Every finding on record at Alameda Healthcare & Wellness Center

Based on interviews and record reviews, the facility failed to ensure that one of the two sampled residents (Resident 2) was timely assessed after a fall and that the physician was promptly notified.This failure resulted in Resident 2 receiving delayed treatment which placed the resident at risk of an adverse outcome from the fall. During a review of Resident 2's Situation, Background, Assessment, and Recommendation notes (SBAR, is a structured communication framework that can help teams share information about the change of condition of a resident) dated 6/22/26, indicated a documentation by night shift Registered Nurse (RN) 2 that Resident 2 had an unwitnessed fall in the evening shift. Review of Resident 2's progress notes did not reveal any documentation by the evening shift nurse of a fall incident (evening shift hours were 3:00 p.m. until 11:30 p.m. and night shift hours were 11 p.m. until 7:30 a.m.). There was also no documentation found that the physician was informed of the fall. Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) dated 8/26/26 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). Review of Resident 2's MDS (an assessment tool) dated 6/12/26, indicated resident had a brief interview for mental status or BIMS of 5 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS dated [DATE] Section GG titled, Functional Abilities and Goals indicated, Resident 2 was unable to walk and needed partial to moderate assistance from a helper when moving from lying on the back to sitting on the side of the bed and needed substantial to maximal assistance in doing bed to chair transfers (partial/moderate assist means the helper does less than 50% of the physical effort and substantial / maximal assist means the helper must do MORE than half of the physical work, though the patient still tries to help). Review of Resident 2's Fall Risk evaluation dated 6/9/26 showed a score of 19. A score of 10 or higher meant the resident had a high risk of falling, therefore Resident 2 required close monitoring. During an interview on 8/27/26 at 10:22 a.m., Resident 2's Responsible Party (RP 1) stated the facility called her on 6/22/26 to report the fall of Resident 2 and was being transferred to the hospital. During an interview and concurrent review with the Director of Staff Development (DSD) on 8/27/26 at 2:48 p.m. , Resident 2's SBAR was reviewed. The DSD stated that the evening shift nurse should have immediately initiated the SBAR and notified the physician immediately following Resident 2's fall to prevent any delay in post-fall treatment in case the resident had injuries. During an interview and concurrent review with the Director of Nursing (DON) on 8/27/26 at 4:20 p.m., Resident 2's progress notes were reviewed . DON stated there was no documentation in the evening shift notes about the resident falling. However, the DON noted that the resident was transferred to the hospital during the night shift on 6/22/26 because of a fall; additionally, the SBAR or change of condition should have been completed immediately after Resident 2's fall, rather than being left for the night shift nurse to do. The DON further noted that failing to complete the SBAR promptly risked delaying the resident's treatment because the physician was not immediately informed of the fall. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, dated 8/25/22, the P&P indicated, 1. It is the responsibility of the person who observes the change to report the change to the Licensed Nurse. 2. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. a. Before notifying the Physician/APP, the licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review. i. Notification to the Physician/APP will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required utilizing a SBAR format (situation, background, assessment, recommendation). 3. A licensed nurse will notify the resident's Physician/APP and legal representative or an appropriate family member when there is an: a. Incident/ accident involving the resident. (APP is an Advanced Practice Provider - a health care provider who is not a physician, but who performs medical activities typically performed by a physician).

Based on interview and record review, the facility failed to ensure the use of a geri-chair safely by a Resident 1. This failure resulted in Resident 1 to sliding down the geri-chair, resulting to a laceration in the right brow requiring a transfer to the emergency room for treatment and further evaluation. A review of Resident 1's Situation, Background, Assessment, and Recommendation notes (SBAR, is a structured communication framework that can help teams share information about the change of condition of a resident) dated 2/26/26 at 12:30 p.m. indicated Resident had a witnessed fall: slid down and hit their head in a geri chair, resulting to a 1-inch laceration over the right brow bone. The SBAR also indicated the resident was sent to the hospital emergency department ( geri chair is short for geriatric chair, it is a medical-grade reclining chair on wheels designed to provide comfortable seating and postural support for people with limited mobility). During a review of Resident 1's admission Record, dated 7/8/25, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included history of falling and fracture of thoracic/lumbar vertebra ( broken bones in the upper and lower back). Review of Resident 1's MDS (an assessment tool) dated 4/3/26, indicated he had a brief interview for mental status or BIMS of 5 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS dated [DATE] Section GG titled, Functional Abilities and Goals indicated, Resident 1 needed partial to moderate assistance from a helper when walking 10 feet in a room, when standing from sitting position and rolling left and right when in bed (partial/moderate assist means the helper does less than 50% of the physical effort). During an interview on 8/26/26 at 2:04 p.m., with Registered Nurse (RN) 1, RN 1 stated that on 6/22/26 at 12:30 p.m., Resident 1 slid down from his geri chair in front of the nurse's station. RN 1 stated he conducted a post-fall assessment and identified a laceration on the resident's forehead. RN 1 stated he called 911 and the resident was sent to the hospital emergency department for medical evaluation. RN 1 further stated he was not trained by the facility on the proper use of geri chair. During an interview and concurrent review on 8/26/26 at 3:42 p.m., with the Director of Rehabilitation (DOR), Resident 1's rehabilitation notes, physician orders and care plans were reviewed. The records did not show a physician's order justifying the use of the geri chair, and there was no care plan explaining why Resident 1 needed it or how to use it properly for resident safety. Additionally, the DOR stated that staff had not received training on the proper use of the geri chair. During an interview and concurrent review on 8/27/26 at 9:36 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's physician orders and care plans were reviewed. The records did not show a physician's order and care plan for the use of the geri chair. The MDSC stated that when a resident used an equipment like a geri-chair, a physician's order and a care plan must be in place. The physician must verify that the geri chair would not harm the resident, and the care plan must outline its proper use to ensure resident safety. During an interview with the Director of Nursing (DON) on 8/27/26 at 4:20 p.m., the DON stated the facility did not have policy and procedures on proper use of geri chair. Stated there should be a care plan for the geri chair to make sure interventions were in place. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, Revised 3/13/21, the P&P indicated, . D. the IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall as needed. (IDT is facility's Interdisciplinary Team , a group of individuals representing different departments of the facility).

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards, when nine cups of six ounces of milk in each cup, were stored at room temperature for an hour on a food preparation table in the kitchen. This failure had the potential to result in food borne illness for residents in the facility.Findings:During a concurrent observation and interview on 8/10/26, at 1:35 p.m., with Dietary Aide 1 (DA 1) a tray with nine (9) cups of six (6) ounces of milk in each cup, was kept on the food preparation table in the kitchen. DA 1 stated the milk cups were left at room temperature, however, they were to be placed in the refrigerator for later use. DA 1 stated the kitchen staff forgot to put it back in the refrigerator. DA 1 also stated those milk cups were left over from lunch tray-line (an assembly line system used in large health care facilities to prepare and send out meal trays to residents) and were left on the preparation table at least an hour ago.During a concurrent observation and interview on 8/10/26, at 1:47 p.m., with Dietary Manager (DM), DM used a thermometer to check temperature of the nine cups of milk that were kept on the food preparation table, and stated the milk was at 62 F at that time. The DM stated that the milk should be kept in the refrigerator at 41 F or less to prevent residents acquiring food borne illness.During a review of facility's Policy and Procedure (P&P) titled Food Temperatures, undated, the P&P indicated, the acceptable serving temperature of milk products should be 41 F or less.

Based on observation, interview and record review the facility failed to follow infection control practices to prevent the spread of infection in the facility during a Coronavirus Disease (COVID-19 - an infectious disease caused by the SARS-CoV-2 virus) outbreak when the following was observed:The facility did not notify the California Department of Public Health they had a COVID-19 outbreak.The facility did not have signs at their front entrance to notify visitors, residents or anyone coming into the facility about their COVID-19 outbreak.One [NAME] Aid (CA 1), and one Laundry Aid (LA 1) wore a surgical mask in the resident hallways.Three facility staff including one receptionist, one Certified Nursing Assistant (CNA 1), and one Restorative Nursing Assistant (RNA 1), did not appropriately wear their face masks. These failures had the potential for increased risk of infection for the 152 residents at the facility.During a review of Resident 1's admission Record, printed 9/4/25, the admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses, including cognitive communication deficit. During a review of Resident 2's admission Record, printed 9/4/25, the admission Record indicated Resident 2 was admitted to the facility with multiple diagnoses, including immunodeficiency (when your immune system is too weak to fight off infections and diseases effectively, leading to more frequent, severe, or long-lasting illnesses) . During a review of Resident 2's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 8/3/25, the record indicated Resident 2's BIMS score was 15. During a review of Resident 3's admission Record, printed 9/4/25, the admission Record indicated Resident 3 was admitted to the facility with multiple diagnoses, including encounter for screening for COVID-19 (medical visit to test for potential health issues in people who are not currently showing symptoms). During an observation on 9/4/25, at 9:50 a.m., the facility's front entrance was observed. The entrance did not have any signs that indicated there was a COVID-19 outbreak in the facility. During a concurrent observation and interview on 9/4/25, at 9:58 a.m., in the lobby, the receptionist did not state the facility had a COVID-19 outbreak. The receptionist was wearing an N95 mask (a type of respirator that forms a seal around the nose and mouth and helps protect the wearer from inhaling airborne particles for infection control) below their nose with their nose open to air. During an observation on 9/4/25, at 10:26 a.m., in the resident hallway, CA 1 was wearing a surgical mask. During a concurrent observation and interview on 9/4/25, at 10:30 a.m., CNA 1 was in Resident 1's room wearing an N95 mask below their nose with their nose open to air. CNA 1 stated they were changing Resident 1's linens, gown and brief. During a concurrent observation and interview on 9/4/25, at 10:47 a.m., in the resident hallway, LA 1 was wearing a surgical mask while they stocked the clean linen closet. LA 1 stated they should have been wearing an N95 and put one on. During a concurrent observation and interview on 9/4/25, 11:17 a.m., RNA 1 was in Resident 2's room wearing an N95 mask below their nose with their nose open to air. RNA 1 stated they were taking Resident 2's weight. During an interview on 9/4/24, at 11:30 a.m., with Resident 2, Resident 2 stated staff did not always wear their face masks correctly. During an interview on 9/4/24, at 12:46 p.m., with Director of Nursing (DON), DON stated they were having a COVID-19 outbreak. DON stated Resident 3 was COVID-19 positive. During an interview on 9/4/24, at 1:45 p.m., with the Administrator (ADM) and the Regional Quality Management Consultant (RQMC), ADM stated everyone was required to wear an N95 upon facility entrance, while in the hallways and in resident rooms because of their COVID-19 outbreak. ADM stated it was important to wear an N95 because it offered more protection than a surgical mask and to prevent the spread of infection. RQMC stated the proper way to wear an N95 was to seal it over the mouth and nose, and it was important to wear it correctly to prevent the spread of infection. RQMC stated their policy was to have a sign at the front entrance to inform visitors and staff about their COVID-19 Outbreak. RQMC stated the sign was important so everyone could have been informed of the outbreak and so they could have taken the necessary precautions to prevent the spread of infection. During an interview on 9/4/24, at 4:46 p.m., DON stated they did not report the facility's COVID-19 outbreak to the California Department of Public Health.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents, staff and the public when the following occurred:1. Facility was overcome with offensive odors from morning to late afternoon on four different days, (7/21-8/8/25).2. Facility did not provide a sufficient amount of clean linens to meet needs of all Residents. 3. Facility did not ensure fans in Station 2 and Laundry room were appropriately cleaned.This failure resulted in Residents feeling forgotten, staff feeling environment is dirty, and anxious about not having enough supplies to perform duties, and exposed the public to unwarranted, offensive odors. 1.During an observation and facility tour on 7/21/25, at 08:30 a.m., the facility smelled like urine and feces throughout all stations in facility. During an interview on 7/21/25, at 09:12 a.m., Resident 1 stated he had been at the facility about 1 month and stated occasionally the facility smelled like pee.During an observation and facility tour on 7/22/25, at 10:30 a.m., the facility smelled like urine and feces throughout all stations in facility. During an observation on 7/24/25, at 09:03 a.m., station 3 bathroom had a foul odor.During an observation and interview on 7/24/25, at 09:18 a.m., with Maintenance Director (MTD), station 2 shower had a foul odor. MTD stated it was important to ensure facility did not have foul odors and the facility should smell good.During an observation and facility tour on 7/24/25, at 11:30 a.m., the facility smelled liked urine and feces throughout all stations in facility. During an interview and observation on 7/24/25, at 3:18 p.m., Responsible Party (RP) 1 was frustrated while attempting to ask a staff member to clean up urine on the floor near a resident room with foul odor noted. RP 1 stated maintenance and housekeeping staff did not respond to repairs and cleaning fast enough or at all. RP 1 stated they were very unhappy with housekeeping and were currently awaiting a staff member to clean urine off of the floor and remove the foul odor. RP 1 stated they feel staff do no respect family's wishes. During a review of facility's Policy and Procedure (P&P), dated 1/1/2012, titled, Resident Rooms and Environment, the P&P indicated, Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to pleasant, neutral scents .Facility Staff work to minimize, to the extent possible, the characteristics of the Facility that reflecta depersonalized, institutional setting, including institutional odors.2.During an observation and interview on 7/21/25, at 09:39 a.m., Certified Nurse Assistant (CNA) 1 changed Resident 2's linens. CNA 1 stated there were not enough linen and towels most of the time, and they arrived to work early to take necessary linen and towels for each of their assigned residents and placed the linen in the residents' rooms before other CNA's arrived to do the same. During an interview on 7/21/25, at 4:43 p.m., MTD stated housekeeping staff (staff responsible for cleanliness, maintenance and aesthetic upkeep of patient care areas, public areas and staff areas) had a daily schedule to empty garbage, wipe high touch areas, sweep and mop each room daily. MTD stated there was no log for daily cleanings, only a daily schedule for each housekeeper. MTD stated he followed up and visited each room to confirm cleaning was completed by housekeeping staff. MTD stated he personally did not document daily room rounds (when a staff member visits each resident's room to review the resident's status) confirming rooms are clean or dirty after housekeeping staff complete tasks. During an observation and interview on 7/22/25, at 11:11 a.m., MTD stated they maintain linen and towel inventory. MTD stated they kept inventory based on observation, using numbers written on stored boxes. MTD was unsure when the last time he ordered more linens or towels. MTD stated backup inventory had not been used, and they were unsure of the exact inventory. MTD stated he had received complaints about lack of linen and towels from staff.During and interview on 7/24/25, at 10:15 a.m., CNA 2 and Licensed Vocational Nurse (LVN) 1 stated there were not enough linens and towels available for all residents for the last six months. CNA 2 and LVN 1 stated they had told the nursing supervisor and charge nurse that there was not enough linen and towels available for patient care. LVN 1 stated they had told MTD available linen and towels were not enough to meet residents' needs. CNA 2 stated lack of linen and towels delayed patient care. During an interview on 7/24/25, at 10:36 a.m., CNA 3 stated often times linen and towels were stained, ripped and not stocked adequately, preventing appropriate patient care. CNA 3 stated the Administrator (Admin) refused to order more linen despite complaints from staff of inadequate supply. CNA 3 stated there were constant odors throughout the facility, especially in the morning, due to many soiled residents, soiled linen and towels needing to be cleaned. CNA 3 stated linen and towel storage closets were typically empty by 9 a.m. and they did not get restocked until 2 p.m. During an interview on 7/24/25, at 11:01 a.m., CNA 2 stated there were never enough trash bags and they had placed several maintenance requests on the online facility reporting system. CNA 2 stated they had reported lack of trash bags, towels and linen available to MTD and Admin.During an interview and observation on 7/24/25, at 11:11 a.m., LVN 1 stated they were currently waiting for a trash bag but housekeeping staff told her they had none. LVN 1 stated lack of supplies and support makes her feel like facility does not care.During an interview and observation on 7/24/25, at 12:00 p.m., Housekeeping/Laundry Staff (HSK) 2 stated there was not enough linen and towels for all residents daily. During an interview and observation on 7/24/25, at 12:11 p.m., MTD gave a tour of emergency linen supply shed that is only available to MTD. MTD stated they were unsure of inventory count in emergency shed at this time. MTD stated he assumed inventory by numbers written on box. Plastic wrapped bath blankets labeled, 50 bath blankets in black marker were observed. MTD stated he guessed there were about 288 bath blankets (a flannel covering used to prevent chilling when administering a bed bath) in emergency storage, based on labels on each item. MTD stated the facility had 168 beds and was unsure how long emergency supply should last, or could last, with the quantities observed in emergency linen supply shed.During an interview and observation on 7/24/25, at 12:19 p.m., Resident 3 stated they had not had a wash cloth (a cloth that is used for washing one's face and body) in three days because all linen was gone by breakfast. Resident 3 stated most linen, gowns, towels, and clothes were stained. Resident 3 stated they had purchased personal wash cloths and face wipes. Resident 3 stated lack of adequate linens and towels made her feel forgotten and made her worry about things that should be unlimited.During an interview on 7/24/25, at 12:30 p.m., Social Services Assistant (SSA) stated they were aware of staff complaints of lack of linen and towels. During an interview on 7/24/25, at 12:50 p.m., CNA 4 stated there had been a lack of linen and towels since March 2025. CNA 4 stated they had personally addressed a lack of linen and towels with Admin.During an interview on 7/24/25, at 1:34 p.m., CNA 5 stated they had worked in the facility for ten years and never experienced a linen or towel shortage until March 2025. CNA 5 stated all staff had complained and reported lack of linen and towels, but nothing had changed. During an observation on 7/24/25, at 4:42 p.m., station 3 linen closet had three wash cloths, eight pillowcases, and four large blankets. No garbage bags were in station 3 linen storage closet.During an interview on 7/24/25, at 4:44 p.m., Admin stated they were informed of linen complaints from staff and residents and they asked MTD to inventory linen and towels. Admin stated it was important for residents to have adequate linen and towels to create a homelike environment and uphold resident's dignity. During a review of facility's P&P, dated 1/1/12, titled, Laundry Services, the P&P indicated, At all times, the facility maintains enough linens for at least three complete bed changes for every licensed bed.During a review of facility's P&P, dated 1/1/12, titled, Housekeeping-Supplies and Equipment, the P&P indicated, To maintain adequate supplies and equipment, the Housekeeping Supervisor keeps an inventory and list of all housekeeping supplies, updated weekly.3.During an observation on 7/24/25, at 11:51 a.m., the fan in the laundry room appeared with grey dusty matter throughout the fan. During an observation and interview on 8/8/25, at 11:52 a.m., the fan in nursing station 2 appeared with grey dusty matter. LVN 2 stated they used the fan in the nursing station regularly and the housekeeping staff were responsible for keeping the fans clean.During an observation and interview on 8/8/25, at 12:04 p.m., MTD stated the maintenance team was responsible for cleaning fans in facility. MTD stated fans should be cleaned as needed when identified during routine facility rounds. MTD stated the fan in nursing station 2 needed to be cleaned. MTD stated it was important to clean fans for infection control purposes and to keep facility clean.During an observation and interview on 8/8/25, at 1:11 p.m., the fan in the laundry room appeared with grey dust matter throughout the fan. MTD stated the fan in the laundry room was dirty and should be cleaned. During a review of facility's P&P, dated 1/1/2012, titled, Housekeeping-General, the P&P indicated, The Housekeeping Staff's general duties are to clean all air vents for heating, cooling, pure air, or oxygen.During a review of facility's P&P, dated 1/1/2012, titled, Laundry-Supply and Storage, the P&P indicated, Any problem with laundry room ventilation or dirt or corrosion on fans or ducts is reported to the Housekeeping Supervisor.

Based on observation, interview and record review, the facility failed to provide enough nursing staff to provide timely medication administration and prevent medication errors when five of eight sampled residents (Residents 1, 2, 3, 4 and 5) did not receive medications according to physician orders and resident care plans. This failure resulted in: 1. Licensed Vocational Nurse 1 (LVN 1) administering 12 medications late to Resident 1 which included a medication to manage seizures (episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) which had the potential to increase Resident 1 ' s risk of seizure, 2. Registered Nurse 2 (RN 2) administered a dose of methadone (medication to control pain) five times higher than ordered by the provider to Resident 2 which placed Resident 2 at risk of narcotic (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) overdose potentially leading to death, 3. Licensed Vocational Nurse 3 (LVN 3) administered 11 medications late to Resident 3 which included medications to control blood pressure and prevent blood clots which placed Resident 3 at risk of high blood pressure and formation of blood clots which could lead to death, 4. Registered Nurse 1 (RN 1) administered 10 medications late to Resident 4 which included a medication to prevent blood clots which placed Resident 4 at risk of formation of blood clot which could lead to death, and 5. LVN 1 administered 13 medications late to Resident 5 which included medications to manage pain which had the potential for Resident 5 to experience uncontrolled pain. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted for epilepsy (a brain disorder in which a person has repeated seizures over time), supraventricular tachycardia (condition which causes a high heart rate), muscle weakness and dysphagia (difficulty swallowing). During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 4/21/25, the MDS indicated Resident 1 had Brief Interview for Mental Status score of 11 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) During a record review of Resident 1 ' s physicians orders set titled, [Facility] Order Summary Report, dated 5/19/25, indicated Resident 1 did not have an order to self-administer medications and was not capable of making medical decisions. The physicians order set indicated Resident 1 had an order for levetiracetam (medication to prevent seizures) 500 mg 1 tablet twice a day for seizures. During a review of Resident 1 ' s care plan titled, Care Plan Report, undated, the care plan indicated Resident 1 had a care plan for alteration in neurological status related to seizure .give medications as ordered, dated 5/18/24. The care plan further indicated Resident 1 had a care plan for altered cardiovascular status as supraventricular tachycardia .medication per MD order, dated 4/21/22. During a concurrent observation and interview on 5/13/25, at 9:30 a.m., with Resident 1, two medication cups with one cup containing a red liquid and a second cup containing 12 tablets were on Resident 1 ' s bedside table. One of the tablet medications was a large yellow oval tablet with E and 11 engraved on one side. Above Resident 1 ' s bed was a sign indicating seizure precautions encourage resident to eat, drink and medication. Resident 1 stated she was waiting for food to take her medications and no one had come in to help her take her medications. Resident 1 stated the pills had been on the table since the morning. During an observation of a medication pass on 5/13/25, at 10:07 a.m. with LVN 1, LVN 1 was performing a medication pass on Resident 5. Resident 5 received 13 medications with the medication pass finishing at 10:37 a.m., and LVN 1 continued to pass medications on another resident. During an observation on 5/13/25, at 11:12 a.m., in Resident 1 ' s room, the two medication cups were still on Resident 1 ' s bedside table. Resident 1 was asleep in bed with the bedside table positioned over her. Inside the medication cup were the same 12 medications. There were no staff in the room. During a concurrent observation and interview on 5/13/25, at 11:38 a.m., with LVN 1, LVN 1 was in Resident 1 ' s room giving Resident 1 the medications which were on the bedside table. LVN 1 stated they had placed Resident 1 ' s medications on the bedside table because Resident 1 was not ready to take the medications yet. LVN 1 stated Resident 1 did not have difficulty taking medications. An inspection of Resident 1 ' s medications in the medication cart indicated the yellow oval tablet with an E and 11 engraving was a levetiracetam 500 mg tablet. LVN 1 stated the levetiracetam tablet needed to be given on time to prevent seizures. LVN 1 stated they attempted to give Resident 1 their medications at 8:00 a.m., 8:30 a.m., and finally administered the levetiracetam tablet at 10:30 a.m. During a record review of Resident 1 ' s medication administration record (MAR), the MAR indicated Resident 1 ' s morning medication pass includeded of 12 medications in tablet form. The MAR indicated portions 12 medications were given at various times with four medications given at 7:48 a.m, four medications given at around 9:32 a.m., and three medications given at around 10:05 a.m. The MAR indicated levetiracetam 500 mg tablet was given at 9:32 a.m The MAR did not indicate any of the 12 medications were given at around 11:38 a.m. During a record review of facility staffing sheet titled, [Facility] Nursing Staff Assignment and Sign-in Sheet, dated 5/13/25, and facility census titled, [Facility] Daily Census, dated 5/13/25, comparison of LVN 1 ' s assignment to the census indicated LVN 1 had 26 patients to pass medications for. A review of Resident 2 ' s admission record indicated Resident 2 was admitted for acute heart failure (disease which causes reduced heart function), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and failure to thrive. During a record review of Resident 2 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 2 had an order for methadone oral tablet 5 mg give 5 mg by mouth two times a day for pain, dated 3/10/25. During a record review of Resident 2 ' s medication admission record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, the record indicated on 3/12/25, at 9:28 a.m., RN 2 gave Resident 2 methadone. During a record review of Resident 2 ' s narcotics count sheet titled, Narcotics Count Sheet methadone 5 mg, dated 3/2025, the count sheet indicated five tablets of methadone was removed on 3/12/25. During a phone interview on 5/14/25, at 2:30 p.m., with RN 2, RN 2 stated on 3/12/25, she was beginning to perform a medication pass for Resident 2. RN 2 stated she had been distracted with the needs of another resident and while rushing to prepare Resident 2 ' s medication she mistakenly gave Resident 2 the wrong dose of methadone. RN 2 stated Resident 2 received 5 tablets of 5 mg methadone instead of 1 tablet of 5 mg methadone and only realized the error the following day when performing a narcotics count. During a review of Resident 2 ' s nursing progress notes titled, [Facility] Progress notes, dated 5/16/25, the progress notes indicated on 3/13/25, RN 2 wrote a progress note writer contacted [hospice] regarding medication administration error for methadone 5mg. Writer stated that they gave 5 tablets instead of 5 mg of methadone. The progress notes indicated on 3/12/25, RN 2 wrote a late entry change of condition note indicating Writer administered 5 tablets of methadone 5mg, instead of prescribed 1 tablet of methadone 5mg. During a record review of facility staffing sheet titled, [Facility] Nursing Staff Assignment and Sign-in Sheet, dated 3/12/25 and facility census titled, [Facility] Daily Census, dated 3/12/25, comparison of RN 1 ' s assignment to the census indicated RN 1 had 25 patients to pass medications for. During an interview on 5/16/25, at 9:33 a.m., with the Director of Nursing, the DON stated RN 2 was assisting another resident and became distracted when she prepared the medications for Resident 2. The DON stated RN 2 was educated on reading medication orders accurately and had three medication passes observed by consultants to ensure RN 2 was reading medication orders accurately. The DON stated distractions during medication preparation and administration can be a cause of medication errors, and there was no plan to address distractions during medication administration. The DON stated educating the nurses to read labels and to be cognizant of time were the two main interventions to prevent medication errors and to give medications on time. A review of Resident 3 ' s admission record indicated Resident 3 was admitted in 2021 for diabetes, paraplegia (the loss of muscle function in the lower part of the body including both legs), muscle weakness and need for assistance with personal care. During a record review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had Brief Interview for Mental Status score of 15 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During a record review of Resident 3 ' s physicians order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 3 had an order for metoprolol (a medication to manage blood pressure) .tablet extended release 24 hour 100 mg. Give 1 tablet by mouth one time a day for [hypertension] and an order for diltiazem (a medication to manage blood pressure) .oral capsule extended release 12 hour 120mg. Give 1 capsule by mouth one time a day for [hypertension]. During a record review of Resident 3 ' s care plan titled, Care plan Report, The resident is at risk for altered cardiovascular status, undated, the care plan indicated the following interventions: metoprolol succinate ER as ordered. Diltiazem as ordered. During a concurrent observation and interview on 5/16/25, at 10:40 a.m., LVN 3 was in Resident 3 ' s room performing a medication pass. LVN 3 stated Resident 3 had his medication pass performed late because there were 28 residents to pass medications for. LVN 3 stated they started their medication pass at 8:00 a.m. and needed to stop frequently to find a CNA when residents were asking for help. LVN 3 stated they would appreciate assistance with medication passes but didn ' t have anyone in the immediate area to call for. LVN 3 stated the nursing supervisor last checked in with her at 9:00 a.m. During an interview on 5/16/25, at 2:20 p.m., with Resident 3, Resident 3 stated he received his medications on 5/16/25, at around 10:30 a.m Resident 3 stated the day shift nurses usually gave his morning medications close to lunch. Resident 3 stated many nurses would give meds late and document the meds were given on time, and when he complained about the practice, the staff looked at the documentation and said the medications were given on time. Resident 3 stated the way his concern was dismissed by the facility caused him to consider about how he would rather be back in prison. During a record review of facility staffing sheet titled, [Facility] Nursing Staff Assignment and Sign-in Sheet, dated 5/16/25 and facility census titled, [Facility] Daily Census, dated 5/16/25, comparison of LVN 3 ' s assignment to the census indicated LVN 1 had 27 patients to pass medications for. During an interview on 5/16/25, at 2:20 p.m., with Resident 3, Resident 3 stated he received his medications on 5/16/25, at around 10:30 a.m Resident 3 stated the day shift nurses usually gave his medications late. When asked if nurses would give meds late and document the meds were given on time, Resident 3 ' s eyes widened and stated this is what many of the nurses do, and when he makes a complaint, the staff look at the documentation and say it was given on time. Resident 3 stated the way he is treated at the facility he would rather be back in prison. A review of Resident 3 ' s medication administration record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated LVN 3 gave Resident 3: 1. eight medications on 5/16/25, at 10:40 a.m. with three medications scheduled to be given at 8:00 a.m. and five medications scheduled to be given at 9:00 a.m. 2. three medications at 10:48 a.m with one medication, diltiazem due at 8:00 a.m. and two medications including a metoprolol due at 9:00 a.m. A review of Resident 4 ' s admission record indicated Resident 4 was admitted to the facility in 2023 with femur (long bone in leg) fracture, pulmonary embolism (obstruction of blood vessels in the lungs causing loss of blood flow to lungs and heart), anemia (low blood), cognitive communication deficit and muscle weakness. During a record review of Resident 4 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 4 had an order for apixaban oral tablet 2.5 mg Give 1 tablet .two times a day for Acute Pulmonary embolism which was dated 3/6/24. A review of Resident 4 ' s care plan titled, Care Plan Report, undated, indicated Resident 4 had a care plan which indicated resident is on anticoagulant apixaban r/t pulmonary embolism .administer anticoagulant medications as ordered by physician. During a concurrent interview and record review on 5/16/25, at 10:50 a.m., with Registered Nurse 1 (RN 1), Resident 3 ' s medication administration record (MAR) was reviewed. RN 1 stated Resident 4 ' s medication administration for the morning was not completed yet. RN 1 stated Resident 4 had medications that needed to be given on time such as cardiac medications. RN 1 stated he was late getting medications done because he had to attend to residents which a CNA could not assist with such as preparing tube feeding setups and getting appointments confirmed for residents. RN 1 stated he had 25 residents to pass medications for and most of the medications were due at 9:00 a.m. RN 1 stated there was one nursing supervisor available for help. During a record review of facility staffing sheet titled, [Facility] Nursing Staff Assignment and Sign-in Sheet, dated 5/16/25 and facility census titled, [Facility] Daily Census, dated 5/16/25, comparison of RN 1 ' s assignment to the census indicated RN 1 had 25 patients to pass medications for. A review of Resident 4 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated on 5/16/25, RN 1 gave Resident 3: 1. seven medications at approximately 11:00 a.m. with two medications due at 8:00 a.m., four medications were due at 9:00 a.m. and one was due at 11:00 a.m., 2. three medications at approximately 11:15 a.m. which all three medications were due at 9:00 a.m. A review of Resident 5 ' s admission record indicated Resident 5 was admitted in 2020 with diagnoses of osteoporosis (condition characterized by weakened bone structure), chronic pain syndrome, anxiety, muscle weakness and need for assistance with personal care. During a record review of Resident 5 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 5 had orders for baclofen (medication to relax muscles) 10mg tab Give 1 tablet .for chronic pain, cymbalta (medication which can be used to manage pain symptoms) oral capsule 20 mg .Give 1 capsule .for chronic pain syndrome, gabapentin (medication to manage pain) oral tablet 600 mg .give 1 tablet .for neuropathic pain. During a record review of Resident 5 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/13/25, indicated Resident 5 received 13 medications at approximately 10:44 a.m. with six medications due at 9:00 a.m. which included cymbalta and gabapentin, and seven medications due at 8:00 a.m. which included Baclofen. During an interview on 5/16/25, at 11:30 a.m., with the Assistant Director of Nursing (ADON), the ADON stated they were acting as the nursing supervisor because there were no nursing supervisors hired by the facility. The ADON stated she tried to round on nurses every two hours but would expect nurses to ask for help with medication administration if needed. The ADON stated no nurses on the current shift came to ask for help. During an interview on 5/16/25, at 2:00 p.m., with the DON, the DON stated medication passes were expected to take less than 10 minutes per resident. The DON stated facility staffing of the nurses was not at her expected level and had difficulty in requesting corporate owners to supply more nurses. The DON stated there were no nursing supervisors on staff for the long term care section of the facility which required the ADON and admissions nurse to fill in nurse supervisor duties. The DON stated medications needed to be given on time to maintain therapeutic effectiveness and was important for medications such as seizure medications, blood pressure medications and anti-coagulants. The DON stated they could not expect nursing staff to administer medications safely and effectively under 5 minutes while having to attend to resident needs. During a concurrent interview and record review on 5/16/25, at 2:30 p.m., with the DON, the facility medication administration QAPI program document titled, [DATE], dated 10/2024, was reviewed. The DON stated the facility had implemented a QAPI program to reduce medication errors and ensure medications were given on time. The document indicated licensed nurses lack education on medication administration policy and procedure. The DON stated they did not investigate whether distractions and staffing levels had impact on medication error or late medication administration. During a phone interview on 6/2/25, at 5:30 p.m., with pharmacy consultant (PC), the PC stated they had replaced the previous PC. The PC stated on the week of 3/13/25, they started to work at the facility and was given notes by the previous PC. The PC stated they were not aware of any medication errors made since they started in March. The PC stated the standards in administering levetiracetam was two doses a day to ensure stable levels of the medication throughout the day and give a dose more than 3.5 hours late was too late. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 01/2012, the P&P indicated the licensed nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time .whenever a medication is held .the licensed nurse will document .the time and reason the medication was held .the licensed nurse will attempt to give the medication several times, but if the resident continues to refuse after one hour, the refused medication will be destroyed. The P&P further indicated nursing staff will keep in mind the seven rights of medication when administering medication .the right amount .the right time.

Based on observation, interview and record review, the facility failed to ensure quality of care for five of eight sampled residents (Residents 1, 2, 3, 4 and 5) when staff did not provide medications according to physician ' s order and resident care plan. This failure resulted in: 1. Licensed Vocational Nurse 1 (LVN 1) administering 12 medications late to Resident 1 which included a medication to manage seizures (episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) which had the potential to increase Resident 1 ' s risk of seizure, 2. Registered Nurse 2 (RN 2) administered a dose of methadone (medication to control pain) five times higher than ordered by the provider to Resident 2 which placed Resident 2 at risk of narcotic (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) overdose potentially leading to death, 3. Licensed Vocational Nurse 3 (LVN 3) administered 11 medications late to Resident 3 which included medications to control blood pressure and prevent blood clots which placed Resident 3 at risk of high blood pressure and formation of blood clots which could lead to death, 4. Registered Nurse 1 (RN 1) administered 10 medications late to Resident 4 which included a medication to prevent blood clots which placed Resident 4 at risk of formation of blood clot which could lead to death, and 5. LVN 1 administered 13 medications late to Resident 5 which included medications to manage pain which had the potential for Resident 5 to experience uncontrolled pain. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted for epilepsy (a brain disorder in which a person has repeated seizures over time), supraventricular tachycardia (condition which causes a high heart rate), muscle weakness and dysphagia (difficulty swallowing). During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 4/21/25, the MDS indicated Resident 1 had Brief Interview for Mental Status score of 11 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) During a record review of Resident 1 ' s physicians orders set titled, [Facility] Order Summary Report, dated 5/19/25, indicated Resident 1 did not have an order to self-administer medications and was not capable of making medical decisions. The physicians order set indicated Resident 1 had an order for levetiracetam (medication to prevent seizures) 500 mg 1 tablet twice a day for seizures. During a review of Resident 1 ' s care plan titled, Care Plan Report, undated, the care plan indicated Resident 1 had a care plan for alteration in neurological status related to seizure .give medications as ordered, dated 5/18/24. The care plan further indicated Resident1 had a care plan for altered cardiovascular status as supraventricular tachycardia .medication per MD order, dated 4/21/22. During a concurrent observation and interview on 5/13/25, at 9:30 a.m., with Resident 1, two medication cups with one cup containing a red liquid and a second cup containing 12 tablets were on Resident 1 ' s bedside table. One of the tablet medications was a large yellow oval tablet with E and 11 engraved on one side. Above Resident 1 ' s bed was a sign indicating seizure precautions encourage resident to eat, drink and medication. Resident 1 stated she was waiting for food to take her medications and no one had come in to help her take her medications. Resident 1 stated the pills had been on the table since the morning. During an observation of a medication pass on 5/13/25, at 10:07 a.m., with LVN 1, LVN 1 was performing a medication pass on Resident 5. Resident 5 received 13 medications with the medication pass finishing at 10:37 a.m., and LVN 1 continued to pass medications on another resident. During an observation on 5/13/25, at 11:12 a.m., in Resident 1 ' s room, the two medication cups were still on Resident 1 ' s bedside table. Resident 1 was asleep in bed with the bedside table positioned over her. Inside the medication cup were the same 12 medications. There were no staff in the room. During an interview on 5/13/25, at 11:25 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 had their breakfast at around 7 to 8 a.m. During a concurrent observation and interview on 5/13/25, at 11:38 a.m., with LVN 1, LVN 1 was in Resident 1 ' s room giving Resident 1 the medications which were on the bedside table. LVN 1 stated they had placed Resident 1 ' s medications on the bedside table because Resident 1 was not ready to take the medications yet. LVN 1 stated Resident 1 did not have difficulty taking medications. An inspection of Resident 1 ' s medications in the medication cart indicated the yellow oval tablet with an E and 11 engraving was a levetiracetam 500 mg tablet. LVN 1 stated the levetiracetam tablet needed to be given on time to prevent seizures. LVN 1 stated they attempted to give Resident 1 their medications at 8:00 a.m., 8:30 a.m., and finally administered the levetiracetam tablet at 10:30 a.m. During a record review of Resident 1 ' s medication administration record (MAR), the MAR indicated Resident 1 ' s morning medication pass consisted of 12 medications in tablet form. The MAR indicated portions 12 medications were given at various times with four medications given at 7:48 a.m, four medications given at around 9:32 a.m., and three medications given at around 10:05 a.m. The MAR indicated levetiracetam 500 mg tablet was given at 9:32 a.m The MAR did not indicate any of the 12 medications were given at around 11:38 a.m. A review of Resident 2 ' s admission record indicated Resident 2 was admitted for acute heart failure (disease which causes reduced heart function), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and failure to thrive. During a record review of Resident 2 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 2 had an order for methadone oral tablet 5 mg give 5 mg by mouth two times a day for pain, dated 3/10/25. During a record review of Resident 2 ' s medication admission record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, the record indicated on 3/12/25, at 9:28 a.m., RN 2 gave Resident 2 methadone tablet 5mg. During a record review of Resident 2 ' s narcotics count sheet titled, Narcotics Count Sheet methadone 5 mg, dated 3/2025, the count sheet indicated five tablets of methadone were removed on 3/12/25 for the 9:28 a.m. medication pass. During a phone interview on 5/14/25, at 2:30 p.m., with RN 2, RN 2 stated on 3/12/25, she was beginning to perform a medication pass for Resident 2. RN 2 stated she had been distracted with the needs of another resident and while rushing to prepare Resident 2 ' s medication, she mistakenly gave Resident 2 the wrong dose of methadone. RN 2 stated Resident 2 received 5 tablets of 5 mg methadone instead of 1 tablet of 5 mg methadone and only realized the error the following day when performing a narcotics count. During a review of Resident 2 ' s nursing progress notes titled, [Facility] Progress notes, dated 5/16/25, the progress notes indicated on 3/13/25, RN 2 wrote a progress note writer contacted [hospice] regarding medication administration error for methadone 5mg. Writer stated that they gave 5 tablets instead of 5 mg of methadone. The progress notes indicated on 3/12/25, RN 2 wrote a late entry change of condition note indicating Writer administered 5 tablets of methadone 5mg, instead of prescribed 1 tablet of methadone 5mg. During an interview on 5/16/25, at 9:33 a.m., with the Director of Nursing, the DON stated RN 2 was assisting another resident and was distracted when she prepared the medications. The DON stated distractions during medication preparation and administration can be a cause of medication errors, and there was no plan to address distractions during medication administration. A review of Resident 3 ' s admission record indicated Resident 3 was admitted in 2021 for diabetes, paraplegia (the loss of muscle function in the lower part of the body including both legs), muscle weakness and need for assistance with personal care. During a record review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had Brief Interview for Mental Status score of 15 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During a record review of Resident 3 ' s physicians order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 3 had an order for metoprolol (a medication to manage blood pressure) .tablet extended release 24 hour 100 mg. Give 1 tablet by mouth one time a day for [hypertension] and an order for diltiazem (a medication to manage blood pressure) .oral capsule extended release 12 hour 120mg. Give 1 capsule by mouth one time a day for [hypertension]. During a record review of Resident 3 ' s care plan titled Care plan Report, undated, the care plan indicated the resident is at risk for altered cardiovascular status .interventions: metoprolol succinate ER as ordered. Diltiazem as ordered. During a concurrent observation and interview on 5/16/25, at 10:40 a.m., LVN 3 was in Resident 3 ' s room performing a medication pass. LVN 3 stated Resident 3 had his medication pass performed late because there were 28 residents to pass medications for. LVN 3 stated they started their medication pass at 8:00 a.m. and needed to stop frequently to find a CNA when residents were asking for help. LVN 3 stated they would appreciate assistance with medication passes but didn ' t have anyone in the immediate area to call for. LVN 3 stated the nursing supervisor last checked in with her at 9:00 a.m. During an interview on 5/16/25, at 2:20 p.m., with Resident 3, Resident 3 stated he received his medications on 5/16/25, at around 10:30 a.m Resident 3 stated the day shift nurses usually gave his morning medications close to lunch. Resident 3 stated many nurses would give meds late and document the meds were given on time, and when he complained about the practice, the staff looked at the documentation and said the medications were given on time. Resident 3 stated the way his concern was dismissed by the facility caused him to consider about how he would rather be back in prison. A review of Resident 3 ' s medication administration record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated on 5/16/25, LVN 3 gave Resident 3: 1. eight medications at 10:40 a.m. with three medications scheduled to be given at 8:00 a.m. and five medications scheduled to be given at 9:00 a.m. 2. three medications at 10:48 a.m with one medication, diltiazem due at 8:00 a.m. and two medications including a metoprolol due at 9:00 a.m. A review of Resident 4 ' s admission record indicated Resident 4 was admitted to the facility in 2023 with femur (long bone in leg) fracture, pulmonary embolism (obstruction of blood vessels in the lungs causing loss of blood flow to lungs and heart), anemia (low blood), cognitive communication deficit and muscle weakness. During a record review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 had Brief Interview for Mental Status score of 1 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of zero to seven is an indication of severe impairment to cognitive status.) During a record review of Resident 4 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 4 had an order for apixaban oral tablet 2.5 mg Give 1 tablet .two times a day for Acute Pulmonary embolism which was dated 3/6/24. A review of Resident 4 ' s care plan titled, Care Plan Report, undated, indicated Resident 4 had a care plan which indicated resident is on anticoagulant apixaban r/t pulmonary embolism .administer anticoagulant medications as ordered by physician. During a concurrent interview and record review on 5/16/25, at 10:50 a.m., with RN 1, Resident 4 ' s medication administration record (MAR) was reviewed. RN 1 stated Resident 4 ' s medication administration for the morning was not completed yet. RN 1 stated Resident 4 had medications that needed to be given on time such as cardiac and anticoagulant medications. RN 1 stated he was late getting medications done because he had to attend to residents which a CNA could not assist with, such as preparing tube feeding setups and getting appointments confirmed for residents. RN 1 stated they had 25 residents to pass medications for and the majority of medications were due at 9:00 a.m. RN 1 stated there was one nursing supervisor for the long term care section of the facility. A review of Resident 4 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated on 5/16/25, RN 1 gave Resident 3: 1. seven medications at approximately 11:00 a.m. with two medications due at 8:00 a.m., four medications were due at 9:00 a.m. and one was due at 11:00 a.m., 2. three medications at approximately 11:15 a.m. which all three medications were due at 9:00 a.m. A review of Resident 5 ' s admission record indicated Resident 5 was admitted in 2020 with diagnoses of osteoporosis (condition characterized by weakened bone structure), chronic pain syndrome, anxiety, muscle weakness and need for assistance with personal care. During a record review of Resident 5 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 5 had orders for baclofen (medication to relax muscles) 10mg tab Give 1 tablet .for chronic pain, cymbalta (medication which can be used to manage pain symptoms) oral capsule 20 mg .Give 1 capsule .for chronic pain syndrome, gabapentin (medication to manage pain) oral tablet 600 mg .give 1 tablet .for neuropathic pain. During a record review of Resident 5 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/13/25, indicated Resident 5 received 13 medications at approximately 10:44 a.m. with six medications due at 9:00 a.m. which included cymbalta and gabapentin, and seven medications due at 8:00 a.m. which included Baclofen. During an interview on 5/16/25, at 11:30 a.m., with the Assistant Director of Nursing (ADON), the ADON stated they were acting as the nursing supervisor because there were no nursing supervisors hired by the facility. The ADON stated she tried to round on nurses every two hours but would expect nurses to ask for help with medication administration if needed. During an interview on 5/16/25, at 2:00 p.m., with the Director of Nursing (DON), the DON stated medication passes were expected to take 10-15 minutes per resident. The DON stated facility staffing of the nurses was not at her expected level. The DON stated medications needed to be given on time to maintain therapeutic effectiveness and was important for medications such as seizure medications, blood pressure medications and anti-coagulants. The DON stated they could not expect nursing staff to administer medications safely and effectively under 5 minutes while having to attend to resident needs. During a phone interview on 6/2/25, at 5:30 p.m., with pharmacy consultant (PC), the PC stated they had replaced the previous PC. The PC stated on the week of 3/13/25, they started to work at the facility and was given notes by the previous PC. The PC stated they were not aware of any medication errors made since they started in March. The PC stated the standards in administering levetiracetam was two doses a day to ensure stable levels of the medication throughout the day and give a dose more than 3.5 hours late was too late. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 01/2012, the P&P indicated the licensed nurse will prepare medications within one hour of administration. Medications may be administered one hour before or after the scheduled medication administration time .whenever a medication is held .the licensed nurse will document .the time and reason the medication was held .the licensed nurse will attempt to give the medication several times, but if the resident continues to refuse after one hour, the refused medication will be destroyed. The P&P further indicated nursing staff will keep in mind the seven rights of medication when administering medication .the right amount .the right time.

Based on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) were free from significant medication errors when Registered Nurse 2 (RN 2) administered a dose of methadone (a narcotic medication to control pain [narcotics are substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence]) five times higher than ordered by the provider to Resident 2, who had received narcotic medications before and after the medication error. This failure resulted in Resident 2 vomiting and placed Resident 2 at risk of narcotic overdose potentially leading to death. Findings: A review of Resident 2 ' s admission record indicated Resident 2 was admitted for acute heart failure (disease which causes reduced heart function), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and failure to thrive. During a record review of Resident 2 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 2 had an order for methadone oral tablet 5 mg (milligram, unit of measurement) give 5 mg by mouth two times a day for pain, dated 3/10/25, an order for hydromorphone (a narcotic medication, belonging to the same class of medications as methadone, for pain) oral liquid 1 mg/mL(unit of measurement of medication concentration) .give 1mL by mouth every 4 hours as needed, dated 3/10/25, and an order for hydromorphone oral liquid 1 mg/mL give 4 mL by mouth every 1 hour as needed for pain, dated 3/10/25. During a record review of Resident 2 ' s medication admission record (MAR) titled, [Facility] Medication Admin Audit Report, dated 5/16/25, the MAR indicated on 3/12/25, at 9:28 a.m., RN 2 gave Resident 2 methadone tablet 5 mg. The MAR indicated on 3/12/25, Resident 2 received one dose of hydromorphone oral liquid .give 1 ml by mouth at 6:38 a.m., one dose of hydromorphone oral liquid .give 4 mL by mouth at 12:26 p.m., and a dose of methadone tablet 5 mg at 4:06 p.m During a record review of Resident 2 ' s narcotics count sheet titled, Narcotics Count Sheet methadone 5 mg, dated 3/2025, the count sheet indicated five tablets of methadone was removed on 3/12/25 for the 9:28 a.m. medication pass and one tablet of methadone was removed on 3/12/25 for the 4:00 p.m. medication pass. During a phone interview on 5/14/25, at 2:30 p.m., with RN 2, RN 2 stated on 3/12/25, she was beginning to perform a medication pass for Resident 2. RN 2 stated she had been distracted with the needs of another resident and while rushing to prepare Resident 2 ' s medication, she mistakenly gave Resident 2 the wrong dose of methadone. RN 2 stated Resident 2 received 5 tablets of 5 mg methadone instead of 1 tablet of 5 mg methadone and only realized the error the following day when performing a narcotics count. RN 2 stated facility staff monitored Resident 2 for narcotics overdose once the medication error was discovered. During a review of Resident 2 ' s nursing progress notes titled, [Facility] Progress notes, dated 5/16/25, the progress notes indicated on 3/13/25, RN 2 wrote a progress note writer contacted [hospice] regarding medication administration error for methadone 5mg. Writer stated that they gave 5 tablets instead of 5 mg of methadone. The progress notes indicated on 3/12/25, RN 2 wrote a late entry change of condition note indicating Writer administered 5 tablets of methadone 5mg, instead of prescribed 1 tablet of methadone 5mg. The progress notes indicated on 3/13/25, RN 2 wrote a note indicating family of resident informed writer that resident was throwing up. Writer observed resident gagging. During a phone interview on 5/30/25, at 9:00 a.m., with resident representative (RP), the RP stated they were contacted by the facility on 3/13/25 about Resident 2 ' s medication error. When RP was with Resident 2, Resident 2 began to vomit while attempting to eat a sandwich. The RP stated Resident 2 appeared over-sedated when they were with Resident 2. During an interview on 5/16/25, at 9:33 a.m., with the Director of Nursing, the DON stated RN 2 was assisting another resident and was distracted when she prepared the medications for Resident 2. The DON stated the medication error should have been discovered during the narcotic count during the night of 3/12/25. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 01/2012, the P&P indicated nursing staff will keep in mind the seven rights of medication when administering medication .the right amount .the right time.

Based on observation, interview and record review, the facility failed to maintain proper storage of medications including controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when the medication room for the sub-acute area was left unlocked and a refrigerator containing an emergency kit (e-kit, kit containing doses of emergency medication) which contained one vial of lorazepam (a controlled medication which is used for sedation)] was also left unlocked. This failure to adequately secure medications had the potential for drug diversion and unauthorized access to medications. Findings: During an observation on 5/13/25, at 9:38 a.m., the medication room of the sub-acute area was inspected. The door was closed and had a number coded lock on the door. Without entering any code, the door could be opened. Inside the medication room was a refrigerator with an unlocked keyed padlock hanging on a hinge. Inside the refrigerator was an e-kit containing a vial of lorazepam. During a concurrent observation and interview on 5/13/25, at 9:38 a.m., with Nurse Supervisor 1 (NS 1), the medication room in the sub-acute area was examined. NS 1 stated e-kits were stored in a locked refrigerator in the medication room. NS 1 stated a mechanism which kept the door unlocked was engaged. NS 1 disengaged the mechanism and left the room with the refrigerator remaining unlocked. During an interview on 5/19/25, at 4:30 p.m., with the Director of Nursing (DON), the DON stated all medication rooms and medication storage needed to be locked at all times to prevent unauthorized access to medications. A review of facility policy and procedure (P&P) titled, Medication Storage in the Facility, dated 1/2025, indicated, the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized controlled medications are stored separately from other medications in a double locked compartment designated for that purpose.

Based on observation, interview and record review, the facility quality assurance committee failed to adequately and effectively implement the QAPI program when a QAPI project to reduce medication errors and prevent late medication administration was not fully implemented, did not adequately address the cause of late medication administration and errors, did not monitor and did not reassess or change the program interventions when medication errors and late medication administrations continued for five of eight sampled residents (Resident 1, 2, 3, 4 and 5) and potentially for all residents in the facility. This failure resulted in: 1. Licensed Vocational Nurse 1 (LVN 1) administering 12 medications late to Resident 1 which included a medication to manage seizures (episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) which had the potential to increase Resident 1 ' s risk of seizure, 2. Registered Nurse 2 (RN 2) administered a dose of methadone (medication to control pain) five times higher than ordered by the provider to Resident 2 which placed Resident 2 at risk of narcotic (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) overdose potentially leading to death, 3. Licensed Vocational Nurse 3 (LVN 3) administered 11 medications late to Resident 3 which included medications to control blood pressure and prevent blood clots which placed Resident 3 at risk of high blood pressure and formation of blood clots which could lead to death, 4. Registered Nurse 1 (RN 1) administered 10 medications late to Resident 4 which included a medication to prevent blood clots which placed Resident 4 at risk of formation of blood clot which could lead to death, and 5. LVN 1 administered 13 medications late to Resident 5 which included medications to manage pain which had the potential for Resident 5 to experience uncontrolled pain. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted for epilepsy (a brain disorder in which a person has repeated seizures over time), supraventricular tachycardia (condition which causes a high heart rate), muscle weakness and dysphagia (difficulty swallowing). During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 4/21/25, the MDS indicated Resident 1 had Brief Interview for Mental Status score of 11 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) During a record review of Resident 1 ' s physicians orders set titled, [Facility] Order Summary Report, dated 5/19/25, indicated Resident 1 did not have an order to self-administer medications and was not capable of making medical decisions. The physicians order set indicated Resident 1 had an order for levetiracetam (medication to prevent seizures) 500 mg 1 tablet twice a day for seizures. During a review of Resident 1 ' s care plan titled, Care Plan Report, undated, the care plan indicated Resident 1 had a care plan for alteration in neurological status related to seizure .give medications as ordered, dated 5/18/24. The care plan further indicated Resident1 had a care plan for altered cardiovascular status as supraventricular tachycardia .medication per MD order, dated 4/21/22. During a concurrent observation and interview on 5/13/25, at 9:30 a.m., with Resident 1, two medication cups with one cup containing a red liquid and a second cup containing 12 tablets were on Resident 1 ' s bedside table. One of the tablet medications was a large yellow oval tablet with E and 11 engraved on one side. Above Resident 1 ' s bed was a sign indicating seizure precautions encourage resident to eat, drink and medication. Resident 1 stated she was waiting for food to take her medications and no one had come in to help her take her medications. Resident 1 stated the pills had been on the table since the morning. During an observation of a medication pass on 5/13/25, at 10:07 a.m., with LVN 1, LVN 1 was performing a medication pass on Resident 5. Resident 5 received 13 medications with the medication pass finishing at 10:37 a.m., and LVN 1 continued to pass medications on another resident. During an observation on 5/13/25, at 11:12 a.m., in Resident 1 ' s room, the two medication cups were still on Resident 1 ' s bedside table. Resident 1 was asleep in bed with the bedside table positioned over her. Inside the medication cup were the same 12 medications. There were no staff in the room. During a concurrent observation and interview on 5/13/25, at 11:38 a.m., with LVN 1, LVN 1 was in Resident 1 ' s room giving Resident 1 the medications which were on the bedside table. LVN 1 stated they had placed Resident 1 ' s medications on the bedside table because Resident 1 was not ready to take the medications yet. LVN 1 stated Resident 1 did not have difficulty taking medications. An inspection of Resident 1 ' s medications in the medication cart indicated the yellow oval tablet with an E and 11 engraving was a levetiracetam 500 mg tablet. LVN 1 stated the levetiracetam tablet needed to be given on time to prevent seizures. LVN 1 stated they attempted to give Resident 1 their medications at 8:00 a.m., 8:30 a.m., and finally administered the levetiracetam tablet at 10:30 a.m. During a record review of Resident 1 ' s medication administration record (MAR), the MAR indicated Resident 1 ' s morning medications included 12 medications in tablet form. The MAR indicated portions of the 12 medications were given at various times with four medications given at 7:48 a.m, four medications given at around 9:32 a.m., and three medications given at around 10:05 a.m. The MAR indicated levetiracetam 500 mg tablet was given at 9:32 a.m The MAR did not indicate any of the 12 medications were given at around 11:38 a.m. A review of Resident 2 ' s admission record indicated Resident 2 was admitted for acute heart failure (disease which causes reduced heart function), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and failure to thrive. During a record review of Resident 2 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 2 had an order for methadone oral tablet 5 mg give 5 mg by mouth two times a day for pain, dated 3/10/25. During a record review of Resident 2 ' s medication admission record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, the record indicated on 3/12/25, at 9:28 a.m., RN 2 gave Resident 2 methadone tablet 5mg. During a record review of Resident 2 ' s narcotics count sheet titled, Narcotics Count Sheet methadone 5 mg, dated 3/2025, the count sheet indicated five tablets of methadone was removed on 3/12/25 for the 9:28 a.m. medication pass. During a record review of facility education documents titled, [Facilty] LN Meeting and Medication Pass – Tips, dated 3/11/25, the education document indicated RN 2 was educated on medication administration. The Medication Pass – Tips document indicated medications were given one hour before and one hour after the scheduled time for administration. During a phone interview on 5/14/25, at 2:30 p.m. with RN 2, RN 2 stated on 3/12/25, she was beginning to perform a medication pass for Resident 2. RN 2 stated she had been distracted with the needs of another resident and while rushing to prepare Resident 2 ' s medication, she mistakenly gave Resident 2 the wrong dose of methadone. RN 2 stated Resident 2 received 5 tablets of 5 mg methadone instead of 1 tablet of 5 mg methadone and only realized the error the following day when performing a narcotics count. During a review of Resident 2 ' s nursing progress notes titled [Facility] Progress notes, dated 5/16/25, the progress notes indicated on 3/13/25, RN 2 wrote a progress note writer contacted [hospice] regarding medication administration error for methadone 5mg. Writer stated that they gave 5 tablets instead of 5 mg of methadone. The progress notes indicated on 3/12/25, RN 2 wrote a late entry change of condition note indicating Writer administered 5 tablets of methadone 5mg, instead of prescribed 1 tablet of methadone 5mg. During an interview on 5/16/25, at 9:33 a.m., with the Director of Nursing, the DON stated RN 2 was assisting another resident and was distracted when she prepared the medications. The DON stated distractions during medication preparation and administration can be a cause of medication errors, and there was no plan to address distractions during medication administration. A review of Resident 3 ' s admission record indicated Resident 3 was admitted in 2021 for diabetes, paraplegia (the loss of muscle function in the lower part of the body including both legs), muscle weakness and need for assistance with personal care. During a record review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had Brief Interview for Mental Status score of 15 (a BIMS score of thirteen to fifteen is an indication of intact cognitive status). During a record review of Resident 3 ' s physicians order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 3 had an order for metoprolol (a medication to manage blood pressure) .tablet extended release 24 hour 100 mg. Give 1 tablet by mouth one time a day for [hypertension] and an order for diltiazem (a medication to manage blood pressure) .oral capsule extended release 12 hour 120mg. Give 1 capsule by mouth one time a day for [hypertension]. During a record review of Resident 3 ' s care plan titled, Care plan Report, undated, the care plan indicated the resident is at risk for altered cardiovascular status .interventions: metoprolol succinate ER as ordered. Diltiazem as ordered. During a concurrent observation and interview on 5/16/25, at 10:40 a.m., LVN 3 was in Resident 3 ' s room performing a medication pass. LVN 3 stated Resident 3 had his medication pass performed late because there were 28 residents to pass medications for. LVN 3 stated they started their medication pass at 8:00 a.m. and needed to stop frequently to find a CNA when residents were asking for help. LVN 3 stated they would appreciate assistance with medication passes but didn ' t have anyone in the immediate area to call for. LVN 3 stated the nursing supervisor last checked in with her at 9:00 a.m. During an interview on 5/16/25, at 2:20 p.m., with Resident 3, Resident 3 stated he received his medications on 5/16/25, at around 10:30 a.m Resident 3 stated the day shift nurses usually gave his morning medications close to lunch. Resident 3 stated many of the nurses would give meds late and document the meds were given on time, and when he complained about the practice, the staff looked at the documentation and said the medications were given on time. Resident 3 stated the way his concern was dismissed by the facility caused him to consider about how he would rather be back in prison. A review of Resident 3 ' s medication administration record titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated on 5/16/25, LVN 3 gave Resident 3: 1. eight medications at 10:40 a.m. with three medications scheduled to be given at 8:00 a.m. and five medications scheduled to be given at 9:00 a.m. 2. three medications at 10:48 a.m with one medication, diltiazem due at 8:00 a.m. and two medications including a metoprolol due at 9:00 a.m. A review of Resident 4 ' s admission record indicated Resident 4 was admitted to the facility in 2023 with femur (long bone in leg) fracture, pulmonary embolism (obstruction of blood vessels in the lungs causing loss of blood flow to lungs and heart), anemia (low blood), cognitive communication deficit and muscle weakness. During a record review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 had Brief Interview for Mental Status score of 1 (a BIMS score of zero to seven is an indication of severe impairment to cognitive status). During a record review of Resident 4 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 4 had an order for apixaban oral tablet 2.5 mg Give 1 tablet .two times a day for Acute Pulmonary embolism which was dated 3/6/24. A review of Resident 4 ' s care plan titled, Care Plan Report, undated, indicated Resident 4 had a care plan which indicated resident is on anticoagulant apixaban r/t pulmonary embolism .administer anticoagulant medications as ordered by physician. During a concurrent interview and record review on 5/16/25, at 10:50 a.m., with RN 1, Resident 4 ' s medication administration record (MAR) was reviewed. RN 1 stated Resident 4 ' s medication administration for the morning was not completed yet. RN 1 stated Resident 4 had medications that needed to be given on time such as cardiac and anticoagulant medications. RN 1 stated he was late getting medications done because he had to attend to residents which a CNA could not assist with, such as preparing tube feeding setups and getting appointments confirmed for residents. RN 1 stated they had 25 residents to pass medications for and the majority of medications were due at 9:00 a.m. RN 1 stated there was one nursing supervisor for the long term care section of the facility. A review of Resident 4 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/16/25, indicated on 5/16/25, RN 1 gave Resident 3: 1. seven medications at approximately 11:00 a.m. with two medications due at 8:00 a.m., four medications were due at 9:00 a.m. and one was due at 11:00 a.m., 2. three medications at approximately 11:15 a.m. which all three medications were due at 9:00 a.m. A review of Resident 5 ' s admission record indicated Resident 5 was admitted in 2020 with diagnoses of osteoporosis (condition characterized by weakened bone structure), chronic pain syndrome, anxiety, muscle weakness and need for assistance with personal care. During a record review of Resident 5 ' s physician order set titled, [Facility] Order Summary Report, dated 5/16/25, the order set indicated Resident 5 had orders for baclofen (medication to relax muscles) 10mg tab Give 1 tablet .for chronic pain, cymbalta (medication which can be used to manage pain symptoms) oral capsule 20 mg .Give 1 capsule .for chronic pain syndrome, gabapentin (medication to manage pain) oral tablet 600 mg .give 1 tablet .for neuropathic pain. During a record review of Resident 5 ' s MAR titled, [Facility] Medication Admin Audit Report, dated 5/13/25, indicated Resident 5 received 13 medications at approximately 10:44 a.m. with six medications due at 9:00 a.m. which included cymbalta and gabapentin, and seven medications due at 8:00 a.m. which included Baclofen. During a concurrent interview and record review on 5/16/25, at 2:30 p.m., with the DON, the facility medication administration QAPI program document titled, [DATE], dated 10/2024, was reviewed. The DON stated the facility had implemented a QAPI program to reduce medication errors and ensure medications were given on time. The document indicated licensed nurses lack education on medication administration policy and procedure. The DON stated they did not investigate whether distractions and staffing levels had an impact on medication error or late medication administration. The DON stated the identification of medication errors and late medication administration relied on the nurses to complete a Change of Condition documentation whenever a medication error or late medication administration occurred. The DON stated the QAPI plan indicated a pharmacy consultant would review Change of Condition documentations for medication errors and an education in-service on medication administration policy would occur and the relevant nurse would have medication passes supervised. The QAPI program document indicated The DON .conducted an audit of all medication orders of residents in SAU to ensure that medications are administered as ordered .will conduct a review of 5 resident medication administration records .in SAU weekly x 4 weeks then bimonthly for 2 months until substantial compliance is achieved to ensure medications are administered as ordered. The DON stated they did not perform checks of medication administration records or audit for additional residents potentially as outlined in the QAPI program. During a phone interview on 6/2/25, at 5:30 p.m., with pharmacy consultant (PC), the PC stated they had replaced the previous PC. The PC stated on the week of 3/13/25, they started to work at the facility and was given notes by the previous PC. The PC stated the notes instructed them to meet with the administrator to ensure they were included on the quarterly quality assurance (QA) meetings. The PC stated they did not attend the April quarterly QA meeting because they were not familiar with the facility. The PC stated they were not aware of any medication errors made since they started in March and was not aware of any QAPI plans regarding medication administration or medication errors. A review of facility policy and procedure titled, QAPI01 Quality Assurance and Performance Improvement (QAPI) Program, dated 6/4/24, indicated the facility implements and maintains an ongoing, facility-wide [QAPI] program designed to .pursue methods to improve quality of care, and resolve identified issues .the facility evaluates the effectiveness of its QAPI program .as needed .the QAPI committee evaluates .to help define issues, plan and implement actions, and ensure monitoring and follow-up.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment and care to maintain good foot health when Podiatry service was not provided after Resident 1's left great toenail came off due to fungal infection (disease caused by fungi). This failure had the potential to result in delayed treatment and further spread of fungal infection on Resident 1's toes. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in December 2022 with diagnoses that included bed confinement status, cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), dependence on respirator status, acute and chronic respiratory failure (condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). During a telephone interview on 1/16/24 at 11:33 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had fungal infection on the toes but had not been seen by a podiatrist (a doctor devoted to the study, diagnosis and treatment of disorders of the foot, ankle and lower limb). During a review of Resident 1's Order Summary Report as of 6/1/24 indicated a physician's order dated 12/28/22 for Resident 1 to have podiatry services as clinically indicated. The report also indicated the following physician orders; - observe avulsed right fifth toe for signs of bacterial infection every day and night shift, dated 1/9/24. - Social Services to arrange outpatient podiatry appointment and critical care transportation, dated 2/7/24. - cleanse avulsed (a toenail that has been partially or completely torn off) left third toe with normal saline, pat dry, apply triple antibiotic and cover with dressing every day and as needed, dated 2/8/24. During a review of Resident 1's Health Status Note dated 3/1/24, the Health Status Note indicated the podiatrist noted fungal infection on Resident 1's right third toe and removed the toenail exposing the nail bed with minimal bleeding. During a review of Progress Note dated 5/5/24, two months after Resident 1's right third toenail was removed due to fungal infection, the Progress Note indicated, during shower, Licensed Vocational Nurse (LVN) 1 noted a mycotic (fungal infection of the nail, mail appears thickened, discolored apperaing white, yeloow, black or green, breaks easily and may separate from the nail bed) nail on the shower bed, Resident 1's Left great toe [nail] is missing, left great toe [nail] avulsed, MD (doctor) made aware, gave order to monitor left great toe. During a telephone interview on 1/24/25 at 5:15 p.m. with LVN 1, LVN 1 stated, during shower on 5/5/24, she noted Resident 1's mycotic nail on the shower bed and noted Resident 1's left great toe was missing. LVN 1 stated she referred Resident 1 for a podiatry visit and had written her request in the Social Services binder. During an interview on 1/22/24 at 11:56 a.m. with Social Services Coordinator, SSC stated residents are seen by an in-house podiatrist (foot doctor who visits and treats residents at the facility) every 61 days. SSC stated if Resident 1 was seen on 3/1/24, the next podiatry visit should have been sometime around May 2024, but the podiatrist returned in July 2024. SSC also stated, if Resident 1 needed a podiatrist appointment sooner than 61 days, the licensed nurse may request for an outpatient visit and Social Services will assist with scheduling the appointment and transportation arrangement. During a review of Resident 1's clinical record, there was no documentation that indicated an outpatient podiatry appointment was arranged for Resident 1 as ordered by the physician on 2/7/24. During a telephoe interview on 1/29/25 at 11:36 a.m. with SSC, SSC stated she was not aware of the physician's order to refer Resident 1 to outpatient podiatry. SSC stated if she had known, she would have referred Resident 1 to another provider and not wait for the in-house podiatrist. During a follow-up telephone interview and concurrent record review on 1/24/25 at 11:57 a.m. with SSC, SSC's Social Services note dated 5/14/24 indicated FM 1 asked SSC what could be done to avoid having Resident 1's toes amputated, SSC told FM 1 podiatrist will see Resident 1 in June 2024 and will give recommendation about FM 1's concern then. SSC stated, Resident 1 was not seen in June 2024 as the podiatrist did not do any visits at the facility until 7/3/24. Resident 1 was transferred to the hospital on 6/29/24 and did not return to the facility. During a review of the facility's policy and procedure (P&P) titled Referrals to Outside Services last revised 12/1/13, the P&P indicated the Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts and referring residents to existing contracted providers. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician's order and referral to outside provider is documented in the resident's medical record. During a telephone interview with Medical Records Staff (MRS) 1 on 1/24/24 at 4:17 p.m., MRS stated there were no podiatry visit notes in Resident 1's medical record.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to develop and implement written policies and procedures that included re-training and re-education of a staff alleged of abuse/mistreatment before returning to work with residents. This failure had the potential to result in exposing vulnerable residents to abuse/mistreatment. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in December 2022 with diagnoses that included bed confinement status, cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), dependence on respirator status, acute and chronic respiratory failure (condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). During an interview on 1/22/25 at 10:30 a.m. with Administrator (Adm), Adm stated an allegation of mistreatment was reported to the facility on [DATE], and investigation was conducted. Admin stated Registered Nurse (RN) 1 was suspended for five days pending the result of the investigation. During an interview and concurrent review with Director of Staff Development (DSD), the facility's policy and procedure titled Abuse-Prevention, Screening & Training Program last revised July 2018 was reviewed. DSD stated after an employee is suspended for allegation of abuse/mistreatment of a resident and before resuming resident care, abuse prevention re-training should be completed by the employee. The facility's P&P indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on: prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property or mistreatment; identifying what constitutes abuse, neglect, exploitation misappropriation of resident property, or mistreatment; recognizing signs of abuse .and mistreatment; reporting abuse .mistreatment and injuries of unknown source . During a joint interview on 1/22/25 at 3:10 p.m. with Admin and Director of Nursing (DON), Admin stated abuse training for employees included having the employee watch the Department of Justice (DOJ) video on abuse prevention and having the employee sign the acknowledgment form indicating the training was completed. Admin stated RN 1 did not complete abuse training and did not sign an acknowledgment that abuse training was completed before returning to work. DON stated, the education provided to RN 1 was to have another staff with her when preparing residents for personal care or repositioning and was not focused on the nature of the allegation. Admin stated the allegation was reported and was investigated as abuse/mistreatment allegation.

Based on observations, interviews, record reviews, and facility policy reviews the facility failed to ensure infection control was maintained for nine residents (Resident (R)15, R19, R30, R81, R87, R92, R94, R99, and R109) out of a total sample of 46 residents. Specifically, the facility did not maintain a sanitary urinal for R109, did not maintain hand hygiene during incontinent care for R15, R30, R87, and R99; did not maintain proper PPE protocol infection for residents on enhanced barrier precautions (EBP) protocol for R19, R81, R92, and R94. These failures had the potential to result in infection and the spread of infection. Findings include: Review of the facility policy's titled, Personal Protective Equipment, revised on 01/01/12 stated, .When gowns are used, they are used only once and discarded into appropriate receptacles located in the room in which the procedure was performed .Hands are washed before and after the removing of gloves . Review of the facility policy titled Resident Isolation- Categories of Transmission-Based Precautions revised on 01/01/12 stated .Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions include, but are not limited to: .MRSA .gloves and handwashing .while caring for a resident, gloves are changed after having contact with infective material .gloves are removed before leaving the room and hands are washed immediately with an antimicrobial agent or a waterless antiseptic agent .The gown is removed and hand hygiene is performed before leaving the resident's environment . Review of the facility's policy and procedure titled Urinal and Bedpan - Offering and Removing with a revised date of 01/01/12 indicated, Policy: l. Assure the bedpan or urinal is clean before use. Procedure:.D. Remove the urinal or bedpan from the resident's bedside stand. Assure that it is clean and dry. l. Empty the bedpan/urinal into the commode. Flush the commode ,. Sanitize the bedpan/urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. store the bedpan or urinal; do not leave it in the bathroom or on the floor. Review of facility policy titled, ''Personal Protective Equipment,'' revised 01/01/12, revealed, ''To ensure the availability of personal protective equipment as required .Procedure .3. Protective clothing provided to our facility staff includes but is not necessarily limited to: A. Gowns .2. When gowns are used, they are used only once and discarded into appropriate receptacles located in the room in which the procedure was performed .B. Gloves .3. Gloves are used only once and are discarded into the appropriate receptacle located in the room in which the procedure is being performed. 4. Hands are washed before and after the removing of gloves.'' Review of facility policy titled, ''Enhanced Barrier Precautions,'' revised 07/05/24, revealed, '' .Process: 2. For residents for whom enhanced barrier precautions (EBP) are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of multidrug-resistant organisms (MDRO)s: b. Bathing/showering .h. Wound care: any skin opening requiring a dressing. 1. Per the Center for Disease Control and Prevention (CDC), this generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks, abrasions, or skin tears covered with a Band-aid or similar dressing. 2. Examples of chronic wounds include but are not limited to: 1. Pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers.'' Review of facility provided CDC Sign titled, ''Enhanced Barrier Precautions,'' undated, revealed, ''Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care: any skin opening requiring a dressing.'' 1. Review of R15's undated Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE] and readmission on 11/01/17. R15's primary diagnosis was chronic respiratory failure. Comorbidities included tracheostomy and gastrostomy tube status. Review of R15's Care Plan updated 04/23/24 and located in the EMR under the Care Plan tab included EBP due to tracheostomy and gastrostomy tube status.Maintain precautions by wearing appropriate PPE during resident care . Review of R15's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/29/24 located in the EMR under the MDS tab did not include a Brief Interview for Mental Status (BIMS) due to the resident not being able to participate. R15 was incontinent of bowel and bladder, had a feeding tube and tracheostomy. Review of R30's Physician Orders located in the EMR under the Orders tab did not include EBP status. During an observation on 08/08/24 at 7:48 PM Certified Nursing Assistants (CNA1 and CNA9) and Licensed Vocational Nurse (LVN5) performed hand hygiene, donned a mask, gown, and gloves prior to entering R15's room that had an EBP sign outside the door. The staff performed incontinent care but did not perform hand hygiene between glove changes and did not clean between the labia. During an interview on 08/08/24 at 8:15 PM with LVN5 confirmed that staff did not perform hand hygiene between glove changes or clean between the labia but should have. 2. Review of R30's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE] and readmission on 09/21/22. R30's primary diagnosis was chronic respiratory failure with hypoxia. Comorbidities included methicillin resistant staphylococcus aureus infection (MRSA), resistance to other specified betalactam antibiotics, tracheostomy and gastrostomy tube status. Review of R30's Care Plan updated 06/04/24 and located in the EMR under the Care Plan tab included contact precautions related to CRE (carbapenem-resistant enterobacterales) /KPC (klebsiella pneumoniae carbapenemase)/ CRAB (carbapenem-resistant acinetobacter baumannii) organisms.Maintain precautions by wearing appropriate PPE during resident care . Review of R30's quarterly MDS with an ARD of 06/02/24 located in the EMR under the MDS tab did not include a BIMS due to the resident not being able to participate. R15 was incontinent of bowel and bladder, had a feeding tube and tracheostomy requiring mechanical ventilation. Review of R30's Physician Orders located in the EMR under the Orders tab did not include contact precautions. During an observation on 08/08/24 at 8:05 PM, CNA1 and CNA9 performed hand hygiene, donned a mask, gown, and gloves prior to entering R30's room that had a Contact Precautions sign outside the door. The staff performed incontinent care but did not perform hand hygiene between glove changes. During an interview on 08/08/24 at 8:13PM with CNA1 and CNA9 confirmed that they had not performed hand hygiene between glove changes but should have. 3. Observation on 08/09/24 at 3:10 PM revealed CNA11 and CNA 8 were observed providing incontinent care to R87. After explaining the procedure to R87, CNA 11 donned a pair of gloves. CNA11 did not perform hand hygiene before donning the gloves. Further observation revealed, CNA8 donned a pair of gloves and did not perform hand hygiene before donning the gloves. CNA8 filled a basin with soapy water and dropped numerous wipes in the soapy water basin. CNA11 then proceeded to take a wipe from the soapy water basin and clean the top of (R)87's pubic area and with the same wipes cleaned the right side of the pubic area in a downward motion. CNA11 was then observed to clean the left side of the pubic area in a downward motion. CNA11 then spread the labia majora and with the same wipes and gloves wiped in a downward motion twice. With the same gloves, CNA11 then turned R87 on her right side. CNA8 was observed to clean fecal material from the resident's buttock cheeks and anal area without donning a clean pair of gloves and or performing hand hygiene. CNA8 then reached for a adult brief with the same soiled gloves and applied the adult brief to (R87). Still wearing the same gloves, CNA11 and CNA 8 were then observed to adjust the resident's gown and pull the bed sheet to the resident's chest. CNA 8 then reached for the residents blanket and placed it on the left side of the resident's face and shoulder. Interview with CNA11 and CNA8 immediately after the incontinent care procedure, on 08/09/24 at 3:10 PM CNA11 and CNA8 stated they should have washed their hands prior to the incontinent care and should have changed their gloves after cleaning the peri and buttock area. CNA11 stated that it was over a year since she has had hand hygiene training and CNA8 stated that she had had hand hygiene training three or four months ago. Review of the attendees for the lecture training for hand hygiene, enhanced barrier precautions and contact precautions, dated 06/07/24 revealed that CNA 11 and CNA8 were not in attendance for the hand hygiene, enhanced barrier precautions and contact precautions lecture. 4. Review of R92's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R92's primary diagnosis was cardiac arrest. Comorbidities included gastrostomy tube and tracheostomy requiring mechanical ventilation. Review of R92's Care Plan updated 04/24/24 and located in the EMR under the Care Plan tab included EBP due to tracheostomy and gastrostomy tube status and Contact Precautions for CRE/KPC.initiate appropriate isolation precautions .initiate isolation precautions per order .staff to follow standard precautions, including proper hand washing techniques to minimize microorganism transmission .maintain contact precautions when providing resident care . Review of R92's annual MDS with an ARD of 05/21/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. R92 was incontinent of bowel and bladder, had a feeding tube and tracheostomy requiring mechanical ventilation. Review of R92's Physician Orders located in the EMR under the Orders tab did not include EBP or Contact Precautions. During an observation 08/07/24 at 1:10 PM it was noted that R92 had an Enhanced Barrier Precautions sign outside his room. LVN4 was seen completing R92's care at the bedside while wearing a gown, mask, and gloves. LVN4 doffed her soiled gloves, exited the room and approached the medication cart outside the room. LVN4 applied hand sanitizer and kept on her gown as she exited the room. 5. Review of R94's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R94's primary diagnosis was nontraumatic intracranial hemorrhage. Comorbidities included gastrostomy tube and tracheostomy requiring mechanical ventilation. Review of R94's Care Plan located in the EMR under the Care Plan tab included ventilator and gastrostomy tube status but did not include enhanced barrier precautions.Initiate appropriate isolation precautions .use universal precautions as appropriate . Review of R94's annual MDS with an ARD of 05/28/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. R94 was incontinent of bowel and bladder, had a feeding tube and tracheostomy requiring mechanical ventilation. Review of R94's Physician Orders located in the EMR under the Orders tab did not include EBP or Contact Precautions. During an observation and interview 08/07/24 at 1:10 PM it was noted that R94 had an Enhanced Barrier Precautions sign outside his room. LVN4 was seen at R94's bedside taking a blood pressure while R94 was lying in bed. LVN4 was wearing a mask, gown, and gloves while at the bedside. LVN4 then doffed her gloves, did not perform hand sanitizing, and then approached the medication cart outside the bedroom while continuing to wear the exposed gown. During an interview at time of observation, 08/07/24 at 1:10 PM, LVN4 confirmed that R92 and R94 were on EBP for tracheostomy and gastrostomy tube status. LVN4 confirmed that she had not changed her gown between R92 and R94 stated that she forgot and that she thought it was okay to wear her gown outside of the room since she was only approaching the medication cart just outside the bedroom door. 6. Review of R99's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R99's primary diagnosis was acute and chronic respiratory failure. Comorbidities included gastrostomy tube and tracheostomy requiring mechanical ventilation. Review of R99's Care Plan updated 04/29/24 and located in the EMR under the Care Plan tab included EBP due to tracheostomy and gastrostomy tube status.Maintain precautions by wearing appropriate PPE during resident care .Observe proper precautions and PPE . Review of R99's quarterly MDS with an ARD of 07/10/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. R15 was incontinent of bowel and bladder, had a feeding tube and tracheostomy requiring mechanical ventilation. Review of R99's Physician Orders located in the EMR under the Orders tab did not include EBP status. During an observation on 08/08/24 at 8:05 PM CNA1, CNA9 and LVN5 performed hand hygiene, donned a mask, gown, and gloves prior to entering R99's room that had an EBP sign outside the door. The staff performed incontinent care but did not perform hand hygiene between glove changes and did not clean between the labia. During an interview on 08/08/24 at 8:15 PM with LVN5 confirmed that staff did not perform hand hygiene between glove changes or clean between the labia but should have. 7. Review of R109's Face Sheet located in the Profile tab of the EMR, revealed R109 was admitted to the facility on [DATE] with the following diagnoses: malignant melanoma of skin, unspecified, , reduced mobility need for assistance with personal care cognitive communication deficit, muscle weakness (generalized). Review of R109's Quarterly MDS with an ARD of 05/22/24, located in the resident's EMR under the MDS tab revealed a BIMS score of 11 out of 15 which indicated R109 was moderately impaired for decision-making. Review of R109's Quarterly MDS with an ARD of 05/22/24, located in the resident's EMR under the MDS tab revealed in Section H Bladder and Bowel R109, is occasionally incontinent of bladder. During an observation on 08/05/24 at 12:51 PM R109 showed this surveyor his urinal that was hanging from his bedside table. The urinal had a yellowish and brown substance sticking to the inside of the urinal on two sides. With consent from R109 this surveyor took pictures of the urinal. In an interview on 08/07/24 at 4:23 PM Licensed Vocational Nurse (LVN) 6 stated when emptying a urinal, it should be emptied in the resident's toilet, spray with a cleaner and rinse. This surveyor showed LVN 6 pictures of the urinal. LVN 6 stated, that is gross, in that case it should be replaced. In an interview on 08/07/24 at 4:26 PM Certified Nurse's Aide (CNA) 4 stated when emptying a urinal it should be emptied in the resident's toilet, cleaned with water, rinse, and put it back in the resident's room. This surveyor showed CNA 4 pictures of the urinal. CNA 4 stated the urinal should have been thrown away and replaced with a new urinal. CNA 4 also stated the urinal should not have been in use. In an interview on 08/07/24 at 4:40 PM the DON stated when emptying a urinal it should be emptied in the toilet, it should not be rinsed in the resident's bathroom sink, it should be rinsed in the utility room. This surveyor showed the DON pictures of the urinal. The DON stated the urinal should have been replaced. 8. During observation upon entering the facility on 08/05/24 at 9:10 AM, Certified Nursing Assistant (CNA) 1, came out of Room C into the hallway with person protective equipment (PPE) on to dispose of a washcloth into the soiled linen basket, and then went back into Room C. Interview with CNA1 on 08/05/24 at 9:28 AM, he confirmed that he should have taken off his PPE prior to leaving the room. 9. During observation on 08/05/24 at 10:46 AM, observed CNA2 come out of Room A, which was an enhanced barrier room and not sanitize her hands with two towels in her arms. CNA2 went into Room B, which was also on EBP; however, CNA2 did not sanitize her hands, nor did she don any PPE. At 10:50 AM, she was observed giving care to bed B without donning a gown. Interview with CNA2 on 08/05/24 at 11:35 AM, said that she did not know Room B was on EBP. Stated that she did not know why Room B was on these precautions and was unsure where she could get PPE, since there was none outside the door. Interview with the DON on 08/09/24 at 6:30 PM, confirmed that when a room is on enhanced barrier precautions, a sign and PPE should be outside the room door. The DON confirmed that hands must be sanitized before and after entering room, and PPE should be worn during care. The DON confirmed that PPE needs to be doffed prior to exiting room and no linen taken from one enhanced barrier precaution room to another.

Based on interview, observation, and facility policy review, the facility failed to ensure the two of two dumpsters located in a fenced area located behind the building was not propped open as well as failed to ensure there was no bagged trash or refuse loose on the ground in the dumpster area. These failures could lead to vermin gathering around the dumpsters and potentially entering the facility. Findings include: Review of the facility policy titled, Waste Management, last revised on 04/21/22 revealed the purpose was, To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable [sic] of all waste. The policy stated, . The Center's waste disposal system includes separate methods, for handling regulated, non-regulated and recycle waste. On 08/05/24 at 8:55 AM, the dumpster area was observed to have a several bags of trash on the ground, a stack of wooden pallets, broken down cardboard boxes, the blue dumpster was filled with items preventing the lid from closing properly, and the large green dumpster had one-half of the lid propped open by a white plastic pipe. On 08/06/24 at 8:55 AM, both dumpsters were observed open and broken-down cardboard boxes. During an interview on 08/07/24 at 12:20 PM, with the Dietary Supervisor about the dumpster area and she confirmed the area was not well maintained on the first two days of the survey. She stated garbage was picked later in the day on Monday and maintenance had cleaned up around the dumpsters. She confirmed the lid on the dumpster should be closed and not propped open by anything.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure side rails were used appropriately for three of four sampled residents (Resident (R)4, R30 and R99). This failure increased the risk for entrapment or injury for the three residents. Findings include: Review of the facility's policy titled Bed Rails revised 11/16/22, stated .A bed rail is an assistive device and must be used in accordance with the following regulations: a. Only permissible if they are used to treat a Resident's medical symptoms .d. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less restrictive methods have not been attempted or ruled out . 1. Review of R30's undated Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE] and readmission on 09/21/22. R30's primary diagnosis was chronic respiratory failure with hypoxia. Comorbidities included encephalopathy, contractures, and anoxic brain damage. Review of R30's Care Plan updated 01/23/24 and located in the EMR under the Care Plan tab included use of bedrails/bilateral grab bars as enabler for bed mobility, turning and repositioning. Review of R30's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/02/24 located in the EMR under the MDS tab did not include a Brief Interview for Mental Status (BIMS) due to the resident not being able to participate. Additionally, the resident was dependent on staff for rolling left and right. Review of R30's Order Review History Report located in the EMR under the Orders tab included bilateral half side rails for assistance with turning and repositioning, dated 01/23/24. Review of R30's Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab, indicated the resident was non-ambulatory, did not have a history of falls, had poor bed mobility, had not expressed a desire to have side rails/assist bars for safety and/or comfort, there were no side rail replacement recommendations, and side rails/assist bars were not indicated at that time. During an observation on 08/05/24 at 11:00 AM, R30 laying supine in her bed, bilateral wrists/hands contracted, looking at the ceiling, non-verbal and had bilateral half rails on her bed. During an interview on 08/09/24 at 4:48 PM with the Director of Nursing (DON) confirmed that R30 had bilateral upper extremity contractures, was unable to move her extremities independently, and unable to use bed rails. The DON confirmed that the side rails should not have been on the bed and that they needed to be removed. 2. Review of R53's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE] and readmission on 06/06/21. R53's primary diagnosis was respiratory failure. Comorbidities included persistent vegetative state and contracture of unspecified joint. Review of R53's Care Plan updated 01/23/24 and located in the EMR under the Care Plan tab included use of bedrails/bilateral grab bars as enabler for bed mobility, turning and repositioning. Review of R53's quarterly MDS with an ARD of 05/16/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. Review of R53's Order Review History Report located in the EMR under the Orders tab included bilateral grab bars as enabler for bed mobility and safety dated 01/23/24. Review of R53's Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab indicated the resident was non-ambulatory, did not have a history of falls, had poor bed mobility, had not expressed a desire to have side rails/assist bars for safety and/or comfort, bilateral side rail replacement recommendation, and side rails/assist bars were indicated to serve as an enabler to promote independence. During an observation on 08/05/24 at 10:56 AM, R53 was laying supine in his bed, bilateral wrists/hands contracted, non-verbal and had bilateral enabler bars on his bed. During an interview on 08/09/24 at 4:54 PM with the DON confirmed that R53 had bilateral upper extremity contractures, was unable to move his extremities independently, and unable to use enabler bars. The DON confirmed that enabler bars should not have been on the bed and that they needed to be removed. Review of R99's undated Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE]. R99's primary diagnosis was acute and chronic respiratory failure. Comorbidities included persistent vegetative state and anoxic brain damage. Review of R99's Care Plan updated 01/10/22 and located in the EMR under the Care Plan tab included use of quarter rails for safety during care provision, and to assist with bed mobility. Review of R99's quarterly MDS with an ARD of 07/10/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. Review of R99's Order Review History Report located in the EMR under the Orders tab included bilateral quarter siderails to aide in bed mobility and for safety dated 01/23/24. Review of R99's Bed Rail assessment dated [DATE] and located in the EMR under the Assessments tab indicated the resident was non-ambulatory, did not have a history of falls, had not expressed a desire to have side rails/assist bars for safety and/or comfort, there were no side rail replacement recommendations, and side rails/assist bars were indicated to serve as an enabler to promote independence. During an observation on 08/05/24 at 1:08 PM, R99 was laying supine in her bed, bilateral wrists/hands contracted, non-verbal and had bilateral quarter side rails on her bed. During an interview on 08/09/24 at 4:41 PM with the DON confirmed that R99 had bilateral upper extremity contractures, was unable to move her extremities independently, and unable to use side rails. The DON confirmed that the side rails should not have been on the bed and that they needed to be removed.

Based on observations, interviews, record reviews, and facility policy reviews the facility failed to provide administration of medication according to physician orders for nine of nine residents (Resident (R)16, R29, R33, R37, R38, R44, R45, R73 and R90) reviewed for medication administration. Specifically, the facility failed to properly document medication administration, failed to administer medication to one resident (R16), and failed to administer medications on time to eight of nine residents reviewed for medication administration (R29, R33, R37, R38, R44, R45, R73, and R90). These failures had the potential to result in decreased therapeutic results of the medications prescribed for the effected residents. Findings include: Review of the facility policy titled, Medication-Administration, revised 01/01/12 stated .Medications may be administered one hour before and after the scheduled medication administration time .The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment . Review of the facility policy titled, Medication-Errors revised 07/2018, stated, .All errors related to the administration of medications or treatments will be reported to the Director of Nursing Services, the attending physician, and the Administrator immediately .Medication Error means the administration of medication: .at the wrong time The Director of Nursing Services or his/her designee will investigate the error to determine the cause . 1. Review of R16's undated Admission Record, located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE]. R16's primary diagnosis was end-stage renal disease. Comorbidities included epilepsy, peripheral vascular disease, and glaucoma. Review of R16's Clinical Physician Orders located in the EMR under the Orders tab included aspirin EC (enteric coated) low strength tablet delayed release 81mg (milligrams) one tablet by mouth (PO) once daily (QD) for stroke prevention, folic acid 1mg one tablet PO QD for supplement, levetiracetam 1000mg one tablet in the morning PO for seizure prevention, vitamin C 500mg one tablet PO QD for supplement, vitamin D3 25 mcg two tablets PO QD for supplement, and refresh tears solution instill one drop in both eyes (OU) two times a day (BID) for dry eyes. Review of R16's Medication Administration Record (MAR) revealed he did not receive aspirin EC 81 mg tablet, folic acid 1mg tablet, levetiracetam 1000mg tablet, vitamin C 500mg tablet, vitamin D3 25 mcg 2 tablets, and refresh tears eye drops on 08/06/24 for the morning dose as evidenced by blank MAR documentation. Aspirin EC, folic acid, levetiracetam, vitamin C, and vitamin D3 were due for administration at 7:30 AM and amlodipine scheduled time on the MAR was for 9:00 AM. During an interview on 08/06/24 at 1:56 PM with Registered Nurse (RN1) confirmed that R16 had not received her morning medication due to the medication pass for R16's hall was very heavy. During an interview on 08/06/24 at 2:00 PM with R16, R16 stated she didn't know why she hadn't received her morning medications. 2. Review of R29's undated Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE] and readmission on 08/23/19. R29's primary diagnosis was seizures. Comorbidities included major depressive disorder. Review of R29's Physician Orders located in the EMR under the Orders tab included orders dated: 01/14/23 bupropion HCl (hydrochloride) ER (extended release) 24 hour 300 mg tablet, give one tablet PO every morning (Q AM) for depression; 04/06/24 ascorbic acid 500 mg tablet, give one tablet PO QD for wound healing; 03/07/24 sertraline HCl 100 mg tablet, give one tablet PO Q AM for depression; 09/30/23 magnesium 400 mg tablet, give one tablet PO QD for supplement; 12/31/22 glycolax powder, give 17 grams PO QD for constipation; 08/06/22 docusate sodium 250 mg tablet, give one capsule PO BID for bowel regularity; 01/13/23 levetiracetam 750 mg tablet, give one tablet PO BID for seizure prevention; and 09/30/23 vitamin D3 1000 units , give one tablet PO QD for supplement. Review of R29's MAR, dated 08/06/24, revealed RN1 documented that she administered glycolax powder, bupropion hydrochloride (HCl) extended release (ER), ascorbic acid, magnesium, sertraline HCl, vitamin D3, docusate sodium, and levetiracetam, however, the resident refused all medications on 08/06/24 at 2:16 PM. Glycolax, bupropion HCl, ascorbic acid, magnesium, sertraline HCl, vitamin D3, docusate sodium, and levetiracetam were listed for 9:00 AM administration daily. During an observation and interview on 08/06/24 at 2:16 PM, Registered Nurse (RN1) did not offer R29 9:00AM medications until 2:16 PM. The resident refused medications at that time. RN1 did not give a reason as to why documentation indicated R29 accepted the medication. 3. Review of R33's Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R33's primary diagnosis was respiratory failure. Comorbidities included chronic obstructive pulmonary disease (COPD), stroke, schizoaffective disorder, benign prostatic hyperplasic, anemia, and gastro-esophageal reflux disease. Review of R33's Physician Orders located in the EMR under the Orders tab included orders, dated 01/06/24, albuterol sulfate HFA (hydrofluoroalkane) inhalation aerosol solution 108 mcg (micrograms)/act (actuation) two puff via tracheostomy four times a day (QID) for COPD, 12/21/23 finasteride 5mg tablet, give one tablet PO QD for BPH (benign prostatic hyperplasia), 12/04/23 docusate sodium 100mg tablets, give 2.5 tablets by mouth (PO), once a day (QD), for constipation, and 02/08/24 glycopyrrolate 1 mg tablet, give one tablet PO, BID for excessive secretions. Review of R33's MAR revealed R33 received the following medications late for August 2024: Albuterol sulfate on 08/05/24 due at 8:00 PM was not administered until 10:34 PM. Albuterol sulfate on 08/06/24 due at 8:00 PM was not administered until 10:29 PM. During an observation and interview on 08/07/24 at 11:18 AM Licensed Vocational Nurse (LVN1) did not offer R33 his 8:00AM medications (finasteride 5 mg, glycopyrrolate 1 (one) mg, vitamin D 25 mcg until 11:26 AM. LVN1 stated she was running behind due to having a lot of residents to pass medications to on this hall this 4. Review of R38's Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE] and readmission on 11/10/17. R38's primary diagnosis was chronic respiratory failure with hypoxia. Review of R38's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/19/24 located in the EMR under the MDS tab did not include a BIMS due to inability to participate. Review of R38's Physician Orders located in the EMR under the Orders tab included orders dated 01/10/22 lorazapam 0.5 mg give one tablet via G-tube TID for anxiety. Review of R38's MAR revealed he did not receive lorazepam 0.5 mg on 08/06/24 at 12:00PM as evidenced by blank MAR documentation. Review of R38's MAR revealed R38 received the following medications were late for August 2024: Lorazepam 0.5 mg tablet on 08/04/24 due at 5:00 PM was not administered until 6:55 PM. 5. Review of R44's Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE] and readmission on 07/06/21. R44's primary diagnosis was end stage renal disease. Comorbidities included hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. Review of R44's Physician Orders located in the EMR under the Orders tab included orders, dated 07/10/23, losartan potassium 50mg tablet, give one tablet PO at HS for hypertension; 02/01/23, diltiazem CD (controlled delivery) ER 120 mg capsule, give one capsule PO every evening for hypertension; and 01/15/23 furosemide 80 mg tablet, give one tablet PO every Monday, Wednesday, Friday and Sunday for fluid retention. Review of R44's MAR revealed R44 received the following medications were administered late in July 2024: Diltiazem CD ER 120mg on 07/01/24 due at 5:00 PM was not administered until 7:02 PM. Furosemide 80 mg on 07/29/24 due at 9:00 AM was not administered until 10:53 AM. 6. Review of R45's Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R45's primary diagnosis was encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Review of R45's Physician Orders located in the EMR under the Orders tab included orders, dated 07/11/24, metoprolol tartrate 25 mg, give 0.5 tablet PO BID for hypertension; 07/10/24 insulin lispro injection solution 100 units/ml, inject as per sliding scale (blood sugar: 70-150= zero units, 151-200= 3 units, 201-250= six units, 251-300= 9 units, 301-350=12 units, 351-400=15 units with meals for diabetes mellitus; 07/10/24 clonidine HCl 0.1 mg, give 1 tablet PO at bedtime for hypertension; 07/10/24 insulin glargine subcutaneous solution, inject 20 units subcutaneously at bedtime for diabetes mellitus; 07/10/24 amlodipine besylate 10 mg, give one tablet PO at bedtime for hypertension. Review of R45's MAR revealed she received the following critical medications late for August 2024: Insulin glargine 20 units on 08/04/24 due at 9:00 PM was not administered until 11:05 PM. Clonidine HCl 0.1mg on 08/04/24 due at 9:00 PM was not administered until 11:05 PM. Amlodipine besylate 10mg on 08/04/24 due at 9:00 PM was not administered until 11:05 PM. 7. Review of R73's Admission Record located in the EMR under the Resident tab revealed an original admitted [DATE]. R73's primary diagnosis was degenerative disease of the nervous system. Review of R73's Physician Orders located in the EMR under the Orders tab included 07/25/23 amlodipine besylate 10 mg, give one tablet PO QD for hypertension, 08/05/24 hydralazine HCl 50 mg, give one tablet PO QD for hypertension, 01/26/24 metoprolol succinate ER 100 mg, give one tablet PO QD for hypertension, 07/25/23 isosorbide mononitrate ER 60 mg, give one tablet PO QD for hypertension, 07/28/23 methadone HCl Oral Solution 10 mg/5 ml, give 50 mg PO QD for pain. Review of R73's MAR revealed she received the following medications were administered late for August 2024: Hydralazine HCl 50mg on 08/02/24 due at 4:00 PM was not administered until 5:53 PM. Amlodipine besylate 10 mg on 08/06/24 24 due at 8:00 AM was not administered until 11:21 AM. Hydralazine HCl 50 mg on 08/06/24 24 due at 8:00 AM was not administered until 11:21 AM. Metoprolol succinate ER 100 mg on 08/06/24 24 due at 8:00 AM was not administered until 11:23 AM. During an observation and interview on 08/06/24 at 10:34 AM R73 was yelling out for a staff member. This surveyor approached the resident who then reported she had not received her morning medications. During an interview on 08/06/24 at 10:40AM with RN 1, RN 1 stated R73's medications were late due to RN 1 being busy. 8. Review of R90's Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE]. R90's primary diagnosis was adjustment disorder with anxiety. Comorbidities included hypertension. Review of R90's MAR revealed she received the following critical medications late for August 2024: Levetiracetam 250 mg on 08/01/24 due at 8:00 AM was not administered until 5:36 PM. Gabapentin 300 mg on 08/01/24 due at 8:00 AM was not administered until 5:36 PM. Gabapentin 300 mg on 08/01/24 due at 12:00 PM was not administered until 5:39 PM. Gabapentin 300 mg on 08/02/24 due at 12:00 PM was not administered until 2:47 PM. During an interview on 08/07/24 at 10:14 AM R90 reported she does not always get her seizure or blood pressure medications. During an interview on 08/08/24 at 12:36 PM with the Medical Director stated it was his expectation for medications to be administered within two hours before to two hours after the designated time. He was made aware of medications not being administered in a timely manner from time to time, but he was not aware of this being a current problem. At times the nurses have called him to verify that it was okay to give medications late or at a different time but the nurses should notify him with any late or missed medications. During an interview on 08/08/24 at 1:26 PM with the Pharmacist confirmed that the DON had previously notified him that the facility had timeliness of medication administration in the issues in the past, but the Pharmacist was not sure if this continued to be an issue. The Pharmacist's expectation was for the medications to be given half an hour before to half an hour after the designated time. The goal was to have medications given on a consistent basis. During an interview on 08/09/24 at 5:53 PM with Licensed Vocational Nurse (LVN) 7 stated if medications are not documented as administered, then it wasn't done. Also, if the nurse didn't administer the medication, then they should document why not administered and notify the physician. Medications may be given up to an hour before or an hour after the listed time on the MAR. LVN7 confirmed that the physician should be notified when medications are administered late. During an interview on 08/09/24 at 5:53 PM with LVN3 stated if medications are not documented as administered, then it wasn't done. Also, if the nurse didn't administer the medication, then they should document why not administered and notify the physician. Medications may be given up to an hour before or an hour after the listed time on the MAR. LVN7 confirmed that the physician should be notified when medications are administered late. During an interview on 08/09/24 at 6:26 PM with the Administrator confirmed that medication reviews and medication documentation were reviewed during the monthly quality assurance and performance improvement meetings (QAPI). She did not indicate that late administration of medications was currently a concern. During an interview on 08/09/24 at 6:50 PM with the DON confirmed that nurses should be administering medications within one hour of the ordered time, one hour before to one hour after the time on the MAR. Additionally, if a resident refused a medication the nurse should reattempt to administer the medication, and if still unsuccessful should notify the physician.

Based on observations, interviews, record review, and policy review, the facility failed to ensure that three of three residents (Resident (R) 21, 77, and 89) reviewed for dignity out of a sample of 47 residents, did not have signs hanging above bed with medical information on them. Findings include: Review of facility policy titled, ''Resident Rights-Quality of Life,'' revised 03/2017, revealed ''To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, consistent with the resident's comprehensive assessment and plan of care. Procedure: .Facility staff treats cognitively impaired residents with dignity and sensitivity.'' 1. Review of R21's ''Admission Record,'' located under tab ''Profile'' in the electronic medical record (EMR) indicated that R21 was readmitted to the facility with a diagnosis of cerebral palsy (CP), and malignant neoplasm of prostate. During observation on 08/05/24 at 12:35 PM, there was a sign on R21's overbed light that read '' [R21 Room number] A is a FEEDER!! Diet: pureed, nectar thick liquid. R21 eats cheerios cereal each meal-pour milk in bowl. He can tolerate unsure? Ask charge nurse!'' Review of quarterly ''Minimum Data Set (MDS)'' assessment, located under the tab ''MDS'' with ''Assessment Reference Date (ARD)'' of 06/14/24 indicated that R21's upper and lower extremities had impairment on both sides, and R21 was dependent on staff for eating. The ''Brief Interview of Mental Status (BIMS)'' was 15 out of 15 making R21 cognitively intact; however, during tour of the facility, R21 was alert yet disorganized. During further observations on 08/06/24 at 9:30 a.m., and 3:00 p.m., revealed that the sign was hanging above R21's bed. In addition, on 08/07/24 at 10:29 a.m., the sign was there. At 10:29 a.m., on 08/08/24, the sign was hanging above R21's bed. 2. Review of R77's ''Admission Record,'' located under tab ''Profile'' indicated that R77 was readmitted to the facility on [DATE] with a diagnosis of nontraumatic intracranial hemorrhage and cognitive communication deficit. During observation on 08/05/24 at 12:35 p.m., observed a sign on the overbed light that indicated ''[R77 Room Number] B -Is a FEEDER!! He takes his time chewing!! Diet: mechanical soft, thin liquid. Aspiration precautions. He has supplement shakes in cabinet if he does not eat at least 50%. Ask charge nurse if you need more information!'' Further observation, on R77's corkboard over nightstand had a sign that indicated ''*[Resident Room Number] B*Alert* Seizure Precautions.'' In addition, observed signs on 08/06/24 at 10:41 a.m., 08/07/24 at 9:30 a.m., and 3:00 p.m. At 08/08/24 at 10:29 a.m., observed signs above R771's nightstand and bed. Review of quarterly ''MDS'' assessment with ''ARD'' of 06/21/24, located under the EMR's tab ''MDS'' indicated R77 was dependent on staff for eating and had upper extremity impairment on both sides. The BIMS was zero out of 15, making R77 severely impaired. 3. Review of R89's ''Admission Record,'' located under the ''Profile'' tab in the EMR indicated that he was readmitted to the facility on [DATE] with a traumatic brain injury (TBI), and schizophrenia. During observation on 08/05/24 at 11:58 a.m., observed three signs hanging on the wall above R89's bed. The first sign which was observed on the left side indicated ''Resident is a Feeder!! *Fall risk* Bed at lowest setting. See nurse for information.'' The second sign was observed in the center indicated ''Seizure Precautions. *Alert. *'' The third sign on the right side indicated ''R89 is Aspiration Precautions!! Diet: Pureed, thicken liquids. Keep resident not less than 30 degrees.'' In addition, the three signs were observed on 08/06/24 at 10:43 a.m., 08/07/24 at 9:40 a.m., and 3:10 p.m. Review of R89's quarterly ''MDS'' assessment with ''ARD'' of 05/07/24, located under tab ''MDS'' in the EMR indicated that R89 was dependent on staff for eating. The BIMS was 13 out of 15 making R89 cognitively intact, and interviewable. Interview with the Director of Nursing (DON) on 08/08/24 at 12:25 p.m., confirmed that these signs should not be up. DON Stated that this information should be covered and/or applied to the Kardex.

40824 Based on observations, interviews, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medication assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 44 and R73) reviewed for self-administration of medications. This failure to assess and care plan residents for self-administration of medications increases the potential risk of medication errors for residents. Findings include: Review of facility's policy titled, ''Medication-Self Administration,'' revised 01/01/12, revealed, ''To provide residents with the opportunity to self-administer medications when determined they are capable to do so by the attending physician and the Interdisciplinary team (IDT). Procedure: . 3. For a final determination of the resident's ability to self-administer medications, the Assessment for Self-Administration of Medications will be presented to the resident's attending physician. A. The resident may not begin self-administration of medications prior to the approval of the IDT and attending physician. i. The attending physician must provide a written order permitting the residents to self-administer medication. B. If the IDT and attending physician do not approve self-administration of medications, the resident or their representative will be informed, and the reason will be documented in the medical record. C. If the IDT team and attending physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident. i. Controlled drugs (i.e. narcotics, hypnotics, etc.) are not to be left for open access to the resident . 7. Documentation A. The physician's order approving the self-administration of medication will be maintained in the resident's medical record. B. The assessment for self-administration of medications will be maintained in the resident's chart. C. Self-administration of medications will be documented in the resident's care plan and the medication administration record.'' 1. Review of R73's ''Admission Record,'' located under the tab ''Profile'' in the electronic medical record (EMR) indicated that R73 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the R73's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/24, located under the MDS tab of the EMR revealed the resident had a Brief Interview for Mental Status score of 15 out of 15 meaning the resident is cognitively intact. During a concurrent observation and interview on 08/05/24 at 10:00 a.m., with R73, a red albuterol sulfate hydrofluoroalkane (HFA) inhaler was observed upside down in a clear cup on her overbed table. R73 stated that this inhaler was the one she used at home as needed (PRN). During a concurrent observation and interview on 08/06/24 at 10:35 a.m. with R73, R73's albuterol sulfate HFA inhaler lying on her overbed table. Interview with Registered Nurse (RN)1 at 10:36 a.m., confirmed that R73 had inhaler in her room and that R73 does not have a physician's order to keep the inhaler. During an observation on 08/06/24 at 10:35 AM, R73's inhaler from home was laying on the overbed table. Review of R73's ''Physician's Orders,'' dated August 2024, located under the tab ''Orders'' in the EMR indicated no evidence to self-administer medication and/or an order for the inhaler. Review of the ''Assessment'' tab in the EMR indicated no evidence of a self-administration of medication assessment. Review of the ''Care Plan'' tab in the EMR indicated no evidence of a care plan developed for self-administration of medication. During an interview on 08/07/24 at 2:25 p.m., with the Director of Nursing (DON), DON confirmed that residents should not have medications at bedside unless the resident has been assessed, has a physician order, care plan developed for self-administration of medication and a way to lock up the medication. Confirmed that R73 does not have any of these. 2. Review of R44's Admission Record located in the electronic medical record (EMR) under the Resident tab revealed an original admitted [DATE] and readmission on 07/06/21. R44's primary diagnosis was end stage renal disease. Review of R44's Care Plan revised 07/26/24 and located in the EMR under the Care Plan tab did not include self-administration of medications. Review of R44's annual MDS) with an ARD of 05/29/24 located in the EMR under the MDS tab included a BIMS score of 15 out of 15, indicated she was cognitively intact. Review of R44's Physician Orders, located in the EMR under the Orders tab included an order. dated 07/02/24, for sevelamer carbonate oral tablet 800 mg (milligrams), give two tablets by mouth with meals. Review of R44's Assessment tab in the EMR, did not include a Self-Administration of Medication assessment. During an observation and interview on 08/05/24 at 11:23 a.m., with R44, R44 had a medication cup on her over the bed table with two white tablets in it. R44 stated the agency nurses don't trust her, but the nurses that had been there a while and knew her are okay leaving medications at the bed side. R44 was unable to state whether she had a Self-Administration of Medication assessment. During an interview on 08/05/24 at 11:39 a.m., with Licensed Vocational Nurse (LVN) 7, LVN7 confirmed that she had administered R44's sevelamer carbonate oral tablet 800 mg tablets and left them on R44's bedside table. LVN7 stated that R44 was very particular and preferred to take her pills with her meals, so she leaves them there for her and goes back after lunch to make sure she had taken them. LVN7 confirmed that R44 had not had a Self-Administration of Medication assessment. During an interview on 08/05/24 at 12:17 p.m., with DON, DON confirmed that R44 did not have a Self-Administration of Medication assessment but should have if medications were going to be left at the bedside.

Based on observation, interview, record review, and policy review, the facility failed to provide privacy during care in the resident's room for one of 45 sampled residents (Residents (R) 108). This failure could potentially have a negative impact on the quality of life for the affected resident. Findings include: Review of R108's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed R30 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, moderate protein-calorie malnutrition, Alzheimer's disease, unspecified disorder involving the immune mechanism, unspecified, essential (primary) hypertension difficulty in walking, Review of R108's Quarterly, MDS with an ARD of 6/17/24 located in the resident's EMR under the MDS tab revealed a BIMS score of eight out of 15 which indicated R108 was moderately impaired for decision-making. During an observation on 08/05/24 at 11:39 a.m., with Certified Nurse Aide (CNA) 5, CNA 5 was providing care to R108 with the door open. R108 was in a three-person room with R108 in the middle bed. The privacy curtain was drawn on each side of R108's bed. While this surveyor was standing outside of R108's room, R108's legs were visible while CNA5 performed peri care (washing the genitals and anal area) on R108. In an interview on 08/05/24 11:45 a.m., with CNA5, CNA 5 stated a resident's room does not have to be closed while doing care with a resident if the curtains are drawn. In an interview on 08/05/24 at 11:52 a.m., the Regional Quality Management Consultant (RQMC) stated best practice is to close a resident's door while providing resident care and ask other residents in the room if it is okay to close the door. In an interview on 08/05/24 at 12:11 p.m., CNA6 stated resident doors should be closed and curtains drawn when doing peri care, not unless resident or residents state keep the door open. In an interview on 08/09/24 at 4:06 p.m., the Director of Nurses stated her expectation while staff are providing peri care is to have the curtains drawn all the way around the bed or close the door. Record review of the facility's policy and procedure titled, Resident's Rights with a revised date of 01/01/12, indicated, l. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: D. Privacy and confidentiality.

Based on observations and interviews, the facility failed to maintain air conditioning filters for one of four residential units. This failure had the potential to negatively affect the respiratory system of 21 residents residing on the subacute unit, 11 of 21 residents were on ventilators. Findings include: Review of the facility's policy titled, Heating and Air Conditioning System Inspection revised on 01/01/12 indicated the purpose of the policy was To protect the health and safety of residents, visitors, and Facility Staff .Inspections are the responsibility of the Maintenance Department . During an observation on 08/07/24 at 1:00 p.m., the portable air conditioner at the end of the subacute resident hall had three filters with a thick, gray film caked on all three filters. During an interview on 08/07/24 at 1:48 p.m., with the Maintenance Supervisor, Maintenance Supervisor stated maintenance was responsible for maintaining and cleaning the portable air conditioner. He stated they last cleaned the filters in July 2024 and after looking at the filters today they need to be done again. When asked if they kept a log or had a system to assist with tracking items needing regular maintenance, he stated he did not.

Based on interview and record review, the facility failed to ensure one (Resident 1) of three residents received services to maintain good foot health when Resident 1 did not receive podiatry services for one year. The facility failed to obtain podiatry services which resulted in excessive toenail growth which resulted in a wound on the great right toe when the nails were trimmed. The wound on the right great toe developed a severe infection progressing to osteomyelitis (bone infection) and required hospitalization and antibiotic treatments. Findings: During a review of Resident 1's Admission Record, undated, the Admission Record indicated the facility admitted Resident 1 in 2016 with diagnoses which included dependency on a ventilator (breathing machine) due to respiratory failure, tracheostomy (artificial opening in the airway to facilitate breathing), inability to swallow correctly requiring feedings via a gastrostomy tube (GT, a surgically created opening through the abdomen to the stomach for direct administration of food, fluids, and medications), anoxic brain damage (brain damage as the result of lack of adequate oxygen to the brain cells), and generalized muscle weakness. The Admission Record indicated RP 1 had Durable Power of Attorney for healthcare decisions (the legal right and authority to make healthcare decisions for another person). During review of Physician's Progress Notes, dated 8/26/21, the Physician's Progress Notes indicated the podiatrist documented, patient has severely thick toenails no ulcers . nails trimmed and debrided. During review of Physician's Progress Notes, dated 9/1/22, by Podiatrist 1 (POD 1) the Physician's Progress Notes indicated, Saw pt (patient) for foot care and noticed bleeding from end of 1st R (right) toe .superficial size about 2.0 centimeters (cm) deeper area bleeding abt (about) 0.5 cm .long toenails .ulcer 1st R toe (with) some swelling/long toenails .nails trimmed and debrided ordered wound care and antibiotics will see about one week for follow up. During a telephone interview on 10/28/22, at 4:30 p.m., with RP 1, RP 1 stated during a telephone conversation on 9/1/22 at 5 p.m., Licensed Vocational Nurse 1 (LVN 1) said the podiatrist had been to visit Resident 1, and that after the visit LVN 1 saw bleeding and a wound on Resident 1 ' s big toe; RP 1 went that evening to the facility to check Resident 1 ' s toe. RP 1 stated Resident 1 ' s right big toe had a visible hole and the toe looked mauled. During an interview on 10/31/22, at 1:30 p.m., with LVN 1, LVN 1 stated on 9/1/22, the podiatrist (POD 1) came to the facility and treated Resident 1. LVN 1 stated after the podiatrist had treated Resident 1, LVN 1 had gone into Resident 1 ' s room and noticed the bed linen was bloody at the foot of the bed. LVN 1 stated upon checking Resident 1 ' s foot, LVN 1 saw a bleeding wound which appeared to be a hole on the end of Resident 1 ' s big toe. LVN 1 stated LVN 1 had called Resident 1 ' s primary care physician (PHY 1), and family member (RP 1) to notify them about the new wound on Resident 1 ' s big toe. During an interview on 10/31/22, at 4 p.m., with POD 1, POD 1 stated he had noticed the end of Resident 1 ' s big toe bleeding when he went to trim Resident 1 ' s toenails. POD 1 stated he had ordered antibiotics and a treatment and had gone to the facility for a follow-up visit but Resident 1 was in the acute care hospital at that time. During a review of Resident 1 ' s physician orders active 9/11/22, there was an order dated 9/7/22, for a wound consultation. During an interview on 10/31/22, at 4:30 p.m., with the wound care physician (PHY 2), PHY 2 stated he was asked to complete a consultation on Resident 1 ' s right great toe wound, and the first evaluation was on 9/8/22. PHY 2 stated the wound appeared to be the result of an ingrown toenail (when the edge of the nail grows into the skin). PHY 2 stated he was aware POD 1 had seen Resident 1 and antibiotics were ordered. PHY 2 stated he observed Resident 1 ' s wound on 9/8/22, 9/29/22, 10/6/22, and 10/13/22. During a review of Resident 1 ' s Wound Assessment and Plan, by PHY 2, the following was indicated: 9/8/22: the wound type was ingrown toenail, and the treatment plan was to paint with betadine (a topical antiseptic that provides infection protection against a variety of germs), as Resident 1 had already been treated by the podiatrist and had completed a course of antibiotics. During a review of Resident 1 ' s, SNF (skilled nursing facility) Visit Note, dated 9/12/22, by Physician 3 (PHY 3), the Note indicated Resident 1 had been sent to acute care hospital the previous week for evaluation of abdominal distention and would be sent back to acute care hospital for evaluation of feeding intolerance and decreased respiratory function. During a review of Resident 1 ' s acute care hospital, Discharge Summary, date of service 9/21/22, the Discharge Summary indicated Resident 1 had been sent to the emergency department on 9/9/22 for a misplaced GT tube and constipation, when the great right toe wound was diagnosed as osteomyelitis. The Summary indicated Resident 1 was started on antibiotics and returned to the facility on ly to require transfer back to the emergency department on 9/12/22 for a small bowel obstruction (a blockage in the digestive system prevents passage of food/fluid) and septic shock (a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure). The Summary indicated the same organism, methicillin-resistant staphylococcus aureus (MRSA, an antibiotic resistant bacteria) was the causative organism for both the right great toe wound and the blood stream infection. The Summary indicated Resident 1 was to have six weeks, until 10/26/22, of intravenous (IV, medications delivered directly into veins through a tube inserted through the skin into a vein) antibiotic therapy for the MRSA infections. During a review of Resident 1 ' s, SNF Visit Note, dated 9/21/22, by Physician 1 (PHY 1), the Note indicated Resident 1 was newly readmitted to the facility after an acute care hospital stay. PHY 1 Note indicated Resident 1 received treatment at the acute care hospital with IV antibiotics for an MRSA blood infection and the treatments would continue at the facility until 10/26/22. During a review of Resident 1 ' s nurse progress notes dated 9/21/22, the notes indicated Resident 1 was readmitted on [DATE] on IV antibiotics, including an IV antibiotic for treatment of the big toe. 49091 During an interview on 4/23/24, at 1:44 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 1 ' s right great toe still required treatments with betadine liquid (a topical antiseptic that provides infection protection) and gauze. During a review of Resident 1's document titled, My Foot Clinic, dated 3/1/24, the document indicated dry gangrene (death of body tissue due to loss of blood flow) and osteomyelitis (a serious bone infection) on Resident 1 ' s right hallux (big toe).

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from neglect when staff did not assess or monitor Resident 1 for a change of condition after Resident 1 fell and began to have difficulty speaking. The failure to reassess for change of condition resulted in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/19/21, indicated Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 1 had minimal hearing impairment, clear speech, was understood by others, and usually understood what others said. The MDS indicated Resident 1 needed only set-up and supervision for eating but required extensive physical assistance from one person for bed mobility, transfer between surfaces, and walking in the room; Resident 1 used a walker for locomotion and required assistance to maintain balance when walking. The MDS indicated Resident 1 had fallen within the previous two to six months before entering the facility. A review of Resident 1's facility form, Situation, Background, Assessment, Recommendation (SBAR), by Licensed Vocational Nurse 1 (LVN 1) dated 4/28/21, at 7:30 a.m., in Situation section, indicated, Suspected, Change of Condition, and Describe the situation: CNA [certified nursing assistant name] called nurses attention to an unwitnessed fall in Room [number]. It happened to be [Resident 1]. He was found lying on his right side facing his bed. He was claimed to be coming from the bathroom when he fell , according to his room mate [resident name] of bed B. Resident was asked how he fell . He was aphasic [unable to speak] . The SBAR indicated at 7:32 a.m., LVN 1 completed vital signs (temperature, pulse, respiratory rate, blood pressure), and oxygen saturation. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum amount of oxygen possible. Normal range is 95-100 %.) The section for Assessed, Categories of Change, indicated Resident 1 showed pain, with a pain site of face, at an intensity of two-mild pain. The SBAR indicated Resident 1 was unable to answer the questions of when the pain occurred, and if the resident was satisfied with the pain management plan. The SBAR Recommendations included notification of the physician and Family Member 1 (FM 1). The SBAR indicated FM 1 asked how Resident 1 was doing, and LVN 1 told FM 1 that Resident 1 was doing fine. During an interview on 6/15/21 at 10:30 a.m., with the Director of Nursing (DON), the DON stated LVN 1 no longer worked at the facility and provided a contact number for LVN 1. Telephone calls made on 6/15/21 at 10:30 a.m. and 6/29/21 at 12 p.m. went unanswered, and the voicemail message box was unable to take messages. During an interview on 6/14/21 at 10:05 a.m., with FM 1, FM 1 stated she had received a call from a facility nurse on 4/28/21 around 7 a.m., the nurse told her Resident 1 had fallen that morning but was doing fine. FM 1 stated she had a video call with Resident 1 in the evening of 4/28/21 and noticed a change in his behavior: normally Resident 1 was excited to talk with her on a video call, but on this occasion Resident 1 had not wanted to talk with her. FM 1 stated she had a video call with Resident 1 on 4/30/21, and FM 1 noticed more changes in Resident 1's behavior: Resident 1 tried to talk but was not able to speak. FM 1 stated she asked facility staff to send Resident 1 to the hospital for further evaluation but was told staff would monitor Resident 1 in the facility. MD stated it was his expectation that after an unwitnessed fall, Resident 1 would have had routine neurological checks (Neurological checks, an assessment of the functional status of the brain and spinal cord, which minimally include assessment of level of awareness and arousal to stimuli, size and reaction of pupils to light, pulse, respiratory rate, blood pressure, temperature, hand grip equality and strength, speech quality, and ability to move extremities.) to identify changes in condition. During an interview and clinical record review, including the 4/28/21 SBAR and nursing progress notes on 7/20/21 at 12:15 p.m., with the Director of Nursing (DON), the DON was unable to provide any documentation that indicated nursing staff had completed neurological checks for Resident 1 between 4/29/21 and 5/3/21. The DON confirmed Resident 1's progress notes showed no entries after 4/26/21 at 3:47 p.m., until 5/3/21 at 1:11 p.m. A review of Resident 1's nursing progress notes dated 5/3/21 at 1:11 p.m., indicated, .Found resident in the bed. Appeared SOB [short of breath] . The nursing progress note indicated Resident 1 had a heart rate of 188 (normal range of 72-80), and an oxygen saturation of 70%. The nursing progress note also indicated Resident 1 was sent to acute care hospital via 9-1-1 transport at 1 p.m. A review of Resident 1's acute care hospital record, Internal Medicine History and Physical, date of service 5/3/21 at 3:10 p.m., indicated upon arrival in the emergency department, Resident 1 was in an altered mental state, and had respiratory distress (difficulty breathing) with oxygen saturation in the low 80's, severe [CONDITION(S)] (infection), severe dehydration, and an acute kidney injury. A review of Resident 1's acute care hospital, head CT without IV contrast (CT, computed tomography, a radiology exam of the head, done without injection of a contrasting dye into a blood vessel), exam time 5/3/21 at 4:57 p.m., signed by the physician on 5/3/21 at 5:39 p.m., indicated Resident 1 had a left parietal bone fracture (a broken bone in the upper side of the skull above the ear) with a left extra-axial hematoma (a collection of blood from broken blood vessels in an area between the skull and the membranes covering the brain). A review of Resident 1's acute care hospital record, Discharge Summary, dated 5/13/21 at 10:33 a.m., indicated Resident 1 was hospitalized from 5/3/21 to 5/13/21, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 10/14/21 at 10:55 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had frequently been assigned to Resident 1 and was very familiar with his care needs. CNA 1 stated Resident 1 had been able to walk on his own and talk before his fall. CNA 1 stated after Resident 1 returned to the facility from the acute care hospital, he was barely able to walk or talk.

Based on observation, interview, and record review, for one of three sampled residents (Resident 1) the facility failed to implement their written abuse policies and procedures. After Resident 1 reported that Certified Nursing Assistant (CNA) 1 punched her in the head, Licensed Vocational Nurse (LVN) 1 did not investigate, report the incident to the administrator or the director of nursing, call an interpreter, or send CNA 1 home at that time. This failure resulted in psychological and physical harm and the potential for further harm to Resident 1. Findings: In a review of the clinical record on 10/17/16 the Minimum Data Set (MDS - a resident assessment tool), dated 9/17/16, showed Resident 1 was cognitively intact (the ability to think, reason, or remember clearly). During an observation and concurrent interview on 10/17/16 at 10:40 a.m., Resident 1 said on 10/6/16 at 4:45 a.m., she was in her bed and felt pain in her back. She wanted to get up and into her wheel chair where she felt she would be more comfortable. Resident 1 pushed her call light and CNA 1 entered her room. Resident 1 said she was sitting up in bed and CNA 1, pushed, her down and then left the room. Resident 1 said she speaks a little English but was able to point at, and say the word, wheel chair, to CNA 1. Resident 1 said she rang her call light a second time. Resident 1 said CNA 1 returned to her room and hit Resident 1 in the head. Resident 1 demonstrated how CNA 1 assisted her to the wheelchair. Resident 1 showed that CNA 1 grabbed her shirt sleeve in a rough manner to get her into the wheel chair. Resident 1 said CNA 1 did not take her hand or lift my arm to assist like they (CNAs) usually do. Resident 1 continued and said after CNA 1 hit her (Resident 1) she was scared and her heart was racing. Resident 1 also said she was so scared she could not scream for help, so she banged her back scratcher on the bedside table in order to get the attention of other staff. Resident 1 said she wanted to tell other staff that this person (CNA 1) hurt her. Resident 1 further said when the charge nurse (LVN 1) entered the room and talked to her, she (Resident 1) could not understand what LVN 1 said. Resident 1 said she felt unable to verbally tell LVN 1 that CNA 1 hit her. Resident 1 said she tried to show LVN 1 that CNA 1 hit her by pointing to CNA 1 and then moving her (Resident 1's) fist against her forehead. In a telephone interview on 10/17/16 at 1:05 p.m., LVN 1 said on 10/6/16 between 4:30 and 5:00 a.m., Resident 1 told her CNA 1 had hit her in the head. LVN 1 stated she did not investigate, report the incident to the administrator or the director of nursing, call an interpreter, or send CNA 1 home at that time. In an interview on 10/17/16 at 10:00 a.m., LVN 2 said on 10/6/16, as she began her day shift, the night nurse (LVN 1) reported to her that CNA 1 hit Resident 1. LVN 2 said she went to check on Resident 1 and discovered a purplish discoloration on Resident 1's forehead. Resident 1 complained of pain, pointed to her forehead, and said a staff member hit her. LVN 2 said communication with Resident 1 was difficult due to the language barrier. LVN 2 said she then asked the facility's Activity Assistant (AA) to interpret. LVN 2 stated she was not sure who hit Resident 1 or what Resident 1 had reported through the interpreter. LVN 2 stated she felt Resident 1 was Ok since she went to activities and said she did not need pain medication. In an interview at 11:30 a.m., the AA said she spoke to Resident 1 in her native language on 10/6/16 at approximately 8:30 a.m. The AA said Resident 1 had tears in her eyes when Resident 1 told her what happened (with CNA 1). The AA said Resident 1 told her that on 10/6/16 between 4:30-5:00 a.m., Resident 1 pushed her call light to call for CNA 1 to help her get up. The AA said Resident 1 also told her the first time CNA 1 went into the room, CNA 1 slammed Resident 1 back onto the bed very hard and told Resident 1 it was too early to get up. The AA said Resident 1 said she pushed her call light a second time and CNA 1 came into her room and punched her on the left side of her forehead and then left the room. The AA continued and said Resident 1 banged her backscratcher on the side table in order to get the staffs' attention. The AA stated she did not think Resident 1 could tell LVN 1 (when she entered the room on 10/6/16) what happened with CNA 1, so Resident 1 used body language and gestures. The AA said ever since the incident on 10/6/16, whenever Resident 1 sees her (AA) she (Resident 1) holds her hands and Resident 1 Won't let me go. The AA said Resident 1 shakes and asks her to stay with her. The AA said Resident 1 was scared because she could not tell anyone exactly what had happened until the she (the AA) spoke to her on 10/6/16 at 8:30 a.m. (four hours after CNA 1 hit her). The AA said Resident 1 told her she tried to tell LVN 1, but she just Walked away. In an interview on 10/17/16 at 12:00 p.m., the Administrator (ADM) said she was not notified that CNA 1 hit Resident 1 until 10:00 a.m. on 10/6/16. The ADM said CNA 1 worked with residents in the facility and finished her shift because she (the ADM) had not been told what had happened until 10:00 a.m. The ADM stated CNA 1 was suspended and then resigned from her position at the facility. In an interview at 12:30 p.m., the Director of Nursing, (DON) said when a resident communicates to staff that another staff person hit them, staff was to first assess the resident and notify the administrator. The DON stated Resident 1 was alert and oriented. The DON stated staff should have called for an interpreter and sent CNA 1 home right away. Review of the facility's policy and procedure titled, Abuse-Reporting and Investigations, dated 11/18/15, showed the administrator or designee will provide for a safe environment for the resident as indicated by the situation .If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facilities (sic) policy. Record review of the facility's policy and procedure titled, Alleged Abuse Investigation Checklist, dated 11/13/15, showed staff are expected to take the following steps when investigating alleged abuse: Initiate investigation, suspend accused staff immediately, perform physical, psycho-social and mental assessment, notify attending physician, notify responsible party, notify administrator, notify the Director of Nursing, and initiate incident/accident reports. Record review of the facility's policy and procedure titled, Translation or Interpretation Services, dated 12/1/13, showed the purpose was to, Ensure that residents with limited English Proficiency or who have hearing deficiencies, have the same access to Facility services as other residents.

Based on interviews, and record review the facility failed to provide the necessary foot care and services for one of three sampled residents (1) so she could maintain her highest physical well being. Resident 1 requested podiatry (toenail) care on 10/20/15 following her admission to the facility. The facility did not request an order from Resident's primary physician to see a Podiatrist until 3/18/16, 150 days later, after her toenails had grown to a length which caused the nails to circle and grow into the bottom of her feet. Resident 1 had a [DIAGNOSES REDACTED]. This failure resulted in Resident 1 suffering unnecessary pain, and a decline in her ability to walk. Findings: On 4/4/16 at 10:40 a.m. Resident 1's record was reviewed at the facility. According to the face sheet Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the nurses progress notes dated 3/18/16 reflected, Resident transferred via w/c (wheelchair ) to physical therapy at 9 a.m. Complained of pain on (R)(right) and (L)(left) feet. Assessed feet and noticed overgrown toenails extending to the rear of foot. Notified MD (medical doctor). 10:00 a.m. Resident sent to the acute hospital emergency room . Review of the Interdisciplinary Team Conference Record, dated 10/20/15, documented Resident 1 had requested to see a podiatrist (foot doctor). The record review revealed there was no physician order for [REDACTED]. During an interview on 4/4/16 at 12:35 p.m., Resident 1 stated she had not seen a podiatrist since her request was made in October and no one had looked at her feet, Until March. Resident 1 stated she had been in a lot of pain and kept telling the staff and,No one did anything. During an interview on 4/4/16 at 10:10 a.m., with the LVN ( Licensed Vocational Nurse) she stated Resident 1 had gone to Physical Therapy on 3/18/16, and the PT (Physical Therapist) came to her and said Resident 1 was in pain. LVN 1 stated she and the PT removed Resident 1's socks and found all of her toenails to be, Extremely long, the toenails had been growing for so long that they were, the shape of the nails, curled around and warping (curled under) her feet. During an interview on 4/5/16 at 11:37 a.m.,with Resident 1's Primary Physician, he said he had been at the facility on 3/18/16 when he was asked by staff to look at Resident 1's feet. The Primary Physician said Resident 1 had trouble standing because her nails were digging into her toes it was, Bad, and the Primary Physician had asked the charge nurse to call the Podiatrist for an appointment. Resident 1's Primary Physician said he wanted Resident 1 to be seen,Urgently. The charge nurse said the podiatrist could see Resident 1 in, A couple of weeks. The Primary Physician stated he did not think it was appropriate to wait that long and directed staff to send Resident 1 to the Emergency Department at the local hospital. Review of the acute hospital's Emergency Department Note dated 3/18/16 at 4:59 PM documented, Presents to ED (Emergency Department ) with complaint of foot problem. The main reason of her pain that her nails are long and curled over taking into the toes of her feet. She has no other complaints other than that she cannot do her physical therapy due to the pain related to this. Which is moderate in severity and with weightbearing/ambulation. During a telephone interview with the Director of Nurses on 4/14/16 at 2:53 p.m. she said, Resident 1 was able to walk 200 feet in November, 2015. She is now back in therapy and is walking two steps. During a telephone interview with C.N.A. (Certified Nursing Assistant) 4 on 4/20/16 at 11:10 a.m. he said, I reported her (Resident 1 ) toenails to my charge nurse. I can't remember when I reported it to her. During a telephone interview with the charge nurse on 4/20/16 at 11:25 a.m. she said, I didn't see her toes. No one reported to me about her toenails. Review of the facility's toenails care policy and procedure last revised 1/1/12 documented, Nail care is given to clean the nail bed and keep the nails trimmed. Fingernails are trimmed by Certified Nursing Assistance, except diabetic residents or residents with circulatory impairments including all toenails except for high risk residents. (Note:a Licensed Nurse will trim those residents).

Based on interview and record review the facility failed to implement their policy and procedure that prohibits neglect by not providing services to necessary to avoid physical harm, and the policy and procedure that gave direction for emergency care, when one resident (1) in a sample of three had a significant change in her physical functioning. Resident 1 had shortness of breath, and fluctuating vital signs including one hour where a blood pressure could not be obtained, and one respiratory therapist (RT) placed Resident 1 on a mechanical ventilator with settings that were not ordered by the medical doctor (MD). The registered nurses (RN 1, 2) did not call 911 when Resident 1's condition deteriorated and when measures taken by respiratory therapist (RT) and RN 2 were not effective, nor upon the telephone request of Resident 1's son when he was notified of her condition change. Additionally, the facility failed to call 911 to send Resident 1 to the hospital when they could not obtain her blood pressure between 10 a.m., and 11 a.m. As a result of this neglect, Resident 1 did not have the benefit of acute hospital services when her heart stopped and she was pronounced dead, six and one half hours after her initial symptoms of shortness of breath first appeared. Findings: Resident 1 was a [AGE] year old woman who was admitted to the facility on [DATE] from the acute care hospital. According to a hospital record "Critical Care" progress note dated 1/4/15, Resident 1 had a past medical history of [REDACTED]. The resident was on [MEDICATION NAME], a medication which prevents blood clots from forming, which is a problem for people with [MEDICAL CONDITION]. Resident 1 stopped taking her [MEDICATION NAME] three weeks prior, and presented to the emergency department (ED) of her local hospital with a blood clot in her right arm. She had surgery on 12/21/14, to remove the clot which was blocking the blood flow to her right arm. On 12/22/14, the resident developed a large right middle cerebral artery (the large artery that delivers [MEDICATION NAME] blood to the brain) stroke (blockage of the artery preventing blood flow) which caused swelling of her brain, and was transferred to another hospital for a decompressive craniotomy, which is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. The resident also had a [MEDICAL CONDITION] (trach) surgically placed to create an opening through her neck into the windpipe to provide an airway and to remove secretions from her lungs. The physician's skilled nursing facility (SNF) admission orders [REDACTED]. The Physician order [REDACTED]. stopped and prolong life by all medically effective means. In a telephone interview with Resident 1's son on 2/3/15 at 10:25 p.m., he stated that he received a phone call from RN 1 between 10 and 10:18 a.m., on 1/18/15, to report that his mother was having trouble breathing and had a fever. He asked RN 1 if she had a stroke, and RN 1 told him, "No, but the doctor had ordered some tests." The son stated that he told RN 1 that his mother should be in a hospital, and RN 1 told him that they could take care of his mother there in the facility. He stated that an hour or two later he received a call from the doctor (MD) and he asked the MD why his mother wasn't in the hospital? When he arrived at the facility his mother was lying in the bed with one eye open, and one eye closed and the tubing was hooked up. He thought she was still alive, but she was dead. He stated that he was very upset that his mother wasn't sent to the hospital. The nurse in charge of Resident 1, RN 2, on 1/18/15 stated in an interview on 2/4/15 at 1:30 p.m., that when she did her first rounds at 6 a.m., on 1/18/15, she noted Resident 1 was having rapid breathing so she notified RT. At 10 a.m., Resident 1's respirations were labored. She said she could see that something was wrong with the resident because of her altered breathing, and she had diaphoresis (sweating). RN 2 told RN 1 to call MD (the physician). RN 2 stated that the entries she made in her nurses notes were a reflection of the resident's condition and that she did not document the resident's vital signs, from 6 a.m., until the MD came in at 11 a.m. RN 2's nurse's note written on 1/18/15 contained the following entries: At "6 a.m., Resident 1 had increased anxiety and mild shortness of breath. Her vital signs were, BP 157/85, (normal range 90-140 (systolic) over 60-90 (diastolic)), temperature 98.6 degrees Fahrenheit (without fever), pulse 100 beats per minute (normal rate 60 to 100 beats per minute), respirations 18 breaths per minute (normal 12 - 20 breaths per minute), blood oxygen saturation was 100 percent." At "7 a.m., Resident 1'[MEDICAL CONDITION] suctioned with a minimum amount of pale yellowish secretions and her oxygen saturation ranged from 97 to 100 percent." At "10 a.m., Resident 1 had labored breathing and the respiratory therapist (RT) was at the bedside. The nursing supervisor RN 1 called the resident's physician, (MD) who said he was coming to the facility. RT placed the resident on a mechanical ventilator (a machine that generates a controlled flow of gas into the patient's airways) and administered the [MEDICATION NAME] nebulizer treatment via the [MEDICAL CONDITION]. The oxygen saturation was 97-100 percent. The resident (1) was noted with diaphoresis (sweating) and her blood sugar at the finger was elevated at 315 milligrams per deciliter (mg/dl) (normal 60-100 mg/dl)." At "11:30 a.m., MD ordered a transfer to the acute hospital and the resident had, "Very weak palpable pulse on both wrist, by RN 1 and RT; despite all treatments administered and given and (she) even was placed on (mechanical ventilator), pt. (Resident 1) continues to have SOB (shortness of breath); RT started bagging (ambu bag) on portable tank with O2 (oxygen); RN 1 called 911...911 paramedics..here and take over." At "12:39 p.m., Pronounced dead by MD with 911 paramedics..." During an interview in the facility with RT on 2/3/15 at 3 p.m., he stated that he started Resident 1 on mechanical ventilation and was with RN 2. He stated that RN 1 called MD and he wasn't sure which of the nurses, RN 1 or RN 2 said, "Put on mechanical ventilation per MD's orders; but he didn't see the written order. He agreed that he did not write progress notes in Resident 1's medical record, but provided a notebook containing a diary of notes regarding several residents titled "Weekly Notes" where he documented on Resident 1. According to RT's "Weekly Notes," on 1/18/15 there was an entry for Resident 1 at 9:15 a.m., that he gave a [MEDICATION NAME] treatment for [REDACTED]. The entry further showed that Resident 1's heart rate was 109 beats per minute, and her respiration rate was 28 breaths per minute. The heart rate and respiration rates were both elevated above normal. In a telephone interview with RN 1 on 2/4/15 at 11:30 a.m., she stated that on that day (1/18/15) she called MD and he gave an order for [REDACTED]. pressure manually. She stated that Resident 1 had a pulse, but it was not documented in the medical record. RN 1 stated that she did not think that she needed to call 911 because MD was coming to the facility and, "We were working on trying to get a blood pressure." In a telephone interview with MD on 2/4/15 at 10:15 a.m., he stated that he received a call from RN 1 on 1/18/15, that Resident 1 was having difficulty breathing. He told her he was going to finish rounds and then come to the facility. He did not recall giving a telephone order for mechanical ventilation or what the settings would be, he stated, "RT knows the standard settings." He did not recall telling the nurse to keep Resident 1 in the facility until he arrived as opposed to calling 911, because that would be "inappropriate." He further stated that the, "Nurses are competent. They should know there is no demand that they must keep her (Resident 1) there (at the facility)." MD wrote a progress note on 1/18/15, timed from 11:30 a.m. - 1 p.m., that showed Resident 1 had a decreased level of consciousness with stable vital signs at 11:30 a.m., but had no response and had to be ventilated. (MD's) discussion with family led to a decision to transfer to the hospital and 911 was called, but Resident 1's heart stopped beating and aggressive cardiopulmonary resuscitation was started. Called family, (they were) upset. Likely [DIAGNOSES REDACTED]. The Nurse Manager (RN 3) of the Subacute Unit where Resident 1 was receiving care, stated in an interview on 2/3/15 at 3:10 p.m., that there were no written orders from the physician (MD) for mechanical ventilation or for what the settings should be, and that RN 1 did not write any progress notes. RN 3 stated that she would have called 911 when it became apparent that the ventilator and breathing treatments didn't have an impact. She also said she would send a resident out to the hospital at the request of the family. A review of the facility's policy and procedure for, "Change of Condition Notification" dated 1/1/12, showed that, "...In emergency situations ...the Licensed Nurse will: Call the Attending Physician STAT;...If the resident deteriorates, the symptoms are serious ...call 911 for transport to hospital..." A review of the facility's undated policy and procedure titled Reporting Abuse to Administrator, which the Administrator provided on 2/24/15 at 2:30 p.m., showed the, "Purpose (was) To protect residents from...neglect...by ensuring that all Facility personnel...report any incident or suspected incident of resident neglect...to the Administrator." Under the heading of "Definitions, "Neglect is described as, "...Failure to provide medical care for physical and mental health needs..."

Based on observation, interview and record review, for one of 25 sampled residents (15) the facility did not identify the cause of significant unplanned weight loss timely and did not implement corrective actions. In four months, Resident 15 lost 11.4 pounds, 13% of her body's weight. These failures resulted in unplanned, severe, weight loss and had the potential to adversely affect the health and well being of the Residents. Findings: During an observation and concurrent interview on 4/14/14 at 11 a.m., Resident 15 sat upright in bed. Resident 15 appeared thin and frail. Resident 15 stated that she recently lost too much weight. Resident 15 stated that the food was not good. Resident 15 further stated that she could not eat the food because it was very dry. Resident 15 stated that she choked very easily because of her swallowing disorder. Resident 15 stated that she requested food with plenty gravy to make it easier for her to swallow, but that the food was still served too dry. Resident 15 stated that if her food was easier to swallow, she could eat more. On 4/14/15, review of the medical record face sheet showed that Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15 weighed 85.4 pounds. Review of the facility's assessment (MDS) of Resident 15's condition, dated 2/11/14, showed that Resident 15 had reasonable and organized thinking and no cognitive impairment. Resident 15 weighed 81.2 pounds; a loss of 4.3 pounds since admission. A Registered Dietitian's (RD) "care notes", dated 3/11/14, recorded that Resident 15 was experiencing weight loss. Resident 15 weighed 77.5 pounds on 3/8/14. This was a severe weight loss of 7.9 pounds or 9.3% of body weight in three months. Resident 15 reported to the RD that she had difficulty swallowing foods and wanted, 'wetter,' foods. The RD recorded that the diet order for Resident 15 was changed to fortified mechanical soft foods and was to include, "extra gravy." Further review of Resident 15's weight record showed that on 4/9/14, she weighed only 74.1 pounds; a loss of an additional 3.4 pounds. During tray line observation and concurrent interviews on 4/15/14 at 11a.m., Resident 15's meal tray was prepared for distribution. The (DA) Dietary Aide who was responsible for telling the cook about each resident's diet modifications, did not tell the cook to add extra gravy. The cook stated that he did not add the gravy because he did not know about the modification. The cook further stated that he scooped the food onto the plate and added extra gravy based on what was called out to him by the DA. The DA acknowledged that the modification was listed on the meal card (an informational card that listed the resident's diet order and preferences), but stated she missed it because she wasn't aware that a change was made nearly a month before and she had not read the card. During an interview on 4/15/14 at 12:30 p.m., the (RD) Registered Dietician indicated that she saw Resident 15 on 3/11/14 to address the weight loss. The RD stated that she changed the diet to include fortification with the addition of extra gravy. During an interview and concurrent record review on 4/15/14 at 12:38 p.m., The (DS) Dietary Supervisor stated that when there was a diet change or modification she verbally communicated the change to the kitchen staff. The DS directed attention to the meal card, which clearly indicated that Resident 15 was supposed to receive extra gravy with meals.

Based on interview and record review, the facility failed to provide services to ensure the physical well-being of one(1) of one sampled residents. The facility failed to assess the respiratory status of Resident 1 in order to provide information to the physician so that a change in treatment would be timely. This failure resulted in Resident 1's decline in the ability to breathe and emergent transport to the hospital when she was in sever respiratory distress. Findings: On 2/21/14, record review revealed Resident 1, an [AGE] year old woman, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the facility's most recent quarterly minimum data set (MDS) assessment of her condition, dated 1/5/14, Resident 1 could make herself understood and she understood others, however Resident 1 had difficulty with short term memory. Resident 1 required only limited assistance from staff for most of her activities of daily living and she was able to walk independently with use of front wheel walker. She had shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring) and when lying flat. According to the assessment, Resident 1 did not receive oxygen therapy during the two week assessment period. The facility's care plan, originally dated 10/1/11, was updated on 1/11/14 to address her risk for respiratory distress. The nursing interventions were to monitor Resident 1's vital signs, respiratory rate, heart rate and observe for the use of accessory muscles for breathing. The facility's licensed nurses were to check Resident 1's oxygen saturation level as a nursing measure as needed and give medications as ordered. Licensed nurses were to assess Resident 1 when she verbalized, "I cannot breathe." A review of the physician's orders [REDACTED]. 1) QVAR 80 micrograms, (a steroid inhalation drug) 2 puffs twice a day, to treat her [MEDICAL CONDITION]. 2) [MEDICATION NAME] (used to treat and prevent symptoms of wheezing and shortness of breath caused by ongoing lung disease) via nebulizer (used for aerosol breathing treatment) every four hours around the clock while awake. 3) [MEDICATION NAME] nebulizer every 4 hours as needed (PRN) for shortness of breath or wheezing. 4) [MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways and increases air flow to the lungs.) inhaler 2 puffs every 4 hours PRN for shortness of breath. 5) Oxygen to be administered at 2 liters per minute via nasal cannula PRN for shortness of breath. The Medication Administration Record [REDACTED]. On 2/2/14: [MEDICATION NAME], at 5:20 p.m. for wheezing. On 2/3/14: [MEDICATION NAME] at 9 a.m., and 1 p.m. for wheezing. [MEDICATION NAME] inhaler, at 8 a.m. and 12 p.m. for SOB. Oxygen 2 liters per minute via nasal cannula for SOB at 11 a.m. The medical record, in nurses' progress notes or the MAR, contained no documentation of an assessment of Resident 1's respiratory status as indicated in the facility's plan of care. According to the MAR, the result of the treatments was recorded as (with) help, or (with) relief. However, there was no record of vital signs or Oxygen saturation level. According to a nurse's note on 2/3/14 at 2:20 p.m., the resident was anxious and her breathing was 34 breaths per minute (normal rate is 12 - 20 breaths per minute). She was yelling, "I can't breathe!" The licensed nurse recorded that she administered, "[MEDICATION NAME] with relief" at 2:25 p.m. The licensed nurse recorded that at 2:30 p.m. Resident 1's oxygen saturation was 84-88% (normal range is 95 - 100%) on room air and oxygen at 2 liters per minute via nasal cannula was started. The oxygen saturation improved and the licensed nurse notified the Nurse Practitioner (NP) who was present in the facility of Resident 1's condition. At 2:50 p.m., contrary to the previous entries, the licensed nurse recorded that Resident 1 was, "still in respiratory distress". Per instructions from NP, Resident 1 was transported via 911 to the hospital for evaluation at 3 p.m. Review of NP's progress note, on 2/3/14 at 4:23 p.m., "...Nursing coming onto evening shift reports that (Resident 1) said repeatedly last night that she 'couldn't breathe'. The licensed nurse asked NP to assess Resident 1. "(RN 1) reports that (Resident 1) was "wheezing and agitated" but had not notified the physician or the provider's advice nurse. NP recorded that Resident 1 completed PRN medications, but immediately says, I can't breathe." NP recorded that Resident 1 was in respiratory distress and required 911 transport to the hospital for evaluation and treatment. In a telephone Interview on 2/25/14 at 8:54 a.m., the NP stated that on 2/3/14 the facility's evening nurse, Licensed Vocational Nurse (LVN 1) asked her to assess Resident 1. LVN 1 told NP that the resident was saying "I can't breathe" all night long the night before and was wheezing and agitated now. NP found the resident in distress. NP stated that when she asked a registered nurse (RN 1) as to nursing assessments of Resident 1's respiratory status, RN 1 would only say that Resident 1 was agitated. NP stated that she reviewed provider call center records and found that the facility had not attempted to notify the physician or the provider advice services of Resident 1's distress. The facility did not attempt to notify NP herself. NP stated that if she had known earlier of Resident 1's respiratory distress and agitation she would have started additional medical treatment. In a telephone interview on 2/25/14 at 9:55 a.m. RN 1 stated that on the day shift of 2/3/14 that she did rounds with the oncoming nurse for the evening shift, and they saw Resident 1 in the bathroom. When they turned to leave the resident screamed out, "I can't breathe, I can't breathe." RN 1 stated that she had assessed her earlier in the day. She said the resident always said "I can't breathe." When asked how long she had been taking care of the resident she stated that this was her first day to take care of the resident. In a telephone interview on 2/27/14 at 10:20 a.m., LVN 1 stated that she gave Resident 1, [MEDICATION NAME] treatments twice as needed on 2/2/14 the evening before she went out to the emergency room . She stated that she did assess the resident, took her vital signs, respiratory rate, oxygen saturation level and listened to her lungs and everything was "o.k." but, she did not document her assessment data anywhere. A review of the nurses notes for Resident 1 revealed no documentation between 1/20/14 at 4 p.m. until 2/3/14 at 2:20 p.m. when the note revealed the resident was yelling, "I can't breathe," and she was sent out to the emergency room . According to the "Discharge Summary Notes" dated 2/5/14 at 2:31 p.m. Resident 1 was admitted for asthma exacerbation and started on around the clock breathing treatments and a high dose of steroids.

Based on interviews and record reviews, the facility staff failed to consult with the physician before changing the discharge feeding tube instructions for two of three sampled residents (2, 3). The staff did not verify the amount of tube feeding with the physicians for Resident 2 and Resident 3. This deficient practice has the potential for residents not to received their prescribed treatments. Findings: 1. Review of medical record on 2/25/13 showed Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Discharge orders instructions to the facility from the acute hospital dated 2/11/13 read, "Glucerna 20 ml(milliliters) per hour." According to the record the facility's "Enteral Flow Sheet" dated 2/11/13 resident 2 was given "Glucerna 1.2 cal(calories) at 20 cc/hr x (hours times) 20 hrs." During an interview on 2/25/13, the day shift supervisor could not show any evidence that the number of hours that the resident was to receive tube feeding was clarified with the physician.. 2. Review of the medical record on 2/25/13 showed Resident 1 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge orders from the acute hospital dated 2/5/13, indicated that Resident 3 was to receive the feeding tube product at 55 ml/hr. The staff wrote that the resident would receive Fibersource at 55 cc per hour for 20 hours. There was no documentation in the record to show that Resident 3's physician instructed the staff on how many hours Resident 3 was to receive his tube feeding. During an interview with the day shift charge nurse on 2/25/13/at 3:20 p.m. she said, "She didn't write she called the doctor."

Based on interviews and record reviews, the facility failed to follow the physician's order for the feeding tube flow rate for one (Resident 1) of three sampled residents resulting in Resident 1 receiving his tube feeding at a higher dosage than his physician intended. Resident 1 had an order for [REDACTED]. every 8 hours with a final goal of 45ml/hr if tolerated. Instead the facility started Resident 1's tube feeding at 45 ml/hr. and increased it 10ml/hr. until the resident received 85 ml/hr. resulting in Resident 1 being admitted to the hospital for treatment of [REDACTED]. Findings: According to the medical record, review on 12/19/12, Resident 1 was admitted to the facility on [DATE] at 3:30 p.m., with [DIAGNOSES REDACTED].), and acute tracheitis ( inflamation of the windpipe) with [MEDICAL CONDITION] (a tube inserted into the windpipe used as an airway for breathing) and systemic [MEDICAL CONDITION] (skin disease). Review of the Skilled Nursing Facility orders from the acute hospital, dated 12/13/12 indicated that Resident 1 was to receive the feeding tube product ([MEDICATION NAME]) continuously at a start rate of 15 cc per hour with a final goal rate of 45 ml per hour. If the the formula was well tolerated the staff was to advance the formula volume by 10 ml per hour every eight hours. The facility may substitute the supplement with equivalent skilled nursing facility formula in compliance with the diet orders. The facility did not follow the instructions from the acute hospital for Resident 1's tube feeding. Review of the facility Enteral Flow Sheet dated 12/13/12 read, "Fibersource 45 ml X 1 H (milliliters times one hours) increase at 10 ml every hour until goal reach at 85 ml per hour times 20 H." The licensed nurse progress notes dated 12/13/12 read at: 8:00 p.m. "GT (gastrotomy tube) feeding on 85 cc per hour." 9:45 p.m. "suction three times." 10:00 p.m. "Coarse breath sounds with pale yellow secretion." During an interview on 12/19/12 at 3:20 p.m. Nurse 2 said, "We didn't have the [MEDICATION NAME] in stock. So I asked the R.D.(Registered dietician) to assess the resident. I told her what kind of formula was available. So that's when she came up with this rate. We thought it was good for the resident. The resident came in late. I didn't call the doctor about the R.D.'s recommendation. I made a mistake." Review of the doctor's progress notes dated 12/14/12 read , "Gastrostomy feedings. He can only tolerate low flow rate max 45 cc per hour starting at 15 cc per hour increasing 10 cc an hour up to 45 cc." During an interview on 12/19/12 at 2:45 p.m. Resident 1's doctor said, "There was no call to me for the formula change. I see what the R.D. was trying to do. Had I not seem him I might nor have known. This was a mistake. I saw him on the 12/14/12 and was able to catch the error that was made this is very unfortunate." During a telephone interview with the registered dietician on 12/20/12 at 11:45 a.m. she said, "If you can't get more than 480 cc per day he shouldn't be on tube feedings. It didn't make sense to me. The order read Final goal rate 45 ml per hour, if well tolerated advance formula rate every hour. May modify diet orders per R.D. recommendation. I didn't feel I needed to notify the doctor. I built on from their final goal rate." The Licensed Nurses Progress Notes dated 12/14/12 read: 12:30 a.m., "Yellow thick secretion in mod.(moderate) amount. Suctioned x(time) 2. 7:30 a.m. "Suctioned lg(large amt(amount) pale yellowish secretion. 10:00 a.m. Vomited about 100 cc residual feeding like vomitus, yellowish in color. 12:00 noon, "noted vomited again about 100 cc residual feeding." 2:00 p.m., "Suctioned 4 x (four times)." The licensed nurse progress notes revealed no documentation that Resident 1's physician was notified of his vomiting. The nurse documented in the licensed nurse progress notes on 12/15/12: at 1:00 a.m., Resident 1 was restless, his heart rate was 105 and his temperature was 99.1 degrees; At 5:30 a.m. his temperature was 100 degrees and at 6:30 a.m. his body temperature was 100.5 degrees. There was no documentation that his physician was notified of his increase body temperature. The licensed nurses progress notes on 12/15/12 at 10:35 a.m. documented that Resident 1 vomited, and his temperature was 99.7 degrees. During an interview on 12/19/12 at 1:30 p.m. Nurse 3 said, "His (Resident 1) temperature was 100.5. We usually notified M.D. if temperature increase to 101.5. The M.D. was not notified of the vomiting because he only vomited times one." According to licensed nurses progress notes on 12/16/12 at 12:00 midnight 911 was called because Resident 1 was lethargic and was transferred to a nearby acute hospital. According to the acute hospital record dated 12/16/12, Resident 1 presented in the emergency room unresponsive with cough and chest congestion. In the emergency room he was noted with abdominal distention, a liter and a half of dark red fluid was extracted from his feeding tube. He was admitted to the Intensive Care Unit for "Profuse upper [MEDICAL CONDITION], Shock secondary to acute blood loss and left lung pneumonia, questionable aspiration."