Every finding on record at Advanced Rehab Center of Tustin

Based on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's comprehensive care plan included speech therapy service, goals, and interventions. This failure posed the risk of the resident not receiving the appropriate treatment, services, and individualized care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated 2001 showed the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implement a comprehensive, person-centered care plan for each resident.The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths ande. reflects currently recognized standards of practice for problem areas and conditions. Medical record review for Resident 1 was initiated on 7/30/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 6/24/26, showed Resident 1 had the capacity to make medical decisions. Review of Resident 1's Order Summary Report dated 7/30/26, showed a physician's order for Speech Therapy- resident to be seen five times a week. Treatment may include memory exercises, focus on task training and circumlocution with order start date of 6/25/26. Further review of Resident 1's medical record failed to show the resident's comprehensive care plan included treatment and interventions related to Speech Therapy as ordered by the physician. On 7/30/26 at 1525 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 verified Resident 1's comprehensive care plan did not include the treatment and interventions related to the Speech Therapy. RN 1 stated the care plan should include all the treatment orders and interventions to reflect the care and services the resident was receiving. On 7/30/26 at 1650 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the personal belongings for one of six sampled residents (Resident 2) were kept safe from loss or theft. * The facility failed to update Resident 2's personal inventory to include Resident 2's Apple iPad. Additionally, the facility failed to ensure the CNA reported the missing Apple iPad according to the facility's policy. These failures resulted in the loss of Resident 2's iPad and had the potential to negatively impact the resident's well being.Findings: a. Review of the facility's P&P titled Personal Property dated 2001 showed the residents personal belongings are inventoried and documented upon admission and updated as necessary. Medical record review for Resident 2 was initiated on 6/23/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 6/22/26, showed the resident had fluctuating capacity. Review of Resident 2's Inventory Log dated 6/22/26, showed the resident had three blouses, two hats, five pairs of pants, one set of slippers, and one pair of glasses. The inventory did not list an iPad. On 6/23/26 at 1636 hours, an interview was conducted with Resident 2. Resident 2 stated her iPad was missing from her room. Resident 2 stated she could not remember when she last saw the iPad and stated she informed the staff, but could not recall whom she spoke to. On 6/23/26 at 1639 hours, an interview was conducted with the SSA. The SSA stated she was familiar with Resident 2 through daily rounds. The SSA stated the resident had a tablet with a purple cover and typically kept it on her bedside table or in the pocket of her wheelchair. The SSA stated she had not seen the tablet recently. On 6/26/26 at 0857 hours, a follow up interview and concurrent medical record review was conducted with the SSA. The SSA stated the last time she saw Resident 2's tablet was sometime the week prior to the resident's most recent hospitalization. The SSA verified the above findings and stated the tablet should have been listed on the resident's inventory log. On 6/26/26 at 1013 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 2 did have a tablet and the last time she saw it was sometime the previous week. CNA 1 stated the CNAs are responsible for updating the residents' inventory logs as needed. b. Review of the facility's P&P titled Investigating Incidents of Theft and/or Misappropriation of Resident Property revised April 2017 showed the facility will exercise reasonable care to protect the resident from property loss or theft and training staff to educate them about activities that constitute and procedures for reporting misappropriation of resident property. On 6/23/26 at 1639 hours, an interview was conducted with the SSA. The SSA stated the missing tablet had not been reported to her. On 6/26/26 at 1013 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 2 informed her the tablet was missing and asked if she had seen it. CNA 1 stated she searched the resident's room, including in between the mattress, under bed, in other residents' room and in trash cans, but she was unable to locate Resident 2's tablet. CNA 1 stated she told Resident 2 she would report the missing tablet but Resident 2 stated she already informed somebody. CNA 1 stated she did not report the missing tablet to the Social Services. On 6/26/26 at 1158 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure assistance in the formulation of an advance directive for four of six final sampled residents (Residents 10, 89, 93, and 118) reviewed for advance directive. * The facility failed to ensure assistance in the formulation of an advance directive was offered for Residents 10, 89, and 118. * The facility failed to follow up on advance directive status after providing educational materials to the resident's representative for Resident 93. These failures had the potential for the residents' healthcare decision and treatment preferences to be unknown, undocumented, and not honored.Findings: Review of the facility's P&P titled Advance Directive (undated) showed the resident has the right to formulate an advance directive, including right to accept or refuse medical or surgical treatment. If the resident or resident representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advanced directives. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. The nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical record review for Resident 10 was initiated on 5/5/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 4/3/26, showed Resident 10 was able to make medical decisions. Review of Resident 10's MDS assessment dated [DATE], showed Resident 10 was cognitively intact. Review of Resident 10's Advance Directive Acknowledgement dated 4/9/26, showed Resident 10 have not executed an advanced directive, and was provided information on right to formulate an advance directive. However, the document did not show if assistance in formulating an advance directive was offered or whether Resident 10 accepted or declined the assistance. Further review of Resident 10's medical record did not show documentation that assistance in formulating an advance directive was offered to Resident 10. 2. Medical record review for Resident 89 was initiated on 5/5/26. Resident 89 was admitted to the facility on [DATE]. Review of Resident 89's H&P examination dated 4/24/26, showed Resident 89 had the capacity to understand and make medical decisions. Review of Resident 89's Advance Directive Acknowledgement dated 4/9/26, showed Resident 89 have not executed an advance directive, and was provided information on right to formulate an advance directive and resident declined the further information. However, the document did not show if assistance in formulating an advance directive was offered or whether Resident 89 accepted or declined the assistance. Further review of Resident 89's medical record did not show documentation that assistance in formulating an advance directive was offered to Resident 89. 3. Medical record review for Resident 118 was initiated on 5/5/26. Resident 118 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 118's H&P examination dated 1/4/26, showed Resident 118 had the capacity to understand and make medical decisions. Review of Resident 118's Advance Directive Acknowledgement dated 1/4/26, showed Resident 118 have not executed an advanced directive, and was provided information on right to formulate an advance directive. However, the document did not show if assistance in formulating an advance directive was offered or whether Resident 118 accepted or declined the assistance. Further review of Resident 118's medical record did not show documentation that assistance in formulating an advance directive was offered to Resident 118. On 5/6/26 at 1450 hours, an interview and concurrent medical record review for Residents 10, 89, and 118 was conducted with the Activity Assistant. The Activity Assistant verified the above findings and was unable to show documentation indicating assistance was offered in formulating an advance directive to Residents 10, 89 and 118, or whether the residents accepted or declined. On 5/8/26 at 1347 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 93 was initiated on 5/5/26. Resident 96 was admitted to the facility on [DATE]. Review of Resident 93's POLST dated 4/2/26, under Section D, showed Resident 93 had no advance directive. Review of Resident 93's Social Service assessment dated [DATE], under Advance Directives section, showed provided reading materials. However, there was no evidence of follow-up with the resident's representative regarding completion or status of the advance directive. Further review of Resident 93's medical record failed to show documented evidence of the discussions regarding the resident's wishes, and follow-up attempts by the facility staff to determine whether Resident 93 had an existing advance directive, wished to complete or decline to formulate an advance directive. On 5/7/26 at 1042 hours, an interview and concurrent medical record review for Resident 93 was conducted with the Social Services Assistant. The Social Services Assistant stated Resident 93 was confused so she discussed the advance directive with the resident's representative and provided the representative with advance directive information. The Social Services Assistant was unable to provide documentation showing a follow-up regarding the status or completions of the advance directive. On 5/8/26 at 0836 hours, an interview for Resident 93 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure three of three staff (LVNs 1 and 4, and CNA 7) reviewed for COVID-19 vaccinations were educated and offered the COVID-19 vaccination. * The facility failed to offer the educational materials of the risks and benefits for the COVID-19 vaccines and offer the COVID-19 vaccine to LVNs 1 and 4, and CNA 7. These failures put the residents at risk for increased risk of infection and transmission of COVID-19.Findings: Review of the facility's P&P titled Employee Infection and Vaccination Status dated 2001 showed prior to or upon an employee's duty assignment, the facility will assess the status of an employee's vaccination against infectious conditions, screening for tuberculosis, and recent history of communicable diseases. Employees will be current with mandated vaccinations prior to performing direct resident care. Employees are offered or provided with vaccinations per state or local agency policies/regulations. Employees are provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form is completed and placed in the employee's health record. Documentation of vaccinations include the signature of a licensed healthcare provider and employee when being administered. Vaccinations that are declined by the employee are documented on the applicable declination form and placed in the employee's health record. Review of the facility's employee screening, education, and offering for the COVID-19 vaccine failed to show documented evidence the facility offered educational materials of the risk and benefits of the vaccine, and offer the vaccine to LVNs 1 and 4, and CNA 7. On 5/6/26 at 1450 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified LVNs 1 and 4,and CNA 7 did not have any documentation to show the facility provided employee screening, education and offering the COVID-19 vaccine to LVNs 1 and 4, and CNA 7. On 5/6/26 at 1111 hours, an interview was conducted with CNA 7. CNA 7 stated she did not remember if she received an employee screening, education or was offered the COVID-19 vaccine. On 5/8/26 at 0945 hours, an interview was conducted with the DSD. The DSD stated he did not provide the employee screening, education or offered the COVID-19 vaccine to the employees. The DSD further stated the IP should provide to the employees. On 5/8/26 at 1030 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident care needs for four of 20 final sampled residents (Residents 4, 83, 123, and 147). * The facility failed to routinely monitor Resident 4 for bleeding and urinary changes per the resident's care plan and clinical history. * The facility failed to rotate the insulin injection sites for Resident 83. In addition, the facility failed to follow the physician's order for hydralazine (a medication used to treat high blood pressure). * The facility failed to consistently complete the Change of Condition assessment for Resident 123 despite having multiple episodes of refusing blood sugar checks. * The facility failed to notify the physician when Resident 147 had episodes of seizures. In addition, the facility failed to follow the physician's order for amiodarone hydrochloride (medication used to treat life-threatening heart rhythm problems) and midodrine hydrochloride (used to treat symptomatic orthostatic hypotension (sudden blood pressure drop upon standing) medications for Resident 147. These failures had the potential for avoidable complications, delayed interventions, worsening health conditions, and overall compromised residents' well being.Findings: 1. Medical record review for Resident 83 was initiated on 5/5/26. Resident 83 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 83's MDS assessment dated [DATE], showed Resident 83 had a BIMS score of 14, indicating intact cognition. a. Review of Resident 83's Order Summary Report dated 5/6/26, showed a physician's order, to administer insulin lispro (a rapid-acting, insulin designed to manage high blood sugar), inject as per sliding scale (amount of insulin to be administered based on the blood sugar results) subcutaneously before meals and at bedtime and to rotate injection sites. Review of Resident 49's Location of Administration Report for April 2026 showed the insulin lispro was administered consecutively on the same injection sites on the following dates and times: - on 4/26/26 at 1630 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/26/26 at 2100 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/27/26 at 1617 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/27/26 at 2040 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/28/26 at 1653 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/28/26 at 2055 hours, lispro insulin was administered to the LLQ of the abdomen; - on 4/30/26 at 16:01 hours, lispro insulin was administered to the LLQ of the abdomen; and - on 4/30/26 at 2043 hours, lispro insulin was administered to the LLQ of the abdomen. On 5/6/26 at 1239 hours, an interview and concurrent medical record review for Resident 83 was conducted with LVN 4. LVN 4 verified the above findings and stated the insulin injection site should be rotated with each insulin administration. On 5/8/26 at 1012 hours, an interview was conducted with the DON. The DON stated the expectation from the licensed nurses was to rotate the insulin injection sites. The DON was informed and acknowledged the above findings. b. Review of Resident 83's Order Summary Report dated 5/6/26, showed a physician's order to administer hydralazine hydrochloride 25 mg tablet by mouth every six hours as needed for hypertension (high blood pressure), if SBP was greater than 160 mmHg. Review of Resident 83's MAR for 4/1 to 4/30/26, showed hydralazine hydrochloride 25 mg tablet was administered to the resident when the SBP was lower than 160 mmHg on the following dates and times: - on 4/17/26 at 0000 hours, the BP reading was 130/75 mmHg; - on 4/17/26 at 0600 hours, the BP reading was 126/74 mmHg; - on 4/17/26 at 1200 hours, the BP reading was 138/84 mmHg; - on 4/17/26 at 1800 hours, the BP reading was 137/62 mmHg; and - on 4/17/26 at 1200 hours, the BP reading was 142/74 mmHg. On 5/6/26 at 1243 hours, an interview and concurrent medical record review for Resident 83 was conducted with LVN 4. LVN 4 verified the above findings and stated the hydralazine hydrochloride 25 mg tablet should not have been administered to the resident with the SBP reading below 160 mmHg as ordered by the physician. On 5/8/26 at 1010 hours, an interview was conducted with the DON. The DON stated the expectation from the licensed nurses was to administer the medication as ordered by the physician. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 147 was initiated on 5/5/26. Resident 147 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 147's H&P examination dated 3/10/26, showed Resident 147 had the capacity to understand and make decisions. Review of Resident 147's MDS assessment dated [DATE], showed Resident 147 had a BIMS score of 12, indicating moderate cognitive impairment. a. Review of Resident 147's Order Summary showed the following physician's order: - dated 3/6/26, to monitor for seizure activity every shift and notify physician if noted; and - dated 3/21/26, to administer lorazepam 1 mg tablet by mouth every six hours as needed for seizures. Review of Resident 147's MAR for 3/1-3/31/26, showed Resident 147 was administered lorazepam 1 mg tablet by mouth on 3/21/26 at 1800 hours and on 3/31/26 at 1505 hours. Further review of the MAR showed Y (yes) was documented for seizure activity on 3/13/26 and 3/31/26 during the evening shift. However, further review of Resident 147's medical record failed to show the resident's physician was notified for the seizure episodes on 3/13 and 3/31/26 during the evening shift and when the resident was administered lorazepam on 3/21 at 1800 hours and on 3/31/26 at 1505 hours. On 5/7/26 at 1146 hours, an interview and concurrent medical record review for Resident 147 was conducted with LVN 3. LVN 3 verified resident MAR for 3/1-3/31/26 showed the resident was administered lorazepam on 3/21 at 1800 hours and on 3/31/26 at 1505 hours, as ordered for seizures and the monitoring for seizure activity every shift was marked Y, indicating the resident had seizures on 3/13 and 3/31/26, during the evening shift. On 5/8/26 at 0836 hours, an interview and concurrent medical record review for Resident 147 was conducted with LVN 2. LVN 2 verified the resident's medical record failed to show the resident was assessed before, during and after the seizure activity, and the physician was not notified of the seizure activities on the above dates and times. LVN 2 stated the resident should have been monitored for at least seventy-two hours for the change of condition and the physician should have been informed of the resident's condition, and duration of the seizure activity. On 5/8/26 at 1010 hours, an interview was conducted with the DON. The DON stated a seizure activity was a change of condition. The DON further stated the expectation from the licensed nurses was to inform the physician for any change of condition and monitor the resident's condition. The DON was informed and acknowledged the above findings. b. Review of Resident 147's Order Summary dated 5/8/26 showed a physician's order dated 3/6/26, to administer amiodarone hydrochloride 200 mg tablet by mouth two times a day, hold if heart rate was less than 60 beats per minute. Review of Resident 147's MAR for 3/1-3/31/26, showed Resident 147 was administered amiodarone hydrochloride 200 mg tablet on 3/8/26 at 0900 hours, when the pulse rate was 57 beats per minute. On 5/7/26 at 1146 hours, an interview and concurrent medical record review for Resident 147 was conducted with LVN 5. LVN 5 verified the above findings. LVN 5 stated the amiodarone hydrochloride 200 mg tablet should not have been administered since it would further lower the resident's pulse. c. Review of Resident 147's Order Summary dated 5/8/26 showed a physician's order dated 3/6/26, to administer midodrine hydrochloride 10 mg tablet by mouth one time a day, hold if SBP was greater than 130 mmHg. Review of Resident 147's MAR for 5/1- 5/31/26, showed Resident 147 was administered midodrine hydrochloride 10 mg on: - 5/1/26 at 0900 hours, with a BP reading of 132/70 mmHg; and - 5/5/26 at 0900 hours, with a BP ready of 131/77 mmHg. On 5/6/26 at 0810 hours, an interview was conducted with Resident 147 in his room. Resident 147 stated he got dizzy at times from taking his medications. Resident 147 further stated he did not know what medications he was taking. On 5/7/26 at 1142 hours, an interview and concurrent medical record review for Resident 147 was conducted with LVN 5. LVN 5 verified the above findings. LVN 5 stated the midodrine hydrochloride 10 mg tablet should not have been administered when the resident's SBP was higher than 130 mmHg as ordered by the physician. On 5/8/26 at 1017 hours, an interview was conducted with the DON. The DON stated the expectation from the licensed nurses was to read and follow the physician's order. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 4 was initiated on 5/5/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed the following physician's orders:- dated 2/28/26, to administer aspirin (used to treat mild pain, reduce fever, and lower inflammation)81 mg by mouth daily; and - dated 5/2/26, to monitor the resident every shift for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or change in vital signs, shortness of breath, and nose bleeds for aspirin use. Notify the physician if noted. Review of Resident 4's Care Plan Report showed a care plan problem initiated on 12/4/25, addressing the resident's alteration in bowel and bladder related to use of an indwelling urinary catheter and frequent bowel incontinence. The interventions included to monitor and report signs and symptoms of a UTI (hematuria, sedimentation, dysuria, flank pain, etc.) Review of Resident 4's Care Plan Report showed a care plan problem initiated on 1/23/26, addressing the resident 's risk for bleeding, bruising and discoloration due to aspirin use. The interventions included to monitor, document, and report blood tinged or red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy , bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. a. Review of Resident 4's Alert Note by LVN 8 dated 2/10/26 at 0940 hours, showed the resident was observed pulling on his urinary catheter with blood noted. LVN 7 was notified. LVN 8 documented upon assessment, no bleeding was noted and the urinary catheter was patent and draining. Review of Resident 4's SBAR Communication Form (General) dated 2/10/26 at 1344 hours, showed the resident's abdomen was visibly distended and firm on palpation, and the resident had no urine output in the Foley catheter since 0700 hours. The physician was notified and the resident was transferred to the acute care hospital. On 5/8/26 at 0927 hours, an interview and concurrent medical record review was conducted with the ADON and LVN 8. LVN 8 stated she wrote the Alert Note on 2/10/26, and explained an Alert Note was triggered by the CNA. LVN 8 stated on 2/10/26, she worked as the QA nurse and saw an alert from a CNA that Resident 4 was pulling on his catheter and blood was observed. LVN 8 stated then assessed the resident and added her note with the CNA's Alert Note. The ADON reviewed the resident's medical record and staffing assignment for 2/9/26, and stated LVN 7 worked 2/9/26 from 1500 – 2300 hours. The ADON verified there was no documentation to show the resident was assessed by the nursing staff on 2/9/26 for either the 1500 - 2300, or the 2300 - 0700 hours shifts, before LVN 8 saw the Alert Note and assessed the resident on 2/10/26 at 0940 hours. The ADON stated LVN 7 should have assessed Resident 4 after the CNA reported bleeding, and documented his assessment to show the CNA's findings were followed-up on. b. Review of Resident 4's SBAR Communication Form (General) dated 2/17/26 at 0200 hours, showed earlier in the evening the resident was noted to have blood-tinged urine. At approximately 0200 hours, the resident was noted to have thick, dark, bright blood throughout the urinary catheter tubing. The licensed nurse left the resident's bedside and returned to change the catheter tubing with the plan to monitor the bleeding through the remainder of the shift, however, upon returning, the resident was unresponsive with abnormal vital signs. The physician was notified and 911 was called at approximately 0240 hours. Further review of Resident 4's medical record failed to show when the initial blood-tinged urine was observed by facility staff earlier in the evening. On 5/8/26 at 0927 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 4's SBAR Communication From (General) dated 2/17/26 at 0200 hours, showed bleeding was noted earlier in the evening. The ADON stated the resident's medical record failed to show when the bleeding was initially identified, and reported on. In addition, the ADON stated per the resident's care plan and with his history of blood in the urine, the facility staff should have monitored and documented for bleeding, including blood in the urine, and any urinary changes per the care plan, prior to the physician's order on 5/2/26. c. Review of Resident 4's medical record failed to show the nursing staff routinely monitored, documented, and reported blood-tinged or red blood in the urine per the care plan interventions dated 1/3/26, and for sign and symptoms of a UTI (blood in the urine, sedimentation, dysuria, flank pain, etc.) per the care plan interventions dated 12/2/25. On 5/8/26 at 0927 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified there was no documentation to show the facility staff routinely monitored and documented the resident for bleeding and urinary changes every shift prior to 5/2/26. Cross reference F580. 4. On 5/5/26 at 0935 hours, an interview was conducted with Resident 123. During the interview, Resident 123 verbalized she was not diabetic. Medical record review for Resident 123 was initiated on 5/5/26. Resident 123 was readmitted to the facility on [DATE]. Review of the facility's matrix (undated) showed Resident 123 was on insulin. Review of Resident 123's quarterly MDS assessment dated [DATE], showed Resident 123 had no cognitive impairment. Review of Resident 123's physician progress note dated 4/30/26, did not address the resident's refusal of insulin administration. Review of Resident 123's MAR for May 2026 showed Resident 123 was to be administered Humulin R (insulin) 100 units/ml per sliding scale. Resident 123's physician was to be notified if Resident 123's blood sugar results were greater than 400 or less than 70 mg/dl as needed. Further review of these MAR showed Resident 123 had multiple episodes of refusing her insulin. On 5/7/26 at 1126 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 verbalized Resident 123 had multiple episodes of refusing blood sugar checks. LVN 6 further stated Resident 123 refused to have her blood sugar checks, including on 5/7/26. When asked what the facility's policy was when Resident 123 refused blood sugar checks in coordination with insulin administration, LVN 6 verbalized when a resident refused their blood sugar checks for more than three days, a change in condition assessment and documentation had to be completed. LVN 6 acknowledged a current change of condition should have been completed to notify Resident 123's physician about the resident's repeated refusals of blood sugar checks.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of nine final sampled residents (Resident 8, 19, 93, 118, and 143) reviewed for accidents remained free from accident hazards. * The facility failed to provide Resident 93 with a WanderGuard (type of wander management system) and failed to monitor the functionality of the WanderGuard as per the physician's order. In addition, the facility failed to ensure Resident 93's elopement assessment was accurate and failed to provide the receptionist an updated list of the residents at risk for elopement. * The facility failed to consistently monitor Resident 8 and 19's bed and chair alarms as per the physician's order. * The facility failed to monitor the presence and safety of an unleashed pet dog within the facility while the animal's owner was hospitalized , during which the dog was being cared for by Resident 118. * The facility failed to complete post-fall Fall Risk Assessments for Resident 143 when assessments dated 4/9 and 4/20/26 were blank. These failures increased the risk of the residents ambulating or transferring without staff awareness or assistance, increased likelihood of avoidable falls, inability to identify individualized fall risk factors due to incomplete assessments. In addition, this failure to implement timely interventions to prevent accidents, and exposure to an unleashed animal could result in bites, tripping hazards, or infection control concerns for the residents, staff, and visitors.Findings: 1. Review of the facility's P&P titled Wandering and Elopements dated 2001showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. On 5/5/26 at 0613 hours, Resident 93 was observed getting out of bed, with incontinent her brief pulled down her knees. Resident 93 then entered another resident's room before being redirected back to bed by a staff. On 5/5/26 at 0641 hours, Resident 93 was observed getting out of bed, with incontinent brief pulled down to her knees. A staff member was observed assisting Resident 93 back to bed. Medical record review for Resident 93 was initiated on 5/5/26. Resident 93 was admitted to the facility on [DATE]. a. Review of Resident 93's Elopement Risk Assessment – V2 dated 4/3/26, showed Resident 93 was independently mobile, with a diagnosis of dementia, Alzheimer's, and sundowning syndrome, with observed wandering and exit-seeking behaviors. The assessment also showed Resident 93 had no history of elopement, wandering or getting lost, and was readily accepting home placement. The assessment scored the resident as a five, below the threshold of six indicating high risk for elopement. However, review of Resident 93's plan of care showed a care plan problem dated 4/3/26, identifying Resident 93's as an elopement risk and wanderer related to history of attempting to leave the facility unattended. Review of Resident 93' Order Summary Report showed the following physician's orders: - dated 4/3/26, to monitor the resident for episodes of wandering, pacing or exit seeking behavior every shift; - dated 4/3/26, to check for WanderGuard function daily during the 0700 to 1500 hours shift. Document if working – Y for yes, and N for no; - dated 4/3/26, to check for WanderGuard placement every shift; and - dated 4/23/26, may have Wander Guard serial #051325900000139J (right arm) to alert the staff of resident trying to leave the facility unassisted b. Review of Resident 93's MARs for April and May 2026 showed the following: - Resident 93 was observed with episodes of wandering, pacing or exit seeking behavior on 4/10, 4/18, 5/3, 5/4, 5/5 and 5/6/26 on the day shift, on 4/5 to 4/9, 4/12 to 4/14, 4/16, 4/19, 4/21, and 4/24/26 on the evening shift, and on 4/11, 4/17, 4/22, 4/23, 4/25 to 4/27, 4/29 to 5/1/26 on the day shift and evening shift; - The placement of Resident 93's WanderGuard was documented with checkmarks on 4/3/26 for the night shift, and on 4/4 to 5/5/26 for the day shift, evening shift and night shift, and on 5/6/26 on the day shift; and - The functionality of Resident 93's WanderGuard (which was to be checked on the day shift) was document with a N or not working on 4/23, 4/25, and 5/2/26. Further review of Resident 93's medical record did not show interventions or corrective actions taken when Resident 93's WanderGuard was not functioning while the resident had episodes of wandering, pacing or exit seeking behavior on 4/23, 4/25 and 5/2/26. On 5/6/26 at 1442 hours, an interview for Resident 93 was conducted with CNAs 2 and 6. CNA 2 stated Resident 93 had been walking and getting out of bed. CNAs 2 and 6 stated Resident 93 did not have a WanderGuard or bed alarm. On 5/6/26 at 1521 hours, an interview and concurrent medical record for Resident 93 was conducted with LVN 6. LVN 6 verified Resident 93 had a history of pacing and wandering behaviors. LVN 6 stated Resident 93 did not have a bed alarm but she has a WanderGuard. LVN 6 verified Resident 93's WanderGuard was documented to be not functioning, but there was no documentation to show it was replaced, and no documentation Resident 93 removed her WanderGuard. On 5/6/26 at 1524 hours, an observation for Resident 93 and concurrent interview was conducted with LVN 6. Resident 93 was observed without a WanderGuard. LVN 6 could not locate the device and acknowledged placement and function checks were not performed. c. On 5/6/26 at 1618 hours, an interview and concurrent medical record review was conducted with the Receptionist. The Receptionist stated she received updated elopement risk list from Social Services. The Receptionist showed a binder containing three discharged residents' face sheets and pictures. When asked if she had been given an updated list of the residents who were at risk for elopement, the Receptionist attempted to look for another binder and could not locate the binder with an updated list. On 5/7/26 at 1329 hours, an interview and concurrent medical record review for Resident 93 was conducted with the ADON. The ADON stated Resident 93 had a history of wandering and that was the reason she had a WanderGuard. The ADON verified Resident 93's care plan showed she had a history of attempting to leave the facility, and the interventions included providing a WanderGiard to the resident. The ADON verified Resident 93's Elopement Risk Assessment showed Resident 93 did not have a history of elopement, wandering, or getting lost. The ADON stated Resident 93 had a history of elopement and wandering per her care plan. When asked about the facility's elopement protocol, the ADON stated the alarms or WanderGuard were in place to notify the staff whenever a resident who was at risk for elopement was near the exit door. The ADON also stated Social Services, the DON or ADON would provide an updated list of residents who were at risk of elopement to the receptionists, and each of the nursing stations. 2. On 5/5/26 at 0629 hours, Resident 19 was observed asleep in bed with a bed alarm device at bedside. Medical record review for Resident 19 was initiated on 5/5/26. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19' Order Summary Report showed the following physician's orders dated on: - 3/23/25, to monitor sensor alarm for function every shift. Document (+) if working, and (-) if not working; and - 5/22/25, may have bed and wheelchair sensor alarms to alert the staff when the resident is trying to get up unassisted every shift. Review of Resident 19's plan of care showed the following care plan problems dated: - 5/22/25, to address Resident 19's bed and wheelchair sensor alarms to alert the staff when the resident is trying to get up unassisted every shift; - 4/1/26, to address Resident 19 requiring sensor alarms in bed or wheelchair; and - 4/26/26, to address Resident 19's high risk of further falls. Review of Resident 19's MARs for April and May 2026 showed the following: - Resident 19's bed and chair sensor alarms to alert the staff when the resident is trying to get up unassisted were documented with checkmarks from 4/1 to 5/5/26 on the day shift, evening shift, and night shift, and on 5/6/26 on the day shift; and - The functionality of Resident 19's sensor alarms were documented with different codes. The MAR showed a documentation of 0 on 4/6 and 4/11/26 on the day shift, on 4/3, 4/24 and 5/4/26 on the evening shift, and N on 5/5/26 on the day shift. The alarms were also not working on 5/4/26 on the evening shift. Further review of Resident 19's medical record did not show interventions or corrective actions provided when Resident 19's bed and chair sensor alarms were not working. On 5/6/26 at 1013 hours, an interview for Resident 19 was conducted with CNA 6. CNA 6 stated Resident 19 had bed and chair sensor alarms to alert the staff if the resident tried to get out of bed or wheelchair, and the CNAs reported to the charge nurse if the alarms did not work. On 5/6/26 at 1104 hours, an interview and concurrent medical record for Resident 19 was conducted with LVN 6. LVN 6 verified Resident 19 had a physician's orders for bed and chair sensor alarms, and the functionality was to be checked by the LVN every shift. LVN 6 verified the nurses were inconsistent with the documentation of the sensor alarms functionality, which should be (+) if working, and (-) if not. LVN 6 verified Resident 19's sensor alarms were documented to be not functioning, but there was no documentation to show it was replaced or fixed. 3. On 5/5/26 at 0625 hours, Resident 8 was observed trying to get out of bed while the bed alarm was sounding, and a CNA was at bedside. Medical record review for Resident 8 was initiated on 5/5/26. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's plan of care showed a care plan problem dated 4/2/26, addressing Resident 8's pad alarms in bed or wheelchair. Review of Resident 8' Order Summary Report showed the following physician's orders dated 4/2/26: - to have sensor alarm in bed to alert the staff when resident was trying to get up unassisted; - to have sensor alarm in wheelchair to alert the staff when resident was trying to get up unassisted; and - to monitor sensor alarms for function every shift. Document Y if working, and N if not working. Review of Resident 8's MARs for April and May 2026 showed the following: - Resident 8's sensor alarms were documented as not working on 4/2 and 4/22/26 on the night shift, on 4/3, 4/7, 4/18, 4/19, 4/20, 4/24, 4/28, 4/29, 4/30, 5/2, and 5/3/26 on the day shift, on 4/5 and 4/21/26 on the day shift and evening shift, on 4/6 and 4/23/25 on the evening shift and night shift, on 4/17/26 on all shifts, and on 5/4 and 5/5/26 on the day shift and night shift. The MAR showed no documentation on 4/20 and 4/24/26 on the evening shift, and a documentation of W on 5/2/26 on the evening shift. Further review of Resident 8's medical record did not show what interventions or corrective actions were provided when Resident 8's bed and chair sensor alarms were not working. On 5/7/26 at 1114 hours, an interview and concurrent medical record for Resident 8 was conducted with LVN 5. LVN 5verified Resident 8 had a physician's orders for bed and chair sensor alarms, and the functionality was to be checked by the LVN every shift. LVN 8 verified the nurses were inconsistent with the documentation of the sensor alarms functionality, which should be Y if working, and N if not. LVN 5 verified Resident 8's sensor alarms were documented to be not functioning, but there was no documentation to show it was replaced or fixed. On 5/8/26 at 0836 hours, an interview for Residents 8, 19, and 93 was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Review of the facility's P&P titled Pets, Animals, and Plants undated showed that animals permitted in the facility must be monitored and managed to prevent the spread of microorganisms and infections. The P&P stated that service animals are allowed in accordance with the Americans with Disabilities Act (ADA) and applicable laws. It also stated that service animals are not required to have documentation or certification, and staff may not request such documentation. Staff may only ask the handler what tasks the service animal performs. Further review of the P&P did not provide guidance on who is responsible for caring for a pet, what actions should be taken if the pet's owner is hospitalized , or whether residents must be assessed to determine if they can safely care for and control the pet at all times. On 5/5/26 at 0633 hours, a Beagle/[NAME] mix dog was observed walking unleashed inside Resident 118's room. On 5/5/26 at 1147 hours, an observation and concurrent interview was conducted with Resident 118. Resident 118 was observed lying in bed receiving oxygen via nasal cannula. The dog was observed walking around the room unleashed. Resident 118 stated she was not the owner of the dog and was helping take care of her roommate's service dog while the roommate was hospitalized . Resident 118 stated staff assisted her in taking the dog outside for urination and defecation and reported the dog had never urinated or defecated inside the room. On 5/5/26 at 1357 hours, an interview was conducted with CNA 8. CNA 8 stated the dog belonged to the hospitalized roommate of Resident 118. CNA 8 stated the dog was usually unleashed inside the room and taken outside with a leash for urination and defecation. CNA 8 stated she assisted Resident 118 when she was able, while the dog's owner remained hospitalized . On 5/6/26 at 0758 hours, an observation and concurrent interview were conducted with the IP. The dog was observed walking unleashed in the hallway outside of Resident 118's room. The IP verified the observation and stated the dog stayed in or just outside the room of Resident 118. On 5/6/26 at 0848 hours, the dog was observed walking unleashed outside the room of Resident 118. The residents in the hallway were observed touching dog. On 5/6/26 at 0956 hours, Resident 118 was observed sitting at the side of her bed with the dog sitting on the bed next to her. Medical record review for Resident 118 was initiated on 5/5/26. Resident 118 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 118's H&P examination dated 1/4/26, showed Resident 118 had the capacity to understand and make decisions. Review of Resident 118's MDS assessment dated [DATE], showed Resident 118 was cognitively intact. Resident 118 had impairment on one side of the upper extremity, and used a manual wheelchair. Review of Resident 118's care plan dated 2/3/26, included a problem statement acknowledging the resident shared a room with a roommate who had an approved pet dog. The interventions included ensuring the dog was supervised and that facility policy was followed. The care plan did not address who was responsible for caring for the dog, whether the dog should be leashed, or whether Resident 118 was able to safely manage and control the dog at all times. Further review of Resident 118's medical record did not show documentation of the resident's ability to care for or control the pet. On 5/6/26 at 1005 hours, an interview and concurrent medical record review for Resident 118 was conducted with LVN 4. LVN 4 was informed the dog had been observed multiple times leaving the room and walking into the hallway. LVN 4 stated the dog belonged to Resident 118's roommate, who was hospitalized at the time. LVN 4 verified there was no documentation indicating whether Resident 118 was able to safely care for the dog or maintain control of the animal at all times. LVN 4 further stated Resident 118 was receiving continuous oxygen and required a wheelchair and portable oxygen for ambulation and therefore would not be able to promptly get out of bed or safely manage the pet when needed. LVN 4 stated that allowing the dog to roam the hallway posed several risks, including potential for resident injury from bites or tripping hazards. LVN 4 also explained that a dog walking on the floor and getting onto the residents' beds could create infection control concerns for the residents, staff, and visitors. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 5. Medical record review for Resident 143 was initiated on 5/5/26. Resident 143 was admitted to the facility on [DATE]. a. Review of Resident 143's SBAR Communication Form (General) dated 4/9/26, showed the resident had an unwitnessed fall and was found lying on the floor next to his bed. Review of Resident 143's Fall Risk Assessment-V2 dated 4/9/26, showed the form was used to determine the resident's fall risk (either low, moderate, or high risk) based on his current status. All nine sections of the form were blank. b. Review of Resident 143's SBAR Communication Form (General) dated 4/20/26, showed the resident had an unwitnessed fall and was found lying on the floor. Review of Resident 143's Fall Risk Assessment-V2 dated 4/20/26, showed all the sections were blank. On 5/7/26 at 1014 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated fall risk assessments were completed routinely, and after each fall, to determine the residents' risk for future falls. The DON reviewed Resident 143's Fall Risk Assessment-V2 forms dated 4/9 and 4/20/26, and verified both forms were incomplete.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with professional standards for two of two final sampled residents (Residents 83 and 118) reviewed for respiratory care. * The facility failed to ensure Resident 83's nasal cannula (flexible tube to deliver oxygen into the nose) was labeled and stored in a bag when not in use. In addition, the facility failed to provide oxygen as ordered by the physician. * The facility failed to ensure Resident 118's nebulizer mask, canister, and tubing were labeled and stored in a setup bag. These failures had the potential to result in inadequate respiratory care and increased infection control risks for the residents.Findings: 1. On 5/5/26 at 0633 hours, Resident 118 was observed lying in bed receiving oxygen at 2 LPM via nasal cannula. A nebulizer mask with canister and tubing was observed on top of the bedside drawer. The nebulizer equipment was not stored in a setup bag and not labeled. The plastic setup bag observed hanging on the bedside drawer was dated 4/13/26. On 5/5/26 at 0637 hours, the RN Consultant was called to the room. The RN Consultant verified the above observations and stated that the nebulizer equipment was not labeled or stored in the setup bag. The RN Consultant stated the nebulizer equipment should have been labeled and stored in a setup bag. Medical record review for Resident 118 was initiated on 5/5/26. Resident 118 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 118's Order Summary Report showed a physician's order dated 4/4/26, to administer ipratropium albuterol (used to control and prevent breathing difficulties) solution 0.5 2.5 (3 mg per 3 ml) via inhalation every six hours for shortness of breath. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the nebulizer equipment should be changed every week and Resident 118's nebulizer equipment should have been dated and changed weekly. 2. Review of the facility's P&P titled Oxygen Administration dated 2001 showed to verify physician's order for administration of oxygen. Review the physician's order. Medical record review for Resident 83 was initiated on 5/5/26. Resident 83 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 83's MDS assessment dated [DATE], showed Resident 83 had a BIMS score of 14, indicating intact cognition. a. On 5/5/26 at 0705 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 83 in the resident's room. Resident 83 was observed in the bed with oxygen set at 1.5 LPM via nasal cannula. Resident 83 stated she was supposedly receiving oxygen at 2 LPM. A wheelchair was observed with a portable oxygen tank with an unlabeled nasal cannula exposed to air and not stored in a bag. There was no bag observed on the wheelchair to store the nasal cannula. Resident 83 stated she used the oxygen when she got up on the wheelchair during the day and did not know when the nasal cannula on the wheelchair was last changed. b. Review of Resident 83's Order Summary Report showed a physician's order dated 4/16/26, for continuous oxygen at 2 LPM via nasal cannula. On 5/5/26 at 0715 hours, an observation and concurrent interview for Resident 83 was conducted with the DSD. The DSD verified the nasal cannula was not labeled and stored in a bag when not in use and stated it should have been. In addition, the DSD verified the resident was receiving oxygen at 1.5 LPM via nasal cannula. The DSD stated he would check the physician's order. On 5/5/26 at 1112 hours, an interview and concurrent medical record review for Resident 83 was conducted with RN 1. RN 1 verified the resident had a physician's order to administer continuous oxygen at 2 LPM via nasal cannula. On 5/8/26 at 1019 hours, an interview was conducted with the DON. The DON stated the licensed nurses are expected to change and label the nasal cannulas weekly and administer oxygen as ordered by the physician. The DON further stated the nasal cannula should be stored in a labeled bag when not in use. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program. * The facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for two of 20 final sampled residents (Residents 8 and 148) and fourteen nonsampled residents (Residents 11, 27, 40, 44, 59, 85, 88, 90, 158, 159, 161, 163, 164, and 165). This failure had the potential for inaccurate identification of true infections and potentially inhibited the residents' physicians from discontinuing unnecessary antimicrobials.Findings: Review of the facility's P&P titled Antibiotic Stewardship dated 2001 showed the facility will implement an antibiotic stewardship program to promote appropriate use of antibiotics optimizing the treatment to infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for the residents. The IP will collect and analyze infection surveillance data, coordinate data collection, and monitor adherence to infection control policies and procedures. The facility has chosen to use guidelines developed by McGeer's/Loeb and Stone and include newer surveillance information by McGeers/Loeb and Stone Criteria for initiation of antibiotics. The nurse will inform the physician of this prescribing protocol. These guidelines may be utilized in the decision to initiate empiric antibiotic use, if the physician chooses to do so due to resident's clinical condition. The physician may decide to initiate antibiotics without meeting these criteria and the nurse will then document the clinical justification for the physician's decision. The SBAR will be utilized in conjunction with McGeer's/ Loeb and Stone guidelines to communicate with the physician when there is a change in condition. Antibiotic-time-out will be utilized when appropriate. The IP will track the antibiotic ordered, dose, route, and ordering physician. The IP will track whether the resident met Criteria when the antibiotic was ordered. The IP will track if cultures were ordered. The IP will track changes in antibiotic orders during therapy. The IP will track outcome of therapy. The IP will provide results of tracking antibiotic use, outcomes, and adverse events to the clinical staff. Review of the facility's Infection Control binder showed the monthly Infection Prevention and Control Surveillance Log for November 2025 through April 2026. The surveillance reports did not completely indicate whether the residents' infection met or did not meet the McGeer's Criteria. Furthermore, the Infection Screening Evaluation on the residents' medical record did not show all the criteria used to assess for McGeer's criteria to determine the true infection. a. Medical record review for Resident 90 was initiated on 5/6/26. Resident 90 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 90's H&P examination dated 3/2/26, showed Resident 90 had no capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for November 2025 showed Resident 90 was prescribed with Ciprofloxacin (antibiotic) eye drops solution. The report showed the infection treated was HAI, and the McGeer's criteria was met. Further review of Resident 90's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0803 hours, an interview, medical record review for Resident 90, and concurrent facility document review was conducted with the IP. The IP verified the findings. b. Medical record review for Resident 40 was initiated on 5/6/26. Resident 40 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 40's H&P examination dated 3/28/26, showed Resident 40 had the capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for November 2025 showed Resident 40 was prescribed with Nystatin (antifungal) powder. The report showed the infection treated was CAI, and the McGeer's criteria was met. Further review of Resident 40's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0813 hours, an interview, medical record review for Resident 40, and concurrent facility document review was conducted with the IP. The IP verified the findings. c. Medical record review for Resident 44 was initiated on 5/6/26. Resident 44 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 44's H&P examination dated 10/15/25, showed Resident 44 was able to make needs known but had no capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for November 2025 showed Resident 44 was prescribed with Acyclovir (antiviral) tablet. The report showed the infection treated was HAI and met the McGeer's criteria. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 44 was prescribed with erythromycin (antibiotic) tablet then was changed to azithromycin (antibiotic). The report did show the infection treated was HAI and met the McGeer's criteria. Further review of Resident 44's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met for both times the resident showed signs and symptoms of infection. On 5/7/26 at 0830 hours, an interview, medical record review for Resident 44, and concurrent facility document review was conducted with the IP. The IP verified the findings. d. Medical record review for Resident 59 was initiated on 5/5/26. Resident 59 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 59's Physician Progress Notes dated 6/6/25, showed the resident had no capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for December 2025 showed Resident 59 was prescribed with Cefepime (antibiotic) IV solution then was changed to doxycycline (antibiotic). The report showed the infection was HAI, however it did not indicate if the McGeer's criteria was met or not met. Further review of Resident 59's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0848 hours, an interview, medical record review for Resident 59, and concurrent facility document review was conducted with the IP. The IP verified the findings. e. Medical record review for Resident 27 was initiated on 5/5/26. Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's Physician Progress Notes dated 12/4/25, showed resident had the capacity to understand and make decisions. Review of Resident 27's Infection SBAR dated 12/8/25, showed the infection analysis did not meet the McGeer's criteria. Review of the facility's monthly Infection Prevention and Control Surveillance Log for December 2025 showed Resident 27 was prescribed with Ceftriaxone (antibiotic) IV solution. The report showed the infection was CAI, however it did not indicate if the McGeer's criteria was met or not met. On 5/7/26 at 0856 hours, an interview, medical record review for Resident 27, and concurrent facility document review was conducted with the IP. The IP verified the findings. f. Closed record review for Resident 158 was initiated on 5/7/26. Resident 158 was admitted to the facility on [DATE], and was readmitted on [DATE]. Resident 158 was discharged on 1/26/26. Review of the facility's monthly Infection Prevention and Control Surveillance Log for December 2025 showed Resident 158 was prescribed with Ceftriaxone (antibiotic) IV solution and Ertapenem (antibiotic) IV solution then doxycycline (antibiotic) tablet. The report did not show the infection was CAI or HAI, and it did not indicate if the McGeer's criteria was met or not met. Further review of Resident 158's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met for the antibiotics prescribed in December 2025. Review of Resident 158's Admission/ readmission Initial assessment dated [DATE], showed the Infection SBAR section was incompletely filled out; and the signs and symptoms were not indicated in the form. Review of Resident 158's Physician Progress Notes dated 1/23/26, showed the resident had the capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 158 was prescribed with cefpodoxime (antibiotic) tablet and meropenem (antibiotic) IV solution; the report showed the infection was HAI and had met the McGeer's criteria. On 5/7/26 at 0908 hours, an interview, medical record review for Resident 158, and concurrent facility document review was conducted with the IP. The IP verified the findings. g. Closed record review for Resident 159 was initiated on 5/7/26. Resident 159 was admitted to the facility on [DATE], and was readmitted on [DATE]. Resident was discharged on 1/5/26. Review of Resident 159's Physician Progress Notes dated 11/27/25, showed the resident had the capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for December 2025 showed Resident 159 was prescribed with metronidazole (antibiotic) tablet. The report showed the infection HAI, however, it did not indicate if the McGeer's criteria was met or not met. Further review of Resident 159's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0915 hours, an interview, medical record review for Resident 159, and concurrent facility document review was conducted with the IP. The IP verified the findings. h. Medical record review for Resident 148 was initiated on 5/7/26. Resident 148 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the facility's monthly Infection Prevention and Control Surveillance Log for December 2025 showed Resident 148 was prescribed with nitrofurantoin (antibiotic) tablets. The report showed the infection was HAI, however, it did not indicate if the McGeer's criteria was met or not met. Review of Resident 148's Physician Progress Notes dated 3/24/26, showed the resident had no capacity to understand and make decisions. Further Review of Resident 148's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0928 hours, an interview, medical record review for Resident 148, and concurrent facility document review was conducted with the IP. The IP verified the findings. i. Medical record review for Resident 85 was initiated on 5/7/26. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's Physician Progress Notes dated 12/7/25, showed resident had the capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 85 was prescribed with doxycycline (antibiotic) tablets. The report showed the infection was HAI and had met the McGeer's criteria. Further review of Resident 85's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 0955 hours, an interview, medical record review for Resident 85, and concurrent facility document review was conducted with the IP. The IP verified the findings. j. Closed record review for Resident 161 was initiated on 5/7/26. Resident 161 was admitted to the facility on [DATE], and was discharged on 1/15/26. Review of Resident 161's H&P examination dated 12/11/25, showed the resident did not have the capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 161 was prescribed with Zosyn (antibiotic) IV solution. The report showed the infection was HAI and had met the McGeer's criteria. Further review of Resident 161's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1050 hours, an interview, medical record review for Resident 161, and concurrent facility document review was conducted with the IP. The IP verified the findings. k. Closed record review for Resident 11 was initiated on 5/7/26. Resident 11 was admitted to the facility on [DATE], and was readmitted on [DATE]. Resident was discharged on 4/2/26. Review of Resident 11's Physician Progress Notes dated 2/23/26, showed the resident had the capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 11 was prescribed with azithromycin (antibiotic) tablet. The report showed the infection was HAI and had not met the McGeer's criteria. Further review of Resident 11's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1025 hours, an interview, medical record review for Resident 11, and concurrent facility document review was conducted with the IP. The IP verified the findings. 1. Closed record review for Resident 163 was initiated on 5/7/26. Resident 163 was admitted to the facility on [DATE], and was discharged on 1/24/26. Review of Resident 163's Physician Progress Notes dated 11/26/25, showed the resident had the capacity to make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 163 was prescribed with azithromycin (antibiotic) tablet. The report showed the infection was HAI and had not met the McGeer's criteria. Further review of Resident 163's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1058 hours, an interview, medical record review for Resident 163, and concurrent facility document review was conducted with the IP. The IP verified the findings. m. Closed record review for Resident 164 was initiated on 5/7/26. Resident 164 was admitted to the facility on [DATE], and was readmitted on [DATE]. Resident was discharged on 1/27/26. Review of Resident 164's Physician Progress Notes dated 11/27/25, showed resident had the capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 164 was prescribed with cephalexin (antibiotic) capsule. The report showed the infection was HAI and had met the McGeer's criteria. Further review of Resident 164's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1105 hours, an interview, medical record review for Resident 164, and concurrent facility document review was conducted with the IP. The IP verified the findings. n. Closed record review for Resident 165 was initiated on 5/7/26. Resident 165 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident was discharged on 2/6/26. Review of Resident 165's Physician Progress Notes dated 11/12/25, showed the resident had no capacity to understand and make decisions. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 165 was prescribed with ciprofloxacin (antibiotic) eye drops. The report showed the infection was HAI and had met the McGeer's criteria. Further review of Resident 165's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1128 hours, an interview, medical record review for Resident 165, and concurrent facility document review was conducted with the IP. The IP verified the findings. o. Closed record review for Resident 88 was initiated on 5/7/26. Resident 88 was admitted to the facility on [DATE], and was readmitted on [DATE]. Resident was discharged on 4/26/26. Review of the facility's monthly Infection Prevention and Control Surveillance Log for January 2026 showed Resident 88 was prescribed with nitrofurantoin (antibiotic) capsules. The report showed the infection was HAI and had met the McGeer's criteria. Review of Resident 88's H&P examination dated 3/18/26, showed the resident had no capacity to make decisions. Further review of Resident 88's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1140 hours, an interview, medical record review for Resident 88, and concurrent facility document review was conducted with the IP. The IP verified the findings. p. Medical record review for Resident 8 was initiated on 5/7/26. Resident 8 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the facility's monthly Infection Prevention and Control Surveillance Log for February 2026 showed Resident 8 was prescribed with Levaquin (antibiotic) tablet. The report showed the infection was HAI and had not met the McGeer's criteria. Review of Resident 8's H&P examination dated 3/16/26, showed the resident had the capacity to understand and make decisions. Further review of Resident 8's medical record failed to show the Infection SBAR was completed for infection analysis if McGeer's criteria was met or not met. On 5/7/26 at 1156 hours, an interview, medical record review for Resident 8, and concurrent facility document review was conducted with the IP. The IP verified the findings. On 5/8/26 at 1030 hours, an interview was conducted with the DON. The DON stated the previous IP left the facility, and the facility had recently employed a new IP.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure complete and accurate medical records for four of 20 final sampled residents (Residents 7, 32, 92, and 143).* Resident 92's initial H&P examination was not completed.* Resident 143's shift pain monitoring did not match the resident's highest pain levels documented when PRN pain medications were administered.* Resident 7 and 143's post-fall neurological assessments had missing dates, and multiple illegible or overwritten time entries.* Resident 32's POLST was incomplete and did not show the resident had an advance directive, despite an advance directive being present in the medical record. These failures resulted in medical records that contained incomplete or inaccurate information, which could negatively affect continuity of care and clinical decision making.Findings: 1. Medical record review for Resident 92 was initiated on 5/5/26. Resident 92 was admitted on [DATE]. Review of Resident 92's medical record failed to show a H&P examination was completed upon admission to the facility. On 5/5/26 at 1122 hours, an interview and concurrent medical record review was conducted with RN 1 and the MRD. RN 1 reviewed Resident 92's medical record and verified a H&P examination was missing. The MRD also reviewed the resident's medical record and stated the H&P could not be located but stated should have been completed. 2. Medical record review for Resident 143 was initiated on 5/5/26. Resident 143 was admitted to the facility on [DATE]. a. Review of Resident 143's MAR for April 2026 showed the acetaminophen (a pain medication) 650 mg medication was administered for mild pain (for a pain level of 1-3 out of 10; with zero being no pain and 10 being the highest pain) on the following times: - On 4/6/26 at 1518 hours, for a pain level of 3;- On 4/9/26 at 0233 hours, for a pain level of 3; and- On 4/10/26 at 1739 hours, for a pain level of 2. Review of Resident 143's MAR for April 2026 showed the hydrocodone-acetaminophen (a opioid based pain medication) 10-325 mg medication was administered for moderate to severe pain (pain level of 4-10) on the following times: - On 4/9/26 at 1825 hours, for a pain level of 8;- On 4/18/26 at 1300 hours, for a pain level of 7;- On 4/22/26 at 0900 hours, for a pain level of 6;- On 4/23/26 at 1100 hours, for a pain level of 7;- On 4/24/26 at 0845 hours, for a pain level of 7;- On 4/28/26 at 0800 hours, for a pain level of 8;- On 4/28/26 at 1300 hours, for a pain level of 7;- On 4/29/26 at 1000 hours, for a pain level of 8; and- On 4/30/26 at 1115 hours, for a pain level of 7. Further review of Resident 143's MAR for April 2026 showed to monitor the resident's level of pain every shift, with a 0-10 pain scale. The MAR showed the resident's pain level was zero for all the above shifts when acetaminophen and hydrocodone-acetaminophen were administered. b. Review of Resident 143's MAR for MAY 2026 showed the hydrocodone-acetaminophen 10-325 mg medication was administered for moderate to severe pain (pain level of 4-10) on the following times: - On 5/4/26 at 0844 hours, for a pain level of 8; and- On 5/5/26 at 1721 hours, for a pain level of 7. Further review of Resident 143's MAR for May 2026 showed to monitor the resident's level of pain every shift, with a 0-10 pain scale. The MAR showed the resident's pain level was zero for all the shifts when hydrocodone-acetaminophen was administered. On 5/7/26 at 1358 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 reviewed Resident 143's MARs for April and May 2026 and verified the resident's pain levels were documented as zero for the shifts listed above when the PRN pain medications were administered for pain. LVN 9 stated the highest level of pain should be documented for each shift, however, when asked why the MAR showed the shift pain levels of zero when the PRN pain medications were administered for pain levels ranging from 2 to 8, LVN 9 stated the zero meant the pain medications were effective. On 5/7/26 at 1411 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when documenting the pain level for each shift, the licensed nurse should document the resident's highest level of pain for the shift, not the pain level after pain medication was provided. c. Review of Resident 143's post fall Neurological Assessment Flow Sheet dated 4/9/26, showed two of 20 time entries were overwritten with differing numbers, making them illegible. Review of Resident 143's post fall Neurological Assessment Flow Sheet dated 4/20/26, showed six of 20 time entries were overwritten with differing numbers, making them illegible. In addition, an entry for 4/21/26 at 0340 hours, instead of the scheduled 0040 hours. On 5/7/26 at 1508 hours, an interview and concurrent medical record review was conducted with the MRD. The MRD stated corrections must be made with a single line, labeled error, with initials. The MRD verified the staff wrote over existing entries, making them illegible, and verified the time discrepancy on 4/21/26. 3. Medical record review for Resident 7 was initiated on 5/5/26. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's post fall Neurological Assessment Flow Sheet dated 2/25 (no year) showed two time entries were overwritten with different numbers resulting in illegible/difficult to read time entries. The dates were left blank for 19 of 20 date entries, which should have covered 2/25 through 2/27/26. In addition, the last neurological assessment due on 2/27/26 at 0015 hours, was recorded at 0815 hours a blank date. On 5/7/26 at 1508 hours, an interview and concurrent medical record review was conducted with the MRD. The MRD verified the dates were missing, entries were overwritten, and the final assessment time was incorrect. 4. Medical record review for Resident 32 was initiated on 5/5/26. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P examination dated 11/15/25, showed Resident 32 had the capacity to understand and make decisions. Review of Resident 32's Advance Health Care Directive Form dated 7/2/18, showed the advance directive was formulated on 7/2/18. However, review of Resident 32's POLST dated 11/14/25, did not show if Resident 32 had an advance directive. On 5/7/26 at 1051 hours, an interview and concurrent medical record review for Resident 32 was conducted with the ADON. The ADON verified the above findings and stated the advance directive was available in Resident 32's medical record, the POLST should have been completed to indicate the resident had an advance directive. The ADON explained an inaccurate POLST documentation could delay or negatively impact emergency care decisions. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Infection Control Prevention and Control Program was established, maintained, and implemented according to accepted standards of practice to prevent the development and transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for November 2025 through March 2026. The facility conducted surveillance only on the residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. In addition, the facility failed to ensure the Infection Prevention and Control Surveillance Log, the Infection Control Monthly/Quarterly Summary Reports, and the facility's infection floor mapping for November and December 2025, and January and February 2026, contained consistent and accurate data. * The facility failed to ensure a clean personal laundry cart was covered and secured when left unattended in a resident hallway. These failures posed the risk for not identifying resident infections, preventing resident infections, and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: Review of the facility's P&P titled Surveillance for Infection dated 2001 showed the following: Infection Control Surveillance Process will include as a minimum outcome surveillance: collection of sign and symptom data as well as laboratory data and comparing to standard written definitions (criteria) of infections, review data to detect clusters and trends review antibiotic orders and laboratory antibiograms, review newly admitted residents, tracking prevalence of infections monthly and reporting communicable disease according to the local State and Federal requirements. Loeb and Stone's or McGeers guidelines will be utilized to define infection surveillance activities. Documentation tools for the surveillance program include Infection control surveillance log, Infection control worksheet (surveillance data sheet or Infection SBAR), nurses' notes or other related documentation, total days of antibiotic treatment or other therapy, results of the surveillance program will be reported at the monthly Infection Control Committee and at the Quarterly Quality Assurance meeting. The Infection Preventionist will report at a minimum the rate of HAI (Healthcare Associated Infections), CAI (Community Associated Infection), the results of the walking rounds and compliance with infection control policies and practices, the results of data collection, patterns and trends identified. 1. a. Review of the facility's Infection Surveillance Reports for February through April 2026 showed the infection control surveillance was only conducted for the residents who were prescribed with antibiotics. There was no documented evidence of residents who exhibited signs and symptoms of infection who met the facility's criteria for a true infection (McGeer's criteria) but were not prescribed antimicrobial medications. On 5/6/26 at 1425 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked the process of how the Infection Surveillance was completed, the IP stated the residents with signs and symptoms of infection and were prescribed antibiotics were included in the Infection Surveillance list. The IP further stated the residents with signs and symptoms of infection and were not prescribed with antibiotics, were not included in the Infection Surveillance list. Further review of the facility's Infection Surveillance Report from November 2025 through April 2026 showed the facility failed to conduct comprehensive surveillance for all the residents, specifically the residents who had signs and symptoms of infection and were not prescribed antibiotic. When asked how the residents with signs and symptoms of infection and were not prescribed antibiotic were monitored, the IP stated the resident monitoring would be on the progress notes. The IP was further asked, if these residents' infection symptoms recur, if she would remember if these residents had prior infection symptoms when they were not included in the Infection Surveillance Report, the IP responded she would not know. b. Review of the facility's Infection Prevention and Control Surveillance Log for: - November 2025 showed: HAI – 6 infections and CAI – 21 infections. - December 2025 showed: HAI – 10 infections and CAI – 19 infections. - January 2026 showed: HAI – 20 infections and CAI – 17 infections. - February 2026 showed: HAI – 19 infections and CAI – 8 infections. Review of the facility's Infection Control Monthly/ Quarterly Summary Report for: - November 2025 showed: HAI – 12 infections and CAI – 18 infections. - December 2025 showed: HAI – 10 infections and CAI – 19 infections. - January 2026 showed: HAI – 17 infections and CAI – 19 infections. - February 2026 showed: HAI – 19 infections and CAI – 8 infections. Review of the facility's infection floor mapping showed the following: - November 2025, total of 27 infections marked; - December 2025, total of 22 infections marked; - January 2026, total of 27 infections marked; and - February 2026, total of 22 infections marked. On 5/8/25 at 0803 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified the data listed in the Infection Prevention and Control Surveillance Log; Infection Control Monthly/ Quarterly Summary Report and the infection floor mapping were inaccurate. The IP stated the previous IP who completed the above was not employed at the facility anymore. On 5/8/26 at 1030 hours, an interview was conducted with the DON. The DON stated a new IP had been hired. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Laundry and Linen revised 1/2014 showed the clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. Medical record review for Resident 92 was initiated on 5/8/26. Resident 92 was admitted to the facility on [DATE]. On 5/7/26 at 1536 hours, an observation of the resident's clean personal clothing cart was conducted. The clean personal clothing cart's cover was observed to be left open, and unattended while the EVS Manager delivered clothing to a resident's room. Resident 92 was observed approaching the open clean clothing cart and proceeded to touch the clean clothing. CNA 1 was observed approaching Resident 92 as the resident was touching the clean clothing inside the cart. CNA 1 was observed walking away from Resident 92, and Resident 92 proceeded to touch more of the uncovered clean clothing inside the cart. On 5/7/26 at 1620 hours, an interview was conducted with CNA 1. CNA 1 was asked if she observed Resident 92 touching the uncovered clean clothing cart. CNA 1 verified she observed Resident 92 touching the clean clothing inside the cart and stated Resident 92 was looking for a blouse. CNA 1 verified Resident 92 should not have touched the clean clothing. On 5/7/26 at 1639 hours, an interview was conducted with the EVS Manager. The EVS Manager stated resident clean clothing was transported on a covered cart and verified the cart should remain closed when left unattended. The EVS Manager verified the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage in two of three medication carts (Medication Carts A and B) inspected. * The facility failed to ensure an expired glucagon emergency kit (containing one vial glucagon for injection: 1 mg glucagon and 49 mg of lactose (natural sugar), one syringe of diluent for glucagon: 12 mg/ml glycerin, water for injection, and hydrochloric acid) was not stored in Medication Cart A * The facility failed to ensure internal and external medications were stored separately. A Tear Plus (eye lubricant) eye drop medication and a bottle of Tylenol (analgesic) were stored together in Medication Cart A. * The facility failed to ensure the medication label on the bubble pack of the gabapentin (nerve pain medication) was accurate and reflected the physician's order. * The facility failed to ensure internal and external medications were not stored separately in Medication Cart B. These failures had the potential for the residents to be exposed to the expired medications and had the potential to lead to medication errors and place residents at risk of receiving the wrong type of medication.Findings: Review of the facility's P&P titled Medication Storage in the Facility revised 1/2025 showed the medications, biologicals are stored safely, securely, and properly, following manufacturer's recommendation or those of the supplier. Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. Further review of the P&P showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of according to procedures for medication disposal. 1. On 5/6/26 at 1059 hours, during inspection of Medication Cart A with LVN 4, the following was observed: a. A small red box of glucagon emergency kit (an emergency medication used to treat severe, life-threatening low blood sugar (hypoglycemia) in diabetes patients who have passed out or are unable to swallow sugar) was observed opened in the top drawer with the expiration date of 2/2026. LVN 4 verified the glucagon emergency kit was expired and should not have been stored in the medication cart. LVN 4 stated the glucagon emergency kit should have been disposed of and LVN 4 was observed removing the glucagon kit from the medication cart for the disposal. b. A bottle of Tylenol (analgesic) and a Tear Plus eye drop (lubricating artificial tears) were observed stored together in the top drawer. LVN 4 verified the observation and stated the eye drops and the oral Tylenol should not have been stored together. LVN 4 was observed separating the medications. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F755 example #2. 2. On 5/6/26 at 0826 hours, a medication administration observation for Resident 99 was conducted with LVN 4. LVN 4 prepared the medications for Resident 99 including two capsules of the gabapentin 100 mg medication. The label on the bubble pack of the gabapentin medication did not include the required hold parameter. Medical record review for Resident 99 was initiated on 5/5/26. Resident 99 was readmitted to the facility on [DATE]. Review of Resident 99's Order Summary Report showed a physician's order dated 5/5/26, to administer gabapentin 100 mg two capsules by mouth two times a day. Hold for respiratory rate less than 12 breaths per minute. On 5/6/26 at 0857 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 4. LVN 4 verified the bubble pack label for the gabapentin medication did not match the physician's order. LVN 4 also verified there was no change of direction sticker applied on the bubble pack. 3. On 5/6/26 at 1448 hours, an inspection of Medication Cart B was conducted with LVN 6. The following medications were observed stored in the same compartment with bottles of internally used medications such as Milk of Magnesia (laxative), Pro-Stat (protein supplement) and Geri-Lanta (antacid): - two bottles of Deep Sea Premium Saline (moisturizing spray) nasal sprays; - a box of Dulera (used to treat persistent asthma by reducing airway inflammation and relaxing the lung muscles) 200 mcg/5 ml inhalation aerosol solution; - a box of oxymetazoline 0.05% nasal spray (a topical nasal decongestant); - a box of ipratropium bromide – albuterol sulfate 0.5 mg/3 mg (bronchodilator), - a box of fluticasone-salmeterol 250mcg/50 mcg (inhaled corticosteroid and long-acting beta2-agonist). LVN 6 verified the above findings. On 5/8/26 at 0836 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to provide necessary treatment and follow-up care to maintain the vision needs for one of one final sampled resident (Resident 123) reviewed for vision and hearing. * The facility failed to ensure Resident 123's follow-up eye specialize appointment was scheduled. This failure posed a risk of the resident not receiving appropriate care for the resident's vision needs.Findings: On 5/5/26 at 935 hours, an interview was conducted with Resident 123. Resident 123 stated she had not been able to see her eye specialist and had not received any information regarding a follow-up appointment. Medical record review for Resident 123 was initiated on 5/5/26. Resident 123 was readmitted to the facility on [DATE]. Review of Resident 123's H&P examination dated 3/10/26, showed Resident 126 had the capacity to understand and make decisions. Resident 123's diagnoses included bilateral eye blindness. Further review of Resident 123's medical record showed an eye specialist progress note dated 1/21/26, documenting diagnoses of diabetes and bilateral eye cataracts. The progress note showed Resident 123 was referred for follow-up with another eye specialist. On 5/6/26 at 0946 hours, an interview and concurrent medical record review was conducted with the Social Services Assistant. When asked about scheduling the follow-up eye specialist appointment noted on 1/21/26, the Social Services Assistant stated she had not received any information about the referral. The Social Services Assistant stated the nursing staff were responsible for informing the Social Services of any follow-up appointments recommended by outside providers. The Social Services Assistant verified the progress note dated 1/21/26, showed a referral to another eye specialist. The Social Services Assistant stated she would begin follow-up. On 5/6/26 at 1001 hours, an interview and concurrent medical record review was conducted with LVN 6. When asked about Resident 123's progress note dated 1/21/26, which showed the referral for Resident 123, LVN 6 stated she informed the SSD and nursing management via a group chat about any appointments for Resident 123.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive, person-centered plan of care to reflect the individual care needs for two of 20 final sampled residents (Residents 143 and 148). * The facility failed to address Resident 143's use of the hydroxyzine HCl medication for anxiety in the care plan. * The facility failed to develop a care plan problem and interventions to address the use of the buspirone medication (antianxiety) for Resident 148. These failures had the potential to result in inconsistent, incomplete, and non individualized care for the residents.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the following: - Comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and - Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition changes. 1. Medical record review for Resident 148 was initiated on 5/5/26. Resident 148 was readmitted to the facility on [DATE]. Review of Resident 148's Order Summary Report showed a physician's order dated 4/28/26, to administer buspirone 5 mg one tablet by mouth every 12 hours a day for anxiety manifested by verbalization of feeling anxious. However, review of Resident 148's plan of care did not show a care plan problem, goal or interventions addressing the use of the buspirone medication. On 5/7/26 at 0907 hours, an interview and concurrent medical record review for Resident 148 was conducted with RN 2. RN 2 verified Resident 148 was receiving the buspirone medication as ordered and confirmed no care plan had been developed to address the use of the medication. On 5/8/26 at 0836 hours, an interview for Resident 148 was conducted with the DON. The DON was informed and acknowledged the above findings 2. Medical record review for Resident 143 was initiated on 5/5/26. Resident 143 was admitted on [DATE]. Review of Resident 143's MAR for April 2026 showed a physician's order dated 4/24/26 (discontinued 5/3/26), to administer hydroxyzine HCl (an antihistamine that can be used to treat anxiety) 25 mg by mouth every eight hours PRN for anxiety, with documented administration on:- 4/25/26 at 2054 hours;- 4/26/26 at 0912 hours;- 4/28/26 at 1539 hours; and - 4/30/26 at 1533 hours. Review of Resident 143's Order Summary report showed a physician's order dated 5/3/26, to administer hydroxyzine HCl 25 mg by mouth every eight hours PRN for anxiety. However, review of Resident 143's Care Plan Report did not show any problem, goal, or interventions addressing the resident's use of the hydroxyzine HCl medication or the resident's anxiety symptoms. On 5/7/26 at 1358 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the resident received hydroxyzine HCl for anxiety and had a current physician's order for the medication. LVN 9 verified the resident's care plan did not address the use of the hydroxyzine HCl medication or any medication management for anxiety, and stated it should have been included.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure accurate and timely PASARR Level I screenings for two of two final sampled residents (Residents 10 and 32) reviewed for PASARR. * The facility failed to ensure PASARR level I screening was completed when Resident 10 entered the facility as an exception (an exempted acute care hospital discharge) and stayed more than 30 days. * The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident 32. These failures posed the risk for Residents 10 and 32 of not properly screened for serious mental illness, intellectual disability, or related conditions, potentially resulting in inadequate levels of service, incomplete assessments, and lack of appropriate interventions and evaluations.Findings: Review of the facility's P&P titled admission Criteria revised 3/2019 showed all new admission and readmissions are screened for mental disorder (MD), intellectual disabilities (ID) or related disorder (RD) per the Medicaid PASARR. The facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process. 1. Medical record review for Resident 10 was initiated on 5/5/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's admission Record dated 5/6/26, showed Resident 10 had diagnoses of bipolar disorder and anxiety disorder. Review of Resident 10's Order Summary Report showed a physician's order dated 3/31/26, to administer duloxetine HCL 30 mg one capsule by mouth one time day for depression as manifested by verbalization of feeling hopelessness. Review of Resident 10's Preadmission Screening and Resident Review (PASARR) level I screening dated 3/31/26, showed Resident 10 had a diagnosed serious mental illness, was receiving psychotropic medication and met the criteria for an exempted acute care hospital discharge. Review of Resident 10's Notice of Exempted Hospital Discharge letter from DHCS dated 3/31/26, showed the PASARR Level I screening determined a Level II Mental Health Evaluation was not required. The letter included a summary of the Level I screening results, which was negative, with the reason noted as exempted hospital discharge. Further review of the letter showed if the resident remained in the nursing facility for more than 30 days, the facility was required to submit a new Level I screening as a resident review on the 31st day. Further review of Resident 10's medical record failed to show a new PASARR Level I screening was completed when Resident 10 remained in the facility beyond 30 days. 2. Medical record review for Resident 32 was initiated on 5/5/26. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's admission Record dated 5/7/26, showed Resident 32 had diagnoses of anxiety disorder and unspecified psychosis. Review of Resident 32's Physician Order Summary Report showed the following physician's orders:- dated 11/14/25, to administer buspirone HCL (antianxiety medication) 7.5 mg one tablet by mouth every 12 hours for anxiety as manifested by restlessness.- dated 4/1/26, to administer Seroquel ( antipsychotic medication ) 25 mg two tablets by mouth at bed time for psychosis as manifested by delusional ideation. Review of Resident 32's PASARR Level I screening completed by the acute care hospital on [DATE], showed Resident 32 had no diagnosed serious mental illness and was not receiving any psychotropic medications. Further review of Resident 32's medical record did not show the facility initiated the new PASARR Level I screening to correct the inaccurate acute care hospital-completed PASARR. On 5/7/26 at 0859 hours, an interview and concurrent medical record review for Residents 10 and 32 was conducted with the ADON. The ADON verified Resident 10 was admitted to the facility under an exempted acute care hospital discharge. The ADON explained if a resident was admitted under this status remained in the facility for more than 30 days, the facility was required to initiate a new PASARR Level I screening. The ADON verified she was unable to provide documentation showing the facility initiated a new Level I PASRR for Resident 10 after the resident stayed longer than 30 days. The ADON also stated the facility was responsible for reviewing PASARR Level I screenings completed by the acute care hospitals to ensure accuracy and if the screening was inaccurate, the facility must initiate a new PASARR. The ADON verified the PASARR completed by the acute care hospital for Resident 32 was not accurate. The ADON also confirmed she could not find documentation indicating that the facility initiated a new PASRR screening for Resident 32. The ADON stated that new PASRR screenings should have been initiated for both Residents 10 and 32. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to timely notify the resident's physician for changes in condition for one of one final sampled resident (Resident 4) reviewed for change of condition. * The facility failed to timely follow-up on and notify Resident 4's physician regarding the resident's urinary changes. This failure resulted in a delay in obtaining and implementing physician interventions.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status dated 2001 showed the facility will promptly notify the physician of changes in the resident's medical condition or with specific instructions to do so. Medical record review for Resident 4 was initiated on 5/5/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Plan Report showed a care plan problem initiated on 12/4/25, addressing the resident's alteration in bowel and bladder related to use of an indwelling urinary catheter and frequent bowel incontinence. The interventions included to monitor and report signs and symptoms of a UTI (hematuria, sedimentation, dysuria, flank pain, etc.) Review of Resident 4's Care Plan Report showed a care plan problem initiated on 1/23/26, addressing the resident's risk for bleeding, bruising and discoloration due to aspirin use. The interventions included to monitor, document, and report blood tinged or red blood in the urine. a. Review of Resident 4's Alert Note by LVN 8 dated 2/10/26 at 0940 hours, showed the resident was observed pulling on his urinary catheter with blood noted. LVN 7 was notified. LVN 8 documented upon assessment, no bleeding was noted and the urinary catheter was patent and draining. Review of Resident 4's SBAR Communication Form (General) dated 2/10/26 at 1344 hours, showed the resident's abdomen was visibly distended and firm on palpation, and the resident had no urine output in the Foley catheter since 0700 hours. The physician was notified and the resident was transferred to the acute care hospital. On 5/8/26 at 0927 hours, an interview and concurrent medical record review was conducted with the ADON and LVN 8. LVN 8 stated she wrote the Alert Note on 2/10/26, and explained an alert note was triggered by the CNA. LVN 8 stated on 2/10/26, she worked as the QA nurse, and saw an alert from a CNA that Resident 4 was pulling on his catheter and blood was observed. LVN 8 stated she assessed the resident and flushed the resident's urinary catheter with approximately 30 ml of irrigation fluid, and observed approximately 30 ml of irrigation fluid return from the tubing. LVN 8 stated she did not observe blood during flushing and did not check the urinary drainage bag for blood or urinary output. LVN 8 stated since she did not observe any abnormal findings, she did not notify the physician. The ADON reviewed the resident's medical record and facility staffing assignment for 2/9/26, and stated LVN 7 (the LVN in the Alert Note showed as being notified of the bleeding) worked on 2/9/26 from 1500 - 2300 hours. The ADON stated when a CNA reported the resident pulling on their urinary catheter with blood was observed, the LVN should have assessed the resident and documented their findings to show whether the LVN verified or did not verify the CNA's observations. The ADON verified there was no documentation to show the resident was assessed by the nursing staff on 2/9/26 during the 1500 - 2300, or 2300 - 0700 shifts. The ADON further stated if blood was observed in the urine by the licensed nurse, the physician should be notified immediately. The ADON verified the only documentation to show the physician was notified was on 2/10/26 at 1344 hours, when his abdominal distension and lack of urinary output was observed and reported, prompting the resident's transfer to the acute care hospital. b. Review of Resident 4's SBAR Communication Form (General) dated 2/17/26 at 0200 hours, showed earlier in the evening the resident was noted to have blood-tinged urine. At approximately 0200 hours, the resident was noted to have thick, dark, bright blood throughout the urinary catheter tubing. The licensed nurse left the resident's bedside and returned to change the catheter tubing with the plan to monitor the bleeding through the remainder of the shift, however, upon returning, the resident was unresponsive with abnormal vital signs. The physician was notified and 911 was called at approximately 0240 hours. Further review of Resident 4's medical record failed to show when the initial blood-tinged urine was observed by facility staff earlier in the evening. On 5/8/26 at 0927 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 4's SBAR Communication Form (General) dated 2/17/26 at 0200 hours, showed bleeding was noted earlier in the evening but was not documented at the time when the bleeding was initially identified. The ADON stated the physician should have been notified immediately when bleeding was first observed. Cross reference F684, example # 3.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 90 residents (Resident 136) observed for call light accessibility. * The facility failed to ensure Resident 136's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being and may cause delays in receiving necessary care.Findings: Review of the facility's P&P titled Answering the Call Light revised 3/2021 showed the purpose of the procedure to ensure timely responses to the resident's request and needs. Under the section General Guidelines, showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the facility P&P titled Accommodation of Needs dated 3/2021 showed in order to accommodate individual needs and preferences, adaptation may be made to the physical environment, including resident's bedroom bathroom, as well as common areas in the facility which included installing longer cords or providing remote controlled overhead or task lighting so that they are easily assessable. On 5/5/26 at 0734 hours, Resident 136 was observed lying in bed and yelling for help. When asked if she could call the facility staff, Resident 136 stated yes and began searching for the call light button. The call light button was observed clipped at the head of the bed. Resident 136 continued searching for the call light but was unable to reach it. On 5/5/26 at 0736 hours, LVN 4 was called into Resident 136's room. During the observation and concurrent interview, LVN 4 verified the call light was not within Resident 136's reach. LVN 4 was observed moving the call light button closer to Resident 136 and repositioning the resident in bed. LVN 4 stated Resident 136 was forgetful but able to use the call light to request staff assistance. LVN 4 stated the call light should have been within the resident's reach. On 5/5/26 at 0742 hours, Resident 136 was observed using the call light and asking staff for a drink. Medical record review for Resident 136 was initiated on 5/5/26. Resident 136 was admitted to the facility on [DATE]. Review of Resident 136's H&P examination dated 4/16/26, showed Resident 136 had no capacity to understand and make decisions. Review of Resident 136's Care Plan dated 4/16/26, showed a care plan problem addressing Resident 136's ADL self -care and mobility performance deficit related to impaired mobility and required staff assistance with the ADLs. The intervention included to place a call light within easy reach, and to encourage the resident to use the call light /bell to call for assistance. On 5/8/26 at 0921 hours, an interview was conducted with RN 2. RN 2 stated Resident 136 had dementia and was forgetful. RN 2 further stated Resident 136 was able to use the call light sometimes if she remembered, and the call light button should always be within the resident's reach. On 5/8/26 at 1049 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered for one of 91 residents (Resident 59). * Resident 59 had Vitamin A and D (skin protectant) ointment at bedside. However, Resident 59 did not have a physician's order to keep the medication at the bedside. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions, and negatively affect the resident's well-being.Findings: Review of the facility's P&P titled Resident Self-Administration of Medications dated 2001 showed as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. Review of the facility's P&P titled Medication Storage in the Facility revised January 2025 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medical record review for Resident 59 was initiated on 5/5/26. Resident 59 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 59's Physician Progress Note dated 6/6/25, showed the resident had no capacity to make decisions. Review of Resident 59's MDS assessment dated [DATE], showed the resident's BIMS was 14, indicating the resident had intact cognition. On 5/5/26 at 0631 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 59 in the resident's room. An unlabeled ointment in a medication cup was observed on top of the resident's bedside table. Resident 59 stated it was Vitamin A&D ointment and the licensed nurses usually gave him the Vitamin A&D ointment for him to apply on his lips. However, review of Resident 59's Order Summary Report dated 5/5/26, failed to show a physician's order for self-administration of the Vitamin A&D ointment. On 5/5/26 at 0640 hours, an observation and concurrent interview for Resident 59 was conducted with LVN 3. LVN 3 verified Resident 59 had the Vitamin A&D ointment on top of his bedside table. On 5/5/26 at 1339 hours, a follow up interview and concurrent medical record review was conducted with LVN 3 for Resident 59. LVN 3 verified Resident 59 had no physician's order for the Vitamin A&D ointment and/or for the resident to administer the medication by himself. On 5/5/26 at 1000 hours, an interview was conducted with the DON. The DON stated the licensed nurse should not have left the Vitamin A&D ointment on the resident's bedside table. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents for unnecessary medications (Residents 19 and 148) and two of 20 final sampled residents (Residents 8 and 93) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure the informed consents for buspirone (antianxiety) and Seroquel (antipsychotic) medications were accurate for Resident 93. * The facility failed to ensure the informed consent for buspirone medication included the indication of use and manifested behavior, and the informed consent for fluoxetine (antidepressant) medication was verified by two licensed nurses for Resident 148. * The facility failed to ensure the informed consent for risperidone (antianxiety) and Depakote (antimanic) medications included administration method and whether the medications had caution and warning summary, FDA-approved use, and black warning label for Resident 19. In addition, the facility failed to ensure the informed consent for risperidone medication included the name of the resident's representative who gave the consent via telephone for Resident 19. * The facility failed to ensure the informed consent for Seroquel medication included the name of resident's representative who gave the consent via telephone for Resident 8. These failures posed the risk of the residents and their representatives to not have informed decision-making regarding treatment risks and benefits related to the use of psychotropic medications.Findings: Review of the AFL 25-27 titled AB 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 10/7/25, showed the prescriber must share the material information a reasonable person in the resident's condition and circumstances would consider necessary for the resident or representative to make a decision about the treatment. Material information that the provider shall provide includes but is not limited to how the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. The AFL also showed the facility must check the medical record for proper informed consent prior to an initial administration. Review of the AFL 25-38.1, titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed effective 1/1/26, the Psychotherapeutic Drug Informed Consent Form or equivalent in-house form must be used for new residents, residents being prescribed a new psychotherapeutic drug, or residents having a psychotherapeutic drug dosage change. The Psychotherapeutic Drug Informed Consent Form Instruction Sheet showed the form will be completed by. entering the drug category and providing the possible side effects and significant risks associated with the use of the psychotherapeutic drug. Review of the facility's P&P titled Informed Consent for Psychotherapeutic Medications dated 9/10/25, showed the following:- Verification of informed consent shall be obtained by a licensed nurse in person/ verbally/ via telephone. This will be recorded in the resident's medical records, a licensed nurse can sign the form and document the name of the person who gave the consent (verbal/ telephone ) and the date;- If the resident or resident's representative cannot sign the informed consent form during the informed consent verification, the licensed nurse can sign the form and document the name of the person who gave the consent and the date- The facility will disclose the material information for proper informed consent for a prescription for psychotherapeutic drugs which includes the following information: the reason for the treatment includes their probably frequency and duration, and the nature, degree, duration and probability of the side effects and significant risks commonly known by the health professions. 1. Medical record review for Resident 93 was initiated on 5/5/26. Resident 93 was admitted to the facility on [DATE]. Review of Resident 93's Order Summary Report showed the following physician's orders:- dated 4/2/26, to administer buspirone 5 mg one tablet by mouth two times a day for anxiety manifested by inability to relax;- dated 4/3/26, to administer Seroquel 25 mg one tablet by mouth in the evening for psychosis as evidenced by angry outburst; and- dated 4/3/26, to administer Seroquel 50 mg one tablet by mouth one time a day for psychosis as evidenced by angry outburst. Review of Resident 93's Psychotropic Medication Administration Informed Consent (Anti-depressant) dated 4/2/26, showed an informed consent for antidepressant medication used for buspirone 5 mg medication. The informed consent included side effects associated with antidepressant medications and did not contain accurate side effects and risks associated with antianxiety medications such as buspirone. Review of Resident 93's Psychotropic Medication Administration Informed Consent (Anticonvulsant/Antimanic) dated 4/2/26, showed an informed consent for anticonvulsant/antimanic medication was used for Seroquel 25 mg medication. The informed consent included side effects associated with anticonvulsant/antimanic medications and did not contain accurate side effects and risks associated with antipsychotic medications such as Seroquel. Review of Resident 93's Psychotropic Medication Administration Informed Consent (Antianxiety) dated 4/2/26, showed an informed consent for antianxiety medication was used for Seroquel 50 mg medication. The informed consent included side effects associated with antianxiety medications and did not contain accurate side effects and risks associated with antipsychotic medications such as Seroquel. Review of Resident 93's MAR for April and May 2026 showed the following:- Resident 93 was administered buspirone 5 mg medication on 4/3 to 5/4/26 at 0900 and 1700 hours, on 5/5/26 at 1700 hours, and on 5/6/26 at 0900 hours;- Resident 93 was administered Seroquel 25 mg medication on 4/3 to 5/5/26 at 1700 hours; and- Resident 93 was administered Seroquel 50 mg medication on 4/3 to 5/4/26, and 5/6/26 at 0900 hours. On 5/6/26 at 1147 hours, an interview and concurrent medical record review for Resident 93 was conducted with RN 2. RN 2 verified the informed consent forms used were inaccurate related to the use of buspirone and Seroquel medications for Resident 93. 2. Medical record review for Resident 148 was initiated on 5/5/26. Resident 148 was readmitted to the facility on [DATE]. Review of Resident 93's Order Summary Report showed the following physician's orders:- dated 3/23/26, to administer dluoxetine 40 mg one capsule by mouth one time a day for depression manifested by persistent feeling of hopelessness; and-4/28/26, to administer buspirone 5 mg one tablet by mouth every 12 hours a day for anxiety manifested by verbalization of feeling anxious. Review of Resident 148's Psychotropic Medication Administration Informed Consent (Antidepressant) dated 3/24/26, showed only one licensed nurse verified the informed consent via phone related to the use of fluoxetine medication. Review of Resident 148's Psychotropic Medication Administration Informed Consent (Antianxiety) dated 4/16/26, did not show the reason for use or behavior manifestation related to the use of buspirone were included in the consent form. Review of Resident 148's MARs for April and May 2026 showed the following:- Resident 148 was administered the fluoxetine medication from 4/1 to 4/26/26, and 4/29 to 5/5/26 at 0900 hours; and- Resident 148 was administered buspirone medication from 4/29 to 5/5/26 at 0900 and 2100 hours On 5/7/26 at 0907 hours, an interview and concurrent medical record review for Resident 148 was conducted with RN 2. RN 2 stated two licensed nurses had to sign the informed consent to verify the resident or resident's representative had given consent for the use of the psychotherapeutic medication. RN 2 verified the informed consent form for fluoxetine showed only one licensed nurse verified the informed consent via telephone. RN 2 further verified the informed consent form for buspirone medication did not include the indication for use or the behavior manifestation related to the use of the buspirone medication for Resident 148. 3. Medical record review for Resident 19 was initiated on 5/5/26. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed the following physician's orders:- dated 9/18/25, to administer Depakote 125 mg three capsules by mouth three times a day for affective mood disorder manifest by anger outburst/ poor impulse control; and- dated 3/21/26, to administer risperidone 0.25 mg one tablet by mouth two times a day for bipolar disorder manifested by persistent yelling and screaming despite ADLs met. Review of Resident 19's Psychotropic Medication Administration Informed Consent (Anticonvulsant/Antimanic Agents) for Depakote medication dated 2/13/26, did not show the administration method, and whether the Depakote medication had caution and warning summary, FDA-approved use, and black box warning label. Review of Resident 19's Psychotropic Medication Administration Informed Consent (Antipsychotic) for risperidone dated 2/13/26, did not show administration method, and whether the risperidone medication had caution and warning summary, FDA-approved use, and black box warning label. Furthermore, the informed consent did not show the name of the resident's representative who gave the consent via telephone. Review of Resident 19's MAR for April and May 2026 showed the following:- Resident 19 was administered the Depakote medication from 4/1 to 5/5/26 at 0900, 1300, and 1700 hours, and on 5/6/25 at 0900 and 1300 hours; and- Resident 19 was administered the risperidone medication from 4/1 to 5/5/26 at 0900 and 1700 hours, and on 5/6/26 at 0900 hours. On 5/6/26 at 1126 hours, an interview and concurrent medical record review for Resident 19 was conducted with RN 2. RN 2 verified the informed consent form for risperidone medication did not show the name of the resident's representative who gave the consent via telephone. RN 2 further verified the informed consent forms for risperidone and Depakote medications did not include the administration method, and whether the medications had caution and warning summary, FDA-approved use, and black box warning label related to the use of the risperidone and Depakote medications for Resident 19. 4. Medical record review for Resident 8 was initiated on 5/5/26. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed a physician's order dated 4/16/26, to administer quetiapine (Seroquel) 25 mg half tablet by mouth every evening for psychosis as evidenced by standing abruptly without asking for staff assistance. Review of Resident 8's Psychotropic Medication Administration Informed Consent (Antipsychotic) for Seroquel medication dated 4/17/26, did not show the name of the resident's representative who gave the consent via telephone. Review of Resident 8's MAR for April and May 2026 showed Resident 8 was administered the Seroquel 25 mg half tablet medication from 4/18 to 4/23, 4/25, 4/28 to 5/6/26 at 1300 hours. On 5/6/26 at 1112 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 2. RN 2 verified the informed consent form for Seroquel medication did not show the name of the resident's representative who gave the consent via telephone. On 5/8/26 at 0836 hours, an interview for Residents 8, 19, 93, and 148 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident care was provided in a manner that maintained and enhanced dignity for one of 20 final sample residents (Resident 19). * The facility failed to ensure CNA 2 sat next to Resident 19 while assisting the resident to eat. This failure had the potential to negatively impact Resident 19's sense of dignity, self-worth, and well-being.Findings: Review of the facility's P&P titled Assisting the Impaired Resident with In-Room Meals dated 2001 showed if the staff is going to be seated during the feeding, to position a chair where it will be convenient for you and the resident. On 5/5/26 at 0800 and 0805 hours, Resident 19 was observed being assisted with eating by CNA 2. CNA 2 was observed standing over Resident 19, who was seated upright in bed. On 5/5/26 at 0810 hours, an observation for Resident 19 and concurrent interview was conducted with CNA 2. CNA 2 verified she had been standing over Resident 19 while assisting the resident with eating. When asked about the facility's expectation for assisting the residents with meals, CNA 2 stated she was supposed to be seated when assisting a resident with eating. Medical record review for Resident 19 was initiated on 5/5/26. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 8/7/25, showed Resident 19 had no mental capacity to make decisions. Review of Resident 19's plan of care showed a care plan problem dated 7/6/23, addressing the resident's alteration in physical functioning. The interventions included to assist with meals. On 5/7/26 at 1350 hours, an interview was conducted with the DSD. When asked about the facility's policy for assisting the residents with eating, the DSD stated the staff should be seated beside the residents when assisting with eating to promote residents' dignity. On 5/8/26 at 0836 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 148) reviewed for unnecessary medication was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 148 was monitored for the side effects related to the use of lorazepam (antianxiety), buspirone (antianxiety), fluoxetine (antidepressant) and mirtazapine (antidepressant). In addition, the monthly behavior summary for mirtazapine medication did not match the documentation of the episodes when Resident 148 ate less than 50%. These failures had the potential to result in unrecognized adverse medication effects, delayed or inadequate clinical intervention, and inaccurate clinical decision-making regarding the continued use of the psychotropic medications for Resident 148.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 2001 showed psychotropic medication management includes adequate monitoring for efficacy and adverse consequences. According to Dailymed.nlm.nih.gov:- The most adverse reactions with lorazepam use include central nervous effects and respiratory depression;- The more commonly observed untoward events associated with the use of buspirone hydrochloride tablets not seen at an equivalent incidence among placebo-treated patients include dizziness, nausea, headache, nervousness, lightheadedness, and excitement;- Residents with major depressive disorder, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs, related to the use of fluoxetine; and- To monitor all antidepressant-treated patients for any indication of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes related to the use of mirtazapine. Medical record review for Resident 148 was initiated on 5/5/26. Resident 148 was readmitted to the facility on [DATE]. Review of Resident 148's Order Summary Report showed the following physician's orders:- dated 3/23/26, to administer fluoxetine 40 mg one capsule by mouth one time a day for depression manifested by persistent feeling of hopelessness;- dated 4/16/26, to administer mirtazapine 15 mg one tablet by mouth one time a day for depression manifested by poor oral intake less than 50% each meal;- dated 4/28/26, to administer buspirone 5 mg one tablet by mouth every 12 hours a day for anxiety manifested by verbalization of feeling anxious;- dated 4/29/26, to administer lorazepam 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days; and-dated 5/3/26, to monitor side effects of antidepressant medications every shift. a. Review of Resident 148's MARs for April and May 2026 showed the following:- Resident 148 was administered the fluoxetine medication from 4/1 to 4/26/26, and 4/29 to 5/5/26 at 0900 hours;- Resident 148 was administered the mirtazapine medication from 4/8 to 4/16/26 at 2100 hours, and on 4/17 to 4/26, 4/29 to 5/5/26 at 0900 hours;- Resident 148 was administered the buspirone medication from 4/29 to 5/5/26 at 0900 and 2100 hours;- Resident 148 was monitored for side effects of antianxiety medication on 5/3/26 on evening and night shifts;- Resident 148 was monitored for side effects of antidepressant medication on 5/3/26 on evening and night shifts, and 5/4 to 5/5/26 on day, evening, night shifts;- Resident 148 was not monitored for side effects related to the use of fluoxetine, mirtazapine, buspirone and lorazepam medications; and- Resident 148's meal intake each meal was not documented in the MAR. Further review of Resident 148's medical record did not show documented evidence the resident was monitored medication side effects related to the use of fluoxetine, mirtazapine, buspirone and lorazepam medications. b. Review of Resident 148's Documentation Survey Report v2 for April and May 2026 under Amount Eaten section, showed the following:- Resident 148 consumed 26 to 50% on 4/8 at dinner, 4/9 at lunch and dinner, and 4/10/26 at dinner (a total of four episodes); and- Resident 148 consumed 0 to 25% on 4/14, 4/23 and 4/24/26 at breakfast and lunch, and on 4/20, 4/21, 4/25 and 4/29/26 at lunch (a total of 10 episodes). Review of Resident 148's Monthly Psychotropic Summary Sheet for the Remeron medication from 4/8 to 4/30/26, showed there were a total of four episodes of poor oral intake less than 50% each meal related to the use of the Remeron (mirtazapine) medication. The monthly psychotropic summary was inconsistent with the documentation of Resident 148's meal intake. On 5/7/26 at 0907 hours, an interview and concurrent medical record review for Resident 148 was conducted with RN 2. RN 2 verified there was no side effect monitoring for the use of lorazepam, buspirone, fluoxetine, and mirtazapine medications. RN 2 further verified the monthly behavior summary for the mirtazapine medication did not match the RNA documentation of episodes when Resident 148 ate less than 50%. On 5/8/26 at 0836 hours, an interview for Resident 148 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the residents' (Residents 2 and 4) rights to be free from the sexual abuse by another resident (Resident 3). * The facility failed to monitor and provide Resident 3 with the 1:1 (one staff to one resident) supervision as per the care plan after an incident of Resident 3 grabbing Resident 2's breasts on 9/6/24, resulting in Resident 3 continuing to fondle Resident 4's breasts during the activities in the dining room on 9/8/24. This failure resulted in Resident 3 continuing to sexually abuse other residents. Findings: Review of the facility's P&P titled Abuse Prevention Program revised 4/2021 showed the residents have the right to be free from abuse, neglect, misappropriate of resident property, and exploitation, which included freedom from sexual abuse. The residents are protected from abuse by anyone including other residents. In addition to protecting residents from any further harm during investigations. Review of the facility's P&P titled Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigation revised 4/2024 showed upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised 12/2016 showed, identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship the resident's problem areas and their causes, and relevant clinical decision making. On 9/7/24 at 1408 hours, the CDPH, L&C Program received an SOC 341 from the facility showing Resident 2 reported to the charge nurse alleging Resident 3 had grabbed her right breast on 9/6/24 at 2345 hours. On 9/10/24 at 1715 hours, the CDPH, L&C Program received an SOC 341 from the facility showing Resident 3 had fondled Resident 4's breasts in the dining room on 9/8/24. 1. Medical record review for Resident 2 was initiated on 9/10/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 6/3/24, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact with a BIMS score of 15. Review of Resident 2's SBAR Communication Form dated 9/7/24, showed Resident 2 reported to staff another resident (Resident 3) grabbed her right-side breast on 9/6/24 at 2345 hours, at the smoking patio. The form further showed Resident 2 felt upset. On 9/10/24 at 1036 hours, an interview was conducted with Resident 2. Resident 2 stated on 9/6/24 at 2345 hours, while she was coming in from the smoking patio, Resident 3 stated, oh boobies, then grabbed her both breasts. Resident 2 stated Resident 3 squeezed so hard that hurt her right breast. Resident 2 further stated the following day when she walked by Resident 3 who again stated oh boobies in front of other people and families. On 9/11/24 at 0835 hours, a follow-up interview was conducted with Resident 2. Resident 2 stated she felt violated and embarrassed and stated that was the first man to ever touch her ever since her husband passed away in 2011. 2. Medical record review for Resident 4 was initiated on 9/10/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], showed Resident 4 was moderately impaired with a BIMS score of 11. Review of Resident 4's SBAR Communication Form dated 9/8/24, showed Resident 4 reported her breast was fondled by another resident (Resident 3) while they were in the activity room. On 9/10/24 at 1129 hours, an interview with the DON was conducted. The DON verified Resident 3 grazed his hands over Resident 4's chest which was witnessed by the Activities Assistant. On 9/10/24 at 1346 hours, an interview was conducted with Resident 4. Resident 4 stated while sitting in the activities room, Resident 3 had reached over, touched her breasts, and laughed and kept doing it. Resident 4 further stated she told Resident 3 to stop, then she got up and moved. When asked if anyone else saw the incident, Resident 4 stated the Activities Assistant saw and told Resident 3 to stop. On 9/10/24 at 1401 hours, an interview was conducted with the Activities Assistant. The Activities Assistant stated on 9/8/24 at 1015 hours, Resident 4 was sitting next to Resident 3 in the dining room for activities when Resident 3 kept reaching his hand over Resident 4 and touching Resident 4's breasts with an open palm. When asked if she witnessed the incident, Activities Assistant stated yes. 3. Closed medical record review for Resident 3 was initiated on 9/10/24. Resident 3 was admitted to the facility on [DATE], and discharged on [DATE]. Review of Resident 3's SBAR Communication Form dated 9/7/24, showed a report was received Resident 3 grabbed a resident's right breast on 9/6/24 at 2345 hours, in the smoking patio. Review of Resident 3's SBAR Communication Form dated 9/8/24, showed Resident 3 was brought to the dining room for the activity time, and Resident 3 kept trying to fondle a female resident's chest even after multiple warnings by the female resident telling Resident 3 to stop. Review of Resident 3's MDS dated [DATE], showed the Section GG for Functional Limitation in Range of Motion for the upper extremity (shoulder, elbow, wrist, hand) indicated 0 (no impairment). Review of Resident 3's Plan of Care showed a care plan problem initiated on 9/7/24, addressing the report of Resident 3 grabbed a resident's right breast at the smoking patio. The care plan goal showed no grabbing other breast behavior on next review date. The care plan interventions included to conduct the frequent visual checks and provide the 1:1 sitter. Review of the facility's Daily Assignment Sheets for 9/7 and 9/8/24, showed the LVNs and CNAs were assigned to multiple residents per shift. Further review of the assignment sheets failed to show documented evidence a staff was assigned to conduct the 1:1 sitter for Resident 3. On 9/11/24 at 1014 hours, an interview was conducted with RN 1. RN 1 stated the 1:1 sitter would consist of one nurse or one CNA to one resident, and the staff would be with the resident at all times to ensure the resident's whereabouts. RN 1 verified there was no documented evidence Resident had the 1:1 sitter after the first incident on 9/6/24, with Resident 3 as per the care plan initiated on 9/7/24, until after the second abuse allegation with Resident 4 on 9/8/24. On 9/12/24 at 1340 hours, an interview was conducted with LVN 5. LVN 5 verified Resident 3 did not have the 1:1 sitter on 9/7 - 9/8/24, prior to the second allegation due to short of staff. LVN 5 stated if Resident 3 was provided a sitter, the 1:1 sitter would also accompany the Resident 3 during the activity time. On 9/13/24 at 1024 hours, a follow-up interview was conducted with the Activities Assistant. The Activities Assistant stated there were no other staff members in the room during the activities on 9/8/24. The Activities Assistant verified Resident 3 did not have the 1:1 sitter in the dining room. On 9/17/24 at 1349 hours, an interview was conducted with CNA 4. CNA 4 verified she was assigned to Resident 3 on 9/8/24. When asked what her role was with Resident 3, CNA 4 stated I needed to monitor him. When asked how many other residents she had on 9/8/24, CNA 4 stated she had eight or nine residents. When asked who was monitoring Resident 3, CNA 4 stated, me I guess. When asked how Resident 3 got into the activities room, CNA 4 stated she assisted Resident 3 to get dressed and Resident 3 self-propelled himself in his wheelchair into activities. When asked if anyone accompanied Resident 3 in the activities room, CNA 4 stated no. When asked if anyone was watching Resident 3 during activities, CNA 4 stated, not that I'm aware. When asked if Resident 3 was being monitored prior to the second abuse allegation with Resident 4, CNA 4 stated, not that I'm aware. On 9/17/24 at 1450 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review and facility document and P&P review, the facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status for one of 19 final sampled residents (Resident 6) when: 1. The severe weight loss of - 10 lbs. (7.7%) from 7/20/23 to 9/25/23, and - 14 lbs. (10.4%) from 5/28/23 to 9/25/23, was not assessed and monitored by the IDT (Interdisciplinary team - members of the care team including but not limited to: the attending physician, nurses, a member of the food and nutrition services staff, social workers, rehabilitation therapists and the resident or the resident's legal representative). 2. The interventions ordered by Physician 1 to maintain Resident 6's nutritional and hydration status were not implemented as ordered. 3. The resident centered plan of care for Resident 6 did not reflect the goals or interventions in regard to dehydration risk. As a result of these failures, Resident 6's severe weight loss of 10 lbs. (7.7%) in three months from 7/20/23 to 9/25/23, and 14 lbs. (10.4%) in six months from 5/28/23 to 9/25/23, and poor PO (oral) intake contributed to the transfer of Resident 6 to the acute care hospital on 10/24/23, with admitting diagnosis of dehydration and sepsis related to UTI (urinary tract infection). Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed in part, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people [AGE] years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-[AGE] years or longer, is associated with increased mortality or morbidity or both. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/> A professional reference review of the Journal of Nutrients titled, Chronic Dehydration in Nursing Home Residents, dated [DATE] showed in part, The adult human body consists of about 60% water, with muscle functioning as the main reservoir of water, but in older adults, this amount is reduced to only around 50% due to reduced muscle mass. Among older adults, dehydration is common and is associated with several serious adverse events, including longer hospital stays and higher mortality (the state of being subject to death) rates . Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration.Chronic dehydration is mainly due to insufficient fluid intake over a lengthy period and is often insidious (proceeding in a gradual way but with harmful effect) . Older adults are considered at risk for chronic dehydration due to their reduced sensitivity to thirst, lower urine concentrating ability, and lower fluid intake compared with young or middle-aged adults. Furthermore, older nursing home residents may be at high risk for chronic dehydration because lower fluid intake is commonly observed in nursing home residents .Chronic dehydration may be more problematic among nursing home residents, and establishing effective preventive strategies for chronic dehydration in this population would require identifying the risk factors for chronic dehydration. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709028/> A professional reference review of the National Library of Medicine titled, Reducing urinary tract infections in care homes by improving hydration, dated July 10, 2019, showed in part, Dehydration may increase the risk of urinary tract infections (UTIs), which can lead to confusion, falls, acute kidney injury and hospital admission . Urinary tract infection (UTI) was the condition with the highest rate of emergency admissions to hospitals in 2012/2013. Dehydration has been highlighted as a common cause of admission to hospital in nursing home residents, and there is evidence that many older residents living in care homes do not receive enough fluids. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629391/> 1. Review of the facility's P&P titled Weight Assessment and Intervention revised 9/2008 showed in part, the multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range, b. appropriate calorie, protein and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight .2. Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident ' s legal surrogate. 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Interventions: b. Nutrition and hydration needs of the resident; chewing or swallowing abnormalities and the need for diet modifications; the use of supplementation and/or feeding tubes . Review of the facility P&P titled Acute Condition Changes revised 3/2018 showed in part, Monitoring and Follow-up 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. Medical record review for Resident 6 was initiated on 11/7/23 at 0920 hours. Resident 6 was readmitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), sepsis (a life-threatening complication of an infection), difficulty in walking, muscle weakness (generalized), and dysphagia (difficulty swallowing). Review of Resident 6's Annual History and Physical Examination dated 12/30/22, showed Resident 6 had fluctuating capacity to understand and make decisions. Review of Resident 6's quarterly Minimum Data Set (MDS, a resident assessment tool) dated 10/2/23, showed under Section C. Cognitive Patterns, a BIMS (brief interview for mental status) score of seven out of a possible 15, indicating Resident 6 had severe cognitive impairment. Section K of the MDS showed Resident 6's weight was 120 lbs and Resident 6 had experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician- prescribed weight-loss regimen. Review of Resident 6's Physician's Order dated 9/1/23 through 11/30/23, showed the following orders: - dated 9/26/23, for weekly weights for four weeks, every day shift, every Saturday until 10/22/23. - dated 10/31/23, for laboratory orders: CBC (complete blood count a measurement of white and red blood cells and platelets), CMP (complete metabolic panel, a blood test that provides information about body fluid balance, electrolytes - minerals in the blood and kidney function), Hgb A1C (a test that measures average blood sugar levels over the past three months), B12 (vitamin), D (vitamin), D25 (vitamin), liver panel, lipid panel (levels of fatty compounds in the blood) and Valproic acid (medication). - dated 11/3/23, to provide snacks three times a day. - dated 11/7/23, for a fortified (additional calories) pureed (smooth blended food) texture diet, regular liquid consistency. Review of the facility document titled Weights and Vitals Summary from 7/20/23 through 9/25/23, showed the following weights and comparisons for Resident 6: - On 9/25/23, weight = 120 lbs., -7lbs., 5.5% severe weight loss since 8/2/23 [comparison weight 127 lbs.], -10 lbs., a 7.7% severe weight loss in three months [comparison weight on 7/20/23, 130 lbs.], and -14 lbs., a 10.4% severe weight loss in six months [comparison weight on 5/28/23, 134 lbs.]. Review of Resident 6's meal intake records dated 9/25/23 - 10/23/23, showed 88% of the 68 meals recorded, the intake was less than or equal to 50%. Review of Resident 6's fluid intake records dated 9/25/23 - 10/23/23, showed for the 68 meals recorded, Resident 6's average meal fluid intake was 430 ml per meal or 1290 ml per day. Review of the facility document titled SBAR communication Form for Resident 6 signed and dated 9/25/23, by LVN 4 showed S. Situation: 1. The change in condition, symptoms, or signs I am calling in is/are weight loss of seven pounds (lbs.) from 127 lbs. (8/2/23) to 120 lbs. (9/25/23). The Physician was notified. R. Request 1a. Monitor vital signs, 1j. Other new orders: dietitian and psych consult. Review of the facility document titled Medicine Progress Notes signed and dated by Physician 1 on 9/27/23, showed in part, Resident 6 weighed 120 lbs. (-7 lbs.) and was noted with weight loss and variable appetite. Assessment: poor PO intake .Plan: Continue with care plan, follow up with psychiatry and dietitian as needed, trend weights. Review of Resident 6's Nursing Services progress notes dated 9/25/23 - 9/28/23, showed on 9/25/23, LVN 4 documented per MD recommending diet and psych consult due to weight loss of seven lbs orders were in place and carried out; and sent a secure message to the social services and dietitian. Review of Resident 6's Post- COC/SBAR dated 9/28/23, showed LVN 5 documented Resident 6 was on monitoring for weight loss from 127 lbs to 120 lbs. Resident 6 refused dinner today and took medications as ordered with no signs or adverse effects. All needs had been met. Review of the facility document titled Weekly Summary for Resident 6 signed and dated on 9/28/23, by LVN 6 showed Section F. Nutrition/hydration as follows: - Section F4, Average intake: 60-75% - Section F6, Weight 120 lbs. - Section F7, Date when weight taken: 9/25/23, - Section F8, Previous weight 127 lbs. - Section F9, Date when weight taken: 8/2/23. - Section F10, Significant weight change: Weight loss. - Section F11, No labs drawn this week. - Section F16, Signs/symptoms of dehydration: None. Review of the facility document titled Weekly Summary for Resident 6 signed and dated on 10/2/23, by LVN 7 showed Section F4 - F16, no changes from the 9/28/23 weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 6 signed and dated on 10/9/23, by LVN 8 showed Section F4- F16, no changes from 9/28/23, weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 6 signed and dated on 10/18/23, by LVN 6 showed Section F4, average intake 70-85%; and Sections F6-F16, no changes from the 9/28/23 weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 6 signed and dated on 11/1/23, by LVN 6 showed Section F4, average intake 70-90% and Sections F6-F16, no changes from the 9/28/23 weekly nursing summary. Nutrition/hydration: Review of the facility document titled Progress Notes signed and dated on 9/27/23, by the RD showed in part, Resident 6's monthly weight/consult: the resident with seven lbs, 5.5% weight loss in one month, 12 lbs., 9.09% weight loss in three months and 11 lbs., 8.4% weight loss in six months. Weight: 120 lbs. (9/25/23) .Fortified diet, mechanical soft texture, regular liquid consistency with poor (less than 50%) PO (oral) intake. Patient is on snacks TID (three times a day), and supplement shakes TID .No new labs noted. Estimated needs: 1375-1650 kcals (kilocalories), 25-30 kcal/kg ABW (actual body weight), 1375-1650 ml (milliliters, a unit of measure). Nutrition DX (diagnosis): inadequate oral food/beverage intake r/t poor intake AEB (as evidenced by) patient meeting 61% of estimated kcal and 64% of estimated protein needs with diet. Recommend to change to appetite stimulant per MD. Recommend to add ice cream BID (twice a day) with lunch and dinner for patient to try and SF (sugar free) prostat (protein supplement) 30cc (unit of measure) BID .Will continue to follow weights, skin, labs and PO intake. Review of the facility document titled Nutritional Quarterly Review signed and dated by the DSS on 10/9/23, showed in part, Resident 6's diet order: fortified mechanical soft texture-regular liquid consistency, snacks TID between meals, ice cream with lunch and dinner. Appetite was poor, meal intake percentage 26-50%. Resident 6 had chewing problems. Most recent weight was 120 lbs on 9/25/23. Recent weight changes: RD note- monthly weight/consult patient with seven lbs., 5.5% weight loss in one month, 12 lbs., 9.09% weight loss in three months, and 11 lbs., 8.4% weight loss in six months. Review of Resident 6's hospital admission report dated 10/24/23, showed in part, Admitting diagnosis: Dehydration; Schizophrenia. Review of Resident 6's History and Physical examination from the acute care hospital dated 10/25/23, showed history of present illness: Resident 6 was noted to have progressively poor po intake. The resident was noted to be weaker and more confused than her usual baseline level. She was referred via regular ambulance to the acute care hospital emergency department where she underwent a preliminary workup. The results showed multiple abnormal values. She was subsequently admitted to the acure care hospital for further medical management. Review of Resident 6's physician hospital records dated 10/27/23 showed in part, Problem 1. Sepsis secondary to UTI (urinary tract infection). Assessment/plan 1. Continue with preadmission medications and diet. Gentle IVF (intravenous fluid) hydration, IV abx (antibiotics), Urine C&S (culture and sensitivity). Problem 2: Poor PO intake related to AFTT (adult failure to thrive; a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). Review of the facility document titled Nutritional Assessment - RD signed and dated by the RD on 11/2/23, showed in part, Resident 6's weight on 9/25/23, 120 lbs, usual body weight 120-135 lbs., goal weight 135 lbs. Weight loss > or = (greater than or equal to) 5% in 30 days: N/A not applicable. Weight loss > or = 10% in 180 days: no. Calorie needs: 1680-1960 kcals, Fluid needs: 1680-1960 ml. Meal intake percentage: 26-50%. Labs: none noted. RD notes/recommendations: Patient readmit. Patient with three lbs. 2.36% weight loss in three months and seven lbs. 5.34% weight loss in six months .Patient on fortified diet, mechanical soft texture, regular liquid consistency with poor (25-50%) po intake .Nutrition DX: inadequate oral food/beverage intake r/t variable po intake aeb patient meeting 55% estimated kcals and 80% of estimated protein needs with diet. Grandson okay with adding snacks b/w (between) meals TID (three times a day), ice cream BID (twice a day) with lunch and dinner and SF (sugar free) [prostat] (protein supplement) 30 cc BID to help meet needs .Patient continues on admit weight and labs scheduled. Will continue to follow weights, skin, labs and po intake. On 11/6/23 at 1230 hours, an observation was conducted of Resident 6 in her room. Resident 6 was lying on the floor spitting food contents onto the floor. Resident 6's lunch meal tray was on the bedside table. During an interview with the RD on 11/6/23 at 1640 hours, the RD stated she charted on the residents with significant weight changes and those residents who were at high risk for altered nutritional status. When asked if the RD attended the facility's weight variance meeting, the RD stated she did not attend a weight variance meeting but would discuss any weight changes with the DON. On 11/7/23 at 1617 hours, an interview was conducted with the DON. The DON was asked to explain the facility process when a resident experienced a significant weight loss. The DON stated the nursing staff completed a Change of Condition (COC) assessment, then informed the Physician. There would also be an RD consult ordered. The DON added she discussed significant weight changes with the RD. When asked for documentation of these discussions, the DON confirmed the discussions were verbal only, no documentation was kept. The DON was asked to provide documentation the severe weight loss of 7 lbs., 5.5% severe weight loss since 8/2/23, -10 lbs., a 7.7% severe weight loss in three months, and -14 lbs., a 10.4% severe weight loss in six months for Resident 6 was discussed with the IDT, the DON stated there had not been an IDT meeting to discuss resident weight changes in over a year. On 11/8/23 at 1005 hours, an interview was conducted with the RD. The RD was asked what the facility protocol was for monitoring a resident with significant weight loss and poor PO intake. The RD stated she would monitor weights weekly, address abnormal lab values, monitor for poor PO intake and check the skin report. The RD agreed that residents with significant weight loss should be monitored until the resident's weight had stabilized. The RD was asked to review her notes for Resident 6. The RD confirmed she assessed Resident 6 on 9/27/23 for the severe weight loss of 10 lbs. (7.7%) in three months from 7/20/23 to 9/25/23, and 14 lbs. (10.4%) weight loss in six months from 5/28/23 to 9/25/23. The RD confirmed Resident 6 had poor PO intake. The RD confirmed there were no recent laboratory values to evaluate Resident 6's hydration status and she did not recommend any laboratory work be ordered. The RD confirmed she had not assessed Resident 6 again until 11/2/23, after Resident 6 was readmitted from the hospital on 10/31/23. When asked why she did not continue to monitor Resident 6 after the severe weight loss of 10 lbs. (7.7%) in three months from 7/20/23 to 9/25/23, and 14 lbs. (10.4%) weight loss in six months from 5/28/23 to 9/25/23, the RD stated she would follow up if there was an RD consult order or poor PO intake. The surveyor pointed out that Resident 6 did have poor intake according to the RD assessment dated [DATE], and asked the RD why Resident 6 was not reassessed the following week. The RD stated she would like to check her RD binder before responding to that question. On 11/8/23 at 1054 hours, a follow up interview was conducted with the RD. The RD was asked what the facility's standard protocol was for monitoring a resident with significant weight loss. The RD stated the facility would implement weekly weights. The RD added she normally kept a list of residents she needed to monitor. When asked if Resident 6 was on the list the RD kept, the RD stated she did not keep the list of residents that needed to be monitored. The RD confirmed Resident 6 was high risk for altered nutritional and hydration status and she should have monitored her weights, PO intake and any recent laboratory values weekly. On 11/08/23 at 1257 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 6 had refused all food from her lunch meal tray. Resident 6 was offered a sandwich but refused. On 11/8/23 at 1400 hours, an interview was conducted with the DON. The DON was asked to explain the facility's protocol to monitor a resident who had experienced significant weight loss. The DON stated nursing would monitor the resident with a COC assessment, weekly weights, and any changes in the resident. The DON stated her expectation was for nursing documentation every shift for 72 hours to address the COC related to significant weight loss. The DON was asked to confirm nursing documented every shift for 72 after the COC related to Resident 6 ' s severe weight loss. The DON confirmed nursing charted on Resident 6's COC for the severe weight loss twice; on 9/26/23 and 9/28/23. The DON was asked if a resident had a severe weight loss with poor PO intake would nursing ask the Physician for any specific orders. The DON stated they would suggest that labs be drawn to check the hydration status of the resident. The DON confirmed no labs were drawn to check Residents 6's hydration status prior to Resident 6's discharge to the hospital on 10/24/23. The DON was unable to confirm the IDT, nursing or the RD assessed Resident 6's severe weight loss, hydration status or poor PO intake after 9/27/23. The DON confirmed Resident 6 was transferred to the hospital on 10/24/23, with an admitting diagnosis of dehydration and schizophrenia. The DON confirmed there could be a correlation between severe weight loss, poor PO intake and dehydration. On 11/9/23 at 1047 hours, Resident 6 was observed in her room sleeping in bed. Two ounces of applesauce with a spoon and a water pitcher without a glass were at the bedside. On 11/09/23 at 1100 hours an interview was conducted with CNA 1. CNA 1 stated Resident 6 could feed herself. CNA 1 stated Resident 6 refused breakfast. CNA 1 offered Resident 6 orange juice but Resident 6 refused. CNA 1 also stated Resident 6 gets snacks between meals but refused them. When asked why Resident 6 did not have a water cup, CNA 1 stated she would get her one. 2. On 11/7/23 at 1451 hours, an interview was conducted with RNAs 1 and 2 regarding the facility process of weekly weights for residents. RNAs 1 and 2 stated they checked the RNA communication log every morning for new weight orders. RNAs 1 and 2 were asked to confirm a weekly weight order for Resident 6 to start on 9/26/23 through 10/22/23. RNAs 1 and 2 stated they did not have an order for Resident 6 to be weighed weekly starting on 9/26/23 through 10/22/23. After reviewing the facility document titled Record of Admission height, weight, and weekly weights for the month of October, RNAs 1 and 2 confirmed they did not weigh Resident 6 from 9/26/23 to 10/22/23. RNA 1 stated the RN supervisor was responsible to enter resident weights into the electronic medical record. On 11/7/23 at 1509 hours, an interview was conducted with LVN 9. LVN 9 confirmed an order written on 9/26/23, for Resident 6 to be weighed weekly for four weeks until 10/22/23. LVN 9 confirmed weekly weights were not completed per the physician's order and the last weight taken for Resident 6 was on 9/25/23. LVN 9 stated nursing relayed the weekly weight order to the RNA by putting the order in the RNA binder. When asked how the facility ensured the weekly weight orders had been completed, the LVN stated nursing checked the weekly weight summary. On 11/7/23 at 1651 hours, an interview was conducted with the DON. The DON confirmed the order for weekly weights written on 9/26/23, for Resident 6 had not been completed. The DON stated if the facility had met as an IDT, they would have noticed Resident 6 had not been weighed weekly as ordered. a. On 11/07/23 at 1550 hours, an interview was conducted with RN 1. RN 1 verified the physician's order for Resident 6 on 10/31/23, for laboratory values (CBC, CMP, Hgb A1C, B12, D, D25, liver panel, lipid panel and Valproic acid). RN 1 confirmed no results for the laboratory order were in the electronic medical record for Resident 6. RN 1 stated Resident 6 sometimes refused blood to be drawn. If the resident refused the blood draw, that was sometimes documented on the SBAR form. RN 1 confirmed there was no documentation Resident 6 refused the blood draw. RN 1 then checked the lab requisition book and verified there was no lab requisition for the 10/31/23 labs for Resident 6. RN 1 stated LVNs who received physician orders for lab draws should complete a test request form and file the lab request on the appropriate date (date the lab work was ordered). If the labs were ordered for the weekend or stat (urgent) the LVN must call the lab and schedule the blood draw. RN 1 stated she would call the physician to let him know the labs had not been completed as ordered on 10/31/23. On 11/8/23 at 1400 hours, a review of Resident 6's electronic medical record and concurrent interview was conducted with the DON. The DON confirmed Resident 6 was transferred to the hospital on 10/24/23, and was admitted to the hospital with diagnosis of dehydration and schizophrenia. The DON confirmed Resident 6 was readmitted to the facility on [DATE], with diagnoses including sepsis. The DON confirmed the physician's orders for laboratory values (CBC, CMP, Hgb A1C, B12, D, D25, liver panel, lipid panel and Valproic acid, a medication) on 10/31/23. The DON confirmed the lab work ordered for Resident 6 had not been completed. b. Review of the facility's P&P titled Fortification of Food: Increasing Calories and/or Protein in the Diet dated 2023 showed in part, the enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status .Adding calories: 1. Extra margarine - 1/2 ounce melted margarine may be added to one food item at breakfast, two at lunch and one at dinner. Review of the facility document titled Cooks Spreadsheet Week 2 showed for the puree diet, three ounces puree lemon chicken piccata, 1/2 cup puree pasta with creamy Italian sauce, 1/3 cup puree spinach au gratin, puree fresh green salad with dressing, and puree gelatin. Review of Resident 6's lunch meal tray ticket showed, Pureed, Fortified diet, four ounces milk, ice cream. During the lunch meal tray line on 11/7/23 at 1129 hours, after the lunch meal cart trays had been checked by the DSS, an observation of Resident 6 ' s lunch meal was conducted with the DSS. Resident 6's lunch meal tray consisted of pureed food items per the cook ' s spreadsheet, and four ounces milk. The DSS was asked what was given to fortified diets. The DSS stated extra margarine on the spinach au gratin. The DSS confirmed the spinach au gratin on Resident 6's lunch tray did not include added margarine. Resident 6's lunch meal tray did not contain ice cream. The DSS confirmed that ice cream was missing and added the ice cream to the tray. 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident ' s condition . Review of the nutrition care plan created by the RD on 11/2/23 showed Resident 6 had actual/potential nutritional problem and dehydration risk r/t diagnosis of hyperlipidemia (high levels of fats in the blood), GERD (gastroesophageal reflux disease- a condition when the stomach contents come back into your esophagus) .dehydration . The goal for Resident 6's care plan showed, the resident will maintain adequate nutritional status as evidenced by gaining weight of 135 lbs.+/- 5%, no signs/symptoms of malnutrition, and consuming at least 50-100% of meals daily through review date. The interventions for Resident 6's care plan did not include specifics to monitor for dehydration. A review of Resident 6's nutrition care plan initiated by the RD on 11/2/23 was reviewed with the DON on 11/9/23 at 0854 hours. The DON confirmed Resident 6 was a risk for dehydration. The DON confirmed the nutrition care plan did not include goals for hydration status or interventions to monitor for dehydration risk.

Based on observation, interview, and clinical record review, the facility failed to provide an environment free from hazards and provide adequate supervision to prevent accidents for two of 15 sampled residents (Residents 10 and 14). *The facility failed to ensure Resident 10 was adequately assisted with transfers from the bed to the wheelchair, resulting in a fall and a dislocation of her right shoulder (upper arm bone pops out of the shoulder socket. This can happen when a strong force pulls the shoulder upward or outward, or from an extreme external rotation). *The facility failed to take reasonable precautions, including providing adequate supervision to prevent a resident to resident altercation involving Resident 14. Resident 14 hit Resident 7 on the legs with his cane. Findings: 1. An interview with Resident 10's family member was initiated on 6/11/14 at 1530 hours, regarding her concerns with a recent fall sustained by Resident 10, and the care provided after the fall. The family member stated Resident 10 has been "dropped" by staff members two separate times. The first incident occurred in December 2013 when Resident 10 was being transferred from the bed to the wheelchair assisted by one staff member. Resident 10 sustained a head laceration, which required 10 stitches. Resident 10's family member stated Resident 10 was "dropped" again on 5/28/14, while being transferred from the bed to the wheelchair, assisted by one staff member. The family member stated she was called by the facility on 5/28/14, and was told Resident 10 had sustained a fall and was not injured. She stated she came to visit Resident 10 on 5/31/14. While attempting to move Resident 10 in the wheelchair, the resident cried out in pain. She stated she informed the charge nurse and requested an x-ray of Resident 10's right shoulder to be done. The result of the x-ray showed Resident 10's right shoulder was dislocated. The family member stated she had to request Resident 10 be sent to the acute care hospital emergency roiagnom on [DATE]. She stated the ER (emergency room ) physician was unable to reduce (realign the joint) the right shoulder. Resident 10 was then sent to an orthopedic physician on 6/3/14, who instructed the family to take Resident 10 to another acute care hospital emergency room , and the shoulder was reduced. Review of Resident 10's clinical record was initiated on 6/12/14. Resident 10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 10 speaks a foreign language. Review of the MDS (a standardized assessment tool) dated 3/31/14, shows Resident 10 has cognitive impairment and is dependant on staff for her ADLs. Resident 10 requires two persons' assistance with transfers. Review of the Change of Condition Documentation form dated 5/28/14, shows CNA 2 was transferring Resident 10 from the bed to the wheelchair when the wheelchair moved "a little bit resulting her to assist or lower" Resident 10 to the floor. The documentation shows LVN 3 performed a head to toe assessment with "no apparent injury observed." The documentation failed to show the time of the injury. At 1500 hours, the physician was notified and no new orders were obtained. A telephone interview was initiated with LVN 3 on 6/13/14 at 1130 hours. LVN 3 verified Resident 10 sustained a fall on 5/28/14. LVN 3 stated, when she got to the room of Resident 10, CNA 2 was sitting on the floor propping Resident 10 up. LVN 3 stated Resident 10 was "dead weight." LVN 3 stated she assessed Resident 10 while on the floor and had a translator ask Resident 10 if she was in pain. Resident 10 was lifted by two CNAs into the wheelchair. LVN 3 stated she performed passive range of motion during the assessment and Resident 10 denied pain. LVN 3 verified Resident 10 requires two persons' assistance with transfer using a Sara lift (a mechanical lift used to assist residents with sit to stand transfers). LVN 3 stated the "care cards" in the ADL book should show how many people are needed to transfer the resident. Review of the MDS Kardex Report form reviewed and revised on 12/30/13, shows Resident 10 is totally dependent on staff for transfers and requires two persons' assistance. Documentation further shows Resident 10 is not steady during transitioning from a sitting to a standing position. A telephone interview was conducted with CNA 2 on 6/13/14 at 1145 hours. CNA 2 stated she was transferring Resident 10 from the bed to the wheelchair and the wheelchair moved. She assisted Resident 10 to the floor and called out for help. The nurse came and assessed Resident 10 on the floor. CNA 2 stated she and another CNA lifted Resident 10 from the floor to the wheelchair. When asked how many staff does it take to transfer Resident 10, CNA 2 stated Resident 10 is a one person transfer. She stated the "ADL book" shows the number of staff required for transfer. On 6/13/14 at 1450 hours, an interview was conducted with CNA 4. CNA 4 stated she was not present at the time of the incident, but assisted CNA 2 to lift Resident 10 from the floor to the wheelchair. CNA 4 stated Resident 10 requires two persons' assistance with transfers and bed mobility. She stated Resident 10 does not assist during transferring and is very heavy. Review of the Interdisciplinary Resident Safety Investigation and Intervention for Resident 10 dated 5/28/14, showed the assisted fall occurred at 1120 hours on 5/28/14. The interdisciplinary team recommends to monitor for pain and notify the physician of any changes. Review of the Licensed Nurses Progress Notes dated 5/31/14, shows an entry for the 7-3 shift. The documentation shows the family requested an x-ray of the right shoulder be performed. The documentation further shows the physician was notified and an order was received to obtain an x-ray of the right shoulder and right elbow "stat" (immediately). Review of the physician's orders [REDACTED]. Review of the x-ray result for Resident 10 dated 5/31/14, shows the humerus (bone of the upper arm) is dislocated. 2. Closed clinical record review for Resident 14 was initiated on 6/13/14. The MDS dated [DATE], showed the resident has cognitive impairment. It also showed the resident has no behavioral symptoms that causes distress to the resident, other residents or staff members. Review of the nurse's note dated 5/29/14 (late entry for 5/28/14), showed Resident 14 was disruptive during activities programs. It showed the resident "tapped" another resident's wheelchair with his foot to wake the resident up. It also showed the resident was trying to wake other residents up and stated "wake up homosapiens, we all need to be awake." The care plan problem dated 5/28/14, to address episodes of waking other residents up, showed the interventions include to encourage the resident to express feelings and concerns, encourage the resident to respect other resident's rights, and monitor behavior during activities. The nurse's note dated 5/30/14 at 1500 hours, showed Resident 14 was observed with multiple episodes of increased agitation. Review of the IDT Resident Safety Investigation and Intervention dated 5/30/14, showed an allegation of a resident to resident altercation. It showed the intervention was to keep the resident separated at all times. The facility's investigation dated 5/30/14, showed Resident 8 reported Resident 14 hit him on the back. Review of the IDT Resident Safety Investigation and Intervention dated 5/31/14, showed Resident 14 attempted to hit another resident. The care plan problem dated 5/31/14, to address attempted to hit another resident, showed the interventions include to educate the resident to let staff take care of the residents, redirect the resident's behavior with activities of choice, and encourage the resident to express feelings/concern. The care plan problem did not include providing precautions and adequate supervision at all times. Review of the IDT Resident Safety Investigation and Intervention dated 6/2/14, showed Resident 14 hit another resident at the hallway. The physician's orders [REDACTED]. During an interview with LVN 2 on 6/13/14 at 1420 hours, she stated Resident 14 is able to propel his wheelchair and goes around the facility. LVN 2 stated she received a report that Resident 14 was "tapping" the wheelchairs of the residents in the dining room. An interview was conducted with CNA 3 on 6/13/14 at 1430 hours, who stated he had taken care of Resident 14 before. CNA 3 stated the resident can propel his wheelchair. CNA 3 stated the resident can be verbally aggressive. CNA 3 further stated there was an instance CNA 3 was wheeling another resident from the dining room, Resident 14 was angry and demanding CNA 3 leave the resident alone. During an interview with RN 1 on 6/13/14 at 1440 hours, she stated Resident 14 can propel his wheelchair. RN 1 stated she received reports that Resident 14 was randomly "tapping" the residents' wheelchairs to wake the residents up in the dining room. RN 1 stated there was an instance when Resident 14 was walking with his cane, with the therapist behind him, and Resident 14 hit a resident on the legs and stated "out of my way." An interview was conducted with the SSD on 6/13/14 at 1445 hours. She stated, prior to admission to the facility, Resident 14 lived in an assisted living facility. She stated she spoke to the assisted living facility staff after Resident 14 was transferred to a psychiatric hospital. She stated the assisted living facility staff told her Resident 14 had behavior problems while the resident was at the assisted living facility. On 6/13/14 at 1545 hours, the Administrator and DON were informed of the concern for Resident 14 not being provided adequate supervision. The DON stated the staff monitored the resident every 15 minutes from 5/29/14, until he was transferred to the psychiatric hospital. She was asked what documentation do they have. She reviewed the clinical record; however, she did not find documentation regarding monitoring Resident 14. She stated she will check the old MAR. She came back and provided monitor forms. Review of the monitor forms from 5/28/14 at 1930 hours to 5/31/14 2345 hours, showed documentation of Resident 14's whereabouts every 15 minutes; however, there was no documented evidence to show monitoring on 5/29/14 at 0200 to 0645 hours, 5/29/14 at 2315 hours to 5/30/14 at 0645 hours, 5/31/14 from 1345 to 1445 hours, 5/31/14 from 1600 to 1945 hours, and 5/31/14 from 2115 to 2245 hours. There was no documented evidence Resident 14 was monitored every 15 minutes on 6/1/14 to 6/2/14.

Based on observation, interview and document review, the facility failed to ensure pasteurized eggs were used in the service of over-easy/undercooked eggs to residents, cantaloupe was properly cleaned prior to preparation and service, and the ice machine in the kitchen was cleaned and sanitized in accordance with the manufacturer's recommendations. Five of five residents who requested over easy eggs were observed to consume eggs with runny yolk that smeared the plate. This practice impacted all residents who would have requested over easy eggs. The ice machine in the kitchen was the only ice machine at the facility and was used to provide ice to all residents at the facility. Findings: 1. On 6/5/13 at 0740 hours, during an observation of the breakfast meal service in the dining room, four nonsampled residents (Residents B, C, D, and E) were noted to be consuming over easy eggs. The egg yolks were noted to be liquid in consistency and spread on the resident's plates. One resident who was consuming breakfast in her room (Resident F), was also served over easy eggs. For Residents D, E, and F, "Over Easy Egg" or "Eggs Over Easy" was indicated on the residents' tray slips as "Special Requests" to be served every day during the breakfast meal. For Residents B and C, the request for over easy eggs was made as a substitute for the quiche being served that day. On 6/5/13 at 0800 hours, observation of the breakfast meal service in the kitchen revealed regular shell eggs were used to make the over easy eggs (with runny yolk) noted to be served to the residents. The shell eggs utilized were noted in the cooking area and were not imprinted with any identifying stamps indicating they were pasteurized eggs (pasteurized eggs are eggs that have been cooked briefly at a high temperature and then cooled in order to reduce the possibility of food-borne illness in dishes that are not cooked or lightly cooked). In a concurrent interview with the Dietary Service Supervisor (DSS), she acknowledged the shell eggs that were being used for the preparation of the over easy eggs were not pasteurized. The DSS stated the pasteurized eggs would be delivered by the vendor the following day. On 6/5/13 at 1005 hours, during an inspection of the kitchen, the Regional Manager of Food and Nutrition and Regional Registered Dietitian B both stated facility staff were not required to purchase pasteurized eggs as long as the Food Code guidelines with regards to cooking eggs (to 145 degrees Fahrenheit (F) for 15 seconds) were met. They confirmed the facility did not have a policy that specifically addressed the cooking of eggs, but instead they referenced the Food Code Section 3-401.11. In a concurrent interview with the DSS, she stated she did not order pasteurized eggs "that much". The DSS could not remember the last time she had purchased pasteurized eggs, but stated it depended on the menu. When asked when she would utilize pasteurized eggs, she stated for the preparation of egg salad. This was confirmed by Regional Registered Dietitian B, who stated, "We allow them to purchase pasteurized eggs for egg salad." When asked how eggs were prepared for egg salad, Regional Registered Dietitian B stated they would be hard boiled. When asked why pasteurized eggs would be the preferred product for the production of a hard boiled egg product, she could not respond. Review of the Food Code 2009, Section 3-401.11, revealed the following guidance, "1 (A) ...., Raw animal foods such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked: 1 (1) 63oC (145oF) or above for 15 seconds for: 1(a) Raw eggs that are broken and prepared in response to a consumer's order and for immediate service." The Regional Manager of Food and Nutrition asked a staff member to demonstrate the method the facility used to prepare over easy eggs in order to indicate the eggs were cooked in accordance with Food Code specifications. Cook 1 proceeded to prepare over easy eggs on the grill top, while the Regional Manager of Food and Nutrition utilized an infra red thermometer to measure the surface temperature of the over easy egg while it was on the grill top, and stated it was above 145 degrees F. After 15 seconds, Cook 1 and the Regional Manager of Food and Nutrition stated the over easy egg was ready. A facility thermometer was utilized to measure the internal temperature of the egg, which still appeared to have a runny yolk. The internal temperature of the egg measured 133 degrees F. The Food Code requirements, which specified that "all parts of the food" should be cooked to 145 degrees for 15 seconds was not met. The Regional Manager of Food and Nutrition then stated pasteurized eggs would be purchased and staff inserviced on the proper preparation of over easy eggs. An inservice training was conducted by the Regional Manager of Food and Nutrition Services with 14 dietary staff members on 6/5/13 at 1300 hours, on the topic of, "Use of Pasteurized Eggs." Objectives covered during the inservice included, "1. Staff will only utilize shelled pasteurized eggs when preparing a style of egg that may not be completely cooked (i.e. Over-easy, fried w/ (with) runny yolk, "sunny side up"), 2. Staff will demonstrate how to properly identify a pasteurized egg." On 6/6/13, the DSS provided a copy of the invoice indicating when pasteurized eggs had last been purchased and received by the facility. The purchase order date on the invoice was 1/23/13 and it indicated one case of pasteurized eggs had been ordered. There had not been any other purchases of pasteurized eggs made and received at the facility since that date. On 6/6/13 at 0804 hours, during an observation of the breakfast meal service in the dining room, Residents D and E were noted to be served over easy eggs. When each resident cut into the egg, the yolk was noted to be runny and spread on the plate. On 6/6/13 at 0806 hours, inspection of the meal preparation activities in the kitchen indicated staff continued to utilize regular shell eggs (not pasteurized) in the preparation of over easy eggs for the residents. Cook 1 confirmed the pasteurized eggs had not been received. On 6/6/13 at 0820 hours, in an interview with the Regional Manager of Food and Nutrition, he confirmed staff had been instructed not to serve over easy or soft cooked eggs until the pasteurized eggs were received at the facility. The Regional Manager of Food and Nutrition and the DSS, who was present at the time of the interview, were unaware that staff continued to serve eggs with runny yolks to the residents. Immediate Jeopardy was identified on 6/6/13 at 0840 hours, regarding the facility's failure to serve unpasteurized eggs cooked to the correct temperature and failure to obtain pasteurized eggs to serve to residents who requested over easy eggs. The Administrator, DON, Medical Director and corporate nurse consultant were made aware of the Immediate Jeopardy on 6/6/13 at 0845 hours. On 6/6/13 at 1030 hours, in a telephone interview with Regional Registered Dietitian A, in the presence of the Administrator, she stated she had identified that the facility was not utilizing pasteurized eggs for the preparation of undercooked eggs in December 2012. Regional Registered Dietitian A stated she provided verbal training to staff on the purpose and need to use pasteurized eggs and assumed the DSS understood the purpose for and proper use of pasteurized eggs. Regional Registered Dietitian A and the Administrator acknowledged the system related to lack of availability of pasteurized eggs on site, and use of pasteurized eggs in the preparation of undercooked eggs had not been adequately monitored. This is a system that impacts all residents who may request over easy/undercooked eggs. On 6/5/13 at 1443 hours and on 6/6/13 at 1015 hours, the RD who was regularly assigned to the facility acknowledged she was unaware that pasteurized eggs were not being used for the service of undercooked eggs at the facility. The RD stated she had seen pasteurized eggs "once before" but did not look for them with every visit. An acceptable written plan of action was provided on 6/6/13 at 1600 hours, by the Administrator. The Immediate Jeopardy was abated on 6/7/13 at 1015 hours, prior to the exit of the survey. The corrections the facility took were: *The kitchen was inspected by the Regional Manager of Clinical Operations on 6/6/13 at 0930 hours to ensure only pasteurized eggs were received in the food delivery. The kitchen will only order pasteurized eggs in the future. Food orders will be placed by the DSS and reviewed by the Administrator or designee. The weekly food delivery will be inspected by the Administrator or designee to ensure only pasteurized eggs are received by the facility. *Residents who received over easy unpasteurized eggs for the breakfast meal on 6/5/13 and 6/6/13 were identified. The residents/responsible parties and the primary care physicians for the affected residents were notified. *The affected residents will be monitored for symptoms of salmonella (fever, abdominal cramps and diarrhea) every shift for 72 hours. *The licensed nursing staff including CNAs were inserviced on food borne pathogens including signs and symptoms of food borne illness, risk factors and methods to reduce risks. *Dietary staff were inserviced on the use of only pasteurized eggs (stamped with "P"), risk of food borne infections (especially eggs and chicken), cross contamination in the kitchen environment and the steps to reduce the risk. *The current RD has resigned. In order to ensure continuity of this plan, when the current RD leaves, the facility has contracted with a professional dietician consulting company. The RD from the consulting company will visit the facility three times per week in order to fulfill the regulatory requirements and duties of the facility RD in the interim. *The Regional RD will conduct visits once per month to audit dietary operations, conduct needed training and assure compliance with facility P&Ps. *The DSS, in coordination with the facility RD, will ensure operations of the dietary department are carried out. *The Administrator or designee will monitor the food order and inspect the kitchen weekly for four weeks and then every two weeks for two months. The findings of the audits will be discussed at the monthly Quality Assurance meeting to determine the efficacy of the monitoring system. 2. On 6/4/13 at 1010 hours, during the initial kitchen tour, peeled cantaloupe was noted to be stored in a container in the walk-in refrigerator. On 6/5/13 at 1045 hours, Dietary Aide 2 was interviewed with regards to the process she utilized in the preparation of fruit, such as cantaloupe, for service to the residents. Dietary Aide 2 stated she washed the cantaloupe with water, peeled the cantaloupe, rinsed it under water and then cut it for service. Dietary Aide 2 confirmed she did not scrub the cantaloupe/utilize a scrub brush during the cantaloupe preparation method. There was no dedicated fruit/vegetable scrub brush noted in Dietary Aide 2's produce preparation area. Regional Registered Dietitian B, present at the time of the interview with Dietary Aide 2, stated there was "guidance" for the need to scrub cantaloupes during the preparation phase, prior to peeling and cutting, but confirmed the Dietary Service Supervisor and staff at the facility had not received training on that "guidance". Review of an inservice provided to dietary staff by the Regional Manager of Food and Nutrition, dated 6/5/13 at 1315 hours, revealed the following guidance for the preparation of cantaloupe: "With skin of melon still intact, scrub whole melon with vegetable brush under clean running water." 3. On 6/4/13 at 1010 hours, during the initial kitchen tour, the DSS stated cleaning of the ice machine bin was the responsibility of dietary staff, while the mechanical part of the machine was the responsibility of the maintenance department. The ice machine in the kitchen was the only ice machine at the facility that provided ice to all residents. On 6/5/13 at 1210 hours, in an interview with the Maintenance Supervisor, he stated he cleaned the ice machine filter every month and cleaned the condenser. The Maintenance Supervisor further stated that every three months, he ran a chemical cleaner (de-lime solution) through the machine. The Maintenance Supervisor was asked twice if a sanitizing solution was also run through the machine at any point, and the Maintenance Supervisor confirmed that the sanitizer solution was only used in the bin portion of the machine. On 6/5/13 at 1455 hours, the manufacturer's recommendations for the ice machine were provided by the Maintenance Supervisor and revealed, "The ice machine's water system should be cleaned and sanitized a minimum of twice per year." The manufacturer's recommendations indicated a step by step process for cleaning and sanitizing the ice machine which included, "Mix 2 gallons of Sanitizer solution. Follow local codes for sanitizer ... Pour 16 ounces of Sanitizer solution into the reservoir water." Review of the facility policy titled, "Ice Machine", revealed, "The Maintenance Director will insure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed."

Based on clinical record review and interview, the facility failed to ensure one of 19 sampled residents (Resident 3) maintained acceptable weight parameters. Resident 3 had a significant weight loss (a 5% or greater weight loss in 30 days, 7.5% or greater in 90 days, or a 10% or greater weight loss in 180 days) in 90 days. The facility did not reassess the resident's nutritional status, notify the physician, or establish any new interventions to prevent further weight loss and there is no documentation the IDT addressed the resident's weight loss. Although the resident was documented as needing extensive assistance with eating, the resident was not started on an assisted eating program, such as an RNA feeding program. The staff documented Resident 3 was eating 40% of her meals, but the facility did not assess why the resident was not eating more. As a result, Resident 3 continued to lose weight over the next 90 days with a significant weight loss of 14.28% in 180 days. Findings: Review of the P&P titled Nutritional Management Program dated 1/08, showed the Nutritional Service Director interviews the resident and completes the food preference interview after admission. The RD will complete a Medical Nutritional Therapy Assessment within 7 days, which provides a more detailed profile of the resident's overall nutritional status. The comprehensive nutritional assessment identifies clinical conditions that effect nutritional status. These factors include refusal to eat, poor oral health, poor eyesight or functional ability, medications that can affect appetite, taste or digestion, decline in sensory functions like taste and smell, and dementia. Clinical record review for Resident 3 was initiated on 12/11/12. Review of the Face Sheet showed Resident 3 was admitted to the facility on [DATE]. Review of the Interdisciplinary Communication to Nutritional Services dated 5/31/12, a dietary order, showed the resident was started on a regular fortified diet (additional fat and protein is added to the foods) with 4 ounce health shakes (a protein nourishment) three times a day. Review of the clinical record showed there is no documented food preference interview completed by the FSD to determine the resident's food preferences. Review of the weight record showed Resident 3 weighed 119 pounds on 6/11/12. Review of the Medical Nutrition Therapy assessment dated [DATE], showed Resident 3's weight had dropped to 109 pounds (significant weight loss of 8.4%). RD 1 documented the resident needed extensive assistance to eat and was eating an average of 40% of her meals. The RD did not assess the reason Resident 3 only ate 40% of her meals or the reasons for the weight loss. The RD showed the resident may benefit from an appetite stimulating medication. Her recommendations were to continue the current diet, recommend an appetite stimulating medication, and continue to monitor the intake and weight of the resident. The RD did not document she called the physician to recommend the appetite stimulating medication, did not recommend weekly weights, and did not interview the resident's family to determine if the resident likes the foods being served or to obtain her food preferences. Although the RD had documented the resident needs extensive assistance to eat, she did not assess what assistance was needed by the resident, such as a feeding program or special eating devices. Review of the Interdisciplinary Attendance Log for Resident 3 showed RD 1 met with the nursing department to discuss the resident's plan of care on 9/19/12. Review of the Interdisciplinary Progress Notes dated 9/19/12, showed no documentation regarding Resident 3's weight loss or poor food intake. Review of the physician's orders for 9/11/12 through 12/11/12, showed Resident 3 was not started on any medication to stimulate her appetite, and no new interventions for weight loss were initiated. Review of the Resident Functional Performance Records for September, October and November, 2012, showed Resident 3 was eating an average of 48% of her meals. Review of the weight record showed on 12/6/12, Resident 3's weight was 102 pounds. The record showed the resident had a significant weight loss. Review of the Interdisciplinary Progress Notes dated 12/6/12, showed no documentation from the IDT regarding Resident 3's weight loss. In addition, review of the Interdisciplinary Attendance Log showed no documentation the RD or the FSD was present during the meeting. An interview with Resident 3's family member was initiated on 12/12/12 at 1300 hours. The family member was asked if the facility discussed the resident's weight loss with him. The family member stated, no. The family member was asked if he was asked about Resident 3's food preferences by the facility; he stated he couldn't recall being asked. An interview with RD 2 was initiated on 12/13/12 at 1100 hours. RD 2 was asked to show any interventions that were initiated for Resident 3 to stop the resident's weight loss. RD 2 stated she was not able to find documentation RD 1 contacted the physician, or recommended an appetite stimulating medication. RD 2 confirmed no new interventions for the resident's weight loss have been initiated since 5/29/12.

Based on interview and clinical record review, the facility failed to ensure Resident 1 was wearing a seatbelt, as ordered by the physician, when sitting up in his wheelchair. The facility assessed Resident 1, to require a seatbelt when sitting up in his wheelchair for trunk support. However, the seatbelt was removed and Resident 1 fell forward out of his wheelchair, hitting his face and sustaining injuries. Resident 1 was transferred to the acute care hospital and admitted into the ICU (Intensive Care Unit) for blunt head trauma and diagnosed with [REDACTED]. Findings: On 3/19/12, clinical record review for Resident 1 was initiated. The Device Evaluation form dated 9/19/11, showed Resident 1 had impaired balance and cognition, weakness, poor trunk control and leaned forward and sideways. An intervention was a self release seatbelt to be used when Resident 1 was sitting up in his wheelchair. The physician's orders [REDACTED]." A care plan titled Risk for Falls dated 12/30/11, showed Resident 1 was at risk for falls due to poor mobility, [DIAGNOSES REDACTED] (paralysis on one side of the body, which can include the arm, leg and side of the trunk), poor safety awareness, a history of falls and lack of coordination. An intervention listed showed a seatbelt would be used when Resident 1 was sitting up in his wheelchair. The Change of Condition Documentation form dated 3/1/12, showed Resident 1 was observed lying on the floor with blood on his face. Resident 1 had a laceration on his nose, lip area and to his right eyebrow. Resident 1 also had a skin tear on his right arm which measured approximately 4 cm by 5 cm. The physician was notified and ordered Resident 1 be transferred to the acute care hospital. The Interdisciplinary Progress Notes dated 3/1/12, showed Resident 1 had a history of [REDACTED]." The Interdisciplinary Progress Notes dated 3/2/12, showed a licensed nurse entered a late entry documenting events occurring on 3/1/12. The note showed the charge nurse was paged to the dining room, where Resident 1 was observed lying on the floor. Resident 1 was bleeding and sustained multiple lacerations to his face, including his right eyebrow, right cheek, nose and lip. The resident was assisted to bed and complained of facial discomfort and pain. Review of the acute care hospital's Trauma Services History & Physical report dated 3/1/12, showed Resident 1 had a head trauma from a fall at the facility. The report showed Resident 1 had multiple facial lacerations and right elbow skin tear which measured 6cm by 6cm. The radiology report dated 3/1/12, showed Resident 1 had a nasal bone fracture. The Trauma Team Admission Assessment form dated 3/1/12, showed Resident 1 was admitted to the ICU. Resident 1 was then discharged back to the facility on e day later on 3/2/12. The facility's Interdisciplinary Progress Notes dated 3/2/12, showed the IDT met to discuss Resident 1's falls on 2/29/12 and 3/1/12. The note showed Resident 1 was seated in his wheelchair in the dining room on 3/1/12 with a personal alarm on and had an order for [REDACTED]. Review of the facility's investigation file showed the seatbelt was released when Resident 1 fell forward out of his wheelchair. The report showed Resident 1 had poor trunk (torso) control and he slumped forward and could not correct his position and he fell out of his wheelchair. The report showed Resident 1 required repositioning two times before he fell out of his wheelchair because he kept scooting towards the edge of the seat. Resident 1's seatbelt was released while he ate dinner and he then fell on the floor. The report showed staff in the dining room were feeding other residents and clearing trays from the tables. The facility's conclusion showed Resident 1 fell on the floor due to poor trunk control, leaning forward and his seatbelt being released. On 3/19/12 at 1430 hours, during an interview with PT 1, PT 1 stated she evaluated Resident 1 on 3/5/12 and Resident 1 was unable to balance himself and sit upright in a neutral position. The PT stated she had Resident 1's tilt-in-space wheelchair backrest angle readjusted so that the resident would be slightly reclined and less upright position to help prevent him from leaning forward so easily. PT 1 stated a PT evaluation for Resident 1 was also done on 1/5/12 which identified Resident 1 leaned to the left in his wheelchair. On 3/19/12 at 1530 hours, during an interview with CNA 1, CNA 1 stated she was in the dining room when Resident 1 fell . The CNA stated she was at another table feeding other residents and heard Resident 1's wheelchair alarm sound but she could not respond in time to prevent his fall. CNA 1 stated Resident 1 was not wearing his seatbelt. On 3/19/12 at 1535 hours, during an interview with CNA 2, CNA 2 stated she had also been in the dining room on 3/1/12 but left to take another resident back to his room. The CNA stated when she returned a few minutes later Resident 1 was on the floor and staff were attending to him. On 3/19/12 at 1545 hours, during an interview with the DON, when asked what interventions the facility implemented to assist Resident 1 with his poor trunk control, the DON stated they conducted a PT evaluation in January but that evaluation focused on bed safety and not wheelchair safety. The DON stated another PT evaluation was done in October of 2011 but there was no mention of wheelchair safety. The DON stated the resident had an order for [REDACTED].

Based on interview and clinical record review, the facility failed to ensure adequate fluid intake for one of 18 sampled residents (Resident 1). The intake and output monitoring for Resident 1, including the 24 totals totals were incomplete for the 25 days. In addition, there were no daily urine output measurements which showed Resident 1 was receiving adequate fluids for 25 days, and no evaluation or follow up. Resident 1 was dependent on staff for fluid intake through a GT (a tube surgically inserted into the stomach to administer fluids and nutrition). Resident 1 was transferred to the acute care hospital and diagnosed with [REDACTED]. Findings: According to the National Institutes of Health, a service of the U.S. National Library of Medicine, online encyclopedia (www.nih.gov), signs and symptoms of dehydration include dry oral mucosa (the lining in the mouth) and dark yellow or amber colored urine. Review of the facility's P&P titled Hydration dated May, 2009, showed sufficient fluid means the amount of fluid needed to prevent dehydration. Intake is the measurable amount of fluid taken in by the body, and output is the measurable fluid that comes out of the body. Signs and symptoms of dehydration include dry lips and mouth and concentrated urine. For residents in which intake and output is being monitored, the licensed nurse will ensure the intake and output amounts are documented on the Intake and Output Record. The night shift staff will tally the 24 hour intake and output totals and evaluate the data. The average daily intake should be equivalent to the daily output (urine). On 10/31/11, clinical record review for Resident 1 was initiated. Resident 1 had a history of [REDACTED]. The MDS dated [DATE], showed Resident 1 was cognitively impaired and dependent on staff for all ADLs, including the intake of fluids. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medical Nutritional assessment dated [DATE], showed the tube feeding provided Resident 1 with 1208 ml of water, and 600 ml of water with the flushes for a total of 1808 ml daily. The RD estimated the resident needed between 1650 ml and 1925 ml daily. The RD based this estimation on a formula of 30 ml to 35 ml per kilogram. On 9/13/11, the RD reassessed Resident 1 and recommended to decrease her tube feeding from 75 ml per hour to 65 ml per hour, due to a weight gain, which provided 1053 ml of free water, and continue the water flush of 600 ml daily (1053 + 600 =1653 ml daily). The RD estimated Resident 1 needed between 1525 ml and 1830 ml daily. The RD based this estimation on a formula of 25 ml to 30 ml per kilogram. The RD documented 1833 ml should be administered based on the formula of 30 ml per kilogram. However, the tube feeding was decreased to 65 ml per hour, due to weight gain, which provided 1053 ml of free water, and the water flush of 600 ml daily continued which provided 1653 ml daily (1053 + 600 =1653 ml daily). The care plan problem titled Risk for Dehydration dated 7/18/11, showed Resident 1 was at risk for dehydration. A goal was the resident would not experience dehydration. Interventions showed to observe the resident for signs and symptoms of dehydration, such as the condition of the oral mucosa. Review of the Weekly Nursing Summary forms dated 9/10/11, 917/11 and 9/24/11, showed no assessment of Resident 1's oral mucosa or urine color. The Total Intake and Output Record forms dated 9/1/11 through 9/26/11, showed incomplete intake and output monitoring and incomplete 24 hour totals on 16 of the 25 days. The Resident Functional Performance Record dated 9/1/11 through 9/26/11 showed the urine output amounts did not match the urine output amounts on the intake and output records for 25 days, from 9/1/11 through 9/25/11. The Resident Functional Performance Record did not show any urine output measurements which showed the resident was receiving adequate fluids to meet her needs for 25 days, from 9/1/11 through 9/25/11. For example, the following urine output amounts were documented on the Resident Functional Performance Record from 9/17/11 through 9/25/11 (eight days prior to the residents hospitalization ): 9/17/11 - 1100 ml 9/18/11 - 800 ml (no night shift entry) 9/19/11 - illegible 9/20/11 - 1150 ml 9/21/11 - 775 ml (no day shift entry) 9/22/11 - 600 ml (no day shift entry) 9/23/11 - 1050 ml 9/24/11 - 1100 ml 9/25/11 - 700 ml (no night shift entry) The Interdisciplinary Progress Notes dated 9/10/11, showed Resident 1's urine color was yellow. However, on 9/12/11, the notes showed the resident's urine color changed to "amber." The Interdisciplinary Progress Notes dated 9/19/11, 9/21/11 and 9/23/11, showed the resident's urine color continued to be "amber." The notes did not show the physician was notified. The acute care hospital's Laboratory Report dated 9/26/11, showed Resident 1 had an elevated BUN (a test used to help diagnose dehydration, an elevated BUN is indicative of dehydration) of 28 mg/dL (normal range is 7 mg/dL to 18 mg/dL). The resident's eGFR (a test which shows kidney function) showed her kidney function was normal. Review of the acute care hospital's history and physical dated 9/27/11, showed Resident 1 was admitted to the hospital and diagnosed with [REDACTED]. The history and physical showed the resident's dehydration was corrected after the IV fluids were administered. On 11/2/11 at 1530 hours, during an interview with the RD, the RD stated the resident received approximately 200 ml less of free water daily when the rate of the tube feeding was decreased from 75 ml to 65 ml per hour. The RD stated the amount of water flushes was not increased. The RD stated, when the resident was readmitted from the acute care hospital, the recommendation was to administer the tube feeding at a rate of 60 ml per hour and increase the water flushes to 250 ml every eight hours. On 11/3/11 at 1345 hours, during an interview with the DON , the DON acknowledged the intake and output records were incomplete for Resident 1. When asked why the facility did not assess Resident 1 for dehydration or identify it prior to the resident's transfer to the hospital, the DON stated it was an acute condition. On 11/8/11 at 1515 hours, during a follow up interview with the DON, the DON acknowledged acknowledged the lack of assessment and stated the nurses are expected to document assessments of the residents. The DON stated he could not find documentation the physician was notified when the resident's urine went from yellow to amber, which was abnormal. The DON was unable to explain why the resident's urine output did not match her intake. (Cross Reference 309, F282 # and 315 #2)

Based on interview and clinical record review, the facility failed to provide coordinated care with hospice for one nonsampled resident (Resident B). Findings: Clinical record review for Resident B was initiated on 12/28/11. Resident B was admitted to hospice services on 11/15/11. Review of the clinical record failed to show a schedule for the planned hospice visits to Resident B. During an interview and clinical record review by LVN 1 and MDS Coordinator 2 on 11/28/11 at 0830 hours, a schedule for planned hospice visits was not found. When LVN 1 was asked when the hospice staff was scheduled to visit Resident B, LVN 1 stated she did not know. During an interview with CNA 4 on 11/28/11 at 1050 hours, CNA 4 stated she did not know when the hospice CNA was scheduled to see Resident B; the charge nurse usually tells her when the hospice CNA is scheduled. CNA 4 stated she had already bathed Resident B early this morning. Review of the hospice schedule for Resident B, faxed to the facility from the hospice agency on 12/28/11, shows the hospice CNA is scheduled to visit Resident B today.

Based on interview and clinical record review, the facility failed to provide appropriate services to restore as much normal bowel and bladder function as possible for one of 10 sampled residents (Resident 31). The facility failed to accurately evaluate Resident 31's bowel and bladder status. The facility failed to provide the appropriate services to restore as much normal bowel and bladder function as possible for Resident 31. This poses the potential for further decline in function of the bowel and bladder for the resident. Findings: On 2/13/12 at 0740 hours, tour rounds was conducted with LVN 3. LVN 3 stated Resident 31 is incontinent of both bowel and bladder. On 2/13/12, clinical record review was initiated for Resident 31. Resident 31 was admitted to the facility on 10/ 6/11, and readmitted on [DATE]. Review of the MDS (a standardized assessment tool) dated 1/23/12, shows Resident 31 has moderate cognitive impairment and is in need of extensive assistance with bed mobility, transfers, toileting, and personal hygiene. The MDS shows Resident 31 is continent of both bowel and bladder, and a toileting program is not in place. The MDS shows the assessment reference date is 1/12/12. Review of the Bowel and Bladder Continence Evaluation form dated 1/6/12, shows Resident 31 is incontinent and, based on the evaluation, a scheduled voiding program is checked, and the comments show the resident is able to transfer. Step 7 of the form shows to document interventions on the resident care plan and Nursing Assistant Care Card. The licensed nurse's signature is dated 1/6/12 for step 7, and the comments section is blank. Review of the Resident Functional Performance Record dated January, 2012, shows from January 1, 2012 through February 12, 2012, Resident 31 is incontinent of bladder on all shifts. The bowel section of the form shows seven episodes of being continent and toileted, otherwise incontinent. A care plan problem to address the resident's incontinence of bowel and bladder and a scheduled toileting program was not found in the current hard copy clinical record or in the electronic clinical record. Review of the Weekly Nursing Summaries dated 1/30/12, 2/6/12 and 2/13/12, shows Resident 31 is incontinent of both bowel and bladder. On 2/13/12 at 0945 hours, an interview was conducted with Resident 31. Resident 31 stated she is incontinent of both bowel and bladder. Resident 31 stated she uses an incontinence brief because the urge comes on fast and she cannot hold it. When asked if she is on a scheduled toileting program, she stated, no. Resident 31 stated she puts on her call light when she is incontinent and needs to be changed. Resident 31 stated she had a bedside commode chair at home which she used, but, since her readmission, staff assist with changing her incontinence brief. On 2/13/12 at 1005 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 31 is incontinent of both bowel and bladder, and sometimes continent of bowel. CNA 4 stated Resident 31 is aware and puts on her call light when she needs to be changed. CNA 4 stated she asks Resident 31 if she needs to go to the bathroom very two hours. On 2/13/12 at 1345 hours, an interview and clinical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 stated the MDS dated [DATE] is not correct and Resident 31 is incontinent of both bowel and bladder. MDS Coordinator 1 stated the scheduled toileting program sheet is keep in the binder with the Functional Performance Record, and the care plan is to be updated to show scheduled toileting. Review of the Toileting Program form (undated) shows please assist Resident 31 with the use of the toilet at 0500 hours (if awake), 0900 hours, 1300 hours, 1600 hours, 2000 hours and 2200 hours. the form shows for the night shift to offer and encourage the use of the toilet every two hours while awake. MDS Coordinator 1 was unable to find a care plan problem to address Resident 31's incontinence of bowel and bladder with the intervention of a scheduled toileting plan. On 2/14/12 at 0745 hours, an interview was conducted with CNA 5. CNA 5 stated most of the time, Resident 31 is incontinent of both bowel and bladder. When ask if Resident 31 is on a toileting program, CNA 5 stated Resident 31 is alert and turns on her call light when she is incontinent. In addition to answering the call light, CNA 5 stated she checks on Resident 31 every two hours. CNA 5 stated Resident 31 had a bedside commode and was continent, but, since she was readmitted , she is incontinent. CNA 5 was unable to explain why Resident 31 does not have a bedside commode at the present time. On 2/14/12 at 1015 hours, an interview was conducted with Resident 31. Resident 31 stated her legs are weak and she is not sure if she could use a bedside commode without the assistance of staff. Resident 31 stated she feels embarrassed when staff have to change her "diaper." (cross reference F-278 and F-279)

Based on observation, interview and clinical record review, the facility failed to ensure accident hazards were as minimal as possible for two of 18 sampled residents (Residents 3 and 8). A pressure pad alarm for Resident 3 was not in place as ordered and the resident was not supervised during meals . An assessment for elevated side rails for Resident 8's use was not done. This places the residents at risk for injuries and choking. Findings: 1a. Review of the facility's P&P titled Fall Management Program dated December, 2010, showed the goal was to provide an environment which promotes safety, and minimizes the risk of injury Review of the facility's Diet Manual - Ground Texture (undated) showed eggs provided should be easily cut with a fork. On 10/31/11, clinical record review for Resident 3 was initiated. The physician's orders [REDACTED]. The care plan problem titled At Nutritional Risk dated 11/2/11, showed Resident 3 was to receive a mechanically altered diet due to difficulty swallowing. An intervention was to provide assistance with all meals, and ensure the resident took small bites of food. On 11/1/11 at 0842 hours, Resident 3 as observed sitting up in bed with her breakfast tray in front of her. No staff was present in the resident's room. The resident's breakfast consisted of a whole breakfast sandwich including two whole slices of bread with a large fried omelette style egg in the middle. The whole sandwich was cut in half and the resident was using her fingers to feed herself. The resident was observed picking up half of the sandwich and placing it in her mouth. On 11/1/11 at 0847 hours, during an observation, interview and review of Resident 3's diet card with the DSS, the diet card showed the resident was to receive a "ground" diet. The DSS stated she could not explain why the food on the resident's tray was not ground. The DSS stated ground food was food that was chopped up. The DSS stated if the resident had been in the dining room, the CNA would have cut up the food for the resident, and that was the problem. On 11/1/11 at 0900 hours, Resident 3 was observed in bed with her breakfast tray in front of her. No staff was present in the resident's room. The resident had a small plastic container of jelly in her mouth, and was biting it. LVN 1 responded after the surveyor called for staff to help the resident. (Cross Reference F282, F312 and F367) b. Resident 3 had a history of [REDACTED]. The physician's orders [REDACTED]. Review of the facility's investigation form dated 7/19/11, showed Resident 3 was found on the floor next to her bed. The form showed a pressure pad alarm was ordered for the resident, but was not turned on or in place at the time of the resident's fall. A recommendation listed to prevent further falls showed for staff to ensure the pressure pad was in place and turned on when the resident is in bed. 2. On 10/31/11 at 1430 hours, LVN 3 stated Resident 8 is at risk for fall. Review of Resident 8's clinical record was initiated on 11/1/11. The resident was admitted to the facility on [DATE]. He has a history of falls, a hip fracture, and is receiving Coumadin (a blood thinner). One of the significant side effects of Coumadin is bleeding. The MDSs (an assessment tool) dated 3/31/11, and 9/28/11, showed the resident's cognition is severely impaired; he needs one person assistance for transferring. Review of the care plan showed a care plan problem dated 1/7/10, to address the risk for falls related to the use of psychotropic medications, unsteady gait, visual deficit, generalized weakness, and decreased safety awareness. The approaches included 1/4 left side rail up while in bed as an enable; assist the resident getting in and out of bed with one person assistance; encourage the resident to use handrails or assistive devices properly; remind the resident to use the call light when attempting to ambulate or transfer; when the resident is in bed, place all necessary personal items within reach; place the call light within easy reach; evaluate effectiveness and monitor for side effects of psychotropic drugs; ensure seating in the dining room is close to the entrance/exit; ensure the environment is free of clutter; encourage the resident to communicate needs/ask for assistance. a. Review of the Resident Fall Evaluation showed the resident had three falls from 12/20/10 to 9/22/11. Review of the investigation report showed Resident 8 had an unwitnessed fall in the hallway on 2/3/11 at 1450 hours. The resident sustained [REDACTED]. The resident fell while ambulating without assistance from the staff. The "Resident has episodes of wedging in thhis FWW (front wheel walker) with seat in the hallway handrail, then sits on the FWW reclining position." The Clinical Management Team determined the fall was related to his cognition. The recommendations were to "Increase visual cuing, Remind resident not to wedge in FWW due to instability of the walker if he sits in." Review of the Interdisciplinary Progress Notes showed entries dated 2/2, and 2/9/11, showing the resident was referred to rehabilitation for screening, ambulation with a FWW daily, and will continue to monitor. The resident had a UTI. There was no documentation to show the resident was evaluated by physical therapy for the safe use of the walker. There was no documentation to show a care plan problem was revised or developed to address the fall on 2/3/11. Review of the investigation report showed Resident 8 was found lying in the hallway at the nurses' station on 2/28/11 at 1800 hours. The fall was unwitnessed. The resident did not have signs and symptoms of injuries from the fall. The Clinical Management Tear determined the fall was related to neuromuscular. The recommendations were to instruct the resident on safe ambulation; to sit on the walker if he feels weak or tired. Review of the Interdisciplinary Progress Notes showed entries dated 3/1, and 3/4/11, showing the resident was found on floor next to the walker. A urinalysis and a urine culture and sensitivity were obtained. The resident had a UTI. There was no documentation to show the resident was evaluated by physical therapy for gait balance, safety, and the use of the walker. There was no documentation to show a care plan problem was revised or developed to address the fall on 2/28/11. Review of the investigation report showed Resident 8 was found sitting on the floor, close to the dining room on 7/27/11 at 0800 hours. According to the CNA, the resident was walking without his walker, lost his balance, fell on the floor, did not hit his head. The recommendations were to reorient the resident with the use of the FWW; discourage from walking without his device; supervision; visual check; verbal cues; keep FWW within reach. The fall was related to impaired gait balance with poor safety awareness and judgement. The resident did not use the FWW to ambulate, resulting in a fall. There was no documentation to show the resident was referred to or evaluated by physical therapy for gait balance, safety, or the use of a FWW after the resident fell on [DATE]. Review of the care plan showed a care plan problem dated 7/28/11, to address falls. The goal was the resident will have no fall episodes in three months. The approaches included frequent visual checks will be done by staff; reality orientation will be provided as needed due to poor memory. The care plan did not specify how often the visual checks will be conducted or who will check the resident to ensure the resident is under supervision. On 11/1/11 at 1030 hours and 1350 hours, Resident 8 was observed sitting on his walker with a seat in the hallway. There was no staff with the resident. During an interview and clinical record review with LVN 3 on 11/2/11 at 1630 hours, the LVN was asked how she prevents the resident from having further falls. She stated she provides frequent visual checks of the resident. She was asked how often she provides visual checks and how she ensures the resident will be sufficiently supervised. She stated the resident walks in the hallway with his walker; all staff members were able to see the resident. She stated the resident has physical therapy to evaluate after each fall. LVN 3 reviewed the resident's clinical record and was unable to find documentation to show the resident was evaluated by physical therapy after the resident fell on ,[DATE], 2/28, and 7/27/11. She was also unable to find documentation to show a care plan problem was developed or revised after the resident fell on ,[DATE] and 2/28/11. She confirmed the resident had two unwitnessed falls, on 2/3/11, and 2/28/11. She stated she will look for information in the resident's overflow record. On 11/2/11 at 1400 hours and 1705 hours, Resident 8 was observed walking with his walker in the hallway. There was no staff with the resident. On 11/3/11 at 0805 hours, the DON stated he was unable to find documentation to show the care plan problem was developed or revised when the resident fell on ,[DATE], and 2/28/11. He was unable to find documentation to show the resident was referred or evaluated by physical therapy for gait balance, safety, or the use of his walker after he fell on ,[DATE], or 2/28, and 7/27/11. He stated the resident should be seen by physical therapy after each fall. The DON stated he will look for this information in the resident's overflow record. On 11/3/11 at 0920 hours, the resident was observed walking with his walker in the hallway. There was no staff with the resident. The resident was observed leaning his walker against the wall, turning around, sitting down on his walker, and standing up from his walker. No staff members were observed in the hallway. On 11/3/11 at 0945 hours, the resident was observed walking with his walker in the hallway. There was no staff with the resident. On 11/3/11 at 1000 hours and 1100 hours, the DON stated the resident was seen by physical therapy when the resident fell on [DATE]. He stated he was unable to find documentation to show the resident was evaluated by physical therapy after he fell on ,[DATE] and 7/27/11. He provided documentation, showing the resident was seen by physical therapy in February, and March, 2010. On 11/3/11 at 1340 hours, the resident was observed walking in the hallway with his walker. There was no staff with the resident. b. In 1995, the FDA (Food and Drug Administration) issued a Safety Alert entitled "Entrapment Hazards with Hospital Bed Side Rails." Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc. that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Review of the physician's orders [REDACTED]. Review of the Device Evaluation dated 7/22/11, showed the resident was evaluated for the use of a left upper 1/4 partial side rail when in bed. On 10/31/11 at 1430 hours, Resident 8 was observed lying on the bed with two 1/2 side rails up. LVN 3 stated the resident had two side rails up to prevent falls and to help for bed mobility. On 11/2/11 at 1110 hours, the resident was observed lying on his bed with two 1/2 side rails up. On 11/2/11 at 1130 hours, LVN 3 reviewed the resident's clinical record and confirmed the resident was evaluated for a left 1/4 side rail up; he was not evaluate for the use of two side rails. She stated the resident should be reevaluated for the use of the side rails.