Every finding on record at Anaheim Point

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate GT care and services were provided for two nonsampled residents (Residents 88 and 149). * The facility failed to ensure RN 1 checked the GT residual prior to flushing the GT with water for Resident 88. In addition, RN 1 failed to administer the water flush and diluted medications via GT by gravity flow as per the facility's P&P. * The facility failed to ensure LVN 2 put the TF (tube feeding) on hold prior to checking the GT residual and flushing the GT with water; and prior to administering the medications for Resident 149. In addition, LVN 2 failed to administer the diluted medications via GT by gravity flow as per the facility's P&P. These failures placed the residents at risk for complications related to GT use, including tube dislodgement or gastrointestinal injury.Findings: Review of the facility's P&P titled P-NP135 Enteral Tube Management: Gastrostomy Tube-Jejunostomy Tube revised 9/28/23, showed the following:- Enteral tubes should be verified for placement and patency prior to intermittent feeding, at every shift, and prior to administering medications, hydration, and nutrition via enteral feeding tubes; and- Check for correct placement of gastrostomy & jejunostomy feeding tube using the following method:a. Withdrawal of Gastric & Jejunum Contents;b. Connect the syringe to the end of the tube;c. Slowly pull back the syringe to aspirate contents;d. Note the characteristics of syringe contents: amount, color, and texture;e. Return aspirated contents to the stomach;f. If gastric or jejunum content cannot be withdrawn, ask the resident to lie on his or her left side and attempt to aspirate again;g. If gastric or jejunum contents still cannot be aspirated, wait one (1) hour and repeat aspiration procedure. Note the tube may become obstructed with gastric contents, feeding formula, or crushed medication, making aspiration difficult. The tube may be in the stomach but above the level of gastric contents making aspiration impossible; andh. If correct placement is not completely assured, do not administer feeding or medication. Contact Physician for further instruction. Review of the facility's P&P titled P-NP47 Feeding Tube-Administration of Medication revised 5/30/24, showed the following:- If continuous or intermittent feeding is infusing, stop the feeding as follows:a. If the medication can be given with food, stop the feeding immediately before administering medications.b. If the medications have to be given on an empty stomach, stop the feeding 30 minutes before administering medications.c. If the medications are incompatible with the feeding product stop the feeding 1 to 2 hours before administering medications and according to manufacture instruction;- Verify tube placement via aspiration method. Return aspirate to stomach;- Flush tube with 15 ml (unless a different amount is specified by the physician/prescriber) of water before administering medication. Medication should not be mixed because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses;- Between each medication, the tube is flushed with 15 ml of water, keeping in mind the patient's fluid volume status (unless a different amount is specified by the physician/prescriber); and - Administer medication by syringe via gravity into the feeding tube. 1. On 6/17/26 at 0905 hours, a medication administration observation for Resident 88 was conducted with RN 1. The following were observed with RN 1:- RN 1 did not check the GT residual for Resident 88 prior to flushing the GT with 30 ml of water;- RN 1 attempted to flush the GT with 30 ml of water for the second time but water was not flowing down the GT. RN 1 used the syringe plunger to push the 30 ml of water into the GT rather than allowing gravity flow; and- RN 1 used the same technique of using the syringe plunger to push the multivitamins (supplements) and Senna (laxative) when the medications were not flowing down the GT. On 6/17/26 at 0940 hours, an interview and concurrent medical record review for Resident 88 was conducted with RN 1. RN 1 verified the findings above for Resident 88. RN 1 stated she should have checked the residual prior to attempting to flush the GT with water to make sure the residual amount was not on the amount where she would need to hold the GT feeding and medication administration. RN 1 stated it was also a way to verify the GT placement. RN 1 stated the medications should be allowed to flow by gravity and she should have checked the patency of the GT when the medications were not flowing down the GT. RN 1 stated Resident 88 was getting 40 ml of water flush via GT every hour. 2. On 6/17/26 at 0817 hours, a medication administration observation and concurrent interview for Resident 149 was conducted with LVN 2. The following were observed with LVN 2:- LVN 2 was observed checking the GT residual of Resident 149 and flushed back the aspirated 10 ml residual to the GT while the TF pump was still on;- LVN 2 was about to administer the first diluted medication via GT to Resident 88 while the TF pump was still on. LVN 2 was stopped and was asked if she needed to hold the TF. LVN 2 stated she should have put the TF on hold prior to checking the GT residual. LVN 2 put the TF pump on hold and proceeded with the medication administration;- LVN 2 administered the first medication, valproic acid liquid (antiseizure) without flushing the GT first with water; and- LVN 2 administered the diluted Namenda (medication for severe dementia) medication and added 5 ml of water to the GT but the medication did not flow down the GT. LVN 2 then added the diluted folic acid (vitamin) medication and added 5 ml of water. The medications were observed not flowing down the GT. LVN 2 used the syringe plunger to push the medications into the GT rather than allowing gravity flow. On 6/17/26 at 0855 hours, an interview and concurrent medical record review for Resident 149 was conducted with LVN 2. LVN 2 verified the above findings for Resident 149. LVN 2 stated the GT should be flushed with 15 ml of water before administering the medications. LVN 2 further stated she should have let the medications flow to the GT by gravity or have checked for the patency if the medications were not flowing down. On 6/17/26 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 88 and 149 during the medication administration observation. Cross reference to F726.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents for unnecessary medications (Resident 6), and two of 29 final sampled residents (Residents 5 and 13) were free from the unnecessary psychotropic medications. * The facility failed to ensure the behavior manifestation related to the use of Risperdal (antipsychotic) medication was monitored for Resident 5. In addition, the resident's psychoactive summary sheet for May 2026 did not match the behavior monitored. * The facility failed to ensure Resident 6 was provided with nonpharmacological interventions when the resident exhibited the behavior manifestation related to the use of the quetiapine (antipsychotic) medication. * The facility failed to ensure Resident 13 was monitored for the behavior manifestation related to the use of the clonazepam (antianxiety) medication as per the physician's order. These failures had the potential for the residents to receive unnecessary psychotropic medication and cause the provider to have incomplete information in determining the psychotropic medication dose adjustments. Findings: Review of the facility's P&P titled P-NP106 Behavior/Psychoactive Medication Management dated 1/30/26, the Policy Interpretation and Implementation section showed the following: - The licensed nurse collaborates with the healthcare practitioner, family, resident, resident representative, and/or IDT members, to identify the contributing factors related to the resident's mood/behavior and the non-medication interventions to be implemented; - The medication maintains or improves the resident's functional capacity; - The IDT will reassess the effectiveness of the psychoactive medication at least quarterly during the IDT care plan meeting, or psychoactive behavior management committee; and - Residents have the right to be free from chemical restraints. 1. Medical record review for Resident 5 was initiated on 6/16/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/18/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Order Summary Report showed a physician's order dated 3/30/26, to administer Risperdal one mg one tablet by mouth two times a day for psychosis as manifested by sudden angry outburst. Review of Resident 5's MAR for May and June 2026 showed Resident 5 was administered the Risperdal medication on the following dates and times: - dated 5/1 to 5/31/26 at 0900 hours and 1700 hours; and - dated 6/1 to 6/17/26 at 0900 hours and 1700 hours, and 6/18/26 at 0900 hours. Review of Resident 5's Psychoactive Summary Sheet for May 2026 showed for the Risperdal medication and the behavior manifestation of sudden angry outburst, Resident 5 was observed with one behavior episode on 0700 to 1500 hours (morning) shift. Further review of Resident 5's medical record did not show if Resident 5 was monitored for psychosis as manifested by sudden angry outburst as the target behavior related to the use of the Risperdal medication as per the physician's order. On 6/18/26 at 1523 hours, an interview and concurrent medical record review for Resident 5 was conducted with the ADON. The ADON verified the above findings. The ADON stated when the physician's order for the Risperdal medication was updated, the monitoring for the target behavior should have been updated as well. The ADON stated the target behaviors for the specific antipsychotic medication should be monitored and documented in the MAR. The ADON further stated the monthly psychoactive summary sheet should match the target behavior being monitored as per physician's order. 2. Medical record review for Resident 6 was initiated on 6/16/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 8/15/25, showed Resident 6 did not have decision making capacity. Review of Resident 6's Order Summary Report, showed the physician's orders dated 4/25/26 for the following: - to administer quetiapine fumarate 25 mg one tablet by mouth at bedtime for schizoaffective disorder as manifested by striking out; and - to monitor target behaviors for the use of quetiapine due to schizoaffective disorder as manifested by striking out. Indicate the number of behavior occurrences followed by the nonpharmacological interventions (NPI) provided. If no behaviors select not applicable for NPI, then Yes or No for effectiveness every shift. NPI: 1=Music/TV; 2=Redirect/divert; 3=Call family/resident representative to talk or visit with resident; 4=Toilet; 5=1:1 Conversation; 6= Reassure/orient; 7=Assess pain/infection; 8=Offer drink/snack; 9=Quiet environment; 10 Walk/wheel resident; 11=Activity/Exercise; or 12 Massage/back rub. Review of Resident 6's MAR for May and June 2026 showed the following: - Resident 6 was administered with quetiapine medication from 5/1 to 5/31/26 at 2100 hours; - Resident 6 was administered with quetiapine medication from 6/1 to 6/18/26 at 2100 hours; Further review of Resident 6's MAR for May and June 2026 showed Resident 6 was observed with the target behavior for the use of quetiapine medication due to schizoaffective disorder as manifested by striking out on the following dates and shifts: - dated 5/1/26, in the evening shift; - dated 5/3/26, in the morning and evening shifts; - dated 5/9 and 5/10/26, in the evening shift; - dated 5/11 and 5/12/26, in the morning shift; - dated 5/22/26, in the morning shift; - dated 5/24/26, in the evening and night shifts; - dated 5/29/26, in the evening shift; - dated 6/2/26, in the morning shift; - dated 6/12/26, in the evening shift; and - dated 6/14/26, in the morning shift. Further review of Resident 6's medical record did not show documented evidence if the nonpharmacological interventions were implemented when the resident had the above behavior episodes. On 6/19/26 at 1102 hours, an interview and concurrent medical record review for Resident 6 was conducted with the ADON. The ADON verified the above findings. The ADON stated it was important to implement or provide nonpharmacological interventions to determine if the behavior could be alleviated without using the chemical intervention. On 6/19/26 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 5 and 6. 3. Medical record review for Resident 13 was initiated on 6/16/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed the following physician's orders: - dated 5/20/26, to monitor the target behaviors for use of the clonazepam medication due to anxiety as manifested by verbalization of feeling anxious; and - dated 6/4/26, to administer clonazepam one mg one tablet by mouth every eight hours as needed for anxiety as manifested by increased agitation for 14 days. Review of Resident 13's MAR for June 2026 showed the following: * Resident 13 was administered the clonazepam medication on 6/2/26 at 0529 and 2050 hours, and 6/3/26 at 1726 hours; and * Resident 13 was monitored for anxiety manifested by verbalization of feeling anxious as the target behavior related to the use of the clonazepam medication from - 6/1 to 6/5/26, on the day, evening and night shifts; - 6/6/26, on the day and evening shifts; and - 6/7 to 617/26, on the day, evening and night shifts. Further review of Resident 13's medical record did not show if Resident 13 was monitored for anxiety manifested by increased agitation as the target behavior related to the use of the clonazepam medication as per the physician's order on 6/4/26. On 6/18/26 at 0849 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated when the physician order for the clonazepam medication was updated, the monitoring for the target behavior should have been updated as well. On 6/18/26 at 1505 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON verified the above findings.

Based on observation, interview, document review, and facility P&P review, the facility failed to ensure the kitchen and front dining room were free of pests. * The facility failed to ensure there was no cockroach the kitchen. * The facility failed to ensure there was no gnat flying in front dining room. These failures posed the risk of contamination of the food prepared in the kitchen and of the front dining room for 127 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix dated 6/16/26, showed 127 residents received food prepared in the kitchen. According to the USDA Food Code 2022, 6-501.111, Controlling Pests, showed insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised 1/2012 showed to ensure the facility is free of insects, rodents and other pests that could compromise the health, safety and comfort of residents, facility staff and visitors, and the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents and other pests. 1. Review of the facility's pest control reports dated 3/21, 4/23, and 5/26/26, showed the facility kitchen interior had been treated for cockroaches. Under the structural concerns the pest control reports showed the following: - dated 3/21/26 and 5/26/26, the rear door had a hole/gap that needed to be sealed off; and - dated 4/23/26, the rear door needs attention. Gaps on both right and left side of frame. Door sweep needed replacement to sit flush to the floor. On 6/16/26 at 1134 hours, during the lunch meal preparation observation in the kitchen, a cockroach ran across the kitchen floor next to the oven. [NAME] 2 verified she saw the cockroach. On 6/16/26 at 1600 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the facility had an outside pest control company who would treat the facility for cockroaches monthly. The Maintenance Director stated the kitchen employees could contact him if they saw any pests in the kitchen. The Maintenance Director stated he was not aware of any cockroaches in the kitchen nor had he been contacted by the kitchen employees regarding cockroaches in the kitchen. On 6/16/26 at 1611 hours, an interview was conducted with [NAME] 2. [NAME] 2 stated if she saw any pests in the kitchen, she would inform the DSS then he would contact the pest company. [NAME] 2 confirmed she had not informed the DSS of any cockroaches in the kitchen. 2. On 6/16/26 at 1242 hours, during the dining observation in the front dining room, a gnat was observed flying around the dining room and subsequently landed on a resident's cup of ice cream. LVN 3 verified the above findings. LVN 3 was observed disposing the contaminated ice cream. On 6/18/26 at 1420, an interview and concurrent facility document review was conducted with the Maintenance Director and Administrator. When asked about the gnats in the dining room, the Maintenance Director stated there were no reports of gnats in the resident rooms nor in the dining room. The Maintenance Director stated the pest prevention company came on 5/20, 5/26, and 6/17/26, to which he showed the pest control company service reports. Review of the service reports conducted by the pest control company dated 5/20, 5/26, and 6/17/26, did not show an inspection by the pest control company was conducted in the front dining room.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five sampled residents for unnecessary medications (Residents 2, 6, and 13), and three of 29 final sampled residents (Residents 3, 11, and 61) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure Resident 2's informed consent for the quetiapine (antipsychotic medication) was signed by the resident or resident's representative. In addition, the facility failed to ensure Resident 2's informed consent for the trazadone medication was verified by two licensed nurses when the resident's representative gave consent via telephone. * The facility failed to ensure Resident 3's informed consents for the duloxetine and escitalopram (antidepressant) medications showed whether the duloxetine and escitalopram medications were off-label use, and FDA-approved use. * The facility failed to ensure Resident 6's informed consent for the quetiapine medication included the diagnosis, manifested behavior, and duration for the use of the medication as per the physician's order. * The facility failed to ensure Resident 11's informed consent for the alprazolam (antianxiety) medication was signed by the resident or resident's representative. * The facility failed to ensure Resident 13's informed consent for the trazodone (antidepressant) medication was signed by the resident. In addition, the facility failed to ensure Resident 13's informed consent for the clonazepam (antianxiety) medication showed whether the clonazepam medication was off-label use and FDA-approved use * The facility failed to ensure Resident 61's informed consents for duloxetine (antidepressant) and trazodone medications showed the caution and warning summary to show whether the duloxetine and trazodone medications had any off-label use, FDA-approved use, and black box warning label. These failures posed the risk of the residents receiving the psychotropic medications without a valid informed consent resulting in a loss of autonomy and self-determination regarding treatment decisions, and the risk of the residents and their responsible parties not understanding the required information related to the use of psychotropic medications. Findings: 1. Review of the AFL 25-38.1, titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed effective 1/1/26, the Psychotherapeutic Drug Informed Consent Form or equivalent in-house form must be used for new residents, residents being prescribed a new psychotherapeutic drug, or residents having a psychotherapeutic drug dosage change. The Psychotherapeutic Drug Informed Consent Form Instruction Sheet showed, under the Caution and Warning Summary section, it is required to answer yes or no for each item (a) off-label use, (b) FDA-approved use, and (c) black box [NAME] label, and the form will be completed by.entering the use and benefits of the psychotherapeutic drug, and the resident or resident's representative is required to read and sign the form. The licensed nurse is only required to sign if the resident or resident's representative is unable to read and sign the form. Review of the facility's P&P titled Behavior/Psychoactive Medication Management dated 1/30/26, showed the facility must obtain a resident's written informed consent for treatment using psychoactive drugs and consent renewal every six months. Review of the facility's P&P titled Informed Consent dated 1/30/26, showed the following: - The licensed nurse will confirm the healthcare practitioner obtained informed consent and will document the verification in the resident's medical record, before administering the first dose or first increased dose of psychoactive medications, applying restraints or medical devices; and - The licensed nurse will contact the healthcare practitioner to request the practitioner obtain the informed consent, if the licensed nurse is unable to verify the healthcare practitioner obtained informed consent from the resident or decision-maker. Medical record review for Resident 13 was initiated on 6/16/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed the following physician's orders dated: - 5/20/26, to administer trazodone 100 mg one tablet by mouth at bedtime for depression manifested by difficulty sleeping; and - 6/4/26, to administer clonazepam 1 mg one tablet by mouth every eight hours as needed for anxiety manifested by increased agitation for 14 days. Review of Resident 13's Psychotherapeutic Drug Informed Consent Form dated 5/20/26, for the trazodone medication, did not show Resident 13's signature. Further review of the informed consent form showed the licensed nurses did not verify if an informed consent for the trazodone medication was obtained from Resident 13. Review of Resident 13's Psychotherapeutic Drug Informed Consent Form dated 5/20/26, for the clonazepam medication, did not show the Caution and Warning Summary section was completed. The form only showed the medication had a black box warning label but did not show whether the clonazepam medication was off-label use and FDA-approved use. Review of Resident 13's MAR for June 2026 showed the following: - Resident 13 was administered the trazodone medication from 6/1 to 6/17/26, at 2100 hours; and - Resident 13 was administered the clonazepam medication on 6/2/26 at 0529 and 2050 hours, and on 6/3/26 at 1726 hours. On 6/18/26 at 0849 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 2. RN 2 verified the above findings. On 6/18/26 at 1505 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON verified the above findings. 2. Medical record review for Resident 61 was initiated on 6/16/26. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Order Summary Report showed the following physician's orders dated 6/2/26: - To administer trazodone 50 mg one tablet by mouth at bedtime for depression manifested by difficulty sleeping; and - To administer duloxetine 60 mg one tablet by mouth one time a day for depression manifested by persistent feeling of sadness. Review of Resident 61's Psychotherapeutic Drug Informed Consent Form dated 6/2/26, for the trazodone medication, did not show the Caution and Warning Summary section was completed to show whether the trazodone medications had any off-label use, FDA-approved use, and black box warning label. Review of Resident 61's Psychotherapeutic Drug Informed Consent Form dated 6/2/26, for the duloxetine medication, did not show the Caution and Warning Summary section was completed. The form only showed the medication had a black box warning label but did not show whether the duloxetine medication was off-label use and FDA-approved use. Review of Resident 61's MAR for June 2026 showed the following: - Resident 61 was administered the trazodone medication from 6/1 to 6/17/26 at 2100 hours; and - Resident 61 was administered the duloxetine medication on 6/3 to 6/18/26 at 1800 hours. On 6/18/26 at 0835 hours, an interview and concurrent medical record review for Resident 61 was conducted with RN 2. RN 2 verified the above findings. On 6/18/26 at 1444 hours, an interview and concurrent medical record review for Resident 61 was conducted with the DON. The DON verified the above findings. 3. Medical record review for Resident 3 was initiated on 6/16/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed the following physician's orders dated 5/13/26: - To administer duloxetine 60 mg one tablet by mouth two times a day for depression manifested by persistent feeling of sadness; and - To administer escitalopram 10 mg one tablet by mouth at bedtime for depression manifested by persistent feeling of sadness. Review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 5/12/26, for the duloxetine medication, did not show the Caution and Warning Summary section was completed. The form only showed the medication had a black box warning label but did not show whether the duloxetine medication was off-label use and FDA-approved use. Review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 5/12/26, for the escitalopram medication, did not show the Caution and Warning Summary section was completed. The form only showed the medication had a black box warning label but did not show whether the escitalopram medication was off-label use and FDA-approved use. Review of Resident 3's MAR for June 2026 showed the following: - Resident 3 was administered the duloxetine medication from 6/1 to 6/17/26 at 0900 and 1700 hours, and on 6/18/26 at 0900 hours; and - Resident 3 was administered the duloxetine medication on 6/1 to 6/17/26 at 2100 hours. On 6/18/26 at 0919 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 2. RN 2 verified the above findings. On 6/18/26 at 1517 hours, an interview and concurrent medical record review for Resident 61 was conducted with the DON. The DON verified the above findings. 4. Medical record review for Resident 2 was initiated on 6/16/26. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 5/5/26, showed Resident 2 was unable to understand and make treatment decisions due to dementia. Review of Resident 2's Order Summary Report, showed the following physician's orders: - dated 5/5/26, to administer quetiapine fumarate 150 mg one tablet by mouth at bedtime for psychosis as manifested by sudden angry outburst; and - dated 5/5/26, to administer trazadone 100 mg one tablet by mouth at bedtime for depression as manifested by inability to sleep. Review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 2/25/26, for the quetiapine medication, showed the informed consent was given by the resident but did not sign the consent and only one licensed nurse verified the informed consent. Review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 2/26/26, for the trazadone medication, showed the informed consent was given by the resident's representative via telephone. Further review of the informed consent form showed only one licensed nurse verified the informed consent. Review of Resident 2's MAR for June 2026 showed: - was administered with quetiapine medication from 6/1 to 6/18/26 at 2100 hours; and - was administered with trazadone medication from 6/1 to 6/18/26 at 2100 hours. On 6/19/26 at 1007 hours, an interview and concurrent medical record review for Resident 2 was conducted with the ADON. The ADON verified the informed consent form for the quetiapine medication showed the resident did not sign the consent. The ADON stated Resident 2 at times refused to sign the documents but gave the verbal consent. The ADON stated ideally if the resident gave the informed consent verbally, but refused to sign the form, two licensed nurses should verify it. The ADON also verified the informed consent form for the trazadone medication showed the resident's representative gave the informed consent via telephone; however, only one licensed nurse verified the informed consent. The ADON stated two licensed nurses were supposed to verify the informed consent when the consent was given via telephone. 5. Medical record review for Resident 6 was initiated on 6/16/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 8/15/25, showed Resident 6 had no decision making capacity. Review of Resident 6's Order Summary Report showed a physician's order dated 4/25/26, to administer quetiapine fumarate 25 mg one tablet by mouth at bedtime for schizoaffective disorder as manifested by striking out. Review of Resident 6's Psychotherapeutic Drug Informed Consent Form dated 4/25/26, for the quetiapine medication, under the Reason for Use of Psychotherapeutic Drug and Benefits section, the form did not include the diagnosis and behavior manifestation related to the use of quetiapine medication. In addition, the form did not show the duration for the quetiapine medication. Review of Resident 6's MAR for June 2026 showed Resident 6 was administered with quetiapine medication from 6/1 to 6/18/26 at 2100 hours. On 6/19/26 at 1140 hours, an interview and concurrent medical record review for Resident 6 was conducted with the ADON. The ADON verified the informed consent for the quetiapine medication did not include the diagnosis and behavior manifestation related to the use of the medication, as well as the duration for the use of the medication. The ADON stated the informed consent for the psychotropic medications should show the diagnosis, behavior manifestation, and the duration for the use of the medication as per physician's order. 6. Medical record review for Resident 11 was initiated on 6/16/26. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's Psychotherapeutic Drug Informed Consent Form dated 5/13/26, showed for the alprazolam medication, the informed consent was given by the resident but did not sign the consent and only one licensed nurse verified the informed consent. Review of Resident 11's H&P examination dated 5/19/26, showed Resident 11 had no capacity to understand and make decisions. Review of Resident 11's Order Summary Report showed a physician's order dated 6/13/26, to administer alprazolam 0.25 mg one tablet via GT (gastrostomy tube, a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications) every 12 hours as needed for anxiety as manifested by verbalization of feeling anxious for 14 days. Review of Resident 11's MAR for June 2026, showed Resident 11 was administered with alprazolam medication on the following dates and time: - 6/3 at 2156 hours, - 6/4 at 2130 hours; - 6/6 at 2350 hours, - 6/8 at 0006 hours; - 6/9 at 0430 hours; - 6/10 at 2143 hours; and - 6/14 at 0048 hours. On 6/18/26 at 1435 hours, an interview and concurrent medical record review for Resident 11 was conducted with the ADON. The ADON verified the informed consent form for the alprazolam medication showed the resident or resident's responsible party did not sign the consent. On 6/19/26 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 2, 6, and 11.

Based on observation and interview, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to protect the residents' clean linen from dust and contamination when the employee personal belongings were stored in the clean linen folding area. * The facility failed to ensure LVN 1 performed hand hygiene and changed gloves before administering the eye drop medications to Resident 25 after contact with potentially contaminated surfaces. * The facility failed to ensure RN 1 performed hand hygiene and changed gloves before administering the insulin medication to Resident 88. These failures posed the risk of infection, cross-contamination and the transmission of disease-causing microorganisms to highly vulnerable residents. Findings: 1. According to CDC, under the Linen and Laundry Management section dated 9/19/24, the best practices for management of clean linen included sorting, packaging, transporting, and storing clean linen in a manner that prevents risk of contamination by dust, debris, soiled linen or other soiled items. Review of the facility's P&P titled Laundry Services dated 1/1/12, showed when the facility operates its own laundry, the laundry is maintained in a clean and sanitary condition. On 6/16/26 at 1516 hours, an observation of the laundry area and concurrent interview was conducted with the Housekeeping Supervisor. The following were observed: - the clean storage area for blankets was observed with a black purse on top of a blanket, and also a book was observed on top of another folded blanket; and - the clean storage area for blue underpads was observed with a bag used to store the underpads; however, the bag used to store the underpads was worn and damaged. In addition, a white binder, sewing kit, small container of grape jelly, black plastic folder, roll of tissue and a small cup were observed stored within the storage area for blue underpads. The Housekeeping Supervisor verified the above findings. On 6/18/26 at 1527 hours, an interview was conducted the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Hand Hygiene revised 9/1/20, showed the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel). Wearing gloves does not replace the need for hand hygiene. On 6/17/26 at 1012 hours, a medication administration observation for Resident 25 was conducted with LVN 1. LVN 1 touched the privacy curtain in Resident 25's room with his gloves on and proceeded in administering the eye drop medication to Resident 25. After administering Resident 25 all his oral medications, LVN 1 donned a pair of gloves without performing hand hygiene and proceeded to administer the second eye drop medication to Resident 25. On 6/17/26 at 1030 hours, an interview was conducted with LVN 1. LVN 1 acknowledged he did not perform hand hygiene and changed gloves before he administered the eye drop medications to Resident 25 after he touched the privacy curtain and administered all the oral medications. LVN 1 stated he should have performed hand hygiene and donned new pair of gloves for infection prevention. 3. On 6/17/26 at 0905 hours, a medication administration observation for Resident 88 was conducted with RN 1. RN 1 was observed administering the insulin injection to Resident 88's right upper arm immediately after she administered all the resident's medications via GT without performing hand hygiene and changing gloves. On 6/17/26 at 0940 hours, an interview was conducted with RN 1. RN 1 acknowledged she did not perform hand hygiene before administering the insulin injection to Resident 88. On 6/18/26 at 0948 hours, an interview was conducted with the IP. The IP stated the licensed nurses were expected to perform hand hygiene and change with new pair of gloves after touching the potentially contaminated surfaces in the resident's room before administering medications to prevent cross contamination. The IP was informed and acknowledged the above findings for Residents 25 and 88. On 6/19/26 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 25 and 88.

Based on observations, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of four sampled residents (Residents 8, 126, and 148) reviewed for respiratory care. * The facility failed to ensure Resident 8 and 148's oxygen were administered as per the physician's order. * The facility failed to ensure Resident 126's Yankauer suction tip was stored in a set-up bag when not in use. In addition, the facility failed to ensure Resident 126 was assessed and provided education on how to independently suction herself, and how to store the Yankauer suction when not in use. These failures posed the risk for the residents to develop complications related to oxygen and suction use. Findings: Review of facility's P&P titled Oxygen Therapy effective 10/31/25, showed in part, administer oxygen and obtain oxygen saturation as ordered by the provider. If the oxygen saturation falls below the level identified by the provider, the provider will be notified immediately. Humidification of oxygen is not necessary unless more the 4 liters per minute is ordered, or the resident requests humidification for liter flow of 4 liters per minute or below. Oxygen equipment shall be maintained. The tubing and mask should be changed at least every 7 days and labeled with the date of change. 1. On 6/16/26 at 1611 hours, during the initial tour of facility, Resident 8 was on her bed receiving oxygen at a rate of 3.5 liters per minute per nasal cannula using the oxygen concentrator. Medical record review for Resident 8 was initiated on 6/17/26. Resident 8 was initially admitted to facility on 6/4/25, and readmitted on [DATE]. Review of Resident 8's Order Summary Report dated 6/18/26, showed a physician order dated 6/13/26, for oxygen at a rate of 2 liters per minute via nasal cannula to keep oxygen saturation at 94% or above every shift. On 6/17/26 at 1015 hours, a follow up observation for Resident 8 and concurrent interview was conducted with LVN 5. LVN 5 verified the oxygen was set at a rate of 3.5 liters per minute. LVN 5 stated only the RN change the setting of the oxygen. 2. On 6/16/26 at 1514 hours, an observation on Resident 148's room was conducted. Resident 148 had oxygen per nasal cannula set at a rate of 1.5 liters per minute. Medical record review for Resident 148 was initiated on 6/17/26. Resident 148 was admitted to facility on 1/12/25, and readmitted on [DATE], with diagnosis of Acute Respiratory failure with hypoxia (medical condition where the body's tissues and organs do not receive enough oxygen to function properly). Review of Resident 148's Order Summary Report dated 6/18/26, showed a physician order dated 6/4/26, for oxygen at a rate of 2 liters per minute via nasal cannula to keep the oxygen saturation at/above 92% every shift for Acute Hypoxic Respiratory Failure. On 6/17/26 at 1220 hours, a follow up observation for Resident 148 and concurrent interview was conducted with the DSD. The DSD verified Resident 148 oxygen was set at a rate of 1.5 liters per minute. The DSD stated the physician order was to administer oxygen at a rate of 2 liters per minute. On 6/19/26 at 1425 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings for Residents 8 and 148. 3. Review of the facility's P&P titled Emergency Airway Placement and Oropharyngeal Suctioning revised 5/29/25, showed the suction equipment must be cleaned and stored according to manufacturer guidelines and facility protocol On 6/16/26 at 0919 hours, Resident 126 was observed asleep in bed. A Yankauer suction tip was observed underneath Resident 126's cloth underpads. On 6/16/26 at 1015 hours, an observation for Resident 126 and concurrent interview was conducted with RN 1. RN 1 verified the Yankauer suction tip was placed underneath Resident 126's cloth underpads. RN 1 stated she suctions herself; she wants it near her. Resident 126 stated the Yankauer suction was just changed. RN 1 was observed labelling a new set-up bag and placing the resident's Yankauer suction into the set-up bag. Medical record review for Resident 126 was initiated on 6/16/26. Resident 126 was readmitted to the facility on [DATE]. Review of Resident 126's Order Summary Report showed a physician's order dated 5/15/26, may suction as needed for increased secretions and congestion. Further review of Resident 126's medical record did not show Resident 126 was assessed and provided education on how to suction herself, and how to store the Yankauer suction when not in use. On 6/18/26 at 0906 hours, an interview and concurrent medical record review for Resident 126 was conducted with RN 2. When asked about Resident 126 suctioning herself, RN 2 stated she was sure an education was provided to Resident 126 on how to suction but RN 2 could not show any documentation. On 6/18/26 at 1510 hours, an interview for Resident 126 was conducted with the DON. The DON acknowledged the above findings. The DON stated the RN supervisors were assigned to change the Yankauer suction tip and the tubing with a set-up bag weekly. When asked about Resident 126's independent use of the suction, the DON stated they were working on getting an assessment and a physician's order for Resident 126 to self-suction.

Based on observation, interview, facility document review, and facility P&P review the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen. * Proper hand hygiene was not followed,* Food preparation equipment was not clean, and* The kitchen floor was not intact.These failures posed a risk for food borne illness for 127 residents who received food prepared in the kitchen.Review of the facility's matrix dated 6/16/26, showed 127 residents received food prepared in the kitchen. 1. Review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees dated 2022 showed, II. Proper Hand Hygiene A. Upon entering the kitchen, F. After handling soiled equipment or utensils. III. Hand Washing Facilities A. Kitchen sinks shall not be used for hand washing. Separate hand-washing facilities with soap, running water and individual towels shall be provided. During the initial tour of the kitchen on 6/16/26 at 0810 hours, an observation of the automatic dishwashing process was conducted. Wearing gloves, Diet Aide 1 loaded soiled dishes into the dish machine. Diet Aid 1 removed his gloves, rinsed his hand in water using the manual ware washing sink, then picked up clean dishes from the clean side of the dishwashing machine. On 6/16/26 at 1048 hours, Diet Aid 1 entered the kitchen, used hand sanitizer on his hands rather than washing his hands in the hand-washing sink then returned to work in the kitchen. On 6/16/26 at 1100 hours, an interview was conducted with the Dietary Services Supervisor (DSS). The DSS confirmed when kitchen employees enter the kitchen they must wash their hands. Use of a hand sanitizer is not to be used in place of handwashing. On 6/18/26 at 1400 hours, during a meeting with the DSS, DON, and Administrator, the above findings were confirmed. 2. Review of the USDA Food Code 2022 Section 4-601.11 Equipment, Food Contact Surfaces, Nonfood Contact Surfaces and Utensils (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. On 6/16/26 at 1152 hours, an observation of the meal preparation for the lunch meal was conducted. [NAME] 2 was observed cooking onions in a fry pan with thick black residue on the inside of the pan. On 6/18/26 at 1400 hours, during a meeting with the DSS, DON, and Administrator, the above findings was confirmed. 3. During an observation of the kitchen on 6/16/26 at 1203 hours, the kitchen floor was noted to have two areas; one in the dish room and one near the grill where the tile was not intact exposing cement. On 6/16/26 at 1600 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Director stated he was aware of the condition of the kitchen floors but confirmed the Administrator had not received any quotes to repair the floors.

Based on observation, interview, and facility document review, the facility failed to ensure the nurse staffing information was posted in a prominent place and readily accessible to residents and visitors. * The facility failed to post the DHPPD, CDPH Form 612 in a prominent place and readily accessible to residents and visitors. This deficient practice had the potential for residents and visitors to not have facility staffing information available at any given time.Findings: On 6/18/26 at 1041 hours, a facility observation was conducted and there was no CDPH Form 612, Nurse Staffing Information with actual hours worked for licensed and unlicensed nurses posted in any prominent areas in the facility that was accessible to residents and visitors. On 6/18/26 at 1109 hours, an interview and concurrent observation of the posting of actual nursing hours worked by the licensed and unlicensed nurses was conducted with the DSD. The DSD stated the facility had only the posting of the daily projected hours for licensed and unlicensed nurses. The DSD verified there was no posting of the actual hours worked for licensed and unlicensed nurses. The DSD further stated the facility will start posting the DHPPD, CDPH Form 612 properly signed and dated from now on. On 6/19/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication for one of 29 final sampled residents (Resident 13) reviewed for self-administration of medication. * The facility failed to ensure a box containing fluticasone propionate (corticosteroid) nasal spray was not left at Resident 13's bedside table. This failure had the potential to negatively impact on the resident's well-being, unsafe administration of the medications, and the potential for the other residents, staff, and visitors to have access to the medication.Findings: Review of the facility's P&P titled Medication - Self Administration revised 7/31/25, showed the following:- Self-administration of medications refers to a resident's ability to independently take their own prescribed medications without assistance from licensed nursing staff. This includes preparing, consuming, or applying the medication as directed by a physician;- For storage and safety, if the IDT and the attending physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident. On 6/16/26 at 0819 and 0824 hours, during the initial tour of the facility, a box of fluticasone propionate nasal spray was observed on the bedside table in Resident 13's room. On 6/16/26 at 0828 hours, an observation for Resident 13 and concurrent interview was conducted with LVN 3. LVN 3 verified a box of fluticasone propionate nasal spray was observed on the bedside table in Resident 13's room. LVN 3 stated she is allowed to have the nasal spray at the bedside table; I am not sure. Medical record review for Resident 13 was initiated on 6/16/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 6/9/26, showed Resident 13 had the capacity to participate in medical decision-making. Review of Resident 13's MDS dated [DATE], showed Resident 13 was cognitively intact, without any impairment to upper extremities. Review of Resident 13's Order Summary Report showed a physician's order dated 5/20/26, to administer fluticasone propionate 50 mcg one spray in each nostril daily as needed for allergy relief, unsupervised self-administration. Review of Resident 13's Self Administration of Medication dated 6/16/26, showed Resident 13 was approved for self-administration of medications, and the resident may keep medications at bedside. On 6/18/26 at 0849 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 2. RN 2 stated Resident 13 was assessed to be fully capable of self-administration of the nasal spray. When asked about the storage of the nasal spray, RN 2 stated Resident 13 could keep the nasal spray at bedside, not in a locked box. RN 2 further stated normally, it was just kept at bedside that she can reach easily. On 6/18/26 at 1505 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 62) reviewed for hemodialysis. * The facility failed to ensure Resident 62's fluid intake related to dialysis was monitored accurately. In addition, the facility failed to monitor Resident 62 and notify the physician when his access site was assessed with redness, pain, swelling, or tenderness. These failures had the potential to result in accurate assessment of fluid status, complications associated with fluid overload, and delayed intervention to the resident in the event of a dialysis access emergency.Findings: Review of the facility's P&P titled Dialysis Management revised 1/25/24, showed the following:- Diet and fluid restriction will be followed as ordered; and - Assessing, observing and documenting care of access sites daily, as applicable, such as evidence of infection at the surgical site, such as drainage, redness, tenderness. Review of the facility's P&P titled Fluid Restriction dated 5/26/26, showed the licensed nurse will complete the intake and output documentation. Medical record review for Resident 62 was initiated on 6/16/26. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 62's Order Summary Report showed the following physician's orders dated 8/31/24:- For fluid restriction of one liter per day. The fluid intake limit for dietary was 360 ml per day, while the fluid intake limit for nursing was 640 ml, which was broken down to 340 ml for 0700 to 1500 hours shift, 200 ml for 1500 to 2300 hours shift, and 100 ml for 2300 to 0700 hours shift.- To monitor hemodialysis access for presence of bruit and thrill every shift. Use (+) or (-) signs;- To monitor hemodialysis access for redness, swelling, drainage, and pain, every shift. Notify the physician if (+). Document the following if necessary: R for redness, S for swelling, D for drainage, P for pain, or N for not applicable. a. Review of Resident 62's fluid intake as per the CNA and licensed nurses' documentation showed inconsistency. In addition, the CNA documentation of Resident 62's fluid intake has also exceeded the daily fluid limit and/or exceeded the amount of the resident's fluid intake documented by the licensed nurses in the Intake and Output Monitoring Record. For example: Review of Resident 62's Task documentation for June 2026, under Nutrition - Fluids section, showed the following Resident 62's fluid intake as per the CNAs' documentation:-6/2/26, there was no documentation of the resident's fluid intake for breakfast and lunch;-6/3/26, the total dietary fluid intake was 1,300 ml;-6/4/26, the total dietary fluid intake was 1,020 ml;-6/5/26, the total dietary fluid intake was 730 ml;-6/6/26, the total dietary fluid intake was 640 ml;-6/7/26, there was no documentation of the resident's fluid intake for breakfast and lunch;-6/8/26, there was no documentation of the resident's fluid intake for breakfast and lunch;-6/10/26, there was no documentation of the resident's fluid intake for breakfast and lunch;-6/11/26, there was no documentation of the resident's fluid intake for breakfast and lunch;-6/13/26, there was no documentation of the resident's fluid intake for breakfast, lunch, and dinner;-6/14/26, the total dietary fluid intake was 1,480 ml; -6/15/26, the total dietary fluid intake was 960 ml;-6/16/26, the total dietary fluid intake was 1,020 ml; and-6/17/26, the total dietary fluid intake was 1,190 ml. Review of Resident 62's Intake and Output Recording for June 2026 showed the following Resident 61's fluid intake as per the licensed nurses' documentation:-6/1/26, the total fluid intake was 660 ml;-6/2/26, the total fluid intake was 660 ml;-6/3/26, the total fluid intake was 660 ml, although the 24-total was not recorded;-6/4/26, the total fluid intake was 650 ml;-6/5/26, the total fluid intake was 650 ml;-6/6/26, the total fluid intake was 640 ml;-6/7/26, the total fluid intake was 720 ml;-6/8/26, the total fluid intake was 660 ml;-6/9/26, the total fluid intake was 660 ml, although the 24-hour total was recorded as 360 ml;-6/10/26, the total fluid intake was 660 ml;-6/11/26, the total fluid intake was 675 ml;-6/12/26, the total fluid intake was 660 ml;-6/13/26, the total fluid intake was 650 ml;-6/14/26, the total fluid intake was 660 ml;-6/15/26, the total fluid intake was 670 ml, although the 24-hour total was not recorded;-6/16/26, the total fluid intake was 640 ml, although the 24-hour total was not recorded; and-6/17/26, the total fluid intake was 660 ml. b. Review of Resident 62's MAR for June 2026 showed Resident 62's hemodialysis access was assessed (+) for redness, swelling, drainage and pain on 6/1/26 in the day shift, on 6/6/26 in the evening shift, and on 6/10/26 in the evening shift. There was no documentation to show Resident 62 was assessed and monitored further nor was the physician notified when the resident's hemodialysis access was assessed (+) for redness, swelling, drainage and pain. Further review of Resident 62's medical record did not show the licensed nurses notified the attending physician, dialysis facility and/or nephrologist of Resident 62's fluid intake, and presence of redness, swelling, drainage and pain on the hemodialysis access site. On 6/18/26 at 0928 hours, an interview and concurrent medical record review for Resident 62 was conducted with RN 2. RN 2 stated the resident's fluid intake from the dietary or meal tray were documented by the CNAs on the Task documentation. RN 2 stated the licensed nurses' documentation of the resident's fluid intake in the Intake and Output Monitoring record included the resident's fluid intake from the nursing and dietary. When asked about the monitoring of Resident 61's fluid intake, RN 2 verified the resident's fluid intake from the dietary under the Task documentation was inconsistent and exceeded the fluid intake documented in the Intake and Output Monitoring record, which should have been the total fluid intake from the nursing and dietary. RN 2 verified the Intake and Output Monitoring record was incomplete as it did not show the 24-hour total of Resident 62's fluid intake. RN 2 further verified Resident 62 was not monitored for fluid overload, and the attending physician, dialysis facility and/or nephrologist were not notified of Resident 62's fluid intake. When asked about the hemodialysis access monitoring, RN 2 verified the licensed nurses documented + on the monitoring for redness, swelling, drainage and pain on the resident's hemodialysis access but there was no documentation if the physician or nephrologist nor the dialysis facility was notified. On 6/18/26 at 1456 hours, an interview and concurrent medical record review for Resident 62 was conducted with the DON. When asked about the residents on fluid restrictions, the DON stated the resident's fluid intake from nursing and dietary was documented by the licensed nurses in the Intake and Output Monitoring record because the nurses do the 24-hour calculation, and weekly intake and output evaluation. When asked about monitoring of the hemodialysis access, the DON stated if there was redness, swelling, drainage or pain, the licensed nurses could document the pain the pain assessment every shift, and also it would generate a change of condition. The DON verified the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure two of two licensed nurses (RN 1 and LVN 2) reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure RN 1 and LVN 2 were able to competently administer the medications via GT. These failures had the potential to put the residents at risks to receive care not provided in a safe and competent manner.Findings: Review of the facility's document titled RN Staff Nurse Job Description (undated) showed the general duties and responsibilities of the RN are to provide nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures, and to administer professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care. One of the clinical duties of the RN is to prepare/administer medications as ordered by the physician and within the legal scope of practice. Review of the facility's document titled LVN Staff Nurse Job Description undated showed the general duties and responsibilities of the LVN are to provide nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures, and administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being. Provides clinical data and observations to contribute to the nursing plan of care. One of the clinical duties of the LVN is to prepare/administer medications as ordered by the physician and within the legal scope of practice. 1. On 6/17/26 at 0905 hours, a medication administration observation for Resident 88 was conducted with RN 1. The following were observed with RN 1:- RN 1 did not check the GT residual for Resident 88 prior to flushing the GT with 30 ml of water;- RN 1 attempted to flush the GT with 30 ml of water for the second time but water was not flowing down the GT. RN 1 used the syringe plunger to push the 30 ml of water into the GT rather than allowing gravity flow; and- RN 1 used the same technique of using the syringe plunger to push the multivitamins (supplements) and Senna (laxative) when the medications were not flowing down the GT. On 6/17/26 at 0940 hours, an interview and concurrent medical record review for Resident 88 was conducted with RN 1. RN 1 verified the findings above for Resident 88. RN 1 stated she should have checked the residual prior to attempting to flush the GT with water to make sure the residual amount was not on the amount where she would need to hold the GT feeding and medication administration. RN 1 stated it was also a way to verify the GT placement. RN 1 stated the medications should be allowed to flow by gravity and she should have checked the patency of the GT when the medications were not flowing down the GT. RN 1 stated Resident 88 was getting 40 ml of water flush via GT every hour. 2. On 6/17/26 at 0817 hours, a medication administration observation and concurrent interview for Resident 149 was conducted with LVN 2. The following were observed with LVN 2:- LVN 2 was observed checking the GT residual of Resident 149 and flushed back the aspirated 10 ml residual to the GT while the TF pump was still on;- LVN 2 was about to administer the first diluted medication via GT to Resident 88 while the TF pump was still on. LVN 2 was stopped and was asked if she needed to hold the TF. LVN 2 stated she should have put the TF on hold prior to checking the GT residual. LVN 2 put the TF pump on hold and proceeded with the medication administration;- LVN 2 administered the first medication, valproic acid liquid (antiseizure) without flushing the GT first with water; and- LVN 2 administered the diluted Namenda (medication for severe dementia) medication and added 5 ml of water to the GT but the medication did not flow down the GT. LVN 2 then added the diluted folic acid (vitamin) medication and added 5 ml of water. The medications were observed not flowing down the GT. LVN 2 used the syringe plunger to push the medications into the GT rather than allowing gravity flow. On 6/17/26 at 0855 hours, an interview and concurrent medical record review for Resident 149 was conducted with LVN 2. LVN 2 verified the above findings for Resident 149. LVN 2 stated the GT should be flushed with 15 ml of water before administering the medications. LVN 2 further stated she should have let the medications flow to the GT by gravity or have checked for the patency if the medications were not flowing down. On 6/19/26 at 1418 hours, an interview and concurrent employee file review for RN 1 and LVN 2 was conducted with the DON. a. Review of RN 1's Feeding Tube: Administration of Medications Competency Validation dated 5/1/26, under the Procedure section showed the following:- Verify tube placement via aspiration method. Return aspirate to stomach. The Met column was checked, and the verification method was return demonstration; and- Administer medication by syringe via gravity into the feeding tube. (Note: Medication may be diluted if necessary.). The Met column was checked, and the verification method was return demonstration. b. Review of RN 1's Feeding Tube: Administration of Medications Competency Validation dated 5/1/26, under the Procedure section showed the following:- If continuous or intermittent feeding is infusing, stop the feeding. The Met column was checked, and the verification method was return demonstration;- Flush tube with 15 ml (unless a different amount specified by the physician/prescriber) of water before administering medication. The Met column was checked, and the verification method was return demonstration;- Between each medication, the tube is flushed with 15 ml of water, keeping in mind the patient's fluid volume status (unless a different amount specified by the physician/prescriber). The Met column was checked, and the verification method was return demonstration; and- Administer medication by syringe via gravity into the feeding tube. (Note: Medication may be diluted if necessary.). The Met column was checked, and the verification method was return demonstration. The DON stated she was involved in providing training and checking/validating the skills competency of the licensed nurses. The DON stated the skills competency validations for the licensed nurses included the medication administration via all routes. The DON stated the licensed nurses were evaluated of their skills competency and knowledge upon hire, three months after they got hired, annually, and as needed if there were issues identified. The DON further stated the Pharmacy Consultant would also assist in checking the licensed nurses' medication administration knowledge and skills. The DON was made aware regarding what RN 1 and LVN 2 did during the medication administration via GT observation and acknowledged the above findings. Cross reference to F693.

Based on interview, medical record review, and the facility P&P review, the facility failed to monitor the fluid intake accurately for one of one final sampled resident (Resident 126) and one nonsample resident (Resident 25) reviewed for hydration and nutritional status. * The facility failed to provide Resident 25's Nephro (nutritional supplements) oral liquid 237 ml as ordered by the physician. * The facility failed to ensure Resident 126's fluid intake was monitored accurately by the charge nurses and CNAs. The CNAs fluid intake documentation did not match the charge nurses' documentation, and often exceeded the volume documented by the charge nurses. In addition, the daily fluid intake documentation was inconsistent and incomplete. These failures placed the residents at risk for undetected fluid imbalances or weight loss and negatively impact the resident's well-being. Findings: 1. Review of the facility's P&P titled Intake and Output revised 2/27/25, showed the fluid intake and output shall be recorded for each resident if ordered per physician. Review of the facility's P&P titled Fluid Restriction dated 5/26/26, showed the licensed nurse will complete the intake and output documentation. On 6/17/26 at 1006 hours, an observation for Resident 126 was conducted. Resident 126 was observed in bed, and a pitcher of ice and a cup of thickened water were observed at bedside. Medical record for Resident 126 was initiated on 6/16/26. Resident 126 was readmitted to the facility on [DATE]. Review of Resident 126's Order Summary Report showed a physician's order dated 5/15/26, for fluid restriction of 1200 ml per day for CHF exacerbation. There was no breakdown shown for the nursing and dietary departments. Review of Resident 126's MAR for June 2026 showed checkmarks and initials by the licensed nurses for each shift but did not show Resident 126's actual fluid intake. Review of Resident 126' POC Response History for June 2026 under Task for Nutrition - Fluids section, showed the following fluid intake by Resident 126 as documented by the CNAs: - dated 6/1/26, the total fluid intake was 970 ml; - dated 6/2/26, the total fluid intake was 1,020 ml; - dated 6/3/26, the total fluid intake was 760 ml; - dated 6/4/26, the total fluid intake was 800 ml; - dated 6/5/26, the total fluid intake was 830 ml; - dated 6/6/26, the total fluid intake was 905 ml; - dated 6/7/26, the total fluid intake was 720 ml; - dated 6/8/26, the total fluid intake was 250 ml; - dated 6/9/26, the total fluid intake was 840 ml; - dated 6/10/26, the total fluid intake was 830 ml; - dated 6/11/26, the total fluid intake was 1,060 ml; - dated 6/12/26, the total fluid intake was 970 ml; - dated 6/13/26, the total fluid intake was 500 ml; - dated 6/14/26, the total fluid intake was 860 ml; - dated 6/15/26, the total fluid intake was 780 ml; - dated 6/16/26, the total fluid intake was 320 ml; and - dated 6/17/26, the total fluid intake was 730 ml. Review of Resident 126's Intake and Output Recording for June 2026 showed the following fluid intake by Resident 126 as documented by the licensed nurses: - dated 6/1/26, the total fluid intake was 1,100 ml; - dated 6/2/26, the total fluid intake was 820 ml; - dated 6/3/26, the total fluid intake was 700 ml; - dated 6/4/26, the total fluid intake was 1,050 ml; - dated 6/5/26, the total fluid intake was 1,180 ml; - dated 6/6/26, the total fluid intake was 1,050 ml; - dated 6/7/26, the total fluid intake was 730 ml; - dated 6/8/26, the total fluid intake was 740 ml; - dated 6/9/26, the total fluid intake was 770 ml; - dated 6/10/26, the total fluid intake was 700 ml; - dated 6/11/26, the total fluid intake was 480 ml; - dated 6/12/26, the total fluid intake was 900 ml; - dated 6/13/26, the total fluid intake was 1000 ml; - dated 6/14/26, the total fluid intake was 600 ml; - dated 6/15/26, the total fluid intake was 560 ml; - dated 6/16/26, the total fluid intake was 580 ml; and - dated 6/17/26, the total fluid intake was 600 ml. On 6/17/26 at 1021 hours, an observation for Resident 126 and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 126 was observed with a pitcher of ice and cup of thickened water at bedside. When asked about Resident 126's fluid restriction, CNA 3 stated Resident 126 was on fluid restriction so she was only given a pitcher of ice and a cup of thickened water at bedside. CNA 3 stated Resident 126's fluid intake from the cup of thickened water at bedside and the fluids from the meal trays were documented under the Task documentation. CNA 3 stated they do not count Resident 126's intake of ice. On 6/18/26 at 0906 hours, an interview and concurrent medical record review for Resident 126 was conducted with RN 2. RN 2 verified Resident 126 was on fluid restriction of 1200 ml per day, and there was no breakdown for the nursing and dietary department. RN 2 stated the resident's fluid intake from the dietary or meal tray were documented by the CNAs on the Task documentation. RN 2 stated the licensed nurses' documentation of the resident's fluid intake in the Intake and Output Monitoring record included the resident's fluid intake from the nursing and dietary. When asked about the monitoring of Resident 126's fluid intake, RN 2 verified the resident's fluid intake from the dietary under the Task documentation was inconsistent and exceeded the fluid intake documented in the Intake and Output Monitoring record, which should have been the total fluid intake from the nursing and dietary. RN 2 further verified Resident 126 was not monitored for fluid overload when the resident exceeded her fluid intake limit. On 6/18/26 at 1510 hours, an interview and concurrent medical record review for Resident 126 was conducted with the DON. The DON verified the above findings. 2. On 6/17/26 at 1012 hours, a medication administration observation for Resident 25 was conducted with LVN 1. LVN 1 prepared and administered Resident 25's medications by mouth, which included the following: - one tablet of cetirizine (antiallergy) of 10 mg; - one tablet of Plavix (anticoagulant) 75 mg; - one capsule of duloxetine (antidepressant) 30 mg; - two tablets of methocarbamol (muscle relaxant) 500 mg; - Miralax (laxative) 17 grams; - one capsule of Lyrica (medication for nerve pain) 100 mg; - pro-stat (liquid protein supplement) 30 ml; - two tablets of senna (laxative) 8.6 mg; and - one tablet of vitamin C and B-complex (supplements). Medical record review for Resident 25 was initiated on 6/17/26. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Active Order Sets dated 6/17/26, showed a physician's order dated 5/14/24, to administer Nephro oral liquid 237 ml by mouth one time a day for supplement. Review of Resident 25's MAR for June 2026 showed the Nephro oral liquid 237 ml supplement was scheduled to be administered at 0900 hours. On 6/17/26 at 1400 hours, an interview and concurrent medical record review for Resident 25 was conducted with LVN 1. LVN 1 reviewed Resident 25's MAR and verified the Nephro oral liquid supplement was scheduled to be administered at 0900 hours. LVN 1 verified the Nephro supplement was not administered during the medication administration observation. On 6/17/26 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 29 final sampled residents (Resident 61). * The facility failed to ensure Resident 61 was administered midodrine (antihypotensive) medication when Resident 61's systolic blood pressure (SBP) was less than 110 mmHg as prescribed by the physician. This failure had the potential to negatively affect Resident 61's health condition and well-being.Findings: Medical record review for Resident 61 was initiated on 6/16/26. Resident 61 was admitted to the facility on [DATE]. Review of Resident 61's Order Summary Report showed the following physician's orders dated 6/2/26:- to administer midodrine 10 mg one tablet by mouth every eight hours as needed for hypotension. Give if the systolic blood pressure is less than 110 mmHg; and- to monitor blood pressure every shift for the midodrine medication use. Review of Resident 61's MAR for June 2026 showed Resident 61's blood pressure was monitored every shift and Resident 61's systolic blood pressure was less than 110 mmHg on the following dates and shifts:- dated 6/2/26 on the evening shift, a blood pressure of 106/52 mmHg;- dated 6/3/26 on the night shift, a blood pressure of 101/50 mmHg;- dated 6/4/26 on the evening shift, a blood pressure of 103/61 mmHg, and on the evening shift, a blood pressure of 102/64mmHg;- dated 6/7/26 on the day shift, a blood pressure of 108/63 mmHg;- dated 6/8/26 on the day shift, a blood pressure of 99/52 mmHg, on the evening shift, a blood pressure of 103/57 mmHg, and on the night shift, a blood pressure of 108/63 mmHg;- dated 6/9/26 on the night shift, a blood pressure of 106/60 mmHg;- dated 6/10/26 on the evening shift, a blood pressure of 104/45 mmHg, and on the night shift, a blood pressure of 102/62 mmHg;- dated 6/12/26 on the evening shift, a blood pressure of 91/37 mmHg, and on the night shift, a blood pressure of 106/64 mmHg;- dated 6/13/26 on the evening shift, a blood pressure of 98/50 mmHg, and on the night shift, a blood pressure of 102/53 mmHg;- dated 6/14/26 on the night shift, a blood pressure of 104/63 mmHg;- dated 6/15/26 on the evening shift, a blood pressure of 99/51 mmHg, and on the night shift, a blood pressure of 96/46 mmHg; and- dated 6/16/26 on the night shift, a blood pressure of 92/47 mmHg. Further review of Resident 51's MAR did not show Resident 61 was administered the midodrine medication when the resident's systolic blood pressure was less than 110 mmHg as prescribed by the physician. On 6/18/26 at 0835 hours, an interview and concurrent medical record review for Resident 61 was conducted with RN 2. When asked about Resident 61's blood pressure monitoring, RN 2 stated the charge nurses checked the vital signs, including the blood pressure, every shift and would give the midodrine medication if the systolic blood pressure was less than 110 mmHg as prescribed by the physician. RN 2 verified Resident 61 was not administered the midodrine medication when the systolic blood pressure was less than 110 mmHg numerous times. On 6/18/26 at 1444 hours, an interview and concurrent medical record review for Resident 61 was conducted with the DON. The DON verified the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 29 final sampled residents (Resident 51) and one nonsampled resident (Resident 149) reviewed for ADL care. * The facility failed to ensure Resident 51 was provided with showers on her scheduled shower days. * The facility failed to ensure Resident 149 was provided with oral care. Resident 149's tongue was observed covered with thick white residue. These failures had the potential for the residents' need not met and for the residents to experience physical discomfort. Findings: Review of the facility's P&P titled Oral Care revised 1/1/12, showed the following: - All residents receive appropriate oral care, including denture care if applicable, daily; - It is the responsibility of each staff member within the nursing department is to ensure good oral care for each resident; - For debilitated residents, use suction toothbrush to brush teeth, gums, tongue, cheeks, and palate; and - Document oral care on any pertinent observations in the resident's medical record. Review of the facility's P&P titled Showering and Bathing revised 1/1/12, showed a tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Residents are given tub or shower baths unless contraindicated. 1. On 6/17/26 at 0817 hours, during the medication administration observation, a concurrent observation for Resident 149 and interview was conducted with LVN 2. Resident 149 was observed with her mouth open, and the tongue was sticking out. Resident 149's tongue was observed covered with thick white residue. LVN 2 stated the Resident 149 was non-verbal, needed total care with the ADL care, and on NPO. Medical record review for Resident 149 was initiated on 6/17/26. Resident 149 was readmitted to the facility on [DATE]. Review of Resident 149's H&P examination dated 6/2/26, showed Resident 149 had no capacity to understand and make decisions. Review of Resident 149's MDS assessment dated [DATE], showed Resident 149 needed substantial/maximal assistance for oral hygiene. Review of Resident 149's plan of care initiated on 7/30/21, showed a care plan problem addressing Resident 149's dental health problems. The interventions included the following: - for the nurses to monitor document/report to the physician as needed the signs and symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, lesions; and - for the nurses and CNAs to provide good oral hygiene daily, report promptly redness, pain swelling or bleeding to the physician. On 6/17/26 at 1441 hours, an observation and concurrent interview was conducted for Resident 149 with CNA 1. CNA 1 stated she was familiar with Resident 149. CNA 1 stated Resident 149 needed total assistance with personal care. CNA 1 stated personal care included oral care. When asked if the resident received oral care and if she noticed something in the tongue, CNA 1 stated oral care was provided to Resident 149 ; however, the resident's tongue was already covered with thick white residue. CNA 1 stated Resident 149 could be resistive at times and the resident at times would roll her tongue backward, so it was hard to clean the tongue, and she did not want to force it. When asked if the nurse was aware of the tongue being covered with thick white residue, CNA 1 stated she did not report Resident 149 tongue's condition to the nurse because she thought the nurse knew about it. On 6/17/26 at 1457 hours, a follow-up observation and concurrent interview was conducted for Resident 149 with LVN 2. LVN 2 verified Resident 149's tongue was covered with thick white residue. LVN 2 stated she was not aware of Resident 149's tongue condition and the resident should not be left with that. LVN 2 stated the CNAs should inform the nurses if they needed help in providing oral care or any personal hygiene care to the resident. LVN 2 stated Resident 149's tongue being covered with thick white residue needed to be reported to the physician. On 6/17/26 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 149. The DON stated they would report Resident 149's tongue condition to the physician for further assessment. 2. On 6/16/26 at 0909 hours, during the initial tour of the facility, Resident 51 was observed in bed. Resident 51 stated she was not given showers on her scheduled shower days and she did not refuse showers. Resident 51 stated she asked the staff, Where is my shower? Why is everyone getting a shower, and I do not? Resident 51 stated she felt frustrated, angry, and neglected. Resident 51 stated she was at the end of the room, and she felt forgotten. Medical record review for Resident 51 was initiated on 6/16/26. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's H&P examination dated 5/28/26, showed Resident 51 had the capacity to understand and make decisions. Review of Resident 51's MDS assessment dated [DATE], showed Resident 51 had moderate cognitive impairment, and was dependent on the facility staff for showering or bathing herself. Review of Resident 51's CNA documentation under Task for Bathing: Shower/Bed bath every Wednesday and Saturday AM showed the following: - Resident 51's showers/bed baths were documented as not applicable on 5/30, 6/3, and 6/7/26; - Resident 51 received a bed/towel bath on 6/5/26, and - Resident 51 received showers on 6/6, 6/10, and 6/17/26; and Further review of the CNA task documentation failed to show if Resident 51 had showers or bed bath, or the resident refused showers or bed bath on 5/30, 6/3, and 6/13/26. On 6/17/26 at 1008 hours, an interview and concurrent facility document review was conducted with CNA 3. CNA 3 stated Resident 51 was scheduled to have showers on Wednesday and Saturday on the day shift. CNA 3 stated the residents could ask for a shower on the days they were not scheduled to shower, and he would try to accommodate it. CNA 3 stated the CNAs were supposed to fill out a skin inspection sheet every after the resident showered. CNA 3 was observed looking into a binder and showed the Shower Day Inspection Sheets. Review of Resident 51's Shower Day Inspection Sheet showed the following: - dated 6/6/26, refused body check. - dated 6/10/26, redness on the sacral area. - dated 6/16/26, open areas on the sacral area. Further review of Resident 51's medical record showed there were no Shower Day Inspection Sheets documented for 5/30, 6/3, and 6/13/26. CNA 3 verified the above findings. CNA 3 was observed going through the binder, and each page but did not locate the Shower Day Inspection Sheets documentation for 5/30, 6/3, and 6/13/26 for Resident 51. CNA 3 stated Resident 51 never refused showers. CNA 3 stated he showered Resident 51 yesterday (6/16/26), and a registry CNA was assigned to her last Saturday (6/13/26). On 6/18/26 at 0812 hours, an interview and concurrent medical record review for Resident 51 was conducted with RN 2. RN 2 stated the residents were scheduled to have showers twice a week, and the schedule was based on the room number, which will then determine the day and the shift, to which RN 2 showed the Shower Schedule for the day shift. Review of the facility's document titled Shower Schedule for 0700 to 1500 hours shift showed Resident 51's room number was under Wednesday and Saturday. RN 2 verified Resident 51 was scheduled to have showers on Wednesday and Saturday, and the CNAs would fill out a Shower Day Inspection Sheet after providing showers to the residents, then the charge nurses will sign the shower sheets. If the resident refused shower, the CNA would have to inform the charge nurse. RN 2 further stated the CNAs would have to document under the Task documentation the resident refused showers or only provided bed bath. When asked about Resident 51's Shower Day Inspection Sheets, RN 2 observed going through the binder, and each page and located Resident 51's Shower Day Inspection Sheets dated 6/16, 6/10, and 6/16/26. RN 2 verified there were no Shower Day Inspection Sheets documented on 5/30, 6/3, and 6/13/26. When asked about the documentation of Resident 51's shower or bed bath under the Task documentation, RN 2 verified Resident 51's showers/ bed baths were documented as not applicable on 5/30, 6/3, and 6/7/26, and Resident 51 received a bed/towel bath on 6/5/26, and showers on 6/6, 6/10, and 6/17/26. On 6/18/26 at 1442 hours, an interview and medical record review for Resident 51 was conducted with the DON. When asked about Resident 51's shower, the DON stated the CNAs documented under Task if Resident 51 was provided with a shower or a bed bath. The DON verified Resident 51's showers/ bed baths were documented as not applicable on 5/30, 6/3, and 6/7/26, and Resident 51 received a bed/towel bath on 6/5/26, and showers on 6/6, 6/10, and 6/17/26. The DON verified there were no documented showers or bed bath provided to Resident 51 on 5/30, 6/3, and 6/13/26.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for one of 29 final sampled residents (Resident 11) and one nonsampled resident (Resident 133). * The facility failed to ensure Resident 11's care plan interventions for the alprazolam (antianxiety) and duloxetine (antidepressant) medications were revised to show the nonpharmacological interventions were included as per physician's order. * The facility failed to ensure the care plan for Resident 133 was updated to reflect Resident 133's dislike of the facility food, and the food brought daily from home. These failures increased the risk for the residents to not receive an individualized and person centered care in accordance with their assessed needs. Findings: Review of the facility's P&P titled P-NP04-Person-Centered Care Planning revised 4/24/25, showed the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Medical record review for Resident 11 was initiated on 6/16/26. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 5/19/26, showed Resident 11 had no capacity to understand and make decisions. Review of Resident 11's Order Summary Report, showed the following physician's orders: - dated 5/13/26, to administer duloxetine hydrochloride delayed release particles 30 mg one capsule via GT at bedtime for depression as manifested by persistent feeling of sadness; - dated 5/13/26, to monitor target behaviors for the use of duloxetine due to depression as manifested by persistent feeling of sadness. Indicate the number of behavior occurrences followed by the NPI (nonpharmacological interventions) # (number) provided. If no behaviors, select not applicable for NPI, then Yes or No for effectiveness every shift. NPI: 1=Music/TV; 2=Redirect/divert; 3=Call family/responsible party to talk or visit with resident; 4=Toilet; 5=1:1 Conversation; 6= Reassure/orient; 7=Asses pain/infection; 8=Offer drink/snack; 9=Quiet environment; 10=Walk/wheel resident; 11=Activity/Exercise; or 12 Massage/back rub; - dated 5/13/26, to monitor target behaviors for use of alprazolam due to anxiety as manifested by verbalization of feeling anxious. Indicate the number of behavior occurrences followed by the NPI # provided. If no behaviors, select not applicable for NPI then Yes or No for effectiveness every shift. NPI: 1=Music/TV; 2=Redirect/divert; 3=Call family/responsible party to talk or visit with resident; 4=Toilet; 5=1:1 Conversation; 6= Reassure/orient; 7=Asses pain/infection; 8=Offer drink/snack; 9=Quiet environment; 10=Walk/wheel resident; 11=Activity/Exercise; or 12 Massage/back rub; and - dated 6/13/26, to administer alprazolam 0.25 mg one tablet via GT (every 12 hours as needed for anxiety as manifested by verbalization of feeling anxious for 14 days. Review of Resident 11's Care Plan Report showed a care plan focus problem to address the following: - the resident's depression and the use of duloxetine medication revised on 4/7/26. The interventions did not include the nonpharmacologic interventions as ordered by the physician; and - the resident's anxiety and the use of alprazolam medication revised on 5/14/26. The interventions did not include the nonpharmacologic interventions as ordered by the physician. On 6/18/26 at 1435 hours, an interview and concurrent medical record review for Resident 11 was conducted with the ADON. The ADON verified the findings for Resident 11. The ADON stated the licensed nurses and members of the IDT team could update or revise the resident's care plan as needed. The ADON further stated whatever interventions being provided to the resident should be reflected in the care plan. On 6/19/26 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 11. 2. On 6/16/26 at 0935 hours, an interview was conducted with Resident 133's family member. Resident 133's family member stated Resident 133 was a vegetarian and she did not like the food provided by the facility so he would bring food daily for Resident 133. Resident 133's family member stated he got the food for Resident 133 from his church. On 6/18/26 at 1500 hours, a medical record review and concurrent telephone interview for Resident 133 was conducted with RD 2. RD 2 acknowledged the care plan for each resident should be resident centered. RD 2 confirmed the care plan for Resident 133 did not include the fact that Resident 133 did not like the food at the facility and Resident 133's family member was bringing food from the outside on a daily basis. RD 2 stated this information should have been in Resident 133's care plan.

Based on observation, interview, medical record review, and P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for three of 29 final sampled residents (Residents 8, 79 and 126). * The facility failed to implement the care plan to address Resident 8's head of bed while the resident was on continuous oxygen. * The facility failed to develop a care plan problem to address Resident 79's use of bed bolster (a raised foam edges along the sides of bed mattress to support positioning and prevent patient from rolling out of bed) for safety. * The facility failed to develop a care plan problem to address Resident 126's self-use of suction equipment. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Person-centered care planning revised 8/24/23, showed the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well- being. To ensure that a comprehensive person-centered care plan is developed for each resident. 1. Medical record review for Resident 79 was initiated on 6/18/26. Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's Order Summary Report dated 6/18/26, showed a physician's order dated 5/17/26, for Low Air Loss Mattress with bolster for skin management every shift. On 6/16/26 at 1313 hours, during room visit, Resident 79 was observed on her bed with low air loss mattress with upper and lower bolster on each side. On 6/18/26 at 0838 hours, a review of Resident 79's comprehensive care plan dated 5/13/25, showed under Focus- at risk for impairment to skin integrity related to fragile skin, decrease mobility, DM ( Diabetes Mellitus (increased sugar level in blood), incontinence of bowel. Under Intervention portion, initiated on 5/17/25, showed use of the low air loss mattress with bolster as ordered. On 6/18/26 at 0943 hours, an interview was conducted with LVNs 3 and 4. LVNs 3 and 4 stated the indication for low air loss mattress was for skin maintenance to prevent recurrence of pressure injury (localized damage to the skin and underlying soft tissue usually occurring over bony prominence). LVNs 3 and 4 stated and clarified that the bolster was for safety to prevent resident from sliding out of bed and not for skin maintenance. LVNs 3 and 4 verified there was no care plan for use of the bolster for safety to prevent resident from sliding out of bed. On 6/19/26 at 1415 hours, an interview was conducted with Administrator and DON. The DON verified the findings. 2. Review of the facility's P&P titled Person-Centered Care Planning, revised 4/24/25, showed the following: - Person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in nursing facility; and - The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; and On 6/16/26 at 0919 hours, Resident 126 was observed asleep in bed. A Yankauer suction tip was observed underneath Resident 126's cloth underpads. On 6/16/26 at 1015 hours, an observation for Resident 126 and concurrent interview was conducted with RN 1. RN 1 verified the Yankauer suction tip was placed underneath Resident 126's cloth underpads. RN 1 stated she suctions herself; she wants it near her. On 6/17/26 at 1006 hours, Resident 126 was observed independently dipping the Yankauer suction tip into a cup of water while the suction machine was turned on. Medical record review for Resident 126 was initiated on 6/16/26. Resident 126 was readmitted to the facility on [DATE]. Review of Resident 126's Order Summary Report showed a physician's order dated 5/15/26, may suction as needed for increased secretions and congestion. Revie of Resident 126's MAR for June 2026 did not show Resident 126 was monitored for suctioning. Review of Resident 126's plan of care did not show a care plan problem was developed to address Resident 126's self-use of the suction equipment. On 6/18/26 at 0906 hours, an interview and concurrent medical record review for Resident 126 was conducted with RN 2. RN 2 verified Resident 126 independently suctions herself. RN 2 further verified Resident 126's plan of care did not show care plan problem was developed to address Resident 126's independent use of the suction equipment. On 6/18/26 at 1510 hours, an interview for Resident 126 was conducted with the DON. The DON was informed and acknowledged the above findings. 3. On 6/16/26 at 1611 hours, during the initial tour of facility, Resident 8 was on her bed receiving oxygen at a rate of 3.5 liters per minute per nasal cannula using the oxygen concentrator. Resident 8's head of the bed was observed to be on a flat position. Medical record review for Resident 8 was initiated on 6/17/26. Resident 8 was initially admitted to facility on 6/4/25, and readmitted on [DATE]. Review of Resident 8's comprehensive care plan date initiated 6/5/25, showed a care plan problem to address Resident 8's had oxygen therapy related to ineffective gas exchange. The interventions included to position the resident to facilitate ventilation/ perfusion matching. Use upright, high fowlers position whenever possible to allow optimal diaphragm. Head of bead elevated to 45 degrees if tolerated to promote lung expansion and improve air exchange by positioning with proper body alignment. On 6/17/26 at 1015 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified Resident 8's head of bed was in a flat position. LVN 5 tried to elevate the head of bed of Resident 8. On 6/19/26 at 1425 hours, an interview was conducted with the DON. The DON was made aware of the findings. The DON verified all the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the office of the State Long-Term Care Ombudsman for one of the two final residents (Resident 9) transfer to the acute care hospital and one of three sampled residents (Resident 145) for closed record reviewed. * The facility failed to ensure the transfer/discharge notification was completed and a copy was sent to the Ombudsman when Resident 9 was transferred to Acute Care Hospital 2 (ACH 2) on 4/2926. * The facility failed to send a copy of Resident 145's notice of transfer/discharge to the representative of the Office of the State LTC Ombudsman. These failures had the potential for the Ombudsman to not be aware of the residents' transfer/discharge status and not being able to provide information regarding the resident options or right to appeal. Findings: Review of the facility's P&P title Discharge and Transfer of Residents revised 2/27/25, showed prior to discharge, the facility will provide the resident/resident representative with Notice of Proposed Transfer and Discharge document. A copy of the Notice of Proposed Transfer and Discharge will be placed in the Resident's medical record and copy faxed to the ombudsman. 1. Medical record review for Resident 9 was initiated on 6/17/26. Resident 9 was admitted to the facility on [DATE], transferred to the acute care hospital on 4/29/26, and readmitted to the facility on [DATE]. Review of Resident 9's Order Summary Report showed a physician's order dated 4/29/26, to transfer Resident 9 to Acute Care Hospital 2 for further evaluation due to elevated WBC and bed hold for 7 days. Further review of Resident 9's medical record failed to show documented evidence of the Notice of Proposed Transfer/Discharge and if the Ombudsman was notified of Resident 9's transfer to the acute care hospital. On 6/17/26 at 0924 hours, an interview and concurrent medical record review for Resident 9 was conducted with the ADON. The ADON verified the Notice of Proposed Transfer Discharge was not found in Resident 9's medical record. The ADON stated the facility stop filling out the form because the Ombudsman informed the facility does not need to fax the Notice of Proposed Transfer Discharge form to the Ombudsman if the resident was to transfer to the hospital. The ADON further stated the facility should have sent the notice so the Ombudsman would have a record of the resident being sent to the acute care hospital. On 6/19/26 at 1310 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was informed and acknowledged above findings. 2. Closed medical record review for Resident 145 was initiated on 6/16/26. Resident 145 was admitted to the facility on [DATE], and discharged on 4/5/26. Review of Resident 145's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 145's Order Summary Report dated 4/5/26, showed a physician's order to transfer the resident to Acute Care Hospital 1 via 911 due to desaturation and SOB, and bed hold for seven days if admitted . Further closed medical record review for Resident 145 failed to show documented evidence of the notification to the LTC Ombudsman regarding the resident's transfer to the acute care hospital. On 6/17/26 at 1525 hours, an interview and concurrent closed medical record review for Resident 145 was conducted with the SSD. The SSD stated Resident 145 was sent to the acute care hospital. The SSD stated the social services did not do the notice of transfer for the residents that went to the acute care hospital. When the SSD was asked about who was responsible for sending a copy of the notice to the LTC Ombudsman, the SSD stated if the transfer was an emergency or the resident was sent to the acute care hospital the licensed nurse would do it. On 6/17/26 at 1548 hours, an interview and concurrent closed medical record review was conducted with RN 2. RN 2 verified the copy of the Notice of Proposed Transfer and Discharge form was not sent to the LTC Ombudsman. RN 2 stated she was not sure why the form was not sent to the LTC Ombudsman. RN 2 further stated when Resident 145 was transferred to the acute hospital, the medical records staff were responsible for faxing the copy of the Notice of Proposed Transfer and Discharge form to the LTC Ombudsman. RN 2 stated if a resident was discharged home the social services staff were the one responsible for faxing the copy to the LTC Ombudsman. On 6/17/26 at 1607 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the licensed nurses or the medical records staff used to fax the Notice of Proposed Transfer and Discharge form to the LTC Ombudsman. However, the LTC Ombudsman told the facility staff he did not need the notification of transfer and discharge, the facility staff stopped faxing the Notice of Proposed Transfer and Discharge form to the LTC Ombudsman's office.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide reasonable accommodation to meet the needs for two of 29 final sampled residents (Residents 52 and 90). * The facility failed to ensure Resident 52 and 90's call lights were within the residents' reach. This failure posed a risk in a delay in providing care to the residents with the potential to negatively impact on the residents' well-being.Findings: Review of the facility's P &P titled Communication-Call System revised 8/24/24, showed the call alert device will be placed within the resident's reach. 1. Medical record review of Resident 52 was initiated on 6/16/26 and 6/19/26. Resident 52 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 52's H&P examination dated 8/18/25, showed the resident had the capacity to understand and make medical decisions. On 6/16/26 at 1028 hours Resident 52 was observed lying in bed. Resident 52's call light was observed hanging behind the headboard of the bed. Resident 52 attempted to reach for the call light and was unable to reach it but refused to be interviewed. On 6/16/26 at 1112 hours, the DON was summoned to Resident 52's room. An observation for Resident 52 and concurrent interview was conducted with the DON. Resident 52's call light was hanging behind the headboard of the bed which was not within Resident 52's reach. When asked, the DON stated the call light should be within the reach of every resident, in case the resident needed assistance it will be available to call for help. 2. Medical record review for Resident 90 was initiated on 6/16/26. Resident 90 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 90's H&P examination dated 7/8/25, showed the resident had the capacity to understand and make medical decisions. On 6/16/26 at 1056 hours, Resident 90 was observed lying in bed. Resident 90's call light was observed on the floor on left side of the bed far from the resident's reach. Resident 90 stated having no idea where the call light was. Resident 90 further stated she needed to use the call light to call the staff then because she wanted pain medication. Resident 90 attempted to reach for the call light and Resident 90 stated she was unable to find the call light and unable to reach the call light. Resident 90 stated, I need my call bell now. On 6/16/26 at 1058 hours, CNA 2 was summoned to Resident 90's room. An observation for Resident 90 and concurrent interview was conducted with CNA 2. Resident 90 was observed lying in bed, and the call light was on the floor on left side of the bed away from the resident's reach. CNA 2 verified the findings and placed the call light back on the resident bed. On 6/19/26 at 1400 hours, an interview was conducted with the DON. The DON informed and acknowledged the above findings. The DON stated the call light should be within the reach of the resident to ensure the resident's safety and allowed the resident to communicate with the facility staff when assistance was needed.

Based on observation, interview, and medical record review, the facility failed to promote dignity and respect for one of 29 sampled residents. * The facility failed to ensure Resident 15's indwelling urinary catheter drainage bag was placed inside the dignity bag. This failure had the potential to affect the privacy and dignity of the resident. Findings: On 6/16/26 at 1240 hours, during the initial tour of the facility, Resident 15 was observed lying on his bed with the indwelling urinary catheter on left side of his bed. The indwelling urinary catheter drainage bag was observed not inside the dignity bag exposing a scanty yellowish urine. On 6/17/26 at 0932 hours, a follow up observation for Resident 15 and concurrent interview was conducted with IP nurse. The IP nurse verified the indwelling urinary catheter drainage bag was still not inside the dignity bag. Medical record review for Resident 15 was initiated on 6/17/26. Resident 15 was initially admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of Neurogenic Bladder (nerve damage from underlying illness or injury causing loss of normal control of urinary bladder resulting to inability to empty urine). Review of Resident 15's Order Summary report dated 6/18/26, showed a physician's order dated 2/16/26, for indwelling urinary catheter size (FR#16) with balloon via gravity drainage for neurogenic bladder. On 6/19/26 at 1144 hours, an interview was conducted with the IP Nurse. The IP nurse stated she had in-service to staff on 12/10/25, regarding Care of Indwelling Catheter, to always place the indwelling urinary catheter drainage bag inside the dignity bag and not touching the floor. On 6/19/26 at 1427 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pain management care and services for two of 29 final sampled residents (Residents 13 and 90) reviewed for pain management. * The facility failed to ensure Resident 13's pain was assessed prior to the administration of hydrocodone (narcotic analgesic) medication. * The facility failed to accurately document the pain level for Resident 90 according to the physician's order when the resident was administered with hydrocodone (narcotic analgesic) medication. These failures posed the risk for the residents not to receive the appropriate and necessary interventions to manage the residents' pain.Findings: 1. Medical record review for Resident 13 was initiated on 6/16/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 6/9/26, showed Resident 13 had the capacity to participate in medical decision-making. Review of Resident 13's Order Summary Report showed a physician's order dated 5/20/26:- to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth every four hours as needed for severe pain (pain level of 7-10, at a scale of 10, 0=no pain and 10=worst pain); and- to monitor for pain every shift and chart intensity of pain using the following pain rating scale: zero for no pain; 1-3 for mild pain; 4-6 for moderate pain; and 7-10 for severe pain. Review of Resident 13's MAR for June 2026 showed the following:a. Resident 13 was administered the hydrocodone medication on the following dates and times, but was not assessed for pain prior to administering the hydrocodone medication:- dated 6/1/26 at 1135 hours;- dated 6/2/26 at 0832, 1442 and 2210 hours;- dated 6/3/26 at 0826 hours;- dated 6/4/26 at 0925 hours;- dated 6/5/26 at 0609 and 1220 hours;- dated 6/6/26 at 0640 hours;- dated 6/7/26 at 0752 and 2041 hours;- dated 6/8/26 at 0544 and 1609 hours;- dated 6/9/26 at 0839 and 2011 hours;- dated 6/10/26 at 0642 hours;- dated 6/11/26 at 0632 hours;- dated 6/12/26 at 1004 hours;- dated 6/13/26 at 0648, 1758, and 2254 hours;- dated 6/14/26 at 1317 and 2107 hours;- dated 6/15/26 at 1137 hours;- dated 6/16/26 at 1132 hours;- dated 6/17/26 at 0822 and 1529 hours; and- dated 6/18/26 at 0830 hours b. Under the monitoring for pain every shift, showed Resident 13 was assessed for pain on the following dates and shift:- dated 6/2/26 in the evening shift, with a pain scale of 7/10;- dated 6/9/26 in the evening shift, with a pain scale of 3/10; and- dated 6/13/26 in the evening shift, with a pain scale of 5/10. Further review of Resident 13's medical record review did not show Resident 13 was assessed for pain prior to administering the hydrocodone medication. On 6/18/26 at 0849 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 2. RN 2 verified the above Resident 13 was not assessed for pain prior to administering the hydrocodone medication. On 6/18/26 at 1505 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON verified the above findings. 2. On 6/16/26 at 1228 hours, an observation and concurrent interview was conducted for Resident 90. Resident 90 stated she had pain and had been receiving pain medications. Resident 90 stated the pain medication did help her pain but not completely taking the pain away. Medical record review for Resident 90 was initiated on 6/16/26. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's MDS assessment dated [DATE], showed Resident 90 had moderate cognitive impairment. Review of Resident 90's Order Summary Report showed the following physician's orders:- dated 2/7/26, to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth every six hours for severe pain (7-10); and- dated 6/8/26, to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth three times a day for severe pain (7-10). Review of Resident 90's MAR for June 2026 showed Resident 90 was administered the hydrocodone medication on the following dates and times and the noted pain level:- date 6/1/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/2/26 at 1200, and 1800 hours with pain level of 0;- dated 6/3/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/4/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/5/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/6/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/7/26 at 0000, 0600, 1200, and 1800 hours with pain level of 0;- dated 6/8/26 at 0000, 0600, 1200, and 1700 hours with pain level of 0;- dated 6/9/26 at 0100, 0900, and 1700 hours with pain level of 0;- dated 6/10/26 at 0100, 0900, and 1700 hours with pain level of 0;- dated 6/12/26 at 0000, 0800, and 1600 hours with pain level of 0;- dated 6/13/26 at 0000, 0800, and 1600 hours with pain level of 0;- dated 6/14/26 at 0000, 0800, and 1600 hours with pain level of 0;- dated 6/15/26 at 0000, 0800, and 1600 hours with pain level of 0;- dated 6/16/26 at 0000, 0800, and 1600 hours with pain level of 0; and- dated 6/17/26 at 0000 and 0800 hours with pain level of 0. On 6/17/26 at 1049 hours, an interview and concurrent medical record review for Resident 90 was conducted with the ADON. The ADON verified the above findings. The ADON stated the nurses should follow the physician's order and administer the pain medication per the pain level parameter. The ADON further stated Resident 90 should have not been given the pain medication when the pain level was 0. On 6/19/26 at 1314 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 90.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for seven of seven smoking residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility and one nonsampled resident (Resident 82) who was at risk for falls. 1. The facility failed to ensure the safe smoking practices were followed for seven residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed and reassessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. - The facility failed to ensure the IDT had reviewed and discussed the evaluation of the data gathered in the Resident Smoking Assessment. - The residents who were assessed as required adaptive safety equipment, such as smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. - The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep their cigarettes, lighters, and other smoking articles/materials in their possessions. - The facility failed to address safe storage and use of the smoking articles. - The facility failed to ensure individualized care plan problems were developed to address the resident's safe smoking practices. - The residents were permitted to share smoking articles with the other residents. 2. The facility failed to ensure safe environment for one nonsampled resident (Resident 82) who was at risk for fall and liked to keep the bed in high position to watch TV. These failures posed the risk of fire and serious injuries to the residents who smoked and to the residents who resided in the facility. On 4/19/23 at 0946 hours, the Administrator and DON were informed an IJ situation was identified due to the facility's failure to ensure safe smoking practices were followed for seven of seven residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility as evidenced by: * The residents were not accurately and thoroughly assessed and reassessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. * The residents who were assessed as requiring adaptive safety equipment, such as a smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. * The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. * The facility failed to address safe storage and use of the smoking articles. * The facility failed to ensure the individualized care plan problems were developed to address the residents' safe smoking practices. * The residents were permitted to share smoking articles with the other residents. On 4/20/23 at 1156 hours, the IJ was abated after the facility submitted a plan of corrective actions: * Conducted accurate and thorough assessments for all residents who smoked in the facility. * Developed and/or revised the care plan problems for seven smoking residents (Residents 40, 52, 55, 62, 73, 87, and 529) to address safe smoking practices. * In-serviced all staff on the facility's smoking P&P and safety measures related to smoking. * Implemented a supervised smoking schedule and ensured all resident who required adaptive equipment were provided with the equipment while smoking. * Ensured the residents who required supervision were not permitted to keep the cigarettes, lighters and other smoking articles in their possession. * Secured the smoking articles in a box container and kept in a locked area. * Educated the residents who smoked on the facility's smoking P&P and safe smoking practices. * Ensured a log was utilized for smoker residents to reflect the smoking needs for each resident who smoked, which will be included with the smoking materials and nursing assignment book. Findings: Review of the facility's P&P titled Smoking by Residents Nursing Manual-Resident Rights revised January 2017 showed the following: - The facility is to provide a safe environment for residents, staff, and visitors. - The facility will accommodate the residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting non-smoking residents. - Resident and their families/responsible parties are informed of this policy prior to or during the admission process and care conferences. - Smoking by residents is allowed outside the facility in designated, marked smoking areas with following safety measures readily available: ashtrays made of noncombustible material and safe design; metal containers with self-closing covers into which ashtrays can be emptied, portable fire extinguisher, and fire-retardant blanket (smoking blanket). - The facility may develop a smoking schedule to ensure a safe environment. - Using the Resident Smoking Assessment (NP-132-Form A), the Licensed Nurse will assess the residents who express the desire to smoke, upon admission, quarterly, annually, and upon significant change of condition identification, and present it to the Interdisciplinary Team (IDT) for review. - The IDT, consisting of, but not limited to, a licensed nurse, Social Services Designee, Activities Director, MDS Nurse, and/or Rehab representative, using the Resident Smoking Assessment (NP-132-Form A), will review the resident assessment, completed by the licensed nurse, who express the desire to smoke, for safety at minimum at the following intervals: when a resident initially expresses the desire to smoke, upon admission, quarterly, annually, and upon significant change of condition identification. - As identified by the Smoking Assessment, the residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied. - The IDT will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. This is documented on the Resident Smoking Assessment (NP-132-Form A) and resident's Plan of Care, and discussed with the resident and Responsible Party at the resident care conference meeting. - The resident and/or Responsible Party will be educated regarding the risks of smoking and the smoking safety measures developed by the IDT. This will be documented in the resident's clinical record. 1. On 4/17/23 at 1657 hours, Resident 62 was observed sitting up in his wheelchair in his room. Resident 62 stated he was a smoker and kept his own cigarettes and lighter. Resident 62 reached in his jacket pockets and pulled out a pack of cigarettes, a lighter, and a container with a half-used cigarette inside. Medical record review for Resident 62 was initiated on 4/17/23. Resident 62 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 62's MDS dated [DATE], showed Resident 62 was cognitively intact. Review of Resident 62's Smoking Safety Evaluation dated 6/13/22, showed Resident 62 required supervision while smoking and Resident 62 did not follow the facility's policy on location and time of smoking. However, the assessment did not specify if Resident 62 may keep his own smoking materials or required a smoking apron. Review of Resident 62's plan of care showed a care plan problem dated 3/22/23, addressing Resident's 62's smoking. The care plan problem showed Resident 62 was an identified as a smoker. The care plan failed to address the safe storage and use of Resident 62's smoking materials. Further review of Resident 62's medical record failed to show documentation of Resident 62's education in the facility's smoking P&P and safe smoking practices. There was no documentation to show there was an IDT conference conducted discussing the evaluation of the data gathered in Resident's 62's Resident Smoking Assessment as per the facility's P&P. On 4/17/23 at 1700 hours, an interview was conducted with the DON. The DON stated they encouraged the residents to give up their cigarettes and lighters, but the residents were noncompliant. The DON stated preferably for the residents not to keep their own smoking materials. The DON verified the above findings. On 4/18/23 at 1522 hours, an interview was conducted with MDS Nurse 1. MDS Nurse 1 verified the care plan problem for smoking did not specify Resident 62 may keep his own smoking material. MDS Nurse 1 stated it was important to revise the plan of care to provide appropriate care to the resident. On 4/19/23 at 0905 hours, an interview was conducted with Resident 62. Resident 62 was upset. Resident 62 stated he knew what he was doing regarding his smoking. Resident 62 stated he had been smoking in the facility since he was admitted and had not been supervise before while he was smoking. Resident 62 refused to provide information about his smoking materials. 2. On 4/17/23 at 1655 hours, Resident 73 was observed sitting up in his wheelchair in the dining room. Resident 73 stated he was a smoker and kept his own cigarette and lighter. Resident 73 reached to his pockets and pulled out a pack of cigarettes and a lighter. On 04/17/23 at 1710 hours, during an observation, Resident 73 was observed smoking in the facility patio without staff supervision. When asked if he was aware of the facility's smoking schedule, Resident 73 stated he did not follow the smoking schedule. When asked if the facility's staff follow him to the patio to watch him smoke, Resident 73 stated, They don't follow me. They don't care about us! Resident 73 was further observed pulling out his black lighter and lighting his own cigarette. Resident 73 stated he kept his lighters and cigarettes with him. He stated he also shared lighters and cigarettes with other residents in the past. When asked if the staff had ever taken away his smoking materials, he stated no. Resident 73 was then observed putting out his hot cigarette butt on his wheelchair. Medical record review for Resident 73 was initiated on 4/17/23. Resident 73 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 73's MDS dated [DATE], showed Resident 73's cognition was moderately impaired. Review of Resident 62's Smoking Safety Evaluation dated 8/24/22, showed Resident 73 required supervision while smoking and Resident 73 did not follow facility's policy on location and time of smoking. However, the assessment did not specify if Resident 62 may keep his own smoking materials or required a smoking apron. Review of Resident 73's Smoking Assessment v2-2014-RHCA dated 12/12/21, showed Resident 73 had a visual deficit and Resident 73 needed the facility to store the resident's lighter and cigarette. Review of Resident 73's plan of care showed a care plan problem revised 1/5/23, addressing Resident's 73's smoking. The care plan problem showed Resident 73 was an identified as a smoker. The care plan problem failed to address safe storage and use of Resident 73's smoking materials. Further review of Resident 73's medical record failed to show documentation of Resident 73's education in the facility's smoking P&P and safe smoking practices. Also, there was no documentation to show there was an IDT conference conducted discussing the evaluation of the data gathered in Resident's 73's Resident Smoking Assessment as per the facility's P&P. On 4/18/23 at 1607 hours, an interview was conducted with the Activities Director. The Activities Director was asked where the smoking materials of the residents were kept. The Activities Director pulled out a clear box container from her office cabinet that contained boxes of cigarettes and lighter. However, the Activities Director verified none of the smoking materials belonged to the current smoking residents in the facility. 43156 3. On 4/17/23 at 1650 hours, Resident 52 was observed smoking cigarette in the patio not wearing an apron and with no staff supervision. Resident 52 stated, I always smoke here in the patio by myself or with other residents and keeps cigarette and lighter with me. On 4/17/23 at 1702 hours during an observation, Resident 52 was observed smoking in the facility patio without a staff supervision. Medical record review for Resident 52 was initiated on 4/17/23. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's H&P examination dated 6/21/22, showed Resident 52 was an oxygen dependent. Review of Resident 52's Smoking Safety Evaluation dated 10/10/22, showed the supervision will be required for all residents during designated smoking times. Review of Resident 52's MDS dated [DATE], showed Resident 52 had no cognitive impairment. Review of Resident 52's plan of care showed a care plan problem dated 4/14/23, addressing Resident 52's smoking. The care plan failed to address the safe storage and use of Resident 52's smoking materials. Cross reference to F656, example #4. On 4/18/23 at 1610 hours, Resident 52 was observed smoking in the patio by herself with no staff supervision and not wearing an apron. Resident 52 stated, I smoked whenever I want, and keep cigarette and lighter with me all the time. On 4/18/23 at 1715 hours, interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON verified Resident 52's care plan problem failed to address safe storage and use of smoking materials. 4. Medical record review for Resident 55 was initiated on 4/17/23. Resident 55 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 55's Smoking Safety Evaluation dated 9/22/22, showed the supervision will be required for all the residents during the facility's designated smoking times. Review of Resident 55's plan of care showed a care plan problem dated 1/6/23, showed Resident 55 was an independent smoker. The care plan failed to address the safe storage and use of Resident 55 's smoking materials. Cross reference to F656, example #5. Review of Resident 55's MDS dated [DATE], showed Resident 55 had a BIMS Score of 14 which meant the resident was cognitively intact. On 4/17/23 at 1545 hours, an observation and concurrent interview was conducted with Resident 55. Resident 55 was observed lying in bed. Resident 55 stated he just got back from smoking. Resident 55 stated he kept his cigarettes and lighter and showed the smoking materials inside his sweater. On 4/18/23 at 0931 hours, an interview was conducted for Resident 55 with LVN 6. LVN 6 stated Resident 55 was a smoker, alert, independently went to smoke in the patio, did not require staff supervision during smoking, and kept his own smoking paraphernalia. LVN 6 verified Resident 55 was a smoker and kept his smoking paraphernalia in his own possession. On 4/18/23 at 1515 hours, an interview was conducted with the DON. The DON verified Resident 55 currently had in possession of his cigarettes and lighter. The DON verified the above findings. 47474 5. On 4/17/23 at 1655 hours, during an observation and concurrent interview conducted with Resident 40 in his room, Resident 40 stated he was about to go outside to smoke. When asked if he held onto his smoking lighter and cigarette, Resident 40 pulled out two lighters and three boxes of cigarettes from his pouch. Resident 40 stated he had shared and lit cigarettes for other residents in the past. When asked if the staff members were present when he smoked outside, Resident 40 stated no. On 4/17/23 at 1702 hours, Resident 40 was observed smoking in the facility patio without staff supervision. On 4/18/23 at 0848 hours, an interview with Resident 40 was conducted. Resident 40 verified he smoked usually at 1000 and 1600 hours, at the smoking patio near the activities room. Resident 40 verified there were times when the residents were not supervised by the staff during their smoke breaks. In addition, Resident 40 stated the facility had smoking aprons, but the resident denied using it. Resident 40 verified his cigarettes and lighter were kept in his bedside drawer but stated the facility staff removed his cigarettes and lighter from his possession on 4/17/23, because the state surveyors were in the facility. Medical record review for Resident 40 was initiated on 4/18/23. Resident 40 was admitted to the facility on [DATE], with a BIMS score of 11 (8 to 12 means moderately cognitive impaired). Review of the MDS dated [DATE], showed Resident 40 was a current tobacco user. Review of the Smoking assessment dated on 11/29/21, showed Resident 40 had dexterity problems, preferred to smoke in the mornings and afternoon, could not light own cigarette, and needed the facility to store the lighter and cigarettes. In addition, the facility did not conduct a smoking safety evaluation until 4/17/23. On 4/18/23 at 0932 hours, a concurrent interview and record review for Resident 40 was conducted with LVN 6. LVN 6 verified Resident 40's care plan problem dated 1/29/20, showed the resident was a smoker, had some safety issues with using the lighters, and needed to wear an apron. LVN 6 also verified Resident 40's smoking assessment was last updated on 11/29/21, instead of quarterly and annually as per the facility's P&P; and the smoking safety evaluation was recently completed on 4/17/23. LVN 6 stated the admitting nurses completed a smoking assessment and evaluation for the residents who smoke. LVN 6 acknowledged the residents were not to have the cigarettes or lighters in their rooms or their possession. LVN 6 stated it was a safety concern. 6. On 4/18/23 at 0858 hours, an interview was conducted with Resident 87. Resident 87 verified he smoked at midnight and 0200 hours, unsupervised. Resident 87 denied wearing a smoking apron and stated he carried his lighter and cigarettes with him. Medical record review for Resident 87 was initiated on 4/8/23. Resident 87 was admitted on [DATE], with a BIMS score of 9 (score of 8 to 12 mean moderately impaired cognition). Review of the MDS dated [DATE], showed Resident 87 was a current tobacco user. Review of Resident 87's care plan problem dated 12/21/22, showed the resident had been observed to smoke periodically. The care plan did not include interventions related to smoking, monitoring of the resident while smoking, or the safekeeping of the smoking materials. Further review of Resident 87's medical record showed the facility did not conduct a smoking safety evaluation until 4/17/23, and the last smoking assessment was completed on 10/5/21. On 4/18/23 at 1123 hours, an interview was conducted with the Activities Director. The Activities Director stated she was not aware of anyone smoking late at night and stated if there was a resident who wanted to smoke outside of smoking times, they could do so with staff supervision. The Activities Director was informed of the above findings. 43119 7. On 4/17/23 at 1652 hours, Resident 529 was observed in her room and lying in bed, pointed to the pillow on top of her wheelchair, and stated to look underneath; and two pieces of cigarettes and a lighter were observed underneath the pillow. Medical record review for Resident 529 was initiated on 4/17/23. Resident 529 was admitted to the facility on [DATE]. Review of Resident 529's admission MDS dated [DATE], showed Resident 529 was cognitively intact. In addition, Section J Health Conditions showed tobacco used was coded as no which was inaccurate. Cross reference to F641. Further medical record review of Resident 529 failed to show the smoking assessment and documentation of Resident 529's education on the facility's smoking P&P and safe smoking practices. Also, there was no care plan and no documentation to show an IDT conference was conducted to discuss the evaluation of the data gathered in Resident's 529's Smoking Safety Evaluation as per the facility's P&P, until 4/17/23. Review of Resident 529's Smoking Safety Evaluation dated 4/17/23, showed Resident 529 followed the facility's policy on location and time of smoking. However, the assessment for supervision was left blank and did not specify if Resident 529 may keep her own smoking materials or required a smoking apron. Review of Resident 529's plan of care showed a care plan problem dated 4/17/23, addressing Resident's 529's smoking. The care plan focus showed Resident 529 was an identified as a smoker. The care plan problem failed to address the use of adaptive safety equipment for Resident 529. On 4/17/23 at 1656 hours, an interview with concurrent medical record review was conducted with the DON. The DON stated they encouraged the residents to give up their cigarettes and lighters, but the residents were noncompliant. The DON verified Resident 529 did not have a Resident Smoking Assessment and comprehensive care plan. On 4/20/23 at 1504 hours, an interview with concurrent medical record review was conducted with MDS Nurse 1. MDS Nurse 1 verified the above findings and stated the MDS was inaccurately coded. MDS Nurse 1 stated Resident 529 was assessed for smoking on 4/17/23, and she was not aware when Resident 529 started smoking. MDS Nurse 1 stated it was important to modify the MDS to provide the appropriate care to the resident. On 4/20/23 at 1629 hours, an interview was conducted with the DON. The DON verified the findings and stated accurate assessment and care plan were important to provide appropriate care to the resident. 32179 8. Review of the facility's P&P titled Fall Management Program dated 3/13/21, showed the facility will implement a fall management program that supports providing an environment free from fall hazards. For fall risk evaluation, as a part of the admission Assessment, the license nurse will complete a fall risk evaluation. If a fall risk factor is identified, document interventions on the Resident's care plan; and to document interventions for every resident regardless of fall risk evaluation score. Medical record review for Resident 82 was initiated on 4/17/23. Resident 82 was admitted to the facility on [DATE]. Review of the H&P examination dated 9/11/22, showed Resident 82 has increased generalized weakness and limited ROM. Review of the Fall Risk Evaluation for Resident 82 dated 2/7/23, showed the resident had intermittent confusion and was at risk for fall. Review of Resident 82's care plan problem dated 11/23/22, showed the resident was at risk for fall related to psychoactive drug use, diabetes mellitus, history of falls, weakness, forgetfulness, Parkinson, tremors, and ataxic gait. The interventions included to follow the facility's fall protocol, review the information on the past fall, attempt to determine the cause of falls, record the possible root causes, alter remove any potential causes if possible, and educate the resident /family/caregivers/IDT as to the causes. On 4/17/23 at 0830 hours, Resident 82 was observed sitting up in the bed elevated to a high position above the floor and the head of the bed at 60 degrees. There was no floor mattress observed. Resident 82 was asked why his bed was high and how long the bed was in a high position. Resident 82 stated he could see the TV closely, so he needed to raise his bed. On 4/17/23 at 1250 hours, Resident 82 was eating his meal and watching TV in the high position bed. On 4/19/23 at 1030 hours, LVN 6 was summoned to the room. LVN 6 asked Resident 82 why his bed was in a high position. Resident 82 stated he wanted to watch the TV closer. LVN 6 lowered the resident's bed down with the resident's permission. LVN 6 acknowledged there were no floor mattress observed. On 4/19/23 at 1045 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 stated the resident noncompliance and like to raise the bed. LVN 6 was asked if she knew and asked the resident what the reason for Resident 82 to like his bed in a high position. LVN 6 was not aware of the reason why the resident liked the high position bed. LVN 6 was asked to provide the documentation if the resident was noncompliant or any other intervention to address the resident's needs for his TV adjustment or preventing fall from the high position bed. LVN 6 was unable to provide the documentation. On 4/19/23 at 1110 hours, an interview was conducted with CNA 1. CNA 1 was asked if he was aware of Resident 82's high position bed. CNA 1 stated Resident 82 liked the bed in a high position so he could watch the TV better. No floor mattress had been in placed per the CNA. CNA 1 stated the charge nurse had been informed about Resident 82's high position bed.

Based on observation, interview, and clinical record review, the facility failed to ensure one of 24 sampled residents (Resident 12) received necessary treatment and services to promote healing, prevent infection, and prevent recurrent pressure ulcers from developing. *Resident 12 was identified with newly developed pressure ulcers to both heels classified as UTD (unable to determine, full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (dead tissue) and/or eschar (dead tissue)) on 2/19/14. The facility failed to follow the physician's orders [REDACTED]. The facility failed to offload (take pressure off the area). Findings: During initial tour on 2/18/14 at 1410 hours, with RN 3, Resident 12 was observed with both heels resting on the bed. An interview was conducted with Resident 12's the family member on 2/20/14 at 1045 hours. The family member stated Resident 12 has big black blisters on both his heels; they were just informed yesterday (2/19/14). An interview was conducted with LVN 1 on 2/20/14 at 1125 hours. When asked how often they do a skin assessment, LVN 1 stated, once a week, on Wednesday. When asked specifically about Resident 12's skin assessment, LVN 1 stated, "Once a week too." LVN 1 stated they found the pressure ulcers yesterday (2/19/14) on both heels. Observation of the pressure ulcer to both heels was conducted with LVN 1 during wound dressing change on 2/20/14 at 1130 hours. LVN 1 measured the pressure ulcers. The pressure ulcer to the right heel measured 6.5 cm by 5 cm. The wound had thick black eschar. The pressure ulcer to the left heel measured 4.5 cm by 5 cm. The wound had thick black eschar. Resident 12 was observed lying on a regular mattress. On 2/20/14 at 1140 hours. Resident 12 was transferred to the acute hospital. Clinical record review was initiated on 2/20/14. Resident 12 was admitted on [DATE], following surgical repair of a fractured right hip. His [DIAGNOSES REDACTED]. Review of the physician's admitting orders failed to show orders to monitor the resident's blood sugar levels or to administer medications related to his [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a Podiatric Evaluation and Treatment record dated 1/30/14, showed Resident 12 had toenails debrided. The assessment showed a [DIAGNOSES REDACTED]. The podiatrist's recommendation was to avoid direct pressure to the bony prominences. Review of Resident 12's care plan showed no documented evidence the licensed nurses developed a care plan problem to address the resident's high risk to develop pressure ulcers. The care plan failed to address interventions to assess the resident's skin every shift and to implement measures to reduce pressure over Resident 12's bony prominences. Review of the Licensed Nurse Weekly Skin assessment dated [DATE], showed no skin problems. At the bottom of the page where the licensed nurse is to document they checked the care plan for completeness and accuracy, it was left blank. Review of the Licensed Nurse Weekly Skin assessment dated [DATE], showed staff identified "black scar" to the right heel measured 5 cm by 3.5 cm. The left heel was identified with "black scar" measuring 5 cm by 4 cm. An interview and clinical record review was conducted with LVN 3 on 2/20/14 at 1520 hours. When asked how often they check Resident 12's skin, LVN 3 stated, only the wound care nurses check the skin for all the residents. LVN 3 verified the physician's orders [REDACTED]. She stated all nurses are responsible to check and carry out the physician's orders [REDACTED]. An interview was conducted with CNA 1 on 2/20/14 at 1530 hours. When asked how Resident 12's skin is assessed and who does the check, CNA 1 stated Resident 12 does not have a skin problem, only on his right hip because of the surgery. When asked what they do to prevent pressure ulcers, CNA 1 stated she usually turns her residents side to side every two hours. When asked if she is doing anything special for Resident 12, like putting pillows or using heel protectors for the lower extremities, CNA 1 stated she just places a pillow for his hip, not on his feet, and no heel protectors are being used. An interview and concurrent clinical record review was conducted with LVN 2 on 2/21/14 at 0825 hours. When asked how often they do a skin assessment, LVN 2 stated, once a week on Wednesday. When asked about her assessment for Resident 12 on 2/12/14. LVN 2 stated she did not see any abnormal skin assessment for Resident 12 that particular day. When asked how she performs the skin assessment, LVN 2 stated she, one by one she checks residents from head to toe. LVN 2 stated she usually does it with one CNA and reports any abnormal findings and initiates treatment. LVN 2 verified the physician's orders [REDACTED]. LVN 2 verified the treatment administration record skin assessments for every shift were signed off by the nursing staff. LVN 2 verified they did not know Resident 12 has diabetes mellitus and [MEDICAL CONDITION]. LVN 2 stated, if they were aware of Resident 12's diagnoses, they should have focused more on how to prevent skin breakdown. An interview was conducted with CNA 2 on 2/21/14 at 1115 hours. When asked what they do to prevent pressure ulcers, CNA 2 stated he turns the residents every two hours. When asked if Resident 12 was using heel protectors or pillows to relieve pressure to the heels, CNA 2 stated he did not see any heel protectors and there is no pillow for his feet.

Based on clinical record review, observation and interview, the facility failed to provide the necessary care and services to help three of 24 sampled residents (Residents 16, 14 and 13) and one nonsampled residents (Resident A) attain or maintain their highest practicable physical, mental, and psychosocial well-being. *The facility failed to assess Resident 16's Perm-A-Cath (a type of intravenous catheter placed in a deep vein) site in the right upper chest after the [MEDICAL TREATMENT] center notified them there were signs of infection and administered an intravenous antibiotic. As a result, Resident 16's infection at the site became worse, requiring a five day hospitalization . *The facility failed to assess Resident 14 for bowel movements, resulting in fecal loading (constipation). *The facility failed to administer a medication to Resident A as ordered, to prevent constipation. This resulted in Resident A complaining of abdominal pain. An x-ray showed significant large bowel fecal loading. *Resident 13 receives insulin at 0630 hours each morning, but is not fed within one hour of this insulin administration as ordered. This has the potential for Resident 13 to experience [DIAGNOSES REDACTED] (low blood sugar). Two oral medications administered to Resident 13 should not have been given at the same time. Giving these medications together may cause one medication to be less effective. Findings: 1. Clinical record review for Resident 16 was initiated on 1/8/13. Resident 16 was readmitted to the facility on [DATE], after hospitalized from [DATE] through 12/10/12 for an infected catheter. Review of the consultation report from the hospital dated 12/5/12, shows "Perm-A-Cath in place in right upper chest...the insertion site is quite inflamed with purulent (pus) material coming out ...a few millimeters distally is an abscess site also draining purulent material surrounded by a large area of [DIAGNOSES REDACTED]. The area is quite tender to touch." Review of the [MEDICAL TREATMENT] coordination form dated 12/2/12, shows the [MEDICAL TREATMENT] center administered [MEDICATION NAME] (an antibiotic), one gram to Resident 16 for an infected right [MEDICATION NAME] (upper chest area) central catheter (Perm-A-Cath). The post [MEDICAL TREATMENT] assessment dated [DATE], completed by the facility fails to show an assessment of the right upper chest catheter site. Review of the Licensed Nurses Progress Notes fails to show any documentation for 12/2/12. Notes dated 12/3/12, and 12/4/12, shows documentation of an infection of Resident 16's nose, but contain no assessment of the Perm-A-Cath site. During an interview with the DSD on 1/9/13, the Licensed Nurses Progress Notes from 11/3/12 through 12/4/12, were reviewed. The DSD agreed the notes fail to show any assessment of Resident 16's Perm-A-Cath site. Review of the Infection Control Interdisciplinary Progress Notes dated 12/4/12, [MEDICAL CONDITION] ([MEDICAL CONDITION], an organism resistant to multiple antibiotics) of the nose, but no mention of the infection of the Perm-A-Cath site. The DSD stated she was unaware of the infection of the Perm-A-Cath site until after Resident 16 was hosptalized on [DATE]. During a telephone call to the [MEDICAL TREATMENT] center on 1/10/13 at 1030 hours, the [MEDICAL TREATMENT] staff was asked to fax any notes pertaining to the infection of Resident 16's Perm-A-Cath site. The faxed note dated 12/1/12, shows redness, drainage at the exit site of the right central venous catheter (Perm-A-Cath) site; contractor notified; wound culture done; [MEDICATION NAME], one gram given. During a second telephone call to the [MEDICAL TREATMENT] center, the [MEDICAL TREATMENT] staff confirmed the facility had been notified of the wound drainage, culture and administration of the [MEDICATION NAME] on 12/1/12. 2. Clinical record review for Resident 14 was initiated on 1/7/13. Resident 14 was readmitted to the facility on [DATE]. Review of the recapitulation of the physician's orders [REDACTED]. Review of the Resident Daily Care Flow Sheet (CNA documentation) shows Resident 14 had no bowel movements from 12/5/12, through 12/8/12. A CNA comment dated 12/8/12, shows the charge nurse was notified Resident 14 did not have a bowel movement for the last three days. Review of the Change of Condition report dated 12/8/12, shows Resident 14 pulled out the GT (small catheter inserted through the abdominal wall into the stomach for the administration of liquid nutrition and medications). After the GT was reinserted, Resident 14's physician ordered an x-ray to check the GT placement. The x-ray dated 12/8/12 at 2323 hours showed "there is large bowel fecal loading (constipation)." When the physician was notified of the x-ray results, a bowel protocol was ordered. The bowel protocol included check bowel movement record, if no bowel movement for three days, give Milk of Magnesia (MOM - a laxative) 30 ml every day as needed; if no results from MOM, give a [MEDICATION NAME] suppository (a bowel stimulant); if no results from the [MEDICATION NAME] suppository, give a Fleets enema. No routine bowel program was ordered to prevent constipation. The MOM was given on 12/9/12. Review of the CNA documentation shows Resident 14 had two bowel movements on 12/9/12. A Change of Condition report dated 1/4/13, shows Resident 14 pulled out the GT. Resident 14's physician was notified. The physician's orders [REDACTED]. The x-ray report dated 1/4/13 showed "significant large bowel fecal loading." After the x-ray results were reported to the physician, new physician's orders [REDACTED]. Review of the Resident Daily Care Flow Sheet for January, 2013, with RN 1 on 1/8/13, showed Resident 14 had one small bowel movement on the night shift of 1/2/13. No other bowel movements were recorded until 1/4/13, after Resident 14 received MOM. Two large bowel movements were recorded on the night shift of 1/5/13, after Resident 14 received a [MEDICATION NAME] suppository. During an interview with RN 1 and clinical record review of Resident 14's x-ray reports dated 12/8/12, and 1/4/13, the Resident Daily Care Flow Sheets for December, 2012, and January, 2013, the physician's orders [REDACTED]. RN 1 was unable to answer and stated she would call Resident 14's physician to discuss a program to prevent constipation. 3. On 1/10/13 at 0745 hours, Resident A stated she had abdominal pain, feels constipated, and wants a suppository. She also stated she went the day before yesterday, but it was not much. On 1/10/13 at 0800 hours, LVN 2 stated Resident A has been receiving [MEDICATION NAME] (a stool softener) as a routine medication for constipation since 9/19/12. Review of Resident A's clinical record was initiated on 1/10/13. The MDS dated [DATE], showed her cognition is intact. The Resident Change of Condition form dated 1/2/13, showed Resident A complained of abdominal pain. The physician was notified. The physician order [REDACTED]. The KUB result dated 1/2/13, showed a significant large bowel fecal loading. The physician's orders [REDACTED]. The MAR for January, 2013, failed to showed Resident A received the [MEDICATION NAME] as ordered. During an interview and clinical record review with the DSD on 1/10/13 at 0840 hours, the DSD was asked for, but was unable to find documentation to show Resident A was assessed for stool consistency. She stated the resident had abdominal pain on 1/2/13. The physician ordered to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] on 1/3/13. She confirmed the resident did not receive the [MEDICATION NAME] as ordered. She confirmed the resident received [MEDICATION NAME] until 1/9/13. She was asked for, but was unable to find documentation to show the resident was assessed for the cause of abdominal pain. 4. Review of Resident 13's clinical record was initiated on 1/7/13. The resident was readmitted to the facility on [DATE]. a. The physician's orders [REDACTED]. According to Lexi-Comp (a drug reference), regular insulin should be administered within 30 to 60 minutes before a meal. The MAR for January, 2013, showed [MEDICATION NAME] R, 16 units every morning was scheduled at 0630 hours; a mechanical soft chopped diet was scheduled at 0700 hours. During an observation on 1/8/13 at 0706 hours, Resident 13 did not have her breakfast meal served. During an observation on 1/8/13 at 0800 hours, the breakfast meal cart arrived. A breakfast meal was brought to Resident 13 at 0805 hours. During an observation on 1/8/13 at 0855 hours, Resident 13 was eating her breakfast. During an observation on 1/9/13 at 0735 hours, Resident 13 was sleeping in her room On 1/9/13 at 0740 hours, CNA 5 stated the breakfast meal cart comes between 0740 to 0750 hours. The residents receive their breakfast meal at 0800 hours. CNA 5 stated Resident 13 did not eat because she was sleeping. The CNA stated the resident would eat later. On 1/9/13 at 0750 hours, the breakfast meal cart arrived. During an interview and clinical record review with LVN 4 on 1/9/13 at 0752 hours, the LVN stated Resident 13 received 16 units of [MEDICATION NAME] R at 0630 hours. She stated her blood sugar was checked, and [MEDICATION NAME] R was given to her at 0630 hours by the night shift. She was asked how she ensures the resident receives the [MEDICATION NAME] R within 30 to 60 minutes before her meal. She stated she would make sure the resident is the first one to receive her meal when the meal cart arrives. On 1/9/13 at 0755 hours, Resident 13's breakfast meal was in the meal cart. LVN 4 confirmed the resident did not receive her breakfast meal. She confirmed [MEDICATION NAME] R was not given within 30 to 60 minutes before the meal. On 1/9/13 at 1235 hours, the pharmacy consultant was asked if [MEDICATION NAME] R should be given within 30 to 60 minutes before a meal. She stated they better know that. b. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Lexi-Comp for the use of [MEDICATION NAME] showed to administer the medication 30 minutes or more before the first food or other medication of the day. According to Lexi-Comp, [MEDICATION NAME] may diminish the therapeutic effect of [MEDICATION NAME]. The MAR for January, 2013, showed [MEDICATION NAME] was scheduled at 0630 hours daily; [MEDICATION NAME] was scheduled at 0630 hours every Tuesday. During an interview and clinical record review with LVN 4 on 1/9/13 at 0752 hours, the LVN stated [MEDICATION NAME] and [MEDICATION NAME] are given to Resident 13 at 0630 hours by the night shift. On 1/9/13 at 1235 hours, the pharmacy consultant stated [MEDICATION NAME] and [MEDICATION NAME] should be separately administered as much as possible.

Based on interview and clinical record review, the facility failed to ensure the licensed nurses provided one nonsampled resident (Resident L) the treatment and services to prevent complications related to the use of [MEDICATION NAME]. Failure to follow the manufacturer's specifications for the administration of [MEDICATION NAME] may result in serious medical complications [REDACTED]. During the medication pass observation on 3/6/13 at 0830 hours, LVN 3 was observed administering [MEDICATION NAME] 0.125 mg to Resident L. LVN 3 was observed to check Resident L's blood pressure, but failed to check the resident's pulse rate. Review of the physician's orders [REDACTED]. According to the Davis drug guide, it shows to monitor the apical pulse (the heart beat obtained by listening to the chest with a stethoscope) for one full minute before administering [MEDICATION NAME]. The person who takes [MEDICATION NAME] must withhold the dose and notify the health care professional if the pulse rate is less than 60 beats per minute in an adult. Review of the facility's P&P titled Physician Orders, Accepting, Transcribing and Implementing dated July 2008, shows new medication administration records are compared to the previous month's sheets. Prior to the implementation of the new sheets, the medications are checked for accuracy by comparing them to the current medication sheets. During an interview and clinical record review conducted with LVN 3 on 3/6/13 on 0855 hours, LVN 3 was asked if he checks the heart rate before administering [MEDICATION NAME]. LVN 3 stated he checks it, but he does not document it. He said the MAR indicated [REDACTED]. He confirmed the nurses have not documented the heart rate for [MEDICATION NAME] on the MAR for the month of March.

Based on observation, interview, clinical record review and facility document review, the facility failed to minimize hazards as much as possible for Resident 1. Resident 1 was not served her dinner as ordered by the physician or the facility's Menu Guide Report spreadsheet (directions for the kitchen staff to follow when preparing residents' meals). Resident 1 was found unresponsive, paramedics were called and food was suctioned from her airway. Resident 1 was transferred to the acute care hospital where she died from asphyxia (a severely deficient supply of oxygen that arises from being unable to breathe normally, choking can cause asphyxia), due to aspiration (entry of a foreign substance such as secretions or food into the lung) of a food bolus (a mass of food). Findings: Review of the facility's P&P titled Blueprint Therapeutic Diets manual dated [DATE], showed the mechanical soft diet is for residents who have difficulty chewing and/or difficulty swallowing (dysphagia). On [DATE], clinical record review for Resident 1 was initiated. The MDS (an assessment tool) dated [DATE], showed Resident 1 had dementia (a condition which affects memory, thinking, language, judgment and behavior) and required extensive to total assistance from staff for activities of daily living, including eating. The Dysphagia Medical Workup form dated [DATE], showed Resident 1 had difficulty swallowing her regular diet and a swallowing evaluation was done by the ST. The ST documented the resident was "pocketing" food (retaining food in the mouth) and had a delay in chewing. The treatment plan consisted of training both the resident and staff to alternate textures and temperatures of foods to facilitate sensation, bolus clearance, and clearing food from her mouth to prevent her from pocketing food. The plan also consisted of ensuring good body positioning to increase safety with eating and drinking. The ST documented Resident 1 had absent pharyngeal swallow, decreased tongue movement and decreased oral motor coordination and control. A care plan problem titled Speech Therapy revised on [DATE], showed Resident 1 had dysphagia. The goal was Resident 1 would tolerate meals without aspirating. An approach was to modify the residents diet, and a mechanical soft, finely chopped diet was ordered. A physician's orders [REDACTED]. On [DATE], the physician ordered the resident to receive double portions of lunch and dinner. Review of the Menu Guide Report spreadsheet dated [DATE], showed residents with an order for [REDACTED]. However, the spreadsheet showed for residents with an order for [REDACTED]. Review of the MAR for [DATE], showed on [DATE] at 1700 hours, Resident 1 received her dinner meal tray with double portions. Review of the Licensed Nurses Progress Notes dated [DATE], showed Resident 1 ate dinner at 1800 hours. At 2055 hours, Resident 1 was found unresponsive in bed with no vital signs detected. Cardio-pulmonary resuscitation was started, emergency services were called and the resident was transferred to the acute care hospital. Review of the paramedics Care Report dated [DATE], showed Resident 1 was not breathing and had no heart rate. The paramedics suctioned the resident's airway and food was removed. Review of the acute care hospital's Emergency Physician Record dated [DATE], showed Resident 1 arrived at the emergency department unresponsive and may have aspirated food. The resident was pronounced deceased at the acute care hospital. The Certificate of Death showed Resident 1's cause of death was asphyxia due to aspiration of a food bolus and Resident 1 choked on the food bolus at the facility. On [DATE] at 1620 hours, during an interview and review of the facility's Menu Guide Report spreadsheet with the DSS, the DSS stated residents with diets ordered as "finely chopped" would receive the mechanical soft dysphagia diet. The DSS stated mechanical soft dysphagia diets are for residents with swallowing problems. On [DATE], a review of the facility's Menu Guide Report spreadsheet dated [DATE] was conducted. The spreadsheet showed salisbury steak, potatoes, peas and carrots, dinner roll or bread and apple cobbler was to be served for the lunch meal. For residents receiving mechanical soft diets, the salisbury steak would be ground up. And for residents receiving a mechanical soft dysphagia diet, the bread would be pureed and the peas would be eliminated. However, on [DATE] at 1145 hours, the lunch tray line service was observed and staff were noted to not be utilizing the correct menu for residents on the mechanical soft dysphagia diet. For example, staff were observed to plate peas and whole slices of bread cut in half, and not the pureed bread. On [DATE] at 1200 hours, Cook 1 continued to place slices of bread on the trays of residents with physician's orders [REDACTED]. The DSS stepped in and explained to the cook that residents with mechanical soft dysphagia diets were to receive pureed bread, not sliced whole bread. On [DATE] at 1250 hours, during an interview with the DSS, when asked why the mechanical soft dysphagia diets were not being prepared according to the diet orders and the facility's spreadsheet, the DSS stated the cooks did not know there was a difference between mechanical soft and mechanical soft dysphagia diets. The DSS stated she immediately provided an inservice to the kitchen staff regarding the two diets and to follow the spreadsheets. On [DATE] at 1500 hours, an interview with the DSS was conducted. The DSS was asked why the dietary spreadsheet dated [DATE] (for Resident 1) showed black beans were not to be served for residents receiving the mechanical soft dysphagia diet, the DSS stated the bean have a skin on them and they are potentially hazardous to residents with dysphagia. The DSS stated the cooks are to follow the facility's spreadsheet when preparing and serving food. Review of the Coroner's Autopsy Report dated [DATE], showed Resident 1's cause of death was asphyxia due to aspiration of a food bolus. The manner of death was an accident. Review of the Orange County Sheriff Coroner's Case Notes report dated [DATE], showed the forensic pathologist (a physician who determines causes of death) discovered what appeared to be black beans in Resident 1's trachea (a tube like structure in the human body which connects the larynx (the voice box) to the lungs, commonly called the windpipe). The report showed the resident was found unresponsive at the facility and the resident was intubated by paramedics who reported an obstruction in the resident's airway. The paramedics suctioned a large firm food particle from the resident's oropharynx (back of the throat where food passes from the mouth to the esophagus). No vomitus was reported on the resident, in her airway or in her bed. The report showed Resident 1 had black beans served to her at dinner time per staff at the facility.