Every finding on record at ACC Care Center

Based on observation, interview, and record review the facility failed to meet professional standards of clinical practice when the International Dysphagia Diet Standardization Initiative (IDDSI) had not been adopted, and instead the facility used the obsolete National Dysphagia Diet for a census of 91 residents. This failure had the potential of leading to choking as well as weight loss due to unsafe oral intake.Findings:During an interview with the Certified Dietary Manager (CDM) on 8/10/26 at 8:42 a.m., the CDM stated that the modified textured diets the facility used were the National Dysphagia Diets (NDD). The CDM further stated that the facility did have access to IDDSI menus through the menu company they used, but they had not implemented the IDDSI diet yet. Review of the lunch meal diet orders for 8/11/26 included NDD modified textured diet orders solely. Review of the iddsi.org website indicated that The International Dysphagia Diet Standardisation Initiative (IDDSI) is . a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties. To accompany this standard, IDDSI has also developed testing methods to determine if any food or drink conforms to the requirements of the IDDSI Standard.Review of the Academy of Nutrition and Dietetics website (eatrightPRO.org) indicated that The Academy of Nutrition and Dietetics, the Association of Nutrition & Foodservice Professionals and the American Speech-Language-Hearing Association support ongoing interprofessional collaborative practice to implement the International Dysphagia Diet Standardization Initiative since its official launch in May 2019 in the United States. IDDSI is an international collaboration of professionals who developed a standardized framework for labeling texture-modified foods and thickened liquids.which affects an estimated 560 million people worldwide.It is imperative that all healthcare providers globally implement IDDSI, both to ensure patient safety and to maintain current standards of practice. The Academy of Nutrition and Dietetics is pleased to announce beginning October 2021, IDDSI will be the only texture-modified diet recognized by NCM (Nutrition Care Manual). The National Dysphagia Diet and associated resources will no longer be included in the NCM past October 2021.Review of the American Speech-Language-Hearing website [NAME].org indicated The International Dysphagia Diet Standardization Initiative (IDDSI) .is designed to avoid the confusion created by variable terminology and definitions to describe modified diets around the world. IDDSI's goal is to improve the safety and care for all individuals with dysphagia, across all cultures.

Based on observation, interview, and record review, the facility failed to meet the care needs of one of 20 sampled residents (Resident 59) when staff did not provide the physician ordered one to one (1:1) feeding assistance for Resident 59 during meals and fluid consumption.This failure had the potential to place Resident 59 at risk for aspiration.Findings:A review of Resident 59's medical record indicated the resident had diagnoses that included type 2 diabetes mellitus (high blood sugar); dysphagia, oropharyngeal phase (difficulty swallowing food or liquids from the mouth into the throat); and senile degeneration of the brain (age related deterioration or decline of brain function).A review of Resident 59's Brief Interview for Mental Status (BIMS, a short test used to check a person's memory, thinking and awareness of time), dated 6/3/26, indicated a BIMS score of 0/15, which means Resident 59 had severely impaired memory, thinking, and awareness.A review of Resident 59's Order Summary Report (OSR) dated 7/1/26 indicated, ASPIRATION PRECAUTIONS: SUPERVISED MEALS AT ALL TIMES MAINTAIN HIGH FOWLER'S DURING ALL MEALS AND CONSUMPTION OF LIQUIDS. OBSERVE FOR SIGNS OF ASPIRATION (COUGHING, SOB, WET/GURGLY VOICE). NO WATER PITCHER AT BEDSIDE; LIQUIDS MUST BE GIVEN SUPERVISED every shift The OSR dated 7/2/26 indicated the following diet order, Carb Control diet, pureed texture, nectar fluid consistency. The directions indicated, Direct supervision, 1:1 feed assist. Pt [Resident] cleared to use straws. Small bites/small sips. Assure complete swallow. Increased time to eat and swallow.A review of Resident 59's Speech Therapy (ST) notes dated 7/2/26 at 9:25 a.m., the ST notes indicated, ST recommends pureed textures, nectar thickened liquids. ST updated PCC [PointClickCare, an electronic healthcare software], nursing, and kitchen. Direct Supervision, 1:1 feed assist. Pt [Resident] cleared to use straws. Small bites/small sips. Assure complete swallow. Increased time to eat and swallow.During a concurrent observation and interview on 8/10/26 at 11:15 a.m. in Resident 59's room, Resident 59 was observed drinking nectar thickened fluid and clearing his throat after each sip. Certified Nursing Assistant (CNA) 1 entered the room and stated that Resident 59 was able to drink and eat without full assistance and required set up only.During a concurrent observation and interview on 8/10/26 at 12:00 p.m. in the dining hall, Resident 59 was observed dozing off while eating, without 1:1 assistance. The Director of Staff Development (DSD) stated that Resident 59 often became sleepy while eating and that staff would check on the resident.During an observation on 8/11/26 at 8:18 a.m. and again at 11:50 a.m. in the dining hall, Resident 59 was observed eating his meals without 1:1 assistance.During a concurrent interview and record review with the DSD on 8/11/26 at 12:09 p.m. in the dining hall, the DSD reviewed the physician's orders for 1:1 feeding assistance and aspiration precautions. The DSD stated that he was not aware of the requirement for 1:1 feeding assistance.During an interview on 8/11/26 at 1:15 p.m., the Speech Language Pathologist (SLP) stated that, based on the evaluation completed for Resident 59 on 7/2/26, staff were required to provide 1:1 supervision during all meals to prevent aspiration or choking.During an interview on 8/12/26 at 2:56 p.m., the Assistant Director of Nursing (ADON) stated that if there was an order for one to one feeding assistance, her expectation was that the CNA would remain with Resident 59 and assist throughout the entire meal immediately upon receiving the meal tray so the CNA could notify and request help if the resident showed signs of coughing or choking.The Department requested the facility's policy regarding 1:1 Feeding Assistance or Meal Assist. The facility was unable to provide a policy.

Based on observation, interview and record review, facility food was not stored and prepared in accordance with professional standards for food service safety when: Two open packages of pasta did not have a use-by dates, Expired almond extract had not been discarded and was available for use, The reach-in refrigerator and food contents were above the safe temperature for preventing food borne illness, A cooked spaghetti noodle was found in the cook's utensil drawer, and A cart holding cooking equipment had a discolored, rough metal ledge.These failures had the potential of leading to food-borne illness for the 91 individuals eating facility prepared meals.Findings:During the initial kitchen tour on 8/10/26 at 9:05 a.m., in the dry storeroom, two out of eight bags of pasta (a bag of spaghetti opened 8/9/26 and a bag of macaroni opened 4/6/26) were observed without use-by dates.During a subsequent interview with the Certified Dietary Manager (CDM) on 8/10/26 at 9:24 a.m., the CDM indicated that it was his expectation that dietary staff label opened products with not only an open date but also a use-by date, to facilitate discarding food before it became unsafe.Review of facility provided policy titled Labeling and Dating of Foods (Health Menus Direct, LLC. 2023) indicated that All food items in the storeroom . need to be labeled and dated. In this policy under the Procedure section, it further indicated that Newly opened food items will need to be . labeled with an open date and used by . date .2. During the initial kitchen tour on 8/10/26 at 9:16 a.m. in the dry storeroom, a bottle of Almond extract had a use-by date of 7/15/26 but was still on the shelves and available for use. During a subsequent interview with the CDM on 8/10/26 at 9:24 a.m., the CDM indicated that it was his expectation that all dietary staff were responsible for discarding expired food products.Review of facility provided policy titled Labeling and Dating of Foods (Health Menus Direct, LLC. 2023) indicated under the Procedure section that Newly opened food items will need to be . labeled with an open date and used by the date that follows the various storage guidelines . Review of US Food and Drug Administration's (FDA) 2022 Food Code section 3-501.17 on . Date Marking indicated that (A) . food . shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. 3. During the initial kitchen tour on 8/10/26 at 9:33 a.m. at the cook's reach in-refrigerator, the temperature gauge was observed at 44 degrees Fahrenheit (F, a unit of measurement). Two food products (shredded egg and cottage cheese) were removed from the refrigerator to determine if their temperatures were within the safe range. Both the egg and cottage cheese had temperatures of 44 degrees F. During a concurrent interview with the CDM, the CDM confirmed the temperatures were above the safe range of 41 degrees F or lower.Review of the temperature log for August (hanging on the front of the refrigerator) was observed to have multiple temperature recorded above 41 degrees F including:8/3=46 degrees F at 7:07 p.m.,8/4=45 degrees F at 7:45 p.m.,8/7=44 degrees F at 7:10 p.m.,8/8=45 degrees F at 7:50 p.m., and8/9=47 degrees F at 7:46 p.m. The log indicated 5 entries (out of 19) that were outside of the safe temperature range for food, yet none of the entries indicated any actions had been taken. The CDM confirmed he had not been notified. The CDM stated that potential actions included notifying himself as well as the maintenance department and moving food to a refrigerator that was within the safe temperature range.Review of US FDA's 2022 Food Code section 4-501.11 on Good Repair and Proper Adjustment indicated (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 4. During the initial kitchen tour on 8/10/26 at 9:51 a.m., a cooked spaghetti noodle was observed in the cook's utensil drawer along with ladles and other serving utensils. During a concurrent interview the CDM confirmed that the cooked noodle should not have been in the utensil drawer. Review of facility provided policy titled Cleaning Schedules ([NAME] Corporate Dietitians, revised 03/01/2014) indicated that The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the community by the Dietary Manager. Under the Procedure section it further indicated that: . 2. A cleaning schedule shall be posted with tasks designated to specific positions in the department.3. All tasks shall be addressed as to frequency of cleaning. Review of the facility provided ACC Dietary Kitchen Daily Cleaning List indicated to Clean and Organized under counters in tray line area daily. During a review of the facility menu, spaghetti was not listed on for any meals on that day or the day prior.Review of US FDA's 2022 Food Code section 4-601.11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The objective of cleaning focuses on the need to remove organic matter from . nonfood contact surfaces so that pathogenic (disease causing) microorganisms (a tiny living thing such as bacteria, viruses, and fungi) will not be allowed to accumulate and insects and rodents will not be attracted.5. During the initial kitchen tour on 8/10/26 at 10:12 a.m. a metal cart holding kitchen equipment was observed with white discoloration and a rough texture on the bottom metal ledge. During a concurrent interview with the CDM, the CDM confirmed the discoloration.Review of US FDA's 2022 Food Code section 4-101.19 on Nonfood-Contact Surfaces indicated that Nonfood-Contact Surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. 'Corrosion-resistant material' means a material that maintains acceptable surface cleanability characteristics under prolonged influence of the food to be contacted, the normal use of cleaning compounds and sanitizing solutions, and other conditions of the use environment.

Based observation, interviews, and a review of facility records, the facility failed to implement a care plan intervention for one of three sampled residents (Resident 1) with history of falls when fall mats were not in place at Resident 1's bedside.This failure had the potential to increase Resident 1's injury related to falls. Findings:Resident 1 was admitted to the facility in January of 2026 with diagnoses which included orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities) and fracture of the pelvic.A review of Resident 1's Progress Notes (PN) dated 4/1/26 indicated, Patient does not have capacity to make medical decisions.A review of Resident 1's Care Plan (CP) dated 3/1/26 showed that Resident 1 experienced an unwitnessed fall on that day, prompting implementation of fall precautions. The care plan dated 3/17/26 noted that Resident 1 sustained a fall resulting in a minor head injury. Additionally, a care plan dated 3/24/26 documented a witnessed fall in which Resident 1 hit her head on the floor and was transferred to the emergency department for evaluation, with ongoing fall precautions maintained.A review of the facility document titled Incidents By Incident Types, dated 4/2/26, revealed that Resident 1 experienced unwitnessed falls on 3/1/26 and 3/17/26. The record further indicated an additional witnessed fall involving Resident 1 on 3/24/26.A review of the Resident 1's PN dated 3/1/26 indicated, @ [at] approx [approximately] 5:05 a.m., RN [Registered Nurse] and CNA [Certified Nursing Assistant] immediately went to check noise from room [ROOM NUMBER]. Upon entering room, resident was observed on floor directly next to bed.Res fell on the L [Left] side of bed.fall mat was place on R [Right] side of the bed.A review of the Resident 1's PN dated 3/17/26 indicated, The Change in Conditions.Resident was found on the floor in her room by the door, lying on her right side by wound nurse. Noted with laceration 2cm [centimeter, a unit of measurement] to the right side of the head.A review of the Resident 1's Hospital Document titled Discharge Summary,' dated 4/1/26, indicated, Date of admission: [DATE] 8:49 p.m.Diagnoses: Possible syncopal episode [Temporarily lose consciousness].Orthostatic hypotension [a form of low blood pressure that happens when standing after sitting or lying down].Acute distal left clavicular fracture [a break in the collarbone].Report: XR [x-ray] Shoulder 2+ views.IMPRESSION: Acute distal left clavicular fracture. 03/25/26During a concurrent observation and interview on 4/2/26 at 12:14 p.m., with Resident 1's family member inside the residents room. The family member confirmed that there were no fall mats in place at Resident 1's bedside and stated that the fall mats should have been placed for Resident 1's safety.During a concurrent observation, interview, and record review on 4/2/26 at 12:37 p.m., with License Nurse (LN 1), it was confirmed that fall mats were not in place for Resident 1. LN 1 confirmed Resident 1's history of falls within the facility and emphasized the significance of having fall mats in place to ensure resident safety. LN 1 also stated that Resident 1 was placed on fall precautions, with fall mats being one of the safety measures used.During an interview with the Quality and Compliance Coordinator (QC), who was also an LN, on 4/2/26 at 4:04 p.m., the QC indicated that following a fall incident, a Change in Condition (CIC) should be documented for the resident, and care plans should be updated to include fall precautions. The QC further explained that fall precautions involve ensuring call lights were within reach, the bed was in its lowest position, and a fall mat was properly placed. The QC also added that the fall mat should have been positioned at Resident 1's bedside and stated that while it did not prevent falls, it served to reduce the severity of potential injuries.A review of the facility Policy and Procedure titled, Care Plans, Comprehensive Person-Centered revised 03/2022 indicated, A comprehensive, person-centered care plan .meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .receive the services and/or items included in the plan or care .

Based on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1), when Resident 1 was left alone in the shower room two times by a Certified Nursing Assistant (CNA 1). This failure resulted in Resident 1 not being supervised while in the shower room increasing the risk potential for accidents for the resident. A review of Resident 1's clinical record indicated, Resident 1 was admitted in March of 2026 with a diagnosis of encounter for orthopedic aftercare.A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 3/17/26 indicated Resident 1 was cognitively intact.During an observation and interview on 4/2/26 at 12:09 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting in her wheelchair with her right leg raised. Resident 1 stated a CNA (CNA 1) left her alone in the shower room twice to get her a brush.During a telephone interview on 4/2/26 at 1:23 p.m. with CNA 2, she stated that she witnessed CNA 1 leave Resident 1 in the shower room alone at least once during her shift.During a review of CNA 1's statement dated 3/22/26, the statement indicated, .I went to supply closet grabbed a brush . she stated that I have a blue brush in my dresser in my room can you grab it . I grabbed the brush . I returned back to shower room .During a telephone interview on 4/2/26 at 1:42 p.m. with CNA 1, CNA 1 stated she left Resident 1 in the shower room alone to grab a brush from the central supply room. CNA 1 further stated she left Resident 1 alone in the shower room a second time to get Resident 1 a brush from Resident 1's room.During an interview on 4/2/26 at 2:54 p.m. with Licensed Nurse (LN 1), LN 1 stated no resident should be left alone in the shower room. LN 1 further stated a resident 1 could have an accident or a fall and get hurt without supervision in the shower room.During an interview on 4/2/26 at 3 p.m. with Nurse Manager (NM), the NM stated the expectation was that no resident was to be left alone in the shower room unattended by staff. NM stated it is a safety risk.During a review of facility policy and procedure (P&P) titled, .Bath/Shower. dated 2001, the P&P indicated, .Stay with the resident throughout the bath. Never leave the resident unattended in the . shower.During a review of facility P&P titled, .Safety and Supervision of Residents. , dated July 2017, the P&P indicated, .Resident supervision is a core component of the systems approach to safety.

Based on observation, interview, and record review, the facility failed to ensure two of 34 sampled residents (Resident 102 and Resident 8) received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plans, when:1.The facility did not follow Resident 102's physician's order for Speech Therapy evaluation and treatment (ST or SLP, a Speech Language Pathologist; an assessment and treatment of swallowing disorders) and did not follow ST recommendations from prior assessment;2. Resident 8's hold parameters for blood pressure (BP) medications were not followed as ordered; and,3. Resident 8's weight changes were not reported to the physician as orderedThese failures placed Resident 102 at risk for complications related to her swallowing and had the potential to affect Resident 102 and Resident 8's health and safety. Findings: 1.A review of the admission Record indicated the facility admitted Resident 102 in 2024 with multiple diagnoses which included dementia (impairment of brain function including loss of memory and judgment) and dysphasia (difficulty or inability to swallow). A review of Resident 102's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/7/25 indicated the resident's cognition was severely impaired. A review of Resident 102' Order Summary Report contained a physician order dated 6/26/25 which indicated, ST eval [evaluation] and treatment. A review of Resident 102's clinical records had no documented evidence that the physician order for speech therapy was followed. There was no documented evidence that the physician was informed that Resident 102 did not receive swallowing evaluation since 6/26/25 as prescribed. A review of Resident 102's clinical records revealed Speech Therapy Evaluation and Plan of Care that was completed 7/2/24. The ST evaluation indicated that Resident 102 had swallowing problem and had history of coughing and choking with meals. The ST documented that the resident was referred to ST services for dysphasia due to need for assistance with meals and risk for aspiration. Speech Therapy treatment was completed on 7/12/24 and the discharge summary indicated, To facilitate safety .it is recommended the patient uses the following strategies .during oral intake: general swallow techniques/ precautions .alteration of liquids/solids upright posture during meals.Supervision for Oral intake=Close supervision. A review of Resident 102's 'Risk for aspiration' care plan dated 7/2/24 indicated that the resident will not experience sign and symptoms of aspiration [aspiration is a major risk of dysphasia, where food or liquids enters the lungs which can lead to infection] given implementation of swallow strategies and environmental modifications (feed assist/supervision). During an observation on 9/2/25, at 9:25 a.m., Resident 102 was observed in her bed eating her breakfast independently. The sign on the wall above the resident's head indicating 'Swallowing Guidelines' was observed hanging upside down and folded in half. During a concurrent observation and interview on 9/2/25, at 9:29 a.m., Certified Nursing Assistant CNA 1) lifted the sign and explained that the sign did not have the resident's name, but it listed Resident 102's son phone number. CNA 1 stated, It does say 1:1 assistance/supervision during meal. CNA 1 stated he was not aware of any swallowing precautions for Resident 102 and added, She always eats by herself, not sure why there is a sign that she needs assistance with feeding. Might be outdated. CNA 1 stated that the resident ate her meals in bed most of the time. During an interview with Restorative Nursing Assistant (RNA 3) on 9/3/25, at 10:20 a.m., RNA 3 stated, The resident always eats in her room independently. Not aware of any swallowing issues, not aware of aspiration precautions.Not seen her coughing or choking. Usually, nurses tell us if any changes in residents or any precautions. During phone interview with Speech Therapist (ST) on 9/3/25, at 4:23 p.m., the ST stated she could not recall if Resident 102 had swallow evaluation and treatment completed in the last 6 months. The ST added that the facility would contact her if the resident had ST evaluation ordered by physician but could not recall if she was contacted. During a concurrent interview and record review on 9/5/25 at 8:50 a.m., the Director of Nursing (DON) validated that Resident 102's physician ordered ST evaluation and treatment on 6/26/25. The DON stated, ST evaluation not done. Not sure what happened, obviously miscommunication. During a continued interview on 9/5/25 at 8:50 a.m., the sign with Swallowing Guidelines posted on the wall was discussed. The DON stated she was not aware of aspiration precautions for Resident 102 since her diet was changed from mechanical chopped to regular diet on 6/30/25. Upon reviewing ST evaluation completed 7/2/24 and ST discharge summary and swallowing recommendations related to aspiration precautions dated 7/12/24, the DON did not provide the answer if the 'Swallowing Guidelines' from previous ST evaluation dated 7/12/24 were to be followed. The DON did not provide documented evidence that the resident's 'Swallowing Guidelines' were discontinued. A review of the facility's policy titled, Dysphasia – Clinical Protocol, revised 9/17, indicated, The staff and physician will identify individuals with a history of swallowing difficulties or related diagnoses such a dysphasia.Based on information collected.the staff and practitioner, in conjunction with SLP [Speech Language Pathologist/ST] will define the situation carefully.will identify and document pertinent information.The staff and physician will identify and address any complications of swallowing disorders and their underlying causes. 2. During a review of Resident 8's admission records, the records indicated Resident 8 was admitted to the facility in April 2025 with diagnoses that included atherosclerotic heart disease (reduction of blood flow due to a build-up of plaque in the arteries of the heart), heart failure, and hypertension (high blood pressure). Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 8 was cognitively intact. During a review of Resident 8's care plan, dated 4/23/25, the care plan indicated, Resident admitted with cardiac instability r/t [related to] CHF [Congestive Heart Failure, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling].HTN [hypertension].Minimize risks of cardiac complications.Medications as ordered. During a review of Resident 8's Medication Administration Record (MAR), the MAR indicated an order for Carvedilol ( a medication that relaxes blood vessels and slows the heart rate to improve blood flow and decrease blood pressure) 6.25 mg (milligrams, a unit of measurement) two times a day for CHF, hold for SBP (systolic blood pressure, the pressure in the arteries when the heart contracts and pumps blood) less than 110 and/or HR (heart rate) less than 60. The MAR indicated Resident 8's carvedilol was given on the following dates with the corresponding blood pressures: - 7/7/25 – 105/58 mmHg (millimeters of mercury, a unit of pressure measurement) - 7/13/25 – 108/62 mmHg - 7/17/25 – 104/55 mmHg During a review of Resident 8's MAR, the MAR indicated an order for Valsartan (used to relax blood vessels, which lowers the blood pressure and makes it easier for the heart to pump blood) 40 mg half tablet two times a day, hold if SBP is less than 105. The MAR indicated Resident 8's valsartan was given on the following dates with the corresponding blood pressures: - 7/14/25 – 100/58 mmHg - 8/3/25 – 102/67 mmHg - 8/8/25 – 102/56 mmHg - 8/24/25 – 97/59 mmHg During a concurrent interview and record review on 9/4/25 at 3:32 p.m. with the Director of Nursing (DON), the DON confirmed Resident 8 received carvedilol and valsartan outside the physician-ordered hold parameters on multiple days in July and August 2025. The DON stated the expectation was for staff to follow physician orders and stated that giving the medications could lead to Resident 8's BP to become too low. During a review of the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, dated 3/2018, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.B. Administration.2) Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled Hypertension – Clinical Protocol, dated 11/2018, the P&P indicated, .1. In conjunction with the patient, family, and staff, the physician will establish targets for blood pressure treatment, monitoring, and reporting.4. The staff and physician will monitor for complications of blood pressure treatments.a. Over-treating blood pressure may increase the risk of significant side effects and complications, such as falling and fractures, especially in compromised or frail individuals. 3. During a review of Resident 8's physician order, dated 7/17/25, the order indicated, Daily weights. Notify MD [Medical Doctor] of weight change of 2 lbs [pounds, a unit of weight measurement] or more in 24 hours, or 5 lb [sic] in 1 week every day shift. During a review of Resident 8's MAR for August 2025, the MAR indicated Resident 8's weight on 8/11/25 was 174.2 lbs and 180.4 lbs on 8/12/25 which had a 6.2 lbs difference in 24 hours. The MAR further indicated Resident 8's weight was 180.4 lbs on 8/20/25 and went up to 186 lbs on 8/25/25 which was 5.6 lbs difference in five days. The MAR also indicated that Resident 8 had a 4 lbs weight change in 24 hours with a weight of 186 lbs on 8/31/25 and 182 lbs on 9/1/25. During a concurrent interview and record review on 9/4/25 at 3:32 p.m. with the DON, the DON confirmed the physician's order for Resident 8's daily weight and for the physician to be notified for weight changes of 2 lbs in 24 hours and 5 lbs in a week. The DON confirmed there was more than 6 pounds difference on Resident 8's weight on 8/11/25 and 8/12/25 and could not find documentation of physician notification. The DON further confirmed Resident 8 had more than 5 lbs gain between 8/20/25 and 8/25/25 and when asked if there were any documentation on physician notification, the DON stated, I don't see anything around that date. The DON stated, Expectation is that they [staff] follow the doctor's order, [Resident 8] could have a significant change of condition and doctor might have put interventions and didn't give him [the doctor] the opportunity [to intervene]. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following:.(4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition.and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing - State of California Department of Consumer Affairs).

Based on interview and record review, the facility failed to ensure adequate catheter care was provided for two of 34 sampled residents (Resident 4 and Resident 8) when: 1. Resident 4's straight catheter (intermittent catheter- use of thin, hollow tube to drain urine from the bladder) was not accurately documented, care planned and evaluated for continued use; and 2. Resident 8's suprapubic catheter (a tube inserted directly into the bladder to drain urine) care and monitoring were not done as ordered. These failures increased the risk for Resident 4 and Resident 8 to develop trauma and bladder infection. Findings: 1.A review of the admission Record indicated Resident 4 was admitted [DATE] with diagnoses including cerebral infarction (ischemic stroke- blood flow to the brain is suddenly blocked) and malignant neoplasm of the prostate (cancer or uncontrolled growth of cells in the prostate [part of the male reproductive system located below the bladder]). A review of Resident 4's physician order dated 8/19/25 indicated an order for straight catheter every shift and to monitor for urinary retention and signs & symptoms of urinary tract infection (UTI or bladder infection). A review of Resident 4's Medication Administration Record (MAR) for August indicated Resident 4's indwelling urinary catheter (foley catheter) was removed on 8/18/25 and a straight catheter was ordered on 8/19/25. Further review of Resident 4's MAR for August indicated the following: -straight catheter order was marked 2 or Drug Refused three times; -straight catheter was marked 5 or Hold/See Progress Notes nine times; and, -straight catheter was marked 9 or Other/See Progress Notes ten times. A review of Resident 4's 'Administration Note' dated 8/19/25 at 8:50 p.m. [20:50] indicated Resident 4 refused straight catheter three times and Resident 4 verbalized I don't want anything inserted in me right now. I've been doing good on my own. A review of Resident 4's 'Health Status Note' dated 8/25/25 at 6:46 a.m. [06:46] indicated, [Resident 4] is able to void on his own. Refused the straight cath [sic] on NOC [night] shift.No straight cath [sic] done. Message MD [Medical Doctor] to discontinue Q shift straight cath. The physician acknowledged said note on 8/27/25 and wrote Noted, Monitor and below the physician note was a signature from a licensed staff. A review of Resident 4's MAR for September indicated the straight catheter order had a check mark on 9/1 (all shifts) 9/2 (day and night shift) and 9/3 for day shift. During an interview on 9/3/25 at 8:43 a.m., Licensed Nurse 1 (LN 1) confirmed Resident 4 did not have a catheter. A concurrent interview and record review was conducted with LN 1 on 9/3/25 at 2:18 p.m. The LN 1 confirmed she placed a check mark on Resident 4's straight catheter order on 9/2 and 9/3. LN 1 stated she did not perform straight catheter on those days since Resident 4 was able to urinate or void on his own and she did not document correctly. LN 1 further stated the order for straight catheter should have been discontinued and it was their responsibility to notify the physician if Resident 4 had been urinating without the use of catheter. A concurrent interview and record review was conducted with LN 2 on 9/4/25 at 3:39 p.m. The LN 2 stated if Resident 4's straight catheter order had 2, 5, and 9 marked in the MAR, this indicated the procedure was not performed. The LN 2 further stated, the physician should have been notified of Resident 4's voiding status. During a concurrent interview and record review on 9/5/25 starting at 9:30 a.m. with the Assistant Director of Nursing (ADON) the ADON stated Resident 4 pulled out his foley catheter and had blood in the urine. The ADON confirmed Resident 4 had no care plan for the straight catheter. The ADON stated the risk for infection is higher when a straight catheter is performed. The ADON further confirmed there were multiple episodes wherein Resident 4 did not require straight catheterization. The ADON further stated if she was the nurse caring for Resident 4, she would ask the physician to discontinue the straight catheter order to prevent trauma and infection. The ADON further stated the physician's response to the 'Health Status Note dated 8/25/25 was not clear, the licensed nurse who carried out the note should have clarified the physician's response. The ADON added she expected documentation in the MAR to be accurate and timely and straight catheter order should be individualized based on resident's need. A review of the facility's policy & procedure (P & P) revised March 2022, titled Care Plans, Comprehensive Person-Centered indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical.and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the facility's P & P revised August 2022 and titled Catheter Care, Urinary indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Review the resident's care plan.Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter.Notify the supervisor if the resident refuses the procedure. A review of the facility's P & P revised July 2017 and titled Charting and Documentation, indicated, All services provided to the resident.any changes in the resident's medical, physical, functional.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.Documentation .will be objective.complete, and accurate. 2. During a review of Resident 8's admission records, the records indicated Resident 8 was admitted to the facility in April 2025 with diagnoses that included chronic kidney disease stage 3 (moderate kidney damage) and neuromuscular dysfunction of bladder (a condition where the nerves and muscles that control the bladder function are impaired, leading to abnormal urination). During a review of Resident 8's care plan, revised on 7/3/25, the care plan indicated, Resident has SUPRAPUBIC Catheter.observe for s/s [signs and symptoms] of infection or changes in skin around site.Provide suprapubic cath [sic] care.Suprapubic insertion site management daily and PRN [as needed]. During a review of Resident 8's physician order, dated 4/13/25, the order indicated, MONITOR FOR SIGNS AND SYMPTOMS OF (FOUL SMELL, DISCHARGE, CLOUDY URING PRESENTATION) Document NUMERICAL VALUE FOR AMOUNT OF UTI INDICATIONS, FOUL SMELL, CLUDY [sic] URINE, DISCHARGE PRESENT every shift. During a review of Resident 8's Medication Administration Record (MAR), the MAR indicated the monitoring for signs and symptoms of UTI were not done on night shift of 7/4/25, and morning shifts of 7/10/25, 7/11/25, 8/5/25, 8/7/25, 8/21/25, and 8/29/25. During a review of Resident 8's physician order, dated 7/3/25, the order indicated, Suprapubic insertion site management: Cleanse with NS [normal saline, a mixture of salt and water], pat dry, cut a slit on calcium alginate [a dressing that promotes wound healing] and 4x4 bordered dressing and place around insertion site. every day shift for suprapubic catheter management. During a review of Resident 8's MAR for August 2025, the MAR indicated the insertion site management for Resident 8's suprapubic catheter was not done on 8/21/25 and 8/26/25. During an interview on 9/4/25 at 8:47 a.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed Resident 8 had a suprapubic catheter in place and stated, Important to make sure we have eyes on insertion site, no sign and symptoms of infection, can be a breeding ground for bacteria, especially for suprapubic catheter. During a concurrent interview and record review on 9/4/25 at 3:32 p.m. with the Director of Nursing (DON), the DON confirmed Resident 8's suprapubic catheter insertion site care was not done on 8/21/25 and 8/26/25, and Resident 8's monitoring for signs and symptoms of UTI were not done on multiple days in July and August 2025. The DON stated the expectation was that staff follow physician orders. The DON further stated there was a risk of infection for Resident 8 because .we might miss them if were not monitoring them. During a review of the facility's policy and procedure titled Catheter Care, Urinary, revised 8/2022, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately.e. if signs and symptoms of urinary tract infection or urinary retention occur.The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given.3. All assessment data obtained when giving catheter care.8. If the resident refused the procedure, the reason(s) why and the intervention taken.

Based on observation, interview, and record review, the facility failed to ensure the medication rate was below 5% for two of 34 sampled residents (Resident 110 and Resident 45) when:1) Licensed Nurse 1 (LN 1) administered the wrong dose of physician ordered medication;2) LN 1 prepared medication for administration with disregard for manufacturer specifications;3) LN 1 administered medication not in accordance with physicians order and manufacturer specifications; and,4) A medication was not available for timely administration by LN 8.As a result, 4 errors were identified out of 33 opportunities for error during the observation of medication administration; the facility medication error rate was 12.12%.Findings:1) During an observation on 9/2/25, at approximately 9:36 a.m., in the hallway outside Resident 110's room, LN 1 was observed preparing and administering 81 milligrams (mg, a unit of measurement) of enteric coated (a protective layer covering the tablet to prevent dissolving in the stomach) aspirin (a medication used to lower the risk of heart attacks and strokes) tablet for oral administration to Resident 110.During a record review of Resident 110's medication order dated, 8/27/25, indicated, Aspirin Oral Tablet Delayed Release 325 mg.During an interview with LN 1 on 9/2/25, at approximately 10:02 a.m., LN 1 stated s/he mistakenly administered 81 mg of enteric coated aspirin instead of the ordered 325 mg.During an interview with the Director of Nursing (DON) on 9/3/25 at approximately 2:20 p.m., DON stated LNs are expected to follow physician orders.During an interview on 9/4/25 at approximately 2:46 p.m. with the facility Consultant Pharmacist (CP), the CP stated, LNs are expected to follow physician orders. A dose higher than 81 mg promotes greater blood vessel health, maintenance, and greater stroke prevention.During a record review of the facility's Policy and Procedure (P&P) for Medication Administration-General Guidelines, dated March 2018, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.2) During an observation of medication preparation and administration on 9/2/25 at approximately 9:20 a.m., in the hallway outside Resident 110's room, LN 1 was observed cutting and administering Resident 110's buprenorphine 2 mg / naloxone 0.5 mg sublingual film (a medication used to treat drug addiction or pain).A review of Resident 110's buprenorphine 2 mg / naloxone 0.5 mg sublingual film package label, the package label indicated, Do not cut, chew or swallow sublingual film.Reconciliation of the observation of medication administration with Resident 110's current Physician Orders indicated an order for buprenorphine 2 mg / naloxone 0.5 mg sublingual film, DISSOLVE [HALF] FILMS UNDER THE [TONGUE] IN AM AND HALF FILM IN THE PM.During an interview with LN 1 on 9/2/25 at approximately 10:03 AM, LN 1 stated the label specifies do not cut, chew, or swallow sublingual film. LN stated, the other half of the sublingual cut film is kept with the medication supply after it is cut to be administered for the next dose. During a record review of the manufacturer's medication package insert for Resident110's Buprenorphine 2 mg / Naloxone 0.5 mg sublingual film, revised June 2025, indicated, Buprenorphine and naloxone sublingual film must be administered whole. Do not cut.During an interview on 9/3/25 at approximately 2:22 p.m. with the DON, DON stated LNs should follow manufacturers' specifications on medications and ignoring manufacturers specifications can cause drug interactions and efficacy issues.During an interview on 9/4/25 at approximately 2:46 PM with the CP, the CP stated that LNs are expected to follow manufacturer specifications and that not following those specifications can result in efficacy and potency issues.3) During an observation of medication administration on 9/2/25, at approximately 9:38 a.m., in Resident 110's room, Resident 110 was observed in bed with his/her uneaten meal tray on his/her overbed table. The tray contained pancakes, cottage cheese, apple slices, glass of apple juice, and a glass of milk.During and observation of medication administration on 9/2/25 at approximately 9:42 a.m., LN 1 was observed administering methenamine hippurate (a medication used to used to help prevent and treat infections of the urinary tract) 1000 mg tablet orally to Resident 110.At approximately 9:48 AM, Resident 110 was observed refusing prescribed medicated mouthwash stating that s/he wanted it after breakfast.Reconciliation of Physician Orders for Resident 110's medication dated, 9/2/25, indicated, Methenamine Hippurate Oral Tablet 1 [gram]. Avoid citrus fruits and juices, milk/dairy.During an interview on 9/2/25 at approximately 10:15 a.m. with LN 1, LN 1 stated, s/he wasn't aware of the order to not administer the medication methenamine with milk or citrus.During an interview on 9/3/25 at approximately 2:25 p.m. with the DON, the DON stated LNs are expected to follow physician orders as well as manufacturers specifications.During an interview on 9/4/25 at approximately 2:46 p.m. with the CP, the CP stated that LNs are expected to follow physician orders as well as manufacturers specifications.According to an online publication on methenamine (oral route) - Side effects & dosage, Drugs and Supplements by the Mayo Clinic, Mayo Foundation for Medical Education and Research (a nonprofit American academic medical center focused on integrated health care, education, and research), dated 2025, indicated, Avoid most fruits (especially citrus fruits and juices), milk and other dairy products, and other foods that make the urine less acid.During a record review of the facility's P&P for Medication Administration-General Guidelines, dated March 2018, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.4) During an observation of medication administration on 9/2/25 at approximately 9:24 a.m., in the hallway outside Resident 45's room, LN 8 was observed not having Resident 45's lidocaine transdermal patch (a patch that delivers pain relieving medication through the skin) 5% (percentage, unit of measure) for administration.Reconciliation of the observation of medication administration with Resident 45's current Physician Orders dated 8/27/25 indicated, Lidocaine External Patch 5% . one time a day for lower back pain and Lidocaine External Patch 5% . one time a day for lower posterior neck pain.During an interview with LN 8 on 9/2/25 at approximately 9:26 AM, LN 8 stated that Resident 45's lidocaine 5% patch was not available for administration and that the medications should have been available for resident administration. During an interview on 9/3/25 at approximately 2:28 p.m. with the DON, the DON stated the expectation was for all medications to be available for administration for the medication pass.

Based on observation, interview, and record review, the facility to ensure medications were stored correctly, when:1) pharmaceutical products were not stored in the proper temperature range; and,2) a medication cart was left unlocked and unattendedThese failures had the potential for residents to receive medications with unsafe and reduced potency from improper storage and the potential for unauthorized residents, staff, and or visitors to misappropriate and or tamper with resident medications and supplies.Findings:1) During an observation in the facility's medication storage room on 9/3/25 at approximately 9:54 AM, after unlocking the medication refrigerator, Licensed Nurse 3 (LN 3) stated the temperature was 36 F (Fahrenheit, unit of measure) in the refrigerator which contained one box of four 20 mg methotrexate injections, two boxes of acetaminophen suppositories (medications you insert into your rectum), three boxes of hemorrhoid suppositories, one bag of hemorrhoid suppositories, and one bag of hydrocortisone suppositories. All of the medication packaging of the above medications included instructions to store at room temperature 68-77F.During a record review of the methotrexate injection package insert revised March 2020 indicated, . store at room temperature 68 to 77 F. During a record review of acetaminophen suppository package insert revised February 2016, indicated, , store at room temperature 68 to 77 F. During a record review of hemorrhoid suppository package insert Preparation H version 2.0, indicated, , store at room temperature 68 to 77 F. During a record review of hydrocortisone suppository package insert revised August 2023, indicated, , store at room temperature 68 to 77 F. During an interview on 9/3/25 at approximately 10:13 a.m. with the Assistant Director of Nursing (ADON) in the medication storage room, ADON stated that methotrexate injections and all the suppositories should be stored at room temperature in the medication carts as the potency and efficacy of these medications can be altered by storing them in the refrigerator at 36 degrees F. During an interview on 9/3/25 at approximately 2:30 p.m. with the Director of Nursing DON, DON stated storing medications at an improper temperature can lead to absorption and efficacy issues and it is best to follow manufacturer's instructions.During an interview on 9/4/25 at approximately 2:50 p.m. with the facility Consultant Pharmacist (CP), the CP stated that methotrexate injections and suppositories should be stored according to manufacturers' instructions at room temperature.During a record review of the facility's Policies and and Procedures (P&P) titled, Medication Storage in the Facility, dated March 2018, the P&P indicated, Medications requiring storage at room temperature are kept at temperatures ranging from 59 F to 86 F.2) During an observation on 9/3/25 at approximately 10:49 a.m., a medication cart was observed unattended and left unlocked in the hallway outside of a residents' room with privacy curtain drawn. No staff was observed using or monitoring the treatment cart.During an interview on 9/3/25 at approximately 10:54 a.m. with Licensed Nurse 9 (LN 9), LN 9 stated s/he the medication cart should be locked when unattended, I forgot to lock it. LN 9 stated there is an expectation to always lock the cart and close the laptop when they are left unattended.During an interview on 9/3/25 at approximately 2:33 p.m. with the DON, the DON stated that the expectation is that unattended medication carts are locked to prevent access to unauthorized residents, staff, and visitors. The [NAME] stated that if the medication cart is not within the line of sight of authorized staff, it is unattended.During a record review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the Facility, dated March 2018, the P&P indicated, Medication. carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety when: 1. Shelving surfaces on the food plating island, as well as in the walk-in refrigerator were observed to be discolored with white and/or rust-colored markings, indicating deterioration and potential contamination risk.2. Nonstick pans used in food preparation were visibly scratched, compromising the integrity of the cookware and increasing the risk of nonstick coating flaking into food.3. A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation.These failures had the potential to contribute to foodborne illness for the 93 residents who consumed meals prepared by the facility's kitchen. 1 1.During the initial kitchen tour on 9/2/2025 at 9:18 a.m., the metal shelving under the cook's station was observed with dull discoloration and loss of sheen. During this same kitchen tour on 9/2/2025 at 9:48 a.m., multiple shelves inside the walk-in refrigerator were observed with dark brown and/or rust colored markings During a return visit to the kitchen on 9/3/2025 at 9:16 a.m., the Plant Operations Manager, observed these same surfaces and confirmed that the surfaces were different in sheen and stated they cannot be cleaned properly anymore. He also observed the shelving inside the walk-in refrigerator and stated the shelving is likely not made for refrigerators, and acknowledged the rusted surfaces could not be sanitized. Review of the U.S. Food and Drug Administration (FDA) Food Code 2022, section 4-202.11 (A) indicated that multiuse food contact surfaces be smooth, free of breaks, cracks, and be accessible for cleaning. Review of the U.S. FDA Food Code 2022, section 4-101.19 indicated that non-food contact surfaces exposed to splash or food debris must also be corrosion resistant, smooth, and cleanable. Review of the FDA Food Code 2022, section 4-201.11 indicated that equipment and utensils must be durable, retain their original characteristics, and remain easily cleanable throughout their intended lifespan. If surfaces deteriorate—such as shelving with rust or discoloration—they may become difficult to clean and can harbor pathogenic microorganisms. 2. During the initial kitchen tour on 9/2/2025 at 9:31 a.m., two nonstick fry pans were observed with scratches on the nonstick coating. Review of the U.S. FDA Food Code 2022, section 4-201.11 indicated that equipment and utensils must be durable, retain their original characteristics, and remain easily cleanable throughout their intended lifespan. If surfaces deteriorate . they may become difficult to clean and can harbor pathogenic microorganisms. Additionally, equipment must be constructed to prevent parts from breaking off and becoming physical contaminants or injury hazards. Review of the U.S. FDA Food Code 2022, section 4-101.18 indicated that non-stick coatings (e.g. frying pans) were to be used with utensils and cleaners that prevent scratching or scoring. 3. During a visit to the kitchen on 9/3/2025 at 9:11 a.m., the can opener blade was observed with significant dark discoloration along the cutting edges, consistent with buildup or corrosion. Review of the U.S. FDA Food Code 2022, section 4-501.11 indicated that .(C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. It further indicated that The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury. Review of the U.S. FDA Food Code 2022, section 4-202.15 on Can Op Facility [NAME], Rajni (53015) Facility [NAME], [NAME] (52937)

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 93 when staff did not wear appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for residents on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of drug-resistant organisms during high contact resident care activities).This failure decreased the facility's potential in preventing transmission of diseases among residents and staff.Findings:1a. During an observation on 9/2/25 at 11:17 a.m. outside Resident 79's room, an EBP signage was observed posted by the door, and plastic drawers containing personal protective equipment (PPE) were observed by the entrance of the room. The Hospice Nurse (HN) was observed entering the room, did not wear PPE, pulled Resident 79's curtain and provided privacy.During an interview on 9/2/25 at 11:39 a.m. with the HN, the HN stated she checked Resident 79's skin and did wound care on the resident's right knee. The HN confirmed there was a signage posted by the door indicating Resident 79 was on EBP and confirmed she was not wearing PPE while providing direct care. The HN further stated that she was not aware that Resident 79 was on EBP. The HN added that it was important to wear PPE for infection control.1b. During a concurrent observation and interview on 9/2/25 at 3:46 p.m. with Restorative Nursing Assistant 1 (RNA 1) outside Resident 68's room, an EBP signage was observed posted by the door, and plastic drawers containing PPE were observed by the entrance of the room. RNA 1 was observed waiting by the door of the room and stated she was waiting for Resident 68 who was inside the bathroom. The bathroom call light was observed lit up, and RNA 1 went inside the bathroom to assist Resident 68 without wearing PPE.During a follow-up observation and interview on 9/2/25 at 4:08 p.m. with RNA 1 in Resident 68's room, RNA 1 was observed assisting Resident 68 to use the bathroom. RNA 1 was observed not wearing PPE. RNA 1 confirmed she was not wearing PPE while assisting Resident 68 inside the bathroom and stated, I don't think we need to use the gown for her.I just need the gloves, but she can clean herself. RNA 1 stated PPEs were important to prevent spread of infection.During an interview on 9/2/25 at 4:14 p.m. with LN 5, LN 5 stated Resident 68 had an EBP signage posted, and gown and gloves were needed when providing direct care activities including assisting in the bathroom.During an interview on 9/4/25 at 1:06 p.m. with the Infection Preventionist (IP), the IP stated that for residents on EBP, staff are expected to wear gowns and gloves if they are doing high contact care activities including assisting with toileting and wound care. The IP further stated visitors and contractors were also expected to wear the proper PPEs if they were doing direct care to residents. The IP stated, Long term patients have increased risk for MDRO [multi drug-resistant organisms - organisms that have developed resistance to multiple drugs, making infections difficult to treat], colonization is pretty common in long term facilities.During an interview on 9/4/25 at 3:32 p.m. with the Director of Nursing (DON), the DON stated the expectation is to follow the protocols especially if there was an EBP sign posted. The DON further stated wearing the proper PPE was important for preventing the potential spread of MDRO.During a review of the facility's policy and procedure (P&P) titled Policies and Practices - Infection Control, revised 7/2019, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors.During a review of the facility's P&P titled Enhanced Barrier Precautions, revised 8/2022, the P&P indicated, 1. Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:.c. transferring; d. providing hygiene;.f. changing briefs or assisting with toileting;.h. wound care (any skin opening requiring a dressing).10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

Based on observation, interview, and record review, the facility failed to ensure the needs were accommodated for 2 of 34 sampled residents (Resident 19 and Resident 2) who had impaired vision, when Resident 19's and Resident 2's call light (a device used to request assistance from facility staff) were not accessible. This failure resulted in Resident 19 and Resident 2 experiencing frustration and anxiety about not having needs met in timely manner and endangered their safety.Findings:1.A review of the admission Record indicated the facility admitted Resident 19 in 2021 with multiple diagnoses which included lung disease, muscle weakness, and blindness. A Review of Resident 19's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/7/25 indicated the resident was cognitively intact. A review of the resident's MDS vision assessment indicated Resident 19's vision was severely impaired. During a concurrent observation and interview with Resident 19 on 9/2/25, at 9:15 a.m., the resident was in his bed with breakfast tray in front of him. Resident 19 was noted to be touching around the tray with his hands and explained that was he was unable to see due to blindness. Resident 19 stated he was unable to find coffee and was waiting for his Certified Nursing Assistant (CNA). Resident started touching the bed around him and under his pillow attempting to find his call light. Resident 19 added, I can't find it [call light]. It's very frustrating and it's not the first time that I can't find my call button. Resident 19 explained, If I can't find it, I yell out for help. They don't like it, but I have no choice. Sometimes it's a simple thing like I want coffee or water, but I'm scared if its emergency, something with my breathing and I can't find my call button, it's life or death situation. Resident 19's call light was observed hanging above his head on the right side of the bed frame, lowered all the way to the floor and not accessible to the resident. During a concurrent observation and interview on 9/2/25, at 9:21 a.m., with Restorative Nurse Assistant (RNA 2) in Resident 19's room, RNA 2 confirmed Resident 19's call light was not within reach. RNA 2 stated Resident 19 was alert and able to call for assistance and validated that the resident was legally blind. RNA 2 stated resident should always have his call light near him to call for assistance because he was at high risk for falls. A review of Resident 19's 'At risk for falls' care plan indicated the resident has vision problems and poor safety awareness. One of the interventions indicated, Encourage and remind to call staff for assistance.Call light within reach. A review of Resident 19's care plan titled, [The resident] has an ADL [Activities of Daily Living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] self-performance deficit initiated on 4/7/21 indicated interventions which included, Encourage the resident to use the call bell to call for assistance.Staff to described [sic] where are his belongings are located and emphasized to ask for staff assistance. A review of Resident 19's care plan titled, Resident has behaviors of calling/yelling staff's name repeatedly.Tends to yell for his needs, initiated 3/9/23 included interventions, Anticipate resident's need [sic].Ask resident his needs before leaving the resident's room.Call light within reach. 2.A review of the admission Record indicated Resident 2 was admitted to the facility in 2024 with multiple diagnoses which included kidney failure with dependance on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), anxiety disorder and legal blindness. Resident 2's clinical record indicated the resident spoke language other than English. A review of Resident 2's MDS dated [DATE] indicated that the resident's cognition was moderately impaired, and the resident had highly impaired vision. During an observation on 9/3/25, at 4:30 p.m., Resident 2 was observed in a specialized high back wheelchair parked parallel to her bed facing other side of the room. The resident was observed sliding down the wheelchair with her legs bent. The resident kept turning her head around and was talking in her native language. The resident rubbed her right hip, moaned and looked uncomfortable. Resident 2's call light was observed on the bed, about 3 feet away from resident's reach. A Licensed Nurse (LN 10) had the medication cart parked next to Resident 2's room entrance and was preparing medications. During a concurrent observation and interview with LN 10 on 9/3/25, at 4:33 p.m., LN 10 stated she did not check on Resident 2 since the resident came back from dialysis around 4 p.m. Upon entering Resident 2's room, LN 10 stated, Ah, no, she looks very uncomfortable.She's tired, she needs to be in bed. LN 10 stated the resident was able to use her call light to ask for assistance and validated that the resident's call light was not within reach and the resident was unable to call for help. LN 10 stated Resident 2 was unable to see and was at risk for falls and should have her call light within reach at all times. A review of Resident 2's care plan titled, At risk for falls, initiated 12/24/24 contained the following interventions, Assist with ADL's and transfers.Call light within reach.Encourage and remind to call staff for assistance. A review of Resident 2's 'ADL self-care performance deficit' care plan initiated 12/24/24 indicated the resident required assistance with personal care and transferring. One of the interventions indicated, Encourage the resident to use the light to call for assistance. A review of the facility's 'Answering the Call Light,' policy dated 9/2022, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Be sure that the call light is plugged in and functioning at all times.Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. During an interview with Director of Nursing (DON) on 9/5/25, at 10:20 p.m., the DON stated that call lights should be within resident's reach whether resident was in bed or in wheelchair so that the resident could communicate their needs, especially for residents who were at risk for falls. The DON agreed that if the call light was not accessible, residents' needs might not be met in a timely manner and had the potential to affect resident safety.

Based on observation, interview, and record review the facility failed to ensure that one of 34 sampled residents, (Resident 42) was free of unnecessary psychotropic medications (drugs that affect the mind and brain, altering mood, perception, and behavior) when Resident 42 received quetiapine (an antipsychotic medication) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorders (mental illnesses that are characterized by mood swings that range from the lows of depression to elevated periods of emotional highs) for an inadequate indication and contrary to the risk of adverse consequences of black box warning (a prominent, bold-faced warning placed on the labels of prescription medications to alert healthcare professionals and patients about serious risks associated with the drug) where the attending physician did not provide an adequate rationale for its use. This failure resulted in the potential for Resident 42 suffering adverse effects such as sedation, falls, abnormal involuntary movements, and death.Findings:Resident 42 was admitted to the facility on [DATE] from the hospital after suffering an intercranial hemorrhage (bleeding within the skull, or cranium, where the brain is located). Resident 42 had an admission history of stroke (a medical emergency that occurs when blood flow to the brain is interrupted), non-Alzheimer's (a disease characterized by progressive decline in mental abilities) dementia (any type of dementia not caused by Alzheimer's disease), difficulty walking, and muscle weakness. Resident 42 was at risk for falls and injury.After admission to the facility, Resident 42 was diagnosed with VASCULAR DEMENTIA (a type of cognitive decline caused by damage to the blood vessels in the brain), UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE, UNSPECIFIED PSYCHOSIS (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION, INSOMNIA (trouble falling asleep or staying asleep) UNSPECIFIED, and REPEATED FALLS.A review of Resident 42's Physician Order, dated 3/7/2025, indicated an order for quetiapine 25 mg (milligram, unit of measure), 12.5 mg in the morning and 25 mg at bedtime. During a record review of Resident 42's Minimum Data Set (MDS-a resident assessment and classification tool), dated 2/12/24, MDS indicated Resident 42 had moderate cognitive impairment. MDS dated [DATE] and 8/15/25 indicated severe cognitive impairment. MDS 2/12/25, 5/19/25, and 8/15/25 indicated signs and symptoms of delirium (temporary state of mental confusion and disorientation that can cause significant changes in a person's behavior, thinking, and perception) were not present. MDS further indicated potential indications of psychosis (sensory experiences that occur without any external stimulus) were not present. MDS 2/12/25 indicated no Psychotic Disorder (other than schizophrenia) diagnosis. MDS dated [DATE] and 8/15/25 indicated an active diagnosis of a Psychotic disorder (other than schizophrenia). During a review of the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) for 3/1/25 to 3/13/25, the MRR indicated a recommendation for quetiapine's indication to be changed to Behavioral and Psychological Symptoms of Dementia manifested by physical and verbal aggression.During a record review of Resident 42's Order Audit Report provided by the facility on 9/5/25, indicated an order for Trazadone (an antidepressant drug used to promote sleep) 50 mg at bedtime for inability to sleep related to insomnia on 4/30/24. Resident 42's Order Audit Report indicated an order for melatonin (a dietary supplement used to promote sleep) 3 mg at bedtime for inability to sleep on 12/13/24. Resident 42's Order Audit Report indicated an order for quetiapine 12.5 mg once a day and 25 mg at bedtime for mood and behavior regulation on 3/7/25.During a review of the CP's MRR for 4/1/25 to 4/12/25, the MRR indicated the pharmacist request for the attending physician to: review the quetiapine order and include a more detailed indication, confirm that the order is continuous, confirm dose reduction due to daytime drowsiness, to include targeted behaviors in the order as well as behavior monitoring, and to consult on discontinuation of the quetiapine order.Resident 42 was diagnosed with Unspecified Psychosis on 4/26/25.During a review of the CP's MRR dated 7/31/25, the MRR indicated the pharmacist alerting Resident 42 had seven falls in two months at varying times of day, that the medications quetiapine, trazadone, blood pressure medications, the diuretic (medications that increase urine output) and gout (a form of arthritis) mediation and conditions that could be contributing to the falls. The MRR also indicated the CP's recommendation of a trial of reduced dosing of quetiapine. The MRR indicated the MD's response to discontinue Trazadone, Melatonin, and the diuretic with no rationale provided.During a record review of Resident 42's Order Audit Report provided by the facility on 9/5/25, indicated discontinuation of Trazadone and Melatonin on 8/1/25.During an interview on 9/4/25 at approximately 11:14 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 42 is a fall risk. CNA 2 stated resident 42 is very friendly with the staff and sometimes yells out, but does not get verbally or physically aggressive. CNA 2 added Resident 42 slept well in bed at night and s/he tried to get out of bed when not tired. CNA 2 stated Resident 42 sleeps in his/her wheelchair during the day. CNA 2 was unaware of any sleep issues.During an observation of Resident 42 at the nurse's station on 9/4/25 at approximately 11:18 a.m., Resident 42 was observed sitting in his/her wheelchair outside of nurses station with magazines and a foreign language newspaper unopened in front of the resident. Resident 42 stated s/he had trouble deciding what to do. Resident 42 appeared awake, but drowsy and confused to place and person as s/he stated that LN 8 was his/her pastor.During an interview with the facility CP on 9/4/25 at approximately 3 p.m., the CP stated that quetiapine was prescribed for Resident 42 for psychosis. The CP was aware of the black box warning for quetiapine which was increased risk of death for dementia patients being treated with quetiapine. The CP stated Resident 42 was not taking any medications for insomnia as trazadone was discontinued on 8/1/25.During an interview with MD on 9/5/25 at approximately 9:56 a.m., MD stated h/she diagnosed Resident 42 with Vascular Dementia because Resident 42 has a history of vascular disease and [stroke] which are associated with Vascular Dementia. MD further stated h/she did not perform any diagnostic tests to confirm the diagnosis for Vascular Dementia. MD stated s/he assumed Resident 42 had vascular dementia and diagnosed Resident 42 with Unspecified Psychosis based on Resident 42 having active visual hallucinations and disorientation prior to taking quetiapine. MD stated s/he observed Resident 42 having active hallucinations and that some hallucination observations were documented in the physician and nurse practitioner notes. MD acknowledged the black box warning for quetiapine, involuntary movements and death. MD stated s/he had considered dementia medications, but Resident 42's dementia is less likely Alzheimer's in his opinion. MD stated the family wanted Resident 42 on quetiapine. MD stated that s/he had not received MRR recommendations from the consultant pharmacist. MD stated quetiapine promotes sleep as a side effect and is not aware of Resident 42 suffering from insomnia currently and that Resident 42 is not currently on medications for insomnia. MD stated that Resident 42 has not been referred to a psychiatrist.During a record review of quetiapine package insert, revised October 2013, the black box warning indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. [quetiapine] is not approved for elderly patients with dementia-related psychosis. and Warnings and Precautions, Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis. The quetiapine package insert indicated quetiapine is indicated for the treatment of schizophrenia and bipolar disorders and Quetiapine may induce orthostatic hypotension (low blood pressure), dizziness, and syncope (fainting) and may lead to falls.During a record review of Resident 42's Order Audit Report provided by the facility on 9/5/25, the report indicated the current active quetiapine order was prescribed on 4/26/25 for, Physical and verbal aggression related to Vascular Dementia Unspecified. During a record review of Resident 42's Preadmission Screening and Resident Review (PASRR- an assessment for serious mental illness, intellectual disability, developmental disability, or related condition(s)), dated 3/6/24 and 5/9/25, the PASRR assessments indicated negative for serious mental illness or intellectual/developmental disability and there was no need for screening and providing care and treatment for serious mental illness at that time.During a record review of Resident 42's orders, review indicated there was no order for monitoring for resident hallucinations.During a record review of Resident 42's physician and Nurse Practitioner (NP) progress notes from 1/2/25 to 3/12/25, the NP's progress notes indicated no documentation of observations of Resident 42 experiencing hallucinations. Both NP visit notes dated 3/3/25 and 3/7/25 indicated NP's plan to order and initiate quetiapine for Behavioral aggression/Dementia. The MD note dated 3/12/25 indicated continuing quetiapine as well as trazadone due to having less behaviors.During a record review of Resident's 42's Fall Care Plan dated 8/20/25, Resident 42 had 8 falls between 5/15/25 and 7/30/25.During a record review of the facility's Policy and Procedure (P&P) titled, Antipsychotic Medications Use, revised July 2022, the P&P indicated, Antipsychotic medications shall generally be used for the following conditions/diagnoses. Psychosis in the absence of dementia. And antipsychotic medications will generally only be considered if. the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity).

Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled residents (Resident 17) received appropriate treatment and services for diagnosis of vascular dementia (impairment of brain function caused by damage to the blood vessels in the brain), by failing to offer non-pharmacological interventions and document the rationale prior to initiation of Seroquel (a psychotropic medication that affect brain activities associated with mental processes and behaviors and indicated for treating psychiatric conditions). In addition, there was no evaluation and rationale provided when Resident 17 was diagnosed with psychosis (a severe mental condition in which thoughts and emotions so affected that contact with reality is lost). These failures had the potential to expose Resident 17 to adverse side-effects (unwanted, uncomfortable, or fatal effects, including but not limited to sedation, increased risk for falls and negatively impact Resident 17's overall health and safety.Findings:A review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, with the revision date of 3/19, indicated, The facility will provide all residents will receive behavioral health services as needed to attain or maintain the highest physical, mental and psychosocial well-being.The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes.that may have contributed to the resident's change in condition, including: physical changes.infection.pain or discomfort.emotional changes.boredom, loneliness, anxiety.Non-pharmacological interventions will be utilized.to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. A review of the admission Record indicated the facility admitted Resident 17 in 2023 with multiple diagnoses which included cerebral infarction (brain bleed) resulting in paralysis of the arm, leg, and trunk on the right side, and vascular dementia without behavioral disturbance. A review of Resident 17's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/13/25 indicated the resident scored 10 out of 15 on cognitive assessment, which indicated mild cognitive impairment. Resident 17's MDS further indicated the resident exhibited no indicators of psychosis, such as hallucinations (seeing or hearing things that are not there), delusions (an impression or belief not based on reality), and disorganized thinking. A review of Resident 17's care plan titled, The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia initiated 10/21/23 indicated the following interventions, Administer medications as ordered.Ask yes/no questions in order to determine the resident's needs.Cue, reorient and supervise as needed, discuss concerns about confusion, disease process.A review of Resident 17 clinical records contained a physician order, with a start date of 5/1/2024 for Seroquel Oral Tablet to give 12.5 milligrams (mg, unit of measurement) at bedtime for verbal aggression, and verbalization of wanting to die related to unspecified dementia. A review of Resident 17's nursing progress notes (NPN) dated 5/1/24, at 2:54 p.m., indicated, Noted to have disruptive behaviors.She has increased restlessness, verbal aggression toward staff, and verbalization of wanting to die.She reports that she does not have plans to hurt herself in any way. The NPN indicated the physician was notified and prescribed Seroquel and laboratory tests to rule out UTI (infection in the bladder and urinary tract). The NPN indicated that the physician directed nursing, While tests are pending, continue with Seroquel. If she has UTI, review antipsychotic dose with MD. If work up is negative, and resident is tolerating Seroquel, may consider dose adjustment. Resident 17's clinical record contained care plan initiated 5/1/24 and titled, The resident uses psychotropic medications (Seroquel) r/t [related to] Behavior Management for vascular dementia with behaviors. One of the interventions indicated to offer GDR (gradual dose reduction) every 6 months and as needed. A review of physician's (PHY) visit notes dated 6/8/24, at 4:34 p.m., indicated, Patient with anxiety with memory loss. sometimes behavioral disturbances.wandering through the facility at nighttime. A review of PHY visit notes dated 7/17/25 at 4:22 p.m., indicated, She [Resident 17] has dementia.She just needs simple reassurance. After the patient is reassured, she is doing great. Smiling.She has memory loss but able to express her needs and wishes. She communicates effectively with me and other members of the facility. A review of Resident 17's clinical records indicated that on 7/29/24 Seroquel dose was increased to 25 mg orally at bedtime. Resident 17's clinical records did not contain physician documentation providing the rationale and explaining why the dose was increased. A review of the clinical records indicated that a new diagnosis of unspecified dementia with psychotic disturbance (the disorder presenting with hallucinations and delusions) was added to Resident 17's list of diagnoses on 9/13/24. There was no documented evidence Resident 17 received another physician's assessment or evaluation prior to 9/13/24. There was no documented rationale why Resident 17 was diagnosed with 'psychotic disturbance.' A review of PHY visit notes dated 1/16/25, at 3:30 p.m., contained history of Resident 17's medical conditions and diagnoses and did not contain history of mental illnesses including psychosis. The physician documented that the resident had no acute issues reported by nursing staff. A review of Resident 17's nursing progress notes from 2/5/25 through 2/20/25 did not contain documentation that the resident experienced hallucinations and/or delusional behaviors or any other symptoms of psychosis. There was no evidence the IDT evaluated for changes in Resident 17's behaviors that indicated signs and symptoms of psychosis. On 2/29/25 a new diagnosis of unspecified psychosis was added to Resident 17's diagnoses. During an observation on 9/2/25, at 9:30 a.m., Resident 17 was observed awake laying in her bed. Resident was pleasant, calm, and answered all questions appropriately. During an interview, Resident 17 mentioned that sometimes she felt very lonely. Resident 17 added, I'm blessed. My daughter usually calls me 1-2 times every day, and she visits me frequently. When Resident 17 was asked if she had any concerns with call light response, the resident stated, Sometimes have to wait, especially at nighttime. I start yelling and they come. During multiple observations on 9/3/25 at 10:40 a.m., on 9/4/25 at 11:04 a.m., and on 9/5/25 at 12:55 p.m., Resident 17 was observed to be pleasant, happy, and no verbal aggression or yelling was noted.During an interview on 9/5/25, at 9 a.m., Restorative Nursing Assistant (RNA 2) described Resident 17 as, Alert, forgetful. Has behaviors of yelling and screaming if she needs something. RNA 2 explained, Sometimes we do not understand what she's trying to say, [we] use communication book, but she gets frustrated and starts shouting more. During a continued interview, RNA 2 stated that sometimes Resident 17 refused personal care and when the staff attempted to explain to her, the resident would get upset and start yelling. RNA 2 stated that Resident 17 had no hallucinations, was not aggressive and not a danger to self or others. During an interview on 9/5/25, at 9:05 a.m., RNA 3 stated Resident 17 was alert and able to use call light and verbalize her needs. RNA 3 stated that Resident 17 had periods of screaming behaviors. RNA 3 added, Sometimes she feels lonely, starts calling where is everyone and starts screaming. Calling names screaming loudly. RNA 3 stated that reassuring the resident worked well and the resident would calm down. RNA 3 stated Resident 17 was not aggressive and not a danger to self or others. During an interview with Licensed Nurse (LN 7) on 9/5/25, at 9:15 a.m., when asked about Resident 17's behavioral disturbances, LN 7 stated, She's very restless and has anxiety. Attention seeking behaviors. If she sees someone walking by in the hall, she will start screaming and yelling for help .Verbally frustrated, not aggressive and not dangerous. LN 7 stated he had not seen Resident 17 being physically aggressive, having hallucinations, delusions, or other signs and symptoms of psychosis. A review of Resident 17's Medical Administration Record (MAR) indicated that the resident had been given antipsychotic medication Seroquel 25 mg every night from 7/29/24 to present for over a year. Resident 17's clinical record did not contain any documentation to show that there were any attempts to reduce the dose of Seroquel since the start of the medication on 5/1/25. Resident 17's clinical record did not indicate the resident was prescribed any Food and Drug (FDA) approved medications to treat dementia. A review of Resident 17's clinical records did not contain any documented evidence the resident had been referred to be seen by a psychiatrist (a medical doctor who specialize in mental health, able to diagnose and treat mental disorders). Resident 17's clinical records did not reveal that the Interdisciplinary Team (IDT, a group of healthcare disciplines who discuss resident care needs) had evaluated if Resident 17's behavioral symptoms may be related to unmet needs or other medical conditions. A review of the facility's 'Antipsychotic Medication Use,' policy dated 7/22, indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition. The policy further explained the diagnoses for which antipsychotic medications will be used and vascular dementia was not included on the list. The policy indicated, Diagnoses alone do not warrant the use of antipsychotic medications.Antipsychotic medications will generally.considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND.The symptoms are identified as being due to mania or psychosis (such as auditory, visual.hallucinations, delusions, paranoia. During a concurrent interview and record review with Director of Nursing (DON) on 9/5/25, commencing at 10:20 a.m., the DON acknowledged that Resident 17 had been receiving Seroquel, a medication to treat mental disorders. The DON reviewed hospital records and validated that the resident had no history of any mental disorder, including psychosis prior to admission. The DON stated that diagnosis of dementia with psychotic disturbance was added to resident's diagnoses on 9/13/24 and diagnosis of psychosis was added on 2/19/25. During a continued interview and record review on 9/5/25, at 10:20 a.m., the DON stated that Resident 17 has behaviors of yelling, repetitive requests and attention seeking, and verbal aggression. When the DON was asked if yelling was presenting danger to self or others, the DON replied, Not dangerous, [but] disruptive to others especially at night. The DON did not provide any answer if resident's yelling behaviors were related to unmet physical needs, medical conditions, or other dementia-related behaviors. The DON stated Resident 17 did not have hallucinations or delusions but had lots of behaviors prior to starting Seroquel. The DON stated she did not remember if IDT addressed resident's behaviors and if any non-pharmacological interventions were provided prior to antipsychotic medication. The DON added, If physician ordered, it was justified at that time. The DON agreed that antipsychotic medication exposed Resident 17 to adverse effects of Seroquel and increased the resident's risks for falls. The DON acknowledged that Resident 17 had multiple falls, including 7/23/24 fall with lacerations and bleeding to her nose and forehead, later diagnosed with nose fracture, 9/9/24 fall resulting in scalp laceration and cut to eye, and 9/25/24 fall resulting in laceration to forehead. During a continued interview and record review on 9/5/25, at 10:20 a.m., the DON was asked the rationale for diagnosis of psychosis added to Resident 17's list of diagnoses on 2/19/25. The DON reviewed Resident 17's clinical records, including physician visit notes dated 1/16/25 and 3/8/25 and stated she was unable to find any notes addressing psychotic behaviors. The DON added, I don't see any written rationale why [physician] wanted psychosis to be added to her diagnoses.The physician verbally told me to add psychosis. During a phone interview and concurrent record review with physician on 9/5/25, at 10:55 a.m., PHY confirmed that Resident 17's admission diagnoses did not include psychosis or other mental disorders. PHY was asked the rationale that Resident 17 was prescribed antipsychotic medication on 5/1/24. PHY explained, I did not see the resident, nurses called me and reported of behaviors- screaming, not sleeping at night, disruptive to other residents.that she would walk up to nursing station repeatedly.So we. started Seroquel. PHY acknowledged that Resident 17 was diagnosed with UTI at the same time and agreed that UTI symptoms can be disruptive and mimic other conditions. PHY stated because Resident 17's dementia was minimal. she still has pretty good memory. can communicate very well, she was not prescribed other medications approved by Federal Drug Administration (FDA) for dementia. During a continued interview with PHY on 9/5/25, at 10:55 a.m., PHY was asked regarding increasing the Seroquel dose to 25 mg and Resident 17 being diagnosed with psychosis on 2/19/25. The PHY acknowledged that Resident 17 did not exhibit typical signs and symptoms of psychosis, including hallucinations, delusions, and paranoia. PHY explained, Nurses reported that resident had symptoms at night and I'm not here at night, I can't see it. I go with what nurses report. Nurses kept reporting that her screaming and calling for help continued, so the dose was increased. They document that she has symptoms.I go what the nurses suggested to me. PHY stated, Yes, I am aware of black box warning, aware of her multiple falls some with injuries.Agree that it is very important to have right diagnoses for any medications, including psychotropics and we have to be very cautious with psychotropic medications. A review of DailyMed, an online database that provides access to FDA information and offers a comprehensive and up-to-date resources for healthcare professionals accessed on 9/10/25 at https://dailymed.nlm.nih.gov/dailymed/ indicated that Seroquel was not approved for treatment of patients with dementia-related psychosis. The black box warning for use of Seroquel indicated it increased mortality in elderly patients with dementia-related psychosis, and suicidal thoughts and behaviors.

Based on observation, interview, and record review, the facility failed to account for and reconcile administered controlled medication for one of five residents, Resident 111. This failure had the potential for accidental medication exposure to Resident 111 and had the potential for drug diversion.Findings:During an observation of medication storage on 9/3/25, at approximately 10:23 a.m. ,in the hallway outside of Resident 111's room, observed Licensed Nurse 4 (LN 4) perform narcotics count (the mandatory procedure of physically counting all controlled substances) for Resident 111's oxycodone ( prescription opioid used to treat moderate to severe pain) 5 milligrams (mg, a unit of measurement). Eight oxycodone pills were left from a dispensed count of 15 pills with six administration entries logged in the medication cart narcotics log (for documentation of a narcotic administered) leaving one oxycodone 5mg pill unaccounted for.During an interview on 10:28 a.m. with LN 4, LN4 stated s/he administered the oxycodone earlier in the morning and that it is charted in the patient chart, but not in the narcotics log. LN 4 stated the expectation is to document medication administration and reconciliation immediately after administering the medication and failing to do so could result in a discrepancy on the medication reconciliation with oncoming staff.During a record review of Resident 111's Medication Administration Record (MAR), indicated oxycodone 5 mg being documented as administered by LN 4 on 9/3/25 at 6:55 a.m.During an interview with the DON on 9/3/25 at approximately 2:35 PM, DON stated, LNs should sign the narcotics log after popping the medication.During a record review of the facility's Policies and Procedures (P&P) titled, Medication Administration-General Guidelines, dated March 2018, the P&P indicated, The individual who administers the medication dose records the administration.directly after the medication is given.During a record review of the facility's P&P titled, Controlled Medication Storage, dated March 2018, the P&P indicated, Current controlled medication accountability records are kept in the MAR or a separate Controlled Drug binder.

Based on observation, interview and record review, Resident 19's allergy to onion was not accommodated when resident was served with mixed vegetables containing onion.This failure had the risk potential for an allergic reaction. Findings:During a review of the lunch meal tickets on 9/3/25 at 11:00 a.m., Resident 19's meal ticket indicated an allergy to onion. This meal ticket also indicated that the resident ate in his room and received food in bowls. Review of Resident 19's diagnosis indicated a history of being legally blind.During an observation of the lunch meal plating on 9/3/25 at 11:35 a.m., the menu included Orange Beef, [NAME] Rice, Oriental Vegetables (including peppers, onions, and broccoli), a roll and cookie. The [NAME] stated that barbequed chicken was available as an alternative to the main entree, but there was not another vegetable available.During a meal observation on 9/3/25 at 12:30 p.m. in Resident 19's room., a Certified Nursing Assistant (CNA) removed his meal tray from the cart. Upon request the CNA allowed the survey team to lift the lids of his meal bowls. One of Resident 19's bowls included mixed oriental vegetables containing onion. During an interview on 9/4/25 at 11:30 a.m. with the Certified Dietary Manager (CDM), the CDM stated that dietary staff are trained to look for food allergies which are listed on the banner of the meal ticket. The CDM expected the cooks to review the allergy list and plan modifications accordingly. The CDM also stated that the nursing floor would check the meal before giving the tray to the resident to ensure the meal does not contain allergens.During an interview on 9/3/25 at 3:30 p.m. with the Director of Nursing (DON), the DON stated that CNAs check meal trays when they are serving meals. The DON stated they should look not at the diet order and food preferences, but also for allergens. Review of facility provided policy Food Allergens and Intolerances (Med-Pass, Inc, Revised October 2008) indicated that Residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergen(s). It further indicated under the section on Assessment and Interventions: in bullet 4 that Meals will be specially prepared for residents with severe food allergies so that cross-contamination with allergens does not occur. During a review of the U.S. Food and Drug Administration's Food Code, 2022 version, it indicated that Recent studies indicate that over 11 million Americans suffer from one or more food allergies. A food allergy is caused by a naturally-occurring protein in a food or a food ingredient . When these sensitive individuals ingest sufficient concentrations of foods containing these allergens, the allergenic proteins . elicit an abnormal immune response. A food allergic response is commonly characterized by hives or other itchy rashes, nausea, abdominal pain, vomiting and/or diarrhea, wheezing, shortness of breath, and swelling of various parts of the body. In severe cases, anaphylactic shock and death may result.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1) when Resident 1's prophylactic (intended to prevent disease) aspirin was discontinued incorrectly. This failure resulted in Resident 1 not receiving aspirin as ordered and had increased potential for developing blood clots. Findings: Resident 1 was initially admitted in November 2024 with an admission diagnosis of a left broken thigh bone and was readmitted in December 2024 with admission diagnoses of blood clot in the lungs and sudden development of a blood clot in the legs. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 which indicated Resident 1 was cognitively intact. During an interview on 1/6/25 at 10:36 a.m. with Resident 1, Resident 1 stated, I had a blood clot. I have no idea whatsoever what happened. I was here and next thing I knew I was back at the hospital. My kids said I was delirious, but I don't know. I was out of it. Review of Resident 1's Progress Note, dated 11/18/24, indicated Resident 1's physician (MD, Medical Doctor) ordered aspirin 81mg (milligrams) by mouth twice daily for six weeks until 12/24/24. During a concurrent interview and record review on 1/6/25 at 11:48 a.m. with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) for November 2024 was reviewed. The MAR indicated Resident 1's last dose of aspirin was given on 11/24/24 and the stop date was 11/24/24. The DON stated the stop date for the aspirin should have been 12/24/24 not 11/24/24. The DON explained she was notified by Resident 1's family member, after he was hospitalized , that Resident 1 wasn't receiving the prescribed aspirin. The DON stated, .somewhere a miscommunication occurred between the [name of doctor] and [name of Licensed Nurse 1 (LN 1)] regarding the aspirin stop date. The DON verified the MD signed a stop aspirin order on 12/24/24. The DON acknowledged LN 1 discontinued aspirin on the wrong date. During a phone interview on 1/6/25 at 12:48 p.m. with MD, MD stated he ordered the aspirin 81mg for Resident 1 to be continued until 12/24/24. MD stated, unfortunately, the aspirin was stopped before it was supposed to be discontinued. Review of the facility's policy and procedure titled, Medication and Treatment Order, dated 2001, indicated, Orders for medications .will be consistent with safe and effective order writing.

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for a census of 84 when multiple doses of controlled pain medications and count sheets were missing and unaccounted for. These failures resulted in the facility's lack of accountability of residents controlled medications with potential for uncontrolled pain and suffering. Findings: During a review of the facility provided statement signed by Licensed Nurse 2 (LN 2), dated 10/15/24, the statement indicated, I was assigned to the first cart on [name of the hall]. I received the report from [LN 3], the NOC [night shift] nurse, at around 0615 [6:15 a.m.]. When we counted the narcotics [controlled medications], we noticed that the medication for [Resident 1] was missing. The count sheet issued by the pharmacy for that medication was in the binder. We also discovered that the count sheet for the medication for [Resident 3] was missing, though the medication itself was present in the narcotic box .We thoroughly searched the narcotic and non-narcotic medications, but the missing medication was nowhere to be found .[LN 3] voiced out her concerns about the narcotics count, according to her the narcotic count from the previous night (10/14/24) had been accurate. Together, we asked [LN 1] if we could check the cart at the back, hoping the medication might be there, but we still couldn't locate it. [LN 1] then checked the computer and informed us that the order for [Resident 1] had been discontinued and changed to a different dose. [LN 1] took the count sheet for [Resident 1] and created a handwritten count sheet for [Resident 3]. I expressed my concerns to her and said I didn't feel comfortable taking over the first cart due to the missing narcotics. [LN 1] said It's okay, let's switch carts and I'll handle it. [LN 3] later mentioned that [LN 1] had borrowed the key to the first cart and searched through the medication cart while [LN 3] was administering medications to patients in another room. Then, [LN 3] and I found the torn pieces of the original narcotic count sheet for the missing medication .I checked the order and saw that the new order was placed earlier that morning. During a review of the facility provided statement by LN 3, dated 10/15/24, the statement indicated, .When [LN 1] and I counted her cart 2, the narcotics were fine. I then went to cart 1 and waited for [LN 2]. [LN 1] asked to borrow my keys for cart 1, so I gave it to her. She opened the cart to look for something, and I proceeded .to give medication. After about 5 mins [minutes], [LN 1] returned the keys. Once I gave report to [LN 2], we did the count and found out that the Oxycodone for [Resident 1] was missing. The count sheet in the narcotic book was still there, but the bubble pack with 20 Oxycodone tablets, delivered on 10/11/24 was gone. The count sheet for [Resident 3] was also missing, but the Oxycodone bubble pack [blister pack, a form of tamper-evident packaging] was still there. At that point, I told [LN 1] that narcotic meds were missing after she borrowed the keys. She responded not to worry because the order has been dc/d [discontinued] and changed. She suggested to [LN 2] that they switch carts and she'll take care of it. When I proceeded to [LN 2] cart 1, I noticed the paper for the missing narcotic meds was shredded. I called [LN 2] and showed her the shredded paper. [LN 2] also told me that [LN 1] had changed the order without any progress notes. During an interview on 10/24/24 at 1:45 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, We had a nurse that we believe is diverting oxycodone, September and October. Thru [through] the audit, 1,915 doses unaccounted for .Initially it was reported, a nurse came to the DON (Director of Nursing) that there was a narcotic discrepancy, a bubble pack was missing and that there's a separate count sheet missing .Nurses said they found the bubble pack. There were handwritten count sheets. I looked on the bubble pack which is smashed on the side .There was a tape at the back of the blister pack .We audited all oxycodone within that timespan when there were missing count sheets .Those orders correlated with her on PCC (electronic chart). During an interview on 10/24/24 at 3:22 p.m. with LN 4, LN 4 stated, The process is to give pills to resident, sign the MAR and sign the narcotic sheet .If there are discrepancies, we try to find why is it off, maybe they make a mistake .If we can't find any reason, we notify the DON .It can mean people took the wrong medication out or maybe someone stole medication, that's a possibility. During an interview on 10/24/24 at 3:45 p.m. with LN 5, LN 5 stated, The expectation is making sure there are no discrepancies, and that we are giving the medication correctly and make sure the numbers are correct .Always protect yourself and make sure residents have what they need. During a continued interview on 10/24/24 at 4:17 p.m. with the ADON, the ADON stated, We believe that [LN 1] had put in an order and discontinued the order, she took the drug sheet as well as the drugs, it would appear that it was not missing, no order, no count sheet, and no drugs. During an interview on 10/24/24 at 4:33 p.m. with the Administrator (ADM), the ADM stated, , [LN 1]'s operation was she will order into PCC (electronic chart), write the prescription and sign it, fax it to [name pharmacy], she would come in the next day and discontinue the order, make sure it's in the cart, get the bubble pack and the count sheet before discontinuing the medication .The only reason why we were alerted was because that morning when she took one pack, she took the wrong count sheet, if she didn't get the wrong sheet, we wouldn't be able to know. During a review of the facility provided document titled F. Employee Conduct, undated, the document indicated, [Facility] expects its employees to act in a professional and respectful manner at all times. Examples of conduct that may lead to disciplinary action are identified below .Unauthorized possession, destruction, use, or removal of property .

Based on interview and record review, the facility failed to ensure professional standards of practice were followed when Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). This failure resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: During a review of the facility provided statement signed by LN 2, dated 10/15/24, the statement indicated, I was assigned to the first cart on [name of the hall]. I received the report from [LN 3], the NOC [night shift] nurse, at around 0615 [6:15 a.m.]. When we counted the narcotics [controlled medications], we noticed that the medication for [Resident 1] was missing. The count sheet issued by the pharmacy for that medication was in the binder. We also discovered that the count sheet for the medication for [Resident 3] was missing, though the medication itself was present in the narcotic box .We thoroughly searched the narcotic and non-narcotic medications, but the missing medication was nowhere to be found .[LN 3] voiced out her concerns about the narcotics count, according to her the narcotic count from the previous night (10/14/24) had been accurate. Together, we asked [LN 1] if we could check the cart at the back, hoping the medication might be there, but we still couldn't locate it. [LN 1] then checked the computer and informed us that the order for [Resident 1] had been discontinued and changed to a different dose. [LN 1] took the count sheet for [Resident 1] and created a handwritten count sheet for [Resident 3]. I expressed my concerns to her and said I didn't feel comfortable taking over the first cart due to the missing narcotics. [LN 1] said It's okay, let's switch carts and I'll handle it. [LN 3] later mentioned that [LN 1] had borrowed the key to the first cart and searched through the medication cart while [LN 3] was administering medications to patients in another room. Then, [LN 3] and I found the torn pieces of the original narcotic count sheet for the missing medication .I checked the order and saw that the new order was placed earlier that morning. During a review of the facility provided statement by LN 3, dated 10/15/24, the statement indicated, .When [LN 1] and I counted her cart 2, the narcotics were fine. I then went to cart 1 and waited for [LN 2]. [LN 1] asked to borrow my keys for cart 1, so I gave it to her. She opened the cart to look for something, and I proceeded .to give medication. After about 5 mins [minutes], [LN 1] returned the keys. Once I gave report to [LN 2], we did the count and found out that the Oxycodone for [Resident 1] was missing. The count sheet in the narcotic book was still there, but the bubble pack with 20 Oxycodone tablets, delivered on 10/11/24 was gone. The count sheet for [Resident 3] was also missing, but the Oxycodone bubble pack [blister pack, a form of tamper-evident packaging] was still there. At that point, I told [LN 1] that narcotic meds were missing after she borrowed the keys. She responded not to worry because the order has been dc/d [discontinued] and changed. She suggested to [LN 2] that they switch carts and she ' ll take care of it. When I proceeded to [LN 2] cart 1, I noticed the paper for the missing narcotic meds was shredded. I called [LN 2] and showed her the shredded paper. [LN 2] also told me that [LN 1] had changed the order without any progress notes. During a review of Resident 1's physician order, dated 10/15/24 at 6:07 a.m., the order indicated, oxycodone HCl [a drug used to treat moderate to severe pain] Oral [by mouth] Tablet 10mg [milligrams, a unit of measurement] .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:07 [a.m.]. During a review of Resident 1's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) . The prescription further indicated the physician's signature and DEA [Drug Enforcement Administration, agency that enforces the controlled substance laws and regulations] number [an identifier assigned to a healthcare provider allowing them to write prescriptions for controlled substances]. During a review of Resident 3's physician order, dated 10/8/24 at 9:41 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/8/24 06:18 [a.m.]. During a review of Resident 3's physician order, dated 10/15/24 at 6:17 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:18 [a.m.]. During a review of Resident 3's Medication Administration Notes (MAR), dated for October 2024, the MAR indicated the oxycodone ordered on 10/8/24 was discontinued on 10/9/24 at 8:48 a.m., and no doses were given. The MAR further indicated the oxycodone ordered on 10/15/24 was discontinued on 10/15/24 at 7:58 p.m., and no doses were given. During a review of Resident 3's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) . The prescription further indicated the physician's signature and DEA number. During a review of Resident 4's physician order, dated 10/15/24 at 6:10 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:12 [a.m.]. During a review of Resident 4's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) . The prescription further indicated the physician's signature and DEA number. During a review of Resident 5's physician order, dated 10/15/24 at 6:51 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:52 [a.m.]. During a review of Resident 5's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) . The prescription further indicated the physician ' s signature and DEA number. During a review of Resident 6's physician order, dated 10/15/24 at 6:12 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:13 [a.m.]. During a review of Resident 6's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) . The prescription further indicated the physician ' s signature and DEA number. During a review of a facility provided document signed by the Medical Director (MD), dated 10/18/24, the document indicated the list of residents with a triplicate [document created in three copies] signed but verified by MD as not his signature. The list included the prescriptions for Residents 1, 3, 4, 5, and 6. During an interview on 10/24/24 at 3:45 p.m. with LN 4, LN 4 stated, For the process of entering orders, we would call the doctor first to confirm the orders, I don't write prescriptions .Nurses don't sign prescription, doctor needs to sign the prescription. During an interview on 10/24/24 at 4:17 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, We believe that [LN 1] had put in an order and discontinued the order, she took the drug sheet as well as the drugs, it would appear that it was not missing, no order, no count sheet, and no drugs .Nurses are not able to write a prescription, not within a scope of nursing .We take orders from doctors, if signature is needed we let them sign. During an interview on 10/24/24 at 4:33 p.m. with the Administrator (ADM), the ADM stated, [LN 1]'s operation was she will order into PCC (electronic chart), write the prescription and sign it, fax it to [name pharmacy], she would come in the next day and discontinue the order, make sure it's in the cart, get the bubble pack [blister pack, a form of tamper-evident packaging] and the count sheet before discontinuing the medication . During a telephone interview on 10/25/24 at 11:03 a.m. with the Consultant Pharmacy Supervisor (CPS), when asked about the process of controlled meds dispensing, the CPS stated, The facility will request the provider to write a prescription, for SNF [Skilled Nursing Facility], they use a document where the doctor signs, it is faxed to the pharmacy and then the pharmacy prepares the meds and delivers it to the facility .prescription has the doctor's signature on it .[pharmacy] look for the DEA number which is specific to a doctor. During a review of the facility's policy and procedure (P&P) titled Medication Orders, dated 3/2018, the P&P indicated, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. During a review of the facility provided document titled F. Employee Conduct, undated, the document indicated, [Facility] expects its employees to act in a professional and respectful manner at all times. Examples of conduct that may lead to disciplinary action are identified below .Dishonesty (including falsification of a document or misrepresentations). During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: .(2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician . (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing - State of California Department of Consumer Affairs).

Based on interview, and record review, the facility failed to ensure accurate accountability of controlled medications (that have high potential for abuse, misuse and are addictive) for a census of 84 when: 1. Multiple doses of and Controlled Drug Records (CDR) for Oxycodone (medication used to treat moderate to severe pain) were missing and unaccounted for; 2. Random controlled medication audits of the Medication Administration Record (MAR) and CDRs for seven of nine sampled residents (Residents 1, 2, 3, 6, 7, 8, and 9) did not reconcile to indicate they were given to the residents; and 3. Licensed Nurse (LN 1) entered orders, wrote prescriptions, and discontinued controlled medications without physician authorization for five of nine sampled residents (Residents 1, 3, 4, 5, and 6). These failures resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. During a review of the facility provided statement signed by LN 2, dated 10/15/24, the statement indicated, I was assigned to the first cart on [name of hall]. I received the report from [LN 3], the NOC [night shift] nurse, at around 0615 [6:15 a.m.]. When we counted the narcotics [controlled medications], we noticed that the medication for [Resident 1] was missing. The count sheet issued by the pharmacy for that medication was in the binder. We also discovered that the count sheet for the medication for [Resident 3] was missing, though the medication itself was present in the narcotic box .We thoroughly searched the narcotic and non-narcotic medications, but the missing medication was nowhere to be found .[LN 3] voiced out her concerns about the narcotics count, according to her the narcotic count from the previous night (10/14/24) had been accurate. Together, we asked [LN 1] if we could check the cart at the back, hoping the medication might be there, but we still couldn't locate it. [LN 1] then checked the computer and informed us that the order for [Resident 1] had been discontinued and changed to a different dose. [LN 1] took the count sheet for [Resident 1] and created a handwritten count sheet for [Resident 3]. I expressed my concerns to her and said I didn't feel comfortable taking over the first cart due to the missing narcotics. [LN 1] said It's okay, let's switch carts and I'll handle it. [LN 3] later mentioned that [LN 1] had borrowed the key to the first cart and searched through the medication cart while [LN 3] was administering medications to patients in another room. Then, [LN 3] and I found the torn pieces of the original narcotic count sheet for the missing medication .I checked the order and saw that the new order was placed earlier that morning. During a review of the facility provided statement by LN 3, dated 10/15/24, the statement indicated, .When [LN 1] and I counted her cart 2, the narcotics were fine. I then went to cart 1 and waited for [LN 2]. [LN 1] asked to borrow my keys for cart 1, so I gave it to her. She opened the cart to look for something, and I proceeded .to give medication. After about 5 mins [minutes], [LN 1] returned the keys. Once I gave report to [LN 2], we did the count and found out that the Oxycodone for [Resident 1] was missing. The count sheet in the narcotic book was still there, but the bubble pack with 20 Oxycodone tablets, delivered on 10/11/24 was gone. The count sheet for [Resident 3] was also missing, but the Oxycodone bubble pack [blister pack, a form of tamper-evident packaging] was still there. At that point, I told [LN 1] that narcotic meds were missing after she borrowed the keys. She responded not to worry because the order has been dc/d [discontinued] and changed. She suggested to [LN 2] that they switch carts and she'll take care of it. When I proceeded to [LN 2] cart 1, I noticed the paper for the missing narcotic meds was shredded. I called [LN 2] and showed her the shredded paper. [LN 2] also told me that [LN 1] had changed the order without any progress notes. During an interview on 10/24/24 at 1:45 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, We had a nurse that we believe is diverting oxycodone, September and October. Thru the audit, 1915 doses unaccounted for .Initially it was reported, a nurse came to the DON (Director of Nursing) that there was a narcotic discrepancy, a bubble pack was missing and that there's a separate count sheet missing .Nurses said they found the bubble pack. There were handwritten count sheets. I looked on the bubble pack which is smashed on the side .There was a tape at the back of the blister pack .We audited all oxycodone within that timespan when there were missing count sheets .Those orders correlated with her on PCC (electronic chart). During a continued interview on 10/24/24 at 4:17 p.m. with the ADON, the ADON stated, We believe that [LN 1] had put in an order and discontinued the order, she took the drug sheet as well as the drugs, it would appear that it was not missing, no order, no count sheet, and no drugs. During an interview on 10/24/24 at 4:33 p.m. with the Administrator (ADM), the ADM stated, , [LN 1]'s operation was she will order into PCC (electronic chart), write the prescription and sign it, fax it to [name pharmacy], she would come in the next day and discontinue the order, make sure it's in the cart, get the bubble pack and the count sheet before discontinuing the medication .The only reason why we were alerted was because that morning when she took one pack, she took the wrong count sheet, if she didn't get the wrong sheet, we won't be able to know. During a review of the facility's policy and procedure (P&P) titled Controlled Medication Storage, dated 3/2018, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations . 2. During a review of Resident 1's MAR for October 2024, the MAR indicated, Roxicodone 5mg (Oxycodone HCl) 5 mg (milligrams, a unit of measurement) .Give 0.5 tablet by mouth every 6 hours as needed for Pain - Severe . The MAR indicated no doses were given to Resident 1 in October 2024. The MAR further indicated the oxycodone order was discontinued on 10/15/24 at 6:05 a.m. and another oxycodone order was entered. During a review of Resident 1's physician order dated 10/15/24 at 6:07 a.m., the order indicated, Oxycodone HCl Oral Tablet 10mg Give 1 tablet by mouth every 4 hours as needed for Pain . During a review of Resident 1's CDR dated 10/15/24, the CDR indicated the quantity of tablets received were 10 tablets. The CDR further indicated the last tablet count was 19 and one dose of oxycodone was given on 10/14/24, which was not reflected in the MAR. During a review of Resident 2's MAR for October 2024, the MAR indicated, Roxicodone .5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain - Severe. The MAR indicated three doses of oxycodone were signed as administered, the last dose was given on 10/13/24 at 6 p.m. and there were no oxycodone doses given after. During a review of Resident 2's CDR for oxycodone, the CDR indicated 18 doses were received on 10/13/24. The CDR further indicated three doses were signed but the last tablet count was 14 which indicated one tablet was missing. During a review of Resident 3's blister pack label, dated 10/8/24, the label indicated, oxycodone HCl 5MG Take 1/2 tab every 6 hours as needed for moderate to severe pain. The blister pack indicated 30 tablets were dispensed for a total of 60 doses and one dose was popped-out. During a review of Resident 3's MAR for October 2024, the MAR indicated, Oxycodone HCl Oral Tablet 5 mg Give 0.5 tablet every 6 hours as needed for Pain . The MAR indicated the last dose of oxycodone was given on 10/10/24 at 6:56 a.m. and the order was discontinued on 10/15/24. During a review of Resident 3's CDR, the CDR indicated 59 tablets were received on 10/14/24 and the last tablet count was 59. There were no CDR for the oxycodone tablets given on 10/10/24. During a review of Resident 6's MAR for October 2024, the MAR indicated, Oxycodone HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for severe pain. The MAR indicated two doses were administered on 10/15/24. During a review of Resident 6's CDR, the CDR indicated there were four doses of oxycodone signed on 10/15/24 which was not reflected on the MAR. During a review of Resident 7's CDR, the CDR indicated oxycodone 10 mg tablet was given 10/1/24 at 3:40 a.m. and on 10/8/24 at [illegible time]. During a review of Resident 7's MAR for October 2024, the MAR indicated there were no doses administered on 10/1/24 and 10/8/24. During a review of Resident 8's CDR, the CDR indicated oxycodone 5 mg tab was signed once on 9/15/24 at 11 a.m., and twice on 9/18/24 at 6 a.m. During a review of Resident 8's MAR for September 2024, the MAR indicated there were no oxycodone doses administered on 9/15/24 at 11 a.m. and on 9/18/24 at 6 a.m. During a review of Resident 9's CDR, the CDR indicated doses for oxycodone 20 mg were signed on 9/11/24 at [illegible time] , on 9/13/24 at 1 p.m., on 9/14/24 at [illegible time], 9/15/24 at [illegible time], and on 9/16/24 at 1 p.m. and signed as wasted. During a review of Resident 9's MAR for September 2024, the MAR indicated there were no doses administered on 9/11/24 , 9/13/24 at 1 p.m., 9/14/24 , 9/15/24, and on 9/16/24 at 1 p.m. During an interview on 10/24/24 at 3:22 p.m. with LN 4, LN 4 stated, The process is to give pills to resident, sign the MAR and sign the narcotic sheet .If there are discrepancies, we try to find why is it off, maybe they make a mistake .If we can't find any reason, we notify the DON .It can mean people took the wrong medication out or maybe someone stole medication, that's a possibility. During an interview on 10/24/24 at 3:45 p.m. with LN 5, LN 5 stated, The expectation is making sure there are no discrepancies, and that we are giving the medication correctly and make sure the numbers are correct. During an interview on 10/24/24 at 4:17 p.m. with the ADON, the ADON stated, The expectation is for the MAR and CDR to reconcile and match .staff should be responsible and accountable. During a review of the facility's P&P titled Controlled Medication Storage, dated 3/2018, the P&P indicated, C. A controlled medication accountability record is prepared by the pharmacy .E. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes reasonable effort to reconcile all reported discrepancies. 3. During a review of Resident 1's physician order, dated 10/15/24 at 6:07 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:07 [a.m.]. During a review of Resident 1's prescription, dated 10/15/24, the prescription indicated, Rx [prescription]: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) .Dispense 90. The prescription further indicated the physician signature and DEA [Drug Enforcement Administration] number. During a review of Resident 3's physician order, dated 10/8/24 at 9:41 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/8/24 06:18 [a.m.]. During a review of Resident 3's physician order, dated 10/15/24 at 6:17 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:18 [a.m.]. During a review of Resident 3's MAR, dated 10/24, the MAR indicated the oxycodone ordered on 10/8/24 was discontinued on 10/9/24 at 8:48 a.m., and no doses were given. The MAR further indicated the oxycodone ordered on 10/15/24 was discontinued on 10/15/24 at 7:58 p.m., and no doses were given. During a review of Resident 3's prescription, dated 10/15/24, the prescription indicated, Rx: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) .Dispense 90. The prescription further indicated the physician signature and DEA number. During a review of Resident 4's physician order, dated 10/15/24 at 6:10 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:12 [a.m.]. During a review of Resident 4's prescription, dated 10/15/24, the prescription indicated, Rx: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) .The prescription further indicated the physician signature and DEA number. During a review of Resident 5's physician order, dated 10/15/24 at 6:51 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:52 [a.m.]. During a review of Resident 5's prescription, dated 10/15/24, the prescription indicated, Rx: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) .The prescription further indicated the physician signature and DEA number. During a review of Resident 6's physician order, dated 10/15/24 at 6:12 a.m., the order indicated, oxycodone HCl Oral Tablet 10mg .Audit Details .Created By: [LN 1] .Created date: 10/15/24 06:13 [a.m.]. During a review of Resident 6's prescription, dated 10/15/24, the prescription indicated, Rx: oxycodone HCl Oral tablet 10 MG .Give 1 tablet by mouth every 4 hours as needed for Pain - Severe (8-10) .The prescription further indicated the physician signature and DEA number. During a review of a facility provided document signed by the Medical Director (MD), dated 10/18/24, the document indicated the list of residents with a triplicate [document created in three copies] signed but verified by MD as not his signature. The list included the prescriptions for Residents 1, 3, 4, 5, and 6. In an interview on 10/24/24 at 3:45 p.m. with LN 5, LN 5 stated, For the process of entering orders, we would call the doctor first to confirm the orders, I don't write prescriptions .Nurses don't sign prescription, doctor needs to sign the prescription. During an interview on 10/24/24 at 4:17 p.m. with the ADON, the ADON stated, We believe that [LN 1] had put in an order and discontinued the order, she took the drug sheet as well as the drugs, it would appear that it was not missing, no order, no count sheet, and no drugs .Nurses are not able to write a prescription, not within a scope of nursing .We take orders from doctors, if signature is needed we let them sign. In an interview on 10/24/24 at 4:33 p.m. with the ADM, the ADM stated, [LN 1]'s operation was she will order into PCC (electronic chart), write the prescription and sign it, fax it to [name pharmacy], she would come in the next day and discontinue the order, make sure it's in the cart, get the bubble pack [blister pack] and the count sheet before discontinuing the medication .Prescription forgery, the pharmacy did not catch it on their end. During a telephone interview on 10/25/24 at 11:03 a.m. with the Consultant Pharmacy Supervisor (CPS), when asked about the process of dispensing controlled medications, the CPS stated, The facility will request the provider to write a prescription, for SNF [Skilled Nursing Facility], they use a document where the doctor signs, it is faxed to the pharmacy and then the pharmacy prepares the meds and delivers it to the facility .prescription has the doctor's signature on it .[pharmacy] look for the DEA number which is specific to a doctor. When asked regarding the process of prescription verification, the CPS stated, [Pharmacy] just look at them, prescription has the doctor's signature on it .As far as I know they don't call doctor to confirm prescription .It's just like another prescription, it comes from the facility fax, its technically printed on the prescription as well, they don ' t necessarily call the doctor to verify the prescription. During a review of the facility ' s P&P titled Medication Orders, dated 3/2018, the P&P indicated, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. During a review of the facility provided document titled F. Employee Conduct, undated, the document indicated, [Facility] expects its employees to act in a professional and respectful manner at all times. Examples of conduct that may lead to disciplinary action are identified below .Dishonesty (including falsification of a document or misrepresentations).

Based on interview and record review, the facility failed to implement measures for the prevention of pressure ulcers for one resident (Resident 1) of three sampled residents when, the resident developed a pressure ulcer (injury to the skin resulting from prolonged pressure) at her coccyx (tailbone). This failure resulted in Resident 1 developing an avoidable pressure ulcer. Findings: According to an admission record, Resident 1 was admitted in 12/30/17 with diagnoses which included: cerebral infarction (stroke, disruption in blood flow to the brain), hemiplegia and hemiparesis (partial paralysis on one side of the body) following stroke affecting the right dominant side, generalized muscle weakness, cancer in the brain and right lung, and diabetes. A review of a MDS (Minimum Data Set, an assessment tool), dated 1/6/18, indicated the resident had severe cognitive impairment and required the extensive assistance of two or more persons for bed mobility. The MDS indicated Resident 1 did not exhibit any rejection of care necessary to achieve her goals for health and well-being. The MDS also indicated Resident 1 had no pressure injuries present on admission but, was at risk for developing them. The MDS indicated Resident 1 was not put on a turning/ repositioning program. A review of a care plan, initiated on 12/30/17, indicated Resident 1 was at risk for pressure injury because of limited mobility, deconditioning, incontinence, metastatic cancer to the brain, and diabetes. A review of Resident 1's clinical record between 12/30/17 and 1/13/17 showed no documented evidence staff had turned and repositioned Resident 1 every two hours to minimize the risk of a pressure injury developing. A review of Resident 1's clinical record between 12/30/17 and 1/13/17 showed no documented evidence Resident 1 refused to be turned or repositioned. A nursing note, dated 1/13/18 and written by Licensed Nurse 2 (LN 2), indicated a new open area had been found on the resident's buttocks during care. A review of a revised care plan regarding Resident 1's risk for pressure injury, created on 1/15/18, indicated the following new interventions for staff to implement, .assist resident to turn and reposition every 2 hours and PRN (as needed) .a low air loss mattress, time in wheelchair limited to 1-2 hours with a pressure relieving cushion in place, and a wedge cushion for effective repositioning. A Skin/Wound Note, dated 1/15/18 and written by the Nurse Wound Specialist (NWS), indicated she evaluated Resident 1 and found her to have a small sacral (at the tailbone) pressure ulcer. A physician's note, dated 1/17/18, indicated Resident 1 had been noted with a stage 2 (an opening in the top layer of the skin and part of the layer below) pressure ulcer two days prior, but the ulcer had been noted by the NWS to have progressed to a stage 3 (extending into the fatty tissue) ulcer. In an interview, on 5/14/18 at 10:45 a.m., LN 3 stated Resident 1 was uncooperative with turning, getting out of bed and being changed. In an interview, on 5/14/18 at 1:05 p.m., the Director of Nursing (DON) stated Resident 1 elected to stay in the supine position. In an interview, on 5/24/18 at 3:45 p.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 1 sometimes refused care and liked to stay in bed. CNA 1 stated he did not fight with Resident 1 if she did not want to move or get out of bed. In an interview, on 6/6/22 at 1 p.m., the DON/ADM (now Administrator) confirmed Resident 1 had severe cognitive impairment and her daughter was her responsible party (RP) for care decisions. The DON confirmed the resident was at high risk for pressure ulcers and stated it was the facility's standard of care to reposition the resident Q2H (every 2 hours) even if it was not documented and Resident 1 had been on a turning and repositioning program. The DON stated if a resident refused care they tried to find out why, looked at risk factors, talked with the family and educated the RP regarding the risks and benefits of the refusal. The DON stated she spoke with the RP regarding the wound but, could provide no documented evidence of a discussion regarding refusal of repositioning. The DON confirmed the pressure ulcer was acquired by the resident while at the facility. A review of the facility's policy titled, Requesting, Refusing and/or Discontinuing Care or Treatment, last revised 2/21, indicated, Residents and resident representatives have the right to request, refuse and/or discontinue treatment. 'Treatment' refers to medical care, nursing care and interventions provided to maintain or restore health and well-being .Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: The date and time the care or treatment was attempted; the type of care or treatment; the resident's response and stated reason(s) for request, discontinuation or refusal; that the resident was informed [to the extent of the ability to understand] of the purpose of the treatment and the potential outcome of not receiving the medication/treatment. A review of the American Medical Directors Association's publication titled Clinical Practice Guidelines for Long Term Care Facilities, undated, indicated, .The cornerstone of pressure ulcer management is prevention. The purpose of the recognition and assessment phases for patients who have not yet developed a pressure ulcer is to provide the framework for implementation of a prevention strategy .that reduces the risk of pressure ulcer occurrence .Pressure Ulcer Prevention Measures .Create a turning and positioning schedule that is based on the patient's individual risk factors .an unavoidable pressure ulcer is a pressure ulcer that develops even though a facility has done the following .Evaluated the patient's clinical condition and risk factors .defined and implemented interventions consistent with patient needs, goals, and recognized standards of practice .monitored .the impact of these interventions .