Artesia Palms Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure facility staff accurately documented in the clinical record for one of five sampled residents (Resident 1) when Resident 1 had multiple prior attempts to elope (an unauthorized departure of a patient from an around-the-clock care setting) from the facility, but documentation indicated he did not attempt to elope.This failure of inaccurate documentation posed a risk for staff not identifying Resident 1 as an elopement risk, which could delay timely interventions and place Resident 1 at risk for injury or death due to unsupervised exit from the facility.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities) and generalized anxiety disorder (a mental health condition where a person experiences excessive, persistent worry or fear that is out of proportion to the situation and hard to control, interfering with daily life).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from staff for his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 9/14/2025 and timed at 7:03 a.m., the SBAR indicated Resident 1 was observed attempting to jump over a facility fence. Facility staff (unknown) immediately approached Resident 1 and redirected him away from the area.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 9/14/2025 and timed at 11:10 a.m., the form indicated Registered Nurse Supervisor (RNS) 1 documented in the History of Elopement Attempts section (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. RNS 1 did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope earlier that day (9/14/2025). During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 9/29/2025, the Minimum Data Set Coordinator (MDSC) documented in the History of Elopement Attempts (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. The MDSC did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025.During a review of Resident 1's SBAR dated 11/02/2025 and timed at 2:25 a.m., the SBAR indicated Resident 1 was observed attempting to elope by trying to climb over a facility fence behind the east building. The SBAR indicated Resident 1 was attempting to use a bedside table (a mobile, height-adjustable C or H shaped table designed to roll under and over beds and chairs) to assist him in climbing the fence. The SBAR indicated Certified Nursing Assistant (CNA) 1 immediately intervened, redirected Resident 1 to his room, and removed the bedside tables from the area.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 11/2/2025 and timed at 8:51 a.m., the Assistant Director of Nursing (ADON) documented in the History of Elopement Attempts (Section F) that Resident 1 expressed he planned to leave the facility but had not attempted to do so. The ADON did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025 and on 11/2/2025.During a review of Resident 1's Elopement and Wandering Risk Observation/Assessment form dated 11/17/2025, RNS 1 documented in the History of Elopement Attempts (Section F) that Resident expressed he planned to leave the facility but had no attempted to do so. RNS 1 did not document in Section F that Resident 1 had made one or more elopement attempts within the past year, as Resident 1 had attempted to elope on 9/14/2025 and on 11/2/2025.During an interview on 3/18/2026 at 12 p.m., the Director of Nursing (DON) stated Resident 1's Elopement and Wandering Risk Observation/Assessment forms were completed incorrectly. The DON stated after Resident 1's first elopement attempt on 9/14/2025, the facility staff should have accurately indicated on the Elopement and Wandering Risk Observation/Assessment forms dated 9/14/2025, 9/29/2025, 11/2/2025, 11/17/2025, and 11/21/2025 Resident 1's actual attempt to elope by jumping over a fence and indicating prior attempts. The DON stated the assessment forms documented by facility staff provided an inaccurate depiction of Resident 1's history.During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, dated 1/2026, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to Identify and to intervene in one of three sampled residents' (Resident 10) history of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again).This failure had the potential to result in Resident 10 experiencing unnecessary re-traumatization.Findings:During a review of Resident 10's admission record, the admission record documented Resident 10 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and legal blindness (a level of visual impairment that makes it difficult to perform daily tasks, even when using regular glasses, contact lenses, medication, or surgery). The admission record documented, Resident 10 had a public guardian (a government official appointed by a court to protect and manage the personal care, finances, and living arrangements for vulnerable adults).During a review of Resident 10's History and Physical (H&P), dated 3/26/2025, the H&P documented, Resident 10 was alert and oriented to self, place, and time.During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool), dated 9/30/2025, the MDS documented Resident 10 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, bed mobility and moderate assistance (Helper does less than half the effort) from one staff for hygiene care, shower, dressing, transfer.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 10's Care Plan Report, revised 10/21/2025 was reviewed. The Care Plan Report Focus documented, Resident 10 was at risk for psychosocial/emotional trauma related to history of stressful events or experiences (PTSD). The Care Plan Report Goal documented, Resident 10 would express feelings of safety and security in the environment. The Care Plan Report interventions documented, the staff help Resident 10 to identify triggers that prompt symptoms. RNS 2 stated, Resident 10's Care Plan Report did not indicate what specific the triggers were for Resident 10. RNS 2 stated, the staff should identify Resident 10's triggers of PTSD. RNS 2 stated, the Care Plan Report interventions would not be individualized without identifying what might trigger Resident 10 to experience re-traumatization. RNS 2 stated, it was important to identify the triggers and implement interventions that were individualized according to Resident 10's needs to prevent re-traumatization.During a concurrent interview and record review on 12/10/2025, at 2:04 p.m., with the Social Service Director (SSD), Resident 10's Social Service Initial admission assessment dated [DATE] was reviewed. The Social Service Initial admission Assessment documented, Resident 10 was diagnosed with PTSD related to homelessness. The Social Service Initial admission did not indicate, documentation of a PTSD assessment on Resident 10. The SSD stated, Resident 10's public guardian mentioned Resident 10 was getting assaulted by her ex-boyfriend when she was homeless. The SSD stated, Resident 10 was concerned with being out on the street and homeless. The SSD stated, the staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization from the triggers to prevent recurrent events. The SSD stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. The SSD stated, he would refer the resident to proper services according to the trauma assessment to prevent re-traumatization.During an interview on 12/11/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, it was important to identify Resident 10's PTSD triggers to prevent re-traumatization and provide the appropriate care. The DON stated, when a resident who has PTSD as a part of their diagnoses was admitted to the facility, the SSD should assess for triggers, and history to prevent re-traumatization. The DON stated re-traumatization would harm Residents' psychosocial well-being.During a review of Resident 10's Behavioral Health Progress Note, dated 12/3/2025, the Behavioral Health Progress Note documented, Resident 10 met the criteria for PTSD. The Behavioral Health Note documented, there was no documentation regarding the triggers of PTSD, and its severity During a review of the facility's Policy and Procedure(P&P) titled, Trauma Informed Care and Culturally Competent Care, revised 8/2025, the P&P documented, Purpose : To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .General Guidelines: 1. Traumatic events which may affect residents during their lifetime include: a. physical, sexual and emotional abuse .f. forced displacement . 3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized .Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments . Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 17 of 91 resident rooms' met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room.This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents.Findings:During a review of the facility's Client Accommodations Analysis form, provided by the facility on 12/9/2025 and revised 12/11/2025, the facility had 17 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms. The residents' rooms were as follows:[NAME] East Unit.Room T1 (4 beds) 305.75 sq. ft. Room T3 (4 beds) 305.25 sq. fl. Room T8 (4 beds) 298.75 sq. fl. Room T10 (5 beds) 360.5 sq. ft. Room T12 (4 beds) 305.25 sq. fl. Room T14 (4 beds) 314.5 sq. ft. Room T15 (4 beds) 314.5 sq. ft. Room T17 (4 beds) 314.5 sq. ft. Room T18 (4 beds) 305.25 sq. ft. Room T20 (4 beds) 305.25 sq. ft.[NAME] Unit.Room T21 (4 beds) 305.25 sq. ft. Room T23 (4 beds) 314.25 sq. ft. Room T27 (4 beds) 314.25 sq. ft. Room T29 (4 beds) 314.5 sq. ft. Room T30 (4 beds) 314.5 sq. fl. Room T32 (4 beds) 314.25 sq. ft. Room T34 (4 beds) 318.25 sq. ft.During observations, from 12/8/2025 through 12/11/2025, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident room size did not affect the nursing care or privacy provided to the residents.During an interview on 12/11/2025 at 12:25 p.m., the Administrator (ADM) stated the facility was aware 17 rooms did not meet the 80 sq. ft. requirement for multi resident rooms. The ADM stated it was important to ensure each resident had enough space and the staff were able to provide resident care with enough room to move around.During a review of the facility's policy and procedure (P&P) titled, Bedrooms, revised 1/2025, the P&P documented, Policy Interpretation and Implementation: 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet of space per resident in double rooms.3. Each room is designed to provide full visual privacy for each resident and equipped for adequate nursing care.

Based on observations, interviews and record review, the facility failed to ensure:26 residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed textured bread a form that meets their needs and in accordance with the international Dysphagia Diet Initiative-level 4 (IDDSI -a framework made up of levels and describes food textures and drink thickness) level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy and liquid seeping out, not smooth and had small pieces of bread crust present requiring chewing before swallowing.This failure had the potential to result in meal dissatisfaction and increased choking risk for 26 out of 166 residents who received the pureed bread from the facility kitchen.Findings:During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 12/8/2025 at 11:52AM, the pureed bread looked lumpy, and milk floating on top while in a pan on the steam table.During the same observation and interview with [NAME] (cook2) indicaon 12/8/2025 at 11:52AM, Cook2 stated the pureed bread is bread mixed with milk and blended a little, it is like bread soaked in milk.During a concurrent interview and taste test of the pureed bread with Dietary Supervisor (DS), Registered Dietitian (RD1) and Registered Dietitian (RD2) on 12/8/2025 at 1:45PM, the pureed bread had a lumpy texture. There were small pieces of bread in the pureed bread and bread residue stayed in the mouth. DS stated the consistency of the pureed bread is not smooth and some bread stays in the mouth; DS stated the bread needs a little more blending. DS stated residents on pureed diet can have difficulty swallowing and need to drink liquid to clear the mouth.During an interview with Cook2 on 12/8/2025 at 2:00PM, cook2 stated cook 2 did not blend the bread as long as the other pureed foods. Cook2 stated the bread was mixed with milk and blended so it's soft. Cook2 stated sliced white bread was used to make the pureed bread. Cook2 stated the pureed bread is not smooth because it was not blended long time.During a review of the facility recipe titled Pureed (IDDSI Level 4)Breads, cakes, cookies, pancakes and other bread products (dated 2025) the recipe documented, puree bread on low speed adding milk gradually.the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline documented that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test.

Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 37) was provided with floor mats on each side of the bed, as ordered by the physician. This failure put Resident 37 at a higher risk for injury in the event of a fall.During a review of Resident 37's admission Record, the admission record documented the facility readmitted Resident 37 on 7/23/2025, with diagnoses including muscle weakness and paranoid schizophrenia (a mental disorder characterized by delusions and auditory hallucinations).During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS documented Resident 37 had moderate cognitive (thought process) impairment and transfers were not attempted due to medical condition.During a review of Resident 37's untitled plan of care revised date 10/21/2025, the care plan documented, (resident) was at risk for falls and injuries due to risk factors: use of psychoactive (medications that affect the mind/brain) drugs, poor safety awareness, impaired mobility, psychiatric (diseases of the mind) conditions: schizophrenia Interventions included, Resident 27 was a high risk for falls with or without injuries and was on the fall prevention program.During an observation on 12/8/2025 at 10:30 a.m., Resident 37 was observed in bed with bed in low position and a floor mat on the right side of the bed, but not the left side.During an observation on 12/9/2025 at 09:31 a.m., Resident 37 was observed in bed with bed in low position and a floor mat on the right side of the bed, but not the left side.During an observation, interview, and concurrent record review with Licensed Vocational Nurse (LVN) 1 on 12/10/2025 at 8:20 a.m., Resident 37 was observed in bed with a floor mat on the right side and not the left side of the bed. LVN 1 stated Resident 3 was a fall risk. LVN 1 reviewed Resident 37's Order Summary Report. The Order Summary Report documented Resident 37 had an order dated 9/23/2025 for, bilateral (both) floor mats for safety and security. LVN 1 stated Resident 37 should have a floor mat on the left side of the bed also. LVN 1 stated the purpose of floor mats is for safety and to prevent injury.During an interview and concurrent record review with the Director of Nursing (DON), Resident 37's medical record was reviewed. The DON stated Resident 37 had an order for bilateral floor mats, and that should have been implemented right away. The DON stated not having the ordered bilateral floor mats could lead to injury related to a fall. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program Policy and Procedure, revised 11/10/2025, the P&P documented the facility's goal is to reduce the number of falls with injury in the facility by implementing resident centered care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monitoring orders were completed and documented as 'complete' as ordered by the physician for one of 35 sampled resident (Resident 47).This deficient practice had the potential to result in unmet medical needs and increased risk of adverse health outcomes for Resident 47.Findings: During a review of Resident 47's admission Record, the admission Record documented Resident 47 was admitted to facility on 2/25/2025 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), dysphagia (difficulty swallowing), type 2 diabetes (a condition where the body does not use insulin effectively or does not produce enough insulin leading to high blood sugar level) and a history of falling.During a review of Resident 47's Minimum Data Det (MDS- a resident assessment tool) dated 9/3/2025, the MDS documented Resident 47's cognition (ability to make decisions of daily living) was severely impaired. The MDS documented Resident 47 needed Setup or clean-up assistance or supervision for activities of daily living such as hygiene, toileting, and getting dressed.During a review of Resident 47's Order Summary Report dated 12/2/2025, the Order Summary Report documented the following orders:- Monitor for bleeding, discolored urine, black tarry (black, sticky shiny indicating blood) stools, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy (feeling weak, tired no energy), bruising, sudden changes in mental status and/or visible signs of shortness of breath, nose bleeds due to antiplatelet (medication to prevent blood clots)- Monitor behavior, document number of episodes of target behavior (continuous calling out without cause) per shift, due to mood stabilizer (Depakote), prescribed for mood disorder manifested by continuous calling out without cause. -Monitor for signs and symptoms of hyperglycemia (high blood sugar level) for diagnosis of type 2 diabetes such as increased thirst and a dry mouth, needing to pee frequently, tiredness, blurred vision, intentional weight loss, recurrent infections such as thrush, bladder infection and skin infection and notify MD immediately every shift for hyperglycemia.-Monitor for signs or symptoms of Hypoglycemia (low blood sugar level) for diagnosis of type 2 diabetes including irritable, confused behavior, moist pale skin, shallow breathing, tremors, sweating and full bounding pulse and notify MD immediately-Monitor/document/report to MD for signs and symptoms of dehydration (occurs when the body uses or loses more fluid than it takes in) including decreased or no urine output, concentrated urine (dark colored urine), strong odor, tenting skin (skin does not return to normal after being pinched) cracked lips, furrowed tongue (grooves or cracks on tongue's surface) new onset confusion, dizziness on sitting/standing, increased pulse (heart rate), headache, fatigue/weakness, dizziness, fever, thirst, recent sudden weight loss, dry sunken eyes every shift.-Monitor pain level every shift-Monitor vital signs (basic measurements of body's essential functions including blood pressure, temperature, pulse, respirations and oxygen level) every shiftDuring a review of Resident 47's Medication Administration Record (MAR) for December 2, 2025, the MAR did not document the above monitoring orders were completed as ordered during the night shift from 11:00 p.m. to 7:00 a.m.During a concurrent interview and record review on 12/11/2025 at 11:30 a.m., with the Director of Nursing (DON), the DON verified the findings and stated that the monitoring orders should be carried out by the licensed nurses as ordered by the physician to prevent delays in care and delivery of appropriate interventions.During a review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration revised 12/2025, the P&P documented that the Electronic Medication Administration Record (eMAR) will be utilized to ensure accurate and timely documentation of all medication administrations and associated physician-ordered monitoring requirements. The eMAR will clearly reflect monitoring orders prescribed by the physician, including but not limited to vital sign monitoring, behavioral monitoring, and other clinically documented assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 7) related to failing to revise and update fall prevention interventions recommended during the Interdisciplinary team (IDT-a group of different experts who work together to help the residents with complex needs) meeting regarding actual fall incidents 8/6/2025 and 8/30/2025 for Resident 7.These failures had the potential to result in Resident 7 and 10's needs not being met, affecting the residents' well-being, and poor patient outcomes.Findings:During a review of Resident 7's admission Record, the admission Record documented, Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and history of falls.During a review of Resident 7's, Psychiatric Follow up Note, dated 11/26/2025, the Psychiatric Follow up Note documented, Resident 7 had limited judgement and insight (understanding) and was oriented to person only.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 8/27/2025, the MDS documented Resident 7 required maximal assistance (Helper does more than half the effort) from one staff for dressing, shower, moderate assistance (Helper does less than half the effort) from one staff for hygiene, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, eating, and transfers. During a concurrent interview and record review on 12/10/2025, at 10:44 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 7's IDT Note, dated 8/7/2025 was reviewed. The IDT Note documented, Resident 7 was found sitting on the floor on the left side of his bed on 8/6/2025 with redness on right upper back. The IDT Note documented, IDT meeting recommended to initiate a care plan for falls, provide proper footwear, bilateral (both) landing mats, continue on falling star program (identify individuals at high risk for falls, using visual cues like yellow gowns, armbands, or door signs to alert staff for extra precautions like bed alarms, closer monitoring, and assistance requests), low bed while in bed resting. RNS 2 stated, all these IDT meeting recommended interventions should be reflected in Resident 7's care plan.During a concurrent interview and record review on 12/10/2025, at 10:50 a.m., with RNS 2, Resident 7's IDT Note, dated 9/2/2025 was reviewed. The IDT Note documented, Resident 7 was found on the floor sitting on his bottom facing the television in the dining room on 8/30/2025. The IDT Note documented, IDT meeting recommended to initiate care plan, continue falling star program for safety measures, place Resident 7 on one-to-one sitter (1:1 sitter- a dedicated staff member assigned to continuously watch a specific high-risk patient in a healthcare setting to prevent falls, self-harm, or harm to others) for safety, and encourage Resident 7 to utilize a wheelchair when tired. RNS 2 stated, all IDT recommended interventions should be reflected in Resident 7's care plan to prevent future incidents of fall.During a concurrent interview and record review on 12/10/2025, at 10:55 a.m., with RNS 2, Resident 7's Care Plan Report, initiated 8/22/2025 and revised 12/8/2025 was reviewed. The Care Plan Report Focus documented, Resident 7 was a high risk for falls. The Care Plan Report Goal documented, Resident 7 will have minimal complications related to falls to extent possible. The Care Plan Interventions documented, place the call light within reach, encourage to participate in activities, encourage to use assistive device during ambulation, evaluate medications for side effects, place floor mats, keep bed in low position, keep personal items frequently used within reach, and provide proper footwear. RNS 2 stated, the care plan interventions did not include: the falling star program, the 1:1 sitter, the wheelchair use, and initiate/revise the care plan for actual fall. RNS 2 stated, the staff should initiate or revise the care plan after the actual fall incident of 8/30/2025. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 4/2023, the P&P documented, Statement: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Interpretation and Implementation include: 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT) . 6. The interdisciplinary team should review and update the care plan: a. When there has been a significant change in the resident's condition . c.At least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 10) by failing to identify triggers of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and develop individualized interventions for Resident 10.These failures had the potential to result in Resident 10's needs not being met, affecting the residents' mental and physical well being. Findings:During a review of Resident 10's admission record, the admission record documented Resident 10 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and legal blindness (a level of visual impairment that makes it difficult to perform daily tasks, even when using regular glasses, contact lenses, medication, or surgery). The admission record documented, Resident 10 had a public guardian (a government official appointed by a court to protect and manage the personal care, finances, and living arrangements for vulnerable adults).During a review of Resident 10's, History and Physical (H&P), dated 3/26/2025, the H&P documented, Resident 10 was alert and oriented to self, place, and time.During a review of Resident 10's minimum data set (MDS a resident assessment tool), dated 9/30/2025, the MDS documented Resident 10 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, bed mobility and moderate assistance (Helper does less than half the effort) from one staff for hygiene care, shower, dressing, transfer.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 10's Care Plan Report, revised 10/21/2025 was reviewed. The Care Plan Report Focus documented, Resident 10 was at risk for psychosocial/emotional trauma related to history of stressful events or experiences (PTSD). The Care Plan Report Goal documented, Resident 10 will express feelings of safety and security in the environment. The Care Plan Report interventions documented, the staff to help Resident 10 to identify triggers that prompt symptoms. RNS 2 stated, Resident 10's Care Plan Report did not indicate what triggers Resident 10 had. RNS 2 stated, facility staff should identify Resident 10's triggers of PTSD (instead of Resident 10 to identify her own triggers) as Care Plan Report interventions documented. RNS 2 stated, the Care Plan Report interventions were not specific to Resident 10 and did not identify what triggers Resident 10 to experience re-traumatization. RNS 2 stated, it was important to identify the triggers and implement interventions that were individualized according to Resident 10's needs to prevent re-traumatization.During a concurrent interview and record review on 12/10/2025, at 2:04 p.m., with the Social Service Director (SSD), Resident 10's Social Service Initial admission Assessment, dated 3/24/2025 was reviewed. The Social Service Initial admission Assessment documented, Resident 10 was diagnosed with PTSD related to events during homelessness. The Social Service Initial admission did not indicate documentation regarding a PTSD assessment for Resident 10. The SSD stated, Resident 10's public guardian mentioned that Resident 10 was assaulted by her ex-boyfriend. The SSD stated, Resident 10 was concerned with being out on the street, homeless. The SSD stated, the staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization from the triggers to prevent recurrent events. The SSD stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. The SSD stated, he would refer the resident to the proper services according to the trauma assessment to prevent re-traumatization. The SSD stated, Resident 10's care plan was not person centered because there was no proper assessment done for the trauma.During an interview on 12/11/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, the resident's care plan is the specific resident's plan of care, and it should be implemented as it stated. The DON stated, care plan interventions should be implemented and reevaluated. The DON stated care plan interventions were from IDT meeting and should be implemented to prevent recurrent events or problems.During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 4/2023, the P&P documented, Statement: A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Interpretation and Implementation: 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT) . 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure minimum data set (MDS a resident assessment tool) assessments were coded accurately for two of 35 sampled resident (Resident 2 and Resident 20). -The facility failed to ensure Resident 20 who has a diagnosis of diabetes mellitus (DM a condition where the body can not process sugar normally and may lead to poor wound healing) was coded accurately.-The facility failed to ensure Resident 2's treatment for DM was coded accurately. These failures had the potential for Resident 2 and Resident 20 not receiving an individualized plan of care based on the resident's specific needs and treatment.a.During a review of Resident 20's admission Record, the admission Record documented Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of DM, hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 20's Order Summary Report, dated 5/24/2025, the Order Summary Report documented a physician order for Novolin Flex-pen (a convenient, prefilled insulin [medication used to assist the body process sugar] delivery device) 100 unit per milliliter (u/mL, a unit of measurement) solution pen injector inject as per sliding scale (the amount of insulin to be administered changes up or down based on the individual's blood sugar) subcutaneously (under the skin) before meals and at bedtime for DM.
During a review of Resident 20's MDS, dated [DATE], the MDS documented Resident 20 was severely cognitively (thinking process) impaired, and required supervision (helper provides verbal cues and/or touch assistance) with self-care abilities such as eating, hygiene, bathing and putting on clothes and required supervision with mobility such as sit to stand and transfers. The MDS did not indicate Resident 20 had an active diagnoses of DM, and was receiving insulin injections seven days a week.
During a concurrent interview and record review on 12/11/2025 at 9:07 a.m., with the MDS Coordinator (MDSC), Resident 20's admission Record, Order Summary Report dated 5/24/2025, and the MDS dated [DATE] were reviewed. The MDSC stated Resident 20 had a diagnosis of DM and was receiving insulin injections seven days a week. The MDSC stated the MDS was not coded (did not indicate) Resident 20 had DM. The MDSC stated the importance of accurate MDS assessment was that DM was a major diagnosis and Resident 20 was receiving medication for the diagnosis. The MDSC stated the MDS should reflect the current medical status of the resident, it should coincide with his diagnosis and the medication he was receiving.
During a concurrent interview and record review on 12/11/2025 at 11:25 a.m., with the Director of Nursing (DON), Resident 20's MDS dated [DATE] was reviewed. The DON stated the MDS assessment was an inaccurate assessment of the resident, and the coding should be accurate. The DON stated the importance of accurate MDS coding was the overall accuracy of what the resident has (diagnosis and care needs), the status of the resident and medical services provided and if it was miscoded, it did not display what the resident had.
During a review of the facility's policy and procedure (P/P), titled Resident Assessments, revised January 2024, the P/P documented the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.all persons who have completed any portions of the MDS resident assessment form must sign the document attesting to the accuracy of such information.information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations and interviews.
b. During a review of Resident 2's admission Record, the admission Record documented Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including DM.
During a review of Resident 2's MDS dated [DATE], the MDS documented Resident 2's cognition was severely impaired. The MDS documented Resident 2 was receiving insulin injections 7 days a week.
During a review of Resident 2's Order Summary Report dated 11/16/2025 to 11/30/2025, the Order Summary Report documented an order of Jardiance (medication to regulate blood sugar levels) oral tablet 25 mg for the treatment of DM. There was no order for insulin injections.
During a concurrent interview and record review on 12/11/2025 at 9:35 a.m. with the MDSC, the MDSC stated Resident 2 had a diagnosis of DM and no orders for insulin injections. The MDSC stated Resident 2 had an oral medication for the treatment of diabetes mellitus. The MDSC stated insulin was inaccurately coded on Resident 2's MDS assessment dated [DATE].
During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised 1/2024, the P&P documented information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 154). This deficient practice had the potential for a delay of care for Resident 154. Findings: During a review of Resident 154's admission Record, the admission Record documented Resident 154 was admitted to the facility 5/12/2010 with diagnoses including Parkinson's disease (a movement disorder of the nervous system that worsens over time) and quadriplegia (unable to move all four limbs). During a review of Resident 154's communication care plan dated 7/24/2025, the care plan documented Resident 154 had altered communication as evidenced by: hearing problem, problems with making self understood, no speech, problem understanding others, dementia (severe cognitive decline affecting memory, thinking, language, and problem-solving). The goal of the care plan was to ensure Resident 154's needs would be met daily. Interventions of the care plan included keeping the soft touch call light (a button is activated with a very light touch which then alerts the caregiver that assistance is needed) with in reach at all times. During a review of Resident 154's Minimum Data Set (MDS, a resident assessment tool) dated 10/9/2025, the MDS documented Resident 154 was severely impaired in daily decision making and never or rarely made decisions. The MDS documented Resident 154 was dependent (helper does all of the effort) for all activities of daily living (ADLs, self-care tasks like bathing, dressing, eating, using the toilet, and moving around, essential for independence). During an observation on 12/8/2025 at 10:25 a.m., Resident 154's soft touch call light (a call light that requires minimal touch to operate) was hanging over Resident 154's tube feeding pump (a medical device that is used to deliver nutrients directly into the gastrointestinal (GI) tract of a patient who is unable to take food or liquids orally) at the side of her bed and not within reach of Resident 154. During an interview on 12/11/2025 at 11:37 a.m., the Director of Nursing (DON) stated a soft touch call light was used for residents that are not able to traditionally call for help using a regular call light. The DON stated the soft touch call light was very sensitive so when it is within resident reach it will activate at the slightest movement to indicate to the staff the resident may need assistance. The DON stated the soft touch call light handing over the tube feeding pump defeated the purpose because it would not pick up the residents movement. The DON stated it was important to ensure call lights were within reach for safety and to ensure residents had access to assistance when needed. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light dated 10/2010, the P&P documented when the resident was in bed be sure the call light was within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 7) by failing to define and monitor resident specific, measurable target behaviors related to the use of Seroquel [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] For Resident 7.The deficient practice of failing to ensure an antipsychotic medication was used to treat a specific, diagnosed condition, and failing to monitor target behaviors related to the use of psychotropic medication increased the risk that Resident 7 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 7's admission Record, the admission Record documented, Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 7's Psychiatric Follow up Note, dated 11/26/2025, the Psychiatric Follow up Note documented, Resident 7 had limited judgement and insight (understanding) and was oriented to person only.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 8/27/2025, the MDS documented Resident 7 required maximal assistance (Helper does more than half the effort) from one staff for dressing, shower, moderate assistance (Helper does less than half the effort) from one staff for hygiene, and supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, eating, transfer. During a review of Resident 7's Order Summary Report, dated 12/10/2025, the Order Summary Report documented, give one tablet Seroquel 50 milligram (mg) by mouth at bedtime for schizoaffective disorder manifested by delusional thoughts/difficulty to redirect was ordered on 6/5/2025.During a concurrent interview and record review on 12/10/2025, at 10:38 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 7's Medication Administration Record (MAR), dated from 9/2025 to 12/2025 was reviewed. The MAR documented, to monitor behavior episodes for Seroquel (antipsychotic [mediation that affects the brain]) use related to schizoaffective disorder, manifested by delusional (having false or unrealistic beliefs) thoughts and difficulty to redirect. The MAR documented, Resident 7 had behavior episodes of delusional thoughts/ was difficult to redirect on 9/28/2025 (two episodes), 9/30/2025 (two episodes), 10/3/2025 (two episodes), 10/10/2025 (2 episodes), 11/1/2025 (one episode), 11/4/2025 (one episode), 11/5/2025 (one episode), 11/6/2025 (two episodes), and 11/9/2025 (one episode). RNS 2 stated, she was not sure what delusional thoughts Resident 7 had. RNS 2 stated, difficulty redirecting could be caused by dementia related behavior. RNS 2 stated, target behavior should be specific and measurable, so the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to and consider Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RNS 2 stated, staff should monitor specific target behaviors. During a phone interview on 12/10/2025, at 4:09 p.m., with Psychiatric Nurse Practitioner (PNP)1, PNP 1 stated, he ordered Seroquel for schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by paranoia (an irrational and intense distrust or suspicion of others, believing they intend to harm you, even without evidence) thoughts that people want to harm him (Resident 7). PNP 1 stated, he did not know why the staff were monitoring delusional thoughts and difficulty to redirect as target behaviors. PNP 1 stated, those are not resident specific target behaviors. PNP 1 stated, he disagreed with doing a GDR on 11/2025, because there are many behavioral episodes reported in the months of November. PNP 1 stated, he realized the staff were monitoring the wrong target behaviors. PNP 1 stated, Seroquel could be an unnecessary medication, and considered a chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition). PNP 1 stated the Seroquel should be tapered down as soon as possible to avoid adverse reaction (an undesired or harmful effect of a drug) and chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition).During an interview on 12/10/2025, at 11:25 a.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnosis. The DON stated, delusional thoughts could be many things, and this should be clarified with PNP 1. The DON stated, monitoring specific target behavior was important, because GDR would be performed based on this data. The DON stated, inaccurate data would lead to delays in treatment, and the resident continuing to receive unnecessary medication. The DON stated, the resident might suffer from unnecessary side effects/adverse reactions. The DON stated, unnecessary medication could be used as chemical restraint as well.During a review of Resident 7's, Psychiatric Follow- up Notes, dated on 7/30/2025, 8/31/2025, 9/28/2025,10/26/2025,11/26/2026 documented by PNP 1, the Psychiatric Follow- up Notes documented, Seroquel 50 milligram (mg) at bedtime for schizophrenia manifested by paranoia thoughts that people want to harm him (Resident 7).During a review of Resident 7's, Note to Attending Prescriber for GDR, dated 11/24/2025, the Note to Attending Prescriber for GDR documented, PNP 1 responded to the GDR request by marking Disagree on 11/24/2025.During a review of Resident 7's, Order Summary Report, dated 12/10/2025, the Order Summary Report documented, monitor behavior episodes of antipsychotic use (Seroquel) related to schizoaffective disorder manifested by delusional thoughts/difficulty to redirect was ordered on 7/25/2025.During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive / Psychotropic Medication Use, dated 1/2025, the P&P documented, Policy Interpretation and Implementation: 1. General Guidelines: b. Residents will only receive Psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. c. The Attending Physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. d. The Attending Physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of Psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1, who discovered a resident on the floor, following an unwitnessed fall (8/21/2025), reported the resident's fall and did not place the resident back in bed prior to a licensed nurse's assessment for one of three sampled residents (Resident 1) reviewed for falls. When the facility was made aware of Resident 1's unwitnessed fall, they failed to conduct a neurological (a series of simple tests to see how well your brain, spinal cord, and nerves are working) assessment, per their policy and procedure (P/P) titled, Neurological Assessment (Routine). These deficient practices resulted in a delay in care (assessment, pain management, evaluation) and transfer to a General Acute Care Hospital (GACH) on 8/22/2025 for continued evaluation and treatment. These deficient practices had the potential for unrecognized injuries as well as unrecognized changes in Resident 1's neurological status. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was moderately impaired and required moderate assistance (helper does less than half the effort) with activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of the facility's Investigation Binder, dated 8/22/2025 and timed at 12:45 a.m., the Investigation Binder indicated CNA 1 documented, Resident 1 was trying to get into bed, then assisted him back into his bed. Continued Documentation in the Investigation Binder by Licensed Vocational Nurse (LVN) 2 indicated, Resident 1 reported that he rolled out of bed, fell to the floor and then began to get up by himself. Resident 1 reported the assigned CNA (CNA 1) saw him while trying to go back to bed and assisted him. During an interview on 9/16/2025 at 9:50 a.m., Resident 1 stated he rolled off his bed onto the floor, there were no staff was present, but stated a female employee (CNA 1) came in and assisted him back to bed. Resident 1 stated he told another staff (LVN 2) later that afternoon he had fallen. During an interview on 9/17/2025 at 11:18 a.m., the Assistant Director of Nursing (ADON) stated he was not made aware of Resident 1's fall until 5 p.m., on 8/21/2025 when Registered Nurse Supervisor (RNS) 2 reported it to him. The ADON stated he should have conducted a more thorough investigation of Resident 1's unwitnessed fall. During an interview on 9/17/2025 at 1:34 p.m., LVN 2 stated if Resident 1 was assisted back to bed by CNA 1, CNA 1 should have reported it to the supervisor. LVN 2 stated, she was first made aware of Resident 1's fall when Resident 1 informed her at approximately 5 p.m., on 8/21/2025 that he had fallen at 1 p.m., that afternoon (8/21/2025) and she immediately reported it to her supervisor. During a review of the facility's Certified Nurse Assistant (CNA) Job Description, the CNA Job Description indicated, Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practicable. Report all accidents and incidents you observe on the shift they occur. The facility was unable to provide a P/P indicating steps to take when a resident is found on the floor. b. During an interview on 9/17/2025 at 8:11 a.m., LVN 3 stated a neurological check should be done following a resident's fall to monitor and assess for possible cognitive changes in the resident. During a concurrent interview and record review on 9/17/2025 at 10:45 a.m., with the Medical Records Supervisor (MRS), the MRS provided Resident 1's Neurological Assessment, which indicated Resident 1's neurological assessment was not initiated after Resident 1's fall was reported to LVN 2 on 8/21/2025 at 5 p.m., and prior to Resident 1's transfer to the GACH on 8/22/2025. During a concurrent interview on 9/17/2025 at 11:18 a.m., after reviewing Resident 1's Neurological Assessment, the ADON stated Resident 1's neurological status was not assessed after learning he had fallen, but it should have been done. The ADON stated neurological checks were important because they identified abnormalities in the resident's cognitive function which could possibly lead to a stroke (occurs when blood flow to the brain is interrupted) or a bleed in the brain. During an interview on 9/17/2025 at 2:24 p.m., the Director of Nursing (DON) stated a neurological assessment should be initiated after an unwitnessed fall or trauma to the head and one should have been initiated for Resident 1 after learning he had fallen. During a review of the facility's P/P, titled, Neurological Assessment (Routine) dated 1/2025, the P/P indicated the purpose of this procedure is to provide guidelines for conducting a routine neurological assessment to evaluate the resident for small changes over time that may be indicative of neurological injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by one of three sampled residents (Resident 1), when Resident 1 punched Resident 2 in the face on 10/31/2025. This deficient practice resulted in Resident 2 sustaining a left periorbital (area around the eye socket) discoloration, discoloration on the bridge (bony, elevated area between the eyebrows and the tip of the nose) of his nose, a left eyebrow skin tear, and a left dorsal (backside) fifth digit (finger) skin tear. Resident 2 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment and was assessed with a mildly depressed nasal bone fracture (a facial injury where the nasal [nose] bones are broken and pushed inward or backward, often causing a noticeable indentation or deformity of the nose) and a left periorbital hematoma (a collection of blood outside of a blood vessel, typically caused by an injury that ruptures the vessel). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), paranoid schizophrenia (the presence of intense paranoid delusions [having false or unrealistic beliefs of persecution and unwarranted suspicion], and hallucinations [sensory experiences like seeing, hearing, or smelling things that aren't real, yet feel very real]), and a generalized anxiety disorder (mental health condition characterized by pervasive worry and fear). During a review of Resident 1's Minimum Datra Set ([MDS] a resident assessment tool), dated 8/13/2025, the MDS indicated Resident 1 had a moderate cognitive (thought process) impairment. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure (when the heart cannot pump enough blood to the body), COPD, paranoid schizophrenia, bipolar disorder (a disorder that causes mood swings ranging from the lows of depression to elevated periods of emotional highs), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. During a review of Resident 2's Change of Condition Evaluation, dated 10/31/2025 and timed at 12:34 a.m., the COC evaluation indicated Certified Nurse Assistant (CNA) 2 heard an altercation while in the hallway of Resident 1 and Resident 2's shared restroom and witnessed Resident 2 lying on his back, on the floor, with Resident 1 standing over Resident 2. Residents 1 and 2 were separated immediately and put on one-to-one monitoring ([1:1] continuous, close supervision of a resident). The COC Evaluation indicated Emergency Medical Services (911) were called. During a review of Resident 2's Nursing Comprehensive Skin Evaluation/Assessment, dated 10/31/2025 and timed at 1:52 a.m., the Nursing Comprehensive Skin Evaluation/Assessment indicated Resident 2 was observed with the following: 1. Left periorbital discoloration, measuring 7.0 centimeters ([cm] a unit of measurement) by 9.0 cm, with mild redness, localized swelling, and dark purple in color. 2. Nose bridge discoloration, measuring 2.0 cm by 2.0 cm, dark purple in color. 3. Left eyebrow skin tear measuring 0.5 cm by 1.0 cm, presented as a dry scab (protective crust that forms over a wound) with mild redness. 4. Left dorsal fifth digit skin tear, measuring 0.5 cm by 0.5 cm, presented as dry scab with mild redness. During a review of Resident 2's Nurse's Notes, dated 10/31/2025 and timed at 10:28 a.m., the Nurse's Notes indicated Resident 2's physician ordered Resident 2 to be transferred to a GACH for evaluation and treatment related to a physical altercation. During a review of Resident 2's 72 Hours Charting, dated 10/31/2025 and timed at 12:19 p.m., the 72 Hours Charting indicated Resident 2 was transferred to a GACH at approximately 12:15 p.m., for evaluation and treatment. During a review the of the facility's Five Day Follow Up Report, dated 11/4/2025, the Five Day Follow Up Report indicated on interview with Resident 1, Resident 1 stated he was using the restroom when his roommate (Resident 2) opened the door and walked in. Resident 1 stated, I told him to get out but Resident 2 refused to leave the restroom and came towards him (Resident 1). Resident 1 stated at that point he made contact with Resident 2. During a review of the GACH's ED (Emergency Department) Provider Notes, dated 10/31/2025 and timed at 12:48 p.m., the ED Provider Notes indicated Resident 2 presented with eye trauma after he (Resident 2) walked in on his roommate (Resident 1) in the bathroom and was punched by Resident 1. During a review of the GACH's Computerized Tomography ([CT] a type of imaging that uses X-ray techniques to create detailed images of the body) scan without contrast (scan performed without using a contrast agent [specific dye to highlight specific tissues, organs, or blood vessels]), dated 10/31/2025 and timed at 12:38 p.m., of Resident 2's head, the CT scan indicated the following: 1. A mildly depressed nasal bone fracture. 2. A left periorbital hematoma. During an interview on 11/12/2025 at 6:32 a.m., Resident 2 stated Resident 1 was taking too long to use the toilet (Resident 2 unable to provide details). Resident 2 stated Resident 1 punched him (Resident 2) in the face once and pushed him backwards and he (Resident 2) fell back onto the floor. During an interview on 11/12/2025 at 8:55 a.m., the Assistant Director of Nursing (ADON) stated Resident 1 punched Resident 2 in the face after Resident 2 walked in the bathroom while Resident 1 was still using it. The ADON stated Resident 2 sustained skin tears on his left little finger, his left eyebrow, and had facial discoloration. The ADON stated Resident 2 was transferred to a GACH for evaluation and treatment. The ADON stated the altercation between Residents 1 and 2 was considered physical abuse and residents had the right to be free from abuse. During an interview on 11/12/2025 at 9:40 a.m., the Director of Nursing (DON) stated residents have the right to be free from abuse because it can damage the residents' physical and mental wellbeing. The DON stated Resident 2 sustained injuries from the physical altercation between him and Resident 1. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised 1/2025, the P&P indicated residents have the right to be free from abuse and this includes physical abuse. The P&P indicated there was a facility wide commitment to protect residents from abuse from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to developed a person centered care plan for two of 25 sampled residents (Residents 68 and 205).
This deficient practice had the potential for the resident's care needs not to be addressed related to the use of clonazepam.
Findings:
1) During a review of Resident 205's admission Record, the admission Record indicated Resident 205 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a nervous system disorder causing severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a nervous system disorder causing mild or partial weakness on one side of the body) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time causing tissue damage) affecting left dominant side.
During a review of Resident 205's Minimum Data Set ([MDS] a resident assessment tool) dated 5/5/25, the MDS indicated Resident 205's cognition (ability to make decisions of daily living)was moderately impaired, without impairment to upper extremities and lower extremities, but dependent on facility staff for toileting hygiene, lower body dressing and transfers.
During a review of Resident 205's Physician'ss Order Summary Report dated 4/30/2025, the Physican's Order Summary Report indicated the resident may have 1/4 bilateral (both)upper side rails per responsible party's request for safety.
During a concurrent interview and record review on 6/12/2025 at 9:10 a.m., with Registered Nurse (RN) 1, RN 1 stated the care plan developed for Resident 205's side rails did not specify which device to use. RN 1 stated the care plan should address the use of partial bed rails or grab bars.
During an interview on 6/13/2025 at 10:48 a.m., with the Director of Nursing (DON), the DON stated the care plans should be individualized or personalized based on the specific care needs of the residents. The DON stated the care plan for Resident 205 should have addressed the use of grab bars.
2. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses including anxiety (a mental condition characterized by excessive apprehensiveness about real or perceived threats, typically leading to avoidance behaviors and often to physical symptoms).
During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was moderately impaired.
During a review of Resident 68's Physican's Order Summary Report dated 6/9/2025, the Physican's Order Summary Report indicated to administer clonazepam 0.5 mg one tablet by mouth for anxiety. Hold if sedated.
During a concurrent interview and record review on 6/12/2025 at 08:54 a.m., with RN 1, Resident 68's medical record was reviewed. RN 1 stated a care plan should be developed for clonazepam use for Resident 68 which includes behavior and side effects monitoring, for Resident 68.
During an interview on 6/13/2025 at 11:05 a.m., the Director of Nursing (DON) stated the care plan for the clonazepam, which should include the monitoring the behavior and side effects, should have been initiated when the physician's order for clonazepam was carried out.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/2025, the P&P indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a new diagnosis of schizophrenia (a mental illness characterized by hallucinations [hearing or seeing things that are not there] or delusions [firmly held beliefs that are untrue despite evidence otherwise]) was based on evidence-based criteria (such as the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-5] criteria) consistent with professional standards affecting one of five residents sampled for unnecessary medications (Resident 209.)
This deficient practice of failing to use evidence-based criteria consistent with professional standards to make a new diagnosis of schizophrenia increased the risk that Resident 209 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status and also increased the risk that Resident 209 could have experienced difficulty in transferring to or from other facilities or other psychosocial harm related to the stigma associated with a diagnosis of schizophrenia.
Findings:
During a review of Resident 209's admission Record (a document containing a resident's diagnostic and demographic information), dated 6/12/25, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life.)
During a review of Resident 209's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 5/28/25, indicated it was unclear whether Resident 209 had the capacity to make medical decisions.
During a review of Resident 209's Physician Order Summary (a monthly summary of all active physician orders), dated 6/11/25, indicated, on 5/27/25, he was prescribed the following psychotropic medication:
1.
Risperdal (an antipsychotic medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) to take 1 tablet by mouth two times a day for schizophrenia manifested by agitation leading to non-compliant with ADLs (activities of daily living such as bathing and brushing teeth) care and medication.
During a review of Resident 209's Psychiatric Follow-Up Note (a clinical progress note summarizing care provided by a psychiatric provider), dated 5/3/25 and authored by the psychiatric nurse practitioner (NP 3), indicated Resident 179 had confusion and disorganized thoughts and was admitted to hospital for aggressive behavior and noncompliant to medication and treatment plan. NP 3 documented Patient with past medical and psychiatric history of schizoaffective disorder (a mental illness with similar symptoms to schizophrenia but also involving mood disturbances such as depression or mania), dementia . NP 3 further documented Per staff, patient focuses on 'going home' and gets irritated easily when redirected and Patient is unable to recall any previous psychiatric history. Further review of the psychiatric progress note indicated there was no discussion of how NP 3 determined Resident 209 had a history of schizoaffective disorder, no indication that NP 3 involved Resident 209's daughter and Responsible Party (FM 1) in order to obtain a reliable psychiatric history and no discussion of how dementia was ruled out as a cause of Resident 209's symptoms and behaviors. NP 3 finally documented Resident 209's principal problem was schizoaffective disorder and documented Patient agrees to be on Risperdal 0.5 mg BID (twice daily) after discussing the case with the supervising physician and psychiatrist (MD 1.)
During a review of Resident 209's admission Documents (documents containing demographic and treatment records from previous facilities), dated 4/16/25, indicated when he was previously a resident at a different facility, he did not have a history of schizophrenia, schizoaffective disorder, or antipsychotic medication use.
During a telephone interview on 6/10/25 at 4:12 PM with FM 1 (Resident 209's daughter), FM 1 stated Resident 209 does not have any history of schizophrenia or schizoaffective disorder or any other mental illness prior to his admission to this facility. FM 1 stated, in his prime, Resident 209 was mentally very sharp and used to work for the secret police in his home country. FM 1 stated she was informed about the new diagnosis of schizoaffective disorder when the resident was recently hospitalized in May 2025 for behavioral issues. FM 1 stated a nurse from this facility called her for permission to start the Risperdal during his readmission to the facility. FM 1 stated her father has a history of dementia which has presented challenges in his care and so she gave permission to use the Risperdal because she trusted the facility was using it appropriately. FM 1 stated Resident 209 does not have any history taking this type of medication prior to his admission to this facility.
During a telephone interview on 6/11/25 at 9:29 AM with MD 1, MD 1 stated he oversaw Resident 209's psychiatric care during his recent admission to the hospital in May 2025. MD 1 stated he believes this resident has a long-standing history of schizophrenia or schizoaffective disorder but would need to review the notes to be certain. MD stated he will review Resident 209's records and return my call.
During a telephone interview on 6/12/25 at 9:34 AM with MD 1, MD 1 stated he agreed with Resident 209's new diagnosis of schizophrenia. MD 1 said Resident 209 was seen by multiple mental health professionals during his recent hospitalization, including a psychologist (PsyD), and two psychiatric nurse practitioners (NP 3 and NP 4.) MD 1 stated all providers involved with Resident 209's care agreed with the diagnosis. MD 1 stated Resident 209 had auditory hallucinations, paranoid delusions, agitation, and resistance to care. MD 1 stated in his professional opinion, these symptoms are more common to schizophrenia than dementia and this is why the diagnosis was made. MD 1 stated he will e-mail notes from the other provider's assessments to review.
During a review of Resident 209's Psychiatric Progress Note, dated 5/7/25 and authored by NP 4, indicated Patient met at pacing in his room, he remains self-isolating and withdrawn from others He is guarded with thoughts and quick to agitation . he remains being forgetful and lacking understanding for care Poor insight into mental wellness.
During a review of Resident 209's Psychology Progress Note, dated 5/22/25 and authored by PsyD, indicated Resident 209 had suspiciousness, lability (prone to sudden mood changes), and sadness . The patient continues to display psychotic symptoms profound enough to cause significant problems in their day-to-day functioning and requires this level of care for continued medication monitoring, support, and ongoing therapeutic intervention after discharge.
During a review of Resident 209's Psychiatric Progress Note, dated 5/26/25 and authored by NP 4, indicated Patient met at bedside. He is calm with no outbursts or events reported by staff. Remains forgetful and lacking understanding for care, but less agitated .
During a collective review of the Psychiatric and Psychology Progress Notes listed above (both available in the resident's medical record and as supplied by MD 1) indicated neither NP 3, NP 4, or PsyD documented that Resident 209 had paranoid delusions or hallucinations of any kind. Review of the records indicated the progress notes contained no discussion of how Resident 209 met DSM-5 criteria for the diagnosis of schizophrenia or schizoaffective disorder, including any discussion of Resident 209's history or length of time with symptoms. Review of the record indicated there was no discussion of how dementia was ruled out as a cause of Resident 209's symptoms. Review of the records indicated MD 1 had signed off on each encounter that he reviewed the notes and agreed with the plan of care.
During an interview on 6/12/25 at 10:30 AM with MD 1, MD 1 stated the notes he provided do not contain a discussion of how DSM-5 or any other objective tool was used to arrive at the diagnosis of schizophrenia or schizoaffective disorder or how dementia was ruled out as a cause of the resident's symptoms. MD 1 stated the diagnosis was made as a consensus of professional opinion from the providers who evaluated this resident during his hospital stay.
A review of the facility policy Antipsychotic Medication Use, revised January 2025, indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medication will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND; 1. the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia or grandiosity); or 2. behavioral interventions have been attempted and included in the plan of care . Resident diagnosis is based on comprehensive assessment and evidence-based criteria and is consistent with professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders (current edition) . Antipsychotic medication will not be used if the only symptoms are one of more of the following: .wandering . restlessness . impaired memory . uncooperativeness .
A review of the facility's policy Dementia - Clinical Protocol, revised January 2025, indicated The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements .
A review of the facility's policy Psychotropic Medication Use, revised February 2025, indicated Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff . Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medication, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction . Adequate indications for use refers to the identified, documented clinical rationale for administering medication that is based on: an assessment of the resident's condition and therapeutic goals, a determination that non-pharmacological interventions are clinically contraindicated: and manufacturer's recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 129) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible, by failing to identify Resident 129 as a candidate for retraining program.
This failure had a potential to result in Resident 129's permanent inability to regain control of bowel and bladder function and can lead to a loss of dignity.
Findings:
During a review of Resident 129's admission Record, the admission Record indicated, Resident 129 was initially admitted to the facility on [DATE] and last re-admission was on 4/10/2025 with diagnoses including morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and generalized muscle weakness.
During a review of Resident 129's History and Physical (H&P), dated 4/10/2025, the H&P indicated, Resident 129 had fluctuating capacity (ability) to understand and make decisions.
During a review of Resident 129's Minimum Data Set (MDS - a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 129 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, dressing, bed mobility, transfer, and maximal assistance (Helper does more than half the effort) from one staff for eating.
During an interview on 6/9/2025, at 11:24 a.m., with Resident 129, in Resident 129's room, Resident 129 stated, she was having incontinence episodes from time to time. Resident 129 stated, she knew when she has to go and had the sensation to urinate. Resident 129 stated, she had more control on bowel movement than urination. Resident 129 stated, she called the nurses when she felt the urge to urinate, but she could not hold too long, and this was the reason why she had incontinent episodes. Resident 129 stated, she did not want to talk about her incontinence issue further because it made her feel embarrassed.
During an interview on 6/12/2025, at 9:57 a.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated, Resident 129 was not in bowel and bladder retraining program and the bowel and bladder assessment was done by the Minimum Data Set Coordinator (MDSC). LVN 8 stated, he was not familiar with the program, but he believed Resident 129 was a possible candidate for retraining because she was alert and was able to let the staff know when she needed to go. LVN 8 stated, preserving the residents' bowel and bladder function was important to promote their well-being.
During a concurrent interview and record review on 6/12/2025, at 11:13 a.m., with Assistant Minimum Data Set Coordinator (AMDSC) 1, Resident 129's Bowel and Bladder Observation/Assessment, dated 5/28/2025 was reviewed. The Bowel and Bladder Observation/Assessment indicated, Resident 129 was not in any toileting program. AMDSC 1 stated, Resident 129 was a possible candidate retraining program because she was alert and knew when to go. AMDSC 1 stated, she should have done the bowel and bladder reatraining program trial for Resident 129 to see if she was the candidate, but it was not done, as indicated in the documentation.
During a concurrent interview and record review on 6/12/2025, at 11:20 a.m., with AMDSC 2, Resident 129's MDS section H (Bladder and Bowel), dated 5/28/2025 was reviewed. The MDS section H indicated, there was no trial of a toileting program. The MDS section H indicated, Resident 129 was always incontinent for urine (no episodes of continent voiding) and Tfrequently incontinent for bowel (two or more episodes of bowel incontinence, but at least one continent bowel movement). AMDSC 2 stated, she should have at least done an initial trial for retraining for Resident 129 to see if she was a candidate because retraining program could preserve and improve the resident's functional ability.
During an interview on 6/13/2025, at 3:21 p.m., with the Director of Nursing (DON), the DON stated, all candidates for bowel and bladder retraining should be in the bowel and bladder retraining program to preserve and maintain their highest function. The DON stated, the facility already had the retraining program but identifying the possible candidates was important, because the retraining program would not be useful without identifying and recognizing the appropriate candidates. The DON stated, incontinence affectes the residents' self-esteem and dignity.
During a review of Resident 129's untitled Care Plan (CP), revised 3/6/2025, the CP Focus indicated, Resident 129 had bladder mixed incontinence. The CP Goal indicated, Resident 129 would not have complications related to incontinence. The CP Interventions indicated, offer toileting on rounds, upon request and as needed, and complete bowel and bladder assessment per policy.
During a review of Resident 129's untitled Care Plan (CP), revised 4/11/2025, the CP Focus indicated, Resident 129 had episodes of bowel incontinence. The CP Goal indicated, Resident 129 would not have complications related to incontinence. The CP Interventions indicated, offer toileting on rounds, upon request and as needed, and complete bowel and bladder assessment per policy.
During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder Management, dated 1/2025, the P&P indicated, Procedure for Assessment: 1. Within 14 days following admission to the facility, all residents identified with incontinence and /or Foley catheters, will have a bowel and bladder assessment completed and appropriate management program implemented . When the assessment has been completed, the nurse will review the information and make a decision as to whether or not the resident is a candidate for the retraining program, prompted toileting program (habit training), or incontinence management program. Utilize the following criteria when making the decision: Bowel & Bladder Re-training Program, if the resident: o Is alert and cognitively intact. o Is motivated to be continent. o Can initiate voiding. 4. Individualized plans or schedules (Re-training, prompted, and scheduled) will be reviewed on a weekly basis. Licensed Nurses will decide on the success of the programs and make any modifications as indicated. Residents will continue on these programs at the Licensed Nurses discretion, who will also be responsible for ensuring successful programs are incorporated into the resident's care plan . Procedure for Bowel & Bladder Re-training: 1. Discuss with resident procedure and ask resident if they have any specific toileting patterns. Discuss pelvic floor strengthening exercises & urge inhibition. 2. Use patterns identified by the resident, or obtain baseline information by monitoring for 3-7 days and documenting findings on the retraining flow sheet. Residents should be checked every hour, and have patterns recorded. 3. When a usual pattern has been identified, arrange for the resident to be toileted1/2 hour prior to designated times. Gradually increase intervals to 1 hour, 2 hours, and then finally 3 hours, as tolerated by the resident. Intervals should be shifted weekly, and all results recorded on the training flow sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 111 and Resident 168) who received enteral feeding (nutrition delivered using the gut) through a gastrostomy tube (GT - a tube inserted through a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) received the appropriate treatment and services by:
A. Failing to ensure sufficient fluid was provided as physician ordered for Resident 111.
B. Failing to ensure Resident 168 was positioned safely at 45 degrees during the enteral feeding via GT.
These failures had the potential to result in dehydration (a dangerous loss of body fluid could be caused by inadequate intake) for Resident 111, and aspiration (inhalation of foreign materials) and can lead to pneumonia (a lung infection) for Resident 168.
Findings:
A. During a review of Resident 111's admission Record, the admission Record indicated, Resident 111 was initially admitted to the facility on [DATE] and last re-admission was on 12/7/2022 with diagnoses including dysphagia (difficulty swallowing) due to cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), gastrostomy placement, and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 111's History and Physical (H&P), dated 10/24/2024, the H&P indicated, Resident 111 had no capacity (ability) to understand and make decisions.
During a review of Resident 111's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 111 required dependent assistance (Helper does all the effort) from two or more staff for hygiene, dressing, bed mobility, transfer, and eating.
During an observation on 6/9/2025, at 11:33 a.m., in Resident 111's room, Resident 111's lips were dry and cracked with two mouth sores appearing small with a whitish pink color, and a small black scab. Resident 111's GT feeding pump was off.
During a concurrent interview and record review on 6/11/2025, 11:20 a.m., with Registered Dietitian (RD), Resident 111's Dietary Note, dated 6/9/2025 was reviewed. The Dietary Note indicated, Resident 111 required one milliliter(ml) fluid per one Kilocalorie (Kcal unit of energy measurement used to quantify the amount of heat or energy contained in food) daily. The Dietary note indicated, Resident 111 required a minimum of 1464 Kcal and 1464 milliliters (ml) of fluid a day per physician. The RD stated, Resident 111 required 600 ml of fluid from the water flush and 864 ml of fluid from tube feeding formula per day. The RD stated, Resident 111's body required 1463 ml of fluid to function normally. The RD stated, Resident 111 should have been getting 600 ml of water from water flush and 1300 ml of formula which contained 864 ml of fluid daily to meet the minimum requirements. The RD stated, if Resident 111 got less than 1464 ml per day, Resident 111 would be at great risk for dehydration.
During a concurrent interview and record review, on 6/12/2025, at 9:57 a.m., with Licensed Vocational Nurse (LVN) 8, Resident 111's Medication Administration Record (MAR), dated from 5/1/2025 to 6/11/2025 was reviewed. The MAR indicated, provide 600 ml of water flush (30ml every hour for 20 hours via automated pump). The MAR indicated the following:
a. Documented by the Day shift (7 a.m. to 3 p.m.) 0 ml given for all, except 5/14/2025 (10 ml), 5/15/2025 (10 ml), 5/16/2025 (10 ml), 5/21/2025 (5 ml), 5/28/2025 (5 ml), 5/30/2025 (520 ml), 6/4/2025 (60 ml), 6/5/2025 (5 ml), 6/8/2025 (600 ml), 6/9/2025 (5 ml), 6/10/2025 (5 ml), 6/11/2025 (5 ml)
b. Documented by the Evening shift (3 p.m. to 11 p.m.) 0 ml given for all, except 5/7/2025 (10 ml), 5/13/2025 (10 ml), 5/14/2025 (10 ml), 5/15/2025 (10 ml), 5/16/2025 (10 ml), 5/20/2025 (5ml), 5/21/2025 (5 ml), 5/25/2025 (10 ml),5/26/2025 (5 ml), 5/27/2025 (10 ml), 5/28/2025 (5 ml), 5/31/2025 (10 ml), 6/8/2025 (10 ml).
c. Documented by the Night shift (11 p.m. to 7 a.m.) 0ml given for all, except 5/13/2025 (10 ml), 5/14/2025 (5 ml), 5/15/2025 (10 ml), 5/16/2025 (10 ml), 5/20/2025 (5 ml), 5/21/2025 (5 ml), 5/26/2025 (5 ml), 5/27/2025 (5 ml), 5/28/2025 (5 ml), 5/30/2025 (5 ml), 6/10/2025 (240 ml).
LVN 8 stated, if staff documented 0ml given, it indicated that fluids were not administered to Resident 111. LVN 8 stated, it was inaccurate and impossible to provide 0ml per each shift because the water flush was given via an automated pump that was programed to deliver 30 ml per hour for 20 hours per day. LVN 8 stated, the automated pump should be turned off at 9 a.m. and turned back on at 1 p.m. LVN 8 stated, if the resident did not get sufficient fluid and got dehydrated, the resident might suffer from organ failure.
During an observation on 6/12/2025, at 1:47 p.m., in Resident 111's room, anew feeding bag and water flush bag was hanged and dated 6/12/2025, at 1:15 p.m. The water flush bag indicated, it contained 1000 ml and feeding formula bag contained 1500 ml.
During a concurrent observation and interview on 6/13/2025, at 9:04 a.m., with LVN 3 in Resident 111's room, the automated feeding pump indicated, 510 ml of water flush delivered. The water flush bag container indicated 800 ml of water remained in the bag. This indicated 200 ml was delivered since 6/12/2025, at 1:15 p.m. (26 hours and 6 minutes from when the bag was hung with 1000 ml's) LVN 3 stated, she did not know why there was a discrepancy. LVN 3 stated, she should have cleared the numbers on the pump before the shift started, but she did not. LVN 3 stated, she thought total amount of water flush delivered would auto populate when she pressed yes button for water flush of 600 ml given on the MAR.
During a concurrent interview and record review on 6/13/2025, at 3:21 p.m., with Director of Nursing (DON), Resident 111's Laboratory ([Lab] medical tests conducted on samples of blood) Results Report, dated 5/27/2025 and 5/20/2025 were reviewed. The Lab Results Report dated 5/27/2025 indicated, BUN/Creatinine Ratio (indicator of kidney health and dehydration status) was 33 (reference range 10-20). The Lab Results Report dated 5/20/2025 indicated, Hemoglobin (a protein in red blood cells that carries oxygen) 9.8 gram per deciliter ([g/dl]-normal range 11.2 g/dl-15.7 g/dl) and Hematocrit (the percentage by volume of red cells in your blood) 30.8 percent ([%]-normal range 34.1%-44.9%). The DON stated, high BUN/Creatinine Ratio (33) and low hemoglobin/hematocrit (9.8 g/dl and 30.8 %) would be indicators for dehydration. The DON stated, all enteral feeding and water flush should be administered as physician ordered to prevent weight loss and dehydration. The DON stated, dehydration could cause low blood pressure that could lead to shock, seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and kidney injury.
During a review of Resident 111's Order Summary Report (OSR), dated 6/12/2025, the OSR indicated, water flush 30 ml per hour for 20 hours to provide 600 ml fluids per day was ordered.
During a review of Resident 111's Care Plan (CP), revised on 5/27/2025, the CP Focus indicated, imbalance nutrition at risk for dehydration. The CP Goal indicated, Resident 111 would maintain normal fluid volume as signs of no active bleeding, stable blood pressure, stable heart rate, and moist mucous membrane/oral cavity. The CP Interventions indicated, monitor/document/report signs and symptoms of dehydration such as cracked lips, tenting (when skin is pinched and doesn't immediately return to its normal position indicating dehydration) skin, furrowed (dry and wrinkly) tongue, and decreased urine output.
During to the National Institute of Health ([NIH] a government agency that is responsible for conducting and supporting biomedical and behavioral research) titled, Adult Dehydration updated 3/5/2025, the article indicated, an elevated blood urea nitrogen (BUN) to creatinine ratio greater than 20:1 indicated not getting enough blood flow to the kidneys that could lead to conditions such as congestive heart failure, dehydration, or gastrointestinal bleeding. (https://www.ncbi.nlm.nih.gov/books/NBK555956)
During a review of the facility's policy and procedure (P&P) titled, Resident Hydration and Prevention of Dehydration, revised 1/2025, the P&P indicated, Policy Interpretation and Implementation: 2. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. 3. Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increased risk for dehydration .10. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration.
B.During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was initially admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time) and gastrostomy.
During a review of Resident 168's MDS, dated [DATE], the MDS indicated Resident 168 had severely impaired cognitive (ability to think, understand and make daily decisions) skills for daily decision-making.
During a review of Resident 168's Order Summary Report dated 6/4/2025, the physician's order indicated to administer Isosource 1.5 (a calorically dense tube feeding formula) at 60 milliliter (ml) per hour for 20 hours, and to elevate the head of the bed at least 45 degrees at all times during feeding.
During an observation on 6/10/2025 at 9:28 a.m., and 9:44 a.m, in Resident 168's room, Resident 168 was receiving Isosource 1.5 at 60 ml per hour via a GT pump, with the head of the bed at less than 30 degrees.
During a concurrent observation and interview on 6/11/2025 at 9:59 a.m., in Resident 168's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 168 was receiving GT feeding and the head of the bed was at less than 30 degrees.
During a concurrent interview and medical record review on 6/11/2025 11:36 a.m. with Registered Nurse (RN) 1, RN 1 stated the head of the bed should be elevated when the resident is receiving GT feeding to prevent aspirations. RN 1 confirmed Resident 168's head of the bed should be elevated at 45 degrees while receiving GT feeding per the physician's order.
During an interview on 6/13/2025 at 10:24 a.m., with the DON, the DON stated the head of the bed should be elevated to 30 to 45 degrees to prevent aspiration. The DON stated the Certified Nursing Assistants (CNA) should inform the LVN or RN to stop the feeding and disconnect the GT/ and start the feeding and connect the GT before and after daily care. The DON stated the CNAs could also elevate the head of bed for the resident while the GT is on.
During a review of the facility's policy and procedure (P&P) titled Enteral Tube Feeding via Continuous Pump revised 1/2025, indicated to position the head of the bed at 30 to 45 degrees (semi-Fowler's Position, a position in which an individual lies on their back on a bed with the head of the bed elevated at 30 to 45 degrees) for feeding, unless medically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide care for use of a Continuous Positive Airway Pressure, (CPAP a machine used to deliver a stream of pressurized air through a mask to keep the airways open during sleep, preventing pauses in breathing) as per the manufacturer's recommendation for one of one sampled resident (Resident 205) by failing to change the CPAP mask cushion every month, and clean the CPAP machine and supplies per the manufacture's guidelines.
These deficient practices had the potential to affect the quality and cleanliness of the CPAP machine and supplies and may result in the growth of bacteria affecting the respiratory health and well-being of Resident 205.
Findings:
During a review of Resident 205's admission Record, the admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (a serious medical condition which occurs when the upper airway repeatedly collapses during sleep, blocking breathing for ten seconds or longer).
During a review of Resident 205's Minimum Data Set ([MDS] a resident assessment tool) dated 5/5/2025, the MDS indicated Resident 205's cognition (ability to make decisions of daily living) was moderately impaired, with no impairment to upper extremities.
During a review of Resident 205's Physicians Order Summary Report dated 5/13/25, the Physician's Order Summary Report indicated to administer CPAP with 12 to 20 centimeters of water pressure at bedtime, and to remove the CPAP in the mornings.
During an interview on 6/9/2025 at 09:01 a.m., with Resident 205, Resident 205 stated he used the CPAP at night.
During an interview on 6/11/2025 at 2:01 p.m., with Resident 205, Resident 205 stated the facility staff had not cleaned the CPAP since his admission on [DATE].
During an interview on 6/11/2025 at 2:12 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she does not clean Resident 205's CPAP. LVN 1 stated the CPAP should be cleaned by the nurse in the NOC shift (nocturnal, a work shift which typically covers the overnight hours, often from 11:00 p.m. to 07:00 a.m.
During an interview on 6/11/2025 at 4:19 p.m., with the Respiratory Therapist, the RT stated resident's CPAP was being cleaned by the RT and the NOC shift nurses after every use of the CPAP by the resident. The RT stated he cleaned the resident's CPAP last Sunday. The RT could not provide documentation to show he or the NOC shift nurses cleaned the CPAP. The RT stated he changed the mask which included the headgear, mask, and the mask cushion every 3 months. The RT stated he did not change the mask cushion every month.
During an interview on 6/13/2025 at 10:48 a.m., with the Director of Nursing (DON), the DON stated the CPAP should be cleaned and changed per the manufacturer's guidelines. The DON stated the CPAP machine should be cleaned and this should be documented in the resident's medical records.
During a review of the facility's policy and procedure (P&P) titled, CPAP/BiPAP (Bilevel Positive Airway Pressure, a machine using a positive pressure ventilation to force air into the lungs) Support, revised 6/2025, the P&P indicated to clean the machine by wiping the machine with warm, soapy water and rinse at least once a week and as needed . for equipment changeouts, refer to the manufacturer's guidelines.
During a review of the CPAP manufacturere's 10 Quick Start Guide dated 11/2020, the guide indicated to wash the water tub and air tubing in warm water using mild detergent, rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat, and wipe the exterior of the device with a dry cloth. The guide also indicated the mask cushion or pillow, and air filters should be changed every month, the mask frame (excludes headgear) and the air tubing should be changed every three months, and the headgear and water tub should be changed every six months.
During a review of the manufacturere's User Guide dated 5/2024, the guide indicated the frame, elbow and cushion a cleaning daily/ after each use by:
-Disassemble the mask according to the disassembly instructions.
- Rinse the frame, elbow and cushion under running water. Clean with a soft brush until dirt is removed.
- Soak the components in warm water (approximately 86 degrees F/30 degrees C) with a mild liquid detergent for up to ten minutes.
- Shake the components vigorously in the water for at least one minute.
- Brush the moving parts of the elbow and around the vent holes.
- Brush the areas of the frame where the arms connect, and inside and outside the frame where the elbow connects.
- Rinse the components under running water. 8. Leave the components to air dry out of direct sunlight. Make sure to squeeze the arms of the frame to ensure that excess water is removed. The guide also indicated a weekly cleaning of the headgear by:
- Disassemble the mask. The magnets can remain attached to the headgear during cleaning.
-Handwash the headgear in warm water (approximately 86 degrees F/30 degrees C) with mild liquid detergent.
- Rinse the headgear under running water. Inspect to ensure the headgear is clean and detergent free. Wash and rinse again, if necessary.
- Squeeze the headgear to remove excess water.
-Leave the headgear to air dry out of direct sunlight.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in sanitary manner.
a.
One of 10 garbage dumpster cover was broken, and trash bin was not closed. The floor area around the trash dumpsters was not clean, there were disposable plastic spoons, paper and debris.
This deficient practice had the potential for harborage and feeding of pests.
Findings:
During a concurrent observation and interview with DS and Maintenance Supervisor (MS) on 6/9/2025 at 11:00AM, one large dumpster located in the main trash area had a broken lid and was not completely covered. There was trash on the floor including plastic utensils, cups, paper, plastic bags, cigarette buds and other debris.
During a subsequent interview on 6/9/2025 at 11:00 a.m. with DS, DS stated the dumpster lids should be covered and there should not be trash on the floor. DS stated housekeeping staff are responsible for sweeping the trash area.
During the same observation, MS stated the trash bin lid is broken and it is not closed. MS stated All trash bins should be covered and floors kept clean free of debris to prevent attracting flies and pests in the facility.
During a review of the facility's policy titled Food-Related Garbage and Rubbish Disposal (dated April 2006) indicated, garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. Outside dumpsters provided by garbage pick up 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices for one sampled resident (Resident 168) and one nonsampled resident (Resident 80) by failing to:
1) Ensure Certified Nursing Assistant (CNA) 1 performed hand hygiene when entering and leaving Resident 168's room who was placed on Enhanced Barrier Precautions (EBP, infection control practices that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]), and to ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene when entering Resident 168's room.
2) Ensure Laundry Aide (LA) 1 performed hand hygiene when entering and leaving Resident 80's who was on EBP room, and to ensure LA 1 fully covered the residents' personal clothing during transportation to another area of the facility from Resident 80's room.
These deficient practices exposed the residents and staff of the facility at risk for transmission of disease-causing microorganisms.
Findings:
1. During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was initially admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time) and gastrostomy.
During a review of Resident 168's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/22/2025, the MDS indicated Resident 168 had severely impaired cognitive (ability to think, understand and make daily decisions) skills for daily decision-making.
During a review of Resident 168's Physican's Order Summary Report dated 6/4/2025, the Physician's Order Summary Report indicated to place the resident on EBP due to Resident 168's gastrostomy tube (GT, a small tube inserted through the abdomen and into the stomach to provide alternative way to deliver nutrition, fluids and medicine)
a. During an observation on 6/11/2025 at 9:44 a.m., in Resident 168's room, an orange EBP sign was observed posted outside Resident 168's room. The sign indicated that everyone must clean their hands, including before entering and when leaving the room. CNA 1 was observed entering and leaving the room without performing hand hygiene.
During a concurrent observation and interview on 6/11/2025 at 9:47 a.m., in Resident 168's room, CNA 1 was observed entering and leaving the room without performing hand hygiene. CNA 1 confirmed she did not perform hand hygiene when entering and leaving the Resident 168's room.
b. During a concurrent observation and interview on 6/11/2025 at 9:59 a.m., in Resident 168's room, an orange EBP sign was observed posted outside of the Room. The sign indicated that everyone must clean their hands, including before entering and when leaving the room. LVN 1 was observed entering and leaving the room without performing hand hygiene. LVN 1 confirmed she did not perform hand hygiene when entering the room on EBP
2. During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnosis of non-pressure chronic ulcer of left heel.
During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80 had severely impaired cognitive skills for daily decision-making.
During a review of Resident 80's Physician Order Summary Report dated 6/4/2025, the Physician's Order Summary Report indicated to place the resident on EBP due to left heel arterial ulcer (a deep, painful wound in the skin which occurs when there is not enough blood supply to the area), sacral (lowest end of the spinal column) deep tissue injury (DTI a type of pressure injury which occurs a deep, painful wound in the skin that occurs when there isn't enough blood supply to the area), and a right elbow stage 2 (an open wound which has broken through the top layer of skin (epidermis) and into the dermis, the layer below) pressure ulcer (skin and underlying tissue injury due to unrelieved pressure)
During an observation on 6/12/2025 at 9:48 a.m., in Resident 80's room, an orange EBP sign was observed posted outside of Resident 80's room. The sign indicated that everyone must clean their hands, including before entering and when leaving the room. LA 1 was observed entering and leaving the room without performing hand hygiene.
During a concurrent observation and interview on 6/12/2025 at 9:50 a.m., LA 1 was observed transporting the residents' personal clothing hanging on a clothing rack which was partially covered with a blanket. LA 1 confirmed the clothing rack was partially covered. LA 1 stated she did not perform hand hygiene before entering and leaving Resident 80's room.
During an interview on 6/12/2025 at 10:10 a.m., with the Maintenance Supervisor, the Maintenance Supervisor stated the residents' personal clothing should be transported on a clothing rack with a clean blanket fully covering the residents' personal clothing.
During an interview on 06/12/2025 at 1:17 p.m., with the Infection Prevention Nurse (IPN), the IPN stated everyone must clean their hands, before entering and when leaving a resident's room that has been placed on EBP.
During an interview on 6/13/2025 at 1:06 p.m. with the Director of Nursing (DON), the DON stated everyone must clean their hands, including before entering and when leaving the room on EBP to prevent transmission of micro-organisms.
During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, revised 9/2024, the P&P indicated clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.
During a review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions in Skilled Nursing Facilities dated 11/15/22, the guidelines indicated EBP is a risk-based approach to PPE use designed to reduce the spread of MDRO. The EBP guidelines indicate that everyone must clean their hands, including before entering and when leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a bed inspection to identify areas of possible entrapment for one of two sampled residents (Resident 205).
This deficient practice had the potential to negatively impact the resident resulting in possible entrapment, serious injury, and death.
Findings:
During a review of Resident 205's admission Record, the admission Record indicated Resident 205 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a nervous system disorder causing severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a nervous system disorder causing mild or partial weakness on one side of the body) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time) affecting left dominant side.
During a review of Resident 205's Minimum Data Set ([MDS] a resident assessment tool) dated 5/5/2025, the MDS indicated Resident 205's cognition (ability to make decisions of daily living) was moderately impaired, without impairment to upper extremities and lower extremities, but dependent to facility staff for toileting hygiene, lower body dressing and transfers.
During a review of Resident 205's Physican's Order Summary Report dated 4/30/2025, the Physician's Order Summary Report indicated the resident may have 1/4 bilateral (both) upper side rails per responsible party's request for safety.
During a concurrent observation and interview on 6/920/25 at 9:01 a.m., and on 6/10/2025 at 4:26 p.m., in Resident 205's room, Resident 205 was in bed with bilateral side rails elevated. Resident 205 stated he uses the side rails as grab bars for turning and repositioning.
During an interview on 6/10/2025 at 4:21 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 205 used the side rails to turn and reposition.
During an interview on 6/11/2025 at 2:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 205 used the side rails to turn and reposition during care.
During a concurrent interview and record review on 6/12/2025 at 9:10 a.m., with the Maintenance Supervisor (MS), the Bed Rail's 7 Zones Entrapment assessment dated [DATE] was reviewed. The MS stated an entrapment assessment was done once a year, or as needed, or when there is a new order to install the side rails for the residents. The MS stated the entrapment assessment was conducted by checking and measuring the different zones of potential entrapment as applicable to the resident. A Review of the Bed Rail 7 Zones Entrapment Assessment indicated the zones of entrapment were not assessed, and the boxes to indicate where it passed or failed were left blank. The MS confirmed the zones of entrapment assessment did not indicate if it passed or failed when the side rails for Resident 205 were installed on 4/30/2025.
During an interview on 6/13/2025 at 10:48 a.m., with the Director of Nursing (DON), the DON stated the bed entrapment assessment was conducted by the MS during the installation of the grab bars or side rails. The DON stated the bed entrapment assessment should be conducted and should be a part of the bed inspection process to make sure there are no gaps, and to minimize the risk of entrapment.
During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 1/2025, the P&P indicated the maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks.
During a review of Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, which is a guidance document published by the U.S. Food and Drug Administration (FDA) dated 8/23/2018, the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, indicated the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:
- Zone 1: within the rail;
- Zone 2: under the rail, between the rail supports or next to a single rail support;
- Zone 3: between the rail and the mattress;
- Zone 4: under the rail, at the ends of the rail;
- Zone 5: between split bed rails;
- Zone 6: between the end of the rail and the side edge of the head or foot board; and
- Zone 7: between the head or foot board and the mattress end.
(https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 41 of 91 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room.
This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.
Findings:
During a review of the facility's Client Accommodations Analysis form, provided by the facility on 6/9/2025 and revised on 6/18/2025, the facility had 39 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms and two rooms that measured less than 100 sq. ft for a single bedroom. The resident rooms were as follow:
Grove Unit;
Room G1 (3 bed) 223.53 sq. ft.
Room G6 (3 beds) 223.53 sq. ft.
Room G7 (3 beds) 223.53 sq. ft.
Room G8 (3 beds) 223.53 sq. ft.
Room G9 (3 beds) 223.53 sq. ft.
Room G10 (3 beds) 223.53 sq. ft.
Room G11 (3 beds) 223.53 sq. ft.
Room G12 (3 beds) 223.53 sq. ft.
Room G13 (3 beds) 223.53 sq. ft.
Room G14 (3 beds) 223.53 sq. ft.
Room G15 (3 beds) 223.53 sq. ft.
Room G16 (3 beds) 223.53 sq. ft.
Room G17 (3 beds) 223.53 sq. ft.
Room G18 (3 beds) 223.53 sq. ft.
Room G19 (3 beds) 223.53 sq. ft.
Room G20 (3 beds) 223.53 sq. ft.
Room G21 (3 beds) 223.53 sq. ft.
Room G22 (3 beds) 223.53 sq. ft.
Room G23 (3 beds) 223.53 sq. ft.
Room G24 (3 beds) 223.53 sq. ft.
[NAME] East Unit;
Room T1 (4 beds) 297.5 sq. ft.
Room T3 (4 beds) 281.93 sq. ft.
Room T5 (4 beds) 296.66 sq. ft.
Room T6 (4 beds) 296.66 sq. ft.
Room T8 (4 beds) 296.66 sq. ft.
Room T10 (5 beds) 369.07 sq. ft.
Room T12 (4 beds) 296.66 sq. ft.
Room T14 (4 beds) 296.66 sq. ft.
Room T15 (4 beds) 296.66 sq. ft.
Room T17 (4 beds) 296.66 sq. ft.
Room T18 (4 beds) 296.66 sq. ft.
Room T20 (4 beds) 296.66 sq. ft.
[NAME] Unit;
Room T21 (4 beds) 296.66 sq. ft.
Room T23 (4 beds) 296.66 sq. ft.
Room T27 (4 beds) 296.66 sq. ft.
Room T29 (4 beds) 296.66 sq. ft.
Room T30 (4 beds) 296.66 sq. ft.
Room T32 (4 beds) 296.66 sq. ft.
Room T34 (4 beds) 296.66 sq. ft.
Palm Villa Unit;
Room V1 (1 beds) 93.265 sq. ft.
Room V20 (1 beds) 93.265 sq. ft
During an interview on 6/13/2025 at 12:26 p.m., with the Administrator (ADM), the ADM stated he was aware of the recommendation of 80 sq. ft. per resident in multiple resident rooms and 100 sq. ft. for residents in a single resident room. ADM stated, there was no renovation or remodeling. ADM stated the regulation specify room sq. ft to ensure resident have a home-like environment, was treated with dignity, and to alleviate any safety concerns. The ADM stated, leadership and social service team were doing daily rounds to ensure residents were having enough spaces to move around.
During a phone interview on 6/17/2025, at 2:59 p.m., with the ADM, the ADM stated, he needed to make correction on number of rooms and room numbers on the room wavier application because four resident rooms were converted to therapy rooms. The ADM stated, he was not aware of these changes that was made prior to his start date.
During observations, from 6/9/2025 through 6/13/2025, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident room size did not affect the nursing care or privacy provided to the residents.
During a review of the facility's policy and procedure (P&P) titled, Bedrooms, revised 1/2025, the P&P indicated, Policy Interpretation and Implementation: 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. 3. Each room is designed to provide full visual privacy for each resident and equipped for adequate nursing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on the denture referral for one of three sampled residents (Resident 182).
This failure resulted in delivery of care and services and had a potential risk for weight loss for Resident 182.
Findings:
During a review of Resident 182's admission Record, the admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy (brain disorder caused by a vitamin B1 deficiency) and dysphagia (difficulty swallowing).
During a review of Resident 182's History and Physical (H&P), dated 2/12/2025, the H&P indicated Resident 182 was not capable of making medical decisions.
During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 182 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required set-up assistance with eating, required supervision assistance for toileting and dressing, and required partial assistance with bathing.
During a concurrent interview and record review on 6/11/2025 at 4:49 p.m., with the Social Service Director (SSD), Resident 182's medical record was reviewed. The SSD stated Resident 182's Dental Progress Notes indicated Resident 182 was seen by the dentist on 2/25/2025, and Resident 182 was consented for dentures. The SSD stated there was no documentation in the record indicating that the dentures were followed up on.
During a continued interview and record review on 6/12/2025 at 8:38 a.m., with the SSD, an updated Dental Progress Note received on 6/12/2025 was reviewed. The SSD stated he called the dental group for an update on the dentures. The updated Dental Progress note indicated on 3/5/2025 the dental group informed Resident 182's dentures were denied due to not lack of insurance coverage.
During a concurrent interview and record review on 6/13/2025 at 9:47 a.m., with the Social Services Assistant (SSA), Resident 182's medical record was reviewed. The SSA stated social services follow up bi-weekly or monthly if a resident has been consented for dentures. The SSA stated she would follow up sooner if not having the dentures was affecting the well-being of a resident such as weight loss or if the resident was not eating. The SSA stated Resident 182 experienced a six-pound weight loss from 2/12/2025 (weighed 120 pounds) to 3/3/2025 (weighed 114 pounds). The SSA stated the consent to dentures occurred on 2/25/2025. The SSA stated the dentures should have been followed up on sooner. The SSA stated Resident 182 refused the dentures, but the SSA could not produce documentation indicating the resident refused dentures or that the facility was aware that the resident was denied dentures due to not have insurance coverage prior to 6/12/2025.
During an interview on 6/13/2025 at 3:26 p.m., with the Director of Nursing (DON), the DON stated the social service department was responsible for following up on dentures. The DON stated if a resident who has been recommended dentures, does not get dentures, there is a risk their ability to eat is affected negativly or a resident can experience unplanned weight loss.
During a review of the facility's policy and procedure (P&P), titled Dental Services, revised January 2025, the P&P indicated: .Residents have the right to select dentist of their choice when dental care or services are needed .Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.

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.Nutritional supplement labeled store frozen with manufactures instructions to use within 14 day of thawing were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. Three boxes each with 50 single serve cartons of strawberry flavored nutrition supplements, two boxes of vanilla flavored nutrition supplements, 10 boxes of chocolate flavored nutrition supplements and one box containing 17 single serve cartons of chocolate and strawberry flavor supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 33 residents who are on nutrition supplements at the facility.
2.One large tray of previously prepared dessert containing fruits and cream and two plates of previously prepared salad (lettuce, tomato and chopped ham) were stored in the reach in refrigerator with no label and date. One opened nondairy creamer was stored in the reach in refrigerator with no open date and two medium size containers of dry cereal one with date 5/30/25-6/2/25 and another with dates 5/29/25 expired were stored in the dry storage area.
3.The coffee machine glass gauge pipe was stained with dark brown color residue.
4. When a cup of yogurt was left over night at Resident 39 bed side table.
These deficiencies 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 foodborne illness in 218 of 223 residents who received food from the facility.
Findings:
1. During an observation in the kitchen on 6/9/2025 at 9:00AM there were boxes of single serve cartons of nutrition supplements stored in the reach- in refrigerator with no date. Three boxes containing 50 cartons of strawberry flavored supplements, two boxes containing vanilla flavored supplements, 10 boxes containing chocolate flavored supplements and one box containing 17 single serve cartons of mixed flavor supplements stored in the reach in with no thaw date.
During a concurrent interview 6/19/2025 at 9:15 a.m. with dietary supervisor (DS), DS stated the single serve carton of nutritional supplements are frozen and are stored in the refrigerator to thaw. DS stated the boxes have the delivery date and the supplements are stored in their original box. DS said once thawed they should be used within 14 days. DS agreed there were no thaw date on the boxes of the supplements. DS stated the one box with only 17 cartons containing mixed flavors is because staff cleaned the refrigerator and combined the remaining nutrition supplements from each almost empty boxes together. DS stated the supplements were delivered at different dates and should not be mixed. DS agreed there should be a date on the supplements to monitor date of thaw and to discard them if expired. DS was not sure when the single serve cartons of mixed flavors were thawed. DS stated shakes that are expired can make the residents sick. DS discarded the shakes that were combined from different boxes.
During a review of the facility's policy titled Procedure for refrigerated storage (dated 2023) indicated, Supplemental shakes which are taken from the frozen stated and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator.
During a review of the 2022 U.S. Food and Drug Administration Food Code titled, Ready to Eat, Time/Temperature control for safety food, Date marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded.
2.During an observation in the reach- in- refrigerator on 6/9/2025 at 8:45AM, there was one large tray of pear mixed with cream stored in the refrigerator with no label and date.
During the same observation there were two plates of salad including lettuce tomato and sliced ham covered with plastic wrap and stored with no date and one open container of non-dairy creamer with a receive date of 5/2/2025.
During a concurrent observation and interview with Dietary supervisor (DS) on 6/9/2025 at 8:45AM, DS stated ready to eat food is kept for 3-5 days in the refrigerator. DS stated all items should have a use by date to discard before they are expired. DS stated expired food can make residents sick.
During the same observation and record review of the menu with the DS on 6/9/2025 at 8:45AM, DS stated the dessert with pear and cream was from last weeks dinner and should have been discarded. DS stated the plates of salad are made daily for residents who request large salad with meals, and it should have a date on it.
During a concurrent interview with DS and review of the facility storage guideline posted on the wall, DS stated salad greens are good for 3-5 days in the refrigerator and non-dairy creamer is good for 3 weeks. DS didn't know when the salad was prepared and when the non-dairy creamer was opened.
During an observation in the dry storage area on 6/9/2025 at 10:00AM, there was one medium size plastic container with dry cereal (granola topping), covered with a plastic wrap and with date 5/30/25-6/2/25 expired, and another medium size plastic container with coconut dry cereal (granola topping) with dates 5/29/25.
During a concurrent observation and interview with DS, DS stated the containers should be tightly covered with a lid and not with plastic wrap. DS could not verify if the dates were accurate and stated will discard the cereal because they are expired.
During a review of facility's policy titled, Labeling and Dating of Foods (dated 2023) the policy indicated, Newly opened food items will need to be closed and labeled with an open date and used b the date that follow the storage guidelines .All prepared foods need to be covered, labeled and dated, leftovers will be covered, labeled and dated.
During a review of facility's policy titled, Storage of Food and Supplies (dated 2023) the policy indicated, Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers .Dry storage items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc. will be tightly closed, labeled and dated.
During a review of facility's Dry goods storage guideless (dated 2023), the guidelines indicted for cereal, ready to eat once opened on shelf store for 2 months, keep them dry and tightly covered.
3.During an observation in the kitchen on 6/9/2025 at 9:45AM, observed the coffee maker machine had glass gauge pipe in front of the machine. There was visible coffee in it and there were dark brown stains inside the pipe.
During a concurrent interview with Dietary Aide (DA1), DA1 stated the coffee machine is cleaned at the end of day but the glass pipe on the outside is not cleaned by staff. DA1 stated they do not have the equipment to clean the glass pipe.
During the same observation and interview with DS on 6/9/25 at 9:45AM, DS stated the coffee machine is cleaned by an outside company once a month. DS stated the coffee machine glass gauge pipe looks dirty and will contact the outside vendor. DS stated outside coffee machine vendor uses a long thin brush to clean the pipe. facility does not have the long thin brush to clean the pipe. DS stated the stained and dirty coffee maker can contaminate the coffee and change the quality of the coffee.
During a review of the facility's cleaning schedule and check list not dated, the coffee machine cleaning was not included in the cleaning schedule.
During a review of the facility's policy titled, Coffee Brewing Equipment (dated 2023) the policy indicated, coffee urns and coffee service equipment must be free of stains and foreign film build-up.
4.During an initial tour and observation on June 9, 2025, at 9:19 a.m. in Resident 39's room, a cup of yogurt was at Resident 39's bedside table.
During an interview, on June 9, 2025, at 9:32 a.m., with Certified Nurse Assistant (CNA) 5, in Resident 39's room, CNA 5 stated the cup of yogurt on Resident 39's bedside table was from the day before. CNA 5 stated she did not see it when she was assisting Resident 39 eat her breakfast. CNA 5 stated staff from night shift should check the snacks if a resident ate it or not and should throw it away if left for a long time.
During an interview, on June 11, 2025, at 9:06 a.m., with the Director of Staff Development (DSD), the DSD stated staff that pass out the snacks should come back around to check if the residents have consumed the snack item and discard it accordingly. The DSD confirmed a snack like yogurt should not have been left at the bed side overnight in room temperature for it may cause stomach upset to a resident if consumed.
A review of facility's policy and procedure (P&P) titled Snacks dated January 2025, indicated .All snacks shall be safely prepared, stored, and distributed in a sanitary and respectful manner .6. Store snacks in compliance with food safety standards .8. Refrigerated snacks must be kept at 41 F .15. Nursing staff/CNAs are responsible for distribution, assistance, and documentation .
A review of facility's P&P titled Food-Borne Illnesses dated January 2025, indicated All food must be prepared, stored, and served per safe food handling guidelines (e.g. temperature, hygiene) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store one open bottle of gabapentin solution (a medication used to treat nerve pain) in the refrigerator as required by the manufacturer's specifications affecting Resident 46 in one of five inspected medication carts (Villa Cart South.)
This deficient practice of failing to store medication according to the manufacturers' requirements increased the risk that Resident 46 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.
Findings:
During a concurrent observation and interview on [DATE] at 2:19 PM of Villa Cart South with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1.
One opened bottle of gabapentin solution for Resident 46 was found stored in the medication cart at room temperature.
According to the product labeling, gabapentin solution should be stored in the refrigerator.
During a concurrent interview, LVN 2 stated the gabapentin solution should always be stored in the refrigerator and never in the cart. LVN 2 stated she administered a dose to Resident 46 recently and failed to return it to the refrigerator and stored it in the cart's bottom drawer by accident. LVN 2 stated this could cause it to become ineffective at treating seizures or nerve pain which could possibly lead to Resident 46 having medical complications possibly leading to hospitalization.
A review of the facility's policy Medication Labeling and Storage, revised [DATE], indicated This facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location .

Based on interview and record review the facility failed to ensure a performance review for two of seven Certified Nurse Assistants (CNA 3 and CNA 4) were completed at least once every 12 months.
This deficient practice had the potential to result in poor resident health outcomes.
Findings:
During an interview and record review with the Director of Staff Development (DSD) on 6/13/2025 at 12:51 p.m. CNA 3 and 4's personnel files were reviewed and the files did not indicate performance evaluations were completed in 2024 or annually.
During an interview with the Director of Nursing (DON) on 6/13/2025 at 3:26 p.m., the DON stated performance evaluations should be completed upon hire, 90 days after hire, and then annually thereafter.
During a review of the facility's Policy and Procedure (P&P) Performance Evaluations, reviewed January 2025, the P&P indicated a performance evaluation will be completed on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter.

Based on interview, record review, the facility failed to ensure residents received their mail in a timely manner, including mail delivery on Saturdays for seven of eleven residents (Residents 75, 76, 115, 122, 166, 191, and 212) who attended the resident council meeting (scheduled gathering of residents in a long-term care facility, where they discuss issues related to their quality of life).
This deficient practice had the potential for violating their right to communicate promptly with individuals within and outside the facility.
Findings:
During a resident council meeting on 6/10/2025 at 2:00 p.m., seven out of eleven residents who attended the meeting stated they did not get mail and packages on Saturdays, because the mail and packages were delivered to them only on Mondays through Fridays.
During an interview on 6/10/2025 at 3:29 p.m., with the Activities Director (AD), the AD stated the activities department assisted the social services department in delivering the mail and packages to the residents. The AD stated the resident mail and packages were not delivered on Saturday, but only Monday through Friday.
During an interview on 6/10/2025 at 3:37 p.m., with the Social Services Director (SSD), the SSD stated the social services department delivered the mail and packages to the residents. The SSD stated the residents' mail and packages were not delivered on Saturdays, but only Monday through Friday. The SSD stated residents' mail and packages were delivered on Saturdays only when he was at the facility on a Saturday. The SSD stated the last time he worked on a Saturday was in May, and he then delivered the mail and packages.
During an interview on 6/10/2025 at 3:56 p.m., with the Receptionist, the Receptionist stated she sorted the mail and packages Monday through Friday, when she was at work. The Receptionist stated she would place any mail and packages received on Saturday, on a table near the front desk, to be sorted on the following Monday and placed in the SSD's mailbox, for delivery to the residents.
During a concurrent interview and record review on 6/10/2025 at 4:48 p.m., with the SSD, the Social Services Department schedule for May and June 2025 were reviewed. The SSD stated the Social Services Department schedules for May and June did not show the SSD or any social services staff worked on Saturday.
During an interview on 6/13/2025 at 11:17 p.m., with the Director of Nursing (DON), the DON stated the mail and packages are delivered to the residents on Monday through Friday because the SSD had to help the residents in opening their mail and packages because they wanted to make sure the residents are safe with their packages. The DON further stated a Manager of the Day or a department head can assist with the delivery of mail and packages on Saturday.
During a review of the facility's P&P titled Mail Delivery Policy dated 1/2025, the P&P documented the purpose of this policy is to ensure that all residents in skilled nursing facilities receive their mail promptly and securely, while maintaining their privacy and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents, who had a history of wandering into other residents' rooms, was free from physical abuse for one of four sampled residents (Resident 233). The facility failed to:
1. Provide Resident 233 with 1:1 (staff member provides dedicated, individualized attention to a single resident) monitoring to prevent him from wandering into Resident 23's room per untitled Care Plan dated 5/12/2025.
2. Implement the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, that indicated the facility would protect a resident's right to be free from abuse.
As a result of these deficient practices Resident 23 struck Resident 233 on the face. Resident 233 sustained a right cheek abrasion (injury to the skin's surface resulting from friction or impact), orbital (socket of eye that protects the eyeball) discoloration, and a nosebleed.
Findings:
During a review of Resident 23's admission record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and was readmitted from a general acute care hospital (GACH 1) on 5/20/2025 with diagnoses including schizoaffective disorder (a mental illness that can negatively affect thoughts, mood, and behavior), antisocial personality (mental health condition characterized by a persistent pattern of disregard for the rights of others often leading to reckless or criminal behavior), and amnestic disorder (significant memory loss affecting the ability to recall past events and form new memories that result from substance abuse and brain injury) due to known alcohol dependence and traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head).
During a review of Resident 23's Social Service Discharge Summary and Recommendations, for Aftercare note from GACH 1 dated 5/20/2025, the Social Service Discharge Summary and Recommendations for Aftercare indicated Resident 23 had a history of severely physically assaulting a peer because the peer refused to share a lighter (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 stated he suffered from memory loss and remained isolated and guarded (cautious, reserved and untrusting), and exhibited limited ability to tolerate conflict as seen by him striking a peer for bumping into him (facility unspecified). The Social Service Discharge Summary and Recommendations for Aftercare dated 5/20/2025 indicated despite Resident 23 verbalizing a motivation for change, Resident 23 continued to exhibit poor impulse control and minimal responses to provided interventions. The Social Service Discharge Summary and Recommendations for Aftercare note indicated Resident 23 took advantage of his lower functioning peers.
During a review of Resident 23's History and Physical (H&P), dated 5/21/2025, the H&P indicated Resident 23 was unable to make medical decisions.
During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 23's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were moderately impaired. The MDS indicated Resident 23 required moderate assistance (staff provide less than half the effort) for shower transfer, bathing, dressing the lower body, personal hygiene, required supervision for toileting hygiene, dressing upper body (above waist), chair/bed-to-chair transfer, required set up for oral hygiene, and was independent in eating. The MDS indicated Resident 23 did not have any impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. The MDS indicated Resident 23 always felt lonely or isolated and was feeling down, depressed, or hopeless for several days (two to six days). The MDS indicated Resident 23 had delusions (misconceptions or beliefs that are firmly held, contrary to reality) as a behavior.
During a review of Resident 23's Physician's Order Summary Report dated 5/20/2025 - 5/31/2025, the Physician's Order Summary Report indicated the following orders:
1. Hydroxyzine Pamoate (antihistamine [medication used to treat allergies] medication used to treat anxiety) capsule 50 milligram (mg- unit of mass) one tablet by mouth every 12 hours as needed for anxiety disorder for 14 days manifested by (m/b) inability to relax as evidenced by restlessness, dated 5/20/2025 to 6/3/2025.
2. Monitor behavior episodes of anxiety disorder m/b inability to relax as evidenced by restlessness dated 5/20/2025.
3. Olanzapine (medication used to treat mental health condition characterized by severe and persistent disruptions in thought, perception, emotion, and behavior) give 30 mg by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025 (discontinued on 5/28/2025).
4. Olanzapine 15 mg tablet to give two tablets by mouth at bedtime for schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/28/2025.
5. Monitor behavior of schizoaffective disorder m/b agitation as evidenced by behavior of stealing and hiding food, dated 5/20/2025.
During a review of Resident 23's Medication Administration Record (MAR- record of medications administered to the resident) from 5/1/2025 to 5/31/2025, the MAR indicated the following:
1. Resident 23 had an episode of mood swing on 5/30/2025 and another episode on 5/31/2025 during the day shift (7:00 a.m. to 3:00 p.m.).
2. Resident 23 had two episodes of anxiety disorder m/b inability to relax as evidenced by restlessness on 5/31/2025 during the day shift.
3. Resident 23 had two episodes of depression m/b inability to sleep during the evening shift (3:00 p.m. to 11:00 p.m.).
During a review of Resident 233's admission Record, the admission Record indicated Resident 233 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought involving a break with reality, feelings of suspicion and distrust towards others), unspecified dementia (a progressive state of decline in mental abilities) with other behavioral disturbances (pattern of actions that disrupt a person's ability to function), and cognitive communication deficit (trouble participating in conversations).
During a review of Resident 233's Physician's Order Summary Report the Physician's Order Summary Report indicated an order for Risperidone (medication use to treat schizophrenia) 3 mg tablet by mouth two times a day for paranoid schizophrenia m/b irritability dated 5/9/2025.
During a review of Resident 233's MAR from 5/1/2025 to 5/31/2025, the MAR indicated to monitor Resident 233's episodes of wandering and to document the resident's location every two hours starting 5/12/2025 with a discontinued date of 5/21/2025.
During a review of Resident 233's H&P, dated 5/12/2025, the H&P indicated Resident 233 was not capable of making medical decisions.
During a review of Resident 233' untitled Care Plan (CP) dated 5/12/2025, the CP indicated Resident 233 was identified at risk for wandering related to communication deficits, dementia, psychotropic and mood-altering medications. The CP indicated the resident wanders aimlessly. The CP interventions included to provide 1:1 supervision, encourage activity participation, encourage social interaction, and redirect resident as needed, initiated on 5/21/2025.
During a review of Resident 233's MDS, dated [DATE], the MDS indicated Resident 233's cognitive skills were moderately impaired. The MDS indicated Resident 233 required moderate assistance with activities of daily living (ADLs- toilet transfer, bathing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer) and required supervision for eating and oral hygiene. The MDS indicated Resident 233 did not have any impairments on the upper and lower extremities. The MDS indicated Resident 233 was feeling down, depressed, or hopeless and had little interest or pleasure in doing things for several days.
During a record review of Resident 233's Elopement and Wandering Risk Observation/assessment dated [DATE] at 10:50 p.m., the Elopement and Wandering Risk Assessment indicated Resident 233 was disoriented or had periods of confusion and/or impaired attention span. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited unsafe wandering or elopement attempts but was easily redirected. The Elopement and Wandering Risk Assessment indicated Resident 233 exhibited behaviors of agitation leading to noncompliance to care and mood swings.
During a review of Resident 23's Change of Condition (COC) dated 5/31/2025 at 7:46 p.m., the COC indicated Resident 23 had behavioral symptoms (e.g. agitation, psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) and was physically aggressive towards a peer (Resident 233), in Resident 23's room. The COC indicated Resident 23 stated he was attacked by another resident (Resident 233) and retaliated by striking the resident back. Resident 23 was sent out to the hospital for further evaluation and treatment. The COC indicated Resident 23's left palm and right hand were noted with redness.
During a review of Resident 23's Physician's Order Summary Report, the Physician's Oder Summary Report indicated an order dated 5/31/2-25 for Resident 23 to have a 1:1 observation until transferred to the hospital.
During a review of Resident 23's Progress Note dated 5/31/2025 at 10:14 p.m., the Progress Note indicated Resident 23 was transferred to GACH 3 at approximately 9:00 p.m., for a psychological (related to mental or emotional) evaluation as a perpetrator of physical aggression towards peer (Resident 233).
During a review of a follow up Progress Note dated 6/3/2025 at 9:00 p.m., the Progress Note indicated Resident 23 was admitted to a behavioral unit at GACH 3 for psychosis and aggressive behavior.
During a review of Resident 23's Interdisciplinary Team (IDT- resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) note, dated 6/2/2025 at 10:34 a.m., the IDT noted indicated on 6/2/2025 (date of incident indicated was an error, incident occurred on 5/31/2025) at 6:35p.m., there was an unwitnessed resident-to-resident altercation involving Resident 233. The IDT note indicated Licensed Vocational Nurse (LVN) 7 heard arguing in Resident 23's room, and upon entering the room, LVN 7 observed Resident 23 standing by the footboard of his bed, and Resident 233 was on the floor, leaning on the neighboring nightstand. The IDT note indicated Resident 23 stated Resident 233 went through his door and punched him, so he (Resident 23) punched him (Resident 233) back with a closed fist.
During a review of Resident 233's COC dated 5/31/2025 at 10:01p.m., the COC indicated Resident 233 stated he was attacked by another resident in his (Resident 23's) room. The COC indicated the nursing staff arrived and immediately separated the residents to separate rooms and both residents were assessed for injuries. The COC indicated Resident 233 was noted with edema (swelling) on the lip, nose and right cheek and a contusion (bruise, collection of blood outside of the blood vessels, under the skin due to blunt impact) to the right cheek. Resident 233 was offered Tylenol (used to relieve mild to moderate pain) and cold compress for pain. The COC indicated Resident 233 occasionally moaned or groaned, had facial grimacing, was tense, distressed pacing, fidgeting, and had a headache. The COC indicated Resident 233 had a pain level rated 6 out of 10 on a pain rating scale (0- no pain, 3-4 -moderate pain, 5-7 severe pain and 8-10-excruciating pain) on the top of the scalp (skin covering the head) on the side of the head. The COC indicated Resident 233 was sent to the hospital for further evaluation and treatment.
During a review of a late entry Progress Note dated 5/31/2025 at 6:35 p.m., the Progress Note indicated Resident 233 had an unwitnessed Resident-to-Resident altercation. The Progress Note indicated Resident 233 had swelling to the face (lip, forehead and check) and bleeding from the nose. The Progress Note indicated Resident 233 was transferred to GACH 3 via 911 at 6:45 p.m. per physician's order.
During a review of Resident 233's IDT note dated 6/2/2025 at 8:31a.m., the IDT note indicated on 5/31/2025 at 6:35 p.m., there was an unwitnessed resident-to-resident altercation in Resident 23's room. The IDT note indicated LVN 7 discovered Resident 23 lying on the floor against a nightside and Resident 23 standing by the foot of the bed. The IDT note indicated Resident 233 was observed with swelling to the face (lip, forehead, and cheek), with scant (minimal) bleeding noted. The IDT note indicated LVN 7 applied a cold compress to Resident 233 and placed on 1:1 for monitoring and safety precautions. The COC indicated Resident 233 had a right cheek abrasion 5.0 centimeter (cm- unit of length) in length by 3.0 cm in width orbital discoloration.
During a review of a Progress Note dated 5/31/2025 at 9:16 p.m. the Progress Note indicated Resident 233 was bleeding from his nose profusely but was able to stop the bleeding with first aid.
During a review of Resident 233's GACH 3 record dated 6/4/2025, GACH 3 record indicated the Computed tomography (CT- medical imagining technique to obtain internal images of the body) of the head without contrast (substance taken by mouth or injection into the vein to help visualize the brain and surrounding area) indicated Resident 233 had a left frontal scalp (front area of head located behind the forehead) hematoma (bruise).
During an interview on 6/11/2025 at 4:47 p.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 233 was always walking around. CNA 4 stated while he (CNA 4) was walking in the hallway (date unspecified), he observed Resident 233 go into another resident's room and redirected him to the patio. CNA 4 stated on 5/31/2025 when he was tending to a different resident in another room, he heard Resident 23 screaming for help and observed CNA 9 and LVN 7 run to Resident 23's room. CNA 4 stated when he got to Resident 23's room he observed Resident 233 on the floor sitting down in the middle of the door against the cabinet with a bloody nose that was dripping over his mouth, chin, and on one side of the cheek.
During an interview on 6/11/2025 at 5:14 p.m., with LVN 7, LVN 7 stated he was in the Nursing Station (West side) charting when he suddenly heard Resident 23 yelling. LVN 7 stated the door to Resident 23's room was closed when he heard the yelling, and he opened the door. LVN 7 stated Resident 23 said get out of my room to Resident 233. LVN 7 stated Resident 23 was standing at the foot of the bed and Resident 233 was close to the bedside table sitting on the floor. LVN 7 stated Resident 233 had blood dripping from his nose. LVN 7 stated he called for assistance, and CNA 4 and CNA 9 arrived to assist, separated the residents, and attended to Resident 233 to stop the bleeding. LVN 7 stated CNA 7 arrived to assist, and indicated he called the Registered Nurse Supervisor 3 (RNS 3). LVN 7 stated while RNS 3 was interviewing the residents, Resident 23 said, What are you doing? What are you doing? LVN 7 stated he asked Resident 23 why he punched Resident 233 and Resident 23 replied Resident 233 was in his home, and he punched him. LVN 7 stated he brought the crash cart (a medical cart equipped with medical equipment and supplies used during emergencies) and grabbed a stack of gauze to stop Resident 233's bleeding from the nose. LVN 7 stated Resident 233 continued to bleed until the paramedics (emergency response team that provide medical care and transport people to hospitals) arrived. LVN 7 stated Resident 23 did not have 1:1 supervision that day (5/31/2025). LVN 7 stated staff need to walk around to check on the residents as anything can happen anytime, so staff have to monitor the residents.
During an interview on 6/12/2025 at 9:32 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 233 wanders. CNA 6 stated he has witnessed him go into other residents' rooms more than once. CNA 6 stated he has told an LVN (unknown) regarding Resident 233 going into other residents' rooms but does not recall who he told.
During an interview on 6/12/2025 at 12:19 p.m., with CNA 9, CNA 9 stated Resident 233 is confused, wanders, and goes in and out of rooms. CNA 9 stated Resident 233 had 1:1 supervision before because he went into someone's room. CNA 9 stated Resident 23 is mostly to himself, would wave, but could not communicate with staff due to a language barrier. CNA 9 stated Resident 23 came from GACH 1 and had a history of being in jail for violence. CNA 9 stated when he (Resident 23) did not get his way (like wanting multiple packs or sugar but not giving him so much), he (Resident 23) would get aggressive.
During an interview on 6/12/2025 at 12:44 p.m., with Resident 233's Family Member 2 (FM 2) FM2 stated she went to visit him (Resident 233) the day after the incident on 6/1/2025, she stated Resident 233 had a black eye, cut up face, and a busted lip. FM 2 stated she did not directly see Resident 233, but did see him through a video call. FM 2 stated she saw his eyes, face, and lips. FM 2 stated the staff did not provide them any information regarding how it happened. FM 2 stated Resident 233 had no recollection of the incident. FM 2 stated Resident 233 was not a fighter and would not say something to provoke you to get mad as that is not his character. FM 2 stated Resident 233 tends to wander when he's restless or when he does not want to be in that place. FM 2 stated if someone is showing him something or he is watching animals on screens, robots, dinosaurs, dominos, it would distract him for a long time.
During a concurrent interview and record review on 6/12/2025 at 4:42 p.m., with the Regional Administrator (RADM), the RADM stated once Resident 233 returned to the facility from GACH 3, Resident 233 was placed on 1:1 for precaution because he wandered into residents' rooms. The RADM stated when he spoke to the staff, the staff indicated Resident 233 tended to roam the halls and to the smoking patio. The RADM stated he believed the incident between Resident 23 and Resident 233 was preventable as both residents were on monitoring every two hours. The RADM stated during the time of the incident, they did not have staff walking around the unit, but had designated people to monitor the residents every two hours and indicated the CNAs and LVNs were monitoring the residents in the facility at that time.
During an interview on 6/13/2025 at 10:13 a.m., with the Administrator (ADM), the ADM stated residents have the right to wander safely and freely and indicated he does not know if a resident would be placed on 1:1 if a resident goes into another resident's room once, but they would address the behavior from the beginning and discuss it during the IDT meeting. The ADM stated regarding the abuse allegation of resident striking another resident; the statement received from Resident 23 was that Resident 233 was going through his belongings, and that may have been what upset Resident 23, and not so much that Resident 233 was in the room. The ADM stated going into another resident's room would be a behavior that would be care planned if it happened repeatedly but is not sure if it would be care planned if it was an incident that occurred for the first time.
During an interview on 6/13/2025 at 3:46 p.m., with the Director of Nursing (DON), the DON stated the residents in the secured unit (unit where Resident's 23 and 233 were housed) are psychologically complex and require closer behavioral monitoring and management. The DON stated residents that have had multiple falls or having behaviors such as wandering or aggression need to be monitored closely, and they would require a 1:1 monitoring. The DON stated in this resident-to-resident altercation; Resident 233 was redirectable. The DON stated Resident 23 had a history of aggression and came from a prison. The DON stated anyone, even dementia residents have the potential for aggression.
During a review of the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1.
Ensure there were adequate indications for the use of Abilify and Risperdal (antipsychotic medications used to treat mental illness) by failing to identify and document the use of non-pharmacological interventions (attempts to modify resident behavior without the use of medications) in two of five residents sampled for unnecessary medications (Resident 179 and 209.)
2.
Ensure Abilify was necessary to treat a specific condition as diagnosed and documented in the medical record in one of five residents sampled for unnecessary medications (Resident 179.)
3.
Monitor and document the target behavior of self-isolation in the Medication Administration Record (MAR - a record of all medication administration and monitoring done for a resident) related to the use of Celexa (an antidepressant medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 179.)
4) The facility failed to monitor the targeted behavior, and side effects related to Olanzapine (antipsychotic [medication used to treat mental illnesses that cause a break with reality]medication) and to ensure the monthly behavior summary report was completed related to Olanzapine use for May 2025 for Resident 168.
5) The facility failed to monitor the behavior manifestation for the use of clonazepam (antianxiety [used to treat a mental condition characterized by excessive fear about real or perceived threats, typically leading to avoidance behaviors and often to physical symptoms] medication) for Resident 68.
6) The facility failed to monitor the side effects for the use of divalproex sodium (antipsychotic medication) for Resident 22.
These deficient practices of failing to identify and document non-pharmacological interventions, ensure antipsychotic medication was used to treat a resident's specific, diagnosed condition, and monitor target behaviors related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior)increased the risk that Residents 179 ,209,168,68 and 22 could have experienced adverse effects (unwanted or dangerous medication-related side effects) for five of five sampled Residents related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.
Findings:
1. During a review of Resident 179's admission Record (a document containing a resident's diagnostic and demographic information), dated 6/12/25, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and major depressive disorder (MDD - a mental illness characterized by depressed mood, difficulty sleeping, and lack of interest in usually enjoyable activities.)
During a review of Resident 179's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/27/25, indicated he did not have the capacity to understand and make medical decisions.
During a review of Resident 179's Physician Order Summary (a monthly summary of all active physician orders), dated 6/11/25, indicated, on 5/12/25, he was prescribed the following psychotropic medications:
1.
Abilify 2 milligrams (mg - a unit of measure for mass) to take 1/2 tablet by mouth one time a day for major depressive disorder manifested by irritability/agitation leading to resistive to care.
2.
Celexa 20 mg by mouth one time a day for major depressive disorder manifested by self-isolation.
During a telephone interview on 6/11/25 at 2:41 PM with the psychiatric nurse practitioner (NP 1), NP 1 stated she did not initially prescribe Abilify for this resident but believes it was prescribed by another psychiatric nurse practitioner (NP 2) for adjunct treatment of depression (a small dose of antipsychotic medication used along with an antidepressant medication in order to increase symptom resolution of depression) along with Celexa. NP 1 stated she has been gradually decreasing the dose of Abilify with a goal to eventually discontinue it.
During a review of Resident 179's Psychiatric Follow-Up Note (a clinical progress note summarizing care provided by a psychiatric provider), dated 12/17/24, indicated the Nurse Practitioner (NP 2) initially prescribed Rexulti (an antipsychotic medication used to treat mental illness) for behaviors of wandering around the unit, verbal outbursts and banging at times. Further review of NP 2's psychiatric progress note indicated Rexulti was not covered by Resident 179's insurance and was subsequently switched to Abilify, Further review of the psychiatric progress note indicated NP 2 made no mention of Abilify being used as adjunct therapy for Resident 179's depression or for which of Resident 179's diagnoses it was prescribed.
During a telephone interview on 6/12/25 at 10:43 AM with NP 2, NP 2 stated she initially prescribed Rexulti for behaviors related to dementia and switched to Abilify because Rexulti was non-formulary (not covered by insurance). NP 2 stated she was advised by facility staff she could not use Abilify for dementia and then asked the facility to discontinue the medication. NP 2 stated, to her knowledge, it has since been managed by another provider (NP 1). NP 2 stated she did not prescribe the Abilify as adjunct therapy for depression. NP 2 stated that it does not make any clinical sense to use Abilify as adjunct therapy for Resident 179's depression as the dose of the Celexa has not been optimized and the target behaviors listed for the Abilify are completely different than those from the Celexa. NP 2 stated using antipsychotic medications without a clear indication for use increases the risk that Resident 179 may have adverse effects related to antipsychotic use which could lead to a decrease in quality of life.
During a review of Resident 179's available Interdisciplinary Care Team (IDT - a team of professionals from various backgrounds who meet quarterly with care providers and family to provide an outline and plan for a resident's care) conference notes, dated between 10/29/24 to 5/9/25, indicated the conference participants did not identify or document any resident-specific, non-pharmacological interventions to utilize as an approach to address Resident 179's behavior of irritability/agitation leading to resistive to care.
During a review of Resident 179's available care plans, last reviewed 5/30/25, indicated the facility did not identify any resident-specific, non-pharmacological approaches as targeted interventions to address Resident 179's behavior of irritability/agitation leading to resistive to care.
During a review of Resident 179's MAR for June 2025 indicated the facility was not monitoring or documenting any non-pharmacological interventions related to Resident 179's behavior of irritability/agitation leading to resistive to care related to his use of Abilify and was not monitoring or documenting behaviors of self-isolation related to his use of Celexa.
2. During a review of Resident 209's admission Record, dated 6/12/25, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life.)
During a review of Resident 209's H&P, dated 5/28/25, indicated it was unclear whether Resident 209 had the capacity to make medical decisions.
During a review of Resident 209's Physician Order Summary, dated 6/11/25, indicated, on 5/27/25, he was prescribed the following psychotropic medication:
1.
Risperdal 0.5 mg to take 1 tablet by mouth two times a day for schizophrenia manifested by agitation leading to non-compliant with ADLs (activities of daily living such as bathing and brushing teeth) care and medication.
During a review of Resident 209's IDT conference notes, dated between 4/17/25 and 6/2/25, indicated the conference participants did not identify or document any resident-specific, non-pharmacological interventions to utilize as an approach to address Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication.
During a review of Resident 209's available care plans, last reviewed 5/1/25, indicated the facility did not identify any resident-specific, non-pharmacological approaches as targeted interventions to address Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication.
During a review of Resident 209's MAR for June 2025 indicated the facility was not monitoring or documenting any non-pharmacological interventions related to Resident 209's behavior of agitation leading to non-compliant with ADLs care and medication related to his use of Risperdal.
During an interview on 6/12/25 at 11:45 AM with the Director of Nursing (DON), the DON stated the facility failed to identify and document the use of resident-specific, non-pharmacological interventions to address Resident 179 or 209's problematic behaviors. The DON stated the facility does have certain non-pharmacological interventions that are used to deal with problematic behaviors in general, but there is no documentation available in the residents' MARs or any other record indicating whether these interventions have been successful or not at mitigating their problematic behaviors. The DON stated the failure to identify and document non-pharmacological approaches to resident behaviors related to dementia increases the risk that they may receive antipsychotic therapy for longer or at higher doses than necessary, possibly causing adverse effects leading to a diminished quality of life. The DON stated the facility also failed to monitor Resident 179 for behaviors of self-isolation related to the use of Celexa in the MAR. The DON stated monitoring for these behaviors allows an objective assessment of whether the benefits outweigh the risks of the continued use of psychotropic medications. The DON stated without monitoring for these behaviors, there is a risk that residents receive psychotropic medications longer than necessary or at higher doses than necessary possibly causing an increased risk of adverse effects leading to medical complications or a diminished quality of life.
During a review of the facility policy Antipsychotic Medication Use, revised January 2025, indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . Diagnoses alone do not warrant the use of antipsychotic medication . antipsychotic medication will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND; 1. the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia or grandiosity); or 2. behavioral interventions have been attempted and included in the plan of care . Antipsychotic medication will not be used if the only symptoms are one of more of the following: .wandering . restlessness . impaired memory . uncooperativeness . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications .
During a review of the facility's policy Dementia - Clinical Protocol, revised January 2025, indicated The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during shift communication and through written documentation . The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements .
During a review of the facility's policy Psychotropic Medication Use, revised February 2025, indicated Residents receiving psychotropic medication are monitored and the response to treatment is documented . Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff . Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medication, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction . Adequate indications for use refers to the identified, documented clinical rationale for administering medication that is based on: an assessment of the resident's condition and therapeutic goals, a determination that non-pharmacological interventions are clinically contraindicated: and manufacturer's recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of medication . The clinical rationale for use of psychotropic medication . is documented in the medical record. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated .
4. During a review of Resident 168's admission Record, the admission Record indicated Resident 168 was admitted on [DATE], and readmitted to the facility on [DATE] with the diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions)
During a review of Resident 168's Minimum Data Set ([MDS] a resident assessment tool) dated 3/22/2025, the MDS indicated Resident 168's cognition (ability to make decisions of daily living) was severely impaired.
During a review of Resident 168's Physician Order dated 3/17/2025, the Physician's Order indicated to administer olanzapine 5 mg via G-tube (gastrostomy tube, a small tube inserted through the abdomen and into the stomach to provide alternative way to deliver nutrition, fluids and medicine) at bedtime for schizophrenia manifested by disorganized thinking. This physician's order was discontinued on 6/4/2025.
During a review of Resident 168's Order Summary Report dated 6/4/2025, the Physician's Order indicated to administer olanzapine 5 mg via PEG-tube (percutaneous endoscopic gastrostomy tube, a soft, plastic tube that's inserted through the skin and into the stomach to deliver nutrition, fluids and medicine) at bedtime for schizophrenia manifested by disorganized thinking.
During a review of Resident 168's Medication Administration Record (MAR) dated 5/2025 and 6/2025, the MAR indicated Resident 168 was administered with olanzapine 5 mg from 5/1 to 6/2/25, and from 6/5 to 6/11/25. The MAR also indicated the side effects and behavior monitoring were documented on 5/1 to 6/3/25.
During a review of Resident 168's Psychotropic Summary Sheet for olanzapine, the Psychotropic Summary Sheet indicated the monthly behavior and side effect monitoring for 5/2025 was not completed.
During an interview on 6/11/2025 at 9:59 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not monitoring Resident 168 for any behaviors and side effects related to the use of olanzapine.
During an interview on 6/11/2025 at 11:36 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 168 should be monitored for adverse reactions and the targeted behavior for olanzapine. RN 1 confirmed there was no monitoring for adverse reactions and the target behavior for olanzapine from 6/5/2025. RN 1 confirmed the monthly behavior summary for 5/2025 was not completed.
During an interview on 6/13/2025 at 10:24 p.m., with the Director of Nursing (DON), the DON stated when administering olanzapine, the nurses should monitor the resident for side effects and to intervene if there are side effects related to the use of olanzapine. The DON stated the target behavior for olanzapine use should also be monitored to determine if the medication is working as intended. The DON stated the resident's behavior manifestation and side effects for olanzapine should be monitored by the nursing staff, and should be documented in the MAR. The DON stated the monthly behavior summary for olanzapine use for May 2025 should have been completed from 6/1 to 6/5/25, to determine if the number of the target behavior increased or decreased.
5. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of anxiety.
During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was mildly impaired.
During a review of Resident 68's Order Summary Report dated 6/9/2025, the Physician's Order indicated to administer clonazepam 0.5 mg one tablet by mouth for anxiety. Hold if sedated.
During a review of Resident 68's MAR dated 6/2025, the MAR indicated Resident 68 was administered with clonazepam 0.5 mg from 6/10 to 6/12/2025.
During an interview on 6/12/2025 at 8:44 a.m., with Licensed Vocation Nurse (LVN) 1, LVN 1 stated she was not monitoring Resident 68 for any behavior manifestation related to the use of olanzapine.
During an interview on 6/12/2025 at 8:54 a.m., with Registered Nurse (RN) 1, RN 1 stated the physician's order for clonazepam should include a behavior manifestation and Resident 168 should be monitored for the targeted behavior. RN 1 confirmed Resident 68 was not being monitored for any behavior manifestation for the use of clonazepam.
During an interview on 6/13/2025 at 11:05 p.m. with the DON, the DON stated the physician's order for clonazepam should include the resident's behavior manifestation, and the resident on clonazepam should be monitored for behavior manifestation for the use of clonazepam every shift. The DON stated Resident 68's behavior was not monitored related to the use of clonazepam.
6. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder).
During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22's cognition was severely impaired.
During a review of Resident 22's Order Summary Report dated 5/12/2025, the Physician's Order indicated to administer divalproex sodium 125 mg two capsules by mouth every 12 hours for schizoaffective disorder manifested by mood swings as evidenced by crawling on the floor.
During a review of Resident 22's MAR dated 5/2025 and 6/2025, the MAR indicated Resident 22 was administered with divalproex sodium from 5/12 to 6/12/2025.
During an interview on 6/12/2025 at 1:53 p.m., with Licensed Vocation Nurse (LVN) 3, LVN 3 stated she was not monitoring Resident 22 for any side effects related to the use of divalproex sodium.
During an interview on 6/12/2025 at 2:16 p.m., with Registered Nurse (RN) 2, RN 2 confirmed Resident 22 was not being monitored for any side effects for divalproex sodium.
During an interview on 6/13/25 at 10:46 a.m. with the Director of Nursing (DON), the DON stated Resident 22 should be monitored for the side effects of the divalproex sodium every shift, and this should be document in the MAR.
During a review of the facility's P/P titled Psychotropic Medication use dated 2/2025, the P/P indicated residents receiving psychotropic medication are monitored and the response to treatment is documented. The P&P also indicated the residents are monitored for adverse consequences associated with psychotropic medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive care plan for accidents one of seven sample residents (Resident 156), when a care plan was not updated for Resident 156 after the resident experienced a fall.
This had the potential for serious harm, including additional falls or injures, due to the facility's failure to reassess and respond to the resident's change in condition.
Findings:
During a review of Resident 156's admission Record, the admission Record indicated Resident 156 was admitted to the facility on [DATE], with diagnoses which included, unspecified sequelae of cerebral infarction (effects or consequences of a stroke caused by a blocked blood vessel in the brain), Type 2 diabetes mellitus (a disease where the body does not make enough insulin), and chronic pulmonary edema (long-term fluid buildup in lungs).
During an initial observation and interview with the Licensed Vocational Nurse (LVN) 9 on 6/9/2025, at 2:50 p.m., in Resident 156's room, LVN 9 stated Resident 156 had a fall incident inside her restroom last month. LVN 9 stated Resident 156 had her bed set in a low bed position since she was a fall risk resident.
During a review of Resident 156's Progress Notes NEW dated 5/14/2025, the progress notes indicated . Interdisciplinary Team (IDT residents health care team consisting of various specialties) note indicated Resident 156 had an unwitnessed fall on 5/13/2025. The progress notes indicated the IDT Team discussed and recommended that the resident should be in the 'Falling Star' (fall risk) program to prevent recurrent falls.
During a review of Resident 156's care plan titled, Care Plan Report' dated 5/1/2025, the Care Plan indicated Resident 156 was at risk for falls with or without injury related to altered mental status, decreased muscular coordination, high risk .Goal .Will minimize complications related to falls .Interventions .Educate/remind resident to call for assistance .
During an interview and record review on 6/11/2025, at 10:15 a.m., with the Director of Nursing (DON), Resident 156's medical records were reviewed. The DON was not able to find documented evidence of a revised care plan for Resident 156's fall on 5/13/2025.
During a concurrent interview and record review on 6/11/2025, at 11:42 a.m., with the DON, the DON stated revision of resident's care plan after a fall is very important for the staff to know to avoid repeating the incident that led to the fall to happen again and to always keep the resident safe. The DON stated Resident's 156's care plan was not updated after the fall on 5/13/2025.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated January 2025, the policy indicated, .includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .12. The interdisciplinary team reviews and updates the care plan .a. when there has been a significant change in the resident's condition .b. when the desired outcome is not met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a written notice Based on interview, and record review, the facility failed to ensure a written copy of the bed hold notice was created and provided to two of two sampled resident's (Residents 1 and 2) responsible parties (RP 1 and RP 2) within 24 hours of transferring Resident 1 and Resident 2 to a General Acute Care Hospital (GACH).
This deficient practice resulted in the incomplete status of Resident 1 and Resident 2's bed hold availability and no documented notice provided to RP 1 and RP 2.
Findings:
a. During a review of Resident 1's admission Record, (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia characterized by false beliefs of being persecuted, harmed, or spied upon) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognition (a noticeable but not severe decline in thinking, learning, remembering, using judgment, and making decisions) and required supervision (helper provides verbal cues and/or touching /steadying to complete the activity) to complete activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1's Progress Note, dated 5/19/2025 and timed at 2:56 p.m., the Progress Note indicated Resident 1 was transferred to a GACH for further assessment and clearance.
During a review of Resident 1's Progress Note, dated 5/20/2025 and timed at 10 a.m., the Progress Note indicated the Social Services Director (SSD) contacted RP 1 to inform them of the seven-day bed hold policy.
During a review of Resident 1's Medical Record, the Medical Record indicated no documented evidence that a written Bed Hold notice was created.
During a concurrent interview and record review on 5/23/2025 at 3 p.m., with the SSD, Resident 1's Bed Hold Informed Consent was reviewed. The SSD stated RP 1 was notified upon Resident 1's admission to the facility (5/22/2025) of the facility's bed hold policy. The SSD stated RP 1 was notified verbally on 5/19/2025 at the time Resident 1 was transferred to the GACH but was unable to show documented evidence that a Bed Hold notice was created and provided to RP 1 within 24 hours of Resident 1's transfer to the GACH
b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia.
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had impaired cognition and required partial/moderate assistance (helpers does less than half the effort) to complete ADLs.
During a review of Resident 2's Progress Note, dated 5/19/2025 and timed at 2:56 p.m., the Progress Note indicated Resident 2 was transferred to a GACH for further assessment and clearance.
During a review of Resident 2's Progress Note, dated 5/20/2025 and timed at 10 a.m., the Progress Note indicated the SSD contacted RP 2 to inform them of the seven-day bed hold policy.
During a concurrent interview and record review on 5/23/25 at 3 p.m., with the SSD, Resident 2's Bed Hold Informed Consent was reviewed. The SSD stated RP 2 was notified upon Resident 2's admission to the facility (5/22/2025) of the facility's bed hold policy. The SSD stated RP 2 was notified verbally on 5/19/2025 at the time Resident 2 was transferred to the GACH but was unable to show documented evidence that a Bed Hold notice was created and provided to RP 2 within 24 hours of Resident 2's transfer to the GACH.
During a review of the facility's Policy and Procedure (P&P), titled Bed-Holds and Returns dated 1/2025, the P&P indicated all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) . at the time of transfer (or, if the transfer was an emergency, within 24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of nine sampled residents (Resident 1 and Resident 2), who were assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), received supervision to prevent elopement from the facility.
These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m. without staff awareness. Resident 1 and Resident 2 were located by Resident 1's Family Member (FM) 1 approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a General Acute Care Hospital (GACH) for evaluation and treatment, where they remained for four days. Resident 1 was admitted to the GACH with altered mental status (a change from a person's normal mental state) and Resident 2 was assessed and treated for a urinary tract infection ([UTI] an infection in the bladder/urinary tract). These deficient practices placed Resident 1 and Resident 2 at risk of exposure to inclement weather (unpleasant or severe weather conditions that can disrupt activities, create hazardous situations, or pose risks to safety), vehicular accident and injury, harm by other individuals and death, and placed 144 residents, who resided in the facility, and who were assessed as high risk for wandering/elopement, at risk for elopement from the facility.
On 5/20/2025 at 7:03 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to identify Resident 1 and Resident 2 prior to allowing them entry into the facility's lobby from a locked unit and permitting them to elope the building through the facility's front door.
On 5/23/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 5/23/2025 at 3:06 p.m., in the presence of the facility's DON and ADM.
The facility's IJRP included the following immediate actions:
On 5/19/2025 - 5/20/2025 a review 228 residents' medical records was conducted by the DON and IDT members to ensure each resident had an updated Elopement/Wandering Risk assessment and care plan. 144 residents were identified at risk for elopement/wandering. 10 of the 144 at risk residents were identified with no elopement risk/wandering care plans, their care plans were updated to reflect interventions to ensure residents were free from elopement episodes and free from any injuries if wandering.
An Elopement binder located at the receptionist desk and in Point Care Click ([PCC] a healthcare management platform designed to simplify resident care and improve efficiency in senior care facilities) Special Instructions (a mechanism in PCC to identify if a resident is at risk for elopement/wandering) were updated on 5/20/2025 to reflect residents' appropriate risk for elopement/wandering.
On 5/18/2025, the Infection Preventionist Nurse (IPN) Nurse Manager and Regional Director of Clinical Services (RDCS) initiated an in-service for the licensed nursing staff regarding the facility's policy and procedure on elopements, and emergency procedure when a resident is missing/has eloped.
On 5/19/2025 an In-service was initiated by the DSD for facility staff regarding residents at risk for elopement, identifying wandering and exit seeking behaviors, interventions for wandering and exit seeking behaviors, new visitor screening process for visitors/outside providers, new staff entrance/exit process, staff/visitor/outside providers' badges are visible and any individuals without proper badge/identification will not be permitted entry or exit through the locked doors, when opening locked doors ensure residents are not following them, vigilance in noticing surroundings when entering or leaving locked doors.
Staff are no longer permitted to enter or exit through the front doors to lessen crowding and increase visibility. Staff will begin utilizing the metal doors located East of the front entrance at the front of the facility. A sign has been placed on the front door directing staff to the new entrance location. All staff will enter the facility through an alternative entrance on the day and evening shifts, and after hours, staff entering the building will press a button and staff inside the building, after viewing a camera, will let them in. Two receptionists are currently assigned to screen visitors from 7 a.m. - 7 p.m., at the front lobby daily Monday through Sunday. During lunch breaks, the two receptionist will relieve each other, there will be only one receptionist during lunch breaks.
On 5/20/2025 the facility upgraded entrance doors with a magnetic security/closure function in addition to a keypad entry that was installed.
On 5/19/2025 the Receptionist and CNA involved were placed on leave pending the outcome of the investigation. The Receptionist and CNA's termination will be processed effective 5/23/2025.
The DSD/designee will conduct hallway rounds three times per week to ensure residents are supervised and redirected to appropriate units.
Findings:
During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia [a mental illness that affects a person's thoughts, feelings and behaviors] marked primarily by distrust of others, and false beliefs of being persecuted, harmed, or spied upon) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with a person's ability to think, learn, remember, use judgement, and make decisions) for daily decision making and required supervision (helper provides verbal cues and/or touching /steadying to complete the activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1's Wandering Risk Observation/assessment dated [DATE], the Wandering Risk Observation/Assessment indicated a score of nine indicating Resident 1 was at risk for wandering.
During a review of Resident 1's untitled Care Plan dated 4/23/2025, the Care Plan indicated Resident 1 was an elopement risk/wanderer related to her attempts to leave the facility unattended. Under this Care Plan, the goal was that Resident 1 would not leave the facility unattended through the review date of 6/23/2025. The Care Plan's interventions included distracting Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books, monitoring Resident 1's location every two hours and document wandering behavior and attempted diversional interventions in the behavior log.
During a review of Resident 1's Change of Condition (COC) form dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 1's Responsible Party (RP) were notified of Resident 1's disappearance.
During a review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., Family Member (FM) 1 reported he located Resident 1 near his residence. The Nursing Progress Note indicated Resident 1 was transported to a GACH by the facility's ADM and SSW for assessment and clearance.
During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH on 5/19/2025.
During a review of the GACH's Emergency Department (ED) Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 1 was admitted with a diagnosis of altered mental status.
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia.
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had impaired cognitive skills for daily decision making and required partial/moderate assistance (helpers does less than half the effort) to complete ADLs.
During a review of Resident 2's Wandering Risk Observation/assessment dated [DATE] the Wandering Risk Observation/Assessment indicated a score of eleven indicating Resident 2 was a high risk for wandering.
During a review of Resident 2's untitled Care Plan dated 9/5/2024, the Care Plan indicated Resident 2 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness. The care plan indicated Resident 2 wandered aimlessly and significantly intruded on the privacy or activities of others. Under this Care Plan, the goal was that Resident 2 would not leave the facility unattended through the review date of 12/04/2024. The Care Plan's interventions included monitoring Resident 2's location, documenting wandering behavior and attempted diversional interventions in the behavior log.
During a review of Resident 2's COC dated 5/18/2025, the COC indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and Code Black was initiated. The COC indicated at 5:41 p.m., the DON, ADM, local police and Resident 2's RP were notified of Resident 2's disappearance.
During a review of Resident 2's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., the Nursing Progress Note indicated FM 1 reported he located Resident 2 near his residence. The Nursing Progress Note indicated Resident 2 was transported to a GACH by the facility's ADM and SSW worker for assessment and clearance.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the GACH on 5/19/2025.
During a review of the GACH's ED Progress Note dated 5/19/2025, the ED Progress Note indicated Resident 2 was admitted to the GACH with a diagnosis of urinary tract infection, and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing).
During an interview on 5/20/2025 at 10:56 a.m., and a subsequent interview at 12:42 p.m., RCP 1 stated on 5/18/2025 at approximately 12:10 p.m. to 12:15 p.m., CNA 1 rang the doorbell from inside the facility's locked area alerting her (RCP 1) to unlock the door, which led to the facility's lobby area, so that the visitors (Resident 1 and Resident 2) could be allowed out. RCP 1 stated she unlocked the door, and Resident 1 and Resident 2 entered the lobby and continued out the facility's front entrance. RCP 1 stated Resident 1 and Resident 2 did not have on green visitors stickers, but she stated that was not uncommon because visitors entered the facility through a different entrance when she was on her lunch break. RCP 1 stated she found out later that evening, those visitors were residents. RCP 1 stated she was not familiar with the residents in the facility, and she did not recognize the visitors were actually residents. RCP 1 stated there was no process to check out visitors when they left the facility, she just told Resident 1 and Resident 2 goodbye and have a nice day when they left out of the building through the facility's front door.
During an interview on 5/20/2025 at 11:48 a.m., CNA 1 stated on 5/18/2025 at approximately lunchtime she was passing by the locked doors that led to the facility's lobby area and saw two ladies that did not look like residents near the doors. CNA 1 stated she pressed the button (doorbell) to signal for RCP 1 to unlock the doors, which she (RCP 1) did, and the two ladies proceeded into the lobby area. CNA 1 stated she saw one of the two ladies wearing a green visitor sticker which was given to visitors when they enter the facility.
During an interview on 5/20/2025 at 2:42 p.m., CNA 4 stated on 5/18/2025 at approximately lunchtime, she did not see Resident 1 or Resident 2 when she delivered lunch trays to their shared room. CNA 4 stated she does rounds on her assigned residents every two hours, during her rounds on 5/18/2025, she did not see Resident 1 and Resident 2 after delivering their lunch trays and did not look for them because she assumed they were on the facility's patio. CNA 4 stated she did notice their lunch trays were still in the resident's room and were untouched. CNA 4 stated she found out later that night, Resident 1 and Resident 2 were missing from the facility.
During an interview on 5/20/2025 at 2:15 p.m., CNA 5 stated when she started her shift at 3 p.m., on 5/18/2025 she noticed Resident 1 and Resident 2's lunch trays were still in their room untouched. CNA 5 stated she asked staff members if they had seen the residents, but nobody had seen them. CNA 5 stated prior to dinner time (unsure of the exact time), she asked other staff to help her look for Resident 1 and Resident 2 and they (her and the other staff) continued looking for them through dinner time. CNA 5 stated she found out the residents had eloped when she heard Code Black (an alert to facility staff to initiate a search of the building and premises for a resident who left the facility without authorization), being activated.
During an interview on 5/20/2025 at 3:04 p.m., the DON stated Resident 1 and Resident 2's whereabouts in the facility should have been monitored every two hours because they were high risk for wandering/elopement. The DON stated staff should have confirmed if the two ladies (Resident 1 and Resident 2) were actual visitors prior to allowing them into the facility's lobby area and then allowing them to exit through the facility's front door. The DON stated the facility had no check out process for visitors and none was utilized by RCP 1 prior to Resident 1 and Resident 2 eloping from the facility. The DON stated the residents' elopement placed them at risk for harm by car accident and/or injury by other individuals, missed medications, no access to food or water, and exposure to different weather conditions.
During a review of the facility's undated Policy and Procedure (P/P) titled Wandering Residents and Elopements the P/P indicated the facility maintains a process to assess residents for elopement risk, or who are at risk of unsafe wandering and will implement risk reduction strategies. The P/P indicated interventions that may be used for residents identified as high risk for elopement include but may not be limited to the physical plant is secured to minimize the risk of elopement through safety locks or keypad entry that restrict access to dangerous areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create and document a Nursing Fall Assessment when one of three sampled residents (Resident 3) experienced a fall and injury to his left eyebrow.
This deficient practice resulted in no documented interventions for Resident 3 following his fall and left eyebrow injury and had the potential for care not to be rendered and/or monitored.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness.
During a review of Resident 3's Minimum Data Set ([MDS] a standardized resident assessment tool) dated 5/1/2025, the MDS indicated Resident 3 had severely impaired cognition (a very hard time remembering things, making decisions, concentrating, or learning) and required partial/moderate assistance (helper does less than half the effort to complete the activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 3's Progress Note, dated 5/8/2025 and timed at 12:30 a.m., the Progress Note indicated Resident 3 experienced an unwitnessed fall in his room and suffered a cut on his left eyebrow. The Progress Note indicated Resident 3's physician was notified and instructed staff to monitor Resident 3 and conduct a neuro checks.
During a concurrent interview and record review on 5/23/2025 at 8:05 a.m., with the Director of Nursing DON, Resident 3's Medical Record was reviewed. Resident 3's Medical Record indicated there was no documented evidence that a Nursing Fall Assessment was conducted when Resident 3 fell on 5/8/2025 and sustained an injury to his left eyebrow. The DON stated when a resident experiences a fall, a licensed nurse should complete a Nursing Fall Assessment so that staff will know which interventions to put into place.
During a review of the facility's Policy and Procedure (P/P), titled, Falls and Fall Risk, Managing dated 3/2018, 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

Based on interview and record review, the facility failed to provide training related to resident elopement (the act of leaving a facility unsupervised and without prior authorization) for eight of eight sampled employees (Certified Nursing Assistants [CNA] 1, 8, 9, 10, 11, 12 and 13 and a Restorative Nursing Assistant (RNA 1) on hire and/or annually, as indicated in their Facility Assessment.
This deficient practice resulted in CNA 1 and Receptionist (RCP) 1 allowing two residents (Resident 1 and Resident 2) to enter the facility's lobby area from a locked location and then wander (a situation in which a resident leaves the premises of a safe area without the facility's knowledge and supervision, if necessary, would be considered and elopement) through the facility's front door on 5/18/2025.
Findings:
During a review CNAs 1, 8, 9, 10, 11, 12, 13, and RNA 1's Employee Files, the Employee files indicated there was no documented evidence that the forementioned employees received training related to resident elopement.
During an interview on 5/22/2025 at 9:40 a.m., and a subsequent interview at 10:12 a.m., the Director of Staff Development (DSD) stated new hire training covered the topic of Code Black (an alert to facility staff to initiate a search of the building and premises for a resident who left the facility without authorization), but did not include training regarding interventions to prevent residents' from elopement or how to identify a resident versus a visitor. The DSD stated elopement training was not a mandatory topic, and she was focused on other topics for CNAs to complete their training hours.
During an interview on 5/22/2025 at 11:46 a.m., the Director of Nursing (DON) stated he believed training related to resident elopement was ongoing (but it was not). The DON stated staff should have received elopement education upon hire, annually and as needed.
During a review of the facility's Facility assessment dated 6/2024, the Facility Assessment indicated staff training/education and competencies that were necessary to provide the level and types of support and care needed for the resident population included CNA skills, competency and review on the topic of residents who are at risk for elopement/wandering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure neurological (relating to disorders of the nervous system) assessments was completed, per protocol, for one of three sampled residents (Resident 3), after Resident 3 experienced a fall and hit his head.
This deficient practice resulted in an incomplete/incorrect neurological assessment of Resident 3 and had the potential for a change of condition (COC) to go unnoticed which could lead to a delay in evaluation and care.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness.
During a review of Resident 3's Minimum Data Set ([MDS] a standardized resident assessment tool) dated 5/1/2025, the MDS indicated Resident 3 had severely impaired cognition (a very hard time remembering things, making decisions, concentrating, or learning) and required partial/moderate assistance (helper does less than half the effort to complete the activity) to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 3's Progress Note, dated 5/8/2025 and timed at 12:30 a.m., the Progress Note indicated Resident 3 experienced an unwitnessed fall in his room and suffered a cut on his left eyebrow. The Progress Note indicated Resident 3's physician was notified and instructed staff to conduct a neuro checks.
During a concurrent interview and record review on 5/21/2025 at 6:15 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 3's Neurological Assessment Flowsheet dated 5/8/2025 and 5/9/2025 was reviewed. The Neurological Assessment Flowsheet indicated the neurological checks were to be conducted as follows:
Every 15 minutes times four Every 30 minutes times two Every hour times two Every four hours times four Every eight hours times six
Continued review of the Neurological Assessment Flowsheet indicated there were 11 missed neurologic assessments. Resident 3's neurological assessments were conducted as follows:
On 5/8/2025:
12:30 a.m., 12:45 a.m., 1 a.m., 1:15 a.m. 1:45 a.m., 2:15 a.m. 3:15 a.m., 4:15 a.m. 12:15 p.m., 2:12 p.m., 5:12 p.m., 9:12 p.m., (the 8:15 a.m., 4:15 p.m., and 8:15 p.m., assessments were missed)
On 5/9/2025:
5 a.m., 7 a.m., 1 a.m., 2 p.m., 5 p.m., and 11 p.m., (the 4:15 a.m., 12:15 p.m., 8:15 p.m., 5/10/2025 at 4:15 a.m., 12:15 p.m., 8:15 p.m., 5/11/2025 at 4:15 a.m., and 12:15 p.m., assessments were missed)
LVN 1 stated she thought she documented Resident 3's neurologic assessment correctly but when pointed out the times of assessment that were incorrect she could not explain why.
During a concurrent interview and record review on 5/21/25 at 8:05 a.m., with the Director of Nursing (DON), Resident 3's Neurological Assessment Flowsheet dated 5/8/2025 and 5/9/2025 was reviewed. The DON verified the neurological assessment was done incorrectly, and stated the neurological assessment schedule should have been followed per the instructions on the Neurological Assessment Flowsheet.
During a review of the facility's Policy and Procedure (P/P), titled, Neurological Assessment (Routine) revised 10/2023, the P/P indicated routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. Steps in the procedure include to conduct neurological checks as frequently as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that for one of three sampled residents (Resident 1) who was prescribed and administered anti-psychotic medication (a class of drugs used to treat psychosis [an abnormal condition of the mind that results in difficulties telling what is real and what is not], that the medication was prescribed and administered for appropriate indications for use, detailed evidence of behaviors were documented, non-pharmacological interventions (any type of healthcare action that does not involve the use of medication) were attempted and evaluated prior to the administration/continuance of the medication, adverse reactions associated with the use of the medication, i.e., weight gain, an increase in cholesterol and dizziness were monitored, documented and evaluated, and a comprehensive evaluation was conducted to determine if continued use of the medication was warranted.
These deficient practices placed Resident 1 at risk for unnecessary medication administration, adverse reactions associated with the medication's use, chemical restraints, and death.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Schizophrenia, unspecified (a diagnosis used when a clinician can't specify why a patient's symptoms don't meet the criteria for a specific schizophrenia diagnosis and when there isn't enough information to make a more specific diagnosis).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/4/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired.
During a review of Resident 1's History and Physical (H&P) dated 10/29/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Progress Notes dated 10/29/2024, the Progress Notes indicated Resident 1 was agitated, crying, and trying to get up from her bed. The Progress Notes indicated Resident 1's physician ordered Zyprexa (an antipsychotic medication used to treat several mental health conditions) 2.5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) on 10/29/2024 and instructed them to call the Nurse Practitioner ([NP] an advance practice registered nurse who can diagnose and treat illnesses, prescribe medications, and manage patient care, often performing many of the same duties as physicians) in the morning. Continued review of Resident 1's Progress Notes indicated no further documented behaviors from Resident 1's and no documented non-pharmaceutical interventions were attempted prior to the administration of Zyprexa.
During a review of Resident 1's Order Summary Report (Physician's Orders) dated 10/29/2024, the Physician's Orders indicated to administer the following medications to Resident 1:
1. Divalproex (used to treat certain types of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] as well as the manic phase [mental state of an extreme highs] of bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) 125 mg one time a day for schizophrenia manifested by agitation during activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) care.
2. Zyprexa 2.5 mg two times a day for schizophrenia manifested by striking out without cause.
During a review of Resident 1's Psychiatric Initial Evaluation Note dated 10/30/2024, the Psychiatric Initial Evaluation Note indicated, Resident 1 was pleasant, and per the treatment team, Resident 1 was compliant with care. The Psychiatric Initial Evaluation Note indicated Resident 1 had no behavioral issues.
During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/2024, and 12/2024, the MARs indicated there was no documentation that adverse/side effects were monitored related to Resident 1's use of Divalproex and Zyprexa.
On 4/23/2025 Resident 1 was observed to be pleasant but confused, sitting in and self-propelling her wheelchair. There was no observation of Resident 1 striking out or yelling at anyone.
During an interview on 4/24/2025 at 11:20 a.m., the Assistant Director of Nursing (ADON) stated, when Resident 1 was admitted to the facility (10/28/2024), she was agitated and disgruntled (unhappy, annoyed and disappointed about something) due to the new environment. The ADON stated, the facility's protocol for new onset behavior included assessing the resident, attempting non-pharmacologic interventions, and monitoring the resident for behaviors. The ADON stated, after reviewing Resident 1's Progress Notes, that there was no documentation to indicate Resident 1 had been assessed, monitored for behaviors or that non pharmaceutical interventions had been attempted prior to administering Divalproex and Zyprexa to Resident 1.
During an interview on 4/25/2025 at 3:43 p.m., the Director of Nursing (DON) stated the NP ordered Zyprexa on 10/29/2024 because Resident 1 was agitated, crying and trying to get up from her bed. The DON stated there was no evaluation of Resident 1's psychotropic medications (drugs that affect mental function, behavior, and experience), or monitoring for adverse/side effects of Divalproex and Zyprexa for 11/2024 and 12/2024, and there had been no further behaviors documented for Resident 1.
During a telephone interview on 4/25/2025 at 4:48 p.m., Resident 1' Physician and the NP stated, the Zyprexa that was ordered on 10/29/2024 should have been given one time only, not as a routine medication.
During a review of the facility's Policy and Procedure (P&P) titled, Psychotropic Medication Use revised 2/2025, the P&P indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident of others and when a resident is exhibiting indications of distress that are significant to the resident. Non-pharmacological approaches have been attempted, but did not relieve the medical symptoms which are presenting a danger or significant distress. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record. Documentation must include that behavioral interventions were attempted but not successful, and these interventions were deemed clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility ' s licensed nurses failed to ensure informed consents were obtained from residents or their Responsible Party (RP) prior to administering antipsychotic medications (medication used to treat serious mental health conditions) and/or they failed to ensure informed consents were obtained by the resident ' s provider and not licensed nurses for three of seven sampled residents (Residents 1, 5, and 6).
This deficient practice resulted in the administration of anti-psychotic medications to Residents 1, 5, and 6 prior to them being informed of the medications risk versus benefits, alternative treatment and opportunity to refuse. This deficient practice had the potential for the residents to receive unnecessary medications.
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with other behavioral disturbances, anxiety disorder (a mental condition characterized by excessive worry and fear) and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face Sheet indicated Resident 1 ' s Family Member (FM 1) was the Resident Representative.
During a review of Resident 1 ' s History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/4/2025, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired.
During a review of Resident 1 ' s Order Summary Report (Physician ' s Order), the Physician ' s Order indicated the following:
10/29/2024 – Ativan oral tablet 1 mg every 6 hours as needed for anxiety disorder for 14 days m/b agitation leading to resistance to care.
10/29/2024 – Divalproex Sodium (medication primarily used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and manic phase [mental state of an extreme highs] of bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) oral tablet delayed release 125 mg, one time daily for schizophrenia m/b agitation during activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
10/29/2024 – Zyprexa (medication used to treat schizophrenia) oral tablet 2.5 mg two times a day for schizophrenia m/b striking out without cause.
11/26/2024 – Ativan (medication used to treat anxiety disorders and severe agitation) 0.5 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) every eight hours for 14 days, as needed for anxiety manifested by (m/b) biting and hitting herself.
During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 11/24/2025, the Facility Verification of Informed Consent indicated:
Ativan 0.5 mg every eight hours for 14 days, as needed for anxiety m/b hitting and biting herself. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling Resident 1 ' s Family Member 1 (FM 1) by phone on 11/26/2025.
During a review of Resident 1 ' s Facility Verification of Informed Consent dated 10/29/2024, the Facility Verification of Informed Consent indicated:
Ativan oral tablet one mg for anxiety disorder m/b agitation leading to resistance to care. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025.
During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 10/30/2024 the Facility Verification of Informed Consent indicated:
Zyprexa oral tablet 2.5 mg for schizophrenia m/b striking out without cause. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025.
During a review of Resident 1 ' s Facility Verification of Informed Consent, dated 10/30/2024 the Facility Verification of Informed Consent indicated:
Divalproex Sodium oral tablet 125 mg for schizophrenia m/b agitation during ADLs. The Facility Verification of Informed Consent indicated the consent was obtained by a licensed nurse by calling FM 1 on the phone on 10/29/2025.
During an interview on 4/23/2025 at 9:52 a.m., FM 1 stated no one at the facility told him what medications Resident 1 was taking, and they were administering two psychotropic medications (drugs that affect mental functions, behavior, and experience [Zyprexa and Divalproex]) without his knowledge or consent.
During an interview on 4/25/2025 at 4:49 p.m., Resident 1 ' s Nurse Practitioner ([NP] an advanced practice Registered Nurse who can diagnose and treat illnesses, prescribe medications, and manage patient care often performing many of the same duties as physicians) 1 stated, if a resident does not have the capacity to make a decision, they will reach out to the next of kin. NP 1 stated, she recalls speaking to FM 2 in 11/2024 when she ordered Ativan 0. 5mg for Resident 1 and stated she did not speak to FM 1 (Resident 1 ' s RP). NP 1 stated licensed nurses can obtain informed consents by educating the residents regarding medication if they (the licensed nurses) feel comfortable doing so. NP 1 stated the licensed nurses can have the residents sign the informed consent, and then they (physician, NP) will cosign the informed consent.
b. During a review of Resident 5 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including vascular dementia (decline in mental ability caused by reduced blood flow to the brain), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 5 ' s H&P dated 12/22/2024, the H&P indicated Resident 5 had the capacity to make medical decisions.
During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognitive skills were mildly impaired.
During a review of Resident 5 ' s Order Summary Report (Physician ' s Order), the Physician ' s Order indicated the following:
12/20/2024 - Prozac (medication used to treat depression) oral capsule 10 mg, one time daily for unspecified depression m/b verbalization of sadness.
12/20/2024 – Seroquel (medication used to treat schizophrenia and depression) oral tablet 50 mg, one time daily for schizoaffective disorder m/b unprovoked agitation towards staff.
During a review of Resident 5 ' s Facility Verification of Informed Consents dated 12/22/2024, the Facility Verification of Informed Consent indicated Resident 5 ' s Responsible Party (RP) 5 consented for the administration of Prozac 10 mg once a day for unspecified depression m/b verbalization of sadness and Seroquel 50 mg once a day (200 mg at bedtime/50 mg daily) for schizoaffective disorder m/b unprovoked agitation towards staff on.
During a review of Resident 5 ' s Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident)dated 12/1/2024 through 12/31/2024, the MAR indicated Prozac oral capsule 10 mg and Seroquel oral tablet 50 mg was administered to Resident 5 on 12/21/2024, prior to the consent being obtained on 12/22/2024.
During an interview on 4/24/2025 at 11:21 a.m., the Assistant Director of Nursing (ADON) stated for psychotropic medications, the psychiatrist should obtain the informed consent from the resident or the resident ' s RP, then the licensed nurses speak to the resident or call the family to verify the physician obtained the informed consent by reviewing the medication and side effects with the resident or RP. The ADON stated informed consents should be obtained prior to administering psychotropic medications.
During an interview on 4/24/2025 at 12:49 p.m., after reviewing Resident 5 ' s MAR dated 12/1/2024 through 12/31/2024, the ADON stated the MAR indicated Prozac oral capsule 10 mg and Seroquel 25 mg was administered to Resident 5 on 12/21/2024. The ADON stated the informed consent for Prozac was dated 12/22/2024 after the medication was administered to Resident 5 and should have been obtained prior to the administration of the medications.
c. During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including dementia, and schizophrenia.
During a review of Resident 6 ' s H&P dated 2/19/2025, the H&P indicated Resident 6 was not capable of making medical decisions.
During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 ' s cognitive skills were mildly impaired.
During a review of Resident 6 ' s Physician ' s Order, the Physician ' s Order indicated the following:
2/18/2025 - Divalproex Sodium oral tablet delayed release 500 mg, give 1 tablet at bedtime for schizophrenia m/b mood swings.
2/18/2025 - Quetiapine Fumarate oral tablet 25 mg, give 1 tablet two times a day for schizophrenia m/b agitation leading to noncompliance with care.
3/1/2025 - Quetiapine Fumarate oral tablet 25 mg, give 1 tablet at bedtime for schizophrenia m/b agitation leading to noncompliance with care.
During a review of Resident 6 ' s Facility Verification of Informed Consent dated 4/15/2025, the Facility Verification of Informed Consent indicated Quetiapine (dose unspecified) for schizophrenia m/b agitation leading to noncompliance with care was obtained from Resident 6 ' s RP on 3/1/2025 and signed by the provider on 4/15/2025.
Continued review of Resident 6 ' s clinical record indicated there were no informed consents obtained for Divalproex Sodium 500 mg at bedtime ordered on 2/18/2025 or Quetiapine Fumarate 25 mg two times a day ordered on 2/18/2025.
During a review of Resident 6 ' s MAR dated 2/1/2025 through 2/28/2025, the MAR indicated both Divalproex Sodium oral tablet delayed release 500 mg at bedtime and Quetiapine Fumarate oral tablet 25 mg 2 times a day were administered on 2/19/2025, without an informed consent being obtained prior to administration of the medications.
During a review of Resident 6 ' s MAR dated 3/1/2025 through 3/31/2025, the MAR indicated Quetiapine Fumarate oral tablet 25 mg 1 tablet at bedtime was administered on 3/1/2025, prior to the consent being obtained.
During an interview on 4/25/2025 at 3:43 p.m., and subsequent interviews at 4:33 p.m., and 4:37 p.m., after reviewing Resident 6 ' s Informed Consents the Director of Nursing (DON) stated the dosage, and date was not documented on Resident 6 ' s informed consent for Quetiapine and the providers signature was dated 4/15/2025 when the medication was ordered on 3/1/2025 and the first dose of the medication was administered on 3/1/2025. The DON stated any changes to Resident 6 ' s psychotropic medication order would need a new informed consent.
During an interview on 4/25/2025 at 4:37 p.m., after reviewing Resident 6 ' s MAR dated 2/1/2025 through 2/28/2025, the DON stated the MAR indicated Quetiapine Fumarate oral tablet 25 mg by mouth two times a day and the Divalproex Sodium 500 mg at bedtime, both ordered on 2/18/2025 were administered to Resident 6 on 2/19/20025 with a verbal consent from the physician. The DON stated there should have been an informed consent completed by the licensed nurses and signed by the physician prior to administration of the medications.
During a review of the facility ' s Policy and Procedure (P&P) titled, Psychotropic Medication Use revised on 2/2025, the P&P indicated prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:
a. non-pharmacological alternatives.
b. the indications and rationale for the recommendation.
c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and
d. the resident's/representative's right to accept or decline the treatment.
During a review of the facility ' s P&P titled, Psychoactive/Psychotropic Medication Use revised on 7/2024, the P&P indicated the prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a Psychotropic medication. Prior to administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. The resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Prior to prescribing a Psychotropic medication, the prescribing clinician must personally examine the resident. Prior to the administration of a Psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record. A licensed nurse must verify informed consent has been obtained from the resident or the resident's representative prior to administering psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and record review the facility failed to ensure:
A. 45 of 95 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room.
B. To accommodate the resident's needs and preferences for safe and unrestricted mobility using a wheelchair for one of one resident (Resident 27).
This failure had the potential to hinder effective evacuation during an emergency and limit the resident's independence by obstructing the path with furniture and large items.
Findings:
A.During a review of the facility's Client Accommodations Analysis form, dated 7/5/2024, provided by the facility on 1/10/2025, the facility had 43 rooms that measured less than 80 sq. ft. per resident in multi-bedrooms and two rooms that measured less than 100 sq. ft for a single bedroom. The resident rooms were as follow:
Palm Unit: Room G1 (3 beds) 223.53 sq. ft. Room G2 (3 beds) 223.53 sq. ft. Room G3 (3 beds) 223.53 sq. ft. Room G4 (3 beds) 223.53 sq. ft. Room G5 (3 beds) 223.53 sq. ft. Room G6 (3 beds) 223.53 sq. ft. Room G7 (3 beds) 223.53 sq. ft. Room G8 (3 beds) 223.53 sq. ft. Room G9 (3 beds) 223.53 sq. ft. Room G10 (3 beds) 223.53 sq. ft. Room G11 (3 beds) 223.53 sq. ft. Room G12 (3 beds) 223.53 sq. ft. Room G13 (3 beds) 223.53 sq. ft. Room G14 (3 beds) 223.53 sq. ft. Room G15 (beds) 223.53 sq. ft. Room G16 (3 beds) 223.53 sq. ft. Room G17 (3 beds) 223.53 sq. ft. Room G18 (3 beds) 223.53 sq. ft. Room G19 (3 beds) 223.53 sq. ft. Room G20 (3 beds) 223.53 sq. ft. Room G21 (3 beds) 223.53 sq. ft. Room G22 (3 beds) 223.53 sq. ft. Room G23 (3 beds) 223.53 sq. ft. Room G24 (3 beds) 223.53 sq. ft. Palm [NAME] East Unit: Room T1 (4 beds) 297.5 sq. ft. Room T3 (4 beds) 296.66 sq. ft. Room T5 (4 beds) 296.66 sq. ft. Room T6 (4 beds) 296.66 sq. ft. Room T8 (4 beds) 296.66 sq. ft. Room T10 (5 beds) 296.66 sq. ft. Room T12 (4 beds) 296.66 sq. ft. Room T14 (4 beds) 296.66 sq. ft. Room T15 (4 beds) 296.66 sq. ft. Room T17 (4 beds) 296.66 sq. ft. Room T18 (4 beds) 296.66 sq. ft. Room T20 (4 beds) 296.66 sq. ft.
B. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted Resident 27 on 3/27/2024, and readmitted on [DATE] with diagnoses including generalized muscle weakness (you feel weak in most of your muscles throughout your body, making it harder to move or perform everyday takes), and acute osteomyelitis (a bone infection that is new or recent in onset) on left ankle and foot.
During a review of Resident 27's History and Physical (H&P), dated 11/30/2024, indicated, Resident 27 had infected ulcers on left ankle.
During a review of Resident 27's Minimum Date Set (MDS-a resident assessment tool), dated 12/23/2024, indicated that Resident 27 had moderately impaired cognitive (ability to reason, understand, remember, judge, and learn). The MDS also indicated Resident 27 had impairment on one side on his lower extremity and needed a wheelchair as mobility devices, not applicable to walk 10 feet in a room, corridor, or similar space.
During an observation on 1/8/2025 at 8:08 a.m. in Resident 27' room, Resident 27 was observed sitting in a wheelchair in front of the restroom in the room, surrounded by the right side of the resident's bed and the foot of another resident's bed. The shortest distance between the two beds was narrower than the width of the resident's wheelchair. Resident 27 was observed attempting to push the beds aside to exit the room, but the beds did not move. Resident 27 then extended to reach pedals under his bed but was unable to access them.
During an interview on 1/8/2025 at 8:10 a.m. in Resident 27's room with Assistant Director of Nursing (ADON) 1, ADON 1 stated that he observed Resident 27 sitting in a wheelchair, attempting to push two beds aside to exit the space where he was located. ADON 1 acknowledged that the resident would struggle with ambulation and would require assistance to exit the room in an emergency.
During a concurrent observation on 1/8/2025 at 8:25 a.m. with a Registered Nurse (RN) 1, the RN 1 observed attempting to push Resident 27's bed and the other bed without adjusting the pedals but was not able to move the beds.
During an interview on 1/9/2025 at 4:23 p.m. with Director of Nursing (DON), the DON acknowledged that the space between the two beds was narrower than Resident's wheelchair, preventing the resident from exiting without adjusting the beds. The DON also stated that this could lead to ineffective evacuation during an emergency and limit the resident's independence.
During a concurrent record review and interview on 1/9/2025 at 4:23 p.m. with the DON, the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 3/2021 reviewed. The P&P indicated that adjustments to the physical environment, such as moving furniture that may obstruct the path of a resident using a walker, should be made to accommodate individual needs and preferences. The DON acknowledged that the residents' bed placement should not obstruct mobility with a walker or wheelchair.
During a review of the facility's policy and procedure (P&P) titled, Bedrooms, revised 5/2017, the P&P indicated, Policy Interpretation and Implementation: 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. 3. Each room is designed to provide full visual privacy for each resident and equipped for adequate nursing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were protected from abuse in the smoking patio area when Resident 54 hit Resident 11 on the nose.
As a result of this failure, Resident 11 sustained a nosebleed and had to be sent out to the hospital for further evaluation and treatment.
Findings:
During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and insomnia (trouble falling asleep or staying asleep).
During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 10/16/2024, the MDS indicated Resident 11 had severe cognitive (thinking process) impairment. The MDS also indicated Resident 11 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for self-care abilities such as eating and needed moderate assistance (helper does less than half the effort. helper lifts, hold or supports trunk or limbs but provides less than half the effort) for self-care abilities such as oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear and personal hygiene and mobility such as rolling left and right, sit to lying position, lying to sitting position, sit to stand position, and transfers.
During a review of Resident 11's history and physical (H&P) dated 10/7/2024, the H&P indicated Resident 11 did not have the capacity to understand and make decisions.
During a review of Resident 11's Interdisciplinary Team (IDT, team members from different departments working together, to set goals, make decisions that ensure residents receive the best care) Nurse's Note dated 1/7/2025, the IDT Nurse's Note indicated on 1/6/2025 nursing staff was in the Court Station patio to supervise residents during their smoke break, when they heard screaming. The IDT Nurse's Note indicated staff assessed immediately and noted Resident 11 in wheelchair with blood coming from his nose. The IDT Nurse's Note indicated Resident 11 reported that he had an altercation with Resident 54. The IDT Nurse's Note indicated Residents 11 and 54 were kept separated and assessed for injuries. Resident 11 was noted with a hematoma (a dark area on the skin due to broken blood vessels pooling under the skin) on the bridge of Resident 11's nose upon skin assessment and an abrasion (wound) on the 3rd metacarpal (bones of the hand). Xray (diagnostic imaging test) completed revealing normal facial series. If clinical concern or symptoms continue to exist, further work up should be considered. Order given to transfer to hospital for further evaluation and treatment secondary to x-ray results.
During a review of Resident 11's Order Summary Report, the Order Summary Report indicated may transfer to hospital for further evaluation and treatment related to x-ray results ordered on 1/7/2025.
During a review of Resident 11's GACH (general acute care hospital) records dated 1/7/2025, the GACH records indicated chief complaint was nasal injury and that patient got in an altercation with another resident with subsequent nose injury and bleeding. The GACH records indicated the facility sent patient for further tests to rule out intracranial (within the brain) bleeding.
During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder, schizophrenia, and anxiety disorder.
During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 had intact cognitive ability. The MDS also indicated Resident 54 required supervision for self-care abilities such as eating, and oral hygiene and needed moderate assistance for self-care abilities such as toileting, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 54 required supervision for mobility such as rolling left and right, sit to lying position, lying to sitting on the side of bed, sit to stand position and transfers.
During a review of Resident 54's H&P dated 2/12/2024, the H&P indicated Resident 54 was able to make decisions.
During a review of Resident 54's Psychology (medical field specializing in treatment of mental illness) consult note dated 12/8/2024, the Psychology consult note indicated Resident 54 was referred to be seen by social services staff following verbal confrontations with staff involving money. The Psychology consult note indicated Resident 54 did not acknowledge or remember verbal disputes with staff members. The Psychology Consult Note indicated Resident 54 presented with agitation (restlessness, uneasiness) hyper-verbal speech (speaking quickly and frequently, sometimes to the point of interrupting others) and symptoms including paranoia (severe distrust of others not rooted in reality) and a response to auditory hallucinations (hearing things that do not exist in realty).
During a review of Resident 54's IDT Nurse's Note dated 1/7/2025, the IDT Nurse's Notes indicated that the resident was involved in a physical altercation with Resident 11. The IDT Nurse's Notes indicated the residents were separated and assessed for injuries. The IDT Nurse's Note indicated Resident 54 stated he asked Resident 11 if he took his money and then struck Resident 11 on the nose with a closed hand. The IDT Nurse's Note indicated Nursing staff performed head to toe assessment with no injuries noted and Resident 54 was sent out to hospital for further evaluation and treatment as indicated for physical aggression.
During a review of Resident 54's Order Summary Report, the Order Summary Report indicated resident may transfer to hospital for further evaluation related to aggression ordered on 1/6/2025.
During a concurrent observation and interview on 1/8/2025 at 9:06 a.m., with Resident 11 in his room, Resident 11 was sitting in his wheelchair. Resident 11's nose appeared a little swollen at the bridge of his nose. Resident 11 stated on 1/7/2025 he was sent to the hospital for his nose because he could not breathe well from his nose.
During an observation on 1/8/2025 at 8:58 a.m., in Resident 54's room, there was no one in the room. The bed was made, and room was clean.
During an interview on 1/10/2025 at 5:19 p.m., with the Director of Nursing (DON), the DON stated the Assistant Director of Nursing (ADON) 1 was around the smoking patio area when the altercation happened in the smoking patio area. The DON stated that CNA 3 should have been in the smoking patio area as well but was tending to another resident in his room when Resident 54 told CNA 3 that Resident 11 took his money. The DON stated he got a call from CNA 3 that Resident 54 hit Resident 11 and he went to the smoking patio area to assess the residents.
During a telephone interview on 1/13/2025 at 10:27a.m, with CNA 4, CNA 4 stated he was in the hallway of the unit charting by the smoking patio area when the incident happened. CNA 4 stated that CNA 3 went to him in the hallway and told him that Resident 54 hit Resident 11. CNA 4 stated he ran to the smoking patio area that was located outside and saw Resident 11's face full of blood. CNA 4 stated he took Resident 11 to his room to clean him up.
During a telephone interview on 1/13/2025 at 10:39 a.m., with CNA 3, CNA 3 stated he was not in the smoking patio area outside when the incident happened between Resident 54 and Resident 11. CNA 3 stated he was inside tending to another resident in room [ROOM NUMBER] when Resident 54 came to tell him that Resident 11 took his money, and then Resident 54 walked out of the room assuming to the smoking patio area outside. CNA 3 stated when he finished helping the Resident (unidentified) in room [ROOM NUMBER] and wheeled him to the smoking patio area the incident between Resident 54 and Resident 11 had already happened and ADON 1 was already there.
During a telephone interview on 1/13/2025 at 10:49 a.m., with ADON 1, ADON 1 stated he was in the smoking patio area walking, doing his rounds when the incident happened. ADON 1 stated he had his back turned to the residents during the altercation as he was tending to another resident in the smoking patio area. ADON 1 stated the incident happened so fast that he did not see Resident 54 hit Resident 11 but heard the incident happened behind him. ADON 1 stated Resident 54 rushed back inside the unit and staff came to render first aid to Resident 11. ADON 1 stated the DON and Administrator were notified and came to assess the situation.
During a review of the facility's policy and procedure (P/P) titled Abuse Neglect, Exploitation and Misappropriation Prevention Program dated May 2024, the P/P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff; other residents; any other individual .ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care plan interventions for one of three sampled residents (Resident 110) were implemented. The facility failed to implement Resident 110's care plan intervention to wear a med alert bracelet that indicates to staff that Resident 110 is on anticoagulant therapy (also known as blood thinning therapy, is the use of medications to prevent or treat blood clots.)
This deficient practice had the potential to result in delayed care and services and decline in Resident 110.
Findings:
During a review of Resident 110's admission Record, the admission record indicated Resident 110 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including displaced spiral fracture of shaft of left femur (a type of a break of the thigh bone that is broken in a spiral pattern, resulting in misalignment and separation of the bone fragments), atherosclerotic disease of native coronary artery without angina pectoris (a heart disease with blood flow problems due to plaque buildup in arteries without symptom of chest pain), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).
During a review of Resident 110's History and Physical (H&P), dated 8/1/2024, the H&P indicated Resident 110 had the capacity to understand and make decisions.
During a concurrent observation and interview on 1/9/2025 at 1:18 p.m., with Resident 110, Resident 110 did have a bracelet indicating anticoagulant therapy. Resident 110 stated they have never had a bracelet for blood thinners.
During a concurrent interview and record review on 1/10/2025 at 1:16 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 110's care plans were reviewed. LVN 3 stated Resident 110 had a care plan indicating Resident 110 was on Anticoagulant therapy. LVN 3 stated the care plan intervention indicated to wear a med alert bracelet that tells staff that tge resident was on anticoagulant therapy.
During a concurrent interview and record review on 1/10/2025 at 2:15 p.m., with LVN 3, in Resident 110's room, Resident 110 was observed. LVN 1 stated, Resident 110 was not wearing or had a bracelet indicating the resident was on anticoagulant therapy.
During an interview on 1/10/2025 at 5:40 p.m., with the Director of Nursing (DON), the DON stated, all care plan interventions should be followed. The DON stated when care plans are not followed, the Resident may not receive appropriate care and services.
During a review of the facility's Nurse Job Description: LVN/LPN, dated November 2018, the job description indicated care plans should be reviewed daily to ensure that appropriate care is being rendered. The job description indicated to ensure that the care plan is being followed when administering nursing care of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
a. Carry out the physician's (MD 1) order for one of four sampled residents (Resident 145), who required a follow up with an orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) specialist after Resident 145 sustained a fractured (broken bone) radius (one of the bones in your forearm) and was placed in a right wrist soft cast (a removable cast used to treat a fracture or other injury) to the distal (away from the center) radius (bone closest to the wrist) bone.
b. Assess one of one sampled Resident's (Resident 101) skin according to standards of practice.
This deficient practice resulted in delay of care for Resident 145 and Resident 101. Resident 145 had an order placed on 11/25/2024 to follow up with the orthopedic specialist in two (2) weeks, Resident 145 was not seen by the orthopedic specialist until 1/10/2024 (46 days or 6 weeks and 4 days later), and Resident 101 who had a swollen left foot with scratches.
Findings:
a.During a review of Resident 145's admission Record, the admission Record indicated Resident 145 was originally admitted to the facility 9/27/2024 and readmitted on [DATE] with diagnoses including difficulty in walking, history of falling, and unspecified fracture of the lower end of right radius, closed (bones are broken but not shifted out of alignment) fracture with routine healing.
During a review of Resident 145's Minimum Data Set (MDS, a resident assessment tool) dated 12/5/2024, the MDS indicated Resident 145 had moderate cognitive (short-term memory begins to be more affected, and the person may entirely forget recent events) impairment and required substantial/ maximal assistance (helper does more than half the effort) with eating and was dependent (helper does all of the effort) for toileting hygiene.
During a review of Resident 145's Nurse's Progress Notes dated 11/25/2024 at 1:32 p.m., the Nurse's Note indicated Resident 145 was readmitted from a general acute care hospital (GACH) due to (d/t) an unwitnessed fall (fall occurred on 11/25/2024 at 1 a.m.) with the following diagnoses (Dx): right radius fracture and a urinary tract infection (UTI, a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys). The Nurse's Note indicated a cast was on the right arm.
During a review of Resident 145's Physician Orders, an order was placed on 11/25/2024 to follow up with ortho in 2 weeks. This order was held (suspended) on 11/29/2024 due to Resident 145 being transferred to the GACH. The physician's orders indicated the order to follow up with ortho in 2 weeks was not reentered when Resident 145 was readmitted from the GACH on 12/3/2024.
During a review of Resident 145's Nurse's Progress Note dated 11/25/2024 at 6:07 p.m., the nurse practitioner (NP 1) working with MD 1 was made aware of the radial fracture and a new order was input to follow up with ortho (orthopedic specialist) in 2 weeks and the social worker (SW 1, unknown) was made aware of the need for follow up.
During a review of Resident 145's 72-Hour Charting Progress Note dated 12/3/2024, the Progress Note indicated Resident 145 was readmitted to the facility on [DATE] and was on monitoring for readmission. Resident 145's Nurse's Progress Notes did not mention the orthopedic specialist appointment for follow up until 1/3/2025 and an appointment was scheduled on 1/7/2025 for Resident 145 on 1/10/2025 at 2 p.m.
During a review of Resident 145's Nurse's Progress Note dated 11/28/2024, the Nurse's Note indicated Resident 145 was transferred back to the GACH to treat extended-spectrum beta-lactamase (ESBL, bacteria that is resistant to antibiotics and difficult to treat) UTI.
During a review of Resident 145's History and Physical (H&P) dated 12/6/2024, the H&P indicated Resident 145 was recently transferred to the GACH status post (s/p) fall (11/25/2024) resulting in a right radius fracture, ortho was consulted and a cast was placed on Resident 145's right arm. The plan of care for Resident 145 included a follow-up with ortho in 1-2 weeks.
During an interview and concurrent record review on 1/9/2024 at 11:31 a.m. with the social services director (SSD) Resident 145's Physician Orders were reviewed. The SSD stated the nursing team was responsible for scheduling appointments and the social services team was responsible for setting up transportation to and from the appointments. The SSD stated the social services team would not know about any appointments unless the nursing team placed an order for an appointment and upon review of Resident 145's Physician Orders, the order placed on 11/25/2024 to follow up with ortho in 2 weeks was not reentered when Resident 145 was readmitted from the GACH on 12/3/2024. The SSD stated there was no other order for an ortho appointment until the order was placed on 1/7/2025 for an ortho appointment on 1/10/2025 at 2 p.m.
During an interview on 1/9/2025 at 12 p.m., Resident 145 stated she was happy to be going to the orthopedic specialist the next day on 1/10/2025 because she had her cast on for 2 months and wanted it off because she was not able to feed herself when she could normally do everything by herself. Resident 145 stated she was right-handed and couldn't do anything, not even blow her nose.
During an interview on 1/10/2025 at 10:12 a.m., registered nurse (RN 2) stated she reviewed Resident 145's electronic medical record (EMR) and there was no follow up for the orthopedic specialist documented between 11/25/2024 and 1/3/2025 when the nursing team began looking for information on the orthopedic specialist. RN 2 stated, when Resident 145 was readmitted from the GACH on 12/3/2024, the order to follow up with ortho in 2 weeks was not reconciled (the process of comparing the resident's previous orders prior to being discharge compared to orders needed upon readmission) and reentered so it was missed. RN 2 stated the potential outcome for not following physician's orders in the case of Resident 145 was a delay in care, Resident 145 was not able to see the ortho on time. RN 2 stated Resident 145 was non weight baring on the right upper extremity (RUE) until she was seen by ortho so there was a possibility she remained non weight baring for an extended amount of time and there was a possibility for muscle deterioration in the RUE.
During an interview on 1/10/2025 at 11:20 a.m., MD 1 stated when physician's orders were placed, he expected nursing staff to carry the orders through and if they were not carried out there was a possibility for a delay in care.
During a review of the Licensed Vocational Nurse (LVN) Job description dated 11/2018, the job description indicated the LVN was to requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and admit, transfer, and discharge resident's as necessary.
During a review of the facility's policy and procedure (P/P) titled admission Assessment and Follow Up: Role of Nurse dated 9/2012, the P/P indicated upon admission the nurse was to conduct an admission assessment including the resident's current treatments and contact the physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The P/P indicated the nurse was to notify the physician of any immediate needs that the resident may have.
b. During a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 8/3/2017 and readmitted on [DATE] with diagnoses including atherosclerosis of native arteries (a condition where plaque [unhealthy tissue] builds up in the walls of the arteries, causing them to harden and thicken) of the left leg with ulceration (skin breakdown) of heel and midfoot, and peripheral (away from the center) vascular (blood vessel) disease (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to peripheral areas of the body.)
During a review of Resident 101's Minimum Data Set (MDS-a resident assessment tool), dated 12/26/2024, the MDS indicated that Resident101's cognitive (the ability to think and process information) was moderately impaired.
During a review of Resident 101's Nursing Progress Notes, dated 1/8/2024, the Nursing Progress Notes indicated that the resident was alert and oriented to person only.
During a review of Resident 101's Skilled Nursing Facility (SNF) Wound Care, dated 1/9/2025, the SNF Wound Care indicated that Resident 101 had no skin issue.
During a concurrent observation and interview on 1/7/2025 at 12:08 p.m. with Resident 101 in the resident's room, one fourth of the resident's foot was observed to be swollen, with scratches visible on top of the swelling. The resident was unable to explain how the injury occurred.
During a concurrent observation and interview on 1/10/2025 at 8:35 a.m., with Licensed Vocational Nurse (LVN) 3 in Resident 101's room, LVN 3 stated that she was not aware of the resident's skin changes on her left foot including the swelling and the scratches.
During an interview on 1/10/2025 at 1:59 p.m., with LVN 3, LVN 3 stated, staff should have assessed Resident 101's skin changes over the past few days. LVN 3 stated that Resident 101 required assistance for activities of daily living, and the Certified Nurse Assistants (CNA general) who assisted the resident did not detect the changes, also the treatment nurse performed a skin sweep (a skin check) on the resident the previous day but did not detect the skin changes. LVN 3 also stated that early detection of skin changes is critical, as changes in a resident's condition can lead to serious health consequences.
During an interview on 1/10/2025 at 3:10 p.m. with CNA 1, CNA 1 stated that she assisted Resident 101 including changing clothes on 1/9/2025 but did not observe any skin changes at that time.
During an interview on 1/10/2025 at 5:31 p.m. with the Director of Nursing (DON), the DON acknowledged that staff did not properly assess Resident 101 and stated that the resident should have been assessed appropriately.
During a review of the facility's policy and procedure (P&P) titled, Job Description: Certified Nursing Assistant, dated 2/2019, the P&P indicated CNA's are required to observe and report residents' skin breakdowns.
During a review of the facility's P&P titled, Job Description: Licensed Practical Nurse (LPN)/ LVN, dated 11/2018, indicated LVN required to make periodic checks to evaluate the resident's physical status.
During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown, revised 4/2018, indicated that the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers, and examine the skin of newly admitted residents of other skin conditions.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) locked one of ten sampled resident's (Resident 156) wheelchair brakes prior to assisting Resident 156 into a standing position.
This deficient practice placed Resident 156 at risk for fall and injury.
Findings:
During a review of Resident 156's admission Record, the admission Record indicated the facility admitted Resident 156 on 5/5/2022 with diagnoses including Alzheimer's disease (a type of disease that affects memory, thinking, and behavior) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing).
During a review of Resident 156's Order Summary Report, the Order Summary Report indicated a physician's order, dated 4/28/2023, for Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) to assist Resident 156 with ambulation (walking) exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking), once a day, five times a week.
During a review of Resident 156's Minimum Data Set (MDS, a resident assessment tool), dated 11/6/2024, the MDS indicated Resident 156 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 156 required partial/moderate assistance for eating, upper body dressing, rolling to both sides, substantial/maximal assistance for oral hygiene, personal hygiene, sit to stand transfers, toilet transfers, and walking, and was dependent in bathing and lower body dressing.
During a review of Resident 156's Fall Risk Observation/Assessment, dated 11/6/2024, the Fall Risk Observation/Assessment indicated Resident 156 received a total score of 14, indicating Resident 156 was a moderate fall risk.
During an observation on 1/8/2025 at 10:28 a.m., in Resident 156's room, Resident 156 was seated in a wheelchair. Restorative Nursing Aide 1 (RNA 1) transported Resident 156 in the wheelchair into the hallway for walking exercises. While seated in the wheelchair, Resident 156 continuously and slowly shifted the body side to side and rocked back and forth. RNA 1 placed a FWW in front of Resident 156 and assisted Resident 156 with walking exercises to the end of the hallway. At the end of the hallway, Resident 156 sat down in the wheelchair to rest. While seated, RNA 1 turned the wheelchair around to face the other direction, moved to Resident 156's right side, locked the right wheelchair brake, placed the FWW in front of Resident 156, and assisted Resident 156 into standing. RNA 1 did not lock the left wheelchair brake prior to standing Resident 156. RNA 1 assisted Resident 156 with walking exercises using a FWW down the hall and back into Resident 156's room.
During an interview on 1/8/2025 at 10:42 a.m., RNA 1 stated she did not lock both of Resident 156's wheelchair brakes before assisting Resident 156 into standing when assisting Resident 156 with walking exercises on the way back to the room. RNA 1 stated she should have locked both wheelchair brakes before standing Resident 156 for safety but did not. RNA 1 stated if both wheelchair brakes were not locked prior to standing a resident seated in a wheelchair, it could result in an accident or a fall.
During an interview on 1/8/2025 at 2:08 p.m., the Director of Rehabilitation (DOR) stated both wheelchair brakes must be locked prior to standing a resident from a wheelchair. The DOR stated if both wheelchair brakes were not locked prior to standing from a wheelchair, it could result in falls, accidents, and/or the resident experiencing increased fear and anxiety from falling due to transferring from an unstable surface.
During an interview on 1/10/2025 at 4:58 pm, the Director of Nursing (DON) stated both wheelchair brakes must always be locked before standing a resident from a wheelchair to prevent accidents or falls.
During a review of the facility's undated Policy and Procedure (P/P), titled Transfers, the P/P indicated the objectives of the policy were to provide safety for the unsteady and confused resident, to prevent injuries to employee and residents, and to allow the resident and aide to feel more secure during the transfer. The P/P indicated one of the general principles of transferring of a resident was to lock the brakes of the wheelchair.
During a review of the facility's P/P titled, Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strived to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents were facility-wide priorities.

Based on observation, interview and record review, the facility failed to:
A.Dispose of needles properly in the, designated containers.
B.Maintain accurate drug records, including proper documentation of signatures and dates on two narcotic (a substance used to treat moderate to severe pain) sheets.
This failure had the potential to increase the risk of accidental needle sticks and drug diversion, compromising resident and staff safety.
Findings:
a.During a concurrent observation and interview on 1/9/2025 at 10:52 a.m., with Licensed Vocational Nurse (LVN) 2, in the medication storage area in the Villa unit, four Enoxaparin (a drug used to treat and prevent blood clots) injections with needles were inside the regular trash disposal bin. LVN2 stated, the four Enoxaparin injections were hazardous and should be disposed of in the sharp container.
During an interview on 1//9/2025 at 4:15 p.m., with the Director of Nursing (DON), the DON stated that the Enoxaparin injections should be disposed of in the designated sharps container. The DON also stated that improperly disposing of needles could cause injuries.
During a review of the facility's policy and procedure (P&P) titled, Sharps Disposal, dated 2001, the P&P indicated that whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.
During a review of facility's P&P titled, Syringe and Needle Disposal, revised 1/2018, the P&P indicated that immediately after use, syringes and needles are placed into puncture resistant, one-way containers (sharps) specifically designed for that purpose.
B.During a concurrent interview and record review on 1//9/2025 at 4:00 p.m., with the DON, documentation titled Endorsed Controlled Medications for Disposition, and the Controlled Medication Count Sheets (Narcotic Sheets) were reviewed. The Narcotic Sheets indicated:
The DON did not sign and date the narcotic sheet upon receiving five acetaminophen-codeine (used to relieve mild to moderate pain) tablets 300 milligram (mg-a unit of measure of weight)60mg for Resident 55 from a staff, member for disposition (destroying).
There was no witness signature and date documented on the narcotic sheet upon the DON receiving eighty-six Tramadol (a strong painkiller from a group of medicine called opiates, or narcotics) 50 mg tablets for Resident 133 from a staff member for disposition.
During an interview on 1//9/2025 at 4:00 p.m., with the DON, the DON stated that it is important to properly document the receipt of narcotics, including witness signatures, the DON's name, and the date on the narcotic sheets. The DON also stated that without proper documentation and signatures, there's a risk of medication misplacement or diversion.
During a review of the facility's P&P titled, Controlled Substance Disposal, revised 1/2018, indicated that accountability records for controlled substances awaiting destructions or disposal must be stored. The P&P also indicated that the signatures of witnesses and the date of destruction to be documented in the controlled substance accountability record/book when controlled medications are destroyed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for three of three sampled residents (Resident 205, Resident 150, and Resident 196) by failing to ensure:
A. Resident 205 did not receive routine psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record.
B. To document daily monitoring for side effects for the use of Seroquel (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) and Trazodone (an anti-depressant to treat depression or anxiety) from October 16, 2024, to January 9, 2025 for Resident 150.
C. Resident 196's medication was ordered appropriately for their diagnosis who was on Risperdal (medication used to treat the symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]) for schizophrenia.
These failures had the potential to result in the use of unnecessary or non-therapeutic use of psychotropic drugs and can lead to side effects and adverse (unwanted or dangerous medication side effects) consequences such as a decline in quality of life and functional capacity for Residents 205, 150 and 196.
Findings:
A. During a review of Resident 205's admission Record, the admission Record indicated, Resident 205 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (amental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
During a review of Resident 205's History and Physical (H&P), dated 11/25/2024, the H&P indicated, Resident 205 had no capacity (ability) to understand and make decisions.
During a review of Resident 205's Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care), dated 11/25/2024, the PASARR indicated, level 1 screening was negative and specialized services were not recommended.
During a review of Resident 205's Order Summary Report (OSR), dated 12/1/2024, the OSR indicated, a physician's order dated 11/22/2024; give four tablets of Lurasidone HCL Lurasidone (Latuda- a medication to treat mental illness and mood disorder) 20 milligram (mg) 80 mg by mouth two times a day for dementia with behavioral disturbance manifested by agitation leading to resisting care.
During a review of Resident 205's Subjective, Objective, Assessment and Plan (SOAP) Note, dated 12/7/2024, the SOAP Note indicated, Resident 205 was seen for a psychiatric (a branch of medicine specializing in the diagnosis and treatment of mental health disease) consultation at the request of the primary care physician to assess Resident 205's behaviors and review any psychotropic medication. The SOAP note indicated, Dose reduction of psychotropic medication was contraindicated because the benefits of administering the Lurasidone HCL to Resident 205 outweighed the risks, and a reduction is likely to impair the resident's function and cause instability.
During a review of Resident 205's Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2024, the MDS indicated Resident 205 required supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for eating, dressing, bed mobility, chair/bed to chair transfer, and maximal assistance (Helper does more than half the effort) from one staff for toilet transfer, and toileting hygiene. The MDS indicated, Resident 205 did not have any potential indicators for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). The MDS indicated, Resident 205 did not have physical and verbal behavioral symptoms directed toward others. The MDS indicated, Resident 205 did not have behavior related to rejection of care.
During a review of Resident 205's Care Plan (CP), revised on 12/19/2024, the CP Focus indicated, Resident 205 had agitation leading to resisting care related to dementia with behavioral disturbance. The CP Interventions indicated, monitor behavior episodes, and attempt to determine underlying cause and document behavior. The CP Interventions indicated, monitor and document for side effects and effectiveness.
During a review of Resident 205's CP, revised on 12/19/2024, the CP Focus indicated, potential for side effects, complications or adverse reaction related to ordered antipsychotic drug Lurasidone. The CP Interventions indicated, attempt a gradual dose reduction as indicated/condition improves.
During a phone interview on 1/9/2025, at 9:37 a.m., with the Facility Pharmacy Consultant (FPC), the FPC stated, Resident 205 was on Lurasidone 80 mg twice a day. The FPC stated, Lurasidone was usually prescribed to treat schizophrenia. The FPC stated, he realized that the order indicated, monitoring for 'resisting care' and it was not proper or targeting a specific behavior related to a diagnosis. The FPC stated, there was no justifiable diagnosis to prescribe Lurasidone. The FPC stated, unnecessary medications would cause side effects such as lethargy (an unusual decrease in consciousness), increased mortality (the state of being subject to death) rate in the elderly, and increased blood glucose levels (blood sugar level).
During an interview on 1/9/2025, at 10:34 a.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated, Resident 205 had never resisted care and was compliant with care. CNA 2 stated, Resident 205 tried to get out of the unit sometimes to go home, but he was able to redirect him back to his room.
During a concurrent interview and record review on 1/9/2025, at 10:36 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 205's Medication Administration Record (MAR), dated 11/1/2024 to 1/8/2025 was reviewed. The MAR indicated, to monitor behavior episodes of dementia with behavioral disturbance manifested by agitation leading to being resistive to care every shift related to Lurasidone. The MAR indicated, Resident 205 did not have any behavior episodes except one episode on 11/27/2024 and one episode on 12/9/2024. LVN 4 stated, resisting care could be anything and she was not sure what episodes of behavior that the staff were monitoring. LVN 4 stated, a resident with dementia could display similar behaviors such as resisting care. LVN 4 stated, dementia related behaviors should have been ruled out before starting an antipsychotic medication to prevent giving medications unnecessarily. LVN 4 stated, monitoring specific behavior was important to determine Resident 205's care because dose adjustment for Lurasidone depended on the number of behavior episodes. LVN 4 stated, Resident 205 was cooperative with care and compliant with taking medications.
During a phone interview on 1/9/2025, at 11:56 a.m., with the Psychiatrist (medical specialty in the diagnosis and treating mental illness) Medical Doctor (PMD), the PMD stated, staff did not report to him that Resident 205 only had two episodes of resisting care from 11/2024 to 1/2025. The PMD stated, he realized Lurasidone was inappropriate for Resident 205, because, Resident 205 did not have justifiable medical diagnoses. The PMD stated 'resisting care', was not the right behavior to monitor related to Lurasidone. The PMD stated, Resident 205 should not suffer from various side effects of unnecessary medication. The PMD stated, Lurasidone would be tapered down (dosage gradually reduced) and discontinued.
During a concurrent interview and record review on 1/10/2025 at 5:07 p.m., with the Director of Nursing (DON), Resident 205's Point of Care (POC) Response History, dated from 12/2024 to 1/2025 was reviewed. The POC Response History indicated, Resident 205 did not refuse any care. The DON stated, POC Response History was the same as Activity of Daily Living (ADL) flow sheet. The DON stated, there was no documentation that indicated Resident 205 resisted care. The DON stated, staff should have ensured that antipsychotic medications were ordered appropriately with proper medical diagnoses, and to monitor specific behavior related to the medical diagnoses. The DON stated, if the medications were prescribed unnecessarily, the residents would needlessly suffer from side effects and adverse reactions from the medications.
B. During a review of Resident 150's's admission record, Resident 150 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), vascular dementia (a progressive state of decline in mental abilities that occurs when blood flow to the brain is reduced or blocked), depression (persistent feeling of sadness and loss of interest in activities of daily living), and anxiety (an emotional state of fear, dread and uneasiness).
During a concurrent interview and record review on 1/10/2025 at 12:33 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 150's order summary report dated 12/5/2024, and medication administration record (MAR) dated October 2024 to January 9, 2025, was reviewed. The report indicated:
1. Resident 150 was incapable of understanding, rights, responsibilities, and Informed consent (order date 4/10/2024)
2. Seroquel Oral Tablet 100 milligrams (MG-unit of measurement) (Quetiapine Fumarate) Give 150 mg by mouth at bedtime for schizoaffective disorder manifested by (M/B) disrobing in public spaces. (Order date 3/11/2024)
3. Antipsychotic Medication (Seroquel) - Monitor for Dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting (n/v) lethargy, drooping, extrapyramidal symptoms (EPS - tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Every 8 hours as needed for if side effect (S/E) noted, document and notify MD. (Order date 8/20/2024)
4. Trazodone HCL Oral Tablet 100 mg Give 50 mg by mouth at bedtime for Depression M/B inability to sleep. (Order date 10/15/2024)
5. Anti-Depressant Medication Use (Trazodone) - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain, special attention for: heart disease, glaucoma, chronic constipation, seizure disorder, edema. Every 8 hours as needed if S/E noted, document and notify MD. (Order date 8/20/2024).
During a record review of Resident 150's medication administration record (MAR) for October 2024 to January 9, 2025, the MAR did not indicate that side effects or adverse effects were monitored for Resident 150.
LVN 3 stated the side effect monitoring for Resident 150's Seroquel and Trazodone medication was on an as needed (PRN) basis. LVN 3 stated there is no daily or shift documentation that would indicate that side effects were monitored. LVN 3 stated facility staff should monitor side effects regularly and more than just PRN. LVN 3 stated if side effects of antipsychotic medication were not monitored appropriately, it places residents at risk for adverse side effects such as sedation, dizziness, withdrawing from activities, or falling.
During an interview on 1/10/2025 at 4:22 p.m., with the PMD, the PMD stated nursing staff should be monitoring for side effects such as shakes, tremors, Tardive dyskinesia (TD- a neurological disorder characterized by involuntary movements of the face and jaw), abnormal facial movements. The PMD stated nurses should monitor residents for side effects every shift.
During an interview with the Director of Nursing (DON) on 1/10/2025 5:06 p.m., the DON stated side effect monitoring was changed because staff was complaining that it was taking too long to document during medication pass, but that side effects should be checked every shift.
C.During a review of Resident 196's admission Record, the admission Record indicated Resident 196 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia, anxiety, and unspecified psychosis (a diagnosis given when there's not enough information to diagnose a specific psychotic disorder).
During a review of Resident 196's MDS, dated [DATE], the MDS indicated Resident 196 was moderately cognitively impaired for daily decision-making and needed set up or clean up assistance (helper sets up or cleans up, resident completes the activity but helper assist only prior to or following the activity) for functional abilities such as eating, oral hygiene, upper body dressing and needed supervision or touch assistance (helper provides verbal cue and/or touching and/or contact guard assistance) with toileting, shower/bathe, lower body dressing and personal hygiene. The MDS also indicated Resident 196 needed assistance with sit to lying, lying to sitting on side of bed and sit to stand position.
During a review of Resident 196's Order Summary Report, the Order Summary Report indicated Risperdal (Risperidone a medication used to treat mental disorders) oral tablet 2 mg give 1 tablet by mouth two times a day for unspecified schizophrenia manifested by disorganized thinking ordered on 11/25/2024.
During a review of Resident 196's Order Summary Report, the Order Summary Report indicated to monitor for episodes or behavior of schizophrenia disorganized thinking every shift for Risperdal use ordered on 12/12/2024. The Order Summary Report indicated to observe, monitor and report side effects of anti-psychotic agent Risperdal. Chart 0 for none or use 1st letter of TCAP, T=tardive dyskinesia (facial, tongue movement), C=cognitive impairment (decreased mental status), A=akathisia (inability to sit still), P=parkinsonism (tremors, drooling, rigidity) every 8 hours as needed ordered on 9/20/2024.
During a review of Resident 196's facility verification of informed consent dated 11/25/2024, indicated psychoactive medication Risperdal 2 mg by mouth two times a day related to unspecified psychosis.
During a record review of Resident 196's Comprehensive Care Plan, dated 9/20/2024, the Comprehensive Care Plan indicated Resident 196 will be/remain free of psychotropic drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date and will reduce the use of psychotropic medication through the review date. The interventions/tasks were to monitor/record occurrence of for target behavior symptoms of unspecified psychosis not due to a substance or known physiological condition manifested by disorganized thinking and document.
During an observation on 1/7/2025 at 11:38 a.m., in Resident 196's room, Resident 196 stated she was taking a medication for mood stabilizer and knew what medication she was taking for her mood.
During a concurrent interview and record review on 1/10/2025 at 1:03 p.m., with LVN 3, a psychiatric consultation note dated 11/22/2024 was reviewed. The psychiatric consultation note indicated Resident 196 had a history of anxiety disorder, depression, dementia, and psychosis. The psychiatric consultation notes indicated the diagnoses attached to this encounter visit was anxiety disorder, major depressive disorder, unspecified dementia, and unspecified psychosis. LVN 3 stated that the consent and doctor's orders should match when ordered and carried out. LVN 3 stated Resident 196 was receiving the medication Risperdal before, and it was prescribed for her unspecified psychosis but does not know why the medication was ordered for schizophrenia this time. LVN 3 stated there was nothing on the psychiatric consultation note indicating Resident 196 had a new diagnosis of schizophrenia. LVN 3 stated she does not know why it was ordered for unspecified schizophrenia if Resident 196 does not have a diagnosis of schizophrenia.
During a telephone interview on 1/10/2025 at 4:22 p.m., with the PMD, the PMD stated Risperdal was ordered short term for Resident 196 to help with behaviors and disorganized thinking. The PMD stated it the Risperdal was being tapered down from 2 mg to 1 mg, and it would be discontinued.
During an interview on 1/10/2025 at 5:06 p.m., with the Director of Nursing (DON), the DON stated the order was input incorrectly. DON stated Resident 196 was diagnose with unspecified psychosis and the medication was ordered for short term use for her unspecified psychosis. DON stated residents that have dementia should not be on antipsychotic medication.
During a review of the facility's Policy and Procedure (P&P) titled, Antipsychotic Medication Use, dated 2001, the P&P indicated, Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition . Policy Interpretation and Implementation: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . 4.
The attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving anti-psychotic medications will be evaluated for the appropriateness and indications for use . 6.
Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . 12. Anti psychotic medications will not be used if the only symptoms are one or more of the following: a.
Wandering; b. Poor self-care; c.
Restlessness; d.
Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; or k. Uncooperativeness .20. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.
During a review of the facility's Policy and Procedure (P&P) titled, Medication Therapy, reviewed 5/2024, the P&P indicated, Policy Statement: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments . Policy Interpretation and Implementation . 4.
Periodically, and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. 5. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: a.
when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale; b. when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely 6. The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. 7. The facility shall review medication-related issues as part of its quality assurance and performance improvement committee and activities.

Based on observation, interview and record review, the facility failed to properly label a tuberculosis (TB-bacterial infection that usually affects the lungs but can spread to other parts of the body) purified protein derivative (PPD a skin test used to check if someone has been exposed to tuberculosis bacteria) vial and a Rybelsus (a medication for diabetes [the body's inability to process sugar]) bottle with the open dates.
This failure has the potential to increase the risk of using compromised or ineffective medications.
Findings:
During a concurrent observation and interview on 1/9/2025 at 10:52 a.m., with Licensed Vocational Nurse (LVN)1, in the Villa unit, one TB PPD vial observed did not have an open date. LVN 1 stated the vial should have been labeled with the open date.
During a concurrent observation and interview on 1/9/2025 at 3:16 p.m., with LVN 2, in the Terrace unit, one bottle of Rybelsus did not have an open date. LVN 2 stated that accurate labeling with an open date is necessary to ensure medications are used before they expire. The LVN 2 stated that administering expired medications, such as Rybelsus, could result in less effective blood sugar control and reduced medication efficacy, potentially leading to adverse effects on the resident's health.
During an interview on 1/9/2025 at 4:00 p.m. with the Director of Nursing (DON), the DON stated that medications should have the open date labeled directly on the medication bottle, to ensure they are used within the appropriate period. The DON stated that failure to label the open date on the bottle, or vial can lead to compromised medication efficacy. The DON stated the TB medication if used outside the recommended period, can result in inaccurate TB test readings, potentially impacting diagnosis, and treatment. The DON stated if the Rybelsus is used outside the proper period, it may lead to ineffective blood sugar control compromising the resident's diabetes management.
During a review of the facility's policy and procedure (P&P) titled, Vials and Ampules of injectable medications, revised 1/2018, indicated it's important to record open date and triggered expiration date on multidose vials. The dated opened and triggered expiration date should be recorded on a label to the vial.

Based on observation, interview, and record review, the facility failed to ensure one unopened box with 24 croissants which had one croissant with a dime (coin currency) sized fuzzy greenish appearing spot indicating spoilage, kept in the dry storage area, was labeled and dated for not to be stored beyound the expiration date
to prevent growth of microorganisms (an organism that cannot be seen with the naked eye) that could cause food borne illness (food poisoning: any illness resulting from food spoilage or contaminated food, illness causing organisms) to the residents.
These deficient practices had the potential to result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (uncontrolled ejection of food from the mouth) and diarrhea (loose, watery stool).
Findings:
During an observation on 1/7/2025 at 8:31 a.m., with the dietary director (DD), the dry storage area contained a brown box covered in clear plastic with croissants inside, the unopened box was not labeled with a use by date of 10/27/2024. The box contained one croissant that had a dime sized greenish fuzzy area on it.
During an interview on 1/7/2025 at 8:34 a.m., the DD stated the unopened box of croissants was not dated and the croissants were only good for seven days. The DD stated all food stored in the facility kitchen needed to be labeled and dated. The DD stated the croissant had a green area on it that appeared to be mold (greenish growth on spoiled or decayed area).
During an interview on 1/10/2025 at 2:46 p.m., the DD stated it was important to ensure all food was labeled and dated to know when the food needed to be served by and the potential outcome of serving food past the use by date (the last recommended day to eat a product while it's at its best quality) was the food was bad (inedible).
During a review of the facility's policy and procedure (P/P) titled Labeling and Dating Foods dated 2023, the P/P all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
During A review of the 2022 U.S. Food and Drug Administration (FDA, a United States government agency that regulates the safety of food, drugs, medical devices, and other products) food Code, Code # 3-701.11 Discarding or Reconditioning Unsafe, adulterated (food that has been intentionally changed to make it appear better, cheaper, or more valuable), or Contaminated Food. (A) A food that is unsafe, adulterated, or not honestly presented as specified under § 3-101.11 shall be discarded or reconditioned according to an approved procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for five of thirteen sampled residents (Residents 1, 21, 23, and 80).
a.
For Resident 1, the RNA Documentation Survey Report (RNA flowsheet, daily record of RNA services provided for each month) task did not match the RNA order and PT discharge recommendations on 9/20/2024.
b.
For Resident 21, the RNA flowsheet task had missing documentation for services on 8/8/2024, 8/15/2024, 8/27/2024 and 9/2/2024.
c.
For Resident 23, the RNA flowsheet task was not resolved (discontinued) when RNA services were discontinued.
d.
[Insert Corey's write up, Resident #80]
These deficient practices had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of services provided.
Findings:
a. During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted Resident 1 on 9/5/2024 with diagnoses including left-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), contractures (loss of motion of a joint associated with stiffness and joint deformity) of the right hand and both knees, and muscle weakness.
During a review of Resident 1's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary recommendation indicated an RNA program for application of splints to Resident 1's both knees, two to four hours a day, three times a week.
During a review of Resident 1's Order Summary Report, the Order Summary Report indicated a physician's order, dated 9/20/2024, for RNA (general) to apply splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 1's both knees for two to four hours a day, three times a week.
During a review of Resident 1's October 2024 RNA flowsheet, the RNA flowsheet indicated an RNA task for RNA to apply splints to Resident 1's both knees for 30 minutes to three to five hours a day, five times a week.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/7/2024, the MDS indicated Resident 1 had unclear speech and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required substantial/maximal assistance in rolling to both sides and was dependent in eating, oral hygiene, bathing, dressing, and transfers. The MDS indicated Resident 1 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot).
During an observation and interview on 1/7/2025 at 9:50 a.m., in Resident 1's room, Resident 1 was side lying in bed facing the window on the right side of the room with a blanket covering both legs. Restorative Nursing Aide 2 (RNA 2) entered Resident 1's room to remove Resident 1's blanket. Resident 1's both hips and knees were bent and rotated to the right side of Resident 1's body. Resident 1 did not move both hips, knees, and ankles when asked. Resident 1 used the left arm to pull the right arm from underneath the body. Resident 1 used the left arm to try to move the right shoulder, elbow, wrist, and hand and was unable to actively move the arm independently when asked. RNA 2 stated Resident 1 was unable to move the right arm and had contractures of both knees. RNA 2 tried to straighten Resident 1's both knees but stopped when Resident 1 became agitated.
During a concurrent interview and record review on 1/10/2025 at 10:06 a.m., the Director of Rehabilitation (DOR) stated the Rehabilitation Department (Rehab) recommended and created the RNA program based on a resident's capabilities and needs to maintain his or her current level of function. The DOR stated the licensed therapist determined a resident's splinting needs along with the splint wear time (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) and wrote specific orders for RNA to carry out to ensure the resident was able to safely tolerate the splints. The DOR stated the licensed therapist was responsible for creating the RNA program and entering the RNA order, RNA task, and RNA frequency once an RNA program was established and implemented. The DOR reviewed Resident 1's PT Discharge summary, dated [DATE], and confirmed PT recommended RNA to apply splints to Resident 1's both knees for two to four hours a day, three times a week. The DOR reviewed Resident 1's physician's orders and confirmed Resident 1 had a physician's order for RNA to apply splints to Resident 1's both knees for two to four hours a day, three times a week. The DOR reviewed Resident 1's October 2024 RNA flowsheet and confirmed Resident 1 had an RNA task for RNA to apply splints to Resident 1's both knees for 30 minutes to three to five hours a day, five times a week. The DOR confirmed the PT discharge recommendations, RNA physicians order, RNA task, and RNA frequency did not match. The DOR stated it was important the therapy recommendations, physicians order, RNA task, and frequency matched because it could result in an inappropriate provision of recommended services if the documentation was inaccurate. The DOR stated it especially important for RNA recommendations and RNA orders involving splinting wear time and frequency to be accurate as recommended by the licensed therapist because if it was inaccurate, it could result in splint application out of the recommended parameters which could lead to skin breakdown, skin irritation, and increased resident agitation.
During a concurrent interview and record review on 1/10/2025 at 3:49 p.m., the Director of Staff Development (DSD) stated she supervised all the RNAs. The DSD reviewed Resident 1's PT Discharge summary, dated [DATE], and confirmed PT recommended RNA to apply splints to Resident 1's both knees for two to four hours a day, three times a week. The DSD reviewed Resident 1's physician's orders and confirmed Resident 1 had a physician's order for RNA to apply splints to Resident 1's both knees for two to four hours a day, three times a week. The DSD reviewed Resident 1's October 2024 RNA flowsheet and confirmed Resident 1 had an RNA task for RNA to apply splints to Resident 1's both knees for 30 minutes to three to five hours a day, five times a week. The DSD confirmed the PT discharge recommendations, RNA physicians order, RNA task, and RNA frequency did not match. The DSD stated if the therapy recommendations, physicians order, RNA task, and frequency did not match and was inaccurately documented, it could cause confusion and inappropriate provision of services.
During an interview on 1/10/2025 at 4:58 pm, the Director of Nursing (DON) stated documentation must always be accurate to prevent misinformation and confusion and to ensure the appropriate care and services were being provided.
b. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and muscle weakness.
During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 was cognitively moderately impaired. The MDS indicated Resident 21 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with self-care abilities such as eating, moderate assistance (helper does less than half the effort. helper lifts, hold or supports trunk or limbs but provides less than half the effort) with oral hygiene and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 21 needed supervision with mobility such as rolling left and right, sit to lying position, lying to sitting on side of bed and chair/bed to chair transfer and was maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toilet and shower transfer.
During a review of Resident 21's Order Summary Report, the Order Summary Report indicated RNA program for passive range of motion ([PROM], range of motion exercises that involve a helper moving a person's joint through its range of motion) exercises to both lower extremities ([BLE], both lower limbs) every day five times a week or as tolerated.
During a review of Resident 21's Documentation Survey Report for RNA Program (RNA flowsheet task) for August 2024, the document indicated Resident 21 was receiving RNA services of BLE PROM every day five times a week or as tolerated, there was missing documentation of services on 8/9/2024, 8/15/2024 and 8/27/2024.
During review of Resident 21's Documentation Survey Report for RNA Program (RNA flowsheet task) for September 2024, the document indicated Resident 21 was receiving RNA services of BLE PROM every day five times a week or as tolerated, there was missing documentation of services on 9/2/2024.
During a concurrent interview and record review on 1/10/2025 with RNA 3, the Documentation Survey Reports for RNA Program for August 2024 and September 2024 were reviewed. RNA 3 stated RNA services were provided for Resident 21 but were not documented. RNA 3 stated if there was no documentation, the services was not provided for this resident, and not providing the services was not following medical doctor's orders.
c. During a review of Resident 23's admission Record, the admission Record indicated the facility initially admitted Resident 23 on 1/27/2012 and re-admitted Resident 23 on 11/22/2024 with diagnoses including Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) and muscle weakness.
During a review of Resident 23's Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 23 was transferred to the hospital on 9/17/2024 and returned to the facility on 9/23/2024.
During a review of Resident 23's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge summary, dated [DATE], the OT Discharge Summary recommendation indicated for RNA to provide PROM exercises to both Resident 1's arms followed by the application of a carrot splint (a device that opens the hand and positions the fingers away from the palm to protect the skin from moisture, pressure, and nail puncture) to the left hand, five times a week, for up to one hour or as tolerated.
During a review of Resident 23's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/12/2024, for RNA to perform PROM exercises to both of Resident 23's arms and apply a carrot splint to Resident 23's left hand, five times a week, for up to one hour or as tolerated.
During a review of Resident 23's September 2024 RNA flowsheet, the RNA flowsheet indicated an RNA task for RNA to perform PROM exercises to both of Resident 23's arms and apply a carrot splint to Resident 23's left hand, three times a week, for up to one hour or as tolerated. The squares on the RNA flowsheet were blank on the following days: 9/18/2024, 9/19/2024, 9/20/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/27/2024, and 9/30/2024.
During an observation on 1/10/2025 at 9:25 a.m., Resident 23 was lying in bed with blankets covering the body from the shoulders down to the feet. RNA 2 removed Resident 23's blanket. Resident 23's both hands were held in tight fists. Resident 23 opened the right hand but was unable to fully straighten all the fingers. Resident 23 did not open the left hand when asked and was unable to actively move the left wrist, elbow, and shoulder.
During a concurrent interview and record review on 1/10/2025 at 10:06 a.m., the DOR reviewed Resident 23's September 2024 RNA flowsheet, Census List, therapy notes, and physician orders. The DOR confirmed Resident 23 had OT recommendations, a physician's order (dated 3/12/2024), and an RNA task for RNA to perform PROM exercises to both of Resident 23's arms followed by the application of a carrot splint to Resident 23's left hand, five times a week, for up to one hour. The DOR confirmed the squares on the RNA flowsheet were blank on the following days: 9/18/2024, 9/19/2024, 9/20/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/27/2024, and 9/30/2024 which indicated RNA services were not provided those days as ordered. The DOR reviewed Resident 1's Census List and confirmed Resident 1 was transferred to the hospital on 9/17/2024 and returned to the facility on 9/23/2024 but the RNA flowsheet did not reflect Resident 1 was not in the facility since the RNA task remained active. The DOR stated RNA services were verbally discontinued upon Resident 1's re-admission to the facility on 9/17/2024 since Resident 1 was being evaluated and treated by Rehab but the RNA task was never discontinued in the electronic clinical record. The DOR stated the active RNA task in conjunction with the blank squares inaccurately reflected the RNA services provided since it appeared as though Resident 1 missed multiple RNA sessions but did not. The DOR stated the RNA task should have been resolved when RNA services were discontinued and/or left the facility but was not. The DOR stated inaccurate documentation could cause confusion and an inaccurate reflection of the services provided.
During a concurrent interview and record review on 1/10/2025 at 3:49 p.m., the DSD stated she supervised all the RNAs. The DSD reviewed Resident 23's September 2024 RNA flowsheet, Census List, and physician orders. The DSD confirmed Resident 23 had a physician's order, dated 3/12/2024, and an RNA task for RNA to perform PROM exercises to both of Resident 23's arms followed by the application of a carrot splint to Resident 23's left hand, five times a week, for up to one hour. The DSD confirmed the squares on the RNA flowsheet were blank on the following days: 9/18/2024, 9/19/2024, 9/20/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/27/2024, and 9/30/2024 which indicated RNA services were not provided those days as ordered. The DSD reviewed Resident 23's Census List and confirmed Resident 23 was transferred to the hospital on 9/17/2024 and returned to the facility on 9/23/2024 but the RNA flowsheet did not reflect Resident 23 was not in the facility since the RNA task remained active. The DSD stated she was not aware RNA services were discontinued upon Resident 1's re-admission to the hospital on 9/23/2024 since the RNA task remained active. The DSD stated that if RNA services were discontinued or the resident left the facility, the RNA task must also be resolved because the RNA flowsheet would inaccurately appear as though RNA should be providing RNA services five times a week and that Resident 1 missed multiple RNA treatment but did not. The DSD stated inaccurate documentation could cause confusion and inappropriate provision of services.
During an interview on 1/10/2025 at 4:58 pm, the Director of Nursing (DON) stated documentation must always be accurate to prevent misinformation and confusion and to ensure the appropriate care and services were being provided.
d.During a review of Resident 80's admission Records, the admission Record indicated Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and muscle weakness.
During a review of Resident 80's history and physical (H/P) dated 3/5/2024, the H/P indicated Resident 80 had did not have the capacity to make decisions.
During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80 was dependent on self-care abilities such as eating, oral hygiene, toileting, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 80 was dependent on mobility such as rolling left and right, sit to lying position, lying to sitting on side of bed and chair/bed to chair transfer, and tub/shower transfers.
During a review of Resident 80's Order Summary Report, the Order Summary Report indicated RNA to perform BLE PROM exercises as tolerated every day five times a week or as tolerated.
During a review of Resident 80's Documentation Survey Report for RNA Program (RNA flowsheet task) for September 2024, the document indicated Resident 80 was receiving RNA services of BLE PROM exercises every day five times a week or as tolerated, there was missing documentation of services on 9/2/2024.
During a review of Resident 80's Documentation Survey Report for RNA Program (RNA flowsheet task) for November 2024, the document indicated Resident 80 was receiving RNA services of BLE PROM exercises every day five times a week or as tolerated, there was missing documentation of services on 11/11/2024.
During a review of Resident 80's comprehensive care plan dated 2/2/2024, the comprehensive care plan indicated the focus was restorative nursing-range of motion: resident at risk for decline and/or complications with range of motion in joints, decrease mobility and movement, decreased muscle strength, decreased functional use of extremity, pain, deformity, contracture, and/or skin breakdown. Requires a restorative nursing range of motion program to lower extremities. The goal was to prevent or reduce the risk of deformity or contracture. The interventions were RNA to perform BLE PROM exercises as tolerated every day five times a week or as tolerated.
During a concurrent interview and record review on 1/10/2025 at 2:59 p.m., with RNA 3, the Documentation Survey Reports for RNA Program (RNA flowsheet task) for September 2024 and November 2024 were reviewed. RNA 3 stated RNA services were provided for Resident 80 on those dates but stated had forgotten to document the services provided. RNA 3 stated if there was no documentation in the chart, it means services was not provided for this resident and there could be a decline in movement if Resident 80 was not getting the RNA services as ordered.
During an interview on 1/10/2025 at 5:24 p.m., with the Director of Nursing (DON), the DON stated if RNA services were provided to the residents, it should have been documented. If the services were not documented, it means the services were not provided on those dates.
During a review of the facility's policy and procedure (P/P) titled Documentation revised May 2024, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record documentation in the medical record will be objective {not opinionated or speculative), complete, and accurate documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment.
During a review of the facility's P/P titled Restorative Nursing Services revised on July 2017, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure Licensed Vocational Nurse (LVN) 5 performed hand hygiene while she was checking lunch trays in the dining room.
This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.
Findings:
During an observation on 1/9/2025, at 12:30 p.m., in the dining room, LVN 5 was checking the residents' trays against the printed sheets of diet orders. LVN 5 adjusted her mask with bare hands. LVN 5 pulled a tray out of the lunch tray cart, and she lifted the plate cover up to check the food items on the plate without performing hand hygiene after touching her mask. LVN 5 was running her fingers through her hair then she touched the juice cups on the tray without performing hand hygiene. LVN 5 was constantly touching her face and hair while she was checking the residents' trays.
During an interview on 1/9/2025, at 12:33 p.m., with LVN 5, LVN 5 stated, she should have washed or sanitized her hands after she touched her hair and adjusted her mask before she touched the residents' trays to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and spreading infection.
During an interview on 1/10/2025, at 4:06 p.m., with the Infection Control Nurse (ICN), the ICN stated, if the staff touched a body part during the task, the staff must wash their hands to prevent cross contamination.
During an interview on 1/10/2025, at 5:07 p.m., with the Director of Nursing (DON), the DON stated, all staff should perform hand hygiene before, after, and between tasks. The DON stated, hand hygiene was the first line of defense against infections. DON stated, touching the body parts or any surfaces could cause cross contamination and staff should have performed hand hygiene to protect the residents and themselves.
During a review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene, reviewed 5/2024, the P&P indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare -associated infections. Policy Interpretation and Implementation . Indications for Hand Hygiene: 1. Hand hygiene is indicated: a.immediately before touching a resident; b.before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.
During a review of the facility's Policy and Procedure (P&P) titled, Infection Control/Preventing Cross-Contamination, undated, the P&P indicated, Policy Statement: The purpose of this policy is to prevent cross-contamination and ensure the safety and well-being of residents, staff, and visitors. Policy Interpretation and Implementation: This policy applies to all staff, providers, and visitors within the facility and pertains to all activities that could pose a risk of cross-contamination, including care giving, food preparation, laundry, and environmental cleaning .Procedure:1. Hand Hygiene-Staff must wash hands with soap and water or use an alcohol-based hand sanitizer before and after resident contact, handling food or medications, contact with bodily fluids and cleaning or handling soiled items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was diagnosed with atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots) and received Warfarin (a medication used to prevent blood clots from forming) was free from significant medication errors for one of three sampled residents (Resident 1).
The facility failed to:
1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's physician's Nurse Practitioner (NP).
2. Ensure licensed nurses did not administer multiple orders of duplicate therapy of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024 that included a dose of Warfarin that should have been discontinued on 11/19/2024.
3. Ensure licensed nurses monitored medication administration times and critical (values that are significantly outside the normal range) laboratory values to prevent and detect medication errors.
These failures resulted in Resident 1's transfer to a General Acute Hospital (GACH) on 12/27/2024 where he was diagnosed with a subdural hematoma ([SDH] a collection of blood on the surface of the brain) measuring 12 millimeters ([mm] a metric unit of measurement, used for medication dosage and/or amount). Resident 1 upon admission to the GACH was intubated (insertion of a tube either through the mouth or nose and into the airway to aid in breathing) and administered Andexxa (a medication given to patients who are on anticoagulant medication [a class of drugs that help prevent blood clots and dissolve existing ones] to treat life-threatening or uncontrolled bleeding.
On 1/4/2025 at 5:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to administer and monitor Resident 1's Warfarin medication according to the prescriber's order.
On 1/5/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After an onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 1/5/2025 at 6:45 p.m., in the presence of the facility's DON and ADM.
The facility's IJRP included the following immediate actions:
a. On 1/4/2025, a comprehensive three-way audit of 13 medication carts was initiated with an expected completion date of 1/5/2025. This audit was conducted collaboratively by the Pharmacy and facility staff to ensure the following objectives were met; medications were administered correctly based on supply availability, medications availability, match of the medication blister pack/medication container to the physician orders, proper documentation, and medications that were revised previous orders were discontinued. Any issues identified were immediately corrected by the auditing nurse and communicated to the DON for review.
b. On 1/5/2025, one on one education was provided to the Consulting Pharmacist ([CP] a licensed pharmacist who provides expert advice on the safe use and administration of medication), by the Pharmacy Regional Director of Operations (PRD). The session focused on the CP's role in conducting monthly drug regimen reviews for residents receiving anticoagulant medications. The key topics included the importance of monitoring medication administration times, critical lab values, and the pharmacist's collaborative role as part of the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals.
c. On 1/5/2025, the Pharmacy Consultant conducted a Drug Regimen Review for 23 current residents who were receiving anticoagulant medication. Recommendations were communicated to the resident's physicians by the facility nursing staff and addressed accordingly.
d. On 1/4/2025, a facility wide audit was conducted by the facility nursing staff for all residents utilizing the Anticoagulant Audit tool to ensure current residents receiving anticoagulant medication had orders to monitor for signs and symptoms (s/s) of bleeding every shift such as but not limited to: bleeding, discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), or nose bleeds. The audit identified all current residents receiving anticoagulant therapy had routine monitoring of anticoagulant side effects.
e. On 1/4/2025, a facility wide audit was conducted by the nursing staff to ensure proper administration of anticoagulant medications utilizing the Anticoagulant Audit tool The audit confirmed that all current residents who were prescribed anticoagulant medications were accurately identified, and no other residents were receiving those medications inappropriately.
f. On 1/4/2025, the Assistant Regional Director of Clinical Services conducted a thorough chart review for 23 residents currently receiving anticoagulant medications. The review was undertaken to ensure the accuracy of medication orders, accurate monitoring of side effects with recommended frequency and to verify there were no instances of incorrect duplicate medications.
g. On 1/4/2025 an in-service was initiated to licensed nurses by the DON focusing on the Anticoagulation Therapy Clinical Protocol including Warfarin's dosage, side-effects, significance of laboratory tests, and International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) therapeutic levels (level of medication in the blood to achieve its desired effect).
h. On 1/4/2025, the DON initiated an in-service for licensed nurses to address key medication management objectives. The training aimed to ensure the following: medications were administered correctly based on the available supply, availability of medication was verified, the medication blister packs or containers matched physician orders, proper documentation was maintained, and any medication changes were accompanied by the discontinuation of previous orders. The expected completion date for the in-service is January 5, 2025. Nurses who were unable to attend the session were instructed to report to the DON/designee during their next scheduled shift to receive the in-service.
1. On 1/4/2025, the DON initiated an in-service for licensed nurses focused on ensuring the accuracy of medication orders, proper monitoring of side effects at the recommended frequency, and verifying the absence of incorrect or duplicate medications. The in-service is expected to be completed by 1/5/2025. Nurses unable to attend the in-service were instructed to report to the DON/designee during their next scheduled shift to receive the in-service.
j. On 1/4/2025, an in-service was provided initiated to licensed nurses by DON regarding policy and procedure on Medication Administration to ensure medications are administered per physician's order, orders are clarified if not available/not matching with supply at hand, and medications that were changed and have ongoing previous orders are clarified and discontinued.
k. The Medical Director (MD) was notified of the IJ on 1/4/2025 at 6:45pm by the ADM.
l. An Ad Hoc (when necessary or needed) Quality Assessment and Assurance ([QA&A] a group that ensures the quality of care and life in a facility by identifying and fixing quality issues) Committee meeting was scheduled for 1/5/2025, to discuss the IJRP.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Afib.
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1's undated Care Plan, the Care Plan indicated Resident 1 was at risk for bleeding and bruising secondary to anticoagulant therapy related to the use of Warfarin. The Care Plan indicated labs should be completed as ordered and abnormal results should be reported to the physician.
During a review of Resident 1's Physician's Order dated 11/5/2024, the Physician's order indicated Resident 1's Prothrombin ([PT] a factor in the blood that helps it clot properly)/INR was to be drawn on 11/7/2024 one time only.
During a review of Resident 1's Physician's Order Summary Report dated 11/7/2024, the Physician's Order Summary Report indicated to administer Warfarin 4.5 milligrams ([mg] unit of measurement) one time a day (9 a.m.) for Afib.
During a review of Resident 1's Physician Order dated 11/7/2024, the Physician order indicated to draw Resident 1's INR on 11/10/2024.
During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 4.27 (INR range 2.0-3.0) and was flagged as critical.
During a review of Resident 1's Change in Condition (COC) Note dated 11/13/2024, the COC note indicated Resident 1's INR was reported as 4.27 to Resident 1's physician, who ordered Vitamin K (a vitamin that plays a role in helping blood clot) 10 mg subcutaneous (beneath the skin) injection one time only, hold warfarin dose for two days, and repeat the INR test on 11/14/2024.
During a review of the Laboratory Services Patient Care Log, the Laboratory Services Log indicated Resident 1 refused to have his blood drawn for his INR level on 11/14/2024 and 11/15/2024.
During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.18 and was flagged as abnormal (below the INR normal range of 2.0-3.0).
During a review of Resident 1's Physician's Order Summary Report dated 11/2024, the Physician's Order Summary Report indicated the following:
1. On 11/19/2024 - Administer Warfarin 4.5 mg in the afternoon every Tuesday, Thursday, and Saturday for Afib, monitor for s/s of bleeding.
2. On 11/19/2024 - Resident 1 may have PT and INR levels drawn every Tuesday and Thursday.
3. On 11/20/2024 - Administer Warfarin 4 mg, give one tablet in the afternoon every Monday, Wednesday, Friday, and Sunday for Afib, monitor for s/s of bleeding.
During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 1.12 and was flagged as abnormal.
During a review of Resident 1's Nursing Note, dated 11/22/2024 and timed at 8:59 p.m., the Nursing Note indicated Resident 1's laboratory results dated [DATE] were sent to Resident 1's physician. The Nursing Note indicated there was no response from the physician.
During a review of Resident 1's Nursing Note dated 11/23/2024 and timed at 7:41 a.m., the Nursing Note indicated the facility refaxed Resident 1's INR results to Resident 1's Physician. The Nursing Note indicated there was no new order, the facility staff endorsed this to the next shift.
During a review of Resident 1's Medication Administration Record (MAR) dated 11/2024, the MAR indicated Resident 1's administration of Warfarin as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP.
1. On 11/21/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg).
2. On 11/22/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
3. On 11/23/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg).
4. On 11/25/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
5. On 11/29/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
6. On 11/30/2024 Warfarin 4.5 mg was administered to Resident 1 at 9 a.m. and 5 p.m. (a total of 9 mg).
During a review of Resident 1's laboratory results dated [DATE], the Laboratory results indicated Resident 1's INR was 6.19 and was flagged as critical.
During a review of Resident 1's Progress Note dated 12/2/2024, and timed at 9:38 p.m., the Progress Note indicated Resident 1's INR results of 6.19 were received and sent to Resident 1's physician and the facility was awaiting orders. Resident 1's lab results and the physician's pending response were endorsed to the next shift. There was no physician response.
During a review of Resident 1's laboratory results dated [DATE] and timed at 6:58 p.m., the Laboratory results indicated Resident 1's INR was 5.83 and was flagged as critical.
During a review of Resident 1's Progress Note dated 12/6/2024 and timed at 4:35 a.m., the Progress Note indicated Resident 1's INR results of 5.83 was relayed to Resident 1's physician, and the staff were waiting for a response.
During a review of Resident 1's MAR dated 12/2024, the MAR indicated Warfarin was administered to Resident 1 as follows: The 9 a.m., dose of Warfarin should have been discontinued, per Resident 1's Physician's NP.
1. On 12/1/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
2. On 12/2/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
3. On 12/9/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 4 mg of Warfarin was administered to Resident 1 at 5 p.m. (a total of 8.5 mg).
4. On 12/10/2024 - Warfarin 4.5 mg was administered to Resident 1 at 9 a.m., and 5 p.m. (a total of 9 mg).
During a review of Resident 1's Physician's Orders dated 12/11/2024, the Physician's Orders indicated to discontinue administration of Warfarin.
During a review of the Resident 1's Physician's Order dated 12/13/2024, the Physician's Order indicated to administer Eliquis (an oral anticoagulant that helps prevent and treat blood clots) 5 mg two times a day for DVT ([deep vein thrombosis] occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (preventative treatment against disease).
During a review of Resident 1's MAR dated 12/2024, the MAR indicated Resident 1 received Eliquis as ordered from 12/13/2024 thru 12/27/2024.
During a review of Resident 1's Nurse's Note dated 12/27/2024, the Nurse's Note indicated Certified Nursing Assistant 1 (CNA 1) observed Resident 1 sitting in a wheelchair, not talking. The Nurse's Note indicated Resident 1 was assessed and 911 emergency services was called. The Nurse's Note indicated Resident 1 was transferred to the GACH for further intervention and assessment.
During a review of Resident 1's Physician's Orders dated 12/27/2024, the Physician's Orders indicated to transfer Resident 1 to the nearest GACH via 911 due to unresponsiveness.
During a review of the GACH's Emergency Physician's note dated 12/27/2024, the Emergency Physician's note indicated Resident 1 was brought to the GACH via ambulance with a chief complaint of a SDH that measured 12 millimeters ([mm] a unit of measurement). The Emergency Physician's note indicated Resident 1 was intubated and administered Andexxa for reversal of Eliquis.
During an interview on 1/2/2025 at 2:04 p.m., and a subsequent interview on 1/3/2025 at 12:15 p.m., Licensed Vocational Nurse (LVN ) 1 stated Resident 1 received multiple doses of Warfarin that overlapped beginning on 11/19/2024. LVN 1 stated when Resident 1's laboratory results indicated his INR level was critically high on 12/2/2024, the results were sent to the physician but there was no follow up by facility's staff when Resident 1's physician did not respond to the fax. LVN 1 stated the staff should have followed up with the physician to determine if the laboratory results were received because the INR values were critically high, and Resident 1 was at risk for bleeding.
During an interview on 1/2/2025 at 4:18 p.m., LVN 2 stated all lab results should be reported to the physician and a response from the physician was expected by the end of the shift. LVN 2 stated, if there was no response from the physician by the end of the shift, the lab results should be reported to the MD.
During an interview on 1/2/2025 at 4:41 p.m., the NP stated when she revised the Warfarin order to indicate it should be administered to Resident 1 on alternating days of the week (11/19/2024), she instructed LVN 2 to discontinue the order for Warfarin 4.5 mg daily. The NP stated she was not aware Warfarin 4.5 mg daily order was still active. The NP stated Warfarin had a very narrow therapeutic range and Resident 1's INR level could be affected if Warfarin was not administered as ordered and closely monitored.
During an interview on 1/4/2025 at 1:18 p.m., the MD stated he had no knowledge that Resident 1's physician had not responded to a report of critical INR levels and was only aware of Resident 1's condition on 12/30/2024, when the GACH reported that Resident 1 sustained an SDH. The MD stated Warfarin was a complicated medication to administer because it involved constant monitoring, blood tests, dose adjustments, and daily monitoring for side effects such as bleeding and bruising. The MD stated if a resident's INR was low, there was a risk that the resident could develop blood clots and if the INR was too high, there was a risk that the resident could develop bleeding.
During an interview on 1/4/2025 at 2:08 p.m., the DON stated when administering Warfarin, INR levels should be monitored because if the levels were out of the therapeutic range, residents could be at risk for bleeding or clotting. The DON stated licensed staff should report abnormal lab results to the physician within 24 hours, and critical lab results should be reported to the physician within 4 hours. The DON stated if there was no response from the physician, the MD should be contacted. The DON stated Resident 1's Warfarin 4.5 mg daily order should have been discontinued on 11/19/2024 when the revised Warfarin order was received.
During an interview on 1/4/2025 at 2:47 p.m., the ADM stated the licensed nurses documented they administered Warfarin 4.5 mg daily (9 a.m.) in error and they did not administer Warfarin to Resident 1, so Resident 1 could not have received extra doses of Warfarin.
During a review of the facility's Policy and Procedure (P/P), titled Administering Medications dated 2001, the P/P indicated medications were administered in accordance with the prescriber's orders, including any required time frame.
During a review of the facility's P/P titled Critical Labs of Tests and Diagnostic Procedures-Reporting of dated 1/2/2024, the P/P indicated the response including any new orders/interventions related to the critical results of tests and diagnostic procedures must occur within four (4) hours of reporting of results. The P/P indicated if the Licensed Independent Practitioner ([LIP] a health care provider who is legally permitted to provide care without direct supervision) and or clinician responsible for the resident is not available and that LIP's alternate cannot be reached or is unavailable, the medical director under which the LIP is privileged shall be notified of the critical result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure facility staff notified the physician within four hours of receiving critical (values that are significantly outside the normal range) laboratory (labs) and/or the Medical Director (MD) if there was no response by the physician for one of three sampled residents (Resident 1).
This deficient practice resulted in the facility's nursing staff receiving no instructions from Resident 1's physician related to Resident 1's critically high International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) results. This deficient practice had the potential to result in the need to significantly alter treatment.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, the MDS indicated Resident 1's cognition was severely impaired, and he was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1's undated Care Plan, the Care Plan indicated Resident 1 was at risk for bleeding and bruising secondary to anticoagulant therapy related to the use of Warfarin (a medication used to prevent blood clots from forming). The Care Plan' goals indicated Resident 1 would have no episodes of abnormal bleeding or extensive bruising. The Care Plan's interventions included carrying out labs as ordered and reporting abnormal results to the physician.
During a review of Resident 1's laboratory results dated [DATE], the Laboratory Results indicated Resident 1's INR was 6.19 (INR range 2.0-3.0) and was flagged as critical.
During a review of Resident 1's Progress Note dated 12/2/2024, and timed at 9:38 p.m., the Progress Note indicated Resident 1's laboratory results were received, sent to Resident 1's physician and the facility was awaiting orders. Continued review of Resident 1's medical record indicated no evidence that facility staff attempted to contact Resident 1's physician after four hours of no response, as indicated in the facility policy and procedure (P/P) Critical Labs of Tests and Diagnostic Procedures-reporting of.
During a review of Resident 1's laboratory results dated [DATE] and timed at 6:58 p.m., the Laboratory Results indicated Resident 1's INR was 5.83 and was flagged as critical.
During a review of Resident 1's Progress Note dated 12/6/2024 and timed at 4:35 a.m., the Progress Note indicated Resident 1's INR result was relayed to Resident 1's physician, the facility staff were waiting for a response. The results of Resident 1's labs and status of the report to Resident 1's physician were endorsed to the next shift. Continued review of Resident 1's medical record indicated no evidence that facility staff attempted to contact Resident 1's physician after four hours of no response, as indicated in their P/P.
During an interview on 1/2/2025 at 2:04 p.m., and a subsequent interview on 1/3/2025 at 12:15 p.m., LVN 1 stated when Resident 1's laboratory results indicated his INR level was high on 12/2/2024, the results were sent to Resident 1's physician. LVN 1 stated there was no response from Resident 1's physician and there was no follow up by facility staff with Resident 1's physician for instructions related to Resident 1's critical INR level. LVN 1 stated facility staff should have followed up with Resident 1's physician to determine if the laboratory results were received because the INR values were critically high, and Resident 1 was at risk for bleeding.
During an interview on 1/4/2025 at 2:08 p.m., the DON stated licensed staff should report abnormal lab values to the physician within 24 hours, critical lab values should be reported within 4 hours, and if there was no response from the physician, the Medical Director (MD) should be contacted.
During a review of the facility's P/P titled Critical Labs of Tests and Diagnostic Procedures-reporting of dated 1/2/2024, the P/P indicated the response including any new orders/interventions related to the critical results of tests and diagnostic procedures must occur within four (4) hours of the reporting of results. The P/P indicated if the Licensed Independent Practitioner (LIP) and or clinician responsible for the resident was not available and that LIP's alternate could not be reached or was unavailable, the Medical Director under which the LIP was privileged should be notified of the critical result.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to clarify an order for aspirin ([ASA] a medication used for mild pain relief and preventions of blood clots [a gel-like substance that forms when blood hardens from a liquid to a solid]) resulting in a discrepancy that was not clarified by licensed nursing staff for three months, for one of three sampled residents (Resident 1). Resident 1's physician ordered ASA, 81 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) by mouth, but the facility documented ASA 1 mg by mouth.
As a result of this deficient practice Resident 1's ASA order was documented as follows:
Administer ASA enteric coated (a coating designed to prevent medications from dissolving in the acidic environment of the stomach), delayed release (a type of medication that is designed to release the active ingredient later than immediately after administration) 81 mg. Give 1 mg by mouth one time daily for cerebrovascular accident ([CVA] a stroke, a condition where blood flow to the brain is blocked, leading to brain tissue damage) prevention. Instead of documentation that should have indicated to give 81 mg by mouth one time daily for CVA prevention. This deficient practice had the potential for staff confusion, misunderstanding of the physician's order and miscommunication of Resident 1's care needs.
Findings:
During a review of Resident 1 's admission Record (Face Sheet), the Face Sheet documented that Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of a cerebral infarction (a stroke).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/6/2025, the MDS documented that Resident 1's cognition (the process of thinking, attention, language, learning, memory and perception) was moderately impaired (a state where a resident has difficulty with certain aspects of daily life but can still function with some assistance or supervision). The MDS documented that Resident 1 used of an antiplatelet (a medication that prevents clots from forming) medication.
During a review of Resident 1's Order Summary Report (Physician's Order), dated 2/28/2025, the Physician's Order documented that facility staff were to administer ASA, enteric coated, delayed release, 81 mg tablet and to give 1 mg by mouth one time a day for CVA prevention.
During a review of Resident 1's Medication Administration Record (MAR), dated 2/2025, 3/2025 and 4/2025, the MAR included the following documentation: ASA, enteric coated, delayed release, 81 mg tablet, give 1 mg by mouth one time a day. The MAR indicated by initial of the licensed nursing staff that Resident 1's ASA was documented as administered from 2/1/2025 through 4/2/2025 at 9 a.m.
During an interview on 4/2/2025 at 12:05 p.m., LVN 1 stated prior to administering medication, the correct medication, dose, time, and route of administration should be checked by the licensed nurses, by comparing the medication on hand with the physician's order. LVN 1 stated, if there were any discrepancies found, facility staff should clarify the order with the physician, and a new order should be obtained. LVN 1 stated during the morning medication administration (4/2/2025 at 9 a.m.) he administered one tablet of an 81 mg ASA enteric coated, delayed release medication to Resident 1. LVN 1 confirmed the order to give ASA 1 mg by mouth daily was a discrepancy and should have been clarified with the physician and corrected.
During an interview on 4/2/2025 at 4:10 p.m., the Director of Nursing (DON) stated during medication administration, licensed nurses were expected to check and compare the medication on hand with the physician's orders, perform multiple checks that included checking the medication pack/container. The DON stated, if a discrepancy was found in the medication order, the licensed nurses were expected to notify the physician to obtain an order clarification.
During a review of the facility's Policy and Procedure (P&P), titled, Administering Medications revised 4/2019, the P&P documented that if a dosage was believed to be inappropriate, the facility staff preparing or administering the medication would contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns. The facility staff administering the medication would check the medication label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration prior to administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review ([MRR] a thorough check of all the medications a patient is taking, done by a healthcare professional, to ensure they are safe, effective, and appropriate for their current health conditions) was conducted by the facility's Consulting Pharmacist (CP) for one of three sampled residents (Resident 1), to include a review of Warfarin (a medication used to prevent blood clots from forming), as well as Resident 1's labs.
This deficient practice resulted in administration of unnecessary doses of Warfarin to Resident 1, placing Resident 1 at risk for adverse side effects of Warfarin, such as abnormal bleeding and/or excessive bruising.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/10/2024, the MDS indicated Resident 1's cognition was severely impaired, and he was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on facility staff to complete his activities of daily of living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1's Physician's Order Summary Report dated 11/2024, the Physician's Order Summary Report indicated the following:
1. On 11/7/2024, Administer Warfarin 4.5 mg one time a day for Afib
2. On 11/19/2024 - Administer Warfarin 4.5 mg in the afternoon every Tuesday, Thursday, and Saturday for Afib, monitor for s/s of bleeding.
3. On 11/20/2024 - Administer Warfarin 4 mg, give one tablet in the afternoon every Monday, Wednesday, Friday, and Sunday for Afib, monitor for s/s of bleeding.
During a review of Resident 1's the facility's Medication Regimen Review (MRR) dated 11/2024 and 12/2024, the MRR indicated there were no recommendations made by from the facility's CP regarding Resident 1's Warfarin administration or Resident 1's labs as they related to Warfarin's administration.
During an interview on 1/3/2025 at 12:59 p.m., the Pharmacy Regional Director (PRD) stated Warfarin had a very narrow therapeutic range (when blood levels are in a range that is medically helpful but not dangerous) and the International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) levels should be closely monitored as well as possible drug interactions with other medications, the resident's diet and medical condition, all of which could affect the resident's INR level. The PRD stated the CP should look at every medication that was ordered for a resident including Warfarin and the resident's labs during the MRR.
During an interview on 1/3/2025 at 3:46 p.m., the facility's CP stated during the facility's monthly MRR, he reviews all medications in the resident's medical record, the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and any significant laboratory results. The CP stated since Resident 1's Warfarin was dosed (prescribed) by Resident 1's physician, and he (the CP) was unaware of the physician's Warfarin dosing protocol he (the CP) could not make any recommendations related to the Warfarin. The CP stated the dosage and administration of Warfarin should be closely monitored because there was a risk of overdosing or under dosing the resident. The CP stated INR levels should be monitored daily until a therapeutic level is reached and adverse side effect such as bleeding and bruising should be monitored daily.
During an interview on 1/4/2025 at 2:08 p.m., the DON stated when administering Warfarin, INR levels should be monitored because if the levels were out of the therapeutic range, residents could be at risk for bleeding or clotting (the process by which blood changes from a liquid to a solid to form a clot). The DON stated their CP pharmacy should review the administration of Warfarin even if the resident's physician ordered the dosage of the Warfarin.
During a review of the facility's P/P titled Medication Regimen Review (MRR) dated 12/2019, the P/P indicated the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The P/P indicated the MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The P/P indicated the MRR also involves thorough review of the resident's records and may include collaboration with other members of the IDT team. The P/P indicated at least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director, and director of nursing, at a minimum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document medication administration in the medical record for one out of eight residents (Resident 5).
This deficient practice resulted in inaccurate documentation of the care provided to Resident 5 after he sustained a fall with injury on 10/14/2024. This deficient practice had the potential for non-continuity of Resident 5's care by other health care providers.
Findings:
During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 11/22/2024, the MDS indicated Resident 5's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 5 required moderate assistance (helper does less than half the effort) for toileting, hygiene, showering/bathing, dressing the lower body, and repositioning in bed.
During a review of Resident 5's Physician's Order dated 8/20/2024, the Physician's order indicated to give two acetaminophen (a pain medication) 325 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) tablets (650 mg total) every four hours as needed for pain management.
During a review of Resident 5's Physician's Order dated 9/17/2024. The Physician's order indicated to give one tablet of Ibuprofen (a pain mediation) 400 mg every six hours as needed for mild to moderate pain.
During a review of Resident 5's MAR dated 10/13/2024, the MAR indicated Resident 5 received acetaminophen 650 mg for a pain level of 2 out of 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) at 5:35 p.m. Continued review of Resident 5's MAR indicated, the location of Resident 5's pain or relief of his pain was not identified or documented.
During a review of Resident 5's MAR dated 10/13/2024, the MAR indicated Resident 5 received Ibuprofen 400 mg for a pain level of 6 out of 10 at 5:14 p.m. Continued review of Resident 5's MAR indicated, the location of Resident 5's pain or relief of his pain was not identified or documented.
During a review of Resident 5's MAR Audit Tool (a tool used to determine the exact time medication administration was documented as given), the MAR Audit Tool indicated acetaminophen 325 mg tablets (650 mg total) was administered to Resident 5 at 10:10 p.m., on 10/13/2924.
During a review of Resident 5's Nurse Note dated 10/13/2024 at 5:33 p.m., the Nurse Note indicated Resident 5 was heard yelling for help and was found on the right side of his body facing the floor. The Nurse Note indicated a full body assessment was done, Resident 1 had no injuries, and his skin was intact. The Nurse Note indicated Licensed Vocational Nurse (LVN) 1 administered Tylenol (acetaminophen) 650 mg to Resident 5 for right side head pain at 5:35 p.m.
During a review of Resident 5's Interdisciplinary Team Care Conference Note ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) dated 10/14/2024, the IDT note indicated Resident 5 fell on [DATE] at 5:30 p.m., and sustained abrasions (a superficial wearing off of the skin, usually by a scrape or brush burn) on both of his knees.
During a concurrent interview and record review on 12/17/2024 at 3:21 p.m., with LVN 1, Resident 5's Nurse Notes were reviewed. The Nurse Notes dated 10/13/2024, indicated Resident 5 had a pain level of 6 out of 10 but did not indicate where Resident 1's pain was located. LVN 1 stated he did not remember where Resident 1's pain was located and stated he should have documented the location of Resident 1's pain and the effectiveness of the pain medication so anyone looking at Resident 1's medical record would know what happened. LVN 1 stated he believed he gave the medication to Resident 5 at approximately 5:30 p.m., but actually documented in Resident 5's record later in the evening (10:10 p.m.) because he was busy.
During an interview on 12/18/2024 at 9:30 a.m., the Director of Nursing (DON) stated in addition to documenting the resident's pain level a pain assessment should include the location, type, and onset of the resident's pain, as well as what makes the resident's pain better or worse. The DON stated assessing a resident's pain level was important in order to evaluate the effectiveness of the resident's pain management, and to see if the resident was getting better or worse. the DON stated he was not certain why Ibuprofen was administered to Resident 5 on 10/13/2024 because Resident 5's medical record did not indicate where his pain was located or what it was ordered for. The DON stated LVN 1, who administered the Ibuprofen, should have documented where Resident 5's pain was located. The DON stated Resident 5 sustained knee abrasions from his fall on 10/13/2024 and LVN 1 should not have documented Resident 5 had no injuries. The DON stated a head to toe assessment should be conducted and documented after a resident sustains a fall or has a change of condition (COC), so the resident's physician will have the correct information when deciding a course of action.
During a review of the facility's P&P titled Charting and Documentation dated 2001, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated the following information is to be documented in the resident medical record, objective observations, medications administered. The P&P indicated documentation of procedures and treatments will include the date and time the procedure/treatment was provided, and how the resident tolerated the procedure/treatment.
During a review of the (P&P) titled Pain Assessment and Management dated 2001, the P&P indicated: The purpose of the procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated general guidelines included recognizing the presence of pain, identifying the characteristics of pain, and monitoring for effectiveness of interventions.
See F697

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure pain medication prescribed to one of eight sampled residents (Resident 5) had a specified indication for use on Resident 1's physician's order, the reason pain medication was administered was specified on Resident 1's medication administration record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and the effectiveness of the pain medication was documented
These deficient practices resulted in the inability to determine what the pain medication was ordered for, the location of Resident 1's pain, and/or the effectiveness of the pain medication administration. These deficient practices had the potential for non-continuity of care, unnecessary medication administration, ineffective pain relief, adverse side effects of the pain medication, and unrecognized/assessed diagnoses.
Findings:
During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 11/22/2024, the MDS indicated Resident 5's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 5 required moderate assistance (helper does less than half the effort) for toileting, hygiene, showering/bathing, dressing the lower body, and repositioning in bed.
During a review of Resident 5's Physician's Order dated 8/20/2024, the Physician's order indicated to give two acetaminophen (a pain medication) 325 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount) tablets (650 mg total) every four hours as needed for pain management.
During a review of Resident 5's Physician's Order dated 9/17/2024. The Physician's order indicated to give one tablet of Ibuprofen (a pain mediation) 400 mg every six hours as needed for mild to moderate pain.
During a review of Resident 5's MAR dated 10/13/2024, the MAR indicated Resident 5 received acetaminophen 650 mg for a pain level of 2 out of 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) at 5:35 p.m. Continued review of Resident 5's MAR indicated, the location of Resident 5's pain or relief of his pain was not identified or documented.
During a review of Resident 5's MAR dated 10/13/2024, the MAR indicated Resident 5 received Ibuprofen 400 mg for a pain level of 6 out of 10 at 5:14 p.m. Continued review of Resident 5's MAR indicated, the location of Resident 5's pain or relief of his pain was not identified or documented.
During a concurrent interview and record review on 12/17/2024 at 3:21 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 5's Nurse Notes were reviewed. The Nurse Notes dated 10/13/2024, indicated Resident 5 had a pain level of 6 out of 10 but there was no indication where Resident 1's pain was located. LVN 1 stated he did not remember where Resident 1's pain was located and stated he should have documented the location of Resident 1's pain and the effectiveness of the pain medication so anyone looking at Resident 1's medical record would know what happened.
During an interview on 12/18/2024 at 9:30 a.m., and a subsequent interview on 12/19/2024, at 8:49 a.m., the Director of Nursing (DON) stated he was not certain why Ibuprofen was administered to Resident 5 on 10/13/2024 because Resident 5's medical record did not indicate where his pain was located or what it was ordered for. The DON stated LVN 1, who administered the Ibuprofen, should have documented where Resident 5's pain was located. The DON stated he was not aware pain medication orders needed to specify what kind of pain the pain medication was needed for, he thought orders indicating mild, moderate, or severe pain was sufficient. The DON acknowledged how not specifying the type and location of pain for administration of pain medication in the physician's order could be an issue when following up for effectiveness of treatment.
During a review of the (P&P) titled Pain Assessment and Management dated 2001, the P&P indicated: The purpose of the procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated general guidelines included recognizing the presence of pain, identifying the characteristics of pain, and monitoring for effectiveness of interventions.
During a review of the facility's Policy and Procedure (P&P), titled, Medication Therapy dated 2001, the P&P indicated as part of medication regiment review, there should be a clear indication for treating individuals with medication.
See F842

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) who had a diagnosis of legal blindness (inability to see) was supervised during mealtime (eating).
This deficient practice resulted in Resident 6 feeling neglected, unsatisfied, and undignified when food particles fell on her clothing, accessories, and on the floor while eating, which had the potential to negatively affect her psychosocial and emotional well-being.
Findings:
During a review of Resident 6's admission Record (Face sheet), the Face Sheet indicated Resident 6 was admitted to the facility with diagnoses including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and wound healing), open angle glaucoma (a chronic eye condition characterized by increased eye pressure which can lead to vision loss [blindness]), legal blindness, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 6's vision was severely impaired, was able to make decisions that were consistent and reasonable. The MDS indicated Resident 6 required supervision with one-person assist to provide verbal cues and/or touching/steadying assistance during mealtime/eating.
During a review of Resident 6's Clinical Record (Care Plan section) dated 6/6/2022, the Care Plan indicated Resident 6 had a self-care deficit with Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) functions which included bathing, personal hygiene, dressing, eating, grooming, toileting, locomotion (the movement of a person from one place to another), and transfer related to legal blindness. Under this Care Plan, the Care Plan goals indicated Resident 6 will be clean, dry, odor free, dressed appropriately, and will maintain dignity and self-esteem every day. The Care Plan's interventions included to provide supervision to Resident 6 during eating.
During an interview on 10/11/2024 at 2:20 p.m., with Resident 6, Resident 6 stated the nursing staff do not consistently supervise and/or assist her during mealtimes. Resident 6 stated, when she asks the nursing staff to supervise her while eating, the Certified Nursing Assistants (CNAs) deny her request, and her food ends up spilling on her clothes, accessories, and on the floor. Resident 6 stated when the staff ignore her, she feels neglected, undignified, and unsatisfied with her food.
During an observation on 10/11/2024 at 2:30 p.m., in Resident 6's room, Resident 6 was observed sitting in her wheelchair alone with her bedside table over her. Resident 6's bedside table was observed having a plate of salad and a plate of chopped fruits sitting on top of it. Resident 6 was observed eating the salad with no staff supervision and was observed having salad dressing on her face, food particles (chopped vegetables) on her shirt, pants, purse (situated on her lap), shoes, and on the floor around her. During a continued observation, two unidentified nursing staff members were observed passing by Resident 6's room, looked at Resident 6 eating unsupervised, and did not stop to supervise Resident 6. Certified Nursing Assistant 1 (CNA 1) was observed walking into Resident 6's room, acknowledge Resident 6, then leaving Resident 6's room without helping nor providing supervision to Resident 6.
During an interview on 10/11/2024 at 2:42 p.m., with CNA 1, CNA 1 stated she did not find anything concerning with Resident 6 when she saw Resident 6 eating by herself in her room nor when she saw Resident 6 having salad dressing on her face and food particles on her shirt, pants, purse, shoes, and on the floor. CNA 1 stated she thought it was normal for Resident 6 to spill food on herself because Resident 6 was blind. CNA 1 stated it was her responsibility to check on the needs of Resident 6 and she should have helped and/or supervised Resident 6 with eating, especially when she saw Resident with salad dressing on her face, and food particles spilled all over her.
During an interview on 10/11/2024 at 3:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated it is the nursing staff's responsibility to aid and supervise Resident 6 during eating because Resident 6 was blind. LVN 1 stated, the purpose of the conducting room rounds is to identify and attend to residents who are in need. LVN 1 stated the nursing staff should have identified Resident 6's lack of supervision and attended to her needs to prevent Resident 6 from feeling insecure, neglected, and undignified.
During a concurrent interview and record review on 10/11/2024 at 3:40 p.m. with Registered Nurse Supervisor 1 (RNS 1), Resident 6's Care Plan was reviewed. RNS 1 stated CNAs and licensed nurses must supervise Resident 6 when she eats to ensure Resident 6 has dignified existence and to aid in prevention of untoward accidents because Resident 6 was legally blind.
During an interview on 10/11/2024 at 4:37 p.m., with the Director of Nursing Services (DON), the DON stated all residents should be assisted and/or supervised with their ADLs as indicated while accommodating their needs and/or preferences. The DON stated all residents shall be always treated with dignity and respect.
During an interview on 10/11/2024 at 5:30 p.m., with the Administrator (ADM), the ADM stated the facility supports the dignified existence of the residents and all staff are expected to recognize the residents' needs, level of supervision, and provide support to the residents as needed.
During a review of the facility's undated P&P titled, Activities of Daily Living (ADL), Supporting, the P&P indicated the residents of the facility shall be provided with care, treatment, and services as appropriate to maintain their ability to carry out activities of daily living (ADLs).
During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated, each resident of the facility shall be cared for in a manner that promotes and enhances the residents' well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; therefore, the residents must be treated with dignity and respect at all times, while honoring their goals, choices, preferences, values and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit a resident, who was transferred to a General Acute Care Hospital (GACH) on [DATE] for evaluation and treatment due to behavioral symptoms, agitation, aggression, and psychosis (mental disorder, disconnection from reality) and was ready to return to the facility from the GACH for one of three sampled residents (Resident 1).
This deficient practice resulted in Resident 1 remaining at the GACH (as of [DATE]) after Resident 1 was ready to be discharged back to the facility on [DATE] but was denied readmission. Resident 1 has remained at the GACH unnecessarily for additional six days, placing Resident 1 at risk for confusion, disorientation and psychosocial harm related to being displaced from the facility, a place that was considered Resident 1's home since initial admission on [DATE].
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (memory loss, thinking abilities that interfere with daily life), metabolic encephalopathy (problem in the brain caused by chemical imbalance), depression (a constant feeling of sadness and loss of interest in activities of daily living), and anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness)
During a review of Resident 1's Minimum Data Set ([MDS] - a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 1had moderately impaired cognitive skills for daily decision making.
During a review of Resident 1 ' s Physician ' s Order dated [DATE], the Physician ' s Order indicated Resident 1 was incapable of understanding rights, responsibilities, and informed consent.
During a review of Resident 1's Change of Condition ([COC] a facility tool to document a resident ' s sudden change from baseline) dated [DATE], the COC indicated Resident 1 had behavioral symptoms of aggressive behavior and psychosis, talking to self, and was verbally aggressive towards staff.
During a review of Resident 1's Physician's Order dated [DATE], the Physician's Order indicated, to transfer the resident to the GACH for further psychiatric evaluation with a seven-day Bed-Hold (facility reserves bed for resident who is emergently transferred out).
During a review of Resident 1's Nurse ' s Progress Notes dated [DATE] and timed 7:00 pm, the Nurse ' s Progress Notes indicated Resident 1 was transferred to a GACH via ambulance for further evaluation on [DATE].
During a review of Resident 1's Notice of Transfer/discharge date d [DATE], the Notice of Transfer/Discharge indicated Resident 1 was transferred to the GACH on [DATE], because it was necessary for the resident.
During a review of the GACH admission Records, the GACH ' s admission Records indicated Resident 1 was admitted to the emergency room on [DATE], with diagnoses of dementia with psychosis, worsening agitation, and aggression, and was subsequently admitted to the inpatient behavioral unit for behavior management.
During a review of the GACH ' s Discharge Plan Records dated [DATE] and timed at 11:28 pm, the Discharge Plan Records indicated, the psychiatrist ' s plan was for Resident 1 ' s discharge back to the facility on [DATE]. The GACH ' s Discharge Plan Records indicated the social worker called the facility and had to leave a voice mail message due to no answer.
During a review of the GACH ' s Discharge Plan Records dated [DATE] and timed at 9:38 pm, the GACH ' s Discharge Plan Records indicated the social worker called the facility to inquire about Resident 1 ' s return to the facility. The GACH ' s Discharge Plan Records indicated the facility ' s Marketer stated Resident 1 was off his seven-day Bed-Hold and the facility was unable to take him back.
During a review of the GACH ' s Discharge Plan Records dated [DATE] and timed at 1:10 pm, the GACH ' s Discharge Plan Records indicated that the social worker talked to Resident 1, and the resident stated he would like to return to the facility.
During an interview on [DATE] at 11:35 a.m., the registered nurse supervisor (RN 1) stated the facility was a special-focus-facility (a facility under monitoring due to a record of poor state inspection results) under Centers for Medicare and Medicaid Services ([CMS] - a federal agency that provides the nation ' s major health coverage program) and are unable to readmit residents who exceed the seven day Bed-Hold, because they are considered a new admission.
During an interview on [DATE] at 12:15 pm, the Administrator (ADM), stated they could not readmit Resident 1 per the interim manager ' s guidance, once Resident 1 had exceeded the seven-day Bed-Hold, Resident 1 would be considered a new admission and the facility would not be reimbursed by CMS for services rendered.
During an interview on [DATE] at 9:30. am, the social worker from the GACH stated on [DATE], the facility ' s response to Resident 1 returning back was unable to accept Resident 1 due to Resident 1 being off his seven-day Bed-Hold and facility is unable to take him back.
During a review of the facility ' s policy and procedure (P&P) titled, Bed-Holds and Returns, revised 10/2022, the P&P indicated that residents are permitted to return to the facility following hospitalization or therapeutic leave regardless of payer source. The P&P indicated that residents who seek to return to the facility after the state seven-day Bed-Hold period has expired are allowed to return to their previous room, if available, or immediately to the first available bed in a semi-private room.
During a review of the facility's policy and procedure (P&P) titled readmission to the Facility revised 3/2017, the P&P indicated that Residents, who have been discharged to the hospital or for therapeutic leave, will be given priority in readmission to the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 87 )was positioned properly by a nursing staff during resident care by failing to identify and recognize a bedside drawer located next to the resident's bed as a potential hazard to resident's safety during care which led to resident hitting the nightstand during repositioning.
This failure placed Resident 87 at risk for fall and serious injury.
Findings:
During a review of Resident 87's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sequalae (consequences) of cerebral infarction (a stroke with full recovery or minor lingering deficits with minimal impact on daily life after a stroke), vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by impaired blood flow to brain), lack of coordination and cognitive communication deficit (person has trouble participating in conversations, has difficulty understanding what is said and unable to respond or has trouble speaking clearly).
During a review of Resident 87's History and Physical ( H&P) dated 3/14/2024, the H&P indicated the resident had no capacity to make decisions.
During a review of Resident 87's Minimum Data Set [MDS] standardized screening tool) dated 5/17/2024, the MDS indicated the resident had severely impaired cognitive skills (problems with person's ability to think, learn, remember, use judgement, and make decisions) for decision making. The MDS indicated the resident had impairment on both upper and lower extremities (arms and legs) and required substantial or maximal assistance (helper does more than half the effort) with bed mobility. The MDS indicated the resident was dependent on the staff with toileting hygiene and bathing.
During a review of Resident 87's Change of Condition([COC] a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) dated 6/23/2024, at 9:33 p.m., the COC indicated the resident hit the right side of his forehead on a bedside drawer, sustaining a cut measuring 2 centimeter ([cm] unit of measurement of length) by 0.5 cm in size while being turned to the right side of the bed.
During a review of Resident 87's Nursing- Comprehensive Skin Evaluation assessment dated [DATE] at 8:18 a.m., the Comprehensive Skin Evaluation/ Assessment indicated the resident had 2 cm. by .5 cm laceration(cut) on the right forehead and steri strips (strips of tape put across an incision or cut and keep edges of the wound together)were applied.
During a review of Resident 87's Care Plan regarding Resident 87's high risk for falls and injuries initiated on 8/25/2021 due to muscle weakness, stroke, vascular dementia, and cognitive communication deficit, the Care Plan's goal indicated the resident would have no injuries related to falls. The Care Plan's interventions included to keep the environment free from obstruction and evaluate possible medical, physical, cognitive, and psychiatric conditions.
During a concurrent observation and interview at Resident 87's room with Certified Nursing Assistant (CNA 5) on 7/10/2024, at 2:10 p.m., a bedside drawer was in close proximity to Resident 87's bed. CNA 5 stated Resident 87 was confused, required a one person assist during positioning in bed and needed clear, repeated instructions to obtain cooperation from the resident. CNA 5 stated and demonstrated how to turn Resident 87 to the right side of the bed. CNA 5 positioned himself on the left side of the resident, raised the bed to his waist level, then pulled the drawsheet closer to his body and pretended to turn a resident to his right side. CNA 5 stated Resident 87 should not be close to the bedside drawer when being turned or too close to the right side of the bed because the resident could roll over from the bed or hit the bedside drawer.
During an interview on 7/10/2024, at 2:16 p.m., with CNA 6, CNA 6 stated Resident 87 could not carry a conversation and had not heard him talk. CNA 6 stated if she would reposition Resident 87 or other residents, she would raise the bed to her hip level to prevent her from getting injured, pull the resident towards her to prevent him from falling or getting too close to the bedside drawer . CNA 6 stated the resident could hit the bedside drawer or fall that could lead to brain injury, bruising (part of the body is injured, blood from damaged small blood vessel leak out and gets trapped under the skin forming a red or purplish mark) or a fracture ( broken bone) if resident was turned too close to the edge of the bed.
During an interview on 7/10/2024, at 3:27 p.m. with CNA 7, CNA 7 stated he was cleaning Resident 87 because the resident had a bowel movement (movement of feces through the bowel and out the anus). CNA 7 stated Resident 87 was not pulled closer to him before he was turned to his right side. CNA7 stated Resident 87 had a cut in the right side of the forehead after the turn and he notified his charge nurse and RN Supervisor right away. CNA 7 stated he should have pulled Resident 87 closer to him before turning him to the right side to avoid getting hit by the furniture close to the bed.
During a phone interview on 7/11/2024, at 12:24 p.m. with Director of Staff Development (DSD), the DSD stated when repositioning a resident proper body mechanics (proper body positioning during movement) are used by staff and the staff should ensure resident's body is in good alignment. DSD stated staff should ensure the bed was at the waistline , brakes of bed are locked, and surrounding areas of the resident is safe by removing or avoiding anything that gets in the way of the resident before repositioning or turning for safety and avoidance of injury.
During an interview on 7/11/2024, at 1:55 p.m. with Licensed Vocational Nurse (LVN 6), LVN 6 stated he was called by CNA 7 to check Resident 87 when the incident happened. LVN 6 stated Resident 87 had slight swelling and laceration on his right forehead. LVN 6 stated CNA7 was turning the resident and the resident accidentally hit his head on the bedside drawer. LVN 6 stated residents could fall off the bed or hit the furniture and the staff could hurt themselves by overextending their body if the residents are repositioned or turned too close to the side of the bed and away from the staff. LVN 6 stated residents should be close to staff's body and not too close to the other side of the bed before turning or repositioning them to avoid injury.
During an interview on 7/12/2024, 1:10 p.m. with Interim Director of Nursing (IDON), the IDON stated when repositioning or turning a resident the staff should pull the residents close to them by pulling the sheets so there is enough space for turning. The IDON stated if there was not enough space for resident during repositioning, there is a potential for injury because rails and bedside drawer can cause injury to the resident.
During a review of facility's policy and procedure(P/P) titled Safety and Supervision of Residents dated 2001, the P/P indicated resident safety and supervision and assistance to prevent accidents are facility wide priorities. The P/P indicated employees are trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who had poor safety awareness with a history of an unwitnessed fall from a wheelchair on 1/2/2024, and who required staff supervision with transfers from bed to a wheelchair, did not fall during unassisted and an unsupervised transfers from bed to a wheelchair sustained an injury for one of three sampled residents (Resident 1).
The facility failed to:
1. Revise Resident 1's care plan after Resident 1's fall on 1/2/2024 and develop comprehensive person-centered interventions to address Resident 1's poor safety awareness and Resident 1's noncompliance when asking for assistance prior to getting out of bed.
2. Ensure staff did not leave a wheelchair within Resident 1's reach next to the resident's bed, enabling Resident 1 not to call for assistance prior to getting out of bed and transfer unassisted to a wheelchair, causing her falls on 1/2/2024 and 6/2/2024.
3. Ensure staff followed the facility's policy and procedure (P/P) titled Fall and Fall Risk, Managing, which indicated that based on previous evaluations and current data, the staff will identify interventions related to Resident 1's specific risks and causes to try to prevent Resident 1 from falling and to minimize complications from falling.
These deficient practices resulted in Resident 1 sustaining a fracture (break in bone) of the left tibia (shin) on 6/2/2024 due to an unsupervised transfer from her bed into a wheelchair on 6/2/2024. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/2/2024 for evaluation and treatment of a displaced (gap developed between break in bones) comminuted (bone broken into three of more pieces) oblique (broken at an angle) fracture of left tibia, pain, and decreased mobility.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty walking, and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors).
During a review of Resident 1's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 3/14/2024, the MDS indicated Resident 1's cognitive skills (thinking process) for daily decision-making were moderately impaired and the resident was able to understand others and was understood by others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) with transfers between surfaces, including from bed to a chair and from chair to bed.
During a review of Resident 1's Fall Risk Observation/assessment dated [DATE], the Fall Risk Observation/Assessment indicated Resident 1's fall risk score was 18. A score of 16 and above indicated a high risk for falls.
During a review of Resident 1's Change of Condition (COC) dated 1/2/2024, the COC indicated on 1/2/2024 at approximately 10 a.m., Resident 1 was found on the floor by a Certified Nursing Assistant (CNA X).
During a review of Resident 1's Care Plan, dated 1/2/2024, the Care Plan indicated Resident 1 had an unwitnessed fall (1/2/2024) and was at risk for falls. The Care Plan's goals indicated, to the extent possible, minimize the risk for additional falls and Resident 1 would be compliant with fall interventions to reduce the risk of additional falls.
During a review of Resident 1's Fall Risk Observation/Assessment, dated 3/14/2024, the Fall Risk Observation/Assessment indicated Resident 1's fall risk score was 22, indicating a high risk for falls.
During a review of Resident 1's Physical Therapy ([PT] treatment used to restore functional movement, such as standing, walking) Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 1's functional status for transfers and for gait (the way a person walks) on level surfaces was contact guard assist (care giver places one or two hands on resident's body to help with balance).
During a review of Resident 1's COC note, dated 6/2/2024, the COC note indicated on 6/2/2024 at approximately 4:45 a.m., Resident 1 was found on the floor in her room next to her wheelchair by CNA 1. The COC note indicated Resident 1 complained of pain to her left lower leg rated 10 out of 10 on a pain scale from zero to 10 (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain).
During a review of Resident 1's Nurse's Notes, dated 6/2/2024, the Nurse's Notes indicated at 4:45 a.m., a noise was noted coming from Resident 1's room. Resident 1 was found on the floor in her room close to her wheelchair. The Nurse's Notes indicated at 5:30 a.m., 911 was called due to Resident 1's uncontrolled pain to her left lower leg, Resident 1 was transferred to a GACH for further evaluation.
During a review of the facility's Unusual Incident/Injury report, dated 6/3/2024, the Unusual Incident/Injury report indicated on 6/2/2024 Resident 1 was found lying on the floor on her left side. The Unusual Incident/Injury report indicated Resident 1 reported she was sitting in her wheelchair and was trying to shift her weight because she was not sitting in her wheelchair properly. Resident 1 reported she tried to get up from her wheelchair, but her legs got stuck/twisted and she fell. The Unusual Incident/Injury report indicated Resident 1 was transferred to a GACH (6/2/2024) for further evaluation and on 6/3/2024, the GACH reported Resident 1 sustained a fracture of the left tibia.
During a review of Resident 1's Face Sheet, from the GACH, the Face Sheet indicated Resident 1 was admitted to the GACH on 6/2/2024.
During a review of Resident 1's History and Physical (H/P), from the GACH, dated 6/2/2024, the H/P indicated Resident 1's Xray result showed Resident 1 sustained a left tibial fracture and she was placed in a long leg splint (an external device used to immobilize an injury or body part).
During a review of Resident 1's Imaging report (Xray), from the GACH, dated 6/5/2024, the Xray report indicated Resident 1 sustained a displaced comminuted oblique fracture of the mid to distal third of the left tibia.
During an interview on 6/5/2024 at 10:30 p.m., Resident 1 stated a few days ago (6/2/2024), she got out of bed and transferred to her wheelchair. Resident 1 stated she was not steady in her wheelchair and fell from it. Resident 1 stated she was able to get into her wheelchair because her bed was high enough and her wheelchair was at her bedside. Resident 1 stated she does not usually ask for assistance to get out of bed to her wheelchair because she was able to transfer independently, and the nursing staff leaves her wheelchair next to her bedside so she can reach it easily. Resident 1 stated she felt frustrated and uncomfortable because she was in pain and could not get out of bed because of her broken leg.
During an interview on 6/6/2024 at 3 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was a high fall risk and should be supervised during transfers from her bed to her wheelchair, but she was noncompliant and did not ask for assistance when transferring. LVN 1 stated, nursing staff often places Resident 1's wheelchair next to her bed within the resident's reach. LVN 1 stated, Resident 1 had poor safety awareness and judgement and placing her wheelchair within reach of her could increase the likelihood that Resident 1 would not call for assistance prior to getting out of bed, causing an increased risk of falls.
During an interview on 6/6/2024 at 3:15 p.m., the Director of Rehabilitation (DOR) stated Resident 1 required supervision when transferring out of bed into a chair or wheelchair and back into bed. The DOR stated Resident 1 was a high fall risk and could be unsteady when transferring or ambulating without supervision The DOR stated, the IDT had not revised Resident 1's comprehensive care plans after her fall on 1/2/2024 and prior to her fall on 6/2/2024 to address Resident 1's noncompliance when asking for assistance prior to getting out of bed. The DOR stated, the IDT should have discussed specific interventions to promote safety and prevent future falls. The DOR stated she was not aware the nursing staff was placing Resident 1's wheelchair at her bedside unattended and because Resident 1 had poor judgment and safety awareness, the wheelchair could be considered an environmental hazard and increase Resident 1's risk of falls.
During an interview on 6/6/2024 at 4 p.m., the Director of Nursing (DON) stated nursing staff should have ensured Resident 1's care plan interventions (resident needs were anticipated, and the resident was supervised during transfers) were implemented and revised as needed to ensure proper care and services were provided to prevent Resident 1 from falling. The DON stated he was not aware Resident 1's wheelchair was left unattended at the resident's bedside. The DON stated placing the wheelchair next to Resident 1's bed enabled the resident to transfer into the wheelchair unsupervised. The DON stated it was important for staff to supervise Resident 1 during transfers to ensure her safety.
During a review of the facility's P/P titled Fall and Fall Risk, Managing, revised 1/2001, the P/P indicated based on previous evaluations and current data, 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 implement resident centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The P/P indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.
During a review of the facility's P/P titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P/P indicated an individualized, resident centered approach to safety, the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, a resident, who lacked the capacity to understand and make decisions, was not discharged from the facility against medical advice ([AMA] choosing to leave the hospital before the treating physician recommends discharge) for one of 141 residents (Resident 1).
The facility failed to:
1. Ensure Resident 1 was competent to make a decision to leave the facility and sign out AMA.
2. Ensure Resident 1 had a valid Out On Pass ([OOP] temporary permission given to a resident to leave the facility for a specified amount of time) and AMA order on 4/19/2024, the day Resident 1 wanted to leave.
3. Assess Resident 1's ability to understand his medication regimen in order to safely take his prescribed Haldol (medication for treating schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others]) for paranoid delusion (profound fear and anxiety [Intense, excessive, and persistent worry and fear about everyday situations] along with the loss of the ability to tell what's real and what's not real) before providing Resident 1 with a total of 41 tablets of Haldol 10 milligrams ([ mg] a unit of measurement of weight) at the time of discharge AMA on 4/19/2024.
4. Ensure there was a referral (preadmission arrangements) made to the shelter before allowing Resident 1 to leave the facility AMA, placing him into a ride-share (a service or network through which ride-sharing trips are arranged) vehicle and sending him to the shelter.
5. Prior to discharge, notify Resident 1's Responsible Party (RP) that Resident 1 was going to sign out of the facility AMA and would be going to a shelter on 4/19/2024.
These deficient practices resulted in Resident 1 leaving the facility without prior arrangements, to the shelter of his choice. Resident 1 was not accepted by the shelter upon Resident 1's arrival to the shelter and is now missing. Resident 1's whereabouts are currently unknown. These failures placed Resident 1 at a high risk for exposure to harsh environmental conditions, possible motor vehicle accidents, and medical complications due to taking antipsychotic medications (medications work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) inappropriately, or overdosing (too much of a drug taken or given at one time), malnutrition (lack of proper nutrition), heart failure, chronic kidney disease complications, dehydration (body doesn't have as much fluid as it needs), and possible death.
On 4/26/2024 at 3:02 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to failure to safely discharge a psychiatric resident (Resident 1) with a 20-days supply of medications without assessing the resident's ability to self-administer his prescribed antipsychotic (medication that affects the brain) medication was called in the presence of the Administrator, the Director of Nursing (DON) and two outside Resource Registered Nurses.
The facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 5/1/2024 at 8:41 a.m., in the presence of the temporary manager and Assistant Director of Nursing (ADON).
The IJRP included the following:
1.On 4/26/2024 the Medical Director reviewed and approved the updated changes to the Policy and Procedure for Out on Pass, to include, residents' discharge, and measures to take if a resident is out on pass and refuses to return to the facility on April 27, 2024.
2.The Medical Director approved the updated changes to the Policy and Procedure for Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) on April 30, 2024.
3.The facility began In-service (education) training for Social Services and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed when employees return to work according to their schedule.
4.At the time of admission, the physician will make the decision regarding the capacity (ability of the resident to make decisions).
The results of the capacity determination will identify if the resident is responsible for decision making. The facility will ascertain if the resident has a responsible party or not, prior to admission. A new policy and procedure will be implemented for capacity. The admission Packet includes the resident's capacity for making decisions and the responsible party who signs on behalf of the resident.
5.Physicians will be asked to reassess their residents' capacity status as needed.
6.The Out On Pass Policy was updated to state that if a resident is refusing to return to the facility from out on pass activity, residents' responsible party, primary MD and Psychiatrist will be notified.
7.Every effort will be made by the staff to assist the resident to return to the facility. They will have a conversation with the resident on why they do not want to return to the facility. Social Services, the Administrator and Director of Nursing will be notified.
8.If the resident is suspected to be a danger to self or others appropriate authorities will be notified to determine if a 5150 hold (an involuntary hold of a person who is deemed to be a danger to themself, a danger to others, or gravely disabled, as a result of a mental disorder, for psychiatric evaluation, assessment, and/or treatment) will be placed and the resident will be transferred to a psychiatric (mental illness) acute (sudden) care hospital for further evaluation. If the resident is determined not to be a danger to self or others, he/she will be educated on the risks and benefits of leaving the facility against medical advice (AMA). As, it is the Residents Right to leave the facility AMA, the staff will follow guidelines of AMA policy and procedure.
9. The facility began In-service training for Social Services staff and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, beginning on April 30, 2024, by the Director of Nursing/Designee to be completed as employees return to work according to their schedule.
10. A facility wide Capacity/Responsible Party (a person that would make decisions for Residents that cannot safely make their own decisions) audit was conducted on April 26, 2024, to determine if there were any other residents found to have unknown responsibility status. At this time all residents have capacity identified and the Responsible Party identified. An audit was conducted by Social Services for other residents if they have fluctuating capacity (a person whose decision-making ability varies). 18 residents were identified with fluctuating capacity. Out of the 18 identified, six residents did not have capacity status (to make decisions); they were referred to the public guardian (a public official that is responsible for the care of individuals who are no longer able to make decisions or care for themselves). Four of those are still being processed and two have been processed and will move forward through the public guardian appointing process. Their physicians will be notified to reassess if they have capacity to make decisions on a quarterly basis.
11. The care plans for those residents with fluctuating or no capacity will be revised to reflect the residents' capacity by Friday May 3rd, 2024.
12.The resident's physician will be notified of the request for AMA discharge. The physician will determine the need to release the resident AMA with or without medications. If the resident does not have capacity, they will not be sent with medications unless there is a Responsible Party present to take responsibility for the medication. If the resident is released with medications and it is expected that they will self-administer those medications, an assessment of the resident, will be conducted by the nursing staff to assure they have the ability to accurately self-administer those medications.
13. Any resident who discharges AMA will be trained on self- administration of medications before they leave the facility. A Discharge Summary will be given to the resident with the directions for taking the medications. The resident will sign the Discharge Summary indicating that they have received self-medication administration training and understand the risks and benefits of taking the medications correctly. The facility staff will also sign the Discharge Summary, witnessing the resident's signature. The progress note will include all steps taken to foster the resident's highest practicable wellbeing because of the resident going out of the facility AMA.
14. Licensed nurses will be in-serviced on the policy and procedure for self-administration of medications, training on self-administration of medications and disposition of remaining medications beginning on April 30, 2024, by the Director of Nursing/Designee using the teach back method by May 3rd, 2024, or upon their next scheduled shift. Medications not given to the resident upon AMA discharge will be disposed of according to State and Federal regulations.
15. The facility will ensure that any resident who leaves the facility AMA is given the best chance possible of succeeding outside of the facility by notifying the receiving facility, including shelters, the resident has requested to move to and that the shelter would be able to meet their needs. Social Services and licensed nurses will be in-serviced on notifying the intended location, assuring availability and capability to meet resident needs. Social Services will be responsible for notifying any shelter of the resident's request. Social Services will be in-serviced on Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024.
16. Social Services will be responsible for follow-up on any resident who went AMA to see if they arrived at their intended location, where practicable. Social Services and Licensed nurses will be in-serviced beginning on April 30, 2024, by the Director of Nursing/Designee to be completed by May 3rd, 2024.
17. The facility has begun an audit of all residents with the inability to make decisions. Conservators (a person who looks after and is legally responsible for someone who is unable to manage their own affairs)/Responsible Party will be notified if one of their residents tries to seek a discharge (AMA). That is the conservator's/ Responsible Party's responsibility to make that decision. The facility will follow the conservators' decisions. The facility will follow its' policies and procedures for AMA Discharge and notification of Responsible Parties pending AMA discharge.
18. Action Plans to manage reoccurrences of leaving the facility against medical advice (AMA) will be implemented in the Quality Assurance and Performance Improvement Committee ([QAPI] a facility committee consisting of department heads, the medical director, physicians and key staff that identifies system failures by data gathering and analysis and implements measure to improve the overall quality of life and quality of care and services delivered to nursing home residents.) on April 29, 2024.
Findings:
During a review of Resident 1's General Acute Care Hospital (GACH 1) Behavioral Health Progress Note dated 2/25/2024, the Behavioral Health Progress Note indicated, Resident 1 exhibited signs of paranoia (unjustified suspicion and mistrust of other people and/or their actions) and was brought to GACH 1 from a jail, with disorganized thoughts, and poor insight. The Behavioral Health Progress Note indicated Resident 1 was a poor historian, unkempt (having an untidy appearance), malodorous (an unpleasant or offensive odor), and with disorganized speech, and on a 5150 hold. The Behavioral Health Progress Note indicated Resident 1 had two recent psychiatric evaluations in the past two months and ongoing intractable (not easily controlled or directed) psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).
During a review of Resident 1's Order Summary Report (OSR), from the SNF, dated 4/24/2024, the OSR indicated, to admit Resident 1 to the facility on 3/4/2024.
During a review of Resident 1's Skilled Nursing Facility (SNF) admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), myocardial infarction ([heart attack] when the heart muscle begins to die because it isn't getting enough blood flow), anxiety disorder, obstructive sleep apnea (a disorder in which a person frequently stops breathing during his or her sleep), and essential hypertension ([HTN] abnormally high blood pressure that's not the result of a medical condition).
During a review of Resident 1's History and Physical (H&P), dated 3/15/2024, the H&P indicated, Resident 1 had a fluctuating capacity to make decisions.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/20/2024, the MDS indicated Resident 1 required assistance (helper does all of the effort) from one staff for toilet use, hygiene, lower body dressing, putting on/taking off footwear, bed mobility, and transfers. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from one staff for personal hygiene, moderate assistance (helper does less than half the effort) from one staff for upper body dressing, oral hygiene, rolling from left to right, and supervised touch assistance (helper provides verbal cues/touching/steadying/contact guard assistance) from one staff for eating and showering.
During a review of Resident 1's Change in Condition Evaluation/Change of Condition (COC) dated 3/4/2024 and timed at 6 p.m., the COC indicated, upon admission Resident 1 was verbally aggressive and attempted to strike at staff and was requesting to leave the facility. The COC indicated a physician's order was obtained to transfer Resident 1 on a 5150 hold to GACH 2 for further evaluation.
During a review of Resident 1's Order Summary Report dated 4/24/2024, the OSR indicated, a physician's order dated 3/4/2024 to transfer Resident 1 to GACH 2 for evaluation and treatment related to paranoid delusion.
During a review of Resident 1's GACH 2 H&P, dated 3/5/2024, the H&P indicated, Resident 1 was brought to GACH 2's emergency department (ED) on a 5150 hold for further treatment, after developing acute agitation and striking out at staff members.
During a review of Resident 1's Order Summary Report, from the SNF, dated 4/24/2024, the Order Summary Report indicated, a physician's order dated 3/13/2024 to admit Resident 1 to the facility.
During a review of Resident 1's Summary of Neurobehavioral and Cognitive (an assessment of a wide range of mental functions, including behavior, to see how well the brain works) consult, dated 4/12/2024, the Neurobehavioral Summary indicated Resident 1 was partially oriented (he did not know the month and the year), with partial awareness of his location, and was unable to express himself verbally. The Summary Neurobehavioral Consult note indicated Resident 1 had difficulty making complex decisions and the help of a designated decision-maker was recommended.
During a review of Resident 1's Interdisciplinary Team [([IDT] - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) Conference Notes, dated 3/13/2024, the IDT Conference Notes indicated, Resident 1 was to remain in the facility at this time. The IDT Conference Notes indicated Resident 1 wished to transition back to community and he would be referred to ancillary (supportive or diagnostic measures that supplement and support a primary healthcare provider in treating a patient) services and psychology for follow up.
During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physicians' order dated 3/13/2024 to give Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions.
During a review of Resident 1's Order Summary Report dated, 4/24/2024, the Order Summary Report indicated a physician's order dated 3/31/2024 to give Ativan one mg, one tablet by mouth, every six hours as needed for anxiety disorder for 14 days as manifested by the inability to relax.
During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated Resident 1 received Ativan 1 mg for anxiety on the following days:
1. 3/15/2024 at 4:15 p.m.
2. 3/16/2024 at 6:00 p.m.
3. 3/17/2024 at 9:56 p.m. and 6:00 p.m.
4. 3/18/2024 at 10:01a.m. and 6:05 p.m.
5. 3/20/2024 at 5:15 p.m.
6. 3/21/2024 at 5:20 p.m.
7. 3/22/2024 at 5:30 p.m.
8. 3/23/2024 at 6:00 p.m.
9. 3/24/2024 at 5:03 p.m.
10. 3/27/2024 at 5:00 p.m.
10. 4/2/2024 at 4:27 p.m.
11. 4/5/2024 at 4:27 p.m.
12. 4/11/2024 at 9:28 p.m.
During a review of Resident 1's Self-Administration of Medication observation form, dated 3/13/2024, the Self-Administration of Medication Observation form indicated, Resident 1 did not want to self-administer medication.
During a review of Resident 1's OOP order, created by the Assistant Director of Nurses (ADON) on 4/19/2024 and a back -date (to date the order earlier than it was actually given) of 3/20/2024, the OOP order indicated Resident 1 could leave the facility on a therapeutic pass, in the company of a facility staff member for safety and supervision.
During a review of Resident 1's AMA order, created by the Director of Nursing (DON) on 4/22/2024 (back-dated three days after Resident 1 left the facility AMA), the AMA order indicated Resident 1 may be discharged from the facility AMA on 4/19/2024.
During a review of Resident 1's clinical record, the clinical record indicated there was no OOP order on 4/19/2024 (the day Resident 1 was accompanied by facility staff OOP).
During a review of Resident 1's Ride-Share receipt, dated 4/19/2024, the Ride Share receipt indicated Resident 1 was picked up at the bus stop near the sidewalk of the fast-food restaurant at 1:52 p.m., and arrived at the destination (shelter) at 2:10 p.m.
During a review of Resident 1's Social Service Notes (SSN), dated 4/23/2024 and timed 9:50 p.m., the SSN indicated, the Social Service Director (SSD) contacted the shelter Resident 1 was sent to, and spoke to the shelter coordinator. The SSN indicated the shelter coordinator stated there was no record of Resident 1 checking in to the shelter as of 4/19/2024.
During an interview on 4/23/2024, at 3:40 p.m., the SSD stated he was not informed that Resident 1 signed out of the facility AMA until after the incident. The SSD stated, many shelters required a referral due to limited space and had he known Resident 1 was being discharged from the facility he could have assisted him to find a place to transfer to. The SSD stated he should have followed up with the shelter Resident 1 was transferred to, to make sure Resident 1 arrived and was admitted there. The SSD stated, some shelters could assist residents with limited medical care, he did not know if the shelter that Resident 1 was sent to could accommodate Resident 1's medical needs or if they would administer Resident 1's medications. The SSD stated there was no discharge plan for Resident 1 because Resident 1 had been transferred in and out of the facility to the GACH on a 5150 hold because of behavioral issues.
During an interview on 4/23/2024, at 4:03 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was usually quiet and cooperative, but there were times when he became verbally aggressive and paranoid. LVN 1 stated that was why Resident 1 was on routine (scheduled) Haldol and as needed Ativan. LVN 1 stated, Resident 1 had a history of noncompliance with taking his medication, and his daily medications were administered by the licensed nurses at the facility and Resident 1 never expressed a desire to self-administer his medications.
During an interview on 4/23/2024, at 4:41 p.m., Registered Nurse Supervisor 1 (RNS 1) stated, Resident 1 was transferred to GACH 2 on 3/4/2024 because of aggressive behavior and was readmitted to the facility on [DATE] to a secured unit (a unit in a nursing home that restricts a resident's ability to freely move in and out of ) for behavior monitoring, but was transferred from the secured unit to a skilled nursing unit (non-secured unit with less intense monitoring for behavior issues and focuses on medical and rehabilitation treatment) on 4/16/2024. RNS 1 stated Resident 1 had a fluctuating mental capacity, and he might not understand the risks of AMA and stated she was not sure if Resident 1 was safe to leave the facility AMA.
During a telephone interview on 4/24/2024, at 8:46 a.m., Family Member (FM 1) stated, no one at the facility called to notify her that Resident 1 wanted to leave the facility or that Resident 1 left the facility AMA. FM 1 stated, Resident 1 was not in his right mind, and she could not understand how the facility let Resident 1 leave the facility even if he wanted to go, or how the sheriff, who were not medical professionals, could assess someone's mental capacity.
During an interview on 4/24/2024, at 10:49 a.m., the ADON stated he took Resident 1 OOP on 4/19/2024 to a fast-food restaurant across the street from the facility. The ADON stated, after Resident 1 ordered and got some food Resident 1 started walking outside of the fast-food restaurant and refused to go back to the facility. The ADON stated, he notified the DON, the Administrator (ADM), and a Registered Nurse that worked with a temporary management team (TMRN 1) that was contracted with and stationed at the facility. The ADON stated TMRN 1 instructed him to call the local sheriff department to evaluate Resident 1 for a 5150 hold, to notify Resident 1's psychiatric (Psychiatrists are trained physicians who specialize in evaluating, diagnosing and treating mental disorders) doctor and follow whatever the psychiatrist asked him to do.
During an interview on 4/24/2024, at 11:00 a.m., the ADON stated, he spoke to Resident 1's psychiatrist via the telephone and received an order from him to sign Resident 1 out AMA if the sheriff did not place Resident 1 on a 5150 hold. The ADON stated, the sheriff reported that Resident 1 did not meet the criteria for a 5150 hold, so he (ADON) believed Resident 1 was safe to be discharged AMA, as instructed by Resident 1's psychiatrist. The ADON stated, there was an order in place on 4/16/2024 which indicated Resident 1 could go out to the courtyard (which was an outside common area on facility grounds surrounded by the facility buildings) for therapeutic services. The ADON stated, the fast-food restaurant was across the street from the facility, so he took Resident 1 to the fast-food restaurant. The ADON stated he did not assess Resident 1's behavior prior to taking him across the street to the fast-food restaurant to determine if it was safe for him to go OOP that day.
During an interview on 4/24/2024, at 11:15 a.m., the ADON stated, he did not know the shelter (Resident 1 chose to go to) required a referral and thought anyone could just walk in and get accepted, nor did he follow up with the shelter to see if Resident 1 arrived there safely. The ADON stated he should have consulted with the SSD for Resident 1's placement, but he did not, and he did not call FM 1 or FM 2 during the process prior to Resident 1 leaving AMA, he only left a message with FM 1 after Resident 1 had already left the facility AMA. The ADON stated he did not notify FM 1 or FM 2 that Resident 1 was not accepted at the shelter or that Resident 1's current location was unknown because he did not follow up with the shelter and did not know Resident 1 was not there.
During a telephone interview on 4/24/2024, at 11:29 a.m., Resident 1's psychiatrist stated, he did not think Resident 1 had the capacity to make decisions, but it did not matter whether he had capacity or not, it was his right to leave AMA if the sheriff did not place him on a 5150 hold. Resident 1's psychiatrist stated he told the facility to give Resident 1 a 10 day-supply of Haldol 10 mg tablets because he did not want Resident 1's medication to be stopped abruptly to prevent relapse (reoccurrence) of psychosis (a severe mental condition in which thoughts and emotions are so affected and contact is lost with reality). Resident 1's psychiatrist stated there was the risk of overdose if Resident 1 took to many Haldol tablets, which could lead to arrythmia (a condition in which the heart beats with an irregular or abnormal rhythm which may increase the risk for a serious heart condition).
During an interview on 4/24/2024, at 11:44 a.m., LVN 3 stated, she received a call from the ADON asking her to bring an AMA form and all Resident 1's medications to the sidewalk near the fast-food restaurant. LVN 3 stated she gave all of Resident 1's medications and AMA form for Resident 1 to sign, to the ADON.
During a telephone interview on 4/24/2024, at 11:56 a.m., the Referral Agent (RA) at the shelter Resident 1 was sent to stated, Resident 1 showed up at the shelter on 4/19/2024, but they could not admit him because he did not have a referral from the facility, he came from, prior to arriving at the shelter and they only accept walk-ins if they had enough beds available. The RA stated Resident 1 came in after 2 p.m., when available beds had already been assigned by that time. The RA stated Resident 1 left the shelter after he was told he could not check in and he (RA) did not know where Resident 1 went or his whereabouts.
During an interview on 4/24/2024, at 1:48 p.m., the DON stated he was not sure if there was an OOP order for Resident 1 prior to 4/19/2024 and he did not create an AMA order until after Resident 1 left the facility (4/22/2024) because he got busy and forgot to do it. The DON stated, he received a call from the ADON on 4/19/2024 regarding Resident 1's refusal to come back to the facility. The DON stated he went with the ADM to the sidewalk of the fast-food restaurant to assist the ADON with discharging Resident 1. The DON stated, he gave Resident 1 a total of 41 tablets of Haldol 10 mg which was a 10-day supply. (According to the Resident 1's physicians' order dated 3/13/2024 to administer Haldol 10 mg, one tablet by mouth, two times a day for schizophrenia manifested by paranoid delusions, the DON gave Resident 1 a 20-day supply of Haldol).
During an interview on 4/24/2024, at 2:00 p.m., the DON stated, he did not check Resident 1's Self-Administration of Medication Assessment nor did he give Resident 1 written instructions related to his Haldol. The DON stated Resident 1 responded OK when he showed him the instructions on the Haldol package on how to take his medication. The DON stated, he forgot to document Resident 1's medication order to give Resident 1 a 10-day supply of Haldol on the eMAR (a digital version of the MAR), or in Resident 1's Medication Disposition Log (any medication dispositioned or supplied to the resident should be documented on medication disposition log for record keeping).
During an interview on 4/24/2024, at 2:05 p.m., the DON stated, he did not know if anyone at the shelter would supervise Resident 1's Haldol self-administration. The DON stated, Resident 1 could be at risk for overdose if he took to many of the Haldol tablets at one time or his symptoms could worsen if Resident 1 did not take the Haldol. The DON stated, it was not safe to discharge Resident 1 but Resident 1 was the one who made the decision to leave the facility AMA. The DON stated, he did not know the shelter required a referral from the facility for Resident 1 to be admitted , had he known that he would have called the shelter with a referral to have Resident 1 admitted . The DON stated, he was not familiar with the facility's AMA policy for residents with mental illness.
During a telephone interview on 4/24/2024, at 6:25 p.m., FM 1 stated, Resident 1 had been suffering from mental illness and other medical conditions for over 23 years and had been in and out of hospitals all of those years for his behaviors. FM 1 stated she received a voice-message from facility staff during the evening of 4/19/2024, when she called back the next morning (4/20/2024) the facility nurse told her Resident 1 left the faciity on 4/19/2024 because he did not want to stay at the facility. FM 1 stated, the facility did not tell her Resident 1 was not accepted to the shelter he was sent to, and that his whereabouts were unknown. FM 1 stated she was scared that Resident 1 would harm himself or someone else, based on her previous experience with him, and she was worried about his safety.
During an interview on 4/25/2024, at 4:42 p.m., the ADM stated, he received a call from the ADON that Resident 1 refused to come back to the facility while her and Resident 1 were OOP at a fast-food restaurant across the street from the facility. The ADM stated, they followed the instructions of Resident 1's psychiatrist and TMRN 1 to discharge Resident 1 AMA. The ADM stated, they could have done better, but the situation was very intense at that time, and they did not have all of Resident 1's previous psychiatric history. The ADM stated, they should have contacted the SSD to arrange placement for Resident 1 before discharging him AMA and they should have followed up with the shelter to see if Resident 1 was admitted . The ADM stated their policy was not very clear about the process and requirements for AMA.
During a telephone interview on 4/27/2024, at 9:51 a.m., Resident 1's psychologist (a person who specializes in the treatment of mental, emotional, and behavioral disorders without prescribing medications) stated, he was not aware that Resident 1 was released from the facility AMA. Resident 1's psychologist stated Resident 1 could not make complex decisions and he was concerned Resident 1 would become noncompliant with his care and not take his medication as he had done in the past, which would make his condition worse.
During a review of the facility's P&P titled, Transfer or Discharge, Emergency, revised 8/2018, the P&P indicated, should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will notify the resident's attending physician, notify the receiving facility that the transfer is being made, notify the representative (sponsor) or other family member.
During a review of the facility's P&P titled, Discharging a Resident Without a Physician's Approval, revised 10/2022, the P&P indicated, if a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location, document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed, document that despite being offered other options that could meet the resident's [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one resident's (Resident 1) primary care doctor (MD) and responsible party (RP) was informed of Resident 1 oral intake of less than 50 percent, in forty-two meal intakes, from 12/22/2023 to 1/5/2024.
This deficient practice had the potential to result in a delay of care and services that can result in further weight loss for Resident 1.
Findings:
A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear and anxiety along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious mental illness which affects how a person thinks, feels, and behaves), dementia (the impaired ability to remember, think, or make decisions which interfere with daily activities), and major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's History and Physical (H/P), dated 1/21/2024, indicated Resident 1 had fluctuating capacity to make decisions.
A review of Resident 1's ([MDS] a standardized assessment and care planning tool), dated 11/7/2023, indicated Resident 1 was able to make independent decisions which were reasonable and consistent and was able to understand and be understood by others.
A review of Resident 1's Order Summary Report (Physician's Orders), indicated a physician's order was placed on 10/24/2023 indicating to monitor Resident 1 for episodes of poor appetite of less than 50%.
A review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Weight Variance Assessment, dated 12/10/2023, the Weight Variance Assessment interventions and implementations included to monitor oral intake and continue to monitor for any significant change of condition.
A review of Resident 1's Care Plan (CP), dated 8/20/2023, indicated Resident 1 had depression manifested by poor appetite less than 50 percent. Under this CP, the goals for Resident 1 were Resident 1 will exhibit indicators of depression, anxiety (feelings of fear, dread, and uneasiness), or sad mood less than daily by the review date of 2/5/2024. The CP interventions included monitor and report any signs and symptoms of depression.
A review of Resident 1's CP for nutrition, dated 12/13/2023, indicated Resident 1 will consume greater than 75 percent of meals, and the care plan interventions included to monitor intake.
A review of Resident 1's Medication Administration Report (MAR), dated 12/2023, indicated Resident 1 ate less than 50 percent of his meals, for a total of 27 meals, on the following days:
1. On 12/22/2023, at 6 p.m., Resident 1 refused his meal.
2. From 12/23/2023 to 12/31/2023, for the 9 a.m., 1 p.m., and 6 p.m. meals, Resident 1 ate 25 percent of each meal. (27 missed opportunities)
A review of Resident 1's MAR, dated 1/2023, indicated Resident 1 ate less than 50 percent of his meals, for a total of 15 meals, on the following days:
1. On 1/1/2024, at 9 a.m., Resident 1 ate 40 percent of his meal.
2. On 1/1/2024, at 1 p.m., and 6 p.m., Resident 1 ate 30 percent of each meal.
3. From 1/2/2024 to 1/5/2024, for 9.am., 1 p.m., and 6 p.m., meals, Resident 1 ate 30 percent of each meal.
A review of Resident 1's Nursing Progress Notes, dated 12/2023 and 1/2024, indicated there was no documentation from the licensed nurses indicating Resident 1's MD and RP were notified of Resident 1's meal intake of less than 50 percent.
During an interview on 3/5/2024 at 9 a.m., with the Licensed Vocational Nurse (LVN 1), LVN 1 stated, she should have notified Resident 1's MD that Resident 1 was not eating so additional monitoring can be done. LVN 1 stated when a resident has a change of condition, the licensed nurses were also responsible for notifying the resident's RP. LVN 1 stated there was a potential for the resident to have further weight loss because the MD was not aware of the resident's decline in meal intake.
During an interview with the Director of Nursing (DON) on 3/6/2024 at 2:52 p.m., the DON stated based on the documentation the nursing staff should have notified the physician and the responsible party since Resident 1 was on monitoring and meal intakes were less than 50 percent.
A review of the facility's policy and procedure (P/P), titled, Change in a Resident's Condition or Status, revised 2/2021, indicated our facility promptly notifies the attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a quarterly Interdisciplinary ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of six sampled residents (Resident 1) and their responsible party (RP), was held on 11/2023.
This deficient practice violated Resident 1 and RP 1's right to be an active participant to discuss the resident's plan of care and services with the IDT and potentially delayed the discussion of needed care and services.
Findings:
A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious mental illness which affects how a person thinks, feels, and behaves), dementia (the impaired ability to remember, think, or make decisions which interfere with daily activities), and major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's History and Physical (H/P), dated 1/21/2024, indicated Resident 1 had fluctuating capacity to make decisions.
A review of Resident 1's ([MDS] a standardized assessment and care planning tool), dated 11/7/2023, indicated Resident 1 was able to make independent decisions which were reasonable and consistent and was able to understand and be understood by others.
During an interview on 3/1/2024 at 10:29 a.m., with Resident 1's RP, the RP stated on several occasions she (RP) had requested an IDT Care Conference meeting to be held due to concerns regarding Resident 1's care.
A review of Resident 1's IDT Care Conference Notes, dated 8/8/2023, indicated there was an IDT Care Conference Conducted for Resident 1. This was the last IDT Care Conference conducted for Resident 1.
A review of Resident 1's Social Service Progress Notes, dated 11/2023 to 1/2024, indicated Resident 1's RP was not contacted to schedule an IDT Care Conference meeting until 1/22/2024.
During an interview on 3/6/2024 at 10:52 a.m., with the Social Services Assistant (SSA 1). The SSA 1 stated, the purpose of the IDT Care Conference meetings was to address questions, concerns, and go over the resident's care plan to ensure it was appropriate for that specific resident. The SSA 1 stated Resident 1's quarterly IDT Care Conference meeting should have been held in November 2023, but the facility was short staffed, and it was very difficult for social service staff to cover all the buildings.
During an interview on 3/6/2024 at 3:20 p.m., with the Social Services Director (SSD). The SSD stated the IDT Care Conference meetings should be held at least quarterly, when there has been a significant change of condition, upon readmission, as needed, and as requested by the resident or the resident's RP.
During a review of the undated facility's policy and procedure (P/P) titled, Care Plans, Comprehensive Person-Centered, (undated), the P/P indicated the care plan interventions should be derived from information obtained from the resident and his/her family/responsible party with possible discretionary modifications resulting from the comprehensive assessment. The P/P indicated each resident had the right, individually or through a responsible party, to participate in the development and implementation of his/her comprehensive person-centered care plan, including the right to request meetings; and participate in suggesting the type, amount, frequency, and duration of care. The P/P indicated the IDT should review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to weigh one of six sampled residents (Resident 1) weekly between 12/19/2023 to 1/10/2024 as indicated in the resident's care plan.
This deficient practice had the potential to result in further weight loss.
Findings:
A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear and anxiety along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious mental illness which affects how a person thinks, feels, and behaves), dementia (the impaired ability to remember, think, or make decisions which interfere with daily activities), and major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's ([MDS] a standardized assessment and care planning tool), dated 11/7/2023, indicated Resident 1 was able to make independent decisions which were reasonable and consistent and was able to understand and be understood by others.
A review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Weight Variance Assessment, dated 12/10/2023, the Weight Variance Assessment interventions and implementations included continue to monitor weight trends.
A review of Resident 1's care plan for nutrition, dated 12/13/2023, indicated Resident 1's goals for Resident 1 were to maintain a usual body weight of plus or minus five pounds in a month, Resident 1 will consume greater than 75 percent of meals, and Resident 1 will have no significant weight change of 5 percent or more per month with a target date of 2/5/2024. The care plan interventions included to weigh Resident 1 weekly.
A review of Resident 1's Weight Summary Report, dated 12/19/2023 to 1/10/2024, indicated Resident 1 was weighed on 12/19/2023 and on 1/10/2024 (22 days after Resident 1's last weight was done on 12/19/2023). There were 2 missed opportunities where the resident should have been weighed.
During an interview on 3/5/2024 at 9 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 validated Resident 1 was not weighed weekly between 12/19/2023 to 1/10/2024 as indicated in the Resident 1's care plan. LVN 1 stated if a resident's weekly weight was missed, especially if a resident was being monitored for a significant weight loss, then there was a possibility the resident could have further weight loss because of the unknown weight. LVN 1 stated the purpose of the care plan was to ensure each resident received the correct care, monitoring, and interventions to prevent incidents from occurring or reoccurring.
During an interview on 3/5/2024, at 3:15 p.m., with the Registered Dietician (RD 1), RD 1 stated because Resident 1's CP interventions were not followed, it had the potential to put Resident 1 at risk for further weight loss. The RD 1 stated, the purpose of Resident 1's CP was to minimize the risk of weight loss and to monitor the wellbeing of his nutritional status.
During an interview on 3/6/2024 at 2:52 p.m., with the Director of Nursing (DON), the DON stated the purpose of implementing the resident's CP interventions was to help prevent resident's further health decline. The DON stated the staff should have followed Resident 1's CP interventions as indicated and done a weekly weight.
A review of the facility's undated policy and procedure (P/P), titled, Care Plans, Comprehensive Person-Centered, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P/P indicated the CP interventions should address the underlying source(s) of the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure abuse training was provided to two housekeeping staff (HK 1 and HK 2), who were contracted by the facility via a outside housekeeping agency.
These deficient practices resulted in HK 1 and HK 2 being unaware of the abuse regulations provided to staff at the facility, which resulted in a verbal altercation with a resident (Resident 1) who resided at the facility. This deficient practice had the potential to subject residents, staff, and visitors to fear, abuse and harm.
Findings:
During a review an undated Witness Interview statement of Registered Nurse 1 (RNS 1), the Witness Interview statement indicated, RNS 1 described the incident were Resident 1 came to the nursing station and stated he was threatened by the housekeeping staff. The Witness Interview statement indicated, Resident was alert, oriented (a function of the mind involving awareness of three dimensions: time, place, and person), and able to answer questions appropriately.
During an interview on 9/18/2023, at 2:30 p.m., the Housekeeping Manager (HKM) from the contracted housekeeping company, where HK 1 and HK 2 were employed, stated general orientation and education were given to HK 1 and HK 2 by his company, but stated the facility was responsible for its own orientation and customized education to special resident populations. The HKM stated, his employees worked for many facilities, so it was not practical to provide education and orientation specific to each individual facility.
During an interview on 9/18/2023, at 3:08 p.m., the Director of Staff Development (DSD) stated there was no orientation packet, training records or background checks for HK 1 or HK 2. The DSD stated, all staff including contracted staff should have had training for abuse, but she could not retrieve HK 1 and HK 2's training records or orientation packets (basic information or training that is given to people starting a new job). The DSD stated, she did not have their employee files, because the contracted company, who HK 1 and HK 2 worked for, kept all their employees' files.
During an interview on 9/18/2023, at 4:46 p.m., RNS 1 stated, the facility should provide customized training and orientation to contracted staff in order to accommodate facility's specific population such as the residents with dementia and mental illness instead of accepting contracted company's general training
During a concurrent interview and record review on 9/19/2023, at 11:28 a.m., with the Administrator (ADM), HK 1 and HK 2's Employee Personnel File from the contracted company, dated 12/20/2022 and 11/9/2022 were reviewed. The Employee Personnel Files for HK 1 and HK 2 indicated, abuse in-service was provided on 12/20/2022 for HK 1 and 11/9/2022 for HK 2 by the contracted company. The ADM stated, the Employee Personnel Files were provided by the HKM of the contracted housekeeping company. The ADM stated, the facility did not have employee files for HK 1 or HK 2 because they were contracted employees. The ADM stated, all employees should receive training for abuse frequently because of the resident populations at the facility were vulnerable to abuse. The ADM stated, it would be the best practice to keep contracted employees' files and to track all training and Inservice.
During a review of HK 1 and HK 2's Online Inservice Log dated from 12/2022 to 9/2023, the Online Inservice Log indicated, abuse in-service online quizzes were submitted on 5/2023 for both HK 1 and HK. The Online Inservice Log indicated, no documented course syllabus, no certificate of completion, and no initial from HK 1 and HK 2 to indicate they completed the training. The ADM stated, the Online Inservice Log was the only proof he could provide at this time.
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included dementia (describe a group of symptoms affecting memory, thinking and social abilities), major depressive disorder ([MDD] a persistent feeling of sadness and loss of interest), anxiety disorder (uncontrollable excessive fear and worry), and post-traumatic stress disorder ([PTSD] a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety).
During a review of Resident 1's Minimum Data Set [(MDS] a standardized assessment and care planning tool) dated 9/8/2023, the MDS indicated Resident 1 required extensive (resident involved in activity, staff provide weight-bearing support) one-person physical assist with bed mobility, transfers, toilet use and personal hygiene.
During a review of the facility's undated policy and procedure (P&P) titled, Accidents and Incidents-Investigating and Reporting, the P&P indicated, to provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure two housekeeping (HK 1 and HK 2) staff, who were contracted by the facility from an outside agency, did not verbally abuse one of three sampled residents (Resident 1).
These deficient practice resulted in HK 1 and HK 2 following Resident 1 from his room, accusing him (Resident 1) of lying, calling Resident 1 names, and impeding Registered Nurse Supervisor 1's (RNS 1) investigation, when Resident 1 accused HK 1 and HK 2 of verbal abuse against him. HK 1 and HK 2 were escorted out of the facility by a local police agency, who were called because of HK 1 and HK 2's aggressive behavior towards Resident 1 and RNS 1. These deficient practices had the potential to subject residents, staff, and visitors to fear, abuse and harm. See F943
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included dementia (describe a group of symptoms affecting memory, thinking and social abilities), major depressive disorder ([MDD] a persistent feeling of sadness and loss of interest), anxiety disorder (uncontrollable excessive fear and worry), and post-traumatic stress disorder ([PTSD] a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety).
During a review of Resident 1's History and Physical (H&P), dated 5/29/2023, the H&P indicated, Resident 1 had a fluctuating capacity (the ability to make decisions for self) to understand and make medical decisions.
During a review of Resident 1's Minimum Data Set [(MDS] a standardized assessment and care planning tool) dated 9/8/2023, the MDS indicated Resident 1 required extensive (resident involved in activity, staff provide weight-bearing support) one-person physical assist with bed mobility, transfers, toilet use and personal hygiene.
During a review an undated Witness Interview statement of Registered Nurse 1 (RNS 1), the Witness Interview statement indicated, RNS 1 described the incident were Resident 1 came to the nursing station and stated he was threatened by the housekeeping staff. The Witness Interview statement indicated, Resident was alert, oriented (a function of the mind involving awareness of three dimensions: time, place, and person), and able to answer questions appropriately.
During a review of the facility's Follow Up Report, dated 9/13/2023, the Follow Up Report indicated, Resident 1 came to the nursing station and reported housekeepers threatened him in his room on 9/8/2023, at 10:30 a.m.
During a telephone interview on 9/18/2023, at 12:08 p.m., Resident 1's Family Member 1 (FM 1), stated Resident 1 reported that HK 1 and HK 2 came into his room to clean the floor and threatened him without any reason. FM 1 reported he (Resident 1) rushed out from his room via his wheelchair and notified the nursing staff at the nursing station. FM 1 stated, RNS 1 called the police to report the HK 1 and HK 2 and Resident 1 was very upset about the incident.
During an interview on 9/18/2023, at 2:05 p.m., the Floor Technician stated, he was a contracted employee of the facility as well. FT 1 stated his last abuse training from the company her worked for was approximately a year ago but never received abuse training or an in-service from the facility. FT 1 stated frequent in-service and training was important to protect the residents from abuse.
During an interview on 9/18/2023, at 2:30 p.m., the Housekeeping Manager (HKM) from the contracted housekeeping company, where HK 1 and HK 2 were employed, stated HK 1 and HK 2 denied allegations of verbal abuse. The HKM stated, HK 1 and HK 2 were upset with RNS 1 because she accused them of verbal abuse against Resident 1. The HKM stated, general orientation and education were given to HK 1 and HK 2 by his company, but stated the facility was responsible for its own orientation and customized education to special resident populations. The HKM stated, his employees worked for many facilities, so it was not practical to provide education and orientation specific to each individual facility.
During an interview on 9/18/2023, at 3:08 p.m., the Director of Staff Development (DSD) stated there was no orientation packet, training records or background checks for HK 1 or HK 2. The DSD stated, all staff including contracted staff should have had training for abuse, but she could not retrieve HK 1 and HK 2's training records or orientation packets (basic information or training that is given to people starting a new job). The DSD stated, she did not have their employee files, because the contracted company, who HK 1 and HK 2 worked for, kept all their employees' files. The DSD stated she did not conduct in-services to staff following the allegation of abuse made by Resident 1.
During an interview on 9/18/2023, at 4:46 p.m., RNS 1 stated, Resident 1 rushed to the nursing station from his room and looked very anxious and upset. RNS 1 stated, HK 1 and HK 2 followed Resident 1 to nursing station, they kept interrupting Resident 1 and calling him a liar while Resident 1 was trying to explain to her what happened. RNS 1 stated, when she tried to ask HK 1 and HK 2 what happened, they started arguing with her, swore at her and threatened her. RNS 1 stated, she called the police to escort them out of the facility because she was concerned about safety of staff and residents. RNS 1 stated, the facility should provide customized training and orientation to contracted staff in order to accommodate facility's specific population such as the residents with dementia and mental illness instead of accepting contracted company's general training
During a concurrent interview and record review on 9/19/2023, at 11:28 a.m., with the Administrator (ADM), HK 1 and HK 2's Employee Personnel File from the contracted company, dated 12/20/2022 and 11/9/2022 were reviewed. The Employee Personnel Files for HK 1 and HK 2 indicated, abuse in-service was provided on 12/20/2022 for HK 1 and 11/9/2022 for HK 2 by the contracted company. The ADM stated, the Employee Personnel Files were provided by the HKM of the contracted housekeeping company. The ADM stated, the facility did not have employee files for HK 1 or HK 2 because they were contracted employees. The ADM stated, all employees should receive training for abuse frequently because of the resident populations at the facility were vulnerable to abuse. The ADM stated, it would be the best practice to keep contracted employees' files and to track all training and Inservice.
During a review of HK 1 and HK 2's Online Inservice Log dated from 12/2022 to 9/2023, the Online Inservice Log indicated, abuse in-service online quizzes were submitted on 5/2023 for both HK 1 and HK. The Online Inservice Log indicated, no documented course syllabus, no certificate of completion, and no initial from HK 1 and HK 2 to indicate they completed the training. The ADM stated, the Online Inservice Log was the only proof he could provide at this time.
During a review of the facility's undated policy and procedure (P&P) titled, Dignity, the P&P indicated, residents are treated with dignity and respect at all times, staff speak respectfully to residents at all times and staff are expected to treat cognitively impaired residents with dignity and sensitivity.
During a review of the facility's undated P&P titled, Resident Rights, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.
During a review of the facility's undated Job Description: Housekeeper, the Job Description indicated, essential duties include excellent customer skills and positive attitude.
During a review of the facility's undated P&P titled, Accidents and Incidents-Investigating and Reporting, the P&P indicated, to provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.During a review of the facility ' s undated policy and procedure (P&P) titled, Dignity, the P&P indicated, residents are treated with dignity and respect at all times, staff speak respectfully to residents at all times and staff are expected to treat cognitively impaired residents with dignity and sensitivity.
During a review of the facility ' s undated P&P titled, Resident Rights, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.
During a review of the facility ' s undated Job Description: Housekeeper, the Job Description indicated, essential duties include excellent customer skills and positive attitude.
During a review of the facility ' s undated P&P titled, Accidents and Incidents-Investigating and Reporting, the P&P indicated, to provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident, who was depended on staff for activities of daily living (ADL), was not subjected to a physical abuse from another resident for one of three sampled residents (Resident 1). The facility failed to:
1. Ensure a certified nursing assistant (CNA 1) monitored the East hallway as assigned to timely intervene to prevent Resident 2 from physically abusing Resident 1 and ensure residents safety.
This failure resulted in Resident 2 punching Resident 1 in the head on 8/28/2023 leading to Resident 1 to sustain a left side lateral (on the side) subconjunctival (underneath the clear surface of eyes) hemorrhage (a broken blood vessel that bleeds on the surface of the eye) and a bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact causing the underlying blood vessels to burst) around his left eye.
Findings:
During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health disorder characterized by at least two weeks of persistently sad mood or loss of interest in activities, causing significant impairment in daily life functioning), diabetes mellitus (a group of diseases that affect how the body uses blood sugar to function normally), muscle weakness (a lack of strength in the muscles), and anxiety disorder (uncontrollable excessive fear and worry).
During a review of Resident 1's, History and Physical (H&P), dated 5/29/2023, the H&P indicated, Resident 1 had a fluctuating (changing frequently) capacity to understand and make medical decisions.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 9/1/2023, the MDS indicated Resident 1 required extensive physical assistance (resident involved in activity, staff provide weight-bearing support) from two or more staff with transfers (from one surface to another), toilet use, personal hygiene, and extensive assistance from one staff for bed mobility (repositioning while in bed), and eating.
During a review of Resident 2's General Acute Care Hospital 1 Psychiatric (study of mental illness) Evaluation (GACH 1 PE), dated 7/26/2023, the GACH 1 PE indicated, Resident 2 was admitted to GACH 1 multiple times due to diagnosis of psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and use of methamphetamine (a very addictive drug commonly referred to as meth, a powerful stimulant which is highly addictive that affects the brain and body). The GACH 1 PE indicated, Resident 2 had auditory hallucinations (to hear voices or noises that do not exist in reality) and visual hallucinations (seeing things that are not real, like objects, shapes, people, animals, or lights) that he was unable to describe. The GACH 1 PE indicated, Resident 2 was kicked out of the social security office for making threats and was paranoid (the unreasonable fear or irrational belief that other people are plotting to harm him or her) that people were talking about him. The GACH 1 PE indicated, Resident 2 had been off his medications and had been using methamphetamine.
During a review of Resident 2's admission record to the facility, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and causes a break with reality), stimulant (a class of drugs that speed up messages travelling between the brain and body) drug abuse, and major depressive disorder.
During a review of Resident 2's H&P, dated 8/4/2023, the H&P indicated, Resident 2 had capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required extensive physical assistance from one staff with toilet use, personal hygiene, dressing, and limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from one staff for bed mobility, and transfer.
During a review of Resident 2's Initial Psychiatry (a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans) Consult Note (IPCN), dated 8/29/2023, the IPCN indicated, Resident 2 had a sudden outburst of anger on 8/28/2023 and hit Resident 1 (unprovoked- occurring without any identifiable cause or justification) in the face causing injury to Resident 1. The IPCN indicated, Registered Nurse Supervisor (RNS 2) reported Resident 2 was verbally aggressive and acting bizarre.
During a review of Resident 1's Change in Condition Evaluation (CICE), dated 8/29/2023, the CICE indicated, Resident 1 was alert and awake and reported to RNS 2 he was hit by his roommate (Resident 2) around 10 p.m. on 8/28/2023. The CICE indicated, there was redness on Resident 1's left eye.
During a review of Resident 1's General Acute Care Hospital 2 Emergency Department Provider Notes (GACH 2 EDPN), dated 8/30/2023, the GACH 2 EDPN indicated, that an [AGE] year-old male presented to the emergency department with dizziness, blunt head injury (physical injuries caused by non-penetrating blows from dull objects or surfaces), and periorbital (around the eye area that extends from the upper and lower eyelids to the eyebrows) ecchymosis (a bruise- the blue or purple skin discoloration that occurs as a result of rupture of blood vessels under the skin )status-post (after) allegedly being punched in the face. In the GACH 2 EDPN was documented Resident 1 had a small left-sided lateral subconjunctival hemorrhage. Resident 1 stated that he occasionally has double vision (seeing two images of a single object). The GACH 2 EDPN indicated the recommendation was to follow-up with ophthalmologist (a medical specialty concerned with the study and treatment of disorders of the eye).
During a concurrent interview and record review on 9/6/2023, at 5:07 p.m., with CNA 1, the facility's Assignment Shift Report (ASR), dated 8/28/2023 for 3 p.m. to 11:00 p.m. shift was reviewed. The ASR indicated; CNA 1 was assigned to the east hallway from 9:00 p.m. to 10:00 p.m. 8/28/2023. CNA 1 stated, he did not monitor the east hallway from 9:00 p.m. to 10:00 p.m. on 8/28/2023. CNA 1 stated, he had never worked (monitored the residents) in the east hallway, and everybody knew it. CNA 1 stated, he did not notify or complain to the Registered Nurse Supervisor (RNS) or an LVN regarding his assignment and that he would not be monitoring the east hallway. CNA 1 stated, he knows he should follow the assignment, but he did not know why he was assigned to the east hallway that day. CNA 1 stated, CNAs must monitor both hallways by looking and listening to assist residents from emergencies like falls and altercations between the residents and to provide safety.
During a concurrent interview and record review on 9/6/2023, at 5:54 p.m., with RNS 1 the facility's ASR, dated 8/28/2023 for the 3:00 p.m. to 11:00 p.m. shift was reviewed. RNS 1 stated, CNA 1 was assigned for the east hallway from 9:00 p.m. to 10:00 p.m. and he should have followed his assigned tasks on the schedule regardless of whether he was familiar with the assignment or not to prevent any incident like the altercation between Resident 1 and Resident 2. RNS 1 stated, hallway monitoring was important to assist residents in a timely manner and keep residents safe from incident like this.
During a concurrent observation and interview on 9/6/2023, at 4:45 p.m., with Resident 2, in Resident 2's room in the East hallway, the resident stated, he did not remember the altercation with Resident 1. Resident 2 stated, he was having issues with his previous roommates because they made lots of noises and he was very sensitive with loud noises. Resident 2 refused to talk further regarding the incident that happened on 8/28/2023 and walked away.
During a concurrent observation and interview on 9/6/2023, at 4:56 p.m., with Resident 1, in Resident 1's room in the west hallway, Resident 1 was observed to have a bruise around his left eye with redness. Resident 1 stated on 8/28/2023 before 10 p.m. on 8/28/2023 Resident 2 punched twice on his (Resident 1) left side of the face and left eye. Resident 1 stated, Resident 2 walked up to him while he (Resident 1) was watching television and punched him on the left side of his face. Resident 1 stated that he yelled for help several times, because he could not reach his call light, but no one showed up. Resident 1 stated, Resident 2 got mad at him because he yelled for help and punched him again on the left eye. Resident 1 stated, he had to be quiet because he did not want to make Resident 2 upset and get punched again. Resident 1 stated, he was scared and felt helpless.
During an interview on 9/6/2023, at 6:05 p.m., the licensed vocation nurse (LVN 3) stated Resident 1 preferred to watch television until 11:00 p.m. while Resident 2 preferred to go to sleep around 9:00 p.m. daily. LVN 3 stated, Resident 2 had a similar issue with noise while he was residing with the previous roommates before he moved to Resident 1's room. LVN 3 stated, Resident 1 was watching television with the volume turned up loud until almost 10:00 p.m., and that could have bothered Resident 2 and triggered the aggression towards Resident 1.
During an interview on 9/7/2023, at 11:59 a.m., the Director of Staff Development (DSD) stated, it was not acceptable for CNA 1 not to comply with the facility's policy of performing the tasks he was assigned. DSD stated CNAs were assigned to both east and west hallways to keep residents safe and to attend to the residents' needs right away while other CNAs were assisting other residents.
During an interview via phone on 9/8/2023, at 1:19 p.m., the Administrator (ADM) stated monitoring the residents from the hallway was important to keep residents safe and respect their autonomy (allow them their independence and personal space) at the same time. The ADM stated it was an effective method to provide monitoring without intimidating the residents like Resident 2. The ADM stated the second punch from Resident 2 might have been avoidable if staff was monitoring in the east hallway as assigned.
During a review of the facility's policy and Procedure (P&P) titled, Resident Rights, undated, the P&P indicated under Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse and neglect.
During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated under Policy Statement: Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The Policy Interpretation and Implementation Systems Approach to Safety: 1. The facility-oriented and resident -oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Systems Approach to Safety: 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the occurrence of an alleged resident-to-resident altercation to the state survey agency (California Department of Public Health [CDPH]) within 2 hours after the allegation occurred for two of two sample residents (Resident 1 and 2) on 8/27/2023 at 7:44 a.m.
This deficient practice had the potential for other abuse incidents to go unreported placing other residents at risk for abuse.
Findings:
During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with the diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
During a review of Resident 1's Minimum Data Set ([MDS]-a standardized assessment tool that measures health status in nursing home residents), dated 7/25/2023, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired and the resident required limited one person assistance with activities of daily living (ADLs).
During a review of Resident 2's AR, the AR indicated Resident 2 was initially admitted on [DATE] with the diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired and Resident 2 required supervision during ADLs.
During a review of Resident 1's eInteract Change of Condition Evaluation (COC) document, dated 8/27/2023, the COC indicated at 7:44 a.m., Resident 1 exhibited aggressive behavior by throwing coffee on Resident 2. The COC indicated Resident 1 was yelling and screaming at staff.
During an interview on 9/6/2023 at 12:45 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated, after the alleged resident to resident altercation on 8/27/2023, LVN 1 did not contact the administrator (ADMIN)/ abuse coordinator. LVN 1 stated the staff should call the abuse coordinator, the director of nursing (DON), the registered nurse supervisor and report the incident immediately to the three agencies (CDPH, the Ombudsman [representatives helping elderly people], and the police) within two hours.
During an interview on 9/6/2023 at 1:17 p.m. with the DON, the DON stated the Interdisciplinary team (IDT- team members from different disciplines working collaboratively) met on 8/29/2023 and learned of the alleged resident to resident altercation between Resident 1 and 2 that took place on 8/27/2023. The DON stated, after discovering the allegations or resident to resident, the IDT decided to report the incident to the three agencies, two days after the incident.
During an interview on 9/6/2023 at 2:18 p.m. with the ADMIN, the ADMIN stated as the Abuse Coordinator, and resident to resident altercations should have been reported to him. The ADMIN stated the facility should have reported it sooner.
During a subsequent interview on 9/6/2023 at 4:01 p.m. with the DON, the DON stated the incident should have been reported sooner. The DON stated delayed reporting places residents at risk for harm and affects the overall safety of the resident.
During a review of the facility's policy and procedure (P/P) titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 4/2021, the P/P indicated the facility should report any allegations withing timeframes required by federal requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of one resident (Resident 2) from Resident 1 by keeping the residents (Resident 1 and 2) as roommates after allegations of Resident 1 having physical/ verbal aggression towards Resident 2 was reported on 8/27/2023 at 7:44 a.m.
This deficient practice resulted in Resident 1 subjecting Resident 2 to preventable verbal abuse in the form of name calling the day after the incident (8/28/2023) and it placed Resident 2 at high risk for other forms of abuse.
Findings:
During a review of Resident admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with the diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
During a review of Resident 1's Minimum Data Set ([MDS]-a standardized assessment tool that measures health status in nursing home residents), dated 7/25/2023, the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired and the resident required limited one person assistance with activities of daily living (ADLs).
During a review of Resident 2's AR, the AR indicated Resident 2 was initially admitted on [DATE] with the diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired and Resident 2 required supervision during ADLs.
During a review of Resident 2's eInteract Change of Condition Evaluation (COC) note dated 8/27/2023 timed at 7:44 a.m., the COC note indicated Resident 1 grabbed Resident 2's food tray and dropped it on the floor. The COC indicated the physician recommended a room change for Resident 2.
During a review of the facility's census dated 8/27/2023, the census indicated Resident 1 and 2 shared the same room and there were no room changes made to separate the two residents.
During a review of Resident 1's progress notes (PN) dated 8/28/2023, the PN indicated:
a.
At 2:04 a.m., Resident was observed to be verbally abusive when awake.
b.
At 1:00 p.m., Resident 1 was screaming at her roommate calling her (Resident 2) a fat pig and required redirection and medication.
During a review of the facility's census dated 8/28/2023 and 8/29/2023, the census indicated Resident 1, and Resident 2 shared the same room. The census indicated Resident 1 and 2 were roommates up until 8/29/2023 at 2:56 p.m. when Resident 1 was discharged from the facility.
During an interview on 9/6/2023 at 12:22 pm with Resident 2, Resident 2 stated, on 8/27/2023 during breakfast, Resident 1 was arguing with staff then Resident 1 came hit Resident 2's breakfast tray while Resident 2 was eating breakfast and knocked it off. When the breakfast tray hit the floor, some of the hot coffee and hot cereal splashed on Resident 2. Resident 2 stated Resident 1 required medication to calm down after the incident. Resident 2 stated Resident 1 calmed down for a while then she would get more violent to the nurses. Resident 2 stated Resident 1 was moved to another hospital after a couple of days.
During an interview on 9/6/2023 at 12:32 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 1 has insulted Resident 2 for being overweight. CNA 1 stated verbal insults can be precursors to abuse and Resident 1 and 2 should not have been roommates. CNA 1 stated Resident 1 had episodes of being mean and would verbalize she (Resident 1) did not like Resident 2 and that she (Resident 1) wanted to change rooms.
During a subsequent interview on 9/6/2023 at 12:42 p.m. with Resident 2, Resident 2 stated Resident 1 in the past (unable to recall date and time) called Resident 2 a fat slob and made comments regarding the size of Resident 2's stomach. Resident 2 stated she did not like having Resident 1 as a roommate and requested a roommate change.
During a concurrent record review of the facility census for 8/27/2023 to 8/29/2023 and interview on 9/6/2023 at 1:17 p.m. with the Director of Nursing (DON), the census was reviewed, and the census indicated Resident 1 and 2 remained roommates from 8/27/2023 up until 8/29/2023 when Resident 1 was discharged at 2:56 p.m. The DON stated, after the incident of verbal/ physical aggression between Resident 1 and 2 on 8/27/2023 at 7:44 a.m., Residents 1 or 2 should have had a room change. The DON stated not changing the residents' room assignment affected Resident 2's safety and placed Resident 2 at risk for verbal abuse.
During a concurrent record review of Resident 1's PN, dated 8/28/2023 timed at 1:00 p.m., and interview on 9/06/2023 at 2:45 p.m. with Licensed Vocational Nurse 1 (LVN 1), the PN indicated Resident 1 was screaming at her roommate calling her (Resident 2) a fat pig. LVN 1 stated Resident 1 was calling Resident 2 a fat pig on 8/28/2023. LVN 1 stated the residents remained roommates from 8/27/2023 to 8/29/2023. LVN 1 stated Resident 1 and 2 should not have been roommates after the verbal and physical aggression incident on 8/27/2023.
During a review of the facility's policy and procedure (P/P) titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 4/2021, the P/P indicated the facility should protect residents from abuse by anyone including other residents. The P/P indicated the facility will protect residents from any further harm during investigations.
During a review of the facility's P/P titled Room change/ Room assignment, revised 5/2017, the P/P indicated changes in room or roommate assignments shall be made when the facility deems it necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented by:
a. Failing to conduct fit testing (test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) of N95 (respiratory protective device designed to achieve a very close facial fit) masks for three of five facility staff.
b. Failing to ensure Certified Nursing Assistant (CNA 1) donned (put on) an isolation gown (protective apparel), eye protection, and N95 (respiratory protective device designed to achieve a very close facial fit) mask before entering one of one isolation room designated for Resident 1 and 2, who were positive for coronavirus disease (Covid-19, contagious respiratory illness); and failing to ensure CNA 1 doffed (take of) used gloves and mask prior to exiting the isolation room for Resident 1 and 2.
c. Failing to ensure the Infection Preventionist Assistant (IPA) doffed the used N95 mask after exiting one of one isolation room for residents (Resident 9,10, and 11) with Covid-19 and donning a new mask prior to proceeding to the common resident care areas.
d. Failing to ensure a soiled towel with brownish substances was bagged and placed in the proper receptacle and not left on the floor in the hallway by a resident's room.
These deficient practices compromised infection control measures to prevent the potential spread of Covid -19 to residents, staff, and visitors.
Findings:
a. During a review of facility's Fit Testing Log, the log indicated CNA1 and social worker 1 (SW1) was not fit tested upon hire on 4/2023 and housekeeping personnel 1 (HP 1) has not been fit tested for the past two years. The log indicated CNA 1 and HP 1 was fit tested 8/21/2023 and SW 1 was fit tested 8/22/2023.
During an interview on 8/21/2023, at 8:15 a.m. with CNA1, CNA1 stated CNA1 was hired last April 2023 and was not fit tested upon hire.
During an interview on 8/22/2023, at 8:37 a.m. with HP1, HP1 stated HP1 did not get fit tested for N95 for the past two years and got fit tested 8/21/2023.
During an interview on 8/22/2023, at 3:15 p.m. with the social service worker (SW1), the SW1 stated SW1 started last April 2023 and did not get fit tested upon hire.
During a review of facility's policy and procedure (P/P) titled Respiratory Protection Program, undated, the P/P indicated the employee will be fit tested at the time of initial assignment and annually thereafter. The P/P indicated training on the appropriate respirator use will occur before the actual use of the respirator and at least annually.
b. During a review of Resident 1's admission Record (AR), the AR indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (mental illness that affect a person's thought process, perceptions, and feelings) and anxiety disorder (mental disorder characterized by feelings of worry, anxiety, or fear that can interfere with daily life).
During a review of Resident 1's Minimum Data Set([MDS] standardized assessment and care screening tool) dated 8/11/2023, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and required one-person physical assist with dressing and personal hygiene.
During a review of Resident 1's Covid-19 Test performed on 8/18/2023, the test indicated the resident tested positive for Covid-19.
During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (person's thought process) and required one-person physical assist with bed mobility, transfer, dressing, toilet use and personal hygiene.
During a review of Resident 2's Covid-19 test performed on 8/18/2023, the test indicated the resident tested positive for Covid-19.
During a concurrent interview and observation on 8/21/2023, at 8:15 a.m. with CNA1, CNA 1 entered Resident 1 and 2's isolation room not wearing an isolation gown, eye protection, and an N95 mask. CNA 1 was wearing gloves and surgical mask. CNA 1 exited the room with the used gloves and surgical mask and proceeded to continue working in the unit. CNA1 stated CNA 1 only wore a surgical face mask and a pair of gloves because CNA 1 was in a hurry and was just passing breakfast trays to the residents. CNA1 stated CNA 1 should have donned an isolation gown, N95 mask, face shield before entering the isolation room. CNA1 stated CNA 1 should have removed the surgical mask and gloves after exiting the isolation room to prevent spread of Covid-19.
During an interview with Infection Preventionist Nurse (IPN) on 8/21/2023, at 9:43 a.m. The IPN stated CNA1 should have worn the appropriate PPE when taking care of Covid-19 residents to prevent the spread of infection to the staff and other residents. The IPN stated CNA1 should have worn an N95 mask, face shield, gown, and gloves before entering the isolation room.
c. During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis that included Covid -19.
During a review of Resident 9's Order Summary Report (OSR), dated 8/20/2023, the OSR indicated Resident 9 had an order to be in contact isolation with novel respiratory precautions (Use of personal protective equipment [PPE]including gown, gloves, eye protection, N95 while in the resident's room and disposing them before exiting) for Covid-19 for 10 days.
During a review of Resident 9's Covid-19 test result, dated 8/18/2023, the test results indicated Resident 9 was positive for Covid-19.
During a review of Resident 10's AR, the AR indicated Resident 10 was admitted at the facility on 10/3/2014 with a diagnosis that included Covid-19.
During a review of Resident 10's OSR, dated 8/20/2023, the OSR indicated Resident 10 had to be in contact isolation with novel respiratory precautions for Covid-19 for 10 days.
During a review of Resident 10's Covid-19 test results, dated 8/18/2023, the results indicated Resident 10 was positive for Covid-19.
During a review of Resident 11's AR, the AR indicated Resident 11 was admitted at the facility on 10/5/2021 with a diagnosis that included Covid-19.
During a review of Resident 11's OSR, dated 8/20/2023, the OSR indicated Resident 11 had an order to be in contact isolation with novel respiratory precautions for Covid 19 for 10 days.
During a review of Resident 11's Covid-19 test results, the results, dated 8/18/2023, indicated Resident 11 was positive for Covid-19.
During an observation and interview on 8/21/2023 at 2:09 p.m., with the IPA, the IPA exited the isolation room of Resident 9, 10, and 11, without doffing the N95 mask used inside the room and the IPA continued to walk along the hallway with other residents present. The IPA stated the used N95 mask should have been doffed after exiting the isolation room and replaced with a new mask. The IPA stated changing the mask was done to prevent the spread of infection.
During an interview on 8/21/2023 at 2:26 p.m., with LVN1, LVN1 stated the staff must change their N95 masks before leaving the isolation rooms because the old N95 mask could be contaminated.
During an interview on 8/21/2023 at 3:19 p.m., with Registered Nurse Supervisor 1 (RNS1), RNS1 stated staff must change their N95 masks to fresh ones prior to leaving the isolation rooms due to possibility of contamination.
During an interview on 8/22/2023 at 9:50 a.m., with the IPN, the IPN stated Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommended that the N95 mask be a single use PPE in an isolation room and must be discarded immediately and changed after use.
d. During an observation on 8/21/2023 at 1:46 p.m., a soiled towel with brown substances was noted on the hallway floor adjacent to the isolation room of Resident 9, 10 and 11. Three nursing staff (Licensed Vocational Nurse 1[LVN 1], CNA 2 IPA and CNA 3) walked past the soiled linen without disposing the dirty linen in the appropriate bin.
During an interview on 8/21/2023 at 2:26 p.m., with LVN1, LVN1 stated the soiled towel was supposed to be placed in the designated bins to prevent the spread of infection; the soiled linen in the hallway may worsen the current facility's current outbreak situation.
During an interview on 8/21/2023 at 3:19 p.m., with Registered Nurse Supervisor 1 (RNS1), RNS1 stated the presence of soiled linen in the resident care area and hallways was not allowed because of the risk of infection.
During an interview on 8/22/2023 at 9:50 a.m., with the IPN, the IPN all staff were accountable for the unit and must be able to dispose of unclean linen in the designated linen bins.
During an interview on 8/22/2023 at 10:30 a.m., with the Director of Nursing (DON), the DON stated cleanliness and disposal of soiled linen was everyone's responsibility. The DON stated the CDC and DPH has recommended that N95 mask be a single use PPE.
During a review of the facility's Policy and Procedure (P/P) titled, Policies and Practices-Infection Control, revised 10/2018, the P/P indicated the facility's infection control practices and policies were intended to facilitate and maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infection.
During a review of the facility's Policy and Procedure (P/P) titled, Outbreak of Communicable Diseases, undated, the P/P indicated all staff and employees were expected to always follow standard precautions (minimum steps followed to prevent spread of infection) and transmission-based precautions (additional steps to follow to prevent infection) as indicated.
During a review of the facility's Policy and Procedure (P/P) titled, Laundry Operations, revised 9/5/2017, the P/P indicated soiled linen must be removed from the units to keep the area infection free and it was important for soiled linen to be stored properly to prevent the spread of infection. The P/P indicated soiled linen and clean must be stored and covered in separate bins while in the unit.
During a record review of an online article from Centers for Disease Control and Prevention titled Use of Personal Protective Equipment when Caring for Patients with Confirmed or Suspected Covid -19 Coronavirus disease 2019 (COVID-19) Factsheet (cdc.gov), dated 6/03/2020, the article indicated PPE must be donned correctly before entering the patient area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one of two sampled residents (Resident 1) after being discharged from the general acute care hospital (GACH) on 8/17/2023. Resident 1 was in the facility premises, accompanied by the paramedics, when Registered Nurse Supervisor 1 (RNS 1) instructed the paramedics to return the resident to the GACH.
This deficient practice delayed Resident 1's return to his home (the facility) and had the potential to result in more than minimal psychosocial harm to Resident 1.
Findings:
During a review of Resident 1's admission Record (AR), The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and antisocial personality disorder (mental health disorder characterized by disregard for other people).
During a review of Resident 1's Minimum Data Set([MDS] a standardized assessment and care screening tool) dated 6/28/2023, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 1 required supervision with bed mobility, transfer, eating, toilet use and personal hygiene.
During a review of Resident 1's History and Physical (H and P), dated 6/22/2023, the H and P indicated the resident can make needs known but cannot make medical (healthcare) decisions.
During a record review of Resident 1's Interdisciplinary team (IDT) notes, dated 8/15/2023 at 10:13 a.m., the notes indicated on 8/14/2023 at 11:40 a.m., a witnessed physical altercation with another resident ensued and interventions included one to one monitoring, (continuous observation and care to individual resident for a period),pending transfer to GACH, and the plan was after readmission of the resident the IDT team will review the resident's plan of care to determine appropriate long-term placement to maintain the resident's and other residents' safety.
During a record review of Resident 1's Bed Hold (when a nursing home holds a bed for the resident when the resident goes into the hospital) Informed Consent form, the form indicated Resident 1 had the option of requesting a seven (7) day bed hold (keep a bed vacant and available for return to the facility). The form indicated the facility transferred Resident 1 to the GACH on 8/17/2023 at 3:00 p.m.
During a review of Resident 1's Physician Order (PO), on 8/17/2023 at 4:06 p.m., the PO indicated Resident 1 was to transfer to GACH with a seven-day bed hold (when a nursing home holds a bed for the resident when the resident go into the hospital).
During a review of Resident 1's GACH Records titled Emergency Department Record (EDR), dated 8/17/2023, the EDR indicated on 8/17/2023 at 7:59 p.m., the ERN advised an RNS, who wouldn't state their name, Resident 1 was returning to the facility at 9:30 p.m. via ambulance. The RNS refused to take report and transferred the ERN's call to the facility's Director of Nursing who did not answer, and the ERN left a message with a call back number for the facility to obtain report. The EDR indicated no evidence that the facility tried to get report regarding Resident 1's status.
During an interview on 8/21/2023, at 8:40 a.m. with RNS 1, RNS 1 stated Resident 1 arrived at the facility around 11:30 p.m. on 8/17/2023 from GACH. RNS 1 stated RNS 1 refused to get report from the hospital because other residents' safety would be in question. RNS 1 stated Resident 1 looked calm in the stretcher upon arrival to the facility. RNS 1 stated RNS 1 should have called the physician to evaluate and check if it was okay to readmit the resident instead of having the paramedics return the resident to the hospital. RNS 1 stated Resident 1 was probably upset and frustrated because he did not return to the facility.
During an interview on 8/21/2023, at 1:03 p.m. with RNS 2, RNS 2 stated on 8/17/2023, at 8:00 p.m. ERN told RNS 2 Resident 1 did not want to stay in the hospital and was coming back to the facility. RNS 2 stated RNS 2 did not receive report on Resident 1's status because Resident 1 was a threat to other residents.
During a review of facility's policy and procedure (P/P) titled Bed-Holds and Returns revised 10/2022, the P/P indicated:
a. Residents who seek to return to the facility within the bed-hold period are allowed to return to their previous room, if available.
b. Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical or behavioral condition at the time of the transfer are evaluated based on their current condition and not on their condition when originally transferred.
Based on interview and record review, the facility failed to readmit one of two sampled residents (Resident 1) after being discharged from the general acute care hospital (GACH) on 8/17/2023. Resident 1 was in the facility premises, accompanied by the paramedics, when Registered Nurse Supervisor 1 (RNS 1) instructed the paramedics to return the resident to the GACH.
This deficient practice delayed Resident 1's return to his home (the facility) and had the potential to result in more than minimal psychosocial harm to Resident 1.
Findings:
During a review of Resident 1's admission Record (AR), The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and antisocial personality disorder (mental health disorder characterized by disregard for other people).
During a review of Resident 1's Minimum Data Set([MDS] a standardized assessment and care screening tool) dated 6/28/2023, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 1 required supervision with bed mobility, transfer, eating, toilet use and personal hygiene.
During a review of Resident 1's History and Physical (H and P), dated 6/22/2023, the H and P indicated the resident can make needs known but cannot make medical (healthcare) decisions.
During a record review of Resident 1's Interdisciplinary team (IDT) notes, dated 8/15/2023 at 10:13 a.m., the notes indicated on 8/14/2023 at 11:40 a.m., a witnessed physical altercation with another resident ensued and interventions included one to one monitoring, (continuous observation and care to individual resident for a period),pending transfer to GACH, and the plan was after readmission of the resident the IDT team will review the resident's plan of care to determine appropriate long-term placement to maintain the resident's and other residents' safety.
During a record review of Resident 1's Bed Hold (when a nursing home holds a bed for the resident when the resident goes into the hospital) Informed Consent form, the form indicated Resident 1 had the option of requesting a seven (7) day bed hold (keep a bed vacant and available for return to the facility). The form indicated the facility transferred Resident 1 to the GACH on 8/17/2023 at 3:00 p.m.
During a review of Resident 1's Physician Order (PO), on 8/17/2023 at 4:06 p.m., the PO indicated Resident 1 was to transfer to GACH with a seven-day bed hold (when a nursing home holds a bed for the resident when the resident go into the hospital).
During a review of Resident 1's GACH Records titled Emergency Department Record (EDR), dated 8/17/2023, the EDR indicated on 8/17/2023 at 7:59 p.m., the ERN advised an RNS, who wouldn't state their name, Resident 1 was returning to the facility at 9:30 p.m. via ambulance. The RNS refused to take report and transferred the ERN's call to the facility's Director of Nursing who did not answer, and the ERN left a message with a call back number for the facility to obtain report. The EDR indicated no evidence that the facility tried to get report regarding Resident 1's status.

Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of a resident elopement (term used to describe incident where a person leaves) from the facility to the Department of Public Health (DPH [ the state department responsible for public health in California. It is a subdivision of the California Health and Human Services Agency. It enforces some of the laws in the California Health and Safety Codes, notably the licensing of some types of healthcare facilities]) within 24 hours after the elopement occurred for one of five sampled residents, (Resident 92).
This deficient practice had the potential to result in placing the residents at risk for neglect and harm.
Findings:
On 6/12/2023 around 6:30 a.m. the window was found broken in the dining room in the locked psychiatry unit and Resident 92 was not found anywhere in the facility. The facility called 911 (an emergency number for any police, fire or ambulance) to report an elopement of Resident 92. The facility administration made a decision not to report the elopement because the resident was found by the police on the street after two hours .
During review of Resident 92's admission Record (AR) dated 10/21/2021, the AR indicated Resident 92 was initially admitted to the facility for a history of falls, schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception and inappropriate actions), seizures (sudden uncontrolled burst of electrical activity in the brain) and dysphagia (difficulty in swallowing).
During a review of Resident 92's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 7/14/2023, the MDS indicated Resident 92 was cognitively moderately impaired with thinking and reasoning skills.
During a review of Resident 92's care plan (CP) initiated 5/8/2023, the CP indicated Resident 92 is a wandering risk and the goal is that Resident 92 will not leave the facility unattended. The CP indicated interventions were to monitor location, document wandering behavior and attempted diversional interventions.
During a review of the Wandering Risk Assessment (WRA) dated 4/18/2023 at 3:21 p.m., the WRA indicated Resident 92 was a High-Risk Wanderer with a score of 11 (low risk 0-8, at risk 9-10, high risk 11-23).
During a review of the WRA dated 6/12/2023 at 9:46 a.m. (after Resident 92 eloped from the facility and was brought back), the WRA indicated Resident 92 was a Low-Risk Wanderer with a score of 6.
During an interview on 7/20/2023 at 10:27 a.m. with the Director of Nurses (DON), stated, Resident 92 eloped through the dining room window on the locked unit. DON stated Resident 92 broke the window using the dining room chair on 6/12/2023 around 6:30 a.m.
During an interview on 7/20/2023 at 11:06 a.m. with the Social Worker (SW 2), the SW 2 stated, Resident 92 did elope from the facility through a broken window in the dining room by the locked unit on 6/12/2023 and it should have been reported to the DPH.
During a concurrent interview and record review of the facility policy Unusual occurrences on 7/21/2023 at 4:48 p.m. with DON, the DON stated the dining room on the locked unit opens at 6:30 a.m. for the residents. The DON stated the dining room doors is usually closed but accessible to staff during night shift (11-7). The DON stated he did not report the elopement to DPH because the resident was found in two hours and was unharmed. The DON further stated the facility called the police and they found Resident 92 right in front of the [NAME] in the Box (fast food restaurant) at the busy main street. The DON if Resident 92 was not found in 24 hours, he would report it to DPH. The DON further added no staff heard the window break in the dining room on the day of the incident (6/12/2023). The DON stated that the facility did an investigation and the Inter Disciplinary Team (IDT) decided not to report the elopement to DPH. The DON reads the facility policy, Unusual Occurrences stated Unusual Occurrences shall be reported via telephone to appropriate agencies as required by current law and or regulations. The DON confirmed, an elopement is an unusual occurrence, and it was the responsibility of everyone to report it.
During an interview on 7/21/2023 at 8:32 a.m. with Certified Nurse Assistant (CNA) 18, the CNA 18 stated Resident 92 attempts to get out of the facility many times before and stands by the facility exit door. CNA 18 stated, Resident 92 always has her pillow with her belongings when she was standing by the door, so she was prepared to get out of the facility.
During an interview on 7/21/2023 at 9:04 a.m. with Licensed Vocational Nurse (LVN) 12, LVN 12 stated the police found Resident 92 standing outside the fast-food restaurant at the busy main street and brought her back to the facility. LVN 12 stated, Resident 92 got out of the locked facility through a broken window in the dining room around 6:30 a.m. on 6/12/2023. LVN 12 stated Resident 92 had multiple attempts of getting out of the building. LVN 12 stated the dining room was usually locked at night but not sure what time it was open in the morning. LVN 12 stated DPH should have been notified of Resident 92's elopement incident.
During a concurrent interview and record review on 7/21/2023 at 2:20 p.m. with the Maintenance Director (MD), the facility's maintenance log was reviewed. The maintenance log indicated the window was requested to be fixed on 6/12/2023 and was completely repaired on 7/6/2023. The MD stated Resident 92 eloped out of a broken window in the dining room.
During a review of the 11-7 shift assignment, the shift assignment indicated a staff member was assigned to watch the dining room from 11p.m. to 7 a.m.
During a review of the Incident Report (IR) dated 6/12/2023 from the Lakewood Sheriff's station, the IR indicated there was a missing report filed by the facility on 6/12/2023.
During a review of the facility Policy and Procedure (P&P) titled Unusual Occurrences dated 12/2007, the P&P indicated the facility will report the any unusual occurrence to the appropriate agencies. The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four hours of such incident or as otherwise required by federal and state regulations. The P&P indicated a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency with forty-eight hours of report the event as required by federal and state regulations.
During a review of the facility P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, the P&P indicated
the facility should:
1.
Identify and investigate all possible incidents of abuse and neglect
2.
Investigate and report any allegations within time frames required by federal requirements.
3.
Develop and implement policies and protocols to prevent and identify neglect of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross referenced to F684.
Based on observation, interview and record review, the facility failed to implement proper infection control practices when one of 17 sampled residents (Resident 1) was suspected of crusted scabies (a contagious, itchy skin condition caused by a tiny burrowing mite) and four residents (Resident 2, Resident 3, Resident 4, and Resident 8), who were roommates of Resident 1, were exposed to scabies by failing to:
A. Place Resident 1 on contact isolation (an infection control practice used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident handled. Staff and visitors are required to wear gowns, and gloves when in the resident ' s room) when he was re-admitted to the facility after being treated at a general acute care hospital (GACH) for diagnosis of scabies.
B. Place Residents 2, 3, 4, and 8 who were roommates of Resident 1, on contact isolation.
C. Assess Resident 2, who also developed a rash and was itching, once Resident 1 was diagnosed and treated for scabies.
D. Conduct the terminal cleaning (a thorough cleaning of a room and its contents after use [by an infected resident] to control the spread of infections) of the room where Residents 1, 2, 3, 4 and 8 resided after Resident 1 was diagnosed and treated for scabies.
E. Identify the components of a possible scabies outbreak (according to Acute Communicable Disease Control [ACDC] an outbreak would be two or more confirmed or suspected cases in residents, staff, or visitors within a six-week period
http://publichealth.lacounty.gov/acd/Diseases/ScabiesToolkit.htm) after Resident 1 was diagnosed and treated for scabies and Resident 2 who was Resident ' s 1 roommate developed a rash and was itching.
F. Report the suspected outbreak of scabies to their local public health department, and the Department of Public Health as required.
G. Assess the facility residents and staff to determine the extent of skin rashes and possible scabies infestations.
H. Notify and educate staff and visitors to be aware and report signs and symptoms of scabies.
I. Create a line list (data gathered and organized in a table of each person who is ill or symptomatic, symptoms, and possible contacts; used to manage and contain an outbreak) of residents and staff who had rashes.
These failures resulted in Residents 2, 3, 4 and 8 not being treated for possible exposure to scabies, and placed the rest of the residents, and staff in the facility as well as visitors, at an avoidable risk of a scabies exposure and contraction.
Findings:
A. According to the facility census on 7/12/2023, there were a total of 283 residents.
During a review of Resident 1 ' s admission Record (face sheet). The face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included depressive disorder (a mental health disorder characterized by persistent loss in interest in activities affecting quality of daily life), Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), dementia (persistent loss of intellectual function, abstract thinking, often with personality change), hypertension (high blood pressure) and diabetes mellitus ( a disease characterized by elevated blood sugar levels which leads to serious damage to the organs of the body).
During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/20/2023, the MDS indicated Resident 1 was able to make his needs known despite periods of disorientation and required extensive assistance from one person to complete his ADL (activities of daily living) such as grooming, personal hygiene and locomotion (movement of the individual from one place to another) in and out of the unit.
During a review of Resident 1 ' s undated care plan titled, Generalized Body Rashes the goal of the care plan is for Resident 1 to be free from rashes and complications with interventions that included assistance with hygiene and informing the Responsible Party/ Guardian as necessary.
During a review of Resident 1 ' s medical record titled, Treatment Record (TAR) dated 6/1/2023 to 6/30/2023, the TAR indicated Resident 1 was prescribed a corticosteroid (an anti- inflammatory medication) body ointment on 5/ 27/ 2023 for body rash.
During a review of Resident 1's medical record titled, Physician Progress Notes (PPN), the PPN did not indicate Resident 1 was evaluated by a dermatologist (a doctor who specializes in conditions that affect the skin, hair, and nails) and there was no plan for any assessments to rule out scabies and diagnose Resident 1's body rash.
During a review of Resident 1's medical record titled, Skin and Wound Note (SWN) dated 6/9/2023, the SWN indicated Resident 1's family (constant visitor) had to call 911 and Resident 1 was transferred to a GACH via 911 on 6/9/2023.
During a review of Resident 1 ' s GACH face sheet, the face sheet indicated Resident 1 was seen on 6/9/2023 at GACH's emergency room and was admitted for sepsis (a serious condition in which the body responds improperly to an infection which is a life-threatening medical emergency) due to cellulitis (a deep infection of the skin), possible scabies.
During a review of Resident 1's GACH Emergency Department Notes (EDN) dated 6/9/2023 at 11:16 p.m., the EDN indicated Resident 1 was positive for erythematous papules (rashes) throughout the body and pustular lesions (small inflamed, pus-filled, blister-like sores on the skin) on bilateral (both) feet with overlying erythema (reddening) to bilateral lower extremities (legs/feet), white blood cell count of 13,000 per microliter (mcl - a unit of measure of volume) (normal range for white blood cell count in adult 4,500 mcl to 11,000 mcl, higher numbers indicate infection) and body temperature of 100.6 degrees Fahrenheit (a unit of measure of temperature). Resident 1 was treated with intravenous (administered through a blood vessel) antibiotics (a medication that destroys infections) and scabicide (topical medication that kill the scabies mite) cream upon arrival at GACH and was given Ivermectin (an antiparasitic drug) by mouth on 6/10/2023.
During a review of Resident 1's GACH Record Internal Medicine Progress Notes (IMPN) dated 6/15/2023, the IMPN indicated Resident 1 presented to the GACH on 6/9/2023 with generalized itchy rashes for a month and was assessed to have sepsis secondary to cellulitis of bilateral lower extremities and crusted scabies.
During a review of Resident 1's GACH Discharge Summary (DS) dated 6/16/2023, the DS indicated the plan was to discharge Resident 1 to nursing facility with a principal diagnosis of cellulitis and a secondary diagnosis of scabies.
During a review of Resident 1's medical record titled, Order Summary (OS), dated 6/16/2023, there was no indication that Resident 1 was re-admitted to the facility with an order for contact isolation/ precaution, to prevent the spread of infection.
During a review of the facility's resident census on 6/17/2023, the census indicated Resident 1 was placed in a regular room together with Resident 2, Resident 8, Resident 4, and Resident 3.
During a review of Resident 1's medical record (from the facility) titled, Treatment Administration Record (TAR) dated June 1 to June 30, 2023, the TAR indicated Resident 1 was treated with two applications a scabicide (products used to treat scabies) on 7/20/2023 and 7/21/2023.
During a review of Resident 1's medical record titled, Medication Administration Record (MAR) dated June 1 to June 30, 2023, the MAR indicated Resident 1 was treated with an antiparasitic (treat parasitic infections) medication one time for scabies.
During an observation and interview on 7/12/2023 at 8:52 a.m. Resident 1 was observed in the dining room with other residents and was observed scratching his stomach. Resident 1 had pinpoint rashes and dry crusts/scabs on his arms and his neck and was also observed scratching his arms and neck from time to time.
During a telephone interview on 7/12/2023 at 3:44 p.m., Resident 1's constant visitor (CV) stated she visited Resident 1 at the facility numerous times these past weeks and had observed Resident 1 with a body rash for a month. CV stated on 6/9/2023 she observed that Resident 1was uncomfortable, could hardly walk and his feet were swollen with a yellowish fluid coming out of his feet, which prompted her to call 911, since the nursing staff and administrator were not paying attention to Resident 1's condition. CV stated she was severely itchy and had some rashes on her body a few days after Resident 1 was discharged back to the facility and was prescribed by her personal doctor a scabicide cream for her and the entire family to use. CV further stated during the previous weeks prior to Resident 1's transfer to the GACH, she noticed one of Resident 1's roommate was itchy and scratching his body.
B. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis (a progressive disorder of the liver that may lead to damage and liver cancer), paranoid schizophrenia (a mental illness where the mind is unreasonably suspicious of others, and has a break from reality) and pulmonary embolism (a condition in which one or more blood vessels in the lungs become blocked by a blood clot).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1 was alert to self with periods of difficulty in focusing attention and disorganized thinking, required supervision during locomotion (movement of the individual from one place to another) in and out of the unit and required a one1 person limited assist to complete his ADLS, such as personal hygiene and grooming.
During a review of Resident 2's undated care plan titled Torso area scattered redness, the care plan had a goal for Resident 2 to be free from scattered redness with interventions that included nursing staff to identify causative factors and eliminate/resolve, monitor scattered redness, report abnormalities and failure to heal to the doctor and carry out treatment, as ordered.
During a review of Resident 2's medical record titled, Treatment Administration Record (TAR) dated June 1 to June 30, 2023, the TAR indicated Resident 2 was prescribed a corticosteroid body ointment on 5/ 27/ 2023 for body rash.
During a review of Resident 2's OS, there was no indication that Resident 2 had an order for a dermatology consult for his body rash.
During a review of the facility's resident census on 6/17/2023, the census indicated Resident 2 was residing in a room together with Resident 4, Resident 8, and Resident 1. Resident 1 had been readmitted at the facility on 6/16/2023 from GACH with a diagnosis of cellulitis and possible scabies.
During a review of Resident 2's medical record Treatment Administration Record (TAR) dated June 1 to June 30, 2023, the TAR did not indicate Resident 2 was given a scabicide as a prophylaxis for being exposed to Resident 1.
During an observation and interview on 7/12/2023 at 9:04 a.m., Resident 2 was observed sitting on a wheelchair and scratching his ears and legs and although he did not respond to questions, Resident was heard saying Itchy.
During a telephone interview on 7/12/2023 at 12:40 p.m., Resident 2's Responsible Party (RP )2 stated that when he visited Resident 2 a few weeks ago, he saw Resident 2 was itching all over and saw some redness and/or rashes to his upper body. RP2 stated he informed the nursing staff about it and did not hear anything from the facility after that.
C. During a review of Resident 8 ' s Face Sheet, the Face Sheet indicated Resident 8 was admitted at the facility on 3/24/2022 with diagnoses that included dementia and dysphagia (difficulty in swallowing).
During a review of the facility's resident census on 6/17/2023, the census indicated Resident 8 was residing in a room together with Resident 4, Resident 2, and Resident 1, who was readmitted at the facility on 6/16/2023 from GACH with a diagnosis of cellulitis and possible scabies.
During a review of Resident 8's TAR, dated June 1 to June 30, 2023, the TAR did not indicate Resident 8 was given a scabicide as a prophylaxis for being exposed to Resident 1.
During a review of Resident 8 ' s OS, the OS indicated Resident 8 was discharged to a lower level of care on 6/28/2023.
D. During a review of Resident 4 ' s Face Sheet, the Face Sheet indicated Resident 4 was admitted at the facility on 1/21/2022 with a diagnoses including congestive heart failure (the heart does not pump blood as well as it should), obesity (excessive body fat that increases the risk of health problems) and hypertension (abnormally high blood pressure).
During a review of the facility's resident census on 6/17/2023, the census indicated Resident 4 was residing in a room together with Resident 8, Resident 2, and Resident 1, who was readmitted at the facility on 6/16/2023 from GACH with a diagnosis of cellulitis and possible scabies.
During a review of Resident 4's TAR dated June 1 to June 30, 2023, the TAR did not indicate Resident 4 was given a scabicide as a prophylaxis to being exposed to Resident 1.
E. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted at the facility on 7/5/2023 with diagnoses including encephalopathy (decrease in blood flow or oxygen to the brain, causing a decline in brain function), heart failure, and chronic pulmonary edema (progressive excess fluid in the lungs).
During a review of the facility's resident census on 7/11/2023, the census indicated Resident 3 was residing in a room together with Resident 2, Resident 4, and Resident 1, who was readmitted at the facility on 6/16/2023 from GACH with a diagnosis of cellulitis and possible scabies.
During a review of Resident 3's OS, there was no indication that Resident 3 was given scabicide as a prophylaxis for being exposed to Resident 1.
During an interview on 7/12/2023 at 8:52 a.m., a Certified Nursing Assistant (CNA 1) stated Resident 1 has had rashes all over his body since he was transferred from a different unit in the facility. CNA 1 stated Resident 1 had rashes on his feet and his CV called 911 because she was worried about Resident 1's his body and swelling to his feet. CNA1 stated she had seen Resident 2 scratching his body sometimes, and Resident 1, Resident 2, Resident 3, Resident 4, and Resident 8 (now discharged ) had resided/residing in the same room ever since Resident 1 was back from the hospital. CNA 1 stated the residents have never been placed on contact isolation, residents' belongings were never bagged, nor the room deep cleaned. When asked if she was informed of the residents' condition and/or needed precautions, and if she was offered any scabicide as a prophylaxis, CNA 1 stated, No.
During an interview on 7/12/2023 at 9:17 a.m., with Treatment Nurse (TX 1) stated she is new to this assignment; however, she had noticed few weeks ago, while on orientation with the previous treatment nurse, Resident 1 and Resident 2 had rashes.
During an interview on 7/12/2023 at 9:55 a.m., the Registered Nurse Supervisor (RNS 1) stated if the residents have rashes and suspected/ possible scabies, the residents must be isolated until treated with scabicide and/ or anti-parasitic medication. RNS 1 stated the residents' belongings must be bagged, and the room must be deep cleaned. RNS 1 further stated all residents, staff and visitors who were exposed to the resident with possible scabies, are considered infectious and must be given prophylactic (intended to prevent a disease/infection) treatment, monitored for signs/symptoms of rashes/itching and should be educated/ informed to control the spread of infestation.
During a concurrent interview and record review on 7/12/2023 at 3:06 p.m., with the Director of Housekeeping (HKD), the HKD stated deep cleaning means detailed cleaning of the residents' care area including the beds/ mattresses, washing of curtains and daily bed linen changes. HKD stated the residents' clothing/ items will be bagged by the nursing staff and the residents soiled clothing/ and or linens, will be washed separately with very hot water. The HKD showed a map of the facility which indicated the room and/ or unit of Residents 1,2,3,4 and 8 was last deep cleaned on 12/ 2022. HKD further stated it was important for the residents to live in a clean environment to be free from infestations that could lead to diseases.
During a concurrent interview and record review on 7/12/2023 at 3:15 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated Resident 1 was treated with a scabicide and an anti-parasitic agent at the GACH and was re-admitted at the facility on 6/16/2023 with a discharge diagnosis of cellulitis and possible crusted scabies and was placed in a regular (not isolated) room with Resident 2, Resident 3, Resident 4, and Resident 8 (now discharged ). When asked why Resident 1 was not placed on contact isolation upon readmission to the facility, the IPN stated there was never a confirmed diagnosis of scabies, only a possibility. The IPN stated Resident 1 was retreated by his primary doctor with 2 doses (applications) of Elimite (scabicide) cream and one dose of Ivermectin (anti-parasitic drug) by mouth as ordered on 6/19/2023. However, Residents 2, 3, 4 and 8 were not prescribed any scabicide or anti-parasitic medication for prophylaxis or treatment and the residents' room was not deep cleaned. The IPN further stated on 6/16/2023, she did not initiate a skin assessment for all the residents in the unit nor a line list of the residents, staff, and visitors to track possible exposure to scabies. The IPN stated she had not contacted the facility ' s public health nurse for any advice nor reported this occurrence to the Department of Public Health because she believes there is no scabies/rash outbreak in the facility.
During a concurrent interview and record review on 7/13/2023 at 3:45 p.m., the Infection Preventionist Nurse (IPN) stated there were 9 more residents with new body rashes identified on the unit.
During an interview on 7/13/2023 at 5:19 p.m., the Director of Nursing (DON), stated the facility has 1 (isolated) resident with possible/ suspected scabies and it was not reported to DPH because it was not diagnosed as confirmed scabies by the doctor. DON was reminded of Resident 2, who had been in the same room with Resident 1 and was identified with body rash since 5/27/2023, and the other 9 residents currently found with new body rash in the same unit of the facility. The DON confirmed the residents in the facility are mostly ambulatory and interact with one another at any time and moving forward he would consult with the public health nurse (PHN) of any more incidences of rashes in the facility immediately, going forward.
During an interview on 7/17/2023 at 4:50 p.m., the Public Health Doctor (PHD), stated a possible crusted scabies is a suspected case and anyone in close contact with Resident 1 is considered infectious. Therefore, the residents must be placed on contact isolation and treated accordingly. he PHD also stated the facility should provide prophylaxis to all the staff, visitors, contractors, and all residents because the probability of exposure is high because of the mostly ambulatory resident population that the facility cares for.
During an interview on 7/17/20203 at 5:00 p.m., the Public Health Nurse (PHN) 1 stated the facility should have reported the ongoing scabies/ rash outbreak to the Department of Public Health (DPH) for guidance, follow up, evaluation, and treatment recommendations.
During an interview on 7/17/2023 at 5:10 p.m., the PHN 2, stated none of these concerns in the past months should have been ignored. PHN 2 stated the facility must understand that reporting this occurrence is for the facility and DPH to work hand in hand to resolve, contain, and control this infection.
During a review of the facility's undated Policy and Procedure (P/P) titled Outbreak of Communicable Diseases), the P/P indicated the outbreaks of communicable diseases in the facility must be promptly identified and managed and the administrator and/or designee must communicate the data to the health department, establish policies to contain the transmission including new admissions, visitation, group activities, cohorting, notification of families and the IPN and the DON to manage surveillance date and monitor ill residents and staff.
During a review of the facility's Policy and Procedure (P/P) titled Policies and Practices-Infection Control, revised 10/ 2018, the P/P indicated the facility ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infestation.
During a review of the facility's Policy and Procedure (P/P) titled Scabies Identification, Treatment and Environmental Cleaning, the P/P indicated Scabies is an itching skin irritation caused by the microscopic (very small) human itch mite .eventually causes itching, tiny irregular red lines .Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. During a scabies outbreak, the affected residents should remain in contact isolation until 24 hours after treatment and the IP must inform the family and friends of residents as well as staff who have had close contact and give instructions regarding self-examination, reporting signs and symptoms of rashes and treatment. Residents with crusted scabies must be in contact isolation until dermatologist determined the residents are scabies-free, the residents' belongings bagged, laundry separated and washed in hot cycle for 20 minutes and the room must be vacuumed daily, and room terminally cleaned upon discharge or transfer of the resident from the room. The P/P also indicated the IP, and the nursing staff will conduct a thorough assessment of the roommates of the affected resident, perform daily assessments and coordinate a rapid and effective treatment program with the residents and affected staff, families, and visitors.
During a review of the facility ' s Policy and Procedure titled, Unusual Occurrence Reporting, undated, the P/P indicated the facility is required by the federal or state regulations to report unusual occurrences or other reportable events which can affect the health, safety, or welfare of the employees or visitors.
During a review of Center for Disease Prevention and Control (CDC) website https://www.cdc.gov/parasites/scabies/prevent.html, indicated When a person is infested with scabies mites the first time, symptoms typically take 4-8 weeks to develop after being infested. However, an infected person can transmit scabies, even if they do not have symptoms. Scabies usually is passed by direct, prolonged skin-to-skin contact with an infected person. However, a person with crusted (Norwegian) scabies can spread the infestation by brief skin-to-skin contact or by exposure to bedding, clothing, or even furniture that he/she has used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 1) was allowed to receive visitor and full visitation rights.
This failure resulted in Resident 1 feeling of disappointment and had the potential to negatively impact his psychological wellbeing.
Findings:
During a review of Resident 1 ' s admission Record (face sheet), indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including depressive disorder (a mental health disorder characterized by persistent loss in interest in activities causing impairment {damage} in daily life), Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions) and dementia (impaired ability to remember, think, or make decisions).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool, dated 6/20/2023, indicated Resident 1 was able to make his needs known despite periods of disorientation and had little interest or pleasure in doing things, feeling or appearing down, depressed, and hopeless almost every day.
During a review of the facility ' s Interdisciplinary Conference Notes ([IDT] a group of professionals all working collaboratively toward a common goal), dated 6/13/2023, indicated Resident 1 ' s visitor ( he called daughter) was inquiring about Resident 1 ' s plan of care and was asked by facility staff to leave the facility ' s premises.
During an observation and interview on 7/12/2023 at 8:43 a.m., with Resident 1, Resident 1 was observed with sad and disappointed expression in his face. Resident 1 stated his daughter (visitor) have not visited him and he misses his 'daughter. He further stated he was happy when his daughter visits him a lot and no other family member come to visit him except her.
During a telephone interview on 7/12/2023 at 11:51 a.m., with Resident 1 ' s Responsible Party 3 (RP 3), stated Resident 1 knows the constant visitor very well, and call her daughter. Resident 1 enjoys her visits and was important to Resident 1 ' s emotional and mental health. RP 3 stated her brother, who was Resident 1 ' s Power of Attorney ([POA] someone tha handle medical, legal, or financial matters) and herself, did not instruct the facility to deny or restrict visitation from his constant visitor. RP 3 further stated, Resident 1 ' s visitor called 911 (requires immediate assistance from the police, fire department or ambulance) because she felt facility was not attending to Resident 1 ' s severe rashes all over his body and noticed his condition had worsened.
During an interview on 7/12/2023 at 8:52 a.m., with Certified Nursing Assistant (CNA) 1, stated, Resident 1 constant visitor was concerned about Resident 1 ' s worsening body rash and swollen feet. CNA 1 stated visitor communicated her concern to the licensed nurses and administrator. The visitor was upset but not acting badly or shouting. The visitor called 911 because she felt nobody was listening to her concerns regarding Residents 1 ' s worsening rashes all over his body. Resident 1 had been refusing showers since her visitor does not visit him often. CNA 1 further stated Resident 1 participates with his care and was happy when his visitor spend time with him. CNA 1 stated Resident 1 needs constant social interaction with his family and visitors to feel less lonely.
During an interview on 7/12/2023 at 10:40 a.m., with the Social Service Assistant (SSA), the SSA stated Resident 1 ' s son who has the POA did not disallow Resident 1 ' s constant visitor to visit Resident 1. SSA stated Resident 1, not the POA, ultimately decides whom he wants to visit him, and the facility should allow the visitor(s) to visit him for as long as the visitor(s) were not disruptive or intervening in the care of the resident. SSA further stated the visitor calling 911 for Resident 1 was not a disruptive behavior, instead it was an act of advocacy for Resident 1.
During an interview on 7/12/2023 at 10:52 a.m., with the Administrator (ADM), the ADM stated the SSA called Resident 1 ' s POA regarding the visitor ' s disruptive behavior and the POA decided the visitor will not be allowed to visit Resident 1 or near the facility ' s premises. The ADM further stated moving forward she or anyone in the facility will not hinder any of the residents ' visitation rights. As of Resident 1 ' s constant visitor, the ADM stated the Interdisciplinary Team (IDT) will conduct a meeting with the Ombudsman, Resident 1 ' s visitor and Resident 1 and will discuss limitations to access of Resident 1 ' s healthcare records and medical decisions, however, not refrain Resident 1 nor his visitor(s) from having access to one another.
During a record review of the facility ' s policy and procedure (P&P) titled Resident Rights, undated, the P&P indicated the Federal and State laws guarantee basic rights to all residents of the facility and such include all residents to be able to visit and be visited by others from outside the facility.
During a record review of the facility ' s policy and procedure (P&P) titled Visitation, undated, the P&P indicated the facility permits the residents to receive visitors subject to the resident ' s wishes. The P&P indicated the residents are permitted to have visitors of their choosing at the time of their choosing and visitors may include, but not limited to spouses, domestic partners, other family members and friends. The P&P further indicated the facility does not restrict visitors based on the request of family members or the healthcare power of attorney.

Based on observation, interview and record review, the facility failed to ensure 2 of 17 sampled residents (Resident 1 and Resident 2) were assessed, treated, and evaluated in a timely manner when Resident 1 and Resident 2 were found to have a body rash.
This failure has resulted to Resident 1 admitted at General Acute Care Hospital for sepsis (a serious condition in which the body responds improperly to an infection which is a life-threatening medical emergency) Due to cellulitis (a deep infection of the skin), with a secondary diagnosis of scabies and Resident 2 not evaluated/ accurately diagnosed and treated for possible scabies (a contagious, itchy skin condition caused by a tiny burrowing mite).
Findings:
A. During a review of Resident 1 ' s admission Record (face sheet). The face sheet indicated Resident 1 was admitted at the facility on 6/7/2021 with a diagnosis that included depressive disorder (a mental disorder characterize by a change in mood or loss of pleasure or interest in activities in daily life), Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), dementia (persistent loss of intellectual function, abstract thinking, and often with personality change), hypertension (high blood pressure) and diabetes mellitus ( a disease characterized by elevated blood sugar levels which leads to serious damage to the organs of the body).
During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/20/2023, the MDS indicated Resident 1 was able to make his needs known despite periods of disorientation and requires extensive assistance with one person to complete his ADL (activities of daily living) such as grooming, personal hygiene and locomotion (movement of the individual from one place to another) in and out of the unit.
During a review of Resident 1 ' s undated care plan titled, Generalized Body Rashes the goal of the care plan is for Resident 1 to be free from rashes and complications with interventions that included assistance with hygiene and informing the Responsible Party/Guardian as necessary.
During a review of Resident 1 ' s medical record titled, Treatment Administration Record (TAR) dated 6/1/to 6/30/2023, the TAR indicated Resident 1 was prescribed a corticosteroid (an anti- inflammatory medication) body ointment on 5/ 27/ 2023 for body rash.
During a review of Resident 1 ' s medical record titled, Physician Progress Notes (PPN), the PPN did not indicate Resident 1 was evaluated by a dermatologist (a doctor who specializes in conditions that affect the skin, hair, and nails) and there was no plan for a skin scraping to diagnose Resident 1 ' s body rash.
During a review of Resident 1 ' s medical record titled, Skin and Wound Note (SWN) dated 6/9/2023, the SWN indicated Resident 1 was transferred to a general acute care hospital (GACH) via 911, as called by his family (constant visitor).
During a review of Resident 1 ' s GACH admission Record (Face Sheet), the Face Sheet indicated Resident 1 was seen at GACH ' s emergency room on 6/9/2023 and was admitted for sepsis (a serious condition in which the body responds improperly to an infection which is a life-threatening medical emergency) due to cellulitis (a deep infection of the skin), possible scabies on 6/9/2023.
During a review of Resident 1 ' s GACH Emergency Department Notes (EDN) dated 6/9/2023 at 11:16 p.m., the EDN indicated Resident 1 was positive for erythematous papules (rashes) throughout the body and pustular lesions (abnormal condition) on bilateral feet with overlying erythema (reddening) to bilateral lower extremities (legs/feet), white blood cell count of 13 and body temperature of 100.6 F. Resident 1 was treated with intravenous antibiotics and scabicide (topical medication that kill the scabies mite) cream upon arrival at GACH and was given an ivermectin by mouth (antiparasitic drug) on 6/10/2023.
During a review of Resident 1 ' s GACH Record Internal Medicine Progress Notes (IMPN) dated 6/15/2023, the IMPN indicated Resident 1 presented to the GACH on 6/9/2023 with generalized body rashes itching for a month and was assessed to have sepsis secondary to cellulitis of bilateral lower extremities and crusted scabies.
During a review of Resident 1 ' s GACH Discharge Summary (DS) dated 6/16/2023, the DS indicated the plan was to discharge Resident 1 to nursing facility with a principal diagnosis of cellulitis and a secondary diagnosis of scabies.
During a review of the facility ' s Residents Census form on 6/17/2023, the census indicated Resident 1 was placed in a regular room (not an isolation room) together with Resident 2.
During an observation and interview on 7/12/2023 at 8:52 a.m., Resident 1 was observed in the dining room with other residents and had episodes of scratching his stomach. Resident 1 was observed to have pinpoint rashes and dry crusts/scabs to his arms and his neck and was observed to scratch his arms and neck from time to time. Resident 1 stated he was okay.
During an interview on 7/13/2023 at 1:45 p.m., the Treatment Nurse (TX 2) stated residents with any skin concerns such as a wound, incision or rashes, must be acknowledged as a change in condition and documented in the progress notes after initial observation and during re- evaluation, to determine if the skin concern has healed or worsened and if the treatment needed to be continued or changed. TX 2 stated a resident weekly skin evaluation and report is necessary so the progress of the resident ' s skin concern is known, and the healthcare team is aware of the resident ' s progress, as these documentations are discussed during the interdisciplinary care meeting with the residents and their responsible parties.
During a telephone interview on 7/12/2023 at 3:44 p.m., Resident 1 ' s constant visitor (CV) stated she visited Resident 1 at the facility multiple times for the month of June and Resident 1 already had body rashes for a month. CV stated on 6/9/2023 Resident 1 ' s was uncomfortable, hardly can walk and his feet were swollen and have yellowish fluid coming out of his feet, which prompted her to call 911, as the nursing staff and administrator were not paying attention to Resident 1 ' s condition. CV stated she was severely itchy and had some rashes on her body a few days after Resident 1 was discharged back to the facility and was prescribed by her personal doctor scabicide (topical medication that kill the scabies mite) cream for her and the entire family to use. CV further stated during the previous weeks prior to Resident 1 transferred to GACH, she noticed one of Resident 1 ' s roommates was itchy and scratching his body.
B. During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted at the facility on 2/15/2022 with a diagnosis that included chronic viral hepatitis (a chronic disorder of the liver that may lead to damage and liver cancer), paranoid schizophrenia (a mental illness where the mind is unreasonably suspicious of others) and pulmonary embolism (a condition in which one or more blood vessels in the lungs become blocked by a blood clot).
During a review of Resident 2 ' s [(MDS)- a standardize assessment and care screening tool] dated 5/9/2023, the MDS indicated Resident 2 was alert to self with periods of difficulty in focusing attention and disorganized thinking, required supervision during locomotion (movement of the individual from one place to another) in and out of the unit and required one person physical limited assistance to complete his ADLS (activities of daily living) such as personal hygiene and grooming.
During a review of Resident 2 ' s undated care plan titled Torso area scattered redness, the care plan had a goal for Resident 2 to be free from scattered redness with intervention that included nursing staff to identify causative factors and eliminate/resolve, monitor scattered redness, report abnormalities and failure to heal to the doctor and carry out treatment, as ordered.
During a review of Resident 2 ' s medical record titled, TAR from June 1 to June 30, 2023, the TAR indicated Resident 2 was prescribed a corticosteroid (an anti- inflammatory medication) body ointment on 5/ 27/ 2023 for body rash.
During a review of Resident 2 ' s medical record titled, Order Summary (OS), the OS did not indicate Resident 2 was ordered a dermatology consult for body rash.
During a review of the facility ' s resident census on 6/17/2023, the census indicated Resident 2 was residing in a room together with Resident 1, who was readmitted at the facility on 6/16/2023 from GACH with a diagnosis of cellulitis and scabies.
During an observation and interview on 7/12/2023 at 9:04 a.m., Resident 2 was observed sitting on a wheelchair and scratching his ears and legs and although he did not respond to questions, Resident 2 was heard saying Itchy.
During a telephone interview on 7/12/2023 at 12:40 p.m., Responsible Party 2 (RP2) stated when he visited Resident 2 few weeks ago, he saw Resident 2 was itching all over and saw some redness and/or rashes to his upper body. RP2 stated he informed the nursing staff about it and did not hear anything from the facility afterwards.
During an interview on 7/12/2023 at 8:52 a.m., a Certified Nursing Assistant 1 (CNA 1), stated Resident 1 has had rashes all over his body since he was transferred from a different unit in the facility and these were noted during daily care such as shower, bath, or incontinence care. When asked how the nursing assistants communicate their findings on the residents' skin, CNA 1 stated there is a skin inspection sheet that the staff completed and give to the charge or treatment nurses, so the nurses are aware of the resident's skin condition. CNA 1 stated Resident 1 had rashes on his feet and CV called 911 because she was worried of Resident 1's condition who was uncomfortable with rashes, itchiness all over his body and swelling of his feet. CNA1 stated she had seen Resident 2 scratching his body sometimes, and Resident 1 and Resident 2 have resided in the same room ever since Resident 1 was back from the hospital. CNA 1 stated the residents have never been placed on contact isolation, residents' belongings were not bagged, and the room was not deep cleaned.
During an interview on 7/13/2023 at 10:44 a.m., the Licensed Vocational Nurse 2 (LVN 2) stated she took care of Resident 1 and Resident 2 on 6/9/2023 and did not find any abnormality on their skin condition. When asked as how she ensures the residents were assessed and evaluated during their care, LVN 2 stated I do residents rounds every shift and I just kind of look at them and check their arms or any of their body parts that I can see. CNAs are supposed to do skin assessments everyday whether it is a shower day or not and the CNAs need to inform the charge nurse and treatment nurse for any abnormalities seen on the residents' skin.
During an interview on 7/12/2023 at 9:17 a.m., TX 1 stated she was new to this assignment. However, she has noticed few weeks ago, while on orientation with TX 4. Resident 1 and Resident 2 had rashes and TX 4 stated the residents were screened, were negative for scabies and there is an ongoing treatment for Resident 1 and Resident 2. When asked how and when does the licensed nurses (charge nurse and treatment nurse) assess, document, and communicate the residents' skin condition to the healthcare team, TX 1 stated, I am not sure as I was not shown during orientation by TX 4, but I think she documents in the progress notes.
During an interview on 7/13/2023 at 1:45 p.m., TX 2 stated residents with any skin concerns such as a wound, incision, or rashes, must be acknowledged as a change in condition and documented in the progress notes after initial observation and during re- evaluation, to determine if the skin concern has healed or worsened and if the treatment needed to be continued or changed. TX 2 stated a resident weekly skin evaluation and report is necessary, so the progress of the resident's skin concern is known, and the healthcare team is aware of the resident's progress, as these documentations are discussed during the interdisciplinary care meeting with the residents and their responsible parties.
During a concurrent interview and record review on 7/13/2023 at 9:30 a.m. the Registered Nurse Minimum Data Set Coordinator (RNMDSC) acknowledged Resident 1 was identified to have body rashes with a treatment of corticosteroid cream that started 5/27/2023. However, this was not documented as a change of condition, nor was there a skin weekly assessment completed by the treatment nurse.
During a concurrent interview and record review on 7/13/2023 at 9:35 a.m. RNMDS acknowledged Resident 2 was identified to have body rashes with a treatment of corticosteroid cream that started 5/27/2023 and there was not a weekly skin assessment completed by the treatment nurse.
During an interview on 7/12/2023 at 9:55 a.m., with the Registered Nurse Supervisor (RNS) 1, the RNS 1 stated 2 residents (roommates) with rashes, must be ruled out for scabies, and their roommates', too. RNS 1 stated all the residents in the unit must be assessed to identify an extent of infestation and control the spread of the parasite. RNS 1 stated aside from the licensed nurses' communication and endorsement, documentation of change of condition and succeeding skin weekly evaluation of the residents affected is important to prevent complications and delay of care and treatment.
During a concurrent interview and record review on 7/12/2023 at 4:52 p.m., with the Director of Staff Development (DSD), the DSD was not able to provide a log of the residents' skin inspection sheets. DSD stated there are skin inspection sheets from the previous months and she just barely started in the month of July. The DSD stated, I figured, there was no delegation of the resident's skin conditions and skin concerns are missed, therefore, I started incorporating the skin inspection sheets as part of the residents' care charting, so that CNAs and licensed nurses are held accountable for the assessment and care of the residents.
During a concurrent interview and record review on 7/13/2023 at 12:01 p.m., with the Director of Nursing Service (DON), the DON stated there were initial change of condition completed for Resident 1 and Resident 2 in regard to skin/ body rashes and the treatment progress for continuity of care and evaluation of Resident 1 and Resident 2 were not documented. The treatment nurse did not complete weekly skin summaries for Resident 1 and Resident 2. The DON stated the care of the residents is collaborative, in the sense, that all members of the team, must be held accountable to do their part for effective and timely delivery of care and services to all the residents.
A review of the facility's Policy and Procedure (P/P) titled, Prevention of Skin Injuries, undated, indicated the facility nursing staff must conduct skin assessment of the residents to inspect presence of erythema (reddened areas that signifies skin abnormalities such as rashes, temperature of the skin as well as edema (swelling).
During a review of the facility's Policy and Procedure (P/P) titled, Change in a Resident ' s Condition or Status, the P/P indicated the nurse will notify the resident's attending physician when there is a significant change in the residents' physical, mental and emotional condition and if there is a need to alter the resident ' s medical treatment significantly.
During a review of the facility's Policy and Procedure (P/P) titled Scabies Identification, Treatment and Environmental Cleaning, the P/P indicated Scabies is an itching skin irritation caused by the microscopic (very small) human itch mite .eventually causes itching, tiny irregular red lines .scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. During a scabies outbreak, the affected residents should remain in contact isolation until 24 hours after treatment and the IP must inform the family and friends of residents as well as staff who have had close contact and give instructions regarding self-examination, reporting signs and symptoms of rashes and treatment. Residents with crusted scabies must be in contact isolation until dermatologist determined the residents are scabies-free, the residents 'belongings bagged, laundry separated and washed in hot cycle for 20 minutes and the room must be vacuumed daily, and room terminally cleaned upon discharge or transfer of the resident from the room. The P/P also indicated the IP, and the nursing staff will conduct a thorough assessment of the roommates of the affected resident, perform daily assessments and coordinate a rapid and effective treatment program with the residents and affected staff, families, and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 2), right to be free from physical abuse by Resident 1. Resident 2, who had a history of pacing (walking) and wandering to other Residents rooms, wandered into Resident 1's room and fell asleep in Resident 1's bed. According to License Vocational Nurse (LVN) 2, a Certified Nurse Assistant (CNA) saw Resident 2 sleeping in Resident's 1 bed and took no action. Resident 1 returned to his room and saw Resident 2 on his bed and started hitting Resident 2.
As a result, Resident 2 was repeatedly hit in the face by Resident 1. Resident 2 sustained a facial laceration (skin cut) that required Resident 2 to be transferred to the general acute care hospital (GACH) for evaluation and treatment. At the GACH, Resident 2 was diagnosed with blunt head trauma (physical injury caused by non-penetrating blows). Resident 2 received 3 sutures (a row of stitches holding together the edges of a wound) to the left ear and was treated for facial laceration and skin tears.
Findings:
During a review of Resident 2's admission Record (AR), indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia unspecified severity with other behavioral disturbance (a progressive and persistent group of thinking and social symptoms, such as thinking and memory impairment, that interfere with daily functioning), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and difficulty walking.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/30/2023, indicated Resident 2 usually understands others and usually able to be understood by staff. The MDS indicated Resident 2 required limited assistance from staff for bed mobility, transfers (from one surface to another), walking in the room and corridor, locomotion on and off unit and toilet use.
During a review of Resident 2's Behavioral Notes (BN) dated 7/2/2023 (the date of the altercation with Resident 1), indicated that Resident 2 was referred to Medical Doctor (MD) by staff following his involvement in a resident-to-resident altercation with another male resident, in which he was struck in the head by the other resident (Resident 1).
During a review of Resident 2's undated Care Plan (CP) titled bipolar disorder manifested by (MB) behavior of continuous pacing episodes of going to other resident's rooms unattended. The interventions indicated to monitor behavior episodes of continuous pacing every shift (QS). The CP interventions also indicated to monitor, observe and document Resident 2's behavior daily.
During a review of Resident 2's undated CP titled Behavior of continuous pacing episodes of going to other resident's room unattended the CP interventions included to monitor episodes of continuous pacing every shift (QS) and document the resident's behaviors daily.
During a review of Resident's 2 undated CP titled High wandering risk with a CP goal of minimize behavior of going to other resident's room unattended, the CP intervention indicated 1:1 supervision (person-to-person directly supervising) as indicated, anticipate, and accommodate daily needs, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book.
During a review of the Change of Condition form (COC- a report used by health care to indicate a sudden, significant change from a resident's baseline in physical, cognitive or behavior areas) dated 07/02/2023, indicated that Certified Nurse Assistant (name unknown) called Licensed Vocational Nurse (LVN) 1 for assistance with Resident 1 and Resident 2 while fighting. LVN 1 wrote Resident 2 was laying in Resident 1's bed and Resident 1 was aggressively hitting Resident 2.
During a review of Resident 1's AR, indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder that causes a persistent feeling of sadness and loss of interest, that can interfere with daily life leading to physical and emotional problems), paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a brain disorder that causes a break with reality), unspecified mood disorder and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 1's MDS dated [DATE], indicated Resident 1 had the ability to understand and be understood by others. Resident 1 required staff supervision for Activities of Daily Living (ADL's - activities related to personal care) such as bed mobility and eating, limited assistance with getting dressed, transfers, locomotion off unit and toilet use. The MDS indicated Resident 1 used a wheelchair for mobility.
During a review of Resident 1's undated CP titled Psychotropic ( a medication that affects the brain by causing changes in mood, awareness, thoughts, feelings and behavior) medications (Haldol) related to(r/t) Paranoid Schizophrenia M/B angry outbursts, interventions indicated that Resident 1 needed to be assisted in avoiding situations that may incite outbursts, monitor and record occurrences for target behavior symptoms and document per facility's protocol.
During a review of Resident 1's undated CP titled Physical Restlessness such as threatening behavior of wanting to fight other residents and being aggressive towards his peers indicated interventions such as to assess and anticipate resident's needs like food, thirst, and toileting. The CP goal was for Resident 1 to understand the need to control his behavior. The CP interventions also indicated to analyze key times, places, circumstances, triggers to cause the behaviors, and what de-escalates (the behaviors) and document.
During an interview on 7/12/2023 at 11:00 a.m. with LVN 2, LVN 2 stated Resident 2 was witnessed walking towards Resident 1's room and Resident 2 had a habit of sleeping in any available bed. LVN 2 stated the staff that was assigned to monitor residents' movement in the hallways saw Resident 2 sleeping in Resident 1's bed. LVN 2 stated staff should have redirected Resident 2 because he was not aware of his surroundings. LVN 2 stated if staff noted that Resident 2 was in another Resident's room, staff should redirect Resident to his room.
During an interview on 7/12/2023 at 11:15 a.m. with LVN 2, LVN 2 stated that the facility has designated staff to monitor the whereabouts of all the residents to make sure all residents are safe from altercations. LVN 2 stated resident to resident altercations are easily preventable, and staff can redirect residents that are wandering into other residents' rooms to prevent altercations.
During an interview on 7/12/2023 at 11:30 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 2 walks in the hallway. If facility staff had closely monitored Resident 2, the altercation with Resident 1 could have been an avoidable incident. Resident 2 was easily redirected.
A review of Resident 2's treatment administration record (TAR) dated 7/3/2023, it indicated Resident 1 had a skin tear at the right forearm, scratch mark on the left eyebrow, left cheek laceration and left ear laceration with 3 sutures.
During an interview on 7/12/2023 at 11:35 a.m. with LVN 3, LVN 3 stated when he observes or sees other Residents go inside other Residents room, he would try to intervene by redirecting the resident to their own room or assisting the resident to the activity room. LVN 3 stated sometimes he offers snacks to the residents to give the resident something to do. LVN 3 stated to prevent resident to resident altercations from occurring and escalating the staff needs to intervene right away, when the staff identify residents that are confused or do not know where their rooms are located. LVN 3 stated for the incident on 7/2/2023, the staff that was responsible for monitoring the hallways should not have missed Resident 2 going inside Resident 1's room. LVN 3 stated residents that sustain lacerations and require suturing indicate it was a deep cut. LVN 3 stated that Resident 2's injuries could have been prevented by continuous monitoring and intervening right away.
During an interview on 7/12/2023 at 12:06 p.m. with the Social Services Director (SSD), the SSD stated this incident that occurred on 7/2/2023 could have been prevented by having the hall monitor redirect Resident 2 and prevent him from wandering into Resident 1's room. Staff should have encouraged Resident 2 to participate in activity groups and get involved in social activity. SSD further added failed supervision can result in resident-to-resident altercations. Residents can wander into other residents' rooms, grab other residents' personal belongings causing agitation, aggravation, irritation with each other, which could lead to injuries.
During an interview on 7/12/2023 at 11:50 a.m. with the monitoring staff (MS), the MS stated his duty was to monitor residents' whereabouts, observe, and divert residents' attention. If the resident start to get agitated, the staff should reorient residents and redirect the residents.' The MS further added that his main role as the MS was to supervise, monitor and prevent residents from having altercations and getting injured. The MS stated if a resident was caught entering another resident's room, he would redirect the resident to the resident's room to prevent any incidents.
During an interview on 7/12/2023 at 12:10 p.m. with the Director of Nursing (DON), the DON stated all CNAs should be monitoring the hallway activity to prevent unusual interactions between residents, in this case both Resident 1 and Resident 2 were not monitored. The DON stated CNAs and/or LVNs are responsible for monitoring residents and ensure care plan interventions were being implemented. The DON further stated the incident on 7/2/2023, could have been prevented if staff were closely monitoring both residents having identified behaviors.
During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program (undated), the P&P indicated, implement measures to address factors that may lead to abusive situations for example adequately prepare staff and instruct staff regarding appropriate ways to address interpersonal conflicts.
During a review of the facility's P&P titled, Resident Rights, (undated), the P&P indicated, the residents shall be free from abuse, neglect, misappropriation of property (to appropriate wrongly), and exploitation (fact of treating someone unfairly).
During a review of the facility's P&P titled, Resident-to-Resident Altercations, (undated), the P&P indicated, facility staff are to monitor residents for aggressive inappropriate behaviors towards other residents, family members, visitors, or to the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide supervision to two of three sampled residents (Residents 1 and 2). Resident 2 wandered into Resident 1's room, got in Resident 1's bed and fell asleep. According to License Vocational Nurse (LVN) 2, on 7/2/2023 Certified Nurse Assistant (CNA), saw Resident 2 sleeping in Resident's 1 bed and took no action. Resident 2 returned to his room and saw Resident 1 in his bed and began to hit Resident 2.
The facility failed to:
1. Supervise and monitor Resident 2 to from going inside Resident 1's room and laying on his bed.
2. Follow Resident 2's care plan (CP) titled high wandering risk with a CP goal to minimize behavior of wandering into other resident's room unattended, the CP intervention indicated a 1:1 supervision (person-to-person directly supervising) as indicated, anticipate, and accommodate daily needs, distract resident from wandering.
3. Follow Resident's 1 CP titled physical restlessness such as threatening behavior of wanting to fight other residents and being aggressive towards his peers with intervention that included to assess and anticipate residents needs and for Resident 1 to understand the need to control his behavior.
As a result, of the facility not providing supervision, Resident 1 repeatedly hit Resident 2 in the face on 7/2/2023. Resident 2 sustained a facial laceration (skin cut) that required Resident 2 to be transferred to the general acute care hospital (GACH) for evaluation and treatment. At the GACH, Resident 2 was diagnosed with blunt head trauma (physical injury caused by non-penetrating blows). Resident 2 received 3 sutures (a row of stitches holding together the edges of a wound) to the left ear and was treated for facial laceration and skin tears.
Findings:
During a review of Resident 2's admission Record (AR), indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia unspecified severity with other behavioral disturbance (a progressive and persistent group of thinking and social symptoms, such as thinking and memory impairment, that interfere with daily functioning), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and difficulty walking.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/30/2023, indicated Resident 2 usually understands others and usually able to be understood by staff. The MDS indicated Resident 2 required limited assistance from staff for bed mobility, transfers (from one surface to another), walking in the room and corridor, locomotion (ability to move from one place to another) on and off unit and toilet use.
During a review of Resident 2's Behavioral Notes (BN) dated 7/2/2023 (the date of the altercation with Resident 1), indicated that Resident 2 was referred to Medical Doctor (MD) by staff following his involvement in a resident-to-resident altercation with another male resident on 7/2/2023, in which he was struck in the head by the other resident (Resident 1).
During a review of Resident 2's undated Care Plan (CP) titled bipolar disorder manifested by (MB) behavior of continuous pacing episodes of going to other resident's rooms unattended. The interventions indicated to monitor behavior episodes of continuous pacing every shift (QS). The CP interventions also indicated to monitor, observe, redirect, and document Resident 2's behavior daily by Activity and Nursing Department.
During a review of Resident 2's undated CP titled Behavior of continuous pacing episodes of going to other resident's room unattended the CP interventions included to monitor episodes of continuous pacing every shift (QS), monitor location attempt diversional intervention, and document the resident's behaviors daily.
During a review of Resident's 2 undated CP titled High wandering risk with a CP goal of minimize behavior of going to other resident's room unattended, the CP intervention indicated 1:1 supervision as indicated, anticipate, and accommodate daily needs, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book.
During a review of the Change of Condition form (COC- a report used by health care to indicate a sudden, significant change from a resident's baseline in physical, cognitive or behavior areas) dated 07/02/2023, indicated that Certified Nurse Assistant called LVN 1 for assistance with Resident 1 and Resident 2 while fighting. LVN 1 documented Resident 2 was laying in Resident 1's bed and Resident 1 was aggressively hitting Resident 2.
During a review of Resident 1's AR, indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including major depressive disorder (a serious mood disorder that causes a persistent feeling of sadness and loss of interest, that can interfere with daily life leading to physical and emotional problems), paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia (a brain disorder that causes a break with reality), unspecified mood disorder and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 1's MDS dated [DATE], indicated Resident 1 had the ability to understand and be understood by others. Resident 1 required staff supervision for Activities of Daily Living (ADL's - activities related to personal care) such as bed mobility and eating, limited assistance with getting dressed, transfers, locomotion off unit and toilet use. The MDS indicated Resident 1 used a wheelchair for mobility.
A record review of the medication administration record (MAR) for the month of July 2023, the MAR indicated that Resident1 was being monitored for behavioral episodes of angry outbursts every shift) indicated that Resident 1 had zero (0) episodes on 7/2/2023 (the date of the incident) day shift.
A record review of the undated CP titled Psychotropic ( a medication that affects the brain by causing changes in mood, awareness, thoughts, feelings and behavior) medications (Haldol) r/t Paranoid Schizophrenia manifested by (M/B) angry outbursts, interventions indicated that Resident 1 needed to be assisted in avoiding situations that may incite outbursts and monitor and record occurrences for target behavior symptoms and document per facility protocol.
During an interview on 7/12/2023 at 11:00 a.m. with LVN 2, LVN 2 stated Resident 2 was witnessed walking towards Resident 1's room and Resident 2 had a habit of sleeping in any available bed. LVN 2 stated on 7/2/2023, CNA2 that was assigned to monitor residents' movement in the hallways saw Resident 2 sleeping in Resident 1's bed. LVN 2 stated staff should have redirected Resident 2 because he was not aware of his surroundings. LVN 2 stated if staff noted that Resident 2 was in another Resident's room, staff should redirect Resident 2 to his room.
During an interview on 7/12/2023 at 11:15 a.m. with LVN 2, LVN 2 stated that the facility has designated staff to monitor the whereabouts of all the residents to make sure all residents are safe from altercations. LVN 2 stated resident- resident altercations are easily preventable and staff can redirect residents that are wandering into other residents' rooms to prevent altercations.
During an interview on 7/12/2023 at 11:30 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 2 walks in the hallway, and if facility staff had closely monitored Resident 2, the altercation with Resident 1 on 7/2/2023, could have been an avoidable incident. Resident 2 was easily redirected.
A review of the Nurses Notes dated 7/3/2023, indicated that Resident 2's diagnosis from the GACH included but not limited to blunt head trauma, facial laceration and laceration of left ear region requiring suturing.
A review of Resident 2's treatment administration record (TAR) dated 7/3/2023, it indicated Resident 1 had a skin tear at the right forearm, scratch mark on the left eyebrow, left cheek laceration and left ear laceration with 3 sutures.
During an interview on 7/12/2023 at 11:35 a.m. with LVN 3, LVN 3 stated when he observes or sees other Residents go inside other Residents room, he would try to intervene by redirecting the resident to the resident's room or assisting the resident to the activity room. LVN 3 stated sometimes he offers snacks to the residents to give the resident something to do. LVN 3 stated to prevent resident to resident altercations from occurring and escalating the staff needs to supervise and intervene right away, when the staff identify residents that are confused or do not know where their rooms are. LVN 3 stated for the incident on 7/2/2023 the staff that was responsible for monitoring the hallways should not have missed Resident 2 going inside Resident 1's room. LVN 3 stated residents that sustain lacerations and require suturing indicate it was a deep cut. LVN 3 stated that Resident 2's injuries could have been prevented by continuous monitoring and intervening right away.
During an interview on 7/12/2023 at 12:06 p.m. with the Social Services Director (SSD), the SSD stated this incident that occurred on 7/2/2023 could have been prevented by having the hall monitor redirect Resident 2 and prevent him from wandering into Resident 1's room, by encouraging Resident 2 to participate in activity groups and get involved in social activity. SSD further added failed supervision can result in resident-to-resident altercations. Residents can wander into other residents' rooms, grab other residents' personal belongings causing agitation, aggravation, irritation with each other, which could lead to injuries.
During an interview on 7/12/2023 at 1:30 p.m. with the Director of Staff Development (DSD), the DSD stated the purpose of supervision is to monitor the residents especially the ones who need more assistance, such as residents that are high fall risk, and wandering residents. DSD stated these residents (high fall risk and wandering residents) should be monitored closely and staff assigned to monitor should document the resident's whereabouts hourly. DSD further added that incidents that happen due to failure to monitor residents such as resident to resident altercations, elopements etc. can lead to injury or even death. DSD stated most likely the CNA or Monitoring Staff (MS) did not supervise the resident that is why the altercation with injury between Resident 1 and Resident 2 happened on 7/2/2023.
During a record review of the monitoring log (ML) for Resident 2, ML indicated on 7/2/2023 at 12:00 p.m. Resident 2 is at smoking patio then at 1:00 p.m., it indicated that Resident 2 at the dining room (there was no documentation indicating Resident 2 had wandered into Resident 1's room).
During an interview on 7/12/2023 at 11:50 a.m. with the MS, the MS stated his duty was to monitor residents' whereabouts, observe, and divert residents' attention. If the resident start to get agitated, the staff should reorient residents and redirect the residents' if the residents' get into somebody's space. The MS further added that his main role as the MS was to supervise, monitor and prevent residents from having altercations and getting injured. The MS stated if a resident was caught entering another resident's room, he would redirect the resident to the resident's room to prevent any incidents.
During an interview on 7/12/2023 at 12:10 p.m. with the Director of Nursing (DON), the DON stated all CNAs should be monitoring the hallway activity to prevent unusual interactions between residents, in this case, incident that occurred on 7/2/2023 at noon time, both Resident 1 and Resident 2 were not monitored. The DON stated CNAs and/or LVNs are responsible for monitoring residents and ensure care plan interventions were being implemented. The DON further stated the incident could have been prevented if staff were closely monitoring both residents having identified behaviors.
During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents (undated), the P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P also indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. The P & P also indicated the monitoring of effectiveness of interventions shall include the following: ensuring that the interventions are implemented correctly and consistently, modifying, or replacing interventions as needed, evaluating the effectiveness of interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident, who was totally dependent on staff for activities of daily living ([ADL] a basic skills needed to carry out tasks of everyday life) and was not able to use a regular call light bell due to loss of ability to move or feel his upper body and legs, was provided with a specialized call light in the form of a pad for one sampled resident (Resident 1).
This failure placed Resident 1 at risk for delay in obtaining necessary care and services.
Findings:
A review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (when multiple peripheral nerves become damaged which can affect sensation and movement of the body), paraplegia (paralysis of the legs and lower body caused by spinal injury or disease), neuromuscular dysfunction of bladder (person lacks bladder control due to brain, spinal cord or nerve problems), Stage 4 pressure ulcer (wounds that penetrate all layers of the skin exposing muscles, tendons, cartilage and bones caused by prolonged pressure on the skin) of the left and right heels, Stage 4 pressure ulcer of sacrum (an area at the bottom of the spine), chronic pain syndrome (pain that continues for more than three to six months even the underlying cause is gone) and a colostomy (an opening in the abdomen when the colon is not working due to an injury or disease).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/16/2023, indicated Resident 1 made independent decisions that were reasonable and consistent. The MDS indicated Resident 1 was totally dependent on staff and required a one-person physical assistance for activities of daily living ([ADL] basic skills needed to carry out tasks of everyday life) and a two-person physical assistance for bed mobility.
During a concurrent observation and interview on 6/30/2023 at 8:10 a.m., in Resident 1's room, Resident 1's call light was noted under Resident 1's pillow. Resident 1 stated, he could not use his call light because he could not pull the string and used his loud voice to call for staff assistance. Resident 1 stated his hands are flat and could not grab or pull the call light string and it could be frustrating at times.
During an interview on 6/30/2023, at 8:20 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 would not be able to pull the call light string because he was paralyzed. LVN 1 stated, if Resident 1 could not use the call light to let staff know he needed help, Resident 1 would feel no one was there to meet his needs.
During an interview on 6/30/2023 at 8:55 a.m., a Certified Nursing Assistant 4 (CNA 4) CNA 4 stated, Resident 1 at one time was on a different station and had an adaptive call light which he could use. CNA 4 stated, Resident 1 yells for a nurse if he needs help because he could not pull the string of his call light.
During a review facility's policy and procedure (P/P) titled Accommodation of Needs, the P/P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining or achieving safe, independent functioning, dignity and well being. Resident's individual needs and preferences including the need for adaptive devices and modifications to their physical environment are evaluated on admission and reviewed on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident, who was diagnosed with chronic pain and experienced pain due to the presence of several Stage 4 pressure ulcers (wounds that penetrate all layers of skin exposing muscles, tendons, cartilage, and bones caused by prolonged pressure on the skin), received effective pain management for one of two sampled residents (Resident 1).
The facility failed to:
1. Ensure Resident 1 received prompt pain relief upon admission to the facility when he complained of severe pain.
2. Ensure Resident 1's physician was promptly notified of Resident 1's continued complaints of severe pain in order to obtain an order for pain medication.
3. Ensure Resident 1's pain level was assessed and reassessed after administration of Tylenol to evaluate the effectiveness of pain medication in relieving pain.
4. Ensure Resident 1's physician was notified in a timely manner when Resident 1's pain management regimen was ineffective.
5. Ensure Resident 1 received appropriate pain relief for severe pain and not Tylenol that was prescribed for mild pain.
These deficient practices resulted in Resident 1 experiencing unnecessary severe pain over almost a 40-hour period causing him great distress and discomfort. These deficient practices had the potential for Resident 1's pain to continue to go unrecognized and untreated.
Findings:
A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (damage of multiple peripheral nerves which can affect sensation and movement of the body), a Stage 4 pressure ulcers of the left and right heels, a Stage 4 pressure ulcer of the sacrum (area at the bottom of the spine), and chronic pain syndrome (pain that continues for more than three to six months).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/16/2023, indicated Resident 1 made independent decisions that were reasonable and consistent. The MDS indicated Resident 1 was totally dependent on staff and required a one-person physical assist for activities of daily living ([ADL] basic skills needed to carry out tasks of everyday life) and a two-person physical assist for bed mobility.
A review of Resident 1's Physician Orders (PO) indicated Resident 1 to receive the following medications:
1. Hydromorphone HCL ([Dilaudid]) 4.0 milligrams ([mg] a unit of measurement), IM ([intramuscular] placed into the muscle), every four hours as needed for severe pain, ordered on 6/27/2023.
2. Norco 5/325 mg, one tablet for pain management, one time per day before pressure ulcer treatment, ordered on 6/27/2023.
3. Acetaminophen (Tylenol) oral solution 325 mg/10.15 ml via gastric tube ([GT] a small tube surgically inserted in the stomach for administration of nutrition and medication) every six hours for mild pain, ordered on 6/26/2023.
During a concurrent observation and interview on 6/27/2023, at 1 p.m., Resident 1 was lying in bed awake, his arm and legs were noted to be stiff (extended and tense). Resident 1 was observed with facial grimacing (an ugly, twisted expression on a person's face, typically expressing disgust and/or pain) and episodes of twitching of his arms and body. Resident 1 stated he had a lot of pain all over his body and the nurse only gave him Tylenol and it was not helping him. Resident 1 stated he had been waiting for his narcotic pain medication since morning (time unknown) and the nurse told him they were waiting for the pharmacy to dispense his medications, or the doctor had not signed for his medication. Resident 1 stated he did not want to get to the point where he would scream because of the pain.
A review of Resident 1's Care Plan (CP), dated 3/11/2023 indicated Resident 1 had chronic pain related to his multiple pressure ulcers and polyneuropathy. The CP's goals indicated Resident 1 would not have discomfort or an interruption in normal activities due to pain. The CP's interventions included to anticipate the needs of Resident 1 for pain relief, respond immediately to any complaint of pain and to notify the physician if interventions were not effective and to monitor, record and report to the nurse, Resident 1's complaints of pain and his request for pain treatment.
A review of Resident 1's Medication Administration Record (MAR) for 6/2023 indicated Resident 1 received Tylenol on 6/27/2023 at 10:30 a.m.
A review of Resident 1's MAR for 6/2023 indicated Resident 1 received Hydromorphone 4 mg, one tablet on 6/28/2023 at 1:12 a.m., and 4:30 a.m., for pain of 6 out of 10 (severe pain) and at 9 a.m., for pain of 8 out of 10 ([severe pain] based on a numerical pain rating scale from zero to ten, where a zero represents no pain and 10 is the worth pain possible).
A review of Resident 1's Pain Observation Assessment (POA) dated 6/26/2023 and timed 10:37 p.m., indicated Resident 1 had a pain level of 9 out of 10. The POA indicated Resident 1 received Dilaudid (Hydromorphone- opioid pain medicine) and Norco ([combination of Hydrocodone with Acetaminophen] narcotic pain medications) for pain.
A review of Resident 1's Nursing Progress Notes (NPN) dated 6/26/2023 indicated no additional assessment of Resident 1's pain level following Resident 1's initial pain assessment on 6/26/2023 at 10:37 p.m.
A review of Resident 1's NPN dated 6/27/2023 and timed at 2:02 p.m., indicated while Resident 1 was being repositioned in bed the resident complained of pain.
A review of Resident 1's NPN dated 6/27/2023 and timed at 3:01 p.m., indicated the Registered Nurse Supervisor (RNS 1) was informed by the Licensed Vocational Nurse (LVN 2) at 2:40 p.m., that Resident 1 was in pain and having muscle spasms. The NPN indicated a review of list of medications from hospital transfer was done and there was no doctor's order to continue Norco and Dilaudid. The NPN indicated Resident 1's physician was notified, and orders were obtained for pain medication.
A review of Resident 1's Treatment Administration Record (TAR) dated 6/27/2023 indicated Resident 1's pain was assessed as 7 out of 10 (severe) when the resident had his Stage IV pressure ulcer dressing changed.
During an interview on 6/27/2023, at 1:26 p.m., LVN 2 stated Resident 1 was in so much pain he kept asking about his narcotic medication and he (Resident 1) would not allow him (LVN 2) to touch or assess him this morning (time unknown but before 9:30 a.m.). LVN 2 stated, Resident 1 was in pain when LVN 1 (the Treatment Nurse) tried to do Resident 1's a Stage IV pressure ulcer treatment before 10:30 a.m., and Resident 1 was given Tylenol at 10:30 a.m. LVN 2 stated he reassessed Resident 1 for pain at 11:15 a.m. but stated he did not document the pain reassessment after Tylenol was administered.
During an interview on 6/27/2023, at 4:38 p.m., RNS 1 stated, Resident 1 would be miserable and his vital signs ([v/s] measurements of the body's most basic functions including temperature, blood pressure, pulse and breathing rate) could be affected if his (Resident 1's) pain was not managed properly because of his chronic pain issues, and Stage IV pressure ulcers on his legs and his sacral area.
During an interview on 6/28/2023, at 11:10 a.m., Resident 1 stated, he was experiencing a lot of pain right now, about 10 out of 10 (severe) in his back and he had spasms that went through his stomach and arms along with his Stage IV pressure ulcers and he needs help right now. Resident 1 stated he was given Hydromorphone 4 mg and Tylenol 325 mg at 9 a.m. but these medications were not helping his pain. Resident 1 stated his thoughts were not good right now and the nurses were not giving him anything to stop his pain.
During an interview on 6/28/2023, at 11:57 a.m., LVN 4 stated she gave Resident 1 Norco today at 9 a.m. and reassessed him after five minutes and again after 15 minutes and at that time Resident 1 had no pain. LVN 4 stated at 11:15 a.m., Resident 1 was complaining of pain again but did not check his pain level because it was not time to give his pain medication which was ordered every six hours. LVN 4 stated she did not call Resident 1's physician to notify him of Resident 1's continued, unrelieved pain.
During an interview on 6/28/2023, at 12:32 p.m., Certified Nursing Assistant (CNA 3) stated, he did not reposition or turn Resident 1 at 10 a.m., today because Resident 1 refused to be repositioned. CNA 3 stated he did not check if Resident 1 was in pain, nor did he notify the charge nurse that Resident 1 refused care.
During a phone interview on 6/28/2023, at 3:50 p.m., RNS 3 stated, on 6/26/2023 Resident 1 reported he was experiencing pain that was 9 out of 10. RNS 3 stated she did not call the physician because she thought Resident 1 had an order for Norco and Dilaudid for pain management. RNS 3 stated she did not administer any pain medication to Resident 1 after the resident complained of severe pain because charge nurse and RNS 2 were aware Resident 1 was having pain. RNS 3 stated Resident 1 was always in pain.
During a telephone interview on 6/29/2023, at 1:06 p.m., LVN 7 stated, Resident 1 was tired and sleepy when Resident 1 arrived to the facility from the General Acute Care Hospital (GACH) on 6/26/2023 at 7:30 p.m. LVN 7 stated Resident 1 screamed when he was transferred from the gurney (wheeled cot or stretcher used to transport patients) to bed and RNS 3 told her (LVN 7) that Resident 1 had no orders for pain medication.
During an interview on 6/29/2023, at 3:35 p.m., RNS 2 stated Resident 1 was not in pain when he arrived from the hospital on 6/26/2023 at approximately 8 p.m. and she was not aware Resident 1 was experiencing a 9 out of 10 pain level during that time.
During an interview on 6/30/2023, at 8:20 a.m., LVN 1 stated on 6/27/2023, at 8 a.m., Resident 1 was in pain, but his medication had not arrived from their pharmacy. LVN 1 stated Resident 1 was still in pain when she did his Stage 4 pressure ulcer treatment at approximately 11:30 a.m., despite receiving Tylenol at 10:30 a.m. LVN 1 stated she was not able to finish Resident 1's pressure ulcer treatment because Resident 1 was experiencing pain rated 8 out of 10. LVN 1 stated she reported to LVN 2 and RNS 1 that Resident 1 was experiencing pain.
During an interview on 6/30/2023, at 9:10 a.m., CNA 1 stated on 6/27/2023 Resident 1 complained of pain all day. CNA 1 stated, at 7:30 a.m., she notified LVN 2 that Resident 1 was in pain and LVN 2 told her (CNA 1) there was nothing much they could do except to give him Tylenol. CNA 1 stated, she checked Resident 1 at 9:30 a.m., and at 12:30 p.m., and he (Resident 1) complained of pain. CNA 1 stated she reported to LVN 2 again that Resident 1 was in pain and LVN 2 again said, there was nothing she could do because Resident 1's medication was not available
During a telephone interview on 6/29/2023 at 5:36 p.m., the Nurse Practitioner (NP) stated, a nurse called her about Resident 1's admission orders on 6/26/2023 at approximately 9:20 p.m. The NP stated, she did not continue Resident 1's medication order for Norco, Fentanyl (a narcotic used to relieve pain) and Dilaudid because she did not know Resident 1 well. The NP stated, she told the nurse to call Resident 1's primary care physician in the morning (6/27/2023) regarding his narcotic pain-relieving medications. The NP stated, she did not receive any more calls from the facility regarding Resident 1's pain.
During an interview on 6/30/2023, at 11:25 a.m., RNS 1 stated, on 6/27/2023 she received report from the outgoing night shift RN that Resident 1's narcotic medications that were prescribed from the GACH had been discontinued by the NP. RNS 1 stated on 6/27/2023 after lunch time, LVN 2 told her that Resident 1 was having unrelieved pain. RNS 1 stated she called Resident 1's physician at approximately 2:40 p.m., on 6/27/2023 to obtain an order for continuation of Resident 1's narcotic pain medications.
During an interview and concurrent record review with RNS 2 on 6/27/2023 at 5:15 p.m., Resident 1's MAR dated 6/2023 was reviewed. Resident 1's MAR indicated there was no narcotic pain medication administered on 6/26/2023 at 10:37 p.m. RNS 2 stated, Resident 1 was in distress and uncomfortable when his pain was not managed and controlled. RNS 2 stated non-pharmacological interventions (a type of health intervention which is not primarily based on medication) for pain level of 9 out of 10 might not work if Resident 1 was having severe pain.
A review of the facility's Policy and Procedure (P/P), titled Pain Assessment and Management, revised 10/2022, indicated residents should be assessed at admission and during ongoing assessments to help identify residents who are experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. Monitor residents for the presence of pain and the need for further assessment when there is a change of condition or whenever there is a suspicion of new or worsening pain. When opioids are used for pain management, the resident is monitored for medication effectiveness and to contact the prescriber immediately if the resident's pain is not adequately controlled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had a known history of physical aggression toward staff and other residents, did not physically hit Resident 2.
The facility failed to:
1. Adequately supervised Resident 1 to prevent Resident 1 from hitting Resident 2 after Resident 1 already had episodes of physical aggression by placing his hands around Resident 3 throat and hit his roommate (Resident 6) in the face causing Resident 6 to bleed from his upper lip.
2. Ensure to follow Resident 1 care plan (CP) titled Potential to demonstrate verbal and or aggressive behaviors with intervention to monitor and document observed behavior to reach the CP goal for Resident 1 not to harm self and others.
3. Ensure the Social Service Worker (SSW) and the Social Services Assistant (SSA 1) informed the Director of Nursing (DON) about Resident 1 wanted to leave the Grove unit (a dedicated locked unit withing the facility), feeling agitated and verbalizing the feeling to hit someone.
4. Administer an Ativan (anti-anxiety medication) as ordered by the physician for Resident 1 agitation and aggression to prevent Resident 1 to hit Resident 2 in the face.
5. Ensure its policy and procedure (P&P) titled, Abuse and neglect clinical protocol (undated), to institute measures to address the needs of residents and minimize the possibility of abuse was followed.
6. Ensure its P&P titled, Safety and Supervision of Residents (undated), was followed to determine Resident 1 frequency and type of supervision due to the resident's aggressive verbal and physical behavior.
These failures resulted in Resident 1 striking out by hitting Resident 2 in the face. As a result, Resident 2 sustained a laceration (skin wound) to the left eyebrow lacerations (skin cut), one measuring 3.0 centimeters [(cm) unit of measurement) long and second 5.0 cm. long and required a transfer to the general acute care hospital (GACH) for evaluation and treatment. At the GACH Resident 2 was diagnosed with nondisplaced ocular (bones surrounding the eye) fracture.
Findings:
During a review of the Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnosis including drug induced subacute dyskinesia (involuntary body movements), diabetes mellitus (poor blood sugar control), and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and a type of psychosis in which the mind doesn't agree with reality).
During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 4/23/2023, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact and the resident required a limited assistance from staff for dressing, transfers, and bed mobility.
During a review of Resident 1's Psychosocial Assessment and Social History ([NAME]) form, dated 1/20/2023, the [NAME] form indicated Resident 1 will display angry outburst and get easily agitated, and will strike unprovoked or provoked when over stimulated.
During a review of Resident 1's care plan (CP) titled Potential to demonstrate verbal and or aggressive behaviors, dated 1/18/2023, the CP indicated the goal for Resident 1 was not to harm self or others through the review date. The CP interventions included to monitor, and document observed and attempted interventions in behavior log.
During a review of the Resident 1's CP, dated 1/20/2023, the CP indicated that Resident 1 gets easily agitated. The CP interventions included to administer Lorazepam ([Ativan, an anti-anxiety medication]) intramuscular [(IM) into the muscle] as ordered by the physician, monitor behaviors daily and review increasing behaviors requiring re-evaluation.
During a record review of a physician's note, dated 1/24/2023, the note indicated Resident 1 hit his roommate (Resident 6) in the face and caused to bleed from his upper lip. Physician note indicated Resident 1 verbalized he hit his roommate because his roommate (Resident 6) did not flush the toilet two times. The physician note indicated Resident 1 was ordered to transfer to GACH emergency room for evaluation and treatment and administer stat Benadryl (fast acting anti-anxiety) 50 mg one dose IM, Ativan 1 mg IM stat (immediately), and Haldol (anti-psychotic) 5 mg IM.
During a review of Resident 1's CP, dated 2/22/2023, and titled History of Physical aggression towards another resident related to diagnosis of paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and psychosis (mental disorder characterized by a disconnection from reality.), the CP indicated Resident 1 was identified as physical and verbally aggressive towards others.
During a review of Resident 1's Change of Condition (COC) note, dated 5/14/2023, the COC indicated Resident 1 was verbally aggressive, yelling, and screaming at peers and staff.
During a review of Resident 1's COC note, dated 5/20/2023, the COC indicated Resident 1 allegedly placed his hands around the throat of Resident 3. The COC indicated Resident 1 was transferred to the Grove Unit (locked unit in the facility) the same day after this incident.
During a review of the Social Services progress notes (SSPN), dated 5/22/2023 and 5/23/23, the SSPN indicated Resident 1 had spent three days in his new room (after he was moved), and did not like being at the Grove unit. The SSPN indicated Resident 1 felt that peers were intrusive and he more likely to strike someone, or someone will strike him. Resident 1 expressed frustration about his new living place to social service worker (SSW) regarding his peers. Resident 1 wanted to be removed from the Grove unit to avoid any altercations with peers. SSW encouraged 1 to remain calm and refrain from any aggressive behavior. The SSPN indicated there was no documentation about SSW communicated to nurses or Resident 1's physician about how Resident 1 felt staying at the Grove unit.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including a major depressive disorder, schizophrenia, unspecified mood disorder and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills were intact, and the resident required staff supervision for dressing, transfers, and bed mobility. The MDS indicated Resident 2 used a walker and wheelchair for mobility.
During a review of Resident 1's COC note, dated 6/5/2023, and timed at 5:20 p.m., the COC indicated Resident 1 was agitated, yelling, screaming, and cursing, and was about to hit at staff but did not. The COC indicated no physical contact was noted during the 7a.m. to 3p.m. shift. COC indicated there were no interventions in place to address Resident 1 agitation.
During a review of Resident 1's PO, dated 6/5/2023, the PO indicated Resident 1 had an order for Lorazepam 0.5 milliliters [(ml) unit of liquid measurement] IM every six hours as needed (PRN) for agitation manifested by aggressive behavior for 14 days.
During a review of Resident 2's COC note, dated 6/5/2023, Resident 2 sustained two left eyebrow lacerations, one measuring 3.0 cm long and second 5.0 cm long. The COC indicated that Resident 2 was hit by Resident 1 and initial treatment was provided. Resident 2 was then transferred to the GACH for further treatment.
During a review of Resident 2's PO dated 6/5/2023, the PO indicated Resident 2 was transferred to the GACH via 911 for treatment and evaluation.
During a review of Resident 1's PO, dated 6/5/2023, the PO indicated to transfer Resident 1 to the GACH for psychiatric (medical doctor who studies, diagnoses and threats mental illnesses) evaluation and treatment related to aggressive behavior.
During a review of Resident 2's a Computed Tomography ([CT] a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) report dated 6/6/2023 and timed at 1:14 a.m., the CT scan report indicated Resident 2 sustained a comminuted fracture (broken bone in at least two places) of the supraorbital rim (located above the eye socket) and the left frontal bone (flat bone of the skull located in the forehead).
During an interview with the Social Services Assistant (SSA 1), on 6/7/23, at 10:35 a.m., SSA 1 stated that Resident 1 was transferred to the lock unit after an alleged altercation with Resident 2. SSA 1 stated that he recalls Resident 1 stated he felt like he was going to strike a resident if he (Resident 1) stayed in the room he was assigned on the Grove unit. SSA 1 stated Resident 1 verbalized he wanted to get out of Grove unit daily. SSA 1 stated that he (SSA 1) told the charge nurse and the other social workers this information. SSA 1 stated that he (SSAA 1) should have reported to the Director of Nursing (DON).
During an interview with the DON, on 6/7/2023, at 11:11a.m., the DON stated Resident 1 had a known history of mood swings and aggressive behavior. The DON confirmed Resident 1 allegedly place his hands around the neck of Resident 3 in mid- May 2023, and had another incident of displaying aggression with another resident (Resident 6) in January of 2023. The DON stated if he (DON) was made aware about the SSA 1's notes regarding Resident 1's not wanting to be in the Grove unit and feelings of hitting another resident, he would have held an Interdisciplinary Team (IDT) meeting and implemented Certified Nurse Assistant (CNA) 1:1 (intervention aimed to keep patients safe through direct observation by staff) behavior monitoring. The DON stated that SSA 1 should have made him (DON) aware during the daily staff huddles and group texts.
During a phone interview with CNA 1, on 6/7/2023 at 12:41p.m., CNA 1 stated that he was called twice during the morning shift (7 a.m. to 3 p.m.) to assist Licensed Vocational Nurse 1 (LVN 1) with the administration of medications to Resident 1. CNA 1 stated Resident 1 was being aggressive and did not want to take his medications. CNA 1 confirmed Resident 1 was agitated and verbally aggressive on and off throughout the morning shift, starting at 10 a.m.
During an interview with LVN 3, on 6/7/2023, at 2:52 p.m., LVN 3 stated that she was working the 3 p.m., to 11 p.m. shift as the desk nurse on 6/5/2023. LVN 3 sated she was endorsed that Resident 1 was being verbally aggressive and tried hitting staff on the previous shift (7 a.m. to 3 p.m.). LVN 3 stated she was aware of Ativan order prn but Resident 1 was calm while she (LVN 3) made her rounds at the shift change. LVN 3 stated Resident 1 had another outburst of aggression around 5 p.m., but Ativan was not given. LVN 3 stated Resident 1 was aggressive toward staff, but not his roommates. LVN 3 stated Resident 1 should have been put on 1:1 monitoring and the incident with Resident 2 probably would have not happened.
During an interview with the Social Worker (SW 1), on 6/8/2023, at 9:34 a.m., SW 1 stated Resident 1 was loud, rude and disrespectful and went off on me one time. SW 1 stated if a resident had verbalized a wish to transfer out of a certain unit and verbalized a feeling to hit someone, we would get the team together, do an interdisciplinary team ([IDT]a group of professionals working together toward a common goal) meeting, and would notify the DON as it was a safety issue.
During a concurrent interview and review of Resident 1's the licensed nurses progress notes (NPN) on 6/8/2023, at 3:40 p.m., with LVN 1, the NPN dated 6/5/2023 indicated Resident 1 was having aggressive behavior trying to attack staff with no physical contact. LVN 1 confirmed that she documented in NPN and had witnessed Resident 1's episode of aggression at 5 p.m. on 6/5/2023. LVN 1 stated she did not administer Ativan to Resident 1 for agitation as ordered. LVN 1 stated that LVN 2 had the keys to access the medication and she had only documented the incident to help out. LVN 2 stated that she endorsed the keys to LVN 1 and LVN 3 before leaving.
During an interview with the DON on 6/8/2023 at 4:07 p.m., the DON stated Resident 1 should have been closely monitored given Resident 1's history of aggression. The DON stated that everyone in the facility is responsible for the safety of the residents.
During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents (undated), the P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P also indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.
During a review of the facility's P&P titled, Abuse and neglect clinical protocol (undated), the P&P indicated, the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.
During a review of the facility's P&P titled, Resident Rights, (undated), the P&P indicated, the residents shall be free from abuse, neglect, misappropriation of property, and exploitation.
During a review of the facility's P&P titled, Resident-to-resident altercations, (undated), the P&P indicated, facility staff are to monitor residents for aggressive inappropriate behaviors towards other residents, family members, visitors, or to the staff.
During a record review of the facility's Job description (JD): Social Services Assistant (SSA), dated 1/2019, the JD indicated the SSA is to assist with providing medically related social services so that the highest practicable physical, mental, and psychosocial well-being of each resident is attained or maintained. The job description also indicated the SSA is to meet with department personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services.