indicated Resident 1 was seen by the pain management physician for follow-up related to bilateral low back pain and thoracic back pain and had been utilizing an adaptive TENS unit. The Progress Note indicated Resident 1 was to continue the current treatment plan and the utilization of the adaptive TENS unit.During a review of Resident 1's Interdisciplinary Team (IDT) Meeting/Care Conference Note dated 5/26/2026, the IDT Note indicated the IDT met with Resident 1 on 5/26/2026 regarding the TENS equipment, that Resident 1 was informed there was physician order in place for the TENS equipment and nursing would follow-up with the pain management physician who approved the TENS unit. The IDT Note further indicated Resident 1 was made aware the patches for the TENS unit would be given to the resident once nursing received a physician order with proper instruction to use the device under supervision. The IDT Meeting Care Conference note indicated Resident 1 would be notified when nursing received the order.During a review of Resident 1's Pain and Rehabilitation Medical Group Facsimile Transmittal Sheet dated 5/27/2026, the Sheet indicated the facsimile was sent to the facility and addressed to the Director of Nursing (DON). The facsimile transmittal sheet notes/comments section indicated, Rx (prescription) for TENS unit, Report attached. The facsimile header indicated the documentation was faxed from Pain and Rehabilitation Medical Group on 05/27/2026 at 1:39 p.m., and received on 5/27/2026 at 2:29 p.m. The prescription attached to the facsimile transmittal indicated Resident 1 to use the TENS unit as directed.During a concurrent observation, interview, and record review on 6/4/2026 at 12:23 p.m., with Resident 1, while in Resident 1's room, Resident 1's facsimile for TENS unit order on 5/27/2026 from the pain management physician was reviewed. Resident 1 was observed retrieving his TENS unit from his bedside drawer and stated his pain management physician instructed him to use the device for pain relief. Resident 1 stated the Director of Nursing (DON) informed him additional paperwork would be required before he could use the TENS unit. Resident 1 stated the pain management physician's order indicated to use the device TENS unit whenever he needed it for pain, but the DON informed him she required an order specifying exact times, settings, and frequency of use. Resident 1 stated the DON directed him to call the prescribing pain management physician to obtain a revised order, however, the pain management physician was on vacation at that time. Resident 1 stated he continued using the device as needed for pain, but the DON told him she did not want him to use the device until she received the revised order. Resident 1 stated he called his pain management physician, and the physician sent another order permitting use of the TENS unit whenever he needed, but the DON continued to tell him a more specific order was required. Resident 1 stated the DON later told him he was permitted to use the TENS unit during the day and night but continued to request detailed parameters for the TENS unit from the resident's pain management physician. Resident 1 stated he received instruction on how to use the device at his pain management physician's office and was connected to a liaison from the manufacturer of the TENS unit to monitor the device use remotely. Resident 1 provided a copy of the pain management physician order, which was faxed from the office on 5/27/2026, and indicated the device should be used as directed. Resident 1 stated his physician instructed him to use the TENS unit whenever he experienced pain and adjust the intensity to a level that relieved his pain. Resident 1 stated the TENS unit would automatically shut off after 60 minutes. Resident 1 stated his physician informed him he could not provide a set schedule for use because the frequency and intensity set on the TENS unit depended on his pain level.During a review of Resident 1's Nursing Progress Notes dated 5/15/2026 through 6/3/2026, the Progress Notes contained no entries indicating receipt of the TENS unit order, no documentation of attempts to clarify the TENS unit order, and no documentation of implementing or monitoring the TENS unit during this period.During a concurrent interview and record review on 6/4/2026 at 1:16 p.m., with LVN 1, Resident 1's Nursing Progress Notes and TENS unit facsimile order dated 5/27/2026 was reviewed. LVN 1 stated she received appointment information from social services, and that the pain management office sometimes called the facility to schedule follow up appointments and sometimes sent paperwork back with the resident. LVN 1 stated she first became aware of the TENS unit order on 6/4/2026, when the DON gave her a new order for the TENS unit that was faxed from the pain management physician's office. LVN 1 reviewed Resident 1's original TENS unit order dated 5/27/2026 and stated the original order required clarification. LVN 1 stated the facility received clarification of the TENS unit order on 6/4/2026. LVN 1 stated when a physician order required clarification, nursing staff should document the clarification request in the nursing progress notes. LVN 1 reviewed the Nursing Progress Notes dated 5/27/2026 to 6/3/2026 and acknowledged there were no entries documenting any attempt to clarify the TENS order during that period. LVN 1 stated the DON had been working on obtaining the clarification but may have forgotten to document the clarification process in the progress notes. LVN 1 stated the DON informed her she entered the clarification order for the TENS device on 6/4/2026, and she was unsure when the DON initially contacted the pain management physician's office for clarification. LVN 1 retrieved a copy of the clarified TENS order dated 6/4/2026 and stated the delay in obtaining the clarified order might have occurred because the order could have been left on the fax machine. LVN 1 stated that clarification of physician orders should be completed promptly, and that an eight day delay did not follow expected practice. LVN 1 stated timely clarification was important so that the resident could receive prescribed treatment, and that the TENS device was part of the resident's pain management regimen. During a telephone interview on 6/4/2026 at 4:12 p.m., with the Medical Director/Primary Care Physician (MD/PCP), the MD/PCP stated he served as the facility's Medical Director and Resident 1's primary care physician. The MD/PCP stated anything ordered in the facility was required to go through him. The MD/PCP stated he did not recall Resident 1 by name but stated if nursing staff contacted him; he would have written an order for Resident 1 to use the TENS device regularly at least three times per day. The MD/PCP stated the Physical Therapy (PT) Department would have assisted Resident 1 with education of the TENS unit and adjustment of the device's intensity (strength of the electrical sensation produced by the TENS device). The MD/PCP stated when the facility received an order from a pain management physician, the nursing staff were expected to call him so he could issue treatment orders and ensure PT provided training. The MD/PCP stated if the TENS order arrived on 5/27/2026, the nursing staff should have contacted him on 5/27/2026 to obtain treatment orders. During an interview on 6/5/2026 at 9:50 a.m., with the Physical Therapist (PT), the PT stated Resident 1 placed the TENS device on himself and adjusted the intensity. The PT stated the resident had the TENS unit equipment before the order on 6/4/2026. The PT stated she went to Resident 1's room before 6/4/2026 to provide initial instructions. The PT stated the DON asked her to go over the equipment with the resident because the DON was very worried about Resident 1 having the TENS unit in his possession.During an interview on 6/5/2026 at 10:30 a.m., with the DON, the DON stated she saw the TENS unit order on the fax machine on 6/4/2026 and entered the order into Resident 1's electronic health record. The DON stated nursing staff attempted to contact the pain management physician for clarification of the TENS unit order and left messages but had not received a call back. The DON stated she did not remember the dates of the calls and did not document the attempts. The DON stated nursing staff was responsible for initiating clarification of orders and documenting attempts to clarify orders in the Nursing Progress Notes. The DON stated if nursing staff could not reach a physician to clarify an order, nursing staff was required to escalate the concern to the MD. The DON stated there were no progress notes with documented attempts to contact the pain management physician or documented escalation to the MD when the pain management physician could not be reached. The DON stated orders should have been initiated and clarified the same day, and the TENS unit should have been addressed right away. The DON stated not following through with order clarification in a timely manner could cause more pain for the resident due to the delay in treatment and could cause frustration for the resident. The DON stated she should have documented the notification attempts to the physician, so nursing staff would have a trail of what had been done for Resident 1 and what had been addressed regarding the TENS unit order and Resident 1's pain. The DON stated when orders were not addressed in a timely manner, it delayed care and could affect the quality of care for the resident. During a review of the facility's undated policy and procedure (P&P) titled, Medical Devices Protocol and Policy, the P&P indicated the policy applied to facility-owned, leased, rented, physician-ordered, therapy-issued, and resident-owned medical devices used within the facility, including TENS units. The P&P indicated the facility would ensure all medical devices were supported by physician orders when clinically indicated, incorporated into the resident's plan of care when applicable, and monitored for adverse events and safety concerns. The P&P indicated devices requiring a physician order would not be initiated without written authorization from the attending physician or other authorized practitioner. The P&P indicated orders would include clinical indication, frequency of use, duration of use, specific settings when applicable, and monitoring parameters. The P&P indicated prior to and during device use, staff would assess clinical need, resident response, skin integrity when applicable, pain or discomfort, device placement, functionality and alarms, and signs of complications. The P&P indicated staff would document physician orders, device initiation, resident education, device settings, monitoring performed, and resident response.During a review of the facility's undated P&P, titled, Physician Order Clarification, the P&P indicated the facility would ensure all physician orders were complete, accurate, clinically appropriate, and implemented as intended by the ordering practitioner. The P&P indicated any physician order that was incomplete, unclear, ambiguous, conflicting, or potentially unsafe would be clarified with the ordering practitioner prior to implementation whenever possible. The P&P indicated the receiving licensed nurse would obtain clarification whenever an order contained incomplete treatment instructions, unclear parameters, questionable frequency or duration, incomplete treatment orders, or any order that could not be safely implemented as written. The P&P indicated the nurse would contact the ordering physician or authorized practitioner as soon as possible to obtain clarification. The P&P indicated clarification activities would be documented in the medical record, including the date and time of clarification, name of practitioner providing clarification, clarified order, and name and credentials of the nurse receiving clarification.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic pain (pain that lasts longer than three months), that their pain was managed. The facility failed to:1. Monitor Resident 1's pain at least every shift.2. Assess Resident 1's pain before and after administration of pain medications.3. Implement non-pharmacological pain-management interventions (therapies and measures to control pain that do not involve taking medication) to Resident 1.4. Document ongoing pain assessments for a resident with chronic pain.This failure resulted in a lack of documented information to determine Resident 1's pain level, whether pain medications were effective, and whether non-pharmacological pain-management interventions were provided, which could delay recognition of uncontrolled pain and needed changes to Resident 1's pain-management interventions.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 was admitted with diagnoses including intervertebral disc disorders with radiculopathy, lumbar region (a worn or damaged disc, pressing on a nerve causing sharp pain, tingling, numbness or weakness to the lower back), spondylosis (inflammation of the joints between the bones of the spine), myalgia (muscle pain), and muscle spasms (an involuntary muscle contraction which can sometimes be powerful and painful). During a review of Resident 1's History and Physical (H&P) dated 4/29/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and supervision (helper provides verbal cues and/or touching/steadying assistance) from staff for toileting, dressing, shower/bathing and personal hygiene. The MDS indicated Resident 1 received scheduled pain medications regiment and received non-medication intervention for pain. During a review of Resident 1's Medication Review Report (Physician's Orders), dated 4/28/2026, the Physician Order's indicated Resident 1 was to receive the following medications:1. Oxycodone-Acetaminophen ([Percocet] an opioid [medication to relieve moderate to severe pain]) 10-325 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), one tablet every eight hours for chronic muscle spasm, ordered on 4/28/2026. 2. Gabapentin (a medication used to control nerve pain) 600 mg, one tablet every eight hours for pain, ordered on 4/28/2026. 3. Tizanidine HCl ([Zanaflex] a medication used to relieve discomfort, cramping, and muscle stiffness caused by injuries, spasms, or conditions) 4 mg, one tablet three times a day for muscle spasm, ordered on 4/28/2026. 4. Cilostazol (a vascular medication specifically used to reduce leg pain or cramping caused by poor circulation in the legs) 100 mg, one tablet two times a day for intermittent claudication (leg pain or cramping that occurs during walking or exercise and goes away with rest, ordered on 4/28/2026. During a review of Resident 1's Physician's Order dated 6/1/2026 to 6/30/2026, there were no orders indicating to monitor Resident 1's pain level or to implement non-pharmacological pain interventions to Resident 1. During a review of Resident 1's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 5/2026 to 6/2026, there was no documentation indicating Resident 1's pain was monitored before or after he received pain medication. During a review of Resident 1's MAR dated 5/2026 to 6/2026, there was no documentation indicating Resident 1 received non-pharmacological interventions to treat his pain. During a review of Resident 1's Pain Scale Log dated 5/6/2026 to 6/4/2026, there was no documentation indicating Resident 1's pain was assessed. During a review of Resident 1's untitled Care Plan, dated 9/24/2025 and revised on 5/15/2026, the Care Plan indicated Resident 1 was at risk for alteration in comfort/pain. The Care Plan interventions indicated staff were to assess pain using an appropriate pain rating scale, provide non-pharmacological interventions for pain management, administer pain medications as ordered, and notify the physician of unresolved pain. During a review of Resident 1's Pain and Rehabilitation Medical Group Progress Note dated 5/12/2026, the Progress Note indicated Resident 1 was seen by the pain management physician for follow-up related to bilateral low back pain and thoracic back pain. The Progress Note indicated Resident 1 had been utilizing an adaptive Transcutaneous Electrical Nerve Stimulation ([TENS] a non-invasive pain relief therapy that uses a compact, battery-powered device to send mild, low-voltage electrical currents through the skin) unit. The Progress Note indicated Resident 1's plan was to continue the current treatment plan, including exercise regimen and medication management, and the utilization of the adaptive TENS treatment. During a concurrent observation, interview, and record review, dated 6/4/2026 at 12:23 p.m., with Resident 1, Resident 1's facsimile for TENS unit order on 5/27/2026 from the pain management physician was reviewed. Resident 1 was observed retrieving his TENS unit from his bedside drawer and stated his pain management physician instructed him to use the device for pain relief. Resident 1 stated the Director of Nursing (DON) informed him additional paperwork would be required before he could use the TENS unit. Resident 1 stated the pain management physician's order indicated to use the device TENS unit whenever he needed it for pain, but the DON informed him she required an order specifying exact times, settings, and frequency of use. Resident 1 stated the DON directed him to call the prescribing pain management physician to obtain a revised order, however, the pain management physician was on vacation at that time. Resident 1 stated he continued using the device as needed for pain, but the DON told him she did not want him to use the device until she received the revised order. Resident 1 stated he called his pain management physician, and the physician sent another order permitting use of the TENS unit whenever he needed, but the DON continued to tell him a more specific order was required. Resident 1 stated the DON later told him he was permitted to use the TENS unit during the day and night but continued to request detailed parameters for the TENS unit from the resident's pain management physician. Resident 1 stated he received instruction on how to use the device at his pain management physician's office and was connected to a liaison from the manufacturer of the TENS unit to monitor the device use remotely. Resident 1 provided a copy of the pain management physician order, which was faxed from the office on 5/27/2026, which indicated the device should be used as directed. Resident 1 stated his physician instructed him to use the TENS unit whenever he experienced pain and adjust the intensity to a level that relieved his pain. Resident 1 stated the TENS unit would automatically shut off after 60 minutes. Resident 1 stated his physician informed him he could not provide a set schedule for use because the frequency and intensity set on the TENS unit depended on his pain level. During a concurrent interview and record review on 6/4/2026 at 1:16 p.m., with LVN 1, Resident 1's Care Plans, Nursing Progress Notes, and TENS unit facsimile order dated 5/27/2026 was reviewed. LVN 1 stated she first became aware of the TENS unit order on 6/4/2026, when the DON gave her a new order for the TENS unit that was faxed from the pain management physician's office. LVN 1 reviewed Resident 1's original TENS unit order dated 5/27/2026 and stated the original order required clarification. LVN 1 stated the facility received clarification of the TENS unit order on 6/4/2026. LVN 1 stated that when a physician order required clarification, nursing staff should document the clarification request in the nursing progress notes. LVN 1 reviewed the nursing progress notes dated 5/27/2026 to 6/3/2026 and acknowledge there were no entries documenting any attempt to clarify the TENS order during that period. LVN 1 stated the DON had been working on obtaining the clarification but may have forgotten to document the clarification process in the progress notes. LVN 1 stated the DON informed her she entered the clarification order for the TENS device on 6/4/2026, and she was unsure when the DON initially contacted the pain management physician's office for clarification. LVN 1 retrieved a copy of the clarified TENS order dated 6/4/2026 and stated the delay in obtaining the clarified order might have occurred because the order could have been left on the fax machine. LVN 1 stated that clarification of physician orders should be completed promptly, and that an eight day delay did not follow expected practice. LVN 1 stated timely clarification was important so that the resident could receive prescribed treatment, and that the TENS device was part of the resident's pain management regimen. During a telephone interview on 6/4/2026 at 4:12 p.m., with the Medical Director/Primary Care Physician (MD/PCP), the MD/PCP stated he served as the facility's Medical Director and Resident 1's primary care physician. The MD/PCP stated anything ordered in the facility was required to go through him. The MD/PCP stated he did not recall Resident 1 by name but stated if nursing staff contacted him; he would have written an order for Resident 1 to use the TENS device regularly at least three times per day. The MD/PCP stated the Physical Therapy (PT) Department would have assisted Resident 1 with education of the TENS unit and adjustment of the device's intensity (strength of the electrical sensation produced by the TENS device). The MD/PCP stated when the facility received an order from a pain management physician, the nursing staff were expected to call him so he could issue treatment orders and ensure PT provided training. The MD/PCP stated if the TENS order arrived on 5/27/2026, the nursing staff should have contacted him on 5/27/2026 to obtain treatment orders. During an interview on 6/5/2026 at 9:50 a.m., with the Physical Therapist (PT), the PT stated the resident placed the TENS device on himself and adjusted the intensity. The PT stated the resident's skin needed regular checks because the device used an electrical current. The PT stated the resident was instructed to remove the device when it was not in use, not to sleep in it so his skin could breathe, and not to shower while wearing it. The PT stated if the device caused pain, the resident was instructed to turn the intensity down and call the nurse. The PT stated the resident could wear the device for a couple of hours at a time and then remove it. The PT stated the resident wore the device on his upper back, and she told him not to change the location unless he notified the nurses before changing the area. The PT stated she went to the resident before 6/4/2026 to provide initial instructions. The PT stated the resident had the equipment before the order. The PT stated she educated the resident on the equipment before 6/4/2026. The PT stated the DON asked her to go over the equipment with the resident because the DON was very worried about the resident having the TENS unit in his possession. During a concurrent interview and record review on 6/5/2026 at 10:30 a.m., with the Director of Nursing (DON), Resident 1's Pain and Rehabilitation Medical Group Progress Note dated 5/12/2026, Physician Orders, Care Plans, and MAR were reviewed. The DON stated there was no monitoring for pain ordered for Resident 1 and that pain monitoring should occur at least once per shift. The DON stated she did not see any pain monitoring for Resident 1, even though the resident had chronic pain, received routine pain medications, and was followed by a pain management physician. The DON stated the last documented pain level was on 5/6/2026 and there was no indication of the resident's pain level after that date. The DON stated when pain medications are administered, nurses must obtain a pain level before administration and must check back 45 minutes to one hour after administration to assess for effectiveness. The DON stated this was not done. The DON stated there should be a standard order for pain assessment. The DON stated pain monitoring was part of the nursing assessment and should have been charted even if there was no specific order. The DON stated pain assessments could have been documented in the progress notes, but they were not. The DON acknowledged that documented pain levels existed from 4/28/2026 to 5/6/2026 and stated there should be documented pain levels every day for every shift and before and after pain medications. The DON stated the Resident 1's Care Plan instructed staff to assess pain using an appropriate rating scale and to provide non pharmacological interventions for pain management, but the MAR dated 5/2026 and 6/2026 did not contain non pharmacological interventions. The DON stated without documentation of interventions there was no way to determine whether any were provided. The DON further stated the nurses were not consistently following up with the Resident's pain management physician after appointments, which resulted in a lack of pain management information, delayed care, and the facility not knowing how to manage the resident's pain. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, undated, the P&P indicated the purpose of the procedure was to help staff identify pain in the resident and develop interventions that were consistent with the resident's goals and needs and addressed the underlying causes of pain. The P&P indicated pain management included assessing the potential for pain, recognizing the presence of pain, identifying the characteristics of pain, developing and implementing approaches to pain management, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The P&P indicated the facility would conduct a comprehensive pain assessment upon admission, quarterly, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. The P&P indicated the facility would assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain, and at least weekly in stable chronic pain. The P&P indicated during the comprehensive pain assessment, staff would gather the history of pain and its treatment, including pharmacological and non-pharmacological interventions, intensity of pain, descriptors of pain, pattern of pain, location and radiation of pain, frequency, timing, duration of pain, factors and strategies that reduced pain, and symptoms that accompanied pain. The P&P indicated staff would assess pain using a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. The P&P indicated non-pharmacological interventions may be appropriate alone or in conjunction with medications and included environmental, physical, exercise, cognitive, or behavioral interventions. The P&P indicated physical non-pharmacological interventions included ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, and other interventions. The P&P indicated staff would re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain, and at least weekly in stable chronic pain. The P&P indicated staff would monitor the resident's response to interventions and level of comfort over time. The P&P indicated staff would document the resident's reported level of pain with adequate detail to gauge the status of pain and the effectiveness of interventions for pain. The P&P indicated staff would report significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions to the physician or practitioner. During a review of the facility's undated P&P titled, Vital Signs, the P&P indicated pain assessment was to be obtained and interpreted by licensed nurses.

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was diagnosed with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) did not sustain a second degree burn (damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin) to his right leg. On 12/28/2025, Certified Nursing Assistant (CNA) 1 placed a lunch tray containing a cup of hot water on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell onto Resident 1's right leg. The facility failed to: 1. Ensure CNA 1 considered Resident 1's risk factors related to Parkinson's disease including tremors, poor coordination and impaired mobility before placing a cup of hot water in close proximity to him. 2. Ensure hot liquids were not placed within reach of Resident 1 and left unattended, when Resident 1 had known tremors and impaired mobility related to his Parkinson's diagnosis. This deficient practice resulted in Resident 1 sustaining a second degree burn to his right leg and had the potential for a more serious injury to occur.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/21/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a stage between normal age-related cognitive decline and dementia [progressive loss of memory], characterized by noticeable, measurable memory or thinking problems) and he required substantial/maximal assistance (helper does more than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 1 required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident complete activity) with eating. During a review of Resident 1's Nursing Note dated 12/28/2025, the Nursing Note indicated Resident 1 sustained a thermal burn (an injury caused by exposure to heat sources such as hot liquids, steam, fire, or hot objects) to his right forearm (this documentation was found to be incorrect, and this injury described a burn to Resident 1's right leg not his right forearm) after an accidental spill of hot tea. The Nursing Note indicated the burned area was noted with erythema (redness) and superficial skin peeling that was consistent with a partial thickness burn (a skin injury that damages both the epidermis and dermis). During a review of Resident 1's Change of Condition (COC) Note dated 1/13/2026, the COC indicated Resident 1 sustained a thermal burn to his right lateral (outer area) leg after an accidental spill of hot tea. The COC indicated the affected area was red with superficial skin peeling consistent with a partial-thickness burn. There was no active bleeding or drainage noted. Resident 1 complained of pain and discomfort to the affected area. During a review of Resident 1's Physician's Order dated 12/28/2025, the Physician's Order indicated to cleanse Resident 1's thermal burn injury to his right lateral lower leg with normal saline (a sterile solution used to cleanse wounds), pat dry, apply triple antibiotic ointment (a medicated ointment used to prevent and treat skin infections cause by small cuts, scrapes, or burns), and to leave open to air every day for one month. During a review of Resident 1's Podiatrist note dated 12/31/2025, the Podiatrist note indicated the dermal layer (the skin layer underneath the outer layer) of Resident 1's right lateral leg had sloughed (peeling of larger sheets of skin due to damage) off with no active drainage. The Podiatrist note indicated the burn on Resident 1's leg was classified as a second-degree burn. During an interview on 2/10/2026 at 1:25 p.m., Licensed Vocational Nurse (LVN) 1 stated CNA 1 reported to him that hot tea spilled on Resident 1, he (LVN 1) went to see what happened and noted a blanket covering Resident 1's legs, a cup on top of the blanket and when he touched the blanket it was wet and warm. LVN 1 stated Resident 1's right leg had a fresh red wound with peeling skin. During a telephone interview on 2/10/2026 at 2:08 p.m., and a subsequent telephone interview on 2/11/2026 at 1:36 p.m., CNA 1 stated Resident 1 experienced frequent shaking in his upper extremities (arms) and required a lot of assistance when eating, and Resident 1 could not bring a utensil or a cup to his mouth by himself. CNA 1 stated she placed Resident 1's lunch tray on his overbed table and placed the overbed table halfway over the resident's legs close to his knees (12/28/2025), then proceeded to assist Resident 5 (Resident 1's roommate) with his lunch tray. CNA 1 stated when she put Resident 5's lunch tray down she saw the cup of hot water falling from Resident 1's lunch tray and tried to grab the cup, but she could not catch the cup before it fell on Resident 1. CNA 1 stated she did not know how the cup of hot water fell but stated she should not have placed Resident 1's lunch tray with hot water so close to Resident 1 because he could have grabbed the cup and caused it to fall. During an interview on 2/11/2026 at 11:39 a.m., the Podiatrist (PD) stated it was obvious the burn to Resident 1's right lateral leg was caused by hot water because the epidermis and dermal layers were affected. During an interview on 2/11/2026 at 2:12 p.m., the Director of Nursing (DON) stated the use of Resident 1's fine motor skills (the coordination of small muscles, typically in the hands and fingers, with the eyes [hand-eye coordination) to perform precise, small-scale movements) were limited and his lunch tray should have been placed on his overbed table next to him just before CNA 1 fed him and not left unattended because there were hot items on the tray. During a review of the facility's undated Policy and Procedure (P/P) titled Accidents and Supervision, the P/P indicated staff were required to observe and identify potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident.

Based on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented in the clinical record for one of four sampled residents (Resident 1) when Resident 1 sustained a thermal burn (an injury caused by exposure to heat sources such as hot liquids, steam, fire, or hot objects) to his right lateral (on the outside) leg, but documentation indicated Resident 1's right forearm. This deficient practice resulted in the inaccurate documentation of Resident 1's status and had the potential for confusion and non-continuity of care.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/21/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a stage between normal age-related cognitive decline and dementia [progressive loss of memory], characterized by noticeable, measurable memory or thinking problems). During a review of Resident 1's Nursing Note dated 12/28/2025, the Nursing Note indicated Resident 1 sustained a thermal burn to his right forearm (this documentation was found to be incorrect, and this injury described a burn to Resident 1's right leg not his right forearm) after an accidental spill of hot tea. The Nursing Note indicated the burned area was noted with erythema (redness) and superficial skin peeling that was consistent with a partial thickness burn (a skin injury that damages both the epidermis and dermis). During a review of Resident 1's Change of Condition (COC) note dated 1/13/2026 (the correct date of the COC and Resident 1's burn injury should have been 12/28/2025), the COC indicated Resident 1 sustained a thermal burn to his right lateral leg after an accidental spill of hot tea. During a telephone interview on 2/10/2026 at 1:25 p.m., LVN 1 stated an audit was conducted (1/13/2026) and his nursing note was flagged because he documented Resident 1's burn injury to his right forearm when it should have been documented as his right lateral leg. LVN 1 stated he was instructed to correct the documentation (1/13/2026) and he could not figure out how to change Resident 1's COC note, which was initially dated 12/28/2025, so he created a new COC note dated 1/13/2026. During an interview on 2/11/2026 at 2:12 p.m., the Director of Nurses (DON) after reviewing Resident 1's Nursing Note dated 12/28/2025 and Resident 1's COC note dated 1/13/2026 stated, LVN 1's documentation made it appear as if Resident 1 had two different burn injuries. The DON stated LVN 1 should have made a late entry note to correct the inaccurate documentation of Resident 1's burn injury and to correct the date of Resident 1's COC note. During a review of the facility's undated Policy and Procedure (P/P) titled Charting and Documentation the P/P indicated documentation or procedures and treatments shall include care-specific details and shall include at a minimum the date and time the procedure/treatment was provided and the assessment data and/or any unusual findings obtained during the procedure/treatment.

Based on interview, and record review, the facility failed to notify the Responsible Party (RP) of one of four sampled residents (Resident 1) when a cup containing hot water was placed on Resident 1's overbed table (a mobile, height-adjustable table with a narrow, rectangular top designed to slide over a bed or chair) and the cup of hot water fell on Resident 1's leg causing a second degree burn (damage to the epidermis [top layer of the skin] and part of the dermis [underlying layer] causing painful, red, blistered, and swollen skin) to Resident 1's right lateral (outside) leg. This deficient practice resulted in Resident 1's RP being unaware that Resident 1 sustained a burn injury on 12/28/2025 until 1/5/2026 (eight days after the injury), the inability of the RP to participate and make decisions in Resident 1's immediate care needs and the potential for the RP to continue to be uninformed regarding Resident 1's health status.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/21/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a stage between normal age-related cognitive decline and dementia [progressive loss of memory], characterized by noticeable, measurable memory or thinking problems). During a review of Resident 1's Nursing Note dated 12/28/2025, the Nursing Note indicated Resident 1 sustained a thermal burn (an injury caused by exposure to heat sources such as hot liquids, steam, fire, or hot objects) to his right forearm (this documentation was found to be incorrect, and this injury described a burn to Resident 1's right leg not his right forearm) after an accidental spill of hot tea. The Nursing Note indicated the burned area was noted with erythema (redness) and superficial skin peeling that was consistent with a partial thickness burn (a skin injury that damages both the epidermis and dermis). During an interview on 2/10/2026 at 1:25 p.m., Licensed Vocational Nurse (LVN) 1 stated he did not get a chance to notify Resident 1's RP regarding Resident 1's burn injury but stated he endorsed Resident 1's injury status to a charge nurse on the 3 p.m., to 11 p.m., shift, whose name he could not remember. During an interview on 2/11/2026 at 12:33 p.m., Registered Nurse (RN) 1 stated LVN 1 reported to her that Resident 1 sustained a burn injury but stated she was unaware that Resident 1's RP had not been notified by LVN 1 and she (RN 1) had not notified Resident 1's RP. During an interview on 2/11/2026 at 2:33 p.m., the Administrator (ADM) stated she received a telephone call from Resident 1's RP on 1/5/2026, and the RP was frustrated because she had not been informed by the facility regarding Resident 1's burn injury. The ADM said she was unaware that Resident 1's RP had not been notified of Resident 1's burn injury that occurred on 12/28/2025. During a review of the facility's Policy and Procedure (P/P) titled Change in a Resident's Condition or Status dated 4/2011, the P/P indicated the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan that honored resident's food preferences for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 expressed dissatisfaction with meals when his food preferences were not consistently followed. Findings:During a review of Resident 1's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 7/9/2025 and was readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anxiety disorder (feeling of fear, dread, and uneasiness that interferes with daily life), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing pr witnessing a traumatic event).During a review of Resident 1's History and Physical (H&P), dated 7/15/2025, the H&P indicated the resident had a fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 1 had intact cognition (ability to think and understand). The MDS indicated Resident 1 was independent for eating, dressing, and toileting hygiene. The MDS indicated Resident 1 needed supervision from staff for personal hygiene and bathing.During a review of Resident 1's Physician Order dated 11/14/2025, the Physician Order indicated an order of regular no added salt, regular texture, thin consistency, vegetarian diet, no meat, may have pancake, French toast, banana and peanut butter jelly at breakfast.During an interview on 12/15/2025 at 12:11 p.m., with Resident 1, Resident 1 stated the meals he received were inconsistent with his diet plan on multiple occasions. Resident 1 stated he completed the dietary request form during the week of 11/24/2025 to 11/29/2025, however on two occasions (11/25/2025 and 11/27/2025), he did not receive the requested egg with tuna sandwich for lunch and was told by kitchen staff there were no eggs available. Resident 1 stated he stopped completing the dietary request forms because the kitchen did not consistently follow his requests. Resident 1 stated he had meeting with the Administrator, Social Worker (SW) and Dietary Technician (DT) on 12/1/2025 regarding his meal plan, however on two subsequent occasions on 12/1/2025 and 12/5/2025 he continued to receive meals inconsistent with his food preferences, including shredded chicken and meat patty for lunch. During a concurrent interview and record review on 12/15/2025 at 1:34 p.m., with Dietary Technician (DT), Resident 1's Physician Order for 11/2025, Dietary Request Forms for 11/21/2025-11/29/2025 and Nutrition/Dietary Food Preference for 7/10/2025 were reviewed. The DT stated resident food preferences were assessed upon admission and quarterly, then forwarded to Dietary Supervisor (DS) to be entered on the meal ticket. The DT stated resident preferences would be honored whenever changes occurred and communicated to the kitchen. The DT stated Resident 1 had changes in his food preferences, which were verbally communicated to the kitchen as needed. The DT stated there was no documentation indicating an update to Resident 1's Nutrition/Dietary Food Preference since his admission to the facility. The DT stated updating and documenting changes were important for other staff to be aware of resident preferences, and failure to document could result in confusion and residents not receiving requested meals. During a review of Resident 1's Care Plan Report dated 11/19/2025, the Care Plan Report indicated no person-centered care plan was developed with goals and interventions addressing Resident 1 changes in food preferences or how the preferences would be met.During an interview on 12/15/2025 at 4:20 p.m., with Director of Nursing (DON), the DON stated care plan is a road map for staff to follow, and interdisciplinary team develop care plan to ensure the resident's needs and preferences were addressed and communicated to all staff for consistent care. The DON stated if care plan was not developed, communicated or followed, staff may provide inconsistent care, resulting in unmet needs or preferences.During a review of facility's policy and procedures (P&P) titled, Individualized Care Planning undated, the P&P indicated Each resident's care plan is developed and maintained as a dynamic, person-centered document based on comprehensive assessment findings and interdisciplinary input.Individualized care planning is informed by initial and ongoing assessments, clinical observations, resident and representative input, and interdisciplinary discussion.Resident choices, cultural considerations, and expressed preferences are incorporated into the care plan to the extent practicable and clinically appropriate. Refusal of care or preferences that differ from recommendations are documented and addressed through alternative approaches and education when indicated.Leadership and designated clinical staff oversee adherence to individualized care planning practices through routine review, education, and quality activities to support consistent resident-focused care.

Based on interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 not consistently receiving his preferred meals and had the potential to affect Resident 1's nutritional intake and satisfaction with meals. Findings:During a review of Resident 1's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 7/9/2025 and was readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anxiety disorder (feeling of fear, dread, and uneasiness that interferes with daily life), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing pr witnessing a traumatic event).During a review of Resident 1's History and Physical (H&P), dated 7/15/2025, the H&P indicated the resident had a fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 1 had intact cognition (ability to think and understand). The MDS indicated Resident 1 was independent for eating, dressing, and toileting hygiene. The MDS indicated Resident 1 needed supervision from staff for personal hygiene and bathing.During a review of Resident 1's Physician Order dated 11/14/2025, the Physician Order indicated an order of regular no added salt, regular texture, thin consistency, vegetarian diet, no meat, may have pancake, French toast, banana and peanut butter jelly at breakfast.During an interview on 12/15/2025 at 12:11 p.m., with Resident 1, Resident 1 stated the meals he received were inconsistent with his diet plan on multiple occasions. Resident 1 stated he completed the dietary request form during the week of 11/24/2025 to 11/29/2025, however on two occasions (11/25/2025 and 11/27/2025), he did not receive the requested egg with tuna sandwich for lunch and was told by kitchen staff there were no eggs available. Resident 1 stated he stopped completing the dietary request forms because the kitchen did not consistently follow his requests. Resident 1 stated he had meeting with the Administrator, Social Worker (SW) and Dietary Technician (DT) on 12/1/2025 regarding his meal plan, however on two subsequent occasions on 12/1/2025 and 12/5/2025 he continued to receive meals inconsistent with his food preferences, including shredded chicken and meat patty for lunch. During a concurrent interview and record review on 12/15/2025 at 1:34 p.m., with Dietary Technician (DT), Resident 1's Physician Order for 11/2025, Dietary Request Forms for 11/21/2025-11/29/2025 and Nutrition/Dietary Food Preference for 7/10/2025 were reviewed. The DT stated resident food preferences were assessed upon admission and quarterly, then forwarded to Dietary Supervisor (DS) to be entered on the meal ticket. The DT stated resident preferences would be honored whenever changes occurred and communicated to the kitchen. The DT stated Resident 1 had changes in his food preferences, which were verbally communicated to the kitchen as needed. The DT stated there was no documentation indicating an update to Resident 1's Nutrition/Dietary Food Preference since his admission to the facility. The DT stated updating and documenting changes were important for other staff to be aware of resident preferences, and failure to document could result in confusion and residents not receiving requested meals. During an interview on 12/15/2025 at 3:43 p.m., with Assistant Dietary Manager (ADM), the ADM stated dietary was responsible for documenting changes in resident food preferences and following up to ensure food preferences were provided. The ADM stated changes should be documented so all staff are informed and for consistency. The ADM stated failure to document changes in resident food preferences can result in residents not receiving preferred meals. During an interview on 12/15/2025 at 4:20 p.m., with Director of Nursing (DON), the DON stated residents' food preferences were assessed upon admission by nursing, with dietary completing an assessment and follow up. The DON stated having documentation to ensure communication with all staff was important and failure to maintain written communication would likely result in residents not receiving preferred meals and lead to poor appetite and weight loss.During a review of facility's policy and procedures (P&P) titled, Policy Food Preferences undated, the P&P indicated Facility will honor and document individual resident food preferences to the fullest extent possible while maintaining physician-ordered dietary restrictions and promoting nutritional well-being.Facility will assess resident food preferences upon admission and as part of quarterly reviews or when there is a significant change in condition. Preferences will include cultural, religious, ethical, and personal dietary choices. Dietary staff will use documented preferences when preparing meals and will offer alternate selections when preferred foods are not available or contraindicated. Communication of changes to dietary preferences will be documented and shared with dietary services promptly. Residents or families may update preferences at any time by informing nursing or dietary staff.

Based on observation, interview, and record review, the facility failed to provide information on how to file a grievance (an official statement of a complaint over something believed to be wrong or unfair) and its process to one of three sampled residents (Resident 1).This failure resulted in Resident 1 being unable to exercise his or her right to file grievance.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 4/17/2025 with diagnoses including cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left above the knee amputation (AKA-surgical removal of the portion of the leg above the knee joint).During a review of Resident 1's History and Physical (H&P), dated 4/17/2025, the H&P indicated, Resident 1 had the capacity (ability) to understand and make decision.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort) from two or more staff for bed mobility, transfer, dressing, hygiene, moderate assistance (Helper does less than half the effort) from one staff for bathing, and set up or touching assistance (Helper sets up or cleans up) for eating.During a concurrent observation and interview on 9/15/2025, at 11:25 a.m., with Resident 1 in her room, Resident 1 was wearing green track pants (soft, comfortable trousers, originally designed for athletic activities and warm-ups, now widely worn as casual wear) and her pants were wet. Resident 1's adult brief (a type of absorbent, tab-style adult diaper designed for moderate to heavy incontinence) was crooked to left side. Resident 1 stated, she felt so uncomfortable and irritated because the staff did not know how to adjust her brief. Resident 1 stated, she has been having this issue since the admission. Resident 1 stated some staff were having an attitude when she asked them to change her before leaking. Resident 1 stated, she has been complaining about this issue, but no one did anything for her. Resident 1 stated, the Social Service Director (SSD) or the staff did not explain how to file the grievance. Resident 1 stated, she would file the grievance if she knew how to file the grievance.During a concurrent interview and record review on 9/15/2025, at 2:00 p.m., with the Social Service Director (SSD), the facility's Grievance/Complaint Log, dated from 6/2025 to 9/2025 was reviewed. There was no grievance documented regarding Resident 1's adult brief-changing complaint. The SSD stated this was the known issue or complaint since the 4/2025. The SSD stated that any complaint regarding the resident's care and rights should be in grievance log and investigated. The SSD stated, she mentioned regarding Resident1's adult brief changing complaint in her note, but she did not file the grievance for Resident 1. The SSD stated, she should have provided information regarding how to file grievance and the process of grievance to Resident 1 and family members as soon as she found out about the issue. The SSD stated she should have formally addressed, investigated, and resolved Resident 1's concern in a timely manner by filing grievance for her as soon as she found out about the complaint. The SSD stated, she should not have assumed that Resident 1 knew how to file the grievance. The SSD stated it was the resident's right to file the grievance.During an interview on 9/15/2025, at 2:50 p.m., with the Director of Nursing (DON), the DON stated, the SSD should have provided the information regarding how to file grievance and the process of grievance to Resident 1 and family members since there was an ongoing complaint regarding brief change. The DON stated that the residents should know how to file grievance to exercise their rights. During a review of the facility's Policy and Procedure(P&P) titled, Grievance/Concerns, undated, the P&P indicated, The staff shall respond promptly and appropriately to concerns or complaints expressed by residents or their family, friends, or responsible party. Filing of Grievance: Grievances must be submitted to the coordinator or designee within 30 days of becoming aware of the alleged discrimination action. The coordinator or designee shall conduct an investigation of the complaint to determine its validity. The investigation may be informal, but it must be thorough, affording all interested parties/persons an opportunity to submit evidence relevant to the complaint. The coordinator or designee will issue a written decision on the grievance no later than 30 days after its filing.During a review of the facility's Policy and Procedure(P&P) titled, Social Service Director: Job Description, undated, the P&P indicated, Major Duties and Responsibilities: The Social Service Director will assist residents in voicing and obtaining resolution to grievances. The Director will review complaints and grievances made by the resident and make a written report indicating what action(s) were taken to resolve the complaint or grievance.

Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives and interventions to meet the residents' needs for one of three sampled residents (Resident 1) regarding adjustment of the adult brief (a type of absorbent, tabs-style adult diaper designed for moderate to heavy incontinence) fitting.This failure resulted in Resident 1 feeling embarrassed due to the leakage of urine from the improper adjustment of the adult brief and avoiding activities due to uncomfortable fitting of the adult brief.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 4/17/2025 with diagnoses including cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left above the knee amputation (AKA-surgical removal of the portion of the leg above the knee joint).During a review of Resident 1's History and Physical (H&P), dated 4/17/2025, the H&P indicated, Resident 1 had the capacity (ability) to understand and make decision.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort) from two or more staff for bed mobility, transfer, dressing, hygiene, moderate assistance (Helper does less than half the effort) from one staff for bathing, and set up or touching assistance (Helper sets up or cleans up) for eating.During a concurrent observation and interview on 9/15/2025, at 11:25 a.m., with Resident 1 in her room, Resident 1 was wearing green track pants (soft, comfortable trousers, originally designed for athletic activities and warm-ups, now widely worn as casual wear) and her pants were wet. Resident 1's adult brief was crooked to left side. Resident 1 stated, she felt so uncomfortable and irritated because the staff did not know how to adjust her brief. Resident 1 stated, she has been having this issue since the admission. Resident 1 stated some staff were having an attitude when she asked them to change her before leaking. Resident 1 stated, she has been complaining about this issue, but no one did anything for her. Resident 1 stated, she did not participate in activities because she was worried about leakage due to crooked adult brief because of poor application by the staff.During an observation on 9/15/2025, at 11:35 a.m., in Resident 1's room, the Director of Nursing (DON) and Certified Nurse Assistant (CNA) 1 were changing Resident 1's adult brief. DON and CNA 1 had to make multiple adjustments per Resident 1's requests and Resident 1 verbalized her frustration when CNA 1 did not follow her instructions.During an interview on 9/15/2025, at 12:10 p.m., with CNA 1, CNA 1 stated, she understood why Resident 1 was frustrated. CNA 1 stated, she witnessed Resident 1's pants get wet due to poorly applied adult brief on many occasions. CNA 1 stated that Resident 1 refused to go to activities sometimes. CNA 1 stated there was no detailed instruction or intervention to follow how to adjust Resident 1's adult brief. CNA 1 stated, she felt bad for Resident 1.During a concurrent interview and record review on 9/15/2025, at 1:04 p.m., with the Director of Staff Development (DSD), Resident 1's Interdisciplinary Team Meeting (IDT meeting - a collaborative discussion among diverse healthcare professionals to develop, coordinate, and support a patient's care plan, ensuring a comprehensive, person-centered approach) Notes, dated from 4/2025 to 9/2025 were reviewed. There were no specific and resident centered interventions for ongoing Resident 1's adult brief adjustment complaint. The DSD stated that the IDT developed the care plan and its interventions for each resident. The DSD stated that the IDT failed to recommend comprehensive and resident centered interventions for Resident 1's adult brief issue.During a concurrent interview and record review on 9/15/2025, at 1:42 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan (CP), revised 8/14/2025, the CP Focus indicated, Resident 1 had aggressive behavior during diaper change. The CP goal indicated, Resident 1 will have no evidence of behavior problems by review date (10/9/2025). The CP Interventions indicated to explain why behavior was inappropriate, approach in a calm manner, and attempt to determine underlying cause. The MDSC stated, Resident 1's care plan goal was not objective and measurable. The MDSC stated that interventions were generic (not specific). The MDSC stated Resident 1's care plan did not address the actual issue of accommodating Resident 1's requests to adjust her adult brief in a comfortable way.During an interview on 9/15/2025, at 2:50 p.m., with the DON, the DON stated, care plans are created to guide the staff on how to care for residents with identified problems. The DON stated, without a care plan with specific interventions, a resident may have a recurrence of an issue or a worsening of a condition. The DON stated, IDT meeting should have developed individualized resident centered care plans and interventions. The DON stated, these interventions should have been implemented and reevaluated for effectiveness. The DON stated that Resident 1's care plan was not specific and individualized due to lack of recommendation from the IDT meeting. The DON stated that Resident 1's adult brief adjustment issue would not be resolved unless specific and resident centered interventions were implemented. The DON stated it might lead to a delay in delivery of care and services.During a review of the facility's Policy and Procedure(P&P) titled, Care Planning-Interdisciplinary Team, undated, the P&P indicated, Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.During a review of the facility's Policy and Procedure(P&P) titled, Comprehensive Care Plan, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. Person-centered care means focusing on the resident as the locus of control and supporting the resident in making their own choices and having control over their daily lives. 2. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 7. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interview and record review, the facility failed to ensure residents' advance directive forms (a legal document indicating resident preference on end-of-life treatment decisions) were executed by the resident or the resident's legally authorized representative ( is someone authorized to act on behalf of another person in legal matters), and medical records were updated to show documentation that advance directives were discussed and written information was provided to the residents and/or responsible parties for six of 10 residents (Resident 11, 12, 15, 22, 30, and 36).The facility failed to:1. Ensure facility's social worker did not sign residents' advance directive forms on behalf of the residents, even though documentation indicated each resident had a low Brief Interview for Mental Status ([BIMS]-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score and inability to provide informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding health care. Findings: A. During a review of Resident 30’s admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and paranoid schizophrenia (a mental health condition where a person experiences intense and persistent distrust and suspicious of others, often without good reason). During a review of Resident 30’s MDS dated [DATE] indicated Resident 30 had severe cognitive impairment. During a review of Resident 30’s History and Physical (H&P) dated 2/10/2025, the H&P indicated Resident 30 does not have the capacity to understand and make decisions. During a review of Resident 30’s Advance Directive Acknowledgement Form dated 8/16/2022, the Advance Directive Acknowledgment Form indicated there was no signature by Resident 30. During a review of Resident 36’s admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia, epilepsy (seizures- a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36’s MDS dated [DATE], the MDS indicated Resident 36 had severe cognitive impairment. During a review of Resident 36’s Advance Directive Acknowledgement Form dated 1/24/2023, the Advance Directive Acknowledgment Form indicated there was no signature by Resident 36. During a concurrent interview and record review on 8/14/2025 at 7:44 a.m., with Social Services Director (SSD) 1, SSD 1 validated both Resident 30 and 36’s Advance Directive’s were not accurately completed and neither resident had the capacity to make a decision regarding formulating an advance directive. During an interview on 8/14/2025 at 12:48 p.m., with the Director of Nursing (DON), the DON stated it is important to ensure the residents’ advance directives were accurately completed so they were aware of the residents’ wishes regarding their care. The DON stated it was not right to have a resident sign a form when they are cognitively impaired. During a review of the facility’s policy and procedure (P&P) titled, “Advance Directives,” undated, the P&P indicated, “Prior to or upon admission of a resident to our facility, the Social Services Director of designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive.” During a review of the Social Services Director Job Description, undated, the Social Services Director Job Description indicated, “The Social Services Director will oversee the process of Advance Care Planning for each resident upon admission, and make sure any Advance Directives are reviewed with the resident/resident representative on a regular basis. The Director will ensure that staff members are made aware of the resident’s code status and end-of-life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications.” B. During a review of Resident 11’s admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia and unspecified mood affective disorder (mental illness that causes persistent and intense changes in person’s mood, energy, and behavior). During a review of Resident 11’s MDS dated [DATE], the MDS indicated Resident 11 had severe cognitive impairment. During a review of Resident 11’s MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive skills and required partial/moderate assistance (helper does less than half the effort) with bathing, dressing and personal hygiene. During a review of Resident 11’s History and Physical(H&P) dated 3/14/2025, the H&P indicated Resident 11 did not have the capacity to understand and make decisions because resident’s judgement was impaired. During a review of Resident 11’s Care Plan titled, “Altered Thought Process,” initiated on 1/20/2025 and revised on 1/22/2025, The Care Plan indicated Resident 11 had periods of confusion, impaired cognitive skills, and disorientation, forgetfulness. The Care Plan’s goals indicated Resident 11 will communicate needs without frustration and accept staff support for ninety days. During a review of Resident 11’s Acknowledgement of Receipt for Advance Directive /Medical Treatment Decisions, the Acknowledgement of Receipt for Advance Directive indicated Resident 11 refused to sign but resident’s name was written under the section stating resident and a staff witnessed the form. The form indicated Resident 11 did not choose to formulate or issue any advance directive at that time. During a concurrent interview and record review on 8/12/2025 at 2:49 p.m., with Social Worker (SW 2), Resident 11’s Acknowledgement of Receipt for Advance Directive was reviewed. SW 2 stated the reason why Resident 11 advance directive was documented as resident refuse because Resident 11’s family did not want to be involved in the decision making about resident’s advance directive. SW 2 stated the facility did not reoffer the advance directive after admission and agreed the Acknowledgement of Advance Directive was not acceptable because the resident was incapable of deciding for himself and not mentally competent( person has the ability to think clearly, understand information and make sound decisions for themselves). C. During a review of Resident 22’s admission Record, the admission Record indicated Resident 22 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia( a progressive state of decline in mental abilities),unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and unspecified mood affective disorder(mental health condition characterized by symptoms of a mood disorder that do not fully meet the criteria for a specific named diagnosis). During a review of Resident 22’s MDS dated [DATE], the MDS indicated Resident 22 had severely impaired cognitive skills and required supervision or touching assistance (helper provides verbal cues and contact guard assistance as resident completes the activity) with eating, oral hygiene, dressing and toileting hygiene. During a review of Resident 22’s History and Physical (H&P-comprehensive assessment of patient’s health, combining a detailed medical history with a physical examination) dated 1/17/2025, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 8/12/2025 at 2:50 p.m., with SW 2, Resident 22’s Acknowledgement Receipt for Advance Directive was reviewed. SW 2 stated Resident 22 signed the Acknowledgement of Receipt for Advance Directive on 11/4/2023 and a facility representative witnessed the form. SW 2 agreed Resident 22 will not be able to decide or make a medical decision BIMS was 3 (BIMS of 3 indicated poor cognition[thought process]). SW 2 stated the facility should have applied for public guardianship ( a court ordered role where the county’s public guardian serves as a legal guardian or conservator for individuals unable to care for themselves or manage their finances due physical or mental disabilities) and he did not know why it was not done. SW 2 stated Advance Directive is important so the resident will get a surrogate decision maker for his health and end of life care. During an interview on 8/13/2025, at 3:30 p.m. with DON, DON stated the licensed nurses should be involved and included in offering and educating residents about advance directives. DON believed the advance directive should be reoffered to residents after admission. DON stated advance directive is important because in the event when a resident cannot speak or decide in regards with end-of-life care, the advance will serve as guide on how to take care of them. D. During a review of Resident 12’s admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and heart failure (heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen). During a review of Resident 12’s History and Physical (H& P) dated 2/10/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12’s Minimum Data Set ([MDS]– a resident assessment tool) dated 6/8/2025, indicated Resident 12 had a BIMS score of 6, indicating severe cognitive (ability to think, understand, learn, and remember) impairment. During a review of Resident 15’s admission Record, the admission Record indicated Resident 15 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and cardiomyopathy ( a disease of the heart muscle that makes it harder to pump blood throughout the body). During a review of Resident 15’s History and Physical (H& P) dated 2/10/2025, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15’s MDS dated [DATE], the MDS indicated Resident 15 had a BIMS score of 3, indicating severe cognitive impairment. During a review of Resident 15’s Advance Directive/Medical Treatment Decisions, dated 3/19/2018, the Advance Directive/Medical Treatment Decisions indicated, the form was signed by the facility’s social worker rather than the resident or the resident’s legally authorized representative. During a concurrent interview and record review on 8/13/2025 at 11:34 a.m. with the Director of Nursing (DON), Resident 12’s Brief Interview for Mental Status (BIMS), dated June 2025 was reviewed. Resident 12’s BIMS score indicated a score of 3, indicating severe cognitive impairment. Further review of Resident 12’s Advance Directive, dated 3/27/2018, showed that the form was signed by the facility’s social worker rather than the resident or the resident’s legally authorized representative. The DON stated the social worker should not have signed the Advance Directive for Resident 12. The DON stated if residents cannot make decisions due to their cognitive status their legal representative or family member should be involved. The DON acknowledged that the process had not been followed appropriately and confirmed that the advance directive should not have been signed by facility staff. The DON stated the social worker should have contacted the responsible party or legal representative to ensure the residents’ wishes were properly documented. The DON stated the advance directive signed by the social worker may not be legally valid, which could lead to confusion during a medical emergency. The DON stated residents may not have their personal wishes honored, and their right to self-determination could be compromised. The DON stated inaccurate or unauthorized advance directives may result in treatment that was inconsistent with the resident’s values, such as unwanted resuscitation or the denial of care they would have chosen. During a review of the facility’s policy and procedures (P&P) titled, “Advance Directive Staff Training Policy,” [undated], the P&P indicated, To ensure that all staff understand the facility’s process for discussing, honoring, and documenting resident advance directives in accordance with state and federal requirements, and to promote respect for resident rights and treatment preferences. During a review of the facility’s job description for the Social Service Director [undated] indicates, The Social Service Director will oversee the process of Advance Care Planning for each resident upon admission, and make sure that any Advance Directives are reviewed with the resident/resident representative on a regular basis. The Director will ensure that staff members are made aware of the resident’s code status and end-of-life wishes and will assist with informing and education residents and their representatives about health care options and ramifications.

Based on interviews and record review the facility failed to ensure staff were competent with facility policies and procedures by failing to:A. Ensure two of two licensed staff (Registered Nurse Supervisor 1 and Licensed Vocational Nurse 3) were able to verbalize the process for securing emergency medication kits (E-kits).B. Ensure annual performance evaluations (supervisor looks at how well staff are doing their job and gives feedback) were documented and completed for five of five facility staff as required by the facility policy and regulatory standards.This deficient practice had the potential to result in staff competency concerns going unrecognized, unmet training needs, and potential to result in delays during medical emergencies, unauthorized access, and loss of critical medications. Findings: A. During a concurrent observation and interview on 8/14/2025 at 10:07 a.m. with Registered Nurse Supervisor (RNS) 1 for intramuscular Emergency Kit (E-Kit) in Medication Storage 1 in building A, RNS 1 stated the E-Kit replacement process was to log the medications taken out on the paper enclosed in the E-Kit, then call the pharmacy to replace the E-Kit. RNS 1 was unable to explain the process of securing the E-Kit after opening. RNS 1 stated she had not received an in-service for E-Kit. During a concurrent observation and interview on 8/12/2025 at 10:42 a.m. with Licensed Vocational Nurse (LVN) 3 for intramuscular E-Kit in building B, LVN 3 stated when the locks are red, the E-Kit had not been opened. LVN 3 stated to secure the E-Kit after opening, place the E-kit back in the original plastic bag, make a note, then place the E-Kit back in the storage room. During an interview on 8/14/2025 at 12:24 p.m. with the Director of Nursing (DON), the DON stated if the E-Kits are not properly locked and placed in a secure storage area, the E-kits would potentially be accessed by anyone for their own use. During a review of the facility’s Policy and Procedure (P&P) titled “Emergency Pharmacy Service and Emergency Kits (E-Kits) dated 01/2024 indicated “One copy of this information should be immediately faxed to the pharmacy or placed within the resealed emergency kit until it is scheduled for exchange…Before reporting off duty, the charge nurse indicates the “opened” or “sealed” status of the emergency kit at the shift change report and transfers the new medication orders to oncoming staff.” B. During a concurrent interview and record review on 8/14/2025 at 10:12 a.m. with the Director of Staff Development (DSD), the DSD acknowledged that five employees did not receive their required annual performance evaluations. The DSD stated the annual performance evaluations for the staff were not done due to the current workload. The DSD acknowledged that this does not meet facility or regulatory expectations. The DSD stated the facility tries to monitor staff performance through direct observation, competency checks, and ongoing in-service training. The DSD stated she acknowledges that without annual evaluations, some competency gaps may not be fully documented. The DSD stated that without annual performance evaluations, staff competency issues may go unrecognized, which could affect the quality and safety of care provided to the residents. During an interview on 8/14/2025 at 2:25 p.m. with the Director of Nursing (DON), the DON stated the facility has a process in place for annual performance evaluations for all staff. The DON stated missing these evaluations could potentially affect residents because staff competencies and areas needing improvement were not formally assessed, which may impact the quality and consistency of care. The DON stated the facility will be taking corrective action to ensure all evaluations are completed on schedule moving forward. The DON stated to ensure better oversight of staff development and maintain compliance with training requirements; she has planned to hire an additional DSD. During a review of the facility’s policies and procedures (P&P) titled, “Evaluation Process,” [undated], the P&P indicated, “It is the policy of our facility to review the work performance of employees with a formal written evaluation yearly. At the time the evaluation is given, the facility may or may not make salary/wage adjustments. The P&P indicated there is no guarantee that a salary/wage rate increase will be given automatically each year. The P&P indicated factors that will be considered in making decisions about salary/wage adjustments include, but are not limited to job performance, achieving preset goals, attendance record, adherence to workplace policies, etc.” During a review of the Director of Staff Development (DSD) job description, the job description indicated the following responsibility: the DSD participates in the completion of the facility assessment at least annually to determine the knowledge and skill required among staff to meet residents’ needs.

Based on interview and record review the facility failed to ensure seven of seven sampled residents (Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108) received their mail on Saturdays.This failure resulted in Resident 25, Resident 29, Resident 41, Resident 58, Resident 59, Resident 96 and Resident 108 rights violated to receive mail on Saturdays.Findings:1. During a review of Resident 25's admission Record (Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and homelessness.During a review of Resident 25's History and Physical (H&P), dated 7/16/2025, the H&P indicated Resident 25 could make needs known but could not make medical decisions.During a review of Resident 25's Minimum Data Set (MDS-a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 25 was independent with eating oral hygiene, toileting, showering, dressing, putting on and taking off footwear, and personal hygiene.2. During a review of resident 29's Face Sheet, the Face Sheet indicated Resident 29 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including lymphedema (swelling of the arms or legs due to a buildup of lymph fluid in the body's tissues), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), obesity, and arthropathy (and disease or condition that affects the joints).During a review of Resident 29's History and Physical (H&P), dated 2/20/2025, the H&P indicated, Resident 29 had the capacity to understand and make decisions.During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 needed partial to moderate assistance from nursing staff with showering, putting on and taking off footwear, and walking. The MDS indicated Resident 29 needed supervision or touching assistance from nursing staff with toileting, lower body dressing, personal hygiene, and transferring. The MDS indicated Resident 29 was independent with eating, oral hygiene, and upper body dressing.3. During a review of Resident 41's Face Sheet, the Face Sheet indicated, Resident 41 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including COPD, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), encephalopathy (a group of conditions that cause brain dysfunction), and major depressive disorder.During a review of Resident 41's H&P, dated 7/17/2025, the H&P indicated, Resident 41 had fluctuating capacity to understand and make decisions.During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41 needed nursing staff supervision or touching assistance with showering and personal hygiene. The MDS indicated Resident 41 was independent with eating, oral hygiene, toileting, dressing, and putting on and taking off footwear.4. During a review of Resident 58's Face Sheet, the Face Sheet indicated, Resident 58 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] diagnoses of but not limited to major depressive disorder, anxiety, diabetes mellitus and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of resident 58's H&P dated 5/22/2025, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's MDS dated [DATE], MDS indicated Resident 58 needed nursing staff supervision or touching assistance with toileting, showering, putting on and taking off footwear, personal hygiene, transferring, and walking 150 feet. 5. During a review of Resident 59's Face Sheet, the Face Sheet indicated, Resident 59 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] diagnoses including schizophrenia, anxiety, major depressive disorder and insomnia (trouble falling asleep or staying asleep).During a review of resident 59's H&P dated 7/18/2025, the H&P indicated Resident 59 had fluctuating capacity to understand and make decisions. During a review of Resident 59's MDS dated [DATE], MDS indicated Resident 59 needed nursing staff supervision or touching assistance with showering, lower body dressing, personal hygiene, and transferring.6. During a review of Resident 96's Face Sheet, the Face Sheet indicated, Resident 96 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] diagnoses of but not limited to COPD, hyperlipidemia (high cholesterol, abnormally high lipids in the blood), paranoid schizophrenia, and bipolar.During a review of resident 96's H&P dated 1/30/2024, the H&P indicated Resident 96 was able to make decisions for activities of daily living.During a review of Resident 96's MDS dated [DATE], MDS indicated Resident 96 needed nursing staff supervision or touching assistance with toileting, showering, and walking 50 to 100 feet.7. During a review of Resident 108's Face Sheet, the Face Sheet indicated, Resident 108 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] diagnoses of but not limited to hypothyroidism (the thyroid hormone does not produce enough thyroid hormone to meet the body's needs) , chronic kidney disease (the kidneys are damaged and lose their ability to filter blood properly), anxiety and schizophrenia.During a review of resident 108's H&P dated 9/18/2024, the H&P indicated Resident 59 had fluctuating capacity to understand and make decisions. During a review of Resident 108's MDS dated [DATE], MDS indicated Resident 108 needed nursing staff partial to moderate assistance with showering and personal hygiene. The MDS indicated Resident 108 needed nursing staff supervision or touching assistance with toileting, dressing, putting on and taking off footwear and transferring. During a concurrent observation and interview in the Resident Council meeting on 8/12/2025 at 1:17 p.m. in the activities room, Residents 25, 29, 41, 58, 59, 96 and 108 agreed they did not get mail on Saturdays because the Business Office staff are off on the weekends. Resident 29 (Resident Council President) stated I have been in the facility 19 years, and I have never received mail on a Saturday. Resident 29 stated we eventually get our mail.During an interview on 8/12/2025 at 2:32 p.m. with the Director of Nursing (DON), the DON stated the business office is responsible for getting the residents' mail. The DON stated on Saturdays the receptionist is responsible for getting the residents' mail. During an interview on 8/12/2025 3:28 p.m. with the Receptionist (REC), the REC stated for a whole year she has never seen the mailman deliver mail to the facility on Saturdays. The REC stated she was never told she needed to give mail to Residents on Saturday. The REC stated it is important for residents to receive mail on Saturday just in case the resident is expecting mail or a delivery. During an interview on 8/13/2025 at 3:09 p.m. with the Business Office Manager (BOM), the BOM stated on Saturdays the post office does not like to deliver mail to the facility because the business office is closed on the weekends. The BOM stated the mailman does not feel comfortable delivering the mail to the nurses' station when the business office is closed. The BOM stated she could speak with the postal services to see if they could deliver on Saturdays because it is causing an issue with the residents not receiving their mail on Saturdays. The BOM stated mail meant for the resident to receive on Saturday is not getting delivered until Monday. During an interview on 8/14/2025 at 12:35 p.m. with the Administrator (ADMIN), the ADMIN stated the mail is supposed to be delivered on Saturdays to the nursing station and the Registered Nurse Supervisors (RNS)are responsible for collecting the mail and making sure the mail is distributed to the residents. The ADMIN stated it the residents right to receive mail on Saturday. The ADMIN stated the residents will become frustrated if they are not receiving their mail. The ADMIN stated she will contact the post office because they use to deliver to the facility all the time on Saturday but now that we have the front door locked, they do not deliver on Saturdays. During a review of the facility's policy and procedure (P&P) titled, Mail, undated, the P&P indicated, Mail will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). During a review of the facility's policy and procedure (P&P) titled, Receptionist Job Description, undated, the P&P indicated, Major Duties and Responsibilities. Sort, distribute, and send incoming and outgoing mail.

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA- develop and implement appropriate plans of action to correct identified quality deficiencies) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementing care plans, social services, pharmacy services, medication storage, and infection control and prevention. Findings:During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies: resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementing care plans, social services, pharmacy services, medication storage, and infection control and prevention.During an interview on 8/14/2025 at 2:30 p.m., with the Administrator (ADM), the ADM stated there are repeat deficiencies from the previous recertification survey. The ADM stated the facility should be stronger with their audits and increased review of the charts by the social workers. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI), undated, the P&P indicated, QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes, while involving residents and families in practical and creative problem solving. The QAA committee shall develop and implement appropriate plans of action to correct identified quality deficiencies. The QAPI plan will address the following elements: process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance improvement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or performance improvement activities, and monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on interview and record review, the facility failed to ensure the arbitration (a form of dispute resolution where a neutral third party helps resolve a dispute between two or more parties) agreements were accurately completed for three of three sampled residents (Resident 29, 68, and 72). The facility failed to:1.Assess mental capacity (ability to make decisions) and provide information to Residents 29, 68, and 72 before signing the arbitration agreement. 2.Ensure the arbitration agreement forms are fully completed.This failure had the potential to result in Resident's 29, 68, and 72 not fully understanding his/her right to limit the opportunity to initiate judicial proceedings that challenge unfavorable decisions. Findings:During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 29's Minimum Data Set (MDS- a resident assessment tool) dated 12/30/2011, the MDS indicated Resident 29's cognition (ability to think, understand, learn, and remember) was intact. During a review of Resident 29's arbitration agreement dated 2/9/2016, the arbitration agreement was incomplete with no facility staff signature. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing). During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was severely impaired.During a review of Resident 68's arbitration agreement undated, the arbitration agreement was incomplete with no resident or resident representative signature. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and Parkinson's Disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). During a review of Resident 72's MDS dated [DATE], the MDS indicated Resident 72's cognition was moderately impaired. During a review of Resident 72's arbitration agreement undated, the arbitration agreement was incomplete with no resident or resident representative signature. During a concurrent interview and record review on 8/14/2025 at 7:44 a.m., with the Social Services Director (SSD) 1, SSD 1 validated Resident 29, 68, and 72's arbitration agreements were incomplete and therefore invalid. SSD 1 stated Resident 68 and 72's should not have been asked to sign an arbitration agreement because of their impaired cognition and not understanding what they were signing. During an interview on 8/14/2025 at 12:48 p.m., with the Director of Nursing (DON), the DON stated that a resident that was mentally incapable of understanding what they were signing, should not be asked to sign an arbitration agreement. The DON stated the arbitration agreement should be addressed with the resident representative or guardian because it was the resident right to sign an arbitration agreement and having them sign something they do not understand was going against their resident rights. During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, undated, the P&P indicated, The facility must ensure that the agreement is explained to the resident and their representative in a form and manner that he or she understands, including in a language the resident and their representative understands. The resident acknowledges that he or she understands the agreement.

Based on observation interview and record review the facility failed to: 1.Ensure an open date was placed on an open gallon of milk and an open bag of potato chips. 2.Ensure a bin of celery and multiple bags of hotdog buns were not expired.3.Ensure that chicken was defrosted safely, when the chicken was left in a tub of standing water while defrosting in the sink. 4.Ensure the sanitation bucket had sanitizer solution in it.These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).Findings:During a concurrent observation and interview on 8/11/2025 at 8:15 a.m. with the Dietary Aide 2 (DA2) in the kitchen, a gallon of milk and a bag of potato chips did not have an open date label. A bin of celery with an expiration date of 8/10/2025 and multiple bags of hotdog buns dated 7/1/2025, 7/9/2025 and 8/3/2025 were observed. Observed two tubs of chicken thawing out in standing water. DA 2 stated there should be an open date on all food after it was opened so the residents will not get sick. DA 2 also stated that chicken needs to be defrosted under cold running water to ensure safe thawing temperatures to prevent salmonella (food born bacteria). DA 2 stated the celery and hotdog buns should have been thrown out because they were expired and not good for the residents to eat.During a concurrent observation and interview on 8/11/2025 at 9:45 a.m. with DA 1 the sanitation bucket was tested, the testing strip indicated there were 10 parts per million (ppm-unit of measure) of quats (sanitizer) solution in the sanitation bucket. DA 1 stated this was not right and should be between 50-100 PPM. The DS stated the residents were at risk for cross contamination and food borne illness when kitchen surfaces were not sanitized properly.During an interview on 8/14/2025 at 8:43 a.m., with the Dietary Supervisor (DS) , the DS stated after the food was opened there needs to be an open date label and food should not be served out of date to prevent food borne illness. The DS also stated that when thawing out meat there needs to always be cold running water to ensure safe thawing temperatures to prevent food borne illnesses. The DS also stated that the sanitation bucket should have 200-400 PPM of quats solution to prevent food borne illnesses from cross contamination.During a review of the Sanitation Bucket Log dated 8/2025, the sanitation bucket log indicated, change all buckets in the kitchen and retail every two hours and check concentration of one bucket. Must be 200-400 PPM manual mixing directions for Oasis 146 Quat Sanitizer: Mix two ounces of Oasis 146 quat sanitizer in 4 gallons of water. This will give you a sanitizer solution that is 200 -400 ppm.During a review of the facility's policy and procedure (P&P) titled Food Preparation, dated 2/2025 the P&P indicated All foods are prepared in accordance with the Food Drug Administration (FDA) food code. The cook thaws frozen items that require defrosting prior to preparation using one of the following methods completely submerging the item under cold water at a temperature of 70 degrees ( Fahrenheit unit of temperature) or below that is running fast enough to agitate and float off loose ice particles.During a review of the facility's P&P titled Food receiving and storage, (undated), the P&P indicated Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated with open and use by date and other containers must be dated and sealed or covered during storage.

Based on observation, interview, and record review, the facility failed to ensure eight of eight residents (Resident 160, Resident 11, Resident 16, Resident 22, Resident 26, Resident 61, Resident 84, and Resident 92) opened medication bottles were labeled with the date opened.This failure had the potential to result in the use of medications beyond their recommended stability period, reducing their efficacy, and compromising resident safety through the administration of expired and contaminated medications. Findings:During a concurrent observation and interview on [DATE] at 10:54 a.m. with Licensed Vocational Nurse (LVN) 2, for morning (AM) medication cart located in building B, the following were inside the cart without opened dates:1. Valproic Acid (medication used to treat seizures, manic episodes associated with bipolar disorder, and to prevent migraine headaches) for Resident 11, 2. Constulose (used to treat chronic constipation) for Resident 61, 3. Constulose for Resident 84, 4. Megestrol (medication used to increase appetite and cause weight gain in patients experiencing unexplained, significant weight loss) and Valproic Acid for Resident 16, 5. Valproic Acid for Resident 160, 6. Constulose for Resident 26, 7. Enulose (used to treat constipation) for Resident 92, 8. Constulose for Resident 22 LVN 2 stated all medications should be labeled with the opened date. LVN 2 stated the potential outcome for not labeling medications with open dates would be the medications will not have the same effect on the residents.During an interview on [DATE] at 11:14 a.m. with Director of Nursing (DON), the DON stated open date labels were placed on the medication bottle upon opening, then returned in the medication cart. The DON stated potential outcomes for residents included decreased effectiveness of the medication.

Based on observation, interview, and record review , the facility failed to ensure Zyprexa (Olanzapine- medicine that treats mental disorders , including schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder[sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs])10 milligrams (mgs.- unit of measurement) were not in the same plastic bag mixed with Zyprexa 5 mgs. and labeled for Zyprexa 5 mgs outside the plastic container for one of four sampled residents (Resident 148).This failure had the potential to place Resident 148 at risk for medication error.Findings:During a review of Resident 148's admission Records, the admission Records indicated Resident 148 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified psychosis(a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizoaffective disorder, bipolar type(a mental illness that can affect thoughts, mood, and behavior with mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 148's Minimum Data Set (MDS- a resident assessment tool) dated 6/11/2025, the MDS indicated the resident had moderately impaired cognitive (ability to think, understand, learn, and remember) skills and required setup or clean-up assistance (helper sets up or cleans up as resident completes the activity) with eating, oral hygiene, transfer and bed mobility.During a review of Resident 148's Medication Administration Record (MAR), the MAR indicated Resident 148 was on Zyprexa 5 mgs. one tablet by mouth in the morning for schizoaffective disorder manifested by auditory hallucinations (hearing voices of people to get him, making him fearful). The MAR indicated Zyprexa 5 mgs. was ordered on 8/5/2025 and was administered to Resident 148 on 8/13/2025, at 9:00 a.m.During a review of Resident 148's MAR , the MAR indicated Zyprexa 10 mgs. one tablet by mouth in the evening for schizoaffective disorder manifested by auditory hallucinations and ordered on 8/4/2025. The MAR indicated Zyprexa 10 mgs., was scheduled to be administered to Resident 148 at 5:00 p.m.During a medication pass observation on 8/13/2025, at 8:39 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 removed the tablet of Zyprexa 5 mgs. from the plastic bag and into a medicine cup. LVN 4 administered Zyprexa 5 mgs. to Resident 148. Observed the Zyprexa 5 mgs. and Zyprexa 10 mgs were mixed in same plastic bag labeled as Zyprexa 5 mgs tablet give 1 tablet by mouth every morning.During an interview on 8/13/2025, at 2:43 p.m. with LVN 4, LVN 4 stated the licensed nurses were responsible in ensuring the correct medications and doses are stored in the plastic bag. LVN 4 stated she did not know who placed the Zyprexa 5 mgs. and 10 mgs in the same plastic bag. LVN 4 stated Zyprexa 10 mgs should be in another plastic bag intended for the evening dose. LVN 4 stated mixing Zyprexa 5 mgs. and Zyprexa 10 mgs in one plastic bag had the potential for medication error.During an interview and review on 8/13/2025, at 3:04 p.m. with Director of Nursing (DON), showed Resident 148's picture of Zyprexa ‘s plastic bag the DON. The DON stated Resident 148 can be at risk of having an overdose of Zyprexa and a possibility of a medication error because both medications with different doses were mixed in the same plastic bag. The DON stated the licensed nurses should have separated Zyprexa 10 mgs. from Zyprexa 5 mgs. then transfer the Zyprexa 10 mgs. in the medication cart for the evening dose. The DON stated it was plain carelessness, and this practice can place the lives of residents at stake.During a review of facility's policy and procedure (P&P) titled, Medication Storage, undated , the P&P indicated The facility will store medications according to the manufacturer's recommendations and will ensure sanitation, moisture control, segregation and security of stored medicines.

Based on interview and record review, the facility failed ensure one of three sampled residents (Resident 168) with Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a traumatic event) was referred to a psychologist (a trained mental health professional who helps people learn healthy ways to handle mental health challenges) per Resident 168 request and physician order. This deficient practice resulted in Resident 168 not receiving the proper assessment, necessary treatment, and resources for his diagnosis of PTSD. Findings: During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses including PTSD, major depressive disorder (a mood disorder that causes a persistent feeling and loss of interest), and anxiety (a common mental health condition characterized by excessive worry, fear, and unease). During a review of Resident 168's Minimum Data Set (MDS- a resident assessment tool) dated 7/16/2025, the MDS indicated Resident 169's cognition (ability to think, understand, learn, and remember) was intact. During a review of Resident 168's Care Plan titled Resident 168 was at risk for disturbed thought processes, panic level of anxiety feelings of tension, worried thoughts ), depressive symptoms (feeling of sadness and loss of interest), lability of mood ( frequent, rapid, and sometimes intense shifts in emotions), and disturbance in sleep (disruptions to the normal sleep cycle ) revised 7/11/2025, the Care Plan goals indicated for Resident 168 to openly discuss fears and use of effective coping behaviors to resume normal life and will exercise control over his intrusive (something unwanted, annoying, or unwelcome that interrupts your thought) thoughts by being calm and relaxed. The Care Plan interventions indicated for Resident 168 to receive medication as ordered, encourage verbalize feelings, psychology consultation (assessment of the patient's present state of mind and how it affects his or her behavior and function) as needed and avoid physical contact. During a review of Resident 168's Medication Review Report, the Medication Review Report indicated an order was placed on 7/9/2025 for Depakote (mood stabilizer medication that works in the brain) twice a day for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by impulsive and unpredictable behavior with no regards to safety. The Medication Review Report indicated an order was placed on 7/9/2025 for Lexapro (a medication to help improve mood) each morning for depression (a mood disorder that causes persistent feelings of sadness and loss of interest in activities such as sleeping and eating) manifested by verbalizing feeling depressed and wanting to overdose (takes more of a substance [like drugs or alcohol] than their body can handle), causing harmful or even deadly effects). During a review of the Order Summary Report, the Order Summary Report indicated an order was placed 7/9/2025 for a psychologist consult.During an interview on 8/12/2025 at 3:03 p.m., with Resident 168, Resident 168 stated he asked the Social Services Director (SSD) 1 to see a psychologist but she did not follow up with him.During an interview on 8/14/2025 at 7:44 a.m., with SSD 1, SSD 1 stated she recalls Resident 168 requesting to see a psychologist but assumed because there was a standing order for a psychologist consult, she did not know an appointment needed to be made for Resident 168. SSD 1 stated she did not document this conversation or follow up with Resident 168's request to see a psychologist but should have, especially since he has PTSD and it could improve his mental well-being. During an interview on 8/14/2025 at 12:48 p.m., with the Director of Nursing (DON), the DON stated if a resident requests to see a psychologist, SSD 1 should make the appointment as well as document Resident 168's request. The DON stated SSD 1 not following through with Resident 168's request to see a psychologist, could cause Resident 168 to feel frustrated and potentially cause his condition to worsen. During a review of the facility's policy and procedure (P&P) titled, Social Services undated, the P&P indicated, The facility, regardless of size, will provide medically related social services to each resident, to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. The social worker, or social service designee, will pursue the provision of any identified need for medically related social services of the resident. Services to meet the resident's needs may include providing or arranging for needed mental and psychosocial counseling services.During a review of the facility's Social Services Director Job Description, undated, the Social Services Director Job Description indicated, The Social Services Director will coordinate implementation and oversight of procedures to ensure social services actions and interactions are adequately documented in each resident's medical record, and that legal, ethical, and professional standards of social work practice and being upheld in written recordings.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and 3) were free from physical abuse when Resident 1, who had a history of schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (excessive worry and feelings of fear, dread, and uneasiness), and major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest), suddenly without any provocation, hit Resident 2 on the left side of his face and then proceeded to hit Resident 3 on the right side of his face causing Resident 3 to fall to the floor. Resident 1 was arrested by the local area police. These deficient practices resulted in Resident 2 being transferred to a General Acute Care Hospital (GACH 1) where he was assessed with facial fractures (break in the bone) and Resident 3 being transferred via 911 (emergency services) to GACH 2 where he was treated for facial lacerations that required stitches. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) MDD and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/23/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired (a level of cognitive decline where individuals experience noticeable difficulties with memory, language judgement, and problem-solving, impacting their ability to manage daily activities independently). The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up; resident completes activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Psychiatric Evaluation dated 6/24/2025, the Psychiatric Evaluation indicated Resident 1 presented with heightened psychomotor agitation (a state of increased physical activity and restlessness, often accompanied by mental distress or inner tension), marked anxiousness, irritability, uncooperativeness, guarded demeanor (a manner of behavior that is cautious, reserved, and restrained, often indicating a reluctance to [NAME] one's true feelings or thoughts) and restlessness. During a review of Resident 1's Change in Condition (COC) Evaluation dated 6/29/2025, the COC Evaluation indicated Resident 1 without any reason, suddenly hit a resident (Resident 3) who was walking in the hallway. The COC Evaluation indicated Resident 3 was hit on his face causing bleeding to his mouth. The COC Evaluation indicated Resident 1 was redirected to his room and away from others but continued to be physically violent to others. The COC Evaluation indicated 911 was called and Resident 1 was closely watched/guarded by male staff until the local police department arrived at the facility. During a review of Resident 1's Nursing Note dated 6/29/2025, the Nursing Note indicated Resident 1 was taken into custody by a local area police department. During a review of Resident 2's Face Sheet, the Face Sheet, indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia (a chronic mental health disorder characterized by persistent delusions (having false or unrealistic beliefs), hallucinations (to see, hear, feel, or smell something that does not exist), and paranoia (an extreme fear and distrust of others). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired The MDS indicated Resident 2 required supervision or touch assistance (helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity) to complete his ADLs. During a review of Resident 2's COC Evaluation dated 6/29/2025, the COC Evaluation indicated Resident 2 was walking in the hallway when Resident 1 suddenly hit him on his left cheek without any provocation. The COC Evaluation indicated Resident 2's skin below his left eye was discolored, an ice pack was applied, neuro checks were initiated, and Resident 2 was closely monitored. During a review of Resident 2's physician order dated 6/29/2025, the physician order indicated to transfer Resident 2 to a GACH for further evaluation. During a review of Resident 2's Face Sheet, from GACH 1, the Face Sheet indicated Resident 2 was admitted to GACH 1 on 6/30/2025, after being transferred from GACH 2's emergency room (ER) where he was initially transported after the assault on 6/29/2025. During a review of Resident 2's GACH 1 Department of Emergency Medicine History of Present Illness, dated 6/30/2025, the History of Present Illness indicated Resident 2 was transferred from GACH 2 following an assault. The report indicated a Computed Tomography Scan ([CT scan] medical imaging that uses x-rays (a form of electromagnetic radiation that can penetrate most objects) was conducted. During a review of Resident 2's CT scan dated 6/30/2025, the CT scan indicated the following: 1. A fracture of the left zygomatic arch (the upper jawbone and cheek). 2. A fracture of the left lateral orbital wall (the outer wall of the eye socket, side of the eye), which is slightly angled medially (a position that points toward the middle of the body) 3. A fracture of the left malar eminence (the cheekbone). 4. A commuted fracture (a type of fracture where the bone breaks into multiple pieces of there or more) of the anterior (nearer the front) and posterior (further back in position) lateral wall of the left maxillary sinus (on the left side of the nose) as well as the left orbital floor (the bottom of the eye socket). 5. A fracture of the posterior left nasal bone as well as the anterior left nasal bone with associated paranasal (near or alongside the nasal cavity) soft tissue swelling During a review of the Department of Emergency Medicine Medical Decision Making note, the Medical Decision Making note indicated for Resident 2 to follow up with Oral Maxillofacial Surgery (a surgical specialty focused on the diagnosis and treatment of diseases, injuries, and defects of the head, neck, face, and jaws) and to schedule an appointment as soon as possible for a visit in two days. During an interview on 7/15/2025 at 11:27 a.m., Resident 2 stated he was standing in the hallway by the double doors, outside Resident 1's room, when Resident 1 hit him on the left side of his face. Resident 2 stated after Resident 1 hit him in his face he (Resident 2) was taken to GACH 2. Resident 2 stated Resident 1 also hit another resident (Resident 3), who was also standing in the hallway immediately after hitting him (Resident 2). During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of MDD, and anxiety. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was intact. During a review of Resident 3's COC dated 6/29/2025, the COC indicated Resident 3 was hit by another resident (Resident 1) on his face/cheek and had minimal bleeding to his mouth. The COC indicated Resident 3 was walking in the hallway when Resident 1 suddenly and unprovoked hit him on his face, resulting in Resident 3 landing on the floor and bleeding from his mouth. The COC indicated Resident 3's physician instructed that Resident 3 be transferred to a GACH via paramedics. During a review of GACH 3's Emergency Department (ED) Provider Note dated 6/29/2025, the ED Provider Note indicated Resident 3 was admitted to GACH 3 on 6/29/2025. The ED Provider Note indicated Resident 3 presented to the ER for evaluation of facial trauma following an assault. The ED Provider Note indicated Resident 3 fell backwards, striking the back of his head, and lost consciousness for several seconds. The ED Provider Note indicated Resident 3 had a small facial laceration to his left cheek, measuring one centimeter ([cm] a unit of measurement) in length, and a laceration to his left lateral lip (measurement unknown), The ED Provider Note indicated Resident 3's facial laceration on his left cheek and mucosa (the moist, inner lining of the mouth) of the mouth were repaired (with stitches). During an interview on 7/15/2025 at 12:10 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 was quite tall, not talkative, and only came to the staff when he needed something. CNA 3 stated on 6/29/2025 around breakfast time (exact time unknow), he was at the nursing station when he heard a commotion (a state of confusion and noisy disturbance) and shouting from the area near Resident 1's room. CNA 3 stated when he responded to the commotion, he saw Resident 3 on the floor with facility staff who were assisting him. During an interview on 7/15/2025 at 1:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was around the corner from Resident 1's room preparing medications when she heard a commotion and shouting. LVN 2 stated when she responded she found Resident 2 in the hallway near Resident 1's room, holding his face. LVN 2 stated, when Resident 2 was asked what happened, he only stated Resident 1's name. LVN 2 stated she saw Resident 1 standing by his room and she yelled Resident 1's name to get his attention when she saw Resident 3 walk past Resident 1 and Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. LVN 2 stated she screamed for help and other staff came quickly to respond to the commotion. During a telephone interview on 7/15/2025 at 1:31 p.m., with CNA 1, CNA 1 stated she was standing in the hallway and saw Resident 2 standing in the hallway next to Resident 1's room, when suddenly Resident 1 came out of his room and hit Resident 2 in the face. CNA 1 stated she screamed and LVN 2 responded. CNA 1 stated she was helping Resident 2 while LVN 2 was trying to get Resident 1's attention when suddenly Resident 1 hit Resident 3 causing Resident 3 to fall to the floor. During an interview on 7/15/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated Resident 1 stepped out of his room and hit Resident 2 and then in a matter of seconds, turned to his left and hit Resident 3. The DON stated Resident 2 and Resident 3 were both transported to separate GACHs following the assault by Resident 1. The DON stated Resident 2 was found to have facial fractures and follow up with an oral surgeon was being done. The DON stated Resident 3 sustained bruises and lacerations to his face and received stitches on the corner of his lip. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect, and Exploitation the P/P indicated each resident had the right to be free from abuse. The P/P indicated residents must not be subjected to abuse by anyone, including, but not limited to other residents.

Based on observation, interview, and record review, the facility failed to ensure 5 of 5 sampled residents (Residents 6, 117, 122, 141, and 157) who were smokers, had an environment free of accident hazards (risk), by failing to: 1. Implement guidance from the Resident Smoking Assessment Form which indicated all residents' smoking materials and paraphernalia must be safely stored by facility staff. 2. Ensure Residents 6, 141, 122, 157, and 117 were not in possession of smoking materials (cigarettes and lighters). 3. Provide supervision while smoking for Residents 141, 157, and 117 identified as unsafe smokers. 4. Follow its policy and procedure (P&P) titled, Accidents and Supervision, which indicated staff will observe and identify potential hazards in the environment. 5. Follow its it P&P titled Resident Smoking, which indicated, smoking materials of residents requiring supervision with smoking, will be maintained by nursing staff . These deficient practices had the potential for Residents 6, 141, 122, 157, and 117 to turn on the lighters, cause a fire that could affect the health, safety, and wellbeing of all 118 residents in the facility, staff and visitors and result in serious injuries, hospitalization , and death. On 7/25/2024 at 5:09 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility failing to supervise smoking activities for Residents 141, 157, and 117. The facility also failed to safely secure store lighters and cigarettes. On 7/26/2024 at 4:51 p.m., the IJ was removed after review of the IJ Removal Plan ([IJRP]a plan with interventions to correct the deficient practice) was reviewed and deemed acceptable through observations, interview, and record review. The IJRP included the following immediate actions: 1. On 7/25/2024 at 8:00 p.m., smoking assessments and care plans for all smoking residents were reviewed to address physical, cognitive, and medical diagnoses affecting to ability to smoke safely. 2. A dedicated staff and reliever were assigned and in-serviced on 7/25/2024 at 8:30 p.m. 3. Met with Residents 157, 117, 141, and 122 on 7/25/2024 at 8:00 p.m. for acknowledgement of the smoking policy. a. Ensured smoking residents did not have smoking paraphernalia (items to perform a specific task). b. Residents 122, 141 gave up their lighters. 4. Facility did a sweep of all residents to ensure smokers were identified. 5. On 7/25/2024 at 9:00 p.m. all staff in-serviced on the facility policy for resident smoking. a. Dedicated smoking monitors identified for cover smoking schedule. 6. Corrective action will be monitored. a. Smoking care plans will be reviewed upon admission and quarterly to ensure interventions have been implemented. b. The DON will complete random weekly chart audits for four weeks for accuracy of assessment and care plan. c. Plan of correction will be monitored at monthly quality assurance meeting for the next six months. Findings: a. During a review of Resident 6's Admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of thinking, remembering, and reasoning), schizophrenia (mental illness that affects how a person thinks and behaves), and seizures (abnormal activity in the brain). During a review of Resident 6's History and Physical (H&P), dated 3/26/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Resident Smoking Assessment Form, dated 6/6/2024, the Resident Smoking Assessment form indicated Resident 6 was not able to light a cigarette safely with a lighter and not able to use an ashtray safely. The Resident Smoking Assessment Form indicated Resident 6 was not able to extinguish a cigarette safely and completely. The Resident Smoking Assessment Form indicated Resident 6 was an unsafe smoker and must be supervised at all times when smoking. During a review of Resident 6's cognitive (thinking, reasoning) loss care plan, dated 3/27/2024, the care plan indicated Resident 6 had periods of forgetfulness. During a review of Resident 6's occupational therapy (therapy focused on abilities for daily activities) care plan, dated 3/27/2024, the care plan indicated Resident 6 had impaired strength to bilateral upper extremities. During a concurrent observation and interview on 7/24/24 at 3:00 p.m. at the bedside of Resident 6, Resident 6 was observed lifting the seat on his rollator walker (a four-wheeled walker with handlebars and a built-in seat) revealing the cigarettes and lighter in his possession. Resident 6 stated he always kept his own cigarettes and lighter. Resident 6 stated the facility staff did not tell him about the smoking policy. Resident 6 stated the staff was aware he had a lighter. b. During a review of Resident 141's Face Sheet, the Face Sheet indicated Resident 141 was admitted to the facility on [DATE] with diagnoses that included deformity of fingers and hand, lack of coordination, and seizures. During a review of Resident 141's H&P, dated 7/11/2024, the H&P indicated Resident 141 had the capacity to understand and make decisions. During a review of Resident 141's Resident Smoking Assessment Form, dated 7/9/2024, the Resident Smoking Assessment Form indicated Resident 141 was not able to light a cigarette safely with a lighter and was not a safe smoker. The smoking assessment indicated Resident 141 was not able to use an ashtray safely or extinguish a cigarette safely and completely. The assessment indicated Resident 141 must be supervised at all times and wear a protective apron when smoking. During a review of Resident 141's smoking care plan, dated 7/9/2024, the care plan indicated Resident 141 was an impaired smoker and needed constant supervision with protective gear. The care plan indicated the facility would provide Resident 141 with constant supervision while smoking. During a review of Resident 141's occupational therapy care plan, dated 7/10/2024, the care plan indicated Resident 141 had impaired strength to the bilateral upper extremities. During a concurrent observation and interview on 7/24/2024 at 2:53 p.m. with Resident 141 on the smoking patio, Resident 141 was smoking unmonitored by staff. Resident 141 stated staff were aware she had cigarettes and a lighter in her possession. Resident 141stated the facility never told her about the smoking policy. Resident 141 showed the surveyor her lighter. c. During a review of Resident 122's Face Sheet, the Face Sheet indicated Resident 122 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, heart failure (heart doesn't work as well as it should), and kidney disease (damage to the kidney). During a review of Resident 122's H&P, dated 1/8/2024, the H&P indicated Resident 122 had the capacity to make decisions for activities of daily living. During a review of Resident 122's Resident Smoking Assessment Form, dated 5/31/2024, the Resident Smoking Assessment Form indicated Resident 122 was not able to light a cigarette safely with a lighter. The Resident Smoking Assessment Form indicated Resident 122 was an unsafe smoker and must be supervised at all times when smoking. During a review of Resident 122's smoking care plan, dated 1/8/2024, the care plan indicated Resident 122 may smoke under supervision. The care plan indicated the facility would observe Resident 122 for unsafe smoking behaviors/practices and supervise Resident 122 based on the Smoking Assessment. The care plan indicated the facility would store smoking and incendiary-related (devices designed to cause fire) material per the facility policy. During an observation on 7/24/2024 at 4:42 p.m, in the room of Resident 122, Resident 122 was observed with three cigarettes and two lighters in his bedside drawer. During a concurrent observation and interview on 7/25/2024 at 8:52 a.m. with LVN 4, at Resident 122's bedside, Resident 122 was observed with one cigarette in his bedside drawer. LVN 4 stated cigarettes should not be in the drawer. LVN 4 stated cigarettes were stored at the receptionist's desk and staff monitor for lighters. LVN 4 stated a resident could start a fire and everyone's safety is in jeopardy. d. During a review of Resident 157's Face Sheet, the Face sheet indicated Resident 157 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and diabetes (abnormal blood sugar). During a review of Resident 157's H&P, dated 2/5/2024, the H&P indicated Resident 157 had the capacity to understand and make decisions. During a review of Resident 157's Resident Smoking Assessment Form, dated 7/23/2024, the Resident Smoking Assessment Form indicated Resident 157 was not able to use an ashtray safely and not able to extinguish a cigarette safely and completely. The assessment indicated Resident 157 was an unsafe smoker and must be supervised at all times when smoking. During a review of Resident 157's smoking care plan, dated 2/5/2024, the care plan indicated Resident 157 may smoke under supervision. The care plan indicated the facility would observe resident for unsafe smoking behaviors/practices and would supervise Resident 157 per the smoking assessment. The care plan indicated the facility would store smoking and incendiary-related material per facility policy. During a review of Resident 157's cognitive loss care plan, dated 2/5/2024, the care plan indicated Resident 157 had periods of confusion. During a review of Resident 157's occupational therapy care plan, dated 2/6/2024, the care plan indicated Resident 157 had impaired strength to the bilateral upper extremities. During an observation on 7/24/2024 at 2:39 p.m., Resident 157 was observed on the smoking patio. Resident 157 handed Resident 117 a cigarette. There were no facility staff observed on the smoking patio at that time. During a concurrent observation and interview on 7/24/2024 at 2:44 p.m. with LVN 3 in the hallway outside the smoking patio, LVN 3 and the surveyor observed Resident 157 was observed in the smoking patio. stand Resident 157 stood up from a chair and lit a cigarette for Resident 117. LVN 3 stated, he (Resident 157) had a lighter. LVN 3 stated Resident 157 should not have a lighter because it was a risk for fire and there was no one monitoring him. LVN 3 stated Resident 157 could have started a fire in the facility if there was a resident on oxygen in the patio area. e. During a review of Resident 117's Face Sheet, the Face Sheet indicated Resident 117 was admitted to the facility on [DATE] with diagnoses that included left hemiplegia (unable to move one side of the body), heart failure, and left above the knee amputation (removal of a body part). During a review of Resident 117's H&P, dated 9/8/2023, the H&P indicated Resident 117 had the capacity to understand and make decisions. During a review of Resident 117's Resident Smoking Assessment Form, dated 4/22/2024, the Resident Smoking Assessment Form indicated Resident 117 was not able to light a cigarette safely with a lighter, was not able to use an ashtray safely, and was not able to extinguish a cigarette safely and completely. The assessment indicated Resident 117 was an unsafe smoker and must be supervised at all times when smoking. During a review of Resident 117's smoking care plan, dated 9/8/2023, the care plan indicated Resident 117 needed observation while smoking. The care plan indicated the facility would provide Resident 117 with observation while smoking. During a concurrent observation and interview on 7/24/2024 at 2:39 p.m. with Resident 117, on the smoking patio, Resident 117 stated she kept her own cigarettes. Resident 117 stated she was told she could not have a lighter in her possession, but the staff never asked if she had a lighter. During a concurrent observation and interview on 7/24/2024 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, in the smoking patio, Resident 117 and Resident 157 was observed actively smoking on the smoking patio and CNA1 stated he had to go answer a call light and was observed leaving the smoking patio. Resident 117 and Resident 157 were observed unmonitored on the smoking patio. CNA 1 stated when he entered the patio no one was monitoring the residents smoking. CNA 1 stated the facility's policy indicated a staff must always monitor residents while smoking. During a concurrent observation and interview on 7/24/2024 at 2:54 p.m. with Activity Assistant (AA) 1, AA 1 was observed checking the pockets of Resident 157 and found cigarettes but did not take the cigarettes. Resident 117 was observed pulling out her lighter for the surveyor to view but AA 1 did not take Resident 117's lighter. AA 1 stated someone must monitor the residents while they smoke to ensure no one burns their clothes. AA 1 stated if no one was monitoring the residents they may get burned. AA 1 stated a staff member should also monitor the patio to make sure residents did not leave through the gate. AA 1 stated some residents kept their own cigarettes and lighters in their possession. During an interview on 7/25/2024 at 9:41 a.m. with AA 1, AA 1 stated cigarettes and lighters should be kept in a locked box at the receptionist's desk where residents did not have access to it. AA 1 stated some residents keep their own cigarettes and lighters in their possession. AA 1 stated Resident 141, Resident 6, and Resident 122 had smoking items in their possession and were not allowed to keep smoking items. AA 1 stated he did not take away smoking items because the residents would be upset. AA 1 stated the residents needed to be monitored to avoid burns. During an interview on 7/26/2024 at 9:05 a.m. with the Director of Nursing (DON), the DON stated per the facility's policy, residents must be supervised at all times while smoking. The DON stated residents must be supervised because there was a risk for burns or injury because some residents were forgetful. The DON stated staff must provide and light the cigarette for the residents. The DON stated residents' personal cigarettes were kept in a locked box at the receptionist's desk should not have cigarettes or lighters in their possession. The DON stated upon admission smokers were assessed using the Resident Smoking Assessment Form to determine if they were safe to smoke. During a review of the facility policy and procedure (P&P) titled, Resident Smoking, (undated), the P&P indicated residents who smoke would be assessed using the Resident Smoking Assessment to determine whether or not supervision was required when smoking, or if the resident was safe to smoke at all. The P&P indicated smoking materials of residents requiring supervision with smoking would be maintained by nursing staff. During a review of the facility P&P titled, Accidents and Supervision, (undated), indicated the resident would receive adequate supervision to prevent accidents. The P&P indicated all staff were to be involved in observing and identifying potential hazards in the environment. During a review of the facility's Resident Smoking Assessment Form, (undated) indicated for safety reasons, residents may not store cigarettes, lighters, or any smoking materials at the bedside, in their bedside stand, in their closets or in any drawers in their room. The Resident Smoking Assessment Form indicated for everyone's safety, any and all smoking materials and paraphernalia must be safely stored by facility staff.

Based on observation, interview, and record review, the facility's nursing staff failed to ensure a resident was adequately supervised on a locked unit, the locked unit was secured, alarms activated, and residents were closely supervised to prevent an elopement (leaving without permission unsupervised) from occurring for one of three sampled residents (Resident A). Resident A, who had a behavior of walking a lot and pushing on doors was not being supervised and went missing from the locked unit on 1/14/2021 for over 20 hours in the middle of the night. Resident A was found five miles away from the facility at the beach and brought back to the facility by police officers. This deficient practice of not ensuring the locked unit was secured, alarms activated, and residents were closely supervised resulted in Resident A leaving in the middle of the night unsupervised through an alarmed door that was deactivated and left ajar. This noncompliance resulted in Resident A being exposed to cold weather temperatures and was placed at a high risk for serious harm, falls and/or death and had the potential for other residents to have eloped. On 1/16/2021 at 6:57 p.m., a system failure was identified regarding the facility's staff not securing the doors in a locked unit and not providing close supervision of the residents in a locked unit, resulting in Resident A eloping. 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 to a resident) was declared due to lack of supervision. The facility's Administrator (ADM) and the Director of Nurses (DON) were notified of the serious non-compliance that threatened the residents' health and safety. The facility submitted an acceptable Plan of Action (POA) on 1/19/2021. The acceptable POA was as follows: 1. The maintenance checked all the doors to ensure that all the alarms were activated and working on 1/16/2021. 2. The maintenance and housekeeping staff beginning 11/2020 was assigned to check the door alarms for proper functioning at beginning and end of each shift and will continue to do so (logs were provided). 3. The maintenance staff will change the passcode to the doors every week beginning 1/16/2021. 4. The alarm codes to the doors will be provided only to the working staff of the facility beginning 1/16/2021. 5. A second alarm was installed on 1/16/2021 on all doors in the facility to ensure the front and side doors would trigger an alarm any time the doors were opened, completed on 1/17/2021. 6. An outside provider was contracted to provide an inspection and maintenance of the door alarms on 1/19/2021 and every month thereafter. 7. Charge Nurses on each shift will check the doors during their routine rounds at start of shift, every 2 hours, and at end of their shift effective 1/16/2021. 8. The facility will designate staff to monitor all exit points on all shifts on the secure building effective 1/16/2021. 9. Charge Nurses will ensure all assigned staff are at their designated locations effective 1/16/2021. 10. Certified nursing assistants will do a headcount of all residents at the beginning of each shift, every 2 hours, and at the end of the shift to prevent elopement and other accidents/incidents beginning 1/16/2021. 11. A video monitor was installed at each exit; completed on 1/19/2021. 12. The facility's codes to gain access to the building was changed on 1/16/2021. All ancillary/essential outside providers, including paramedics, lab techs, and ambulance staff will be escorted in and out of the building to ensure full closure of the doors beginning 1/16/2021. 13. The facility completed a sweep of the residents (92) in Building B (secured unit) on 1/16/2021 to ensure all elopement/wandering assessments were complete. 14. In-services started on 1/16/2021 and were completed on 1/19/2021 on the Plan of Action items; eg. Procedure to secure the exits (doors/windows) and in-services will be done monthly for three (3) months, and quarterly thereafter. 15. In-services started on 1/16/2021 and was completed on 1/19/2021 regarding the importance of monitoring/supervising residents to prevent elopement and other accidents/incidents. In-service will be done monthly for three (3) months and quarterly thereafter. 16. In-services started 1/16/2021 and completed on 1/19/2021 to ensure full closure of the exit door/s upon entering and exiting the building. In-service will be done monthly for three (3) months and quarterly thereafter. 17. The Nursing Supervisors, Director of Nursing or Designee shall monitor compliance for the above plans of actions on a daily basis. Any episodes of non-compliance shall be reported to the Administrator immediately. The Administrator shall report any findings to the Quality Assurance Committee (QAA) on a quarterly basis. QAA Committee shall review the systems and revise as necessary. Effective 1/16/2021. On 1/19/2021 at 2:30 p.m., after an onsite verification and confirmation via observation, interview and record review that the POA was implemented the ADM was notified the IJ was lifted. Findings: During a review of Resident A's Admission Records (Face Sheet) the Face Sheet indicated Resident A was initially admitted to the facility on [DATE] and last readmitted to the facility on [DATE]. Resident A's [DIAGNOSES REDACTED]. During a review of Resident A's Minimum Data Set (MDS), an assessment and care screening tool, dated 1/12/2021 the MDS indicated Resident A's cognitive (thought process) skills for daily decision-making were moderately impaired. The MDS indicated Resident A required extensive one-person physical assist to walk in his room, the corridors/unit and to complete his activities of daily living ((ADLS) task such as eating, bathing, dressing, grooming and toileting). According to the MDS, Resident A's balance while moving from a seated to standing position, walking and turning around was not steady. During a review of Resident A's Wandering/Elopement Risk Assessment, dated 10/5/2020, the Assessment indicated Resident A was at risk for wandering/elopement. The staff's interventions included frequent monitoring. During a review of Resident A's Fall Risk Assessment, dated 1/5/2021, the assessment indicated Resident A had a score of 17 and the assessment indicated a total score of 10 or above represented a high risk for falls. During a review of Resident A's care plan, dated 10/5/2020, the care plan indicated Resident A was at risk for elopement as evidenced by episodes of confusion. There was no goal identified on the care plan. The staff's approaches included to monitor Resident A for tailgating (the resident would follow closely behind a person) when visitors are in the building. During a review of Resident A's Nurse's Note, dated 1/14/2021 and timed at 5 a.m., the Nurse's Note indicated at 11:10 p.m. on 1/13/2021, the resident (Resident A) was noted walking near Station A. The Nurse's Note indicated at 1 a.m. on 1/14/2021, the resident was noted walking in the hallway near his room. The Nurse's Note indicated a Certified Nursing Assistant (CNA) observed the resident (Resident A) sleeping in his room at 2 a.m. (1/14/2021). At 3 a.m., the same morning, during rounds a Licensed Vocational Nurse (LVN 2) saw Resident A was not in his room or in the hallway. The Nurse's Note indicated the staff searched the rooms, closets, bathrooms, outside the building, and the vicinity surrounding the facility and Resident A was not found. The Nurse's Notes indicated the local police department was notified of the resident being missing. During a review of Resident A's Nurse's Notes, dated 1/14/2021 and timed at 11 p.m., the Nurse's Note indicated the local police department called the facility and reported Resident A had been found. According to the note, Resident A returned to the facility with dry, calloused (hardened skin) feet due to only wearing socks but was unharmed. During an interview with LVN 1 on 1/16/2021 at 3:58 p.m., LVN 1 stated Resident A was alert to name, but was very delusional (believing things that are not true) and he ambulated (walked) and liked to hide in other resident's rooms, closets and dark places and had a behavior of pushing on the doors. During an observation on 1/16/2021 at 4:10 p.m., all three doors in the facility were inspected. All alarms on the three doors were activated following application of pressure on the door handles. The alarm would sound and became progressively louder, and after approximately 30 seconds the door would unlatch allowing it to be pushed open. During an interview with the Director of Nurses (DON) on 1/16/2021 at 4:20 p.m., the DON stated she was called by facility's staff between the hours of 3:30 a.m. and 4 a.m., on 1/14/2021. The DON stated staff reported to her the resident (Resident A) was last seen at 2 a.m., and had eloped from the facility. The DON stated staff searched the interior and exterior of the building the premises outside and the local community but could not find the resident (Resident A). The DON stated they it was determined Resident A left from the facility's side door that was left unlatched and ajar. The DON stated the police found Resident A on the beach and brought him back to the facility and the resident was wearing a shirt, sweatpants, and a hospital gown. During an observation on 1/16/2021 at 5:40 p.m., Resident A was in his room lying in bed. Resident A was alert and oriented to name only and very confused. Resident A stated he had not gone to the beach and denied leaving the facility. During a review of the local weather forecast for 1/14/2021, the forecast indicated the weather in the area, the beach, where Resident A eloped, was 52 degrees Fahrenheit ((F) measurement of temperature) that night and 57 F during the day. During a telephone interview, on 1/27/2021 at 11:07 a.m., after several attempts were made to interview him, LVN 2 stated Resident A was alert, ambulatory and had behaviors that included hiding in other resident's rooms, closets and bathrooms. LVN 2 stated Resident A walked constantly and at times would approach doors and push on them. LVN 2 stated when he came to work that night on 1/13/2021 he made his rounds and did a head count of the residents. LVN 2 stated at 12 a.m., on 1/14/2021, Resident A was in his room and at 1 a.m. the resident was seen in the hallway. LVN 2 stated Resident A was seen in his room at 2 a.m., on 1/14/2021. LVN 2 stated he took his break at approximately 2:30 a.m.-3 a.m., and when his break was over he did his rounds and found Resident A was not in his room. LVN 2 stated he called his staff and they searched for Resident A inside and outside of the building and in the surrounding community, but they could not find Resident A. LVN 2 stated he called the police department and reported Resident A was missing from the facility. LVN 2 stated earlier that evening (1/14/2021) he saw another resident (Resident B) banging on the doors and throwing things, which was his normal behavior. LVN 2 stated he believes Resident B may have dislodged the door and the alarm possibly malfunctioned. LVN 2 stated the staff were responsible and assigned to monitor the hallways and doors but prior to Resident A eloping from the facility those assignments were not really enforced. During a review of the facility's policy and procedure (P/P), dated in the year 2019 and titled, Elopements and Wandering Residents, the P/P indicated the facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. Alarms are not a replacement for necessary supervision. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview and record review, the facility failed to implement its own abuse policies and procedures by not safeguarding and protecting from further harm after a resident to resident physical altercation that resulted in lacerations (cut) to the left side of nose and under the left eye which resulted in hospitalization for one of 29 sampled residents (10) and a Randomly Selected Resident. (RSR 3) Findings: During an initial tour of the facility on October 13, 2016 at 4:25 p.m., Resident 10 was observed in his room with wounds under his left eye and left side of his nose. When asked what happened, the resident pointed to his roommate (RSR 3) who was in the room, shrugged his shoulders in a frightful manner, and whispered my roommate punched me on the face. Resident 10 stated today while eating lunch in his room, his roommate (RSR 3) just walked toward him, punched him in the face, and dropped his lunch tray on the floor. The resident stated he felt like a prisoner in his own room. On October 13, 2016 at 5:30 p.m., during an observation, even though Resident 10 claimed he was punched by his roommate (RSR 3) both residents were still observed sitting in the same bedroom. There was no evidence Resident 10 was safeguarded and protected from RSR 3. A review of Resident 10's admission records, dated September 24, 2016 indicated the resident was initially admitted to the facility which has two separate buildings (building A and B). The records included [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a resident assessment and care screening tool), dated October 1, 2016 indicated Resident 10 had the ability to understand and be understood by others. The assessment further indicated the resident required extensive assistant from the staff with transfer, ambulation, bathing, dressing, and required supervision with meals. The resident required wheelchair for mobility. According to the licensed nurses progress notes, dated October 13, 2016 at 2:20 p.m., indicated RSR 3 reported striking his roommate in the face after a verbal altercation. The notes indicated the resident's physician was notified of the assault behavior and ordered the transfer. The notes at 8:15 p.m., indicated RSR 3 was transferred to the GACH. The licensed nurses progress notes, dated October 13, 2016 at 2:30 p.m., indicated Resident 10 reported being struck twice on the left side of his face. The notes indicated the resident sustained [REDACTED]. The wounds were cleansed with a gauze soaked with normal saline, pat dry, and A and D ointment was applied. The notes on the same day at 10 p.m., indicated the resident was transferred to the General Acute Care Hospital (GACH) for further evaluation of aggressive and threatening behavior. On October 13, 2016 at 3:45 p.m., during the tour of the facility and in an interview Registered Nurse (RN 1) stated Resident 10 reported to her that he was struck by RSR 3. RN 1 stated the resident had wounds under the left eye and nose which was cleaned. At the same time, Resident 10 and RSR 3 were both observed in the same bedroom. When asked why Resident 10 and RSR 3 were both still in the same bedroom, she stated because Resident 10 was going to be transferred to the GACH. RN 1 stated both residents should have been separated for safety reasons. RN 1 stated CNA 3 was assigned 1:1 in order to monitor Resident 10. However, when asked how CNA 3 was going to care for all the other residents assigned to her for the shift and do 1:1 monitoring of Resident 10, RN 1 was not able to comment. RN 1 stated RSR 3 becomes aggressive when there is a new resident assigned to the same room. A review of the abuse allegation investigation notes, dated October 14, 2016 indicated Resident 10 was struck by another resident (RSR 3). The notes further indicated both residents were immediately separated and Resident 10 was transferred to the GACH. However, on the day of the incident dated October 13, 2016 at 5:30 p.m., Resident 10 and RSR 3 were both observed sitting in the same bedroom. During an interview on October 14, 2016 at 3:35 p.m., with a Certified Nursing Assistant (CNA 3) stated around 12 noon while feeding the residents in the back lunch room, she heard an abnormal sound like someone dropped a tray. CNA 3 stated she left the dining room, walked in to Residents 10's and RSR 3's room. CNA 3 found Resident 10 bleeding from his face and his tray was on the floor. CNA 3 stated she brought Resident 10 to the nursing Station B with the help of another CNA so the nurse can clean his face. CNA 3 stated after the nurse cleaned the wounds, she told her to take Resident 10 to the patio area to eat lunch. CNA 3 stated after Resident 10 ate his lunch, she took him back to his room. CNA 3 stated she was never assigned to monitor the residents on a 1:1 basis. On October 14, 2016 at 4:30 p.m. during an interview with the Director of Nursing (DON) stated she was notified by RN 1 about the physical altercation between Resident 10 and RSR 3. DON stated on October 12, 2016 Resident 10 was moved from building A to B, where he became roommates with RSR 3. She further stated RSR 3 did not like any of his new roommates. When questioned about why both of the residents were still left in the same bedroom, the DON stated they should had been separated because RSR 3 could have further harmed Resident 10. On October 19, 2016 at 10:15 a.m., in an interview with RSR 3 stated he could not remember what happened in his bedroom but if someone punched him, he would punch the person back. RSR 3 further stated he wished his roommate and himself a long life. A review of RSR 3's clinical records indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated December 10, 2015 indicated RSR 3 was alert and oriented, with verbal behavioral symptoms (threatening, screaming, cursing) towards others, required supervision from staff for ambulation, bed mobility, and transfers. A review of RSR 3's care plan dated December 1, 2014 indicated the resident was on medication for [MEDICAL CONDITION] manifested by resisting to care with behavior of striking out, and hearing voices telling him to harm others. The intervention included monitoring of behaviors to assist and assure lowest possible therapeutic dose given, monitor behavior every shift, and tally using hashmarks. According to the physician's orders [REDACTED]. A review of an undated facility's policy and procedures titled Elder Abuse and Neglect Prohibition, indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation. The facility will report such allegation to the state, as per state regulation. The facility will protect residents from harm during the investigation. If suspected abuse resulted in serious bodily injury, then facility will report the incident immediately and no later than two (2) hours by telephone to local enforcement and send a written report two hours to the local agency, the licensing and Certification Program and the ombudsman.