Every finding on record at Apple Valley Post-Acute Rehab

Based on interview and record review, the facility failed to ensure Licensed Nurses (LNs):1. Administered medication per the physician's order and resident's plan of care to one resident (Resident 60) of six sampled residents; and,2. Followed the facility's policy and procedure for the receipt of pharmaceuticals when medications, including narcotics, were not reconciled for 19 residents (Residents 6,50,73,60,81,77,79,8,103,95,7,22,1,48,115,44,84,24,43) upon delivery. These failures decreased the facilities potential to safely administer medications to residents and prevent drug diversion (when healthcare providers obtain or use prescription medications illegally). 1. A review of Resident 60's admission record indicated admission to the facility in April 2025 with medical diagnoses of essential hypertension (high blood pressure with no known secondary medical cause) and atherosclerosis of aorta (the buildup of fat, cholesterol, and calcium on the inner walls of the aorta [the body's largest main artery] which hardens and narrows the vessel, increasing the risk of stroke, heart attack, or aneurysm). This admission record also indicated Resident 60 was her own responsible party. A review of Resident 60's Brief Interview for Mental Status (BIMS) assessment conducted on 7/23/26, indicated a score of 13, which meant Resident 60 had normal memory and thinking processes. A review of Resident 60's order summary report indicated an active order for hydralazine hydrochloride (HCL) oral tablet. LNs were expected to give one tablet of hydralazine HCL by mouth every 8 hours to Resident 60 if her systolic blood pressure (SBP- the top number of her blood pressure measurement) was greater than 150. A review of Resident 60'sMedication Administration Record (MAR) dated August 2026 indicated: LN 1 documented Resident 60's SBP measured 167 during the evening (PM) shift on 8/1/26; LN 2 documented Resident 60's SBP measured 155 during the morning (AM) shift on 8/6/26; LN 3 documented Resident 60's SBP measured 155 on the PM shift on 8/6/26; and, LN 2 documented Resident 60's SBP measured 153 on the AM shift on 8/8/26. This MAR also indicated that one tablet of hydralazine HCl 10 mg was not administered to Resident 60 when her SBP was greater than 150. During an interview with Resident 60 on 8/20/26 at 1:43 p.m., Resident 60 stated she was aware that she was taking medication for high blood pressure but did not know the names of the medication. Resident 60 acknowledged the nurses took her blood pressure reading before administering her medications and she had never refused to take her medications. A review of Resident 60's order administration progress notes between 8/1/26 and 8/9/26 did not indicate that LN1, LN 2, and LN 3 administered Resident 60's as needed (PRN) hydralazine HCL nor was it refused and communicated to the prescribing physician. A review of Resident 60's care plan regarding her diagnosis of essential hypertension indicated Resident 60's goal was to maintain a blood pressure within the physician's set parameters. One of the interventions LNs were expected to carry out was Give the hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension [a sudden drop in blood pressure that happens when you stand up from a sitting or lying position] and increased heart rate (Tachycardia) and effectiveness. During an interview with the Director of Nursing (DON) on 8/20/26 at 2:55 p.m., the DON stated she expected licensed nurses to read the MAR and follow the physician's order. A review of the facility's policy and procedure (P&P) titled, Administering Medication, dated October 2025, indicated, Medications are administered in a safe and timely manner, and as prescribed. As required or indicated for a medication, the individual administering the medication records on the resident's medical records.The date and time the medication was administered; Any complaints or symptoms for which the drug was administered; Any results achieved and when those results were observed; and The signature and title of the person administering the drug. 2. During a review of the pharmaceutical packing slips on 8/19/26 at 1:35 p.m. located in a binder at Nursing Station 1, several sheets were missing required LN signatures for the following medication reconciliations: 8/7/26 for 9 routine medications 8/17/26 for 5 routine medications and 1 narcotic 8/18/26 for 12 routine medications 8/19/26 for 2 routine medications During a concurrent interview and record review on 8/19/26 at 1:40 p.m., LN 5 stated two LNs are required to verify the delivery when medications are received from the pharmacy. The LNs check the medications against the packing slip to ensure all medications are correct doses and are present. One LN must sign the packing slip to indicate the medication and count are correct, after which the medications are then placed in the corresponding medication cart. During a concurrent interview and record review on 8/19/26 at 1:49 p.m., LN 6 stated the LN receiving the medication delivery must sign the packing slip to verify the accuracy of the count and dosage. LN 6 emphasized this step was essential to prevent potential medication diversion. LN 6 further explained the narcotic logs at each medication cart should contain two LN signatures: one at the time of reconciliation and a second when the narcotic is received and placed in the medication cart. During a concurrent interview and record review on 8/19/26 at 1:55 p.m., the DON stated it was considered best practice for LNs to sign packing slips upon the delivery of medications. The DON explained this step supported accurate reconciliation and helped prevent potential medication diversion. A review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy, updated February 2020, indicated, A licensed nurse.receives medications delivered to the facility and documents that the delivery was received and was secure on the medication delivery receipt [packing slip].Verifies medications received and directions for use with the medication order form.

Based on observation, interview, and record review, the licensed nursing staff failed to ensure pharmaceutical products were properly handled and stored for a census of 86 residents when inspection of three medication carts revealed:1. Pill cutters had powdery residue in the crevices and brown matter in the hinges;2. An expired medicated inhaler;3. Two unlabeled vials of insulin;4. The bottom of the medication drawers had visible dirt and sticky residue; and,5. Loose pills of unknown identity.These failures decreased the facility's potential to maintain clean and organized medication carts and ensure residents received medications with their expected potency.FindingsDuring a concurrent observation and interview on 8/18/26 at 10:37 a.m., Licensed Nurse 7 (LN 7) opened Medication Cart 3 for inspection. The bottom surface of the top drawer was observed to be dirty, with accumulated light brown debris around the raised portions of the drawer. LN 7 confirmed the drawer required cleaning and stated the debris had the potential to contaminate medications and equipment stored within the drawer. Two pill cutters were observed to have a powdery substance on the interior cutting surfaces and visible brown debris accumulated in the hinges. LN 7 confirmed the pill cutters were not clean or ready for use in their current condition, stating residue from prior medications could mix with medications prepared for other residents. LN 7 further stated the debris in the hinges could contribute to illness in residents. The bottom drawer contained one opened, unlabeled vial of Humulin R(R) insulin (a short acting insulin used to control blood glucose levels) and one opened, unlabeled vial of glargine insulin (a long acting insulin used once daily to control blood glucose levels). LN 7 stated all insulin vials must be labeled with the date opened to ensure expired medications are not administered to residents. LN 7 further explained opened multi dose vials expired 28 days after opening. LN 7 stated expired medications are to be disposed of in the drug deactivator bottle.During a concurrent observation and interview on 8/18/26 at 11:12 a.m., LN 8 opened Medication Cart 2 for inspection. The top drawer contained loose pills of unknown identity and dose. LN 8 confirmed the presence of the loose pills and stated they could not be identified. LN 8 further stated loose pills must be destroyed immediately to prevent a medication error. In one of the middle drawers, a tiotropium inhaler (a long acting medication used to open the airways) measuring 2.5 mcg/act (micrograms per puff) was found with an expiration date of 5/2026. LN 8 confirmed the inhaler was expired and stated administering an expired inhaler could alter the medication's efficacy and potency, potentially resulting in under dosing or over dosing. LN 8 further stated the expired inhaler needed to be destroyed.During an interview on 8/19/26 at 10:47 a.m., the Director of Nursing (DON) stated medication carts were required to always remain clean and must not contain expired medications, loose pills, or dirty supplies used for medication administration. The DON further explained medication destruction was made simple for nursing staff through the use of the drug destroyer located in each medication cart. The destroyer was a chemical compound into which pills and liquid medications can be placed, rendering them unusable.A review of the facility's policy titled Medication Labeling and Storage, revised October 2025 indicated, The nursing staff is responsible for maintaining medication storage.in a clean, safe and sanitary manner. If the facility has.outdated medications, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Multidose vials that have been opened or accessed are dated and discarded within 28 days.

Based on observation, interview, and record review, the facility failed to prepare foods by methods that conserved nutritive value and flavor when recipes were not followed for a facility census of 85 residents who were served food from the kitchen.This failure decreased the facility's potential to prevent weight loss, impaired wound healing, and malnutrition. Cross reference F804.FindingsDuring a concurrent observation and interview on 8/19/26 at 2:35 p.m. with [NAME] 2 (CK 2) in the kitchen, CK 2 was observed preparing food for the dinner menu, which included: sloppy joes, onion rings, buttered carrots and mandarin oranges. CK 2 referred to the facility's recipe titled, SLOPPY [NAME].85 Servings. CK 2 stated she combined tomato paste, ketchup, white vinegar, and onions to start the sauce. CK 2 pointed to a food container that contained the mentioned food items and onions were confirmed and observed in the sauce. CK 2 added one quart (qt- a unit of volume) of water to the prepared sauce. While reading the recipe, CK 2 stated the recipe indicated one and a half qts of water. CK 2 confirmed that she added one qt of water to the sauce. CK 2 further confirmed the sauce was complete, and it was combined with the ground beef on the stovetop to simmer.During the preparation of the vegetarian sloppy joe, CK 2 referred to the facility's recipe titled, VEGETARIAN SLOPPY [NAME].5 Servings. CK 2 added a 13.7 ounce (oz- a unit of measure) unopened bag of vegetarian crumbles (a pre-made vegetarian plant-based ground beef) into a saucepan on the stovetop. CK 2 confirmed the recipe indicated 16 oz of vegetarian crumbles. CK 2 stated 13.7 oz was enough. CK 2 combined chopped onions, half of a 12 oz can of tomato paste, and one tablespoon (tbs- a unit of volume) plus one teaspoon (tsp- a unit of volume) of white vinegar to a food container to make the sauce. CK 2 combined the sauce with the vegetarian crumbles in a saucepan on the stovetop.During the same dinner meal preparation at 3:55 p.m., CK 2 removed the ground beef mixture and the vegetarian crumble mixture from the stovetop and transferred the mixtures into separate steam table pans, covered, and confirmed that both dishes were completed.During the preparation of pureeing the buttered carrots, CK 2 referred to the facility's recipe titled, BUTTERED CARROTS.85 Servings. In a blender, CK 2 added an undisclosed combination of boiled chopped carrots with an undisclosed amount of cooking water. CK 2 stated the recipe was for pureed chopped carrots. CK 2 stated the mixture was 40 oz. when combined. The mixture was observed to measure 40 oz in the blender. CK 2 could not confirm the amount of water added to the chopped carrots. CK 2 added one tbs plus two and a half tsp of salt, and one tbs plus two and a half tsp of pepper to the blender with the carrot and water mixture. CK 2 confirmed the measurement of salt and pepper. CK 2 added three-fourths of a cup of melted butter to the blender with the carrot mixture. CK 2 confirmed the measurement of melted butter. CK 2 blended the carrot mixture and stated it was too watery. CK 2 added one-third cup of powdered thickener to the carrot mixture, whisked, and added another one-third cup of powdered thickener. CK 2 transferred the pureed buttered carrots to a steam table pan, covered and confirmed it was completed.During the preparation of the minced buttered carrots, CK 2 added an undisclosed amount of steamed chopped carrots to a food processor. CK 2 stated, it's half a bag but did not know the measurement. Observed, the chopped carrots measured approximately two and a half cups. CK 2 minced the chopped carrots. CK 2 combined one-fourth cup of melted butter, one tbs of pepper and one tbs of salt to the minced carrots. CK 2 transferred the carrot mixture to a steam table pan, covered, and confirmed it was completed.A review of the facility's recipe titled, SLOPPY [NAME], dated 2026, indicated, 85 Servings.Water two and a half [2.5] qts.SLOPPY [NAME] METHOD.BROWN BEEF AND ONIONS TOGETHER. DRAIN.ADD REMAINING INGREDIENTS.A review of the facility's recipe titled, VEGETARIAN SLOPPY [NAME], dated 2026, indicated, Five [5] Servings.VEGTRN [vegetarian] CRUMBLES 16 oz.TOMATO PASTE one-eighth [1/8th] CAN.VINEGAR, WHITE one [1] tbs plus two [2] and a half [1/2] tsp.VEGETARIAN SLOPPY [NAME] METHOD.COOK ONIONS AND CRUMBLES TOGETHER.ADD REMAINING INGREDIENTS.A review of the facility's recipe titled, BUTTERED CARROTS, dated 2026, indicated, 85 Servings.CARROTS SLICED 16 lb [pounds- a unit of measure] plus three [3] oz.SALT one [1] tbs plus two [2] and one-eighth [1/8TH] tsp.BLACK PEPPER one [1] tbs plus two [2] and one-eighth [1/8TH] tsp.MARGARINE, MELTED three-fourths cup [3/4 c].BUTTERED CARROTS METHOD.PLACE VEGETABLES IN STEAM TABLE PANS WITH SMALL AMOUNT OF WATER. STEAM.ADD SALT, PEPPER, AND MARGARINE TO THE COOKED VEGETABLES.PUREE: TAKE DRAINED PORTIONS NEEDED FROM REGULAR PREPARED RECIPE AND PLACE IN A FOOD PROCESSOR.FOR EVERY FIVE [5] PORTIONS, ADD THREE [3] TBS THICKENER AND ONE FOURTH [1/4TH] CUP LIQUID.During an interview on 8/20/26 at 2 p.m., the Registered Dietitian (RD) stated, I expect them [cooks] to follow the recipes because the recipes provide adequate nutrition and affects the taste of the food. The RD stated nutritive value maintained muscle mass and body function, and further stated, Inadequate nutrition could prolong a resident's recovery.During an interview on 8/21/26 at 8:02 a.m., the Dietary Manager (DM) stated she expected the cooks to know how to follow a recipe. The DM confirmed on 8/19/26 during dinner meal preparation, CK 2 required assistance with measurement conversions on multiple occasions. The DM stated CK 2 struggled with the smaller serving sized recipes. A review of the facility's policy and procedure titled, Standardized Recipes, no date, indicated, A standardized recipe adjusted to appropriate yield is available for each menu item and is used in the preparation of each. Nutrition Services personnel will locate the recipe.and use it for direction in item preparation.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to maintain palatability for 10 residents (Resident 17, Resident 25, Resident 28, Resident 29, Resident 37, Resident 46, Resident 61, Resident 70, Resident 87 and Resident 94) of a census of 85 residents who ate food from the kitchen when:1. Resident 17, Resident 61, and Resident 70 stated the food was not good; and,2. Recipes for pureed and minced buttered carrots were unpalatable.This failure had the potential to decrease the nutritive value of the foods being served, compromise the residents' enjoyment of meals, reduce adequate intake, and contribute to unintended weight loss or decline in nutritional status. Cross Reference F803.Findings1. A review of Resident 61's admission record indicated he was admitted to the facility in January 2023 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and moderate protein-calorie malnutrition (the body receives an insufficient amount of protein and calories to meet its needs).A review of Resident 61's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 7/27/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 15, which indicated his cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact).A review of a facility provided documented titled, [name of facility] Diet Roster 8/26/26, indicated Resident 61's diet order was a regular diet with regular consistency.During an interview on 8/18/26 at 10:52 a.m., Resident 61 stated his main issue was the food that was served. Resident 61 stated, It's awful. It has no taste. Resident 61 further stated at times, the food was served cold. Resident 61 stated most of his meals were provided from an outside source because he did not like the food that was served at the facility. Resident 61 confirmed he lost weight.A review of Resident 70's admission record indicated he was re-admitted to the facility in June 2026 with medical diagnosis which included encounter for surgical aftercare following surgery on the nervous system (includes the brain, spinal cord, and nerves that control body functions, movement, and sensation) and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance).A review of Resident 70's MDS dated [DATE], indicated his BIMS score was 12, which indicated his cognition was moderately impaired.A review of Resident 70's order summary report indicated the following active orders as of 8/20/26, VEGAN [excluded all animal products] diet Soft & Bite Size texture.During an interview on 8/18/26 at 11:32 a.m., Resident 70 stated his dietary needs were not met. Resident 70 stated he was not happy with his food choices and further stated the food did not taste good. Resident 70 confirmed he lost weight. A review of Resident 17's admission record indicated he was admitted to the facility in May 2025 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) and unspecified protein-calorie malnutrition.A review of Resident 17's MDS dated [DATE], indicated his BIMS score was 14, which indicated his cognition was intact.A review of a facility provided documented titled, [name of facility] Diet Roster 8/26/26, indicated Resident 17's diet order was a regular diet with regular consistency.During an interview on 8/19/26 at 8:30 a.m., Resident 17 stated he did not like the food that was served because it did not taste good. Resident 17 stated particularly he did not like the roux (sauce) that was added to the food.2. A review of a facility provided documented titled, [name of facility] Diet Roster 8/20/26, indicated Resident 94, Resident 29, and Resident 37's diet consistency was minced and moist. The same document indicated Resident 87, Resident 25, Resident 28, and Resident 46's diet consistency was puree.During a concurrent observation and interview on 8/19/26 at 4:10 p.m. with [NAME] 2 (CK 2) in the kitchen for dinner meal preparation, CK 2 referred to the facility's recipe titled, BUTTERED CARROTS.85 Servings. In a blender, CK 2 added an undisclosed combination of boiled chopped carrots with an undisclosed amount of cooking water. CK 2 stated the recipe was for pureed chopped carrots. CK 2 stated the mixture was 40 oz when combined. The mixture was observed to measure 40 oz in the blender. CK 2 could not confirm the amount of water added to the chopped carrots. CK 2 added one tbs plus two and a half tsp of salt, and one tbs plus two and a half tsp of pepper to the blender with the carrot and water mixture. CK 2 confirmed the measurement of salt and pepper. CK 2 added three-fourths of a cup of melted butter to the blender with the carrot mixture. CK 2 confirmed the measurement of melted butter. CK 2 blended the carrot mixture and stated it was too watery. CK 2 added one-third cup of powdered thickener to the carrot mixture, whisked, and added another one-third cup of powdered thickener. CK 2 transferred the pureed buttered carrots to a steam table pan, covered and confirmed it was completed.During the preparation of the minced buttered carrots, CK 2 added an undisclosed amount of steamed chopped carrots to a food processor. CK 2 stated, it's half a bag but did not know the measurement. Observed, the chopped carrots measured approximately two and a half cups. CK 2 minced the chopped carrots. CK 2 combined one-fourth cup of melted butter, one tbs of pepper and one tbs of salt to the minced carrots. CK 2 transferred the carrot mixture to a steam table pan, covered, and confirmed it was completed.Subsequently, at 5:30 p.m., CK 2 confirmed dinner meal service was ready for tray line. A taste test was conducted on the pureed and minced carrots. Observed, the pepper was smelt as the foil was removed from both covered steam pan trays, and the taste of salt and pepper in both dishes was overpowering. CK 2 confirmed the pureed and the minced buttered carrots were over salted and peppered. CK 2 stated, This [pureed and minced buttered carrots] cannot be served. The Dietary Manager (DM) tasted the minced buttered carrots and stated, too peppery, and was observed with a grimaced face.During an interview on 8/20/26 at 2 p.m., the Registered Dietitian (RD) stated, I expect them [cooks] to follow the recipes because the recipes provide adequate nutrition and affects the taste of the food. The RD stated nutritive value maintained muscle mass and body function, and further stated, Inadequate nutrition could prolong a resident's recovery.During an interview on 8/21/26 at 8:02 a.m., the DM stated she expected the cooks to know how to follow a recipe. The DM confirmed on 8/19/26 during dinner meal preparation, CK 2 required assistance with measurement conversions on multiple occasions. The DM stated CK 2 struggled with the smaller serving sized recipes. The DM confirmed the minced carrots prepared on 8/19/26 were over peppered. The DM further stated the minced carrots was a choking hazard.A review of the facility's policy and procedure titled, Standardized Recipes, no date, indicated, A standardized recipe adjusted to appropriate yield is available for each menu item and is used in the preparation of each. Nutrition Services personnel will locate the recipe.and use it for direction in item preparation.A review of the facility's document titled, JOB DESCRIPTION: Cook, no date, indicated, The [NAME] ensures that quality food.is always provided.A review of the facility's recipe titled, BUTTERED CARROTS, dated 2026, indicated, 85 Servings.CARROTS SLICED 16 lb [pounds- a unit of measure] plus three [3] oz.SALT one [1] tbs plus two [2] and one-eighth [1/8TH] tsp.BLACK PEPPER one [1] tbs plus two [2] and one-eighth [1/8TH] tsp.MARGARINE, MELTED three-fourths cup [3/4 c].BUTTERED CARROTS METHOD.PLACE VEGETABLES IN STEAM TABLE PANS WITH SMALL AMOUNT OF WATER. STEAM.ADD SALT, PEPPER, AND MARGARINE TO THE COOKED VEGETABLES.PUREE: TAKE DRAINED PORTIONS NEEDED FROM REGULAR PREPARED RECIPE AND PLACE IN A FOOD PROCESSOR.FOR EVERY FIVE [5] PORTIONS, ADD THREE [3] TBS THICKENER AND ONE FOURTH [1/4TH] CUP LIQUID.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, sanitary conditions, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety when:1. Smallware was not discarded when damaged (e.g. one cutting board was stored with brown debris and textured groves on the surface);2. An opened food item was stored with no use-by date;3. Kitchen environment was not maintained (e.g. an area in the cooking galley [where food was prepared and cooked] had grime [hard to remove dirt, soot, or grease], dust particles, and rust-colored areas); and,4. Kitchen staff did not protect food from physical contaminants and choking hazards (e.g. kitchen staff were wearing jewelry, and cook was wearing a watch).These failures decreased the facility's potential to prevent food borne illness for 85 residents eating the facility prepared meals.Findings1. During a concurrent observation and interview on 8/18/26 at 8:10 a.m. during the initial kitchen tour with the Registered Dietitian (RD), a white cutting board with brown splashes of an unknown substance on one side and blade markings on both sides were observed stored from a hanging cutting board rack. The RD stated the white cutting board was evident of debris, and confirmed both sides were with textured grooved cuts. The RD further stated the textured cuts in the cutting board could harbor bacteria.A review of the facility's policy and procedure (P&P) titled, Sanitization, dated 2001, indicated, All.equipment are kept clean, maintained in good repair and are free from.open seams, cracks.that may affect their use or proper cleaning.Cutting boards are washed and sanitized between uses.A review of Food and Drug Administration's 2022 Food Code, section 4-501.12, titled Cutting Surfaces, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms [infectious agents that can cause disease] transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.2. During a concurrent observation and interview on 8/18/26 at 8:35 a.m. during the initial kitchen tour with the Dietary Manager (DM), one 32 oz (ounce- a unit of measure) carton of liquid thick and easy (a food and beverage thickener) was observed open in the refrigerator. The facility placed label on the product indicated, Item: 611.Prep Date: [was left blank].Use By: [was left blank]. The DM stated the open date indicated June 1st as 6/1. The DM further stated the thick and easy should not be stored for use because it was past the use-by time frame. A review of the facility's P&P titled, Food Storage, no date, indicated, All opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area.A review of Food and Drug Administration's 2022 Food Code, section 3-501.17 (D)(3), titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, indicated, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. was required.3. Subsequently, during the concurrent observation and interview during the initial kitchen tour with the DM in the cooking galley, an area between a food preparation table that stored dry goods, spices, and kitchen equipment and the cooking range was observed to have a pipe coated with grime, dust particles, and rust colored residue. The exterior surface of the food preparation table was also observed with accumulations of grime, dust particles, and rust-colored residue. The area measured approximately 6 inches (in- unit of measure) wide by 36 in. tall and 30 in. deep. The DM stated the area needed to be deep cleaned. The DM further stated the area could attract rodents and harbored bacteria.A review of the facility's P&P titled, Sanitization, dated 2001, indicated, The food service areas is maintained in a clean and sanitary manner.All.kitchen areas.are kept clean.protected from rodents and insects.A review of the Food and Drug Administration's 2022 Food Code, section 4-202.16, titled Nonfood-Contact Surfaces, indicated, NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. It further stated that Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms.4. During an observation on 8/19/26 at 8:10 a.m. in the kitchen, [NAME] 1 (CK 1) was observed wearing a watch on her left wrist, one stud earring per ear, a stud in her left nare (nostril), and a left lower lip stud.During a concurrent observation and interview on 8/19/26 at 11 a.m. in the kitchen with the DM, Dietary Aide 1 (DA 1) was observed wearing a nose ring in her right nare, and an open semi-circled hoop in her septum (the wall of cartilage and bone that separates the left and right nostrils in the nose). The DM confirmed CK 1 was wearing studs in both ears, and facial jewelry. When asked to confirm if CK 1 was wearing a watch, the DM stated, If you saw it, then yes, she could be wearing a watch. The DM further confirmed DA 1 was wearing facial jewelry. The DM stated jewelry that dangled was not accepted. The DM further stated, Jewelry, especially a watch, could harbor bacteria. The DM confirmed that jewelry could fall off into food and presented as a choking hazard or could damage a resident's teeth.During an interview on 8/20/26 at 2 p.m. with the RD, she stated she expected kitchen staff not to wear a watch. The RD further stated hands were used for food preparation and watches were worn next to the hand. The RD stated, A watch could have bacteria and the bacteria could transfer over into the food. The RD stated she accepted a simple stud.just, nothing dangling off the body.During a concurrent observation and interview on 8/21/26 at 8:02 a.m. in the kitchen, DA 2 stated her responsibilities involved washing dishes, tray line, and beverage preparation. DA 2 was observed wearing three earrings in the right ear, a nose stud in the right nare, four earrings in the left ear (one with a dangling gem from a hoop), and a left eyebrow jewelry.During an interview on 8/21/26 at 9:18 a.m., the Infection Preventionist (IP) stated a cook should not wear a watch. The IP further stated, You can't wash your hands properly if you have a watch on. The IP further stated, It's a standard for health care and food management wise that only a wedding band is accepted. The IP confirmed jewelry could fall off and become a choking hazard and was a risk for infection control reasons. The IP verified a DA wearing three earrings in one ear, four earrings in the other, a nose and left eyebrow jewelry was excessive. A review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, dated 2001, indicated, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.Jewelry will be kept to a minimum.A review of the facility's document titled, JOB DESCRIPTION: Cook, no date, indicated, Always follows food safety regulations and guidelines and ensures that all dietary procedures are followed in accordance with established policies.A review of the facility's document titled, JOB DESCRIPTION: Dietary Aide/Assistant, no date, indicated, Follows food safety regulations and guidelines at all times.keep work areas clean.free of hazardous equipment, supplies, etc.A review of the Food and Drug Administration's 2022 Food Code, section 2-303.11, titled Jewelry, indicated, Expect for a plan ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hand. It further stated, Items of jewelry such as.watches may collect soil and the constructions of the jewelry may hinder routine cleaning. As a result, the jewelry may act as a reservoir of pathogenic organisms transmissible through food. The term 'jewelry' generally refers to the ornaments worn for personal adornment.An additional hazard associated with jewelry is the possibility that pieces of the item or the whole item itself may fall into the food being prepared. Hard foreign objects in food may cause medical problems.such as chipped and/or broken teeth and internal cuts and lesions.

Based on observation, interview and record review the facility failed to ensure its medication rate was below five percent when two errors were observed during 31 medication passes, resulting in a 6.45% error rate.This failure decreased the facility's potential to ensure medication was administered as ordered by the physician and decreased the expected efficacy of the medication. FindingsDuring a medication pass observation on 8/20/26 at 8:50 a.m., Licensed Nurse 5 (LN 5) administered budesonide-formoterol fumarate dihydrate inhalation aerosol (an inhaler used to open and decrease swelling in the airways) 80/4.5 mcg/act (micrograms per puff) 2 puffs to Resident 1. LN 5 did not wait 1-3 minutes between puffs and did not have Resident 1 rinse her mouth after using the inhaler.A review of Resident 1's physician orders, dated 3/6/26, indicated, budesonide-formoterol fumarate dihydrate inhalation aerosol 80/4.5 mcg/act. 2 puffs inhale orally every 12 hours.prime first, allow 1-3 minutes between puffs***rinse mouth after each use***During an interview on 8/20/21 at 9:01 a.m., LN 5 stated he forgot to have Resident 1 wait in between puffs of the inhaler and to rinse Resident 1's mouth after administering the inhaler.During a medication pass observation on 8/20/26 at 11:37 a.m., LN 7 administered Insulin Aspart (a rapid acting medication used to lower blood sugar levels) injectable pen, 5 units subcutaneously (just beneath the skin) to Resident 100's left lower abdomen for a blood sugar level of 290. LN 7 held the insulin pen to Resident 100's skin for two seconds, LN 7 did not hold the insulin pen to Resident 100's skin as per clinical standards.A review of Resident 100's physician orders, dated 6/29/26, indicated, Insulin Aspart subcutaneous solution pen-injector 100 units/ml [units per milliliter- a unit of measure]. Inject as per sliding scale if BG [blood glucose].250-299 = 5 units.During an interview on 8/20/26 at 11:40 a.m., LN 7 stated she should have held the injector pen needle to Resident 100's abdomen for 30 seconds.A review of the facility's policy titled Administering Medications, revised October 2025 indicated, .medications are administered in a safe and timely manner, and as prescribed.A review of the manufacturer's instructions for use of Novolog Flex-pen(R), undated, indicated, Push the needle into the skin fold. Press the push button all the way in. With the push button fully depressed, keep the needle in the skin for at least 6 seconds to ensure the full dose has been delivered.

Based on interview and record review, the facility failed to ensure resident rights when nursing staff did not administer Parkinson's (a progressive brain disorder that damages nerve cells, leading to problems with movement, balance, and coordination) medications within a 30 minute window of the scheduled administration time for one resident (Resident 83) out of a sampled seven residents, as requested by Resident 83's family on 62 occasions. This failure resulted in Resident 83 experiencing symptoms of increased tremors and hallucinations and increased Resident 83's potential to fall.Findings:A review of Resident 83's admission record indicated Resident 83 was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease.A review of Resident 83's order summary dated 7/24/26, indicated the physician ordered the following medications:Carbidopa-levadopa (medications used to ease symptoms of Parkinson's Disease such as tremors, stiffness and movement) oral tablet 25-100 mg (milligrams- a unit of measure). Give 0.5 tablet by mouth three times a day.Carbidopa-levadopa oral capsule extended release 52.5-210 mg. Give 1 capsule by mouth four times a day.Carbidopa-levadopa oral capsule extended release 70-280 mg. Give 1 capsule by mouth four times a day.A review of Resident 83's Medication Administration Record (MAR), dated 9/1/26- 9/19/26 indicated scheduled medication administration times at 6 a.m., 11 a.m., 4 p.m., and 9 p.m. The MAR further indicated, nursing staff did not administer carbidopa levodopa within a 30 minute window:on 8 occasions at the 6 a.m. time slot;on 18 occasions at the 11 a.m. time slot;on 22 occasions at the 4 p.m. time slot; and,on 14 occasions at the 9 p.m. time slot.A review of Resident 83's progress note dated 8/14/26 at 11:53 p.m., indicated Resident 83's wife complained that she did not think [Resident 83] got his pm [evening] medication administration appropriately last night (Thurs) due to being told by the [morning] nurse that 'he had a bad night'.During an interview on 8/19/26 at 10:20 a.m. in Resident 83's room, Family Member 1 (FM 1) stated Resident 83's Parkinson's medications needed to be administered on time, and that FM 1 had spoken with the nursing staff on several occasions about this requirement. FM 1 stated when Resident 83 did not receive his Parkinson's medications on time, he experienced side effects related to his disease; if the medications are given too early, he experienced hallucinations.During an interview on 8/20/26 at 11:45 a.m. in Resident 83's room, Family Member 2 (FM 2) stated early in Resident 83's admission, she spoke directly with the Director of Nursing (DON) and requested Resident 83's Parkinson's medications be administered within a 30 minute window of his established home schedule of 6 a.m., 11 a.m., 4 p.m., and 9 p.m. FM 2 stated this request was made to prevent Resident 83 from experiencing symptoms. FM 2 explained when the medications were administered after the 30 minute window, Resident 83 experienced uncontrolled tremors, and if the medications were given too close together, he experienced hallucinations.During an interview on 8/21/26 at 11:31 a.m. in the conference room, the DON acknowledged speaking with FM 2 and understood her request for Resident 83 to have his Parkinson's medication delivered within a 30-minute window of scheduled times. The DON further acknowledged late administration of Parkinson medications had the potential to place Resident 83 in a stressful situation and increased his risk of falling.A review of facility policy titled Resident Rights, revised October 2025, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination.A review of facility policy titled Administering Medications, revised October 2025, indicated, Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication.honoring resident choices and preferences.

Based on interview and record review, the nursing staff failed to provide resident care and services according to professional standards and facility policy when:Licensed Nurses failed to implement the facility's hypoglycemic (a medical condition when the blood sugar levels drop below a healthy range, typically under 70 milligrams per deciliter [mg/dL]) protocol for Resident 103 during a low blood sugar event in the 50s; and,Resident 70's weights were not monitored per facility protocol.These failures had the potential to place Resident 103 in a medically compromised state which could have resulted in permanent brain damage, coma or death, and placed Resident 70 at risk for unmet care needs and delayed identification of clinically significant weight changes. Findings: 1. A review of Resident 103's admission record indicated Resident 103 admission to the facility on 8/5/26 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels). A review of Resident 103's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 6/23/26 indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation and judgment status of the resident) score was 13 which indicated Resident 103's thinking and memory were intact. A review of Resident 103's care plan, dated 8/6/26, indicated a risk for complications related to her Diabetes diagnosis. The care plan established a goal for Resident 103 to remain free from symptoms of hypoglycemia, and directed nursing staff to follow the intervention: If the resident becomes hypoglycemic, intervene and call MD. During an interview on 8/18/26 at 2:25 p.m. in Resident 103's room, Resident 103 stated her blood sugar dropped to 59 the previous night. She explained she was made to eat all of her chocolate candy, some of her gluten free cookies, and four orange juices to increase her blood glucose level. She stated after consuming the food and drinks, she felt she was going to puke. During an interview on 8/20/26 at 3:45 p.m. in the conference room, Licensed Nurse 1 (LN 1) stated that a student nurse informed her that Resident 103 had a blood sugar of 50 something. LN 1 rechecked the resident's blood sugar, which measured 57. LN 1 stated she instructed Resident 103 to begin eating the sugary foods available on her bedside table, including chocolate candies and cookies, and also provided multiple orange juices to drink. LN 1 further stated she obtained repeated blood sugar readings approximately every 5 to 10 minutes but did not document them. LN 1 recalled that the only blood sugar she documented was 75. LN 1 confirmed she did not enter a progress note and did not contact the physician. LN 1 verified the facility had a hypoglycemia policy and acknowledged she did not follow it. LN 1 stated because the blood sugars were rising with each 5-10 minute interval, she would not need to do all the things listed in the hypoglycemic policy. LN 1 added she should have been a better role model for the student nurse who was observing her. During an interview on 8/20/26 at 4:15 p.m., the Director of Nursing (DON) stated the facility's hypoglycemic policy and procedure should be followed at all times, including follow up with the physician and the resident. All interventions and notifications should be documented in the resident's medical record. A review of the facility's policy titled Management of Hypoglycemia revised October 2025, indicated, For level 1 hypoglycemia (<70 mg/dL): give the resident an oral form of rapidly absorbed glucose [simple sugar and primary source of cell energy]; notify the provider immediately.recheck blood glucose in 15 minutes.document the resident's blood glucose before intervention. Note blood sugar after each administration of rapid acting glucose and the follow up blood sugar. Record the resident's level of consciousness before and after intervention. Document provider instructions. 2. A review of Resident 70's admission record indicated he was re-admitted to the facility in June 2026 with medical diagnosis which included encounter for surgical aftercare following surgery on the nervous system (includes the brain, spinal cord, and nerves that control body functions, movement, and sensation) and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance). A review of Resident 70's MDS dated [DATE], indicated his BIMS score was 12, which indicated his cognition was moderately impaired. A review of Resident 70's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition [COC] among the residents) form, dated 6/11/26 indicated that Resident 70 transferred to a hospital after a COC. A review of Resident 70's admission/readmission screener document indicated he was re-admitted to the facility on [DATE]. A review of Resident 70's weights and vitals signs summary indicated he weighed 169.5 pounds (lbs- a unit of weight) on 5/29/26. The summary further indicated he weighed 157 lbs on 6/26/26, a 12.5-pound difference that signified a significant weight loss of -7.4% in less than 30 days. The summary indicated no evidence that his weight was assessed on 6/17/26. A review of Resident 70's active order summary report as of 8/20/26 indicated no evidence that an order was obtained to monitor weekly weights. During an interview on 8/18/26 at 11:32 a.m., Resident 70 stated he lost weight. During a concurrent interview and record review on 8/20/26 at 2 p.m., the Registered Dietitian (RD) confirmed Resident 70 returned to the facility on 6/17/26. The RD stated that following a new admission or a return from the hospital, she expected weekly weights to be obtained for one month. The RD verified that Resident 70's weight was not re-assessed until 6/26/26 and acknowledged a gap between Resident 70's return and the facility's first documented weight. The RD attributed Resident 70's weight loss to his recent hospitalization and further stated his weight was dramatically less. The RD verified she expected Resident 70's weight to be taken when he returned to the facility once a week for one month. The RD stated weekly weight monitoring was essential to ensure residents received adequate nutrition and reached weight goals. The RD further stated weekly weights assisted the facility to promptly identify and intervene when weight loss was detected. A review of the facility's undated policy titled, Weight Management indicated, All residents are monitored for weight changes on a regular basis.Residents at high risk of weight loss or experiencing weight loss should be monitored weekly for a specified period of time.

Based on observation, interview and record review, the nursing staff failed to provide appropriate respiratory care to one resident (Resident 43) out of seven sampled residents, when Resident 43's Continuous Positive Airway Pressure (CPAP-a machine which provides continuous mild air pressure to keep the airway open during sleep) machine was not filled with distilled water and was not cleaned per the manufacturer's instructions and the facility's policy.This failure caused Resident 43 mild discomfort and decreased the facility's potential to prevent Resident 43 from developing a respiratory infection.FindingsA review of Resident 43's admission record indicated admission to the facility on 7/30/26 with a diagnosis of Obstructive Sleep Apnea (OSA-a common sleep disorder when breathing repeatedly stops and starts due to the throat muscles relaxing, blocking the airway).A review of Resident 43's Inventory list, dated 7/30/26, indicated a CPAP was among the items brought with Resident 43 upon arrival to the facility. This form was signed by a facility representative in addition to Resident 43.A review of Resident 43's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 8/5/26 indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation and judgment status of the resident) score of 15 which indicated Resident 43's thinking processes and memory were intact.During a concurrent observation and interview on 8/18/26 at 9:09 a.m. in Resident 43's room, a CPAP machine was observed on the resident's nightstand. The water chamber was attached to the machine but contained no water, and no jug of distilled water was present in the room. Resident 43 stated she had been using the machine nightly without water and this had caused mild discomfort in her nasal passages. Resident 43 further stated the CPAP filter, tubing, water chamber, and nasal pillows had not been cleaned since her admission to the facility.During an interview on 8/19/26 at 3:19 p.m., the Director of Nursing (DON) stated the facility was unaware that Resident 43 brought a CPAP machine into the facility. The DON explained that the Infection Preventionist (IP) rounded on residents daily, and if the IP observed a resident had respiratory equipment such as a CPAP, he ensured physician orders were obtained and assigned appropriate cleaning tasks to the nursing staff. Because the facility was not aware of the CPAP, no physician orders were obtained, and the CPAP was not cleaned according to facility policy.During an interview on 8/21/26 at 10:37 a.m. in the conference room, the IP stated he rounded on the facility's residents daily and was unsure how he missed Resident 43's CPAP machine. He stated the CPAP tubing, headgear, and exterior should be cleaned weekly or when soiled, and the water chamber and nasal pillows should be cleaned daily. The IP further stated if the CPAP was not cleaned, bacteria could grow and be pushed into the resident's lungs via the CPAP, potentially causing respiratory illnesses such as pneumonia.A review of the facility's undated policy titled CPAP/BiPAP Equipment Cleaning and Disinfection indicated, Purpose.establish a consistent process for cleaning, disinfecting, handling, and storing CPAP.equipment to reduce contamination and transmission of respiratory pathogens while maintaining equipment safety and function. The facility will ensure CPAP/BiPAP equipment is maintained in a clean and sanitary condition. Cleaning.will follow the equipment.instructions for use. Licensed nurses and/or trained staff are responsible for ensuring resident CPAP.equipment is cleaned according to the policy and manufacturer's instructions. The IP provides oversight, education, and monitoring of compliance.A review of the CPAP manufacturer's instructions for cleaning indicated, the cushion [nasal pillows] should be cleaned daily. Headgear and frame should be cleaned weekly. water chamber and tubing should be cleaned weekly with a mild soap or solution of water and vinegar.

Based on observation, interviews, and record reviews, the licensed nurses failed to ensure medications were not administered as prescribed fortwo residents (Resident 30 and Resident 100) of 14 sampled residents when:1. Resident 30's carbidopa-levodopa (medication used to treat symptoms of Parkinson's disease [a movement disorder of the nervous system that worsens over time]) was administered at least one hour later than scheduled; and, 2. Resident 100's insulin was not administered per manufacturer's instructions. These failures decreased the facility's potential to prevent exacerbation of disease symptoms. Findings 1. A review of Resident 30's admission record indicated she had medical diagnoses of Parkinson's Disease, difficulty walking, and age-related Osteoporosis (a disease that weakens your bones and makes them much more likely to fracture). This admission record also indicated Resident 30 was her own responsible party. A review of Resident 30's Minimum Data Set (MDS, an assessment tool) dated 5/19/26 Brief Interview for Mental Status (BIMS) indicated she had a score of 15 which meant Resident 30 had no problems with thinking processes and memory. A review of a facility document titled Resident Council Response, indicated that on the resident council meeting held on 7/28/26, Resident 30 voiced out her concerns about getting her Parkinson's meds [medication] in a timely manner. A review of Resident 30's order summary report indicated an order for, Carbidopa-Levodopa 25-100 mg. Give 1 tablet by mouth six times a day for Parkinsons Disease ***SCHEDULED TIME PER NEUROLOGIST ORDERS***. This order summary report indicated Resident 30 had the capacity to make medical decisions. A review of Resident 30's Medication Administration Record (MAR) dated August 2026 indicated Resident 30 was scheduled to receive her carbidopa-levodopa at 6 a.m., 9 a.m., 12 p.m., 3 p.m., 6 p.m., and 9 p.m. A review of Resident 30's Medication Admin Audit Report, for her Carbidopa-Levodopa medication indicated the following: 8/1/26, 6 a.m. dose was administered at 7:32 a.m. 8/1/26, 12 p.m. dose was administered at 13:07 p.m. 8/1/26, 6 p.m. dose was administered at 7:37 p.m. 8/2/26, 6 p.m. dose was administered at 7:17 p.m. 8/2/26, 9 p.m. dose was administered at 10:12 p.m. 8/6/26, 9 a.m. dose was administered at 10:48 a.m. 8/6/26, 3 p.m. dose was administered at 4:16 p.m. 8/7/26, 6 a.m. dose was administered at 7:29 a.m. 8/9/26, 12 p.m. dose was administered at 1:55 p.m. 8/11/26, 9 a.m. dose was administered at 10:12 a.m. 8/12/26, 3 p.m. dose was administered at 4:15 p.m. 8/12/26, 6 p.m. dose was administered at 7:42 p.m. 8/12/26, 9 p.m. dose was administered at 10:29 p.m. 8/18/26, 9 p.m. dose was administered at 10:48 p.m. During an interview with Resident 30 on 8/19/26 at 10:30 a.m., , Resident 30 stated she knew she was not getting her Parkinson's medication on time because she started having hand tremors. During an interview with the DON (Director of Nursing) on 8/21/26, at 10:29 a.m., the DON stated if Resident 30 did not get her carbidopa-levodopa medication as scheduled by the physician, she could become rigid while walking and had the potential to fall. A review of the carbidopa-levodopa patient information leaflets indicated, It is important that Carbidopa-Levodopa be taken at regular intervals according to the schedule outlined by the physician. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated October 2025 indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering documents in the Electronic Medication Administration Record (EMAR) after giving each medication and before administering the next ones. 2. A review of Resident 100's admission record indicated admission to the facility on 6/26/25 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels). A review of Resident 100's physician order dated 6/29/26 indicated, Insulin Aspart subcutaneous solution pen-injector 100 units/ml [units per milliliter- a unit of measure]. Inject as per sliding scale if BG [blood glucose].250-299 = 5 units. During a medication pass observation on 8/20/26 at 11:37 a.m., LN 7 administered Insulin Aspart (a rapid acting medication used to lower blood sugar levels) injectable pen, 5 units subcutaneously (just beneath the skin) to Resident 100's left lower abdomen for a blood sugar level of 290. LN 7 held the insulin pen to Resident 100's skin for two seconds, LN 7 did not hold the insulin pen to Resident 100's skin as per clinical standards. During an interview on 8/20/26 at 11:40 a.m., LN 7 stated she should have held the injector pen needle to Resident 100's abdomen for 30 seconds. During an interview on 8/21/26 at 9:21 a.m., the DON confirmed holding an insulin pen to the injection site for a short period of time was best practice to ensure a full dose of insulin is received. During a phone interview on 8/21/26 at 10:17a.m., the Pharmacist (Ph) recommended holding the needle to the skin after injection for at least 6-10 seconds. The Ph stated insulin leakage could occur if removing the needle too quickly resulting in dose loss or underdose; leading to potential hyperglycemia (high blood sugar). A review of the manufacturer's instructions for use of Novolog Flex-pen , undated, indicated, Push the needle into the skin fold. Press the push button all the way in. With the push button fully depressed, keep the needle in the skin for at least 6 seconds to ensure the full dose has been delivered.

Based on interviews and record reviews, the facility failed to ensure a dignified existence and the right to receive services promptly for one of three sampled residents (Resident 1), when staff did not respond in a timely manner to Resident 1's repeated calls for assistance while experiencing a life-threatening medical emergency.This failure delayed access to emergency care and made Resident 1 feel frightened and ignored, and had the potential to result in severe harm including death. A review of Resident 1's admission record (facility demographic) indicated she was admitted to the facility on [DATE] with diagnoses of left ankle fracture, diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor healing), and congestive heart failure (a disorder which causes the heart to not pump efficiently). This document also indicated Resident 1 was her own representative.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/09/26 indicated it was incomplete with no cognitive (relates to the mental processes involved in acquiring, processing, storing, and using information) assessment.A review of Resident 1's Nursing Admission/readmission Screener dated 6/10/26 indicated Resident 1 was alert and oriented to person, place, time, situation and was verbally appropriate. This document further indicated Resident 1 was bedfast, had very limited mobility, and noted a left chest and lower abdomen heart monitor.A review of Resident 1's General Acute Care Hospital (GACH) History and Physical on admission to the facility, dated 6/10/26 at 11:18 a.m., indicated Resident 1 was alert and oriented and what was most important to her for quality of life was her ability to communicate, prevent pain and suffering, and minimize hospitalization.A review of the GACH Cardiology Clinical Documentation dated 6/10/26 at 5:14 p.m. indicated the heart monitoring company had noted a significant event on the monitor at 3:18 p.m. with a full pause in heart rate for 24 seconds and again for 6 seconds.During an interview on 6/18/26 at 4:30 p.m. with Resident 1, she stated on 6/10/26 she started to have cardiac arrest symptoms at 3:00 p.m., which included becoming sweaty and short of breath, which prompted her to make a note in her health journal. Resident 1 stated she was hitting her call button and trying to yell out for help until 3:20 p.m., at which time her GACH diabetes manager called her but she was too distressed to speak, and told her to keep hitting the call button and if still no help came to call 911. According to Resident 1, as soon as she hung up a family member called and Resident 1 asked her to please call the front desk or 911 immediately as she had been trying to get help for over 20 minutes now and nobody came. Resident 1 stated she could not understand how no one had heard her, especially as her roommate joined in by calling out for help. Resident 1 stated she felt frightened and ignored.A review of Resident 2's admission record indicated she was admitted on [DATE] with the diagnoses of fracture of left femur (thigh bone) and hypertension (high blood pressure).A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had no cognitive impairment.During an interview on 6/18/26 at 12:40 p.m. with Resident 2, she stated she recalled the event and her roommate had been hitting her call button and calling out for help, but her voice was weak. Resident 2 stated Resident 1 had been trying to get help for a significant amount of time, so Resident 2 joined in, and they both tried hitting the call button and calling out for at least another 15 minutes before someone came into the room.During an interview on 6/17/26 at 3:30 p.m. with Licensed Nurse 1 (LN1), she stated she recalled that there was a lot going on that day: she had two admissions, it was shift change and there was a staff training going on as well. LN 1 stated she was in another room with a resident who had fallen when another nurse came and told her Resident 1's family member was on the phone and that she was going to call 911 because Resident 1 was having a heart and respiratory event. LN 1 stated she then went to check on Resident 1 and noticed she was short of breath and distressed. According to LN 1, she got the Physician on site to assess her and they called 911 and she was transferred to the hospital.During an interview on 6/18/26 at 12:54 p.m. with Certified Nursing Assistant 1 (CNA 1), she stated she was working with LN 1 that day and remembered she was in a training from 3-3:30 p.m. CNA 1 stated when the training ended she was called immediately to a room where a resident had fallen, and when she returned to her assigned hallway the physician was already in with Resident 1, and LN 1 told her Resident 1 had been calling for help. During an interview on 6/18/26 at 9:50 a.m. with Family Member 1 (FM 1), she stated she had a bad feeling while she was driving to work and she pulled over to call Resident 1. According to FM 1, when Resident 1 answered she was in distress with reported chest pain and impaired breathing, and FM 1could hear the roommate yelling for help in the background. FM 1 continued stating Resident 1 reported trying to hit her call button and calling out for help for over 20 minutes. FM 1 stated she hung up and called the front desk and according to her cell phone record this was on 6/10/26 at 3:32 p.m. FM 1 told the nurse at the front desk Resident 1 needed help immediately and she was going to call 911.A review of a nursing Situation, Background, Assessment & Situation (SBAR, a standardized, highly structured communication framework used in healthcare to quickly and accurately exchange patient information), report dated 6/10/26 documented by LN1 indicated Resident 1 was found to be panicked and sweaty and reported chest pain at a level 10 (on a scale of 0-10, where 0 signifies no pain, and 10 is the highest level of pain a person has experienced during her lifetime). The report indicated the facility Physician was notified Resident 1 was in distress at 3:35 p.m. on 6/10/26, 911 was called and Resident 1 was transferred to the GACH. A review of Resident 1's Progress Notes indicated Resident 1 left the facility at 3:50 p.m. and was taken to the GACH's emergency department.During an interview on 6/18/26 at 1:07 p.m. with the Director of Nursing (DON), she stated they dd not have a system of recording call light response times, but the expected response time was three to five minutes.During an interview on 6/18/26 at 1:30 p.m. with the DON, she stated she did not feel a response time of 20 minutes, or more, was acceptable for a medical emergency and she could understand how this would make Resident 1 feel frightened.A review of the undated facility policy and procedure titled, Answering the Call Light, indicated the purpose of the procedure was to ensure timely responses to residents' requests and needs and. It is the responsibility of all floor staff to answer all call lights in a timely manner.A review of the undated facility policy titled, Resident Rights and Dignity, indicated, Federal and State laws guarantee certain basic rights to all Residents of this facility. These rights include the Resident's right to a dignified existence and be treated with respect, kindness and dignity.

Based on interview and record review, the facility failed to report an allegation of abuse within the mandated timeframe for one resident (Resident 2) of two sampled residents when the facility submitted notification to the California Department of Public Health (CDPH) on 8/25/25 when the allegation of abuse was reported to a nurse on 8/24/25.This failure decreased the facility's potential to protect residents.Findings:A review of Resident 2's admission record indicated admission to the facility on 7/17/25 with diagnoses which included dementia (a progressive state of decline in mental abilities), mild cognitive impairment of unknown cause, and a need for assistance with personal care.A review of Resident 2's Minimum Data Set (an assessment tool) dated 7/20/25 indicated a Brief Interview for Mental Status (BIMS, a screening tool used to monitor cognitive function (the mental processes our brain uses to perceive, learn, remember, and reason)) score of 11 which indicated moderate cognition.A review of Resident 2's progress note dated 8/24/25 at 5:25 p.m. indicated, Resident's daughter .reported to desk nurse that [Resident 2] stated that she was 'slapped two times' .During the skin assessment, the resident stated that she was 'slapped twice on the face, 3 weeks ago'.A review of a fax confirmation receipt of an SOC 341 (a state form used in California for mandated reporters to report suspected elder and dependent adult abuse or neglect) sent to CDPH from the facility regarding Resident 2's allegation of abuse was received on 8/25/25 at 10:15 a.m.In an interview on 9/9/25 at 12:58 p.m., the Administrator (ADM) stated he was the Abuse Coordinator and acknowledged allegations of abuse were to be reported to CDPH within 2 hours. The ADM stated he had faxed the SOC 341 to CDPH again on 8/25/25 when he realized it had not been confirmed as received on 8/24/25. The ADM also stated he called CDPH and left a message notifying the Department of Resident 2's allegation of abuse.A review of CDPH's voice message log on 9/9/25 at 3:55 p.m. showed no evidence that a call was received from the facility on 8/24/25. A review of CDPH's fax log confirmed a document regarding Resident 2's allegation of abuse was received from the facility on 8/25/25.A review of the facility's policy and procedure titled Elder/Dependent Adult Abuse revised 5/31/19 indicated, All alleged violations of abuse .the mandated reporter shall .Make phone report immediately .(no later than (2) two hours) to the .licensing agencies of .obtaining knowledge of, or suspecting abuse .Fax within (2) two hours .written report (SOC 341) to .the licensing agency.

Based on interview and record review, the facility failed to honor a resident's desire to go outdoors when one of two sampled residents, Resident 1, was asked repeatedly by multiple staff members to go inside to his room where he was in isolation for COVID-19. This failure potentially resulted in an escalation of Resident 1's anxiety prompting a call to the police and Resident 1's subsequent arrest. Finding: On 3/25/25, the Department received a report from the facility that on 3/24/25 at approximately 11:30 a.m., [Resident 1] became agitated in his covid isolation room. He exited the room using his walker without shoes or a mask on and went to exit the facility, to get fresh air and sun. As he approached the exit of the facility, the [facility] receptionist let him know he was not wearing the proper PPE (personal protective equipment) and was supposed to stay in his isolation room. Once inside, Resident 1 became significantly more agitated, 911 was called, police arrived, and after he became physical with one of the police officer, Resident 1 was arrested and escorted to the county jail. During a record review on 4/22/25 at 2:45 p.m., Resident 1's face sheet revealed an admitted [DATE] with multiple diagnoses including prostate cancer, anxiety disorder, difficulty in walking, and depression. Resident 1's face sheet also indicated he was his own responsible party. Review of Resident 1's MDS (minimum data set, an assessment tool) dated 2/23/25 indicated he had a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 indicates intact cognition) and he had exhibited no behaviors in the past five days such as physical or verbal aggression or resisting care. During an interview on 4/22/25 at 1:25 p.m. with Director of Nursing (DON) and Administrator, DON stated that on 3/24/25 Resident 1 was in isolation because he had tested positive for COVID-19. DON stated Resident 1 had four days left of isolation. DON stated Resident 1had a roommate who was getting a therapy session that day (3/24/25) and Resident 1 had gotten tired of the therapy staff talking to his roommate. DON stated Resident 1 left his room and went outside. Administrator stated staff were trying to ask Resident 1 not to go out, he had no shoes and no mask on. Administrator stated two nurses went outside with Resident 1 because he was unsteady on his feet. Administrator stated DON and a nurse tried to calm Resident 1, but Resident 1 would not calm down, Resident 1 said he was tired of being on isolation. Administrator stated Infection Prevention Nurse (IPN) called 911. Administrator stated that while the police were here, Resident 1 got so worked up contact was made, Resident 1 was arrested for resisting arrest and assault on a police officer. When queried, DON stated that even though Resident 1 was already outside, Resident 1 could not remain outside because he was COVID-positive and was on isolation. During an interview on 4/22/25 at 1:51 p.m., IPN stated that on 3/24/25 someone came and told her that Resident 1 had left his room and she went outside to talk to Resident 1. IPN stated he was in the front of the building without shoes or a mask, just his walker. IPN stated Resident 1 was angry and he stated he felt hot. IPN stated she asked Resident 1 to go back to his room to talk, which he did. IPN stated that when they got to his room, Resident 1 told her the air purifier in his room was too noisy, the room was hot, and he said he wanted to get away from you f---ing people. IPN stated she told Resident 1 she would get him a fan, and Resident 1 asked for lorazepam (an antianxiety medication) which Resident 1's nurse, Licensed Staff B, gave to him. IPN stated that while she got the fan, Resident 1 left his room again. IPN stated Licensed Nurse C approached her and told her, We need to 5150 (an involuntary psychiatric hold) him. IPN stated DON told staff to call 911, which they did. IPN stated she spoke to the dispatcher and explained Resident 1's situation and told them a peace officer would be good to de-escalate Resident 1. IPN stated an officer came and talked to Resident 1 in the dining room. IPN stated the officer started yelling and shuffling around, and then called for backup and a second officer came. IPN stated the two officers tried to restrain Resident 1 and Resident 1 hit one of the officers. IPN stated the police escorted Resident 1 out and put him in the police car. IPN denied any visitors or residents were out in the front of the building during the time of this incident. When queried, IPN stated Resident 1 was never aggressive prior to this incident. IPN stated Resident 1 would let his needs be known, and he would let staff know if he was anxious, which was handled with lorazepam, and then she would talk to him about how he was doing. When queried, IPN stated any time a resident was on isolation the resident could be outside safely with PPE and the resident could take their mask off when outside to get fresh air. IPN stated she had not in-serviced the staff on how to let someone on isolation go outside safely. During an interview on 4/22/25 at 2:08 p.m., Receptionist A stated that on 3/24/25 Resident 1 was agitated, he was unmasked and COVID- positive. Receptionist A stated that when Resident 1 headed towards the door, he (Receptionist A) tried to approach Resident 1, but he bashed me with his walker. I got out of the way, and I got help from other staff members. Receptionist A stated Resident 1 said, F--- you. I'm going outside, I'm getting the f--- out of here, and Resident 1 went outside. Receptionist A stated, It happens (resident aggression towards staff), it's not the first time. I just roll with it. During an interview on 4/22/25 at 2:27 p.m., Licensed Nurse B verified he was Resident 1's nurse the day he went to jail. Licensed Nurse B stated Resident 1 was on isolation for COVID, and it was reported to him that Resident 1 was out of his room going to the main door to go out. Licensed Nurse B stated IPN guided Resident 1 back to his room. Licensed Nurse B stated Resident 1 was very anxious, Resident 1 was verbalizing that he was feeling isolated, and he was anxious and confused about what was going on. Licensed Nurse B stated he administered lorazepam to Resident 1 for his anxiety and then after that Resident 1 attempted again to get out of the room. Licensed Nurse B stated he was following Resident 1, letting him know he was on isolation, and he has to go back to the room. Licensed Nurse B stated Resident 1 went to the dining room and he and DON and were watching Resident 1 at that time. Licensed Nurse B stated Resident 1 was aggressive in the dining room, he put his leg on a box, and he was trying to grab something, and we were trying to get it away from him because we thought he might throw it. Licensed Nurse B stated Resident 1 was very anxious. When queried, Licensed Nurse B stated that was his first day working with Resident 1 and he did not know the plan for Resident 1's anxiety except to give the lorazepam as needed. When queried, Licensed Nurse B stated that what Resident 1 needed in that moment was to get out of the room. Licensed Nurse B stated Resident 1 could not be out of his room at that time because he was on isolation, so his (Licensed Nurse B's) understanding was that all activities, therapy, and visitation happened in his room. During a phone interview on 4/22/25 at 4:15 p.m., Licensed Nurse C stated that on 3/24/25 Resident 1 had COVID, no mask, no shoes, and no socks and had gone outside. Licensed Nurse C stated he tried to get Resident 1 to come inside, but Resident 1 was saying, I want to go, this is like a jail. Licensed Nurse C denied anyone else was outside at the time, except maybe staff. During an interview on 4/23/25 at 1:24 p.m., Social Services Director (SSD) stated Resident 1 did not have aggressive behaviors prior to 3/24/25, just frustrated behaviors. SSD stated Resident 1 found out about his cancer diagnosis just before he got here, he lost his ability to live independently and found out he was not going to be able to go home to the same situation, he lost his apartment, and then he got the COVID diagnosis, which delayed his transfer out, and all that compounding was a lot for him. During an interview on 4/24/25 at 3:32 p.m., Administrator stated yes, Resident 1 could absolutely go outside as long as he followed protocol for infection control. Administrator verified someone could have brought Resident 1 a chair and his shoes. During a record review on 4/23/25 at 4:05 p.m., Resident 1's medication administration record for March 2025 indicated Resident 1 had a physician order for lorazepam 0.5 mg (milligrams) every six hours as needed for anxiety and Licensed Nurse B documented a dose given to Resident 1 on 3/24/25 at 11:41 a.m. Review of Resident 1's nurse progress notes indicated a note written by IPN dated 3/20/25 at 11:51 a.m., Resident tested positive for COVID 19 on 3/20/2025. He presents with a low grade fever and overall feeling of weakness. No other documentation of COVID symptoms was noted. Review of Resident 1's vital signs (blood pressure, pulse, respiratory rate, and temperature) revealed no fever after 3/20/25. Review of facility policy Resident Self Determination and Participation, last revised 8/2022, indicated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.

Based on record review, interview, and facility policy review, the facility failed to issue a written notice of bed hold when a resident transferred to a local hospital for 1 (Resident # 78) of 2 sampled residents reviewed for hospitalization . This failure resulted in a bed not being available upon discharge of the resident from the acute care hospital. Findings included: Review of a facility policy titled; Bed Hold Acknowledgement/Notification, revised 03/29/2018, indicated 1. facility will issue two notices related to bed-hold: a The first notice will be given upon admission to the facility. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were changed; b Second notice will be given at the time of transfer of a resident for hospitalization or therapeutic leave which specifies the duration of the bed-hold policy. An Admission Record indicated the facility admitted Resident #78 on 09/19/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type I diabetes mellitus and personal history of transient ischemic attack (TIA) and cerebral infarction without residual effects. Per the Admission Record, Resident #78 discharged (transferred) to an acute care hospital on 10/09/2024. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #78 had an unplanned discharge to a short-term general hospital on 10/09/2024. Resident #78's Progress Notes, dated 10/09/2024 at 2:55 PM, revealed the physician visited the resident related to ongoing complaints of nausea and uncontrolled pain. Per the Progress Note, there was a physician's order given to transfer the resident to an acute care hospital for further evaluation and treatment. Resident #78's medical record revealed no evidence to indicate the resident was provided a bed hold notice on transfer from the facility to the hospital on 10/09/2024. During an interview on 11/07/2024 at 9:01 AM, the Director of Admissions stated she was not responsible for the issuance of a second written bed hold notice to Resident #78 or the resident's responsible party on transfer from the facility and was not aware that was included in the facility policy. The Director of Admissions stated she was responsible for checking with the hospital discharge planner to determine if the resident would readmit to the facility. Per the Director of Admissions, after the resident transferred to the hospital, she spoke with resident's spouse and informed the spouse that the facility was at capacity and therefore did not have a bed available for the resident. The Director of Admissions stated she referred the resident's spouse to other local skilled nursing facilities. The Director of Admissions stated during the resident's hospitalization , the hospital staff reached out to her and she informed the hospital staff that the facility did not have any beds available for the resident. During an interview on 11/07/2024 at 9:40 AM, the Director of Social [NAME] stated the admissions team was responsible for the issuance of all bed hold notices during transfer from the facility. During an interview on 11/08/2024 at 8:23 AM, the Director of Nursing (DON) stated a member of the admission teams would provide the bed hold documentation to the resident and/or the resident's responsible party during the admission process. Per the DON, if the resident had a change of condition that required a transfer to the hospital, staff would ask the resident and/or the resident's responsible party, if they wished to have a bed hold, and that request and/or denial would be documented in the resident's medical record. During an interview on 11/08/2024 at 1:02 PM, the Administrator stated he expected the staff to follow the facility policy and procedures related to bed hold notification.

Based on record review, interview, and facility policy review, the facility failed to resubmit a Level I screening for 1 (Resident #6) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR, a tool to ensure residents are not inappropriately placed in nursing homes for long term care). This failure had the potential to affect the care the resident received. Findings included: An undated facility policy titled, Preadmission Screening and Resident Review, indicated 1. The facility will obtain/complete a Preadmission Screening and Resident Review timely. An Admission Record indicated the facility admitted Resident #6 on 11/04/2019. According to the Admission Record, the resident had a medical history that included diagnoses of adjustment disorder (an excessive reaction to stress), bipolar disorder (disorder characterized by mood swings between depressive lows and manic highs), and dementia. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include dementia and manic depression (bipolar disease), A letter from the State of California Department of Health Care Services, dated 10/26/2021, indicated Resident #6 had a positive Level I screening and a Level II mental health evaluation was required. A letter from the State of California Department of Health Care Services, dated 12/14/2021, indicated the Level II mental health evaluation was unable to be completed as Resident #6 was in isolation as a health and safety precaution. Per the letter, a new Level I screening must be submitted. Resident #6's medical record revealed no evidence to indicate a new Level I screening was submitted. During an interview on 11/06/2024 at 8:40 AM, the Director of Nursing (DON) stated she was able to retrieve a document that indicated a level II was attempted; however, Resident #6 was under isolation at the time of the attempt. The DON stated the facility did not attempt to file a new Level I screening after Resident #6 was removed from isolation. During an interview on 11/06/2024 at 9:10 AM, Licensed Vocational Nurse #1 stated the facility did not resubmit a new Level I screening for Resident #6 when the resident came off isolation. During an interview on 11/08/2024 at 12:53 PM, the Administrator stated he expected the staff to follow the PASARR policy for the completion of Level I screenings.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene when soiled gloves were removed and before a new pair of gloves were put on during the provision of wound care for 1 (Resident #4) 1 sampled resident reviewed for pressure ulcer/injury. This failure had the potential to cause the spread of infection between residents. Findings included: A facility policy titled, Handwashing/Hand Hygiene revised 08/2019, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy specified, 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handing an invasive device; f. Before donning (putting on) sterile gloves; g. Before handing clean or soiled dressings, gauze pads, etc.; h Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects in the immediate vicinity of the resident; m. After removing gloves; Per the policy, 8. The use of gloves does not replace hand washing/hand hygiene. An Transfer / Discharge Report indicated the facility admitted Resident #4 on 08/24/2021. According to the Transfer/Discharge Report, the resident had a medical history that included diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), quadriplegia (a form of paralysis that affects all four limbs), acquired absence of the right leg above the knee, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS, an assessment tool), with an Assessment Reference Date (ARD) of 09/15/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS, a tool to assess cognition) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one Stage 3 pressure ulcer (a deep wound when skin loss extends through the entire thickness of the skin into the underlying tissue, but not to muscle, tendon, or bone). Resident #4's Order Summary Report, that contained active orders as of 11/05/2024, revealed an order dated 08/17/2024 that directed staff to cleanse the resident's left buttock with cleanser, pat dry, and apply a thin layer of paste to the periwound (an area of tissue around a wound), and calcium alginate to the wound bed and cover with a foam dressing daily and as needed. During an observation of wound care for Resident #4 on 11/05/2024 at 2:26 PM, Licensed Vocational Nurse (LVN) #3 did not perform hand hygiene after she removed a soiled pair of gloves and before she applied a new pair of gloves. During an interview on 11/05/2024 at 2:48 PM. LVN #3 stated she was educated to perform hand hygiene and put on clean gloves between each step of wound care to include the removal of the old dressing, cleansing the wound, and the application of the clean dressing. LVN #3 confirmed she did not perform hand hygiene with hand sanitizer and/ or soap and water with gloves changes. During an interview on 11/07/2024 at 9:25 AM, the Infection Preventionist (IP) stated staff had been educated to perform hand hygiene during wound care whenever gloves were removed and a new pair was put on. The IP stated it was never acceptable to not perform hand hygiene. During an interview on 11/08/2024 at 8:12 AM, the Director of Nursing stated hand hygiene should be performed before applying gloves, with each glove change, and at the completion of the care provided.

Based on observation, interviews, and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received an accurate reconciliation of medications (A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) during her discharge, when Resident 1 received three (3) over the counter medications that were ordered for another resident, Resident 2. This failure had the potential to result in a medication error and could affect the safety and well-being of Resident 1, if she accidentally took the medications that were not ordered for her. Findings: On 7/2/2024, at 1:51 p.m., the facility's DON (Director of Nursing) provided a list of residents who were discharged in June 2024. The list included Resident 1, who was discharged on [DATE]. During a concurrent observation and interview on 7/2/24, at 11:26 a.m., with Licensed Nurse A, she stated she remembered discharging a resident who called her pharmacy because she was discharged with medications that did not belong to her. Licensed Nurse A confirmed that it was Resident 1. Licensed Nurse A stated that she drove to Resident 1's home and took back the medications that were ordered for Resident 2. Licensed Nurse A stated that she still has the medications kept in a transparent plastic bag which she showed this surveyor. This surveyor took pictures of the contents of the bag with labels indicating that these three medications were for Resident 2. Licensed Nurse A stated that she was taking responsibility for the incident. Licensed Nurse A stated that Resident 1 could be at risk if she was allergic to any of the three medications that were sent home with her during her discharge. Licensed Nurse A stated that she did not document the incident, but stated she might have verbally notified the DON. Licensed Nurse A stated that the over-the-counter medications were all sealed and unopened. This surveyor verified that the medications were unopened during inspection. A review of Resident 1's Progress Notes, dated 6/7/24, at 9:10 a.m., authored by Licensed Nurse A, indicated, Resident 1 is schedule to discharge home today as per MD (Doctor's) orders. All discharge instructions including medication regimen review with resident (Resident 1) who verbalized understanding .Resident 1 left the facility at this time .all belongings taken at this time. During an interview on 7/2/24, at 12:30 p.m., with the DON, she stated that it was her expectation that medications should be discharged to the right resident. The DON stated that if the resident was not alert as Resident 1, there would be a potential for harm if that resident accidentally took the medications. The DON stated that it was the facility's responsibility, not the pharmacy, to double check the medications being discharged to the residents. A review of a facility document titled, Discharge Instructions, dated 6/7/24, indicated, IMPORTANT: You (Resident 1) will be provided a discharge medication list before you leave the facility. It is important to continue with this medication list as prescribed by your physician at this facility until you see your regular doctor.

Based on interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe from elopement (Leaving the facility without notice), when he had a history of attempting to elope from the facility and was able to walk without a wheelchair. The facility's intervention to prevent him from elopement included a wander guard (Bracelets that trigger alarms at exit monitored doors to prevent the resident from leaving unattended) placed on his wheelchair. As a result, Resident 1 eloped from the facility by foot, left the wheelchair at the facility, which did not trigger the wander guard system, fell during the process, and hitchhiked to a neighboring town 8.5 miles away. This failure had the potential to result in serious harm, including death, to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Nontraumatic Intracerebral Hemorrhage (Bleeding in the brain, not caused by trauma), Alcohol Abuse, Metabolic Encephalopathy (A neurological disorder that occurs when a chemical imbalance in the blood causes brain dysfunction), and Unsteadiness on Feet, according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 3/29/24 indicated his BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 9, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 1's care plan for elopement initiated on 3/29/24 indicated, ALARM (Wander guard) WAS PLACED ON THE HANDLE OF HIS WHEELCHAIR. Other interventions in this care plan included, DEVELOP AN ACTIVITIES PROGRAM TO DIVERT ATTENTION AND MEET NEEDS .DISCUSS WITH RESIDENT/FAMILY RISKS OF ELOPEMENT AND WANDERING. There was no mention of increased supervision, or another system other than the wander guard to prevent elopement. This care plan was not revised until 4/14/24, after Resident 1 eloped from the facility. Record review of a facility document titled, Elopement/Wondering Risk Assessment, dated 3/29/24 at 12:03 p.m., indicated Resident 1 had attempted to leave the building 1-2 times within a week, unattended. This document indicated Resident 1 was at risk for wandering, but the intervention was to place the wander guard device on his wheelchair. Record review of a nursing note dated 3/31/24 at 1:10 p.m., indicated, patient [Resident 1] exhibited increased agitation this afternoon and attempted elopement through the front doors of [Name of facility]. Re-direction was provided in the parking lot, and patient agreed to return inside. He states he is ready to walk to Gualala however he is unable to correctly state his current location, appears confused. During a phone interview with Licensed Staff A (Who wrote the note on 3/31/24 at 1:10 p.m., above) on 4/25/24 at 11:30 a.m., she stated that on 3/31/24 Resident 1 attempted to elope from the facility by foot, although he was walking unsteady on his feet. Licensed Staff A stated that when she saw Resident 1, he was outside in the parking lot of the facility with another staff member, attempting to walk off. Licensed Staff A stated staff brought out Resident 1's wheelchair, and he agreed to come back inside the building. Licensed Staff A stated a decision was made to place a wander guard on Resident 1's wheelchair, as he did not want it placed on his body. Record review of a note dated 4/02/24 at 4:54 p.m., indicated, [Resident 1] has attempted to leave facility three times .staff run outside of facility trying to persuade resident to return to facility. Resident receptive to return to facility. Record review of a report sent to the DEPARTMENT on 4/14/24 of an elopement that occurred that same day (On 4/14/24) indicated, Around 8:45 AM (Morning) we received a call from a concerned citizen that a Caucasian male jumped over the fence. Staff alerted to check all residents. All Staff checked inside and surrounding area and at this time resident in 17A [Resident 1] cannot be located. Staff called [Local police department] for assistance. At 9:20 AM, received a phone call from the person who gave resident [Resident 1] a ride to make us aware that resident is in [Name of neighboring town} area, Police Officer [Name of Officer] made aware of resident's whereabouts. SAFE team (mental health team) brought resident back to the facility. Upon resident's return, LN (Licensed Nurse) made a thorough assessment. Resident made comfortable. Medicated for pain as needed. MD/RP (Medical doctor/Patient Representative) notified. Resident had a wander guard on in WC (Wheelchair). Therapy made him independent in the facility yesterday (Saturday). Record review of a nursing note dated 4/14/24 at 13:22 p.m. indicated, Pt (Patient [Resident 1]) has eloped this morning .PT is alert and verbalized that he fell by sliding down when he jumped out of the fence and leaned to his left shoulder, Pt noted to have no injuries. Record review of Resident 1's care plan for elopement, revised after the elopement on 4/14/24 indicated, 4/14/24 Wander guard applied on left ankle. During an interview with Resident 1 on 4/18/24 at 1:30 p.m., he stated that on 4/14/24 he wanted to leave the facility, so he left by foot, leaving the wheelchair with wander guard inside the building, which did not trigger the alarm. Resident 1 stated he jumped over the fence of the facility, and fell in the process, scraping his knee, but managed to get back up on his feet, and was given a ride by a vehicle passing by. Resident 1 stated he was driven to [Neighboring town 8.5 miles away, according to Google maps]. During an interview with the Director of Nursing (DON) on 4/25/24 at 11:00 a.m., she stated that after the elopement attempt on 3/31/24, facility staff should have placed a wander guard on Resident 1's wheelchair, and another one on his body to prevent him from eloping again. Record review of an e-mail sent to the DON and Medical Records Staff B on 4/24/24 at 10:53 a.m., indicated the Surveyor requested the policy on wander guard use, among other documents. Other requested documents were e-mailed to the Surveyor by Medical Records Staff B on 4/24/24 at 1:50 p.m., but the policy on wander guard use was not provided. Record review of the facility policy titled, Elopements, last revised in December of 2007, indicated, If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner .Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .When the resident returns to the facility, The Director of Nursing Services or Charge Nurse shall: e. Complete and file an incident report and f. Document relevant information in the resident's medical record.

Based on observation, interview and record review, the facility failed to manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing. Findings: During an interview on 10/31/23, at 3:03 p.m., Resident 1 stated she had pain on the lower back, neck, and her whole body. Resident 1 stated her scheduled pain medication was not given on time. The longest she had to wait was half hour, depending on the nurse on duty. Resident 1 stated she did not like to wait because it messed up her schedule and made her pain worse. Resident 1 stated, about two weeks ago, a night shift nurse refused to give her pain medication, because the previous nurse supposedly already gave her 11 p.m. pain medication. The night shift nurse told her she would give the medication at 3 a.m. but did not come back. Resident 1 stated she missed her 11 p.m., and 3 a.m. pain medication and finally received medication at 7a.m. Resident 1 stated she did not receive medication from the nurse who was supposed to give her pain medication at 11 p.m. Resident 1 stated her pain level was always 10 (numerical pain rating scale 0-10: where 0 is no pain and 10 is the worst pain imaginable), and it took twice as long to relieve the pain. The Nurse argued with her like she was crazy, or not stable, and did not know about her medication. Resident 1 stated she did not feel respected by that nurse. A review of Resident 1's admission Minimum Data Set (MDS - a federally mandated clinical assessment tool) dated 9/6/23 indicated she was admitted [DATE] with a Brief interview for Mental Status (BIMS - a tool to assess cognitive function) score of 13 indicating Resident 1 was cognitively intact. Resident 1's facesheet (resident demographics) indicated she was admitted with a diagnosis of cancer of the breast, pressure ulcer of the sacrum, diabetes, and depression among other medical conditions. A review of Resident 1's Medication Administration Record (MAR) for 9/23 and 10/23 indicated she was prescribed Morphine (narcotic pain medication) 30 milligram (mg - unit of measure equal to a thousandth of a gram) to be given one (1) tablet twice a day routinely and Oxycodone (another type of narcotic pain medication) 10 mg to be given one (1) tablet every four (4) hours as needed (PRN - to be administered when it is requested by, or as needed by, the patient; is not scheduled and not required on a regular basis) for moderate (level 4-6) and severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:15 p.m., Resident 1 stated she expected the Oxycodone every four hours. Resident 1 did not understand the order for the medication was to be administered every 4 hours PRN (as needed/ requested by the patient). During an interview on 10/31/23, at 3:33 p.m., Resident 2 stated she had back pain on the right side, had level 7 pain, and she had to wait at least 30 to 45 minutes for her pain medication. By that time the medication arrived she would be in tears. Resident 2 stated except for the two nurses who gave her medication on time, the others did not. Resident 2 states she did not feel respected, she felt like she was so much baggage. A review of Resident 2's admission MDS dated [DATE] indicated she was admitted [DATE] with a BIMS score of 14, suggesting she was cognitively intact. She had moderate level pain and was on pain medication. A review of Resident 2's Medication Administration Records for 10/23 indicated she was prescribed Oxycodone 5 mg to be given 1 tablet every 4 hours PRN for moderate (level 4-6) pain, and 2 tablets every 4 hours PRN for severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:23 p.m., Resident 2 stated she thought the pain medication order was for Oxycodone every 6 hours. Resident 2 did not understand the order for her pain medication was to be administered every 4 hours PRN (as needed/per patients request). During a concurrent observation and interview on 10/31/23, at 4:28 p.m. Licensed Nurse A was observed administering 2 tablets of Oxycodone to a resident. Licensed Nurse A stated she had not asked the resident's pain level before she administered the medication. Licensed Nurse A stated she was told by her Certified Nursing Assistant that the patient was in pain. During an interview on 12/12/23, at 1:45 p.m., when asked who provides information to the residents about their pain medication, the Director of Nursing stated nurses explain the pain medication order and time of administration schedule to residents. Nurses educate patients about routine and PRN medication - it is a standard of practice. In cases when a medication is given early, [brand name ] -the computer program used by the facility for medication administration-, gave nurses a warning of an early administration of medication, but they could administer as early as an hour before schedule, then the nurse would have to complete a supplemental documentation of the early medication administration. During an interview on 12/13/23, at 11:17 a.m., Licensed Nurse B was asked what information was provided to a resident about their pain medication. Licensed Nurse B stated, depending on the physician order, a routine medication the resident did not have to ask for, it was [NAME] to them; it was usually ordered for consistent pain. A PRN (as needed) medication, the resident had to ask for, and the nurses would assesses pain if controlled or not. It was a nurse's duty to assess pain. Routine medication education included how early the medication may be given. When asked when this information was provided to the resident, Licensed Nurse B stated, every day or every time the resident verbalized misunderstanding. When asked why information on medication was not provided to a resident, Licensed Nurse B stated, some nurses did not know their patient well - they had not observed when (pattern or time) the patient took their medication, had not assessed the effectiveness of the pain medication, were lazy, or had not reviewed the patient's medication order.

Based on observation, interviews and record reviews, the facility failed to provide safety reminders, guidance, and assistance to one of four residents (Resident 1) before he tripped on a transition strip on the floor and fell while walking at the lobby of the facility. This failure resulted in Resident 1 sustaining a closed or incomplete fracture of the neck of the right thigh bone, pain, and hospitalization . Findings: A review of records indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma, cognitive (natural skills including attention, memory, processing speed, reasoning, planning, problem solving, and multitasking) communication deficit, anxiety disorder, and major depressive disorder, among other conditions. Resident 1 ' s Minimum data set (MDS - federally mandated process for clinical assessment of each resident in Medicare and Medicaid certified nursing homes of their functional capabilities and help nursing home staff identify health problems) dated 6/3/23, indicated he had short term memory problem and required limited assistance (staff providing guided maneuvering of limbs or other non-weight-bearing assistance) while walking the corridors, moving between his room and adjacent corridor on the same floor, or moving to and from distant areas on the floor. A review of the Resident 1 ' s care plan dated 1/16/21, indicated interventions to prevent falls included providing the resident/family/caregivers safety reminders and a safe environment with even floors, etc. A review of facility documents titled: 1) SBAR Communication Form and progress Note V-3 (pneumonic for Situation-Background-Assessment-Recommendation a framework for communication between members of the health care team about a patient's condition) dated 6/3/23 indicated Resident 1 had a witnessed fall on 6/3/23, and; 2) Progress Notes dated 6/3/23 titled: Post Fall indicated Resident 1 was sent to the acute hospital for a closed or incomplete fracture of the neck of the right thigh bone. During an interview on 6/14/23, at 1:03 p.m., Licensed Nurse A (LN A) stated Resident 1 fell on [DATE], around 3:30 p.m. during change of shift. LN A stated she was inside the admission office when she heard a commotion at the lobby and when she went to check was informed by another Licensed Nurse and the Receptionist about Resident 1 ' s fall. LN A stated she had briefly assessed Resident 1 before he was moved using a Hoyer lift (a portable total body lift or a patient lift used to allow a person to be lifted and transferred with a minimum of physical effort) and returned to his room. LN A stated Resident 1 was alert and oriented, lying flat on his back, his right leg was slightly over his left leg, refused to bend his legs because his back hurt and denied he had hit his head during the fall. LN A stated Resident 1 was using his walker independently. During an interview on 6/14/23, at 1:18 p.m., Unlicensed Staff B (ULS B) stated Resident 1 was walking and was maneuvering his walker to go over the transition strip on the floor near the receptionist counter at the lobby. ULS B stated the slider on Resident 1 ' s walker got stuck on the lip of the transition strip between wood floor to tile, and Resident 1 fell backward to the right still holding on to his walker. ULS B stated she ran to Resident 1, told him not to move while she called for assistance. ULS B stated Resident 1 was forgetful, asking why he was in pain several times. A review of Activities of Daily Living (ADL) record of Resident 1 between 5/27 to 6/3/23, titled: Follow-up Question Report 5/28/23 - 6/3/23, indicated, Resident 1 required limited 1-person physical assistance on: 5/28/23 at 2:19 p.m., 5/31/23 at 8:14 a.m., 5/31/23 at 2:18 p.m., 6/2/23 at 10:37 a.m., 6/2/23 at 2:16 p.m., and 6/3/23 at 10:53 a.m. during the 7-day look back period. A review of the facility ' s policy titled: Falls-Clinical Protocol revised 9/2021, indicated under the subheading Treatment/Management: based on resident assessment, the staff and physician will identify pertinent interventions o try to prevent falls and to address risks of serious consequences of falling. A review of facility policy titled Fall risk assessment, revised 12/2007, indicated under policy interpretation and implementation: the staff with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, ADL capabilities and identify environmental factors that may contribute to falling and will collaborate and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The policy did not specifically discuss implementation of interventions, such as adequate supervision consistent with a resident ' s needs and ADL capabilities, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident.

Based on interview and record review, the facility failed to ensure quality healthcare services for one of 18 sampled residents (Resident 76), when facility staff did not: 1. Utilize an accurate medication administration record (MAR, a clinical record indicating medications used by an individual, including the medication names, dosages, and administration times) that reflected the resident's current opioid regimen. Resident 76 received opioid medication orally and by intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord) for pain management. 2. Administer the opioid-reversal agent Narcan, as ordered, when the resident appeared pale and sleepy on [DATE]. 3. Provide coordinated, safe physician services for pain management involving more than one physician-prescriber. These failures resulted in Resident 76 receiving higher, more frequent doses of opioid medication than expected by Physicians H and A, and a higher dose of intrathecal opioid medication than indicated by the MAR, and caused two emergent hospital transfers for opioid overdoses, which caused the resident's death on [DATE]. Findings: 1. On [DATE] the Department received a complaint that indicated Resident 76 had been sent to the emergency department multiple times related to opioid overdoses, and on one of these occasions he died in the ambulance on his way to a hospital's emergency department. Review of Resident 76's medical record revealed the resident was admitted to the facility on [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body cannot regulate blood sugar levels effectively) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and accidental poisoning by opioids (dated [DATE]), among others. During an interview on [DATE], at 2:25 p.m., Licensed Nurse F stated he was not aware the dose of opioid infused by Resident 76's intrathecal pain pump had been increased on [DATE]. Licensed Nurse F stated he did not know the method to communicate a dose change among facility staff when a provider changed the dose while on-site in the facility. During an interview on [DATE], at 10:31 a.m., Physician A stated she had been Resident 76's physician for several years. Physician A stated Resident 76 preferred pain relief that placed him on the edge of unconsciousness. Physician A stated she was unaware Resident 76's dose of intrathecal opioid was increased on [DATE] by the resident's pain specialist physician (Physician H). During an interview on [DATE] at 9:44 a.m., Licensed Nurse C stated she was unaware Resident 76's dose of pump-infused opioid increased on [DATE]. Licensed Nurse C stated nurses should communicate dose increases during verbal report at change-of-shift. Licensed Nurse C stated nursing would not document the information anywhere in the patient's record. During an interview on [DATE] at 9:18 a.m., Physician H stated Resident 76 was a new patient to him. Physician H stated Resident 76's primary pain specialist was unavailable and Physician H was asked to refill Resident 76's pump with medication on [DATE]. Physician H verified that 3.0 mg/day was the amount of opioid the pump infused each day, continuously. Regarding communication of dose adjustments, Physician H stated sometimes he would tell the patient's attending physician, but in the case of Resident 76, Physician H told Resident 76's nurse that he had adjusted the dose and then later faxed a visit note, too. Physician H stated he was not aware Resident 76 was getting 4 mg of opioids orally, twice daily. Physician H stated he would not have ordered Resident 76 to be administered oral opioids twice daily, but rather for administration as needed. Physician H stated he never spoke with Physician A, Resident 1's attending physician at the facility. During an interview on [DATE], at 11:00 a.m., Medical Director stated if a resident care requires two different physicians to prescribe opioid medication for pain management, then the resident's attending physician and the pain specialist should coordinate with each other about their orders for opioid medication. Medical Director stated Resident 76's situation sounded like a communication breakdown. During a record review and concurrent interview on [DATE] at 2:00 p.m., the DON stated the nurse caring for a resident requiring an intrathecal pump was responsible for updating the MAR if the dosage of medication changed. The DON reviewed Resident 76's MAR from [DATE] MAR. The DON reviewed Resident 76's visit note from Physician H dated [DATE]. The DON stated facility staff did not update Resident 76's MAR after Resident 76's dose of intrathecal opioid increased on [DATE]. When informed that the dose of intrathecal opioid after [DATE] was 3.0 mg/day, twice as much as the MAR indicated, DON stated she would have to ask the medical records staff about it. The DON stated the facility leadership did not perform a root cause analysis after Resident 76's overdose on [DATE], or after his overdose and death on [DATE]. Resident 76's pain specialist's (Physician H) visit note, dated [DATE], indicated Resident 76's intrathecal pump was refilled on [DATE] with opioid medication. The visit note indicated that before refill, the pump was administering of 2.8 mg/day of opioid medication. The visit note further indicated, After reprogramming, the infusion rate was increased to administer 3.0 mg/day of opioid medication. Under section Medication List at End of Visit the visit note indicated the following direction for oral opioid medication: As of [DATE] . Hydromorphone (Dilaudid) 2 mg tablet, take 2 mg by mouth daily as needed for pain. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid, a pain medication stronger than morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Resident 76's MAR for [DATE] indicated facility staff administered oral opioid, 4 mg per administration, to Resident 76 from [DATE] through [DATE], at noon and in the evening each day (8 mg total, daily). From [DATE] through [DATE], doses were held related to Resident 1's hospital admission for opioid overdose. On Resident 76's return to the facility, facility staff continued administering oral opioid, 4 mg per administration, to the resident on [DATE] and [DATE], at noon and in the evening (8 mg total, daily). The MAR for [DATE] reflected no change in the dose of oral opioid administered to Resident 76. Resident 76's MAR for [DATE] indicated facility staff administered oral opioid, 4 mg per administration, to Resident 76 on [DATE], at noon and in the evening (8 mg total, daily). On [DATE], the MAR indicated facility staff held each administration of oral opioid for Resident 76. The noon dose was held due to Resident 76's diminished respiratory rate, and the evening dose could not be administered because Resident 76 was at the hospital when the dose was due. The MAR for [DATE] reflected no effective change in the dose of oral opioid administered to Resident 76. Resident 76's MARs for August and [DATE] indicated the resident received 1.5 mg of opioid pain medication daily though an intrathecal pump. Despite that Resident 76's dose increased to 3.0 mg per day on [DATE], on [DATE] and days subsequent, the facility's MARs for August and [DATE] still indicated the resident was administered only 1.5 mg daily through the intrathecal pump. 2. During an interview on [DATE] at 10:31 a.m., Physician A stated she was Residenbt 76's attending physician at the facility and had been the resident's physician for several years. Physician A stated no nurse administered Narcan on [DATE], when Resident 76 was sent to the ED by ambulance for opioid overdose and died enroute. Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest secondary to opiate overdose. During an interview on [DATE], at 9:40 a.m., Licensed Nurse J stated she was Resident 76's nurse on [DATE], when the resident required emergency transfer to an acute care hospital. Licensed Nurse J stated she called 911 for Resident 76 because the resident appeared sleepy and not himself, despite being arousable. Licensed Nurse J stated she did not believe Resident 76 had overdosed on opioid medication because his vital signs were stable, and she did not administer Narcan for the same reason. Licensed Nurse J stated the signs and symptoms of opioid overdose were respiratory depression and unresponsive[ness]. When asked if there were any other signs or symptoms, Licensed Staff J stated No, that's all. During record review and concurrent interview beginning on [DATE] at 2:00 p.m., the DON stated that she spoke with Licensed Nurse J about her nursing care on [DATE]. The DON stated Licensed Nurse J told her that she did not administer Narcan to Resident 76 Narcan on [DATE] because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the Narcan physician's order and call 911 as soon as the first dose was given. During a review of Resident 76's medical record, the resident's Polypharamcy care plan, initiated [DATE], indicated a Black Box Warning for the oral opioid medication (Dilaudid) administered to Resident 76 twice daily. The Black Box Warning indicated [s]erious, life-threatening, or fatal respiratory depression may occur with use of [Dilaudid]. The care plan further indicated for facility staff to observe for respiratory depression, especially . following a dose increase. The care plan did not indicate guidance on managing polypharamcy risks associated with opioids administered via Resident 76's intrathecal pump. Review of Resident 76's physician orders, dated [DATE], indicated a provider ordered Narcan (e.g., a reversal agent for opioids, which blocks opioid receptors in the body) for Resident 76, to administer as needed for [signs or symptoms] of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. The physician order did not direct staff to not administer, or hold Narcan if a resident's vital signs are stable. Resident 76's progress note written by Licensed Nurse C dated [DATE], at 5:56 p.m., indicated information about Resident 76's first opioid overdose following the [DATE] dosage increase. The record indicated: Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan and called the physician between each dose, with no sustained improvement. The progress note further indicated, MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Resident 76's MAR for [DATE] indicated facility nurses administered Narcan to Resident 76 three times on [DATE], at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated [DATE], which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. Review of Resident 76's physician orders, dated [DATE], indicated a provider ordered Narcan for Resident 76, to administer as needed for [signs or symptoms] of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. The physician order did not direct staff to not administer, or hold Narcan if a resident's vital signs are stable. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 5:51 p.m., indicated information about Resident 76's second overdose after the increase in opioid dosages. The record indicated: [At] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's MAR for [DATE] indicated facility nurses did not administer Narcan to Resident 76 on [DATE], the second time Resident 76 was transferred for higher level services for overdose. Resident 76's hospital record included an ED physician note, dated [DATE], which indicated that EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . The package insert (e.g., a document included in the package of a medication that provides information about that drug and its use) for Resident 76's oral opioid medication (Dilaudid), revised ,d+[DATE], indicated the medication could cause: Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression may occur with use of DILAUDID Oral Solution and DILAUDID Tablets. Monitor for respiratory depression (slow, shallow breaths), especially during initiation of . or DILAUDID Tablets or following a dose increase. The section of the insert titled OVERDOSAGE indicated: Acute overdosage with . DILAUDID Tablets can be manifested by respiratory depression, somnolence (drowsiness) progressing to stupor or coma, . cold and clammy skin, . and, in some cases, . [low heart rate], [low blood pressure], . and death. According to the Centers for Disease Control and Prevention, updated [DATE], signs and symptoms of an opioid overdose include: Falling asleep or loss of consciousness, as well as pale, blue, or cold skin. From: https://www.cdc.gov/opioids/overdoseprevention/index.html (accessed [DATE]). 3. On [DATE] the Department received a complaint that indicated Resident 76 had been sent to the emergency department multiple times related to opioid overdose, and he had died in the ambulance on his way to the emergency department. Review of Resident 76's medical record revealed an admitted [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body's blood sugar levels are too high) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and accidental poisoning by opioids (dated [DATE]), among others. Care of Resident 76's chronic pain syndrome required pain management though oral opioid medication as well as continuously infused opioid medication via intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord). During an interview on [DATE] at 10:31 a.m., Physician A stated she had been Resident 76's physician for several years. Physician A stated Resident 76 wanted to be right on the edge of unconsciousness with his pain medication dose. Physician A stated a pain-specialist physician recommended the dose of oral opioid medication for Resident 76 and she would modify the resident's orders to reflect the recommendation. When asked if she knew Resident 76 had a dose increase on his intrathecal pump on [DATE], Physician A first stated she was not aware, then stated she was not sure and would have to check. Physician A stated she did not expect the nurses to call 911, as per the physician order, when administering an initial dose of Narcan (e.g., the reversal agent for opioid medication). Physician A stated she preferred that the nurses call her. Physician A stated the nurse caring for Resident 76 on [DATE] did not administer Narcan when Resident 76 was sent to the ED by ambulance and died . Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest (heart and breathing stopped) secondary to opiate overdose. During an interview on [DATE] at 9:18 a.m., Physician H, the pain-specialist physician, stated Resident 76 was a new patient to him. Physician H stated Resident 76's previous pain-specialist physician had left, and Physician H was asked to refill Resident 76's pump with medication on [DATE]. Physician H verified that 3.0 mg/day is the amount of opioid the pump infused each day, continuously. Physician H stated the 3.0 mg dose was a 5% increase from Resident 76's previous opioid dose. Physician H stated sometimes he told the a patient's attending physician about dose changes on the pump. Physician H stated in Resident 76's case, the physician told the resident's nurse of the dose adjustment and also faxed a visit note to the facility later that day. Physician H stated he was not aware Resident 76 continued to receive a scheduled, 4 mg dose oral opioid medication by mouth, twice daily. Physician H stated he would not have ordered the oral opioid for administration twice daily, but for administration as needed. Physician H stated he had never spoken with Physician A. During an interview on [DATE] at 11:00 a.m., Medical Director stated he did not have much knowledge of the circumstances of Resident 76's overdose or death. Medical Director stated he did not interfere with residents' medical management, but only reviewed whether physician followed policy in regard to ordering Narcan. Medical Director stated Physician A followed policy in ordering Narcan. When two different doctors order opiates for a resident, Medical Director stated the resident's attending physician and the pain-specialist physician should coordinate care by reaching-out to each other to communicate about opioid orders. Medical Director stated Resident 76's situation sounded like a communication breakdown. During a record review and concurrent interview on [DATE] at 2 p.m., DON stated the facility leadership did not perform a root cause analysis after Resident 76's overdose on [DATE] or after his death on [DATE]. DON stated the only action she took in response to these events was to inform Physician A and discuss with her Resident 76's pain medication regimen. When asked the reason these events did not trigger a root cause analysis, DON stated it was because Resident 76 was no longer here and we don't do them after the fact. Review of Resident 76's physician orders, initiated [DATE], indicated Resident 76 was prescribed to receive oral opioid medication (Dilaudid, a pain medication stronger than morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Review of Resident 76's physician orders, initiated [DATE], indicated Resident 76 continued to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Resident 76's physician order dated [DATE] indicated, FYI (for your information): Patient has pain pump LUQ (left upper quadrant of abdomen) managed by [clinic named] Sterile water [solution] by intrathecal route continuous Drug/Concentration: Hydromorphone [(e.g., an opioid)] 6 mg/ml [(milliliters, a unit of volumetric measure)], Baclofen [(muscle relaxant)] 1000 mcg/ml and Bupivacaine [(numbing medication)] 8 mg/ml Infusion . 1.5 mg/day . Resident 76's pain-specialist physician visit note, dated [DATE], indicated Resident 76's intrathecal pump was refilled with opioid medication. The visit note indicated that before the procedure, the pump was interrogated and revealed a rate of 2.8 mg/day. The visit note further indicated, After reprogramming, the following settings were noted: . Infusion mode/rate: 3.0 mg/day. Under section Medication List at End of Visit the visit note indicated, As of [DATE] . Hydromorphone (Dilaudid) 2 mg tablet, take 2 mg by mouth daily as needed for pain. Resident 76's progress note written by Licensed Nurse C dated [DATE] at 5:56 p.m., indicated, Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan, calling the physician between each dose, with no sustained improvement. The progress note further indicated, MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Resident 76's medication administration record (MAR) for [DATE] indicated that on [DATE] Resident 76 received Dilaudid 4 mg by mouth, at 12:00 p.m. and 6:00 p.m. The MAR further indicated Narcan was administered to Resident 76 on [DATE] at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Resident 76's document Hospitalist History and Physical, dated [DATE], indicated, Patient has known history of opiate induced narcosis and oversedation. It seems his dose of Dilaudid in his pump was just increased which is likely contributing towards his current presentation he was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. His risk of opiate induced sedation is much higher. We will have to be somewhat firm with him so that he does not go through this again. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 5:51 p.m., indicated, [at] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's ED physician note dated [DATE] indicated, EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . Review of facility policy Physician Services, last revised [DATE], indicated, It is the attending physician's responsibility to supervise the resident's medical care and services . Surveyor: Famularcano, Rena 46132

Based on observation, interview, and record review, the facility failed to ensure sufficient licensed nurses competent to manage one resident's (Resident 76) opioid-overdoses and intrathecal (e.g., continuous delivery of medication directly into the spinal cord via a pump system) opioid-delivery system, and manage another resident's (Resident 78) chest pain, when the facility's licensed nurses: 1. Could not consistently demonstrate the process for accessing and administering the opioid-reversal agent Narcan; 2. Were not trained how to safely care for residents using an intrathecal pump to deliver medication for pain management; 3. Did not appropriately respond to Resident 78's complaints of chest pain. Resident 76 required use of oral opioid medication as well as opioid medication administered via an intrathecal pump. Twice, on [DATE] and [DATE], Resident 76 was found unconscious and transferred to an acute care hospital for emergency services. On [DATE], Resident 76 was pronounced dead at the hospital, secondary to opioid overdose. The facility's failures regarding Resident 76 resulted in facility staff not timely identifying or responding to an opioid overdose concern, and contributed to the Resident 76's demise and ultimate death. The facility's failure in managing Resident 78's chest pain resulted in unresolved chest pain and transfer to the hospital for emergency services. Findings: 1. Review of Resident 76's medical record indicated the resident as admitted on [DATE]. Resident 76's medical diagnoses included chronic ulcers of both legs, Type-2 Diabetes Mellitus (a disease in which the body's blood sugar levels are too high) with Diabetic Neuropathy (damage to nerves caused by high blood sugar, often resulting in pain in hands and feet), peripheral vascular disease (reduced blood flow to the limbs), chronic pain syndrome, and an accidental poisoning by opioids (dated [DATE]), among other diagnoses. During an observation and concurrent interview on [DATE] at 12:57 p.m., Licensed Nurse A stated that if a resident became sedated after taking an opiate pain medication, she would call the doctor and let them determine the next actions to take. Licensed Nurse A stated the Narcan protocol was at the nurses' station. Licensed Nurse A was observed entering the nurses' station. She pulled out two binders, though stated she could not locate the protocol. When asked where the facility kept its emergency supply of Narcan, Licensed Nurse A stated it was in the Cubex (e.g., an automated drug dispenser), and she could not remove it without entering a resident's name and the specific order. During an observation and concurrent interview on [DATE] at 1:16 p.m., Licensed Nurse B stated the emergency supply of Narcan was kept on the medication carts and in the medication room. Licensed Nurse B was observed entering the medication room where Director of Nursing (DON) was showing Licensed Nurse A the location where Narcan was kept-a shelf above the Cubex. The DON stated the store in the medication room was a house supply of Narcan available for emergencies. DON pointed to a row of boxes of Narcan that sat on a shelf above the Cubex. Licensed Nurse A stated she did not know the Narcan was there. Licensed Nurse B exited the medication room, then proceeded to her medication cart. Licensed Nurse B opened the bottom drawer and pulled out a box of intranasal (e.g., administered via nostrils) Narcan. Licensed Nurse B stated the protocol for Narcan was contained in the medication administration record (MAR) for residents whose physician ordered Narcan. Licensed Nurse B opened a resident's MAR that contained an order for Narcan, which described the steps to take when giving Narcan. During an interview on [DATE] at 1:38 p.m., Licensed Nurse C stated that the steps for giving Narcan were to give one dose if the resident had an order, then wait two minutes, and give again if needed. When asked if there were any other steps to giving Narcan, Licensed Nurse C stated, No. During an observation and concurrent interview on [DATE] at 3:50 p.m., when asked where the Narcan was kept, Licensed Nurse D stated it was not on the cart, it was in the medication room. Licensed Nurse D entered to the medication room and stated, I don't know where the eKit is (kit containing emergency supply of medications). Licensed Nurse D stated he would look in the refrigerator for it, then unlocked the refrigerator. At that point, Licensed Nurse A entered the medication room and educated Licensed Nurse D that the Narcan was kept on the shelf above the Cubex. Licensed Nurse D stated, I learned something new. Licensed Nurse D stated he did not know the protocol for giving Narcan, and stated he would follow the instructions on the package. During an interview on [DATE] at 2:15 p.m., Licensed Nurse E stated she had not received training on Narcan for a few years. During an interview on [DATE] at 2:55 p.m., DON stated she gave an in-service to the nurses on Narcan when they started using Narcan about two years ago. DON stated after that in-service, if the nurses had any questions about Narcan they were expected to ask her or the pharmacist. During an interview on [DATE] at 10:31 a.m., Physician A stated that with Resident 76, she did not expect the nurses to call 911 after administering the first dose of Narcan, as directed by physician order. Instead, Physician A stated she preferred the nurses call her. Physician A verified no nurse administered Narcan on [DATE], when Resident 76 was sent to the ED by ambulance and died enroute. Physician A stated Resident 76 should have been given Narcan. Physician A stated Resident 76's cause of death was cardiopulmonary arrest secondary to opiate overdose. During an interview on [DATE], at 9:40 a.m., Licensed Nurse J stated she was Resident 76's nurse on [DATE], when the resident required emergency transfer to an acute care hospital. Licensed Nurse J stated she called 911 for Resident 76 because the resident appeared sleepy and not himself, despite being arousable. Licensed Nurse J stated she did not believe Resident 76 had overdosed on opioid medication because his vital signs were stable, and she did not administer Narcan for the same reason. During a record review and concurrent interview on [DATE] at 2:00 p.m., the DON reviewed her in-services binder and verified the facility had not trained licensed nurses on Narcan administration between the initial training and [DATE]. Also, DON stated that she spoke with Licensed Nurse J about her nursing care on [DATE]. The DON stated Licensed Nurse J told her that she did not administer Narcan to Resident 76 Narcan on [DATE] because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the physician's order for Narcan and call 911 as soon as the first dose was given. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid, a pain medication stronger than morphine but with shorter duration and greater sedation) administered twice daily, for a total of 8 milligrams (mg, a unit of measure) daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive oral opioid medication (Dilaudid) administered twice daily, for a total of 8 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders, dated [DATE], indicated a provider ordered Narcan for Resident 76, for signs or symptoms of opiate overdose, and to [u]se 1 spray in one nostril and seek immediate emergency medical assistance. Resident 76's MAR for [DATE] indicated facility nurses administered Narcan to Resident 76 three times on [DATE], at 9:05 a.m., 12:32 p.m., and 1:03 p.m. Resident 76's progress note written by Licensed Nurse C dated [DATE], at 5:56 p.m., indicated information about Resident 76's first opioid overdose. The record indicated: Resident unresponsive at beginning of this shift and low O2 sats (blood oxygen saturation, normal percentage is 92 to 100%) of 80 [percent] on [room air] . MD called by this [nurse] and reported above [change in condition]. Licensed Nurse C wrote that she gave Resident 76 three doses of Narcan and called the physician between each dose, with no sustained improvement. The progress note further indicated, MD called for the fourth time and ordered to send resident out to ED for further eval[uation]. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated [DATE], which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. Resident 76's MAR for [DATE] indicated facility nurses did not administer Narcan to Resident 76 on [DATE], the second time Resident 76 was transferred-out for higher level services for overdose. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 5:51 p.m., indicated information about Resident 76's second overdose. The record indicated: [At] 5pm resident found to be arousable, but lethargic. Resident found to be clammy and pale . 911 was called; MD aware. Resident 76's progress note written by Licensed Nurse J, dated [DATE] at 6:34 p.m., indicated, [Local hospital] ED called to inform that [Resident 76] passed away on route to ED. Resident 76's MAR for [DATE] indicated an order for Narcan, dated [DATE], directing licensed nurses to administer 1 spray in nostril as needed for [signs and symptoms] of opiate overdose *Use 1 spray in one nostril and seek emergency medical assistance. If the desired response is not obtained after ,d+[DATE] minutes, administer second dose using a new device in the other nostril until emergency medical assistance arrives. Resident 76's hospital record included an ED physician note, dated [DATE], which indicated that EMS (emergency medical services) reports that they were coming from a nursing facility and on the way here in the ambulance he lost his pulse. The patient has a DNR and DNI (do not resuscitate or intubate) form completed and with him so they did not perform any resuscitation. Per EMS, call was initially for 'lethargy'. On exam, the patient is pulseless, apneic (not breathing), and unresponsive . According to the Centers for Disease Control and Prevention, updated [DATE], signs and symptoms of an opioid overdose include: Falling asleep or loss of consciousness, as well as pale, blue, or cold skin. From: https://www.cdc.gov/opioids/overdoseprevention/index.html (accessed [DATE]) 2. During an interview on [DATE] at 2:25 p.m., Licensed Nurse F stated that when a resident has pain pump, the only care a licensed nurse must render is to assess the resident's skin. Licensed Nurse F stated he was not aware the dose of opioid infused by Resident 76's pain pump increased on [DATE]. Licensed Nurse F stated he did not know the method to communicate a dose change among facility staff when a provider changed the dose here in the facility. During an interview on [DATE] at 9:44 a.m., Licensed Nurse C stated Resident 76 had a pain pump and oral pain medications for pain management. When queried, Licensed Nurse C stated she did not know what kind pump Resident 76 used. Licensed Nurse C stated she was not trained on managing Resident 76's pump, and the pump was managed entirely by another provider. Licensed Nurse C stated the resident's assigned nurse was only required to assess the resident's skin after the pump was refilled. Licensed Nurse C stated she was unaware Resident 76's dose of pump-infused opioid increased on [DATE]. Licensed Nurse C stated nurses should communicate dose increases during verbal report at change-of-shift. Licensed Nurse C stated nursing would not document the information anywhere in the patient's record. During an interview on [DATE] at 11:00 a.m., Medical Director stated the nurses caring for residents with intrathecal pain pumps should be able to assess pain level, ensure vital signs were within normal limits, watch for change in level of consciousness, and recognize overdose symptoms. Medical Director verified a resident with a Do Not Resuscitate order should be given Narcan if they have an opiate overdose. During an interview on [DATE], at 9:40 a.m., Licensed Nurse J stated no nursing care was required when managing Resident 76's pump. During a record review and concurrent interview on [DATE] at 2:00 p.m., the DON stated nurses caring for residents with intrathecal pain pumps should know the side effects of the medications being administered through the pump, the risk for overdose, how to assess for overdose, documenting their monitoring on the MAR, and be aware that Narcan was available. DON stated the nurses were responsible for updating the MAR to reflect a dose increase on the pump. DON reviewed Resident 76's [DATE] MAR and verified she did not see that licensed nurses had updated the MAR to reflect the pump's dose increase on [DATE]. DON stated that when she asked Licensed Nurse J the reason she did not give Resident 76 Narcan on [DATE], Licensed Nurse J told her it was because Resident 76's vital signs were within normal limits. DON stated it was her expectation that the nurses follow the Narcan physician's order and call 911 as soon as the first dose was given. DON stated that if the resident's doctor did not agree with calling 911, the nurse should question the doctor, or call the medical director. DON reviewed her in-services binder and verified she did not do any training on Narcan administration prior to [DATE]. DON also stated she did not do any training with the nurses on intrathecal pumps. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's physician orders indicated Resident 76 was prescribed by order, active [DATE] through [DATE], to receive opioid medication (Dilaudid) delivered by means of intrathecal pain pump, which administered opioid solution continuously into the resident's body, for a total of only 1.5 mg daily. Review of Resident 76's pain specialist visit note, dated [DATE], indicated Resident 76's intrathecal pump was refilled with opioid medication. The visit note also indicated the pump had been running at a rate of 2.8 mg/day, and further indicated the pain specialist increased the dose rate to, 3.0 mg/day. Resident 76's hospital record included a document titled Hospitalist History and Physical, dated [DATE], which indicated Resident 76's dose of [opioid medication] in his pump was just increased which is likely contributing towards his current presentation [for emergency services. H]e was unsure why he is here since he was completely knocked out and received multiple intranasal and intra-muscular Narcan injections to become awake and alert. 46132 3. A review of Resident 78 face sheet (demographics) indicated he was [AGE] years old with a diagnoses of Atherosclerotic Heart Disease (AHD, a common condition that develops when a sticky substance called plaque builds up inside your arteries ( a blood vessel that carries blood from the heart to tissues and organs in the body). Disease linked to atherosclerosis is the leading cause of death in the United States) and Hyperlipidemia (also known as dyslipidemia or high cholesterol, means you have too many lipids (fats) in your blood) During a review of the nursing note dated [DATE] at 3:44 a.m. on [DATE] 4:26 p.m., the nursing note indicated that on [DATE] at 3:00 a.m., Resident 78 had a chest pain radiating to his left arm. The nursing note indicated Resident 78 received Tylenol (a medication that could treat minor musculoskeletal aches and pains, and reduces fever) to address the chest pain. It indicated that 15 minutes after the nurse administered Tylenol, the nurse checked Resident 78 who continued to complain of chest pain. Resident 78 was then transferred to the hospital on [DATE] at 3:30 a.m. The nursing note did not indicate whether the physician was notified of Resident 78's complaint of chest pain, or whether the physician was notified of Resident 78's transfer to the hospital. During an interview on [DATE] at 8:48 a.m., Minimum Data Set coordinator ( MDS - part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) stated that whenever a resident was complaining of chest pain, the nurse would have to contact the doctor right away. He stated it was not the facility's practice for residents complaining of chest pain to be receiving Tylenol. He stated that chest pain radiating to left arm could be cardiac in nature and if inappropriate treatment was given to the resident, a negative outcome could occur. During a concurrent interview and nursing note record review on [DATE] at 9:33 a.m., the Director of Nursing (DON) stated that per facility policy, staff should have called the physician when Resident 78 complained of chest pain radiating to left arm. DON stated that the nurse should have requested the physician for an order of Nitroglycerin (a medication that can treat and prevent chest pain) per facility policy. DON stated the facility was non compliant when the nurse administered Tylenol to Resident 78 when he was complaining of chest pain. The DON verified that although Resident 78 had no order for Nitroglycerin, the nurse should have called the physician for an order. DON stated that Resident 78 could have a heart attack and could have irreversible negative outcome such as death, paralysis and change in mental status and functionality. During an interview on [DATE] at 3:15 p.m., the Director of Staff development (DSD) stated that chest pain radiating to left arm could be a sign that Resident 78 was experiencing stroke (a medical emergency, resulting in damage to the brain from interruption of its blood supply). She stated that once a resident had this type of symptom, staff should have called 911 immediately. She stated that administering Tylenol to a resident complaining of chest pain was not an appropriate intervention. She stated Resident 78 was placed at risk for irreversible negative outcome such as death or paralysis. During an interview on [DATE] at 10:03 a.m., the DON verified the assessment and intervention the nurse did in response to Resident 78's complaint of chest pain was inappropriate and dangerous. She stated Resident 78 could end up with paralysis (the loss of the ability to move some or all of your body), functional changes or worse, death. During a review of Nitroglycerin on National Library of Medicine, updated [DATE], it stated that Nitroglycerin was a vasodilator (medications that open (dilate) blood vessel) used primarily to provide relief from angina (type of chest pain caused by reduced blood flow to the heart). It was currently Food Drug Administration (FDA) approved for the acute relief of an attack or acute prophylaxis (preventive) of angina pectoris (chest pain) secondary to coronary artery disease (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). During a review of facility's policy and procedure (P&P) titled,Pain Assessment and management, undated, the P&P indicated its purpose was to help the staff identify pain in resident's .pain management interventions should address the underlying cause of resident's pain.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was at high risk for falls, had revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. The facility also failed to follow its policy on fall prevention for residents with recurrent falls. As a result, Resident 1 suffered a fall with major injury which consisted of a fracture to the right tibia(The larger of the two bones in the lower leg) and a fracture to the right fibula (A small bone located on the outside of the lower leg), which required hospitalization and surgery. Resident 1, a [AGE] year-old female, was initially admitted to the facility on [DATE], according to an e-mail sent by the Medical Records Director on 7/15/21 at 10:34 a.m. The facility Admission Record indicated Resident 1 had medical diagnoses including Alzheimer's Disease (A condition that causes memory loss and difficulties with thinking, problem-solving or language), Repeated Falls, and Personal History of Traumatic Fracture. Record review revealed Resident 1's MDS (Minimum Data Set-A clinical assessment), dated 1/07/21, indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition) score was 3, which indicated her cognition was severely impaired. Resident 1's MDS also indicated she required extensive assistance with bed mobility, transfers and personal hygiene. In addition, Resident 1's MDS indicated Resident 1 was not steady while walking, and was only able to stabilize with staff assistance. Record review showed a Fall Risk assessment dated [DATE] indicated Resident 1's fall risk score was 9, which indicated she was at low risk for falls. Record review revealed a Nursing Care Plan for prevention of falls initiated on 2/07/19 included the following interventions, ASSIST WITH AMBULATION .ASSIST WITH TRANSFERS .ATTEND TO RESIDENT PROMPTLY .BED ALARM .CALL LIGHT WITHIN REACH .CHAIR ALARM .ENCOURAGE RESIDENT TO BE UP IN WHEEL-CHAIR WHEN EXHIBITING RESTLESSNESS. First Fall: Record review revealed an Incident Note dated 8/27/19 at 10:56 p.m., indicated, Resident had a witnessed fall by her bed this shift. Witness stated she tripped on foot of bedside table. Scratch noted on right arm. According to an e-mail sent by the Director of Nursing (DON) on 7/14/21 at 5:24 p.m., the Nursing Care Plan for falls was not updated after the fall on 8/27/19 because the resident evacuated the facility due to wild fires, and did not return to the facility until 11/02/19. The DON confirmed through this e-mail the care plan was not updated after the fall on 8/27/19. No revisions to the care plan were identified until 3/17/20. An e-mail sent by the Medical Records Director on 7/15/21 at 10:34 a.m., indicated Resident 1 evacuated the facility on 10/27/19 (Two months after the fall) and returned to the facility on [DATE]. Record review showed the Fall Risk Assessment was updated on 8/28/19 at 3:34 p.m., but indicated Resident 1's fall risk score was 7 (Lower than the previous assessment), which indicated Resident 1 was at low risk for falls, although, she had suffered a fall the day prior, on 8/27/19. The Fall Risk Assessment also indicated Resident 1 had no falls in the last three months, which contraindicated the Incident Note dated 8/27/19 at 10:56 a.m., which documented a fall for Resident 1. According to an e-mail sent by the Director of Nursing (DON) on 7/14/21 at 5:24 p.m., no Post-Fall Assessment was found, after the fall on 8/27/19. Second Fall: Record review revealed an Incident Note dated 4/06/20 at 12:15 a.m., indicated, Resident standing at doorway. Reminded to use her w/c (Wheelchair) or walker when up. She was standing and locking wheelchair preparing to sit in it when it rolled, she went to her knees and sat down on to floor. She did not strike her head. Record review indicated the Fall Risk Assessment was updated on 5/12/20 at 9:51 a.m., 36 days after the fall, and indicated Resident 1 was at high risk for falls. Record review showed the Nursing Care Plan for falls was not updated or revised after the fall on 4/06/20. Record review also showed the Post Fall Risk Assessment, which was required to be completed within 72 hours after a fall per facility policy, was not completed either. During an interview on 4/07/21 at 9:50 a.m., the Director of Nursing (DON) confirmed this information. During an interview with the DON on 4/07/21 at 10:45 a.m., she stated the Medical Records Department missed auditing of the fall on 4/06/20, and as a result, the care plan to prevent further falls was not updated. Third Fall: Record review revealed an Incident Note dated 6/04/20 at 7:46 p.m., indicated, Resident heard calling for help from her room and discovered on floor next to bed, partially sitting up complaining of right lower leg pain but refusing to allow staff to approach for assessment. Resident eventually persuaded to allow writer to lift right pan leg at which time deformity was noted along with visible movement of what appeared to be displaced bones near mid-point of right tib (Tibia- The larger of the two bones in the lower leg)/fib (Fibula- A small bone located on the outside of the lower leg) .transfer to acute hospital for emergency treatment. Record review revealed a Skin/Wound Note dated 6/10/20 at 6:24 p.m., indicated, admitted s/p (Status post) fall with R (Right)-tib/fib FX (Fracture) with ORIF (Open reduction and internal fixation- A type of surgery used to stabilize and heal a broken bone) .surgical incision to RLE (Right Lower Extremity) with 4 sutures and 28 staples well approximated with min (minimal) serosang (Serosanguinous- Discharge that contains both blood and a clear yellow liquid) drainage noted. Record review showed the Fall Risk Assessment was updated on 6/09/20 at 6:15 p.m., and indicated Resident 1 was at high risk for falls, but the Post-Fall assessment was not completed. During an interview on 4/07/21 at 9:50 a.m., the DON confirmed this information. Record review indicated a root cause analysis of the incident dated 6/4/20 listed appropriate interventions to prevent further falls, but these were not documented in the nursing care plan to prevent further falls. The care plan for falls was revised after the fall on 6/04/20, but no new interventions were added. During an interview on 7/14/21 at 12:15 p.m., the DON stated the Licensed Nurse (Licensed Nurse B) who documented the Incident Note on 6/04/20 at 7:46 p.m., no longer worked for the facility. Fourth Fall: Record review revealed an Incident Note dated 6/30/20 at 4:53 a.m., indicated, 0445 (4:45 a.m.), 2 CNAs (Certified Nursing Assistants) were doing H2O (Water) pass. They heard movement from this room and walked in as resident slid from her bed onto the floor. She did not strike her head. Assisted back to bed. Record review showed the care plan for falls was updated after the fall on 6/30/20 with appropriate interventions to prevent further falls, however, the Fall Risk assessment was not updated and the Post Fall Assessment was not completed. During an interview on 4/07/21 at 9:50 a.m., the DON confirmed this information. Fifth Fall: Record review revealed an Incident Note dated 7/25/20 at 8:05 a.m. indicated, At 0345 (3:45 a.m.), this LN (Licensed Nurse C) heard a crash followed by resident calling out OHHHH! from room 27. Resident found sitting on the floor next to her bed, RT. (Right) shoulder leaning on trash can, holding onto bed rail with her L. (Left) hand. Record review showed a short-term care plan was initiated after the fall on 7/25/20 with effective interventions; however, a Post Fall Assessment could not be found, according to the DON during an interview on 4/07/21 at 9:50 a.m. The Fall Risk Assessment was not updated until 8/04/20 at 10:51 p.m. (10 days after the fall). This was confirmed by the DON through an e-mail sent on 7/12/21 at 5:29 p.m. During an interview on 3/15/21 at 10:30 a.m., MDS Nurse A stated Licensed Nurses on the floor were responsible for creating short-term care plans after residents' falls. MDS Nurse A stated he updated the long-term care plans for falls, but this was only done every three months. During an interview on 7/14/21 at 12:15 p.m., the DON stated Licensed Nurses were responsible for updating care plans after every fall, but if they could not do it, they were responsible for communicating the fall through a standard report sheet, so other members of the interdisciplinary team could update the care plans. The DON also stated the Fall Risk Assessments were required to be updated within 72-hours after a fall. Record review indicated the undated facility policy titled, FALLS, indicated, Residents will be assessed for risk for falls, using the Falls Risk Assessment Tool. Residents that score a 10 or greater will be considered at risk for falls. A plan of care will be initiated to address the fall risk factors .Residents will be re-evaluated, using the Fall Risk Assessment Tool on a quarterly basis, annually or with a significant change in condition .A care plan will be started immediately after a fall, identifying the fall, goals and approaches to provide care as well as to reduce the potential for further falls .A Post-Fall Assessment will be completed by the licensed nurse within 72 hours of the fall .The resident's plan of care will be reviewed and updated as appropriate to reflect potential for falls and approaches to reduce the potential for future falls.

The facility failed to treat one of three sampled residents (Resident 1) with dignity and respect, and ensure Resident 1 was free from retaliation when the facility parked the facility van (cargo van) permanently right in front of Resident 1's window blocking Resident 1's view and creating a glare. This failure resulted in Resident 1, an outdoors and gardening enthusiast who treasured the view out her window, being tearful and feeling disrespected and demeaned by the facility. This failure also resulted in Resident 1 being very depressed and feeling like nothing; like a bag of potatoes. Findings: During an interview on 9/17/18 at 10:09 a.m., Complainant X stated Resident 1 had been admitted to the facility for Rehabilitation. Resident 1 needed to stay in the facility for long term care due to medical issues after the end of Rehabilitation. Resident 1's payment source had changed at the end of rehabilitation, and facility staff had wanted her to move to the long term care side of the building. Resident 1 had been in a room in a bed next to a window. Resident 1 did not want to move because she enjoyed the view. After Resident 1 refused to move, facility management had decided to park the facility cargo van in front of her window blocking her view. Complainant X stated facility management had given the explanation it was for 'advertisement' purposes. Complainant X stated it blocked Resident 1's view completely, and caused a glare when the sun hit the van's windshield. Complainant X stated the fact the facility parked the van right in front of Resident 1's window felt like retaliation to both of them because Resident 1 had not wanted to move to the long term care side and give up the view. Complainant X stated having the van block her view had caused Resident 1 to be very depressed. A document titled Record of Admission, not dated, revealed Resident 1 was admitted to the facility on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. A document titled Discharge/Transfer Instructions signed and dated 2/8/18 by a physician in the acute care hospital and sent to the facility, revealed Resident 1 had additional [DIAGNOSES REDACTED]. During an observation on 9/19/18 at 7:50 a.m in the facility parking lot, a large cargo van was parked in front of the building towards the end of the west side parking lot. It was parked in front of a resident room's window. Other parking spaces were empty. During an observation on 9/19/18 at 8:40 a.m., Resident 1 was observed in her bed, eating breakfast. The facility van was parked in front of her window blocking the view. During an observation on 9/19/19 at 9:45 a.m., the facility van was parked in the same location in front of Resident 1's window. There were empty parking spaces in front of the building. During an observation on 10/9/18 at 9:35 a.m., the facility van was parked in the same location in front of Resident 1's window. Parking spaces were available in front of the building. During an interview on 10/9/18 at 10:20 a.m., Resident 1 was observed in her bed. The facility van was not parked in front of her window. Resident 1 stated she was [AGE] years old and could no longer walk. She stated she liked to look out the window, pointing to the window and the view and stating that's all I have left. At 10:22 a.m., the facility van was driven into the parking spot in front of her window blocking her view. Resident 1 became very tearful when the van was parked and her view blocked. Resident 1 stated it's very demeaning .they are treating me like a thing. Resident 1 stated she was very depressed, and they make you feel like nothing .like a bag of potatoes. Resident 1 pointed to a photograph of her yard at home and stated she looked at the photograph when she could not look outside. Resident 1 stated it means a lot to me to have a view . now they block it. Resident 1 stated she had declined to move to another side of the building when she finished rehabilitation and give up the window bed. Having the van parked in front of her window made her very depressed. Despite her grievances, the facility declined to move the vehicle. Review of Resident 1's MDS (Minimum Data Set) (an assessment tool) dated 3/10/18, 5/18/18, and 8/17/18 revealed BIMS (Brief Interview for Mental Status) scores of 13, 15 and 15 respectively (a score of 13-15 reveals a resident is cognitively intact; 15 is the highest score). A facility document titled Discharge Care Conference Summary dated 3/9/18 revealed (family) wants to keep her in her room and bed (needs window). A facility document titled (Resident 1's name), dated 4/26/18 and signed by four department managers, revealed .she enjoys being outdoors . A facility document titled Interdisciplinary Progress Notes dated 8/21/18 at 2:39 p.m., revealed She refuses to change rooms to longer term care. During an interview on 10/9/18 at 1:40 p.m., Licensed Staff A stated he was very much aware of the issue with the facility van parked in front of Resident 1's window. Licensed Staff A stated it caused Resident 1 to be upset a lot. Licensed Staff A stated facility management had been informed multiple times about how the van affected Resident 1. Licensed Staff A stated Resident 1 used to be an outdoors person, a poet who did not enjoy watching TV. Licensed Staff A stated it was understandable Resident 1 was upset about it. Licensed Staff A stated I feel for her. During an interview on 10/9/18 at 1:50 p.m., Unlicensed Staff B stated she had heard about the van bothering Resident 1. Unlicensed Staff B stated she was not sure what was bothering Resident 1 more, the van blocking her view or the glare it created. During an interview on 10/9/18 at 2:55 p.m., Management Staff C, in charge of social services, stated Resident 1 had been warned the van would be parked there. Management Staff C stated social services had not been involved in the decision to park the facility van in front of Resident 1's window. During an interview on 10/16/18 at 2:40 p.m., Management Staff D stated Resident 1's family has requested a bed next to a window when Resident 1 was admitted because Resident 1 likes to look out. Management Staff D stated none was available at that time, but one opened up a couple of days later and Resident 1 was moved to a bed next to the window. Management Staff D stated moving Resident 1 made sense since she likes to look out the window. During an interview on 10/16/18 at 11:35 a.m., Management Staff E stated he was the driver for the facility van. Management Staff E stated the facility van had been parked in another spot but residents, who liked to sit outside, had complained that it was blocking the sun. Management Staff E stated where it was parked now had more room for the ramp to go down and made it easier to load and unload patients. Management Staff E stated he had been told to park the van in front of the window (Resident 1's room) about a month or two ago (around the time Resident 1 refused to change rooms). During an interview on 10/16/18 at 3:35 p.m., Management Staff F stated the facility had decided to park the facility van permanently when not in use in front of the window because resident had complained it was blocking the sun during outdoor activities when it was parked in the old spot. Management Staff F stated the new spot was the only spot that allowed the ramp to be lowered without blocking traffic. Management Staff F stated the van was used for customer service. Management Staff F stated the facility had no policy for the van. During an interview on 11/14/18 at 12:08 p.m., Physician A stated Resident 1 was a talented poet who treasured a view of trees and the sky all her life. Resident 1 was very involved in nature. Physician A stated having the van parked in front of the window made her depressed and impacted her quality of life. A document titled Quality of Life--Dignity, dated 2001, revised (MONTH) 2009, revealed the policy statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.The document revealed 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The above violation caused significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1.

Based on interviews and facility record review, the facility failed to ensure staff followed it's policy and procedures to treat 3 of 18 sampled residents (Resident 1, 2, 4), and two unsampled residents (Resident 19 and 20), with dignity and respect when: 1. Two residents and three staff members reported having observed Unlicensed Staff F treat residents (Resident 2, 4, & 20) in a very rough, rushed, and disrespectful manner during personal care. These failures made the residents feel jerked around, and become agitated and frightened. 2. Staff did not toilet Sampled Resident 1 prior to showering her, making her feel embarrassed when having a bowel movement on the shower floor. 3. Staff did not place call bells within reach for Sampled Resident 1, and Unsampled Resident 19, making it difficult to call for pain medication and personal care when needed. Findings: 1. During an interview on 11/25/15 at 2:55 p.m., Unsampled Resident 20, identified by the facility as alert and oriented, with a BIMS score of 15, ( A Brief Interview for Mental Status cognitive assessment tool of 15 questions. Accurate answers of 12 to 15 indicate intact memory, ability to understand, and to be understood.), stated Unlicensed Staff F was no longer taking care of her, but had been rough with her in the past. Unsampled Resident 20 stated Unlicensed Staff F would jerk my legs over .leaving blue marks. Unsampled Resident 20 stated she had told Unlicensed Staff F in the past stop grabbing me . just tell me what you want me to do I'll turn. Unsampled Resident 20 stated Unlicensed Staff F grabbed residents like we are a piece of meat. Unsampled Resident 20 stated Unlicensed Staff F no longer took care of her because she refused to work with her, but Unlicensed Staff F still assisted Unsampled Resident 20's roommate, Sampled Resident 4 who had dementia (non-interviewable, and unable to advocate for themselves). Unsampled Resident 20 reported she witnessed Unlicensed Staff F be rough with Sampled Resident 4. Unsampled Resident 20 stated Unlicensed Staff F grabbed (Sampled Resident 4's) shoulders and shook her. Resident 4 yelled don't hurt me, and Unlicensed Staff F responded Shut up. During an interview on 11/25/15 at 3:20 p.m., Unsampled Resident 21 (identified by the facility as alert and oriented) (BIMS score 15) reported Unlicensed Staff F yelled at his dementia diagnosed roommate, Sampled Resident 2. Unsampled Resident 21 witnessed Unlicensed Staff F yell at Sampled Resident 2 for turning his call bell on. Unsampled Resident 21 stated Unlicensed Staff F told Sampled Resident 2 Quit pushing the button. I'm too busy to answer the call light. Unsampled Resident 21 also stated Unlicensed Staff F would not wait for Sampled Resident 2 to turn on his own, but would turn him into the rail (side-rail on bed), and jerk him around when changing Sampled Resident 2's incontinent brief. During an observation on 3/22/16 at at 4:19 p.m., Sampled Resident 1 sat upright in her wheelchair and held her contracted hands in her lap. When asked if she had pain, Sampled Resident 1 stated she had tremors, and chronic pain in her joints. During an interview at 4:28 p.m., when asked whether staff were gentle with her during incontinence care, Sampled Resident 1 stated there were times when, I'm hurting and they're turning me, and they're rough. I say ouch a lot. Sampled Resident 1's Minimum Data Set, (a comprehensive assessment tool), dated 1/8/16, indicated Sampled Resident had a BIMS score of 14. During an interview on 3/22/16 at 4:56 p.m., Unlicensed Staff J stated it would not be appropriate to continue turning a resident when they were hurting. During a phone interview on 3/24/16 at 9:45 a.m., Unlicensed Staff E stated she observed Unlicensed Staff F treat residents in a disrespectful manner. Unlicensed Staff E stated she observed Unlicensed Staff F aggressively change residents' adult briefs despite their refusals to be changed. Unlicensed Staff E stated she reported the incidents. (Cross Reference F 226). During a phone interview on 3/24/16 at 10:15 a.m., Unlicensed Staff G stated he observed Unlicensed Staff F treat residents in a rough manner. Unlicensed Staff G stated he witnessed Unlicensed Staff F go into a residents room, remove the resident's blanket, sheet and their adult brief (adult undergarment) while the resident was still asleep. Unlicensed Staff F would not address the resident or explain what she was going to do. Unlicensed Staff G stated this behavior caused the residents to become agitated. Unlicensed Staff G also stated he witnessed Unlicensed Staff F speak to residents in an impolite and disrespectful manner. Unlicensed Staff G stated the incident had been reported to Administrative Staff A at the time it occurred. During an interview on 3/24/16 at 11 a.m., Administrative Staff K stated staff were expected to knock on the door before entering a resident's room, and to explain what they were going to do before doing it. During a phone interview on 3/24/16 at 11:15 a.m., Unlicensed Staff H stated she witnessed Unlicensed Staff F approach residents in a disrespectful manner. Unlicensed Staff H stated she observed Unlicensed Staff F just pull the covers back instead of approaching the resident in a respectful manner and explaining what she was going to do. Unlicensed Staff H stated this caused the residents to react, and they became agitated and frightened. Unlicensed Staff H stated she observed Unlicensed Staff F get frustrated and throw a resident's blanket towards the head of the residents bed while the resident was in the bed. Unlicensed Staff H stated the incident had been reported to Administrative Staff A at the time it occurred. The facility's policy, Quality of Life - Accommodation of Needs, revised 9/2009, indicated staff attitudes and behaviors must be directed towards assisting residents to maintain independence, dignity and well-being in accordance with their wishes at all times, and; staff should accommodate the physical or sensory limitations of residents, promoting communication, and maintaining dignity. The policy further indicated staff promoted dignity with the following examples: Staff knocked prior to entering residents' rooms; staff spoke respectfully to residents, keeping the residents informed of procedures before they are performed; staff promoted, maintained and protected residents privacy during assistance with personal care, and; staff treated cognitively impaired residents with sensitivity. 2. During an interview on 3/22/16 at 4:28 p.m., when asked whether staff treated her with dignity and respect, Sampled Resident 1 stated she had quite an accident this morning when I went to the shower. I had a poop on the floor, and it embarrasses me. When asked why she thought that had happened, Sampled Resident 1 stated she had asked staff to toilet her before her shower, but they had taken her directly to the shower instead. During an interview on 3/22/16 at 4:56 p.m.,when asked whether Sampled Resident 1 knew when she had to urinate or have a bowel movement, Unlicensed Staff J confirmed Sampled Resident 1 knew when she had to go to the bathroom. The facility's policy, Quality of Life - Dignity, revised 9/2009, indicated staff promoted dignity when staff promptly responded to resident's request for toileting. 3. During an initial tour on 3/21/16 at 11:40 a.m., Unsampled Resident 19's call light hung off the outside aspect of the right bedrail. Unsampled Resident 19 sat up in bed, and had contracted hands. Unsampled Resident 19's bedside table was positioned on her left. When asked if she could reach her call light, Unsampled Resident 19 stated she could not. Unsampled Resident 19 demonstrated her left arm had more reach than her right arm, and she could reach items on her bedside table, but not on her right bedrail. Unsampled Resident 19 stated she was bedridden, and dependent on staff for full care. During an observation on 3/22/16 at 4:19 p.m., Sampled Resident 1 sat in a wheelchair beside her bed. A bedside table was extended across her bed, behind her. A call light stretched across the bedside table. Sampled Resident 1's hands were contracted. During a concurrent interview on 3/22/16 at 4:19 p.m., Sampled Resident 1 stated, Right now I don't have a lot of movement in my hands. Sampled Resident 1 stated she had chronic pain in her joints. Sampled Resident 1 stated she had a headache, and wanted pain medication. When asked if she could reach the call light behind her, Sampled Resident 1 could not. Sampled Resident 1's grip was too weak to engage the call light button, when it was placed in her hands. Sampled Resident 1 stated the call light was often out of reach at night. During an interview on 3/22/16 at 4:56 p.m., Unlicensed Staff J stated Sampled Resident 1 had limited reach, and would be unable to reach back for a call light. The facility's policy, Quality of Life - Accommodation of Needs, revised 9/2009, indicated staff arranged residents' call lights and personal items in easy reach to ensure residents maintained independence, dignity and well-being in accordance with their wishes.

Based on interview and facility record review, the facility failed to prevent and protect Resident 1 from physical and verbal abuse when Family Member A forced Resident 1's contracted fingers open and Family Member A yelled at Resident 1 telling Resident 1 to f--k off, you are going to eat s--t, and put her middle finger in Resident 1's face. These failures caused Resident 1 and Resident 2 emotional distress. Findings: Resident 1's demographic record dated 10/19/13 revealed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a telephone interview on 6/3/15 at 10:05 a.m., CNA K stated she spoke Spanish. CNA K stated that Family Member A was abusive to Resident 1 all the time. CNA K stated Member A forced opened Resident 1's contracted fingers on the left hand. This activity made Resident 1 cry. CNA K stated Family Member A spoke Spanish to Resident 1 in a loud, aggressive voice. CNA K stated she reported the incidents to Staff Development F. During a telephone interview on 6/3/15 at 11:00 a.m., CNA L stated she spoke Spanish. CNA L stated that Family Member A yelled and cussed in Spanish. Family Member A made derogatory statements that included f--k off, you going to eat s--t, Family Member A puts her middle finger in Resident 1's face, and you are going to hell. CNA L reported the above incidents to Director of Nursing E, Social Services Director G, Nursing Supervisor Q and Staff Development F. During a telephone interview on 6/3/15 at 12:50 p.m., Family Member C stated she was the responsible party for Resident 3, Resident 1's roommate. Family Member C stated she understands Spanish and visits Resident 3 once or twice a week and witnessed numerous times Family Member A verbally abusing Resident 1. Family Member C stated she heard Family Member A said to Resident 1 stupid, shut up. Family Member C was visiting on 5/26/15. Family Member A started screaming at Resident 1. Family Member C saw Resident 1 shaking, and started to cry. The more Resident 1 cried the more Family Member A yelled at Resident 1. Family Member C stated, This is real uncomfortable for me, very disturbing. Family Member C reported this to Social Services Director G. During a telephone interview on 6/3/15 at 3:50 p.m. CNA N stated she spoke Spanish. CNA N stated she was in a room next to Resident 1's room when she heard screaming. CNA N went to Resident 1's room and saw Family Member A's third finger ( middle finger) up in Resident 1's face. CNA N asked, Is everything okay? Family Member A responded, I'm helping shave Resident 1's face and asked CNA N to get the license nurse and give Resident 1 [MEDICATION NAME] (treat anxiety disorders). CNA N reported to Director of Nursing E and Case Manager H. During an interview on 6/9/15 at 2:25 p.m., Resident 2 stated it is unpleasant when Family Member A started yelling at Resident 1 and Resident 1 looked hurt. Resident 2 stated she gets very uptight and feels bad for Resident 1. Resident 2 stated that Family Member A used her fingers and said, Bad, bad, bad mommy. Resident 2 stated that she has no place to go, I have to stay during Family Member A's visit. Resident 2 stated I do not look forward to Family Member A's visit and the unpleasantness happens most every time. Resident 2 stated that Family Member A's behavior are very distressing. During an interview on 6/9/15 at 1:35 p.m., Administrator D stated he got a call from the Director of Nursing E, stating that Family Member C, overheard and saw Family Member A yelling at Resident 1 and using bad language. Administrator D instructed Case Manager H to give the Department's phone number to Family Member C. Administrator D stated that we did not witness, we may not want to accuse a family member of abusing Resident 1 unless we believed she was abused. Administrator D stated Case Manager H asked the following: if someone is yelling and swearing at your mom, Do you think it's okay? The Administrator stated, I would rather have the roommate's sister report to the state. Review of the facility document titled Elder/Dependent Abuse policy, indicated in #2. This facility will protect the rights, safety and wellbeing of each resident (regardless of physical or mental condition), for whom we provide care and treatment against any and all forms of physical, verbal, sexual, mental abuse, neglect, financial abuse (including misappropriation of property), abandonment , isolation/involuntary seclusion, abduction, corporal punishment, any form of mistreatment, or any other treatment that would result in physical harm, pain or mental suffering, including the deprivation by a care custodian of goods/services that are necessary to avoid physical harm, and to attain/maintain physical, mental, and psychosocial well-being of the residents.

The facility violated the regulation by failing to ensure that a resident who had an enlarged prostate had an on going assessment and a nursing plan of care developed to prevent and/or to provide early detection of [MEDICAL CONDITION]. These failures resulted in a delay in treatment and contributed to acute kidney failure secondary to opioids and bladder retention. Resident 1 was a seventy-one year old male admitted to the facility on [DATE] for rehabilitation and discharged back to the acute care hospital on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. The acute care hospital's history and physical dated 5/2/09, indicated that Resident 1, "Complains of frequency of urination and difficulty with urination suggesting prostate issues. He has not had a workup or treatment for [REDACTED]. An acute care multidisciplinary progress note dated 5/4/09, documenting that the Hospitalist had discussed (sign interpreter present) with Resident 1, that his [MEDICAL CONDITION] needed a, "Follow up evaluation/prostate exam/urology evaluation". A skilled nursing facility admission and assessment form dated 5/5/09, indicated that Resident 1's [MEDICAL CONDITION] system history and baseline assessment, was incomplete. There was no assessment of frequency of urination related to Resident 1's [MEDICAL CONDITION]. A nursing evaluation for bowel and bladder training, dated 5/5/09, indicated that Resident 1 was, "Continent of bowel and bladder". There was no documentation of his, "Present bladder status: frequency, voiding pattern, or associated symptoms". The facility's admission history and physical, dated 5/6/09, indicated that Resident 1's physician had noted that, "His complaints have to do with urinary issues, large prostate", and that Resident 1 was, "Resistive to therapy and all treatment." A physician's orders [REDACTED]. The manufacturer's full prescribing information system sheet for [MEDICATION NAME] (patch), dated 7/09, revealed that opioids can in some cases produce difficulty in urination and [MEDICAL CONDITION]. During an interview on 7/27/09 at 1:15 p.m., Unlicensed Staff H stated that, "All the time Resident 1 wanted bedpan under him, sometimes 1 hour on and refused removal. He could place self on bedpan and I would find him on it." During an interview on 7/28/09 at 6:15 a.m., Unlicensed Staff J stated that Resident 1 was constantly using the bed pan to urinate and refused to get off the bedpan. During an interview on 7/29/09 at 2:45 p.m., Unlicensed Staff K stated that the first time she went in to take care of Resident 1, she reported to the night shift charge nurse that the afternoon certified nursing assistant had told Unlicensed Staff K that Resident 1 had been on the bedpan all afternoon. Unlicensed Staff K further stated that the night shift charge nurse told Unlicensed Staff K that Resident 1 had to be removed from the pan. When Unlicensed Staff K returned to Resident 1, "He was uncooperative, it needed two of us to turn him over and take the pan away." During an interview on 7/29/09 at 3:30 p.m., Unlicensed Staff L stated he had reported to his charge nurse that Resident 1, "Refused to let us take bedpan away, would sit on it too much." A Medication Record, dated 5//09, documented that Resident 1 had eighteen episodes of agitated refusal of care during a 5 day monitored period from 5/8/09-5/12/09. A Care Plan Conference Summary, dated 5/14/09, documented that the five facility staff present had reviewed his "Care Plan Elements and Medications". There were, "No concerns", regarding his Nursing Plan of Care or Social Services Plan of Care. The facility staff had not identified Resident 1's refusal to be removed from the bed pan as a problem and had not determined the cause. There were no Nursing Care Plans to address Resident 1's: a) urine frequency due to a large prostate; b) constant need to sit on the bedpan; c) agitated refusal of care, refusal to allow staff to do a physical assessment or peri-anal care, and refusal to be taken off the bedpan d) possible side effects([MEDICAL CONDITION]/sedation) of [MEDICATION NAME] once a [MEDICATION NAME] had been ordered by his physician on 5/8/09. During an interview on 7/29/09 at 1:30 p.m., Licensed Staff D, who was assigned to Resident 1, stated, "I had no idea he was having freqency or urgency." A Nurse's Note written by Licensed Staff D, dated 5/18/09, documented that Resident 1 was, "Noted with increased lethargy today. Falling asleep easily yet easily araised (sic). Resident not wanting to communicate with staff or let writer access resident". No nursing assessment of the bladder or abdominal area was documented in Resident 1's clinical record before Resident 1's transfer to the acute care hospital. physician's orders [REDACTED]. The BUN and creatinine tests indicate kidney function. Resident 1's creatinine was 5.47 (normal range is 0.6-1.2) and Resident 1's BUN was 66 (normal range 8-20). An increase in BUN and creatinine indicates impaired kidney function (Mosby's Diagnostic and Laboratory Test Reference 2003). Nurse's notes dated 5/18/09 at 8:00 p.m., indicated Resident 1 was transferred to the acute care hospital emergency room . An Emergency Department Patient Care Record dated 5/18/09 at 11:05 p.m., indicated that a Foley catheter (a flexible or rigid hollow tube to drain urine from the bladder) had been inserted into Resident 1's bladder, was left in and had drained 2700 milliliters (ml) of dark urine. According to the U. S. National Institute of Health the bladder of an average person can hold 350 ml to 550 ml of urine. A History and Physical, dated 5/19/09 at 01:50 a.m., indicated that Resident 1 had, "Acute [MEDICAL CONDITION], Acute [MEDICAL CONDITION]", and, "A urologist will be contacted in the morning...the patient was recently started on [MEDICATION NAME]. It is possible that may have contributed to his [MEDICAL CONDITION]". A Multidisciplinary Progress Note, dated 5/19/09 at 2:50 p.m., that indicated that Resident 1 was in, "Acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], Bladder disfunction secondary to opioids, and Prostate disease". During a telephone interview on 9/16/10 at 4:30 p.m., Physician M stated that Resident 1, "Did need a follow-up consultation due to his report of frequent voiding but I have not seen him back in the office. He did not have frequency in the hospital (acute care) as a catheter had been placed. I would have expected the nursing staff to document his frequency or any problems with his prostate or urinary function and notify me if he had not had a Foley catheter in". During a telephone interview on 12/8/10 at 10 a.m., Physician N stated that, "The nursing staff at the facility never told me that Resident 1 was constantly on the bedpan or using the urinal in bed all the time. Had I been aware of his 'bedpan parking' I would have followed up with a urinary exam based on his history of untreated prostatism. Therefore the facility violated the regulation by failing to ensure that a resident who had an enlarged prostate had an on going assessment and a nursing plan of care developed to prevent and/or to provide early detection of [MEDICAL CONDITION]. These failures resulted in a delay in treatment and contributed to acute kidney failure secondary to opioids and bladder retention The violation of this regulation had a direct relationship to the health, safety, or security of patients.