Advanced Health Care Of Glendale

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) regarding end of insurance coverage and discharge for one resident (#69) was provided timely according to regulation and facility policy. The deficient practice could lead to inadequate notice for a resident or resident representative to appeal the decision.Findings include:Resident #69 admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, metabolic encephalopathy, type 2 diabetes mellitus without complications, and other abnormalities of gait and mobility.Review of the clinical record revealed no evidence that a NOMNC was delivered to the beneficiary/representative at least two (2) days before the Medicare covered services ended.An admission Nursing Observation assessment dated [DATE], revealed Resident #69's preferred language was a language other than English, and the document revealed unable to determine whether the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Additionally, the resident had unclear speech-slurred or mumbled words, was sometimes understood, and sometimes could understand others' verbal communication.A Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 1, indicating severe cognitive impairment.A baseline care plan dated January 9, 2026, revealed Resident #69 had an alteration in communication, with a goal that the resident's needs would be met daily. The care plan revealed that the resident had a language barrier, and had aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult. The care plan revealed that the check boxes for a communication board, written communication, and/or translation application were not checked.A Provider Notification progress note dated January 10, 2026, revealed Resident #69 would not take any medications or allow her blood sugar to be checked that morning. A language communication board was used but the resident pushed medications away from her and tried to wheel herself away from nursing staff with one arm. The note revealed that staff attempted to provide education on risks / benefits to the resident, but unable to verify understanding due to language barrier. There was no evidence of attempts to use an interpreter or a translator application.An Occupational Therapy (OT) Evaluation and Plan of Treatment dated January 10, 2026, revealed Resident #69 primarily spoke a foreign language other than English, and that the resident was pleasant, cooperative, and attentive. The document revealed Resident #69 required maximum assistance to perform lower body dressing and toileting, and required moderate assistance to perform upper body dressing and bathing. The goals of the plan of care included for the resident to reach an independent level of functioning in these tasks, and the frequency of the plan of care included 3-7 times per week for 4 weeks.An OT Service Log revealed on January 10, 2026, Resident #69 participated in 15 minutes of OT evaluation, 20 minutes of therapeutic activity, and 25 minutes of self-care management training.A Nursing note dated January 11, 2026, revealed Resident #69 was alert and uncooperative, and had an unwitnessed fall. The note revealed a certified nursing assistant (CNA) found the resident on the ground next to her bed sitting upright while holding her call light in her hand. The documentation revealed the resident was asked what happened but was unable to provide any information about the fall.An OT Service Log revealed on January 11, 2026, Resident #69 participated in 21 minutes of therapeutic activity. The Service Log included that the resident refused treatment on January 13, 14, and 15, 2026, with the same male therapist.A Physical Therapist (PT) Evaluation and Plan of Treatment dated January 12, 2026, revealed the reason for referral included that Resident #69 presented to the hospital with increased dizziness, confusion, and right sided weakness, and was diagnosed with a cerebral vascular accident (CVA / stroke). The evaluation revealed the resident's primary language was a foreign language other than English. The evaluation included that the resident required partial assistance to perform bed mobility and transfers with a hemiwalker, and required moderate assistance to be able to propel 30 feet in a wheelchair, with therapy goals to improve mobility to an independent level. The plan included for a frequency of 3 to 5 times per week, for 6 weeks.A PT Service Log included that on January 12, 2026, Resident #69 participated in 15 minutes of PT evaluation and 25 minutes of therapeutic activity.A Speech Therapy (ST) Evaluation and Plan of Treatment dated January 12, 2026, but signed January 16, 2026, revealed the resident predominantly spoke a foreign language other than English, was alert and oriented only to herself, and was pleasantly confused and impulsive. The evaluation revealed the resident had a diagnosis of dysphagia, and had goals for safe swallowing. The evaluation included it should be noted that (the resident) would not cooperate with attempts to assess her cognitive linguistic skills. The evaluation included no evidence of any attempts to use a language board, a translator application, or interpreter.An ST Service Log included that on January 12, 2026, Resident #69 participate in 10 minutes of ST evaluation, and 45 minutes of treatment of swallowing dysfunction and/or oral function for feeding.A Nursing note dated January 13, 2026, revealed the resident had a fall, and was found next to the bed on the floor, and was unable to describe the event. The note included that the provider was notified of the resident's fall.A PT Treatment Encounter Note dated January 13, 2026, revealed that resident #69 was refusing, pushing therapist away and holding onto a rail from her wheelchair, and refusing to leave her room. Regarding a pain assessment, the documentation included unable to communicate pain. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.An ST Service Log revealed that on January 13, 2026, Resident #69 participated in 55 minutes of treatment of swallowing dysfunction and/or oral function for feeding. The ST Treatment Encounter Note for January 13, 2026, included that Resident #69 was alert to herself only and confused, and required maximum verbal cues and gestures to increase her participation. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.An ST Service Log revealed on January 14, 2026, that Resident #69 participated in 57 minutes of treatment of swallowing dysfunction and / or oral function for feeding. The ST Treatment Encounter Note for January 14, 2026, included the resident was oriented only to herself and pleasantly confused, and willing to comply / cooperate with the treatment only if it took place in her room. The documentation included no evidence of attempts to use a language board, or translator application, or interpreter to communicate with the resident.A Nursing note dated January 14, 2026, revealed at 6:15 a.m., two CNAs attempted to change the resident, and the resident was observed screaming, kicking, scratching staff, and refusing medications and blood sugar checks at times. The documentation revealed the resident was redirected, and was changed. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 12:10 p.m., revealed Resident #69 was observed attempting to get out of bed and stand by herself without assistance, and when staff tried to assist the resident, the resident smacked staff's arm and gestured with her hand to move and get out. The note revealed that additional staff were able to assist the resident into the wheelchair. The note included that the resident started throwing things onto the floor and into the trash, including the resident's leg brace, sensor pad, and wheelchair pad. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 9:38 p.m., revealed Resident #26 remained combative and refused all care and medications. There was no evidence of notification to the provider of the resident's continued behaviors.A Nursing note dated January 14, 2026, at 9:52 p.m. revealed Resident #60 had 3 unwitnessed fall events that evening alone. The note revealed that the resident would not allow any staff to touch her and continued to be very distressed and seemed unable to be safe at that time, and that the provider was notified.A care plan initiated January 14, 2026, included a problem that the resident had behavioral symptoms of noncompliant with medications and treatments and occasionally combative with caregivers. The approaches / interventions dated January 14, 2026, included to administer medications per physician orders, aid in avoiding stressful situations, allow resident adequate time to complete task on own, if able, allow quiet, calm environment during acute phase, anticipate resident's needs, approach resident calmly and introduce self during encounters or cares, consult with physician regarding drug regimen as needed, encourage independence in activities of daily living (ADLs) as resident is safely able, encourage positive expressions of concerns, anxieties, and fears, gently explain all cares before processing, keep pathway clear of clutter, labs as ordered, and validate positive expressions of concerns, anxieties, and fears.The care plan was reviewed and revealed no evidence of updates to the care plan regarding communication with the resident whose primary language was a foreign language other than English, and no evidence of any interventions to include attempts to use a translator application or interpreter.A Nursing note dated January 14, 2026, at 9:59 p.m. revealed that a psychiatric consult was ordered for Resident #69. The note included that the resident's family was contacted and urged to sit bedside with her or hire someone to sit bedside with her 24/7 for the resident's safety. The note revealed that the resident's family stated that they are not in the city and unable to hire someone that evening. The note included that the family was informed to speak with management tomorrow for a plan of action. Additionally, the note revealed that the resident was refusing all medications that evening, was sitting on the floor and refusing to get back in bed, refusing staff to come near her, was not receptive to redirection, and appeared comfortable at that time. The documentation revealed no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Nursing note dated January 14, 2026, at 10:10 p.m. revealed that the physician ordered to send the resident to the hospital.A Nursing note dated January 14, 2026, at 10:26 p.m. revealed Resident #69 had barricaded herself in the room, and that staff were attempting to get into the room in order to check on her, and that the physician was aware.A physician order dated January 14, 2026, included for a psychiatric consult, and to discharge the order when completed.A Nursing note dated January 15, 2026, at 1:05 a.m., revealed transportation arrived to take the resident to the hospital at 10:45 p.m., and that due to it being an all male crew, it was requested per their supervisor to wait to exchange care with a female crew, and that an all female crew arrived at 12:05 p.m.An Acute Care Transfer nursing progress note dated January 15, 2026, at 1:05 a.m., revealed the resident was transferred to the hospital due to having 3 unwitnessed fall events on evening shift, and the resident was unable to answer questions.A Nursing progress note dated January 15, 2026, at 4:27 a.m. revealed Resident #69 returned to the facility with no findings per the hospital Emergency Department (ED), and had no injury and no evidence of urinary tract infection (UTI) or other abnormal lab results. Additionally, the documentation revealed the resident was resting comfortably in bed.A Social Services progress note dated January 15, 2026, at 9:48 a.m., signed by the administrator (Staff #81), revealed that the administrator spoke with the resident's son and stated concerns about the resident's safety and need for a caregiver with her from 4:00 p.m. to 6:00 a.m. The note revealed that the son stated he will plan to take her home with him or have her stay with her brother for safety reasons, but revealed no evidence of a timeframe for a planned discharge. The note revealed that the administrator shared with the resident's son information for a private caregiver company for hire in case the son needed it for that night. The note revealed that the son stated at worst, he would be at the facility by tomorrow to take Resident #69 home.An ST Service Log dated January 15, 2026, revealed Resident #69 participated in 45 minutes of treatment of swallowing dysfunction and/or oral function for feeding. The ST Treatment Encounter Note dated January 15, 2026, included that the resident was treated in her room as she refuses to leave the room, and cooperated with treatment. The note included a recommendation to continue the plan of care.Despite the recommendation to continue the plan of care, an ST Discharge summary revealed dates of service included January 12 - 15, 2026, and the Discharge Summary was signed on January 18, 2026. The Discharge Summary included that the resident had made minimal progress and was discharged home with her son.A PT Treatment Encounter Note dated January 15, 2026, included that Resident #69 was waving her left upper extremity indicating no. The note revealed education was provided that the resident could stay in her room, and the resident appeared to accept and sat quietly, and demonstrated an increased quiet demeanor. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application. The note revealed the response to the session was nonparticipative.A PT Discharge Summary revealed the dates of service included January 12 - 15, 2026, and signed on January 17, 2026. The documentation included no evidence that the resident met her goals, and no evidence of attempts to use a language communication board, or an interpreter, or a translator application. The documentation revealed the resident was refusing.A Nursing progress note dated January 15, 2026, at 9:54 p.m., revealed Resident #69 had direct 1 to 1 supervision with a private sitter, and that the resident refused medications, blood glucose checks, and a skin check. The note revealed that the resident was calm and not calling out. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Discharge Planning note dated January 15, 2026, revealed the resident was discharging home with the resident's son on January 16, 2026, and that communication was with Resident #69's son, and the discharge location and discharge letter were discussed, and the Notice of Medicare Non-Coverage (NOMNC) was signed. The documentation revealed no evidence that the NOMNC timeframe was waived, or that information regarding appeal was given to the son, or that the discharge was driven by the resident or family, or that the discharge was due to the facility not able to meet the resident's needs, or due to safety concerns.A Discharge BIMS assessment dated [DATE], revealed the Resident had a score of 4, indicating severe cognitive impairment.Despite the order for psychiatric evaluation, the clinical record revealed no evidence that either an emergency or standard psychiatric consult were provided to Resident #69 at any time during her stay at the facility.A Discharge Instructions and Summary document, dated January 16, 2026, signed by the discharge nurse (Staff #88) on January 15, 2026, and also signed by the resident's son on January 16, 2026, revealed that the resident was discharged to home, and the reason for discharge was completed skilled services, and the recapitulation of stay, included that the resident participated in therapy sessions as tolerated.Despite the documentation that the reason for discharge was due to completion of skilled services, a Notice of Transfer or Discharge document, revealed the reason for discharge was the resident's needs cannot be met in the facility. The documentation revealed information to appeal the discharge decision, and information to contact the Long-Term Care Ombudsman. The document revealed conflicting information; the first page of the document revealed the notice was given on January 15, 2026, however, the second page of the document revealed the notice was given on January 16, 2026. The document was signed by the resident's son on January 16, 2026.The clinical record was reviewed, and revealed no evidence of a physician note stating that the resident was not safe to remain in the facility or that the resident's needs could not be met in the facility.Additionally, despite the Discharge Planning note revealing that the NOMNC was signed on January 15, 2026, the Notice of Medicare Non-Coverage (NOMNC) document revealed that the Medicare coverage of your current skilled nursing services will end on January 15, 2026. The document was signed by Resident #69's son on January 16, 2026. The document revealed information regarding the right to appeal the decision.A Discharge progress note dated January 16, 2026, revealed Resident #69 left the facility at 11:20 a.m. to discharge home and that transportation was provided by the resident's son, and the resident's family was made aware of the resident's continued refusal of medications.A telephonic interview was conducted with Resident #69's son on February 4, 2026, at 8:45 a.m. who stated that he was called by facility staff on January 15, 2026, informing him that Resident #69 could no longer stay at the facility because she was resisting staff and was difficult at night. The son stated that the facility staff stated that the only condition that the resident could stay in the facility the night of January 15, 2026, was if the resident had a family member who could stay overnight with the resident or if the resident's family hired a private sitter to come to the facility overnight with the resident. The son stated he was panicking because he lived out of town and could not be there, and stated that he did not want the facility to kick her out to the curb, so he hired a private caregiver / sitter to stay with the resident overnight on the night of January 15, 2026. The son stated that he had to pay for the sitter out of pocket, because the facility staff had told him that the facility could not provide that level of one to one care. The son stated that the facility did not give him 48 hours' notice for the end of coverage or discharge, or information to appeal the decision, and that he found out about Resident #69's discharge on the January 15, and had to come to the facility the morning of January 16, 2026, to pick her up.An interview was conducted on February 5, 2026, at 9:59 a.m. with a licensed practical nurse / discharge nurse (LPN / Staff #88) who stated that the facility's discharge process included that the interdisciplinary team (IDT) meets to determine a discharge, and that there is a notification process that typically requires 48 hours' notice to be given to a resident or a resident's responsible party before end of Medicare coverage prior to discharge. Staff #88 stated that the importance of the 48-hour advanced notice is because there is an appeal process that patients or their representative or family can initiate, and the advanced notice of end of coverage or discharge allows time for the appeal process. Additionally, Staff #88 stated that the advanced notice also keeps the discharge process from being rushed, so residents and families can reduce stress surrounding the discharge process. Staff #88 stated that Resident #69 had met her therapy goals, and completed her skilled stay. The clinical record was reviewed, and Staff #88 stated that Resident #69's son was called and notified on January 15, 2026 of the planned discharge on [DATE], and the son was going to come to the facility on January 16, 2026, to transport the resident home. Staff #88 stated that the resident's NOMNC and notice for discharge were signed on January 16, 2026 by the resident's representative, who was her son. Despite his previous statements, Staff #88 then stated that Resident #69 was given the NOMNC and notice of discharge on [DATE], and that the resident was alert, of sound mind, and could make her own decisions. Additionally, Staff #88 stated that Resident #69 had a rushed discharge because of safety concerns, because the resident was combative, was refusing therapy, and the resident needed a caregiver/sitter between the hours of 4:00 p.m. to 6:00 a.m.An interview was conducted with a licensed practical nurse (LPN / Staff #10) who stated that he had cared for Resident #69, and that the resident could understand very basic things, but did not speak English, and would have bouts of confusion and was impulsive and very forgetful. Staff #10 stated that from his experience, the resident's behaviors never became too much for staff to handle, and that she was able to calm down with staff interventions.An interview was conducted with the Rehab Service Manager and Activities Director (Staff #5) on February 5, 2026, at 9:24 a.m., who stated that typically residents are scheduled for physical therapy 5 times per week, and occupational therapy 5 times per week, and speech therapy as needed. Staff #5 stated that if a resident were to miss or refuse a session, that therapy staff have a general practice to try 2-3 times during the day to get the resident to participate in therapy, and if still missed or refused, then the session would be attempted to be made up on the weekend. Regarding Resident #69, Staff #5 stated that the resident primarily spoke a foreign language other than English, and that he did not know of a language interpreter service or translator service that the facility had. Staff #5 stated that the resident was hit or miss whether she would participate in therapy, that some days the resident would participate, and other days the resident was really upset and would refuse. Staff #5 reviewed the clinical record and stated that regarding physical therapy (PT), Resident #69 was evaluated by PT on January 12, 2026, and had a PT treatment session on January 13, refused the session on January 14, and then had a physical therapy session on January 15, and was discharged by PT services later that day on January 15, 2026. Regarding occupational therapy (OT), Staff #69 was evaluated by OT on January 10, 2026, and then was discharged by OT services on January 12, 2026. Staff #5 stated that he did not believe the resident was being treated by speech therapy.An interview was conducted with the administrator (Staff #81) on February 5, 2026, at 10:17 a.m. who stated that the facility is equipped to care for residents with cognitive impairments, dementia, and/or behaviors by first pre-screening residents prior to admission to ensure the residents are appropriate for the facility, and additionally by discussing possible interventions with resident's family, physicians, and care team members to ensure the appropriate interventions are in place for those residents. Regarding Resident #69, the administrator stated he remembered the resident. The administrator stated the resident became progressively more confused over the course of her stay at the facility, and reverted back to speaking her native foreign language other than English, and that with that came the challenges of her participation in therapy. The administrator stated that Resident #69 was discharged because she met her goals physically, and could get around, but there was no cognitive carryover. Additionally, the administrator stated he was aware there was a requirement for notice of discharge, and requirement for the NOMNC to be issued 48 hours prior to end of coverage of a resident, and he believed that the resident's son was given 48 hours advanced notification.An interview was conducted with a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #85) on February 5, 2026, at 10:33 a.m. who stated if a resident had impaired cognition or dementia and had behaviors, then staff would re-orient the resident to the room, perform additional safety checks, ask the resident's family for assistance and to provide re-assurance to the resident, and if needed, refer the resident and the family to an outside caregiving company for additional caregiver support. Additionally, Staff #85 stated that a resident with behaviors could be referred for a psychiatric consult, which would provide the resident with additional interventions such as activities or medications to assist with managing the resident's behaviors. Regarding Resident #69, Staff #85 stated that she remembered the resident primarily spoke a foreign language other than English, and that the resident could understand some English. Staff #85 stated that she was not aware that the facility had a translator or interpreter service, but that there was a sign with some pictures on it to help identify basic wants or needs of a resident. The clinical record was reviewed, and Staff #85 stated that the reason the resident was discharged was because she refused everything, including therapy, and that she did not meet her therapy goals. Staff #85 stated that a psychiatric consult was ordered on January 14, 2026, but that the resident did not receive it before she was discharged on January 16, 2026.A telephonic interview was conducted with a registered nurse (RN / Staff #146) on February 5, 2026, at 12:00 p.m. who stated that she recalled Resident #69, and that she received report from the previous shift staff that the resident had some aggressive behaviors, and that during her shift, the resident had some episodes of refusing some care, and that she observed the resident throw some of her equipment onto the floor. Staff #146 stated that the resident was able to be calmed down and redirected, and that she felt the resident was appropriate for the facility. Staff #146 also stated that she did not know the extent of the resident's language barrier or how much of the communication the resident could understand.An interview was conducted on February 5, 2026, at 12:20 p.m. with the Director of Nursing (DON / Staff #86), who stated that the discharge planning process includes that the discharge nurse (Staff #88) starts communicating with families early in the resident's stay to determine the appropriate and planned discharge setting. The DON stated that every week, the interdisciplinary team (IDT) meets to decide if residents are ready for discharge and safe to go home. Regarding the NOMNC, the DON stated that it is required to give 48 hours advanced notice from the termination of services. The DON stated that the risk to a resident if not given the 48 hours advanced notice of a resident's termination of services, with the information on how to appeal the decision would be that the resident or resident's family may not have enough time to appeal the decision. The DON stated that resident's and their families should be given notice and made aware that they have the right to appeal the decision. Regarding behavioral services, the DON stated that the facility has two psychiatrist providers and a psychologist to assist residents who are having behavioral problems. The DON stated that including a psychiatric provider can be beneficial to a behavioral resident because the provider would discuss additional interventions, recommendations, or medications if necessary, and that would be added to the resident's care plan. Additionally, the DON stated that the psychiatric provider can perform emergency visits if needed. Regarding Resident #69, the DON stated that she was not very familiar with the resident, and that prior to the day the resident was discharged , the DON stated she received a call from the nurse that the resident had barricaded herself in her room, and the nurse had to walk around the outside of the building to look into the resident's window to ensure the resident was safe. The DON stated that she believed it was the resident's son who wanted the resident to discharge home, and she was not sure where she had heard that information.An interview was conducted with a regional corporate resource (Staff #15) on February 5, 2026, at approximately 12:25 p.m. who stated the NOMNC should be given 72 hours before a resident's discharge.Review of the facility policy titled Notice of Medicare Non-Coverage (NOMNC), version A0717 (undated), revealed that the facility will deliver a NOMNC for all beneficiaries eligible for the expedited process, even if the resident agrees with the termination of services. The NOMNC must be prepared using the OMB approved for (CMS-10123) by either typing or writing in the appropriate fields the following information:The resident's nameThe Medicare patient number or unique medical record numberThe type of coverageThe effective date (last date of coverage)The NOMNC will be delivered to the beneficiary at least two (2) days before the Medicare covered services end. The beneficiary must sign and date the NOMNC to demonstrate that they received the notice and understand the termination decision can be appealed or disputed. If the beneficiary refuses to sign the NOMNC, annotate the notice to that effect and indicate the date of refusal on the notice. The date of refusal is considered to be the date of notice receipt. The NOMNC may be delivered to a beneficiary authorized representative who has been appointed to act on behalf of the beneficiary during the appeal process. Whenever possible, delivery of the NOMNC should occur in person; however, the following alternative means of delivery are acceptable:TelephoneIf contact by telephone is necessary, the date you communicate the information is considered the NOMNC's receipt date.Annotate the NOMNC to document the telephone contact on the day that you make the telephone contact, reflecting that all of the required information was included in the communication.The annotation should include the name of that staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.Place a dated copy of the annotated NOMNC in the beneficiary's medical file and mail a NOMNC to the representative the day the telephone contact is made.Retain the original signed document in the beneficiary's file, and provide the beneficiary copies of all notices that include all of the required information such as the effective date and covered service at issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of observations, staff interviews, and policy and procedures the facility failed to ensure that one resident (#78) had documentation and orders in place for dressings to the wrists and elbow. The universe was 52 and the sample size was 16. The deficient practice could impact the doctors available information on the resident, improper documentation/ communication among staff and potential for infection and worsening of the wound.Findings include:Resident #78 was admitted with pleural effusion, acute respiratory failure with hypoxia, syncope and collapse, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, sick sinus syndrome, left bundle branch block, endocarditis, metabolic encephalopathy, acute embolism and thrombosis of the left peroneal vein, long term (current use) of anticoagulants and presence of a cardiac pacemaker.A review of the 5-day MDS (minimum data set) dated 01/31/2026 revealed no observed BIMS (brief interview of mental status) score.A review of the admission assessment dated [DATE] revealed that the resident was alert, cooperative and oriented to person, place, time and situation, and affirmed that the resident had clear comprehension. The admission assessment revealed no evidence of wounds to the wrists or elbow.A review of the care plan revealed no evidence of the presence of wounds to the wrists or elbow or corresponding wound care.An observation was conducted on February 3, 2026 at 9:13 AM which revealed the resident seated in his wheelchair with his daughter present in the room. The resident was further observed with bandages/ dressings to both the left and right wrist as well as the left elbow. None of the bandages were dated or initialed by staff. The daughter stated that the bandage to the right wrist was coming off, but that the resident was getting ready to leave for a medical appointment. The staff #2, RN (registered nurse) was advised of the lose bandage to the right wrist.A review of the physician's orders on February 3, 2026 at 9:20 AM revealed no evidence of documented wound care orders to the left wrist and elbow or the right wrist. A subsequent physician order entry revealed an initial order of wound care to the right wrist on February 3, 2026.A review of the progress notes on February 3, 2026 revealed no documentation regarding any wounds to the wrist(s) or left elbow.An observation was conducted on February 4, 2026 at 8:12 AM. Resident #78 was observed seated in his wheelchair. The dressing to his right wrist was observed to be securely in place with a date and initial displayed on the bandaging; however, the dressing to the left wrist and elbow showed no evidence of a date or staff initial.A follow-up review of the physician orders revealed an order dated February 4, 2026 noting wound care to the right wrist, left elbow and left wrist area. Indicating that the areas should be cleaned with wound cleanser, patted dry and a foam dressing applied twice a day as needed.An interview was conducted on February 4, 2026 at 8:01 AM with staff #43 RN (registered nurse). Staff #43 stated that the wound team rounds every Wednesday and that orders outside of Wednesday, regarding wound care, are addressed by the nursing staff. Staff #43 stated that post ordered wound care, all bandages are required to be dated and initialed. Staff #43 stated that if they are not dated and initialed, you would not know when the dressing was last changed or who changed it. Staff #43 stated that for each wound site an order needs to be in place. The RN stated that if wound care is conducted during an outside appointment, nursing staff review the documentation from the appointment and conduct a head to toe assessment when the resident returns from the appointment. The RN stated that that if orders for wound care were not in place for each wound, the risk could include a wound not being cared for and a potential for infection.An interview was conducted on February 4, 2026 at 8:30 AM with staff #2 RN. Staff #2 stated that wound care orders are required for each wound. Staff #2 stated that if orders were not in place for each wound, that there could be a chance for infection, since the wound care would not be addressed. Staff #2 stated that all wounds need to be looked at, including those that a resident may have been admitted with. Staff #2 further stated that all dressings should have a date and the initial of the nurse who conducted the wound care. Staff #2 pulled up the electronic health record for resident #78 and stated that she had asked the doctor yesterday for wound care orders for the right wrist, after she was notified of the lose bandage. She stated that she did not know why the dressing was not dated or initialed, but stated that it should have been. Staff #2 further stated that this morning she had noticed a few more areas, but stated that she wasn't sure how long these dressings had been in place. Staff #2 reviewed the record again and stated that there were no orders in place for the left wrist or left elbow. Staff #2 stated that the risk for not having orders in place can include the doctor not being aware of the wound, improper monitoring of the wound and the risk of infection.A telephone call was placed on February 4, 2026 at 8:45 AM to staff #73 LPN (licensed practical nurse), who conducted the initial admission assessment. A message was left on the voicemail, but no return call was received.An interview was conducted on February 4, 2026 at 9:09 AM with staff #85 ADON (assistance director of nursing). Staff #85 stated that if a resident has a wound on admission, then it would be identified in the admission assessment and orders would need to be put in place. Staff #85 stated that if wound care was conducted during an offsite appointment, then nursing staff would confirm that orders were put in place. Staff #85 stated that any bandaging/ dressings have to be documented in the electronic health record and have corresponding orders. Staff #85 further stated that per facility policy all dressings are required to have a date and initial of the staff who completed the wound care or observation. The ADON stated that if dates and initials on the dressing were not in place that the risk could include a worsening of the wound, progression or regression of the wound and or infection. Staff #85 pulled up resident #78 in the electronic health record and confirmed the new orders for the right wrist but stated that she did not see any orders for the left wrist and elbow. She further reviewed the electronic health record and stated that she did not see any entries indicating when the dressings were applied and by who. Staff #85 stated that this did not meet her expectations and stated that the risks wound include the wound(s) not being monitored, not healing and the risk for infection. Staff #85 further stated that orders always need to be in place to provide treatment/ services. An interview was conducted on February 4, 2026 at 10:00 AM with staff #75 (Wound Care Nurse). Staff #75 stated that she was not aware when the injuries to the wrist(s) and elbow occurred. She stated that the nurse, staff #2, had made her aware of the missing orders, dates and initials and that she was in the process of creating education for staff regarding wound dressings. She stated that the expectation would be to have orders in place, documentation of the wound and that dressings are dated and initialed. She stated that the risk would include not knowing what happened, who provided the care and what was done.A review of the facility policy titled Documentation of Wounds, version F1008, revealed that the licensed nurse assigned to each individual patient will be responsible for completing all daily monitoring, treatments and weekly skin assessments on the day and shift indicated. The policy further noted that eh licensed nurse will sign that he/ she has completed the assigned daily monitoring and treatment. A review of the facility policy titled Standards of Professional Nursing Practice, version A0717, revealed the American Nurses Association standards of practice documented as 1-16, noting that registered nurses collect comprehensive data pertinent to the healthcare consumer's health or situation, implements coordination of care, evaluates progress towards attainment of outcomes, contributes to quality of nursing practice.A review of the facility policy titled Charting Requirements, version E0325, revealed that all new admits will be charted on every shift for the first 72 hours and daily thereafter. Charting for new admissions noted a head to toe assessment. The policy further documented that daily charting will include a thorough head to toe assessment, in addition to alert charting including any incident or acute medical issues and that treatment nurses will be responsible for charting on each treatment they complete including condition of site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure sufficient staffing regarding provision of a caregiver / sitter to meet a resident's (#69) needs. The deficient practice could place the resident at risk for physical or psychosocial harm, or place a resident at risk of undue financial burden of having to provide the staffing out-of-pocket for themselves.Findings include:Resident #69 admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, metabolic encephalopathy, type 2 diabetes mellitus without complications, and other abnormalities of gait and mobility.An admission Nursing Observation assessment dated [DATE], revealed Resident #69's preferred language was a language other than English, and the document revealed unable to determine whether the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Additionally, the resident had unclear speech-slurred or mumbled words, was sometimes understood, and sometimes could understand others' verbal communication.A Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 1, indicating severe cognitive impairment.A baseline care plan dated January 9, 2026, revealed Resident #69 had an alteration in communication, with a goal that the resident's needs would be met daily. The care plan revealed that the resident had a language barrier, and had aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult. The care plan revealed that the check boxes for a communication board, written communication, and/or translation application were not checked.A Provider Notification progress note dated January 10, 2026, revealed Resident #69 would not take any medications or allow her blood sugar to be checked that morning. A language communication board was used but the resident pushed medications away from her and tried to wheel herself away from nursing staff with one arm. The note revealed that staff attempted to provide education on risks / benefits to the resident, but unable to verify understanding due to language barrier. There was no evidence of attempts to use an interpreter or a translator application.A Nursing note dated January 11, 2026, revealed Resident #69 was alert and uncooperative, and had an unwitnessed fall. The note revealed a certified nursing assistant (CNA) found the resident on the ground next to her bed sitting upright while holding her call light in her hand. The documentation revealed the resident was asked what happened but was unable to provide any information about the fall.The care plan revealed no evidence of updates or added interventions to address the resident's fall on January 11, 2026.A Nursing note dated January 13, 2026, revealed the resident had a fall, and was found next to the bed on the floor, and was unable to describe the event. The note included that the provider was notified of the resident's fall.The care plan revealed no evidence of updates or added interventions to address the resident's fall on January 13, 2026.A Nursing note dated January 14, 2026, revealed at 6:15 a.m., two CNAs attempted to change the resident, and the resident was observed screaming, kicking, scratching staff, and refusing medications and blood sugar checks at times. The documentation revealed the resident was redirected, and was changed. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 12:10 p.m., revealed Resident #69 was observed attempting to get out of bed and stand by herself without assistance, and when staff tried to assist the resident, the resident smacked staff's arm and gestured with her hand to move and get out. The note revealed that additional staff were able to assist the resident into the wheelchair. The note included that the resident started throwing things onto the floor and into the trash, including the resident's leg brace, sensor pad, and wheelchair pad. There was no evidence of notification to the provider of the resident's behaviors.A Nursing note dated January 14, 2026, at 9:38 p.m., revealed Resident #26 remained combative and refused all care and medications. There was no evidence of notification to the provider of the resident's continued behaviors.A Nursing note dated January 14, 2026, at 9:52 p.m. revealed Resident #60 had 3 unwitnessed fall events that evening alone. The note revealed that the resident would not allow any staff to touch her and continued to be very distressed and seemed unable to be safe at that time, and that the provider was notified.The care plan was reviewed and revealed no evidence of updates to the care plan regarding communication with the resident whose primary language was a foreign language other than English, and no evidence of any interventions to include attempts to use a translator application or interpreter.A Nursing note dated January 14, 2026, at 9:59 p.m. revealed that a psychiatric consult was ordered for Resident #69. The note included that the resident's family was contacted and urged to sit bedside with her or hire someone to sit bedside with her 24/7 for the resident's safety. The note revealed that the resident's family stated that they were located out of town and unable to hire someone that evening. The note included that the family was informed to speak with management tomorrow for a plan of action. Additionally, the note revealed that the resident was refusing all medications that evening, was sitting on the floor and refusing to get back in bed, refusing staff to come near her, was not receptive to redirection, and appeared comfortable at that time. The documentation revealed no evidence of attempts to use a language communication board, or an interpreter, or a translator application.The care plan was reviewed and revealed no evidence of a revision or added intervention specifying the need for 1 to 1 sitter or caregiver 24/7.A Nursing note dated January 14, 2026, at 10:10 p.m. revealed that the physician ordered to send the resident to the hospital.A Nursing note dated January 14, 2026, at 10:26 p.m. revealed Resident #69 had barricaded herself in the room, and that staff were attempting to get into the room in order to check on her, and that the physician was aware. There was no evidence that the facility had provided a sitter or caregiver as was previously recommended 24/7.A physician order dated January 14, 2026, included for a psychiatric consult, and to discharge the order when completed.A Nursing note dated January 15, 2026, at 1:05 a.m., revealed transportation arrived to take the resident to the hospital at 10:45 p.m., and that due to it being an all male crew, it was requested per their supervisor to wait to exchange care with a female crew, and that an all female crew arrived at 12:05 p.m.An Acute Care Transfer nursing progress note dated January 15, 2026, at 1:05 a.m., revealed the resident was transferred to the hospital due to having 3 unwitnessed fall events on evening shift, and the resident was unable to answer questions.A Nursing progress note dated January 15, 2026, at 4:27 a.m. revealed Resident #69 returned to the facility with no findings per the hospital Emergency Department (ED), and had no injury and no evidence of urinary tract infection (UTI) or other abnormal lab results. Additionally, the documentation revealed the resident was resting comfortably in bed.A Social Services progress note dated January 15, 2026, at 9:48 a.m., signed by the administrator (Staff #81), revealed that the administrator spoke with the resident's son and stated concerns about the resident's safety and need for a caregiver with her from 4:00 p.m. to 6:00 a.m. The note revealed that the son stated he will plan to take her home with him or have her stay with her brother for safety reasons, but revealed no evidence of a timeframe for a planned discharge. The note revealed that the administrator shared with the resident's son information for a private caregiver company for hire in case the son needed it for that night. The note revealed that the son stated at worst, he would be at the facility by tomorrow to take Resident #69 home.The care plan was reviewed and revealed no evidence of a revision or added intervention specifying the need for 1 to 1 sitter or caregiver between the hours of 4:00 p.m. to 6:00 a.m.A Nursing progress note dated January 15, 2026, at 9:54 p.m., revealed Resident #69 had direct 1 to 1 supervision with a private sitter, and that the resident refused medications, blood glucose checks, and a skin check. The note revealed that the resident was calm and not calling out. The note included no evidence of attempts to use a language communication board, or an interpreter, or a translator application.A Discharge BIMS assessment dated [DATE], revealed the Resident had a score of 4, indicating severe cognitive impairment.A Notice of Transfer or Discharge document, revealed the reason for discharge was the resident's needs cannot be met in the facility.The clinical record was reviewed, and revealed no evidence of a physician note stating that the resident was not safe to remain in the facility or that the resident's needs could not be met in the facility.A Discharge progress note dated January 16, 2026, revealed Resident #69 left the facility at 11:20 a.m. to discharge home and that transportation was provided by the resident's son, and the resident's family was made aware of the resident's continued refusal of medications.A telephonic interview was conducted with Resident #69's son on February 4, 2026, at 8:45 a.m. who stated that he was called by facility staff on January 15, 2026, informing him that Resident #69 could no longer stay at the facility because she was resisting staff and was difficult at night. The son stated that the facility staff stated that the only condition that the resident could stay in the facility the night of January 15, 2026, was if the resident had a family member who could stay overnight with the resident or if the resident's family hired a private sitter to come to the facility overnight with the resident. The son stated he was panicking because he lived out of town and could not be there, and stated that he did not want the facility to kick her out to the curb, so he hired a private caregiver / sitter to stay with the resident overnight on the night of January 15, 2026. The son stated that he had to pay for the sitter out of pocket, because the facility staff had told him that the facility could not provide that level of one to one care. The son stated he found out about Resident #69's discharge on [DATE], and had to come to the facility the morning of January 16, 2026, to pick her up.An interview was conducted on February 5, 2026, at 9:59 a.m. with a licensed practical nurse / discharge nurse (LPN / Staff #88) who stated that Resident #69 had met her therapy goals, and completed her skilled stay. The clinical record was reviewed, and Staff #88 then stated that Resident #69 was given notice of discharge on [DATE], and that the resident was alert, of sound mind, and could make her own decisions. Additionally, Staff #88 stated that Resident #69 had a rushed discharge because of safety concerns, because the resident was combative, was refusing therapy, and the resident needed a caregiver/sitter between the hours of 4:00 p.m. to 6:00 a.m. Staff #88 stated that the facility administrator (Staff #81) had informed the resident's son that there needed to be a sitter in the facility with the resident from 4:00 p.m. to 6:00 a.m., and that there was not a facility staff who could sit with the resident then, and that the resident's son could not provide the sitter in order for the resident to stay longer in the facility.An interview was conducted with a licensed practical nurse (LPN / Staff #10) who stated that he had cared for Resident #69, and that the resident could understand very basic things, but did not speak English, and would have bouts of confusion and was impulsive and very forgetful. Staff #10 stated that from his experience, the resident's behaviors never became too much for staff to handle, and that she was able to calm down with staff interventions.An interview was conducted with the Rehab Service Manager and Activities Director (Staff #5) on February 5, 2026, at 9:24 a.m., who stated that Resident #69 primarily spoke a foreign language other than English, and that he did not know of a language interpreter service or translator service that the facility had.An interview was conducted with the administrator (Staff #81) on February 5, 2026, at 10:17 a.m. who stated that the facility is equipped to care for residents with cognitive impairments, dementia, and/or behaviors by first pre-screening residents prior to admission to ensure the residents are appropriate for the facility, and additionally by discussing possible interventions with resident's family, physicians, and care team members to ensure the appropriate interventions are in place for those residents. The administrator stated that the facility staff can provide more frequent checks on a resident, such as every 30 minutes, however if the resident required one on one care, that would be above the scope of the facility. In the case that a resident would require one on one supervision for safety, the administrator stated that the facility could provide a sitter for a very short period of time, up to a few hours, but if a sitter were needed longer than that, then a pamphlet for caregivers for hire is then provided to a resident's family, so that the family could hire a sitter to stay with the resident at the facility. The administrator stated that ultimately, he is responsible for ensuring sufficient and competent staff to meet the needs of the residents. Regarding Resident #69, the administrator stated he remembered the resident. The administrator stated the resident became progressively more confused over the course of her stay at the facility, and reverted back to speaking her native foreign language other than English, and that with that came the challenges of her participation in therapy. The administrator stated he contacted the resident's son, who lived out of town in another city, and informed the resident's son that the resident required above what we are able to care for and informed the son that Resident #69 needed a sitter / caregiver for safety. The administrator stated that the son stated that he could not come to the facility, and the administrator stated that he informed the resident's son that the facility could not provide a sitter, and then gave the son information for a private caregiver company to hire a sitter. The administrator stated that he believed the son hired a private caregiver for Resident #69 just during the night hours, for the two days prior to the resident's discharge.An interview was conducted with a registered nurse / Assistant Director of Nursing (RN / ADON / Staff #85) on February 5, 2026, at 10:33 a.m. who stated if a resident had impaired cognition or dementia and had behaviors, then staff would re-orient the resident to the room, perform additional safety checks, ask the resident's family for assistance and to provide re-assurance to the resident, and if needed, refer the resident and the family to an outside caregiving company for additional caregiver support. Staff #85 stated that the facility did have staff who could act as a sitter for a resident who needed one, however the additional staffing would have to be approved through the administrator first. Additionally, Staff #85 stated that a resident with behaviors could be referred for a psychiatric consult, which would provide the resident with additional interventions such as activities or medications to assist with managing the resident's behaviors. Regarding Resident #69, Staff #85 stated that she remembered the resident primarily spoke a foreign language other than English, and that the resident could understand some English. Staff #85 stated that the facility did not have a translator or interpreter service, but that there was a sign with some pictures on it to help identify basic wants or needs of a resident. The clinical record was reviewed, and Staff #85 stated that a psychiatric consult was ordered on January 14, 2026, but that the resident did not receive it before she was discharged on January 16, 2026. Staff #85 stated based on reviewing the clinical record, that Resident #69 needed a sitter. Additionally, Staff #85 stated that when the resident returned from the hospital on January 15, 2026, that it appeared that the resident had calmed down and was resting comfortably in bed with no behaviors.A telephonic interview was conducted with a registered nurse (RN / Staff #146) on February 5, 2026, at 12:00 p.m. who stated that she recalled Resident #69, and that she received report from the previous shift staff that the resident had some aggressive behaviors, and that during her shift, the resident had some episodes of refusing some care, and that she observed the resident throw some of her equipment onto the floor. Staff #146 stated that the resident was able to be calmed down and redirected, and that she felt the resident was appropriate for the facility. Staff #146 also stated that she did not know the extent of the resident's language barrier or how much of the communication the resident could understand.An interview was conducted on January 5, 2026, at 12:20 p.m. with the Director of Nursing (DON / Staff #86), who stated that regarding behavioral services, the facility has two psychiatrist providers and a psychologist to assist residents who are having behavioral problems. The DON stated that including a psychiatric provider can be beneficial to a behavioral resident because the provider would discuss additional interventions, recommendations, or medications if necessary, and that would be added to the resident's care plan. Additionally, the DON stated that the psychiatric provider can perform emergency visits if needed. Regarding Resident #69, the DON stated that she was not very familiar with the resident, and that prior to the day the resident was discharged , the DON stated she received a call from the nurse that the resident had barricaded herself in her room, and the nurse had to walk around the outside of the building to look into the resident's window to ensure the resident was safe.Review of the facility policy on staffing (undated and untitled) revealed that the facility does not adjust staffing based on fluctuation in census. The facility considers both census and acuity levels that impact staffing needs and staff accordingly. Census and patient acuity are discussed daily in stand-up meeting. If the resident population contains higher acuity residents, additional staff are added. The facility has the ability to hire sitters as needed. Additionally, the policy revealed if the facility experiences an event that requires additional resources but does not require activation of the Emergency Plan, off-duty staff will be called in to provide additional support as needed. If necessary, the facility has contracts in place for temporary agency personnel. The facility is also able to use resources from sister facilities as needed. The policy revealed a re-statement that the facility has the ability to hire sitters as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of observations, staff interviews, and policy and procedures the facility failed to ensure that one resident's (#86) medication/treatments were not left at bedside. The universe was 52 and the sample was 16. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include:An observation of Resident #86's room was conducted on February 3, 2026 at 11:45 AM. Two containers of ZAL cream were observed on the counter next to the sink, in the resident's room. The containers were observed with pharmacy label attached. When interviewed the resident stated that she applied the ZAL cream herself on her buttocks and labia. The resident stated that she had been cleared to use the cream, and that staff knew that she was using the cream since her admission. The resident also stated that one of the containers was empty. There was no evidence of a lockbox for medications at the bedside.Resident #86 was admitted on [DATE] with diagnoses that included Sjogren syndrome, urinary tract infection, Type 2 diabetes mellitus.An admission Observation assessment form dated January 28, 2026 revealed that the resident was alert/oriented to person, place, time, situation.Orders dated January 28, 2026 through February 3, 2026 revealed no evidence of provider orders regarding medication/treatment self-administration.Further review of provider orders revealed no evidence of an order for ZAL cream from January 28, 2026 through February 3, 2026.Review of the clinical record revealed that the admission Minimum Data Set assessment had been submitted, and was still in process. However, a Brief Interview of Mental Status (BIMS) form dated January 28, 2026 revealed a score of 13, which indicated that the resident was cognitively intact.A care plan revealed evidence of the following areas of focus:Altered skin integrityIndwelling catheterThe care plan revealed no evidence of a focus or interventions regarding self-administration of medication/treatments.Provider orders dated February 4, 2026 were written for:4 ounces of equal parts topical lidocaine 3%, zinc oxide 20% ointment, Vitamin A/D ointment; sparingly topical, 1 application twice a day; preventative per patient request.ZAL topical cream (zinc oxide/A&D/Lidocaine), twice a day.Another observation of the resident's room was conducted on February 5, 2026 at 7:45 AM. A container of ZAL ointment was observed on the counter next to the sink, along with a box of Baqsimi (glucagon), and there was no evidence of a lockbox for medication storage at the bedside. An interview was conducted on February 2, 2026 at 3:53 PM with a Certified Nursing Assistant (CNA/staff #57), who stated that it is not ok for medications or treatments (creams/ointments) to be left in the resident's room at bedside, and if she observed this she would immediately tell the nurse. The CNA further stated that residents are not supposed to have any medications/creams unattended at the bedside, and staff should also report to the nurse when a family member/visitor/resident brings any medications/creams/ointments into the facility. An interview was conducted on February 5, 2026 at 8:08 AM with a Licensed Practical Nurse (LPN/staff #10), who stated that residents can have ointments left unattended at the bedside, but a nurse would apply the ointment, unless there was a provider order that the resident may self-administer. He reviewed the resident's clinical record and stated that there were no orders for medication/treatment self-administration. The LPN entered the resident's room along with the surveyor and stated that there was a box of Baqsimi nasal spray (glucagon) sitting on the counter, next to the sink, unattended. The LPN stated that this is generally kept in the medication cart and should not have been left in the resident's room unattended. He also stated that he observed a container of ZAL (zinc oxide, vitamin A & D cream, topical BID (twice a day), and the label on the container was from the acute care hospital. The LPN stated that he did not know that these medications were in the resident's room, and that neither of the medications should have been left unattended in the resident's room without a provider order. The nurse stated he talked to provider about the ZAL cream yesterday, February 4, 2026, and received an order for 4% lidocaine, zinc oxide and A & D ointment. The LPN reviewed the resident's provider order and stated that there was no evidence of a physician order for ZAL ointment, and that 4% lidocaine was ordered by the provider on February 4, 2026, or orders for Baqsimi nasal spray or [NAME] cream to be self-administered. The LPN stated that leaving medication/ointments unattended at the bedside did not meet the facility standard, and the risk could result in medication error.An interview was conducted on February 5, 2026 at 8:25 AM with the Director of Nursing (DON/staff #86), who stated that when residents request to self-administer medications/ointments, nurses are expected to conduct an observation to determine if the resident knows how to administer the mediation, the medication/ointment needs to be kept in a lock box. The DON stated that the observation would be documented on a form that is found the observation tab on a form titled AHC Self Medication Administration observation. The DON also stated that a provider order would be required prior leaving any medications/creams/ointments in a resident's room for medication self-administration. The DON reviewed the resident's clinical record and stated that there was no evidence of a nursing administration observation form for medication self-administration at the bedside. The DON stated that there was a standing order to administer glucagon, but there was no order to store the medications/cream at bedside, and there was evidence of a provider order for ZAL cream dated February 4, 2026. However, the DON stated that there was no provider order for ZAL cream to be left at the bedside. The DON stated that she would have expected that staff would have noticed the Baqsimi and ZAL cream unattended in the resident's room. She stated that this did not meet her expectations and could result in another resident taking the medications.An interview was conducted on February 5, 2026 at 8:44 AM with CNA (staff #38), who stated that the resident was assigned to him for care today, but he had not observed any medications on the residents sink counter when he was providing care this morning.A policy titled, Administration of Medication, Version F0505, revealed that licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. A Policy titled, Self-Medication Administration, version A1014, revealed that patients may self-administer medications if it is determined that they are capable of doing so in a safe and consistent manner. As part of their overall evaluation, staff will assess each patient's mental and physical abilities to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, staff will perform a more specific skill assessment utilizing the Self-Medication Administration Assessment form which includes the patient's ability to read and understand medications labels, comprehension of the purpose/proper dosage and administration time for his/her medications. the Self-Medication Administration Assessment form will be maintained in the medical record. Patients requesting to self-administer medications will be assessed as above. Staff shall identify and remove any medications found at the bedside that are not authorized for bedside storage, for proper storage or return to the family or responsible party.A policy titled, Medication Orders, Version B0113, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and policy review, the facility failed to ensure opioid medication regimen was administered according to physician's ordered parameters for one patient (#8). The deficient practice could result in the side effects of exacerbated respiratory failure or cause life-threatening breathing problems.
Findings:
The subacute rehab patient (#8) was admitted on [DATE] with diagnoses of GLF-ground level fall, acute respiratory failure with hypoxia, lobar pneumonia, single subsegmental thrombotic pulmonary embolism, gastrostomy, acute embolism and thrombosis of right distal lower extremity, edema, acute post hemorrhagic anemia, adult failure to thrive, dementia. History of breast cancer.
An admission 5-day Minimum Data Set (MDS) included the patient's Brief Interview for Mental status (BIM) score of 12 out of 15 which indicated the resident was moderately impaired. The MDS also included the resident experienced frequent pain and was receiving (PRN) as needed pain medication.
A physician's order dated September 03, 2024 included oxycodone 5 mg tablet every 6 Hours PRN 5 mg, gastric tube, Every 6 Hours - PRN, Pain parameters 8-10/10
Review of the Medication Administration Record (MAR) and the opioid oxycodone PRN pain management treatment was administered to patient outside of the provider's ordered pain level parameters of 8-10 of a pain scale 1-10. There is no evidence or documentation within the clinical records that the physician had been notified when oxycodone was administered outside of ordered perimeters on dates:
9/04/2024 at 19:09 for pain level 7
9/11/2024 at 19:41 for pain level 7
9/12/2024 at 19:33 for pain level 6
9/16/2024 at 21:04 for pain level 5
9/18/2024 at 19:14 for pain level 7
9/19/2024 at 02:16 for pain level 7
An interview was conducted on September 26, 2024 12:51 PM with nurse (#28) who stated about pain management opioid treatment, that if a patient has an order for pain medication, the patient has a related pain scale with parameters, and it is the facility policy and procedures to follow physician orders as written including parameters. Nurse referred to patient #8's oxycodone order having the pain scale of 1-10, and she stated that the opioid is prescribed for 8-10 pain level treatment on patient provider's order and that the floor nurse would only administer that opioid treatment if the patient's pain is within that range of 8-10 parameters. But, if the patient requested the opioid medication and their pain level is not within the prescribed 8-10 perimeters, then the nurse would call the patient's physician for clarification, then put in a new order or parameter change and document the change in either the MAR or progress note, or both locations.
Nurse #28 stated patient #8's oxycodone, that the oxycodone was given outside of provider's 8-10 pain level perimeters order and she counted six times this occurred from 9/4/24-9/19/24. She stated that the order is written for the pain scale of 8-10 and the medication should have been administered only for the pain levels in that range. She further stated, that when a medication is administered outside of provider's orders, the physician would be notified, and if a new one-time order was received, there should be documentation of a change in the current order or parameter. Nurse #28 reviewed the progress notes on patient #8 and stated there were no related notes that the physician had been notified nor a note of a change in orders. The Nurse (#28) expressed that the risk of administering an opioid outside of the ordered parameters could result in the resident becoming lethargic, respiratory distress, and the doctor would not know or beaware.
Interview was conducted September 27, 2024 08:15 AM with the Director of Nursing (DON staff #119) who stated, the facility's expectation of opioid oxycodone being dispersed to patient would be to follow the MD's (Medical Doctor's) orders, including parameters. The Director of Nursing expressed that the facility has a policy in place, that pain medication at times can be administer outside of parameters with documentations in place, or note that the opioid medication was requested by the patient and the MD is informed. Furthermore, that documentation should be in nursing progress note or within the patient's MAR, and it is expected that the nurses document in progress notes all MD order changes or parameter changes. Director of Nursing stated, the orders are changed to patient's needs by the physician.
DON mentioned that she did talk to nurse #28 on September 26, 2024 and they reviewed patient #8's MAR of the six times oxycodone medication that were given to patient outside of parameters. DON stated she did not see any orders to change those parameters, nor identified any nursing progress note of a nurse calling MD to change parameters nor change the order. DON stated, she expects the nursing to notified the physician and document, and that the risk of not following the MD administration order, is that the MD would not be aware.
Review of facility's policy Pain Management revealed that patients will be assessed for intensity of pain by utilizing a standard pain scale of 0-10 and the physician will be notified for further orders/interventions and asked to clarify parameters based upon pain intensity. Documentation of PRN medications will be documented on the EMAR. Additionally, the EMAR will prompt the administering nurse to include the reason given, location, and intensity of pain as per the 0-10 scale or FLACC numerical score prior to administration. The policy notes, it is not the purpose of this policy to neither dictate physician orders nor contradict current standards of care. Optimal pain control shall be determined with respect to patient goals in collaboration with the interdisciplinary team and the patient's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338).
Findings include:
Resident #338 was admitted on [DATE] with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety.
A review of clinical record Minimum Data Set (MDS) is still in process.
During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking.
A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand.
During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea.
An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas.
An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation.
The facility's policy Resident Rights included that (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338).
Findings include:
Resident #338 was admitted on [DATE] with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety.
A review of clinical record Minimum Data Set (MDS) is still in process.
During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking.
A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand.
During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea.
An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas.
An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation.
The facility's policy Resident Rights included that (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect. The deficient practice could lead to residents suffering from psychosocial harm.
Findings include:
Resident #4 was admitted to the facility on [DATE] with a diagnosis of orthostatic hypotension and fracture of vertebrae.
Resident #20 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease.
Resident #60 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia.
An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied you're dry and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, if you don't do things at his pace then he just does if for you. Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over. There really isn't any compassion from him and that is a real problem.
Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care.
An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's,
Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway. When asked if she had personally interviewed the resident, she stated no, I didn't have to because my nurse reported it to me. When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said that's what I get paid to do. Resident didn't like that he said it and he didn't want the CNA in his room anymore, so we made sure of this. When this author asked if it was the same CNA in both incidents,. Staff #101 stated Actually, yes, it was now that I think about it.
An interview was conducted on September 10, 2024 at 6:40 PM with Resident #4. She stated Well, I don't want to get anyone in trouble but I don't like Staff #42. He's rude, uncaring and full of himself. He's good looking and he knows it type attitude. I need help getting up because I have orthostatic blood pressure and he had an attitude and said to me why don't you have a fall bracelet on? Staff #42 said you should have a fall bracelet on if you need help getting up. So, I asked one of the nurses here about it and she said they don't even have fall bracelets here, so what is that guy talking about! He's never been inappropriate with me but I'd prefer he does not come into my room.
An interview was conducted on September 10, 2024 at 7:00 PM with Resident #60. When asked why he filed a grievance on September 9, 2024, he stated well, he (Staff 342) came in here because I rang the call bell because my commode needed emptied. He came in and said it's a win-win, I get paid and you get taken care of. What kind of a statement is that? He's very uncaring, he's rude and I think all he cares about is money. I mean we are people that are having a hard time right now and need some help and someone is here and just cares about money. Actually, he took my commode out of the room, which I though was weird but when he returned it he said I was rude to him. So I said I was sorry if he misunderstood anything I said, but I apologized to him! Can you believe that? So, the next day I spoke with what's his name, the big boss (Staff #101) and told him what happened and that I did not want him back in my room. I just don't trust him and I'm not sure what he is really capable of.
An interview was conducted, via phone, on September 11, 2024 at 11:40 AM with RN, (Registered Nurse),
Staff #108. When asked if she received any complaints from any residents on the night of September 5th and 6th, she stated yes. Resident #20 said that the CNA, (Staff #42), changed his brief and did not do peri-care. Then on the 6th, in the morning, the same CNA at about 4:00 AM came into the room and did not wake him and just checked his brief. He woke up and said what are you doing?' and the CNA said I'm checking your brief. Resident #20 said it was more of an attitude problem. When asked if Resident #20 told her that he felt like he was groped, she stated what is groped? It was explained that groped means when someone grabs your genital area without permission and feels you in an inappropriate manner. She then stated oh no, he did not say that. Afterwards I talked to the management team, Staff #105, about the incident. Staff #105 told me to talk to the CNA and she would hold a class so this does not happen again. That's all I know.
The facilities policy on Resident Rights, Version A0717, states Respect and Dignity-The resident has a right to be treated with respect and dignity.