Every finding on record at Alta Skilled Nursing and Rehabilitation Center

Based on interview, clinical record review, and document review, the facility failed to ensure a consent was obtained for an opioid pain medication for 1 of 31 sampled residents (Resident #137). This deficient practice had the potential to result in the resident receiving an opioid medication without having been informed of the risks, benefits, and alternatives, and an opportunity to make an informed decision.Findings include: Resident #137 Resident #137 was admitted to the facility on [DATE], with a diagnosis of bilateral primary osteoarthritis of knee. A physician's order dated 06/19/2026, documented Hydrocodone-Acetaminophen Oral Tablet, 10-325 Milligrams (mg), give one tablet by mouth every four hours, as needed, for pain management related to bilateral primary osteoarthritis of knee. Resident #137's Medication Administration Record dated June 2026, documented Hydrocodone-Acetaminophen Oral Tablet, 10-325 mg, was administered on 06/19/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/23/2026, and 06/24/2026. On 06/24/2026 at 2:32 PM, the [NAME] President of Clinical Services verbalized not having been able to locate a signed consent for Resident #137's Hydrocodone-Acetaminophen medication. On 06/25/2026, at 12:11 PM, the Director of Nursing (DON) confirmed a consent had not been obtained from Resident #137 for the Hydrocodone-Acetaminophen Oral Tablet prior to administration of the medication. The DON confirmed a consent should have been obtained to ensure the resident was aware of the risks and benefits of the medication. The facility policy titled, Pain Assessment and Management, dated 02/01/2019, documented an informed consent would be obtained from the resident at the start of a prescribed opioid pain medication and pain management interventions would be consistent with the residents goals for treatment.

Based on observation, interview, clinical record review, and document review, the facility failed to accommodate the needs and preferences for 1 of 31 sampled residents (Resident #26) when the resident requested to get out of bed. This deficient practice had the potential to result in a decline in functional mobility, feelings of isolation and harm to the resident. Findings include:Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including polyneuropathy, unspecified, ankylosing spondylitis of unspecified sites in spine, unspecified osteoarthritis, and spinal stenosis, thoracic region. A physician's order, dated 04/24/2026, documented the resident was to get up in the chair every day per resident and doctor. A care plan focus, initiated 03/06/2025, documented Resident #26 had alterations in physical mobility related to impaired balance, weakness, pain, and decreased activity tolerance. A care plan intervention, initiated 03/06/2025, documented transfer equipment to use included a Hoyer Lift and two staff. A Documentation Survey Report for CNA task notes, dated 06/25/2026, documented an intervention of bed to chair transfer did not occur on the following dates in 2026:May 01, 02, 03, 06, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 25, 26, 28, 29, and 30.June 02, 06, 07, 08, 10, 12, 13, 14, 15, 20, 21, and 22. On 06/22/2026 at 11:37 AM, Resident #26 was in the resident's bed in the resident's room. Resident #26 verbalized the resident wanted to get out of bed once or more per day; however, was unable to. When the resident requested to transfer into a wheelchair, staff often denied the transfer and informed the resident the facility was short staffed. On shower days, the facility believed the shower was the same as a transfer and the resident would not be assisted into the resident's wheelchair. The resident relied on staff assistance transferring from the bed to the wheelchair and from the wheelchair to the bed. The resident verbalized wanting to get out of bed daily, but often being told the facility was too short-staffed. The resident was assisted out of bed twice weekly for showers. The resident verbalized the resident complained to the physician and subsequently received an order to be assisted into the wheelchair daily. Resident #26 explained the resident would like to get out of bed more often to retain the resident's strength. On 06/24/2026 at 12:30 PM, a Certified Nursing Assistant (CNA) explained Resident #26 depended on staff for assistance transferring from the bed to the wheelchair and from the wheelchair to the bed. The CNA explained a physician's order requested daily transfers; however, staff were not always able to accommodate due to short staffing and instead assisted Resident #26 out from bed approximately three times weekly. The CNA verbalized the resident was always in bed and looked forward to transfers from the wheelchair. On 06/24/2026 at 1:43 PM, a Licensed Practical Nurse (LPN) explained Resident #26 required two person Hoyer Lift transfer assistance. The resident's preference was to be up in a wheelchair, however there was not always enough staff to accommodate daily transfers. The LPN confirmed the resident was assisted out of bed at minimum twice per week for showers. On 06/25/2026 at 8:55 AM, the Director of Nursing (DON) verbalized Resident #26's diagnoses of polyneuropathy, spinal stenosis, osteoarthritis and spondylitis made it difficult for the resident to transfer to a wheelchair without assistance. The resident required two CNAs and a Hoyer Lift to get out of bed. Resident #26's physician recently placed a treatment order for staff to assist the resident up into a chair once a day. The DON explained CNAs were responsible to document activities in the CNA tasks and confirmed the CNA task notes documented bed to chair transfers did not occur as ordered by the physician. The facility policy, titled Activities of Daily Living (ADLs), Supporting, dated 02/01/2019, documented appropriate care and services would be provided for residents unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including mobility related to transfer and ambulation. The facility policy titled Resident Rights, dated 02/01/2019, documented the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The resident had the right to make choices about aspects of their life in the facility significant to the resident.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was afforded the choice of wearing an identification wrist band for 1 of 31 sampled residents (Resident #23). This deficient practice had the potential to impede a resident's self-determination and right to make choices about aspects of the resident's daily life.Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified, pulmonary hypertension, unspecified, and dependence on supplemental oxygen. On 06/22/2026 at 9:03 AM, Resident #23 was sitting on the side of the resident's bed. The resident had a plastic wrist band on the resident's left wrist. The wrist band documented the resident's name, room number, and allergies. On 06/22/2026 at 9:04 AM, Resident #23 verbalized the resident did not want to wear the wristband and had asked the facility to remove the wristband several times. The resident verbalized the Unit Manager Licensed Practical Nurse (LPN) would ensure the resident was wearing the wristband at all times and the Unit Manager LPN would, have a fit, if the resident was found not wearing the wrist band. On 06/23/2026 at 11:43 AM, the Unit Manager LPN confirmed Resident #23 had been requesting the wristband removed since February 2025. The Unit Manager LPN verbalized having been responsible for completing monthly audits to ensure each resident had been wearing the wristband and the information on the wristband was correct. The Unit Manager LPN verbalized having been informed during a staff meeting on the morning of 06/23/2026, if a resident did not want to wear the wristband, the wristband was to be removed, and the removal was to be documented in the resident's care plan. On 06/24/2026 at 8:21 AM, Resident #23 was in the resident's room. The wristband was still on the resident's left wrist. On 06/24/2026 at 10:26 AM, the Registered Nurse, completing medication administration on the unit, verbalized the wristbands were a double check for accurate medication administration. On 06/25/2026 at 11:57 AM, the Director of Nursing (DON) confirmed residents were asked to wear the wristband for verification during medication administration and Unit Managers were to ensure residents were wearing the wristbands. The DON verbalized not having been aware of any new instructions related to residents not wanting to wear the wristband, or of Resident #23's request not to wear it. On 06/25/2026 at 12:34 PM, Resident #23 was in the resident's room. The wristband was still on the resident's left wrist. On 06/25/2026 at 12:35 PM, Resident #23 verbalized no one from the facility had spoken to the resident about removing the wristband. On 06/25/2026 at 1:37 PM, the Administrator confirmed the wristbands were a secondary check for medication administration and verbalized the instruction to remove the wristband, if a resident did not want to wear it and to document the removal in the resident's care plan, had not been disseminated to the nursing staff or the Unit Manager's yet. The facility policy titled, Quality of Life-Resident Self-Determination and Participation, dated 02/01/2019, documented the facility promoted the right of each resident to exercise their autonomy regarding what was important to the resident and each resident was allowed to choose and participate in their health care needs consistent with their interests and choices. The facility policy titled, Resident Rights, dated 02/01/2019, documented a resident had the right to self-determination related to services provided by the facility and the resident had the right to make choices about aspects of the resident's life that were significant to the resident.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was not punched on the side of the face by another resident in the activity room for 1 of 31 sampled residents (Resident #49). This deficient practice had the potential to result in a resident suffering physical injury and emotional distress causing the resident to avoid socializing in the activity room. Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acquired absence of right leg above knee and major depressive disorder, recurrent, unspecified. Resident #43 Resident #43 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, moderate and essential (primary) hypertension. A Facility Reported Incident (FRI) for physical abuse submitted by the facility on 04/26/2026, documented the following: Nursing staff reported having heard an altercation in the activity room. A Nurse responded to the area and Resident #49 reported Resident #43 had punched the resident on the left side of the resident's face. A physical examination of Resident #49 revealed a superficial abrasion to the resident's left, posterior ear with minimal bleeding. A progress note for Resident #43, dated 06/29/2025, documented the resident had thrown a water pitcher at a Physical Therapist as the Physical Therapist was working with the resident's roommate. A progress note for Resident #43, dated 10/07/2025, documented the resident was screaming, cursing, and swinging the resident's fists at a Certified Nursing Assistant (CNA). A progress note for Resident #43, dated 10/23/2025, documented the resident was verbally abusive and behaving aggressively towards staff. A progress note for Resident #43, dated 11/29/2025, documented the resident had slapped a CNA's hand. A progress note for Resident #43, dated 04/26/2026, documented the resident had physically hit another resident in the activity room. The resident stated, I don't care that I did that. The Care Plan for Resident #43 lacked a care plan to address the resident's history of physical aggression prior to the incident on 04/26/2026. On 06/24/2026 at 3:01 PM, Resident #49 recalled Resident #43 had punched the resident in the side of the face when the resident had been in the activity room. The resident had made a comment regarding not being able to hear the movie because residents were talking. Resident #43 reacted to the comment by yelling and punching the resident in the face. Resident #49 verbalized the resident had not had issues with Resident #43 prior to the incident in the activity room, but the resident had observed Resident #43 behaving aggressively towards facility staff prior to the incident. The resident verbalized the resident believed Resident #43 was dangerous and could have hurt someone. Resident #49 explained the resident had changed the resident's behavior after the incident to avoid the activity room. On 06/25/2026 at 8:33 AM, the Director of Nursing (DON) confirmed the Care Plan for Resident #43 did not include a care plan to address physically aggressive behaviors prior to the incident on 04/26/2026, and the Care Plan should have included interventions to address the resident's previous aggressive behavior.The facility policy titled, Abuse Prevention Program, adopted 02/01/2019, documented residents had the right to be free from abuse. Residents would be protected from abuse by other residents.FRI 2994951Cross reference with F656

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of physical and verbal aggression towards other residents had a care plan addressing the aggression implemented for a resident involved in 1 of 5 Facility Reported Incidents (FRI) investigated (Resident #43) and a resident's wound care plan was implemented for 1 of 31 sampled residents (Resident #56). These deficient practices had the potential to result in the resident continuing aggressive behaviors and causing the resident to suffer psychosocial harm from unaddressed behaviors and to negatively impact the physical and psychosocial well-being of other residents in the facility and a resident's wound worsening or becoming infected due to staff not implementing the care plan to complete wound care as ordered.Findings include: Physical and Verbal Aggression Resident #43 Resident #43 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, moderate and essential (primary) hypertension. A FRI for physical abuse submitted by the facility on 04/26/2026, documented the following: Nursing staff reported having heard an altercation in the activity room. A Nurse responded to the area and found Resident #43 had punched another resident on the left side of the resident's face. A progress note for Resident #43, dated 04/26/2026, documented the resident had physically hit another resident in the activity room. The resident stated, I don't care that I did that. A progress note for Resident #43, dated 06/20/2026, documented the resident was observed yelling and using foul language in the hallway. The resident was upset because another resident was wheeling around the hallway and Resident #43 believed the resident was too close. The resident became verbally aggressive and yelled at staff. The Care Plan for Resident #43 included a care plan initiated on 04/26/2026. The focus of the care plan was Resident #43 demonstrated being physically aggressive by punching another resident related to anger and poor impulse control. The interventions/tasks included Licensed Practical Nurses, Registered Nurses, and Social Workers would analyze and document the times of day, places, circumstances, and triggers for the resident's aggressive behaviors, and document what de-escalated the resident's behaviors. On 06/25/2026 at 8:33 AM, the Director of Nursing (DON) verbalized the care planned interventions would be documented under the task for Regressive Behavior - Yelling out and/or At Others. The data entered in the tasks would be used to analyze the resident's behavior patterns and determine triggers. The DON verbalized the resident's clinical record and treatment plan did not include methods staff would utilize to de-escalate the resident's aggressive behaviors.The Regressive Behavior Task, dated 06/20/2026, documented the resident had not exhibited regressive behavior on 06/20/2026.The DON confirmed the resident had exhibited behaviors when the resident had been verbally aggressive on 06/20/2026, and the behaviors were directed towards another resident and staff. The DON verbalized it was important to accurately document the care planned interventions, per the care plan, to ensure the resident's behaviors could be analyzed to determine triggers and methods to de-escalate in order to update the resident's treatment plan.Wound CareResident #56 Resident #56 was admitted to the facility on [DATE], with diagnoses including unspecified open wound, right foot, subsequent encounter and other acute osteomyelitis, right ankle and foot. On 06/22/2026 at 1:30 PM, the resident verbalized the resident had injured the resident's foot recently. The resident verbalized the resident was not sure what had happened, but the resident's foot had started bleeding. A Nursing Narrative Note for Resident #56, dated 06/09/2026, documented a Certified Nursing Assistant (CNA) had noticed bright, red blood on the floor of the resident's room. The bleeding was from the heel of the resident's right foot. An order for Resident #56, dated 06/10/2026, documented to cleanse the open area to the right heel, apply xeroform followed by an abdominal (ABD) pad and then wrap with a woven gauze bandage (Kerlix) and secure with an elastic bandage (ACE wrap). A care plan for Resident #56, initiated 06/10/2026, documented the resident had an actual alteration in skin related to a right heel wound. Interventions included administering treatments as ordered and monitor for effectiveness. The June 2026 Treatment Administration Record (TAR), documented to cleanse small open area to the right heel, apply xeroform followed by an ABD pad and then wrap with Kerlix and secure with an ACE wrap in the morning every Monday, Wednesday, and Friday. The treatment was documented as completed on Monday 06/22/2026. On 06/23/2026 at 2:57 PM, the Wound Care Licensed Practical Nurse (LPN) verbalized the wound care for the traumatic wound on Resident #56's heel was the responsibility of the floor nurse. The Wound Care LPN verbalized the LPN primarily performed wound care for complex or worsening wounds and minor injuries such as the wound on Resident #56's heel would be the responsibility of the floor nurse assigned to the resident. On 06/23/2026 at 3:17 PM, the floor nurse (LPN2) assigned to Resident #56 verbalized the LPN2 had been assigned to the resident on 06/22/2026. The LPN2 verbalized the LPN had not seen the resident's wound and had not performed wound care on Resident #56 as the Wound Care LPN was managing the resident's wound. On 06/23/2026 at 3:28 PM, the Wound Care LPN confirmed the Wound Care LPN was not performing Resident #56's wound care. The Wound Care LPN assessed Resident #56's right heel and confirmed the resident did not have a dressing to the resident's heel. The Wound Care LPN confirmed the wound care had been documented as completed on 06/22/2026, by the floor nurse. On 06/23/2026 at 3:40 PM, the DON verbalized the wound care should not have been documented as complete by the floor nurse unless the nurse had completed the wound care. The DON verbalized it was important to follow wound care orders and document accurately to ensure the resident did not develop an infection and the wound did not worsen. The DON confirmed staff were responsible for reviewing and implementing the care plan. The facility policy titled, Care Plan, Comprehensive Person-Centered, adopted 02/01/2019, documented the comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well-being, incorporate identified problem areas and risk factors, and build on resident's strengths. Care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Cross reference with tag F600 and F684

Based on observation, clinical record review, interviews, and document review, the facility failed to ensure professional standards of quality were maintained when medications were left at residents' bedsides and when pain management practices did not adhere to professional standards for 3 of 31 sampled residents (Residents #137, #133, and #6). This deficient practice had the potential to result in unverified and unsupervised medication administration, medication misuse or diversion, adverse medication outcomes, and inadequate pain management. Findings include:Resident #137 Resident #137 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, bilateral primary osteoarthritis of knee, type II diabetes mellitus with diabetic neuropathy, unspecified, anxiety disorder unspecified, major depressive disorder, recurrent, unspecified, unspecified mood (affective) disorder, essential (primary) hypertension, hypothyroidism, unspecified, and unspecified diastolic (congestive) heart failure. On 06/22/2026 at 8:38 AM, the door to Resident #137's room was closed and the resident was the only resident assigned to the room. Resident #137 was lying on the resident's side in bed. Two small medication cups, both containing an assortment of pills of different colors and shapes, and one larger medication cup containing a liquid, were located on top of the tray table next to the resident's bed. On 06/22/2026 at 8:39 AM, Resident #137 verbalized the nurse had left the medications on the tray table for the resident to take on their own. The resident confirmed the pills in both cups were the resident's morning medications and the liquid was liquid potassium. The resident verbalized the nurse often left medications on the tray table, and the resident would sometimes wake up and find the medications left on the table from the previous day. The resident verbalized, just throwing the meds away, if they were left overnight. Resident #137's care plan, last updated 12/10/2025, documented medications were to be administered as ordered by the physician. Resident #137's clinical record lacked documentation in the resident's care plan or of a physician order for the resident to self-administer medications. Resident #137's physician orders for medications to have been administered in the morning were as follows and documented on the resident's Medication Administration Record as having been administered the morning of 06/22/2026: -12/01/2025, Propranolol Hydrochloride Tablet, 10 MG, give three tablets by mouth every 8 hours for hyperthyroidism (three tabs =30MG), (hold for systolic blood pressure less than 100 millimeters of mercury (mmHg), diastolic blood pressure less than 60 mmHg, and heart rate less than 60 beats per minute). -12/02/2025, Folic Acid Oral Tablet 400 micrograms (MCG), give two tablets by mouth in the morning for supplementation (two tabs=800 MCG). -12/02/2025, Methimazole Oral Tablet, 10 MG, give one tablet by mouth in the morning for hyperthyroidism. -12/02/2025, Multi Vitamin Oral Tablet, give one tablet by mouth in the morning for supplementation. -12/02/2025, Furosemide Oral Tablet 80 MG, give one tablet orally two times a day for diastolic congestive heart failure (take twice daily at 8:00 AM and 2:00 PM). -12/03/2025, Ascorbic Acid Oral Tablet, 500 milligrams (MG), give one tablet by mouth in the morning for supplementation. -12/05/2025, Senna Oral Tablet 8.6 MG, give one tablet by mouth two times a day for constipation. -12/11/2025, Aspirin Enteric Coated Tablet Delayed Release, 81 MG, give one tablet by mouth one time a day for peripheral artery disease. -12/11/2025, Atorvastatin Calcium Tablet, 20 MG, give one tablet by mouth one time a day for peripheral artery disease. -12/11/2025, Spironolactone Oral Tablet, 25 MG, give two tablets by mouth in the morning for diastolic congestive heart failure. -12/20/2025, MiraLAX Oral Powder 17 Grams (GM)/SCOOP, give one scoop by mouth in the morning for constipation. -01/01/2026, Fluoxetine Hydrochloride Oral Tablet, 80 MG, give one tablet by mouth in the morning for depression. -01/01/2026, Metformin Hydrochloride Extended-Release Oral Tablet 24 Hour, 500 MG, give one tablet by mouth in the morning for hyperglycemia. -03/07/2026, Omeprazole Oral Capsule Delayed Release, 20 MG, give one capsule by mouth in the morning for gastroesophageal reflux disease. Do not Crush. -03/09/2026, Potassium Chloride Oral Packet, 20 milliequivalent (MEQ), give one packet by mouth one time a day for potassium loss due to diuretic use. -03/14/2026, Loratadine Oral Capsule, 10 MG, give one capsule by mouth one time a day. -04/25/2026, Bupropion Hydrochloride Oral Tablet, 5 MG, give 2.5 tablets (12.5 MG) by mouth in the morning for anxiety. On 06/24/2026 at 8:31 AM, the Licensed Practical Nurse (LPN) confirmed having left the medications on Resident #137's tray table as the resident was alert and able to take the medications on their own. The LPN confirmed the LPN should have waited and watched the resident consume the medications to ensure the resident received all physician ordered medications. On 06/24/2026 at 8:39 AM, the Director of Nursing (DON) verbalized medications were not to be left at the bedside for residents to take on their own and could result in missed administrations and potential negative adverse effects to the resident. The DON confirmed having been aware of the LPN leaving medications at Resident #137's bedside. The DON verbalized the facility applied the Fundamentals of Nursing, by [NAME] and [NAME], as the standards of practice. On 06/25/2026 at 9:31 AM, the Administrator verbalized medications were to be visualized by the administering nurse to ensure residents took the medications per the physician orders. The Administrator verbalized medications were not to be left at the resident's bedside as the resident could potentially have an adverse effect by not taking the medication or potentially overdosing. The facility policy titled, Liberalized Medication Administration-Policy and Procedure, dated 02/2023, documented medications would be administered in a safe manner and per physician orders. Resident #133 Resident #133 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including active primary progressive multiple sclerosis, unspecified severe protein-calorie malnutrition, and fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. On 06/25/2026 at 8:56 AM, located in Resident #133 room, on a table next to the resident's bed, was a cup of unknown pills. There was not a nurse within line of sight nor within the resident's room. Resident #133 explained the pills were left with the resident by the RN. On 06/25/2026 at 9:01 AM, the RN was walking into a residents room to administer medications to the resident. The RN waited with the resident until all medications were swallowed. On 06/25/2026 at 9:04 AM, the RN explained when administering medications, make sure you have the right resident, right medication, and right dosage. Once confirmed, watch the resident take the medications. The RN explained medications were not to be left with the resident. The RN entered Resident #133's room and confirmed there was a cup of medications, unattended and unsecured, on the resident's side table. The RN verbalized leaving the medications with the resident because there were no controlled medications in the cup and the RN had faith Resident #133 would take the medications. The RN confirmed leaving the medications unattended and out of the line of sight with Resident #133 in the room. The RN did not leave the resident's room verbalizing I have to watch the resident take the medications now. On 06/25/2026 at 9:16 AM, the DON explained when administering medications, the nurse must ensure the nurse knocks on the residents room prior to entering, the RN needs to introduce themselves to the resident, make sure the right person is being administered the medications, follow the parameters of administration, and make sure the resident swallows the medications prior to leaving the residents room. The DON verbalized if a nurse did not ensure a resident took their medications, it could alter a residents health and cause a negative impact. Failure to do so could result in false monitoring of a medication and false side effects of a medication. There would also be a potential other residents could take the medications not belonging to them and that residents health could worsen. The facility policy titled Liberalized Medication Administration-Policy & Procedure (Alta), undated, documented the facility was to administer medications to residents in a safe manner but in a way that correlated with daily activities and natural schedules. The facility would properly assess residents and plan care to meet the residents needs. Medications would be administered in a safe manner and per physician orders. The Fundamentals of Nursing, by [NAME] and [NAME], Twelfth Edition, Copyright 2026, Section Medication Administration, documented medications were to be administered per physician orders and to enhance accuracy and resident safety, nurses were required to administer all medications rather than allowing residents to self-administer. Failing to administer medication properly was a medication error. Resident #6 Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] and 03/27/2025, with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, major depressive disorder, recurrent, unspecified, and intentional self harm by other specified means, initial encounter. A Psychiatric Follow Up Progress Note dated 05/14/2026, documented Resident #6 possessed bags of partially decomposed narcotic pills the resident verbalized the pills were being saved for a transfer to another facility. The resident denied suicidal intent. A Nursing Progress Note dated 05/26/2026, documented the resident continued hoarding pain pills due to frustration about not receiving a pain pump. On 06/24/2026 at 8:19 AM, Resident #6 explained a Registered Nurse (RN) would leave oxycodone and morphine pills with the resident and leave the resident's room. The resident verbalized pills were hoarded without staff knowledge and kept so pain could be self managed if staff were unavailable. A physician's order dated 06/20/2026, documented Morphine Sulfate Extended Release oral tablet, 15 milligram (mg). Give one tablet by mouth three times a day for chronic pain; pain management for 30 days for a diagnosis of chronic pain syndrome. A physician's order dated 06/19/2026, documented Oxycodone HCl oral tablet 10 mg. Give one capsule by mouth two times a day for chronic pain; pain managed for 30 days until finished for a diagnosis of chronic pain syndrome. Resident #6's clinical record lacked documented evidence the resident was able to self-administer medicaitons. On 06/24/2026 at 8:56 AM, the Unit Manger LPN explained a staff member discovered unsecured medications in the resident room and reported the finding to the Unit Manager LPN. The Unit Manager LPN recalled approximately 15 pain pills were present and could not describe how the medications were destroyed. The Unit Manager LPN verbalized staff had no idea how the resident obtained and hoarded pain pills. The Unit Manager LPN verbalized licensed nurses were required to bring medications into the resident's room, confirm correct resident, explain medications, observe ingestion, and remain with the resident until medications were swallowed. The Unit Manager LPN explained the resident was supposed to receive a pain pump months earlier but cancelled the resident's travel due to unforeseen circumstances. The resident was cheeking the pain pills when the nurses would attempt to administer and spit the pills out to hoard after the nurses left the resident's room. The Unit Manager LPN reported the pills appeared wet and discolored. The Unit Manager LPN verbalized nurses were never permitted to leave medications with residents and no staff admitted to leaving medications unattended. On 06/24/2026 at 9:01 AM, the DON verbalized nurses were reminded during meetings to ensure residents swallowed medications. The DON verbalized mouth checks were only performed if a resident had a history of not swallowing medications; however, Resident #6 had no history of cheeking medications prior to the incident. On 06/24/2026 at 9:02 AM, the Unit Manger LPN verbalized Resident #6 possessed oxycodone and morphine. The Unit Manager LPN explained nurses were not administering or monitoring medication ingestion any differently after the incident. The Unit Manager LPN confirmed the resident's oxycodone and morphine pills were unsecured in the facility and accessible to residents and staff. The Unit Manager LPN approximated three days of the resident hoarding pain medications in the resident's room and wondered if the resident had any actual pain throughout the resident's body. The Unit Manager LPN verbalized the Unit Manager LPN often wondered if the pain Resident #6 claimed to have was true and accurate. Resident #6's Pain Evaluations dated 09/18/2025 and 04/28/2026, documented the resident had a pain frequence almost constantly. The pain had an effect sleep, therapy activities, and day to day activities. On 06/24/2026 at 10:57 AM, the DON explained pain assessments were conducted at admission, every shift, and during medication administration. Pain assessments were also completed quarterly as part of the Minimum Data Set (MDS). The DON verbalized pain discussions occurred during clinical meetings but were not documented in Interdisciplinary Team Meeting (IDT) notes. The DON explained the resident's pain was associated with stroke, chronic low back pain, polyneuropathy, migraines, and chronic pain syndrome. The resident received gabapentin three times daily, methocarbamol every eight hours as needed, oxycodone every four hours as needed, pregabalin twice daily, and morphine extended release three times daily. The DON verbalized pain management was essential for the psychosocial well being, Activities of Daily Living (ADL), sleep, and rehabilitation participation for the resident. The DON verbalized non pharmacological interventions were minimal since the resident was cognitive and primarily involved redirection. The DON explained if Resident #6 had not taken the resident's pain pills for three days, the resident would experience high levels of pain and even after administration on the fourth day, the pain pills would likely not be effective in relieving the resident's pain. The DON verbalized Resident #6 experienced pain daily and confirmed it was not appropriate for nurses to suggest a resident was not in pain, as pain was subjective and must be respected, and the resident was not administered pain pills according to the physician order. The facility policy titled Pain Assessment and Management, adopted 02/01/2019, documented the pain management program was based on a facility-wide commitment to resident comfort. Staff would be trained on recognizing pain, assessing pain, identifying causes of pain, defining goals and appropriate interventions, implementing pain management strategies, monitoring and modifying approaches, documenting pain, and reporting any significant changes in the residents pain levels. Medications would be administered in a safe manner and per the physician's orders. The Fundamentals of Nursing, by [NAME] and [NAME], Twelfth Edition, Copyright 2026, Section Medication Administration, documented medications were to be administered per physician orders and to enhance accuracy and resident safety, nurses were required to administer all medications rather than allowing residents to self-administer. Cross Reference with F689 and F761

Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a resident's wound care was completed as ordered for 1 of 31 sampled residents (Resident #56). This deficient practice had the potential to result in a resident's wound worsening, a resident developing an infection in the wound, or causing unnecessary pain for a resident. Findings include: Wound Care Resident #56 Resident #56 was admitted to the facility on [DATE], with diagnoses including unspecified open wound, right foot, subsequent encounter and other acute osteomyelitis, right ankle and foot. On 06/22/2026 at 1:30 PM, the resident verbalized the resident had injured the resident's foot recently. The resident verbalized the resident was not sure what had happened, but the resident's foot had started bleeding. A Nursing Narrative Note for Resident #56, dated 06/09/2026, documented a Certified Nursing Assistant (CNA) had noticed bright, red blood on the floor of the resident's room. The bleeding was from the heel of the resident's right foot. An order for Resident #56, dated 06/10/2026, documented to cleanse the open area to the right heel, apply xeroform followed by an abdominal (ABD) pad and then wrap with a woven gauze bandage (Kerlix) and secure with an elastic bandage (ACE wrap). A care plan for Resident #56, initiated 06/10/2026, documented the resident had an actual alteration in skin related to a right heel wound. Interventions included administering treatments as ordered and monitor for effectiveness. The June 2026 Treatment Administration Record (TAR), documented to cleanse small open area to the right heel, apply xeroform followed by an ABD pad and then wrap with Kerlix and secure with an ACE wrap in the morning every Monday, Wednesday, and Friday. The treatment was documented as completed on Monday 06/22/2026. On 06/23/2026 at 2:57 PM, the Wound Care Licensed Practical Nurse (LPN) verbalized the wound care for the traumatic wound on Resident #56's heel was the responsibility of the floor nurse. The Wound Care LPN verbalized the LPN primarily performed wound care for complex or worsening wounds and minor injuries such as the wound on Resident #56's heel would be the responsibility of the floor nurse assigned to the resident. On 06/23/2026 at 3:17 PM, the floor nurse (LPN2) assigned to Resident #56 verbalized the LPN2 had been assigned to the resident on 06/22/2026. The LPN2 verbalized the LPN had not seen the resident's wound and had not performed wound care on Resident #56 as the Wound Care LPN was managing the resident's wound. On 06/23/2026 at 3:28 PM, the Wound Care LPN confirmed the Wound Care LPN was not performing Resident #56's wound care. The Wound Care LPN assessed Resident #56's right heel and confirmed the resident did not have a dressing to the resident's heel. The Wound Care LPN confirmed the wound care had been documented as completed on 06/22/2026, by the floor nurse. On 06/23/2026 at 3:40 PM, the Director of Nursing (DON) verbalized the wound care should not have been documented as complete by the floor nurse unless the nurse had completed the wound care. The DON verbalized it was important to follow wound care orders and document accurately to ensure the resident did not develop an infection and the wound did not worsen. The facility policy titled Skin and Wound Management, dated 02/01/2019, documented each resident with skin breakdown would receive the services and treatment to prevent infection and promote wound healing. A plan of care would also be initiated to address areas of actual skin breakdown. The plan of care would be reviewed and revised as needed. Cross reference with tag F656 and F842

Based on observation, interview, clinical record review, and document review, the facility failed to ensure medications were not left unsecured at residents' bedside for 1 of 31 sampled residents (Resident #6). This deficient practice had the potential to have medications diverted, medications left unsecured, used or ingested by other residents, and lacked verification of unsupervised medication administration resulting in adverse medication outcomes. Findings include:Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE] and 03/27/2026, with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, major depressive disorder, recurrent, unspecified, and intentional self-harm by other specified means, initial encounter. A Psychiatric Follow Up Progress Note dated 05/14/2026, documented Resident #6 demonstrated concerning medication hoarding behavior by possessing bags of partially decomposed narcotic pills the resident verbalized was saving for transfer to another facility. Resident #6 denied suicidal intent. A Nursing Progress Noted dated 05/26/2026, documented the resident was having issues with hoarding pain pills due to frustration about not having a pain pump. On 06/24/2026 at 8:19 AM, Resident #6 explained there was a Registered Nurse (RN) that would leave the resident's oxycodone and morphine pills with the resident. The resident was able to hoard the pain pills without staff knowledge and wanted to keep the pain pills so if the resident experienced pain and could not get a hold of anyone, the resident could administer the pain pills to themself. On 06/24/2026 at 8:56 AM, the Unit Manager LPN explained a staff member had discovered unsecured medications in the resident's room and reported the unsecured medications to the Unit Manager LPN. The Unit Manager LPN recalled there were a lot of pain pills in the resident's room and approximated to be about 15 pain pills. The Unit Manager LPN spoke to staff and staff had no idea how the resident was able to possess and hoard pain pills. The Unit Manager LPN verbalized all licensed nurses were to take medications into a resident room, make sure the right resident was being administered the medications, inform the resident what medications the resident would be taking, watch the resident swallow the medications, and were not able to leave the resident until the medications were swallowed. On 06/24/2026 at 9:01 AM, the Director of Nursing (DON) explained during the nurse staff meetings, discussion was held with all of the nurses to confirm residents swallow the medications. The DON verbalized if a resident had a history of not swallowing medications, the nurses would check the mouths of residents to ensure medications had been swallowed. On 06/24/2026 at 9:02 AM, the Unit Manager LPN explained the resident had possession of Oxycodone and Morphine pain pills; however, since the incident, the nurses were not administering nor checking successful administration of the resident's medications any differently than prior to the incident. The Unit Manager LPN confirmed the resident's Oxycodone and Morphine pills were unsecured in the facility and accessible to all residents and staff. On 06/25/2026 at 9:16 AM, the DON explained when administering medications, the nurse must ensure the nurse knocks on the resident's room prior to entering, the RN needs to introduce themselves to the resident, make sure the right person is being administered the medications, follow the parameters of administration, and make sure the resident swallows the medications prior to leaving the resident's room. The DON verbalized if a nurse did not ensure a resident took their medications, it could alter a resident's health and cause a negative impact. Failure to do so could result in false monitoring of a medication and false side effects of a medication. There would also be a potential other residents could take the medications not belonging to them and that residents' health could worsen. The facility policy titled Liberalized Medication Administration-Policy & Procedure (Alta), undated, documented the facility was to administer medications to residents in a safe manner but in a way that correlated with daily activities and natural schedules. The facility would properly assess residents and plan care to meet the resident's needs. Medications would be administered in a safe manner and per physician orders. The Fundamentals of Nursing, by [NAME] and [NAME], Twelfth Edition, Copyright 2026, Section Medication Administration, documented medications were to be administered per physician orders and to enhance accuracy and resident safety, nurses were required to administer all medications rather than allowing residents to self-administer. Failing to administer medication properly was a medication error Cross Reference with F658, F697, F761

Based on interview, observation, clinical record review and document review, the facility failed to ensure a resident's pain was managed with care planned interventions, pain was evaluated per physician orders, and appropriate administration of pain medication for 2 of 31 sampled residents (Resident #71 and #6). This deficient practice had the potential for unrelieved pain, discomfort, and inadequate pain management.Findings include:Resident #71 Resident #71 was admitted to the facility on [DATE], with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below knee, difficulty walking, and other reduced mobility. A physician's order dated 06/09/2026, documented acetaminophen oral tablet 500 milligrams (mg), give two tablets (1000 mg) by mouth every eight hours as needed for mild to moderate pain levels of one to five. Resident #71 was administered acetaminophen 1000 mg on the following dates: -06/09/2026 at 8:45 PM, for a pain level of seven. -06/10/2026 at 4:55 AM, for a pain level of six. -06/14/2026 at 9:21 PM, for a pain level of seven. -06/15/2026 at 5:20 AM, for a pain level of seven. -06/15/2026 at 7:15 PM, for a pain level of six. -06/16/2026 at 4:22 AM, for a pain level of six. -06/17/2026 at 1:38 AM, for a pain level of six. The care plan for Resident #71 documented the resident had an amputation (left below knee amputation). Analgesics would be given as ordered by the physician. Pain management monitoring/documenting included frequency, duration, intensity of pain, and phantom pain. Report to physician if medications were not effective. A physician's order dated 06/09/2026, documented oxycodone HCl 10 mg, give one tablet by mouth every six hours as needed for severe pain levels of seven to 10. Resident #71 was administered oxycodone HCl 10 mg on the following dates: -06/11/2026 at 1:00 PM, for a pain level of two. -06/13/2026 at 6:46 PM, for a pain level of six. -06/14/2026 at 12:48 AM, for a pain level of six. -06/14/2026 at 6:52 AM, for a pain level of six. A physician's order dated 06/13/2026, and discontinued on 06/15/2026, documented oxycodone HCl 10 mg, give one tablet by mouth every six hours as needed for severe pain for pain levels of seven to 10. Resident #71 was administered oxycodone HCl 10 mg on 06/15/2026 at 7:15 PM, for a pain level of six. A physician's order dated 06/15/2026, and discontinued on 06/18/2026, documented oxycodone HCl 10 mg, give one tablet by mouth every four hours as needed for moderate to severe pain levels of seven to 10. Resident #71 was administered oxycodone HCl 10 mg on the following dates: -06/16/2026 at 4:22 AM, for a pain level of six. -06/16/2026 at 9:06 PM, for a pain level of six. -06/17/2026 at 1:36 AM, for a pain level of six. -06/17/2026 at 9:22 PM, for a pain level of six. -06/18/2026 at 5:30 AM, for a pain level of six. -06/18/2026 at 9:34 AM, for a pain level of six. A physician's order dated 06/17/2026, documented oxycodone HCl 10 mg, give one tablet by mouth every four hours as needed for moderate to severe pain levels of five to 10 for fourteen days. Resident #71 was administered oxycodone HCl 10 mg on the following dates: -06/18/2026 at 7:04 PM, for a pain level of two. -06/25/2026 at 11:45 AM, for a pain level of two. The care plan for Resident #71 documented the resident used oxycodone for pain. Interventions were to complete the pain assessment prior to opioid administration and document the effectiveness of the medication. Administer opioid medication (oxycodone) as ordered. On 06/23/2026 at 8:03 AM, Resident #71 explained feeling frequent phantom pain in the area of the newly amputated left leg. The resident expressed being concerned the nursing staff did not understand how phantom pain feels and the pain medications did not always help. On 06/24/2026 at 4:08 PM, the Director of Nursing (DON) confirmed the medications were not administered to Resident #71 appropriately for the pain levels as written in the physician orders. The prescribed oxycodone was ordered for moderate to severe pain and the acetaminophen was ordered for mild to moderate pain. The DON verbalized the expectation of the nursing staff to follow all orders as written by the provider. The DON confirmed a resident should not receive a narcotic pain medication for a pain level of two and could cause adverse effects such as drowsiness, oversedation, and respiration suppression. The DON communicated acetaminophen was not ordered for moderate to severe pain and would not have effectively controlled Resident #71's pain. On 06/25/2026 at 7:48 AM, a Licensed Practical Nurse (LPN) explained a mild to moderate pain scale was a level of one to five. A moderate to severe pain level was five to 10. The LPN communicated the nursing staff would follow the orders for pain medication as written and the provider would specify if the pain scale was different than the normal parameters. The facility policy titled Pain Assessment and Management, dated 02/01/2019, documented pain would be assessed using a consistent approach and standardized pain assessment. Pain medication would be given as ordered and would be carefully documented. The facility policy titled, Liberalized Medication Administration-Policy and Procedure, dated 02/2023, documented medications would be administered per physician orders. Resident #6 Resident #6 was admitted on [DATE] and readmitted on [DATE] and 03/27/2025 with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, major depressive disorder, recurrent, unspecified, and intentional self harm by other specified means, initial encounter. A Psychiatric Follow Up Progress Note dated 05/14/2026 documented Resident #6 possessed bags of partially decomposed narcotic pills the resident verbalized were being saved for transfer to another facility. The resident denied suicidal intent. A Nursing Progress Note dated 05/26/2026 documented the resident continued hoarding pain pills due to frustration about not receiving a pain pump. On 06/24/2026 at 8:19 AM, Resident #6 explained a Registered Nurse (RN) would leave oxycodone and morphine pills with the resident and leave the resident's room. The resident verbalized pills were hoarded without staff knowledge and kept so pain could be self managed if staff were unavailable. A physician's order dated 06/20/2026, documented Morphine Sulfate Extended Release oral tablet, 15 milligram (mg). Give one tablet by mouth three times a day for chronic pain; pain management for 30 days for a diagnosis of chronic pain syndrome. A physician's order dated 06/19/2026, documented Oxycodone Hydrochloride (HCl) oral tablet 10 mg. Give one capsule by mouth two times a day for chronic pain; pain managed for 30 days until finished for a diagnosis of chronic pain syndrome. On 06/24/2026 at 8:56 AM, the Unit Manager LPN explained a staff member discovered unsecured medications in the resident room and reported the finding to the Unit Manager LPN. The Unit Manager LPN recalled approximately 15 pain pills were present. The Unit Manager LPN verbalized staff had no idea how the resident obtained and hoarded pain pills. The Unit Manager LPN verbalized licensed nurses were required to bring medications into the room, confirm correct resident, explain medications, observe ingestion, and remain with the resident until medications were swallowed. The Unit Manager LPN explained the resident was supposed to receive a pain pump months earlier but cancelled the resident's travel due to unforeseen circumstances. The resident was cheeking the pain pills when the nurses would attempt to administer and spit the pills out to hoard after the nurses left the resident's room. The Unit Manager LPN reported the pills appeared wet and discolored. The Unit Manager LPN verbalized nurses were never permitted to leave medications with residents and no staff admitted to leaving medications unattended. On 06/24/2026 at 9:01 AM, the DON verbalized nurses were reminded during meetings to ensure residents swallowed medications. The DON verbalized mouth checks were only performed if a resident had a history of not swallowing medications; however, Resident #6 had no history of cheeking medications prior to the incident. On 06/24/2026 at 9:02 AM, the Unit Manager LPN verbalized Resident #6 possessed oxycodone and morphine. The Unit Manager LPN explained nurses were not administering or monitoring medication ingestion any differently after the incident. The Unit Manager LPN confirmed the resident's oxycodone and morphine pills were unsecured in the facility and accessible to residents and staff. The Unit Manager LPN approximated three days of the resident hoarding pain medications in the resident's room and wondered if the resident had any actual pain throughout the resident's body. The Unit Manager LPN verbalized the Unit Manager LPN often wondered if the pain Resident #6 claimed to have was true and accurate. Resident #6's Pain Evaluations dated 09/18/2025 and 04/28/2026, documented the resident had a pain frequence almost constantly. The pain had an effect on sleep, therapy activities, and day to day activities. On 06/24/2026 at 10:57 AM, the DON explained pain assessments were conducted at admission, every shift, and during medication administration. Pain assessments were also completed quarterly as part of the Minimum Data Set (MDS). The DON verbalized pain discussions occurred during clinical meetings but were not documented in Interdisciplinary Team Meeting (IDT) notes. The DON explained the resident's pain was associated with stroke, chronic low back pain, polyneuropathy, migraines, and chronic pain syndrome. The resident received gabapentin three times daily, methocarbamol every eight hours as needed, oxycodone every four hours as needed, pregabalin twice daily, and morphine extended release three times daily. The DON verbalized pain management was essential for the psychosocial well being, Activities of Daily Living (ADL), sleep, and rehabilitation participation for the resident. The DON verbalized non pharmacological interventions were minimal since the resident was cognitive and primarily involved redirection. The DON explained if Resident #6 had not taken the resident's pain pills for three days, the resident would experience high levels of pain and even after administration on the fourth day, the pain pills would likely not be effective in relieving the resident's pain. The DON verbalized Resident #6 experienced pain daily and confirmed it was not appropriate for nurses to suggest a resident was not in pain, as pain was subjective and must be respected, the resident was not administered pail pills according to the physician order, and the resident experienced pain daily. The facility policy titled Pain Assessment and Management, adopted 02/01/2019, documented the pain management program was based on a facility-wide commitment to resident comfort. Staff would be trained on recognizing pain, assessing pain, identifying causes of pain, defining goals and appropriate interventions, implementing pain management strategies, monitoring and modifying approaches, documenting pain, and reporting any significant changes in the residents pain levels. Cross Reference with F658 andF689

Based on observation, interview, clinical record review, and document review, the facility failed to ensure medications were not left at a resident's bedside unattended for 1 of 31 sampled residents (Resident #133). This deficient practice had the potential to result in facility residents accessing and ingesting medications with the potential for severe or lethal consequences and unauthorized individuals having access to resident medications. Findings include: Resident #133 Resident #133 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including active primary progressive multiple sclerosis, unspecified severe protein-calorie malnutrition, and fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. On 06/25/2026 at 8:56 AM, located in Resident #133's room, on a table next to the resident's bed, was a cup of unknown pills. There was not a nurse within line of sight nor in the resident's room. Resident #133 explained the pills were left with the resident by the Registered Nurse (RN). On 06/25/2026 at 9:01 AM, the RN was walking into a resident's room to administer medications to the resident. The RN waited with the resident until all medications were swallowed. On 06/25/2026 at 9:04 AM, the RN explained when administering medications, the RN made sure to have the right resident, right medication, and right dosage. Once confirmed, the RN watched the resident take the medications. The RN explained medications were not to be left with the resident. The RN entered Resident #133's room and confirmed there was a cup of medications, unattended and unsecured, on the resident's side table. The RN verbalized leaving the medications with the resident because there were no controlled medications in the cup and the RN had faith Resident #133 would take the medications. The RN confirmed leaving the medications unattended and out of the line of sight with Resident #133 in the room. The RN did not leave the resident's room verbalizing I have to watch the resident take the medications now. On 06/25/2026 at 9:16 AM, the DON explained when administering medications, the nurse was to ensure the nurse knocks on the resident's room prior to entering, introduce themselves to the resident, ensure the right person was being administered the medications, follow the parameters of administration, and make sure the resident swallows the medications before leaving the resident's room. The DON verbalized if a nurse did not ensure a resident took their medications, it could alter a resident's health and cause a negative impact. Failure to do so could result in false monitoring of a medication and false side effects of a medication. The DON further stated there would also be a potential for other residents to take the medications not prescribed to them which could worsen the residents' health. The Fundamentals of Nursing, by [NAME] and [NAME], Twelfth Edition, Copyright 2026, Section Medication Administration, documented failing to administer medication properly was a medication error. The facility policy titled Liberalized Medication Administration-Policy & Procedure (Alta), revised 02/2023, documented the facility was to administer medications to residents in a safe manner but in a way that correlated with daily activities and natural schedules. The facility would properly assess residents and plan care to meet the resident's needs. Cross Reference with F658.

Based on observation and interview, the facility failed to ensure 500 and 600 hall satellite resident pantry and refrigerator food and drink items were protected from cross contamination. This deficient practice had the potential to affect residents in 500 and 600 hall by increasing the risk of cross contamination and causing infection and foodborne illnesses.Findings include:On 06/22/2026 at 9:15 AM, three refillable water bottles, one open soda can, one open Red Bull, one open Gatorade and one Starbucks drink which belonged to staff were on the countertop, which is part of the resident food service area in 500 and 600 satellite pantry. The Kitchen Manager confirmed the pantry was meant only for resident's food and drink items and that it could be much cleaner. On 06/23/2026 at 2:13 PM, a Certified Nursing Assistant (CNA) confirmed the 500 and 600 hall pantry were for resident's food and drink items. The CNA confirmed having staff personal drink containers in the pantry room posed the risk of cross contamination. CNA confirmed staff personal drinks were to be stored in the employee break room. On 06/24/2026 at 12:15 PM, the Kitchen Manager confirmed the 500 and 600 hall pantry was for resident's food and drink items. Kitchen Manager confirmed having staff personal drink containers in the pantry room posed the risk of cross contamination. Kitchen Manager confirmed staff personal drinks were to be stored in the employee break room.The facility did not provide a policy related to where staff personal belongings were to be stored.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's record contained accurate documentation of a resident's wound care for 1 of 31 sampled residents (Resident #56). This deficient practice had the potential to cause a resident's wound to worsen without staff's knowledge and cause a delay in necessary treatment to prevent infection or promote healing.Findings include: Resident #56 Resident #56 was admitted to the facility on [DATE], with diagnoses including unspecified open wound, right foot, subsequent encounter and other acute osteomyelitis, right ankle and foot. On 06/22/2026 at 1:30 PM, the resident verbalized the resident had injured the resident's foot recently. The resident verbalized the resident was not sure what had happened, but the resident's foot had started bleeding. A Nursing Narrative Note for Resident #56, dated 06/09/2026, documented a Certified Nursing Assistant (CNA) had noticed bright, red blood on the floor of the resident's room. The bleeding was from the heel of the resident's right foot. An order for Resident #56, dated 06/10/2026, documented to cleanse the open area to the right heel, apply xeroform followed by an abdominal (ABD) pad and then wrap with a woven gauze bandage (Kerlix) and secure with an elastic bandage (ACE wrap). A care plan for Resident #56, initiated 06/10/2026, documented the resident had an actual alteration in skin related to a right heel wound. Interventions included administering treatments as ordered and monitor for effectiveness. The June 2026 Treatment Administration Record (TAR), documented to cleanse small open area to the right heel, apply xeroform followed by an ABD pad and then wrap with Kerlix and secure with an ACE wrap in the morning every Monday, Wednesday, and Friday. The treatment was documented as completed on Monday 06/22/2026. On 06/23/2026 at 2:57 PM, the Wound Care Licensed Practical Nurse (LPN) verbalized the wound care for the traumatic wound on Resident #56's heel was the responsibility of the floor nurse. The Wound Care LPN verbalized the LPN primarily performed wound care for complex or worsening wounds and minor injuries such as the wound on Resident #56's heel would be the responsibility of the floor nurse assigned to the resident. On 06/23/2026 at 3:17 PM, the floor nurse (LPN2) assigned to Resident #56 verbalized the LPN2 had been assigned to the resident on 06/22/2026. The LPN2 verbalized the LPN had not seen the resident's wound and had not performed wound care on Resident #56 as the Wound Care LPN was managing the resident's wound. On 06/23/2026 at 3:28 PM, the Wound Care LPN confirmed the Wound Care LPN was not performing Resident #56's wound care. The Wound Care LPN assessed Resident #56's right heel and confirmed the resident did not have a dressing to the resident's heel. The Wound Care LPN confirmed the wound care had been documented as completed on 06/22/2026, by the floor nurse. On 06/23/2026 at 3:40 PM, the Director of Nursing (DON) verbalized the wound care should not have been documented as complete by the floor nurse unless the nurse had completed the wound care. The DON verbalized it was important to follow wound care orders and document accurately to ensure the resident did not develop an infection and the wound did not worsen. The facility policy titled Charting and Documentation, adopted 02/01/2019, documented the medical record would facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record would be complete and accurate. Cross reference with tag F684

Based on observation, interview, clinical record review, and document review, the facility failed to ensure staff performed hand hygiene in between glove changes when providing wound care to 1 of 31 sampled residents (Resident #9). This deficient practice had the potential to contaminate a wound and spread infection causing a resident to experience delayed healing or prolonged illness.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified open wound, right thigh, subsequent encounter, unspecified open wound, left thigh, subsequent encounter, and pressure ulcer of sacral region, unspecified stage. The wound care orders for Resident #9 documented the following: Cleanse right buttock pressure injury with normal saline solution (NSS), pat dry with gauze, apply Medihoney and collagen particles to the wound bed followed by calcium alginate, apply barrier cream to peri wound and then cover with a silicone dressing daily. The start date was 06/15/2026. On 06/24/2026 at 10:03 AM, the Wound Care Licensed Practical Nurse (LPN) and a Registered Nurse (RN) prepared to perform the wound care for Resident #9. The following was observed. The LPN and RN performed hand hygiene (HH) with an alcohol-based hand rub (ABHR) and donned gloves.The LPN removed the old dressing, removed gloves and donned new gloves, but did not perform HH in between the glove change.The LPN then put a barrier cloth under the resident and removed gloves and donned new gloves but did not perform HH in between the glove change.The LPN then cleansed the wound with NSS and gauze pads and then removed gloves and donned new gloves but did not perform HH in between the glove change.The LPN then patted the wound bed dry with dry gauze and then removed gloves and donned new gloves but did not perform HH in between the glove change.The LPN then applied Medihoney and collagen particles to the wound bed followed by calcium alginate and a silicone dressing. The LPN then removed gloves and donned gloves but did not perform HH in between the glove change.The RN then removed gloves, retrieved a box of gloves from the bathroom and donned new gloves but did not perform HH in between the glove change.The LPN then cleansed the resident's thigh with NSS and patted dry. The LPN then removed gloves and donned new gloves but did not perform HH in between the glove change.The LPN applied collagen particles to the thigh and barrier cream to the peri wound. The LPN then removed gloves and donned new gloves but did not perform HH in between the glove change.The LPN then applied a silicone dressing and removed gloves and donned new gloves before assisting to apply a clean brief to the resident but did not perform HH in between the glove change. On 06/24/2026 at 10:16 AM, the LPN verbalized HH did not need to be performed in between glove changes and performing HH before starting wound care and after completing wound care was acceptable. The LPN confirmed the LPN had not performed HH in between the glove changes. On 06/24/2026 at 10:18 AM, the RN verbalized HH should have been performed in between glove changes. The RN confirmed the RN had not performed HH in between glove changes. On 06/25/2026 at 10:09 AM, the Infection Preventionist verbalized HH should have been performed anytime gloves were removed in order to stop the spread of infection as the soiled dressing could carry microorganisms. The facility policy titled Handwashing/Hand Hygiene, revised 08/2015, documented the facility considered hand hygiene the primary means to prevent the spread of infections. Use of an ABHR or soap and water to wash hands would be used after removing gloves.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Care Plan was integrated with the hospice plan of care and included a care plan addressing the resident's wound care for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in staff caring for the resident not being aware of the care to be provided to the resident by hospice staff versus care to be provided by facility staff leading to a potential decline in the quality of care the resident received in the facility and the resident not receiving wound care as ordered. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including encounter for palliative care and abnormal findings on diagnostic imaging of other specified body structures. On 05/12/2025 at 2:12 PM, the representative for Resident #19 verbalized the resident had a large mass on the resident's breast and the mass had begun tunnelling and now required wound care. The representative verbalized the resident was on hospice and hospice was providing the resident's wound care. A Hospice Visit Note, dated 05/05/2025, documented the dressing was removed from the lateral wound bed. The wound was actively bleeding. Topical treatment was applied per wound care protocol. On 05/14/2025 at 3:48 PM, the Registered Nurse (RN) for Resident #19 verbalized the resident did not have an order for wound care or a care plan addressing wound care but the resident was on hospice and the hospice agency was managing the resident's wound. On 05/15/2025 at 8:46 AM, the Unit Manager confirmed the resident did not have a care plan for the wound care provided by the hospice agency. On 05/15/2025 at 8:58 AM, the Director of Nursing verbalized a resident's wound care should have been ordered in the facility's electronic health record and the Care Plan should have been integrated with the hospice plan of care and include the wound care provided by the hospice agency. The facility policy titled Care Plans, Comprehensive Person-Centered, adopted 02/01/2019, documented a comprehensive, person-centered care plan would be developed and implemented for each resident. The comprehensive, person-centered care plan would incorporate identified problem areas, reflect treatment goals, identify the professional services responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Cross reference with tags F684 and F849

Based on observation, interview, clinical record review, and document review, the facility failed to ensure resident's care plans were updated to include a resident's need for an appointment with a neurologist due to an increase in the resident's tremors from Parkinson's disease and a resident's continued habit of smoking and storing smoking paraphernalia in the resident's room for 2 of 32 residents (Resident #25 and #13). This deficient practice had the potential to result in staff not being aware of a resident's need for an appointment with a specialist physician to address a resident's medical needs and staff not being aware of the need to continue to assess a resident for safety concerns related to the resident smoking independently and keeping smoking paraphernalia in the resident's room. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and multiple sclerosis. On 05/12/2025 at 1:16 PM, the representative for Resident #25 verbalized the resident needed to see a neurologist to adjust the resident's medications. The representative verbalized the representative had requested an appointment for the resident at each care conference the representative had attended over the last several months. The representative verbalized the staff at the care conference agreed with the need for the resident to see a neurologist, but the facility had not yet made the resident an appointment. A Physician's Order for Resident #25, dated 03/20/2025, documented appointment request: needs neurology appointment for noted increase in tremors related to a diagnosis of Parkinson's disease. The Care Plan for Resident #25 did not include a care plan revision regarding the resident's symptoms of increased tremors or the need to schedule an appointment with a neurologist. On 05/15/2025 at 11:37 AM, the Director of Nursing (DON) and the Unit Manager explained the facility had utilized verbal communication regarding the status of the resident's neurology appointment and confirmed the resident did not yet have an appointment scheduled and the appointment request had not yet been sent to all neurologist offices in the area. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including tobacco use and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On 05/12/2025 at 12:03 PM, Resident #13 returned to the resident's room and smelled strongly of tobacco smoke. The resident confirmed the resident had returned from outside of the facility and the resident was allowed to go outside of the facility to smoke. On 05/13/2025 at 7:35 AM and on 05/14/2025 at 7:05 AM, Resident #13 was observed in the resident's wheelchair smoking in a parking lot adjacent to the facility's parking lot. On 05/14/2025 at 11:23 AM, the Certified Nursing Assistant (CNA) for Resident #13 verbalized the CNA would assist Resident #13 to get out of bed and into the resident's wheelchair to go outside to smoke but the CNA did not know where the resident kept the resident's cigarettes and smoking paraphernalia. On 05/14/2025 at 11:24 AM, the Licensed Practical Nurse (LPN) for Resident #13 verbalized the LPN did not know where the resident's cigarettes were stored. On 05/14/2025 at 11:34 AM, Resident #13 verbalized the resident kept the resident's cigarettes and lighter in the resident's bed side table when not on the resident's person. The Care Plan for Resident #13 documented the resident had a history of Nicotine use and was last revised on 07/23/2024. The care plan did not address the resident's continued use of nicotine or a plan to ensure the safe storage and use of the resident's smoking paraphernalia. On 05/14/2025 at 1:56 PM, the DON verbalized the facility did not care plan interventions to ensure a resident was safe when smoking off facility property but would only care plan to remind the resident of the facility's no smoking policy. The facility policy titled, Care Plans, Comprehensive Person-Centered, adopted 02/01/2019, documented the Care Plan would describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and incorporate the resident's identified problem areas and risk factors associated with identified problems. Cross reference with tags F658 and F684

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's physician order for a neurologist referral due to an increase in the resident's tremors from Parkinson's disease was acted on in a timely manner and monitored for completeness by clinical leadership for 1 of 32 sampled residents (Resident #25). This deficient practice had the potential to result in a resident's symptoms not being managed timely and causing a resident unnecessary discomfort and decreased quality of life from a delay in care. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and multiple sclerosis. On 05/12/2025 at 1:16 PM, the representative for Resident #25 verbalized the resident needed to see a neurologist to adjust the resident's medications. The representative verbalized the representative had requested an appointment for the resident at each care conference the representative had attended over the last several months. The representative verbalized the staff at the care conference agreed with the need for the resident to see a neurologist, but the facility had not yet made the resident an appointment. A Care Conference note, dated 02/21/2025, documented a request for neurology follow up. A Progress Note, dated 02/27/2025, documented the referral for neurology was rewritten. The neurologist Resident #25 used to see no longer took the resident's insurance. The referral would be faxed to multiple offices. A Physician's Order for Resident #25, dated 03/20/2025, documented appointment request: needs neurology appointment for noted increase in tremors related to a diagnosis of Parkinson's disease. The Care Plan for Resident #25 did not include a care plan revision regarding the resident's symptoms of increased tremors or the need to schedule an appointment with a neurologist. The following referrals were documented: - A referral sent to the resident's previous neurologist on 10/31/2024. The faxed response from the neurologist's office documented the office was not contracted with the resident's insurance plan. - A referral was again sent to the resident's previous neurologist on 02/25/2025. The faxed response from the neurologist's office documented the patient had not been seen at the office since 2021. The office was not contracted with the resident's health plan. The office could not see the patient. On 05/14/2025 at 4:14 PM, the Unit Manager (UM) verbalized the resident's representative had requested for the resident to see the resident's previous neurologist, but the resident's previous neurologist no longer accepted the resident's insurance. The UM verbalized Transportation Services was responsible for coordinating resident referrals and appointments. On 05/15/2025 at 11:11 AM, a Transportation Coordinator (TC) verbalized a referral had been sent to Resident #25's previous neurologist on 10/31/2024 and again on 02/25/2025. The TC confirmed the referral had not been sent to any other neurologists in the area. The TC explained the information to make a referral was communicated to the TC through a spreadsheet and the information on the spreadsheet was entered by the nursing staff. The TC verbalized the information for Resident #25's referral documented to send the referral to a specific neurologist's office and the referrals were sent to the same neurologist's office in both October and February and had not been sent to other neurologist offices. On 05/15/2025 at 11:37 AM, the Director of Nursing (DON) and the UM explained the facility had utilized verbal communication regarding the status of the resident's neurology appointment and confirmed the resident did not yet have an appointment scheduled and the appointment request had not yet been sent to all neurologist offices in the area. The DON explained the TCs were not part of the care conferences, and the DON would ask the TCs about the resident's appointment status and had been told the TCs were unable to find an office to accept the resident's insurance. The DON confirmed the DON did not review the TC's spreadsheet to ensure referrals were sent appropriately and the physician order for the referral was not for a specific neurology office. The facility policy titled, Referrals, adopted 02/01/2019, documented the facility would coordinate resident referrals. Facility staff would help arrange transportation to appointments. Referrals for medical services would be based on physician evaluation of resident need and a related physician order. Cross reference with tags F657 and F684

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's symptoms of increased tremors was managed timely per the physician's order to make a referral to a neurologist and a resident's wound was monitored by the facility and the facility had an order and care plan to address the facility's role in providing care for the resident's wound for 2 of 32 sampled residents (Resident #25 and #19). This deficient practice had the potential to result in a resident experiencing increased physical discomfort due to not receiving a timely appointment with a specialist physician as ordered and a resident's wound not receiving necessary care and potentially worsening without the facility's knowledge. Findings include: Resident #25 Resident #25 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and multiple sclerosis. On 05/12/2025 at 1:16 PM, the representative for Resident #25 verbalized the resident needed to see a neurologist to adjust the resident's medications because the resident was having increased tremors. The representative verbalized the representative had requested an appointment for the resident at each care conference the representative had attended over the last several months. The representative verbalized the staff at the care conference agreed with the need for the resident to see a neurologist, but the facility had not yet made the resident an appointment. A Care Conference note, dated 02/21/2025, documented a request for neurology follow up. A Progress Note, dated 02/27/2025, documented the referral for neurology was rewritten. The provider Resident #25 used to see no longer took the resident's insurance. The referral would be faxed to multiple offices. A Physician's Order for Resident #25, dated 03/20/2025, documented appointment request: needs neurology appointment for noted increase in tremors related to a diagnosis of Parkinson's disease. The Care Plan for Resident #25 did not include a care plan revision regarding the resident's symptoms of increased tremors or the need to schedule an appointment with a neurologist. The following referrals were documented: - A referral sent to the resident's previous neurologist on 10/31/2024. The faxed response from the neurologist's office documented the office was not contracted with the resident's insurance plan. - A referral was again sent to the resident's previous neurologist on 02/25/2025. The faxed response from the neurologist's office documented the patient had not been seen at the office since 2021. The office was not contracted with the resident's health plan. The office could not see the patient. On 05/14/2025 at 4:14 PM, the Unit Manager (UM) verbalized the resident's representative had requested for the resident to see the resident's previous neurologist, but the resident's previous neurologist no longer accepted the resident's insurance. The UM verbalized Transportation Services was responsible for coordinating resident referrals and appointments. On 05/15/2025 at 11:11 AM, a Transportation Coordinator (TC) verbalized a referral had been sent to Resident #25's previous neurologist on 10/31/2024 and again on 02/25/2025. The TC confirmed the referral had not been sent to any other neurologists in the area. The TC explained the information to make a referral is communicated to the TC through a spreadsheet and the information on the spreadsheet is entered by the nursing staff. The TC verbalized the information for Resident #25's referral documented to send the referral to a specific neurologist's office and the referrals were sent to the same neurologist's office in both October and February and had not been sent to other neurologist offices. On 05/15/2025 at 11:37 AM, the Director of Nursing (DON) and the UM explained the facility had utilized verbal communication regarding the status of the resident's neurology appointment and confirmed the resident did not yet have an appointment scheduled and the appointment request had not yet been sent to all neurologist offices in the area. The DON explained the TCs were not part of the care conferences, and the DON would ask the TCs about the resident's appointment status and had been told the TCs were unable to find an office to accept the resident's insurance. The DON confirmed the DON did not review the TC's spreadsheet to ensure referrals were sent appropriately and the physician order for the referral was not for a specific neurology office. The facility policy titled, Referrals, adopted 02/01/2019, documented the facility would coordinate resident referrals. Facility staff would help arrange transportation to appointments. Referrals for medical services would be based on physician evaluation of resident need and a related physician order. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including encounter for palliative care and abnormal findings on diagnostic imaging of other specified body structures. On 05/12/2025 at 2:12 PM, the representative for Resident #19 verbalized the resident had a large mass on the resident's breast and the mass had begun tunnelling and now required wound care. The representative verbalized the resident was on hospice and hospice was providing the resident's wound care. A Hospice Certification, dated 03/27/2025, documented the resident had a non-healing right breast wound with underlying mass. A Hospice Visit Note, dated 05/05/2025, documented the dressing was removed from the lateral wound bed. The wound was actively bleeding. Topical treatment was applied per wound care protocol. On 05/14/2025 at 3:48 PM, the Registered Nurse (RN) for Resident #19 verbalized the resident did not have an order for wound care or a care plan addressing wound care but the resident was on hospice and the hospice agency was managing the resident's wound. On 05/15/2025 at 8:46 AM, the UM confirmed the resident did not have a care plan for the wound care provided by the hospice agency. On 05/15/2025 at 8:58 AM, the DON verbalized a resident's wound care should have been ordered in the facility's electronic health record and the Care Plan should have been integrated with the hospice plan of care and include the wound care to be provided by the hospice agency and the responsibilities of facility staff in managing the wound. The facility policy titled Skin and Wound Management, revised 03/03/2025, documented the facility would develop and use care planning protocols and interventions would be implemented based on the resident's assessment. All wound care protcols would be reviewed by the medical director. Cross reference with tags F656, F657, F658, and F849.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident determined to be at risk for pressure injury did not develop a pressure injury, and 2) a resident received wound care per physician orders and the facility policy for 1 of 32 sampled residents (Resident #3). The deficient practices had the potential to place the resident at risk for delayed wound healing and infection. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive, long term use of anticoagulants, unspecified sequelae of cerebral infarction, and chronic kidney disease, stage III, unspecified. The admission Braden Scale for Predicting Pressure Score Risk assessment dated [DATE], documented Resident #3 did not have a skin impairment and was at risk for pressure-related skin impairment due to shear friction and bed confinement. A care plan with an initiation date of 01/21/2025, documented Resident #3 was at risk for skin pressure injury formation. Interventions included keeping the resident as clean and dry as possible, provide peri care after incontinent episodes, and a Licensed Nurse to perform weekly skin checks. A Skin/Wound Progress Note dated 02/25/2025, documented Resident #3 was evaluated by the Wound Care Nurse to have a Stage III pressure injury (a skin injury developed from pressure over an area or bony prominence which involves full thickness skin tissue loss) to the coccyx area measuring 1.2 centimeters (cm) in length by 1.0 cm in width and was unable to determine the depth. The coccyx pressure injury was initially observed on 02/24/2025, after a post shower skin check. A care plan with an initiation date of 02/25/2025, documented Resident #3 had a coccyx pressure injury related to decreased mobility. Interventions included administer treatments as ordered and monitor for effectiveness. Resident #3's physician order dated 02/25/2025, and discontinued on 04/17/2025, documented to cleanse coccyx pressure injury with normal saline, pat dry with gauze, apply skin prep to peri wound, allow to air dry and cover with silicone bordered dressing every day shift and as needed (PRN) every 24 hours for soiled/dislodgement. Resident #3's physician order dated 04/18/2025, documented to cleanse coccyx pressure injury with normal saline, pat dry with gauze, apply medi-honey, followed by zinc oxide and leave open to air every shift and PRN every 24 hours for soiled/dislodgement. A Wound Care Treatment Administration Record (TAR) dated April 2025, lacked documented evidence wound care was provided to the coccyx wound on the following dates and shifts: 04/17/2025: all shifts blank 04/18/2025: evening shift blank 04/20/2025: all shifts blank 04/21/2025: evening shift blank 04/22/2025: evening shift blank 04/23/2025: all shifts blank 04/24/2025: evening shift blank 04/26/2025: day and evening shifts blank 04/27/2025: all shifts blank 04/28/2025: evening shift blank 04/29/2025: evening shift blank 04/30/2025: evening and night shifts blank A Wound Care TAR dated May 2025, lacked documented evidence wound care was provided to the coccyx wound on the following dates and shifts: 05/01/2025: evening and night shifts blank 05/02/2025: evening and night shifts blank 05/03/2025: evening shift blank 05/04/2025: all shifts blank 05/05/2025: evening shift blank 05/06/2025: evening and night shift blank 05/07/2025: night shift blank 05/08/2025: evening shift blank 05/09/2025: evening shift blank 05/10/2025: evening shift blank 05/11/2025: all shifts blank 05/12/2025: evening shift blank On 05/13/2025 at 4:16 PM, the Director of Nursing (DON) confirmed Resident #3's pressure injury was identified on 02/24/2025. The DON confirmed Resident #3's current wound care order and explained the order was not written correctly as the wound care would not occur each shift of each day. The DON confirmed Resident #3's Wound Care TAR was left blank on several dates in April and May of 2025, and the blanks indicated the wound care was not completed on those dates. The DON confirmed wound care was not provided as the physician had ordered and expected nursing to follow physician orders as written. On 05/14/2025 at 8:14 AM, the Wound Care Nurse confirmed Resident #3's current wound care orders for a facility acquired Stage III coccyx wound was first observed on 02/24/2025, after a shower skin check. Residents received a skin check on the assigned shower days and was performed by a Certified Nursing Assistant, who would then notify the nurse of any skin changes. The coccyx wound/pressure injury was not identified prior to 02/24/2025, when it was assessed as a Stage III. The Wound Care Nurse explained writing the wound care order and had thought it was written for daily wound care and every shift wound observation. The Wound Care Nurse confirmed Resident #3's wound care was not provided every shift as written by the provider for several dates in April and May 2025. The facility policy titled Prevention of Pressure Ulcers/Injuries, adopted 02/01/2019, documented the resident's skin would be inspected daily when performing or assisting with personal care. Identify any signs of developing pressure injuries and inspect pressure points such as sacrum, heels, buttocks, coccyx, elbow, etc). Prevention included following the plan of care and identified interventions. Monitoring included evaluating, reporting, and documenting potential skin changes. The facility policy titled Skin and Wound Management, adopted 02/01/2019, documented any resident who entered the facility without pressure ulcers would have appropriate preventive measures taken to ensure the resident did not develop pressure ulcers. The Physician was notified of the development of pressure ulcers and treatment would be initiated as ordered. The wound treatment nurse would audit the orders weekly with the DON or Unit Manager Nurse. Treatment record reviews would be conducted to ensure the administration of treatments as prescribed.

Based on observation, interview, clinical record review, and document review the facility failed to ensure a resident's gastric residual volume (the amount of fluid remaining in the stomach) was checked prior to administration of a medication via the resident's gastrostomy tube (a feeding tube providing a direct path to the stomach for delivering nutrition, fluids, and medications) (G-tube) for 1 of 32 sampled residents (Resident #84). This deficient practice had the potential for delayed gastric emptying to not be recognized in a resident with the potential to result in aspiration pneumonia (a type of lung infection due to inhaling substances into the lungs). Findings include: Resident #84 Resident #84 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dysphagia, oropharyngeal phase, gastroparesis, and gastrostomy status. On 05/12/2024 at 11:23 AM, Resident #84 was resting in bed and had a tube feeding pump administering formula to a G-tube. A Physician's Order for Resident #84, dated 02/20/2023, documented to check for residual prior to administration of water, medications, and formula through the G-tube. A Physician's order for Resident #84, dated 02/20/2023, documented levetiracetam solution 100 milligrams (mg) per milliliter (ml) give 5 ml via G-tube three times a day. On 05/13/2025 at 1:57 PM, the Licensed Practical Nurse (LPN) for Resident #84 administered the levetiracetam via the resident's G-tube but did not check residual prior to administration. On 05/13/2025 at 2:00 PM, the LPN confirmed the LPN had not checked residual prior to administration of the medication and residual should have been checked prior to administering medication via the G-tube. On 05/13/2025 at 2:52 PM, the Director of Nursing (DON) verbalized residual should be checked prior to administering anything through a G-tube to ensure the G-tube is patent and had the appropriate placement. The facility policy titled, Enteral Feedings - Safety Precautions, adopted 02/01/2019, documented to prevent aspiration enteral tube placement would be checked prior to administration of medication and gastric residual volume would be checked as ordered.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure there were no discrepancies between a resident's available medications and the resident's medication orders and medication administration record (MAR) for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in a resident not receiving medications the resident could have potentially needed to alleviate symptoms of anxiety, agitation, restlessness, nausea, and vomiting. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and encounter for palliative care. On 05/15/2025 at 8:30 AM, during a review of Resident #19's medications with the resident's Registered Nurse (RN) the resident had a 30 milliliter (ml) bottle of lorazepam 2 milligrams (mg) per ml concentration located in the medication storage room. The label documented the medication had been prescribed for Resident #19 with the direction to administer 0.25 ml under the tongue every 30 minutes as needed for anxiety, agitation, and/or restlessness. The RN verbalized the medication had been delivered to the facility from the pharmacy used by the resident's hospice agency. The RN confirmed the facility's electronic health record did not include an order for the lorazepam and the medication was not listed on the resident's MAR. The Order Review History Report for Resident #19 documented an order for C-PDR 25/2/10 mg cream, apply 1 ml to skin every six hours as needed for nausea or vomiting (part of comfort package of hospice). On 08/15/2025 at 8:34 AM, the RN for Resident #19 verbalized the facility did not have the C-PDR cream for Resident #19. On 05/15/2025 at 8:41AM, the Director of Nursing (DON) verbalized all medications ordered for a resident should have been available in the facility. The facility policy titled Medication Orders, adopted 02/01/2019, documented the facility would establish uniform guidelines in the receiving and recording of medication orders. A current list of orders would be maintained in the clinical record for each resident. A Pharmacy Services Contract Amendment, dated 12/22/2021, documented the standard services included monthly visits by a Consultant Pharmacist to conduct a medication regimen review for each resident. The facility staff would provide the Consultant Pharmacist with access to medication storage areas, including those secured or locked areas. Cross reference with tag F849

Based on interview, clinical record review, and document review, the facility failed to 1) ensure a resident with a deep vein thrombosis (DVT) (a blood clot in one or more of the deep veins in the body) received the necessary care to prevent the resident from developing gangrene in a lower extremity and requiring hospitalization for 1 of 3 residents reviewed for closed records (Resident #305). This deficient practice resulted in a resident suffering the actual harm of loss of blood flow to the resident's lower extremity and caused the resident's representative to have to choose between an above the knee amputation of the resident's lower extremity or having the resident receive end of life care, and 2) ensure a resident was not physically abused by another resident for 2 of 2 residents investigated for resident to resident abuse (Resident #83 and #122). Findings include: Resident #305 Resident #305 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including other pulmonary embolism without acute cor pulmonale, other specified peripheral vascular diseases, cognitive communication deficit, and disturbance, psychotic disturbance, mood disturbance, and anxiety. A Skin/Wound Note, dated 04/30/2024, documented the Nurse noticed bluish discoloration to the resident's right lower extremity. The affected area was cold and clammy with positive pedal pulses. The resident was experiencing generalized pain due to contracture of the right leg. The Nurse called the Physician to relay the condition. The Physician ordered a bilateral leg arterial ultrasound. A physician order, dated 04/30/2024, documented bilateral leg arterial ultrasound. A Weekly Skin Check for Resident #305, dated 05/01/2024, documented the resident had bluish discoloration and cold, clammy skin to the resident's right lower leg and the leg was starting to be painful. The Physician was notified on 04/30/2024, and a bilateral arterial ultrasound was ordered. An Appointment Note, dated 05/03/2024, documented a transport request was placed for bilateral lower extremity ultrasound as the facility's current contracted diagnostics company did not have an ultrasound technician. A Nursing Note, dated 05/03/2024, documented the resident was confused and crying out. The right lower extremity was cool to touch from mid-calf to toes and was tender to touch. The resident's lower extremity was purplish in color to the pads of the toes. A Monthly Nursing Summary for Resident #305, dated 05/04/2024, documented the resident had increased pain to bilateral lower extremities, cold, clammy skin, and bluish discoloration to the right lower extremity. The resident likely had some circulatory problem. The resident now had complaints of 10 out of 10 pain. The physician had ordered an arterial ultrasound of bilateral lower extremities but there was no in house ultrasound available. A Nursing Note, dated 05/06/2024, documented the resident continued to cry out in pain when the resident's right lower extremity was touched or moved during care. A Nursing Note, dated 05/06/2024, documented the facility's contracted diagnostics company was called to see if they still did not have an ultrasound technician and the company confirmed they did not have one. A request was made to transport to see if the resident could go to an outpatient imaging center. The resident's right lower extremity had blue discoloration and was painful to touch. The Unit Manager (UM) advised the nurses to call the Physician if the resident's leg became worse. A Behavior Note, dated 05/06/2024, documented the resident kept yelling and screaming. A Transfer to Hospital Summary, dated 05/07/2024, documented the resident had an order for an arterial ultrasound of bilateral lower extremities related to swelling and discoloration. The ultrasound could not be completed in the facility. The Physician was notified and ordered the resident sent to the hospital. The resident's representative was notified of the situation. The resident was sent to the hospital via emergency transport. The Mayo Clinic document titled Deep vein thrombosis (DVT), dated 06/11/2022, documented leg swelling, leg pain, and change in skin color as possible symptoms of a DVT. The clinical record for Resident #305 lacked documentation of pedal pulses assessed after 04/30/2024. On 06/11/2024 at 10:04 AM, the UM verbalized the resident's nurse had reported to the UM on 04/30/2024, the resident had discoloration of the resident's leg and the discoloration did not improve when the leg was elevated. The UM verbalized the Physician had ordered an ultrasound, but the facility's contracted ultrasound provider did not have an ultrasound technician available. The UM verbalized the UM instructed the Nurse to send the resident to the hospital if the resident experienced increased pain or further discoloration of the extremity. The UM explained the UM attempted to get the resident an appointment with an outpatient imaging facility on 05/06/2024, but no appointments were available. The UM verbalized the resident's leg was getting worse and the resident was sent to the hospital on 05/07/2024. The UM verbalized the facility should have sent the resident to the hospital earlier and there was a delay in the care provided to the resident. The UM confirmed the only documented pedal pulse was on 04/30/2024, and pedal pulses should have been monitored at least daily for a suspected DVT. The UM verbalized increasing pain in the leg and discoloration were all symptoms indicative of loss of blood flow. On 06/11/2024 at 10:46 AM, the Director of Nursing (DON) verbalized the resident had an order for an ultrasound on 04/30/2024, and the resident did not receive the ultrasound because the facility's contracted ultrasound provider did not have an ultrasound technician. The DON verbalized the resident should have been sent to the hospital for any changes in condition if the facility could not manage the issue. The DON verbalized continued assessment of the resident would have included assessing for pain and the perfusion to both lower extremities. The DON confirmed the assessment should have included checking pulses. The DON verbalized the resident should have been sent to the hospital when the skin checks on 05/01/2024, documented the resident had cold and clammy skin with bluish discoloration. The DON verbalized the DON did not see any documentation the Physician had been notified of the lack of an ultrasound technician and the inability to have the ultrasound completed in the facility. On 06/11/2024 at 10:58 AM, the Physician verbalized the facility had not informed the physician the resident was declining while awaiting an ultrasound. The Physician verbalized the Physician would expect pedal pulses to be assessed when a resident had a suspected DVT, and an ordered ultrasound was delayed. The Physician verbalized if the Physician had been notified of the resident's clinical decline, including discoloration to the leg and the leg being cool to touch, while awaiting an ultrasound, the Physician would have ordered for the resident to be sent to the hospital with no delay. The documentation from the resident's hospital stay documented the following: - The Emergency Department (ED) to Hospital Admission, dated 05/07/2024, documented the resident was brought in via ambulance from the skilled nursing facility with complaints of a discolored purple and cool to touch leg times one week. Per staff the leg had been getting worse. - Results of an Ultrasound of the right lower extremity, dated 05/07/2024, documented the right common femoral, profunda femoral, superficial femoral, popliteal, peroneal, posterior tibial, and anterior tibial arteries appeared to be occluded. - A Skin Assessment, dated 05/07/2024, documented the resident's right leg was shiny, black, purple, and cold. There was an open area near the right heel. The right leg was dark and discolored from the mid knee down. The right heel and toes were boggy and had black and purple discoloration. The right foot had an open wound. - A Vascular Surgery Consultation, dated 05/07/2024, documented the reason for consultation was a dead right lower extremity. An arterial duplex ultrasound confirmed there was no flow from the common femoral artery down throughout the remainder of the right lower extremity. The leg from the knee down was completely gangrenous (death of body tissue due to a lack of blood flow). The resident had severe dense acute ischemia (inadequate blood supply) of the right lower extremity with gangrenous changes of the lower leg and foot. The resident most likely had suffered an acute thromboembolic event of the right lower extremity sometime in the past few days or maybe a week. The lower extremity had enough time to demarcate (boundary between living and dead tissue) up to the mid knee and the gangrenous changes of the right lower leg and foot were so advanced there was no chance of limb salvage. The resident would either need hospice care or an above the knee amputation. The facility policy titled Abuse Prevention Program, adopted 02/01/2019, documented residents had the right to be free from neglect. The Centers for Disease Control and Prevention defines neglect in older persons as the failure to meet an older adult's basic needs. These needs include essential medical care. Complaint #NV00071241 Cross reference with tags F580 and F684 31739 Resident to Resident Abuse Resident #83 Resident #83 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including schizophrenia, unspecified, and anxiety disorder with irritability and anger. An Incident Note dated 04/09/2024, documented a nurse had heard Resident #83 screaming and cursing while an aide had witnessed Resident #83 spit on and throw a cup with water at the resident's roommate while the roommate was lying in bed, asleep (Resident #122). Resident #83's Care Plan dated 05/25/2020, documented the resident had the potential for disruptive behaviors, and to monitor for inappropriate language around other residents and intervene as necessary. Care Plan dated 06/08/2023, documented the resident had demonstrated verbally aggressive behaviors towards others related to schizophrenia diagnosis and to administer medications as ordered and monitor and document for side effects and effectiveness. A physician's order dated 04/10/2024, documented Resident #83 may be discharged to behavioral health center today, when bed was available. Resident #122 Resident #122 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, and dysphagia, oropharyngeal phase. An Incident Note dated 04/09/2024, documented Resident #122 had been asleep when Resident #83 spit on and threw water on the resident. The residents were separated, and the nurse manager was informed. Plan to move Resident #122 to another room. A Communication Note dated 04/10/2024, documented the social worker had met with Resident #122 to follow up on the room change. The resident verbalized to the social worker the resident had slept well and, just had to get out of there, referring to the old room. On 06/13/2024 at 10:51 AM, the DON confirmed Resident #83 had spit on and thrown a cup of water on Resident #122. The DON verbalized Resident #83 had been receiving behavior health services prior to the altercation and the facility had not been able to implement any new interventions due to Resident #83's increased behaviors; Resident #83 was transferred to a behavioral health center for additional services, and Resident #122 was moved to another room. The facility policy titled, Abuse Prevention Program, adopted 02/01/2019, documented as part of the resident abuse prevention program, the facility would protect residents from abuse by anyone, including other residents. FRI #NV00070898

Based on interview, record review, and document review, the facility failed to investigate a resident's allegation of abuse for 1 of 18 sampled residents (Resident #2). Resident #2 alleged a Certified Nursing Assistant (CNA) slapped the resident and handled the resident roughly when providing care. The CNA named in the abuse allegation was scheduled to work with the resident of concern and throughout the facility from the time the facility was made aware of the allegation on [DATE], until [DATE]. The facility did not report the incident to the State Survey Agency or law enforcement. The lack of investigation and measures to prevent further potential abuse allowed the alleged perpetrator continued access, with the potential for further physical abuse and harm, to the alleged victim and all residents within the CNA's assignment. Furthermore, the facility failed to conduct a thorough investigation into an allegation of a Registered Nurse (RN) verbally abusing a resident for 1 of 18 sampled residents (Resident #7). On [DATE] at 3:24 PM, the Administrator was notified of Immediate Jeopardy (IJ) related to the failure to investigate and report an allegation of abuse and failure to protect Resident #2 and all residents included in the assignments for the alleged perpetrator. The IJ began on [DATE], when the facility was made aware of the allegations of abuse by Resident #2, including being slapped by the CNA and the CNA was rough when providing care. The lack of investigation into the allegations and protection of residents (suspending the CNA during an investigation into the allegations) had the potential to result in physical abuse and cause harm to all residents within the CNA's assignment. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic (diastolic) congestive heart failure, type 2 diabetes mellitus with diabetic neuropathy, unspecified, and anxiety disorder, unspecified. The resident expired on [DATE]. An Adult Protective Services (APS) report, dated [DATE], documented an APS Social Worker (SW) met with Resident #2 on [DATE] and the resident had informed the SW a CNA had handled the resident roughly when providing care and had slapped the resident on the cheek. The APS SW discussed the incident, including the name of the CNA the resident alleged to be the perpetrator, with the Administrator of the facility on [DATE]. On [DATE] at 12:34 PM, the Administrator/Abuse Coordinator (AC) verbalized the Administrator/AC recalled the visit from the APS SW. The Administrator/AC verbalized the APS SW had informed the Administrator/AC Resident #2 alleged the CNA was rough when handling the resident. The Administrator/AC verbalized the Director of Nursing (DON) had completed the bulk of the investigation and the allegation was not substantiated. The Administrator/AC verbalized a final report would have been submitted to the State agency within five working days. On [DATE] at 12:47 PM, the Administrator/AC and the DON verbalized the abuse allegation made by Resident #2 was not investigated and was not reported to the State agency or law enforcement. The Administrator/AC verbalized the incident was not investigated because the resident had a history of unfounded allegations. The Administrator/AC explained the facility was required to investigate all new allegations of abuse. The facility Staffing Record documented the CNA named in the abuse allegation had continued to work the [NAME] Wing 300 unit for 20 days in [DATE] days in [DATE] days in February 2024, and 25 days in [DATE]. On [DATE] at 2:02 PM, the DON confirmed the CNA continued to work on the 300 halls after Resident #2 had made the allegation of abuse and the CNA had worked directly with Resident #2. The facility policy titled Abuse Investigation and Reporting, adopted [DATE], documented all reports of resident abuse would be promptly reported, within two hours for alleged violations of abuse, to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The Administrator would immediately suspend any employee who had been accused of resident abuse, pending the outcome of the investigation. The Administrator would ensure any further potential abuse, neglect, exploitation, or mistreatment was prevented. The Administrator would provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. 34524 Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including unspecified chronic bronchitis, unspecified severe protein calorie malnutrition, and depression. Resident #19 Resident #19 was admitted to the facility on [DATE], with a diagnosis of paroxysmal atrial fibrillation. A Facility Reported Incident (FRI) documented on [DATE], the allegation a staff member was witnessed verbally berating a resident at the nurse's station. A Nursing Note dated [DATE], documented the Director of Nursing (DON) received a telephone call from a Certified Nursing Assistant (CNA) who, along with a family member of a resident witnessed a Registered Nurse (RN) verbally berate Resident #7 at the nurse's station. The nurse was cursing and throwing medication bottles around the nurses' station. Comments were aimed at the resident, per the CNA and the family member statement. The on-call manager was notified, and the nurse was relieved, taken off the floor and sent home. A statement from the DON dated [DATE], documented the DON received a phone call from a CNA requesting the DON contact Resident #19's family member regarding the way an RN was treating a resident at the nurse's station. The DON called Resident #19's family member and the family member stated they were concerned because the RN was being very unprofessional; cursing and using terrible language that could be overheard down the hall. The family member was visiting Resident #19 when they heard the incident. The family member poked their head out of the door and looked down the hall and saw a resident sitting in a wheelchair at the nurse's station. The family member was not sure if the RN was yelling at the resident or just cursing in general and throwing items around the nurse's station. The family member asked the DON to not have the RN care for Resident #19 any longer. On [DATE] at 11:05 AM, during a telephone interview, a CNA verbalized the CNA was at the nurse's station speaking with another resident's family member when the RN began yelling at Resident #7 at the nurse's station regarding medication. The RN was saying you can take the whole bottle, I don't care, it's not going to kill you. The RN was yelling and slamming medication containers down. Resident #19 resided down the hall from the nurse's station. Resident #19's family member heard the yelling and came out to the hall. The family member was concerned as their minor child was in the room and could hear the cursing. The family member asked the nurse not to provide care to Resident #19 any longer. On [DATE] at 10:20 AM, the Administrator verbalized FRI investigation documentation should include interviews with the alleged staff and residents and staff involved or affected by the incident. The Administrator explained the Administrator and the DON shared the responsibility of Abuse Coordinator. The DON was notified of the allegation and completed the initial report, interviewed staff who witnessed the incident, suspended the alleged employee, and ensured trauma screening was completed. On [DATE] at 10:21 AM, the DON confirmed the incident was witnessed by a staff member and a visitor of the facility. The DON confirmed the DON did not interview Resident #19 or the resident the CNA noted in their statement regarding the incident. On [DATE] at 10:30 AM, the Administrator verbalized the statement from Resident #19's family member was not included in the FRI investigation documentation. The Administrator explained if the statement was not included in the FRI investigation packet and the residents mentioned by the CNA that witnessed the incident were not interviewed, the Administrator would not consider it to be a complete investigation. The Administrator confirmed Resident #19 and the other resident noted by the CNA were not interviewed and the investigation was not complete. FRI #NV00070435

Based on interview, observation, clinical record review, and document review, the facility failed to ensure 2 of 153 total residents (Resident #124 and #29) were not exposed to bodily fluids (urine and feces) from 07/09/23-07/11/23, when a shared bathroom commode overflowed and remnants of the urine and feces were left soaking overnight in towels on the floor, tracked remnants were in the residents' room where Resident #124 always dined and Resident #29 snacked, Resident #124 rested with a soiled sock on linens in resident's bed, and household Lysol wipes were used as disinfectant by placing under the Certified Nursing Assistant's (CNA) foot and dragged around the floor of the bathroom on 07/10/23, leaving the residents' room floor uncleaned and not disinfected. Housekeeping did not attempt to clean and disinfect the bodily fluids from 07/09/23-07/11/23 per the Centers for Disease Control and Prevention (CDC) recommendations for spillage of bodily fluids. Fecal matter remained visible on the commode, the seat of the commode and the bathroom floor in splatter pattern and thicker drops, after the CNA used the Lysol wipe on 07/10/23. The exposure to bodily fluids with lack of disinfecting put Resident #124 and #29 at imminent risk for serious harm, serious impairment, or death from exposure to bacteria with the potential for uncontrolled spread of a communicable disease or infection. On 07/11/23 at 5:10 PM, the Administrator was notified of an Immediate Jeopardy (IJ) related to room [ROOM NUMBER]'s bathroom floor having had towels on the floor saturated with toilet water and bowel movement (BM) dispersed and infused throughout the towels indicative of the brown substance. The toilet seat and floor had splatter marks of BM. The bathroom floor was wet and track marks were from the bathroom to the residents' room. The floor was soiled with dirty streaks. From 07/10/23-07/11/23 at 2:30 PM, the commode had become layered with additional urine and BMs indicative by the building layers observed. A plan to remove the IJ was submitted by the facility on 07/12/23 at 9:58 AM, 1:09 PM, and 6:10 PM. On 07/12/23 at 7:12 PM, the plan to remove the immediacy was accepted by the State Agency. The immediacy was removed on 07/18/23 at 5:01 PM, after the plan was verified to have been implemented. Review of the approved Plan of Removal/Abatement of Immediate Jeopardy dated 07/12/23, provided by the facility, documented the following: No residents have suffered or were at risk during this alleged incident. Residents in room [ROOM NUMBER] were checked. Resident in bed B was doing well. No signs and symptoms of infection or distress were noted. (The resident) asked for the toilet to be fixed as all it does is run and water gets all over the floor. The other resident was doing well. No signs and symptoms of infection or distress were noted. (The resident) wanted coffee at the time of the interview. (The resident) does not use the bathroom. Housekeeping and Maintenance Services will be in-serviced on appropriate timelines to clean and fix bathrooms, respectively. Non housekeeping staff and maintenance staff will be in-serviced on cleaning expectations. Expectations are outlined in the attached presentation and Facility Scheduled titled Housekeeping and Laundry Service Cleaning Schedule and dated April 2021 and the policy titled Work Orders, Maintenance and dated April 2019. The expected timelines are as follows: During normal business hours, within 2 hours for cleaning a bathroom that is visibly soiled during normal business hours, within 2 hours for an attempted plumbing; Otherwise, 24 to 72 hours for snaking and availability of plumbing services. Outside of normal business hours, this type of work may not be done until the next business day. In this particular instance, all of the above timelines were met. Additional plungers will be left in the soiled utility closet to ensure CNAs and other staff have access to a plunger during abnormal business hours. CNAs or designee will utilize the plunger during abnormal business hours. If the plunger fails to fix the toilet, an out of order sign will be placed on the bathroom and a maintenance ticket in TELS created. The residents affected will be asked to use another toilet/bathroom on the unit, or a portable commode will be provided. The out of order sign will be available to print at each nurse station computer. This will be completed 7/12/2023. What is the actual potential for harm? Occupational Safety and Health Administration (OSHA) says feces, unless there's blood, is not an Other Potentially Infectious Materials (OPIM.) Attachments included trainings, out of order signage, Cleaning and Disinfection of Environmental Surfaces, Work Order Maintenance, and cleaning schedules. The facility's implementation of the plan to remove the immediacy of the Immediate Jeopardy was verified as follows: Interviews were conducted with the Director of Nursing, Housekeeping/Laundry Director, and five CNAs. Interviews revealed a disinfectant would be used such as bleach or Q Force 256 for the cleaning of urine and feces from a overflowed toilet. The cleaning and disinfecting would occur immediately. A clogged toilet would be unclogged with the use of a plunger. Signage would be posted, and the bathroom would be closed if a toilet was unable to be unclogged. Staff were aware Housekeeping and Maintenance were not the only staff responsible for fixing a clogged toilet or disinfecting urine and feces. Observations were made of available disinfectants (Q Force 256 and bleach wipes), Central Supply, janitor's closet, Utility Room, and availability of plunger. Findings include: Cornell University's Environment, Health and Safety (EHS) produced Biological Agent Reference Sheets (BARS). BARS were a collaborative product developed by EHS/Biosafety with the assistance of various subject matter experts within and outside the Cornell community. BARS offered standardized information about the health risks, recommended Personal Protective Equipment (PPE), and handling conditions for different agents. The Feces and Urine-Human Biological Agent Reference Sheets referenced feces and urine as the following: Agent Type: Biohazard. Description: Human fecal material may contain a variety of pathogens, including bacteria, viruses, and parasites. Pathogens potentially present in human feces include Bacteroides spp., Salmonella, Shigella, Yersinia, Campylobacter, Aeromonas, Candida, E. coli 0157:H7, Klebsiella, Cryptosporidium, Entamoeba histolytica, viruses including Norovirus and Hepatitis A, and intestinal parasites. Additionally, visible blood in feces may indicate the presence of bloodborne pathogens including human immunodeficiency virus (HIV), Hepatitis B, and Hepatitis C. Human urine is typically not hazardous. It can be potentially hazardous if there is visible blood or if originating from an individual with a urinary tract infection. As such, urine should be treated with universal precautions. Host Shedding: Feces, Urine (with visible blood) Route of Exposure to Humans: Direct Contact, Mucous Membranes, Animal Bites, Ingestion, Percutaneous https://ehs.cornell.edu/research-safety/biosafety-biosecurity/biological-safety-manuals-and-other-documents/bars-other Resident #124 Resident #124 was admitted to the facility on [DATE], with diagnosis of acquired absence of left leg below the knee. Resident #124's Minimum Data Set (MDS) note/ interview for quarterly assessment, dated 06/28/23, documented the resident was occasionally incontinent of bladder and bowel and used a walker and wheelchair for mobility. A Psych Eval Provider note dated 07/20/23, documented the following for Resident #124: -The resident was verbal and could communicate with staff effectively. There was no clear indication of significant cognitive impairment. Memory, complex attention, concentration and language all appeared predominately intact. -The resident was alert and oriented times four. -The resident was verbal and was able to make needs known and understood. -The resident answered questions appropriately. Resident #29 Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including severe sepsis with septic shock, personal history of traumatic brain injury, other abnormalities of gait and mobility, unspecified dementia, unspecified severity, with other behavioral disturbance. Resident #29's Bladder, Bowel & Catheter Quarterly Evaluation dated 07/13/23 documented the resident's functional status for toileting was a one to two person assist and briefs were worn while sleeping and awake. Resident #29's MDS note/ interview for quarterly assessment, dated 07/13/23, documented the resident was occasionally incontinent of bladder and bowel. Resident #124 and #29 shared room [ROOM NUMBER]. On 07/10/23 at 11:53 AM, Resident #124, in room [ROOM NUMBER], requested an observation of the resident's bathroom to be made. There was fecal matter, urine and water saturating towels partially covering the bathroom floor, covering the floor surrounding the toilet and approximately half of the bathroom floor. Resident #124 verbalized the towels had poop on them and the resident had not been able to use the bathroom. The resident explained the roommate traipses the urine and fecal matter all over the residents' room. The residents' room floor had streak marks and foot traffic markings from the bathroom to the residents' room, throughout the room and toward the window. The streak marks were indicative of a wheelchair exiting the bathroom and the wheels leaving marks after rolling through wet soiled substances. The floor appeared dirty as if a substance had dried with a dark and dingy color. The facility's Work Order #3313 documented Resident room [ROOM NUMBER]'s toilet over floaded when the resident went to empty the resident's urinal. The Work Order was created on 07/09/23 at 10:03 AM. It was marked completed on 07/10/23 at 11:27 AM, by the Plant Operations Manager, 26 minutes prior to the wet towels being observed on the floor of the bathroom. On 06/13/23 at 12:54 PM, a Behavior Note documented a CNA was in a room across from the staff restroom and saw Resident #124 coming out of the bathroom. The resident was told the resident could not use the staff bathroom because it was for the staff and the resident had their own bathroom. The resident told the CNA it was not working but had not let the resident's CNA or nurse know. On 06/20/23 at 8:27 PM, a Behavior Note documented Resident #124 had been using the staff bathroom (staff - 100/200) instead of the bathroom the resident had in the resident's room, despite the warning. On 6/30/23 at 10:31 AM, a Behavior Note documented the resident was opening up the staff bathroom and the CNA told the resident the resident could not use our staff bathroom because the resident had to use the one in the resident's room. On 07/10/23 at 4:36 PM, the commode in the bathroom in room [ROOM NUMBER] contained a bowel movement and urine. Fecal matter was splattered in the toilet, resting on the bowl of the commode above the water line, fecal splatter on the toilet seat, and a thicker substance of fecal matter was dropped on the floor. The residents' room floor remained unchanged from the 07/10/23 at 11:53 AM, observation. On 07/11/23 at 7:51 AM, a CNA was present in the residents' room. The bathroom commode contained a bowel movement and urine. The urine was in addition to the observation of 07/10/23 at 4:36 PM. The fecal matter remained splattered in the toilet, resting on the bowl of the commode above the water line, fecal splatter on the toilet seat, and a thicker substance of fecal matter was dropped on the floor. The residents' room floor had streak marks from the bathroom to the resident's side of the room, near the window. It remained unchanged from 07/10/23 at 11:53 AM, observation. The following observations of staff in residents' room [ROOM NUMBER] were made, without staff initiating cleaning and disinfecting of the residents' room: On 07/11/23 at 7:55 AM, a CNA exited room [ROOM NUMBER]. On 07/11/23 at 8:29 AM, staff delivered breakfast trays for the residents to eat in their room. On 07/11/23 at 8:33 AM, a staff member walked into room [ROOM NUMBER] and walked out with a remote in hand. On 07/11/23 at 9:34 AM, Resident #124 verbalized being able to still use the commode however, it barely flushed. The resident explained having told staff about the problem with the toilet not flushing and was told the resident could use the staff bathroom. The resident recalled then being screamed at by staff to not use the staff bathroom anymore. The resident explained having gone into the resident's bathroom the previous day but there was poop in there. Two nights ago, a CNA had told the resident there was nobody available to clean it up, so the CNA threw towels on the overflowed debris of the toilet. The resident had become used to the odor from the bathroom and the dirty floors because it (the odor) was always in the residents' room. The resident explained using the bathroom to shave and the roommate also used the bathroom but wore briefs too. Resident #124 was in bed, with the right foot exposed, in a yellow dirty sock, resting upon the resident's bed linens. The bathroom commode contained a bowel movement and urine. The urine was in addition to the observation of 07/10/23 at 4:36 PM, and more urine in addition to 07/11/23 at 7:51 AM. The fecal matter remained splattered in the toilet, resting on the bowl of the commode above the water line, fecal splatter on the toilet seat, and a thicker substance of fecal matter was dropped on the floor. The residents' room floor remained unchanged from 07/10/23 at 11:53 AM. On 07/11/23 at 9:43 AM, the Housekeeping/Laundry Director was cleaning the staff bathroom in the residents' hall and verbalized it was to be cleaned two times a day. On 07/11/23 from 9:48 AM to 5:52 AM, the Housekeeping/Laundry Director mopped the hallway of room [ROOM NUMBER], to include in front of the open door of room [ROOM NUMBER] but did not enter. On 07/11/23 at 10:08 AM, a CNA with a cleaning cart, entered room [ROOM NUMBER], in the same hallway as room [ROOM NUMBER]. On 07/11/23 at 11:11 AM, Resident #124 was in bed. A urinal containing urine was on the floor, next to the resident's bed. There had been no change to the residents' bathroom or residents' room floor since earlier observations. On 07/11/23 at 1:56 PM, Resident #124, verbalized having eaten today's lunch in the resident's room as it was typical for the resident to always eat meals in the resident's room. The resident explained housekeeping had not been in, to clean room [ROOM NUMBER] and the resident usually wiped the room their self. Cleaning of the room by housekeeping typically occurred every eight or nine days. The resident explained Resident #29 traipses stuff out of the bathroom but Resident #124 just tried to keep off the floor. The bathroom commode contained a bowel movement and urine. The urine was darker in color to the observation of 07/11/23 at 11:11 AM, indicative of the time it set or additional urine added to the commode. The fecal matter remained splattered in the toilet, resting on the bowl of the commode above the water line, fecal splatter on the toilet seat, and a thicker substance of fecal matter was dropped on the floor. An unused brief was laid out, open and exposing the inside of the brief on the countertop of the sink area. The residents' room floor remained unchanged from 07/10/23 at 11:53 AM. On 07/11/23 at 2:04 PM, a CNA explained being an Ambassador as the CNA's main role. The job duty included asking how the residents were doing. The CNA verbalized being familiar with Resident #124 and #29 but was not familiar with an issue in the bathroom. The CNA explained having not gone into their bathroom today but had been in and out of their room five times today. The CNA entered room [ROOM NUMBER]'s bathroom and verbalized this (the bathroom) is gross and flushed the toilet. The toilet would not flush and clogged. The CNA verbalized this was nasty. The CNA verbalized the residents' bathroom should be cleaned daily when the facility had enough staff. The CNA explained needing to put a ticket into the system to have the toilet unclogged. The CNA exited room [ROOM NUMBER] with a clogged toilet. The facility policy titled Establish and Maintaining a Resident Ambassador Program, dated 03/2023, documented the purpose of the policy was to establish and maintain a Resident Ambassador Program to ease the transition into a Skilled Nursing Facility and ensure the facility maintained Customer Service standards. It was expected the staff assigned to resident rooms completed an Ambassador Program checklist. The checklist included verification of resident bathroom and room being clean and free of odor. The Ambassador CNA failed to identify room [ROOM NUMBER] had dirty floors, coming from the bathroom, after verbalizing the Ambassador CNA had entered the room five times on 07/11/23. On 07/11/23 at 2:10 PM, the Ambassador CNA reviewed the electronic system and confirmed there was not a current workorder for the clogged toilet. The CNA verbalized the electronic system showed the clogged toilet in room [ROOM NUMBER] was a repeat occurrence. The CNA confirmed there was a work order entered on 07/09/23 and completed on 07/10/23 for a clogged toilet in room [ROOM NUMBER]. On 07/11/23 at 2:21 PM, the Nurse Manager confirmed being the Nurse Manager for room [ROOM NUMBER]. The Nurse Manager verbalized having heard Resident #124 pooped too big. On 07/11/23 at 2:23 PM, the Nurse Manager explained there had been no problems with the room [ROOM NUMBER]'s toilet since 06/13/23. The Nurse Manager verbalized going into the residents' rooms every day and had been in room [ROOM NUMBER] at 7:00 AM today (07/11/23). The Nurse Manager verbalized there had been no reports of a dirty floor or issue with a clogged toilet. The Nurse Manager verbalized having not been aware towels were laid down Sunday night (07/09/23) for the overflowed toilet. It was not appropriate to leave towels overnight to soak up the overflowed urine and feces debris. There was an infection control issue with the towels being left overnight to soak up the spillage. There was a nurse on duty Sunday, but the Nurse Manager felt the Nurse Manager should have been informed about the towels yesterday (07/10/23). On 07/11/23 at 2:27 PM, the Nurse Manager entered room [ROOM NUMBER] and verbalized this is filthy, filthy. The Nurse Manager peaked in the bathroom then closed the door of the bathroom quickly. The Nurse Manager stated, I don't live this way so I'm not going in the bathroom. It was messy and needed to be cleaned. The Nurse Manager made these statements in the presence of Resident #29. Upon duplicate request to enter the bathroom in room [ROOM NUMBER], the Nurse Manager reopened the bathroom door and verbalized the substance on the toilet seat and the floor looked like bowel movement. The Nurse Manager confirmed seeing the trail on the floor and verbalized not being willing to comment on how long the trail from the bathroom to residents' room had been there. The Nurse Manager stated, of course I noticed it. On 07/11/23 at 2:29 PM, in the presence of the Nurse Manager, the Housekeeping/Laundry Director verbalized housekeeping was short of staff and the room was last cleaned Sunday (07/09/23). The job Duties and Responsibilities of the Housekeeping/Laundry Director, prepared date 01/2020, documented the Housekeeping/Laundry Director performed daily rounds to ensure a healthy, clean safe environment was maintained at all times. On 07/11/23 at 2:30 PM, in the presence of the Nurse Manager and the Housekeeping/Laundry Director, a CNA confirmed there were towels in the bathroom yesterday morning (07/10/23), left by the night staff, and the CNA had picked them up from the floor. The CNA explained using Lysol wipes to clean the bathroom floor. The CNA confirmed not using the CNA's hands to clean the floor with the wipe and physically demonstrated how the CNA cleaned the urine and feces from the residents' floor by throwing an invisible wipe on the floor and stepping on the wipe with the CNA's foot to clean up the spillage of the toilet. The CNA verbalized everything was clean before the CNA left the day before and the toilet was working; just the sink kept running. The CNA verbalized not having cleaned the streak marks of debris in the residents' room, coming from the residents' bathroom. The CNA explained the process for an overflowed toilet was for the CNAs to clean up the feces and urine then go get housekeeping. The job Duties and Responsibilities of the CNA, prepared date 01/2020, documented the CNA was to maintain cleanliness of assigned units and follows established safety and infection control precautions, policies, and procedures. On 07/11/23 at 2:33 PM, the Housekeeping/Laundry Director verbalized the spillage from the toilet had not been reported to housekeeping and the residents' bathroom floor and room had not been cleaned. Housekeeping had a kit to use for feces and the Lysol wipes used were not appropriate to disinfect. On 07/11/23 at 2:33 PM, the CNA verbalized the condition of the bathroom should have been reported to the nurse. The first thing the CNA did when coming on shift was to check the assigned rooms. The CNA became aware of the bathroom when the CNA attempted to take Resident #29 to the bathroom and noticed the floor was wet. The CNA recalled having told the nurses to check the bathroom when the CNA picked up the towels. On 07/11/23 at 2:35 PM, the Nurse Manager verbalized having not been made aware of the towels left on the floor. The job Duties and Responsibilities of the Nurse Manager, prepared date 01/2020, documented the Nurse Manager was responsible for daily operations of assigned unit to ensure quality service in accordance with current nursing standards of practice. On 07/11/23 at 2:41 PM, the Infection Preventionist (IP) verbalized the precautions for an overflowing toilet would depend on infection and what bodily fluids were coming out of the toilet. Any disease can be found in urine and fecal matter. If it was the IP finding the toilet overflowed with urine and feces then the IP would inform the residents to stay out of the bathroom, grab supplies, then grab housekeeping to help. It would require the use of bleach and PPE. PPE would definitely include gloves and booties if it was all over the floor and a face shield. The cleaning would need to take place right away. Fecal matter on a toilet seat and floor posed a danger to residents with bacteria from touch and transferred to other surfaces. Just from touch, a resident could get a bacterial infection. A resident's fecal matter with bacteria could come from anyone, they did not have to be sick. Towels should not have been left over night in a bathroom with an overflowing toilet. They should have been put in a red biohazard bag, so housekeeping knew it was potentially hazardous. Norovirus could cause an outbreak and posed as a risk. It could be any possible disease found in feces and urine. If a resident was exposed to bacteria it would depend on their immune system mainly. Immune compromised residents could be at a high risk for infection compared to other residents. The IP verbalized not being made aware of an overflowing toilet. The IP confirmed the facility followed CDC Guidance, was aware of CDC signage posted in a visitor's bathroom and confirmed the signage had accurate data. The signage posted in the visitor's bathroom, throughout the entirety of the survey, documented one trillion germs can live in one gram of poop, the weight of a paper. On 07/11/23 at 2:59 PM, the Plant Operations Manager confirmed the electronic ticket form indicating completed was completed for the clogged toilet on 07/10/23 at 11:27 AM. The Plant Operations Manager verbalized having snaked the toilet and then flushed it three times. On 7/11/2023 at 8:13 PM, a Nursing Note documented this resident said the toilet was clogged; confirming with CNAs, the housekeeping has gone home, and we have no key accessing to the janitor's room. On 07/12/23 at 7:18 AM, Resident #124 had just woken up and explained the toilet had plugged up again. The resident explained having told the nurse the previous evening. The resident recalled not using the commode from Monday 07/10/23 to 07/11/23, and someone else had been dumping the resident's urinals. The resident confirmed using the resident's right foot to propel self in wheelchair. The resident was in bed with a dirty sock from propelling self in wheelchair with right foot. On 07/12/23 at 8:47 AM, Owner #1 verbalized the following: -Resident #124 had clogged the toilet everyday surveyors had been in the building. The resident was doing it purposefully at this point. -Sunday night was an inconvenient time for a toilet to clog because there was not a lot of people in the building. -The Plant Operations Manager only came in on Sundays for an emergency. A clogged toilet was not an emergency. -The bathroom should be closed until housekeeping or maintenance cleaned it. It (room [ROOM NUMBER]) was cleaned on Monday. -We established it (the floor) was cleaned by Lysol wipes on Monday and the toilet was snaked. -Residents had a bathroom in the shower room to use as backup. The facility did not have a policy on offering backup toilet facilities. No facility has a policy on these standards of practice. -It was the resident clogging the toilet, not the toilet. The toilet has been looked at. -It was not the toilet or the pipes, it was the resident. The resident had large bowel movements and used a lot of toilet paper. The resident went repeatedly without flushing. -There was a toilet in the shower room, and it was available to all residents. The facility did not document education for residents (regarding the availability of an alternate toilet.) -The facility had notated video camera footage confirming on 07/10/23 at 9:40 AM, the Plant Operations Manager attempted to snake the toilet, then went to the store for a larger snake. -The facility had notated video camera footage confirming on 07/10/23 at 11:40 AM, the Plant Operations Manager successfully snaked the toilet. -The facility had notated video camera footage confirming on 07/10/23 at 1:29 PM, the CNA went in to clean the room and removed the towels from the bathroom. The video footage confirmed the toilet was snaked 13 minutes after it had been documented as already being completed in the electronic system. The work order indicated the toilet overflowed on 07/09/23 at 10:03 AM, staff laid towels down to attempt to absorb the spillage from the commode and the CNA did not remove the wet towels until approximately 27 hours after the toilet overflowed and cleaned the bathroom floor with a Lysol wipe under the CNA's foot. The facility document titled, Cleaning Essentials, Housekeeping and Laundry Department, Job Expectations and Responsibilities, last updated 07/2019, documented cleaning resident bathrooms included scrubbing and disinfecting the toilet and mopping the floor. Cleaning resident rooms included sweeping and mopping. The facility policy titled, Maintenance Service, last revised 12/2019, documented functions of maintenance personnel included maintaining plumbing fixtures in good working order and establishing priorities in providing repair service. The facility policy titled, Work Orders, Maintenance, last revised 04/2019, documented work order requests were read daily, Monday through Friday. Emergency requests should be called to the Maintenance Director or the Administrator. Emergency requests, such as Life Safety related issues were to be given priority in making necessary repairs. Whenever possible, emergency requests would be completed within two to four hours of normal business hours. On 07/12/23 at 11:46 AM, Owner #1 verbalized the following: -Lysol wipes were an approved hospital disinfectant. -Pointed at a container of Lysol wipes and confirmed the facility used those for disinfecting urine and feces. -Verbalized not knowing if the Lysol wipes were listed on the Environmental Protection Agency (EPA) list D or E of approved disinfectants for bodily fluids and would continue researching. The CDC website documented regardless of the risk-level of an area, spills or contamination from blood or body fluid must be cleaned and disinfected immediately using a two-step process. Use intermediate-level disinfectant. https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html The CDC's publication Biosafety in Microbiological and Biomedical Laboratories, 5th Edition, Health and Human Services (HHS) Publication No. (CDC) 21-1112, revised 12/2009, defined Intermediate-level Disinfection: This procedure kills vegetative microorganisms, including Mycobacterium tuberculosis, all fungi, and inactivates most viruses. Chemical germicides used in this procedure often correspond to Environmental Protection Agency (EPA)-approved hospital disinfectants that are also tuberculocidal. They are used commonly in laboratories for disinfection of laboratory benches and as part of detergent germicides used for housekeeping purposes. The CDC website documented toilets in patient care areas can be shared amongst patients and visitors. They have high patient exposure and were frequently contaminated. Therefore, they posed a higher risk of pathogen transmission than in general patient areas. The recommended method was to clean and disinfect a public or shared toilet area at least twice daily. The high-touch and frequently contaminated surfaces in toilet areas included toilet seats and floors. https://www.cdc.gov/hai/prevent/resource-limited/general-areas.html On 07/12/23 at 2:37 PM, Owner #1 verbalized bleach was not normally used in institutions. On 07/12/23 at 4:52 PM, Owner #1 verbalized the facility did not treat these soils as hazardous. Lysols were more expensive, but they were okay for feces and urine. Every facility used these. The Lysol package of wipes label documented use of the product was a convenient way to clean and disinfect household surfaces. It was a violation of Federal law to use this product in a manner inconsistent with its labeling. The CDC website documented how to read a disinfectant label. The label was to identify directions for use and included it was a violation of Federal law to use this product in a manner inconsistent with its labeling. The label was also to indicate where the disinfectant would be used, such as for disinfection of healthcare organisms. https://www.cdc.gov/hai/pdfs/howtoreadalabel-infographic-508.pdf The CDC website documented to clean spills of body substances, use EPA-registered hospital disinfectants labeled tuberculocidal or registered germicides on the EPA Lists D and E (products with specific label claims for HIV or hepatitis B virus [HBV]) in accordance with label instructions to decontaminate spills of blood and other body fluids. An EPA-registered sodium hypochlorite product is preferred, but if such products were not available, generic versions of sodium hypochlorite solutions (e.g., household chlorine bleach) may be used. Use a 1:100 dilution (500-615 parts per million (ppm) available chlorine) to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings. https://www.cdc.gov/infectioncontrol/guidelines/environmental/recommendations.html On 07/13/23 at 4:16 PM, A CNA delivered a peanut butter and jelly sandwich to Resident #29 for snack, in the resident's room. The resident began to eat it. room [ROOM NUMBER]'s floor was dirty with unknown grimy substance from exiting of the bathroom door. The bathroom floor was dirty with unknown grime substance and the toilet was running. A plung [TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent a resident from drinking hand sanitizer causing the resident to admit to an acute care hospital for alcohol intoxication, create and implement care plans for alcohol withdrawal and suicidal ideation, and complete daily alert charting for behaviors related to alcohol use, alcohol intoxication, and suicidal ideation for 1 of 30 sampled residents (Resident #112). Findings include: Resident #112 Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, moderate, post-traumatic stress disorder, unspecified, and alcohol dependence with withdrawal, unspecified. A Hospital Progress Note dated 12/02/22, documented Resident #112 was admitted to an acute hospital for alcohol withdrawal syndrome without complication, diabetic mellitus type two obese, and alcohol withdrawal. The resident had been sober for seven months and had recently gone on a drinking binge due to stress and homelessness. A care plan dated 02/15/23, documented Resident #112 had a behavior problem related to noncompliance with leave of absence procedures and suspected marijuana and alcohol use. The care plan lacked problem areas and interventions for suicidal ideation and alcohol withdrawal. A Psychiatric Therapy Note, dated 03/16/23, documented Resident #112 stated the resident had considered suicide several times during the last year due to circumstances. A Nursing Progress Note dated 03/31/23, documented the Nurse and Certified Nursing Assistant (CNA) noted an alcohol smell in the room despite the room being sprayed with air freshener visible in the patient's bed. A Nursing Progress Note dated 03/31/23, documented while the nurse was doing wound care the nurse noticed the resident occasionally slurred his words and had a flushed face. The assigned CNA reported to the Nurse the resident had been slurring words at times as well. The Director of Nursing (DON) assessed the resident, noted pupil dilation, and flushed face. Blood tests and a chest X-ray were ordered once the physician was notified. A Nursing Progress Note dated 04/07/23, documented Resident #112 looked different, was sleeping more, and had closed the room door. Two empty containers of hand sanitizer were observed in the resident's room and was reported to the Unit Manager. A Nursing Progress Note dated 04/07/23, documented Resident #112 had extreme somnolence, was lethargic, confused, spoke nonsense, and cried. The resident was observed to have signs and symptoms of suicidal ideation and depression. The resident admitted to drinking a gallon of hand sanitizer to end his life. A Situation Background Assessment and Recommendation (SBAR) note dated 04/07/23, documented Resident #112 had an elevated pulse of 120 beats per minute and an oxygen saturation level of 86%. The change in condition included an altered level of consciousness, increased confusion, social withdrawal, suicide potential, and required 1:1 therapeutic talk with the nurse due to signs and symptoms of suicidal ideation and depression. The provider recommended the resident be sent to the emergency department for evaluation. A Hospital History and Physical dated 04/08/23, documented Resident #112 had drank large quantities of hand sanitizer daily over the past three weeks and the last use was a few hours prior to admitting to the acute hospital. The resident had an elevated ethanol level, and the Poison Control Center was contacted for direction. The resident was admitted for acute alcohol use. A Hospital Physician Progress Note dated 04/08/23, documented Resident #112 reported the resident drank hand sanitizer because of alcohol cravings and had a history of alcohol abuse in the past. The resident wanted to feel better and make the pain go away. A Social Service Note dated 04/10/23, three days after the resident had discharged from the facility, documented a Licensed Social Worker (LSW) assessed Resident #112 for feeling down, depressed and/or hopeless, indicated feeling bad about himself, and stated life was not worth living, wished death, and attempted self-harm. Nursing was already aware of the resident's self-harm behavior of ingesting hand sanitizer on 04/07/23. A Hospital Discharge Summary dated 04/12/23, documented Resident #112 was hospitalized from 04/08/23 through 04/12/23, with a diagnosis of acute alcohol use. The resident had experienced alcohol withdrawals which included symptoms of fatigue and tremors. A Physician Progress Note dated 04/12/23, documented Resident #112 was admitted to an acute hospital for an altered level of consciousness and low oxygen saturation after drinking two bottles of hand sanitizer over a two-week period. The physician documented the resident drank alcohol daily and had alcoholism with alcohol withdrawal and intoxication from acute alcohol use. The recommendation was to encourage alcohol cessation. On 07/13/23 at 7:59 AM, the Unit Manager (UM) explained Resident #112 admitted the resident consumed two large bottles of hand sanitizer in an attempt to suicide. The UM verbalized the facility knew the resident had an alcoholic history and substance abuse problem and there was nothing in place to monitor the resident for alcohol seeking, use, or abuse or for suicidal ideation. The UM explained the investigation of the incident consisted of the creation of an SBAR and sending the resident to the acute hospital. On 07/13/23 at 12:18 PM, the Administrator verbalized the facility could not determine where Resident #112 obtained the hand sanitizer which the resident ingested and was subsequently hospitalized on [DATE]. The Administrator verbalized the Administrator did not perform an investigation of the situation and thought the resident had sufficient supervision with an alcohol-based hand sanitizer because the resident was alert and oriented and knew the hand sanitizer was harmful. The Administrator verbalized the resident was on alert charting and had signed a Behavior Contract to follow facility rules pertaining to smoking and substance use. The Administrator could not produce the Behavior Contract signed by the resident and verbalized the lack of interventions in place for enhanced supervision or alcohol dependence. On 07/13/23 at 12:24 PM, the Administrator in Training (AIT) verbalized the investigation of Resident #112 drinking hand sanitizer consisted of reviewing progress notes, making sure the hand sanitizer dispensers on the walls were locked, and speaking to staff. The AIT did not think the situation warranted an incident report and video footage was not reviewed to ascertain where the large bottles of hand sanitizer came from. The AIT explained the preventive measures used were alert charting and a Behavior Contract for possessing contraband and these measures were not care planned. Alert charting meant the resident's room and person were searched for cigarettes, lighters, and any alcohol and the outcome would be documented. The Behavior Contract included the resident's promise to follow facility policies and allow staff to search the resident's room and/or person, however, the AIT could not verify or produce documentation Resident #112 signed a Behavior Contract. On 07/13/23 at 2:27 PM, an LPN verbalized Resident #112 was on alert charting for drinking hand sanitizer. The LPN explained alert charting meant the resident was observed every two hours for safety and the resident's room was checked for anything with alcohol, hand sanitizer, or anything the resident could use for self-harm. On 07/18/23 at 12:19 PM, Resident #112 verbalized the resident had not signed a Behavior Contract and was unaware of the document or what it specified. On 07/18/23 at 3:44 PM, the UM verbalized alert charting kept the resident safe by providing frequent rounding. The UM explained alert charting meant staff were going into and searching the resident's room for illegal or harmful substances and did not start until after the resident consumed hand sanitizer. On 07/18/23 at 4:20 PM, the Director of Nursing (DON) explained Resident #112 was on alert charting and had a Behavior Contract for smoking and drinking in the facility, however this did not occur until after the resident drank hand sanitizer. The DON confirmed the investigation into the incident included staff interviews and physician notification but did not include an incident report. The DON verbalized the resident's clinical record did not include interventions or preventive measures for hand sanitizer or alcohol consumption and was not sure if the facility would provide such interventions. On 07/24/23 at 9:55 AM, an LSW explained the LSW was aware Resident #112 had a history of suicidal thoughts and alcohol abuse. The LSW verbalized the LSW had made a referral to Behavioral Health Services (BHS) upon the resident's re-admission on 04/12/23, five days after the resident ingested the hand sanitizer, and did not follow up afterwards. The LSW confirmed access to the BHS Physician Progress and Visit Notes and had not been concerned about anything contained in the notes. The LSW acknowledged the LSW may not have read all the BHS notes. The facility policy titled Resident Rights, revised 12/2016, documented the resident had the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. The resident had the right to be treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. A facility policy titled Behavioral Health Services, revised 02/2019, documented staff must promote safety as appropriate for each resident and were trained in ways to support residents in distress. Staff training included recognizing changes in behavior that indicated psychological distress. Residents who exhibited signs of emotional/psychosocial distress would receive services and support that address individual needs and goals for care. A facility policy titled Investigating Injuries, revised 12/2016, documented the Administrator would ensure all injuries were investigated. The DON or a designee would assess all injuries and document clinical findings in the clinical record. If an accident/incident was suspected, a nurse or nurse supervisor would complete a facility-approved accident/incident form. The documentation would include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms. Descriptions in the medical record would be objective and sufficiently detailed and should not speculate about causes. Cross Reference with Tag F742

Based on clinical record review, interview, and document review the facility failed to assess and monitor a resident after the resident began vomiting and had a change in baseline vitals, resulting in acute pain, altered mental status, and death within 26 hours of onset of symptoms for 1 of 14 sampled residents (Resident #10), with failure to identify and prevent further such incidents to residents resulting in immediate jeopardy. Findings include: Resident #10 Resident #10, [AGE] years old, was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, adult failure to thrive, muscle weakness, and repeated falls. A Nursing Note dated [DATE] at 5:52 AM, documented Resident #10 verbalized Resident #10 was not feeling good and had been vomiting. The resident was given ondansetron at 1:00 AM on [DATE]. Blood pressure was documented as ,d+[DATE]. The resident was alert and oriented to person, place, time, and event. The resident vomited again at 2:00 AM and at 3:00 AM on [DATE] and reported headache and dizziness. The resident's Physician was called at 5:32 AM and 5:33 AM on [DATE], with no response. The Assistant Director of Nursing (ADON) was notified at 5:35 AM on [DATE]. A voicemail was left for the Physician at 5:47 AM on [DATE]. The incoming floor nurse was informed of the resident's status, Physician call back status, and to monitor the resident. Ondansetron was indicated for use to prevent nausea and vomiting. The normal range for blood pressure was ,d+[DATE]. On [DATE] at 1:04 PM, the Assistant Director of Nursing (ADON) verbalized the ADON was contacted at 5:35 AM by LPN2 the morning of [DATE], regarding Resident #10's complaints of nausea. The ADON instructed LPN2 to offer ice chips and saltines, notify the Physician, inform the incoming nurse of the resident's symptoms, and ensure the incoming nurse followed up with the Physician. On [DATE] at 4:36 PM, during a telephone interview, LPN2 verbalized LPN2 informed the incoming LPN1 of Resident #10's status the morning of [DATE] and explained LPN2 had left a voicemail for the Physician and was waiting for a return call to discuss further treatment options. On [DATE] at 7:04 PM, during a telephone interview, LPN2 verbalized on [DATE] at 5:47 AM, LPN2 left a voicemail for the Physician to inform the Physician of Resident #10's status and to ask if an intravenous (IV) therapy should be started. LPN2 expected to receive a return call from the Physician with guidance on how to treat the resident. Resident #10's clinical record lacked evidence of a current physician's order for ondansetron for the [DATE] at 1:00 AM administration. A Nursing Note dated [DATE] at 12:34 PM, documented Resident #10 had complaints of nausea and two episodes of yellowish vomit. The Physician was informed and provided orders to start ondansetron 4 milligrams (mg) every six hours as needed. The Medication Administration Record (MAR) lacked evidence the ondansetron was administered on [DATE], after receipt of the physician order on [DATE] at 12:34 PM. On [DATE] at 11:31 AM, a Licensed Practical Nurse (LPN1) verbalized LPN1 had received a report from the night shift on [DATE] at 6:00 AM, Resident #10 was vomiting overnight, and the nurse had attempted to contact the Physician, however no response had been received during the night shift. The resident had vomited again, and LPN1 contacted the Physician at approximately 12:00 PM on [DATE], to obtain an order for ondansetron. LPN1 verbalized the MAR lacked evidence the ondansetron was administered after LPN1 received the order from the physician. LPN1 confirmed there was no evidence in the clinical record the vitals were measured on [DATE] during LPN1's shift from 6:00 AM to 6:00 PM. LPN1 explained LPN1 was responsible for taking the resident's vital signs and monitoring the resident. LPN did not A Nursing Note dated [DATE] at 12:40 AM, documented Resident #10 had an altered mental status and abnormal vital signs. On [DATE] at 11:10 PM, the resident had complaints of 10 out of 10 on a 1 to 10 pain scale for acute, severe back pain. The Physician was notified of the resident's status at 11:41 PM on [DATE]. Blood pressure at this time was ,d+[DATE]. The Physician gave a phone order for Tramadol hydrochloride 50 mg tablet by mouth as needed for pain, one time only. At 11:45 PM on [DATE], the resident vomited. On [DATE] at 12:25 PM, the Physician was notified the resident's blood pressure was ,d+[DATE] and ordered the resident to be sent to the Emergency Department (ED). The resident was transported to the ED at 12:57 AM on [DATE]. The MAR documented Resident #10 was administered a Tramadol hydrochloride 50 mg tablet at 12:53 AM on [DATE]. A Nursing Note dated [DATE] at 2:38 AM, documented the ED called and notified the facility Resident #10 expired from respiratory arrest. On [DATE] at 11:57 AM, the Director of Nursing (DON) verbalized the DON would consider a change of condition to be anything off baseline, such as blood pressure and nursing staff should notify the resident's Physician and the Unit Manager. The Unit Manager should notify the DON of a resident change in condition. The reasonable expectation of Physician response would be within two hours of notification. The protocol for a vomiting resident would be to notify the Physician and obtain orders for ondansetron. The Physician should tell the nurse to continue to monitor the resident and report any changes in vital signs. The Physician would send the resident to the ED if vital signs were not stable or if the vomiting did not subside. The DON explained vitals should be taken at least once a shift and more frequently as needed. The DON confirmed vital signs were not taken for Resident #10 for approximately 22 hours, from [DATE] at 1:00 AM until [DATE] at 11:41 PM. The DON verbalized the resident was not assessed or monitored after the resident began vomiting. The DON confirmed the MAR lacked evidence the ondansetron was administered after the LPN received the order from the Physician. A Weights and Vitals Summary report for Resident #10 documented the following blood pressures: -[DATE] ,d+[DATE] -[DATE] ,d+[DATE] -[DATE] ,d+[DATE] -[DATE] ,d+[DATE] Resident #10's clinical record lacked evidence blood pressure was taken on [DATE] and [DATE]. On [DATE] at 12:35 PM, the Physician verbalized a change in condition was a change in vital signs or a neurological change. Vomiting could be considered a precursor to a change in condition. The Physician would have expected vitals to be taken for the resident throughout the day. The Physician explained the Physician triaged calls and did not respond right away regarding Resident #10. The Physician confirmed the Physician did not respond to the nurse's calls the morning of [DATE]. The Physician was contacted by a nurse and was informed by the nurse the resident was stable with minimal symptoms at approximately 12:00 PM on [DATE]. The Physician ordered ondansetron for the resident's nausea and vomiting at the time. At approximately 4:00 PM on [DATE], the Physician called the facility to check on Resident #10 and was informed the resident was stable. The Physician was contacted again when the resident became unstable. The Physician was informed the resident's vital signs had spiked and the resident had an altered mental status. The Physician ordered transport to the ED. The Physician explained vital signs for the resident throughout the day on [DATE] would have been helpful, however they were not necessary as the nurse had conducted bedside assessments of the resident throughout the day. Bedside assessments included hearing the resident speak to know they were breathing appropriately and to hear if they had an altered mental status. The resident had no trouble breathing and no indication of altered mental status per the nurse. The Physician explained the bedside assessments may not have been charted. On [DATE] at 2:20 PM, the Administrator verbalized the expectation when residents were vomiting was to assess the resident, notify the Physician, interview the resident, and review medications, attempt to determine the cause of vomiting, monitor the resident for distress or change in condition and take baseline vital signs. Vitals should have been taken when medication such as ondansetron was administered. The Administrator would have expected a response from the Physician within two hours of notification of the resident's status. The facility did not have a written protocol for vomiting and as such, the nurses would rely on the resident's Physician to provide additional direction. On [DATE] at 2:20 PM, during the LPN and DON interviews, they failed to recall a conversation with the Physician when the resident was reported stable and bedside assessment had occurred. On [DATE] at 10:31 AM, during a telephone interview, Resident #10's family member verbalized Resident #10 had visited the resident's apartment on [DATE]. The resident had vomited on the bus on the way to the apartment and did not feel well. The resident told the family member the resident had eaten an egg salad sandwich at the facility and thought the sandwich had made the resident ill. On [DATE] in the morning, the family member spoke with the resident over the phone and the resident told the family member the resident was still vomiting. The resident's family member brought the resident ginger ale and chicken noodle soup at approximately 4:30 PM on [DATE]. The resident's family member called the resident later in the day and the resident verbalized the resident had asked to go to the emergency room several times, however the nurse refused and told the resident You don't get to go to the hospital just because you are throwing up. At 9:00 PM on [DATE], the resident texted the family member the resident had eaten some soup. The resident's family member texted the resident at 10:00 PM on [DATE] and did not receive a response. At 12:45 AM on [DATE], the family member received a call from the facility nurse that the resident was confused and was being transported to the ED. The family member received a call from the ED at 1:24 AM on [DATE], informing the family member the resident was not responsive and lifesaving interventions would be discontinued due to a signed Do Not Resuscitate form on file. On [DATE] at 11:15 AM, the LPN1 verbalized a bedside assessment would include taking vital signs, asking the resident if they are in pain or discomfort and documenting the results in the clinical record. LPN1 would not consider hearing a resident speak a bedside assessment. LPN1 confirmed no assessments were completed for Resident #10 on [DATE]. On [DATE] at 12:21 PM, the DON verbalized LPNs were not able to assess, however they were able to observe. A bedside assessment would be conducting a head-to-toe assessment and checking the resident's systems. On [DATE] at 12:38 PM, Resident #10's roommate verbalized Resident #10 was coughing and breathing hard throughout the day and evening on [DATE]. Resident #10 told the roommate the resident had asked to go to the hospital and was told no by LPN1. The roommate informed LPN1 Resident #10 needed to go to the hospital and was told Resident #10 did not need to go to the hospital by LPN1. The facility policy titled Change in a Resident's Condition or Status, revised [DATE], documented the nurse will record the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility policy titled Acute Condition Changes - Clinical Protocol, revised [DATE], documented the healthcare provider will help identify individuals with a significant risk for having acute changes of condition during their stay. The nurse shall assess and document/report baseline information such as vital signs, neurological status, and onset, duration, severity. The nursing staff would contact the health care provider based on the urgency of the situation. The attending healthcare provider would respond in a timely manner to notification of problems or changes in condition or status. The nurse and healthcare provider would discuss and evaluate the situation. The healthcare provider should request information to clarify the situation, for example vital signs. The staff would monitor and document the residents progress and response to treatment. The healthcare provider will help the staff monitor a resident with a recent acute change of condition until the problem has resolved or stabilized. Complaint #NV00067085

Based on observation, interview, record review and policy review the facility failed to initiate a gradual dose reduction or discontinuation of antipsychotic medication (Resident #23) and failed to discontinue duplicate medications for (Resident #4). Findings include: Resident #23 Resident #23 was originally admitted on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Observation in the afternoon of 7/6/15, noted Resident #23 walking around while exhibiting exaggerated, repetitive involuntary rapid mouth/lip movements, tongue thrusting and blinking. Observation in the morning of 7/9/15, the resident was again walking the facility halls exhibiting the same repetitive facial and tongue movements. Review of the clinical record included a physician order dated 12/28/11, for [MEDICATION NAME] 5 mg. (milligrams) by mouth once a day for dementia with behavior disturbances as evidenced by repetitive complaints. Another order dated 5/4/13, indicated the medication was ordered to treat uncontrollable pacing. Resident #23 while in the facility remained on [MEDICATION NAME] 5 mg. for three years, two months and eighteen days when the medication was reduced on 3/18/15, to 2.5 mg daily, and discontinued on 4/9/15. Review of the medication list from a home care agency which indicated the Resident was originally prescribed [MEDICATION NAME] 5 mg. on 12/3/11. Review of the [MEDICATION NAME] pharmaceutical package insert contained a Black Box Warning for INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] and [MEDICATION NAME] is not approved for the treatment of [REDACTED]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. The [MEDICATION NAME] insert further warned of tardive dyskinesia (involuntary movement of lips, tongue, face, and eyes) and described as a potentially irreversible involuntary muscle movement of lips, tongue, face, and eyes where the prevalence appears highest among elderly women. Further, the risk and likelihood the condition will become irreversible is thought to increase as the duration of treatment and total cumulative dose increase. And since there is no known treatment for tardive dyskinesia the medication should be prescribed in such a way to minimize the occurrence and or when less harmful treatments are not available. Review of the Nursing Drug Handbook 2013, adopted by the facility and used as reference by the nurses and confirmed by the Nurse Manager (NM) under the heading Adverse Reactions on page 1003, warned tardive dyskinesia and extrapyramidal (involuntary movement) events are associated with the use of [MEDICATION NAME]. Under the heading Contraindications and Cautions on page 1004, the Black Box Warning cautioned against administering the medication to the elderly with dementia. A review of a Northern Nevada Adult Mental Health Services (NNAMHS) clinical record dated 12/1/11, indicated the tongue thrusting behavior associated with tardive dyskinesia was diagnosed by the psychiatrist just before the resident was originally admitted to the facility on [DATE]. Review of the facility consulting psychiatrist's progress note dated 2/7/12, indicated the resident exhibited t.d. (tardive dyskinesia) tongue and continued [MEDICATION NAME] 5 mg. daily. A 6/25/13, note documented, continue psych (psychiatric) meds (medications). A 9/9/13, note documented, no adjustment to [MEDICATION NAME]. A 7/31/14, note read continue [MEDICATION NAME] 5 mg. for same dx (diagnosis)/AEB (as evidenced by) because pt. (patient) is calm and contented even tho (though) the med (medication) causes [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION]. The 1/6/15, note revealed a recommendation to try to discontinue [MEDICATION NAME] in the future, yet [MEDICATION NAME] was not discontinued for another three months on 4/9/15, where the note indicated, the less unnecessary meds (medications), the better the existing can enhance. Review of the Medication Administration Record [REDACTED]. The record also failed to identify non-pharmacological interventions for identified behaviors. Review of the nurse's notes, attending physician and nurse practitioner notes, social services and activity periodic reviews lacked evidence of documented behaviors until a recent nurse's note dated 6/9/15, the day of readmission, indicating the resident demonstrated lip smacking. A communication note dated 6/12/15, requested that the resident be seen by the physician assistant (PA) for tongue protrusion. The PA signed the communication on 6/13/15 and subsequently documented in the progress note, tongue thrusting. The note also included a [DIAGNOSES REDACTED]. Review of the Abnormal Involuntary Movement Scale (AIMS) test performed on 12/23/11, 6/22/12, 12/19/12, 6/17/13, 12/17/13, 6/16/14 and 12/24/14 indicated the resident scored zero in each category. Review of the consulting pharmacist notes revealed recommendations for medication reduction on [MEDICAL CONDITION] medications such as [MEDICATION NAME], Donepezil, [MEDICATION NAME], and Klonopin however the record lacked evidence of a recommendation to reduce or discontinue [MEDICATION NAME]. Review of the Interdisciplinary Team (IDT) meeting minutes dated, 12/25/13 (annual), 3/2014, 6/2014, 9/2014, 12/2014 (quarterlies) included, behavior monitoring and [MEDICATION NAME] for dementia with agitated features. The minutes lacked evidence of a discussion about reducing or discontinuing [MEDICATION NAME]. An interview with the Director of Nurses (DON) at 7:00 AM on 7/9/15, acknowledged a dose reduction of [MEDICATION NAME] was not attempted until 3/18/15 when reduced to 2.5 mg. The DON indicated the reduction of [MEDICAL CONDITION] was beyond the DON's control. The DON further indicated Resident #23 was not diagnosed with [REDACTED]. and [DIAGNOSES REDACTED]. An interview with the NM in the afternoon of 7/8/15, indicated the resident was not exhibiting tongue thrusting before being hospitalized in June 2015, yet stated, now does this more than ever. An interview with the Minimum Data Set Coordinator (MDSC) in the afternoon of 7/8/15, acknowledged the tardive dyskinesia [DIAGNOSES REDACTED]. The MDSC submitted pre-acute care admit (6/4/15) care plans for side effects related to [MEDICATION NAME] that identified extrapyramidal movements. The care plans directed the nurse to monitor for extrapyramidal movements. The MDSC confirmed tardive dyskinesia is a side effect of [MEDICATION NAME]. Review of the facility policy titled, Adverse Consequences and Medication-Related Problems dated April 2007, indicated the facility evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. The policy defined an adverse drug reaction as a secondary and usually undesirable effect of a drug. and an adverse consequence as an unpleasant symptom or event due to or associated with a medication. Review of the facility policy titled, Chemical Restraint Protocol undated under the heading Antipsychotics indicated the facility must attempt a dose reduction in two quarters separated by one month with in the first year of admission. And, the reduction must be attempted annually thereafter. The policy further indicated, Antipsychotic med (medication) can't be used for: wandering., impaired memory, anxiety [MEDICAL CONDITION],agitated behaviors. Review of the facility policy titled, Guidelines on [MEDICAL CONDITION] Medication Review dated 4/15/15, indicated [MEDICAL CONDITION] medication was reviewed at least quarterly by the (IDT) to ensure the least dose is used to manage identified target behaviors. Resident #4 Resident #4 was admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. Observations of Resident #4 while watching television on 07/06/15 at 8:15 AM, revealed the resident was able to move the upper extremities limitedly, adjust position in bed and use the television remote control. An interview with Resident #4 on 07/06/15 at 2:15 PM, revealed the resident did not feel depressed, or had difficulty with sleeping. The resident did not have any issues with care or treatments received. Resident #4 stated an understooding all of the [DIAGNOSES REDACTED]. Resident #4's record showed an order for [REDACTED]. Resident #4's records showed the resident had been on [MEDICATION NAME], classified as an antidepressant, since the original admission of 01/14/10 at 150 mg every night with no evidence of a dose reduction until 01/05/15. Social services assessments for depression on 09/22/14, 12/06/14 and 01/05/15 showed no evidence of depression. The medical record also showed the resident had been on the following hypnotic medications: [REDACTED] -[MEDICATION NAME] 30 mg as needed at night during the previous admission. -Ambien 5mg on 11/08/14. -Ambien 10 mg on 02/11/15. -[MEDICATION NAME] 30 mg on 07/06/15, then increased to a routinely at night. Nursing documentation from 09/22/14 to 01/05/15, showed the resident had six to eight hours of sleep per night. Facility policy titled, Chemical Restraint Protocol dated 04/15/15, showed antidepressants for [DIAGNOSES REDACTED]. Dose reduction must be attempted in two quarters then annually. Facility policy titled, Chemical Restraint Protocol, dated 04/15/15, indicated hypnotics (sleeping medications) must be attempted to be taper at least quarterly.