Every finding on record at Virgil Rehabilitation & Skilled Nursing Center

Based on observation, interview, and record review the facility failed to provide the care, assistance, and supervision to ensure an environment free of risks and hazards for one out of three sampled residents (Resident 1), by failing to ensure Resident 1 who required moderate assistance from facility staff with both upper and lower body dressing was not left alone undressed in the Resident's room after a shower on 6/22/2026. This failure resulted in Resident 1 falling on 6/22/2026 sustaining left hip redness, and left elbow skin excoriation (scraping or wearing away the skin) and placing the resident at risk for serious injury and hospitalization.Findings: During a review of Resident 1's admission record dated 6/23/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses that included kidney cancer (a disease where the cells in one or both kidneys start to grow in an uncontrolled way), lung cancer (a disease where bad cells in the lungs start growing out of control), muscle weakness, and hypertension (high blood pressure). During a review of Resident 1's Minimum data set (MDS, a resident assessment tool) dated 5/8/2026. The MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was intact and the resident required moderate assistance from facility staff with both upper and lower body dressing. During a review of Resident 1's care plan titled The resident has a self-care performance deficit . dated 5/9/2026, the care plan indicated Resident 1 needed moderate assistance from facility staff for dressing. The care plan indicated Resident 1 was at risk for falls and staff were to provide a safe environment and the floor was to be kept non-slippery. During a concurrent observation at the doorway looking into Resident 1's room and interview on 6/22/2026 at 1:22 pm with Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1, LVN 1 opened the door and found Resident 1 was observed undressed and sitting on the floor, water was observed on Resident 1's body. Resident 1 stated he (Resident 1) had just returned from a shower and was left in his room standing. Resident 1 stated he slid down and was trying to call for help. Staff were observed assisting Resident 1 back to bed and helping Resident 1 get dressed. During an interview on 6/22/2026 at 2:20 pm with CNA 1, CNA 1 stated Resident 1 had just returned from a shower and Resident 1 needed help with putting on his clothes. CNA 1 stated he (CNA 1) should have stayed with Resident 1 and instead he went to help other residents and did not notify the charge nurse. During an interview on 6/22/2026 at 2:30 pm with LVN 1, LVN 1 stated Resident 1 had a fall that resulted in left hip redness, and left elbow skin excoriation. LVN 1 stated Resident 1 required assistant for dressing and CNA 1 should not have left Resident 1 undressed after the shower. LVN 1 stated if CNA 1 needed to go somewhere, he (CNA 1) should have notified the charge nurse. During an interview on 6/22/2026 at 3:00 pm with Director of Nursing (DON), the DON stated CNA 1 should have stayed with Resident 1and if Resident 1 wanted privacy, CNA 1 could have used the curtain and provided privacy for Resident 1. The DON stated Resident 1's fall was preventable and that CNA 1 failed to remain with the resident and assist the resident with dressing, placing Resident 1 at risk for injury and possible hospitalization. During a review of the facility's policy and procedure (P&P) titled, Certified Nurse Assistant Position Responsibilities, dated 9/2025, the P&P stated, CNAs were to implement preventive measure and comply with safety policies and practices. During a review of the facility policy and procedure (P&P) titled, Fall and Fall Risk, Managing, dated 11/21/2025, the P&P stated staff should identify risks and prevent residents from falling.

Based on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications and supplements in one of two inspected medication carts (Station 2 Medication Cart) and one of one inspected medication room (Station 2 Medication Room), according to manufacturer's specifications and the facility's policy and procedures (P&P), titled Storage of Medications, dated 1/20/2025, Discontinued Medications, dated 1/20/2025 and Hazardous Drug Handling, dated 1/20/2025, by failing to: A. Ensure that three unopened latanoprost (a medication used to treat glaucoma [high eye pressure]) ophthalmic solution vials in Station 2 Medication Cart were stored in the refrigerator or labeled with an open date when they were removed from the refrigerator.One in-use (opened) Humulin R ([generic name - insulin human regular] a type of insulin [a hormone that removes excess sugar from the blood] used to treat high blood glucose) vial in Station 2 Medication Cart was not labeled with an open date.Remove and discard expired in-use bottle of vitamin C (a vitamin used to treat low levels of vitamin C and to support immunity) tablets. Microdot Glucose Gel (a type of glucose gel used in emergency situations to rapidly treat low blood glucose levels), and Boost Breeze (a nutrition drink to support energy and muscle maintenance) nutrition drink from Station 2 Medication Cart.Remove and discard expired insulin aspart (a type of insulin used to treat high blood glucose) prefilled pens from Station 2 Medication Room Refrigerator after the physician order was discontinued and the medication had expired. B. Ensure that the label on the bicalutamide (a medication used to treat progressive prostate cancer) medication card and administration instructions in the electronic medication administration record (eMAR) had instructions for nursing staff to wear gloves and/or follow hazardous drug handling procedures while preparing bicalutamide for administration during medication administration observation for one of six sampled residents (Resident 4). These deficient practices had the potential to result in residents receiving medications and supplements that were discontinued, expired, ineffective and/or toxic due to improper storage, handling and labeling possibly leading to health complications such as glaucoma, hyperglycemia (high blood glucose), hypoglycemia (low blood glucose), lethargy, coma and hospitalization. These deficient practices also had the potential of causing harm to the facility's nursing staff and/or Resident 4 due to unsafe handling of Resident 4's hazardous medication.Findings: A. During a concurrent inspection of the Station 2 Medication Cart and interview on 2/4/2026 at 11:02 AM with the Licensed Vocational Nurse (LVN) 5, the following medication was found stored and labeled in a manner contrary to manufacturer specifications:One sealed vial of latanoprost ophthalmic solution 0.005% was observed with no open date.One opened vial of Humulin R 100 units ([U] a unit of measurement for dose of insulin) / milliliters ([mL] a unit of measurement for volume) insulin was observed with no open date. The manufacturer's product labeling on the vial indicated: in-use (opened) Humulin R vial had to be used within 31 days.One opened bottle of vitamin C 500 milligrams ([mg] a unit of measurement for mass) gluten-free was observed with an expiration date of 01/2026, containing approximately one-quarter of the quantity remaining in the bottle.One Microdot Glucose Gel 40% was observed with an expiration date of 02/2025.One Boost Breeze nutritional drink was observed with an expiration date of 06/2025.LVN 5 stated she (LVN 5) had no idea if the Humulin R was used, but if the seal was opened the Humulin R must have been used. LVN 5 stated the latanoprost eye drops and Humulin R should have had an open date because the medications would only be good for 28 days. LVN 5 stated if the facility nursing staff did not place an open date on Humulin R and latanoprost eye drops then facility staff would not be able to determine latanoprost and Humulin R's expiration dates. LVN 5 stated the latanoprost vials were sealed and should have been stored in the refrigerator when received from the pharmacy but someone who received it probably placed in the medication cart instead. LVN 5 stated there was a risk for negative side effects if the medications were not stored according to the manufacturer's guidelines, for example, if the resident received insulin with an unknown expiration date, there was a risk that insulin would not effectively control blood glucose. LVN 5 stated she did not know side effects related to latanoprost because it was not part of her morning administration, but after some research, LVN 5 stated it would not be safe or effective for the residents to receive latanoprost that did not have an open date to treat glaucoma. During a follow up interview on 2/4/2026 at 11:39 AM with LVN 5, LVN 5 stated the vitamin C should have been removed from the medication cart because it (vitamin C) expired in January 2026. LVN 5 stated vitamin C was a supplement so it would not have a big side effect but still not safe to administer to the facility residents. During a follow up interview on 2/4/2026 at 11:54 AM with LVN 5, LVN 5 stated the Boost Breeze had expired 06/2025 and Microdot Glucose Gel had expired 02/2025 so the Boost Breeze and Microdot Glucose Gel should have been removed from the medication cart. LVN 5 stated the glucose gel was for emergency use to treat hypoglycemia and the expired glucose gel would not have been effective to save a resident's life if they were hypoglycemic (low blood sugar). During a concurrent inspection of the Station 2 Medication Room and interview on 2/4/2026 at 12:16 PM with LVN 1 and Registered Nurse (RN) 2, three unopened insulin aspart flexpen 100 units/mL prefilled pens with an expiration date of 5/31/2025 were found in the medication refrigerator. LVN 1 stated the expired insulin aspart flexpens should have been removed from medication storage before May 2025. LVN 1 stated there was a risk of medication errors if insulin aspart was administered to facility residents. LVN 1 stated the expired insulin would not reduce high blood glucose which would increase the risk for complications such as diabetic retinopathy (diabetes complication damaging retinal blood vessels, potentially leading to blindness), eye problems, kidney problems, hyperglycemia and hospitalization. During an interview on 2/5/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated the facility should have removed the expired medications and supplements from the medication storage areas at least two weeks before they expired. The DON stated it would not be safe to administer expired medications to the facility residents. The DON stated the latanoprost ophthalmic solution should have been stored in the refrigerator to maintain its quality. The DON stated the facility staff was instructed to discard ointments, eye drops and insulin vials within 28 days after opening to ensure that quality and strength were maintained. The DON stated it was important to label latanoprost with an open date and if the latanoprost was not stored in the refrigerator, it would not be safe or effective to be administered to the residents. The DON stated the Humulin R insulin should have had an open date so that the facility's nursing staff could determine the expiration date and discard the medication. The DON stated improper labeling and storage of insulin would negatively affect the insulin's potency (strength) and would not be effective for lowering blood glucose level, causing hyperglycemia (elevated blood sugar) and other serious health consequences such as mental status changes and hospitalization. During an interview on 2/5/2026 at 3:05 PM with the DON, the DON stated insulin aspart flexpen should have been removed from medication storage as soon as it was discontinued and/or expired. The DON stated it was unsafe and there was a risk for accidental administration of expired insulin aspart to facility residents leading to medication errors. B. During a review of Resident 4's admission Record, dated 2/5/2026, the admission record indicated the facility originally admitted Resident 4 on 6/17/2024 and readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of the prostate that commonly affects men, causing lower urinary tract symptoms like weak stream, frequency, urgency, and incomplete emptying) without lower urinary tract symptoms, and encounter for attention to gastrostomy (a surgical or endoscopic creation of an opening (stoma) into the stomach to insert a feeding tube (G-tube) for delivering nutrition, fluids, or medication directly, or for gastric decompression), essential hypertension (high blood pressure). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was left blank. The MDS indicated Resident 4 was dependent on the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering upper and lower body dressing, putting on/taking off footwear and personal hygiene and the ability to eat was not attempted due to medical condition or safety concerns. During a concurrent medication administration observation and interview on 2/5/2026 at 9:13 AM with LVN 3, LVN 3 was observed preparing medications for administration via gastrostomy tube. At the time of preparation, LVN 3 was observed wearing a surgical mask and personal eyeglasses. LVN 3 wore a blue surgical gown and one pair of regular gloves before entering Resident 4's room. LVN 3 was observed removing one tablet of bicalutamide 50 mg from the medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) without wearing gloves by popping it out into a medicine cup. LVN 3 then placed the bicalutamide 50 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device without wearing any gloves. LVN 3 showed medication the bubble pack and eMAR for bicalutamide 50 mg to the surveyor. The pharmacy label indicated, Take one tablet by mouth daily with an additional label indicating directions changed refer to chart, neither the pharmacy label nor the eMAR indicated to wear gloves or to follow hazardous drugs handling procedures. LVN 3 stated the pharmacy label indicated to give the medication by mouth but the order was changed in eMAR to indicate by g-tube. LVN 3 was then observed removing the blue gloves and resumed crushing the remainder of Resident 4's medications. During a review of Resident 4's Order Summary Report dated 2/4/2026, the order summary report indicated Casodex ([generic name - bicalutamide]) 50 mg, give 1 tablet via G-tube one time a day for prostate cancer (CA), order date 1/23/2026, start date 1/24/2026. During an interview on 2/5/2026 at 1:18 PM with LVN 3, LVN 3 stated she did not see instructions to wear gloves or double gloves when administering bicalutamide. LVN 3 stated she would need to research to check what conditions bicalutamide was given to treat. LVN 3 then stated she found in her research that she had to be careful when handling bicalutamide because these meds had a risk for baby or toxicity to babies if handled or touched by women who were young, pregnant or those with childbearing age. LVN 3 stated she needed to inform pharmacy because the bicalutamide administration instructions did not indicate it was a hazardous drug on the pharmacy label. LVN 3 stated there was a risk for skin irritation, respiratory problems, or women of childbearing age or immunocompromised could have issues with neonatal toxicity or could affect fetus. LVN 3 stated there was a risk of breathing in the particles while preparing Resident 4's bicalutamide so it was important to wear a N95 mask (a mask that is NIOSH- approved disposable respirators designed to filter at least 95% of airborne particles, offering superior protection against viruses, bacteria, and dust compared to cloth masks). During an interview on 2/5/2026 at 3:10 PM with the DON, the DON stated she needed to do some research and look on WebMD (a medical search engine for drug information) and google to learn more about bicalutamide. The DON stated bicalutamide was a nonsteroidal, anti-cancer medication. The DON stated hazardous drugs could be very strong and toxic so should not have been handled with bare hands. The DON stated healthcare personnel could get gastrointestinal (stomach/digestive) side effects. The DON stated, pregnant women should follow special precautions, handle carefully, wear gloves and should not have had direct contact. The DON stated there would be a risk for the bicalutamide to be absorbed via skin for the nurse and could also pose a safety risk for the resident if the resident touched the bicalutamide. During a review of the facility's P&P titled Storage of Medications dated 1/20/2025, the P&P indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated, Temperature - Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. The P&P indicated, Certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. The P&P indicated, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. (Note: the best stickers. notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating (See. dates). The P&P indicated, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. During a review of the facility's P&P titled Discontinued Medications dated 1/20/2025, the P&P indicated When medications are discontinued by the prescriber or the resident. are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued . until destroyed. The P&P indicated, Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration). During a review of the facility's P&P titled United States Pharmacopeia (USP) Chapter <800>: Hazardous Drug dated 1/20/2025, the P&P indicated USP General Chapter <800> provides standards for safe handling hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the environment.Facilities are recommended to check with local and state regulatory agencies to verify requirements for Hazardous Drug Handling. The National Institute for Occupational Safety and Health (NIOSH) considers a drug to be hazardous if it exhibits one or more of the following characteristics in humans or animals: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity. The P&P indicated, The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: A. List of Hazardous Drugs (HDs), B Facility and engineering controls; . E. Proper use of appropriate Personal Protective Equipment (PPE); and F. Policies for HD waste segregation and disposal. This policy applies to all healthcare personnel who handle HD preparations and all entities that store, prepare, transport, or administer HDs. The P&P indicated a list of Hazardous Medications - Quick Safety Guide with Most Common Hazardous Medications (Skilled Nursing Facility [SNF] / Long-Term Care [LTC]), the list indicated but not limited to Casodex (Bicalutamide) with the key risk of reproductive/hormonal toxicity with the instructions of 'crushing not allowed', and Proscar (Finasteride), with the key risk of teratogenic (pregnancy risk) with instructions of 'crushing not allowed'. The Hazardous Medications - Quick Safety Guide indicated, Safe Handling Guidelines that indicated to always wear chemo-rated gloves when handling hazardous medications. Do NOT crush, split, or open hazardous tablets or capsules unless pharmacy-approved containment is used. Avoid direct contact with powder, residue or bodily fluids when applicable. If swallowing difficulty exists, request alternative formulations or therapies. Reminder: When in doubt, treat the medication as hazardous and consult pharmacy before altering dosage form.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.One expired medium container of tomato sauce with use by date (the last day the manufacturer guarantees the food's peak quality, flavor, and nutrient value) of 1/29/26 was stored in the facility's walk-in refrigerator. 2. One package of beef patty was stored in the facility's walk-in refrigerator to thaw with no date (indicates when a frozen food item was moved to the refrigerator to thaw). 3. The blade of the can opener located in the facility's food preparation area was worn and dented and had dried and sticky brown residue on it. 4. Apple sauce was stored at room temperature on two of two sampled medication carts in Nurses' station 2 (medication cart 1and 2) for longer than 4 hours. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 69 out of 73 residents who received food from the facility kitchen. Findings: 1. During an observation in the kitchen on 2/2/2026 at 8:00AM, a medium container of tomato sauce with a use by date of 1/29/2026 was observed stored in the walk-in refrigerator. During a concurrent observation with the [NAME] 1 on 2/2/2026 at 8:10AM cook1 stated the tomato sauce should have been discarded to make sure kitchen staff only cooked with quality foods. Cook1 stated expired foods could cause sickness in residents who received food from the facility kitchen. 2. During an observation in the facility's walk-in refrigerator on 2/2/2026 at 8:15AM there was one package of raw ground beef stored with no date. During a concurrent observation and interview with Cook1 on 2/2/2026 at 8:15AM, Cook1 stated the beef was to be used on the date of the observation (2/2/2026) but the beef should have had a thaw date to alert kitchen staff when to prepare the beef. Cook1 verified with a phone call that the previous day (2/1/2026) staff removed the raw ground beef from the freezer to thaw and forgot to label and date. During a concurrent observation and interview with the Dietary Supervisor (DS) on 2/2/2026 at 8:30AM, the DS stated food was discarded on use by date and everything had to be labeled and dated to make sure it was used or discarded before the food expired. The DS was then observed discarding the raw thawed ground beef and the tomato sauce. During a review of facility's policy and procedure (P&P) titled Procedure for refrigerated storage dated 2023, the P&P indicated Frozen food should be left in a refrigerator to thaw. Once thawed uncooked meat is to be used within 2 days. Leftovers will be covered, labeled and dated. Individual packages of refrigerator or frozen food taken from the original packing box need to be labeled and dated. During a review of facility's policy and procedure (P&P) titled, Thawing of meats dated 2023, the P&P indicated thawing meat properly can be done in these four ways: 1) in a refrigerator at 41 F or colder. Allow 2 to 3 days to defrost. 3. During an observation in the kitchen food preparation area on 2/2/2026 at 8:30AM, one can opener's blade was observed to be worn out and dirty. The blade was not smooth to touch, stained, and covered with sticky and dry brown colored residue. During a concurrent observation and interview with the DS on 2/2/2026 at 8:30AM, the DS observed the can opener and verified that there was sticky brown residue, and the blade was worn out. The DS stated the can opener needed to be washed. The DS stated the blade had to be replaced to prevent cross contamination of canned food. During a review of the facility's policy and procedures (P&P) titled Can opener and base dated 2023, the P&P indicated proper sanitation and maintenance of the can opener is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade. The can opener must be thoroughly cleaned each work shift. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Good Repair and proper Adjustment Code # 4-501.11(C), the code indicated Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. During a review of 2022 Food Code titled, Can Openers Code# 4-202.15, the code indicated Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. 4. During an observation in nurses' station 2 of medication cart 1 on 2/2/2026 at 11:30AM, a small plate of apple sauce with a date of 2/2/2026 was observed to be stored on the nurse's medication cart at room temperature and not set on ice. During a concurrent observation in nurses' station 2 of medication cart 1 and interview with LVN3 on 2/2/2026 at 11:30AM, LVN 3 stated the apple sauce was used to mix with crushed medications for residents. LVN 3 stated the apple sauce was delivered from the kitchen that morning (2/2/2026) at 7am. LVN 3 stated the plates of apple sauce did not come set on ice. During a concurrent observation in nurses' station 2 of medication cart 2 and interview with LVN2 on 2/2/2026 at 11:40AM, LVN2 was observed administering medications to residents. Medication cart 2 contained a plate of apple sauce. LVN2 stated the apple sauce was delivered from kitchen that morning (2/2/2026) at 7am and the apple sauce was not on ice. LVN2 stated the apple sauce had been used for longer than 4 hours. During a concurrent observation in nurses' station 2 of medication cart 2 and interview with the DS on 2/4/2026 at 12:30PM, the DS stated apple sauce was delivered from the kitchen to the nurse's station in the mornings and afternoons. The DS stated the apple sauce should have been on ice for the duration of the medication administration to prevent the apple sauce from going bad. The DON verified that there was a plate of apple sauce on medication cart 2 and the apple sauce was not on ice. The DON stated all snacks and apple sauce from kitchen had to be delivered on ice. During a review of the manufacturer's instructions for storage located on the label of the canned apple sauce, the label indicated to Refrigerate in separate container any unused portions of the applesauce.

Based on observation, interview and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner, when two of two trash bins were overfilled with the lids open. This deficient practice had the potential for harborage (accumulation of garbage, waste, debris, or materials that provide shelter, protection, food, or a breeding ground for pests such as rodents [rats, mice], insects, and other vermin) and feeding of pests and/or animals.Findings: During an observation in the main dumpster area located outside of the kitchen back door on 2/2/2026 at 11:00AM; there were two large trash bins that were overfilled and the trash bins were pushed back against a wall with the lids open. During a concurrent observation and interview with the Dietary Supervisor (DS), housekeeping supervisor (HS), and Central Supply manager (CM) on 2/2/2026 at 11:15AM. The DS stated the trash should have been covered to not attract pests to the area. The HS stated the trash bins were pushed back against a wall and the lids were not accessible to close. The CM stated the trash was picked up every day except Sundays and Tuesday. The CM stated the lids had to be closed always to maintain a clean area because all the deliveries for the facility passed through the trash area. During an interview with the Maintenance Supervisor (MS) on 2/4/2026 at 1:00PM, the MS stated the lids had to be closed always to prevent pests from going in the trash and eating the trash. The MS stated the lids were pushed all the way back to the wall and facility staff could not close the lids. A review of facility's policy titled Garbage and rubbish disposal (dated 2023) the P&P indicated, all garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on interview and record review, the facility failed to inform one of five sampled residents (Resident 54) in advance of the risks and benefits of a psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior). This failure violated Resident 54's right to make an informed decision regarding the use of a psychoactive medication. Findings:During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 on 4/9/2024 and readmitted Resident 54 on 1/14/2026 with diagnoses that included other seizures (involuntary events caused by brain electrical changes, stress, or trauma rather than epilepsy [a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures]), other muscle spasm (painful contractions and tightening of your muscles), hepatic encephalopathy (decline in brain function caused by severe liver disease) and other sequelae of cerebral infraction (long-term, lasting complications or physical/mental issues that remain after a stroke, loss of blood flow to a part of the brain). During a review of Resident 54's Progress Note dated 5/13/2024, the Progress Note indicated Resident 54's Family Member (FAM 1) was the first emergency contact and would assist with decision-making. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 54 had the ability to make himself understood and had the ability to understand others. During a review of Resident 54's Progress Note dated 1/9/2026 at 6:50 PM, the Progress Note indicated Resident 54 had continuous body muscle spasms (involuntary contraction [increase in the tension or a decrease in the length] of a muscle) and was given diazepam (medication to treat a range of conditions including muscle spasms and seizures) two milligrams (mgs, a unit of mass) as needed for tremors (involuntary shaking or trembling). During a review of Resident 54's Order Summary Report dated 2/5/2026, the Order Summary Report indicated Resident 54 had a telephone order for diazepam two mgs orally every eight hours as needed for muscle spasm dated and started on 1/14/2026. During a review of Resident 54's physical and electronic medical record (EMR - a digital, computer-based version of a patient's paper chart), Resident 54's History and Physical (H&P), physician progress notes, consent for diazepam, and documentation of Resident 54's capacity (ability) to understand and make decisions could not be located. During a concurrent interview and record review on 2/5/2026 at 2:20 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 54's informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure) dated 1/14/2026 for diazepam was reviewed. LVN 1 stated the informed consent indicated Medical Doctor 1 (MD 1) did not sign the informed consent. LVN1 stated the informed consent indicated Resident 54 and Resident 54's representative's name and date were blank and not signed. LVN 1 stated the informed consent was not signed by Resident 54's physician or by Resident 54's responsible party. During a concurrent interview and record review on 2/5/2026 at 2:25 PM with Registered Nurse 2 (RN 2), Resident 54's informed consent dated 1/14/2026 for diazepam was reviewed. RN 2 stated the informed consent had not been signed by the prescriber (MD1) or by Resident 54's representative (FAM 1). RN 2 stated Resident 54 and FAM1 needed to be informed regarding the risks and benefits of taking diazepam. During an interview on 2/5/2026 at 2:56 PM with the facility's Medical Records (MR), the MR stated she (MR) could not find any consents for Resident 54 for the use of diazepam. The MR stated Resident 54's physician did not do a history and physical since Resident 54 was readmitted on [DATE]. During an interview with Resident 54's FAM 1 on 2/5/2026 at 3:20 PM, FAM 1 stated that no one from the facility talked with her (FAM1) regarding Resident 54's informed consent for the use of diazepam. During an interview on 2/5/2026 at 3:26 an attempt was made to speak with Resident 54 about the informed consent for medications. Resident 54 was not able to participate in the interview. During a concurrent interview and record review on 2/5/2026 at 4:01 PM with the facility's Director of Nursing (DON), the facility's policy and procedure (P&P) titled Resident Rights, dated 1/2025 was reviewed. The DON stated the P&P indicated All residents have rights guaranteed to them under Federal and State laws and regulations. The P&P indicated residents (in general) had the right to be informed/make treatment decisions. The DON stated Resident 54's physician should have gotten informed consent from Resident 54 or Resident 54's representative before giving Resident 54 diazepam. The DON stated the facility did not follow their Resident Rights policy.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation to meet resident needs for three of three sampled residents (Residents 12, 53, and 74). By failing to:1.Ensure Resident 12 and Resident 74 were provided with a communication board (a bedside tool used to bridge gaps in verbal communication for residents who speak another language or have limited speech. These boards feature pictures, letters, or words representing basic needs, pain levels, and feelings, allowing residents to point to express themselves) in the language that Resident 12 and Resident 74 were able to understand.2. Provide Resident 53 who had limited use of hands with an appropriate call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance). These failures had the potential to result in a delay in the delivery of necessary care to Residents 12, 53, and 74.Findings: 1.During a review of Resident 12's admission Record, the admission Record indicated the facility re-admitted the resident on 12/11/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), 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 period of emotional highs). During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 1/5/2026, the MDS indicated the resident's preferred language was Korean. The MDS indicated Resident 12 had severely impaired cognition (impairment in the ability to think, understand, and reason). The MDS indicated Resident 12 required partial/moderate assistance (helper does less than half the effort) for eating. The MDS indicated Resident 12 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene and was dependent on facility staff for showering, bathing herself, and putting on/taking off footwear. During a review of Resident 12's Care Plan Report dated 1/14/2026, the Care Plan Report indicated the resident had a communication problem. The Care Plan Report indicated the resident's primary language was Korean and the resident was able to speak and understand simple English words. The Care Plan Report indicated goals for Resident 12 included being able to communicate through non-verbal gestures, Resident 12's language barrier would not interfere with the resident's ability to communicate, and that staff would anticipate and meet Resident 12's needs. The Care Plan Report indicated an intervention which included staff to provide Resident 12 with a visual and Korean communication board. During a concurrent observation and interview on 2/2/2026 at 12:19 PM with the Infection Preventionist (IP), in Resident 12's room, Resident 12 was observed without a Korean communication board at the bedside. The IP confirmed by stating that Resident 12's primary language was Korean, and the resident could speak and understand some English words. The IP was observed asking Resident 12 if she needed help with anything. Resident 12 was observed responding to the IP in a language that was not English. The IP stated he did not speak Korean. The IP stated there should have been a communication board at Resident 12's bedside so the resident could communicate her needs to the staff (in general) more easily. The IP stated that Resident 12 had a Korean communication board before but did not know what happened to it. The IP stated there was a potential for Resident 12 to not be able to easily convey her needs to staff if a Korean communication board was not available for the resident. During an interview on 2/2/2026 at 12:22 PM with the Director of Nursing (DON), the DON stated that residents should have communications boards in the room if the resident spoke another language (not English). The DON stated a communication board would help residents who spoke another language to covey their needs to staff. The DON stated there would be a potential for Resident 12 to not be able to communicate needs and resulting in a delay in care if without a Korean communication board at bedside. During a review of Resident 74's admission Record, the admission record indicated the facility admitted Resident 74 on 4/25/2023 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). During a review of Resident 74's Care Plan Report dated 12/18/2025, the Care Plan Report indicated the resident had hearing problems related to hearing loss with an intervention to provide communication board as needed. During a review of Resident 74's Minimum Data Set (MDS – a resident assessment tool) dated 1/22/2026, the MDS indicated the resident had minimal difficulty hearing. During a concurrent observation and interview on 2/2/2026 at 10:37 AM in the doorway in Resident 74's room, with Restorative Nurse Assistant (RNA) 1, RNA 1 stated Resident 74 was going to the dining room. RNA 1 stated that Resident 74 did not have a communication board in his room. RNA 1 stated she (RNA 1) was able to speak a little Korean. RNA 2 stated Resident 74 understood a little English. During an interview on 2/2/2026 at 10:00 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated communication boards were in each room for those residents (unspecified) who spoke two languages. CNA 2 stated communication boards in the rooms (unspecified) were important. CNA 2 stated social services was responsible for placing a communication board in Resident 74's room. During an interview on 2/2/2026 at 12:22 PM with the Director of Nursing (DON), the DON stated that residents were to have communications boards in the room if the resident (unspecified) spoke another language (not English). The DON stated Resident 74 would be at risk for not being able to communicate needs. During a review of the facility's policy and procedure (P&P) titled Providing Meaningful Communications with Persons with Limited English Proficiency, dated 7/2025, the P&P indicated The Facility will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits.This facility will promptly identified the language and communication needs of the LEP person. If necessary, staff will use a language identification card (or I speak cards,) or posters to determine the language. 2. During a review of Resident 53's admission Record, the admission Record indicated the facility admitted Resident 53 on 6/27/2019 and readmitted the resident on 3/21/2025 with diagnoses that included acute respiratory failure (a life-threatening , sudden condition where the lungs cannot get enough oxygen into the blood) with hypoxia (a dangerous medical condition where the body tissues are starved of oxygen to function properly), unspecified lack of coordination(a broad, non-specific symptom where the person experiences difficulty with movement control, balance, or fine motor tasks), primary osteoarthritis(a progressive disorder of the joints, caused by a gradual loss of cartilage) left hand, metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), unspecified glaucoma (a group of eye disease that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), dementia (a progressive state of decline in mental abilities) in other diseases classified elsewhere, unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), blindness, one eye, low vision other eye, unspecified eyes, ataxia (a lack of muscle control and coordination, causing shaky, unsteady, and clumsy movements). During a review of Resident 53's Care Plan Report dated 3/24/2025 indicated Resident 53 had vision problems. The Care Plan Report indicated interventions included was to teach Resident 53 on how to locate and use the call light. There were no specific indications documented on how the resident would receive instructions or what was to be taught to locate and use the call light as indicated on the care plan. During a review of Resident 53's Ophthalmology Exam Consult note dated 10/26/2025, the note indicated Resident 53 was unable to open his eyes. The note indicated Resident 53's left cornea (outermost clear layer of the eye) had opacity (cloudy, white, or scarred spot) and a right cataract (a clouding of your eyes' natural lens, like looking through a foggy window, which makes vision blurry and hazy). During a review of Resident 53's Minimum Data Set (MDS – a resident assessment tool) dated 11/26/2025, the MDS indicated Resident 53's ability to see in adequate light was highly impaired (reduced) and did not use corrective lenses (contacts, glasses, or magnifying glass). The MDS indicated resident 53 had severe cognitive (ability to think, understand, learn, and remember) impairment, had limitation in range of motion (ROM-the full distance and direction a joint[where two or more bones meet] can move, measured by how far it can bend, straighten, or twist) in the upper extremity (shoulder, elbow, wrist, hand) on one side and required substantial/maximal assistance (helper does more than half the effort) for eating, oral (mouth) hygiene, upper body dressing, personal hygiene, rolling left and right, sitting to lying, and lying to sitting on the side of the bed . During a concurrent observation in Resident 53's room and interview on 2/4/2026 at 12:17 PM, Resident 53 was observed lying in bed with his eyes closed and a push button call light next to the resident. Resident 53 responded yes to his name being called but did not open his eyes. Resident 53 was observed to have the ability to move his head slightly. Resident 53 was asked if he could push the call light for help, Resident 53 did not respond and did not respond to any other questions and was observed not moving his hand or fingers. During an interview on 2/4/2026 at 12:23 PM, with Certified Nuse Assistant (CNA) 2 stated Resident 53 could not use the call light and was not able to move his hands and fingers very much but could move his head. CNA 2 stated if Resident 53 needed help, he would not have been able to call for help and could not speak out. CNA 2 stated Resident 53 was dependent on the staff for all care and needs. During an interview on 2/4/2026 at 12:26 PM with Registered Nurse (RN 2), RN 2 stated Resident 53 had been in the facility for a long time and was not sure if the resident was able to use the call light. RN 2 stated a push pad call light (a large soft pad designed for residents with limited hand strength) would have been ideal for Resident 53. During an interview on 2/4/2026 at 2:44 PM, with the Director of Nursing (DON), stated a resident who had limited ROM, was blind and had dementia would not have been able to use a traditional call light button. The DON stated Resident 53 would not have been able to call for assistance and would not have had any of his needs tended to. The DON stated a push pad call light would be more appropriate for Resident 53. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting dated 1/2025, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLS independently. The P&P indicated .in accordance with the plan of care, including appropriate support and assistance with communication. any functional communication system. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs dated 1/2025, the P&P indicated The resident's individual needs and preferences shall be accommodated to the extent possible. The P&P indicated The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 11's) medical information was kept private from unintended public view. This deficient practice had the potential to result in a breach of Resident 11's privacy and confidentiality.Findings: During a review of Resident 11's admission Record (a document containing demographic and diagnostic information) dated 2/4/2026, the admission record indicated, Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE]. During an observation on 2/4/2026 at 1:27 PM in the facility's hallway near Station 2, a computer screen on a medication cart a computer screen was observed to have been left on and unattended with a page showing Resident 11's medical information. The computer screen indicated Resident 11's name, date of birth , physician name, room number, code status, allergy information and physician orders. The computer screen indicated, Monitor blood pressure for as needed clonidine order, monitor pain level every shift using pain scale, MiraLAX ([generic name - polyethylene glycol] a medication used to treat constipation) oral packet 17 gram ([gm] a unit of measurement for mass) and ondansetron (a medication used to treat nausea) hydrochloride (HCl) oral tablet 4 milligrams ([mg] a unit of measurement for mass). During a concurrent observation and interview on 2/4/2026 at 1:31 PM with the Licensed Vocational Nurse (LVN) 5, a computer screen on a medication cart was observed to have been left on and unattended facing the public hallway. LVN 5 was observed working at Nurses' Station 2 desk looking at another computer screen. The computer screen on the medication cart indicated Resident 11's medical information. LVN 5 stated she was unaware that the computer screen was open, and she was very careful about locking her medication cart computer. LVN 5 stated, oh no, the computer screen with Resident 11's medical information should not be open for public view because of all the information on it. LVN 5 stated it was important to ensure that Resident 11's medical information was always protected and kept private. During an interview on 2/6/2026 at 3:03 PM with the Director of Nursing (DON), the DON stated facility resident's information should always be kept private. The DON stated the computer screen with residents' information should not have been left open to public view. During a review of the facility's policy and procedure (P&P) titled Resident Dignity & Personal Privacy, dated 01/2025, the P&P indicated, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. The P&P indicated, Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. During a review of the facility's P&P titled, Specific Medication Administration Procedures - Administration Procedures For All Medications, dated 1/20/2025, the P&P indicated, Privacy: Secure (cover) records containing protected health information, (e.g., Medication Administration Records (MARs) and Treatment Administration Records (TARs).

Based on interview and record review, the facility failed to ensure to obtain an informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits, and alternatives offered) for the use of antipsychotic medication (medication used to treat the symptoms of schizophrenia, a mental illness that is characterized by disturbances in thought) from a resident who did not have the capacity to make healthcare decisions (the ability to use and understand information to make a decision and communicate any decision made) for one of five sampled residents (Resident 8). This failure had the potential to result to restrict Resident 8's movement and had the potential for Resident 8 to receive unnecessary psychotropic (medication that affect brain chemicals to alter mood, thoughts, perceptions, and behaviors, primarily used to treat mental illnesses) medication.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility re-admitted Resident 8 on 8/2/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and schizophrenia. The admission Record indicated Resident 8 was responsible for herself. During a review of Resident 8's History and Physical (H&P) dated 8/3/2025, the H&P indicated the resident did not have the capacity to make complex healthcare decisions; however, the resident was able to decide for activity of daily living and was able to make her needs known. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 9/29/2025, the MDS indicated the resident's preferred language was Vietnamese. The MDS indicated Resident 8 had severe cognitive impairment (impairment in the ability to think, understand, and reason) with a BIMS score (a 0-15 point assessment used in long-term care to measure a person's cognitive function, particularly memory, orientation, and ability to recall information; 0-7 indicates severe cognitive impairment) of 4. The MDS indicated Resident 8 was taking antipsychotic medication. During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 10/21/2025 for Risperidone (a type of antipsychotic medication) 2 Milligrams (mg, a unit of mass) via g-tube (a feeding tube inserted through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medication) at bedtime for schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) manifested by derogatory auditory hallucination (a symptom commonly found in schizophrenia where individuals hear voices insulting, belittling, or criticizing them). During a review of Resident 8's Informed Consent Verification Form dated 10/21/2025, the Informed Consent Verification Form indicated Registered Nurse 2 (RN 2) verified that Resident 8 provided informed consent for the use of Risperidone 2 mg via the g-tube at bedtime. During a review of Resident 8's Medication Administration Record (MAR) dated 10/21/2025 - 10/31/2025, the MAR indicated the resident received 11 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 11/6/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 received Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated the resident had no change in her behavioral symptoms. The Behavioral Management Team Psychotropic Medication Review indicated a Gradual Dose Reduction (GDR, the step-by-step reduction of a medication's dosage over time, with the goal of reaching the lowest effective dose or completely discontinuing the medication) was contraindicated (should not be done) because Resident 8's behavior persisted (continued to exist). The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions was reviewed. During a review of Resident 8's MAR dated 11/1/2025 - 11/30/2025, the MAR indicated the resident received 30 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 12/13/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 was receiving Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated Resident 8 had an increase in behavioral symptoms. The Behavioral Management Team Psychotropic Medication Review indicated a GDR was contraindicated because Resident 8's behavior persisted. The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions was reviewed. During a review of Resident 8's MAR dated 12/1/2025 - 12/31/2025, the MAR indicated the resident received 31 doses of Risperidone 2 mg. During a review of Resident 8's Behavioral Management Team Psychotropic Medication Review dated 1/30/2025, the Behavioral Management Team Psychotropic Medication Review indicated Resident 8 was receiving Risperidone 2 mg at bedtime for schizoaffective disorder manifested by derogatory auditory hallucinations. The Behavioral Management Team Psychotropic Medication Review indicated a GDR was contraindicated for Resident 8. The Behavioral Management Team Psychotropic Medication Review did not indicate Resident 8's capacity for making health care decisions was reviewed. During a review of Resident 8's MAR dated 1/1/2026 - 1/31/2026, the MAR indicated the resident received 31 doses of Risperidone 2 mg. During a concurrent interview and record review on 2/05/2026 at 12:11 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. LVN 3 stated that she (LVN3) was assigned to care for Resident 8 and was familiar with the resident. LVN 3 stated Resident 8 was confused but could make her needs known. LVN 3 stated Resident 8 had impaired cognition and did not have the capacity to make medical decisions. LVN 3 stated that Resident 8 was self- responsible and did not have family. LVN 3 stated Resident 8 was taking Risperidone 2 mg every night for schizoaffective disorder. LVN 3 stated that the Informed Consent Verification Form dated 10/21/2025 indicated consent for the administration of Risperidone 2 mg was obtained from the resident. LVN 3 stated that informed consent for Risperidone should not have been taken from Resident 8 because the resident did not have the capacity to make healthcare decisions. LVN 3 stated that the aging department should have been contacted for Resident 8. LVN 3 stated the aging department helped make decisions for a resident if the resident did not have capacity to make healthcare decisions. LVN 3 stated if consent was obtained from a resident (in general) for Risperidone when the resident did not have capacity, the resident may not be aware of what kind of medication they were taking. During a concurrent interview and record review on 2/5/2026 at 12:19 PM with RN 2, Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. RN 2 stated he was familiar with Resident 8. RN 2 stated Resident 8 was confused and could not make medical decisions. RN 2 stated Resident 8 had a history of dementia and schizophrenia. RN 2 stated informed consent for Risperidone 2mg dated 10/21/2025 was obtained from Resident 8, however, the resident did not have the capacity to make medical decisions. RN 2 stated when a resident (in general) was unable to make health care decisions, they would normally ask the family for consent. RN 2 stated Resident 8 did not have family and was self-responsible. RN 2 stated that Resident 8's physician should have been informed the resident did not have capacity to make healthcare decisions. RN 2 stated Resident 8 should have been referred to the aging department. RN 2 stated there was a potential for Resident 8 to not know about the medication she was taking. RN 2 stated there was a potential for Resident 8 to not know about the risks and benefits of taking Risperidone if consent was obtained from the resident when the resident did not have capacity to make healthcare decisions. During a concurrent interview/record review on 2/5/2026 at 12:28 PM with the Minimum Data Set Coordinator (MDSC), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. The MDSC stated she was familiar with Resident 8. The MDSC stated Resident 8 was able to answer simple direct questions but was confused. The MDSC stated Resident 8 had a history of dementia and schizophrenia. The MDSC stated Resident 8 had severely impaired cognition which indicated the resident did not have the capacity to make complex healthcare decisions. The MDSC stated informed consent for Risperdal 2 mg dated 10/21/2025 was obtained from Resident 8. The MDSC stated Resident 8 did not have the capacity to make healthcare decisions when informed consent was obtained from the resident on 10/21/2025. The MDSC stated informed consent for antipsychotic medication was usually obtained from the resident; but if the resident did not have capacity, consent would then be obtained from family or a friend. The MDSC stated if the resident did not have family, the resident would be referred to the aging department. The MDSC stated Resident 8 did not have family and was self-responsible, however, the resident did not have the capacity to make healthcare decisions. The MDSC stated Resident 8 should have been referred to the aging department. The MDSC stated there was potential for Resident 8 to not be aware of the risks and benefits of the medication she was taking if consent was obtained for Risperidone when the resident did not have capacity to make healthcare decisions. During an interview using an interpreter on 2/5/2026 at 12:44 PM with Resident 8, Resident 8 was asked if she (Resident 8) knew about Risperidone. Resident 8 did not acknowledge the interpreter and did not answer the questions the interpreter asked. Resident 8 repeatedly stated she (Resident 8) was cold. During a concurrent interview and record review on 2/5/2026 at 12:51 PM with the Director of Nursing (DON), Resident 8's Informed Consent Verification Form dated 10/21/2025 was reviewed. The DON stated Resident 8 did not have mental capacity. The DON stated Resident 8's decision making ability was not intact and was not normal. The DON that when obtaining informed consent for a resident (in general) who did not have decision making capacity, the person who was identified as the responsible party could give consent. The DON stated this may be a family member or a friend who was designated by the resident. The DON stated if the resident (in general) did not have a responsible party, then consent must be obtained through the IDT (Interdisciplinary Team, a collaborative group of professionals-including nurses, physicians, therapists, social workers, and dieticians-who work together to develop and implement personalized, patient-centered care plans) or physician. The DON stated Resident 8 did not have an IDT meeting to discuss the resident's capacity for making healthcare decisions. The DON stated the purpose of informed consent was to ensure that the resident was aware of what was being done and what medication they were receiving. The DON stated the residents (in general) must understand the consequences of the medication they were taking. The DON stated an informed consent for Risperidone dated 10/21/2025 was obtained from Resident 8 when the resident did not have the capacity to give consent. The DON stated the licensed nurses (in general) should have notified Resident 8's physician about the resident's capacity. The DON stated Resident 8 should have had an IDT meeting for her capacity to make healthcare decisions. The DON stated there was a potential for Resident 8 to not be aware of the medications she (Resident 8) was taking and not be aware of the risks and consequences of the medication because an informed consent for Risperidone was obtained when the resident could not make healthcare decisions. During a review of the facility's Policy and Procedure (P&P) titled Interdisciplinary Team Resident Representative from Long Term Care Patient Representative Program Policy and Procedure dated 9/4/2024, the P&P indicated The purpose of this policy is to provide a process for making ethically and medically appropriate treatment decisions on behalf of persons who lack health care decision-making capacity. This policy may be used when all of the following conditions are met:1. The resident has been determined by the primary physician (with assistance from appropriate consulting physicians if necessary) to lack capacity to make health care decisions.2. No agent under a durable power of attorney for health care, conservator, orally-designated surrogate or guardian has been designated to act on behalf of the patient.3. There is no individual health care directive or instruction in the patient's medical record or other available sources that would eliminate the need for a substitute decision maker.4. No decision maker, family member, or friend can be located who is reasonably available and who is willing and able to serve. When the facility receives from the attending physician an order for medical intervention that requires informed consent and determination that resident lacks capacity to make healthcare decisions the facility will promptly seek a friend or relative to serve as patient representative and participate in the IDT review. The facility should document efforts in resident's records. If the facility is unable to locate a friend or relative within 72 hours of physician's notice the facility must submit a request for Public Patient Representative from the Long-Term Care Patient Representative Program. Convene the IDT Review which can be held in-person or virtually and must include:1. The physician's assessment of resident's condition2. The reason for the proposed medical intervention3. A discussion of whether the proposed treatment is consistent with the resident's preferences/prior expressions of their healthcare wishes. The IDT shall give particular consideration to the resident's preferences/prior expressions of health care wishes unless they are inconsistent with the best interest of the resident, require medically ineffective health care, or contrary to generally accepted health care standards.4. The type of medical intervention - its frequency and duration and risks and benefits5. Probable impact on the resident's condition, with or without the intervention or inappropriateness6. Any reasonable alternatives considered or utilized and reasons for their discontinuance or inappropriateness. During a review of the facility's P&P titled Psychotropic Medication Use dated 1/2025, the P&P indicated When determine whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether.the actual or intended benefit of the medication is understood by the resident/representative. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on interview and record review the facility failed to report an injury of unknown origin to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours when one of eight sampled residents (Resident 62) developed an acute fracture of the left distal fibula (broken left ankle bone). This failure had the potential to result in a delay of the onsite inspection by the SSA and had the potential for Resident 62's to suffer more injuries.Findings: During a review of Resident 62's admission Record, the admission Record indicated the facility admitted the resident on 8/12/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body), dementia (a progressive state of decline in mental abilities), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage), history of falling, age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 62's Minimum Data Set (MDS, a resident assessment tool) dated 11/10/2025, the MDS indicated the resident had moderately impaired cognition (impairment in the ability to think, understand, and reason). The MDS indicated Resident 62 required partial/moderate assistance (helper does less than half the effort) for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 62 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering/bathing herself, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 62's 72 Hours Charting - Change of Condition progress note dated 1/27/2026 at 12:27 PM, the progress note indicated that during morning (1/27/2026) assessment Resident 62 was noted with left ankle swelling and moderate pain. The progress note indicated Resident 62's left lateral (the side of the body that is away from the midline of the body) ankle also had a bluish discoloration (a change in natural color) of the skin. The progress note indicated Resident 62's left ankle was stabilized for safety purposes. The progress note indicated Resident 62 was provided with 50 milligrams (a unit of mass) of Tramadol (a medication used to treat moderate to severe pain) for moderate pain. The progress note indicated Resident 62's physician was notified and a new order for a left ankle three view (three distinct two-dimensional images) x-ray (a type of medical imaging that uses radiation to take picture of the inside of the body) was received and carried out. During a review of Resident 62's Radiology Interpretation dated 1/27/2026, the Radiology Interpretation indicated Resident 62 had an acute fracture of the left distal fibula. During a review of Resident 62's 72 Hour Charting progress note dated 1/28/2026 2:58 AM, the progress note indicated the resident's x-ray results were received and faxed to the resident's physician. The progress note indicated Resident 62's physician response to the x-ray result was pending. During a review of Resident 62's Health Status Note dated 1/28/2026 at 10:38 AM, the Health Status Note indicated a physician order was received to transfer Resident 62 to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment for the resident's acute fracture of the distal fibula. During a review of Resident 62's Discharge Summary progress note dated 1/28/2026 at 12:18 PM, the progress note indicated the resident was transferred out to GACH 1 via a gurney for further evaluation and treatment of the resident's acute fracture of the distal fibula. During a review of Resident 62's GACH 1 documentation dated 1/28/2026 at 6:50 PM, the documentation indicated that based on the resident's evaluation it was difficult to tell whether the resident had a subacute (a bone injury in the process of healing) or acute fracture in the left distal fibula. The documentation indicated Resident 62 had a non-operative fracture. The documentation indicated that based on discussion with orthopedics (the branch of medicine dealing with conditions affecting the bones or muscles) the most conservative treatment for Resident 62 would be to treat the resident for an acute fracture. The documentation indicated Resident 62 was to use a CAM boot (a specialized, rigid walking brace designed to immobilize the foot and ankle, protecting injuries like fractures) for protection until the resident could follow and get assessed by orthopedics. The documentation indicated Resident 62 was to be non-weight bearing for six weeks. During a review of Resident 62's admission Summary progress notes dated 1/28/2026 at 7:10 PM, the progress notes indicated the resident was re-admitted at the facility with a CAM boot on her left leg. The progress note indicated Resident 62 was to continue wearing the CAM boot to immobilize her left leg until the resident's orthopedic appointment. During an observation and interview on 2/4/2026 at 1:35 PM with Resident 62, in the resident's room, the resident was observed with a CAM boot to her left leg. Resident 62 was unable to answer the surveyor's questions about why she was wearing the CAM boot. During an interview on 2/4/2026 at 1:51 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was familiar with Resident 62 and had noticed the resident's left ankle swelling on 1/27/2026. LVN 3 stated that on 1/27/2026 she noticed Resident 62 was having left ankle swelling and pain. LVN 3 stated Resident 62's left ankle was also slightly discolored. LVN 3 stated she called Resident 62's physician to notify him of the resident's x-ray results. LVN 3 stated Resident 62's physician gave orders to send the resident to the hospital. LVN 3 stated Resident 62 was sent out to the hospital by Registered Nurse 2 (RN 2). LVN 3 stated she could not figure out how Resident 62 got the left ankle swelling. LVN 3 stated she did not know how Resident 62 developed the fracture. LVN 3 stated Resident 62 was confused and could not tell her (LVN 3) how the fracture happened. LVN 3 stated Resident 62 did not fall. LVN 3 stated she did not report Resident 62's injury to the SSA because it was not abuse. During an interview on 2/4/2026 at 2:38 PM with Registered Nursing 2 (RN 2), RN 2 stated he transferred Resident 62 to the hospital after the resident's x-ray results indicated the resident had an acute fracture. RN 2 stated he did not know how the resident developed the fracture. RN 2 stated he did not report Resident 62's fracture to the SSA or ombudsman. RN 2 stated Resident 62's fracture should have been reported as it was an unusual occurrence and injury of unknown origin. RN 2 stated there was a potential for a delay in the investigation of the resident's injury or for the injury to get worse because it was not reported to the SSA or ombudsman. During an interview on 2/5/2026 at 1:10 PM with the Director of Nursing (DON), the DON stated she was familiar with Resident 62 and was aware of the resident's left ankle fracture. The DON stated staff had noticed Resident 62 had some discoloration and swelling to her left ankle. The DON stated Resident 62's physician was notified and ordered a x-ray of the resident's ankle. The DON stated Resident 62's x-ray showed the resident had a left ankle fracture. The DON stated Resident 62's physician was notified of the resident's x-ray results and fracture and ordered for the resident to be transferred to the hospital. The DON stated she did not know how the resident developed a fracture. The DON stated she investigated and found the resident did not have a fall. The DON stated she interviewed the staff that took care of Resident 62 and found there was no rough handling of the resident. The DON stated Resident 62's fracture was an injury of unknown origin because she did not know how the resident obtained the fracture and the source of the fracture was not clear. The DON confirmed by stating she did not report Resident 62's injury of unknown origin to the SSA or ombudsman. The DON stated an injury of unknown origin should have been reported to the SSA and ombudsman within two hours. The DON stated there could have been a potential for a delay in investigation by the SSA if an injury of unknown origin is not reported. During a telephone interview on 2/6/2026 at 10:14 AM with RN 4, RN 4 stated she received Resident 62's x-ray results that indicated the resident had a fracture of the left distal fibula on 1/28/2026 at around 2 AM. RN 4 Stated that she did not report Resident 62's injury of unknown origin to the department, law enforcement, or ombudsman because it was not abuse. RN 4 stated only abuse had to be reported immediately. During an interview on 2/6/2025 at 3:01 PM with the Administrator, the Administrator stated she was aware of Resident 62's x-ray that indicated the resident had a fracture. The Administrator stated that she did not initially know how Resident 62 developed the fracture in her left ankle. The Administrator stated that she and the DON had to investigate to determine what could have happened to Resident 62's left ankle. The Administrator stated she did not report Resident 62's injury to the SSA or ombudsman. The Administrator stated Resident 62's injury should have been reported to the SSA and ombudsman immediately once the injury was found. The Administrator stated there was a potential for there to be a delay in an investigation of Resident 62's injury because the injury was not reported to the SSA and ombudsman. During a review of the facility's Policy & Procedure (P&P) titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 10/14/2025, the P&P indicated It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse an do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law.

Based on observation, interview, and record review, the facility failed to ensure to follow safe hazardous (dangerous) medication/drug handling procedures before the preparation and administration of medications that required to be administered with caution for one of six sampled residents (Resident 4) by failing to: -Ensure that on 2/5/2026 at 9:13 AM Licensed Vocational Nurse 3 (LVN3) followed safe hazardous drug handling procedures and checked the National Institute for Occupational Safety and Health (NIOSH, a federal agency responsible for research and recommendations to prevent work-related injuries, illnesses, and deaths) list of drugs before LVN3 prepared and administered Casodex ([generic name -bicalutamide], a medication used to treat progressive prostate cancer [a serious medical condition characterized by an uncontrolled growth of cells within the prostate gland [an organ in the male reproductive system]) and finasteride (a medication used to treat symptoms of benign prostatic hyperplasia ([BPH] a noncancerous enlargement of the prostate that commonly affects men, causing lower urinary tract symptoms like weak stream, frequency, urgency, and incomplete emptying) to Resident 4 via gastrostomy tube ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) This failure had the risk for Resident 4, LVN3, and the environment to be exposed to hazardous medication particles (very small pieces) that could cause skin and respiratory complications, and could cause reproductive/hormonal toxicity (refers to the ability of chemicals, drugs, or environmental agents to cause harmful effects on the ability to conceive, carry a pregnancy to term, or develop normally) . Findings:During a review of Resident 4's admission Record (a document containing demographic and diagnostic information), dated 2/5/2026, the admission Record indicated the facility originally admitted Resident 4 on 6/17/2024 and readmitted on [DATE] with diagnoses that included but not limited to BPH without lower urinary tract symptoms, encounter for attention to gastrostomy (a surgical or endoscopic creation of an opening (stoma) into the stomach to insert a feeding tube (G-tube) for delivering nutrition, fluids, or medication directly, or for gastric decompression). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 4's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was left blank. The MDS indicated Resident 4 was dependent on the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering upper and lower body dressing, putting on/taking off footwear and personal hygiene and the ability to eat was not attempted due to medical condition or safety concerns. During a concurrent observation and interview on 2/5/2026 at 9:13 AM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 prepared seven medications for administration via G-tube. At the time of preparation, LVN 3 was wearing a surgical mask and personal eyeglasses. LVN 3 wore a blue surgical gown and one pair of regular gloves before entering Resident 4's room. that included but not limited to the following medications:a. One tablet of bicalutamide 50 milligram ([mg] a unit of measurement for mass)b. One tablet of finasteride 5 mgDuring a concurrent observation and interview on 2/5/2026 at 9:13 AM LVN 3 was observed removing one tablet of bicalutamide 50 mg from the medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) without wearing gloves by popping it out into a medicine cup. LVN 3 then removed a finasteride 5 mg tablet from the medication bubble pack into a medicine cup. LVN 3 placed the bicalutamide 50 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device without wearing any gloves. LVN 3 wore a pair of gloves on both hands, placed the finasteride 5 mg tablet in a small transparent plastic bag and then crushed the tablet using a crushing device. LVN 3 stated she wore gloves while crushing finasteride because she could touch it accidentally, but while removing from the medication bubble pack, I was not going to touch tablet. LVN 3 stated the finasteride was in hazardous list of medications, so she needed to wear gloves especially for women who could become pregnant or are at childbearing age. LVN 3 showed medication bubble pack for bicalutamide 50 mg, and the pharmacy label indicated, Take one tablet by mouth daily with an additional label directions changed refer to chart but no instructions to wear gloves or to follow hazardous drugs handling procedures. LVN 3 showed medication bubble pack for finasteride 5 mg and the pharmacy label indicated, Take one tablet by mouth daily *Use gloves when handling*. LVN 3 stated the cards indicated by mouth but the order was changed in eMAR to indicate by g-tube. LVN 3 then removed gloves and resumed crushing the remainder of Resident 4's medications. During an observation on 2/5/2025 from 9:34 AM to 10:09 AM in Resident 4's room, LVN 3 placed all the medications in their individual medicine cups on a bedside cart and dissolved each medication separately that included Casodex and finasteride in five milliliters ([mL] a unit of measurement for volume) of water and administered one-by-one via G-tube. During a review of Resident 4's medication reconciliation on 2/5/2026, Resident 4's Order Summary Report, dated 2/4/2026, the order summary report indicated but not limited to the following physician orders: Casodex ([generic name - bicalutamide]) 50 mg, Give 1 tablet via G-tube one time a day for prostate cancer (CA), order date 1/23/2026, start date 1/24/2026. Finasteride 5 mg, Give 1 tablet via G-tube one time a day for BPH, wear gloves when handling medication, order date 1/23/2026, start date 1/24/2026. During an interview on 2/5/2026 at 1:18 PM with LVN 3, LVN 3 stated she (LVN3) only wore gloves for finasteride because there were instructions to wear a single pair of gloves. LVN 3 stated she (LVN3) did not see instructions to wear gloves or double gloves for either Finasteride or Casodex. LVN 3 stated she (LVN3) would need to research to check what Casodex was for and then LVN 3 stated she (LVN3) found from her research that she (LVN3) had to be careful while handling Casodex because these medications had a risk for baby or toxicity to babies if handled or touched by women who were young, pregnant or those with childbearing age. LVN 3 stated she (LVN3) needed to inform pharmacy because Casodex did not indicate it was a hazardous drug on the pharmacy label. LVN 3 stated she (LVN3) researched online regarding finasteride and stated finasteride must be handled with care because it belonged to the hazardous drug class that could be absorbed through skin posing significant risk to developing male fetus, pregnant women or those who could become pregnant and they must not handle broken or crushed tablet. LVN 3 stated there was a risk for skin irritation, respiratory problems, or those with women childbearing age or immunocompromised (people who can easily get sick) could have issues with neonatal toxicity or could affect fetus. LVN 3 stated there was a risk of breathing in the particles while preparing Resident 4's finasteride and Casodex so it was important to wear a N95 mask (a mask that is National Institute for Occupational Safety and Health [NIOSH] approved disposable respirators designed to filter at least 95% of airborne particles, offering superior protection against viruses, bacteria, and dust compared to cloth masks). During an interview on 2/5/2026 at 3:10 PM with the Director of Nursing (DON), the DON stated she (DON) would need to do some research and look on WebMD (a health search engine for drug information) and google to learn more about Casodex. DON stated it was a nonsteroidal [not a steroid], anti-cancer medication. The DON stated she (DON) would check with the pharmacy to double check about Casodex that she (DON) was not aware of. The DON stated hazardous drugs could be very strong and toxic so should not have been handled with bare hands. The DON stated the healthcare personnel (in general) could get gastrointestinal (relating to the stomach) side effects. The DON stated, pregnant women should follow special precautions, handle carefully, wear gloves and should not have had direct contact. The DON stated there would be a risk for the Casodex to be absorbed via skin for the nurse (unidentified) and could also pose a safety risk for the resident (unidentified) if they took the Casodex out in their hands. The DON stated there was a lot of risk for pregnant women and pregnant women should not even handle crushed or broken tablets of finasteride. The DON stated there would be a risk for finasteride to be absorbed via skin for the nurse and would have been a risk for the resident if they took the medication out in their hands. During an interview on 2/6/2026 at 3 PM with the DON, the DON stated the facility did not have the necessary chemotherapy (cancer treatment that uses powerful drugs) gloves or gowns to aid in safe preparation and the administration of hazardous drugs. During a review of the facility's P&P titled, United States Pharmacopeia (USP) Chapter <800>: Hazardous Drug, dated 1/20/2025, the P&P indicated, USP General Chapter <800> provides standards for safe handling hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the environment.Facilities are recommended to check with local and state regulatory agencies to verify requirements for Hazardous Drug Handling. The National Institute for Occupational Safety and Health (NIOSH) considers a drug to be hazardous if it exhibits one or more of the following characteristics in humans or animals: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity. The P&P indicated, The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: A. List of Hazardous Drugs (HDs), B Facility and engineering controls; .E.Proper use of appropriate Personal Protective Equipment (PPE); and F. Policies for HD waste segregation and disposal. This policy applies to all healthcare personnel who handle HD preparations and all entities that store, prepare, transport, or administer HDs. The P&P indicated a list of Hazardous Medications - Quick Safety Guide with Most Common Hazardous Medications (Skilled Nursing Facility [SNF] / Long-Term Care [LTC]), the list indicated but not limited to Casodex (Bicalutamide) with the key risk of reproductive/hormonal toxicity with the instructions of 'crushing not allowed', and Proscar (Finasteride), with the key risk of teratogenic (pregnancy risk) with instructions of 'crushing not allowed'. The Hazardous Medications - Quick Safety Guide indicated, Safe Handling Guidelines that indicated to always wear chemo-rated gloves when handling hazardous medications. Do NOT crush, split, or open hazardous tablets or capsules unless pharmacy-approved containment is used. Avoid direct contact with powder, residue or bodily fluids when applicable.If swallowing difficulty exists, request alternative formulations or therapies. Reminder: When in doubt, treat the medication as hazardous and consult pharmacy before altering dosage form.

Based on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation for one of four sampled residents (Resident 14) with ROM limitations, after identifying a decline in range of motion (ROM, full movement potential of a joint) on 5/14/2025, to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation), monitor the skin, and train the RNA on applying the splint establish goals for the splint. As a result, a right knee extension (straightening) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was placed on Resident 14 without a PT Evaluation, placing Resident 14 at risk of developing additional ROM limitations and skin integrity (health and condition of the skin) issues. Findings: During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 11/18/2022 and readmitted Resident 14 on 1/8/2026. The admission Record indicated Resident 14's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following nontraumatic intracerebral hemorrhage (bleeding in the brain tissue) affecting the left non-dominant side, dysphagia (difficulty swallowing), aphasia (disorder that makes it difficult to speak), and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left elbow, left hand, both knees, and the left ankle. During a review of Resident 14's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs), dated 12/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50-75 percent [%] limitation of normal joint movement) in the left shoulder, left hand, left hip, left knee, and minimal ROM limitations (25-50% limitation of normal joint movement) in the left elbow and ankle. The JMA indicated Resident 14 had within functional limits (WFL, sufficient joint movement without significant limitation) ROM on the right shoulder, elbow, both wrists, right hand, right hip, right knee, and right ankle. During a review of Resident 14's quarterly JMA, dated 5/14/2025, the JMA indicated Resident 14 did not have any change of condition noted on both arms and the leg. The JMA indicated Resident 14's right knee was always on a bending position and the resident would benefit from a right knee extension splint to prevent tightness or contracture. During a review of Resident 14's physician's orders, dated 5/15/2025, the physician's order indicated for the Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) to perform gentle passive range of motion (PROM, movement of a joint through the range of motion with no effort from person) to both legs then apply both knee extension splints and the left ankle splint for two to four hours or as tolerated with skin checks every two hours, seven times per week. During a review of Resident 14's physician's orders, dated 1/8/2026, the physician's orders indicated for the RNA to perform gentle PROM on the left arm, applications of the left elbow extension splint and towel/hand roll for up to 2 hours, seven times per week as tolerated. Another physician's order, dated 1/8/2026, indicated for the RNA to perform gentle PROM exercises to both legs then apply both knee extension splints and the left ankle splint for two to four hours or as tolerated with skin checks every two hours, seven times per week. During an interview on 2/2/2026 at 10:35 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of the JMA was to obtain a resident's (in general) baseline (reference point) ROM in both arms and legs. The DOR stated the therapist would then ask the nurses to request therapy orders from the physician for an evaluation, when a change was found on the JMA. During an observation on 2/4/2026 at 3:18 p.m. in the resident's room, Resident 14 was observed lying in bed with the head-of-bed elevated. Resident 14 was observed to have active movement in the right arm. Blankets covered both Resident 14's legs. During an observation of Resident 14's RNA session on 2/5/2026 at 9:24 a.m. with Restorative Nursing Aide (RNA 1) in the resident's room. Resident 14 was observed lying in bed with the left shoulder rotated toward the body, the left elbow bent, the left wrist slightly bent, and the left fingers bent into a closed fist. RNA 1 performed exercises on Resident 14's left shoulder, elbow, and hand. RNA 1 then applied a left elbow extension splint and a gauze (woven cotton blend wound dressing) roll in the left hand. Resident 14's left leg was positioned in hip flexion (bent at the hip joint toward the body), knee flexion (bent), and ankle plantarflexion (ankle bent with toes pointing away from the body). RNA 1 performed exercises to the left hip, knee, and ankle. RNA 1 then applied a left knee splint, but Resident 14 did not want RNA 1 to apply the left ankle splint. Resident 14's right leg was bent at the knee joint. RNA 1 performed right hip and knee exercises and then applied the right knee splint. During a concurrent interview and record review on 2/5/2026 at 12:17 p.m. with the DOR, Resident 14's JMA, dated 5/14/2025, was reviewed. The DOR stated the professional standard for providing a splint to a resident (in general) included to screen the resident for any changes, obtain a physician's order for therapy services, and evaluate the resident to establish goals for splint wear tolerance. The DOR stated the splint would then be ordered, PT treatment would be provided, and the RNA would be trained on the application of the splint. The DOR reviewed Resident 14's JMA, dated 5/14/2025 completed by the DOR. The DOR stated Resident 14's right knee was consistently in a bent position and recommended a right knee extension splint to prevent muscle tightness or the development of contractures. The DOR stated the physician should have been contacted to request an order for a PT Evaluation due to Resident 14's change of condition. The DOR reviewed Resident 14's PT Evaluation history and did not locate a PT Evaluation after noticing Resident 14's decline in right knee ROM on the JMA, dated 5/14/2025. The DOR stated a PT Evaluation should have been completed prior to providing the right knee splint to obtain a baseline measurement, adjust the splint to the right knee, set a goal for the splint wear tolerance, monitor the skin, and train the RNA on applying the splint. During a review of a textbook titled, Guide to Physical Therapist Practice, revised 6/2003, page 2-3, the textbook indicated the physical therapy uses tests and measures to assess the need for splints. The textbook indicated these tests and measures included the fit and safety during the use of the splint. During a review of the facility's policy and procedure (P&P) titled, Joint Mobility Screen, dated 8/2025, the P&P indicated a Joint Mobility Screen would be completed by Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) for new admissions, readmissions, quarterly, annually, and for residents identified with a functional change. The P&P indicated the physician will be contacted for therapy orders if a PT evaluation was recommended based on the findings from a joint mobility screen.

Based on observation, interview, and record review, the facility failed to ensure to cap (cover) the enteral feeding (a way to deliver liquid nutrition directly into the stomach or small intestine through a soft, flexible tube) tube for one of two sampled residents (Resident 14) reviewed for enteral feeding. This failure had the potential for Resident 14's enteral tube feeding to become contaminated (the presence of unwanted or harmful substances that make something impure, unsafe, or unsuitable for its intended use, often by making it dirty) and increased the risk of infection.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 11/18/2022 and readmitted Resident 14 on 1/8/2026 with diagnoses that included esophagitis, unspecified bleeding (the tube connecting your mouth to your stomach is inflamed, irritated, or swollen, causing it to bleed), gastrointestinal bleeding (bleeding in the tube-like system running from the mouth to your butt), aphasia (a disorder that makes it difficult to speak), gastric ulcer (an open, painful sore or raw spot that develops on the inner lining of the stomach), dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition (a condition where the body does not receive enough calories or protein to function properly, leading to noticeable muscle loss, unintentional weight loss, reduced strength, and weakness). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2025, the MDS indicated Resident 14 usually had the ability to understand others and usually had the ability to make himself understood. During a review for Resident 14's History and Physical (H&P - a doctor's comprehensive check-up that combines your medical background with a physical exam to figure out what is wrong and how to treat it) dated 1/10/2026, the H&P indicated Resident 14 did not have the capacity (ability) to understand and make decisions. During a review for Resident 14's Order Summary Report dated 2/2/2026, the Order Summary Report indicated Resident 14 had physician orders for Jevity (specialized, thick liquid food designed for people who cannot eat normally, often delivered through a feeding tube ) 1.5 cal (calorie - a unit of energy that measures the power your body gets from food and uses for activities like breathing, thinking, and exercising)/ml (milliliter - a metric unit of liquid volume) at 70ml/hr (per hour) for 20 hours via GT (g-tube - a small, soft tube surgically placed through the belly directly into the stomach to deliver food, fluids, and medicine). During a concurrent observation and interview on 2/2/2026 at 10:21 AM with Licensed Vocational Nurse 2 (LVN 2) and the facility's Infection Preventionist (IP), Resident 14's enteral feeding tube that was connected to the enteral feeding bag was observed to be uncapped and exposed to the air. LVN 2 stated the exposed enteral feeding tube could create potential for Resident 14 to become infected. LVN 2 stated Resident 14's entire enteral feeding bag, including the tubing, would need to be changed. The IP stated Resident 14's enteral feeding tube was exposed and could become a source of infection and the enteral feeding bag including the tubing would need to be changed to prevent possible spread of infection. During a concurrent interview and record review on 2/2/2026 at 12:42 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Enteral Feedings - Safety Precautions, dated 1/2025, was reviewed. The DON stated the P&P indicated to ensure the safe administration (to give) of enteral nutrition. The P&P indicated the facility would maintain strict aseptic technique (a set of practices and procedures used to prevent infection by minimizing the presence of harmful germs in a specific area, ensuring they don't enter the body or cause the unwanted presence of harmful, dirty, or impure substances in something that was previously clean) at all times when working with enteral nutrition systems and formulas. The DON stated the facility did not follow their policy. The DON stated leaving Resident 14's enteral tube feeding uncapped could lead to Resident 14 getting an infection. The DON stated the facility should have followed their enteral feeding P&P.

Based on interviews, and record reviews, the facility failed to: 1. Clarify one of six sampled residents (Resident 31's) physician order for famotidine (a medication used to reduce the amount of acid produced by the stomach) dated 12/24/2025, which did not indicate a frequency (number of times) for taking the medication. 2. Ensure one of six sampled residents (Resident 80's) lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) was available in stock at the facility. These deficient practices had the potential to cause medication errors for Resident 31 and inadequate pain relief for Resident 80 and placed both residents at risk for adverse health consequences such as acid-reflux, and decline in resident's mental, physical, functional or psychosocial status due to inadequate pain management.Findings: 1. During a review of Resident 31's admission Record (a document containing demographic and diagnostic information), dated 2/5/2026, the admission record indicated the facility originally admitted Resident 31 on 12/8/2023 and readmitted on [DATE] with diagnosis that included Gastro-Esophageal Reflux Disease (GERD, a medical condition when stomach acid flows back up into the esophagus and causes heartburn) without esophagitis (inflammation, irritation, or swelling of the esophagus, the tube carrying food from the mouth to the stomach). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 31's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 31 needed supervision or touching assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, moderate assistance for oral hygiene, upper body dressing and personal hygiene, and maximal assistance for toileting hygiene, lower body dressing and putting on or taking off footwear. During a review of Resident 31's medication reconciliation on 2/5/2026, Resident 31's Order Summary Report (a document containing a summary of all active physician orders), dated 2/4/2026, the order summary report indicated Famotidine Oral Tablet 40 milligram ([mg] a unit of measurement for mass), give 1 tablet by mouth has needed for GERD, order date 12/24/2025, start date 12/24/2025. During a concurrent interview and record review on 2/5/2026 at 1:39 PM with Licensed Vocational Nurse (LVN) 3, Resident 31's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/1/2026 to 2/5/2026 was reviewed. LVN 3 stated she did not have Resident 31's famotidine medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles). LVN 3 stated the MAR from 2/1/2026 to 2/5/2026 indicated famotidine 40 mg was not administered to Resident 31. LVN 3 reviewed the physician's order for famotidine and stated the famotidine was missing the frequency indicating how often the medication had to be given. LVN 3 stated there was a risk that someone could give one dose and someone else could give it again as needed without clear understanding of how to give medication, before meals or after meals or there would be a risk for medication error if given too much too frequently or not given at all. During an interview on 2/5/2026 at 3:24 PM with the Director of Nursing (DON), the DON stated each medication order had to indicate the dose, route, frequency and patient name. The DON stated the famotidine order should have had a frequency, for example, one tablet once a day and if the order did not have a frequency, the facility nurse should have clarified the order with a physician. During a review of the facility's policy and procedure (P&P) titled, Physicians' Medication Orders, dated 1/20/2025, the P&P indicated, Orders for medications must include name and strength of the drug; quantity or specific duration of therapy; dosage and frequency of administration; route of administration if other than oral; and reason or problem for which given. 2. During a review of Resident 80's admission Record, dated 2/4/2026, the admission record indicated the facility admitted Resident 80 on 1/29/2026 with diagnoses that included encounter for orthopedic (a term used for musculoskeletal system - bones, joints, ligaments, tendons, and muscles) aftercare following surgical amputation (a surgery to remove all or part of a body appendage), acquired absence of right leg below knee, osteomyelitis (a serious bone infection) of vertebra (bones forming the vertebral column or spine) in humans, thoracic region, Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve pain), Type 2 DM with diabetic Chronic Kidney Disease (CKD - a long-term condition involving the gradual loss of kidney function over time) and Stage 3A CKD. During a review of Resident 80's History & Physical (H&P) dated 1/31/2026, the H&P indicated Resident 80 had the capacity to understand and make decisions. During a review of Resident 80's MDS dated [DATE], the MDS indicated Resident 80's cognition was intact. The MDS indicated Resident 80 needed supervision or touching assistance from facility staff for performing ADLs such as eating, moderate assistance for oral hygiene, maximal assistance for toileting hygiene, showering, upper body dressing and personal hygiene, and dependent on facility staff for lower body dressing and putting on or taking off footwear. During a medication reconciliation on 2/5/2026, Resident 80's Order Summary Report, dated 2/4/2026, the order summary report indicated the following physician orders: Lidocaine External Patch 4 percent (% - a unit of strength or potency of the medication), apply to affected area topically every 24 hours as needed for right below the knee amputation (R BKA) site pain, order date 1/29/2026, start date 1/29/2026. Lidocaine External Patch 4%, apply to lower back topically every 24 hours as needed for lower back pain apply 2 patch, order date 1/29/2026, start date 1/30/2026. During a concurrent interview and record review on 2/6/2026 at 1:27 PM with LVN 4 and LVN 5, Resident 80's physician's order instructions and administration details for lidocaine patch 4% and availability of lidocaine patch 4% in stock at facility were reviewed. The administration details on MAR, dated 1/1/2026 to 1/31/2026 and 2/1/2026 to 2/6/2026, indicated there was no documented administration of lidocaine patch 4% as needed for R BKA and lower back pain. LVN 5 stated she did not have Resident 80's lidocaine patch 4% in stock because it was prescribed as needed. LVN 5 stated the facility should have ordered lidocaine 4% patch from the pharmacy and have it available in case Resident 80 needed the lidocaine patch for pain management. LVN 5 stated sorry the facility might have forgotten to request, or the pharmacy did not send them to us. LVN 4 interrupted and stated she (LVN 4) checked in the system and saw a note that indicated the facility requested lidocaine patch 4% from the pharmacy on 1/29/2026 but had not received it yet. LVN 4 stated it had been 8 days since the request, so it was important to follow up with the pharmacy. LVN 4 stated the lidocaine patch would help with local sites and topical pain relief and would be a better option for Resident 80 to try rather than taking opioids (a class of drugs used primarily to reduce moderate to severe pain) with the risk of addiction associated with them. During an interview on 2/6/2026 at 3:03 PM with the DON, the DON stated medications prescribed on an as needed basis should have been in stock at the facility regardless of the type of medication. The DON stated there would be a risk that the resident would not be adequately treated for pain if lidocaine patches were not available in stock. The DON stated the facility nursing staff should have followed up with the pharmacy every day when the lidocaine patch was not in stock. During a review of the facility's P&P titled, Specific Medication Administration Procedures - Administration Procedures For All Medications, dated 1/20/2025, the P&P indicated, To administer medications in a safe and effective manner.

Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to ensure the staff wore full personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including use of a face mask to cover both nose and mouth, during influenza ([flu] illness that infect the nose, throat, and lungs, causing sudden fever, cough, sore throat, body aches, and fatigue) season in accordance with the facility's policy and procedures titled Respiratory Virus Prevention and Control Plan, updated on 11/21/2025. These deficient practices had the potential to result in the spread of disease and illness throughout the facility, which could result in severe respiratory illness, hospitalization and/or death.Findings: During an interview on 2/5/2026 at 8:24 a.m. with the Infection Prevention Nurse (IPN), the IPN stated facility staff needed to wear face masks while inside the facility due to the current flu and Coronavirus disease 2019 ([COVID-19] a highly contagious viral disease that can cause respiratory illness) season. During an observation on 2/5/2026 at 11:49 a.m. Certified Nursing Assistant 1 (CNA 1) was observed sitting on a seat in a resident room not wearing a face mask. During a concurrent observation and interview on 2/5/2026 at 12:01 p.m. in the same room, CNA 1 was observed sitting on a seat without wearing a face mask. CNA 1 stated a different CNA (unidentified) was assigned to the room and was at lunch. CNA 1 was assigned to three other resident rooms. CNA 1 stated she came back from lunch at 11:30 a.m. and went straight to the room to relieve the other CNA. CNA 1 stated the staff were supposed to wear a face mask while inside the facility to protect both the staff and residents from the flu. During an interview on 2/5/2026 at 1:00 p.m. with the IPN, the IPN stated the staff were required to wear masks inside the facility to protect the residents from respiratory (affecting the lung) viruses. The IPN stated staff should definitely wear a face mask while inside resident rooms. During an interview on 2/5/2026 at 1:36 p.m. with the Director of Nursing (DON), the DON stated the facility required the staff to wear face masks during flu season. The DON stated the residents, and staff could be exposed to viruses, bacteria, and anything that could be transmitted from one person to another without wearing a face mask. During a concurrent interview and record review on 2/5/2026 at 2:46 p.m. with the IPN, the facility's P&P titled, Respiratory Virus Prevention and Control Plan, updated 11/21/2025, was reviewed. The IPN stated the number of individuals infected with the flu was increasing in Los Angeles County. The IPN stated the facility staff had to wear a face mask while in the facility due to the increased community transmission of the flu. The IPN stated the facility staff received a recent in-service education about the facility's respiratory virus prevention and control plan. During a review of the facility's in-service attendance log titled, Respiratory Virus Prevention & Control Plan, dated 1/16/2026, the in-service indicated the facility residents were at increased risk for severe disease, hospitalization, death, and outbreaks caused by COVID-19, influenza, and other respiratory viruses. The in-service indicated the use of face masks or respirators for source control of respiratory infections to prevent healthcare professionals from infecting residents and other staff with respiratory viruses. During a review of the facility's policy and procedure (P&P) titled, Respiratory Virus Prevention and Control Plan, updated 11/21/2025, the P&P indicated health care professionals would use face masks or respirators (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) for source control of respiratory infections. The P&P indicated the facility would implement source control masking during period of increased community transmission of respiratory viruses.

Based on observation, interview, and record review, the facility failed to ensure four of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the requirement of no more than four beds per room. This failure had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents who resided in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].Findings:During a review of the facility's Room Variance Waiver Request dated 2/4/2026, the Room Variance Waiver Request indicated the facility requested a room variance waiver for room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. The Room Variance Waiver Request indicated there was enough space to provide each resident's care, dignity, privacy, and that the rooms were in accordance with the special needs of residents. The Room Variance Waiver Request indicated the rooms were in accordance with the special needs of residents and would not have an adverse effect (unwanted result) on the residents' health and safety or impede with the ability of any resident in the rooms to attain his or her highest practicable well-being. The Room Variance Waiver Request indicated the facility would ensure that all measures would be taken to assure the comfort of each resident in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. During an observation on 2/4/2026 at 1:36 PM room [ROOM NUMBER] appeared to have enough space for therapy and nursing services to be provided to the residents (in general) in the room. During an interview on 2/4/2026 at 1:38 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated there was enough space in room [ROOM NUMBER] for therapy, to maneuver (move around), and to provide residents (in general) with nursing services. During an observation on 2/4/2026 at 1:42 PM room [ROOM NUMBER] was observed to have enough space for therapy, resident activity, and nursing services for the residents (in general) in the room. During a concurrent observation and interview on 2/4/2026 at 1:47 PM with Certified Nursing Assistant 1 (CNA 1) the space in room [ROOM NUMBER] was observed to have enough space for therapy, resident activity, and nursing services. CNA 1 stated there was enough space to perform therapy and for the staff to provide residents in the room with services. During an observation and interview on 2/4/2026 at 1:55 PM facility staff (in general) were observed assisting residents (in general) in room [ROOM NUMBER]. The staff had enough room to provide services for the residents (in general). During an interview on 2/4/2026 at 1:57 PM with Resident 13, Resident 13 stated he (Resident 13) did not have any complaints about the size of room [ROOM NUMBER] with five beds. During a review of the facility's policy and procedure (P&P) titled, Resident Room Size, dated 1/2025, indicated the residents would have at a minimum of 80 square feet of living space and no more than 4 residents to a room. Any room not meeting the requirements would require the facility to request a room waiver from CDPH annually (every year). The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review, the facility failed to ensure that two of four sampled residents (Resident 1 and 2) who were fall risk, were provided with ordered and care-planned safety devices to reduce the risk of accidents. For Resident 1, the facility failed to ensure Resident 1's 's wheelchair had footrests and alarm as ordered by physician, and for Resident 2, the facility failed to ensure Resident 2 had footrests applied as recommended by Physical Therapy. These deficient practices had the potential to result in injury for Resident 1 and 2, during wheelchair transfer by facility staff.1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of degeneration of brain, dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), weakness, and bilateral osteoarthritis (OA- is the most common form of arthritis, a degenerative joint disease where the protective cartilage cushioning the ends of bones wears down over time, leading to pain, stiffness, swelling, and reduced mobility as bones start rubbing together) of knees.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 1 had severely impaired cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 1 required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting, upper and lower body dressing, putting on footwear, personal hygiene, toilet transfer, shower transfer, and walking 10 feet. The MDS indicated Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating, roll left and right, sit to lying, lying to sitting, sit to stand, and chair to bed-chair transfer.During a review of Resident 1's Comprehensive Care Plan (CP- a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care), dated 12/24/2025 , indicated Resident 1 required maximal assistance while using locomotion (refers to a person's ability to move from one place to another like walking, transferring from bed to chair, using a wheelchair) on and off the unit.During a review of Resident 1's Order Summary, dated 10/23/20205, indicated Resident 1 may have wheelchair alarm while up in wheelchair to alert staff when resident is trying to get up unassisted. The Order Summary dated 9/25/2025 indicated a floor mat should be placed on right side of Resident 1's bed to prevent injury for any fall.2.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of weakness, osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones), and Alzheimer's disease (a progressive brain disorder, the most common type of dementia, that slowly destroys memory, thinking, and reasoning skills, eventually impairing the ability to perform daily activities).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 2 required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting, showering, upper and lower body dressing, putting on footwear, sit to stand, chair/bed transfer, and toilet transfer. The MDS indicated Resident 2 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene, personal hygiene, roll left and right, sit to lying, lying to sitting, and required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating.During a review of Resident 2's Comprehensive Care Plan, dated 1/7/2026 , indicated Resident 1 required maximal assistance while using locomotion on and off the unit.During a concurrent observation and interview on 1/13/2026 at 11AM with the Activity Assistant, in the activity room, Resident 1 and Resident 2 sat down in their wheelchairs without footrest around a round table. The activity assistant offered to transfer Resident 2 back to her room so that she could talk in private with the surveyor. The activity assistant stated he had not been trained in transferring residents on wheelchairs and did not know why they didn't have footrest.During a concurrent observation and interview on 1/13/2026 at 11:14 AM with Certified Nursing Assistant 2 (CNA2) in Resident 1's room, CNA2 stated the wheelchair did not have footrests, no wheelchair alarm, and there was no floor mat in the room. CNA2 stated Maintenance should have the foot rests placed on the wheelchair and began searching the closets for the footrests.During an interview on 1/13/2026 at 11:49 AM with the Quality Assurance (QA) nurse, the QA nurse mentioned that if a resident can move themselves using their feet while in a wheelchair, footrests are not attached. However, if the residents have hemiplegia, weakness, or are at risk of falling, the footrests should be used, especially if advised by physical therapy staff.During an interview on 1/13/2026 at 11:53 AM with the Physical Therapy Director (PTD), the PTD mentioned that residents who need a footrest on their wheelchair are typically those with weakness, depending on their history. The PTD noted that Resident 2 should have a footrest since she recently returned from the hospital, has weakness, and attends therapy three times a week. Regarding Resident 1, the PTD said he provided a footrest for her wheelchair but did not actually recommend it.During an interview on 1/13/2026 at 12 PM with the Minimum Data Set (MDS) Nurse, the MDS Nurse stated Resident 1 was at high risk for falls, required maximal assist which would indicate to a staff member they should be doing maximal assist for wheelchair transfers, and a footrest should be in place. The MDS Nurse stated Resident 2 had a low fall risk, however due to her recent hospitalization she was weaker than usual and if these residents had any weakness to assist in lifting their feet during a wheelchair transfer, their feet could drag and result in injury. The MDS Nurse stated if residents have orders for alarms and floor mats, these should be implemented to ensure resident safety and failure to do so would impact resident safety negatively.During a review of the facility's policy and procedures (P&P) titled Managing Falls and Fall Risk, dated 11/21/2025, the P&P indicated staff will identify appropriate interventions to reduce the risk of falls with the input of the Attending Physician. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to minimize serious consequences of falling.

Based on interview and record review the facility failed to report the elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) from the facility of one out of three sampled residents (Resident 1) to the California Department of Public Health (CDPH), Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement no later than 2 hours after Resident 1 went out on pass on 10/7/2025 at 12:50 PM and did not return to the facility, as per the facility's policy and procedures (P&P) titled Elopement, dated 1/2025. This failure resulted in the facility waiting until 10/8/2025 at 3 PM to notify CDPH, local law enforcement, and the Ombudsman, delaying the onsite inspection and investigation. This failure also Placed the resident at risk for worsening medical conditions, delayed care, being assaulted, accidents, injuries, and even death. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses that included end stage heart failure (when the heart is so weak that it can no longer pump enough blood for the body's needs, even with treatment), dilated cardiomyopathy (a condition where the heart's main pumping chamber becomes enlarged, stretched, and weakened, making it harder to pump blood effectively, chronic kidney disease stage 2 (kidneys have mild damage and are working less effectively than they should, but are still filtering blood), patient's non-compliance (does not follow the rules) with medical treatment and regimen (plan) due to unspecified reason, acute pulmonary edema (when fluid suddenly builds up in the lungs, making it very difficult to breathe), cocaine (a highly addictive drug that makes a person feel intensely energetic and euphoric [an intense sense of happiness, excitement, and well-being] for a short period of time) abuse, and that the resident was on hospice (care for people nearing the end of life that focuses on comfort, pain management, and quality of life rather than on curing the disease). During a review of Resident 1's Care Plan Report dated 6/12/2025, the Care Plan Report indicated Resident 1 was a risk for elopement and falls. The Care Plan Report Indicated the facility staff was to monitor Resident 1's where abouts frequently, document Resident 1's wandering behavior in the facility's behavior log (a record of a resident's health information), and attempt diversional activity (any pleasant, engaging activity that distracts a patient from their pain, boredom, or anxiety). During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 9/7/2025, the H&P indicated Resident 1 had the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool), dated 9/15/2025, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. 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 completes activity) to walk 10 feet, for toileting, oral hygiene (brushing teeth and mouth care), and for eating. The MDS indicated Resident 1 required moderate to partial assistance (helper does less than half the effort and helps the resident lift, hold, or support themselves) for showering/bathing, putting on shoes/socks, personal hygiene (shaving, washing/drying face and hands), and for tub/shower transfer (ability to get in and out of a tub/shower). During a review of Resident 1's Progress Notes dated 10/6/2025 at 1:07 PM, the Progress Notes indicated Resident 1 left the facility and went out on pass. During a review of Resident 1's Progress Notes for 10/7/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 7:33 PM, 10:08 PM couple of times, and at 11:01 PM. During a review of Resident 1's Progress Notes for 10/8/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 12:02 AM (2 attempts), 3:11 AM (2 attempts), 9:09 AM, and at 2:31 PM, the Progress Notes indicated the Social Services Director (SSD) had been trying to reach Resident 1 since 10/7/2025 at 3:07 pm. During a review of Resident 1's Order Summary Report, dated 10/9/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass starting 10/1/2025. During a review of Resident 1's Progress Note dated 10/9/2025 at 4:59 PM, the Progress Note indicated RN 2 documented a late entry (when information that was forgotten or left out of an original note is added later, after the original entry was made and signed). The Progress Note indicated the effective date and time of the Progress Note was 10/7/2025 at 1:54 AM and indicated Resident 1 was discharged after he had not returned from pass since yesterday. The Progress Note indicated RN 2 had been calling Resident 1, but Resident 1 did not respond. The Progress Note indicated RN 2 informed Resident 1's emergency contact that Resident 1 had not returned from going out on pass yesterday. The Progress Note indicated RN 2 Resident 1's hospice, called the police to inform the police the facility considered Resident 1 a missing person, and notified the Ombudsman's office. During a concurrent interview and record review on 10/9/2025 at 1:02 PM with LVN 2, the facility's policy and procedure (P&P), titled Elopement, dated 1/2025 was reviewed. LVN 2 stated the facility should have considered Resident 1 missing if he had not returned after several hours. LVN 2 stated she (LVN 2) could not answer why the facility's nursing staff did not notify local law enforcement, the Ombudsman, CDPH, and document out an unusual occurrence after the facility could not locate Resident 1 per the facility's P&P. LVN 2 stated the facility should have followed their P&P. During an interview on 10/9/2025 at 1:44 PM with RN 2, RN 2 stated she waited until the morning of 10/8/2025 before following up on Resident'1 whereabouts because Resident 1 was out on pass. RN 2 refused to answer whether she (RN 2) followed the facility's policy for elopement after not being able to locate Resident 1 after 15 minutes that required the facility to notify police, the Ombudsman, and CDPH. RN 2 stated she opted to wait until morning on 10/8/2025 to endorse to the next shift (7 AM to 3 PM shift) that Resident 1 had not returned to the facility. During a concurrent interview and record review on 10/9/2025 at 1:57 PM with RN 1, Resident 1's Care Plan Report dated 6/12/2025 RN 1 stated the facility did not create a care plan for Resident 1 for going out on pass. RN 1 stated he would consider Resident 1 missing if Resident 1 had gone out on pass and did not return any of the facility's calls to him (Resident 1). RN 1 stated based on facility policy, the facility should have searched for Resident 1 and if the staff could not locate Resident 1, the facility should have called the police, Ombudsman, CDPH, and documented an unusual occurrence. RN 1 stated the facility did not follow their policy for Resident 1. During an interview on 10/9/2025 at 3:44 PM with the DON and ADM, the ADM stated the facility would consider any resident missing if they did not return from out on pass after 24 hours. The DON stated she (DON) would consider a resident missing if the resident did not return after midnight. The DON stated the facility should have called the police, notified the Ombudsman, and CDPH when Resident 1 did not return after midnight. The DON stated anything could happen to Resident 1 while out on pass. The ADM stated Resident 1 could have gotten into an accident when Resident 1 did not return from out on pass. The ADM stated she (ADM) could not guarantee Resident 1 was safe after not returning to the facility. During an interview on 10/10/2025 at 12:02 PM with the ADM, the ADM stated the facility notified the police, Ombudsman, and CDPH on 10/8/2025 that Resident 1 did not return to the facility after going out on pass on 10/7/2025. During a concurrent interview and record review on 10/10/2025 at 12:09 PM, the facility's fax confirmation sheets dated 10/8/2025 were reviewed with the ADM. The confirmation sheets indicated the facility sent a fax regarding Resident 1 not returning to the facility from out on pass on 10/7/2025 to the CDPH on 10/8/2025 at 3:39 PM and to the Ombudsman on 10/8/2025 at 3:48 PM. The ADM stated the fax confirmations sheets were proof of when the facility notified CDPH and the Ombudsman. During a review of the facility's P&P titled Elopement, dated 1/2025 was reviewed. The P&P indicated if a resident (in general) could not be located within 15 minutes, the police had to be notified, and the facility would need to document an unusual occurrence (something that happens that is not common or expected) and report the incident to CDPH.

Based on interview, and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for one of three sampled residents (Resident 1). By failing to create and initiate a care plan for Resident 1's out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) physician's order as indicated in the facility's Policy and Procedures (P&P) titled Out on Pass Policy and Procedures, dated 4/2024 and the facility's P&P titled Care Plans - Comprehensive, dated 1/2025 . These deficient practices had the potential for the residents to receive inadequate care and/or supervision which could affect the residents' quality of care and cause the resident harm.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses that included end stage heart failure (when the heart is so weak that it can no longer pump enough blood for the body's needs, even with treatment), dilated cardiomyopathy (a condition where the heart's main pumping chamber becomes enlarged, stretched, and weakened, making it harder to pump blood effectively, chronic kidney disease stage 2 (kidneys have mild damage and are working less effectively than they should, but are still filtering blood), patient's non-compliance (does not follow the rules) with medical treatment and regimen (plan) due to unspecified reason, acute pulmonary edema (when fluid suddenly builds up in the lungs, making it very difficult to breathe), cocaine (a highly addictive drug that makes a person feel intensely energetic and euphoric [an intense sense of happiness, excitement, and well-being] for a short period of time) abuse, and that the resident was on hospice (care for people nearing the end of life that focuses on comfort, pain management, and quality of life rather than on curing the disease). During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 9/7/2025, the H&P indicated Resident 1 had the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool), dated 9/15/2025, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. 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 completes activity) to walk 10 feet, for toileting, oral hygiene (brushing teeth and mouth care), and for eating. The MDS indicated Resident 1 required moderate to partial assistance (helper does less than half the effort and helps the resident lift, hold, or support themselves) for showering/bathing, putting on shoes/socks, personal hygiene (shaving, washing/drying face and hands), and for tub/shower transfer (ability to get in and out of a tub/shower). During a review of Resident 1's Order Summary Report, dated 10/9/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass starting 10/1/2025. During concurrent interview and record review on 10/9/2025 at 1:02 PM with Licensed Vocational Nurse (LVN 2), Resident 1's complete and active care plans were viewed. LVN 2 verified that Resident 1 did not have a plan of care for being out on pass. LVN 2 could not locate the Interdisciplinary Team (IDT, a team of health care professions, which includes the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) Assessment as indicated in the policy for Out on Pass. LVN 2 stated the facility should have done an IDT. During an interview on 10/9/2025 at 1:57 PM with Registered Nurse (RN1), RN 1 verified that Resident 1 did not have a care plan for out on pass. RN 1 stated if the facility did not follow the policy for out on pass, the facility would not be able to assess Resident 1's safety and the IDT would need to determine Resident 1's ability to go out on pass. During an interview on 10/9/2025 at 3:44 PM with the Director of Nursing (DON), the DON stated that since there was not an out on pass care plan the facility would not know when Resident 1 was supposed to return. During an interview on 10/10/2025 at 10:45 AM with the Administrator (ADM), the ADM stated Resident 1's going out on pass should have been care planned. During a review of the facility's policy and procedures (P&P) titled, Out on Pass Policy and Procedures, dated 4/2024, indicated, it is the policy of the facility to meet resident's physical and psychosocial needs to go out on pass. The facility will make reasonable efforts to ensure the residents' safety and uphold resident rights. The P&P indicated when residents request to go out on pass, the IDT team will assess the resident's ability to participate in activities outside the facility. During a review of the facility's policy and procedures (P&P) titled, Care Plans - Comprehensive, dated 1/2025, indicated, the Care Planning/IDT team, with the resident and/or his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The IDT team documents the Resident Assessment Protocol (RAP - a problem-oriented framework used in nursing homes to guide additional assessment after an initial evaluation, based on specific triggered conditions) summary sheet and/or record in the clinical record: the resident's status, the team's rational for deciding whether to proceed with care planning, and evidence the team considered the development of care planning interventions for all RAP's triggered by the MDS.

Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1), who required supervision with walking, was assessed as risk for elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing), and was under Hospice (compassionate care for people who are near the end of life) care, did not leave the facility unsupervised while out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal) on 10/7/2025 at 12:50 PM. By failing to: 1. Conduct an IDT (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) meeting in collaboration with the Hospice agency to assess Resident 1's ability to participate in activities outside the facility (unsupervised) as indicated in the facility's Policy and Procedures titled out on Pass Policy and Procedure dated 4/2024. 2. Ensure Resident 1's Physician specified in the resident's out on pass order whether Resident 1 needed to be accompanied by a responsible person and/or supervised while out on pass. 3. Ensure facility staff (licensed nurses, and Resident 1's physician) informed Resident 1 on what time to return to the facility from out on pass as indicated in the facility's policy and procedures (P&P), titled Out on Pass Policy and Procedure dated 4/2024. This failure resulted in Resident 1 leaving the facility unsupervised on 10/7/25 at 12:50 PM and eloping (aka elopement: a patient or resident leaving a healthcare facility without permission and without being properly discharged ) from the facility. Placing the resident at risk for worsening medical conditions, delayed care, being assaulted, accidents, injuries, and even death.Cross Reference: F711During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses that included end stage heart failure (when the heart is so weak that it can no longer pump enough blood for the body's needs, even with treatment), dilated cardiomyopathy (a condition where the heart's main pumping chamber becomes enlarged, stretched, and weakened, making it harder to pump blood effectively, chronic kidney disease stage 2 (kidneys have mild damage and are working less effectively than they should, but are still filtering blood), patient's non-compliance (does not follow the rules) with medical treatment and regimen (plan) due to unspecified reason, acute pulmonary edema (when fluid suddenly builds up in the lungs, making it very difficult to breathe), cocaine (a highly addictive drug that makes a person feel intensely energetic and euphoric [an intense sense of happiness, excitement, and well-being] for a short period of time) abuse, and that the resident was on hospice (care for people nearing the end of life that focuses on comfort, pain management, and quality of life rather than on curing the disease). During a review of Resident 1's Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) Report dated 6/12/2025, the Care Plan Report indicated Resident 1 was a risk for elopement and falls. The Care Plan Report Indicated the facility staff was to monitor Resident 1's where abouts frequently, document Resident 1's wandering behavior in the facility's behavior log (a record of a resident's health information), and attempt diversional activity (any pleasant, engaging activity that distracts a patient from their pain, boredom, or anxiety). During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 9/7/2025, the H&P indicated Resident 1 had the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool), dated 9/15/2025, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. 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 completes activity) to walk 10 feet, for toileting, oral hygiene (brushing teeth and mouth care), and for eating. The MDS indicated Resident 1 required moderate to partial assistance (helper does less than half the effort and helps the resident lift, hold, or support themselves) for showering/bathing, putting on shoes/socks, personal hygiene (shaving, washing/drying face and hands), and for tub/shower transfer (ability to get in and out of a tub/shower). During a review of Resident 1's Progress Notes dated 10/6/2025 at 1:07 PM, the Progress Notes indicated Resident 1 went out on pass (10/7/2025 at 12:50 PM). During a review of Resident 1's Progress Notes, dated 10/6/2025 at 8:55 PM, the Progress Notes indicated Resident 1 went to the Social Services office, then to the housing authority (a local government agency that helps provide affordable housing to low-income people, such as families, the elderly, and individuals with disabilities) and went to a downtown auction to buy car. During a review of Resident 1's Progress Notes, dated 10/7/2025 at 12:50 PM, the Progress Notes indicated Resident 1 went out on pass to take care of his housing. During a review of Resident 1's Progress Notes for 10/7/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 7:33 PM, 10:08 PM couple of times, and at 11:01 PM. During a review of Resident 1's Progress Notes for 10/8/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 12:02 AM (2 attempts), 3:11 AM (2 attempts), 9:09 AM, and at 2:31 PM, the Progress Notes indicated the Social Services Director (SSD) had been trying to reach Resident 1 since 10/7/2025 at 3:07 pm. During a review of Resident 1's Progress Notes for 10/9/2025 at 9:08 AM, the progress notes indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 9:08 AM (3 attempts). During a review of Resident 1's Progress Notes dated 10/9/2025 at 12:29 PM, the Progress Notes indicated the facility called the Los Angeles County Jail at 213 473 6100 and was informed Resident 1 was not at the Los Angeles County Jail. During a review of Resident 1's Order Summary Report, dated 10/9/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass starting 10/1/2025. The Order Summary Report indicated Resident 1 had orders for the following medications:1. Amiodarone (medication used to get a dangerously fast or irregular heartbeat back into a [NAME]) 200 mg milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) one tablet one time a day for arrythmia (irregular or abnormal heartbeat).2. Aspirin 81 mg chewable tablet one tablet by mouth for clot (a clump of blood that forms to stop bleeding) prevention.3. Atorvastatin (a medicine that helps lower high cholesterol) 80 mg one tablet by mouth at bedtime for hyperlipidemia (a medical condition where there are abnormally high levels of lipids [fats], such as cholesterol and triglycerides, in the blood), prevent heart attack4. Carvedilol (medication that helps reduce stress on your heart by slowing your heart rate and relaxing your blood vessels) 6.25 mg one tablet by mouth two times a day.5. Clopidogrel (blood thinner that prevents platelets, which are tiny blood cells, from clumping together to form a dangerous clot) 75 mg one tablet by mouth one time a day for inhibitor platelet (medication that stops tiny blood cells called platelets from sticking together and forming dangerous clots inside your arteries) and clot prevention. 6. Lasix (a powerful water pill that removes excess fluid and salt from your body through increased urination) 40 mg by mouth two times a day for edema (when body tissues swell because of extra fluid trapped in them).7. Losartan Potassium (a blood pressure medication that prevents a hormone in your body from tightening your blood vessels) 25 mg one tablet by mouth one time a day for HTN (hypertension - high blood pressure). During an interview on 10/8/2025 at 12:03 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 wore slippers when leaving the facility. CNA 1 stated Resident 1 was given a form by LVN 1 to sign out of the facility and Resident 1 left the facility approximately at 12:50 PM on 10/7/2025. CNA 1 stated Resident 1 did not return by the time her (CNA 1) shift ended (approximately 3 pm on 10/7/2025) and would be concerned if any resident (in general) did not return to the facility on the same day. During a concurrent interview and record review on 10/9/2025 at 1:02 PM with LVN 2, Resident 1's care plans were reviewed. LVN 2 stated Resident 1 did not have a care plan for going out on pass. During a concurrent interview and record review on 10/9/2025 at 1:02 PM with LVN 2, the facility's policy and procedure (P&P), titled Out on Pass Policy and Procedure dated 4/2024 was reviewed. LVN 2 reviewed the policy and stated she (LVN 1) could not find an IDT assessment for Resident 1. LVN 1 stated the facility did not follow their Out on Pass Policy and Procedure and the facility should have done an IDT assessment according to the facility's P&P. LVN 2 stated the facility should have followed their P&P. During an interview on 10/9/2025 at 1:44 PM with LVN 3, LVN 3 stated he (LVN 3) was worried Resident 1 did not return after he (LVN 3) called Resident 1's daughter approximately 7 PM on 10/7/2025. LVN 3 stated he notified RN 3. LVN 3 stated RN 3 notified the facility's administrator that Resident 1 had not returned to the facility on [DATE]. LVN 3 stated he was given report from the previous shift and was informed Resident 1 had a habit of coming back late. During an interview on 10/9/2025 at 1:44 PM with RN 2, RN 2 stated she waited until the morning of 10/8/2025 before following up on Resident 1's whereabouts because Resident 1 was out on pass. RN 2 refused to answer if she (RN 2) followed the facility's policy for elopement. RN 2 stated she opted to wait until morning on 10/8/2025 to endorse to the next shift (7 AM to 3 PM shift) that Resident 1 had not returned to the facility. During a concurrent interview and record review on 10/9/2025 at 1:57 PM with RN 1, Resident 1's Care Plan Report dated 6/12/2025, RN 1 stated the facility did not create a care plan for Resident 1 for going out on pass. RN 1 stated Resident 1 should have been considered missing if Resident 1 had gone out on pass and did not return any of the facility's calls. RN 1 stated based on facility policy, the facility should have searched for Resident 1 if the staff could not locate the resident at the facility. RN 1 stated if not able to reach the resident the police, Ombudsman, and CDPH should have been called, and an unusual occurrence documented. RN 1 stated the facility did not follow their policy for Resident 1 to go out on pass because they did not perform an IDT meeting to assess Resident 1's safety and ability to go out on pass. RN 1 stated the facility did not follow their policy regarding looking for a missing resident. RN 1 stated Resident 1 could have had an accident and poor health because Resident 1 was not taking his medication. During an interview on 10/9/2025 at 2:51 PM with the facility's Social Services Director (SSD), the SSD stated she was not asked to participate in an IDT prior to going out on pass. The SSD stated Resident 1 went to an auction and purchased a car. The SSD stated Resident 1 possibly used the car to leave the facility. During an interview on 10/9/2025 with RN 3, RN 3 stated she thought Resident 1 would return from out on pass on 10/7/2025 since he came back late (after 8 PM) the day prior (10/6/2025). RN 3 stated she (RN 3) notified the facility's Director of Nursing (DON) and Administrator (ADM)when Resident 1 did not return around 11 PM on 10/7/2025. RN 3 stated she did not receive any additional instructions from the DON and ADM. During an interview on 10/9/2025 at 3:44 PM with the DON and ADM, the ADM stated a resident would be considered as missing if the resident did not return from out on pass after 24 hours. The DON stated she (DON) would consider a resident missing if the resident did not return after midnight. The ADM stated facility staff did not follow the facility's out on pass policy. The DON stated since a care plan was not created for Resident 1's out on pass, facility staff would not know when the resident was supposed to return. The DON stated the facility should have called the police, notified the Ombudsman, and CDPH when Resident 1 did not return after midnight. The ADM stated she contacted the facility at 10:35 PM on 10/7/2025 and instructed the facility staff to contact Resident 1's doctor. The ADM stated she instructed RN 3 to text Resident 1. The ADM stated RN 3 informed the ADM the resident and resident's daughter were not responding. The ADM stated the lack of response should have been a red flag. The ADM stated Resident 1 did not have an agreed upon return time. The ADM confirmed by stating the facility did not provide Resident 1 with medications upon leaving the facility on 10/7/2025. The DON stated anything could happen to Resident 1 while out on pass. The ADM stated Resident 1 could have gotten into an accident. The ADM stated she (ADM) could not guarantee Resident 1 was safe after not returning to the facility. During a concurrent interview and record review on 10/9/2025 at 3:44 PM with the DON, Resident 1's Medication Administration Record dated 10/9/2025 (MAR - a logbook, either on paper or a computer, that healthcare staff uses to track all the medicines a patient has been given) was reviewed. The DON stated Resident 1 did not receive Carvedilol 6.25 mg on 10/7/2025 at 5 PM because Resident 1 was out on pass. The DON stated Resident 1 should have been given Carvedilol 6.25 mg on 10/7/2025 at 5 PM because Resident 1 could have had a heart issue without the medication. During a telephone interview on 10/10/2025 at 11:13 AM with the Hospice Doctor (HD), the HD stated he was the Medical Director for Resident 1's hospice and was Resident 1's hospice doctor. The HD stated he could not recall 100 % giving the order for Resident 1 to go out on pass. The HD stated Resident 1 had 6 months to live due to heart failure issues. The HD stated he (HD) was not aware Resident 1 had an out on pass order and would not have allowed Resident 1 to go out independently (by himself) and should have been accompanied by a responsible party (the person responsible for Resident 1). The HD stated the facility did not inform him (HD) Resident 1 had a car or could drive himself. The HD stated he did not know Resident 1 was independent. The HD stated the facility did not invite HD to participate in an IDT meeting. The HD stated Resident 1 should not have been allowed to be out on pass for longer than four hours and should have gone out with a responsible party. The HD stated he would never place an order for out on pass without a specified time for return. During a follow up telephone interview on 10/10/2025 at 11:22 AM with the HD, the HD called to say Resident 1 was supposed to be out on pass with a family member. During a review of the facility's policy and procedures (P&P) titled Elopement Policy & Procedure with a review date of 1/2025, the policy indicated It is the responsibility of the staff to initiate a search as soon as any resident is noted to be missing. The policy indicated: A. The resident/responsible person is encouraged to give the Facility reasonable notice when anticipating going out on pass.B. The resident/responsible person will verbally notify a Licensed Nurse prior to going out on pass and will sign out on Resident Out on Pass Log. C. The resident/responsible person will return to the Facility at the agreed upon time, or else notify the Facility of any unexpected delay in return to the Facility. D. The resident/responsible person will report any unusual occurrence that took place during the out on pass period. During a review of the facility's P&P titled Out on Pass Policy and Procedure with an update date of 4/2024, the policy indicated When a resident requests to go out on pass, the interdisciplinary Team (IDT) will assess the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The IDT assessment will be documented in the IDT notes. The policy indicated The Attending Physician and Psychiatrist (if applicable) will review the IDT's assessment and evaluate the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The policy indicated The Attending Physician's order should indicate whether the resident needs to be accompanied by a responsible person while out on pass. The resident must be accompanied by a responsible person when leaving the Facility unless the Attending Physician determines that the resident is capable of being on an independent pass. During a review of the facility's P&P titled Physician orders and Telephone Orders with a review date of 1/2025, the policy indicated All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order.

Based on interview and record review the facility failed to follow its policy and procedures (P&P), titled Out on Pass Policy and Procedure dated 4/2024 and P&P titled Physician orders and Telephone Orders with a review date of 1/2025, for one of three sampled residents (Resident 1) allowed to go out on pass (temporary leave for a non-medical reason, such as a family visit or holiday meal). By failing to ensure: 1. Resident 1's physician completed a medical evaluation of a resident's condition and reviewed the appropriateness of the resident's ability to safely leave the facility unsupervised and without direct access to facility staff. This failure resulted in Resident 1 leaving the facility unsupervised on 10/7/2025 at 12:50 PM and eloping (aka elopement: a patient or resident leaving a healthcare facility without permission and without being properly discharged ) from the facility. Placing the resident at risk for worsening medical conditions, delayed care, being assaulted, accidents, injuries, and even death. Cross Reference: F689 During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses that included end stage heart failure (when the heart is so weak that it can no longer pump enough blood for the body's needs, even with treatment), dilated cardiomyopathy (a condition where the heart's main pumping chamber becomes enlarged, stretched, and weakened, making it harder to pump blood effectively, chronic kidney disease stage 2 (kidneys have mild damage and are working less effectively than they should, but are still filtering blood), patient's non-compliance (does not follow the rules) with medical treatment and regimen (plan) due to unspecified reason, acute pulmonary edema (when fluid suddenly builds up in the lungs, making it very difficult to breathe), cocaine (a highly addictive drug that makes a person feel intensely energetic and euphoric [an intense sense of happiness, excitement, and well-being] for a short period of time) abuse, and that the resident was on hospice (care for people nearing the end of life that focuses on comfort, pain management, and quality of life rather than on curing the disease). During a review of Resident 1's Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) Report dated 6/12/2025, the Care Plan Report indicated Resident 1 was a risk for elopement and falls. The Care Plan Report Indicated the facility staff was to monitor Resident 1's where abouts frequently, document Resident 1's wandering behavior in the facility's behavior log (a record of a resident's health information), and attempt diversional activity (any pleasant, engaging activity that distracts a patient from their pain, boredom, or anxiety). During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 9/7/2025, the H&P indicated Resident 1 had the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool), dated 9/15/2025, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. 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 completes activity) to walk 10 feet, for toileting, oral hygiene (brushing teeth and mouth care), and for eating. The MDS indicated Resident 1 required moderate to partial assistance (helper does less than half the effort and helps the resident lift, hold, or support themselves) for showering/bathing, putting on shoes/socks, personal hygiene (shaving, washing/drying face and hands), and for tub/shower transfer (ability to get in and out of a tub/shower). During a review of Resident 1's Progress Notes dated 10/6/2025 at 1:07 PM, the Progress Notes indicated Resident 1 went out on pass (10/7/2025 at 12:50 PM). During a review of Resident 1's Progress Notes for 10/7/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 7:33 PM, 10:08 PM couple of times, and at 11:01 PM. During a review of Resident 1's Progress Notes for 10/8/2025, indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 12:02 AM (2 attempts), 3:11 AM (2 attempts), 9:09 AM, and at 2:31 PM, the Progress Notes indicated the Social Services Director (SSD) had been trying to reach Resident 1 since 10/7/2025 at 3:07 pm. During a review of Resident 1's Progress Notes for 10/9/2025 at 9:08 AM, the progress notes indicated the resident had not yet returned to the facility and facility staff attempted to contact the resident without success at 9:08 AM (3 attempts). During a review of Resident 1's Order Summary Report, dated 10/9/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass starting 10/1/2025. The Order Summary Report indicated Resident 1 had orders for the following medications:1. Amiodarone (medication used to get a dangerously fast or irregular heartbeat back into a [NAME]) 200 mg milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) one tablet one time a day for arrythmia (irregular or abnormal heartbeat).2. Aspirin 81 mg chewable tablet one tablet by mouth for clot (a clump of blood that forms to stop bleeding) prevention.3. Atorvastatin (a medicine that helps lower high cholesterol) 80 mg one tablet by mouth at bedtime for hyperlipidemia (a medical condition where there are abnormally high levels of lipids [fats], such as cholesterol and triglycerides, in the blood), prevent heart attack4. Carvedilol (medication that helps reduce stress on your heart by slowing your heart rate and relaxing your blood vessels) 6.25 mg one tablet by mouth two times a day.5. Clopidogrel (blood thinner that prevents platelets, which are tiny blood cells, from clumping together to form a dangerous clot) 75 mg one tablet by mouth one time a day for inhibitor platelet (medication that stops tiny blood cells called platelets from sticking together and forming dangerous clots inside your arteries) and clot prevention. 6. Lasix (a powerful water pill that removes excess fluid and salt from your body through increased urination) 40 mg by mouth two times a day for edema (when body tissues swell because of extra fluid trapped in them).7. Losartan Potassium (a blood pressure medication that prevents a hormone in your body from tightening your blood vessels) 25 mg one tablet by mouth one time a day for HTN (hypertension - high blood pressure). During a concurrent interview and record review on 10/9/2025 at 1:02 PM with LVN 2, the facility's policy and procedure (P&P), titled Out on Pass Policy and Procedure dated 4/2024 was reviewed. LVN 1 stated she (LVN 1) could not find an IDT assessment for Resident 1. LVN 1 stated the facility did not follow their Out on Pass Policy and Procedure and the facility should have done an IDT assessment according to the facility's P&P. LVN 2 stated the facility should have followed their P&P. During a concurrent interview and record review on 10/9/2025 at 1:57 PM with RN 1, RN 1 stated the facility did not follow their policy for Resident 1 to go out on pass because they did not perform an IDT meeting to assess Resident 1's safety and ability to go out on pass. RN 1 stated the facility did not follow their policy regarding the facility looking for a missing resident. RN 1 stated Resident 1 could have an accident and could have poor health because Resident 1 was not taking his medication. During an interview on 10/9/2025 at 3:44 PM with the DON and ADM, the ADM stated a resident would be considered as missing if the resident did not return from out on pass after 24 hours. The DON stated she (DON) would consider a resident missing if the resident did not return after midnight. The ADM stated facility staff did not follow the facility's out on pass policy. The DON stated since a care plan was not created for Resident 1's out on pass. The ADM stated Resident 1 did not have an agreed upon return time. The ADM confirmed by stating the facility did not provide Resident 1 with medications upon leaving the facility on 10/7/2025. The DON stated anything could happen to Resident 1 while out on pass. The ADM stated Resident 1 could have gotten into an accident. The ADM stated she (ADM) could not guarantee Resident 1 was safe after not returning to the facility. During an interview on 10/10/2025 at 11:46 AM with RN 1, RN 1 stated he was not sure what the facility's policy for going out on pass was. RN 1 stated the facility allowed residents (in general) to go out on leave independently (by themselves). RN 1 stated he placed the order may go out on pass on 10/1/2025 for Resident 1. RN 1 stated the order he placed for may go out on pass for Resident 1 was not clear. RN 1 stated he (RN 1) did not clarify the may go out on pass order, the order was vague and put Resident 1 at jeopardy (risk) because there was no agreed upon time for Resident 1 to return to the facility after going out on pass. RN 1 stated the facility did not follow their out on pass policy because the facility did not conduct an IDT meeting before allowing Resident 1 to go out on pass by himself. During a telephone interview on 10/10/2025 at 11:13 AM with the Hospice Doctor (HD), the HD stated he was the Medical Director for Resident 1's hospice and was Resident 1's hospice doctor. The HD stated he could not recall 100 % giving the order for Resident 1 to go out on pass. The HD stated Resident 1 had 6 months to live due to heart failure issues. The HD stated he (HD) was not aware Resident 1 had an out on pass order and would not have allowed Resident 1 to go out independently (by himself) and should have been accompanied by a responsible party (the person responsible for Resident 1). The HD stated the facility did not inform him (HD) Resident 1 had a car or could drive himself. The HD stated he did not know Resident 1 was independent. The HD stated the facility did not invite HD to participate in an IDT meeting. The HD stated Resident 1 should not have been allowed to be out on pass for longer than four hours and should have gone out with a responsible party. The HD stated he would never place an order for out on pass without a specified time for return. During a follow up telephone interview on 10/10/2025 at 11:22 AM with the HD, the HD called to say Resident 1 was supposed to be out on pass with a family member. During a review of the facility's P&P titled Out on Pass Policy and Procedure with an update date of 4/2024, the policy indicated When a resident requests to go out on pass, the interdisciplinary Team (IDT) will assess the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The IDT assessment will be documented in the IDT notes. The policy indicated The Attending Physician and Psychiatrist (if applicable) will review the IDT's assessment and evaluate the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The policy indicated The Attending Physician's order should indicate whether the resident needs to be accompanied by a responsible person while out on pass. The resident must be accompanied by a responsible person when leaving the Facility unless the Attending Physician determines that the resident is capable of being on an independent pass. During a review of the facility's P&P titled Physician orders and Telephone Orders with a review date of 1/2025, the policy indicated All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1) who was confused, had a diagnosis of dementia (a progressive state of decline in mental abilities), and had a history of falls, did not elope (the act of leaving a facility unsupervised and without prior authorization) the facility on 8/20/2025 at approximately 3:45 AM by failing to: -Ensure Registered Nurse 1 (RN1) and other licensed nurses (in general) identified and assessed Resident 1 as a high risk for elopement. -Ensure RN2, Licensed Vocational Nurse3 (LVN3), and LVN2 supervised Resident 1 when Resident 1 tried to leave the facility on 8/20/2025 at 3:20 AM. -Ensure RN supervisors (in general) ensured the facility's door alarms were enabled (on) as indicated in the facility's Audible (able to be heard) Battery-Operated Door Alarm policy and procedure (P&P). On approximately 8/20/2025 at 3:20 AM, RN2 and LVN3 noticed Resident 1 tried to leave the facility and redirected Resident 1 to Resident 1's room. On 8/20/2025 at approximately 3:45 AM, Certified Nursing Assistant 8 (CNA 8) reported to LVN2 Resident 1 disappeared, from the facility. On 8/20/2025 at 4:28 AM, the Emergency Medical Services (EMS-professionals who provide emergency care to people who require medical attention outside of a hospital) arrived with Resident 1 by an ambulance from a public area (unidentified) to the General Acute Care Hospital (GACH) with complaints of unsteady (not firm) gait (how a person walks), left knee pain, and unable to ambulate (walk) witnessed by bystanders (unidentified). The GACH admitted Resident 1 for evaluation of unsteady gait and confusion. These failures resulted in Resident 1's elopement on 8/20/2025 at approximately 3:45 AM, was at high risk for falls, serious harm, and the GACH admitted Resident 1 for evaluation of unsteady gait and confusion. On 8/21/2025 at 5:33 PM, the California Department of Public Health (CDPH, the Department) called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Chief Operating Officer (COO), the Administrator (ADM), and the Director of Nursing (DON) related to the failure to ensure Resident 1 did not elope from the facility on 8/20/2025 at approximately 3:45 AM and was at high risk for falls and serious harm, and placed other residents (Resident 2, Resident 3, Resident 4, and Resident 7) at risk for elopement. On 8/23/2025 at 2:51 PM, the facility provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ). While onsite at the facility, the surveyor verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record review, and determined the IJ situation regarding Resident 1's elopement was no longer present. The surveyor removed the IJ on 8/23/2025 at 3:44 PM in the presence of the ADM, the DON, the Director of Staff Development (DSD), the Infection Preventionist nurse (IP, a healthcare professional who make sure healthcare workers and patients are doing all the things they should to prevent infections), the Social Services Director (SSD), the Minimum Data Set Nurse (MDS Nurse - a nurse to documents using the resident assessment tool), the Social Service Assistant, and the Maintenance Supervisor (MS). The acceptable IJRP included the following summarized actions: On 8/21/2025, the facility readmitted Resident 1 and the admitting nurse (unidentified) updated Resident 1's elopement assessment and diagnoses. The elopement assessment indicated Resident 1 was at high-risk for elopement and the facility placed Resident 1 with one CNA (unidentified) at all times. On 8/21/2025, the DSD provided an in-service regarding elopement prevention and response to fifty-five staff(unidentified) with a plan for the DSD to perform in-services for staff who were on vacation, off schedule, and for new hires. On 8/21/2025, the MDS nurse and the facility's Medical Records (MR) staff identified four residents who were at high-risk for elopement. The facility ensured the care plans and assessments were in place for the four residents. On 8/22/2025, the facility updated Resident 1's care plan to include Resident 1 was at risk for elopement and had a history of elopement. On 8/22/2025, an emergency Quality Assurance and Performance Improvement (QAPI, a program that healthcare providers use to constantly check and improve the quality of their services) meeting was held with the facility's Medical Director, Department Heads (leaders of a specific group of people within a company, who makes sure that team's work gets done smoothly and on time), and the Administrator Consultant (ADMC) to address the facility's systemic issues (the problems with the facility's systems) on elopement. On 8/22/2025, the ADMC and the ADM updated the Audible Battery-Operated Door Alarms Policy and Procedure (P&P). On 8/22/2025, the ADMC provided an in-service to thirty-nine staff including licensed nurses, CNAs, dietary, and housekeeping staff on the Audible Battery-Operated Door Alams P&P to ensure staff were aware of the times the door alarms were to be activated. The facility planned for the DSD or designee (someone who has been officially chosen) to provide an in-service for staff on vacation before the start of the staff's first shift back from vacation. The facility planned to in-service new hires before the first scheduled shift. Current staff, who were not on schedule, would be in-serviced before the start of their first shift back on schedule. On 8/22/2025, the facility created an elopement binder with a list of residents who were at high-risk for elopement and placed the binder in each nursing station. On 8/22/2025, the DON provided a one-on-one in-service to Registered Nurse 1 (RN 1) on the Elopement Prevention and Audible Alarm policies. On 8/22/2025, the DON provided a one-on-one in-service to Registered Nurse 2 (RN 2) regarding elopement prevention.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/4/2025 and readmitted the resident on 8/21/2025 with diagnoses that included dementia, weakness, hypertension (HTN-high blood pressure), and history of falling. During a review of Resident 1's Risk of Elopement assessment dated [DATE], the Risk of Elopement Assessment indicated RN1 completed the assessment. The Risk of Elopement Assessment indicated Resident 1 was not at risk for elopement. The Risk of Elopement Assessment indicated Resident 1 was ambulatory (able to walk). The Risk of Elopement Assessment indicated Resident 1 did not have any indications of a diagnosis of dementia. The Risk of Elopement Assessment indicated if Resident 1 was ambulatory and had a diagnosis of dementia, the facility was supposed to initiate (start) a care plan for potential elopement. During a review of Resident 1's Care Plan Report dated 7/4/2025, the Care Plan Report indicated Resident 1 was at risk for falls related to the history of falls, dementia, general weakness, and hospice (care for people who are nearing the end-of-life prioritizing comfort and quality of life by reducing pain and suffering). The Care Plan Report indicated the intervention was to implement fall precautions (unidentified). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/10/2025, the MDS indicated Resident 1 usually could make himself understood and had the ability to understand others. The MDS indicated Resident 1's had severe cognitive (ability to think and process information) impairment (loss). During a review of Resident 1's History and Physical (H&P) dated 7/27/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. During a review of Resident 1's Emergency Department (ED) GACH note dated 8/20/2025 at 4:28 AM, the ED GACH note indicated the EMS arrived with Resident 1 from a public area (unidentified) with complaints of unsteady gait, unable to ambulate, and left knee pain, witnessed by bystanders (unidentified). During a review of Resident 1's Progress Notes dated 8/20/2025 at 5 AM, the Progress Notes (documented by LVN2) indicated Resident 1 woke up around 2:40 AM. The Progress Notes indicated at 3:20 AM a charge nurse (LVN 3) found out that Resident 1 tried to go out (unidentified) and he (LVN3) called him (LVN2) to put Resident 1 in Resident 1's room. The Progress Notes indicated RN2 and LVN 2 gave Resident 1 emotional support. The Progress Notes indicated at 3:45 AM a CNA (CNA8) found that Resident 1 had disappeared. The Progress Notes indicated all nurses (unidentified), and CNAs (unidentified) could not find Resident 1 inside or outside the facility. During a review of Resident 1's ED note dated 8/20/2025 at 7:28 AM, the ED note indicated Resident 1 presented to the emergency room with the EMS for evaluation of unsteady gait and confusion. The ED note indicated Resident 1 was found next to a car in a standing position and no other information was known. The ED note indicated Resident 1 was unable to give any additional informationDuring a review of Resident 1's Progress Notes dated 8/20/2025 at 9:32 AM, the Progress Notes indicated the facility received a report from the local police department that Resident 1 was found at the GACH. During a review of Resident 1's Progress Notes dated 8/20/2025 at 10 AM, the Progress Note indicated the facility was able to verify Resident 1 was brought to the GACH via emergency services and the GACH planned to admit Resident 1 to the GACH. During an interview on 8/20/2025 at 1:11 PM with the GACH emergency room (ER ) Registered Nurse (ERRN), the ERRN stated Resident 1 was admitted to the GACH due to a mental status change (when a person's thinking, awareness, or behavior suddenly shifts from their normal state, often described as being confused, disoriented, agitated, or having trouble focusing). During an interview on 8/20/2025 at 3:40 PM with CNA 1, CNA 1 stated Resident 1 would attempt to leave the facility in general (unidentified date and time) and that she (CNA1) notified LVN 1. During a concurrent interview and record review on 8/20/2025 at 3:45 PM with LVN 1 and RN 5, Resident 1's Risk of Elopement dated 7/4/2025 was reviewed. LVN 1 and RN 5 stated Resident 1 had a diagnosis of dementia, and the licensed nurse (RN1) should have identified Resident 1 as a risk for elopement. During a concurrent interview and record review on 8/20/2025 at 4:25 PM with the ADM and the DON, the facility's admission Inquiry form (medical history prior to the facility's admission), dated 7/2/2025 was reviewed. The ADM and DON stated the admission Inquiry form indicated Resident 1 had dementia. The ADM and DON stated the nurse (RN 1) who performed the Risk of Elopement should have identified Resident 1 as an elopement risk. During an interview on 8/20/2025 at 4:42 PM with LVN 2, LVN 2 stated Resident 1 tried to get out of bed on the night of his (Resident 1) elopement (8/20/2025). LVN 2 stated the other charge nurse (unidentified) whose name he (LVN2) did not know, noticed Resident 1 tried to leave the facility. LVN 2 stated a CNA whose name LVN 2 did not know, and a charge nurse whose name LVN 2 did not know, took Resident 1 back to Resident 1's room. LVN 2 stated 30 minutes later the staff (unidentified) could not locate Resident 1. LVN 2 stated he (LVN2) did not hear any door alarms go off. During an interview on 8/20/2025 at 4:46 PM with RN 2, RN 2 stated she (RN2) redirected Resident 1 and LVN 3 brought Resident 1 back to his bed in the early morning of 8/20/2025. RN 2 stated 15 minutes later the facility staff (unidentified) could not locate Resident 1. RN 2 stated she (RN2) could not explain why the alarms did not sound on the morning of 8/20/2025 and Resident 1 eloped from the facility. During an observation on 8/21/2025 at 5:50 AM, CNA3 was observed sitting in front of a room next to one of the exits to the front of the facility. The surveyor knocked and CNA 3 came to the front exit/entrance to the facility facing a street avenue and opened the door from the inside and the door alarm did not sound. There were no staff observed at the front desk. During a concurrent observation and interview on 8/21/2025 at 5:52 AM, with RN 1 and CNA 4, the facility's front door entrance/exit facing a street avenue did not sound. RN 1 stated she (RN1) disarmed the front door entrance/exit at 4 am because the housekeeping staff (unidentified) came in at 4 AM. RN 1 stated the facility would disarm (turn off) the alarm in the front door entrance/exit for a long time, (RN 1 could not give a specific timeframe). Station 1 exit door was open, and the alarm did not sound. RN 1 stated she (RN 1) left station 1 exit door unarmed to let the housekeeping staff (unidentified) inside. RN 1 stated if the front door was not armed, a resident (in general) could leave the facility without the staff (in general) knowing. RN 1 stated the facility's policy (unidentified) allowed her (RN1) to disarm the alarms (in general) at 4 am to let the housekeeping staff inside the facility. During a concurrent interview and record review on 8/21/2025 at 5:52 AM, with RN 1, the facility's policy and procedure (P&P) Audible Battery Operated Door Alarms, dated 1/2023, RN1 stated the P&P indicated the front door alarm should be armed from 10 PM to 7 AM. RN 1 stated the front door was not armed because staff (in general) would go in and out of the facility. During an observation on 8/21/2025 at 5:55 AM, the front door alarm did not sound when the surveyor opened the door. During an observation on 8/21/2025 at 5:57 AM, the station 1 back exit door was wide open without an alarm sound. During an interview on 8/21/2025 at 6:50 AM with CNA 4, CNA 4 stated the RN Supervisors (in general) would disarm the alarms for station 1 back door and the front lobby door alarms around 4 am to let housekeeping staff (in general) inside the facility. CNA 4 stated RN 2 would disarm the alarms around 4 am. During an interview on 8/21/2025 at 7 AM with CNA 5, CNA 6, and the Laundry Aid (LA), CNA 5, CNA 6, and LA, they all stated that the night RN Supervisors (in general) would disarm the facility's alarms (in general). During an interview on 8/21/2025 at 7:05 AM with Housekeeper 1 (HK 1), HK 2, and HK 3, HK 1, HK 2, and HK 3 they all stated the night RN Supervisor (in general) would disarm the alarms (in general) in the early morning to let them (housekeeping staff) into the facility. During an interview on 8/21/2025 at 7:20 AM with the IP, the IP stated he (IP) did not know why the doors were not armed on 8/20/2025 in reference to Resident 1's elopement. During an interview on 8/21/2025 at 9:02 AM with Resident 1's Power of Attorney 1 (POA 1 - a legal document where a trusted person makes healthcare decisions for you if you become unable to make them yourself), POA1 stated Resident 1 had a history of trying to elope from two previous GACHs (unidentified) on two previous occasions. The POA1 stated Resident 1 was very good at escaping. POA 1 stated Resident 1 lived alone and could no longer take care of himself (Resident 1). POA 1 stated the facility did not ask him (POA 1) about Resident 1's history of attempting to elope. During a concurrent interview and record review on 8/21/2025 at 12:05 PM with RN 3, DON, and the ADM, Resident 1's all care plans (in general) were reviewed. RN 3 and the DON stated there was no care plan for elopement for Resident 1. During an interview on 8/21/2025 at 3:44 PM with the ADM, the ADM stated Resident 1 eloped from the facility on 8/20/2025 at 3:45 AM. During an interview on 8/21/2025 at 4:27 PM with the ADM, the ADM stated CNA 8 reported Resident 1went missing from the facility on the morning of 8/20/2025. During a review of the facility's Audible Battery-Operated Door Alarm P&P dated 1/2023, the P&P indicated the facility provides a safe environment for all staff and residents. The P&P indicated the RN supervisor on duty was responsible for ensuring the alarms are enabled. The P&P indicated the nursing staff should be notified if the alarms are not working and to check on resident's who are at high risk for elopement frequently. During a review of the facility's Elopement P&P dated 1/2025, the P&P indicated impaired (decreased) judgment (mental abilities that help a person understand and decide on something), perception (awareness), and thought processes of cognitively impaired persons make the residents at high risk for elopement. The P&P indicated precautions, procedures (unidentified) and staff and visitor education have been put into place to maximize resident safety. The P&P did not indicate how to prevent an elopement.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely monitored (constant observation) to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force). The facility was aware that Resident 1 was confused (is the inability to think as clearly or quickly as you normally do), legally blind (severe vision loss), at high risk for falls, at risk for elopement (leaving a facility unsupervised and unnoticed), restless (feeling uneasy, agitated, or unable to relax or stay still), and was unable to sit still. As a result, Resident 1 had a fall witnessed by Resident 2 (unidentified date and time) that resulted for Resident 1 to sustain a left hip fracture (broken bone). On 7/22/2025 at 11:30 PM, Resident 1 was transported to the General Acute Care Hospital (GACH) where Resident 1 was admitted and underwent a left femur (thighbone) intramedullary (inside of a bone) rodding (bones or bone fragments are repositioned into their normal positions) surgery with general anesthesia (a temporary loss of feeling and complete loss of awareness that feels like a very deep sleep).Findings: During a review of Resident 1's admission Record, the admission Record indicted the facility admitted Resident 1 on 5/15/2025 with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, dementia (a progressive state of decline in mental abilities), other abnormalities of gait (your pattern of walking) and mobility (the ability to move), abnormal posture (the way you hold your body), age-related osteoporosis (a condition in which bones become weak and brittle), vitamin D deficiency (when the body does not have enough vitamin D and primarily causes issues with your bones and muscles), and sensorineural hearing loss (when the inner ear or the nerve connecting the ear to the brain is damaged, making it hard to hear clearly) bilateral (both ears/sides). During a review of Resident 1's Fall Risk Assessment (a tool to figure out how likely someone is to fall, especially for older adults) dated 5/15/2025, the Fall Risk Assessment indicated Resident 1 was legally blind and at high risk for falls. The Fall Risk Assessment indicated Resident 1 was disoriented (confused) at all times to name, place, and time and had balance (being able to stay upright and/or steady) problems while standing and while walking. The Fall Risk Assessment indicated to provide frequent visual monitoring (monitor by watching) and to anticipate (expecting something to happen and often to prepare for it in advance) needs in a timely manner. During a review of Resident 1's Care Plan Report (a structured and individualized document that spells out how a facility will meet a resident's health or personal care needs), dated 5/15/2025, the Care Plan Report indicated Resident 1 was at risk for fall related to Alzheimer's, dementia, and legally blind. The Care Plan Report indicated the goal was to minimize (limit) the occurrence (something that happens or takes place) of falls and /or injury for Resident 1. The Care Plan Report indicated the nursing interventions (an action taken to prevent, treat, or manage a health problem) were to provide Resident 1 with a safe environment, bilateral (both sides) floor mat (cushioned pad you put on the floor next to a bed in case someone falls to reduce the chance of injury), keep the call light (a device used by a patient to signal his or her need for assistance) within Resident 1's reach and answer the call light promptly (with no delay), and place Resident 1's bed in the low position. During a review of Resident 1's Physical Therapy notes dated 5/15/2025, the Physical Therapy notes indicated Resident 1 needed maximum assistance (the individual receiving care can participate in a task or activity, but requires significant assistance from a caregiver or therapist, typically performing only 25% or less of the work according to healthcare resources) to walk 25 feet (take steps for a distance of 25 feet in a straight line). The Physical Therapy notes indicated Resident 1 had balance deficits (having trouble staying steady on your feet). During a review of Resident 1's Care Plan Report dated 5/16/2025, the Care Plan Report indicated Resident 1 was at risk for elopement risk as evidenced by impaired cognition (someone has difficulty with thinking, learning, remembering, or making decisions), memory impairment (problems with remembering things). The Care Plan Report indicated Resident 1 would ambulate (walk) with assistance, and used medication that could cause confusion and disorientation (lack of awareness). The Care Plan Report indicated the nursing intervention was to monitor Resident 1's location (whereabouts) every __ (blank) min (minute). The Care Plan Report indicated to document wandering (move about aimlessly or without any destination) behavior and attempted diversional interventions (refers to the use of recreational and leisure activities to help patients cope with their medical conditions) in behavior log. The Care Plan Report indicated the nursing intervention was to provide Resident 1 with assistance during ambulation (the ability to walk or move from place to place). The Care Plan Report indicated the goal was to maintain Resident 1's safety. During a review of Resident 1's Interdisciplinary Team Conference Record (IDT - refers to a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care) notes dated 5/16/2025, the IDT Conference Record indicated Resident 1 needed maximum assistance with activities of daily living (ADLs - basic self-care tasks needed to take care of oneself), was a fall risk, and was educated to use call lights. During a review of Resident 1's Order Summary Report dated 5/16/2025, indicated for Resident 1 to have bilateral floor mats. During a review of Resident 1's History and Physical (H&P - comprehensive document that records a resident's medical history and a detailed physical examination performed by a health care professional) dated 5/17/2025, the H&P indicated Resident 1 had fluctuating (changed frequently) capacity (person's ability to understand information and make decisions can change from day to day, or even hour to hour) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/21/2025, the MDS Resident 1 had severe cognitive (reasoning) impairment. The MDS indicated Resident 1 needed substantial (at lot)/maximal (maximum) assistance with toileting (using the toilet). The MDS indicated Resident 1 was dependent (someone does all the effort) for showering/bathing. The MDS indicated Resident 1 needed substantial (extensive)/maximal assistance to walk ten feet (a unit of measure) to go from a sitting to standing position, and to transfer from chair/bed to chair. The MDS indicated Resident 1 needed partial/moderate assistance to go from sitting to lying position and to go from lying to sitting on the side of the bed. The MDS indicated Resident 1 did not have a fall prior to admission. During a review of Resident 1's Progress Notes dated 7/15/2025 at 11:44 PM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another (unidentified), standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to sit still, unable to calm herself, disoriented and Resident 1 wanted to walk outside her (Resident 1's) room and unable to determine the time. During a review of Resident 1's Order Summary review dated 7/15/2025, indicated to monitor Resident 1 for restlessness/inability to sleep every shift. During a review of Resident 1's Progress Notes dated 7/17/2025 at 7:14 AM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another (unidentified), standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to sit still, unable to calm herself, disoriented, and Resident 1 wanted to walk outside her (Resident 1's) room and unable to determine time (documented the same as the Progress Notes dated 7/15/2025 at 11:44 PM). During a review of Resident 1's Medication Administration Record dated 7/17/2025 indicated Resident 1 did not have behaviors related to anxiety (nervousness) manifested by sleeplessness on all three shifts.During a review of Resident 1's Change in Condition (Situation Background Appearance Review, SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/22/2025 at 11:45 PM, the SBAR indicated Resident 1 complained of left hip pain, left knee pain, and left foot pain (pain levels unidentified). The SBAR indicated Resident 1 had a left hip x-ray (a medical scan to get pictures of the inside of your body) that showed a fracture (broken bone) of the acetabulum (a cup-shaped socket in the pelvis that forms the hip joint) and was transferred to the ED (emergency department). During a review of Resident 1's GACH Clinical Notes dated 7/26/2025, the Clinical Notes indicated Resident 1 had a mechanical fall (a type of fall that occurs due to an external, physical factor rather than an underlying medical condition) and sustained a left hip intertrochanteric fracture (refers to a break in the upper part of the thigh bone [femur]. The Clinical Notes indicated Resident 1 underwent under general anesthesia and had a left femur intramedullary rodding surgery. During a review of the facility's Summary of Investigation report dated 7/27/2025, the Summary of investigation report indicated Resident 2 could not recall the date when she (Resident 2) saw and witnessed Resident 1 fall from the bed to the floor. The Summary of Investigation report indicated the facility concluded Resident 1 had a fall witnessed by Resident 2. During an interview on 7/28/2025 at 11:15 AM with the Director of Nursing (DON) and the facility's Administrator (ADM), the DON and ADM stated Resident 1 was currently in the GACH. The DON and ADM stated Resident 1's bed was on hold and the facility would accept Resident 1 back once stable for discharge from the GACH. During an interview on 7/28/2025 at 11:54 AM with the General Acute Care Hospital Registered Nurse (GACHRN), the GACHRN stated Resident 1 was still in the general acute care hospital. The GACHRN stated Resident 1 had a left femur intermedullary rodding. The GACHRN stated Resident 1 was confused, and unable to be interviewed. The GACHRN stated Resident 1 would be discharging from the GACH back to the skilled nursing facility on 7/28/2025. During an interview on 7/28/2025 at 12:51 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA1) was familiar with Resident 1. CNA 1 stated Resident 1 was confused, sometimes combative (a display of aggression) and sometimes would get agitated (feeling restless, uneasy, or disturbed, often with a strong urge to move around or act out). CNA 1 stated Resident 1 was blind and was unable to use a call light. CNA 1 stated the certified nursing assistants (in general) were required to make rounds (when someone goes to check on a resident) to monitor the resident. CNA 1 stated she (CNA1) did not document when she (CNA1) would make rounds and could not provide proof when she (CNA1) would do her rounds on Resident 1. CNA 1 stated Resident 1 was totally dependent (a person needs complete help from another person to do all or most of their everyday tasks) on the with care. CNA 1 stated Resident 1 was not safe to get up out of bed by herself. During a phone interview on 7/29/2025 at 1:06 PM with Resident 1's Family Member 1 (FAM 1), FAM 1 stated Resident 1 was blind and hard of hearing. FAM 1 stated he (FAM1) thought there was a disconnect between staff members at the facility because he (FAM 1) stated when he communicated something to one staff member, he (FAM 1) felt what he (FAM 1) communicated was not passed along to other staff members (unidentified). FAM 1 stated he (FAM1) thought Resident 1 sustained her injury (fractured left hip) sometime between 7/21/2025 and 7/22/2025. FAM 1 stated the floor mats that were supposed to be placed around Resident 1's bed were not always present when he (FAM 1) would visit (unknown date) Resident 1. FAM 1 stated he (FAM 1) would sometimes noticed Resident 1's floor mats were placed up against the wall instead of around Resident 1's bed. During a concurrent interview and record review on 7/28/2025 at 1:19 PM with the Quality Assurance Nurse (QA - a nurse who works to make sure patients get the best and safest care possible), Resident 1's Care Plan Report dated 5/16/2025 was reviewed. The QA nurse stated Resident 1 was at risk for elopement and required assistance with ambulation. The QA nurse stated the Care Plan Report did not indicate how often the nursing staff (in general) needed to monitor Resident 1's location (whereabouts). The QA nurse stated the Care Plan Report indicated nursing interventions included to monitor Resident 1's location (whereabouts) every __ (blank) min. The QA nurse stated the licensed nurses (in general) needed to add an intervention that indicated how many minutes Resident 1's location should have been monitored instead of leaving the number of minutes blank. The QA nurse stated the facility did not have a tool for documenting Resident 1's locations. The QA nurse stated Resident 1 was blind and confused. The QA nurse stated she (QA nurse) could not produce any documentation that Resident 1 knew how to use her (Resident 1) call light. The QA nurse stated Resident 1's floor mats were sometimes removed by the cleaning/maintenance staff (unidentified) to clean the floor when Resident 1 was up in a chair or out of the room. The QA nurse stated she (QA nurse) could not say how long the floor mats were removed from around Resident 1's bed. The QA nurse stated she (QA nurse) could not explain why the facility's staff (in general) did not see Resident 1 go(by t out of her (Resident 1's) bed and fell even though Resident 1's room was directly in front of the nursing station. During an interview on 7/28/2025 at 1:42 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was confused, hard of hearing, and blind. LVN 1 stated Resident 1 did not have the ability to use her call light. LVN 1 stated that even if the staff (in general) would give Resident 1 the call light Resident 1 would not use the call light. LVN 1 stated she (LVN1) could not explain why the facility created a care plan for Resident 1 to use a call light when Resident 1 did not have the ability to use it (call light). LVN 1 stated Resident 1 had a history of trying to get out of bed by herself and required frequent(unspecified) monitoring. LVN 1 stated the facility placed Resident 1 close to the nursing station and she (LVN1) would look inside Resident 1's room but did not document when she (LVN 1) would monitor Resident 1. LVN 1 stated if the facility did not document interventions, there was no proof the facility was monitoring Resident 1. LVN1 stated Resident 2 told her (LVN1) that Resident 1 fell (unspecified date and time). During a phone interview on 7/28/2025 at 2:06 PM with Family Member 1 (FM 1) and Family Member 2 (FM 2), FM 1 stated he (FM1) witness Resident 1's floor mats were not on the floor and were against the wall while Resident 1 was in her room. FM 2 stated she (FM2) had some safety concerns. FM 2 stated when she (FM2) would visit (unknow dates) Resident 1, she (FAM2) would see Resident 1 left alone and did not see the facility staff (in general) making rounds for approximately (about) one hour. FM 2 stated Resident 1's privacy curtains were usually drawn (by unidentified staff) closed around the bed) and Resident 1 was hard to see when the privacy curtains were drawn. During an interview on 7/28/2025 at 2:21 PM with Registered Nurse 1 (RN 1), RN 1 stated the facility gave Resident 1 a call light because it was the facility's standard to place the call light beside her (Resident 1). RN 1 stated giving Resident 1 a call light when she (Resident 1) could not use one was not an effective intervention because Resident 1 had not used the call light. When asked for proof that staff (in general) made rounds on Resident 1, RN 1 stated the facility documented when adult briefs (disposable underwear) were changed for Resident 1. RN 1 stated that documentation of adult briefs was not the same as documentation of rounds being performed to monitor Resident 1 and could not provide documented proof rounds were made. RN 1 stated the facility considered using a bed alarm for Resident 1 but could not provide documented proof. During an interview on 7/28/2025 at 2:37 PM with Resident 2, Resident 2 stated she (Resident 2) could not remember when Resident 1 fell. Resident 2 stated she (Resident 2) saw Resident 1 fall and could not remember the date. Resident 2 preferred not to answer more questions. During an interview on 7/28/2025 at 3:50 PM with the facility's Physical Therapist (PT, is a healthcare provider who helps you improve how your body performs physical movements), the PT stated Resident 1 was at risk for falls due to her poor cognition, lack of balance deficit (difficulty staying steady on your feet), and lack of coordination. The PT stated Resident 1 was discharged from the physical therapy program and placed in the Restorative Nursing Assistant Program (RNA - specially trained certified nursing assistants [CNAs] who help residents in healthcare facilities regain or maintain their ability to perform daily tasks like bathing, dressing, and eating). During an interview on 7/28/2025 at 4 PM with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated when she (RNA 1) worked with Resident 1, she (RNA 1) required the assistance of another RNA while working with Resident 1 (unknown date) because Resident 1 was sometimes confused and resistive to therapy. RNA 1 stated the last time she worked with Resident 1 was on 7/22/2025 and reported to the charge nurse (unidentified) Resident 1 was resistive to therapy. RNA 1 stated the charge nurse (unidentified) medicated (unidentified medication) Resident 1. RNA 1 stated 40 minutes after the charge nurse (unidentified) medicated Resident 1, RNA 1 try to work with Resident 1 again but Resident 1 did not cooperate. During an interview on 7/28/2025 at 4:07PM with the Social Services Director (SSD), the SSD stated Resident 1 had dementia and was often disoriented and had to work with Resident 1's family (FM 1 and FM 2). During an interview on 7/28/2025 at 4:23 PM with the facility's ADM and DON, the ADM stated she (ADM) could not say if staff (in general) had a line of sight (unobstructed view when looking from one point to another) of Resident 1 when Resident 1's privacy curtain was drawn (by unidentified staff). The DON stated if Resident 1's floor mats were not on the floor; Resident 1 could fall and injure herself. The DON stated the licensed nurse's (in general) rounds were not documented by the facility. The DON stated giving a confused resident (in general) a call light and expecting them to use it was not prudent (sensible) because Resident 1 could not be taught to use it. The DON stated if the facility did not document the facility's monitoring of Resident 1's location, the facility did not have proof that the monitoring was done. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 1/2025, the P&P indicated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic (done or acting according to a fixed plan or system) evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e to try one or a few at a time, rather than many at once). The P&P indicated in conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis as applicable) to try to minimize serious consequences of falling. The P&P indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. During a review the facility's policy and procedure (P&P) titled Elopement Policy & Procedure, dated 1/2025, the P&P indicated the safety of all residents is the primary care standard at the facility. Impaired judgement, perception, and thought processes of cognitively impaired persons make the residents at a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures and staff and visitor education have been put into place to maximize resident safety. During a review of the facility policy and procedures (P&P), titled, Routine Resident Checks, revised 1/2025, the P&P indicated, Routine resident checks shall be made to assure that the resident's safety and well-being are maintained.1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least every 2 hours throughout each 24-hour shift.2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each checks. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.)

Based on interview and record review the facility failed to provide a safe environment for one of three sampled residents (Resident 1). The facility failed to: -Develop and implement a person-centered comprehensive Elopement (when a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave) care plan upon admission on 10/12/2022. -Ensure the door in Resident 1's room that led outside the facility had the alarm activated and in working condition. - Implement the facility policy titled, Audible Battery-Operated Door Alarms, to alert staff of all persons exiting the facility, and the policy Safety and Supervision of Residents, to identify risk factor of accident hazards. As a result, on 1/5/2023, at 4 a.m., Resident 1 eloped (leaving the facility without notice or permission) and was found by the police the same day, trying to break into a stranger's house. The police escorted Resident 1 to the general acute hospital (GACH 1) where Resident 1 complained of pain, was given pain medication and had a four centimeters (cm) laceration (deep cut or tear in the skin) on the left thigh requiring stitches. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on 10/12/2022 with diagnoses including schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), anxiety disorder, and generalized muscle weakness. A review of the Risk of Elopement assessment dated [DATE], indicated Resident 1 scored a two and did not have a risk for elopement. A review of the Physician's Order dated 10/13/2022 indicated Resident 1 received Seroquel (medication used to improve mood, thoughts, and behaviors for people with schizophrenia) 100 milligrams (mg) every 12 hours for schizophrenia, manifested by hearing disturbing voices. According to a review of the History and Physical dated 10/15/2022, Resident 1 had fluctuating capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/29/2022, indicated Resident 1 was oriented to year, month, and day. The MDS indicated Resident 1 needed supervision with bed mobility, transfer, eating, personal hygiene and limited assistance with dressing, toilet use and bathing. According to a review of the Audible Door Alarm Log dated 1/4/2023 and 1/5/2023, all the facility doors were activated and in working condition. A review of the Nursing Note dated 1/5/2023 at 4:50 a.m., indicated at 2 a.m., Resident 1 was in bed sleeping soundly and at 4 a.m., during rounds, Resident 1 was not in her bed and not in the restroom. The Nursing Note indicated the registered nurse supervisor and facility staff searched all rooms, restrooms and facility premises, nearby stores, and gas stations but were unable to locate Resident 1. The Nursing Note indicated at 4:30 a.m., the police, Resident 1's primary physician, the Director of Nursing (DON) and the Administrator (ADM) were all notified. A review of the Nurses Notes dated 1/5/2023 at 6:34 p.m. indicated Resident 1 was found at the GACH 1. During an interview on 1/6/23, at 10:51 a.m., Licensed Vocational Nurse (LVN) 1 stated during Resident 1's admission, the risk for elopement assessment indicated Resident 1 had a score of two, meaning Resident 1 had no risk for elopement. LVN 1 stated there was no care plan created because Resident 1 was not at risk for elopement. During an interview on 1/6/23 at 11:15 a.m., the Social Service Designee (SSD) stated she called several local hospitals on 1/5/2023 to find Resident 1. The SSD stated she called GACH 1 in the afternoon and was informed that an unidentified female fitting Resident 1's description had been admitted . The SSD stated she notified the ADM. During an interview on 1/6/2023 at 11:21 a.m., the ADM stated that on 1/5/2023 at 4 a.m., Resident 1 was missing, and the facility searched for Resident 1. The ADM stated the police found Resident 1 breaking into a stranger's property and took Resident 1 to GACH 1. The ADM stated she went to GACH 1 to identify the resident and Resident 1 would not talk about what happened. On 1/6/2023 at 11:33 a.m., during a telephone interview, the Registered Nurse Supervisor (RNS 1), stated Resident 1's room had a door with an alarm, the alarm was off, and Resident 1 exited through the door. RNS 1 stated the resident turned off the switch due to the alarms used by the facility were accessible by anyone. RNS 1 stated Resident 1 walked towards the facility gate which led to the parking lot and out to the community. RNS 1 further stated the gate also had an alarm that would emit a sound once opened for 30 seconds and after 30 seconds it automatically turned off. RNS 1 stated no one heard the alarm and Resident 1 was able to leave the facility. A review of the GACH 1 Emergency Department (ED) Progress Note dated 1/6/2023 at 4:32 p.m., indicated the police brought Resident 1 to GACH 1 after Resident 1 was found trying to break into a stranger's house. The ED Note indicated while at the GACH, Resident 1 complained of pain on the left hip and was found to have four cm laceration on the left thigh. The notes indicated Resident 1 was given lidocaine (local anesthesia [numb a small area of the body]) to the left lateral thigh and sutures were needed to close the laceration. During a telephone interview on 1/20/2023 at 1:30 p.m., the DON stated when Resident 1 eloped on 1/5/2023, it placed the resident at risk for injury. The DON stated the security alarm emitted a sound, but staff did not acknowledge the alarm. The DON stated there was no excuse for the staff not to hear the alarm and respond to it. The DON stated the alarm should be responded to immediately as soon as staff heard the alarm. During a telephone interview on 1/26/2023 at 4:20 p.m., the Risk for Elopement Assessment form dated 10/13/2022 was reviewed with LVN 2. LVN 2 stated the Risk for Elopement Assessment indicated Resident 1 was ambulatory and was resistant to being placed in the long-term care facility. LVN 2 further stated Resident 1 was taking Seroquel (medication used to improve mood, thoughts, and behaviors for people with schizophrenia) 100 milligrams (mg) every 12 hours, and this medication had the potential to cause confusion. LVN 2 stated these factors made Resident 1 a risk for elopement and this should have been care planned upon admission to the facility. LVN 2 agreed that the Risk for Elopement Assessment was not accurate. During a telephone interview on 1/27/2023 at 1:50 p.m., the DON stated Resident 1 was not identified as at risk for elopement when admitted on [DATE]. The DON stated Resident 1 was ambulatory, was placed in a long-term care facility, and was on psychotropic medications (affecting behavior, mood, thoughts, or perception) that may cause confusion or disorientation. The DON stated and confirmed these factors indicated Resident 1 was indeed a risk for elopement and a care plan should have been created upon facility admission to address the risk of elopement. A review of the facility policy titled, Audible Battery-Operated Door Alarms dated 8/23/2022 indicated it was the policy of the facility to provide a safe environment for all staff and residents. The policy indicated the facility used six audible battery-operated door alarms to alert staff of all persons entering and exiting the facility. In addition, it alerts staff if a resident wanders. A review of the facility policy titled, Mini Audible Battery-Operated Door Alarms, dated 8/23/2022 indicated all residents' rooms have mini audible battery-operated alarms on the exit doors leading outside to alert staff of all persons entering and exiting from resident rooms. A review of the facility policy titled, Policy and Procedure Safety and Supervision of Residents, updated in 2018, indicated resident safety and supervision and assistance to prevent accidents were facility wide priorities. The policy indicated staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical examination, observation of the resident and the MDS. The policy further indicated the interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. A review of the facility policy titled, Elopement Policy and Procedure, updated on 12/2020 indicated safety of all residents is the primary care standard of the facility. Impaired judgment, perception and thought processes of cognitively impaired make the residents a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures and staff and visitor education have been put into place to maximize resident safety.

Based on observation, interview and record review, the facility failed to ensure two of 35 sampled residents Resident 107 and Resident 4 were provided necessary treatment and services to prevent formation of and promote healing of pressure sore by: 1. Failure to promptly act upon the interdisciplinary team (IDT -a coordinated group of staff from different fields who work together toward a common goal) recommendations for Resident 107 to have wound care consultation (10 day delay), Registered Dietitian (RD) consultation (12 day delay), and increased frequency of Pro-stat (a liquid protein to promote wound healing - five day delay). 2. Failure to continuously monitor Resident 107's wound to include October 5, 2017 during 3 p.m. to 11 p.m. shift, October 6, 2017 during 7 a.m. to 3 p.m. shift, and October 7, 2017 during 11 p.m. to 7 a.m. shift, when the resident's skin condition changed to ensure timely medical intervention. 3. Failure to provide Resident 107 with a low air loss mattress (a pressure relieving mattress for the management of pressure sores) to prevent the progression of a stage 2 pressure ulcer identified on October 5, 2017, until the pressure ulcer worsened to a stage 4, on October 16, 2017. 4. Failure to ensure a resident was provided with heel protector (pressure relieving devices) to left and right heels as directed by the physician (Resident 4). 5. Failure to ensure a resident was provided with functional Alternating Pressure Pad (APP mattress - systems used to prevent stage 1 bedsores) as directed by the physician for Resident 4. Findings: As a result, Resident 107's healed pressure sore on the coccyx reopened, and between October 5, 2017 and October 16, 2017, the resident's pressure sore worsened to a stage 4 pressure sore (full thickness tissue loss with exposed bone, tendon, or muscle), and Resident 4 was placed at additional risk for developing pressure sores. Findings: a. A review of the Admission Record indicated Resident 107 was initially admitted to the facility on [DATE], with the most recent readmission on October 31, 2017, with [DIAGNOSES REDACTED]. The body assessment dated [DATE], indicated Resident 107 did not have any skin breakdown and was noted with an old scar on the coccyx (a bone at the base of the spinal column) area. A review of the Nutritional Screening Data of September 11, 2017, indicated Resident 107 had a 14.9 % weight loss in the last 180 days. Laboratory test results dated September 5, 2017, indicated hemoglobin (red protein responsible for transporting oxygen in the blood) was 33.2 percent (%) with a reference range of 34.1- 44.9 %, the hematocrit (the ratio of the volume of red blood cells to the total volume of blood) 10.3 grams per deciliter (g/dl) with a reference range of 11.2 g/dl to 15.7 g/dl. There was no [MEDICATION NAME] or pre [MEDICATION NAME] laboratory test result indicated on the Screening Data. (Serum proteins such as [MEDICATION NAME] and pre [MEDICATION NAME] (PAB) have are used to determine patient nutritional status). The Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated September 12, 2017, indicated Resident 107 was rarely/never able to understand or be understood, required total assistance with one-person physical assistance with bed mobility, toilet use, and personal hygiene, eating, and was at risk of developing pressure sore. A review of the Care Plan developed on September 15, 2017, for Resident 107's potential for pressure sore development related to impaired bed mobility and incontinence of bowel and bladder functions, had a goal for Resident 107 to have intact skin, free of redness, blisters or discoloration through review date. The interventions included administering treatment as ordered and monitoring effectiveness; educating the resident/family/caregivers as to causes of skin breakdown, and follow the facility's policies/protocols for the prevention/treatment of [REDACTED]. A review of the Braden Scale (a tool to assess a resident's risk for pressure sore) dated September 20, 2017, indicated Resident 107 had a total score of 14 (moderate risk for pressure sore development). A review of the Care Plan developed on September 25, 2017, for Resident 107's altered skin integrity at the coccyx area, had a goal for the pressure sore to improve in size and stage without any complications. The interventions included baseline laboratory work -any test than measures current or pre-treatment parameters, against which response(s) to therapy, if any, is evaluated, (as available), monitoring the pressure sore weekly, RD consult, and wound consult and weekly follow-up. A review of Resident 107's Skin Integrity Review dated October 6, 2017, indicated the IDT recommended for the stage 2 pressure ulcer on the coccyx, for the resident to have a wound consult, and Registered Dietitian consult and Pro-stat increase. A review of Resident 107's Wound Evaluation Flowsheet indicated: -On September 25, 2017 the pressure sore Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) measuring 1.5 centimeter (cm) length by 1.7 cm width. - On October 5, 2017, the pressure sore was a Stage 2 (partial thickness loss of skin presenting as a shallow open sore with red pink wound bed) measuring 2.5 cm length by 2.0 cm width by 0.1 cm depth with scant (very little) drainage. - On October 12, 2017, the pressure sore worsened to an unstageable (full thickness tissue loss in which the base of the sore is covered by slough (dead tissue), measuring 2.5 cm length by 2.0 cm width by 0.1 cm depth, with scant drainage and 80 percent (%) slough. - On October 16, 2017, the sore was a Stage 4 measuring 4.5 cm length by 5.1 cm width by 2.5 cm depth, with scant drainage, 50 % slough, and 50% eschar (dead tissue). The flowsheet indicated a low air loss mattress was added as a current preventative intervention. A review of Resident 107's laboratory result dated October 17, 2017, indicated the resident had an [MEDICATION NAME] level of 2.1 gram per deciliter (low in a reference range of 3.5-5.7 g/dl) and pre-[MEDICATION NAME] level of 8 mg/dl (low in a reference range of 17-34 mg/dl). On December 21, 2017 at 10:13 a.m., during an observation in the presence of Certified Nursing Assistant 1 (CNA 1), Resident 107 was lying in bed. During a concurrent interview, CNA 1 stated the resident had a pressure sore. On December 22, 2017 at 9:20 a.m., during a wound care treatment observation, Resident 107 was lying in bed, on a low air loss (LAL) mattress, Licensed Vocational Nurse 2 (LVN 2) removed the soiled dressing, irrigated (washed) the wound with normal saline (salt water) and described the wound as Stage 4 pressure sore with 95% pink wound bed and slight whitish tissue. On December 22, 2017 at 2:14 p.m., during an interview, LVN 1 stated Resident 107 developed an unstageable pressure sore on October 12, 2017. LVN 1 stated if ordered, the LAL mattress is received within 24 hours. LVN 1 stated she could not explain why the LAL mattress was not ordered before the pressure sore deteriorated. (The wound evaluation flowsheet indicated a low air loss mattress was added as a current preventative intervention on October 16, 2017. On December 27, 2017 at 9 a.m., during an interview while reviewing the nursing notes, LVN 1 stated the licensed nursing staff did not monitor Resident 107's unstageable pressure sore from October 12, 2017 to October 16, 2017, as indicated in the facility's change of condition policy. On December 27, 2017 at 3:15 p.m., during an interview, LVN 1 stated she reviewed Resident 107's nutritional notes and stated the RD did not evaluate the resident until October 18, 2017, 12 days after the IDT recommendation. LVN 1 stated the wound consultant did not evaluate Resident 107's pressure sore until October 16, 2017, 10 days after the IDT recommendation. LVN 1 reviewed Resident 107's physician orders [REDACTED]. On December 27, 2017 at 4:01 p.m. during an interview, the Director of Nursing (DON) stated the IDT recommendation should have been acted upon as soon as possible. LVN 1, who was present during the interview, stated the development of the Stage 2 pressure sore dated October 5, 2017, was a change of condition (C(NAME)). LVN 1 stated after Resident 107's C(NAME), the nursing staff was to monitor the resident's skin every shift for 72 hours. LVN 1 stated the licensed nursing staff did not monitor Resident 107's skin status on October 5, 2017 during 3 p.m. to 11 p.m. shift, October 6, 2017 during 7 a.m. to 3 p.m. shift, and October 7, 2017 during 11 p.m. to 7 a.m. shift. A review of Resident 107's IDT Conference Record dated October 19, 2017, indicated the resident developed the pressure ulcer on the coccyx area where the old scar is. (Scar tissue is not as strong as healthy tissue and is more likely to break down again). A review of the facility's undated policy titled Comprehensive Person-Centered Care Planning Process indicated that the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. A review of the facility's undated policy titled Change of Condition indicated that when a resident's condition changed for any reason, the facility will initiate Change of Condition assessment which is based on SBAR communication tool and insure proper care and follow-up by using a monitoring system using a 72 hours charting. The charting will be completed during each shift for 72 hours from the time of condition noted. When a resident's condition changes, the physician will be called promptly. A review of the facility's undated policy and procedure titled Pressure Sore Risk Assessment Tool indicated the licensed nurse is responsible to initiate the use of appropriate prevention protocols: prevent pressure, skin care, prevent shearing/friction, nutrition, control of incontinence, pressure relief. A review of the facility's undated policy and procedure titled, Wound Management and Skin Integrity, indicated wound management minutes should include: meeting dates, members present, resident reviewed and any necessary follow-up. The procedure includes frequency of assessment (changes in condition with a potential to trigger a care plan for pressure sores) and discussion terms (interdisciplinary goals, resident's progress, resident's identifies with condition, equipment needs/revision, and care planning). b. A review of the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated September 18, 2017, indicated Resident 4's cognition was severely impaired in daily decision-making. According to the MDS, the resident was assessed as needing full staff assistance with eating, toilet use, personal hygiene, and bathing, transferring, and requiring extensive assistance with bed mobility and dressing. According to the MDS, the resident was identified as at risk for developing pressure ulcer. The Braden Scale - For Predicting Pressure Sore Risk dated, September 18, 2017 indicated Resident 4 had a score of 13 that corresponded to as moderate risk. A record review of the physician's orders [REDACTED]. On May 11, 2017 at 8:37 a.m., Resident 4 was observed lying in his bed without wearing heel floater on the right heel in the presence of a Licensed Vocational Nurse (LVN 3). On concurrent interview at 8:37 a.m., LVN 3 stated there was only one heel floater on because the resident did not like having the boot or floater on his left foot. Resident 12 was observed talking to self, confused, and listening to the radio unable to explain why he did not want to have the heel protector on. On December 20, 2017 at 9:24 a.m., during an observation, Resident 4 did not have heel protectors on. During a concurrent interview, Registered Nurse 2 (RN 2) stated the heel protectors were in the closet. RN 2 also stated the heal protectors were usually placed on the resident after morning care. RN 2 stated the Restorative Nursing Assistant (RNA) usually applies the heel protector. A record review of Resident 4's care plan titled The resident has potential for pressure ulcer development related to history of ulcers, immobility, [MEDICAL CONDITION] disorder, initiated on September 14, 2016, indicated heal protector for skin maintenance and to administer treatment as ordered and monitor for effectiveness an intervention. A review of the physician order [REDACTED]. On December 20, 2017 at 9:22 a.m., during an observation and interview, RN 2 verified Resident 4's APP matters pump was not functioning. RN 2 stated the APP mattress was on but the pump was not working thus the maintenance is replacing it now. A review of the facility's undated policy and procedure and titled Pressure Ulcer Treatment, indicated to implement pressure-relieving device(s) in accordance with resident's assessed needs.

Based on observation, interview, and record review, the facility failed to ensure four of 35 sampled residents (Residents 107, 93, 75 and 4) with or without limited range of motion (ROM the extent of movement of a joint), and limited mobility, received appropriate treatment and services to increase ROM, prevent further decrease in ROM, and maintain or improve mobility, including: 1. Failure to identify Resident 107's decline in ROM. 2. Failure to notify the rehabilitation department of Resident 107's limitation in joint mobility. 3. Failure to monitor Resident 107's pain and stiffness as indicated in the care plan. 4. Failure to ensure Residents 107, 93, and 75 were provided with complete ROM exercises to all joints as indicated in the facility's policy and procedure for Range of Motion Exercises. 5. Failure to accurately assess Resident 75's ROM of his left hand fingers. 6. Failure to apply hand roll as ordered by the physician and document the RNA treatment provided to the resident (Resident 4). As a result, by December 21, 2017, Resident 107 had limited (decline) ROM to her lower extremities joints, left elbow, right wrist, and right hand fingers. This also resulted in placing Residents 93, 75 and 4, at increased risk for ROM decline. Findings: a. A review of Resident 107's admission record indicated an initial admission to the facility on [DATE] and the most recent readmission was on October 31, 2017, with [DIAGNOSES REDACTED]. A review of Resident 107's quarterly Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated December 21, 2016, indicated the resident was rarely/never able to understand others and rarely/never made herself understood. The resident required total assistance with one person physical assistance with dressing and personal hygiene. The MDS also indicated the resident had no impairment with functional limitation in ROM to both sides of her upper (shoulder, elbow, wrist, and hand) and lower (hip, knee, ankle, and foot) extremities. A review of Resident 107's quarterly MDS dated [DATE], indicated Resident 107 had functional limitation in ROM to both sides of her upper and no impairment to both sides of her lower extremities. A review of Resident 107's significant change MDS dated [DATE], indicated Resident 107 had functional limitation in ROM to both sides of her upper and lower extremities. A review of the Joint Mobility Assessment (JMA) dated November 1, 2017, indicated Resident 107 had ROM within functional limitation (variance due to normal aging process allowed) to her left and right hip, knee, and ankle, left elbow, right wrist, and right hand fingers joints. The physician's orders [REDACTED]. 1. Restorative Nursing Assistant (RNA) to perform passive range of motion (PROM no participation of the resident) exercise to both (right and left) upper extremities and lower extremities seven times a week or as tolerated. 2. RNA to apply right elbow splint for 4 to 6 hours or as tolerated with skin check, seven times a week, one time a day. A review of Resident 107's care plan dated November 1, 2017, indicated the resident was at risk for decline in ROM. The care plan goal indicated Resident 107 will maintain current ROM. The interventions indicated for the RNA to perform gentle PROM exercise to both (right and left) upper and lower extremities and apply right elbow splint for 4 to 6 hours or as tolerated with skin check. A review of Resident 107's care plan dated November 15, 2017, indicated the resident had potential for further contracture related to impaired mobility. The resident will have no further contracture in the next three months. The care plan interventions indicated to keep contracted areas clean and odor free, monitor for pain or increased stiffness, and perform ROM as ordered. A review of Resident 107's RNA weekly progress notes dated November 15, 2017, indicated the resident's overall participation was uncooperative and her overall tolerance to the ROM exercises was fair. A review of the Quarterly JMA dated December 13, 2017, indicated Resident 107 had no change in condition noted. The JMA also indicated the ROM exercise maintained Resident 107's assessed mobility. The plan was to continue with the RNA program. A review of Resident 107's RNA weekly progress notes dated December 14, 2017, indicated the resident's overall participation was combative and her tolerance fair. On December 21, 2017 at 02:01 p.m., during an observation in the presence of RNA 1 (assisting), RNA 2 was observed performing PROM exercise for Resident 107. The resident was grimacing and moaning at times during ROM exercises. RNA 2 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA 2 did not attempt and/or perform flexion and extension (bending and straightening) of the left shoulder, left and right wrist, left and right hip, and left and right toes; abduction and adduction (moving away and into starting position)of the right and left shoulder, and left and right hip; ulnar and radial deviation (moving wrist side to side) of the left and right wrist; plantar flexion and dorsiflexion (moving foot up and down) of the left and right ankles. During observation, Resident 107 had limited ROM to the right shoulder, left hand fingers, right and left elbows, knees, and elbows. On December 21, 2017, during an interview after performing the PROM exercises to Resident 107, RNA 2 stated she only performed PROM to the knees and right elbow because the resident was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). RNA 2 stated she did not perform PROM to the feet, hips, and left shoulder because RNA focused on the contracted knees and right elbow. RNA 2 stated she did not perform PROM to left shoulder because by performing PROM to left elbow, she was also exercising the left shoulder. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), and Physical Therapist (PT 1), stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. Per OT 1, RNA 2 should have performed ROM to each joint because Resident 107 had limited ROM of her upper extremities. On December 22, 2017 at 10:11 a.m., during observation, Physical Therapist 1 (PT 1) assessed the ROM of Resident 107's right and left lower extremities. Resident 107, had limited ROM to her knees (unable to extend the knees). Per PT 1, resident was tight. During a concurrent interview, PT 1 stated he was unable to assess Resident 107's hip joints to be within functional limit because her knees needed to be straight (extended). PT 1 stated he did not want to force it (continue assessing Resident 107's hip). Resident 107 was grimacing and moaning at times during the assessment; she would bring her knees toward her body when PT 1 attempted to straighten them. On December 22, 2017, during an observation following PT 1's assessment, Occupational Therapist 1 (OT 1) assessed the ROM of Resident 107's upper extremities. Per OT 1, Resident 107 was tight, which resulted in Resident 107 having limited ROM to the following joints: right shoulder flexion: moderate to severe, right shoulder abduction moderate to severe, right elbow extension (severe), right wrist (moderate to severe), right fingers metacarpal (minimal to moderate), left shoulder (moderate limitation for extension and abduction), left elbow flexion (minimal to moderate OT 1 stated resident was resisting). On December 22, 2017 at 01:53 p.m., during a follow up interview, RNA 2, stated she had been working with Resident 107 about once a week. RNA 2 stated Resident 107 had limited ROM to her knees (unable to straighten knee). RNA 2 stated the RNAs and therapists (PT/OT) knew about the limitation. RNA 2 stated Resident 107 was unable to have her knees' ROM within functional limit even when she was not in pain and/or stiff. RNA 2 stated she did not personally report Resident 107's limitation. On December 22, 2017 02:50 p.m., during an interview, RNA 1 stated Resident 107's ROM of her knees had been limited since working with the resident (six to seven months ago). RNA 1 stated she was unable to perform full ROM to Resident 107's knees (unable to extend the knees). RNA 1 also stated Resident 107's knees could not be fully extended even when the resident was relaxed and not tense/stiff. On December 22, 2017 at 05:50 p.m., during an observation, the Director of Nursing (DON) attempted to assess Resident 107's ROM. The DON was unable to assess the ROM of the resident's lower extremities (unable to extend the legs). Resident 107 was moaning and grimacing. During a concurrent interview, the DON stated Resident 107 was tense at the time and she would stop the ROM assessment to request for pain medication. On December 27, 2017 at 08:10 a.m., during a phone interview, Resident 107's family member (FM 1) stated Resident 107's legs were stretched out more when she was initially admitted to the facility in June 2016. FM 1 stated Resident 107 had been more in a fetal position (in this position, the back is curved, the head is bowed, and the limbs are bent and drawn up to the torso) since insertion of the gastrostomy tube (GT a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow). FM 1 stated she did not remember when the GT was inserted, maybe a couple of months ago. On December 27, 2017 at 9:19 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 107. Resident 107 was opening her eyes and mouth wide and pulling back her extremities during ROM exercises. RNA 3 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA 3 did not attempt and/or perform flexion and extension (bending and straightening) of the right and left shoulders, left and right wrists, left and right hips, and left and right toes; abduction and adduction (moving away and into starting position) of the left and right hip; ulnar and radial deviation (moving wrist side to side) of the left and right wrist; plantar flexion and dorsiflexion (moving foot up and down) of the left and right ankles. During observation, Resident 107 had limited ROM to her knees. On December 27, 2017, during an interview after performing the PROM exercises to Resident 107, RNA 3 stated Resident 107 was sometimes hard to move her joints during exercise. RNA 3 stated she would notify the charge nurse or therapists. RNA 3 also stated she did not perform flexion/extension of the wrist and shoulders and abduction/ adduction of the hips. On December 27, 2017 at 10:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she reviewed Resident 107's nursing notes and the RNA weekly notes dated November 15, 2017 and December 14, 2017, but could not find documented evidence the RNA reported to the licensed nursing staff and/or the rehabilitation department the resident was uncooperative or combative during ROM exercises. LVN 1 could not provide documented evidence the physician was notified of Resident 107's limited ROM. LVN 1 stated if the resident was uncooperative or combative, the RNA should have stopped the treatment (ROM exercise) and notified the licensed nurse. On December 28, 2017 at 12:31 p.m., during a follow up interview, LVN 1 stated she reviewed Resident 107's care plan for contracture prevention dated November 15, 2017, and could not find documented evidence the licensed nursing staff and the RNAs were monitoring for pain and/or stiffness as indicated in the care plan intervention. On December 28, 2017 at 3:20 p.m., during an interview, PT 1 and OT 1 stated it was the facility's procedure for the RNAs to notify the charge nurse if there was a change of condition (limited ROM, contracture development). The charge nurse would then notify the rehabilitation department of the change. PT 1 stated it was the expectation of the RNA to notify the charge nurse if a resident experienced pain or stiffness, and/or exhibited resistive behavior during ROM exercises. PT 1 and OT 1 stated the rehabilitation department was not notified of Resident 107's tightness, stiffness, or resistance during ROM exercises. A review of the Facility's undated policy and procedure titled Range of Motion Exercises indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled Comprehensive Person Centered Care Planning Process indicated the purpose of the policy was to develop and implement a baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. A review of the facility's undated policy titled Change of Condition indicated when a resident's condition changed for any reason, the facility will initiate Change of Condition assessment which is based on SBAR communication tool and insure proper care and follow up by using a monitoring system using a 72 hours charting. The charting will be completed during each shift for 72 hours from the time of condition noted. When a resident's condition changes, the physician will be called promptly. b. A review of Resident 93's admission record indicated an initial admission to the facility on [DATE] and the most recent readmission was on May 31, 2016, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of Resident 93's care plan dated September 13, 2017, indicated the resident was at risk for decline ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every two hours and as needed, keep resident in good body alignment, and provide RNA program as ordered. A review of the quarterly Joint Mobility Assessment (JMA) dated December 1, 2017, indicated Resident 93 had ROM within functional limitation (variance due to normal aging process allowed) to her left and right hip, knee, elbow, wrist, and hand fingers joints. The JMA also indicated Resident 93 had ROM limitation to her left and right shoulder and ankle joints. A review of Resident 93's Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated December 1, 2017, indicated the resident was rarely/never able to understand others and rarely/never made herself understood. The resident required total assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of her upper (shoulder, elbow, wrist, and hand) and lower (hip, knee, ankle, and foot) extremities. On December 21, 2017 at 09:26 a.m., during an observation, Resident 93 was up in her Geri chair, non verbal. Resident 93 had foot drop (describes a difficulty in lifting the front part of the foot). On December 22, 2017 at 02:16 p.m., during an observation in the presence of RNA 2 (assisting), RNA 1 was observed performing PROM exercise Resident 93. RNA 1 was observed to not fully perform PROM as follows: Right and left extremities range of motion RNA 1 did not attempt and/or perform flexion and extension (bending and straightening) of the left and right shoulders and toes; abduction and adduction (moving away and into starting position) of the left shoulder, and left and right hips; ulnar and radial deviation (moving wrist side to side) of the left and right wrists. During observation, Resident 93's had limited ROM to the left and right knees and ankles. On December 22, 2017, during an interview after performing the PROM exercises to Resident 93, RNA 1 stated she did not perform flexion/extension of both shoulders, and abduction/adduction of the left shoulder and both hips. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), Physical Therapist 1 (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. A review of the Facility's undated policy and procedure titled Range of Motion Exercises indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled Comprehensive Person Centered Care Planning Process indicated the purpose of the policy was to develop and implement a baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. c. A review of Resident 75's admission record indicated an initial admission to the facility on [DATE] and the most recent readmission was on November 11, 2013, with [DIAGNOSES REDACTED]. The history and physical dated January 18, 2017 , indicated the resident has above the knee amputation of both legs (legs are missing from above the knees). A review of the physician's orders [REDACTED]. A review of Resident 75's care plan dated September 13, 2017, indicated the resident was at risk for decline in ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every two hours and as needed, provide RNA exercises daily as tolerated, and apply hand roll daily. A review of Resident 75's Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool) dated November 16, 2017, indicated the resident had moderate impairment of cognitive skills for daily decision making. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of his lower (hip, knee, ankle, and foot) extremities and to his upper (shoulder, elbow, wrist, and hand). A review of the Joint Mobility Assessment (JMA) dated November 16, 2017, indicated Resident 75 had ROM within functional limitation (variance due to normal aging process allowed) to his shoulders, hips, knees, elbows, wrists, and hand fingers joints. On December 22, 2017 at 9:53 a.m., during an interview in the presence of the Occupational Therapist (OT 1), the Physical Therapist (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. On December 27, 2017 at 10:35 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 75's hip and left hand fingers. RNA 3 did not attempt and/or perform flexion and extension (bending and straightening) of the left and right knees. Resident 75's left fourth and fifth fingers were contracted (unable to extend fingers). On December 27, 2017 at 10:55 a.m., during an interview, RNA 3 stated Resident 75 had full ROM to his left hand fingers. RNA 3 stated she did not perform ROM to Resident 75's knees. On December 27 at 11:09 a.m., during an interview in the presence of RNA 3, Resident 75 stated he lost ROM of his 4th and 5th left fingers about two and half years ago due to a stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Resident 75 stated he was unable to use his 3rd, 4th, and 5th left fingers. When asked to demonstrate his left fingers ROM, Resident 75 was able to partially extend his left 3rd finger, and was not able to extend his left 4th and 5th fingers. On December 27, 2017 at 12:01 p.m., during an interview, Occupational Therapist 1 (OT 1) stated Resident 75's proximal interphalangeal joints (the joints between the bones of the fingers) of the left hand third, fourth, and fifth fingers were contracted. OT 1 stated she missed to document the fingers contractures. A review of the Facility's undated policy and procedure titled Range of Motion Exercises indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled Comprehensive Person Centered Care Planning Process indicated the purpose of the policy was to develop and implement a baseline and comprehensive person centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. On December 22, 2017 at 9:53 a.m., during an interview in the presence of Occupational Therapist 1 (OT 1), Physical Therapist 1 (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP-bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. A review of the Facility's undated policy and procedure titled Range of Motion Exercises indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled Comprehensive Person-Centered Care Planning Process indicated the purpose of the policy was to develop and implement a baseline and comprehensive person-centered care planning for each resident which meets the standards of quality of care in a timely manner and provided by qualified professionals who are culturally competent. c. A review of Resident 75's admission record indicated an initial admission to the facility on [DATE] and the most recent readmission was on November 11, 2013, with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 75's care plan dated September 13, 2017, indicated the resident was at risk for decline in ROM and contracture formation due to limited mobility. The care plan goal indicated Resident 93 will maintain current ROM for three months. The interventions indicated to change the resident position every two hours and as needed, provide RNA exercises daily as tolerated, and apply hand roll daily. A review of Resident 75's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated November 16, 2017, indicated the resident had moderate impairment of cognitive skills for daily decision making. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated the resident had functional limitation in ROM to both sides of his lower (hip, knee, ankle, and foot) extremities and to his upper (shoulder, elbow, wrist, and hand). A review of the Joint Mobility Assessment (JMA) dated November 16, 2017, indicated Resident 75 had ROM within functional limitation (variance due to normal aging process allowed) to his shoulders, hips, knees, elbows, wrists, and hand fingers joints. On December 22, 2017 at 9:53 a.m., during an interview in the presence of the Occupational Therapist (OT 1), the Physical Therapist (PT 1) stated he did not see any problems with the RNAs performing ROM exercises, when conducting random competency skills evaluation of the RNAs. PT 1 and OT 1 stated they instructed the RNAs to provide ROM exercises as follow: flexion/extension of the hip, knee, wrist, ankle, shoulder, elbow, hand digits, and metacarpal (MCP-bones of the hand) joints, abduction/adduction of the shoulder and hip joints. PT 1 and OT 1 stated the rehabilitation department did not have a resource material and/or manual on how to perform ROM exercises. PT 1 and OT 1 stated the expectation was for the RNAs to provide ROM exercises to all the resident' joints as instructed. On December 27, 2017 at 10:35 a.m., during an observation, RNA 3 was observed performing PROM exercise to Resident 75's hip and left hand fingers. RNA 3 did not attempt and/or perform flexion and extension (bending and straightening) of the left and right knees. Resident 75's left fourth and fifth fingers were contracted (unable to extend fingers). On December 27, 2017 at 10:55 a.m., during an interview, RNA 3 stated Resident 75 had full ROM to his left hand fingers. RNA 3 stated she did not perform ROM to Resident 75's knees. On December 27 at 11:09 a.m., during an interview in the presence of RNA 3, Resident 75 stated he lost ROM of his 4th and 5th left fingers about two and half years ago due to a stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Resident 75 stated he was unable to use his 3rd, 4th, and 5th left fingers. When asked to demonstrate his left fingers ROM, Resident 75 was able to partially extend his left 3rd finger, and was not able to extend his left 4th and 5th fingers. On December 27, 2017 at 12:01 p.m., during an interview, Occupational Therapist 1 (OT 1) stated Resident 75's proximal interphalangeal joints (the joints between the bones of the fingers) of the left hand third, fourth, and fifth fingers were contracted. OT 1 stated she missed to document the fingers contractures. A review of the Facility's undated policy and procedure titled Range of Motion Exercises indicated the purpose of the procedure was to exercise the resident's joints and muscles. Review the resident's care plan to assess for any special needs of the resident. Exercise the shoulder, elbow, wrist, thumb, fingers, hip, knee, feet, and toes. Document the date and time the exercise was performed, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure. Notify the charge nurse or supervisor if the resident refuses the exercises. Report other information in accordance with the facility policy and professional standards of practice. A review of the facility's undated policy titled Comprehensive Person-Centered Care Planning Process indicated the purp (TRUNCATED)