Every finding on record at Childrens HC Org No Ca Saratoga Pediatric Subacute

Based on interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of two residents (Resident 1). This failure could potentially result in complications of the residents' medical conditions.Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy ( a permanent physical disability affecting both arms, legs, facial muscle, trunk and making movements is difficult).Review of Resident 1's Physician Order Summary Report dated 2/13/26 and 3/14/26 indicated Atropine Sulfate Ophthalmic Solution 1% (a medication used in the eye, medication also with off label to treat severe drooling) administer three drops sublingually (under the tongue) three times a day for excess saliva.During a concurrent interview and record review with the Administrator (ADM) on 6/24/26, at 10:05 a.m., the ADM reviewed Resident 1's clinical record and stated that on 6/21/26 p.m. shift (3 p.m. to 11 p.m.) there was an incident of medication administration error administered by Registered Nurse A (RN A). The ADM further stated that Atropine Sulfate Ophthalmic Solution 1% was administered as one drop OU (both eyes) instead of the prescribed sublingual route to Resident 1. The ADM stated Resident 1's physician order was revised after the incident.During an interview with the Medical Doctor (MD) on 6/24/26 at 10:32 a.m., the MD stated that he ordered Atropine Sulfate Ophthalmic Solution 1% give three drops sublingually three times a day for excess saliva. The MD further stated that he was aware about the medication administration error identified on 6/21/26 that the Atropine Sulfate Ophthalmic Solution 1% was given to Resident 1's both eyes instead of the sublingual route. The MD stated he was in the facility on 6/23/26 to assess Resident 1's condition and ordered to hold the medication from 6/23/26 through 6/28/26. The MD stated that Atropine Sulfate Ophthalmic Solution 1% was designed as eye drops but this medication could also be given sublingually as ordered for Resident 1.During a concurrent interview and record review with the ADM on 6/24/26, at 11:50 a.m., the ADM reviewed Resident 1's Medication Administration Record (MAR) and the ADM confirmed that the MAR indicated Atropine Sulfate Ophthalmic Solution 1% give three drops sublingually three times a day and was scheduled to be given by the licensed nurses (LNs) at (5 a.m., 1 p.m., and 9 p.m.) for excess saliva as ordered by the physician and should not have been given to Resident 1's eyes.During an interview with Registered Nurse B (RN B) on 6/26/26 at 9:43 a.m., RN B stated LNs need to follow the five basic rights in giving medications to residents such as; Right Patient, Right Medication, Right Dose, Right Route of administration and Right Time. RN B further stated that before giving the Atropine Sulfate Ophthalmic Solution 1% sublingual three drops three times a day to Resident 1, she checks the physician order, MAR and medication prescription label in the bottle and LNs will never make a mistake.During an interview with RN C on 6/26/26 at 12:37 p.m., RN C stated before giving the Atropine Sulfate Ophthalmic Solution 1% sublingual three drops three times a day to Resident 1, she checks the physician order or review and confirm medication by comparing the name of medication, dosage, route, time and Resident 1's name. RN C further stated that she was giving the medication sublingually as ordered by the physician.A review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 2007, indicated, prior to administration , review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label.Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to develop and implement specific, individualized and resident-centered care plans for the side or bed rails (adjustable rigid bars attached to the side of a bed) of twelve, (Residents 16, 19, 4, 27, 5, 1, 29, 6, 32, 14, 24 and 12), out of thirty-three residents in the facility, when these twelve residents who used side rails did not have specific, individualized and resident-centered care plans for their side rails. These failures had the potential for these residents to be at risk, for not being properly monitored and provided with the appropriate interventions with regards to their use of side rails, which could compromise their safety and quality care.Findings: 1. During the observation of Resident 16, on 2/5/26 at 12:55 p.m., Resident 16 was in his wheelchair inside his room, comfortable and not talking. Resident 16 had bilateral (both sides) padded upper side rails that were up. Review of Resident 16's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 16 was admitted to the facility on [DATE], with the principal diagnosis of anoxic brain damage (occurs when the brain is completely deprived of oxygen, causing brain cells to begin dying within roughly four minutes), not elsewhere classified. Review of Resident 16's order summary report dated 2/6/26 indicated, Resident 16 had an order of hospital bed with padded upper side rails for safe sleep or rest environment every shift for seizure (abnormal electrical activity in the brain causing changes in awareness and muscle control) precautions, ordered on 7/2/25. Review of Resident 16's care plans indicated, Resident 16 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 16's care plans and interview with minimum data set coordinator (MDSC) on 2/9/26 at 10:44 a.m., MDSC verified that Resident 16 did not have a specific, individualized and resident-centered care plan for the side rails. 2. During the observation of Resident 19, on 2/4/26 at 1:17 p.m., Resident 19 was up in his wheelchair inside his room, comfortable and not talking. Resident 19 had four padded half side rails that were up. Review of Resident 19's admission record indicated, Resident 19 was readmitted to the facility on [DATE], with the principal diagnosis of diffuse traumatic brain injury (a severe brain injury caused by rapid shaking, twisting, or acceleration-deceleration of the head, leading to widespread tearing of nerve fibers or axons), with loss of consciousness of unspecified duration, sequela (any complication or condition that results from a pre-existing illness, injury, or other trauma to the body). Review of Resident 19's order summary report dated 2/6/26 indicated, Resident 19 had an order of high, low bed with all 4 side rails up with full paddings for safe sleep or rest environment every shift, ordered on 8/9/24. Review of Resident 19's care plans indicated, Resident 19 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 19's care plans and interview with MDSC on 2/9/26 at 11:11 a.m., MDSC verified that Resident 19 did not have a specific, individualized and resident-centered care plan for the side rails. 3. During the observation of Resident 4, on 2/5/26 at 1:03 p.m., Resident 4 was up in her wheelchair on her way to school, comfortable and not talking. Resident 4 had 2 padded bilateral upper half side rails that were up. Review of Resident 4's admission record indicated, Resident 4 was readmitted to the facility on [DATE], with the principal diagnosis of cerebral palsy (group of conditions that affect movement and posture), unspecified. Review of Resident 4's order summary report dated 2/6/26 indicated, Resident 4 had an order of hospital bed with padded upper side rails to prevent injury during seizure every shift, ordered on 8/8/24. Review of Resident 4's care plans indicated, Resident 4 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 4's care plans and interview with MDSC on 2/9/26 at 11:11 a.m., MDSC verified that Resident 4 did not have a specific, individualized and resident-centered care plan for the side rails. 4. During the observation of Resident 27, on 2/4/26 at 1:22 p.m., Resident 27 was up in her wheelchair, comfortable and not talking. Resident 27 had upper side rails that were up. Review of Resident 27's admission record indicated, Resident 27 was readmitted to the facility on [DATE], with the principal diagnosis of traumatic subarachnoid hemorrhage (occurs when trauma, such as falls or motor vehicle accidents, causes bleeding into the subarachnoid space, often presenting with a severe, sudden headache) with loss of consciousness of unspecified duration, subsequent encounter. Review of Resident 27's order summary report dated 2/6/26 indicated, Resident 27 had an order of hospital bed with upper side rails for safe sleep or rest environment every shift, ordered on 2/5/26. Review of Resident 27's care plans indicated, Resident 27 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 27's care plans and interview with MDSC on 2/9/26 at 11:11 a.m., MDSC verified that Resident 27 did not have a specific, individualized and resident-centered care plan for the side rails. 5. During the observation of Resident 5, on 2/5/26 at 1:00 p.m., Resident 5 was laying in bed, comfortable and not talking. Resident 5 had padded upper side rails that were up. Review of Resident 5's admission record indicated, Resident 5 was readmitted to the facility on [DATE], with the principal diagnosis of nontraumatic intracerebral hemorrhage, intraventricular (a severe, often fatal stroke subtype where blood leaks from ruptured brain vessels into the ventricle primarily caused by chronic hypertension or cerebral amyloid angiopathy). Review of Resident 5's order summary report dated 2/6/26 indicated, Resident 5 had an order of hospital bed with padded upper side rails for safe sleep or rest environment every shift, ordered on 12/29/25. Review of Resident 5's care plans indicated, Resident 5 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 5's care plans and interview with MDSC on 2/9/26 at 12:08 p.m., MDSC verified that Resident 5 did not have a specific, individualized and resident-centered care plan for the side rails. 6. During the observation of Resident 1, on 2/4/26 at 12:21 p.m., Resident 1 was laying in bed, confused and not talking. Resident 1 had padded four side rails that were up. Review of Resident 1's admission record indicated, Resident 1 was readmitted to the facility on [DATE], with the principal diagnosis of myotonic muscular dystrophy (common, inherited, multisystem genetic disorder characterized by progressive muscle wasting, weakness and delayed relaxation or myotonia). Review of Resident 1's order summary report dated 2/6/26 indicated, Resident 1 had an order of high, low bed with all four side rails up with full paddings for safe sleep, rest or play environment every shift, ordered on 10/29/25. Review of Resident 1's care plans indicated, Resident 1 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of Resident 1's care plans and interview with MDSC on 2/9/26 at 12:30 p.m., MDSC verified that Resident 1 did not have a specific, individualized and resident-centered care plan for the side rails. 7. During the observation of Resident 29, on 2/4/26 at 12:56 p.m., Resident 29 was in bed, comfortable and not talking. Resident 29 had padded upper side rails that were up. Review of Resident 29's admission record indicated, Resident 29 was readmitted to the facility on [DATE], with the principal diagnosis of necrotizing enterocolitis (serious, often fatal, neonatal gastrointestinal disease where the intestinal wall becomes inflamed, dies and can rupture, often affecting premature infants within the first few weeks of life), unspecified. Review of Resident 29's order summary report dated 2/9/26 indicated, Resident 29 had an order of hospital bed with padded upper side rails to prevent injury during seizure every shift, ordered on 12/6/24. Review of Resident 29's care plans indicated, Resident 29 did not have a specific, individualized, resident-centered care plan for the side rails. 8. During the observation of Resident 6, on 2/4/26 at 1:10 p.m., Resident 6 was in bed, comfortable and not talking. Resident 6 had padded upper side rails that were up. Review of admission record of Resident 6 indicated, Resident 6 was admitted to the facility on [DATE], with the principal diagnosis of diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela. Review of the order summary report of Resident 6 dated 2/9/26 indicated, Resident 6 had an order of hospital bed with padded upper side rails for safe sleep or rest environment every shift, ordered on 7/31/24. Review of the care plans of Resident 6 indicated, Resident 6 did not have a specific, individualized, resident-centered care plan for the side rails. 9. During the observation of Resident 32, on 2/4/26 at 1:14 p.m., Resident 32 was sleeping in bed and appeared comfortable. Resident 32 had padded upper side rails that were up. Review of Resident 32's admission record indicated, Resident 32 was admitted to the facility on [DATE], with the principal diagnosis of anoxic brain damage (occurs when the brain is completely deprived of oxygen, causing brain cells to begin dying within roughly four minutes), not elsewhere classified. Review of Resident 32's order summary report dated 2/9/26 indicated, Resident 32 had an order of hospital bed with padded upper side rails for safe sleep or rest environment every shift, ordered on 3/20/25. Review of Resident 32's care plans indicated, Resident 32 did not have a specific, individualized, resident-centered care plan for the side rails. 10. During the observation of Resident 14, on 2/4/26 at 1:14 p.m., Resident 14 was in bed, calm, comfortable and not talking. Resident 14 had four padded side rails that were up. Review of Resident 14's admission record indicated, Resident 14 was readmitted to the facility on [DATE], with the principal diagnosis of other encephalitis (dangerous inflammation of the brain, usually caused by viral infections or autoimmune reactions) and encephalomyelitis (inflammation of the brain and spinal cord, often caused by autoimmune responses to infections or rarely, vaccinations, predominantly affecting children). Review of Resident 14's order summary report dated 2/9/26 indicated, Resident 14 had an order of hospital bed with all four side rails up with full paddings to prevent injury during seizure every shift, ordered on 6/27/25. Review of Resident 14's care plans indicated, Resident 14 did not have a specific, individualized, resident-centered care plan for the side rails. 11. During the observation of Resident 24, on 2/5/26 at 12:48 p.m., Resident 24 was in bed, calm, comfortable and not talking. Resident 24 had four padded side rails that were up. Review of Resident 24's admission record indicated, Resident 24 was readmitted to the facility on [DATE], with the principal diagnosis of respiratory failure (condition where there's not enough oxygen gas or too much carbon dioxide or non-flammable gas in the body), unspecified with hypoxia (low levels of oxygen in the body tissues). Review of Resident 24's order summary report dated 2/9/26 indicated, Resident 24 had an order of hospital bed with all four side rails up with full paddings to prevent injury during seizure every shift, ordered on 8/9/24. Review of Resident 24's care plans indicated, Resident 24 did not have a specific, individualized, resident-centered care plan for the side rails. 12. During the observation of Resident 12, on 2/5/26 at 12:55 p.m., Resident 12 was in the wheelchair, calm, comfortable and not talking. Resident 12 had bilateral upper side rails that were up. Review of Resident 12's admission record indicated, Resident 12 was readmitted to the facility on [DATE], with the principal diagnosis of facioscapulohumeral muscular dystrophy (rare genetic, progressive muscle disorder causing weakness primarily in the face, shoulders, upper arms and lower legs, typically appearing before age [AGE]). Review of Resident 12's order summary report dated 2/9/26 indicated, Resident 12 had an order of hospital bed with upper side rails and winged mattress to prevent injury during seizure every shift, ordered on 2/17/25. Review of Resident 12's care plans indicated, Resident 12 did not have a specific, individualized, resident-centered care plan for the side rails. During the concurrent review of the care plans of Residents 29, 6, 32, 14, 24 and 12 and interview with MDSC on 2/10/26 at 10:03 a.m., MDSC verified that these residents did not have specific, individualized and resident-centered care plans for their side rails. During the interview with the administrator (ADM) on 2/10/26 at 3:25 p.m., he acknowledged that the residents should have a separate, specific, individualized and resident-centered care plans for their side rails and would follow up on these concerns. Review of the undated facility policy titled, Interdisciplinary Care Plans indicated, Each child will have an interdisciplinary care plan . after comprehensive assessments are completed . to provide an individualized care plan for each child to identify and document treatment and services appropriate to the patients' needs, strengths, goals and limitations . Long term and short term goals will be established with expected outcomes and time frames identifying the expected completion .

Based on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, in order to provide safe environment for residents when there were missing logs in their laundry dryer lint tray cleaning monitoring sheet for February 2026. These failures had the potential for causing fire accident that might result in injury and harm to the thirty-three residents residing in the facility.Findings: During the laundry room observation on 2/10/26 at 11:05 a.m., there were missing logs in the dyer lint tray cleaning monitoring sheet for February 2026, that included the removal of the dryer lint (a collection of fine fabric and yarn pieces that accumulate in a dryer's filter while clothes were being dried). There were logs missing for the nocturnal shift (NOC, the overnight, third shift of the facility), which would start from 10:00 p.m. at night until 5:00 a.m. in the morning. The NOC shift laundry staffs missed to log in the dryer lint tray cleaning monitoring sheet for the following dates: 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26 and 2/9/26, for their 2 large dryyers. During the interview with maintenance director (MDIR) on 2/10/26 at 11:07 a.m., MDIR verified that they have morning shift, from 5:00 a.m. to 1:30 p.m., afternoon shift, from 1:30 p.m. to 10:00 p.m. and NOC shift, from 10:00 p.m. to 5:00 a.m. staffs that would do laundry. MDIR further verified that laundry staffs should check, clean or replace the dryer lints if needed, after using the dryers to avoid overheating. He then verified the missing signature logs of the NOC shift laundry staffs for the dryer lint tray cleaning monitoring sheet for February 2026. MDIR then stated that there should be no missing signature logs of the laundry staffs in the dryer lint tray cleaning monitoring sheet to ensure that they checked, cleaned or replaced if needed, the dryer lints after using the dryers for safety. He then continued that he would remind the laundry staffs about this concern. Review of the undated facility's policy titled, Laundry Procedure indicated, . Check for lint and clean accordingly to avoid fire.

Based on observation, interview and record review, the facility had a medication error rate of 14.29% when 4 medication errors out of 28 opportunities were observed during medication pass for two of ten residents (Residents 8 and Resident 16). These failures had the potential to compromise the health and safety of the residents.Findings: During a medication pass on 2/6/26 at 2:16 p.m., licensed vocational nurse (LVN) A was observed preparing two medications for seizures for Resident 8. Included in the medications were a tablet of topiramate 25 milligrams (mg, unit of measurement) dissolved in 3 milliliter (ml, unit of measurement) of water and 3 ml of levetiracetam. On 2/6/26 2:20 p.m., LVN A was observed that he combined and administered topiramate dissolved in 3 ml of water and 3 ml of levetiracetam 100mg/ml all at once via G-Tube (a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications.) During an interview with LVN A on 2/6/26 at 2:25 p.m., LVN A confirmed that he combined the medications topiramate and levetiracetam in a purple syringe and administered them to Resident 8. LVN further stated that he did not flush between administering each medication, but only did so before and after the final administrationDuring a medication pass on 2/9/26 at 4:58 p.m. registered nurse (RN) B was observed preparing medication for Resident 16. The medications included were a tablet of glycopyrrolate 1 mg and two and a half tablets of tizanidine 2 mg. RN B crushed both glycopyrrolate and tizanidine together, dissolved them in 10 ml of water, and then administered the mixture to Resident 16 via G-tube. During an interview with RN B on 2/9/26 at 5:16 p.m., she confirmed that one tablet of glycopyrrolate and two and a half tablets of tizanidine were crushed together and administered to Resident 16. She further stated that she only separates medication when administering narcotics. During a concurrent interview and record review with RN C on 2/10/26 at 1:54 p.m., RN C stated that medication via G-tube should be administered separately and flush with water in between. RN C further stated that there would be a possible drug to drug interaction if medications are mixed together. A review of the facility's policy and procedure (P&P) titled, Medication Administration Enteral Tubes, dated 2007, the P&P indicated, Crushed medications are not mixed together . The standard of practice is that crushed medications should not be combined and given all at once via feeding tube . Each medications is administered separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications.

Based on observation, interview, and record review, the facility failed to ensure an expired medication was removed from one of four medication carts inspected for one of thirteen sampled residents (Resident 3); and, three expired control solutions (liquid solution used to verify that a blood sugar machine and test strips are working accurately together) were not removed from an active use supply area of a medication room.These failures had the potential for the residents to receive expired medication and/or be inaccurately assessed for blood sugar.Findings:During an inspection of the medication room with the infection control preventionist (IP) on [DATE] at 10:41 a.m., the IP confirmed one Assure dose control solution had expired on 2025-03-09 and two [NAME] control solution had expired on 2025-10-10 and 2025-08-10 and stated that the solutions should be discarded.During an inspection of the medication cart (Med Cart B) with the IP on [DATE] at 10:55 a.m., Resident 3's medication hydralazine (medication to treat hypertension) was found in the medication compartment. The IP confirmed the discard date was [DATE] and stated that it should be removed from cart.A review of Resident 3's clinical record indicated, Resident 3 had active order of Hydralazine HLC oral tablet 10 mg via J-tube (jejunostomy tube) every 6 hours as needed for hypertension. During an interview with the minimum data set coordinator (MDSC) on [DATE] at 1:30 p.m., the MDSC stated that expired medication should not be stored in the medication cart. She further stated that an expired control solution could lead to false calibration or inaccuracies. The facility's policy titled Medication Storage Storage of Medication, dated 2027, indicated, Medications and biological are stored properly, following manufacture's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observation, interview, and record review, the facility failed to report an allegation of abuse involving one of two sampled residents (Resident 1) to the State Survey Agency. This failure had the potential to delay investigations and compromise Resident 1's safety. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including congenital central alveolar hypoventilation syndrome ( a rare, life-threatening genetic disorder that affects normal breathing), short bowel syndrome with colon in continuity (a rare malabsorption disorder that occurs when the small intestine is damaged or shortened preventing it from absorbing enough nutrients from food), chronic respiratory failure with hypercapnia (a condition where the body cannot adequately remove carbon dioxide from the blood), dependence on respirator status (unable to breathe independently after being on a ventilator). During an interview on 12/19/24 at 10:09 a.m., with the Respiratory Therapist (RT), the RT stated Resident 1 suddenly lunged at him when the RT disconnected the television and started scratching, hitting and biting. The RT stated he held the forearms of Resident 1 and placed him on the bed. The RT stated Resident 1 started to kick his groin area, so he turned sideways and raised one of his leg to protect his groin area. During an interview on 12/19/24 at 10:36 a.m., with Registered Nurse (RN) B, RN B stated she saw the RT holding Resident 1's wrists and pinned on the bed. RN B stated she told the RT to get off of Resident 1 two to three times before the RT let go of Resident 1. RN B stated she reported the incident to the Administrator (ADM). RN B stated she reported the incident to the police. During a review of RN B's Incident Note, dated 11/30/24, the Incident Note indicated Local authorities were notified for suspected child abuse.Two policemen arrived at the facility and spoke to primary nurse, charge nurse, and patient. During an interview on 12/19/24 at 12:45 p.m., with RN C, she stated she heard the RT yelling at Resident 1 in the hallway to turn the television volume down. RN C stated she saw the RT going into Resident 1's room and heard more yelling. RN C stated she went in to Resident 1's room and saw the RT and Resident 1 standing at the back of the room facing at each other then the RT grabbed Resident 1's head and neck with one hand and the shoulder with the other hand and pushed Resident 1 on the bed. RN C stated the RT held Resident 1's wrist while lying flat in bed and one knee on the chest or stomach. RN C stated she assessed Resident 1 and saw red markings on both wrists and Resident 1 made a punching like motion to his stomach and grimaced. RN C stated she informed the ADM of the incident. During an interview on 12/19/24 at 4:28 p.m., with the Director of Staff Development (DSD), the DSD stated the ADM informed the staff during the stand up meeting that the incident was not an abuse based on the investigation of the ADM. During an interview on 3/5/25 at 4:15 p.m., with the ADM, the ADM stated he did not report the incident because it was not an abuse. The ADM stated that RN C informed him that Resident 1 had no marking on him. During a review of the facility's policy and procedure, titled Abuse prevention, intervention, reporting and investigation, revised 5/14, indicated In accordance with California penal code .requires that all mandated health care practitioners must report .any reasonable suspicion that a child has been abused or neglected .Staff is mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse .For suspected child abuse cases of all types, a written report must be filed using Department of Justice form SS8572 .completed in detail and mailed within 36 hours of the telephone report .Will notify Department of Health Services. Licensing and Certification Program of an alleged abuse situation upon an adult and or child within 24 hours .

Based on observation, interview, and record review, the facility failed to follow their Bed/Side Rails policy for 20 of 22 residents (1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331) when they did not attempt alternative measures prior to applying bed side rails. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: During an observation in Resident 11's room on 7/15/24, at 10:19 a.m., Resident 11 was in bed with side rails up. Review of Resident 11's physician order, dated 2/7/23, indicated she had an order for Upper Side Rails. Review of Resident 11's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/19/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 1's room on 7/15/24, at 10:20 a.m., Resident 1 was in bed with left side rail up. Review of Resident 1's physician order, dated 7/12/23, indicated she had an order for Left Side Rail. Review of Resident 1's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/9/23, indicated alternative measures were not attempted prior to the use of side rail. During an observation in Resident 2's room on 7/15/24, at 10:22 a.m., Resident 2 was in bed with side rails up. Review of Resident 2's physician order, dated 11/29/21, indicated he had an order for Side Rails. Review of Resident 2's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/20/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 181's room on 7/15/24, at 10:25 a.m., Resident 181 was in bed with side rails up. Review of Resident 181's physician order, dated 2/16/24, indicated he had an order for Full Side Rails. Review of Resident 181's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 25's room on 7/15/24, at 10:27 a.m., Resident 25 was in bed with side rails up. Review of Resident 25's physician order, dated 10/18//23, indicated she had an order for Upper Side Rails. Review of Resident 25's Postural Support/Developmental Safety Device Rationale and Consent, dated 1/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 16's room on 7/15/24, at 10:28 a.m., Resident 16 was in bed with side rails up. Review of Resident 16's physician order, dated 2/15/23, indicated she had an order for Upper Side Rails. Review of Resident 16's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/27/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 5's room on 7/15/24, at 10:29 a.m., Resident 5 was in bed with side rails up. Review of Resident 5's physician order, dated 2/15/23, indicated she had an order for Left Right Side Rails. Review of Resident 5's Postural Support/Developmental Safety Device Rationale and Consent, dated 4/9/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 182's room on 7/15/24, at 11:19 a.m., Resident 182 was in bed with side rails up. Review of Resident 182's physician order, dated 11/10/23, indicated he had an order for Full Side Rails. Review of Resident 182's Postural Support/Developmental Safety Device Rationale and Consent, dated 11/7/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 3's room on 7/15/24, at 11:31 a.m., Resident 3 was in bed with side rails up. Review of Resident 3's physician order, dated 5/23/24, indicated she had an order for All Side Rails. Review of Resident 3's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 330's room on 7/15/24, at 12:11 p.m., Resident 330 was in bed with bilateral (both sides) upper side rails and one lower side rail up. Review of Resident 330's physician order, dated 12/12/23, indicated he had an order for Upper Side Rails. Review of Resident 330's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/12/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 4's room on 7/15/24, at 12:11 p.m., Resident 4 was in bed with one upper and one lower side rails up. Review of Resident 4's physician order, dated 2/17/23, indicated he had an order for Upper Side Rails. Review of Resident 4's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 24's room on 7/15/24, at 12:12 p.m., Resident 24 was in bed with bilateral upper and lower side rails up. Review of Resident 24's physician order, dated 2/27/24, indicated he had an order for Upper Side Rails. Review of Resident 24's Postural Support/Developmental Safety Device Rationale and Consent, dated 2/28/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 27's room on 7/15/24, at 12:12 p.m., Resident 27 was in bed with bilateral upper side rails and one lower side rail up. Review of Resident 27's physician order, dated 1/30/24, indicated he had an order for Full Side Rails. Review of Resident 27's Postural Support/Developmental Safety Device Rationale and Consent, dated 3/22/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 9's room on 7/15/24, at 12:13 p.m., Resident 9 was in bed with bilateral upper side rails up. Review of Resident 9's physician order, dated 11/14/23, indicated she had an order for Side Rails. Review of Resident 9's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 14's room on 7/15/24, at 12:27 p.m., Resident 14 was in bed with bilateral upper and lower side rails up. Review of Resident 14's physician order, dated 2/13/23, indicated she had an order for Full Side Rails. Review of Resident 14's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/23/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 6's room on 7/16/24, at 8:15 a.m., Resident 6 was in bed with bilateral upper side rails up. Review of Resident 6's physician order, dated 10/11/19, indicated she had an order for Side Rails. Review of Resident 6's Postural Support/Developmental Safety Device Rationale and Consent, dated 5/17/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 331's room on 7/16/24, at 8:33 a.m., Resident 331 was in bed with bilateral upper and lower side rails up. Review of Resident 331's physician orders indicated there was no order for the use of side rails. Review of Resident 331's Postural Support/Developmental Safety Device Rationale and Consent, dated 8/25/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 18's room on 7/16/24, at 8:33 a.m., Resident 18 was in bed with bilateral upper and lower side rails up. Review of Resident 18's physician order, dated 2/15/23, indicated he had an order for Upper and Lower Side Rails. Review of Resident 18's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/14/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 184's room on 7/17/24, at 11:25 a.m., Resident 184 was in bed with side rails up. Review of Resident 184's physician order, dated 7/16/24, indicated he had an order for Upper Side Rails. Review of Resident 184's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/8/24, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 23's room on 7/17/24, at 11:32 a.m., Resident 23 was in bed with side rails up. Review of Resident 23's physician order, dated 7/16/24, indicated she had an order for Upper Side Rails. Review of Resident 23's Postural Support/Developmental Safety Device Rationale and Consent, dated 7/11/24, indicated alternative measures were not attempted prior to the use of side rails. During an interview with the rehabilitation supervisor (RS) on 7/22/24, at 11:33 a.m., she stated the alternative measures such as frequent visual check for safety, pillow/wedged cushions, or frequent repositioning, etc. would be attempted only if the responsible party (the party responsible to making health care decisions when the principal party is unable to make health care decisions for him or herself) of the resident refused to give the consent for side rail. Otherwise, the side rail would be used. The RS acknowledged that the alternative measures should be attempted prior to the use of side rail. During an interview with the director of nursing (DON) on 7/22/24, at 11:36 a.m., she confirmed alternative measures were not attempted for Residents 1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331 prior to the use of side rail. Review of the facility's undated policy, Bed/Side Rails, indicated, . 4. Appropriate alternative interventions are to be utilized prior to using bed/side rails . 48590

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Food was kept beyond their open and expiration dates, 2. Temperature logs for two refrigeration units had missing entries, 3. Five opened spice containers were without expiration dates, 4. Three cutting boards had deep cut marks on their surface, 5. Five red onions and four yellow onions were moldy, six potatoes were soft and wrinkled, and 6. A fan had dark particles on its fan blades and grills. These failures had the potential to cause food-borne illness for residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the dietary supervisor (DS) on [DATE] at 8:40 a.m., the DS confirmed the following food items located in active use areas of the kitchen were expired: potato salad, left over beans in an unsealed bag dated [DATE], an open bag of broccoli dated [DATE]. The DS stated left over food are kept ,d+[DATE] days the left over beans you have been in a sealed bag. Review of facility's undated policy and procedure (P&P) Food Labeling Policy for Open Food Items, indicated, 3 days open for produce, turkey ham, tuna .deli salad, opened ROP (Reduced Oxygen Packaging) bags and other canned items. Review of facility's P&P Food Safety and Sanitation policy, dated 2013, indicated, Foods with expiration date are used prior to the use by date on the package. Review of The Federal Food and Drug Administration (FDA) Food Code 2022, chapter ,d+[DATE].17 (A) (B) (C) (D) indicated the day the original [food] container is opened in the food establishment shall be counted as Day 1 such that, . The date marked shall not exceed a manufacturer's use-by date . mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. 2. During a concurrent interview and record review with the DS on [DATE] at 8:35 a.m., the DS reviewed the formula refrigerator temperature log located in the hallway, which had missing temperature entries on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; and, the standing refrigerator temperature log located in the kitchen had missing temperature entries on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The DS stated the temperature monitoring of these refrigeration units should have been documented on their respective temperature logs twice daily. Review of the Daily Refrigerator/Freezer Temperature Log, dated ,d+[DATE] indicated, A designated food service employee will record the time, air temperature and their initials (preferably upon arrival) once in the morning and once (preferably just before leaving the facility) in the afternoon. 3. During a concurrent observation and interview with the DA on [DATE] at 8:43 a.m., the DA confirmed five spice containers were labeled with open dates, but no expiration or best-by-dates as follows: a. Onion Powder [DATE]. b. Ground [NAME] Pepper [DATE]. c. Ground paprika [DATE]. d. Granulated onion [DATE]. e. Whole Oregano Leaves [DATE], The DA stated the spices will be thrown out. Review of the facility's undated P&P Food Labeling Policy for Open Food items indicated, 90 days for spices, uncooked pasta, rice, nuts . Review of the facility's P&P Food Safety and Sanitation, dated 2013, indicated, Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines. 4. During a concurrent observation and interview with the DS on [DATE] at 8:48 a.m., the DS confirmed the three cutting boards had deep cut marks on their surfaces. The DS stated they should not be used and should be replaced. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022, chapter ,d+[DATE].12, indicated surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized . 5. During a concurrent observation and interview with the DS on [DATE] at 8:51 a.m., the DS confirmed six potatoes in a bag were soft and wrinkled, and five red onions and four yellow onions in a plastic container were moldy. The DS stated these would be thrown out. Review of the facility's P&P Food Safety and Sanitation, dated 2013, indicated, . food must be clean, wholesome, and free from spoilage. 6. During a concurrent observation and interview with the DS on [DATE] at 8:51 a.m., the DS confirmed the electric fan on the floor of the kitchen has dark particles on the fan blades and grills. The DS stated the fan should be cleaned. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022, chapter ,d+[DATE].11 (C) indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to implement infection control practices when the filters of oxygen concentrators were dusty for five of 13 residents (3, 23, 25, 183, and 184). This failure had the potential to spread infection in the facility. Findings: Review of Resident 3's Admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure (a condition that makes it difficult to breathe; respiratory failure develops when the lungs cannot get enough oxygen into the blood) diagnosis. Review of Resident 3's physician order, dated 5/10/24, indicated she had an order for oxygen as needed to keep her oxygen saturation (O2 Sat, the amount of oxygen that's circulating in the blood) above 92%. During an observation with respiratory therapist D (RT D) on 7/15/24, at 10:41 a.m., the filter of Resident 3's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 3's oxygen concentrator was dusty. Review of Resident 23's Admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure diagnosis. Review of Resident 23's physician order, dated 7/9/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. During an observation with RT D on 7/15/24, at 10:44 a.m., the filter of Resident 23's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 23's oxygen concentrator was dusty. Review of Resident 25's Admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure diagnosis. Review of Resident 25's physician order, dated 4/24/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. During an observation with RT D on 7/15/24, at 10:49 a.m., the filter of Resident 25's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 25's oxygen concentrator was dusty. Review of Resident 183's Admission Record indicated she was admitted to the facility on [DATE] with dependence on a ventilator (a machine that helps a person breathe or breathes for the person) status (if people are unable to wean off and breathe independently, they become ventilator dependent) diagnosis. Review of Resident 183's physician order, dated 4/24/24, indicated she had an order for oxygen as needed to keep her O2 Sat above 92%. During an observation with RT D on 7/15/24, at 11 a.m., the filter of Resident 183's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 183's oxygen concentrator was dusty. Review of Resident 184's Admission Record indicated he was admitted to the facility on [DATE] with respiratory failure and dependence on ventilator status diagnoses. Review of Resident 184's physician order, dated 7/1/24, indicated he had an order for oxygen as needed to keep his O2 Sat above 92%. During an observation with RT D on 7/15/24, at 11 a.m., the filter of Resident 184's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 184's oxygen concentrator was dusty. During a concurrent interview with RT D, she stated the filters of oxygen concentrators should be kept clean. Review of the facility's 2021 service manual, [machinery make/model name] 5-Liter Oxygen Concentrator Service Manual, indicated, Cleaning: The recommended cleaning interval for the air filter is 7 days.

Based on interview and record review, the facility failed to implement their abuse policy by failing to obtain background checks for one of three certified nursing assistants (CNA C), when CNA C was hired without a background check. This failure had the potential to put the residents at risk for abuse. Findings: Review of CNA C's personal file indicated she was hired to the facility on [DATE], but there was no background screening found for her. During an interview with the director of staff development (DSD) on 7/19/24, at 4:05 p.m., he stated he would check with human resources for CNA C's background check document. During an interview with the DSD on 7/23/24, at 12:36 p.m., he stated he checked with human resources and confirmed that CNA C did not have a background screening done when she was hired on 2/8/24. Review of the facility's undated policy, Abuse, indicated, . C. Screening: a. The facility will not knowingly employ any individual convicted of resident abuse, misappropriation of resident property, or reported abuse as noted by licensure boards of registries. Upon hire, the facility will . a. Obtain reference and background checks .

Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered a medication accurately according to the manufacturer's specifications for one of 12 sampled residents (Resident 331), when Resident 331's Lansoprazole (drug used to reduce stomach acid) Oral Disintegrating Tablet (ODT, fast-melting tablet that dissolves quickly in saliva/water) 30 milligrams (mg, unit of mass measurement) was crushed before administration, contrary to the manufacturer's guidelines. This failure had the potential to reduce medication efficacy for Resident 331. Findings: During an observation of a medication administration on 7/15/24 at 8:28 a.m., Licensed Vocational Nurse A (LVN A) crushed a tablet of lansoprazole ODT 30 mg then mixed it with water prior to administering the mixture to Resident 331. During an interview with LVN A on 7/15/24 at 8:38 a.m., she stated she crushed all of Resident 331's medications according to Resident 331's physician's orders. During a concurrent interview and record review on 7/15/24 at 2:32 p.m. with LVN A, review of the facility's Nursing drug Handbook, 2024 edition, page 1421, with LVN A indicated lansoprazole ODT should not be broken. LVN A acknowledged and stated she should not have crushed the lansoprazole tablet . During a concurrent interview and record review with Registered Nurse B (RN B) on 7/17/24 at 8:59 a.m., he stated he administered the lansoprazole ODT tablet to Resident 331 earlier this morning by crushing it and mixing it in water before administration. RN B reviewed the above-mentioned Nursing Drug Handbook, and stated he forgot that it is not to be crushed. A review of the pharmacy label on the bag containing Resident 331's lansoprazole ODT tablets indicated, Do not chew or crush. Review of Resident 331's physician's order, dated 1/12/24, indicated to give lansoprazole 30 mg via G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) one time a day for gastritis (inflammation of the lining of the stomach). Review of Resident 331's July 2024 Medication Administration Record indicated LVN A administered the lansoprazole ODT 30 mg to the resident four times on: 7/3/24, 7/4/24, 7/12/24, and 7/15/24; and, RN B administered it four times on: 7/9/24, 7/10/24, 7/11/24, and 7/17/24. Review of the facility's policy and procedure titled, Medication Administration, dated 10/2023, indicated, Each nurse should comply with the recommended medication administration guidelines and specific hospital policies developed to foster safety and efficacy in the current published references available on the nursing units.

Based on observation, interview, and record review, the facility failed to ensure a multi-dose medication was labeled with an open date after opening, and not stored beyond its discarding date. This failure had the potential for residents to receive expired, contaminated, or deteriorated medication. Finding: During an observation and record review with Registered Nurse B (RN B) on [DATE] at 10:12 a.m., an open 10 milliliter (mL) multi-dose vial of lorazepam (a controlled medication to treat seizures and agitation) 2 milligrams/mL was identified in the medication refrigerator without an open date on the vial. RN B reviewed the Controlled Drug Record and stated the lorazepam vial was opened on [DATE] (4 months ago). He acknowledged the vial should have been labeled with an open date. During a follow-up interview on [DATE] at 2:08 p.m., RN B stated he checked with the pharmacy and was told the lorazepam vial should be discarded 28 days after it was punctured. During a telephone interview with the Consultant Pharmacist (CP) on [DATE] at 2:50 p.m., she stated multi-dose vials should be discarded 28 days after opening to minimize cross contamination (a process by which harmful bacteria are unintentionally transferred from one object to another). A review of the facility's Multiple dose Vial policy and procedure, dated ,d+[DATE], indicated, all multi-dose vials with preservatives shall be dated and initialed when opened, and discarded within 28 days unless a shorter expiration date is indicated on the label.

Based on interview and record review the facility failed to follow-up with the dental services for one (Resident 1) of three residents when Resident 1's tooth was avulsed. This failure resulted in Resident 1's tooth not reimplanted for 11 months or not having the replacement tooth for 11 months. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including anoxic brain injury, persistent vegetative state and dependence on respirator. Review of Registered Nurse's (RN A) notes, dated 3/31/22, indicated resident 1 banged his tooth to side rail during activity of daily living (ADLs) while being turned. Review of the facility dentist (DT) notes, dated 4/3/22, indicated Resident 1 sustained avulsion injury of a permanent tooth after hitting his tooth on the bed side rail. Further review of the DT notes indicated Resident 1's responsible party (RP; person who makes all care decisions for the resident) was to pursue a dental implant to restore the empty space in the mouth where a tooth was. Review of Licensed Vocational Nurse's (LVN B) notes, dated 4/16/22, indicated Resident 1 was approved for dental referral for consultation. Review of the inter-disciplinary team care conference, dated 4/25/22, did not indicate how the tooth reimplantation will pursue. During an interview with the facility dentist (DT), on 1/30/23 at 3:00 p.m., the DT indicated for an implant Resident 1 would need hospitalization and anesthesia (use of medications to prevent pain during surgery). Review of Resident 1's clinical record did not indicate Resident 1 was hospitalized for the reimplantation. During an interview with the Social Services Director (SSD), on 1/30/2023 at 2:15 p.m., the SSD confirmed the RP wanted Resident 1 to have an implant. She stated the Administrator was hesitant to pay for services and to only find a place that took the RP's insurance. The SSD stated the burden fell on to the RP to cover with her insurance. The SSD stated she left her position at the facility, in part, because of the handling of this incident. She stated the previous administer did not want to cover it. She indicated she provided to the RP the state agency (SA) contact information along with the ombudsman's contact information so the RP could file a complaint with the SA. She stated she had a meeting with the owner of the facility who indicated the facility should pay for expenses. She stated she returned to working for the facility after the previous administrator left employment. During an interview with the ombudsman (OMB), on 1/30/2023 at 2 p.m., the OMB indicated her understanding was the facility said no on the implant and she indicated she believed the facility was responsible for the implant given it happened while Resident 1 was under their care. Review of the facility's email sent to the surveyor, dated 2/24/23, indicated the facility's plan was to reimburse for any dental expenses. Review of the facility's policy Dental Services, reviewed 10/2021, indicated if dental services cannot be provided at the facility, the facility will assist in making appointments and arranging for transportation to and from the service location.

Based on observation, interview, and record review, the facility failed to ensure proper cleaning of suction canisters at the bedside for 25 of 25 residents who require suctioning, when the canisters were being emptied and rinsed with sterile water before being placed back into suction machine. This failure had the potential of spreading infectious agents from bodily fluids. Findings: During an interview on 1/4/23 at 9:35 a.m., with the minimum data set nurse (MDSN), she stated there were 25 residents who had a tracheostomy (trach, a surgically created hole into windpipe for an alternate way of breathing) who needed to be suctioned. During an interview on 1/4/23 at 10:15 a.m., with certified nursing assistant A (CNA A), CNA A stated, staff were emptying the suction canisters into the toilet and rinsing them in the sink before putting it back where it was from. CNA A further stated, about two months ago the facility used to throw the canister after each use. During an interview on 1/4/23 at 10:45 a.m., with respiratory therapist B (RT B), RT B stated, staff were emptying the suction canister by dumping its content into toilet, then rinse out using sterile water. RT B confirmed the suction canisters were being rinsed out and replaced with a new one every two weeks. During an interview on 1/4/23 at 11:03 a.m., with the central supply staff (CS), the CS stated, the facility tried to switch to suction canister liners that would be thrown away after each use, but the liners were backordered. The facility started using the prior canister system, since the canister liners were backordered. During an interview on 1/4/23 at 11:10 a.m., with CNA B, CNA B explained how the suction canisters were being emptied. CNA B stated, staff disconnect the tubing, take the canister to the restroom where they dump its content into the toilet, rinse the canister with sterile water, empty into the toilet and then flush the toilet before returning the canister where it came from. CNA B further stated CNAs, license nurses and RTs were responsible in emptying the suction canisters. During a review of an email sent on 1/4/23 at 4:06 p.m. from the director of staff development (DSD), the email indicated, The announcement regarding going back to our previous P/P [policy and procedure] of emptying suction canisters were communicated through the meeting with all staff. During a review of the suction canister manufacturer's cleaning instruction indicated, .3. Collection bottle should be thoroughly cleaned after each use by one of the following three methods: a. Wash in hot water/dishwashing detergent solution, and rinse with clean, hot tap water. Then wash in one part vinegar to three parts hot water solution. Rinse with hot tap water and air dry. b. Wash with rubbing alcohol and air dry. c. Wash with a commercial (bacterial-germicidal) disinfectant, follow disinfectant manufacturer's recommended instructions and dilution rates carefully. Clean suction unit and collection bottle lid: .2. Wipe the suction unit housing and collection bottle lid with a clean cloth and any commercial (bacterial-germicidal) disinfectant. Clean tubing: .2. Tubing should be rinsed thoroughly after every use by running hot tap water through it followed by a solution of one part vinegar to three parts hot water.

Based on interview and record review, the facility failed to investigate an injury of unknown origin for one of two sampled residents (Resident 2) when a fracture of right humerus (arm bone between shoulder and elbow) was found and no documented evidence to indicate the injury was thoroughly investigated in a timely manner. This failure had the potential to place the resident for further injury. Findings: Review of Resident 2's clinical record indicated she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's progress note dated 4/10/21, indicated Resident 2's arm was swollen from below the shoulder and elbow. Review of Resident 2's X-ray (an image of internal body structures such as bones or organs) result dated 4/10/21, indicated Resident 2 had a fracture of the humerus. During an interview with the director of nursing (DON) on 10/12/21 at 10:50 a.m., she stated she could not find the narrative investigation for Resident 2's right humerus fracture. DON also stated there was no documented evidence for interdisciplinary team (IDT, team members from different disciplines working collaboratively, a common purpose, make decisions, and share resources and responsibilities) investigation report related to Resident 2's injury of unknown origin. During an interview with the administrator (ADM) on 10/14/21 at 10:55 a.m. he stated he was not responsible for the investigation report regarding Resident 2's injury of unknown origin and he was not the ADM when the incident happened. Review of the facility's 2018 policy, Unusual Occurrences, indicated all unusual occurrences which threaten the welfare, safety, and health of the patients, an incident report would be completed as well as narrative or investigation. This information will be either be faxed or mailed to the Department of Health Licensing and Certification.

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for one of two sampled residents (Resident 1), when Resident 1's bed side rails were not padded and Resident 1's hand splints were not applied as ordered by the physician. These failures had the potential to cause injury and compromise the safety of the resident. Findings: Review of Resident 1's clinical record indicated she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of Resident 1 on 10/11/21 at 9:05 a.m., the resident was lying in bed and the bed side rails were not padded. The Resident had no hand splints on neither left hand nor right hand. During an observation and interview with registered nurse A (RN A) on 10/11/21 at 4 p.m., Resident 1 was observed lying in bed, the side rails were not padded, and hand splints were not applied to either left or right hand. RN A confirmed Resident 1 side rails were not padded and hand splints were not applied. RN A stated they could not find Resident 1's left hand splint. During an interview with the director of nursing (DON) on 10/12/21 at 12:15 p.m., DON confirmed Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(4), indicated RNs have a role on the observation of signs and symptoms of illness reactions to treatment, assess physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, (B) implementation, based on observed abnormalities, of appropriate reporting, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures.

Based on observation, interview, and record review, the facility failed to properly implement the strategies to prevent the spread of coronavirus 2019 (COVID-19, a new strain of virus that can cause mild to severe illness) when: 1. There was no staff to share the role as Infection Preventionist (IP) for infection control program when the designated IP was not available; 2. Registered Nurse A (RN A) did not wear an N95 (a filtering piece of airborne particles) mask properly; 3. The trash disposable bin was not positioned near the exit door for COVID-19 observation room; 4. The housekeeping staff did not follow the proper cleaning procedure for COVID-19 observation room; 5. The facility did not properly document the COVID-19 screening log for visitors and staff; and 6. Diagnostic screening testing was not properly documented for unvaccinated facility staff. These deficient practice had the potential to result in the spread of COVID-19 in the facility. Findings: 1. During an interview with the administrator (ADM) on 9/13/21 at 9:17 a.m., he stated the designated IP was not in the building and the staff that shares the role as IP, was at the day program. The ADM also stated the IP was not in the building since last Thursday (9/9/21). During an interview with the service coordinator (SC) on 9/13/21 at 12:10 p.m., she stated she was not the back-up IP of the facility and her responsibility was the interdisciplinary meetings. According to the Centers for Disease and Control Prevention (CDC) website https://www.cdc.gov/coronavirus/2019-ncov/hcp/longterm care.html Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes indicated there should be a full-time role at least one person in the facilities. According to the California Department of Public Health (CDPH) All Facilities Letter 20-52 (AFL 20-52), Coronavirus Disease 2019 Mitigation Plan Implementation and Submission Requirements for Skilled Nursing Facilities (SNF) and Infection Control Guidance for Health Care Personnel dated 5/11/2020, indicated infection prevention and control that the skilled nursing facility must have a full-time, dedicated IP. This can be achieved by more than one staff member share the role but a plan must be in place for infection prevention quality control. 2. During an observation with the ADM on 9/13/21 at 10:30 a.m., RN A wore an N95 mask over a surgical mask and she entered the observation room for COVID- 19. During a concurrent interview with RN A, she stated she should have worn the N95 with no surgical mask inside. During an interview with the director of nursing (DON) on 9/13/21 at 3:05 p.m., she stated RN A should not have worn an N95 mask with a surgical mask inside. According to the Centers for Disease and Control Prevention (CDC) website https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf indicated Do not allow facial, hair, jewelry, glasses, clothing, or anything else to prevent proper placement or come between your face and the respirator. 3. During an observation with the ADM on 9/13/21 at 10:30 a.m., RN A removed her disposable gown inside the COVID-19 observation room; the trash disposable bin was positioned at the end of the room. During an interview with the DON on 9/13/21 at 3:00 p.m., she stated the trash disposable bin should have been positioned near the exit door. Review of the facility's undated COVID-19 Mitigation Plan, indicated that each facility room should have disposable bins and bins should be positioned as near as possible to the exit door, inside the resident room. 4. During an observation and interview with the housekeeping (HK) on 9/13/21 at 10:40 a.m., she stated she was assigned to clean the COVID-19 observation room and the resident rooms with no COVID-19 known exposure. HK stated she cleaned the COVID- 19 observation room first and then she cleaned the residents room with no COVID-19 known exposure with the same HK equipment. HK also stated she cleaned rooms depending on which room was available During an interview with the DON on 9/13/21 at 3:06 p.m., she confirmed HK should have cleaned the resident rooms with no COVID-19 known exposure first before the COVID-19 observation room. According to the California Department of Public Health (CDPH) All Facilities Letter 20-74.1(AFL 20-74.1), COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category, dated 7/22/21, indicated to consider grouping activities such that health care provider care for all residents in the Green (residents with no known exposure to COVID-19)-negative area before caring for residents in the yellow (COVID exposed residents) -areas. 5. Review of the facility's Visitor's Screening log from 9/11/21 to 9/9/21, indicated the questionnaire for COVID-19 symptoms was blank for one visitors and temperature for one visitor was 38.4 degrees Celsius (101.12 Fahrenheit). Review of the facility's Staff's Screening log for 9/13/21, indicated the questionnaire related to COVID-19 symptoms for three (3) staff were not properly filled out. During an interview and record review with the DON on 9/13/21 at 3:15 p.m., she confirmed the visitor and staff screening log were not properly filled out. Review of the facility's undated COVID-19 Mitigation Plan, indicated the screener would ask the staff/visitor if they are experiencing any of the following symptoms related to COVID-19 in the past 48 hours. If any symptoms are present, the staff/visitor should not enter the building. The screener would use the thermometer to check the staff/visitor temperature. Any individual that was screened with any grade of fever 37.2 degrees Celsius (99.0 degrees Fahrenheit) and above would not be allowed to enter the facility. 6. During an interview and record review with the DON on 9/13/21 at 3:17 p.m., she stated the unvaccinated staff should have a diagnostic screening testing twice a week but two staff were tested three (3) times for the month of August 2021. The DON stated the diagnostic screening testing for unvaccinated staff was not properly documented. According to the California Department of Public Health (CDPH) All Facilities Letter 21-28 (AFL 21-28), Coronavirus Disease 2019 (COVID-19) Testing, Vaccination and Personal Protective Equipment for Health Care Personnel (HCP) at Skilled Nursing Facilities (SNF) dated 8/3/21, indicated HCP who are unvaccinated or incompletely vaccinated must undergo at least twice weekly [CONDITION(S)]-CoV-2 diagnostic screening testing.

Based on interviews and record review, the facility failed to ensure a nursing staff followed the facility's medication administration policy and procedures by using two resident identifiers to verify the resident's identity (ID) before medication administration. This failure resulted in one of two sampled residents (Resident 1) receiving the wrong medications, which could potentially result in adverse effects (such as respiratory [breathing] distress, seizures, etc.) for the resident. Findings: During an interview with the director of nursing (DON) on 8/31/21 at 11:15 a.m., she stated a medication error happened on 8/28/21 around 10:15 p.m., when registered nurse A (RN A) was preparing medications for Resident 2 while the alarm in Resident 1's room went off. RN A went into Resident 1's room to respond to the alarm. After clearing the alarm, RN A proceeded to give Resident 2's medications to Resident 1, which he had brought in with him. The DON said the medications involved were: [MEDICATION(S)] (to treat pain and muscle stiffness), [MEDICATION(S)] (to treat anxiety, muscle spasm, and seizures) and [MEDICATION(S)] (to reduce saliva and drooling). A review of Resident 2's medical record indicated the resident had the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 60 milligrams (mg, unit of measurement) via gastrostomy-tube (or G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) four times daily for muscle spasm/stiffness, dated 6/30/2021. - [MEDICATION(S)] 4 mg via G-tube four times a day for muscle spasm/stiffness, dated 6/30/2021. - [MEDICATION(S)] 3.5 mg via G-tube four times daily for secretion reduction, dated 6/29/2021. During an interview with the director of staff development (DSD) on 8/31/21 at 1:15 p.m., he stated RN A brought the prepared medications for Resident 2 with him into Resident 1's room and inadvertently administered them to Resident 1. The DSD stated RN A should have locked the medications in the medication cart before responding to the alarm and RN A did not check the resident's ID before giving the medications. During a telephone interview with RN A on 9/1/21 at 3:50 p.m., he stated at around 10 p.m. on the day of incident, he was preparing 3 medications (as stated above) for Resident 2 when the alarm in Resident 1's room went off. He went in to respond to the alarm. RN A said he brought the prepared medications with him because he did not want them unattended in the medication cart. Prior to that, he had crushed each medication individually and mixed each medication with about 5 - 7 milliliters (ml, unit of measurement) of water. After clearing the alarm, he began to give the medications to Resident 1. He stated after attaching the syringe to the G-tube, he flushed it with 10 ml of water, then poured the first and second medications into the syringe, one at a time. He said as he poured the third medication into the syringe, he said to Resident 1, Ok, [Resident 2's first name], here's your third medication. I hope it helps you with your pain. RN A said just then he looked up at the resident's face and realized it was not Resident 2 he was administering the medications to. He immediately clamped the tubing, removed the syringe, and aspirated (draw out using suction) about 20 ml of the medication contents out of Resident 1's G-tube. RN A stated he believed he removed most, if not all, of the volume he administered from the resident's G-tube. He said, I missed checking the patient's ID. My mind was on the alarm. I didn't check the patient's armband. He said the normal process was to use two resident identifiers such as comparing the resident's face against the picture on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's medical record indicated she was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's medical record reflected the nursing notes, written by RN A on 8/28/21 at 10:15 p.m. It indicated During shift nurse was preparing meds for [Resident 2] when an alarm went off in [Resident 1's first name's] room. After checking on the patient and ensuring they were okay the nurse flushed the patient and then began to give the medications for [Resident 2] to [Resident 1's first name]. This was stopped w/in 5 seconds of the medication administration however 20 ml had been instilled and nurse immediately aspirated the volume that had been given . Resident 1's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Medication Administration policy and procedures dated 2/13/2020, indicated Medications supplied for one patient are not administered to another patient, The nurse . should verify it is the 'right patient', using two patient identifiers, before administration of any medication, and The patient's identity must be verified before administration of a medication by checking the patient's armband and MD order.

Based on interview and record review the facility failed to implement their abuse policy and procedure for five of five sampled residents (Residents 1, 2, 3, 4, and 5) when: 1. After an abuse allegation was made by Resident 1, the certified nursing assistant A (CNA A) continued to provide care for the resident who accused him of abuse; 2. After the abuse allegation was made, CNA A was reassigned to care for other residents (Residents 2, 3, 4, and 5). This failure to follow the facility's policy and procedure had the potential for negative impacts on the emotional and psychological well-being of the residents. Findings Review of Resident 1's face sheet indicated Resident 1 was an [AGE] year old male, with an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. During a phone interview with CNA A on 8/18/21 at 4:15 p.m., he stated he was positioning Resident 1 on a slide sheet (used with a mobility tool to lift individuals who cannot bear weight) on 8/11/21 around 5:30 p.m., when Resident 1 hit CNA A in the stomach. CNA A stated he immediately reported this to Registered Nurse B (RN B). CNA A stated RN B asked Resident 1 why he hit CNA A and Resident 1 responded with .he squished my brain. CNA A stated he continued to stay with Resident 1 and monitor Resident 1 as he ate his dinner. During a phone interview with certified nursing assistant B (CNA B) on 8/24/21 at 4:00 p.m., she confirmed CNA A remained in Resident 1's room after the allegation of abuse and continued to observe Resident 1 eat dinner. Record review of the facility's policy and procedure Abuse, dated 2018, indicated residents and staff are to be protected during an incident investigation by ensuring .accused employees are removed from resident contact immediately 2. During a phone interview with CNA A on 8/18/21 at 4:15 p.m., he stated after Resident 1 completed his dinner, he was then reassigned to care for other residents (Residents 2, 3, 4, and 5) at roughly 7:00 p.m. CNA A confirmed he worked the rest of his shift providing direct care to residents until 11:30 p.m. During a phone interview with CNA B on 8/24/21 at 4:00 p.m., she confirmed CNA B was then reassigned to a different hall to care for other residents (Residents 2, 3, 4, and 5) after Resident 1 had completed dinner. During an interview with Director of Nursing (DON) on 8/11/21 at 4:30 p.m., the DON stated CNA A continued to provide direct resident care for the rest of his shift until it ended at 11:30 p.m. Record review of the facility's policy and procedure Abuse, dated 2018, indicated residents and staff are to be protected during an incident investigation by ensuring .accused employees are removed from resident contact immediately

Based on observation, interview, and record review the facility failed to provide accurate visitation information to residents and their families for 27 of 27 sampled residents when: 1. The facility website which parents and residents accessed for visitation information inaccurately indicated no visitation was allowed; 2. The letter posted in the entryway to the facility for visitors inaccurately indicated no Sunday visitation and that 1.5 hours were permitted per visitation; 3. Visitation was limited due to staffing availability and another parent's visitation schedule; These failures had the potential to result in psychosocial harm (social factors and the relationship between social factors and behavior) for 27 of the 27 sampled residents and had the potential to negatively impact the remaining resident's psychosocial development and mental health. Findings: This is a licensed skilled nursing facility and is a children's subacute facility with the residents living there and receiving medical care. The residents vary in ages and can live at the facility up to [AGE] years of age and are dependent on medical care like [CONDITION(S)] care (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube), ventilators (machine that moves air into and out of the lungs), intravenous medications (to deliver a medication into a vein), [CONDITION(S)] (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), tube feeding (medical device to provide nutrition to people), and other medical technology needed to sustain life. 1. During observation, interview, and record review on 7/21/2021 at 1:46 p.m., registered nurse 1 (RN 1) confirmed the website, www.chonc.org Saratoga, indicated .our facilities are on lockdown except for essential employees until further notice. RN 1 confirmed this was inaccurate information and visitation resumed in May 2021. RN 1 confirmed this could confuse visitors looking to the website for visitation information. During an interview and concurrent record review with the Activities Director (AD), on 7/21/21 at 2:00 p.m., she indicated visitation per resident was to be scheduled in advance for twice weekly, for 2 hours, and for 2 visitors with visitation hours between 8:00 a.m. and 8:00 p.m The AD stated .we encourage Zoom (video conferencing) instead. During a telephone interview with the Santa [NAME] County Registered Nurse (SCC RN) on 7/20/2021 at 3:15 p.m., she indicated the county was not limiting visitation in the facility and stated parents need to be allowed to visit and the facility should follow the California Department of Public Health, All Facilities Letter (CDPH AFL) 20-22.8. Record Review of CDPH AFL 20-22.8, dated 6/2/2021, indicated visitors for pediatric residents at long term care facilities are vital for the mental health and developmental needs of the resident and indicated visitation must be permitted. Review of the facility's admission packet, dated 4/2021, indicated under Safety and Security Policies indicated immediate family may visit at any time. Review of the facility's admission packet, dated 4/2021, indicated under Resident Rights that residents can associate and communicate privately with persons of their patient's choice. In the facility packet, under California Welfare and Institutions Code Sections 4502-4505,4512, indicated residents have a right to social interaction and visitation hours need to be established and available. 2. During observation, interview, and record review on 7/21/2021 at 1:46 p.m., with registered nurse 1 (RN 1), she confirmed the letter dated 6/11/2021, from the Infection Prevention (IP) nurse in the entryway to the facility indicating visits are to be prescheduled with the IP Monday through Saturday and with no visitation on Sundays for a total of 1.5 hours each visit and twice weekly. RN 1 indicated the letter was not reflective of the current visitation practice, which allowed for two hours per visit and can also be scheduled on Sunday. Record Review of CDPH AFL 20-22.8, dated 6/2/2021, indicated visitors for pediatric residents at long term care facilities are vital for the mental health and developmental needs of the resident and indicated visitation must be permitted. Review of the facility's admission packet, dated 4/2021, indicated under Safety and Security Policies indicated immediate family may visit at any time. Review of the facility's admission packet, dated 4/2021, indicated under Resident Rights that residents can associate and communicate privately with persons of their patient's choice. In the facility packet, under California Welfare and Institutions Code Sections 4502-4505,4512, indicated residents have a right to social interaction visitation hours need to be established and available. 3. During observation, interview, and record review on 7/21/2021 at 1:46 p.m., with registered nurse 1 (RN 1), she confirmed the letter from the Infection Prevention (IP) Nurse, dated 6/11/2021, in the entryway to the facility indicated visitation was based on staffing availability since the visits required staff assistance and/or observation. RN 1 stated prior to the COVID-19 pandemic having staffing present for visitation was not a requirement. During a telephone interview with the IP on 8/12/2021 at 9:34 a.m., the IP indicated the resident's nurse and the Director of Nursing (DON) decide if a respiratory therapist (RT) and a registered nurse (RN) be present for a visitation. The IP indicated this began after COVID-19 and stated if the staffing was not available for the visit, it would have to be rescheduled. The IP stated visitation is changed if there are too many visits in one day in the facility and stated this would be due to other parents scheduling visitation appointments. The IP indicated she was unsure what was stopping increasing visitation. The IP was unable to provide an explanation for the need for a RT and RNs to be present for a visit and stated there was nothing guiding this practice and the facility considered it to be safer. The IP agreed it made visitation more complicated because staffing had to be considered. Review of the facility's admission packet, dated 4/2021, indicated under Resident Rights that residents can associate and communicate privately with persons of their patient's choice. In the facility packet, under California Welfare and Institutions Code Sections 4502-4505,4512, indicated residents have a right to social interaction visitation hours need to be established and available.

Based on interview and record review, the facility failed to ensure a medication was administered as prescribed for one (Resident A) of one sampled resident. For Resident A, an excessive amount of a muscle relaxant medication ([MEDICATION NAME]) was received, resulting in a clinically evident overdose, and Resident A was transferred to an emergency room service. Findings: On 12/29/10 at 2:55 PM, Resident A received a clinically evident overdose of a muscle relaxant medication ([MEDICATION NAME]) during refilling of the [MEDICATION NAME] (ITB) pump when the medication entered the side port (the infusion port) instead of the reservoir port and the medication was injected into the resident [MEDICATION NAME] (infused into the membranes of the central nervous system) instead of being stored for gradual administration by the pump. Resident A became unresponsive and had decreased blood pressure, temperature, heart rate and respirations. Resident A was sent to an acute care hospital, emergency room service. Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident A had developed [DIAGNOSES REDACTED] (a state of increased muscular spasms). The 12/30/10 Minimum Data Set (MDS, a resident assessment) indicated Resident A had severely impaired decision making ability and needed total staff assistance for all care. Record review of Resident A's 12/06/2010 physician's orders [REDACTED]." Record review of Resident A's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Review of Resident A's Progress Record, dated 12/29/10 at 2:55 PM, indicated, "Resident MD try to refill [MEDICATION NAME] pump. Another RN... present at bedside with Resident MD. Before the [MEDICATION NAME] pump refill (ITB) procedure, patient alert and awake, open eyes, vs (vital signs) stable. During the [MEDICATION NAME] pump refill procedure, patient LOC (level of consciousness) changed. (L) eye closed, not waking up to touch. ...BP (blood pressure) 82/51 (reference range 120/80)...O2 Sat (oxygen saturation) 96% (reference range above 90%) RA (on room air), T (temperature) 96.6 F (Fahrenheit- reference range 98.6), RR (respiratory rate) 14 (reference range 14 - 20), HR (heart rate) 54 (reference range 60 - 100)..." Addition, at 3:15 PM, Resident A's BP dropped to 77/41, the HR dropped to 48 and one liter of normal saline was administered intravenously (IV). Review of Resident A's Progress Record, dated 12/29/10 at 3:30 PM, indicated, "BP 91/69...RR 4, O2 Sat 88%..... RT (Respiratory Therapist) bagged the patient with 100% O2. RT place the patient on vent (ventilator)." Review of Resident A's Progress Record, dated 12/29/10 at 4:30 PM, indicated, "Procedure: [MEDICATION NAME] pump refill. ...It was determined that we were likely in the side port (the infusion port). Therefore the 8 cc (centimeters = milliliters (ml) of 2000 meq/ml (milli-equivalents per milliliter) was injected [MEDICATION NAME] (infused into the membrane of the central nervous system for a suspected total of meq in 8 ml at one time instead of gradual administering by the pump at the rate of 473 mcg/day). The fluid that was pulled out was completely clear, not suggesting CSF (cerebrospinal fluid). The procedure was halted, pump was reinterigated (sic) (reinterogated- checking the reservoir volume registered by the pump) showing reservoir volume of 3 ml. This confirms either a subq (subcutaneous) or [MEDICATION NAME] injection. The pt (patient) was placed on close observation, vent was brought into room for resp (respiratory) support. He was noted to have decreasing temp, decreasing BP, which bottomed out at 71 SBP (systolic blood pressure). 2 peripheral IVs were started & ... [MEDICATION NAME] NS (normal saline) was given. His BP returned to 103 SBP. He continued to be sedated, his tone significantly decreased." Review of Resident A's physician's note, dated 12/29/10 at "Time 3-8 PM" indicated, "Pt (patient) received overdose of ITB amt (amount) unknown...Amt enough to make (Resident A) unresponsive with decreased respiratory excursions...BP...below his normal...given N/S (normal saline) with restoration of BP to his baseline...Remains unresponsive..." Addition, the physician's impression was, "ITB overdose- clinically evident - all VS (vital signs) stable and at baseline. Continue to monitor closely." Review of Resident A's physician's orders [REDACTED]." Review of Lexi-Drugs Online (http://online.lexi.com/crlsql/servlet/crlonline?doc&bc=patch_f&mn=&id=6414&mid=... 10/18/2011; copyright (c) Lexi-Comp, Inc. 1978-2011) information about [MEDICATION NAME] indicated an adverse effect of [MEDICATION NAME] was that it may cause "Central nervous system: Drowsiness, [MEDICAL CONDITION], psychiatric disturbances, [MEDICAL CONDITION], slurred speech, ataxia, [DIAGNOSES REDACTED]; Neuromuscular and skeletal: Weakness." Addition, a high alert medication indicated, "Heightened risk of causing significant patient harm when used in error." Review of Resident A's 11/1/08 Long Term Care Plan (Care Plan) for, "Potential for Overdose/Withdrawal of ITB," indicated the Interventions, "Give ITB per MD (Medical Doctor). Monitor for signs of overdose: drowsiness/dizziness, coma, lethargy, lightheadedness, breathing slowly/respiratory depression, [MEDICAL CONDITION], and [MEDICAL CONDITION]." During an interview on 1/12/11 at 12:00 PM, the Director of Nurses (DON) stated Resident A was overdosed by a muscle relaxant medication ([MEDICATION NAME]) during refilling and re-setting of ITB pump ([MEDICATION NAME], a surgically implanted infusion pump that directly delivered medication to the central nervous system) by Physician 1 (a resident physician) and Registered Nurse (RN) 1 on 12/29/10. DON also stated RN 1 was not certified by the facility by an in-service training in the procedures to use and refill the ITB pump; Resident MD did not have document to show competence to refill the ITB without supervision. During the re-filling process, the medication was accidently entered into the side port (the infusion port) instead of the center port (The center port is a reservoir port for re-filling the side port under a pre-set timing and a pre-set amount of medication for infusion into the resident). In addition, DON stated Resident A became unresponsive, had difficulty breathing, and was transferred toER on [DATE] and admitted to an acute care hospital. DON also stated on 12/29/10, the facility had no policy and procedure for administering ITB pump. Therefore, the facility failed to ensure that medication was administered as prescribed when Resident A received an excessive amount of a muscle relaxant medication ([MEDICATION NAME]), resulting in a clinically evident overdose, and was transferred to an acute care hospital, emergency room .