Every finding on record at Bonnie Brae Skilled Nursing

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of schizoaffective disorder (mental disorder) bipolar type (a mental health condition characterized by significant mood swings), received the necessary behavioral health care by failing to ensure to: -Address Resident 1's episodes of aggressive behaviors. - Create individualized interventions for Resident 1's refusals of care. As a result, on 4/4/2026 at 4:57 PM, Resident 1 was involved in a verbal and physical altercation with Resident 2 and placed other residents (in general) and staff (in general) at risk for injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 7/8/2025 with diagnoses including schizoaffective disorder bipolar type. During a review of Resident 1's SBAR form (Situation, Background, Assessment, Recommendation is a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) dated 11/20/2025, indicated Resident 1 became verbally aggressive with staff (unidentified) and residents (unidentified). During a review of Resident 1's Social Services Progress Note dated 11/20/2025, the Social Services Progress Note indicated Resident 1 had an episode of agitation and became verbally abusive to staff and other residents (unidentified) purposely spilling coffee on the floor saying oops repeatedly. The Social Services Progress Note indicated Resident 1 was also knocking very had on the door of a resident (unidentified) he (Resident 1) had previously argued with. During a review of Resident 1's Care Conference notes dated 11/24/2025, the Care Conference notes indicated an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was held for Resident 1 to discuss Resident's 1 behavior. Resident 1 refused to attend the meeting. During a review of Resident 1's History and Physical Examination (H&P) dated 1/3/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Psychosocial Care Plan developed on 1/3/2026, the Psychosocial Care Plan indicated for the resident's schizophrenic behaviors, manipulative tendencies and diagnosis of schizoaffective disorder, bipolar type, had a goal for the resident of fewer daily episodes. The interventions included psychiatric consult; assessing negative emotions, anger, anxiety, and depression; providing emotional support; encouraging expression of feelings; and providing education to the residents and staff about special care needs. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2026, the MDS indicated Resident 1 had intact cognition, experiencing symptoms of depression such as feeling down, depressed or hopeless, and had little interest or pleasure in participating in activities at the facility. The MDS indicated Resident 1 did not hallucinate (sensory experiences that appear real but are created by the person's mind), did not manifest physical, behavior symptoms towards others, and was prescribed antipsychotic medications (used to control behavioral symptoms), and was not on antidepressant medications (used to reduce symptoms of depression). The MDS indicated Resident 1 required limited assistance with activities of daily living (ADLs, such as walking, dressing, locomotion, and personal hygiene). During a review with Resident 1's Progress Notes dated 4/4/2026 timed 4:57 PM, the Progress Notes indicated Resident 1 was being verbally abusive to a charge nurse (unidentified) as well as to other residents (unidentified) who were in the hallway near the nursing station. The Progress Notes indicated Resident 2 passed by made an attempt to calm Resident 1, but Resident 1 started to argue with Resident 2. The Progress Notes indicated Resident 2 pushed Resident 1 on his (Resident 1) stomach. The Progress Notes indicated Resident 1 said Resident 2 hit and spit at him (Resident 1). During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 3/21/2026 with diagnoses including bipolar disorder and major depressive disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition, and would have symptoms of depression (sadness) such as feeling down, depressed or hopeless, and enjoyed participating in activities at the facility. The MDS indicated Resident 2 did not hallucinate (sensory experiences that appear real but are created by the person's mind), did not manifest behavior symptoms towards others, was not prescribed antipsychotic medications (used to control behavioral symptoms), and was not on antidepressant medications (used to reduce symptoms of depression). The MDS indicated Resident 2 required limited assistance with activities of daily living (ADLs, such as walking, dressing, locomotion, and personal hygiene). During a review of Resident 2's H&P dated 4/8/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an interview on 4/16/2026 at 9:20 AM with Registered Nurse Supervisor (RN 1), RN1 stated that on 4/4/2026 Resident 1 was at nursing station arguing with staff (unidentified) and was aggressive about keeping his (Resident 1) smoking material after designated smoke times. During an interview on 4/16/2026 at 9:45 AM with Resident 2, Resident 2 stated that Resident 1 would just terrorize the staff (unidentified) and create problems if he (Resident 2) did not get his way on things. Resident 2 stated that Resident 1 often would go to the nursing station and just yell at staff (unidentified). Resident 2 stated Resident 1 was very malicious and disrespected female staff (unidentified) often. During an interview on 4/16/2026 at 11 AM with Licensed Vocational Nurse 1 (LVN 1), LVN1 stated he (LVN1) was familiar with Resident 1. LVN1 stated Resident 1 had a history of refusing services then later reported that the services were never offered. LVN1 stated Resident 1 would refuse to participate in any planned activities, games, or exercises at the facility. LVN1 stated Resident 1 would not follow facility rules or participate in any care meetings. During an interview on 4/16/2026 at 11:35 AM with Certified Nursing Assistant 1 (CNA 1), CNA1 stated that specifically for Resident 1 there was a set of behaviors they (staff) were taught to look out for aggressive mannerism (often manifest through body language and behaviors that convey dominance, anger, or hostility), yelling, and manic (irritable mood) episodes. CNA1 stated that once Resident 1 had those behaviors, they (staff) would notify the licensed nurses. CNA 1 stated Resident 1 refused to participate in anything. During an interview on 4/20/2026 at 9:30 AM with the Social services Director (SSD), the SSD stated Resident 1 did not participate in any scheduled meetings, interdisciplinary meetings, psychiatric consults, or daily services. The SSD stated Resident 1 would not attend any social service meetings, even if he (Resident 1) requested the meetings for service. The SSD stated Resident 1 had many aggressive episodes often and any new interventions added to Resident 1s care plan would be ineffective because Resident 1 refused all services all the time. During an interview on 5/1/2026 at 10 AM, with the Director of Nursing (DON) and a concurrent review of Resident 1's IDT meetings and nursing notes dated 11/20/2025 and 4/4/2026, the DON stated Resident 1 refused to attend his (Resident 1) own IDT meetings. The DON stated Resident 1 refused psychiatric evaluation and treatment as ordered and as needed due to his (Resident 1) diagnosis and behavioral manifestation, and Resident 1 refused to take any medication to treat his (Resident 1) mental illness. The DON stated Resident 1 he refused all interventions and the facility ran out of ideas to continue to try new interventions. During an interview on 5/2/2026 at 9AM with the Administrator (ADM), the ADM stated Resident 1 was not a good fit for the facility. The ADM stated the facility was at its limits with trying to create individualized interventions for a resident that refuses everything recommended. The ADM stated, we should have not readmitted him back to the facility for safety reasons. The ADM stated that Resident 1's behavioral issues lowered the quality of services received at the facility, and scared other residents. The ADM stated, We didn't know what to do next with [Resident 1's] behavioral episodes. During a review of the facility's Behavioral Health Services policy and procedure (P&P) dated 3/16/2026, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for two out of five sampled residents (Resident 8 and Resident 12) on Low Air Loss Mattresses (LAL M- a pressure-relieving mattress used to prevent and treat pressure injuries). By failing to:Ensure Resident 8's physician's order for LALM dated 12/19/2025 indicated a specific setting for the LALM.Ensure Resident 8's physician's order for LALM dated 1/1/2026 indicated a specific setting for the LALM.This deficient practice placed Resident 8 and Resident 12 at risk for developing pressure injuries and complications from pressure injuries which could result in systemic infections that could lead to death.Findings: During a review of Resident 8's admission Record, the admission record indicated the facility admitted Resident 8 on 8/1/2022, with diagnoses that included respiratory failure with hypoxia (a severe condition where the lungs can't get enough oxygen into the blood), muscle weakness (a loss of strength in one or more muscles, making it hard to move them normally), and osteoporosis (a bone disease causing bones to become weak, thin, and fragile). During a review of Resident 8's Care Plan Report dated 12/20/25, the Care Plan Report indicated Resident 8 was at risk for developing pressure sores, bruising, and other skin breakdown. The care plan indicated an intervention to use pressure relieving devices as needed. During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool), dated 12/24/2025, the MDS indicated Resident 8 had a memory problem and was severely impaired with decision making. The MDS indicated the resident was at risk for pressure injuries and had a pressure-reducing device for the bed. During a concurrent observation and record review on 1/5/2026 at 9:45 AM in Resident 8's room, Resident 8's physician order and weights were reviewed. Resident 8 was observed lying on the bed with closed eyes. Resident 8 was lying on a LAL mattress; the setting was set at a little under 120lbs on normal pressure. Resident 8's physician order dated 12/19/2025 indicated may use low air loss mattress. Resident 8's weight indicated the resident weighed 91lbs on 1/1/2026. During a concurrent interview and record review on 1/6/2026 at 11:10 AM with Licensed Vocational Nurse (LVN) 2, Resident 8's physician order for LALM dated 12/19/2025 was reviewed. LVN 2 reviewed Resident 8's LALM setting and LVN 2 stated the LALM was set between 80 to 120 pounds (lbs.). LVN 2 stated Resident 8's weight ranged between upper 80s to lower 90s. LVN 2 reviewed Resident 8's physician's order for LALM which indicated they may use the LALM, but no instructions were given. LVN 2 stated the physician's order should have indicated a specific setting for the LALM. LVN 2 stated Resident 8 was bed bound, and the LALM was to prevent pressure injuries. LVN 2 stated Resident 8 was at risk for developing pressure ulcers/injuries without orders for LALM settings. During a concurrent interview and record review on 1/6/2026 at 11:18 AM with the Director of Nursing (DON), Resident 8's physician order dated 12/19/2025, the facility's policy and procedures titled, Pressure Injuries Prevention dated 12/2025, and facility policy and procedures titled, Low Air Loss Mattress dated 12/2025. The DON stated the order for LAL mattress should have had specific instructions for the settings. The DON reviewed the facility's policies for weight settings. The DON stated the facility should have followed the policy, which indicated to adjust the LALM setting by weight. The DON stated Resident 8's physician order should have had instructions for setting the LALM settings. The DON stated Resident 8 would be at risk of a pressure ulcer without proper weight setting. During a review of the facility's policy and procedure titled, Pressure Injuries Prevention dated 12/2025, indicated, for prevention measures associated with specific devices, consult current clinical practice guidelines. During a review of the facility's policy and procedure titled, Low Air Loss Mattress dated 12/2025, indicated, adjust weight setting for patient comfort/pressure relief. During a review of Resident 12's admission Record, the admission Record indicated the facility initially admitted the resident on 5/23/2013 and readmitted on [DATE] ,with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), hypertensive disease(high blood pressure) with heart failure( a long-term condition in which your heart can't pump blood well enough to meet your body's needs), partial(not complete) intestinal obstruction(a blockage in the gut), muscle weakness (generalized), cerebral infarction(a stroke caused by a blocked blood vessel in the brain), cerebrovascular disease (problems with the blood vessels in the brain) affecting the right non-dominant(less used) side, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis(weakness on one side of the body) following unspecified cerebrovascular disease. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 12/22/2025, the MDS indicated the resident had moderate cognitive impairment (impaired ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 12 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 12 was dependent (helper does all of the effort) from the staff for toileting, personal hygiene, shower/bathe self, lower body dressing, sit to lying, lying to sitting on the side of the bed, putting on and/or taking off footwear and chair/bed to chair transfer. During a review of Resident 12's Dietary Profile dated 9/23/2025, the Dietary Profile indicated the resident weighed 157 lbs. on 9/23/2025. During a review of Resident 12's Order Summary Report dated 1/1/2026, the Order Summary Report indicated an order for LALM with no specific parameters for settings. During a review of Resident 12's Care Plan Report titled High Risk of Developing Pressure Sore, Bruising, and Other Types of Skin Breakdown dated 12/23/2025, indicated the resident was to have a Specialized Mattress as Ordered on Low Air Mattress. During an observation on 1/5/2026 at 10:25 AM Resident 12 was observed in bed with a LALM turned on and set to 180 pounds. During a concurrent interview and record review on 1/6/2026 at 11:18 AM with the Director of Nursing (DON), Resident 12's Order Summary Report dated 1/1/2026 was reviewed, the Order Summary Report indicated LAL Mattress. The DON stated the LALM needed specific instructions and the setting was usually placed based on a resident's weight. The DON stated there were no specific instructions on Resident 12's orders for LALM and the order should have had specific instructions. The DON stated there was no weight recorded for Resident 12 for the month of December 2025 or January 2026 in the resident's medical record. The DON stated if the facility did not have a weight for Resident 12, facility staff would not know what setting to set for the resident's LAML. The DON stated LALMs were to be set based on the physician orders. The DON stated a resident could get a pressure ulcer if the LALM was too soft or hard for the resident. During a concurrent interview and record review on 1/6/26 at 12:26 PM with Licensed Vocational Nurse (LVN)1, Resident 12's Order Summary Report dated 1/1/2026 was reviewed. LVN 1 stated LALM required an order from the physician and the setting was based on a resident's weight. LVN 1 confirmed by stating there was no specific order for Resident 12's LALM. LVN 1 stated facility staff should have clarified Resident 12's order for LALM with the doctor. LVN 1 stated Resident 12 could have developed a pressure injury if the LALM was not at the correct setting. During a review of the undated operational manual titled Proactive medical products Operation Manual for Protekt Aire 4000DX/5000DX, the operational manual indicated Product Function .Press up or down buttons to select the correct patient weight. The operational manual indicated Press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements. The operational manual indicated Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion of the health care professional. During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries Prevention revised 12/2/2025, the P&P indicated, Review and select medical devices with consideration to the ability to minimize tissue damage The P&P indicated Monitor regularly for comfort and signs of pressure related injury. For prevention measures associated with specific devices, consult current clinical practice guidelines.

Based on observation, interviews, and record reviews the facility failed to honor a resident's right to dignity (a person's worth as a human being, deserving of respect, honor, and fair treatment, regardless of their situation, status, or abilities) for one out of one sampled residents (Resident 17) when Certified Nursing Assistant 1 (CNA 1) stood over Resident 17 while assisting Resident 17 with his lunch on 1/5/2025. This failure had the potential to cause emotional distress, affect Resident 17's self-esteem (your overall opinion of yourself-how much you like, value, and respect yourself as a person), cause loss of dignity, and a decline in psychosocial wellbeing (feeling good and functioning well in your life, covering your mental, emotional, and social health).Findings: During a review of Resident 17/s admission Record, the admission Record indicated the facility originally admitted Resident 17 on 6/10/2019 and readmitted Resident 17 on 11/24/2025 with diagnoses that included pneumonitis (swelling of lung tissue) due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD- progressive condition that affects lung function), Diabetes Mellitus type II (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), muscle weakness, dysphagia (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 17's Minimum Data Set (MDS - a standardized resident assessment tool) dated 12/31/2025, the MDS indicated Resident 17 sometimes had the ability to understand others and sometimes had the ability to make himself understood. The MDS indicated Resident 17 needed substantial/maximal assistance (helper does more than half the effort and helper lifts or holds chest or arms) for eating. During a review of Resident 17's Care Plan titled Resident has self-care deficits (unable to fully care for self) related to generalized weakness, reduced mobility (ability to move around), cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment dated 11/25/2025, indicated Resident 17 needed moderate assistance with eating. The care plan indicated an intervention (a specific action the nursing staff takes to help a resident meet their health goals, like giving medication, repositioning them, or providing education, all detailed in their personalized care plan to ensure consistent, effective care) of encourage resident to do as much as possible for himself as much as possible to increase independence. During a review of Resident 17's Order Summary Report, dated 12/31/2025, the Order Summary Report indicated Resident 17 had an order for a regular diet pureed-4 (all food is blended, ground, or strained into a smooth, lump-free, pudding-like consistency, requiring no chewing and making it easier to swallow), moderately thick-3 consistency. During a review of Resident 17's PT (Physical therapy - focused on restoring, maintaining, and improving movement and physical function)/OT (Occupational Therapy - focused on helping residents participate in activities of daily living [ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating]), notes dated 1/5/2026, indicated Resident 17 was receiving OT for ADL retraining. During a concurrent observation and interview on 1/5/2026 at 11:46 AM with CNA 1 and Licensed Vocational Nurse 1 (LVN 1) in Resident 17's room, CNA 1 was observed standing over Resident 17 while assisting Resident 17 with his meal. CNA 1 stated he (CNA 1) was standing over Resident 17 because the occupational therapist told CNA 1 to assist Resident 17 with eating/feeding himself (Resident 17). LVN 1 stated CNA 1 should have been sitting while helping Resident 17 with his (Resident 17) meal and not standing over Resident 17 to provide Resident 17 with dignity. During an interview on 1/5/2026 at 11:54 AM with the Assistant Director of Nursing (ADON), the ADON stated CNAs (general) had to assist residents with their meals and had to be at the same eye level as the residents, to monitor residents for choking. The ADON stated CNAs needed to be on the same level as the residents when assisting the residents with their meals to provide the residents with dignity. During an interview on 1/6/2026 at 12:03 PM with the Director of Nursing (DON), the DON stated CNA 1 should have been at the same eye level as Resident 17 when assisting with the lunch meal on 1/5/2026, to provide Resident 17 with dignity. The DON stated when CNA 1 stood over Resident 17, Resident 17 could have felt overpowered (something is too strong, intense, or dominant) by CNA 1. During a concurrent interview and record review on 1/8/2026 at 9:22 AM with the DON, the facility's policy and procedures (P&P) titled, Assistance with Meals, dated 12/2025 and P&P titled Dignity, dated 12/2025, were reviewed. The DON stated CNA 1 should have sat down with Resident 17 when CNA 1 was assisting Resident 17 with his lunch on 1/5/2026 to provide Resident 17 with a dignified dining experience. During a review of the facility's P&P titled Assistance with Meals, dated 12/2025, the policy indicated 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals During a review of the facility's P&P titled Dignity, dated 12/2025, the policy indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are: d. provided with a dignified dining experience.

Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 5) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: -Ensure Resident 5's Medical Doctor obtained an informed consent (a process where someone voluntarily agrees after fully understanding the details, including its benefits, risks, and alternatives, ensuring they can make a free and educated decision) and to include the indication of the use of Seroquel (an antipsychotic [medications work by altering brain chemistry] used to treat mental health conditions) to Resident 5 or Resident 5's responsible party. This failure had the potential to restrict Resident 5's mobility (movement).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the Resident 5 on 6/4/2022 and readmitted Resident 5 on 5/16/2025 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), psychotic disturbance(hallucinations or strong delusions), mood disturbance (disruptive sadness, irritability), and anxiety disorder (excessive worry, fear, and nervousness), unspecified. During a review of Resident 5's Order Summary Report, the Order Summary Report dated 8/11/2025, indicated Resident 5 had an order for Seroquel 25 milligrams (mg-unit of measurement), one tablet via gastrostomy tube (G-Tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) two times a day (BID) related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During a review of Resident's 5 History and Physical (H&P), dated 8/13/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Order Summary Report dated 11/14/2025, the Order Summary Report indicated to monitor Resident 5's behavior of unconsolable screaming/yelling every shift tally (simple way of counting) by hash (strokes or lines) mark. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 5 was rarely/never understood had short-term and long-term memory problems and had no recall ability. The MDS indicated Resident 5 was dependent on staff for oral and personal hygiene, bathing, rolling left and right, and dressing. The MDS indicated Resident 5 had no potential indicators of psychosis and had no verbal symptoms directed toward others (threatening others, screaming at others, cursing at others). During a review of Resident 5's Facility Verification of Resident Informed Consent dated 8/11/2025, the Facility Verification of Resident Informed Consent indicated Resident 5, resident's representative or legal empowered representative (a person who has the legal authority to act on someone else's behalf) did not receive an informed consent for the use of Seroquel. The Facility Verification of Resident Informed Consent indicated there was no medical symptom (any feeling or change in your body that tells you something is wrong) indicated for the use of the chemical restraint (using medication like sedatives or antipsychotics to control a person's behavior, making them calmer, quieter or less mobile) and the medical doctor had not verbally indicated informed consent had been obtained. The Facility Verification of Resident Informed Consent indicated the signature of the medical doctor who obtained informed consent was signed on 1/26/2026. During a review of Resident 5's Resident Care Plan Psychotropics dated 8/11/2025m the Care Plan indicated Resident 5 had episodes of agitation manifested (shown) by yelling/screaming calling out names of others, and the nursing interventions was to administer medication as per physician order. During a review of Resident 5's Note to Attending Physician/Prescriber dated 9/7/2025 from the facility's pharmacist indicated the use of this class of medications (antipsychotic) for dementia-related behaviors is non(not) Food and Drug administration (FDA-a US government agency that protects public health by ensuring the safety, and effectiveness of drugs) approved. The Note to Attending Physician/Prescriber indicated for the physician to review the therapeutic (treating sickness) benefits versus (vs-as opposed to) potential risks for Resident 5's having received Seroquel 25mg BID and to have provided a brief statement that the benefit on continued therapy outweighed (more important) the potential risks. The Note to Attending Physician/Prescriber indicated the prescriber had disagreed with the pharmacist indicating Resident 5 had episodes of agitation and signed on 12/27/2025. During a review of Resident 5's Interdisciplinary Team Conference Record (IDT - a group of experts with different specialties who work together to solve a problem or help someone) dated 9/8/2025, the IDT indicated Resident 5 was on psychotherapeutic drug Seroquel and did not indicate a gradual dose reduction(GDR-slowly lowering the amount of medicine you take over time, instead of stopping suddenly, to see if still needed) had been attempted, and if the medication continued to be appropriate or necessary. The Interdisciplinary Team Conference Record indicated family, responsible party, or resident had not acknowledged that indications for psychotherapeutic drugs were obtained from the physician and informed consent was not given for use of psychotherapeutic drugs. The IDT Conference Record indicated to have continued Resident's plan of care. During a review of Resident 5's Monthly Behavioral Summary dated 11/14/2025 indicated all fields were left blank. During a review of Resident 5's Nursing Administration Report dated 11/1/2025 through 11/30/2025 indicated Resident 5 did not have any behavior of unconsolable screaming or yelling. During a review of Resident 5's Nursing Administration Report dated 12/1/2025 through 12/31/2025 indicated Resident 5 had one episode on 12/6/2025 during the night shift of unconsolable screaming or yelling. During a review of Resident 5's Psychiatrist Note dated 12/27/2025 indicated Resident 5 had dementia and was on Seroquel 25 mg BID. The Psychiatrist Note did not indicate a medication dose(amount) reduction was clinically contraindicated (anything that is a reason for a person to not receive a particular treatment because it may be harmful and did not indicate the current dosage of Seroquel was the lowest effective dose for Resident 5. During a review of Resident 5's Nursing Administration Report dated 1/1/2026 through 1/7/2026 indicated Resident 5 did not have any behavior of unconsolable screaming or yelling. During an observation on 1/5/2026 at 10:23 AM in Resident 5's room, Resident 5 was lying in bed, the bed rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed. Resident 5 would open his eyes when voice prompted. During an interview on 1/7/2026 at 12:02 PM with Certified Nurse Assistant (CNA)1, CNA 1 stated Resident 5 was calm and was not restless. During a concurrent interview and record review on 1/7/2026 at 1:21PM with Registered Nurse (RN) 2, Resident 5's Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drug or [Prolonged Use of a Device] and Note to Attending Physician/Prescriber from PH and was reviewed. RN 2 stated Resident 5 had returned from the general acute care hospital (GACH) on 8/11/2025, and Seroquel was ordered from GACH. RN 2 stated Resident 5 was on Seroquel due to his behavior at GACH. RN 2 did not specify what Resident 5's behavior was. RN 2 stated a GDR for Seroquel was not done for Resident 5 and there was not an IDT done for Resident 5's psychotropic medication Seroquel upon return from GACH on 8/11/2025. RN 2 stated Resident 5's Psychiatrist signed the Note to attending Physician/Prescriber on 12/27/2025 from the facility's PH dated 9/7/2025 for Seroquel 25mg BID that indicated provide a brief statement that benefits on continuing therapy outweigh the potential risk. RN 2 stated the box on the form was checked off disagrees due to note indicating Resident 5 had episodes of agitation. RN 2 stated the form does not indicate specifically when Resident 5 had episodes of agitation. RN 2 stated Resident 5 had not received informed consent for Seroquel as indicated on Resident 5's Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drug or [Prolonged Use of a Device]. RN 2 stated the nurse received the order for Seroquel on 8/11/2025 and the physician signed the informed consent on 1/6/2026. During a concurrent interview and record review on 1/7/2026 at 2:50 PM with the Director of Nursing (DON) and RN 2 Resident 5's orders for medication Seroquel 25mg BID and the California Department of Public Health All Facilities Letter (AFL) dated 2/28/2024 were reviewed. The DON stated Seroquel for Resident 5 was ordered on 8/11/2025 and Resident 5 was currently on Seroquel. The DON stated according to AFL 24-07 indicated written informed consent and disclosure (telling someone important information they need to know to make a good decision). The DON [NAME] stated we could not get the signature from Resident 5 or their representative. RN 2 stated to have given informed consent the risks and benefits of medication needed to be given by the doctor. The DON stated if Resident 5 could not have given informed consent and did not have any family or representative, the facility would have involved the ombudsman and would have done an IDT meeting for psychotropic medication. The DON stated she did not know who the doctor received informed consent from or had given informed consent to for Resident 5. The DON and RN2 confirmed Resident 5 was getting psychotropic medication without informed consent. The DON and RN 2 stated they were advocates for the residents (in general). During a telephone interview on 1/7/2026 at 3:17PM T with the medical doctor (MD) for Resident 5 with the DON, RN 2 present, the MD stated Resident 5 was discharged from GACH back to the facility on Seroquel. The MD stated Seroquel was given to Resident 5 at the GACH in August 2025. The MD stated Resident 5 was given Seroquel because he was fighting and there was concern about pulling out his G tube. The MD stated Resident 5 was discharged from the GACH with Seroquel, and it would not have been appropriate to stop the medication upon being discharged because we were unable to get informed consent. The MD stated Resident 5 could not give informed consent I agree with you but it's the best, it's in the best of his interest and after discussion with the staff we did this after discussion with the staff is it's not only the physician we've decided this is the best for the patient given the current situation. The MD stated he did not receive consent upon admission for Resident 5's Seroquel. The MD stated, The informed consent for psychotropic medication that it's signed by me yesterday (1/6/2026). The MD stated he's 90 something years old and there was concern from the team and pulling out the G-tube right and you know sometimes the behavior may not have been too much of concern but it was If he pulls out the g-tube he is going to end up in going back to the hospital OK that's the issue we are discussing. The MD stated yesterday 1/6/2026 I signed the informed consent myself to carry out the order from the hospital but now we can decide whether it would be appropriate to discontinue the medication. The MD stated the informed consent form was given to him on 1/6/2026 and Seroquel was given to Resident 5 upon his admission to the facility from GACH. The MD stated he could not explain why he did not sign the informed consent form until 1/6/2026. During a concurrent interview and record review on 1/7/2026 at 3:35 PM with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Policy and Procedure Informed Consent, dated 7/10/2025 was reviewed. The DON stated we should have advised the doctor we needed to have gotten informed consent first from someone for Resident 5's Seroquel. The DON stated the doctor could not explain why he signed the informed consent form on 1/6/2026. The DON stated it was the facility's responsibility to obtain informed consent. The DON stated, the policy indicates If the resident is adjudicated incompetent, informed consent could be given by a legal guardian. The [NAME] stated the policy indicates If the resident was confused with no decision maker, legal guardian or no one with Durable Power of Attorney for health Care Purposes, then the facility IDT team will review and make the necessary decision. During a telephone interview on 1/8/2026 at 1:14 PM with the facility's pharmacist (PH) stated the medication region review (MRR - a thorough check up of all medicines to make sure they are safe) for Resident's 5's Seroquel 25mg BID was done on 9/7/2025 when Resident 5 was admitted to the facility with the medication on 8/12/2025. The PH stated I had noticed that Seroquel 25mg BID was indicated for mood disturbance, anxiety and dementia. The PH stated I questioned that and left a note for the psychiatrist on 9/7/2025 to address the use of the medication since it was not FDA approved for dementia and had a black box warning (BBW- a most serious warning for prescription drugs to alert doctors and patients about the potential life-threatening or permanently disabling risks). The PH stated Seroquel for the use of Alzheimer's dementia was not indicated by the FDA. The PH stated on 9/7/2025 I had addressed to have clarified Resident 5's behavior. The PH stated on 12/1/2025, he had left a note for the psychologist for a GDR, and the reason Resident 5 was on Seroquel 25mg BID from 8/12/2025. The PH stated the DON would have my monthly review of medication. During a telephone interview on 1/8/2026 at 1:41 PM with Medical Director (MDIR) stated he was the new medical director. The MDIR stated in his professional history for residents receiving psychotherapeutic medication (drugs that help managemental health conditions) GDRs were done and made sure the psychiatrist came frequently and routinely reviewed medications to see if residents had meet their dose reduction, and had a chance to review the psychotherapeutic medications to have seen what was the lowest dose that could be given to prevent side effects(unwanted reaction to a medication). The MDIR stated the best thing to have done, the most appropriate for residents (in general) to have received psychotherapeutic medications was to have the psychiatric team provide informed consent rather than the primary care physician. The MDIR stated medical doctors (in general) were not trained in psychiatry and one of the purposes of the informed consent was to explain the side effects to the residents. The MDIR stated the whole idea is the word informed, we needed to place emphasis on informed, not just the residents, the doctor needs to be informed of what they were giving. The MDIR stated it would have been ideal for the psychiatrist to have been the person to have prescribed Seroquel instead of the primary care physician. The MDIR stated for Resident 5, it would have been ideal for the physician to have consulted the psychiatrist, prescribed the medication, and have obtained informed consent if the law allowed. The MDIR stated if Resident 5 did not have capacity(ability) to have given informed consent the facility should have brought it up in Utilization Review( a quality check on medical care to ensure treatments, tests and hospital tests your doctor recommends are necessary) would have been the first step, or an IDT to have had two physicians, preferably two psychiatrists if the benefits of the medication outweighed( more important than another) the risks. The MDIR stated If the benefit outweighed the risk, two psychiatrists could sign the informed consent, and the medical director could have be one of the doctors. The MDIR stated it had to be two signatures on the informed consent. The MDIR stated the proper thing to have done would have been to have brought Resident 5's informed consent and medication Seroquel through the bioethics committee (a diverse group of experts navigate through tough moral questions in medicine). The MDIR stated he was willing to put aside his time and could do an in -service (training to improve skills) for the staff since he was new to the facility and could do a policy and procedures implementation or add an addendum (an addition or supplement to an existing document). During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure Informed Consent, dated 7/10/2025, the P&P indicated This facility shall comply with the requirements as established concerning informed consent for all of its residents. The P&P indicated It is the policy that the physician has the responsibility to actually obtain consent, and it is additionally established that the patient's rights to be free from .chemical restraints be observed to the fullest The P&P indicated It is additionally established that the patient's rights to provide informed consent be accepted from the patient's representative when the patient lacks the ability to understand. The P&P indicated If the Resident is adjudicated incompetent, informed consent can be given by a legal guardian. If the resident is confused with no decision maker Legal Guardian or no one with Durable Power of Attorney for Health Care purposes, then the facility interdisciplinary team will review and make the necessary decision.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 12/2025, the P&P indicated Residents on psychotropic medications receive gradual dose reductions.

Based on observation, interview, and record review the facility failed to ensure to implement the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated 7/2025 for one of one sampled resident (Resident 18) by failing to: -Ensure the Administrator (ADM) reported Resident 18's allegation of financial abuse to the local police timely and suspended Certified Nurse Assistant 2 (CNA2) on 1/5/2026. Resident 18 alleged that CNA2 took $500.00 dollars from Resident 18 (unidentified date) and the ADM was aware on 1/5/2026. The ADM reported Resident 18's allegation of financial abuse to the local police and suspended CNA2 on 1/6/2025. This failure had the potential for delays in the investigation process of Resident 18's allegation of financial abuse.Findings:During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 4/9/2025 with a diagnoses of schizoaffective disorder bipolar type (a mental illness that blends symptoms of hallucinations, delusions, disorganized thinking with symptoms of extreme mood swings between manic highs and depressive lows), major depressive disorder (a serious mood condition causing persistent sadness, loss of interest, and affecting how you feel, think, and act), and anxiety disorder (mental health conditions causing excessive fear, worry, and dread that significantly interfere with daily life). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 4/22/2025, the MDS indicated Resident 18 had good recall but not oriented to the day of the week. During an observation and interview on 1/5/2026 at 12:08 PM with Resident 18 inside Resident 18's room, Resident 18 stated CNA 2 owed the resident (Resident 18) $500.00 dollars. Resident 18 stated CNA 2's wife (unidentified) gave CNA 2 the money. Resident 18 stated CNA 2's wife worked at the facility, but Resident 18 did not know the name of CNA 2's wife. Resident 18 stated the money was given to CNA 2 in December (unidentified year). During an interview on 1/5/2026 at 12:42 PM with the ADM, the ADM stated the allegation of money taken from Resident 18 by CNA 2 was reported to the ADM. The ADM stated Resident 18 had accused others (unidentified) of taking money and other items (unidentified) in the past. The ADM stated the amount of money changed every time. The ADM stated the facility did not report the allegations in the past due to Resident 18's mental capacity. During a review of Resident 18's Social Services Note dated 1/5/2026, the Social Services Note indicated the Social Services Designee (SSD) sent an SOC 341(a form used in California to report suspected abuse of dependent adults) to the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and to the Department. The SSD note indicated Resident 18 reported to one of the surveyors (during annual survey) that a facility staff (unidentified) took Resident 18's $500.00 dollars. The SSD note indicated that the facility started an investigation on 1/5/2026. During an interview on 1/6/2026 at 12:55 PM with the Social Worker (SW), the SW stated that monitoring for Resident 18 for 72 hours had not begun since the allegation was reported on 1/5/2026. The SW stated she (SW) could not recall when the facility conducted the last abuse in-service. During a concurrent interview and record review on 1/6/2026 at 1:35 PM with the ADM and Registered Nurse1 (RN 1), the Abuse/Neglect policy dated 12/2025 was reviewed. The ADM proceeded to describe the process of reporting and investigating an abuse allegation. The ADM stated the facility would report the allegation to the ombudsman and the California Department of Public Health (CDPH). The ADM stated that the police would get involved when there was an altercation or physical injury and a resident was sent out to the hospital. The ADM stated the police would get involved at the resident's (unspecified) request. RN 1 stated on 1/5/26, Resident 18 reported that CNA 2 took $500.00 dollars in cash in December 2025. RN 1 stated that CNA 2 obtained the money from the safe (the computer), and that CNA 2's wife gave CNA 2 the money. RN 1 stated the police were not notified. RN 1 stated that Resident 18 should be monitored for 72 hours. RN 1 stated that abuse training was conducted in the facility in December of 2025. The ADM stated that if an abuse allegation involved an employee, that the employee would be told to not have any contact with the resident (unidentified) in question. The ADM stated CNA 2 was told not to have any contact with Resident 18. The ADM stated CNA 2 had not been suspended and was currently working in the facility. The ADM stated that there had not been an Interdisciplinary Team Meeting (IDT, group of diverse health care professionals from different fields) scheduled for the abuse allegation for Resident 18. The ADM and RN 1 were both unsure if a psychological consultation had been scheduled for Resident 18. The ADM reviewed the Abuse/Neglect policy. The ADM stated that the policy did not mention that a staff member involved in an allegation of abuse should be placed on suspension. The ADM stated that the facility in an allegation of abuse would do an incident report then report to the ombudsman, CDPH but not necessarily to the police. RN 1 stated Resident 18 would be at risk for the allegation not to be investigated correctly. During an interview on 1/7/2026 at 9:29 AM with the Director of Staff Development (DSD), the DSD stated that abuse training was conducted every six months and as needed. The DSD stated during abuse training staff (unidentified) were asked about the different types of abuse, reporting and investigating. The DSD stated that reporting of abuse should occur immediately and should be to the supervisor, charge nurse, or to the ADM. The DSD stated the ADM should report to CDPH, the ombudsman, and in certain circumstances to the police. The DSD stated the police should be involved when the abuse involved physical altercation and if financial abuse can be proven. The DSD stated if a staff member (in general) was accused of abuse, the staff member would be suspended. During a concurrent interview and record review on 1/7/2026 at 9:57 AM with the ADM, the Abuse, Neglect, exploitation, or Misappropriation - Reporting and Investigating policy dated 7/2025 was reviewed. The ADM stated that CNA 2 was suspended on 1/6/2026 and was not in the building. The ADM stated CNA 2 received a verbal notification of suspension. The ADM provided the abuse policy, which was reviewed, the ADM stated that on 1/6/2026 when the policy Abuse/Neglect was given to the surveyor, the ADM did not recognize the policy. The ADM stated the Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating was the policy the facility recognized. The ADM stated she (ADM) agreed that regardless of which policy was recognized, the facility was not following their policies on abuse. During an interview on 1/7/2026 at 9:58 AM with the Director of Nursing (DON), the DON stated the facility would notify the abuse coordinator, family members of the residents, MD, CDPH, Ombudsman, and law enforcement (in general). The DON stated the facility would start the investigation, and the abuse coordinator would designate who would perform the investigation and reporting was done immediately. The DON stated that for an allegation of abuse involving a staff member (unspecified) and a resident (unspecified) the facility would report to the abuse coordinator, CDPH, law enforcement, family members, Ombudsman, and MD. The DON stated the staff would be put on leave till the investigation was complete. The DON stated the residents were monitored for at least 72 hours (in general). The DON stated nursing would provide documented monitoring. The DON stated the SSD would be involved with reporting to the entities and documenting monitoring. The DON stated a psychological consult would be provided for the resident (in general). The DON stated the residents were monitored for at least 72 hours. DON stated nursing would provide documented monitoring. The DON stated the SW would be involved with reporting to the entities and documenting monitoring. The DON stated a psychological consult would be provided for the resident. The DON stated that Resident 18 would be at risk for improper investigation of the abuse without following the policy. During a review of the facility's policy and procedures (P&P) titled, Abuse/Neglect, dated 12/2025, indicated, that verbal abuse is any use of oral, written or gestured language that willfully include disparaging and derogatory terms to resident or to their families, or within their hearing distance, regardless of their age ability to comprehend or disability. The P&P indicated abuse included, but was not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The P&P indicated the company takes all allegations seriously. The P&P indicated all staff will be in-serviced at least quarterly on abuse prevention, detection of abuse and reporting requirements. The P&P indicated that the facility would report all allegations and substantiated occurrences of abuse, neglect and misappropriation of property to the state agency and law enforcement officials as designated by state law. During a review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated 7/2025, indicated, the administrator immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency, local state ombudsman, and law enforcement officials. The P&P indicated that any employee who has been accused of resident abuse would be placed on leave with no resident contact until the investigation was completed.

Based on interview and record review the facility failed to provide an accurate Minimum Data Set (MDS - a resident assessment tool) Assessment for one out of three sampled residents (Resident 1) as indicated in the facility's policy and procedures titled Resident Assessments, dated 7/31/2025. This failure resulted in the facility not accurately identifying Resident 1's Brief Interview for Mentals Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) and delivery of services.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 4/1/2022 and readmitted Resident 1 on 12/2/2025 with diagnoses that included chronic combined systolic and diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, hypertension (HTN-high blood pressure), atherosclerotic heart disease (thickening or hardening of the arteries), schizoaffective disorder, bipolar type (a serious mental illness where someone experiences symptoms of schizophrenia [like hearing voices or having strange beliefs] mixed with the mood swings of bipolar disorder, meaning they have intense highs [mania] and often lows [depression], making it hard to tell reality from fantasy during mood shifts), functional quadriplegia (someone can't move their arms and legs due to severe illness, frailty, or conditions like advanced dementia not from a direct spinal cord injury), dementia (a progressive state of decline in mental abilities), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's History and Physical (H&P - formal and complete assessment of the patient and the problem) dated 11/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a concurrent interview and record review on 1/6/2026 at 2:37 PM with the MDS Licensed Vocational Nurse (MDSLVN), Resident 1's MDS dated [DATE] was reviewed. The MDS indicated Resident 1's BIMS score was 99 (a BIMS score of 99 indicated the BIMS was unable to be completed). The MDS indicated the following: C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? - YesC0200. Repetition of Three Words - NoneC0300. Temporal Orientation (orientation to year, month, and day)A. Able to report correct years - Missed by >5 years or no answerB. Able to report correct month - Missed by >1 month or no answerC. Able to report correct day of the week - Incorrect or no answerC0400. RecallA. Able to recall sock - not assessedB. Able to recall blue - not assessedC. Able to recall bed - not assessed. The MDSLVN stated Resident 1's MDS assessment was not accurate because she (MDSLVN) asked Resident 1 to recall the words sock, blue, and bed and Resident 1 was not able to recall the words. The MDSLVN stated she pressed override (to disregard) on the assessment instead of answering the questions correctly. The MDSLVN stated when she pressed override the questions for recalling sock, blue, and bed automatically changed the answers to not assessed. The MDSLVN stated Resident 1's BIMS score of 99 was not correct because the MDSLVN stated she completed Resident 1's BIMS assessment. The MDSLVN stated she should have marked the form correctly and answered Resident 1 could not recall the word sock, blue, and bed instead of pressing override. The MDSLVN stated Resident 1's BIMS score should have been 0. The MDSLVN stated the MDS Assessment needed to be accurate for the facility to correctly care for Resident 1's needs. During a concurrent interview and record review on 1/6/2026 at 2:48 PM with Registered Nurse 1 (RN1), Resident 1's MDS dated [DATE] was reviewed. RN 1 stated Resident 1's MDS was not accurate. RN 1 stated the MDS had to be accurate for the facility's staff to know how to appropriately care for Resident 1. During a concurrent interview and record review on 1/7/2-26 at 9:35 AM with the facility's Director of Nursing (DON), Resident 1's MDS dated [DATE] was reviewed. The DON stated the MDSLVN should not have pressed override on the recall questions in the BIMS assessment section of the MDS assessment. The DON stated when the MDSLVN pressed override the answers to the recall questions defaulted to not assessed, rendering the assessment (MDS) inaccurate. During a concurrent interview and record review on 1/7/2-26 at 9:35 AM with the facility's Director of Nursing (DON), P&P titled Resident Assessments, dated 7/31/2025 was reviewed. The DON stated the MDSLVN did not perform the MDS assessment accurately. The DON stated the MDSLVN should have performed the MDS assessment accurately because the MDS assessment was used to develop, review, and revise the resident's (in general) comprehensive care plan per the P&P titled Resident Assessments, dated 7/31/2025. During a review of the facility's P&P titled Resident Assessments, dated 7/31/2025, the P&P indicated the following: 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The P&P indicated 9. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan (a detailed, personalized roadmap for someone's health, written down to guide everyone involved [doctors, nurses, family] on all their needs to ensure consistent, coordinated, and goal-oriented care, covering everything from medications and treatments to personal routines and emergency steps).

Based on observation, interviews, and record reviews the facility failed to provide medically related social services, by failing to: Advocate for and obtain a public guardian (a court-appointed, government-funded helper or manager for adults who can't care for themselves because of severe mental or physical disabilities, often when no family or friends are available) when the one of three sampled residents (Resident 5) was assessed to not have the capacity to make or understand medical decisions on [DATE]. Ensure the ombudsman (a neutral, independent advocate to find fair resolutions) was notified prior to updating a Physician Order for Life-Sustaining Treatment (POLST: a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) as per the facility's policy and procedures (P&P) titled POLST, updated 12/2025. This failure had the potential not to follow Resident 5's wishes for medical care and end-of-life.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), chronic obstructive pulmonary disease(COPD-a chronic lung disease causing difficulty in breathing), persistent atrial fibrillation (an irregular heart beat), ventricular tachycardia (the heart's lower chambers[ventricles] beat too fast to pump enough blood to the body), blindness in bilateral(both) eyes, metabolic encephalopathy (a condition where brain dysfunction occurs due to a chemical imbalance in the body), bilateral hearing loss, adult failure to thrive (a severe, rapid decline in physical and mental health), unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, anxiety disorder (excessive worry, fear, and nervousness), unspecified. During a review of Resident's 5 History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings), dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS- a standardized resident assessment tool), dated [DATE], the MDS indicated Resident 5 was rarely/never understood had short-term and long-term memory problems and had no recall ability. The MDS indicated Resident 5 was dependent on staff for oral and personal hygiene, bathing, rolling left and right, and dressing. During an observation on [DATE] at 10:23 AM in Resident 5's room, Resident 5 was observed lying in bed, the bed rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed. Resident 5 opened his eyes when voice prompted but did not respond verbally. During an interview on [DATE] at 8:01 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated an advance directive was a document signed by the resident for medical care and if the resident was unable to make decisions for health care the document would let facility staff know the next steps to take for the resident. LVN 1 stated the advanced directive would speak for the residents if the residents could not speak for themselves. LVN 1 did not know if a POLST was the same as an advanced directive. LVN 1 stated a referral would have to be made to social services if a resident did not have an advanced directive. During a review of Resident 5's Resident Care Conference Record, dated [DATE], the Resident Care Conference Record indicated an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals who work together) conference was conducted secondary to (resulting from) a Change of Condition (COC- change in a resident's health or functioning). The Resident Care Conference Record indicated Resident 5 did not attend or participated and the stated reason was cognitive impairment. The record indicated Resident 5 was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) and was not to receive CPR (cardiopulmonary resuscitation. It is an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped). The record indicated the agent (person) responsible portion section was blank and the IDT was attended by nursing (unspecified) and the social services director. The Resident Care Conference Record indicated Discussed with Medical Director resident's current condition and he concurs with IDT recommendations to discontinue hospice care. During a concurrent interview and record review on [DATE] at 8:16 AM with the Social Worker (SW) Resident 5's POLST dated [DATE] was reviewed. The POLST indicated a POLST was to compliment (Support) an Advanced Directive and was not intended to replace the Advanced Directive. The SW stated a POLST was not the same as an advanced directive. The SW stated Resident 5's POLST indicated Resident 5 was unable to sign due to cognitive impairment as indicated on the signature portion of patient or legally recognized decisionmaker. The SW stated if a resident was unable to sign the POLST, two doctors were supposed to sign the POLST. The SW confirmed by stating there was only one doctor that signed the POLST on [DATE] for Resident 5. The SW stated if a resident was incapacitated (unable to function, make decisions, or care for oneself due to illness, injury or disability) the SSD had to find a public guardian. The SW stated, I filled out the POLST form on [DATE] and I wrote unable to sign due to cognitive impairment and then I left the doctor to sign the form. During a concurrent interview and record review on [DATE] at 9:01 with Registered Nurse (RN)1, Resident 5's POLST dated [DATE] was reviewed. RN 1 stated an advanced directive and POLST were two separate documents. RN 1 stated there was only one physician signature on the POLST and indicated Resident 5 could not sign the form for himself due to impaired cognition. RN 1 stated Resident 5 could not communicate and had no family members and no advanced directive. RN 1 did not know if the facility had an ethics committee (a group of diverse people [nurses, doctors, social workers, clergy, families] who help sort out tough moral problems or disagreements about resident care, making sure choices respect the resident's rights, dignity, and best interests, acting as advisors, not bosses, to guide fair and compassionate decisions, especially for things like end-of-life care or consent). During an interview and record review on [DATE] at 11:51 AM with the SW, the SW could not provide an answer and remained silent on how the facility determined Resident 5's code status (medical instructions for facility staff about what to do if a resident's heart or breathing stops). During an interview on [DATE] at 1:25 PM with RN 1 stated the facility did have a bioethics committee. RN 1 stated the IDT and the bioethics committee were the same and had the same members. RN 1 stated there was no IDT done for Resident 5 for not having an advanced directive and for his POLST being updated on 1/18/ 2024. RN 1 stated the facility did not have a policy for conservatorship (court appointed person[conservator]to make important decisions for another adult[conservatee]). RN 1 stated the ombudsman should have been included in the decision to change the POLST for Resident 5. During a concurrent interview and record review on [DATE] at 12:46 PM with the Director of Nursing (DON), Resident 5's POLST and the facility policy and procedures (P&P) titled, POLST, updated 12/2025 was reviewed. The DON stated if a resident did not have any family or elected representative, the facility would have an IDT meeting and discuss the diagnosis and the plan. The DON stated if a resident did not have a family member, a friend, or designated representative the facility was to contact a public guardian or another conservatorship. The DON stated a new POLST was signed for Resident 5 on [DATE] for CPR and full treatment. The DON stated the facility should have tried to obtain a public guardian or conservatorship for Resident 5. The DON stated the facility should have also invited the ombudsman to join and discussed the advanced directive during the care conference. The DON stated the facility policy on POLST indicated The Physicians Orders for Life-Sustaining Treatment (POLST) is a physician order form that complements an advanced directive by converting an individual's wishes regarding life- sustaining treatment and resuscitation into physician orders. The DON stated Resident 5 did not have a legally recognized healthcare decision maker and policy and procedure was not followed. During a review of the facility's (P&P) titled, POLST, updated 12/2025, indicated The Physician Orders for Life-Sustaining Treatment (POLST) is a physician order form that complements an advance directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders. The P&P indicated A qualified healthcare provider , preferably a social service director, will conduct an initial review of the POLST with the resident, or if the resident lacks decision making capacity the legally recognized healthcare decisionmaker (Ombudsman or Public Guardian's Office), within the first required 14-day assessment period as part of the comprehensive assessment and care planning process.

Based on observation and interviews, the facility failed to ensure 10 out of 18 (room [ROOM NUMBER], 3, 4, 5, 6, 12, 15, 18, 23, and 24) resident rooms met the required 80 square feet per resident.This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.Findings: During a review of the facility's room wavier letter dated 1/5/2026, the letter indicated the facility was requesting a room variance (room size different from required amount) for 11out of 18 resident rooms (room [ROOM NUMBER], 3, 4, 5, 6, 9, 12, 15, 18, 23, and 24). The room waiver letter indicated the following rooms had less than 80 square feet per bed:Room NumberFloor AreaCapacityroom [ROOM NUMBER].642room [ROOM NUMBER].12room [ROOM NUMBER].164room [ROOM NUMBER].82room [ROOM NUMBER].164room [ROOM NUMBER]room [ROOM NUMBER].953room [ROOM NUMBER].13room [ROOM NUMBER].744room [ROOM NUMBER].382room [ROOM NUMBER].762 The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not inhibit residents from getting in and out of wheelchairs and affording sufficient freedom of movement. The space of each room would not have adverse effect on the residents' health and safety; and would not impede the ability of any resident in the rooms to attain his/her highest practicable well-being. The room wavier letter indicated all measures would be taken to ensure the comfort of each resident, staff, and visitor and would not be compromised by the facility's existing room square footage. During an observation on 1/8/2026 at 12:40PM, the Maintenance supervisor (MS) measured rooms [ROOM NUMBERS]. The rooms measured as follows:room [ROOM NUMBER].62room [ROOM NUMBER].12 During multiple observations of nursing care conducted on 1/8/2026 in rooms [ROOM NUMBERS], nursing staff were observed with adequate space to provide care to the residents in each resident room [ROOM NUMBER] and room [ROOM NUMBER]. Each resident was observed to have privacy curtains, working call-lights, storage, and a bedside table with personal belongings stored in each resident's choice of location. During an interview on 1/8/2026 at 9:51am with Resident 90 in room [ROOM NUMBER] bed A, Resident 90 stated the room was big enough to accommodate him (Resident 90) and his wife. The Resident stated the size of the room has never stopped care of services from being completed. During a concurrent observation and interview on 1/8/2026 at 9:34am, the surveyor and occupational therapist (OT) toured the resident rooms listed with room waivers (1,3,5,9,10,11,14,16,17,23, and 24). The OT stated that she had sufficient space within the rooms that had room waivers to give care and complete the residents' plan of care. During an Interview on 1/8/2026 at 10:00am with Resident 10 in room [ROOM NUMBER] the resident stated that she had not noticed that the room was smaller than other rooms. The resident states that the room is big enough, and nursing care has never been compromised. A review of the facility's policy and procedures (P&P) titled Resident bedrooms revised on 8/2024, the policy indicated resident bedrooms had to be designed and equipped for adequate nursing care, comfort and privacy of resident and would measure at least 80 square feet per resident in multiple resident bedrooms The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review, the facility failed to have an effective pest control program to ensure the facility was free from pests (roaches).This failure had the potential for the spread of harmful bacteria (tiny cells that can cause infections and illnesses) and infection to residents in the facility.Findings:During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a long term lung condition that makes it hard to breathe), hypertension (high blood pressure), epilepsy (a brain disorder that causes recurring seizures), old myocardial infarction (a heart attack sometime in the past), heart failure (heart muscle doesn't pump blood as well as it should), atherosclerotic heart disease of native coronary artery( buildup of fats, cholesterol in the artery walls) unspecified psychosis(symptoms that affect the mind, where there has been some loss of contact with reality), and Type II Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing)and malignant neoplasm of right and left bronchus and lung).During a review of Resident 4's Minimum Data Set (MDS- a standardized assessment tool) dated 7/2/2025, the MDS indicated Resident 4 had intact cognition (ability to think and reason).During an observation of the facility nurses' station on 7/19/25 at 2:15p.m. with Registered Nurse (RN) 1, a large brown bug approximately 2 inches in length with an oval shaped body, flat head, two long antennas, and multiple legs was observed crawling on the floor away from the nurses' station. RN 1 was asked to identify insect and stated it was a cockroach. RN 1stated having cockroaches in the facility was an issue with cleanliness and residents could fall ill from the bacteria roaches carried. RN1 stated cockroaches in the facility was not sanitary. and was a pest control issue and infection control issue.During an interview on 7/28/25 at 2:24 p.m. with Resident 4, Resident 4 stated, I see cockroaches every day and it's not right. It needs to be cleaned right away; it means it's not a clean environment. It's possible that I can get sick from there being roaches.During an interview on 7/28/25 at 2:27p.m., the Administrator stated, the pest control company was at the facility on 7/3/25. The administrator stated the pest control company would go to the facility monthly and when needed. During an interview on 7/28/25 at 2:27p.m., the Interim (temporary) Director of Nursing (IDON) stated, cockroaches in the facility could cause the residents to get sick, develop nausea, vomiting, diarrhea, and residents could end up in the hospital. The IDON stated all residents could be negatively affected, especially the residents with weakened immune systems.During a review of the facility's policy and procedures (P&P) titled Pest Control revised in May 2021, the policy indicated This facility maintains an on-going pest control program to ensure that the building is kept free of insects.During a review of the facility's P&P titled Infection Prevention and Control Committee revised in July 2021, the policy indicated Provide facility guidelines for a safe and sanitary environment. The policy further indicated, Assist in reviewing food handling practices, laundry practices, waste disposal and pest control.

Based on Observation, Interview, and record review the facility failed to protect the resident ' s right to be free from resident-to-resident verbal and physical abuse for two of two sampled residents (Resident 1 and Resident 2) by failing to: 1. Provide necessary behavioral health assessment monitoring and ordered psychiatrist/psychology referrals when Resident 1 was exhibiting behavioral health symptoms of entering other resident ' s rooms without their permission to shout at other residents. 2. Protect Resident 2 from Resident 1 ' s verbal abuse, when on 11/28/24 at 9:30 AM Resident 1 to yell and Resident 2 (roommate), leading a resident-to-resident physical altercation (fight). This deficient practice resulted in Resident 2 hitting Resident 1 with his phone on the right side of the face on 11/28/24 at 9:30 AM. Resident 1 exhibited redness and bruising (bluish discoloration mark) on the right side of the face and above the right eye, complained blurry vision. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses that included combined forms of age-related bilateral cataract (a condition in which the lens of an eye becomes cloudy and affects vision) and other unspecified peripheral vascular diseases (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/12/24 indicated, assessment for verbal behavioral symptoms directed toward others (e.g. Threatening others, screaming at others, cursing at others) indicated; behavior not exhibited. Overall present of behavioral symptoms assessment indicated; behavior not exhibited. A review of Resident 1 ' s History and Physical (H&P) record dated 9/26/24, indicated the resident had a history of drug and alcohol use and had been homeless for 2 years. The H&P indicated the resident had the capacity to make and understand decisions. A review of Resident 1 ' s Care Plan for Behavioral Symptoms initiated on 11/16/24 indicated, the resident had behavioral problems related to socially inappropriate/disruptive symptoms: talking harshly and loudly. The goal for Resident 1 included but was not limited to, not making disruptive noises, behaviors, and to interact peacefully in social situations. The care plan intervention indicated, not argue with the resident, allow control and decision making as able, redirect behavior, provide diversional activities, monitor behavior, and refer to Interdisciplinary Team (IDT, a team of health care professions, which include the facility ' s medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents), psychiatry/psychology consult as needed. A review of Resident 1 ' s Order Summary Report with order date 11/16/24 indicated, Monitor inappropriate behavior m/b (manifested by) talking harsh and loud often disruptive every shift, order date 11/30/24 indicated, Refer to Psych d/t (due to) behavior of constantly yelling. A review of Resident 1 ' s psych notes from 11/16/24 to 11/28/24 did not indicate Resident 1 was seen by a psychiatrist or psychologist. A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) dated 11/28/24 at 9:30 AM indicated, the resident had an altercation with his roommate (Resident 2). The SBAR indicated a change in skin or wound status to redness to right side of face, scratch to upper forehead, monitor and refer to ophthalmologist (an eye doctor who specializes in diagnosing and treating eye and vision conditions) consult for evaluation. A review of Resident 1 ' s Progress Note dated 11/28/24 at 9:30 AM, indicated, Resident 1 noted yelling [NAME], [NAME], [NAME] irritating roommate (Resident 2) who was stationary behind him, stood face to face imitating roommate. Resident 1 was struck with cellphone to right side of face. On assessment, noted redness to right side of face with a small scratch. Resident 1 stated Vision blurry. A review of Resident 1 ' s Nursing Progress Note dated 11/29/24 at 10:12 AM indicated, the resident noted in front of room [ROOM NUMBER], yelling [NAME], [NAME], [NAME] and irritating roommate who was standing behind him. Resident stood face to face with roommate irritating him when he was struck with cellphone to right side of face. First aid rendered, ophthalmologist consult for evaluation and continue to monitor. A review of Resident 1 ' s Physician ' s Order record dated 12/2/24 indicated, Psychiatry evaluation, history of past mood disorder, history of anxiety. A review of Resident 2 ' s admission record indicated the facility admitted the resident on 4/1/24 with diagnoses that included generalized muscle weakness, aphasia (difficulty speaking) following a cerebral infarction (a serious medical condition when a blood flow to the brain is blocked due to problems with blood vessels leading to brain cell death). A review of Resident 2 ' s H&P dated 4/5/24 indicated the resident had the capacity to make and understand decisions. A Review of Resident 2 ' s Progress note dated 11/28/24 at 9:30 AM, indicated Resident 2 was noted to be standing behind roommate (Resident 1), when roommate turned around and started to imitate resident face to face, Resident 2 then struck roommate with cellphone. A review of Resident 2 ' s care plan for communication deficit related to aphasia (no date) indicated, the goal for the care plan was for the resident ' s needs to be met and anticipated daily. The care plan interventions indicated for staff to allow ample time for the resident to respond, speak slowly and clearly, and to allow ample time for the resident to respond. A review of Resident 2 ' s SBAR dated 11/28/24 at 9:30 AM, indicated the resident had an altercation with his roommate (Resident 1). The SBAR indicated facility staff was to monitor the resident for outbursts and the resident was to have a psych consult. During an interview on 12/16/24 at 3:15 PM, Resident 2 stated Resident 1 (roommate) was yelling in front of their room in the hallway irritating him and Resident 1 would get aggressive at times. Resident 1 was pacing in and around their room. Resident 2 stated Resident 1 came in the room and raised his fist, there was no verbal cue, Resident 1 is taller than me, when he raised a fist, I felt threatened and raised my hand for defense holding my phone and hit him on the right side of the face. (Unable to recall date and time of incident, stated it happened few days ago). During an interview on 12/16/24 at 3:55 PM with Resident 1 in room [ROOM NUMBER], Resident 1 stated, I had an eye surgery and was admitted to the facility for rehab in August. Stated, on thanksgiving morning I was up walking around making turkey jokes saying [NAME] to entertain other people, my roommate (Resident 2) came up to me and mumbled because he can ' t speak well then cracked me with his phone on my face. I did not try to attack him, I did not raise my hand, I did not make a fist. He hit me on the right side of my face, when he brought down his hand he scratched my eyes with his finger. My vision is blurry, an ophthalmologist came to see me and told me the surgery looks good and no problems. Stated, before coming to the facility I used to be in a residential facility and taking antidepressant medications. I stopped all the medications when I became a homeless since January 2024. During an interview on 12/16/24 at 3:40 PM with Social Services Director (SSD), SSD Stated, Resident 1 was known to be very loud, when that happens, the resident was reminded to lower his voice. The SSD stated the resident required a lower-level care and the SSD was working for placement. The SSD stated it was appropriate to have Resident 1 referred for psychological consult prior to the altercation between Resident 1 and Resident 2. During an interview and record review on 12/17/24 at 10:02 AM with minimum data set coordinator (MDS), Resident ' s 1 ' s care plan was reviewed. The MDS stated when a resident did not come to the facility with a psychiatry/psychological diagnosis, the facility conducted ongoing observations and ordered psychiatry/psychological consults when symptoms were exhibited. The MDS stated Resident 1 did not come to the facility with a psych diagnosis. Thee MDS stated Resident 1liked to go to other resident ' s rooms, but the MDS did not see the resident as a threat. The MDS reviewed Resident 1 ' s care plan and stated based on the residents ' behavior since admissions and according to the care plan interventions, Resident 1 was supposed to be referred for psychology consult and evaluated on 11/16/24 and was not. During an interview on 12/17/24 at 11:38 AM with Certified Nursing Assistant (CNA 1), CNA 1 stated, Resident 1 liked to go around other resident ' s rooms and nursing stations, spoke very loudly, and was in a hallway most of the time. During an interview on 12/17/2024 at 11:38 AM with the Director of Nursing (DON), DON stated, the altercation between Resident 1 and Resident 2 took place in a hallway in front of Resident 1 and Resident 2 ' s room, Resident 1 was in Resident 2 ' s face irritating him, Resident 1 was raising his voice. The DON stated Resident 1 was loud and liked going around rooms usually in the evenings. The DON stated Resident 1 was not referred for psychology evaluation because he was not a threat, there was no safety concerns or complaints from other residents. The DON agreed the behavioral assessments did not reflect Resident 1 ' s behavior, based on care plan goals and interventions. The DON stated Resident 1 was supposed to be referred for psychology evaluations and was not. During an interview on 12/17/2024 at 12:50 PM with the facility ' s Administrator (ADM), the ADM stated, I oversee abuse coordination and investigations. Received a call from the DON on Thanksgiving Day after the incident between Residents 1 and 2 took place. Stated, Resident 1 likes to be in a hallway, I have observed him to be naturally loud, he was not a threat to anyone, Resident 1 could have benefited from psychology consult. A review of the facility ' s policy and procedures titled Resident Assessment revised November 2024, indicated A comprehensive assessment includes completion of MDS, completion of the care area assessment process and development of comprehensive care plan. A review of the facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised November 2024, indicated Residents have the right to be free from abuse, neglect. Including but not limited to protect residents from abuse, neglect from other residents. Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents and neglect of residents. A review of the facility ' s policy and procedures titled Care Plans, Comprehensive Person-Centered revised November 2024, indicated, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident ' s condition, when the desired outcome is not met.

Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and 2), three Licensed Vocational Nurses (LVN 3, 4 and 5) and Registered Nurse (RN) 2 had a completed annual competency and annual performance evaluation. This deficient practice violated the facility's Competency and Performance Evaluations policy and had the potential for residents to not receive appropriate services. Findings: A review of CNA 1's employee file indicated the date of hire was 4/23/2016 and the competency evaluation was last completed on 8/16/2023. A review of CNA 2's employee file indicated the date of hire was 8/13/2020 and the competency evaluation was last completed on 10/23/2021. A review of LVN 3's employee file indicated the date of hire was 3/3/2014 and there was no competency nor performance evaluations noted in file. A review of LVN 4's employee file indicated the date of hire was 5/19/2017 and the performance evaluation was last completed on 12/12/2023. There was no competency evaluation noted in file. A review of LVN 5's employee file indicated the date of hire was on 3/24/2017 and the performance evaluation was last completed on 9/10/2023. The competency evaluation was last completed on 4/23/2021. A review of RN 2's employee file indicated the date of hire was 10/23/2012 and there was no competency nor performance evaluation noted in file. During an interview and record review on 11/27/2024 at 12:24 PM, the Administrator (ADM) stated that all competency and performance evaluations should be done annually for all licensed staff. The ADM stated the Director of Staff Development (DSD) was responsible for ensuring the evaluations were completed on time and updated in the employee files. After review with the ADM of the employee files for CNA 1 and 2, LVN 3, 4, and 5, and RN 2, the ADM confirmed there were no updated annual competency or performance evaluations for CNA 1 and 2, LVN 3, 4, and 5 and RN 2. The ADM stated the potential risk for not completing the evaluations timely would be that the quality of care to the resident could be compromised. A review of the facility's policy and procedure (P&P) titled, Performance Evaluations, revised 2024, indicated the job performance of each employee shall be reviewed and evaluated at least annually. A review of the facility's P&P titled, Competency of Nursing Staff, and revised 2024, indicated that facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled, properly stored or discarded in accordance with current accepted professional standards of practice for insulin (medication used to regulate blood sugar levels), Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]), and Pneumovax 23 (a vaccine that helps protect against serious infections of the ears, sinuses, lungs, blood and brain, especially in person's with high risk conditions and over the age of 65, such as pneumonia). In addition, the expired emergency medication kit (storage container for emergency use medications) in Medication room [ROOM NUMBER] was not removed or discarded. These deficient practices increased the risk that residents in the facility could receive medication that had become ineffective or toxic. Findings: During an observation on 11/25/24 10:42 a.m., in Medication Cart 1, in the presence of Licensed Vocational Nurse (LVN) 2, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: -One open insulin Humulin R vial for Resident 21 was found stored at room temperature, without a date indicating when storage or use at room temperature began. According to the manufacturer's product labeling, opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began. -One open insulin Humulin R vial for Resident 26 was found stored at room temperature with a label indicating that use at room temperature began on 8/25/24 and the vial expired on 9/22/24. According to the manufacturer's product labeling, opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began. During an interview on 11/25/24 10:43 a.m., LVN 2 stated the insulin Humulin R multi-dose (containing more than one dose) vial for Resident 21 was opened, used, stored at room temperature, and not labeled with a date when use at room temperature began, and the insulin Humulin R multi-dose vial for Resident 26 was open and labeled with a date indicating that use began on 8/25/24 and expired on 9/22/24. LVN 2 stated that LVN 2 was unaware when the insulin Humulin R vial for Resident 21 was stored at room temperature therefore unknown when it would expire and need to be discarded. LVN 2 stated that most insulin vials expire within 28 days of opening the vial, and that the Humulin R vials for Resident 21 and 26 needed to be removed from the medication cart to ensure expired insulin was not administered in error to Resident 21 and 26. LVN 2 stated administering expired insulin would not be effective in keeping the blood sugar stable and can harm Resident 21 and 26 by causing high or low blood sugar levels, leading to coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. LVN 2 stated the insulin Humulin R vials needed to be immediately replaced with new ones from pharmacy for Resident 21 and 26. During an observation, on 11/25/24 at 11:05 a.m., with LVN 2, in Medication room [ROOM NUMBER], the following medication was found either stored and not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored contrary to facility policies: -Two open Aplisol multi-dose vials for facility stock were found stored in the refrigerator with a label indicating use began on 10/19/24 and 10/20/24, respectively. According to the manufacturer's product storage and labeling, Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial. -One unopened Pneumovax 23 prefilled syringe for facility stock was found stored at room temperature with a manufacturer label indicating an expiration date on 11/24/24. According to the manufacturer's product storage, unopened Pneumovax 23 vials should be stored under refrigeration from 36 to 46 degrees Fahrenheit and used until the manufacturer indicated expiration date. -One expired emergency medication kit labeled with an expiration date of 8/24. According to pharmacy label and facility policy, expired emergency medication kits should not be used and discarded by the indicated expiration date. During a concurrent interview, LVN 2 stated two Aplisol vials stored in the refrigerator in Medication room [ROOM NUMBER] were opened on 10/19/24 and 10/20/24, respectively. LVN 2 stated the Pneumovax syringe expired on 11/24/24. LVN 2 stated the emergency kit was open and expired on 8/24. LVN 2 stated both Aplisol vials and Pneumovax syringe were expired and needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents, and the emergency kit needed to be replaced with a new one from pharmacy before August 2024. LVN 2 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to the residents, and administering expired Pneumovax may not provide protection against pneumonia for residents. LVN 2 stated emergency medications were needed in emergency situations and used from the emergency kits. LVN 2 stated giving residents expired medications from the emergency kits during emergency situations would only make the emergent situation worse for residents. During an interview and concurrent record review on 11/26/24 at 12:10 p.m., with the Director of Nursing (DON,) the DON stated that the emergency medication kit in the medication room had expired August of 2024 and should have been replaced with a new one from pharmacy. The DON stated the medication storage areas should have been checked daily for expired medications and any expired medication removed from those areas. The DON stated the facility failed to remove the expired emergency medication kit from the medication room. During the same interview, the DON stated that two Aplisol vials were opened on 10/19/24 and 10/20/24, respectively, and stored in the medication refrigerator for facility stock use. The DON stated multi-dose vials usually expire 28 days after opening the vials and should be discarded beyond that date to prevent accidental use. The DON stated expired multi-dose vials were no longer sterile (free from contaminants) and not effective. The DON stated using Aplisol vials beyond the expiration date in error may potentially provide inaccurate results for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) leading to inaccurate treatment for residents. The DON stated both Aplisol vials were expired and needed to be removed from the medication room and be discarded to prevent accidental use. During the same interview, the DON stated that the Pneumovax vaccine was expired on 11/24/24, and the facility failed to remove it from the medication room refrigerator. The DON stated using expired Pneumovax would not be effective in providing protection against pneumonia to residents. During the same interview the DON stated that the insulin Humulin R vial for Residents 21 and 26 were considered expired and should have been removed from the medication cart. The DON stated several LVN's failed to label an open vial of Humulin R and failed to remove an expired vial of Humulin R from the medication cart, which can lead to the administration of expired insulin to Resident 21 and 26, resulting in significant medication error. The DON stated the Humulin R vials needed to be replaced with new ones from pharmacy because one vial had an unknown expiration date due to lack of labeling, and one vial was expired. The DON stated that expired insulins lost potency (the strength of medication) and effectiveness and when administered would not be effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar levels) and adverse effects for Resident 21 and 26, potentially resulting in hospitalization . A review of the facility's Policy & Procedures (P&P) titled, Medication Labeling and Storage, revised 2024, the P&P indicated If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying the items. -Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. -Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. A review of the facility's P&P titled, Storage of Medications, [undated,] indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. A review of the facility's P&P titled, Procedure for Disposal, [undated,] indicated Discontinued or outdated non-controlled drugs are to be stored in a secured area designated for that purpose until picked up by the pharmaceutical waste disposal service or the pharmacy personnel. A review of the facility's P&P titled, Administering Medications, [undated,] indicated When opening a multi-dose container, the date opened is recorded on the container. A review of the facility's P&P titled, Medications Requiring Notation of Date Opened, [undated,] indicated All medications requiting an open date will be dated immediately upon opening. Date will be applied using a Date Open label or written directly on the packaging by the charge nurse. The following expiration periods are based on currently accepted standards of practice and/or the manufacturer's recommendations. -Expires 28 days after opening: All insulins except . -Expires one month after opening (refrigerate after opening) PPD (e.g.Tubersol) solutions. -Expires one (1) month after opening; -Multi-dose injectables not noted above.

Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for two of of 12 sampled residents (Resident 2 and 4). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/10/2024, indicated the resident had severe cognitive impairment (problems with a person's ability to remember, concentrate, and make decisions that affect daily life) and had the inability to make decisions. A review of Resident 2's Advance Directive Acknowledgment form dated 1/30/2024, indicated the resident was unable to sign because they did not have the capacity to understand and make decisions. The form did not indicate a signature from Resident 2's responsible party to acknowledge receipt of written information regarding the resident's right to formulate an advance directive. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including senile degeneration of the brain (a progressive decline in cognitive function that can lead to memory loss, impaired thinking, and a loss of independence) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 4's MDS dated [DATE], indicated the resident had severe cognitive impairment and did not have the ability to make decisions. A review of Resident 4's Advance Directive Acknowledgment form dated 2/1/2021, indicated the resident was unable to sign because they did not have the capacity to understand and make decisions. The form did not indicate a signature from Resident 4's responsible party to acknowledge receipt of written information regarding the resident's right to formulate an advance directive. During a concurrent interview and record review with the Social Services Director (SSD) on 11/26/2024 at 8:42 AM, the Advance Directive Acknowledgement form for Resident 2 and 4 was reviewed. The SSD stated and confirmed written information regarding the resident's right to formulate an advance directive was not provided to the responsible parties for Resident 2 or 4. A review of the facility's policy titled, Advance Directive, revised 2024, indicated that if a resident was incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 18's and Resident 25's) Minimum Data Set (MDS- a federally mandated resident assessment tool) accurately reflected the resident's diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and support the administration of psychotropic medications (drugs that affect the brain and mind, altering a person's thoughts, emotions, feelings, awareness, and perceptions). This deficient practice had the potential to result in a delay of the continuity of care such as monitoring signs and symptoms of adverse reactions and had the potential to negatively affect the resident's delivery of care and services. Findings: a. A review of Resident 18's Admission Record indicated the resident was originally admitted to the facility on [DATE]. A review of Resident 18's History and Physical dated 2/20/2023 indicated the resident had a diagnosis of COPD and had capacity to understand and make decisions. A review of Resident 18's MDS dated [DATE], under active diagnoses, did not include the diagnosis of COPD (inaccurate assessment). A review of Resident 18's care plan revised on 11/2024 indicated the resident was at risk for respiratory distress related to COPD. During an interview on 11/26/2024 at 2:20 PM, the Minimum Data Set Nurse (MDSN) stated Resident 18 had a history of COPD and the diagnosis of COPD was not included in the latest MDS dated [DATE] under the section of active diagnoses. The MDSN stated it was important to reflect all the resident's diagnosis for accuracy of care and there was a risk of delayed treatment when a diagnosis was not included. During an interview on 11/27/2024 at 2:20 PM, the Director of Nursing (DON) stated all active diagnoses should be included in the residents MDS. The DON stated it was important the MDS reflected the accurate diagnoses of residents because there was a risk of missing a diagnosis and delaying treatment. A review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised 2024, indicated all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 50296 b. A review of Resident 25's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorders the slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), and dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning). A review of the Physician's Orders dated 8/1/24, indicated Resident 25 received Lexapro for depression (a mental health condition that causes low mood and loss of interest), Depakote for bipolar disorder (mood swings that range from the low feelings to elevated periods of emotional highs), and Risperidone for schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 25's MDS dated [DATE], indicated the resident was not oriented to time, and did not exhibit feeling down, depressed, or hopeless. The MDS indicated under Section I - Active Diagnoses, subsection psychiatric / mood disorders, indicated the diagnoses of depression, bipolar disorder, and schizophrenia remained blank. During concurrent interview and record review on 11/26/24 at 9:30 AM with the MDSN, Resident 25's MDS and Active Diagnoses, dated 10/16/24 were reviewed. In Resident 25's MDS under Section I - Active Diagnoses subsection psychiatric/mood disorder indicated, none of the diagnoses were triggered. The MDSN stated Resident 25 had a diagnoses of bipolar and psychosis in the MDS Section I - Active Diagnosis, dated on 4/8/22. The MDSN stated Resident 25 was transferred to the General Acute Care Hospital (GACH) often and each visit, all diagnoses follow the resident to the GACH from the facility. The MDSN stated when Resident 25 returned to the facility, the psychiatric diagnoses were not in the admission paperwork and the admitting nurse at the facility did not continue all the resident's current diagnoses. The MDSN stated not continuing all the diagnoses could be the reason the diagnoses of bipolar, depression and schizophrenia were missed. The MDSN stated all diagnoses should be continued when the residents returned to the facility. The MDSN stated the result to the resident would be a delay of care for continuity of care for psychotropic medications. During concurrent interview and record review on 11/27/24 at 9:45 AM with Licensed Vocational Nurse (LVN) 2, Resident 25's electronic chart was reviewed. LVN 2 stated Resident 25 was taking antipsychotic medications, and that It is important that the diagnoses and medication match, because if you're giving psych meds there must be a reason. LVN 2 stated when the resident went to the hospital, the discharge medical record was included. LVN 2 stated once the resident was readmitted to the facility, the same diagnoses from the hospital should be continued. LVN 2 stated the effect to the resident would be psychotropic medications were given without proper diagnoses. During an interview on 11/27/24 at 12 PM, the DON stated, the facility takes the admission information for the residents from the history and physical from the GACH which includes the diagnoses from the facility. The DON stated all diagnoses should be in the history and physical from the GACH. The DON stated that the admitting nurse performed the re-admission including the assessment, checking the orders, labs, and informed the physician that the resident arrived. The physician would write orders with the admitting diagnoses but not all diagnoses. The DON stated the physician would write the orders out, but the admitting nurse was the one to check all orders, diagnoses. The DON stated the LVNs admit the residents, the RN supervisor or Assistant Director of Nursing assist by performing the assessments. The DON stated the result to the resident by not transposing all diagnoses during admission would be a delay of proper care, medication signs and symptoms and proper monitoring could be missed. A review of the facility's policy and procedure (P&P) titled, Resident Assessment, dated 2024 indicated, all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of the information. A review of the facility's P&P titled, Psychotropic Medications, dated 2024, indicated psychotropic medication management includes: indication of use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying, and responding to adverse consequences. The P&P indicated situations that may prompt an evaluation or re-evaluation of the resident included admission or re-admission. A review of the facility's P&P titled, Abstract of Medical Records, dated 12/2006, indicated specific data concerning a resident's medical condition may be released when the resident was transferred to the hospital, the abstract included current diagnosis and current resident assessment or MDS.

Based on interview and record review, the facility failed to ensure residents with limited range of motion (ROM movement of joints) receive quarterly joint mobility assessments for one of three sampled residents (Resident 11). This deficient practice caused an increased risk in the prevention and maintenance of mobility for Resident 11, with potential for contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of Resident 11's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness. A review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/19/2024, indicated the resident had intact cognitive skills for daily decision-making and was dependent on staff with bed mobility, transfer, toilet use, personal hygiene, and bathing. A review of the Joint Mobility Assessment form dated 7/24/2024 indicated Resident 11 was not within normal limits. There were no other joint mobility assessments found completed after this date in Resident 11's medical record. During an interview on 11/27/2024, at 11 AM, the Director of Nursing was asked about the facility's policy on the timing of assessments. The DON stated the facility did not have any policies that focus on time frame for joint mobility assessments, however the facility had a policy on resident assessment, resident mobility / ROM, and comprehensive assessment. The DON stated any quarterly assessment should be completed within three months and that the Physical therapist was responsible for completing joint mobility assessments. The DON was not able to locate a recent joint mobility assessment after the date of admission for Resident 11 and explained that the resident should have a quarterly assessment completed. The DON stated if assessments were not completed then, We have no measurement to show if the resident is doing better or worst. On 11/27/2024, at 11:57 AM, during an interview, the PT stated there should be a quarterly evaluation done every three months after the initial assessment at admission. The PT stated the workload at the facility was low but remained very demanding for one therapist. The PT stated there were many residents that have yet to be reassessed, but he could only get to them when he can. The PT stated Resident 11's joint mobility evaluation should have been completed and there was no measurement of progress. A review of the facility's policy titled, Resident Mobility and Range of Motion, dated 2024 indicated residents would not experience an avoidable reduction in range of motion. Residents with limited mobility would receive appropriate services, and assistance to maintain or improve mobility unless reduction in mobility was unavoidable. The policy indicated documentation of the resident's progress toward the goals and objectives would include attempts to address any changes in decline in the resident's condition or needs. Interventions may include therapies and / or exercises and would be based on professional standards of practice and be consistent with the state laws and practice acts.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 18 and 34). Resident 18 and Resident 34 with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), did not have a label or date on the resident's oxygen humidifier bottle (a device used to make supplemental oxygen moist). This deficient practice caused an increased risk in infection control when handling oxygen equipment, leading to resident discomfort and/or infection. Findings: a. A review of Resident 18's Admission Record indicated the resident was originally admitted to the facility on [DATE]. A review of Resident 18's History and Physical dated 2/20/2023 indicated the resident had a diagnosis of COPD and had capacity to understand and make decisions. A review of the Physician's Order dated 2/13/2023, indicated Resident 18 received oxygen at two liters per minute via nasal cannula as needed for shortness of breath. A review of Resident 18's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/1/2024 under special treatments, procedures, and programs indicated the resident received zero days of respiratory therapy for at least 15 minutes in the past seven days. A review of Resident 18's care plan revised on 11/2024 indicated the resident was at risk for respiratory distress related to COPD. The intervention included giving medication as ordered. During a concurrent observation and interview on 11/25/2024 at 10:05 AM in Resident 18's room, with Licensed Vocation Nurse 1 (LVN 1), LVN 1 confirmed the resident's oxygen humidifier bottle was not labeled nor dated. LVN 1 stated it was important the oxygen humidifier bottle was dated so staff were aware of when the bottle was last changed. During an interview with the Director of Nursing (DON) on 11/27/2024 at 9:58 AM, the DON stated respiratory equipment like the oxygen humidifier bottle should be labeled with a date, time, and staff initials. The DON stated it was important the oxygen humidifier bottle was labeled so staff know how long it had been there and if it was time to change it. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 2024, indicated the purpose was to provide guidelines for safe oxygen administration. The policy indicated the humidifier bottle should be labeled with date, time, and signature. b. A review of Resident 34's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including COPD. A review of the Physician's Order dated 2/13/2023, indicated Resident 34 was to receive oxygen administerion at two liters per minute via nasal cannula as needed for shortness of breath and oxygen less than 90%. A review of Resident 34's At risk for respiratory distress related to COPD care plan revised on 9/2024, indicated the intervention included giving medication as ordered. A review of Resident 34's MDS dated [DATE], indicated the resident was cognitively intact and under special treatments, procedures, and programs indicated Resident 34 received zero days of respiratory therapy for at least 15 minutes in the past seven days. During a concurrent observation and interview on 11/25/2024 at 10:35 AM in Resident 34's room with LVN 1, LVN 1 confirmed the resident's oxygen humidifier bottle and nasal cannula were not labeled nor dated. LVN 1 stated it was important the oxygen humidifier bottle and nasal cannula were labeled with a date so staff were aware of when the equipment was last changed. During an interview with the Director of Nursing (DON) on 11/27/2024 at 9:58 AM, the DON stated respiratory equipment like the oxygen humidifier bottle and nasal cannula should be labeled with a date, time, and staff initials. The DON stated it was important the oxygen humidifier bottle and nasal cannula were labeled so staff know how long it had been there and if it was time to change it.

Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 1 and 2) had a completed annual performance evaluation. This deficient practice caused an increased risk in identifying the staffs areas of weakness with the potential for residents to not receive appropriate services. Findings: A review of CNA 1's employee file indicated that their date of hire was 4/23/2016 and there was no performance evaluation was noted in file. A review of CNA 2's employee file indicated the date of hire was 8/13/2020 and there was no performance evaluation was noted in file. During a concurrent interview and record review with the Administrator (ADM) on 11/27/2024 at 12:24 PM, the employee files of CNA 1 and 2 were reviewed with the ADM. The ADM stated that all performance evaluations should be done annually for the CNA's. The ADM stated the Director of Staff Development (DSD) was responsible for ensuring the performance evaluations were completed on time and updated in the employee files. The ADM confirmed that there were no updated performance evaluations for CNA 1 and 2 and that the potential risk for not completing the evaluations timely would be that the quality of care to the residents could be compromised. A review of the facility's policy and procedure (P&P) titled, Performance Evaluations, revised 2024, indicated the job performance of each employee shall be reviewed and evaluated at least annually.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five (5) percent (%) or lower by having three medication errors out of 35 opportunities contributing to an overall error rate of 12% for two of four sampled residents (Resident 34 and 36) observed during Medication Administration. The medication errors were as follows: -Resident 34 was not instructed to seal their mouth over the mouthpiece of Qvar (a medication used for Chronic Obstructive Pulmonary Disease [COPD -a disease that blocks air flow and makes breathing difficult]) oral inhaler (a device containing the medication that is orally inhaled,) according to manufacturer instructions. -Resident 36 received pantoprazole (medication used to treat acid in the stomach) oral packet at a different time and received a form of ferrous sulfate (a medication used to produce a protein in red blood cells that carries oxygen throughout the body) that was different than the Physician's Order. These failures had the potential to result in Resident 34 and 36 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 34's and 36's health and well-being to be negatively impacted. Findings: a. A review of Resident 36's Admission Record dated 11/25/24, indicated the resident was originally admitted to the facility on [DATE] with diagnoses including Gastro-Esophageal Reflux Disease ([GERD] - a condition where there is a backward flow of stomach acid into the tube that connects the mouth to the stomach) and anemia (a condition where the body does not have enough healthy red blood cells, and iron deficiency anemia was the most common type of anemia), chronic obstructive pulmonary disease (a condition that makes it difficult to breathe). A review of Resident 36's Order Summary Report, for November 2024, indicated Resident 36 was prescribed ferrous sulfate oral solution 220 mg per 5 ml to give 7.5 ml via G-tube two times a day for supplement, starting 6/2/24, and was prescribed pantoprazole 40 mg oral packet to give one packet via G-tube before meals for GERD, starting 10/14/24. A review of Resident 36's Medication Administration Record (MAR), dated November 2024, indicated Resident 36 was prescribed ferrous sulfate oral solution 220 mg per 5 ml to give 7.5 ml via G-tube two times a day for supplement, at 9 a.m. and 5 p.m., and was prescribed pantoprazole 40 mg oral packet to give one packet via G-tube before meals for GERD, at 11:30 a.m. During an observation on 11/25/24 at 9:45 a.m., in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 2 was observed administering ferrous sulfate 325 milligram ([mg]-a unit of measure of mass) tablet that was crushed (pressed very hard so that the shape is destroyed and formed into a soft powder) and pantoprazole 40 mg oral packet via gastrostomy tube ([G-tube] - a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 36. During an interview on 11/25/24 at 10:01 a.m., LVN 2 stated that LVN 2 administered ferrous sulfate 325 mg crushed tablet and pantoprazole 40 mg oral packet via G-tube at 9:45 a.m. to Resident 36. LVN 2 acknowledged the physician's order specified to administer ferrous sulfate 7.5 milliliter ([ml] - a unit of measure of volume) oral liquid containing 220 mg per 5 ml at 9 a.m., and to administer pantoprazole 40 mg oral packet at 11:30 a.m. LVN 2 stated that LVN 2 administered ferrous sulfate 325 mg by crushing the tablet instead of administering ferrous sulfate 7.5 ml liquid and that per facility policy, there was a 60-minute window for medication administration before and after the specified time. LVN 2 administered the pantoprazole 40 mg oral packet sooner than that timeframe to Resident 36. LVN 2 stated these were considered medication errors and that LVN 2 did not follow the physician's orders. b. A review of Resident 34's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including COPD with exacerbation. A review of Resident 34's Order Summary Report, for November 2024, indicated Resident 34 was prescribed Qvar to give one puff inhaled orally once a day related to COPD with exacerbation, starting 6/19/24. A review of Resident 34's MAR dated November 2024, indicated Resident 34 was prescribed Qvar to give one puff inhaled orally once a day related to COPD with exacerbation, at 9 a.m. During an observation on 11/26/24 at 9:04 a.m., in Medication Cart Station 2, Registered Nurse (RN) 3 was observed administering QVAR one puff orally to Resident 34. Resident 34 was observed orally inhaling one puff of QVAR without fully closing lips around the mouthpiece and with open gaps on both sides of his mouth. During an interview on 11/26/24 at 9:11 a.m., RN 3 stated that RN 3 administered QVAR one puff orally at 9:04 a.m. to Resident 34 and failed to instruct Resident 34 to fully close lips around the mouthpiece of the inhaler to get a good seal. RN 3 stated Resident 34 had gaps on the side of the mouth when inhaling the medication, and as a result some medication had escaped into the air and not fully inhaled. RN 3 stated QVAR manufacturer instructions indicated to fully seal lips around the mouthpiece to prevent medication from escaping. RN 3 stated that not administering medication according to manufacturer instructions was considered a medication error and that not receiving the full dose Resident 34 was not being fully treated and at risk for COPD exacerbation (the process of making a problem or situation worse,) potentially resulting in hospitalization . During an interview on 11/26/24 at 12:10 p.m., the Director of Nursing (DON) stated that LVN 2 failed to administer the correct form of ferrous sulfate and failed to administer pantoprazole at the indicated time on 11/25/24 to Resident 34, as ordered by the physician. The DON also stated RN 3 failed to instruct Resident 34 to fully seal lips around the QVAR inhaler while administering the dose, as instructed by the manufacturer. The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician's orders were followed and the right medications were administered at the right times to residents, and to follow manufacturer instructions to ensure medications were administered correctly to prevent potential harm to residents such COPD exacerbation for Resident 34. A review of the facility's policy and procedures (P&P) titled, Administering Medications, [undated], indicated that Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required timeframe. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's P&P titled, Administering Medications through a Metered Dose Inhaler, revised 2024, indicated the purpose was to provide guidelines for the safe administration of inhaled medications. The following equipment and supplies will be necessary when performing this procedure. -Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around the mouthpiece. A review of the facility's P&P titled, Adverse Consequences and Medication Errors, revised 2024, indicated Adverse Consequences -An adverse consequence refers to an unwanted, uncomfortable, or dangerous effect that a drug may have . -The staff and practitioner shall strive to minimize adverse consequences by: -Following relevant clinical guideline and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. Medication Errors -A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. manufacturer specifications or accepted professional standards and principles of the profession(s) providing services. -Examples of medication errors include: -Wrong drug (e.g. liquid ordered, capsule given) -Wrong time -Failure to follow manufacturer instructions and/or accepted professional standards. A review of a facility provided manufacturer's guideline on QVAR, last revised 1/21, indicated Place the mouthpiece in your mouth and close your lips around it so you form a good seal.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one sampled residents (Resident 14) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use, by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. This deficient practice increased the risk of adverse effects (unwanted, unintended result) from same site administration such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: A review of Resident 14's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type II diabetes mellitus (DM II - [a condition where there are high blood sugar levels]). A review of the Physician's Order Summary Report, dated 11/1/24, indicated Resident 14 was prescribed Humulin 70/30 (intermediate-acting insulin combined with the more rapid onset regular insulin) to 35 units ([un] - measure of insulin dose) subcutaneously ([SQ] - under the skin) once a day, and 15 un SQ in the evening, related to DM II, starting 8/1/24. A review of Resident 14's Medication Administration Record (MAR) for November 2024, indicated Resident 14 was prescribed Humulin 70/30 to 35 un SQ once a day at 9 a.m., and 15 un SQ in the evening at 5 p.m., related to DM II. Further review of the MAR indicated Humulin 70/30 35 un was administered at 9 a.m. by the following licensed nurses, on the following days, and sites: 11/2/24 on Right Arm (RA) by Licensed Vocational Nurse (LVN) 2 11/3/24 on RA by LVN 2 11/5/24 on RA by LVN 6 11/6/24 on RA by LVN 2 11/7/24 on RA by LVN 2 11/8/24 on RA by LVN 6 11/9/24 on RA by LVN 2 11/10/24 on RA by LVN 2. During a concurrent interview and record review on 11/26/24 at 11:08 a.m., Registered Nurse (RN) 3 reviewed Resident 14's MAR for November 2024. RN 3 stated several licensed nurses failed to rotate the insulin administration sites and that failure to rotate sites could harm Resident 14 by damaging the skin, causing bruises and lumps. During a concurrent interview and record review on 11/26/24 at 12:10 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 14's MAR for November 2024. The DON stated that for Resident 14 the MAR indicated there were instances where the insulin administration sites were not rotated for the Humulin 70/30 by several licensed nurses, as expected by facility policy, standard of practice and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 14 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. A review of the facility's Policy & Procedures (P&P) titled, Adverse consequences and Medication Errors, revised 2024 indicated an 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have. The staff and practitioner shall strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. An adverse drug reaction (ADR), a form of adverse consequences, was defined as a secondary and usually undesirable effect of a drug. A review of facility's P&P titled, Subcutaneous Injections/Insulin Administration, revised 2024, indicated the purpose was to provide guidelines for the safe administration of medication by subcutaneous / insulin injection and to select an appropriate injection site. A review of a facility provided manufacturer's guide titled, Highlights of Prescribing Information, for Humulin 7030, dated June 2022, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps).

Based on interview and record review, the facility failed to ensure necessary care was provided consistently for one of three sampled residents (Resident 4), who was receiving hospice service (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease and offers physical, emotional, social, and spiritual support for residents and their families). For Resident 4, there was no coordination of personal care and nursing needs with the hospice staff. This deficient practice had the potential to result in a delay of care and delivery of hospice care and services to Resident 4. Findings: A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including senile degeneration of the brain (a progressive decline in cognitive function that can lead to memory loss, impaired thinking, and a loss of independence) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of the Physician's Orders dated 7/9/2024, indicated to admit Resident 4 for hospice care and treatment. A review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/11/2024, indicated the resident had severe cognitive impairment (problems with thinking, reasoning) and had the inability to make decisions. The MDS indicated Resident 4 received hospice services while a resident at the facility and had a condition or chronic disease that could result in a life expectancy of less than six months. A review of Resident 4's hospice records sign in sheets did not indicate visits from a skilled nurse (care provided by a registered nurse or licensed vocational nurse) or home health aide (person who assists clients in their daily personal tasks, such as bathing or dressing). During a concurrent interview and record review with the Registered Nurse (RN) 1 on 11/26/2024 at 8:52 AM, Resident 4's hospice records were reviewed. RN 1 stated that a hospice skilled nurse visited once a week and a home health aide visited twice per week for Resident 4. RN 1 reviewed Resident 4's hospice records and confirmed there were no signatures from the skilled nurse or home health aide on the sign in sheets and that there was no hospice care plan for Resident 4. RN 1 stated that it was important to ensure the hospice staff was visiting Resident 4 as ordered and that there should be a hospice plan of care for the staff to know the specific needs of the resident. During an interview with the Director of Nursing (DON) on 11/27/2024 at 9:02 AM, the DON stated that all hospice staff should be signing in the hospice sign in sheet and should also have a hospice care plan. The DON stated the facility staff should be communicating with the hospice staff during their visits and by not having a record of hospice visits from the hospice staff and no hospice care plan, it could potentially compromise Resident 4's care. A review of the facility's policy and procedures titled, Hospice Program, revised 2024, indicated it was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure the level of care provided was appropriately based on the individual resident's needs.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of COVID-19 (Coronavirus disease 2019, a highly contagious [MEDICAL CONDITION] infection that spread from person-to-person affecting the respiratory system) for two of two residents (Residents 2 and 3) quarantined (restricted movement of people intended to prevent the spread of disease) for possible COVID-19 infection out of a total of 47 residents in the facility. The facility also failed to provide a safe environment for four nursing staff (Certified Nursing Assistants 1, 2, 3 (CNAs 1, 2, and 3) and Licensed Vocational Nurse 1 (LVN 1) and three kitchen staff (KSs 1, 2 and 3) out of 30 facility staff, who required to be quarantined and off work. The facility failed to: a. Ensure LVN 1 and CNAs 1 and 3 donned (put on) Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) while caring for Residents 2 and 3, who were potentially COVID-19 positive (Persons Under Investigation (PUI)) quarantined for 14 days since admission to rule out COVID-19. b. Ensure there were PPE supplies and a signage outside the room of Residents 2 and 3, indicating the type of isolation needed and the PPE to use to enter the room. c. Ensure newly admitted Residents 2 and 3 were quarantined for 14 days as PUI for potential COVID-19. d. Ensure the Infection Preventionist (IP) nurse was knowledgeable on cohorting (imposed grouping of people, such as residents, potentially exposed to designated diseases) residents as per recommendation from the Public Health Nurse (PHN). e. Ensure only assigned dedicated healthcare staff to care for Residents 2 and 3 who were PUIs and for Residents 1 and Resident 4 (was not in the facility at the time) who were positive for COVID-19. f. Ensure CNA 1, LVN 1, KS 1 and KS 2 were off work and quarantined, as per PHN recommendation. These deficient practices had the potential to result in the spread of COVID-19 placing remaining residents in the facility and the staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 7/16/2020 at 4:25 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator, the Director of Nursing (DON), and the Infection Preventionist (IP) Nurse for the facility's failure to implement measures to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. On 7/18/2020 at 1 p.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA through observation, interview and record review. The IJ situation was removed in the presence of the Administrator, DON, and IP. The accepted POA included the following actions: 1. In-service education to all staff on infection control prevention with emphasis on proper use of PPE, signage outside the residents rooms, PPEs outside resident rooms, transmission-based precautions, cohorting and zoning, dedicated staff for positive COVID-19, PUIs and not infected residents, and mandatory 14 days quarantine of residents and staff who were potentially infected. 2. The DON informed LVN 1 and CNA 2 on 7/18/2020 Resident 4 was identified to have COVID-19 positive diagnosis. 3. The Director of Staff Development (DSD) and DSD Designee assigned trained staff to work on the COVID-19 positive residents Red Zone unit exclusively and provided staff with necessary PPEs (N95 masks, gloves, gowns, and face shields). 4. On 7/17/2020, proper signages were posted, infection control carts with the necessary supplies and PPEs were placed outside the rooms. 5. Dedicated staff would continue to care for residents in the COVID-19 unit and PUI unit until residents completes 14 days without symptoms and are moved to the general population, per PHN recommendation on 7/14/2020 as they had been exposed to positive COVID-19. Findings: A review of the facility's census dated 7/16/2020, indicated facility had 47 residents in-house. A review of Resident 1's Admission Record (Face Sheet) indicated an admission on 5/4/2016 and a re-admitted d 7/11/2020 with [DIAGNOSES REDACTED]. A review of Resident 1's the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/18/2020 indicated Resident 1 was unable to make decisions, and required limited assistance with one person assist with activities of daily living (ADLs - transfers, personal hygiene, dressing, and toilet use). A review of Resident 1's COVID-19 test result collected 7/9/2020 indicated positive for COVID-19. A review of Resident 4's Admission Record (Face Sheet) indicated an admitted d 12/22/15 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE] indicated Resident 4 was able to make decisions, and required extensive assistance with one person assist with activities of daily living (ADLs - personal hygiene, and dressing). A review of Resident 4's COVID-19 test result collected 7/9/2020 indicated positive for COVID-19. A review of Resident 4's physician's orders [REDACTED]. A review of Resident 2's Admission Record (Face Sheet) indicated an admitted d 7/8/2020 with [DIAGNOSES REDACTED]. A review of Resident 2's the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/15/2020 indicated Resident 2 was able to make decisions, had no memory problems, and required limited assistance with one person assist with activities of daily living (ADLs - transfers, personal hygiene, walking, and bathing). A review of Resident 2's physician's orders [REDACTED]. A review of the facility's COVID-19 Mitigation Plan indicated newly admitted residents would be placed in droplet isolation (quarantined) for potential COVID-19 for a 14-day period. A review of Resident 3's Admission Record indicated the facility admitted the resident on 7/8/2020 with [DIAGNOSES REDACTED]. A review of Resident 3's MDS dated [DATE] indicated Resident 3 was cognitively intact and required limited assistance with one-person assist with ADLs. A review of Resident 3's physician's orders [REDACTED]. On 7/16/2020 at 7:35 a.m., Residents 2 and 3 were observed in their room without any signage indicating they were on droplet isolation precautions. The two residents' room did not have outside the door, a cart containing supplies and equipment dedicated to use with them only (PPEs, stethoscope (medical device for listening to internal sounds of human body), blood pressure cuff, etc.). At the time of the observation, Certified Nursing Assistant 1 (CNA 1) entered Resident 3's room to provide care. CNA 1 did not put on PPE. On 7/16/2020 at 7:50 a.m. during an interview, CNA 1 stated he was assigned to care for Residents 2 and 3, who were not in isolation precautions because there were no isolation signs outside the rooms or isolation carts (with PPE and equipment) by the entrance of their rooms. CNA 1 stated he was also assigned to other residents (non-quarantined residents). On 7/16/2020 at 7:57 a.m., during an observation and concurrent interview on CNA 2 was observed exiting Resident 1's room, who was on droplet isolation precaution for COVID-19 (there was a sign posted outside the room and a cart with PPEs and supplies). CNA 2 stated she was assigned to provide care to resident with COVID-19 and residents who did not have COVID-19. CNA 2 stated she worked full time in the facility and during her shifts, she alternated between taking care of residents in quarantine and non-quarantine zones. On 7/16/2020 at 8:50 a.m., after taking care of Resident 1, who had COVID-19, CNA 2 proceeded to assist Resident 4 who was not on isolation precautions. CNA 2 was observed wheeling Resident 4 from the shower room to his room, after a shower. CNA 2 was not wearing PPEs. On 7/16/2020 at 8:55 a.m., CNA 1 was observed entering Resident 2's room to take Resident 2's vital signs (blood pressure, respiratory and heart rate and temperature) without putting PPEs. Upon leaving the room, in an interview, CNA 1 stated he did not need PPEs because Resident 2 was not in isolation precautions. On 7/16/2020 at 9 a.m. during an interview, Resident 2 confirmed CNA 1 took his vital signs without any personal protective equipment. Resident 2 stated he has been at the facility since 7/8/2020. During an interview on 7/16/2020 at 1:25 p.m. the Director of Nursing (DON) confirmed Residents 2 and 3 were admitted on [DATE] and were not placed on quarantine for 14 days as recommended by the PHN. The DON stated new admitted residents are tested for COVID-19 and the policy is to quarantine and isolate new Residents for 14 days regardless of initial COVID-19 test results. Then, re-test for COVID-19, and if negative the resident is removed from quarantine. The DON could not explain the reason the staff did not quarantine Residents 2 and 3. On 7/16/2020 at 4 p.m., during an interview, CNA 3 stated she had been assigned to Residents 2 and 3 and she did not wear any PPE because there was no signs outside the rooms indicating the residents were on isolation precautions and the licensed nurses did not advise her to wear PPEs. On 7/16/2020 at 4:10 p.m., during an interview, the IP confirmed Residents 2 and 3 were not placed in droplet isolation precautions since their admitted d 7/8/2020. The IP did not explain the reason the policy and the PHN recommendations were not followed. A review of the Staffing Assignments for 7/9 and 7/16/2020, indicated CNAs 1 and 3 and LVN 1 were assigned to quarantine and non-quarantined residents during the morning shift. On 7/17/2020 at 7:40 a.m., during an interview, LVN 1 he stated the facility had only Resident 1 in the Red Zone (for COVID-19 positive residents). LVN 1 stated Residents 2 and 3 were not on isolation. on 7/17/2020 at 11:15 a.m., during an interview, the Administrator stated the facility's policy and procedure on transmission-based precaution and COVID19 mitigation plan indicated new admitted residents are to be placed in isolation for 14 days in the Yellow Zone. The Red Zone was for COVID-19 positive residents and the Green Zone was for COVID-19 negative residents. b. During an observation on 7/16/2020 at 8:15 a.m. KS 1, KS 2 and Dietary Service Supervisor were working in the kitchen. KS 1 and KS 2 were observed preparing food and cleaning the kitchen. At the time of the observation, three kitchen staff (KS1, KS2, and KS3) stated they were scheduled to work on that day (7/16/2020) and they prepared and served breakfast. On 7/16/2020 at 8:30 a.m. during an interview, PHN stated KS 1, KS 2, LVN 1, and CNA 2 were last exposed to a COVID-19 positive Resident/Staff on 7/11/2020 and the recommendation was for them to quarantine for 14 days or allowed to work only on the Red Zone (COVID-19 positive residents) only if there was staffing shortage. A review of an email from the PHN, dated 7/14/2020, to the facility indicated PHN recommended exposed or positive staff should quarantine, but if staffing issues nursing staff could work on the Red Zone only, and kitchen staff to be quarantined. A review of facility's policy and procedures titled, Isolation - Initiating Transmission Based Precautions, revised April 2012 indicated if a resident is suspected of, or identified as, having a communicable infections disease, the charge Nurse or Nursing Supervisor shall notify the infection Preventionist and the resident's attending physician for appropriate Transmission Based precautions. When transmission-based precautions are implemented, the IP or designee shall ensure that protective equipment, gloves, gowns, masks, etc., is maintained near the resident's room ensuring everyone entering the room can access what they need. The policy indicated to post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of the precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. The facility's policy titled, Mitigation Plan, undated, indicated to test residents prior to admission or re-admission, including transfers from hospitals or other healthcare facilities. If the hospital does not test the resident, the facility will test and quarantine the resident upon admission. Residents admitted should be tested prior to admission and if they test negative, should be quarantined for 14 days and then re-tested . If negative, the resident can be released from quarantine. Place residents into three separate cohorts based on the test results. Facility will cohort all unknown asymptomatic and untested residents in the Yellow Zone and will be treated with contact and droplet precautions until a negative test result can be achieved or the resident meets the time criteria to return to the Green Zone based on current Centers for Disease Control (CDC) guidance for removal of transmission-based precautions. Residents positive for COVID-19 are cohorted on the Red Zone.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) who received four blood pressure (The pressure of the blood in the circulatory system, often measured for diagnosis) medications ([MEDICATION NAME], and [MEDICATION NAME]), identified with repeated low blood pressure (BP) and had a change of condition was provided with necessary care and services, including but not limited to: 1. Failure to notify Resident 1's physician of low blood pressure on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 2. Failure to follow physician order [REDACTED]. 3. Failure to notify the physician when Resident 1 complaint of dizziness when standing up and low blood pressure reading on [DATE] at 8:34 p.m. 4. Failure to re-assess and monitor Resident 1 after [DATE] at 8:34 p.m., after the resident complaint of dizziness and was identified with low blood pressure. These deficient practices resulted to Resident 1 found unresponsive, pale skin, cold to touch, and fixed, dilated pupils on [DATE] at 5:50 a.m. and was pronounced dead at 6:04 a.m. by paramedics. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted back to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool) dated [DATE], indicated the resident had no cognitive (process of acquiring knowledge and understanding through thought, experience, and the senses) impairment. The MDS indicated Resident 1 required supervision of staff with bed mobility and walking, limited assistance with transfers, dressing, toilet use, and personal hygiene. A review of Resident 1's physician's orders [REDACTED]. 1. [MEDICATION NAME] (for high blood pressure) 3.125 milligram (mg) tablet twice a day for hypertension (high blood pressure). Hold medication if blood pressure (The pressure of the blood in the circulatory system, often measured for diagnosis) is less than ,[DATE] millimeters of mercury (mm/Hg). Normal blood pressure reading is less than 120 /80 mm Hg. 2. [MEDICATION NAME] (for high blood pressure) 2.5 mg tablet once a day for hypertension. Hold medication if blood pressure is less than ,[DATE] mm/Hg. 3. [MEDICATION NAME] (water pill) 25 mg tablet once a day for [DIAGNOSES REDACTED] (Disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). Hold medication if blood pressure is less than ,[DATE] mm/Hg. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's recapitulated (summarized) Physician order [REDACTED]. Hold if systolic blood pressure (SBP-pressure in the blood vessels when the heart contracts) less than 100, diastolic blood pressure (DBP-the blood pressure when your heart muscle is between beats) of less than 60, and heart rate (HR) of less than 60 beats per minute (bpm) (Reference range 60 to 100 bpm). A review of Resident 1's Medication Sheets dated [DATE] to [DATE], indicated the following: 1. [MEDICATION NAME] was held for nine days, at 7 a.m. because Resident 1's blood pressure was less than ,[DATE] mm/Hg, on; [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] - [MEDICATION NAME] was held for three days at 5 p.m. because Resident 1's blood pressure was less than ,[DATE] mm/Hg, on; [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] 2. [MEDICATION NAME] was held for seven days because Resident 1's blood pressure was less than ,[DATE] mm/Hg, at 9 AM on; [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] 3. [MEDICATION NAME] was held for six days because Resident 1's blood pressure was less than ,[DATE] mm/Hg; [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] [DATE] for BP of ,[DATE] - [MEDICATION NAME] was administered outside of the blood pressure parameters on [DATE] for BP of ,[DATE] 4. [MEDICATION NAME] was held for five days because Resident 1's blood pressure was less than ,[DATE] mm/Hg, on; [DATE] for BP of ,[DATE] and HR of 72 [DATE] for BP of ,[DATE] and HR of 74 [DATE] for BP of ,[DATE] and HR of 90 [DATE] for BP of ,[DATE] and HR of 88 [DATE] for BP of ,[DATE] and HR of 70 - [MEDICATION NAME] one tablet was administered outside of the blood pressure parameter on [DATE] for BP of ,[DATE] and HR of 88, and on [DATE] for BP of ,[DATE] and HR of 74 A review of Resident 1's Licensed Nurses Progress Notes dated [DATE], at 12:54 p.m., indicated Licensed Vocational Nurse 2 (LVN 2) notified Nurse Practitioner 1 (NP 1 - a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) of Resident 1's blood pressure medications being held in the mornings due to low blood pressures. The notes indicated no new orders. A review of Resident 1's Nephrology (a doctor that specialized with kidney disease)/Internal Medicine Notes dated [DATE], written and signed by NP 1, indicated that Resident 1 had complained of one episode of nausea. The progress note did not indicate Resident 1's repeated low blood pressure results. A review of Resident 1's Physician order [REDACTED]. - [DATE] at 7:05 a.m., indicated [MEDICATION NAME] (relaxes muscles in the airways) two puffs every six hours, as needed for shortness of breath. - [DATE] at 11 a.m., indicated [MEDICATION NAME] 4 mg, one tablet by mouth every six hours as needed for nausea and vomiting. A review of Resident 1's care plans there was no care plan for Resident 1 multiple blood pressure medication and the repeated occurrences of low blood pressure. There was no care plan regarding Resident 1 shortness of breath or nausea and vomiting. A review of Resident 1's 72 Hour Observation dated [DATE], 3 pm to 11 pm shift, indicated to observe Resident 1 because of complaint of dizziness and low blood pressure. A review of Resident 1's Licensed Nurses Progress notes indicated the following: - [DATE] at 5:38 p.m., indicated Resident 1 complained of feeling dizzy when he stood up. The notes indicated Resident 1's vital signs included a blood pressure of ,[DATE] mm/Hg, pulse rate of 60, respiration of 18, and temperature of 97.9 degrees Fahrenheit and fingerstick blood sugar (FSBS- measuring sugar in the blood) of 130 mg/dL. - At 8:34 p.m., indicated Resident 1's blood pressure of ,[DATE] mm/Hg. The notes indicated the NP 1 was call and there was no answer. The note indicated that LVN 4 left a message to NP 1. - [DATE] at 7:34 a.m., indicated Resident 1 was found unresponsive at 5:50 a.m. with skin pale and cold to touch, pupils fixed and dilated, with a very faint, weak pulse. LVN 1 documented calling [DATE] (emergency number to summons paramedics). The notes indicated when the paramedics arrived, Resident 1 was pronounced dead at around 6 a.m. LVN 1 documented that NP 1 . was made aware. A review of Resident 1's Licensed Nurses Progress notes there was no documented evidence that Resident 1's was assessed from 8:34 p.m. on [DATE] (When the resident was identified with low blood pressure) to 5:50 a.m. on [DATE], (10 hours and 16 minutes) when the resident was found unresponsive. A review of Resident 1's Prehospital Care Report Summary from the Los Angeles Fire Department dated [DATE], indicated that the paramedics arrived in the facility at 6:04 a.m. The report summary indicated that Resident 1 was dead prior to the paramedics' arrival. The assessment indicated that Resident 1's skin color was pale, cold, and with absent of lung sounds. The assessment indicated that Resident 1's body was mottled (patches of different shades of colors) and had lividity (a dark purple discoloration of the body, after death had occurred). A review of Resident 1's death certificate indicated that the resident died on [DATE]. The death certificate indicated that the immediate cause of death was cardiopulmonary arrest (loss of heart function) secondary to [MEDICAL CONDITION] infarction (loss of heart muscle due to loss of blood supply) and [MEDICAL CONDITIONS] (the narrowing and hardening of blood vessels. On [DATE] at 12:50 p.m., during an interview and concurrent record review of Resident 1's Licensed Nurse Progress Notes with LVN 1, LVN 1 stated that on [DATE] during the 11 p.m. to 7 a.m. shift, LVN 4 informed her that Resident 1 had a change of condition. LVN 1 stated the resident had a low BP and was feeling dizzy. LVN 1 stated that LVN 4 wrote Resident 1's change of condition on the facility's 72-hour observation communication book. LVN 1 stated that she Peeked in on Resident 1's room around midnight and observed Resident 1's chest was rising. LVN 1 stated she could not find documented vital signs during her shift. LVN 1 stated she could not recall calling NP 1 or MD 1 after LVN 4 called NP 1 on [DATE] at 8:34 p.m., LVN 1 stated NP 1 called back on [DATE] at 6 a.m., after Resident 1 had expired. LVN 1 stated that Resident 1 had already expired when the paramedics arrived in the facility. LVN 1 could not find documented evidence of Resident 1's medical status and recorded vital signs after LVN 2's last note on [DATE] at 8:34 p.m. On [DATE] at 1:26 p.m., during a telephone interview with LVN 4, LVN 4 stated that she was the nurse on duty on [DATE], during the 3 p.m. to 11 p.m. shift, LVN 4 stated she could not recall if she called NP 1 again after the first attempt. LVN 4 stated she did not recheck Resident 1's blood pressure and did not call the NP nor the physician. On [DATE] at 3:14 p.m., during an interview and concurrent review of Resident 1's care plans with the Director of Nurses (DON), the DON stated that there was no care plan develop for four blood pressure medications of Resident 1. The DON reviewed Resident 1's Licensed Nurses Progress Notes, the DON was not able to provide documented evidence that Resident 1 was assess and a follow-up call was made to NP 1 or MD 1 after 8:34 p.m., on [DATE]. On [DATE] at 8:18 a.m., during a telephone interview Certified Nurse Assistant 1 (CNA 1) stated that on [DATE], during the start of his shift (11 p.m.-7 a.m.), he saw Resident 1 in his room and the resident was sleeping normally. CNA 1 stated that he would usually wait until the licensed nurse tells him to check the resident's vital signs. CNA 1 stated that when LVN 1 saw Resident 1 in the morning of [DATE], he was called right away and yelled to go to Resident 1's room because he was not okay. On [DATE] at 3:05 p.m., during a telephone interview, the DON stated that that she could not find a specific care plan developed for the use of multiple blood pressure medications. The DON stated that when Resident 1 was placed on the 72-hour monitoring log, the nurse should monitor and document the resident's status at least every shift, and more if needed depending on the licensed nurses' assessment. The DON stated she could not find licensed nurses' documentation or Resident 1's blood pressure after the 3 p.m. to 11 p.m. shift. On [DATE] at 11:25 a.m., during a telephone interview, NP 1 stated that on [DATE], he was informed of Resident 1's repeated low BPs. NP 1 stated he told LVN 2 to continue to monitor Resident 1 blood pressure and to hold the blood pressure medications according to the parameters and to call if the resident blood pressure continued to go down or the heart rate was abnormal. NP 1 stated he did not receive a call or voicemail on [DATE]. NP 1 stated that if the facility called to inform him that the BP was low at ,[DATE] mm/hg, NP 1 stated he would have ordered to transfer Resident 1 to the acute hospital or call [DATE] because the BP was very low. NP 1 stated he did not remember getting a voicemail about the Resident 1 on [DATE]. NP 1 stated the facility called early in the morning ([DATE]) to inform him that [DATE] was called and that was the time he called the facility immediately. On [DATE] at 11:30 a.m., during an interview, Physician 1 stated that it would be helpful when the licensed nurses call and notify him when medications had been held for so many days. Physician 1 stated that he would try to rule out any other causes of the resident's condition. A review of the facility's undated policy and procedure titled, Change in a Resident's Condition or Status, indicated the charge nurse would notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition. The charge nurse would record in the resident's medical record information relative to changes in the resident's status. A review of the facility's policy and procedures titled Blood Pressure, Measuring with revised date ,[DATE], indicated that [MEDICAL CONDITION] was defined as blood pressure less than ,[DATE] mm/Hg. [MEDICAL CONDITION] should be reported to the physician. Staff should record several readings throughout the day, including before and after meals.

Based on observation, interview, and record review the facility's nursing staff failed to ensure 1 of 15 sampled residents (14) was free from physical restraints (bedside rails - full rails cover the full length of the mattress, which the resident cannot release, and prevents from gettin out of bed independently), used for staff convenience and not out of medical necessity. Resident 14, who was assessed as confused with an unsteady gait, had a behavior of wandering, getting up unassisted, and had a history of [REDACTED]. Per documentation, the resident sustained [REDACTED]. The resident was transferred to a general acute care hospital (GACH) emergency department (ED) for evaluation and treatment (repair with staples). There was no documented evidence that the side rails (restraints) were used for a medical symptom, or that least restrictive measures were evaluated for effectiveness prior to the determination to use side rails, in accordance with the facility's policy on Use of Restraints. Findings: A review of Resident 14's Admission Records indicated he was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On August 25, 2011, a care plan was developed for episodes of restlessness and wandering. There were no interventions related to getting out of bed unassisted. According to an incident report, dated December 1, 2011, Resident 14 had a previous episode of wandering outside of the building. He was transferred to a GACH for evaluation and returned to the facility on [DATE]. An Initial Restraint assessment dated [DATE], after the wandering episode, and an interview with the Director of Nursing (DON) on June 25, 2012, at 11:30 a.m. indicated the following: Mental Status: Alert with episodes of confusion and disorientation secondary to dementia, with a history of falls (nonspecific as to location). Psychoactive Medication and Reason: [MEDICATION NAME] for depression, [MEDICATION NAME] for depression, [MEDICATION NAME] for depression and [MEDICATION NAME] for anxiety. Less Restrictive Measures Used: Pillows, repositioning and visual checks every two hours. Recommendations: Interdisciplinary team (IDT) highly recommends the use of bed rails (bedside rails) to prevent falls/injury. A Care Plan, dated December 9, 2011, reviewed March 2012 and June 2012, indicated the Problem/Concerns of, "On S/P ((status [REDACTED]." The Goal was, "Will be free from fall or injury daily through next review." The interventions included side rails up while in bed to aid in bed mobility, keep environment free of hazards, repositioning, and to define parameters of safety. physician's orders [REDACTED]. On June 20, 2012, at 9:20 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated at approximately 5 a.m., certified nursing assistant 1 (CNA 1) reported to her that Resident 14 was on the floor in his room. LVN 1 stated when she arrived in the resident's room he was on the floor at the foot of his bed. She stated both of the side rails on his bed were raised and it appeared as though he had climbed over the side rails to get out of bed and fell on his head. She stated he had a large laceration on the top right side of his head, 5 centimeters ((cm) 1 cm = 3/8 inch) in length and blood was flowing from the wound. Licensed Personnel Weekly Progress Notes, dated June 20, 2012, at 5:30 a.m., indicated Resident 14 was found on the floor by his bed. He had a laceration on his right parietal (slightly below the top and slightly above the side of the head) area measuring 5 cm long, with bleeding. He was sent to the GACH for evaluation at 6:30 a.m. On June 20, 2012, at 11:50 a.m., Resident 14 was observed lying on a gurney, returning to the facility. The resident was observed with a large bandage on the top right side of his head. On June 22, 2012, at 3:15 p.m., Resident 14 was observed sitting in a wheelchair in front of his room. He had multiple staples visible, which were used to close a head wound on the top right side of his head which appeared to be approximately about 5 cm in length. On June 25, 2012, at 11:25 a.m., during an interview, Registered Nurse Supervisor 1 (RN 1) stated he signed the restraint assessment dated [DATE], but did not document the less restrictive measures attempted prior to the use of the bedside rails. He stated he could not explain how the use of pillows, repositioning and two hour visual checks would help prevent Resident 14 from wandering and/or falling, and he did not know what lead to the decision to use the side rails. There was no documentation related to how repositioning, pillows and visual checks every two hours would help prevent Resident 14 from getting out of bed unassisted or falling. Least restrictive measures such as a low bed, floor mat, moving the resident closer to the nursing station, one on one supervision, every 15 minute visual checks, re-evaluating his medication regimen, physical therapy evaluation and/or a bed alarm were never considered, according to the Director of Nursing (DON). There was no documentation to show how it was determined that the least restrictive measures the facility put in place (pillows, repositioning and visual checks every two hours) were not successful, and why the determination to use side rails was made, as related to the facility's policies on Use of Restraints. During the interview, the DON also stated it may have been better to do the visual checks more frequently than every two hours, and she did not know why or could not explain pillows and repositioning as interventions. She stated she was not sure how the determination to use side rails was made and thought the use of a low bed, bed alarm, evaluation of the resident ' s medications and other interventions may have been more relevant than the pillows, repositioning and two hour visual checks. A Minimum Data Set (MDS), an assessment and screening tool, dated March 22, 2012, indicated Resident 14's cognitive skills for decision-making were severely impaired. He required one person assist with transfers and ambulation, with staff providing weight-bearing support. The MDS documentation indicated the resident's balance when moving from a seated position to a standing position was not steady, but he was able to stabilize himself without human assistance. When walking Resident 14's balance was not steady and he was only able to stabilize himself with human assistance. Resident 14 had a functional limitation in range of motion ((ROM) - how far the joint can be moved) to one side of his lower extremities (legs) and used a walker and/or wheelchair for mobility. A review of Resident 14's Medical Records which included the licensed nursing notes, IDT notes, care plans, and medication assessment records, indicated no written documentation regarding medical symptom(s) to warrant the use of side rails, no documented evaluation or quarterly review to determine if the side rails could be reduced or eliminated once applied, no care plan addressing the resident's medical symptom(s) or underlying problem that could be causing the symptom(s) that would warrant side rail use, the risk and benefits of the side rails, and no documentation of the data or episode leading up to the use of the side rails as indicated in the facility ' s policy on Use of Restraints. A facility policy on Use of Restraints, dated August 2007, indicated restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for staff convenience, or for the prevention of falls. Physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it, given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. The policy continued to say practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including: Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine the possible underlying cause of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc..) that may improve the symptom. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints or total restraint elimination. The policy stated care plans for restraints will reflect interventions that address not only the immediate medical symptom but the underlying problems that may be causing the symptoms. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. Documentation regarding the use of restraints shall include: full documentation of the episode leading to the use of the physical restraint This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; a description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; how the restraint use benefits the resident by addressing the medical symptom; the length of effectiveness of the restraint time.

Based on observation, interview, and record review, the facility's nursing staff failed to ensure three of 15 sampled residents, two with pacemakers, had their pacemakers assessed (4 and 9), and one with a skin rash was properly assessed (5), and one randomly selected resident (RS1), who had a non-healing, progressively worsening wound, was provided with care and treatment necessary to improve his wound. Failure to provide the necessary care and services to residents placed them at risk for unrecognized cardiac distress and failure to progress towards healing of a wound, which could lead to permanent tissue damage and potential for serious complications including osteo[DIAGNOSES REDACTED] (infection of the bone) [MEDICAL CONDITION] (systemic infection). Findings: a. On June 21, 2012, at 1 p.m., Licensed Vocational Nurse 2 (LVN 2), the treatment nurse, was observed doing a wound treatment to RS1's left heel. The foot was observed with a large open wound that covered the inner portion of the ankle. LVN 2 stated the wound was not healing and had gotten worse. On June 21, 2012, at 1:10 p.m., during an interview, RS1 stated he could feel the water and medication traveling/moving inside the wound. (Tunneling wounds have channels extending from a wound into and through subcutaneous (beneath the skin) tissue or muscle. They often are difficult to manage and may persist for long periods of time.) A review of RS1's Admission Records indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan for the Problem/Concerns of, "Stasis ulcer on left ankle at risk for infection", dated December 28, 2011, reviewed March and June 2012, indicated RS1 had a stasis ulcer on his left foot and he was at risk for infection. The initial goal was for the resident's stasis ulcer to heal one centimeter (cm) per month. The initial approaches/interventions included to provide treatment as ordered and to notify the physician if the treatment was ineffective. The care plan interventions were not updated after December 28, 2011. physician's orders [REDACTED]. 1. July 15, 2011 - Apply [MEDICATION NAME] 0.1% cream (a medicine used to decrease skin swelling) to both left and right feet, dry skin area daily. 2. January 23, 2012 - Negative pressure wound therapy for left heel ulcer (utilizing a [DEVICE] which delivers a therapy technique to promote healing using a sealed wound dressing connected to a vacuum pump). It was discontinued February 6, 2012, because the wound was infected. 3. February 6, 2012 - Wash with normal saline and Iodine (an antiseptic cleanser (ice tea color)) to ulcer site two times daily and apply [MEDICATION NAME] cream (a topical antibiotic). 4. February 23, 2012 - Wash with normal saline apply Santyl ointment (an enzyme that removes dead tissue) to left ankle ulcer cover with a non-stick dressing daily. There was no documented evidence of further changes to the treatment after February 23, 2012, in the clinical record. A Decubitus Report, dated August 1, 2011, indicated RS1's left foot wound was assessed as a Stage-II (a superficial wound resembling a blister or abrasion) and measured 2 centimeters (cm) x 2 cm, with a depth of 0.2 cm, with drainage. A Decubitus Report, dated November 14, 2011, indicated RS1's left foot wound had progressed to a Stage-III (full thickness skin loss involving damage to or necrosis (death) of subcutaneous tissue) and measured 3 cm x 3 cm, with a depth of 0.5 cm with drainage. Weekly Licensed Documentation, on the back of the Decubitus Report, dated December 26, 2011, indicated RS1's left foot wound progressed to a Stage-IV (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures) and measured 4 cm x 4 cm, with a depth of 0.3 cm. There was no consistant documentation on the Decubitus Report forms or the Weekly Licensed Documentation forms from August 2011 through June 2012 to indicate that the attending physician was notified the treatment interventions were unsuccessful, the goal of healing one cm per month was not met, or of the deterioration of the resident's left foot wound. Weekly Licensed Documentation, on the back of the Decubitus Report, dated June 20, 2012, indicated RS1's left foot wound was a Stage-IV and increased in size to 7 cm x 5 cm, with a depth of 0.3 cm. On June 21, 2012, at 1:15 p.m., during an interview, the director of nursing (DON) stated the facility in-serviced the licensed nurses on wound treatments. She stated if there was a wound that was not healing and needed a consultant, the resident could be referred for evaluation, but didn't say why RS1 wasn't referred. She was not sure of the status of the resident's wound and did not know the last date the wound consultant saw the resident. On June 21, 2012, at 1:17 p.m., during an interview, RN 1 stated there was a wound physician who came to the facility to see another resident. However, RS1 was not referred to a wound consultant. RN 1 did not state why, but added that Medi-Cal, the primary payer for RS1, would not pay for a wound specialist. b. A review of Resident 4's Admission Records indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated June 16, 2012, indicated Resident 4 had a risk for pacemaker malfunction. The goal was for the resident to maintain a normal heart rate and rhythm. Approaches/interventions included a routine pacemaker check as ordered. On June 21, 2012, at 12:15 p.m., during an interview, Registered Nurse Supervisor 1 (RN 1) stated Resident 4 was transferred to an acute care hospital for a hernia repair and he assumed they would clear his heart prior to surgery. The resident ended up not having the surgery, but RN 1 thought his heart had been cleared and assumed it would include a check of his pacemaker. A facility policy on Pacemakers, not dated, indicated when the following information is available, it will be recorded on the resident's medical record: type of pacemaker, date of insertion, rate at which pacemaker is set. c. A review of Resident 5's clinical records (face sheet), indicated he was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a resident assessment and care screening tool, dated June 15, 2012, indicated Resident 5 had short and long term memory problems, and was fed via a gastrostomy feeding tube ((GT) feeding tube surgically placed in the stomach). On June 20, 2012, at 2 p.m. and June 21, 2012, at 8:05 a.m., red spots (rashes) were observed on both of Resident 5's arms. An observation on June 21, 2012, at 8:05 a.m., with Registered Nurse 1 (RN 1) Resident 5 had multiple red spots to his bilateral arms. RN 1 stated the rashes were reoccurring (no time was given)and he would call the physician. However, the resident's rashes were observed for two days prior and were not assessed. A review of Resident 5 ' s Treatments, dated June 2012, indicated [MEDICATION NAME] (([MEDICATION NAME] 0.1% cream) a dermatological medication used for skin conditions) was ordered to be applied topically to body rashes twice daily for one month. The treatment sheet on June 10, 2012, indicated that rashes were marked as cleared and the treatment was discontinued. d. A review of Resident 9's clinical records indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set, an assessment and screening tool, dated May 31, 2012, indicated Resident 9 usually understood others and usually made self-understood. The resident required extensive assistance (one person assist) from staff with eating, transfers, and bed mobility, and total dependence (full staff performance every time) with dressing, hygiene, bathing, and toileting. The resident had functional limitations in range of motion (extent that the arms and legs can move) to both sides of her arms and legs. A review of the physician's orders [REDACTED]. A review of the Nurse's Admitting Record, dated May 31, 2012, the diagram indicated the resident had an incision site to the left upper chest area. A review of the plan of care for the resident's risk for pacemaker malfunction, dated June 1, 2012, did not indicate the date the pacemaker was inserted, pacemaker model and type, and the set rate. An interview and record review with Registered Nurse 1 (RN 1) on June 21, 2012, at 9 a.m., when asked about documentation of the resident ' s pacemaker assessments, RN 1 did not make any comment and stated he would notify the physician.

Based on observation, interview and record review, the facility failed to ensure two of fourteen sampled residents (8 and 10) received range of motion exercises and positioning devices to prevent the development of contractures (joint deformity). The facility also failed to implement the physician's order for an "orthotics consult". Resident 8 was assessed as having no range of motion (ROM) limitation when initially admitted to the facility on [DATE]. The facility's Minimum Data Set (MDS) assessment, dated February 13, 2011, indicated the resident had developed limited range of motion in her lower extremities only. Resident 8 was not evaluated by a physical therapist and did not receive range of motion (ROM) exercises to any of her extremities despite having a [DIAGNOSES REDACTED]. Also, the physician's order for an orthotic evaluation was not implemented. These deficient practices resulted in Resident 8 developing contractures to both arms, both hands, and both legs. Resident 10 was not assessed and care planned for reduction in range of motion (extent of movement of a joint) to the resident's left upper and lower extremities. Also, the physician's order for an orthotics evaluation was not implemented. The resident did not receive care and treatment to the left upper and lower extremities that led to left hand and left knee contractures and left foot drop (inability to lift the top part of the foot due to paralysis or weakness causing the toes pointing downward). These deficient practices resulted in the residents' developing contractures in the arms, hands and legs. Findings: 1. A review of Resident 8's clinical record, Admission and Discharge form, indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 8's admission Minimum Data Set (MDS), a systematic, comprehensive assessment tool, dated May 14, 2010, indicated she was severely cognitively impaired, communicating using signs, gestures and sounds and rarely to never able to make herself understood. The MDS indicated Resident 8 was totally dependent on staff for all activities of daily living (ADLs). Section G4 of the MDS which assesses functional limitation in range of motion indicated Resident 8 had full range of motion of all extremities. A review of Resident 8's quarterly MDS, dated [DATE], also indicated Resident 8 had full range of motion in all extremities. A review of Resident 8's quarterly MDS, dated [DATE], indicated Resident 8 had impaired range of motion to both lower extremities. In addition, Section O of the MDS under special treatments, procedures and programs indicated Resident 8 did not receive physical therapy. On March 10, 2011 at 9:30 a.m., Resident 8 was observed in bed, both arms bent up at the elbow at a 45 degree angle and both hands clenched, tightly closed into a fist. At 4:35 p.m., Certified Nurse Assistant 2 (CNA 2) stated she cared for Resident 8 often. CNA 2 further stated Resident 8 was not able to move her arms or legs. When asked how long the resident had been unable to move her arms or legs, CNA 2 replied she did not know. A review of the Nurse Assistant Flow Sheets for February 2011 and March 2011 indicated Resident 8 had not received any PROM (passive range of motion) exercises. A review of the physician's order, dated February 2, 2011, indicated Resident 8 was to have an orthotics consult (specializes in external orthopedic appliances or device) for upper and lower extremities. On March 14, 2011, at 10:15 a.m., the registered nurse (RN) supervisor stated he called the physician's office on February 2, 2011, to obtain the verbal order for the orthotics consult because the prosthetics company the facility has a contract with had asked him to get a physician's order. The RN supervisor further stated he did not know if the orthotics consult was ever done. A review of the undated RN supervisor's job description indicated he would make patient rounds every hour, be aware of the patient's condition at all times, take doctor's orders and ensure the orders were carried out. On March 14, 2011 at 1:30 p.m., when asked if Resident 8 had received any ROM exercises since admission, the Director of Nurses (DON) stated she did not know. The DON was given Resident 8's current and closed clinical records and verified there was no documentation the resident had ever been evaluated by a physical therapist and no documentation of any ROM treatments. The DON further stated the facility's restorative nursing assistant (RNA) was currently on vacation and had been on vacation since the last week of February 2011. When the DON was asked who was doing ROM exercises, the DON stated no one was doing ROM exercises with the residents. During the same interview, the DON verified there was no documentation, care plans or change of condition MDS assessment in the clinical record indicating Resident 8 had acquired contractures. A review of the responsibilities listed on the facility's undated Director of Nurse's job description indicated the DON would be responsible for coordinating nursing services with other patient care services provided such as physician, dietary, and physical therapy. On March 14, 2011 at 2:30 p.m., the MDS nurse stated she obtained the information for the MDS by direct observation of the residents and input from the nursing staffs. The surveyor asked the MDS nurse to accompany her to Resident 8's room. The MDS nurse was asked to demonstrate how range of motion is assessed. The MDS nurse was unable to extend any of Resident 8's arms from the 45 degree angle, and was only able to place one finger into the resident's hands because the fingers were contracted closed. The MDS nurse stated, "I will look at that assessment again"; referring to the MDS assessment dated [DATE] that indicated Resident 8 had impaired mobility to her lower extremities only. The MDS nurse further stated Resident 8 had not received any ROM exercises at any time during her stay at the facility. An article titled, "Exercise Program for [MEDICAL CONDITION]" published by the Parkinson Research Foundation, defined [MEDICAL CONDITION] as a neuromuscular disorder that produces progressive muscle rigidity, movement impairment and tremors. The article further indicated patients with [MEDICAL CONDITION] should be evaluated by a physical therapist so an exercise program that includes stretching and range of motion exercises is initiated. The article stated the range of motion exercises enhance the patient's strength and mobility. <http://www.disability-resource.com/medical-health/[MEDICAL CONDITION]/what-is-[MEDICAL CONDITION]-disease.html> Copyright ? 1996 - 2011 Disability Resource Directory 2. According to the admission record, Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Contracture Screening Scale Joint Mobility Assessment, dated February 5, 2005, indicated the resident's right knee with moderate restrictions of 25 percent to 75 percent of normal range; and the resident required passive range of motion. The Annual Minimum Data Set (MDS), Resident Assessment and Care Screening, dated November 18, 2010, indicated the resident speaks with distinct intelligible words. The resident has limited ability to make concrete requests, and sometimes understands and responds adequately to simple direct communication. The resident is totally dependent upon the nursing staff for her activities of daily living, transferring, personal hygiene, dressing, feeding, and bathing. Under Section G0400, Functional Limitation in Range of Motion indicated the resident had impairment on the right side that includes in the upper extremity, the shoulder, elbow and hand, and in the lower extremity, the hip, the knee, the ankle and foot. The plan of care dated November 14, 2010, indicated the resident will reach her highest level of physical functioning. The resident was identified having poor movement in her right leg, unable to bend her right leg, and a right knee contracture. The nursing intervention was for the staff to provide range of motion. There was no plan of care addressing potential risk for contractures to the resident's left upper/lower extremities. There was no plan to provide nursing interventions with routine preventive measures, passive/active range of motion exercises, and monitoring for stiffness and changes in the resident's joint mobility on the resident's left upper/lower extremities. A review of the Annual Joint Mobility Assessment, dated December 9, 2010, indicated a right leg contracture, and the resident was non-ambulatory. The Quarterly Joint Assessment, dated March 9, 2010, indicated right leg contracture, non ambulatory. There was no written documentation in the clinical record Resident 10 had contractures on the left side. On March 11 and 14, 2011, at 7:30 a.m., the surveyor observed the resident lying on her back in bed, the surveyor observed the resident's left hand fingers, the middle finger, the ring finger, and little finger were closed and no hand roll or hand splint was in place. During an observation and interview on March 14, 2011 at 1:30 p.m., the surveyor observed Certified Nursing Attendant 1 (CNA 1) reposition the resident in her bed. The surveyor asked CNA 1 regarding the resident's left hand fingers; CNA 1 stated the resident cannot open some of her fingers on her left. The surveyor asked CNA 1 if the resident had a hand roll, CNA 1 said, "No." A review of the physician's order dated February 2, 2011, indicated may have orthotics consultation for upper and lower extremities. There was no physician's order for preventive measures such as physical therapy evaluation and/or restorative nursing assistant (RNA) treatments for range of motion exercises to the left upper/lower extremities. A review of the clinical record revealed there was no Joint Mobility Assessment conducted to assess Resident 10's reduction in range of motion to the left upper and lower extremities. There was no documentation that an orthotics consultant evaluated the resident for an orthotic device (the use of specialized mechanical device to support or supplement weakened or abnormal joints or limbs) a splint and/or a brace. During an interview on March 15, 2011 at 9 a.m., with Registered Nurse (RN) Supervisor 1, the surveyor asked the RN Supervisor regarding the resident's left upper and lower extremities. The RN Supervisor 1 said, "I will reassess the resident's joint mobility." During an interview on March 15, 2011 at 1 p.m., RN Supervisor 1, he stated three of the resident's fingers she was unable to open, the little finger, the ring finger and the middle, and the resident's left leg and knee the resident was unable to straighten out, and a left foot drop. A review of the RN Supervisor 1's Joint Mobility Assessment, dated March 15, 2011, indicated the resident's left hip was in continuous flexion, the resident was unable to straighten. The resident's left knee was in a continuous flexed position and a left foot drop. The resident was unable to open three fingers on the left hand. The resident's left shoulder with minimum abduction (moving a body part away from the midline) and flexion.