Every finding on record at Citrus Heights Post Acute

Based on observation, interview, and record review, the facility failed to follow proper sanitation and storage practices in accordance with professional standards for food service safety when:1a. One steam table pan had food residue in the pan, one pot had food residue on the bottom of the pan.b. One steam table pan was stored wet.2a. The dry storage area floor had an unopened bag of rice on the floor.b. The dry storage area had debris on the floor. These failures had the potential to lead to food borne illness for the 150 Residents out of 158 Residents eating facility prepared meals.Findings:1a. During an observation and concurrent interview on 4/13/26 at 7:06 a.m., with the Assistant Dietary Supervisor (AKS) during the initial kitchen tour, one steam table pan had food residue in the pan, one pot had food residue on the bottom of the pot in the ready to use storage rack. The AKS removed the pan and pot to the washing area, stating they are supposed to be checked for debris before being placed back on the ready to use storage rack.b. During a continued observation and interview on 4/13/26 at 7:07 a.m., with the AKS during the initial kitchen tour, a steam table pan was stored wet (wet nesting) in the ready to use storage rack. The AKS removed the steam table pan to the washing area, stating the expectation was that the pans are to be air dried before placing in the ready to use storage rack.During an interview with the Registered Dietician (RD) on 4/22/26 at 12:09 p.m., regarding what may happen with food residue left on pans, pans stacked away wet, RD confirmed it may harbor bacteria.Review of the facility policy titled Pot and Pan Washing (Healthcare Menus Direct, LLC., 2023) stated pots and pans will be properly sanitized. Review of the facility policy Kitchen Sanitation: Definition of Terms (Healthcare Menus Direct, LLC., 2023) stated under Cleaning: Removal of soil, particles, debris, and microorganisms adherent to the surface.Review of the facility policy Compartment Procedure for Manual Dishwashing (Healthcare Menus Direct, LLC., 2023) stated under step 6 that All items are to be air-dried, which means no water droplets are present.Review of the 2022 Federal Food and Drug Administration Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The food contact surfaces of cooking equipment and pans shall be free of encrusted grease deposits and other soil accumulations. 1/18/23 version, indicated .(C) Surfaces . shall be kept free of an accumulation of dust, dirt, food residue, and other debris.2a. During a continued observation and interview on 4/13/26 at 7:23 a.m., with the AKS during the initial kitchen tour, the dry storage area had an unopened 50 pound bag of rice stored on the floor by the door. The AKS placed the bag of rice on a rack. The AKS confirmed that the rice should not be stored on the floor.b. During a continued observation and interview o 4/13/26 at 7:24 a.m., with the AKS during the initial kitchen tour, the dry storage area had two forks, a piece of cardboard, a piece of plastic wrap with brown paper on the floor. The AKS confirmed that there should not be any items on the floor.Review of the 2022 Federal Food and Drug Administration Food Code, section 3-305.11, titled, Food Storage, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview and record review, the facility failed to ensure two out of 34 sampled residents (Resident 35 and Resident 12) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when;1. Resident 35's order for the use and monitoring of for Jackson Pratt (JP) drain bulb (closed-suction device used after surgery to remove fluids-like blood or serum-from the wound site, reducing infection risk and aiding healing) was not followed; and,2. Resident 12's elevated blood sugar (BS-the main sugar in body that gives you energy) was not monitored according to physician's order and plan of care. These failures had the potential for Resident 35 and Resident 12's medical condition to get worse, and for the residents to not achieve their highest practicable well-being. Findings: 1. A review of Resident 35's clinical record indicated Resident 35 was admitted March of 2026 and had diagnoses that included other postprocedural [after medical procedure or surgery] complications and disorders of digestive system, infection following a procedure, diabetes mellitus (a chronic condition causing too much sugar in the blood which inhibits the body's natural wound-healing capabilities), and muscle weakness. A review of Resident 35's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 4/2/26, indicated Resident 35 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 35 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). During a concurrent observation and interview on 4/20/26 at 9:08 a.m. with Resident 35, in Resident 35's room, Resident 35 was observed awake and was lying on his bed. Resident 35 had a drainage tube coming from the right side of his abdomen, labelled 4/18, and was connected to a drainage bag. The drainage bag was draining dark yellow fluid and was placed on the bed which was on the same level as the drainage site. Resident 35 confirmed the observation. Resident 35 stated he had an infection, that was why he had a drain. Resident 35 further stated that staff would sometimes drain the fluids from the bag, but he doesn't know if they would change the drainage bag. A review of Resident 35's Care Plan Report, dated 2/13/26, indicated, Pain: at risk for [ x] pain or discomfort due to: Acute cholecystitis [inflammation of the gallbladder], s/p [status post- after] subtotal cholecystectomy [surgical removal of a large portion of the gallbladder] 2/7, Resident has [NAME] Prtt [sic] surgical drain . A review of Resident 35's active physician's order, dated 3/31/26, indicated, JP Drain / Bulb Monitoring: Monitor for decreased/absent output, sudden increase in output, or change in color (e.g., bright red, purulent). Report signs of infection or complications to provider every shift for JP Drain. A review of Resident 35's active physician's order, dated 4/14/26, indicated, JP Drain Insertion Site Care: .Ensure bulb remains compressed to maintain suction. Empty JP drain, measure and record output, noting color and consistency. as needed for Soiling/Loosening. During a concurrent observation and interview on 4/20/26 at 1:27 p.m. with Licensed Nurse (LN) 5, in Resident 35's room, Resident 35 was observed lying on his bed, awake, has a drainage tube coming from the right side of his abdomen, and was connected to a drainage bag which was draining dark yellow fluid and was placed on the bed. LN 5 confirmed the observation. LN 5 stated Resident 35 always had a drainage bag and never had a JP drain bulb. LN 5 further stated the drainage bag should always be placed lower than the drainage site to facilitate draining and prevent further infection and complications. During a concurrent interview and record review on 4/20/26 at 1:30 p.m. with LN 5, Resident 35's medical records were reviewed. LN 5 confirmed that Resident 35 came back from the hospital on 3/30/26 with a drain and has an order to monitor JP drain bulb on 3/31/26. LN 5 stated the order for JP drain bulb should have been followed because the JP drain bulb provides suction which would prevent complications and would provide faster and better healing. During an interview on 4/22/26 at 2:13 p.m. with the Director of Staff Development (DSD), the DSD stated the order for drainage bulb should have been followed because a drainage bag does not provide sufficient suction to drain. The DSD also stated if they were using a drainage bag, the bag should be placed below the drainage site to promote drainage. The DSD further stated the resident would be at risk for wound complication and infection if the physician's order was not followed. A review of an online article titled, Jackson Pratt (JP) Drain, dated 10/23/23, indicated, A Jackson Pratt (JP) drain is a surgical suction drain that gently draws fluid from a wound to help you recover after surgery. To use one, you'll need to regularly empty a collection bulb that catches the fluid draining from your wound. The bulb pulls the fluid out when it's squeezed. It can speed up your healing time and reduce your risk of an infection. (https://my.clevelandclinic.org/health/articles/21104-[NAME]-[NAME]-jp-drain) A review of the facility's P&P titled, Jackson Pratt (JP) Drain, revised 3/2019, indicated, The purpose of this procedure is to empty the Jackson Pratt drain bulb, clean the surgical wound, and monitor for infection .Emptying the drain: .5. Squeeze the bulb flat. 6. While the bulb is flat, put the plug back into the bulb. 7. The bulb should stay flat after it is plugged so that the vacuum suction can restart. 8. If you can't squeeze the bulb flat and plug it at the same time, use a hard, flat surface (such as a table) to help you press the bulb flat while you replug it . 2. Review of Resident 12's clinical record indicated Resident 12 was admitted to the facility on [DATE] with multiple diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) and adult failure to thrive (substantial decline in overall health and functional abilities). A review of Resident 12's April 2026 Order Summary Report contained a physician's order dated 6/28/25 for HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400 = 14 units Notify MD for >400, subcutaneously (under the skin) before meals for DM (Notify MD for BS<70,>350). During a concurrent interview and record review on 4/21/26 12:41 p.m. with the Director of Nursing (DON) and the Resource Nurse, Resident 12's Medication Administration Record (MAR) dated March 2026 was reviewed. The March MAR indicated on 3/24/26 at 11:30 a.m. Resident 12's blood sugar was 502 and there was a 9 in the LN's initial box for Resident 12's Humalog. The Resource Nurse stated 9 indicated the LN wrote a note. Review of a eMar - Medication Administration Note, dated 3/24/26 at 1:04 p.m. the LN documented, NP (Nurse Practitioners) informed to give 14 units sliding scale. Review of Resident 12's Progress Note eINTERACT SBAR Summary for Providers, dated 3/24/26 at 3:50 p.m. indicated on 3/24/26 at 1:04 p.m. Resident 12's blood glucose (blood sugar) was 502. The LN further documented under Nursing observations, evaluation, and recommendations are: resident blood sugar 502 no sign symptom of hyperglycemia (high blood sugar) NP informed give schedule sliding scale insulin and recheck. no complain of pain. refused to recheck blood sugar Np informed nonew (sic) order monitor. During a concurrent interview and record review on 4/21/26 at 12:41 p.m. with the DON and the Resource Nurse, Resident 12's MAR dated March 2026 was reviewed. The MAR indicated on 3/24/26 at 4:30 p.m. the LN documented NA (not applicable) in the box for Resident 12's blood sugar and there was 9 in the LN's initial box for Resident 12's Humalog. The Resource Nurse stated 9 indicated the LN wrote a note. The Resource Nurse stated there was no progress note written for the entry, 3/24/26 at 4:30 p.m. The Resource Nurse stated there was no documentation that Resident 12's blood sugar was re-checked at 4:30 p.m. and no documentation that Resident 12 received his insulin as prescribed. The DON stated she would expect the LN to have re-checked Resident 12's BS and administer insulin as prescribed. A review of Resident 12's April 2026 Order Summary Report contained a physician's order dated 5/31/24 for Humalog KwikPen Subcutaneous Solution 100 UNIT/ML Inject as per sliding scale: if 70 - 150 = 0; 151 - 200 = 0; 201 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units Notify MD for BS>400, subcutaneously at bedtime for DM (Notify MD for BG<70 or >400). During a concurrent interview and record review on 4/21/26 at 12:41 p.m. with the DON and the Resource Nurse, Resident 12's MAR dated March 2026 was reviewed. The March MAR indicated on 3/24/26 at 9 p.m. Resident 12's BS was 401 and there was 9 in the LN's initial box for Resident 12's Humalog. The Resource Nurse stated there was no note written by the LN for the entry 3/24/26 at 9 p.m. The DON stated she would expect the LN to have re-checked Resident 12's BS and administer insulin as prescribed. Review of Resident 12's care plan titled, Diabetes: Resident has a diagnosis of diabetes and is at risk for complications manifested by elevated BS 502, dated 3/24/26. Under the Interventions/Tasks was listed, Administer medication as ordered and Interventions to manage hypo/hyperglycemic (low/high blood sugar) episodes as indicated. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revision dated February 2021 indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to follow physician orders for three of 34 sampled residents (Resident 3, Resident 30 and Resident 129) when blood pressure medications were given outside of ordered parameters for Resident 30 and Resident 129 and pulse was not taken prior to medication administration for Resident 3.These failures had the potential to cause adverse medication outcomes such as low blood pressure and dizziness.Findings:Resident 3 was admitted to the facility in early 2025 with diagnoses that included atrial fibrillation (condition when the heart beats irregularly), heart failure (heart muscles are weak and do not effectively pump blood), and hypertension (HTN, high blood pressure).During a review of Resident 3's Order Summary Report [OSR], dated 3/2/26, the OSR indicated, Amiodarone [medication to treat atrial fibrillation] 200 MG [milligram, unit of measurement] .Give 1 tablet by mouth daily for A [atrial] fibrillation hold for HR [heart rate] <60.During a review of Resident 3's Medication Administration Record [MAR], dated 4/1/26-4/30/26, the MAR did not include a documented heart rate associated with the administration of Amiodarone from 4/1/26-4/15/26. The Amiodarone was marked as administered.Resident 30 was admitted to the facility late 2025 with diagnoses that included hypertension.During a review of Resident 30's OSR dated 4/26, the OSR indicated, amLODIPine Besylate [medication to treat high blood pressure] Oral Tablet 10 MG.Give 1 tablet by mouth one time a day for HTN Hold if SBP [systolic blood pressure] <110.During a review of Resident 30's MAR, dated 4/1/26-4/30/26, the MAR indicated Resident 30 received a dose of amlodipine on 4/7/26 when the SBP was 107 and on 4/12/26 when the SBP was 106. Resident 30's amlodipine was not held as directed in the physician orders for SBP less than 110.Resident 129 was admitted to the facility early 2025 with diagnoses that included atrial fibrillation and hypertension.During a review of Resident 129's OSR, dated 4/26, the OSR indicated, carvedilol [ medication to treat high blood pressure] oral tablet 12.5 MG.Give 2 tablets by mouth two times a day for HTN Hold if SBP <110.During a review of the Resident 129's MAR, dated 4/1/26-4/30/26, the MAR indicated received a dose of carvedilol on 4/6/26 when the SBP was 103. Resident 129's carvedilol was not held as directed in the physician orders for an SBP less than 110).During a concurrent interview and record review on 4/23/26 at 10:19 a.m. with the Unit Manager (UM) of Resident 3, Resident 30 and Resident 129's MAR, the UM confirmed the heart rate was not checked prior to the administration of Resident 3's Amiodarone, the amlodipine was administered outside of the physician ordered parameters for Resident 30 and the carvedilol was given outside of the physician ordered parameters for Resident 129. The UM stated the amlodipine and carvedilol should have been held because it [SBP] was less than 110. The UM stated she expected nurses to read the orders carefully and follow physician orders.During an interview on 4/23/26 at 11:19 a.m. with the Director of Nursing (DON) the DON stated she expected nurses to check vital signs (blood pressure, heart rate) before they administered medications and follow physician orders.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any time frame.The following information is checked/verified for each resident prior to administering medications.vital signs, if necessary.

Based on interview and record review, the facility failed to ensure two out of 34 sampled residents (Resident 35 and Resident 9) were free from significant medication error when:1. Resident 35 did not receive prescribed insulin (medication used to manage blood sugar level) in accordance with the standards of practice; and,2. Resident 9's insulin was not administered as prescribed.These failures had the potential to result in Resident 35 and Resident 9 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect Resident 35's health.Findings: 1. A review of Resident 35's clinical record indicated Resident 35 was admitted March of 2026 and had diagnoses that included diabetes mellitus type 2 (DM2- a chronic condition causing too much sugar in the blood), respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), and muscle weakness. A review of Resident 35's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 4/2/26, indicated Resident 35 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 35 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 35's MDS Functional Abilities, dated 4/2/26, indicated Resident 35 needed set-up or clean-up assistance with eating. A review of Resident 35's Care Plan Report, dated 2/13/26, indicated, Diabetes: Resident has a diagnosis of diabetes and is at risk for complications manifested by hyperglycemia [high blood sugar], hypoglycemia [low blood sugar], skin breakdown. A review of Resident 35's active physician's order, dated 3/30/26, indicated, Insulin Lispro [a fast-acting type of insulin used to manage high blood sugar] .Injection Solution 100 UNIT/ML [unit/milliliters- unit of measurement] Inject 5 unit [unit of insulin measurement] subcutaneously [under the skin] three times a day for DM2 . A review of Resident 35's active physician's order, dated 3/30/26, indicated, Insulin Lispro Injection Solution 100 UNIT/ML .Inject as per sliding scale [a method of managing blood sugar levels where insulin doses are adjusted based on current blood sugar reading]: if 71 - 150 = none; 151 - 200 = 1 unit; 201 - 250 = 2 unit; 251 - 300 = 3 unit; 301 - 350 = 4 unit; 351 - 400 = 6 unit more than 400 = 8 units, subcutaneously three times a day for DM2 . During a concurrent interview and record review on 4/20/26 at 1:14 p.m. with Licensed Nurse (LN) 5, Resident 35's medication administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of April 2026 was reviewed. LN 5 stated that Resident 35 had a blood sugar reading of 155 units and was given a total of 6 units before 1 pm. LN 5 also stated that the lunch meal should have been given to the resident within 15 minutes of the insulin administration and she was not sure why the lunch meal was late today. LN 5 further stated Resident 35 was at risk for hypoglycemia if the lunch meal was not given within 15 minutes from the time the insulin was administered. During an interview on 4/20/26 at 1:45 p.m. with Resident 35, Resident 35 stated he was still waiting for his lunch meal. Resident 35 further stated he was hungry, but he could not do anything but wait. During a concurrent observation and interview on 4/20/26 at 1:56 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 was observed passing Resident 35's lunch meal tray to Resident 35. CNA 3 confirmed the observation. During an interview on 4/22/26 at 2:13 p.m. with the Director of Staff Development (DSD), the DSD stated lispro is a rapid acting insulin and a resident should be given meals within 10-15 minutes of administration of the medication. The DSD also stated that 1 hour was a big gap between lispro administration and the receiving his meal. The DSD further stated the Resident's blood sugar could drop and could endanger the resident's health condition if the lunch meal was given late. 2. A review of Resident 9's clinical record indicated Resident 9 was admitted to the facility on [DATE] with multiple diagnoses which included diabetes, Stage 3 chronic kidney disease (moderate kidney damage which impairs waste removal from the body). A review of Resident 9's April 2026 Order Summary Report contained a physician's order dated 2/26/26 for Insulin Lispro Injection Solution 100 UNIT/ML (milliliter) (Insulin Lispro) Inject 4 unit subcutaneously (under the skin) three times a day for DM2 (diabetes) Hold for blood sugar (BS-main sugar in body that gives you energy) less than 150 or when patient does not eat. Administer with meals. Notify MD (Medical Doctor)/NP (Nurse Practitioner) for blood sugar less than 70 or greater than 300. During a concurrent interview and record review on 4/22/2026 11:36 a.m. with the Director of Nursing (DON) and the Resource Nurse, Resident 9's Medication Administration Record (MAR) dated April 2026 was reviewed. The DON confirmed a check mark in the box with the LN's initials indicated the LN gave the medication. The April MAR indicated on 4/4/26 at 12:30 p.m. Resident 9's blood sugar was 119 and there was a check mark in box with the LN's initials. The DON confirmed this indicated the LN gave the insulin and stated the LN should not have given the insulin per parameter and should have been held for a blood sugar less than 150. The April MAR further indicated on 4/20/26 at 12:30 p.m. Resident 9's blood sugar was 148 and there was a check mark in the box with the LN's initials. The DON confirmed this indicated the LN gave the insulin and stated the LN should not have given the insulin per parameter and should have been held for a blood sugar less than 150. Administering insulin when blood sugar is below 150 can increase the risk of hypoglycemia, which may lead to adverse health outcomes for Resident 9. A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, indicated, 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions .10. 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, Insulin Administration, revised 3/2025, indicated, 2. The type of insulin, dosage requirements, strength, and method of administration are verified with the order on the medication sheet and the physician's order before administration .4. The nursing staff have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use .General Guidelines .1. Insulin therapy is individualized based on prognosis, treatment goals, and blood glucose levels. 2. The three key characteristics of insulin are: a. Onset of action – how quickly the insulin reaches the bloodstream and begins to lower blood glucose .6. The types of insulin and their pharmacokinetics are: Category .Rapid-acting .Type .Insulin Lispro .Onset* .within 15 min [minutes] .

Based on observation, interview, and record review, the facility failed to follow the prepared menu and meet the nutritional needs for one out of 34 sampled residents (Resident 155) when Resident 155 was not served with a regular portion of protein during the 4/20/26 lunch meal. This failure had the potential to result in Resident 155 not being able to meet and maintain her nutritional needs and achieve her highest practicable wellbeing.Findings:A review of Resident 155's clinical record indicated Resident 155 was admitted November of 2023 and had diagnoses that included dementia (memory loss that interferes with daily functions), diabetes mellitus (a chronic condition causing too much sugar in the blood), severe protein-calorie malnutrition (PCM- a severe nutritional deficiency where inadequate intake of protein and calories leads to dangerous changes in body composition, function, and weight loss), and muscle weakness.A review of Resident 155's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/15/26, indicated Resident 155 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 155 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 155's MDS Functional Abilities, dated 2/15/26, indicated Resident 155 needed set-up or clean-up assistance with eating.A review of Resident 155's active physician's order, dated 10/22/25, indicated, CCHO diet [Consistent Carbohydrate Diet/Controlled Carbohydrate- a nutrition plan designed for people with diabetes or prediabetes to keep blood glucose levels stable] .Regular texture .small starch portions.A review of Resident 155's Care Plan Report, revised 12/31/25, indicated, Nutritional Risk: [Resident 155] has the potential for altered nutrition and/or hydration status related to .DM, Severe PCM .muscle weakness .Hx [history] of sig wt loss [significant weight loss] and poor PO [oral] intake .A review of Resident 155's NUTRITIONAL RISK REVIEW (QUARTERLY), dated 2/15/26, indicated, Diet approx [approximately] provides 1917kcal [kilocalorie- unit of energy measuring the nutritional value of food and beverages] and 94g [grams- unit of measurement] protein .5. Diet Order .CCHO diet .Regular texture .small starch portions .A review of the facility's Good For Your Health Menus, dated 4/20-26/26, indicated the lunch menu for 4/20/26, Monday, included, Baked Hamburger with [NAME] Sauce, Diced Fried Potatoes, Capri Blend Vegetables, Wheat Roll, Spring Fruit Crisp.During a concurrent observation and interview on 4/20/26 at 12:56 p.m. with Resident 155 at MedBridge Dining Room, Resident 155's lunch meal was observed which included a half slice of hamburger patty with brown sauce. Resident 155's meal ticket was checked and indicated, Texture: .Regular, Special Diets: CCHO .Notes: .SMALL STARCH PORTION . Resident 155 confirmed the observation. Resident 155 stated it has been recently that they started giving her half portion of meat. Resident 155 also stated she never requested for a half portion of meat. Resident 155 further stated she would always end up eating a lot of cookies and extra sweets because they would only serve her half portion of meat. During a concurrent observation and interview on 4/20/26 at 1:01 p.m. with the Clinical Resource Nurse (CRN) at MedBridge Dining Room, the CRN confirmed that Resident 155 only received a half slice of hamburger patty. The CRN checked Resident 155's meal ticket and stated the meal ticket did not indicate that Resident 155 would have half portion of meat so she should have received a regular portion of meat. The CRN further stated the meal ticket should have been followed. During an interview on 4/20/26 at 1:13 p.m. with the Registered Dietician (RD) at MedBridge Dining Room, the RD stated Resident 155 should receive a regular portion of protein and should not be getting a half portion only. The RD further stated Resident 155 was supposed to get regular portion of protein to maintain her desired nutritional intake. A review of the facility's policy and procedure (P&P) titled, Tray Identification, revised 4/2007, indicated, Appropriate identification/coding shall be used to identify various diets .2. The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the nurse supervisor will notify the dietary department immediately by phone so that the appropriate food tray can be served.

Based on observation, interview and record review, the facility failed to provide timely dental services to two of 34 sampled resident (Resident 16 and Resident 52) when the facility did not carry out recommended tooth extractions.This failure had the potential to cause tooth pain and infection.Resident 16 was admitted to the facility in late 2018 with diagnoses that included a stroke with left side weakness.During an interview on 4/21/26 at 9:35 a.m. with Resident 16 in her room, Resident 16 stated she had a bad tooth and was waiting for the dentist to fix her mouth.During a review of Resident 16's dental exam notes, dated 10/2/25, the dental note indicated Resident 16 had tooth pain in the top left side of her mouth and that the tooth is mobile [loose] and needs EXT [extraction, removal].During a concurrent interview and record review on 4/22/26 at 9:33 a.m. with the Social Service Director (SSD) of Resident 16's dental exam, the SSD confirmed the dental note indicated Resident 16 needed a tooth extraction, the SSD acknowledged the facility had not completed any follow up on Resident 16's dental needs since September 2025. The SSD stated a six month delay was unacceptable and that she expected dental care to be provided as needed to prevent infection, weight loss, and pain.During an observation on 4/22/26 at 10:54 a.m. with Licensed Nurse (LN 4) of Resident 16's tooth, LN 4 asked to see Resident 16's tooth, Resident 16 had a blackened tooth loosely hanging from the back left upper side of her mouth. Resident 16 stated her tooth hurt. LN 4 confirmed the blackened tooth.During a review of Resident 16's dental visit notes dated 4/22/26, the dental notes indicated resident's tooth was mobile and decayed. Resident 16 was prescribed antibiotics for likely infection.Resident 52 was admitted to the facility in late 2024 with diagnoses that included memory loss and muscle weakness.During a concurrent observation and interview on 4/21/26 at 9:22 a.m. with Resident 52, Resident stated she had broken teeth and wanted to see a dentist. Resident 52 opened her mouth and revealed several broken jagged teeth with several dark blackened areas along the gumline.During a review of Resident 52's dental notes dated 5/15/25, the dental note indicated Resident 52 needed (tooth) extractions on the next visit.During a concurrent interview and record review on 4/22/26 at 9:30 a.m. with the SSD of Resident 52's dental notes dated 5/15/25, the DDS confirmed the dental notes which indicated Resident 52 needed dental extraction. The SSD acknowledged the facility had not completed any follow up to schedule them. She stated the delay was unacceptable and could lead to pain and infection.During a review of Resident 52's dental notes dated 4/22/26, the dental note indicated Resident 52 had two teeth that appeared decayed. Resident 52 was prescribed antibiotics for likely dental infection.During an interview on 4/23/26 at 11:12 a.m. with the Director of Nursing (DON), the DON stated she expected dental care and follow-up services to be provided for residents.During a review of the facility's policy and procedures (P&P) titled, Dental Consultant, dated 4/26, the P&P indicated, Dental care shall be provided through the services of a Consultant Dentist.A consultant dentist is retained by our facility and is responsible for.providing consultation to physicians and providing other services relative to dental matters.

Based on interview and record review, the facility failed to ensure one out of 34 sampled residents (Resident 24) received dialysis care services consistent with professional standards of practice, facility's policy and procedure (P&P) when Resident 24 had an inaccurate dialysis medical record.This failure had the potential for Resident 24 to not receive safe and appropriate dialysis care treatment and services and to not achieve her highest practicable well-being.Findings:A review of Resident 24's clinical record indicated Resident 24 was admitted February of 2026 and had diagnoses that included end stage renal disease (ESRD- occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and muscle weakness.A review of Resident 24's Weekly Summary Notes, dated 4/15/26, indicated Resident 24 was on dialysis and was alert and oriented to person, place, time, and situation. A review of Resident 24's Minimum Data Set (MDS- an assessment tool used to guide care) Special Treatments, Procedures, and Programs, dated 2/7/26, indicated Resident 24 was on hemodialysis (a treatment to filter waste and water from the blood) on admission and while she is a resident in the facility.A review of Resident 24's Care Plan Report, dated 2/5/26, indicated, Dialysis: Resident Requires [x ] Hemodialysis [x ] End Stage Renal Failure .is at risk for bleeding at access site, hypotension [low blood pressure], infection .weakness, weight fluctuations. Resident requiring Hemodialysis 3x/wk [three times a week] on Tuesday, Thursday, Saturday. Chair time: 1500 (3PM) to 1830 (6:30PM) .A review of Resident 24's active physician's order, dated 2/9/26, indicated, End Stage Renal Disease (ESRD) requiring Hemodialysis 3x/wk [three times a week] on Tuesday, Thursday, Saturday. Chair Time: 1500 (3PM) .A review of Resident 24's active physician's order, dated 2/9/26, indicated, Epoetin Alfa (epoetin alfa-ephz .Retacrit) [short-acting erythropoiesis-stimulating agent (ESA) used to treat anemia by stimulating the bone marrow to produce red blood cells] 1 ml [milliliters- unit of measurement] Intravenous [IV- directly into the vein] every Tuesday, Thursday and Saturday in Hemodialysis clinic.During an interview on 4/21/26 at 12:04 p.m. with Licensed Nurse (LN) 6, LN 6 stated they would fill out the dialysis communication paper to assess the resident before going to the dialysis center and send the resident to the dialysis center with the paper. When the resident comes back, they would check the dialysis communication paper for any post dialysis [after dialysis] assessment and communication from the dialysis center and would clarify it as needed. A review of Resident 24's DIALYSIS CENTER HEMODIALYSIS COMMUNICATION OBSERVATION/ASSESSMENT, dated 3/31/26, indicated, Resident Name: [Resident 24] .Medication Administered: .Mircera [Epoetin beta- a long-acting ESA used to treat anemia associated with kidney diseases] .During a concurrent phone interview and record review on 4/22/26 at 3:47 p.m. with the Administrative Assistant (AA) from Resident 24's dialysis center, Resident 24's medical records were reviewed. The AA confirmed that Resident 24 was receiving Mircera 50 mcg [micrograms- unit of measurement] IV push once every 2 weeks. The AA stated Resident 24 has been receiving Mircera since March of 2024. The AA also stated their center has discontinued the use of epoetin alfa long time ago because of the side effects of the medication. The AA further stated Resident 24 should not be receiving epoetin alfa because it would be double dosing of ESA medication.During a concurrent interview and record review on 4/23/26 at 9:04 a.m. with the Director of Staff Development (DSD), Resident 24's medical records were reviewed. The DSD confirmed Resident 24 has an active order that indicated Resident 24 was receiving Epoetin Alfa (Retacrit) at the dialysis center. The DSD also confirmed that Resident 24's hemodialysis communication sheet indicated Resident 24 was receiving Epoetin Beta (Mircera) at the dialysis center. The DSD further confirmed that Resident 24's medical record was not accurate. The DSD stated that nurses were supposed to check and reconcile the dialysis communication sheet. The DSD further stated that residents should have an accurate medical record so they could safely receive dialysis treatments.A review of the facility's P&P titled, CARE OF THE DIALYSIS RESIDENT, undated, indicated, Dialysis resident will be provided care and services in a manner that promotes the resident's quality of life, and to attain or maintain the resident's highest possible physical, mental and psychosocial well being .The nursing staff will follow established protocol for all dialysis residents .b. The Provider's dialysis nurse will be responsible for documentation of dialysis treatment. Documentation will be maintained in the resident medical records.A review of the facility's AGREEMENTS FOR RESIDENT CARE SERVICES BETWEEN A DIALYSIS UNIT AND NURSING FACILITY with Resident 24's dialysis center, signed on 7/10/02, indicated, 4. Coordination of care may include the following: .Information transmitted to the Dialysis Unit by the Facility prior to dialysis .Information transmitted to the Facility by the Dialysis Unit after dialysis .

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for one out of 34 sampled residents (Resident 11) when Resident 11's call light button was not within reach.This failure placed the resident at risk for unmet needs and compromised safety.Findings:A review of Resident 11's clinical record indicated Resident 11 was admitted February of 2026 and had diagnoses that included myasthenia gravis (a disorder causing fluctuating weakness in muscles, particularly those controlling the eyes, face, swallowing, and breathing), dementia (memory loss that interferes with daily functions), congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and muscle weakness.A review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/7/26, indicated Resident 11 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 11 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 11's MDS Functional Abilities, dated 4/7/26, indicated Resident 11 needed substantial/maximal assistance with toileting hygiene, supervision or touching assistance with oral hygiene, and setup or clean-up assistance with eating. A further review of Resident 11's MDS Functional Abilities indicated Resident 11 needed supervision or touching assistance Sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfer, and toilet transfers.A review of Resident 11's care plan, dated 2/23/26, indicated, Falls: Resident is at risk for falls with or without injury related to cardiovascular disease, decreased muscular coordination, unsteady gait, dementia .history of falling .Keep call light within reach.During a concurrent observation and interview on 4/20/26 at 10:09 a.m. with Resident 11 in Resident 11's room, Resident 11 was observed lying on her bed, awake. Resident 11 stated she does not know where her call light button was. Resident 11's call light button was observed on the floor, at the back of Resident 11's bedside drawer, which was 3-4 feet away from the resident. During a concurrent observation and interview on 4/20/26 at 3:25 p.m. with Certified Nurse Assistant (CNA) 2, in Resident 11's room, Resident 11 was observed lying on bed, awake, and there was no call button within Resident 11's reach. CNA 2 confirmed the observation. CNA 2 searched Resident 11's room and found Resident 11's call light button on the floor, at the back of Resident 11's bedside drawer, which was 3-4 feet away from Resident 11. CNA 2 also confirmed that Resident 11's call system was not within her reach. CNA 2 stated Resident 11's call light button should be within her reach when she was in bed so she could call for help when she needs assistance. During an interview on 4/21/26 at 12:04 p.m. with Licensed Nurse (LN) 6, LN 6 stated call light buttons should be placed within the resident's reach so that the resident can call for help during emergencies or when they need assistance.During an interview on 4/22/26 at 2:13 p.m. with the Director of Staff Development (DSD), the DSD stated that staff should always be sure to place call light within the reach of the residents when they are in bed so they could use it to call for help if needed. During an interview on 4/23/26 at 9:16 p.m. with the Administrator (ADM), the ADM stated they try to keep the call light buttons next to the resident A review of the facility's policy and procedures titled, Call Light Policy and Procedure, undated, indicated, It is the policy of this facility to ensure all resident/patient call lights are answered promptly, courteously, and safely to promote comfort, dignity, and timely care. Staff are expected to respond to all call lights as soon as possible .Procedure .1. All staff are responsible for responding to call lights immediately when able, regardless of department .

Based on interview and record review, the facility failed to ensure one of 34 sampled residents (Resident 12) received adequate supervision to prevent accidents.This lack of supervision and assistance resulted in Resident 12 sustaining a fall that caused a fracture (break in a bone), severe pain, and a decline in functional ability.Findings:Review of Resident 12's clinical record indicated Resident 12 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness and reduced mobility.Review of Resident 12's Annual Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/2/26 indicated Resident 12 had moderately impaired cognition. The MDS described Resident 12 as needing setup or clean-up assistance with eating, partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and upper body dressing and substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, lower body dressing and personal hygiene.Review of Resident 12's Fall Risk Observation/assessment dated [DATE] indicated Resident 12 was moderate risk for having a fall.Review of Resident 12's Progress Note, dated 2/18/2026 at 3:28 p.m., indicated, The resident returned from hospital after being sent out for fall. Resident returned with right pattiler (sic patella-knee) fracture. Resident has a new order to apply knee brace. Upon arrival resident noted to have skin tear on right elbow. Treatment nurse was notified. Resident requested pain medication upon arrival and stated that he was in severe pain.Review of Resident 12's hospital CT (Computerized Tomography-a more detailed picture of inside the body) results dated 2/18/26 at 7:30 a.m. indicated, FINDINGS: Acute comminuted (broken into three or more pieces typically caused by high-force accident or trauma) nondisplaced fracture of the involving the patella. The CT results also indicated, Diffuse patchy osteopenia (loss of bone density) is present throughout the knee. Chondrocalcinosis (painful type of arthritis) is present.During a concurrent record review and interview on 4/21/2026 3:32 p.m. with the Resource Nurse and the Director of Nursing (DON), Resident 12's Progress Notes dated 2/18/26 at 3:20 a.m. and Resident 12's Progress Note labeled, IDT-Fall dated 2/18/26 at 10:44 a.m. were reviewed. The Resource Nurse stated the IDT documented the fall as witnessed fall. The Resource Nurse confirmed the LN note documented Resident 12's bed to be elevated above the waist level. The Resource Nurse stated Resident 12' sustained a right knee fracture and left elbow skin tear from the fall. The DON was asked what she would have expected staff to do in this situation she stated she would expect staff to utilize two people if needed or keep one hand on resident to help prevent from falling. In a concurrent interview and record review on 4/22/2026 at 1:24 p.m. with the MDS Coordinator, Resident 12's MDS's were reviewed. The MDS Coordinator stated Resident 12's trigger to complete a significant change MDS was a fall with fracture. The MDS Coordinator compared Resident 12's Annual MDS dated [DATE] with Resident 12's Significant Change MDS dated [DATE] and stated Resident 12 had a significant change in his functional abilities. The MDS Coordinator stated his functional abilities went down to mostly dependent, (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for most of his activities of daily living after the fall and fractured knee.During a review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, revision dated March 2018 indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation 1. Review the resident's care plan to assess for any special needs of the resident.3. Assemble the equipment and supplies as needed.During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, revision dated March 2018 indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.

Based on observation, interview, and record review, the facility failed to provide appropriate assistive eating and drinking utensils to one out of five sampled residents (Resident 2) when Resident 2 was not provided a specialized drinking cup and plate guard (a curved, removable rim that snaps onto the edge of a dinner plate to prevent food from being pushed off, assisting with independent dining) during the 4/14/26 lunch meal. This failure had the potential to result in Resident 2 not being able to properly and safely eat and drink and had the potential for nutrition and hydration problems. Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted December of 2023 and had diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), polyneuropathy (a condition characterized by damage to multiple peripheral nerves causing numbness, burning pain, and muscle weakness), and muscle weakness.A review of Resident 2's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 3/7/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 2 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 2's MDS Functional Abilities, dated 3/7/26, indicated Resident 2 needed supervision or touching assistance with eating.A review of Resident 2's care plan, revised 12/27/24, indicated, Nutritional Risk: [Resident 2] has the potential for altered nutrition and/or hydration status related to .hx [history] of malignant neoplasm [cancer] of large intestine, muscle wasting [loss of muscle tissue] .chronic pain .weakness .A review of Resident 2's care plan, revised 2/6/25, indicated, Weight Loss: [Resident 2] is at risk for weight loss [x] Resident has an actual significant weight loss [x] 5% [percent- measurement of one part in every hundred] in 1 month patterned/persistent weight loss monthly related to reported weakness in her hands and arms poor appetite.A review of Resident 2's NUTRITIONAL RISK REVIEW, dated 9/8/25, indicated, .She [Resident 2] continues to receive .divided plate, plate guard, and sippy cup for meals .RD Recommendations .Noted with weight loss x3 and x6 months [within 3 months and within 6 months], however not clinically significant .A review of Resident 2's NUTRITIONAL RISK REVIEW, dated 3/6/26, indicated, .She [resident 2] continues to receive .divided plate, plate guard, and sippy cup for meals .RD Recommendations .Noted with weight loss x3 and x6 months, however not clinically significant .During a concurrent observation and interview on 4/14/26 at 12:37 p.m. with Resident 2 in Resident 2's room, Resident 2 was observed not touching her lunch meal on her bedside table. Resident 2 was also observed to have shaky hands. On the corners of Resident 2's meal tray were beverages which included two cups of reddish beverages in a regular 8 fl oz. (fluid ounce- unit of measurement) drinking cups which were still full, and a small can of ginger ale with a white straw. Resident 2 was provided with a divided plate but not with a plate guard. Resident 2 stated she could not hold the regular cups because of her shaky hands, that was why she was not able to drink her beverages. Resident 2 further stated she would like to have a better cup so she could hold her drinks steadier and it would not spill.A review of Resident 2's lunch meal ticket, dated 4/14/26, indicated, .Adaptive Equip [adaptive equipment- any tool, device, utensil, or machine that is used to help with any task associated with daily living]: .Plate Guard, Sippy Cup [a specialized drinking cup designed to be held more steady in several ways for people with tremors or reduced coordination] (x4) .During a concurrent observation and interview on 4/14/26 at 12:40 p.m. with Certified Nurse Assistant (CNA) 2 in Resident 2's room, CNA 2 confirmed that Resident 2 was not provided with a plate guard and sippy cups. CNA 2 stated Resident 2 has shaky hands so she should be provided with a plate guard and sippy cups so she could eat and drink safely and properly.During an interview on 4/14/26 at 1:52 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 has tremors and muscle weakness. LN 1 also stated that Resident 2's meal ticket should have been followed and that Resident 2 should have been provided with plate guard and sippy cups so she could drink and eat well. LN 1 further stated that nurses would normally check the resident's meal tray first to make sure the tray contents are appropriate and complete before being given to the resident.During a concurrent interview and record review on 4/14/26 at 3:12 p.m. with the Registered Dietician (RD), Resident 2's clinical records were reviewed. The RD confirmed that Resident 2 has been losing weight. The RD also confirmed that Resident 2 needed assistive utensils when eating. The RD stated that there were no indicated refusals on Resident 2's care plan and no reported changes on Resident 2's functioning so she should continue to receive plate guard and sippy cups every meal. The RD also stated that she would expect the indicated assistive utensils in the meal ticket to always be provided to the residents. The RD further stated that assistive utensils are provided to residents to improve their meal and liquid intake.During an interview on 4/14/26 at 3:56 p.m. with the Administrator [ADM], the ADM stated she would expect the assistive eating and drinking utensils to be provided to the residents if it was indicated in their meal tickets.A review of the facility's policy and procedure titled, SELF-FEEDING DEVICES, dated 2023, indicated, POLICY: Residents will receive self-feeding devices to maintain or improve their ability to eat or drink independently .PROCEDURE .2. Devices commonly used .will be kept in stock .3. The Food & Nutrition Services Department will store self-feeding devices. Residents needing devices will receive them with each meal or snack, on their meal trays. Tray cards and diet profile will record which device is needed .COMMONLY USED SELF-FEEDING DEVICES .PLATE GUARD .

Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 1) was treated with dignity and respect, when Restorative Nursing Assistant (RNA 1) spoke inappropriately to Resident 1.This failure caused Resident 1 to feel upset, humiliated, and disrespected and had the potential to negatively impact Resident 1's psychosocial well-being.A review of the facility's ‘Resident Rights' policy dated 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. A review of the admission Record indicated the facility admitted Resident 1 in the spring of 2025 with multiple diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and anxiety.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/17/25, indicated the resident had no cognitive impairment and had no behavioral symptoms including hallucinations and delusions.During a concurrent observation and interview on 7/9/25, at 9:45 a.m., Resident 1 was sitting in wheelchair in her room. Resident 1 answered appropriately and was speaking in a soft low tone voice. When Resident 1 was asked to recall the 7/4/25 incident in the dining room, the resident became very tearful and lowered her voice to a whisper. Resident 1 explained that she had been sitting at the same table with two residents [Resident 2 and Resident 3] every day since her admission and added that everyone knew that they liked to sit together during activities and eating meals. Resident 1 added, On July 4th, I went to sit to my usual spot. [Resident 3's name and [Resident 2's name] were already seated there. Someone brought another patient to sit at our table. [RNA 1] approached me and in authoritative tone told me, You have to move to another table. Resident 1 stated that she attempted to explain to RNA that this was her table where she usually sat with her two friends, but RNA 1 insisted that I have to be moved and told her, Your name is not here. Resident 1 stated she felt bad and disrespected that [RNA 1] picked on her. Resident 1 stated that two other staff, Activity Director and dietary head, [RD] overheard the entire conversation and one of them put her hand on my shoulder and said, It's ok [Resident 1's name], you can sit here.During a continued interview on 7/9/25, commencing at 9:45 a.m., Resident 1 stated that a few minutes later, RNA 1 brought her lunch tray and the resident noted that there were some food and drink that she could not eat due to her medical condition. Resident 1 stated she politely asked RNA 1 if she would take away the food and drink that she could not eat. Resident 1 became tearful again and added, I did not request anything, just told her that I can't have strawberries and juice, but RNA 1 raised her voice and said, I am not a waitress here, I am not here to serve you. Resident 1 stated RNA 1 walked away and started texting on her phone. During a continued interview on 7/9/25 at 9:45 a.m., Resident 1 added, I felt very humiliated and disrespected. I tried to tell her that I thought she was here to help some of us that needed help, but she was totally disrespectful and did not give me chance to talk .I did not argue with her, I am not a confrontational person, I gave her 100% of respect and expected her to be respectful to us and I felt very upset about the incident. Resident 1 stated that the same day RNA 1 spoke in a very disrespectful tone of voice to her friend, Resident 2 when he asked for something. Resident 1 stated that later that day she explained to a nurse at the desk what happened in the dining room and how humiliated she felt. Resident 1 added she woke up at 3 a.m., cried uncontrollably and called nursing station asking for her nurse to come. Resident 1 stated she detailed the incident in the dining room to her nurse (Licensed Nurse, LN 1) and told the nurse how humiliated she felt. Resident 1 added that she had a history of PTSD (Post Traumatic Stress Disorder, a mental condition caused by an extremely stressful or terrifying event; symptoms may include flashbacks, nightmares, and severe anxiety) and the incident at the dining room surfaced her PTSD condition. During an interview with Activity Director (AD) on 7/9/25, at 11:45 a.m., the AD stated that Resident 1, Resident 2, and Resident 3 always sit together during activities and 3 of them always sit together for meals. The AD stated there was a commotion in the dining room on July 4th and added that staff wanted to move Resident 1 to another table because it was too crowded at that table. The AD continued, [Resident 1] had told me that she was upset, but I was not sure why she was upset. During an interview with Registered Dietician (RD) on 7/9/25, at 11:58 a.m., the RD stated she witnessed RNA 1 telling Resident 1 that she needed to be moved to another table because it was too crowded, and the resident refused to be moved. The RD stated that Resident 2 mentioned that [Resident 1's name] was upset because [RNA1's name] had said something inappropriate to her.During an interview with Certified Nursing Assistant (CNA 2) on 7/9/25, at 12:12 p.m., CNA 2 stated that she overheard Resident 1 talking to nursing staff at the desk telling them that RNA 1 was rude to her during lunch in the dining room. CNA 2 stated that normally Resident 1 goes around the facility and socialized with other residents but that day she observed the resident staying in her room.During an interview with RNA 2 on 7/9/25, at 12:42 p.m., CNA 2 stated Resident 1 was picky about her food, always complains that she did not receive what she likes to eat . she likes to have food specially catered to her. RNA 1 validated that on July 4th during a conversation with Resident 1 and Resident 2 she replied to Resident 1 I am not a waitress here. RNA 1 added, I did not mean to disrespect her when I said I' not a waitress, but she reported to the entire facility that I disrespected her. RNA 1 stated that she assisted residents in the dining room with eating and telling a resident I'm not your waitress was inappropriate.During a telephone interview with LN 1 on 7/9/25, at 1:10 p.m., LN 1 stated the morning of 7/5/25, around 3 a.m., Resident 1 called nursing station crying. LN 1 stated that she went to the resident's room and talked to Resident 1. LN 1 continued, Initially she said that she had bad dreams, then she mentioned that she was really upset because earlier in the day someone was verbally aggressive to her. LN 1 stated that Resident 1 calmed down after they talked but did not go into details and did not tell the nurse who the person was that spoke inappropriately with the resident. LN 1 stated she informed her charge nurse what Resident 1 had told her but was told that there was nothing to report since the resident did not want to give any information who was that person.During an interview with Administrator (ADM) on 7/9/25, at 1:15 p.m., the ADM stated that Resident 1 was different type of resident and explained that the resident easily involves in areas that do not involve her. The ADM stated she was informed by RD there was an incident when Resident 1, Resident 2, and Resident 3 did not like that another resident was seated at the same table and requested to move that resident to another table. The ADM stated she was not aware that Resident 1 was upset because someone was disrespectful to her and added, It is the resident's interpretation, but I don't know if it happened or not. The ADM agreed that residents have rights to choose who they want to sit with, talk to, or eat together with and it was inappropriate and unacceptable to say, ‘I'm not a waitress here to residents.A review of the facility's policy titled, Resident Rights, dated 2021, indicated, Federal and state laws guarantee certain basic right s to all residents of this facility. These rights include the resident's rights to . a dignified existence .be treated with respect, kindness, and dignity .self-determination .exercise his or her rights as a resident of the facility and . citizen of the United states . be supported by the facility in exercising his or her rights .Staff will have appropriate in-service training on resident rights prior to having direct care responsibilities for residents.

Based on interview and record review, the facility failed to ensure required documentation for discharge was present in the medical record for one of four sampled residents (Resident 1), when there was no physician order indicating the basis of Resident 1 ' s discharge, there was no discharge summary, and there was no notice of discharge in Resident 1 ' s medical record. This failure had the potential for delay in Resident 1 ' s care after discharge. Findings: During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted to the facility in May 2025 with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), and local infection of the skin and subcutaneous tissue (under the skin). Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had intact cognition. During a review of Resident 1 ' s case management progress notes, dated 5/29/25, the notes indicated, .[Resident 1] verbalized she is refusing care by our provider rt [related to] a self-proclaimed lawsuit. This nurse offered to have her sent back to acute to have alternate placement. [Resident 1] verbalizes she agrees with transfer . During a review of Resident 1 ' s nurse progress notes, dated 5/29/25, the notes indicated, .[Resident 1] discharged to [name of hospital] due to conflict of interest . During a review of the intake information received by the Department, dated 5/30/25, the information indicated, .when [name of NP – nurse practitioner] seen [Resident 1], [NP] said, there would be someone else that could tend to [Resident 1] .[Staff] came to [Resident 1] and told [Resident 1] that [Resident 1] had to leave, that there was a conflict of interest and the facility kicked [Resident 1] out . During a concurrent interview and record review on 6/4/25 at 11:44 a.m. with the Case Manager (CM), the CM stated the NP came to see Resident 1 and they recognized each other. The CM further stated that according to Resident 1, Resident 1 had a lawsuit with the NP and the NP realized the conflict of interest. The CM stated, .We offered to send [Resident 1] to [the hospital] .[Resident 1] agreed to have alternate placement arranged because of the conflict of interest . The CM reviewed Resident 1 ' s medical record and stated, .I don ' t think [NP] wrote the order [for discharge] because the resident refused our provider .I don ' t believe an order was written before and after [Resident 1] left . During an interview on 6/4/25 at 12:32 p.m. with the Social Services Director (SSD), the SSD stated, .For all discharges, there has to be an order before they go, otherwise it ' s against medical advice (AMA – when a resident leaves before the medical team recommends discharge) .The doctor also write the discharge summary .Notice of proposed transfer or discharge should also be completed for planned, unplanned, or even AMA discharges .The resident is supposed to sign it and to be sent to the Ombudsman . During a concurrent interview on 6/4/25 at 12:46 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, .There should be an order from the doctor for discharge .As soon as the resident left, I write the discharge summary .Important because that ' s the recap of the resident ' s stay in the facility and the plan for their discharge . The ADON confirmed there was no order for discharge, no discharge summary, and no notice of the proposed discharge in Resident 1 ' s medical records. During an interview on 6/4/25 at 1:07 p.m. with the Medical Records Director (MRD), the MRD stated, The nurses complete the notice of proposed discharge .It is for all discharges .I expect that this form was completed once the resident got discharged .To make sure that we are doing the correct discharge/transfer, that everything is done correctly and steps are completed correctly . During an interview on 6/4/25 at 1:16 p.m. with the Director of Nursing (DON), the DON stated, .I don ' t think there was an order because the doctor doesn ' t get involved with [Resident 1] .There should be notes from the NP at that time when the resident refused the care .There should be one completed on the nurses side so people are aware why [Resident 1] left . During an interview on 6/4/25 at 2:30 p.m. with the NP, the NP stated, When [Resident 1] got here [the facility], I recognized [Resident 1] name .I went to her room to do her assessment .[Resident 1] was being seen by wound nurse .I came back later .and before I saw the resident again, the wound nurse told me about the lawsuit .I confirmed with the resident that I was part of the lawsuit .I told the resident that [Medical Director] will be following up with the resident and [Resident 1] said okay .At some point, I was informed that she will be sent back to the hospital for alternate placement .I didn ' t document that I told the resident that [Medical Director] will be taking over because [Medical Director] was my supervising physician .I told him right away and he was aware of it .For discharge, there must be signed discharge orders . During a concurrent interview and record review on 6/4/25 at 2:52 p.m. with the Administrator (ADM), the ADM stated, .[NP] went to do assessment and [Resident 1] recognized her .The resident confirmed NP was part of the case .It ' s a conflict .We were calling to arrange [Resident 1] to go back to the referring hospital .We got the okay from the hospital .to send her back .We didn ' t have a physician for her so we have to do it .I don ' t know if [NP] talked to [MD] .I didn ' t talk to [MD] .[MD] is part of the physician group with the lawsuit .It would be hard for [MD] to give that order .As the administrator, I decided to communicate with the hospital to see if they will accept [Resident 1] back . The Administrator confirmed there were no physician order for Resident 1 ' s discharge, no discharge summary, and no notice of proposed discharge in Resident 1 ' s medical records. During a review of the facility ' s policy and procedure (P&P) titled Transfer or Discharge, dated 3/2025, the P&P indicated, .1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: a. The basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or legal representative; .f. A summary of the resident ' s overall medical, physical, and mental condition . During a review of the facility ' s P&P titled Discharging a Resident Without a Physician ' s Approval, revised 3/2025, the P&P indicated, A physician ' s or provider ' s order is obtained for discharges, unless a resident or representative requests the discharge against medical advice .1. An order of an approved discharge must be signed and dated by the physician or provider and recorded in the resident ' s medical record no later than seventy-two (72) hours after the discharge .5. Regardless of the resident or representative ' s request to leave the facility against medical advice, the facility will provide a Notice of Discharge, discharge orientation, and a Discharge Summary .before the resident leaves the facility .

Based on observation, interview, and record review, the facility failed to ensure safe delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 35 sampled residents (Resident 78) Resident when, Resident 78 was provided with oxygen therapy without a physician's order. This failure had the potential to result in unsafe delivery of oxygen to Resident 78 and for Resident 78 to not achieve her highest practicable well-being. Findings: 1. A review of Resident 78's clinical record indicated Resident 78 was admitted February of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should), and sleep apnea (a sleep disorder that causes people to stop breathing or breathe shallowly while they sleep). A review of Resident 78's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/28/25, indicated Resident 78 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 which indicated Resident 346 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 78's MDS Health Conditions, dated 1/29/25, indicated Resident 78 experienced shortness of breath or trouble breathing when lying flat. A review of Resident 78's MDS Special Treatments, Procedures, and Programs, dated 3/28/25, indicated Resident 78 had was on oxygen therapy on admission and while she was a resident in the facility. A review of Resident 78's care plan, revised 3/12/25, indicated, has altered respiratory status/Difficulty Breathing r/t [related to] CHF, COPD. A review of Resident 78's care plan intervention, dated 3/12/25, indicated, Provide oxygen as ordered. During a concurrent observation and interview on 4/21/25 at 11:03 a.m. with Resident 78, in Resident 78's room, Resident 78 was seen sitting in her wheelchair, awake, and had an oxygen concentrator (machine) in her room connected to a nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils). Resident 78 stated she uses her oxygen whenever she has some trouble breathing and she last used it yesterday (4/20/25). A review of Resident 78's active physician's orders did not indicate an order for Resident 78 to receive supplemental oxygen. During a concurrent interview and record review on 4/22/25 at 9:28 a.m. with Licensed Nurse (LN) 1, Resident 78's clinical records were reviewed. LN 1 stated that staff would administer oxygen to Resident 78 when she has difficulty breathing. LN 1 then confirmed that there was no active physicians order for Resident 78 to receive supplemental oxygen. LN 1 stated that staff needs to have an active physician's order for oxygen therapy before administering oxygen to a resident. A review of Resident 78's Weights and Vitals Summary indicated that Resident 78 was on oxygen on the following dates: 3/30/25 at 3:14 a.m.- 96.0% (percent- measurement of one part in every hundred) .Oxygen via Nasal Cannula 4/2/25 at 4:15 a.m.- 96.0% .Oxygen via Nasal Cannula 4/3/25 at 9:11 p.m.- 95.0% .Oxygen via Nasal Cannula 4/8/25 at 8:12 p.m.- 96.0% .Oxygen via Nasal Cannula A review of Resident 78's progress notes, dated 4/16/25, indicated, Oxygen used: Yes .Oxygen administered via: Nasal Cannula . During an interview on 4/23/25 at 10:53 a.m. with the Director of Staff Development (DSD), the DSD stated that there should be an active physician's order for oxygen therapy before administering oxygen to a resident because it's a treatment and to safely administer oxygen to the resident. The DSD further stated that having a physician's order for oxygen therapy is a standard of practice. During an interview on 4/23/25 at 1:23 p.m. with the Director of Nursing (DON), the DON stated that she would expect to have an active physician's order for oxygen therapy before administering oxygen to a resident. A review of the facility's P&P titled, Oxygen Administration, revised 10/2010, indicated, Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services according to policy and procedures to meet the needs of residents for a census of 158 when: 1. The facility failed to accurately document and secure emergency medications (E-kit, a sealed container of essential medications and supplies designed for immediate use in emergency situations); 2. Dispose of expired E-Kit insulin (medication used to control blood sugar) and 3. Ensure the narcotic (substance used to treat moderate to severe pain) count was correct for Resident 37. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and potential for diversion of controlled medications. Findings: 1a. During a concurrent observation and interview on [DATE] at 11:01 a.m. with the Assistant Director of Nursing (ADON) an inspection of the Medbridge Medication Room was conducted. The First Dose Oral Emergency Kit [E-Kit] was observed to have a red color-coded lock. The ADON stated when the emergency kits have been opened they are resealed with a red coded lock. The ADON was unable to provide documentation in the Emergency Kit Log about what medication was taken out of the emergency kit or the date. 1b. During a concurrent observation and interview on [DATE] at 11:24 a.m. with the ADON of the Medication Cart in the 500 Hall, the First Dose Narcotic Emergency Kit was observed. The First Dose Narcotic Emergency Kit was observed to have a red color-coded lock. There were multiple white slips observed in the E-Kit, indicating the E-Kit had been opened by staff multiple times. The ADON was unable to provide documentation in the Emergency Kit Log what medications were taken out of the emergency kit or the dates. During an interview with the ADON on [DATE] at 9:28 a.m., the ADON stated her expectation would be for the Licensed Nurses (LN) to record the medication taken out of the Emergency Kits in the Emergency Kit Log Book and then fax the medication order form to the pharmacy to let them know the E-Kit needed to be replaced. During a review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kit, revised [DATE], As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating that the first dose was used from the kit. The nurse flags the kit with a red color-coded lock to indicate need for replacement of kit .The nurse opening the kit also records use of the kit in the Emergency kit log book. The nurse records the date, time, resident name, medication name, strength, and dose. 2. During a concurrent observation and interview on [DATE] at 11:01 a.m. with the ADON an inspection of the Medbridge Medication Room was conducted. An emergency kit, from Omnicare (a pharmacy), containing insulin was observed in the refrigerator with an Ekit expiration date: [DATE]. The ADON indicated the facility's current pharmacy is Pacific [NAME] Pharmacy and confirmed the insulin was expired. During an interview with the ADON on [DATE] at 9:28 a.m., the ADON stated she would have expected Omnicare to have taken the E-Kit once they were no longer the pharmacy providing service and should have been destroyed. The ADON stated they switched from Omnicare to Pacific [NAME] Pharmacy a couple of months ago. During a review of the facility's policy and procedure titled, Medication Labeling and Storage, Emergency Pharmacy Service and Emergency Kit, dated 2001, indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these item. 3. During a concurrent observation, interview and record review on [DATE] at 8:25 a.m. with LN 5 an inspection of the Medication Cart 600 Hall Controlled Drug Record (medications that the use and possession of are controlled by the federal government) was conducted and reviewed. When LN 5 was asked how many of Resident 37's Percocet (narcotic pain medication) were left she stated there were four tablets left. Review of Resident 37's Controlled Drug Record indicated there were five tablets left. LN 5 confirmed the Controlled Drug Record indicated there were to be five tablets. LN 5 stated she saw the night nurse give the medication right before they left, in front of her, but she guessed they forgot to document it. During an interview with the ADON on [DATE] at 9:28 a.m., the ADON stated she would have expected the night nurse to document that the pain medication was given on the Controlled Drug Record. During a review of the facility's policy and procedure titled, Narcotics, Controlled Substances, and Preventing Drug Diversion, undated, indicated, At the end of each shift, the staff member responsible for medication completing his/her shift, and the staff member responsible for medications who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches what is listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet confirm the accurate count of narcotics on hand.

Based on observation, interview and record review, the facility failed to ensure two out of 35 sampled residents (Resident 68 and Resident 77) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 68 and Resident 77's wound treatment orders were not consistently done. This failure had the potential for Resident 68 and Resident 77's wounds to get worse and not achieve healing, and for the residents to not achieve their highest practicable well-being. Findings: 1a. A review of Resident 68's clinical record indicated Resident 68 was admitted July of 2020 and had diagnoses that included peripheral vascular disease (PVD- a condition where blood flow to the arms, legs, and feet are restricted due to narrowed or blocked blood vessels), venous insufficiency (a condition where the veins in the legs don't effectively return blood back to the heart, leading to blood pooling in the legs), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 68's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/4/25, indicated Resident 68 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 68 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 68's MDS Skin Conditions indicated Resident 68 was at risk for developing pressure related ulcers or injuries. A review of Resident 68's care plan, revised 1/29/21, indicated, at risk for alteration in skin integrity . A review of Resident 68's care plan intervention, revised 2/5/24, indicated, Administer treatment per physician orders . During an interview on 4/21/25 at 9:41 a.m. with Resident 68, Resident 68 stated he has open wounds on his legs, but he was not getting his treatment every time. During an interview on 4/22/25 at 9:21 a.m. with Treatment Nurse (TN) 1, TN 1 stated Resident 68 has long term lower leg conditions were his legs get itchy, he scratches his legs and then he gets scattered open areas on his skin. TN 1 further stated Resident 68 was currently being treated with hydrocortisone cream (a medication used to reduce inflammation, itching, and swelling) and Aquaphor ointment (a medication used to treat or prevent dry, rough, scaly, itchy skin and minor skin irritation). A review of Resident 68's physician's order, dated 10/6/23, indicated, Hydrocortisone External Cream 1 % [percent- measurement of one part in every hundred] .Apply to Left Lower Leg topically every day shift for Chronic Ulcer of Lt [left] Lower Leg. A review of Resident 68's physician's order, dated 10/17/23, indicated, Hydrocortisone External Cream 1 % .Apply to Rt [right] Lower Leg topically every day shift for Chronic Ulcer of Rt Lower Leg Apply to peri-wound [skin surrounding a wound]. A review of Resident 68's treatment administration records (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for March and April 2025 indicated the hydrocortisone cream orders for both left and right lower legs of Resident 68 were not done from 3/1/25 to 4/18/25 and from 4/20/25 to 4/22/25. A review of Resident 68's physician's order, dated 12/11/24, indicated, Aquaphor External Ointment .Apply to left leg chronic ulcer topically three times a day for chronic leg ulcer apply and exposed to air. A review of Resident 68's physician's order, dated 10/17/23, indicated, Aquaphor External Ointment .Apply to ulcer [on] right lower leg topically three times a day for chronic leg ulcer non pressure apply to the peri-wound and exposed to air. A review of Resident 68's TAR for March and April 2025 indicated the Aquaphor ointment orders for both left and right lower legs of Resident 68 were: -not done on 3/3/25, 3/4/25, 3/27/25, 4/12/25, and 4/13/25 -only done once in a day on 3/1/25, 3/2/25, 3/5/25 to 3/26/25, 3/28/25 to 4/11/25, 4/14/25 to 4/18/25, and 4/20/25 to 4/22/25. -only done twice in a day 4/19/25. During a concurrent interview and record review on 4/23/25 at 9:55 a.m. with the Nurse Supervisor (NS) 1, Resident 68's clinical records were reviewed. NS 1 confirmed that Resident 68's wound treatment orders for his lower legs were not consistently done. NS 1 stated that nurses should follow wound treatments according to the physician's order and if the resident refused, it should have been documented. NS 1 further stated that the risk if the wound treatment orders for Resident 68 were not consistently followed was that the resident's wound might get worse. 1b. A review of Resident 77's clinical record indicated Resident 77 was admitted July of 2024 and had diagnoses that included vascular parkinsonism (a movement disorder caused by damage to the blood vessels in the brain, leading to impaired movement and balance), adult failure to thrive (AFTT- a decline in older adults characterized by frailty, weight loss, reduced appetite, and cognitive and functional challenges), morbid obesity (a severe form of obesity), and overactive bladder (a condition where the bladder muscle contracts involuntarily, causing a sudden, strong urge to urinate that can be difficult to control). A review of Resident 77's MDS Cognitive Patterns, dated 4/4/25, indicated Resident 77 had a BIMS score of 15 out of 15 which indicated Resident 77 had an intact cognition. A review of Resident 77's MDS Skin Conditions indicated Resident 77 was at risk for developing pressure related ulcers or injuries. A review of Resident 77's care plan, revised 6/28/24, indicated, Resident is at risk for skin breakdown . A review of Resident 77's care plan intervention, dated 6/28/24, indicated, Administer treatments as ordered .Apply barrier cream as indicated . During an interview on 4/21/25 at 9:57 a.m. with Resident 77, Resident 77 stated he has open sores on his back, but staff are not taking care of them properly. Resident 77 further stated the sores on his back are not getting better. During an interview on 4/22/25 at 9:24 a.m. with TN 1, TN 1 stated Resident 77 has MASD (Moisture-Associated Skin Damage- a term used to describe skin damage caused by prolonged contact with moisture, such as urine, stool, perspiration, wound exudate, or mucus) on his back. TN 1 further stated Resident 77 was ordered zinc oxide (a skin protectant) twice a day. A review of Resident 77's physician's order, dated 12/12/24, indicated, Zinc Oxide External Paste 20 % .Apply to Rear Lt Thigh topically every day and evening shift for MASD AND Apply to Rear Rt Thigh topically every day and evening shift for MASD AND Apply to Rt Buttock topically every day and evening shift for MASD. A review of Resident 77's TAR for March and April 2025 indicated the zinc oxide paste order for Resident 77's left and right thighs, and right buttock were: -not done on 3/3/25, 3/4/25, 3/27/25, and 4/13/25 -only done once in a day on 3/1/25, 3/2/25, 3/5/25 to 3/26/25, 3/28/25 to 4/12/25, and 4/14/25 to 4/21/25. During a concurrent interview and record review on 4/23/25 at 9:55 a.m. with NS 1, Resident 77's clinical records were reviewed. NS 1 confirmed that Resident 77's wound treatment orders for his left and right thighs, and right buttock were not consistently done. NS 1 stated that nurses should follow wound treatments according to the physician's order and if the resident refused, it should have been documented. NS 1 further stated that the risk if the wound treatment orders for Resident 77 were not consistently followed was that the resident would be at risk to develop more skin issues. During an interview on 4/23/25 at 10:53 a.m. with the Director of Staff Development (DSD), the DSD stated that nurses must follow the frequency of wound treatment per the physician's order. The DSD also stated that if it was not documented, it would imply that it was not done. The DSD further stated that the risk if wound treatments were not consistently done was that either the resident would develop new skin issues or the resident's wound might get worse. During an interview on 4/23/25 at 1:23 p.m. with the Director of Nursing (DON), the DON stated that she would expect staff to follow the wound treatment frequency ordered by the physician. A review of the facility's P&P titled, Wound Care, revised 10/2010, indicated, .1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident . A review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/2020, indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Prevention .4. Use a barrier product to protect skin from moisture .

Based on observation, interview and record review, the facility failed to ensure infection control practices and procedures were followed for three of 35 sampled residents (Residents 48, 55, and 78) when: 1. Resident 48's Incentive Spirometer (a device used to exercise the lungs) was left unlabeled and not covered. 2. Resident 55's Enhanced Barrier Precautions (EBP) were not followed. 3. Resident 78's Nasal Cannula (a device used to deliver oxygen through the nose) was left uncovered. These failures had the potential to result in the spread of infection among residents. Findings: 1. A review of Resident 48's clinical record, indicated the facility admitted Resident 48 in 2017 with multiple diagnoses which included chronic respiratory failure. A review of Resident 48's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 3/4/25, indicated Resident 48 had a Brief Interview for Mental Status (a tool to assess a person's cognition) score of 13 out of 15 which indicated Resident 48 was able to understand. During a concurrent observation and interview on 4/21/24 at 9:37 a.m., an Incentive Spirometer (IS) was observed on a shelf between Resident 48 and their roommate. The IS was unlabeled and not contained in a protective covering. Resident 48 stated I think that's mine. During a concurrent observation and interview with Licensed Nurse 7 (LN 7) on 4/21/24 at 9:51 a.m., LN 7 verified the IS was not labeled or contained in a protective covering. LN 7 stated, The IS should be labeled with the residents' name and stored in a bag. A review of the Physician's Order dated 4/18/25, indicated an order for an Incentive Spirometer four times a day every Monday Tuesday, Wednesday, Thursday, and Friday until 5/9/25. During an interview with the Director of Nursing (DON) on 4/22/24 at 3:17 p.m., the DON stated, The IS should have been labeled with the resident's name and be stored in a bag. A review of the facility policy titled, Incentive Spirometry undated indicated, Label the spirometer with the patient's name. Place the mouthpiece in a storage bag . 2. A review of Resident 55's clinical record indicated the facility admitted Resident 55 in 2018 with multiple diagnoses which included cellulitis (an infection of the skin and underlying tissues) of the lower left limb. During an observation on 4/23/25 at 9:48 a.m., Certified Nursing Assistant 5 (CNA 5) was observed in Resident 55's room providing personal care to the Resident and not wearing any personal protective equipment (PPE). Next to the entrance to Resident 55's room, signage was posted indicating enhanced barrier precautions (EBP). The sign indicated to wear a gown and gloves for high-contact resident care activities prior to entering the room. During an interview with CNA 5 on 4/23/25 at 9:53 a.m., CNA 5 verified Resident 55 was on EBP, and she had not worn the required PPE while providing direct care to the Resident. A review of Resident 55's Plan of Care dated 4/15/25 indicated, Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of chronic wound . Interventions included, Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g., dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care.). During an interview with the Infection Preventionist (IP) on 4/23/25 at 2:48 p.m., the IP stated, If a resident is on EBP and the staff is providing direct patient care they need to wear the appropriate PPE. A review of the facility policy and procedure P&P titled, Enhanced [NAME] Precautions undated indicated, EBP involves the use of personal protective equipment (PPE), specifically gowns and gloves, during high-contact resident care activities . 47197 3. A review of Resident 78's clinical record indicated Resident 78 was admitted February of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), congestive heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should), and sleep apnea (a sleep disorder that causes people to stop breathing or breathe shallowly while they sleep). A review of Resident 78's MDS Cognitive Patterns, dated 3/28/25, indicated Resident 78 had a BIMS score of 12 out of 15 which indicated Resident 346 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 78's MDS Health Conditions, dated 1/29/25, indicated Resident 78 experienced shortness of breath or trouble breathing when lying flat. A review of Resident 78's MDS Special Treatments, Procedures, and Programs, dated 3/28/25, indicated Resident 78 was on oxygen therapy on admission and while she was a resident in the facility. A review of Resident 78's care plan, revised 3/12/25, indicated, has altered respiratory status/Difficulty Breathing r/t [related to] CHF, COPD. A review of Resident 78's care plan intervention, dated 3/12/25, indicated, Provide oxygen as ordered. During a concurrent observation and interview on 4/21/25 at 11:03 a.m. with Resident 78, in Resident 78's room, Resident 78 was seen sitting in her wheelchair, awake, and had an oxygen concentrator (machine) in her room connected to a nasal cannula. Resident 78's nasal cannula was observed placed on top of Resident 78's oxygen concentrator and was uncovered. Resident 78 stated she uses her oxygen whenever she has some trouble breathing and she last used it yesterday (4/20/25). During a concurrent observation and interview on 4/21/25 at 11:09 a.m. with CNA 3, in Resident 78's room, CNA 3 confirmed that Resident 78's nasal cannula was placed on top of Resident 78's oxygen concentrator and was uncovered. CNA 3 stated the nasal cannula should be placed inside a bag when not being used. During an interview on 4/23/25 at 10:53 a.m. with the Director of Staff Development (DSD), the DSD stated respiratory tubing such as nasal cannulas should be placed inside an antimicrobial bag when not in use so the tubing would not be exposed to germs. The DSD further stated that the risk if a nasal cannula being not placed inside an antimicrobial bag when not in use was possible contamination of the nasal cannula which could lead to potential infection of the resident. During an interview on 4/23/25 at 1:23 p.m. with the DON, the DON stated nasal cannulas should be placed inside an antimicrobial bag when not in use. A review of the facility's P&P titled, Oxygen Administration, dated 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration .Oxygen therapy is administered by way of an oxygen .nasal cannula .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1a. Three steam table pans were stored wet, and one had food residue in the pan, b. The food processor and blender were both stored wet with food residue in them, with the lids on, 2. The dry storage area floor had debris on it. These failures had the potential to lead to food borne illness for the 152 Residents eating facility prepared meals. Findings: 1a) During an observation and concurrent interview on 4/21/25 at 8:52 a.m., with the Dietary Supervisor (DS) during the initial kitchen tour, three steam table pans were found stored wet (wet nesting) in the ready to use area and one pan had food residue inside the pan. The DS stated she expected the steam table pans to be clean and air dried before storage. 1b) During a continued observation and interview on 4/21/25 at 8:56 a.m., with the DS during the initial kitchen tour, the food processor and food blender were both stored with a lid on top, wet with food residue inside. The DS stated she expected the equipment to be dry and free of food residue. The DS further stated that if the steam table pans and kitchen equipment are not properly washed and dried there is a chance for food borne illness. Review of the facility provided policy titled Dishwashing (Healthcare Menus Direct, LLC., 20 23) included the statement that All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order 1. Gross food particles shall be removed by careful scraping and pre-rinsing in running water .5. Dishes are to be air dried in racks before stacking and storing. Review of the 2022 Federal Food and Drug Administration Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Surfaces . shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 2) During an observation and interview on 4/21/25 at 9:58 a.m., with the DS during the initial kitchen tour, the dry storage area had food packets, a piece of plastic wrap, and paper on the floor. The DS confirmed that the floor needed to be swept. Review of the 2022 Federal Food and Drug Administration Food Code, section 3-305.11, titled, Food Storage, . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

Based on interview and record review, the facility failed to ensure two out of 35 sampled residents (Resident 77 and Resident 141) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 77 and Resident 141 pain medication orders were not consistently followed. This failure had the potential for Resident 77 and Resident 141 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being. Findings: 1a. A review of Resident 77's clinical record indicated Resident 77 was admitted July of 2024 and had diagnoses that included vascular parkinsonism (a movement disorder caused by damage to the blood vessels in the brain, leading to impaired movement and balance), and osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet). A review of Resident 77's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/4/25, indicated Resident 77 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 77 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 68's MDS Health Conditions indicated Resident 77 received 'as needed' pain medications and non-medication intervention for pain. A review of Resident 77's care plan, initiated 6/28/24, indicated, Pain: At risk for pain or discomfort due to .chronic Parkinson's, Osteoarthritis . A review of Resident 77's care plan intervention, initiated 6/28/24, indicated, Administer medication as ordered . During an interview on 4/21/25 at 9:57 a.m. with Resident 77, Resident 77 stated he often experiences pain, and he was taking pain medications for it. A review of Resident 77's physician's order, dated 3/17/25, indicated, Acetaminophen [a potent pain reliever] Capsule 500 MG [milligrams- unit of measurement] Give 1 tablet by mouth every 8 hours as needed for mild pain 1-3 [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain]. A review of Resident 77's physician's order, dated 3/17/25, indicated, Ibuprofen [pain medication] Oral Tablet 200 MG . Give 600 mg by mouth every 6 hours as needed for moderate pain 4-6. A review of Resident 77's physician's order, dated 3/17/25, indicated, HYDROcodone-Acetaminophen [a medication for pain which contains a combination of hydrocodone; a controlled pain medication, and Acetaminophen] Oral Tablet 10-325 MG . Give 1 tablet by mouth every 4 hours as needed for Pain severe pain (7-10). A review of Resident 77's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of March and April 2025 indicated Resident 77 received acetaminophen which was indicated for mild pain on the following occasion: 4/5/25 at 2:35 a.m.- pain level was 5 (moderate pain) A review of Resident 77's MAR for the month of March and April 2025 indicated Resident 77 received Hydrocodone-Acetaminophen which was indicated for severe pain on the following occasions: 3/18/25 at 12:39 p.m.- pain level was 5 (moderate pain) 3/21/25 at 12:41 p.m.- pain level was 6 (moderate pain) 3/27/25 at 10:41 a.m.- pain level was 6 (moderate pain) 4/2/25 at 2 p.m.- pain level was 6 (moderate pain) 4/3/25 at 2:45 p.m.- pain level was 4 (moderate pain) 4/4/25 at 12:31 p.m.- pain level was 4 (moderate pain) 4/9/25 at 1:14 p.m.- pain level was 5 (moderate pain) 4/10/25 at 2:37 p.m.- pain level was 5 (moderate pain) 4/11/25 at 10:04 a.m.- pain level was 6 (moderate pain) 4/16/25 at 1:18 p.m.- pain level was 4 (moderate pain) 4/17/25 at 2:21 p.m.- pain level was 6 (moderate pain) 4/18/25 at 12:54 p.m.- pain level was 6 (moderate pain) 4/21/25 at 1:20 p.m.- pain level was 6 (moderate pain) 4/2/25 at 1:08 p.m.- pain level was 6 (moderate pain) During a concurrent interview and record review on 4/23/25 at 9:55 a.m. with the Nurse Supervisor (NS) 1, Resident 77's clinical records were reviewed. NS 1 confirmed that Resident 77's pain medication orders were not consistently followed. NS 1 stated that nurses should follow the physician's order when administering pain medication. 1b. A review of Resident 141's clinical record indicated Resident 141 was admitted February of 2025 and had diagnoses that included fracture (break in the continuity of a bone) of right and left lower legs, multiple fractures of bilateral (both sides) ribs, and osteoarthritis. A review of Resident 141's MDS Cognitive Patterns, dated 2/9/25, indicated Resident 141 had a BIMS score of 12 out of 15 which indicated Resident 141 had a moderately impaired cognition. A review of Resident 141's MDS Health Conditions indicated Resident 141 frequently experiences pain or hurting and has received scheduled and 'as needed' pain medications and non-medication intervention for pain. A review of Resident 141's care plan, initiated 2/6/25, indicated, Pain: Experiencing chronic pain discomfort due to: fracture(s) . A review of Resident 141's care plan intervention, initiated 2/6/25, indicated, Administer medications as ordered . During an interview on 4/21/25 at 1:30 p.m. with Resident 141, Resident 141 stated her pain medications were not given to her correctly. A review of Resident 141's physician's order, dated 2/6/25, indicated, Acetaminophen Oral Tablet 325 MG . Give 2 tablet by mouth every 4 hours as needed for Mild Pain (1-3) . A review of Resident 141's physician's order, dated 2/7/25, indicated, Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Moderate pain (4-6) . A review of Resident 141's physician's order, dated 2/7/25, indicated, Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for severe pain (7-10) . A review of Resident 141's MAR for the month of March and April 2025 indicated Resident 141 received 1 tablet of Norco which was indicated for moderate pain on the following occasions: 3/3/25 at 3:55 p.m.- pain level was 8 (severe pain) 3/28/25 at 9:45 p.m.- pain level was 7 (severe pain) A review of Resident 141's MAR for the month of March and April 2025 indicated Resident 141 received 2 tablets of Norco which was indicated for severe pain on the following occasions: Pain level was 4 (moderate pain)- 1 time Pain level was 5 (moderate pain)- 17 times Pain level was 6 (moderate pain)- 57 times During a concurrent interview and record review on 4/23/25 at 9:55 a.m. with the NS 1, Resident 141's clinical records were reviewed. NS 1 confirmed that Resident 141's pain medication orders were not consistently followed. NS 1 stated that nurses should follow the physician's order when administering pain medication. During an interview on 4/23/25 at 10:53 a.m. with the Director of Staff Development (DSD), the DSD stated that nurses should always follow the physician's order when administering pain medications to resident. The DSD also stated that it would be a risk for medication overdose which could lead to medication dependence and addiction if a resident was given too strong medication. The DSD further stated that if a resident was administered too little medication, the resident would not achieve the expected level of pain relief. During a phone interview on 4/23/25 at 11:47 a.m. with the Consultant Pharmacist (CP), the CP stated he had noticed the issue of staff not consistently following physician's order when administering pain medications on his monthly medication review for April 2025. The CP further stated that he would expect staff to follow physician's order for pain management, and if not, there would be a risk of either medication dependence or inadequate pain relief. During an interview on 4/23/25 at 1:23 p.m. with the Director of Nursing (DON), the DON stated that pain medication orders should be followed. A review of the facility's P&P titled, Administering Pain Medications, revised 10/2022, indicated, Preparation .1. Review the resident's care plan to assess for any special needs of the resident . General Guideline .1. The pain management program is .based on professional standards of practice, the comprehensive care plan .Steps in the Procedure .6. Administer pain medications as ordered . A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to follow policy and procedure for the proper storage of drugs and biologicals for a census of 158 when: 1. Loose pills were found in a medication cart, and; 2. A bottle of Drug Buster (medication disposal system) was observed with brown substance on the outside of the bottle and on the bottle of the drawer. These failures had the potential for drug diversion and medication at risk of degradation. Findings: 1. During a concurrent observation and interview on 4/22/25 at 8:25 a.m. with Licensed Nurse (LN) 5, an inspection of the 600 Hall Medication Cart was conducted. Multiple loose pills were observed in the medication cart. LN 5 verified the loose pills in the cart. 2. During a further concurrent observation and interview on 4/22/25 at 8:25 a.m. with LN 5, an inspection of the 600 Hall Medication Cart was conducted. A white bottle of Drug Buster was observed with brown substance on the outside of the bottle and on the bottom of the drawer. LN 5 confirmed the brown substance on the outside of the Drug Buster bottle and on the bottom of the drawer. During an interview with the Assistant Director of Nursing (ADON) on 4/24/25 at 9:28 a.m. she would have expected the LN to destroy the loose pills and to throw the Drug Buster bottle away if its contents were spilled outside the bottle. During a review of the facility's policy and procedure titled, Medication Labeling and Storage, dated 2001, indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure two out of 35 sampled Residents (Resident 110 and Resident 80) were assisted with nail care as part of their Activities of Daily Living (ADLs - normal daily functions required to meet basic needs) when; 1. Resident 110 had long toenails; and, 2. Resident 80 had long fingernails with grayish substance underneath them. These failures had the potential for Resident 110 and Resident 80 to have sustained a skin injury, and to possibly acquire an infection. Findings: 1. During a review of Resident 110's Face Sheet (front page of the chart that contains a summary of basic information about the resident). The face sheet indicated she was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly), type 2 diabetes mellitus (high blood sugar levels due to the body's inability to use insulin effectively), dermatophytosis (fungal infection of the skin that may affect skin, hair, and nails), varicose veins of unspecified lower extremity with ulcer of unspecified site (type of leg ulcer that develops due to poor circulation and back pressure in the veins). During a review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/7/25, indicated Resident 110 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 110 had normal cognitive function (mental process of acquiring knowledge and understanding). A review of Resident 110's MDS Functional Abilities and Goals, dated 4/7/25, indicated Resident 110 was dependent on staff for shower/bathing self, required substantial/maximal assistance with toileting hygiene, putting on/taking off footwear, and personal hygiene. Resident 110 required partial/moderate assistance for lower body dressing, and supervision or touching for upper body dressing. During a review of Resident 110's care plan dated 3/6/25 for skin- the care plan indicated the resident is at risk for skin breakdown related to activity intolerance due to impaired ADL ability and impaired mobility. During a review of Resident 110's care plan dated 4/11/25 for occupational therapy - resident requires skilled therapy due to ADL deficit for bathing and grooming. During an observation on 4/21/25 at 2:15 p.m. in Resident 110's room, Resident 110 was lying on the bed with the left foot uncovered and the toenails were observed to be thick, long and started to curl over the toes. During a concurrent observation and interview on 4/23/25 at 11:28 a.m. with Resident 110 and Licensed Nurse (LN 4) in the Residents room, Resident 110 had long toenails that were curved. LN 4 asked Resident 110 if her toenails were bothering her and Resident 110 stated that she would like them to be trimmed. LN 4 stated that because of Resident 110's diagnosis of diabetes, the podiatrist (medical specialist who diagnoses and treats conditions affecting the foot, ankle, and related structures of the leg) would need to trim her nails the next time they came to the facility. During an interview on 4/23/25 at 12:18 p.m. with the Social Services Director (SSD), the SSD stated that the podiatrist comes to the facility every two months and Resident 110 was currently not on the list. During an interview on 4/23/25 at 12:20 p.m. with the Director of Nursing (DON), regarding long toenails, the DON stated that her expectation was that Resident 110 should see the podiatrist. Resident 110 is at risk for ingrown toenails, skin injury, and broken toenails if the toenails are not trimmed. 47197 2. A review of Resident 80's clinical record indicated Resident 80 was admitted August of 2022 and had diagnoses that included sequelae of cerebral infraction (aftereffects of stroke which can include various impairments, such as cognitive deficits, speech and language difficulties, and movement problems), muscle wasting and atrophy (loss of muscle mass and strength), diabetes mellitus and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 80's MDS, Cognitive Patterns, dated 1/30/25, indicated Resident 80 had a BIMS score of 13 out of 15 which indicated Resident 80 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 80's MDS Functional Abilities and Goals, dated 1/30/25, indicated Resident 80 required substantial/maximal assistance with upper body dressing and personal hygiene, was dependent on toileting hygiene, showering/bathing, lower body dressing and putting on/taking off footwear, and needed setup or clean-up assistance with eating and oral hygiene. A review of Resident 80's care plan intervention, dated 8/22/22, indicated, Assist with daily hygiene, grooming .as needed During a concurrent observation and interview on 4/21/25 at 10:15 a.m. with Resident 80, in Resident 80's room, Resident 80 had long fingernails with grayish substance underneath the fingernails. Resident 80 stated he wanted his fingernails to be trimmed and cleaned because they were not comfortable. During a concurrent observation and interview on 4/21/25 at 10:50 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 80's room, CNA 1 confirmed that Resident 80 had long fingernails with grayish substance underneath the fingernails. CNA 1 stated she would expect that Resident 80's fingernails to be trimmed and cleaned to prevent possible infection. During an interview on 4/22/25 at 9:48 a.m. with the Director of Staff Development (DSD), the DSD stated that residents' nail care was an implied task for nurses to monitor every day and to provide the care as needed. The DSD also stated that if a resident has diabetes, the nurses will do the nail care or if the nails were too long or too complicated, it should be referred and done by a podiatrist. The DSD further stated that if a resident has long fingernails, it would be a risk for skin injury and possible infection. During a concurrent interview and record review on 4/22/25 at 11:43 a.m. with the SSD, the list of podiatry referrals was reviewed. The SSD stated the podiatrist would visit the facility every 62 days and the last scheduled visit was on 2/28/25. The SSD confirmed that Resident 80 had not been referred for fingernail care. The SSD further stated that either the CNA or nurse could refer the resident to her so the resident would be referred for a fingernail care visit. During an interview on 4/23/25 at 1:23 p.m. with the DON, the DON stated that she would expect that nail care for residents would be done. A review of the facility's policy and procedures titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated, .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene ( .grooming .) .

Based on observations, interviews and record review the facility failed to provide the necessary wound care preventions for one of four sampled resident (Resident 1), when Resident 1 developed a Stage 4 pressure injury (skin injury past the top layer of skin with exposure of bone and muscle) when: 1. Wound treatment, assessment and documentation of care were not performed per the facility's practice; 2. Resident's need for increased repositioning in bed was not addressed in the Interdisciplinary Team (IDT) meetings; and, 3. Physician's transfer orders were not initiated per the facility's practices. This failure caused Resident 1 to experience unnecessary pain and psychosocial harm. Findings: Resident 1 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Per the facility's form titled, Admission/Readmission Screen-V2 , dated [DATE], Resident 1's skin assessment findings included the following integrity concerns: Bilateral lower leg [MEDICAL CONDITION], lower abdomen bruises, and right side of abdomen old surgical scar. The assessment notes stated, No, pressure ulcers were present. Review of Resident 1's clinical record titled, Progress Notes validated the following nursing assessments indicated: On [DATE] at 5:46 p.m., Licensed nurse's note indicated, Skin verification assessment complete, .Scab present 0.3 x 0.5 x 0.1 cm.(centimeters, a unit of measure) Stage 3 deep tissue injury,(skin injury with exposure of fat past the top layer of the skin) present at sacral region, 1.2 cm fissure, yellow necrotic tissue present with light serous exudate (a fluid caused by inflammation of a wound) . On [DATE] at 5:09 p.m., Licensed nurse's note indicated, Wound note clarification to Stage 3 pressure injury noted on ,[DATE] .opening fissure (a crack or tear in the skin) to skin in internal area. RP (responsible person) states this was present prior to admission as was due to peri-care and friction from episodes of thin, loose stools. Wound is not pressure related, but cause of friction from wiping. No drainage noted at this time. Wound size: 1.2 (length) x 0.5(width) x 0.1 cm (depth), no drainage. Barrier cream applied, and left open to air .Educated pt (patient) to continue shifting weight off coccyx for preventive measures . Weight shifted at this time by pillows. Review of Resident 1's clinical record included the document titled, Medication Review Report, dated [DATE]-[DATE], which indicated the following physician orders: 1.Apply z-guard (moisture barrier ointment) to internatal/coccyx (tailbone) area to open wound r/t (related to) friction every shift until resolved .Start date [DATE]; 2. Body audit daily every day shift for skin observations .Start date [DATE]; and, 3. Santyl ointment (an ointment used to debride necrotic tissue) 250 unit/gm (unit of measure) ([MEDICATION NAME]) coccyx topically one time a day for healing cover with calcium alginate (type of dressing) and cover with dry dressing .Start date [DATE]. Review of Resident 1's clinical record included the document titled, ETAR (electronic treatment record), dated [DATE]-[DATE], which indicated 1. There were 66 administration times due for the application of the z-guard, of which 19 were not documented (29%), 2. There were 22 dates a body audit should have been performed, of which 11 were not documented (50%). 3. There were 9 administration times due for the application of the Santyl, of which 6 were not documented (67%). During an interview with the Director of Nursing (DON) on [DATE] she verified the missing documentation of the protective barrier (z-gaurd) and stated it was used when the resident was soiled and other times they may not need it. The DON stated the body audits should be done daily and the treatment nurses perform and document it. The DON also stated that the dressing change with application of Santyl are done every third day once a day, there was an error in entering the dressing change (order) and the nurses should have corrected the order to reflect what the doctor told them. Review of Resident 1's clinical record titled, Wound Care Specialist (Medical Doctor, MD) Initial Evaluation, dated [DATE], indicated the following findings: [DATE] DOS (date of service) .She presents with a Stage 2 (a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure wound of the Right Buttock of a least 3 days duration. There is a light serous exudate .(Site 1, Coccyx) .,Removed Necrotic tissue and establish the margins of viable tissue .Stage 3 (full thickness skin loss involving damage or necrosis of tissue below the skin), pressure wound Coccyx (site 1), Etiology: Pressure, Wound size (L x W x D): 6 x 3 x 0.1 cm.(centimeters), Surface Area: 18.00 cm (squared) (a unit of measure that indicates the area equals 1 centimeter on each side). , .Procedure: Surgical Excisional Debridement of (Site 1) ., Stage 2 Pressure wound of the Right Buttock (Site 2), Etiology: Pressure, wound size 1 x 1 x 0.1 cm, Surface area 1.00 cm (squared) ., Stage 2 pressure wound of the Left Buttock (site 3), Etiology: Pressure, Wound Size: 1 x 1 x 0.1 cm, Surface area 1.00 cm squared. The MD's recommendations included off-load (to reduce pressure) wounds and repositioning per facility protocol. The DOS confirmed the evaluation was completed 17 days after Resident 1 was admitted to the facility. Review of Resident 1's clinical record titled, Assessment and Plan of Care Recommendations, dated [DATE] indicated the following: [DATE] DOS .There was some foul odor, though not too strong, however, due to size and depth of wound, I send patient out to hospital for surgical intervention in OR (operating room) for better pain control/tolerance (sic) .Dressing: Calcium Alginate (a substance used to decrease secretions in the wound and minimize bacterial contamination)-Once Daily, Dry Protective Dressing-Once Daily, Santyl -Once Daily. On [DATE], Resident 1 was transferred to a general acute care hospital (GACH) for further assessment due to increased body temp, and assessment of wound and urine output. During an interview with licensed nurse (LN1) on [DATE] at 10 a.m., LN1 shared the wound care was directed by the wound care specialist (MD). Per LN1, the team (wound care treatment team) would provide all aspects of care ordered that included daily dressing changes, weekly assessment and documentation of the wound, and to report any changes in wound assessment to the MD. LN1 stated the MD performed wound rounds every Monday and updated orders as needed. When the Department asked LN1 if the wound care documentation met the facility's chart by exception expectations, LN1 stated, It was not documented but it was done everyday. When asked if he could validate dressings were changed although not documented, LN1 was unable to provide supporting documentation. During an interview with the DON on [DATE] at 11 a.m., the DON expressed We document by exception. When asked if the treatment nurses' documentation met her expectations and the facility's policy she stated, It's not the normal documentation; ok, nurses failed to document. During an interview with the DON on [DATE] at 10:20 a.m., the DON expressed, We know there are documentation issues. It (documentation of care) was a hit or miss. The treatment was done but no documentation to support it. We had a brand new nurse that had an issue with charting care done. We now train to document. The treatment nurses are to describe the wound, measure, use Push Tool (a tracking tool used to calculate and monitor the rate of wound healing) and document size, drainage, color of skin, moisture include slough and wound bed description. They are to document location, length, width and depth .When asked if the treatment nurses used a reference to guide wound care prevention and treatment documentation, the DON, replied This is what we use, and provided the department a form titled, Pressure Ulcer Prevention Pathway. Review of the facility's form titled, Pressure Ulcer Prevention Pathway, dated 2013, indicated skin documentation recommendations as follows: .Head to toe skin evaluation, document skin issues including: color, temperature, turgor, moisture status, integrity, pressure ulcer, if present or known healed pressure ulcer. Presence of Current or healed pressure ulcer, document pressure ulcer: location, length, width, depth, Push Tool. Wound team stage, obtain order for treatment from physician and obtain consultation as needed, daily body audit and Braden scale(sic). Review of Resident 1's clinical record from [DATE] to [DATE] included the documents titled, Progress Notes which confirmed the following physician wound assessments and care documentations: [DATE] at 5:46 p.m., Skin verification assessment complete, .Scab present 0.3 x 0.5 x 0.1 cm.(centimeters, a unit of measure) Stage 3 deep tissue injury,(skin injury with exposure of fat past the top layer of the skin) present at sacral region, 1.2 cm fissure, yellow necrotic tissue present with light serous exudate (a fluid caused by inflammation of a wound) . [DATE] at 5:09 p.m., Wound note clarification to Stage 3 pressure injury noted on ,[DATE] .opening fissure (a crack or tear in the skin) to skin in internal area. RP (responsible person) states this was present prior to admission as was due to peri-care and friction from episodes of thin, loose stools. Wound is not pressure related, but cause of friction from wiping. No drainage noted at this time. Wound size: 1.2 (length) x 0.5(width) x 0.1 cm (depth), no drainage. Barrier cream applied, and left open to air .Educated pt (patient) to continue shifting weight off coccyx for preventive measures . Weight shifted at this time by pillows. [DATE] at 5:53 p.m., During scheduled wound care, noted redness and rash to peri-area and abdominal folds. MD notified, Treatment orders updated. [DATE] at 9:21 a.m., Patient assessed by (MD name) for the following wounds: Stage 4 pressure wound to the coccyx. Wound size (L(length)x W(width) x D(depth), 6 x 5 x 3 cm( centimeters- a unit of measure), Surface area: 30 cm (squared), Periwound Radius: Odor, Exudate: Moderate Serous, Thick Adherent Devitalized Necrotic Tissue: 100%, Wound Progress: Deteriorated, Dressing: Santyl, Calcium Alginate, Dry Protective Dressing- Once Daily. Unstageable DTI (Deep Tissue Injury) of the Right Buttock, Wound size (LxWxD): 7 X 2.5 x not measurable cm, Surface Area: 17.50 cm (squared), Exudate: None, Wound Progression: Deteriorated, Dressing: House Barrier Cream - Q (every) Shift. Review of Resident 1's clinical record titled, Progress Notes, from [DATE] to [DATE] confirmed there was a two week period in which treatment, and assessment of wound were not documented. The DON was unable to provide documentation to confirm wound care was provided during the weeks of [DATE] and [DATE]. 2. Review of a Resident 1's clinical record titled, Occupational Therapy Treatment Encounter note, confirmed the following documentation: [DATE], 6:47 p.m., confirmed, .Noted blu (blue)/blk (black) discoloration RLE (right lower extremity): medial aspect of heel. RN (registered nurse)(at desk and medication) notified immediately. Nursing caregiver educated on floating heels when patient in bed. Patient edified (sic) about pressure relief positions, communicated concerns with IDT. [DATE] at 6:04 p.m., confirmed, .Rolling side to side with Max(A)(assist), pt. (patient) having pain stating she was in one position for too long. [DATE] at 7:57 a.m., confirmed, . instruction and reinforcing positioning with cna (Certified Nurse Assistant) and husband with Pt. In supine (sic) in bed for carryover of pressure relief system with alternating positioning in side lying, using pillow prop for weight off tail bone; B (bilateral) heel float. [DATE] at 3:43 p.m., confirmed, .PT(Physical Therapist) Therapist communicated with desk nurse (staff name) about patient c/o (complaint of) lack of turning per schedule every ,[DATE] hours, and lack of floating B (bilateral) heels. During an interview with the Physical Therapist Assistant (PTA), on [DATE] at approximately 11:40 a.m., the PTA shared concerns regarding residents's complaint regarding lack of turning and new skin assessment findings. Per the PTA, the concerns were to be relayed to,The charge nurse and the cnas. The PTA expressed, I would also have made a note of it on the department's (24 hour log). The info (information) would then be taken to the (facility meeting) by (facility staff name) to address in IDT, (interdisciplinary team meeting, a multiple discipline team meeting to discuss Resident's plan of care). The Department asked the facility for the 24 hour log records. Per the Director of Physical Therapy and Rehabilitation (DPTR), the logs are not part of the Resident's permanent medical record, therefore the logs are not stored for long periods of time. However, per the DPTR, the concerns were shared in the IDT meeting. The Department requested IDT meeting notes on [DATE] at 11:40 a.m. The facility provided progress notes from [DATE] to [DATE]. The facility records failed to validate Resident 1's care needs required repositioning in bed every two hours. The DON was asked to provided documentation to support Resident 1's every 2 hour repositioning need. The DON was unable to locate IDT notes to validate the concern was addressed in the facility's IDT meetings. During a telephone interview with the complainant on [DATE] at approximately 4:00 p.m., the complainant shared the resident was unable to reposition body weight in bed without assist and the weakness was a change from Resident's baseline physical strength. Per the complainant, on a visit to the facility on Thursday [DATE], no time provided, Resident 1's diaper was removed and the following findings were present: .wound was huge and black, bandage was soaked, smell was horrendous like death. The complainant shared Resident 1 was transferred to the GACH for further assessment on the day of the finding. During a telephone interview with Resident 1 on [DATE] at 8:11 a.m., Resident 1 stated Before I was in the [DIAGNOSES REDACTED] ([MEDICAL CONDITION], a potentially life threatening bacterial infection that causes watery diarrhea) room (patient placement in a single room is preferred to prevent spread an of an infection), I would be up in my wheelchair four to five hours a day. They were not repositioning me in the wheelchair nor told me not to sit up in the chair that long. After I was diagnosed with [REDACTED]. Resident 1 expressed she Do not recall them (staff) waking me up at night to turn me, particularly when I had [DIAGNOSES REDACTED]. Resident 1 shared she was transferred to the hospital (GACH) after becoming delirious. Resident 1 stated My (family) said my wound had a smell. They (staff and family) investigated the wound and then sent me to the hospital (GACH). Resident 1 shared surgeries to the wound were performed during her GACH admission. In an interview with DON on [DATE] at approximately 10:20 a.m., the DON shared there was a care plan already in place, so there wasn't a need to proceed to another preventative care plan. The care plan in place was followed, the care did not change. When asked if the plan of care addressed Resident 1's physical needs, the DON confirmed the care plan directed the staff to reposition Resident 1 before and after meals, to assist with bathroom needs, reposition during and after ADLS and as needed. Per the DON, the care plan was the same for all dependent patients. If the resident was bedridden then the care plan would be changed. Review of Resident 1's clinical record titled, Physical Therapy, Therapy Progress Report, confirmed the following assessment notes: Dated [DATE], at 6:38 p.m., . patient currently at a level where she is unable to provide self pressure relief . Dated [DATE] at 3:38 p.m., .patient's progress has begun to plateau, maybe a result of C.Diff infection and limited out of room treatment secondary to infection. Patient is TD+Max (A) ( total dependence, Maximum assistance of staff) with slide board transfers x 2 people, as for past session, patient has not been able to perform any assistance with transfers. At this point, mechanical lift is highly recommended for all transfers Patient and her (family member) have been educated on need for extra help, whether at home or at ALF (assisted living facility) . Dated [DATE], at 6:38 p.m., . without the use of a Hoyer lift, the patient would be bed bound . Resident's 1 care plan, created on [DATE] and revised on [DATE] care focus was documented as, At risk for alteration in skin integrity related to [MEDICAL CONDITIONS],UTI (urinary tract infection), incontinence, impaired mobility .Goal was documented as decrease/minimize skin breakdown risks .Interventions included: .Encourage to reposition as needed .Observe skin condition with ADL care daily, report abnormalities . Review of facility's document titled, ADL charting in P[NAME] (Plan of Care) with CP (Care Plan) access, stated Bed Mobility: Self Performance - How the resident moves to and from a lying position side to side, and positions body while in bed or alternative sleep furniture. If you (sic) is in bed, day or night your res (resident) has to be repositioned Q (every) 2 hours, or PRN (as needed). The only time you can use not applicable is if your res. died (sic), Otherwise even if your res. is independent you will still have to chart Q 2 hrs that your res. is independent .Transfer: Self Performance: How resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/ from bath/toilet). At Noc (nocturnal or night), if the patient is not transferred you can and should use not applicable. But you have to chart on it (sic)) 3. Review of MD notes in Resident 1's clinical record dated [DATE] confirmed the MD documented the stage four wound to the coccyx etiology was related to pressure and the wound progress was described as deteriorated. Per the MD notes, there was some foul odor, though not too strong. However, due to size and depth of wound, I send patient out to hospital for surgical intervention in OR for better pain control/tolerance (sic). During an interview with the LN1 on [DATE] at 1:20 p.m., LN1 explained, The doctor (Dr.) rounded weekly with the team (wound care nurses, Registered Dietician) may be present. Dr.(name) sometimes wrote his instructions in his wound documentation notes. The nurses would initiate orders from the wound care documentation notes. Sometimes he would use the order form. When asked what is considered the appropriate way to receive orders for the doctor, LN1 provided the Department with a blank copy of the facility's official MD order form and showed the Department an order for [REDACTED]. During an interview with the DON on [DATE] at 10:20 a.m., the DON expressed the MD notes dated [DATE] were downloaded on the 22nd ([DATE]). The DON confirmed the nurses were not aware the MD wanted to transfer Resident 1 to the GACH until the 22nd. Per the DON, the delay was related to time frame in which the MD's company provided access to the notes. Per the DON, If he (MD) really wanted the resident to go out, a P.O. (physician order) should have been completed. He did not tell the nurse, We found the note on the 22nd. We needed a P.O.; we got the P.O. from the medical doctor, the nurse entered the order, we then transferred the resident to the hospital. The DON expressed the (MD name) often left without sharing his thoughts with the staff nurse. He (MD) delayed his response because he didn't speak to the nurse before he left (exited the facility). Review of a Resident 1's clinical record titled, Progress Notes, dated [DATE] at 21:41 (9:41p.m.), confirmed the MD notes were reviewed prior notes (MD name), plan: send pt (patient) to ER (emergency room ) for more rapid eval (evaluation) and treatment. Review of a Resident 1's clinical record titled, Progress Notes, dated [DATE] at 23:43 (11:43 p.m.), validated the nurse documentation addressed, .patient is alert with confusion to place/time states that she does not feel well, states that she feels confused family here along with board and care providers here. Per CNA, they looked at wound to coccyx/buttocks also reviewed chart. I found dressing soiled and dislodged wound bed presents severe foul odor with large amount of serosanguinous (clear pink to red fluid) drainage. Edges are bright red with moderate tenderness with cleansing of wound bed. Notified (staff name) of current patent status including temp of 102 (degrees Fahrenheit) .patient sent to (name of GACH) for assessment/testing . Review of GACH documents in Resident 1's clinical record titled, Consultation, confirmed the following wound assessments and treatments provided: [DATE] at 5:58 p.m., NP (Nurse Practitioner) and MD ( Medical Doctor) physical examination notes described wound as Back: midline sacral decub, Stage 4 (wound with bone or muscle exposure) with deep tunnel in center ., surrounding skin [DIAGNOSES REDACTED]tous: pt (patient) having formed stool without her knowledge during exam. Ext (extremities) R (right) medial heel with 3 x 2 cm fluctuant (containing a palpable fluid) wound. [DATE] at 08:34 a.m., Podiatry physical examination notes described assessment as Full thickness wound noted under plantar heel of R(right) foot under blister. Post op (operative) debridement, full thickness wound measures 3 cm x 2 cm x 0.2 cm to the level of subq (subcutaneous, beneath the skin) tissue .Bedside excisional debridement of the wound was performed. Review of Resident 1's GACH documents titled, Operative /Procedure Reports, dated [DATE] at 5:23 p.m., confirmed Resident 1 underwent a debridement of the sacral wound. Sacral wound measured 18 cm deep, 12 cm wide, and 20 cm long after the surgical procedure. R buttock decub was approximately 3 x 3 cm, stage 2, sharply debrided .the midline sacral decub was sharply debrided circumferentially but the necrotic tissue seems to extend to the sacrum, which I can palpate through the tunnel; it also tunnel inferiorly. Continued review of Resident 1's GACH documents titled, Progress Notes, confirmed the following: [DATE], confirmed Resident 1's assessment plan included d/c (discharge) to home with wound vac and f/u (follow up) outpt (outpatient) plastics (plastic surgeon) for continued eval (evaluation), possible closure. [DATE] at 4:04 p.m.,confirmed right heel wound was debrided on [DATE] and [DATE]. The sacral pressure ulceration with abscess'' was debrided on [DATE]. A bedside I&D was performed on [DATE].

Based on observation, staff interview, clinical record, and facility policy review the facility failed to ensure necessary standards of care and services were planned and provided for 1 of 6 residents (1) when she was not monitored appropriately for potential life threatening complications of [MEDICAL CONDITION]. This failure resulted in Resident 1's condition deteriorating and she suffered from overwhelming respiratory and urinary tract infections, [MEDICAL CONDITION] (a whole-body [MEDICAL CONDITION] response caused by an infection) which are potentially treatable adverse effects of [MEDICAL CONDITION]. Patient 1 subsequently expired [MEDICAL CONDITION], aspiration (material swallowed into lungs) pneumonia, and a urinary tract infection. Findings: Resident 1 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. According to the Comprehensive Minimum Data Set (MDS - an assessment tool) dated [DATE], active discharge planning was occurring to return to the resident to the community. An additional document in the record titled Occupational Therapy dated [DATE] established Pt (patient) & Caregiver goals: .return back to the community. Potential for Achieving Goals: Patient demonstrates good rehab potential as evidenced by high PLOF (prior level of function), Low number of comorbidities (multiple diseases at the same time), Active participation wPOT (plan of treatment) and Strong family support. The discharge goal was for the patient to return home with family. Review of the document in the clinical record of Resident 1 titled Discharge Summary (acute hospital) dated [DATE] included the following notation under medications: [REDACTED] Review of the document titled Order Summary Sheet in the clinical record of Resident 1 included a physician order dated [DATE] which read: Week 4 Chemo (medicine to [MEDICAL CONDITION]) apt (appointment) on [DATE] at 8 am.one time only for 1 Day. During a concurrent interview and clinical record review with the Director of Nurses (DON) on [DATE] at 4:20 p.m., the care plan of Resident 1 was reviewed. The focus area titled [MEDICAL CONDITION] for treatment of [REDACTED]. rest after [MEDICAL CONDITION]. The DON verified there were no nursing interventions in the care plan of Resident 1 associated with the high risk for immunosuppression (diminished ability of the body to fight infection) , [MEDICAL CONDITION] (low red blood cell count resulting in decreased oxygen carrying capacity of blood), bleeding, and infection secondary to high risk of potential adverse effect of decreased blood counts caused by [MEDICAL CONDITION]. When asked about these potential adverse effects and the plan of care for Resident 1, the DON replied the Resident 1 was in a private room and had lab works (sic) and that the clinic monitor lab work (sic) and would notify the facility of abnormal labs done at the clinic. The DON verified there was no lab work done by the facility to evaluate Resident for potential low blood cell counts that often occur with [MEDICAL CONDITION] and lead to immunosuppression, bleeding, and [MEDICAL CONDITION]. During a concurrent interview and record review with MD 1 on [DATE] at 11:30 a.m., MD 1 verified there was no evidence of any laboratory studies in the clinical record after [DATE]. MD 1 stated there should be some from the [DATE] oncology clinic appointment and we will call the clinic and get copies. During an interview with the DON on [DATE] at 9:15 a.m., she stated she had contacted the clinic to obtain copies of lab work and there was no lab work done on [DATE]. Review of the document titled Progress Notes included an entry on [DATE] at 14:16 (2:16 p.m.) by a Licensed Nurse (LN) included the following entry: during ST (Speech Therapy) pt (patient) noted to be coughing thus further assessed pt and noted crackles (clicking, rattling, or crackling noises associated with respiratory disease that are heard with a stethoscope) @ upper bilateral (both sides) lung fields. cxray (chest X-ray) done as of [DATE] w(with)/ no aspiration (entry of food or material from the mouth into the lungs), atelectasis (deflation of the air sacs in the lungs) and effusion (fluid in the cavity that holds the lungs) noted, downgraded diet, rp (responsible party) agreed, DR (MD 1) notified awaits advice and endorsed. Further review of the Progress Notes included an entry by Social Services on [DATE] at 13:32 (1:32 p.m.) which revealed: Care Conference:.Speech downgraded to nectar thick liquids (milkshake consistency to prevent choking) because of hearing sounds while swallowing and to eliminate aspiration. Goals are to be highest functioning and to get the family trained to care to return home. An additional entry in the Progress Notes by the Registered Dietician dated [DATE] 11:34 (11:34 a.m.) read: S.T. (Speech Therapy) downgraded texture from mechanical Soft (foods that require less chewing) to Pureed. Review of the document titled Physician's Progress dated [DATE] included the following notation: She is improving.Lungs clear anteriorly and laterally. Review of the document titled Progress Notes in the clinical record of Resident 1 dated [DATE] at 17:32 (5:32 p.m.) included the following entry by LN 2: resident has crackles, wheezing in the lungs, request MD (medical doctor) for chest Xrays. MD decline. Additional review of the Progress Notes of Resident 1 included the following notation dated [DATE] at 13:50 (1:50 p.m.): spoke to (Nurse Practitioner (NP) 1) on call for (MD 1) c/o (complaint of) frequent use of [MEDICATION NAME] neb (nebulizer (a method to deliver medication into lungs) prn), swolen legs and burning upon urination, as stated will come to SNF (skilled nursing facility) later this afternoon to see pt, will cont (continue) to monitor and endorsed. Review of the document titled Order Summary revealed a physician order dated [DATE] which read: UA (urinalysis) with C&S (culture and sensitivity - a test to identify bacteria and effectiveness of antibiotics) one time only. MD 1 stated the urinalysis results in the clinical record indicated a sub-clinical (low grade) UTI (urinary tract infection). Further review of the record included a document titled Order Summary with a physician order dated [DATE] that read the following: [MEDICATION NAME] (an antibiotic medication) 100 MG (milligram - a unit of measure).Give 100 mg orally two times a day for UTI for 10 days. Review of the document titled Progress Notes entered by LN 3 dated [DATE] included the following notation under [MEDICATION NAME] Capsule 100 MG: difficulty swallowing. During an interview with LN 3 on [DATE] at 1:30 p.m., she stated she had cared for Resident 1 on [DATE] and had done a test with applesauce to assess her ability to swallow. LN 3 stated Resident 1 had been unable to swallow and her medications were not given. The medication prescribed to treat Resident 1's urinary tract infection was not administered. There was no evidence in the record of assessment of Resident 1's white blood cell count to determine her immune system function (which was at risk for being compromised secondary to common adverse effects of [MEDICAL CONDITION]) when she demonstrated evidence of urinary tract infection. Review of a document titled EMAR (Electronic Medication Administration Record) dated [DATE]-[DATE] in the clinical record of Resident 1 included the following entries: [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML (milliliter - a unit of measure) 0.083% 2.5 mg inhale orally via nebulizer every 6 hours as needed for sob, wheezing. The as needed medication was noted as administered only 4 times from [DATE] to [DATE], however from [DATE] to [DATE] it was noted as administered 2 times daily. Review of the document titled Progress Notes in the clinical record of Resident 1 dated [DATE] at 09:42 (9:42 a.m.) included the following notation: has wheezing sounds, with crackles in upper part of chest. has air hunger. has hard time swallowing food. MD notified. waiting for MD to reply. Further review of the clinical record of Resident 1 included a document titled Order Summary and a physician order dated [DATE] which read: Chest x-ray on [DATE] for SOB, asthma one time only. Review of the document titled Diagnostic Imaging Report dated [DATE] included the following conclusion: Mild bilateral (both sides) perihilar (area around the main airway enters the lungs) infiltrates (a shadow seen on a chest xray and assumed to represent blood, pus, or other body fluids in the lung) and/or areas of atelectasis (a collapsed or airless condition of the lung). There was no evidence in the record of assessment of Resident 1's white blood cell count to determine her immune system function, which was at risk for being compromised, when she demonstrated evidence of respiratory tract infection. Review of the Licensed Nurse Progress Note in the record of Resident 1 dated [DATE] at 23:37 (11:37 p.m.) revealed the following: 02 Sat=(a measurement of peripheral oxygen saturation of the blood) 94% with 02. All other entries in the clinical record of Resident 1 related to her oxygen saturation prior to this date indicated she was on room air and not receiving any oxygen until this entry noted she was on oxygen. Review of a Licensed Nurse Progress Note in the clinical record of Resident 1 dated [DATE] at 12:35 p.m. indicated the following: Resident has xray results, infiltration of lungs or atelectasis. Family notified. MD aware. faxed to MD received back singed (sic). but without any new order. called MD twice for clarification. faxed back. waiting for MD response. Further review of Licensed Nurse Progress Notes dated [DATE] at 17:37 (5:37 p.m.) revealed the following: Received call from (Nurse Practitioner (NP) 1) on call for MD 1, MD stated that he reviewed results of the chest x-ray that was done on [DATE] and clarified that patient doesn't need antibiotic therapy for this findings, recommended cont (continue-sic) with current orders and monitor for sputum. Family aware of doctor decision. Will cont to monitor. Again there was no evidence in the record of assessment of Resident 1's white blood cell count to determine her immune system function when she demonstrated evidence of respiratory tract and urinary tract infection. During an interview with the DON on [DATE] at 10:25 a.m., she stated that normally when a resident is on an antibiotic for an infection, daily charting is done related to effective or not and any side effects. Review of the document titled Order Summary Report in the record of Resident 1 disclosed an order dated [DATE] which indicated the following: [MEDICATION NAME] Suspension (an antifungal medication to treat oral fungal infection).Give 5 ml by mouth four times a day for oral thrush for 14 Days. Review of the Progress Notes of Resident 1 ranging from [DATE] - [DATE], the EMAR, and the facility provided care plan revealed no evidence of any plan of care, physical assessment of the oral cavity, or effectiveness of the treatment. Review of the document titled Progress Notes in the clinical record of Resident 1 dated [DATE] 16:54 (4:54 p.m.) established the following: [MEDICATION NAME] (Tylenol) Tablet 325 MG .given fo (for) loe (low) grade temp of 99.0 and for headache. Review of the document in the clinical record of Resident 1 titled Discharge Summary (acute hospital) dated [DATE] included the following notation under medications: [REDACTED] According to Management of Infections (Oncology) found at Lexicomp Online: (a comprehensive and trusted online drug and clinical reference website) Certain oncology patients are at increased risk of morbidity (a diseased state, disability, or poor health) and mortality (death) from infectious complications secondary to disease- or treatment related loss of immunity.Most anticancer treatments reduce immunity by causing [DIAGNOSES REDACTED] (low white blood cell count - white blood cells protect the body from infection) and mucositis (inflammation of mucous membranes). Retrieved from http://www.online.lexi.com/lco/action/doc/retrieve/docid/patch_f/5250 on [DATE]. Lexicomp Online also revealed the following: higher than 10% of patients experience the following adverse reactions when receiving [MEDICATION NAME]: Hematologic: Cytopenias (decrease in the number of cells in the blood or other tissue) [MEDICAL CONDITION] (low red blood cell count - red blood cells carry oxygen to the tissues in the body) (8%-35%.[DIAGNOSES REDACTED] (low white blood cell count - white blood cells protect the body from infection) , . 14%[MEDICAL CONDITION] (low platelet count - platelets form blood clots to prevent bleeding) (12%. Under Warnings/Precautions, Lexicomp listed the following concern related to adverse effects: Infections.serious and potentially fatal bacterial, fungal, and either new or reactivated [MEDICAL CONDITION] infections may occur during treatment and after completing rituximab ([MEDICATION NAME]).Special Populations: Elderly Use with caution.higher risk of .pulmonary adverse events (pneumonia (lung inflammation caused by bacteria or virus), pneumonitis (lung inflammation usually caused by virus)). Retrieved on [DATE] from http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7634. Important [MEDICATION NAME] Safety Information retrieved from http:/www.[MEDICATION NAME].com/hem/hcp/safety on [DATE] included the following additional warnings/precautions: Laboratory Monitoring; In patients with lymphoid malignancies, during treatment with [MEDICATION NAME] monotherapy, obtain complete blood counts (red blood cell and white blood cells) (CBC) and platelet counts prior to each [MEDICATION NAME] course. During treatment with [MEDICATION NAME] and [MEDICAL CONDITION], obtain CBC and platelet counts at weekly to monthly intervals and more frequently in patients who develop cytopenias. The duration of cytopenias caused by [MEDICATION NAME] can extend months beyond the treatment period. Review of the document obtained from the General Acute Care Hospital (GACH) revealed Patient 1 was admitted to the GACH on [DATE]. A document in the clinical record titled History and Physical dated [DATE] at 23:45 (11:45 p.m.) disclosed the following entry by the medical doctor: Physical Examination: Vital Signs: Temperature is 39.4 (102.9 degrees Fahrenheit).Assessment and Plan:.Possible aspiration pneumonia. Chest x-ray shows what appears to be an aspirate pneumonia, bilateral [MEDICAL CONDITION], otherwise stable. Further review of the GACH records included the following on the document titled Discharge (upon death) Summary dated [DATE]: Discharge Diagnosis: [REDACTED]. Review of the document titled Sacramento County Department of Health and Human Services Certificate of Death dated [DATE] established the following cause of death of Patient 1: [MEDICAL CONDITION] Pneumonia.Urinary Tract Infection. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content under Care Plans included the following statement: A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment.

Based on staff interview, clinical record, and facility policy review the facility failed to ensure a comprehensive care plan was developed based on patient assessments that included necessary care and services for 1 of 6 sampled Residents (1) to ensure she was monitored and treated appropriately for: 1) immunosuppression (depressed function of the immune system) and a decline in her health and 2) oral candidiasis (thrush - a fungal infection of the mouth) 3) difficulty swallowing and possible aspiration (entry of food or material from the mouth into the lungs) 4) urinary tract infection This failure contributed to Resident 1 developing a respiratory infection, a urinary tract infection, and a systemic infection which caused her death. Findings: Clinical recored review indicated Resident 1 was admitted to the facility in July 2014 with [DIAGNOSES REDACTED]. According to the Comprehensive Minimum Data Set (MDS - an assessment tool) dated 7/30/14, active discharge planning was occurring to return the resident to the community. The discharge goal was for the patient to return home with family. 1) Care planning did not include monitoring of immune function - During a concurrent interview and clinical record review with the Director of Nurses (DON) on 4/23/15 at 4:20 p.m., the care plan of Resident 1 was reviewed. The focus area titled [MEDICAL CONDITION] for treatment of [REDACTED]. rest after [MEDICAL CONDITION]. The DON verified there were no nursing interventions in the care plan of Resident 1 associated with the high risk for immunosuppression (diminished ability of the body to fight infection due to low white blood cell count) , [MEDICAL CONDITION] (low red blood cell count resulting in decreased oxygen carrying capacity of blood), bleeding (due to low platelet cell count- which are the cells that initiate blood clotting), and infection secondary to high risk of potential adverse effect of decreased white, red, and platelet counts commonly associated with [MEDICAL CONDITION]. When asked about these potential adverse effects and the plan of care for Resident 1, the DON replied the Resident 1 was in a private room and had lab works (sic) and that the clinic monitor lab work (sic) and would notify the facility of abnormal labs done at the clinic. The DON verified there was no lab work done by the facility to evaluate Resident for potential low blood cell counts that often occur with [MEDICAL CONDITION] and can lead to immunosuppression, bleeding, and [MEDICAL CONDITION]. During a concurrent interview and record review with the Medical Doctor (MD) 1 on 4/24/15 at 11:30 a.m., MD 1 verified there was no evidence of any laboratory studies in the clinical record after 7/30/14. MD 1 stated there should be some from the 8/6/14 oncology clinic appointment and we will call the clinic and get copies. During an interview with the DON on 5/1/15 at 9:15 a.m., she stated she had contacted the clinic to obtain copies of lab work and there was no lab work done on 8/6/14. The DON also stated that there was no evidence in the record that the facility attempted to obtain any lab work from the oncology clinic prior to 5/1/15. According to Management of Infections (Oncology) found at Lexicomp Online: (a comprehensive and trusted online drug and clinical reference website) Certain oncology patients are at increased risk of morbidity and mortality from infectious complications secondary to disease- or treatment related loss of immunity. Impaired immunity is generally associated with malignancies that arise from hematologic cells and lymphoid tissues ([MEDICAL CONDITION]).Most anticancer treatments reduce immunity by causing [DIAGNOSES REDACTED] (low white blood cell count - white blood cells protect the body from infection) and mucositis (inflammation of mucous membranes).Environmental sources of opportunistic pathogens (disease producing organisms) include the surface of fresh fruits and vegetables (bacteria), .and tap water. Retrieved from http://www.online.lexi.com/lco/action/doc/retrieve/docid/patch_f/5250 on 5/6/15. Review of the document in the clinical record of Resident 1 titled Discharge Summary (acute hospital) dated 7/23/14 included the following notation under medications: [REDACTED] Review of the document titled Order Summary Sheet in the clinical record of Resident 1 included a physician order dated 7/30/2014 which read: Week 4 Chemo (medicine to [MEDICAL CONDITION]) apt (appointment) on 8/6/14 at 8 am.one time only for 1 Day. Important [MEDICATION NAME] Safety Information retrieved from http:/www.[MEDICATION NAME].com/hem/hcp/safety on 5/6/15 included the following additional warnings/precautions: Laboratory Monitoring: In patients with lymphoid malignancies, during treatment with [MEDICATION NAME] monotherapy, obtain complete blood counts (red blood cell and white blood cells) (CBC) and platelet counts prior to each [MEDICATION NAME] course. During treatment with [MEDICATION NAME] and [MEDICAL CONDITION], obtain CBC and platelet counts at weekly to monthly intervals and more frequently in patients who develop cytopenias (below normal number of blood cells). The duration of cytopenias caused by [MEDICATION NAME] can extend months beyond the treatment period. Lexicomp Online also revealed the following: higher than 10% of patients experience the following adverse reactions when receiving [MEDICATION NAME]: Hematologic: Cytopenias [MEDICAL CONDITION] (low red blood cell count - red blood cells carry oxygen to the tissues in the body) (8%-35%.[DIAGNOSES REDACTED], . 14%[MEDICAL CONDITION] (low platelet count - platelets form blood clots to prevent bleeding) (12%. Under Warnings/Precautions, Lexicomp listed the following concern related to adverse effects: Infections.serious and potentially fatal bacterial, fungal, and either new or reactivated [MEDICAL CONDITION] infections may occur during treatment and after completing rituximab ([MEDICATION NAME]).Special Populations: Elderly Use with caution.higher risk of .pulmonary adverse events (pneumonia, pneumonitis). Retrieved on 5/5/15 from http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7634. 2) Lack of care planning to include monitoring of an oral fungal infection - Review of the document titled Order Summary Report in the record of Resident 1 disclosed an order dated 7/24/14 which indicated the following: [MEDICATION NAME] Suspension (an antifungal medication to treat oral fungal infection).Give 5 ml by mouth four times a day for oral thrush for 14 Days. Review of the Progress Notes of Resident 1 ranging from 7/23/14 - 8/8/14, the EMAR (electronic medication administration record), and the facility provided care plan revealed no evidence of any plan of care, physical assessment of the oral cavity, or effectiveness of the treatment. During an interview with the DON on 5/7/15 at 10:25 a.m., she stated that normally when a resident is on an antibiotic for an infection, daily charting is done related to effective or not and any side effects. During a subsequent interview with the DON on 5/7/15 at 1:40 p.m., she verified there was no plan of care in the clinical record of Resident 1 which addressed her oral thrush and she stated there was no mention of assessment of her mouth in the record that I could find. The DON stated we must be more vigilant and make sure care plan is done correctly and comprehensively, we missed it. 3) Lack of care planning to include monitoring and care and treatment of [REDACTED].>Review of the Progress Notes of Resident 1 dated 7/29/14 at 14:16 (2:16 p.m.) entered by a licensed nurse revealed the following: during ST (Speech Therapy) eval (evaluate) pt (patient) noted to be coughing thus further assessed pt and noted crackles (clicking, rattling, or crackling noises associated with respiratory disease that are heard with a stethoscope) @ (at) upper bilateral (both sides) lung fields, cxray (chest X-ray) done as of 7/20/14 w/no aspiration, atelectasis (deflation of the air sacs in the lungs) and effusion (fluid in the cavity that holds the lungs) noted, downgraded diet, rp (responsible party) DR (MD 1) notified awaits advice and endorsed. Patient 1 showed signs and symptoms of possible aspiration. Review of the document titled Speech Therapy Treatment Encounter Note dated 7/29/14 included the following entry by a Speech Language Pathologist (SLP): ST (speech therapy) suspects pharyngeal (throat) residue unnoticed by pt and possible delayed aspiration, as cough increased at end of meal.ST consulted nursing who listened to pts (patient's) lungs and recommended downgrade to nectar thick liquids (milkshake consistency to prevent choking). During an interview with SLP 1 on 5/21/15 at 1:35 p.m., she stated that a care plan should have been initiated by the SLP for the high risk patient assessment as noted above. According to the SLP documented assessments, Patient 1 continued to show signs and symptoms and possible aspiration. Further Review of the Progress Notes of Resident 1 included an entry by Social Services (SSC) dated 7/30/14 at 13:32 (1:32 p.m.) which read: Care Conference: SSC, DCD (Director Care Delivery), PT.Speech downgraded to nectar thick liquids because of hearing sounds while swallowing and to eliminate aspiration. An additional entry by the Registered Dietician in the Progress Notes dated 8/5/14 at 11:34 (a.m.) disclosed the following: S. T. (Speech Therapy) downgraded texture from Mechanical Soft (foods that require less chewing) to Pureed (food prepared at the consistency of a creamy paste). Diet now reads: CHO (Carbohydrate)- Controlled, Pureed with Nectar Thick Liquids. Patient 1 continued to show signs and symptoms and possible aspiration. An entry in the Progress Notes by Licensed Nurse (LN) 2 dated 8/6/14 at 17:32 (5:32 p.m.) noted the following: .resident has crackles. wheezing in lungs, request MD for chest xrays. MD decline. Review of the licensed nursing Progress Notes dated 8/9/14 at 13:50 (1:50 p.m.) included the following notation: spoke to (Nurse Practitioner (NP) 1) on call for (MD 1) c/o frequent use of [MEDICATION NAME] neb. (nebulizer - an aerosol machine to deliver medicine for breathing) prn (as needed).will come to SNF (skilled Nursing Facility) later this afternoon to see pt. Review of the care plan in the clinical record of Patient 1 revealed the following licensed nursing entries dated 7/24/14: Focus: At risk for respiratory impairment related to asthma.Position as upright as possible for meals and afterwards.Elevate the head of the bed. Further review of the care plan of Resident 1 revealed no evidence of a care plan addressing Resident 1's identified problem of possible aspiration or any interventions or precautions to prevent/treat this complication. 4) Lack of care planning to include monitoring and treatment of [REDACTED]. Review of the licensed nursing Progress Notes dated 8/9/14 at 13:50 (1:50 p.m.) included the following notation: spoke to (NP 1) on call for (MD 1) .burning upon urination, as stated will come to SNF (skilled Nursing Facility) later this afternoon to see pt. Review of the document titled Order Summary revealed a physician order dated 8/10/14 which read: UA (urinalysis) with C&S (culture and sensitivity - a test to identify bacteria and effectiveness of antibiotics) one time only. MD 1 stated the urinalysis results in the clinical record indicated a sub-clinical UTI (urinary tract infection). Further review of the record included a document titled Order Summary with a physician order dated 8/10/14 that read the following: [MEDICATION NAME] (an antibiotic medication) 100 MG (milligram - a unit of measure).Give 100 mg orally two times a day for UTI for 10 days. During an interview with the DON on 5/7/15 at 10:25 a.m., she stated that normally when a resident is on an antibiotic for an infection, daily charting is done related to effective or not and any side effects. There was no evidence of daily charting associated with the administration of the [MEDICATION NAME] (antibiotic) being given to Patient 1 for a urinary tract infection. Review of the care plan in the clinical record of Patient 1 revealed the following licensed nurse entries dated 7/24/14: Focus: Urinary incontinence related to impaired Mobility.Goal: Will have no complications due to incontinence.Reports S&S of UTI (such as flank pain, c/o burning/pain, fever, hematuria (blood in the urine), change in mental status, etc. Further review of the care plan of Resident 1 revealed no evidence of a care plan addressing Resident 1's identified problem of urinary tract infection or any interventions or precautions to prevent/treat this complication. Review of the document obtained from the General Acute Care Hospital (GACH) revealed Patient 1 was admitted to the GACH on 8/12/14. A document in the clinical record titled History and Physical dated 8/12/14 at 23:45 (11:45 p.m.) disclosed the following entry by the medical doctor: Physical Examination: Vital Signs: Temperature is 39.4 (102.9 degrees Fahrenheit).Assessment and Plan:.Possible aspiration pneumonia. Chest x-ray shows what appears to be an aspirate pneumonia, bilateral [MEDICAL CONDITION], otherwise stable. Further review of the GACH records included the following on the document titled Discharge (upon death) Summary dated 8/13/14: Discharge Diagnosis: [REDACTED]. Review of the document titled Sacramento County Department of Health and Human Services Certificate of Death dated 8/13/14 established the following cause of death of Patient 1: [MEDICAL CONDITION] Pneumonia.Urinary Tract Infection. Review of the facility policy titled Requirements and Guidelines for Clinical Record Content under Care Plans included the following statement: A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment.

Based on observations, resident and staff interviews, clinical record reviews, and review of the facility's policies and procedures, the facility failed to keep residents drug regimen free from unnecessary drugs, as medications were used without adequate monitoring, or indication for use for 5 of 25 sampled residents (Residents, 2, 3, 5, 15, 18), and Random Resident B as follows: 1. The facility failed to monitor effects when giving pain medications (levels of pain) and failed to monitor side effects associated with pain medications (such as sedation) for Resident 5. Resident 5 was found to be unresponsive to verbal and physical stimulation. Resident 5's respirations were found to be 10 per minute after she was stimulated. This pattern of failures to monitor Resident 5 caused her to develop medication related side effects such as respiratory depression and sedation with the potential for death. The cumulative effect of this systemic failure resulted in the potential of immediate threat to the health and safety of residents receiving pain medications. Because of the above failures, an Immediate Jeopardy (IJ) was called. On [DATE] at 5:22 p.m., the facility's administrator, director of nurses, and nurse consultant, were informed of the IJ situation for system breakdown that permitted use of duplicate pain medications to be administered without adequate indication or monitoring. The Administrator presented a interim plan of corrective actions, on [DATE] at 8:05 p.m. On [DATE] at 3:49 p.m., after verification of the facility's interim plan of corrections had been implemented, the administrator was informed that the IJ was abated. The new scope and severity is therefore E. 2. The facility failed to ensure medications were ordered for adequate indications or monitored. Random Resident B was started on the medications [MEDICATION NAME] and [MEDICATION NAME] for pain when there was no documented evidence of pain. Resident B also received an escalating (increasing) dose of [MEDICATION NAME] from 2 milligrams to 8 milligrams every hour, over 6 days until her death, even though there was no documented evidence of increased pain. 3. The facility failed to monitor the effectiveness of pain medication administration and the effectiveness of antipsychotic medications (medication to reduce [MEDICAL CONDITION]). The facility failed to monitor for the side effects of these medications such as sedation or involuntary movement for Residents 2, 3, 5, 15, and 18. These failures resulted in residents' development of side effects that were not detected or documented by staff, including sedation and respiratory depression which had the potential to result in death. Findings: 1. A. The facility failed to monitor Resident 5 for side effects related to pain medication administration. On [DATE] at 11:15 a.m. the clinical record for Resident 5 was reviewed. Resident 5, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 was observed to be lying in bed with a private caregiver at her bedside. The caregiver stated that Resident 5 did not have breakfast earlier in the day due to sleeping for long periods of time. According to the manufacturer's package insert for [MEDICATION NAME]es, "Elderly have been found to be twice as sensitive as younger patients to the effects of [MEDICATION NAME] ...When choosing a dose, take into consideration the following patient factors: age, weight, physical status, underlying disease states, other drugs used ... " [MEDICATION NAME] is a potent narcotic or opioid [MEDICATION NAME] medication used to treat pain. This medication has a black box warning which is the most serious warning required by the Food and Drug Administration. Potential problems can lead to serious injury or death. The boxed warning for the [MEDICATION NAME] documents that it has an associated risk of fatal overdose due to respiratory depression. Respiratory depression is slowed breathing, which can lead to decreased oxygenation and possibly death. [MEDICATION NAME]es are indicated for the management of persistent moderate to severe chronic pain that cannot be managed by other pain medications. [MEDICATION NAME] is a potent pain medication or opioid [MEDICATION NAME] that is similar to [MEDICATION NAME] and is associated with the same side effects: respiratory depression and sedation. According to a lexicom , a drug resource online, [MEDICATION NAME] sulfate has a boxed warning that "Fatal respiratory depression may occur. Greatest risk during initiation and dose increases..." It was also stated that "All [MEDICATION NAME] sulfate formulations are capable of causing respiratory depression; risk increased in elderly patients, debilitated patients, and patients with conditions associated with [MEDICAL CONDITION] (low amount of oxygen in the bloodstream) .... Monitor for respiratory depression especially during initiation and titration." [MEDICATION NAME] also affects mental status: "Sedation is common; may cause...dizziness...confusion, and depression." Resident 5 was receiving both medications on a regular basis: [MEDICATION NAME] every 72 hours and [MEDICATION NAME] every 4 hours simultaneously. However, there was no documented evidence that the facility staff was monitoring for side effects related to these medications. The physician orders [REDACTED]. There was no documented evidence of monitoring Resident 5's respiratory rate or sedation status to hold the medication if needed in accordance with the physician order. The physician order [REDACTED]. There was no documented evidence that monitoring was done. The absence of monitoring for side effects was verified by Licensed Nurse (LN) 1. During an interview on [DATE] at approximately 2 p.m., LN 1 stated that the practice in the facility is to document by exception such as when the resident develops respiratory depression or is sedated. Staff documents observations of respiratory depression or sedation. This practice is not consistent with the physician order. On [DATE], there were 2 observations of Resident 5: - At 9 a.m., Resident 5 was observed lying in bed on her right side with her eyes closed. - At 11:15 a.m., Resident 5 was observed lying in bed, with her eyes closed and unlabored respirations. During both observations, Resident 5 did not respond to repeated verbal greetings. On [DATE] there were 5 observations of Resident 5: - At 9:20 a.m. she was observed lying in bed on her left side with eyes closed. - At 11:55 a.m. she was observed lying in bed on her back with eyes closed. During both observations, Resident 5 did not respond to repeated verbal greetings. -On [DATE] at 12:20 p.m. LN 5 and the care giver (CG, private pay care provider paid for by Resident 5's family) tried to move the resident to her side so that the [MEDICATION NAME] could be viewed. The CG and CNA 1 were positioning resident with pushing and pulling motions to turn Resident 5 her to her side. Throughout the process, Resident 5 was observed to be deeply sedated. During that time Resident 5 did not open her eyes, blink, or speak. The CG said that Resident 5 did not have breakfast or lunch the day before ([DATE]) or breakfast on [DATE] because she was in the same level of somnolence (sleepiness). -At 12:30 p.m. Resident 5 was observed lying in bed with the lunch tray at the bedside. The CG stated that the resident drank the milk and ate a couple of spoons of pudding, while keeping her eyes closed and that she was not able to stay awake for lunch. - On [DATE] at 1:40 p.m. during a concurrent interview with LN 1 and the facilities pharmacy consultant (Pharm 1) regarding the pain medication regimen and associated side effects for Resident 5, Pharm 1 stated that she had not identified any concerns with the medication regimen. LN 1 and Pharm 1 were asked to observe the state of Resident 5 for themselves. This observation found Resident 5 to be lying in bed on her right side. LN 1 confirmed that Resident 5 was deeply somnolent and then unsuccessfully attempted to arouse Resident 5. LN 1 also attempted to obtain Resident 5's blood oxygen level (by use of a device placed on the fingertips) without success, stating that Resident 5's "fingers are too cold." LN 1 used physical touch, including sternal rub (rubbing of the chest) and deep nail bed pressure (pressing the fingertips), in an attempt to arouse Resident 5. It took approximately 5 minutes of stimulation before Resident 5 began to moan and grimace. LN 1 was not able to obtain the oxygen level during that time. After the physical stimulation described above, Resident 5's respirations were assessed at 10 breaths per minute. On [DATE] at 4 p.m. during a telephone interview with MD 1, he stated that he could not recall the specific reason for the duplicate therapy for pain ([MEDICATION NAME] and [MEDICATION NAME].) for Resident 5, "but we did everything appropriately." He recommended the surveyors review the interdisciplinary team (IDT) notes, where MD 1 stated the medications were addressed. A review of Resident 5's IDT notes dated [DATE] revealed no evidence of review of medication regimen for Resident 5 or any discussion or rationale for the duplicate therapy. On [DATE] there were 2 observations of Resident 5: - At 9 a.m. she was observed lying on her right side with eyes closed. - At 11:30 a.m. she was observed lying on her back with eyes closed. During both observations, Resident 5 did not respond to repeated verbal greetings. On [DATE] there was 1 observation of Resident 5. At 9 a.m. she was observed lying on her right side with her eyes closed. During this observation, Resident 5 did not respond to repeated verbal greetings. During all observations, CG was at Resident 5's bedside confirming Resident 5's failure to respond to verbal greetings. A review of Resident 5's electronic record and the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the facility's policy and procedure dated ,[DATE] titled "Medication Administration: Oral" indicated "Suggested Documentation: Document medication administration on MAR. Unusual observations or complaints and subsequent interventions..." The facility's administrator provided a copy of its policy and procedure titled, "Pain Practice Guide," issue date ,[DATE]. The summary indicated that this guide "uses the nursing process framework: assess, plan, implement, and evaluate." The document also included: "Pain may fluctuate over time so appropriate pain evaluation is essential." As related to monitoring side effects, the document included the following: "Patients receiving opioid [MEDICATION NAME] (narcotic medication) are routinely evaluated and monitored for side effects which include but not limited to:... respiratory depression, sedation." There was no documented evidence from [DATE] to [DATE], that the facility staff, consistent with its policy, monitored Resident 5 for side effects associated with opioid [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]). This lack of documentation was confirmed with LN 1. Review of Resident 5's plan of care dated [DATE] for pain, generalized included the following interventions: - Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. - Administer pain medication per physician orders - Encourage/Assist to reposition frequently to position of comfort - Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective There was no documented evidence that the facility staff, consistent with the plan of care, monitored Resident 5 for signs and symptoms of pain interventions. 1. B. The facility failed to monitor Resident 5 for effectiveness of pain medication administration. On [DATE], review of Resident 5's electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 5 received the [MEDICATION NAME] every 72 hours as ordered. In addition to the [MEDICATION NAME], clinical record review for Resident 5 had a physician's orders [REDACTED]. Resident 5 had another physician's orders [REDACTED]. Resident 5 received both pain medications ([MEDICATION NAME] and [MEDICATION NAME] sulfate) around the clock as ordered. There was no documented evidence of the effectiveness of these medications for controlling pain for this resident. Resident 5's [DATE] eMAR under the section "Pain evaluation one time a day," contained ratings from [DATE] to [DATE] were marked 0. Zero pain scale means no pain. Resident 5 was receiving very potent pain medication, a [MEDICATION NAME], and [MEDICATION NAME] sulfate every four hours. There was only one documentation per day of pain assessment which was zero, meaning no pain. There was no documentation justifying use of two powerful pain medications simultaneously ([MEDICATION NAME] and [MEDICATION NAME]). On [DATE] at 12:40 p. m. Licensed Nurse (LN) 1 was asked about pain monitoring; she stated during the interview that pain medication when given "routinely does not need every shift documentation per our policy." This practice is in conflict with standard practice for pain management which includes resident assessment in correlation to the medication intervention effectiveness. According to "The Nursing Practice Act, Section 2725(b)(1),...the registered nurse provides direct and indirect patient care services that insure the ...comfort ...of patients... Proper management of patient's pain is a nursing function... The nursing function of appropriate pain management includes, but is not limited to: * Assessing pain and evaluating response to pain management interventions using a standard pain management scale. * Documenting pain assessment, intervention, and evaluation activities in a clear and concise manner. * Intervening to minimize drug side effects..." 2. A. The facility failed to ensure adequate indication for use of pain medication for Random Resident B. On [DATE] at 11:30 a.m., during an evaluation of the facility's process for accountability of controlled substances, the clinical record for Resident B was randomly selected. Review of the eMAR revealed that Resident B was receiving [MEDICATION NAME] concurrent with [MEDICATION NAME] sulfate by continuous infusion (intravenously) and intermittent doses on an as needed basis. Resident B, a [AGE] year old patient, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record for Random Resident B revealed physician's progress notes on [DATE] indicating that Random Resident B's son was "...requesting further increase in dose of [MEDICATION NAME] to keep this patient comfortable." The medical record included a note by the physician assistant (PA), on [DATE] at 9:42 p.m., indicating that the "Patient seen and examined today at the request of her son." In addition, the same note included, "Son states that she is confused and restless. Does not feel that she is having any respiratory problems." MD 3 progress notes, dated [DATE] at 2:04 p.m., indicated that Random Resident B was seen that day and she was on [MEDICATION NAME] 5 milligrams every hour by continuous infusion, and 2 milligrams every hour as needed for breakthrough pain, and that the [MEDICATION NAME] was discontinued. The note indicated that Resident B was "resting comfortably in no acute distress." On [DATE] at 1:16 p.m., MD 3 progress notes indicated that the [MEDICATION NAME] dose was increased to 7 milligrams every hour by continuous infusion and 2 milligrams every hour (mg/hr) as needed for breakthrough pain. There was no note by MD 3 addressing Random Resident B's pain. A review of Random Resident B's flow sheet titled, "[MEDICATION NAME] Administration Flow Sheet," indicated that for the [MEDICATION NAME] infusion, for 5 days from [DATE] until [DATE], the pain rating was documented 22 times as follows; 1, 0, 0, 0, 0, 1, 0, 0, 2, 2, 2, 0, 0, 1, 0, 0, 5, 3, 0, 0, 0, 0. Zero indicated no pain and 4 indicated very severe. The documented pain ratings on [DATE] at 6:30 A.M., 13:00, 13:45, and 14:45 were all documented and rated zero. There was no other clinical justification documented for the increase of the [MEDICATION NAME] rate to 7 mg/hr. On [DATE] at 12 p.m., a progress note in the clinical record, written by the PA, indicated that Random Resident B was "unresponsive to verbal stimuli, sleeping," and the plan was "will increase the continuous MS ([MEDICATION NAME] sulfate) to 8/mg/hour and the bolus to 4 mg q hour PRN (every hour as needed)." The pain rating from the flow sheet, on [DATE] at 12 was zero. The PA's supervising physician cosigned the notes, and even though Random Resident B was unresponsive, the [MEDICATION NAME] order was increased to 8 mg/hr and 4 mg every hour when needed. On [DATE] at 9:35 p.m., the PA's progress note in Random Resident B's clinical record included, "Nurses tell me that she is not waking up ..." and that Random Resident B is "unresponsive to verbal stimuli, sleeping." On [DATE], at 1:35 p.m., MD 2 and 3 were interviewed regarding Random Resident B's medication regimen. MD 3 did not provide any justification for the increase in [MEDICATION NAME] rate considering the absence of documentation of pain assessment or evidence of increasing pain. Review of the eMAR revealed that even though Random Resident B was unresponsive, the increased dose of [MEDICATION NAME] was administered starting on [DATE] at approximately 2 p.m and continued until Random Resident B died on [DATE]. According to the eMAR, Resident B received a [MEDICATION NAME] 50 mcg/hr every 72 hours on [DATE], [DATE] and [DATE]. Random Resident B was unresponsive (according to the doctor's progress notes) from [DATE]. Review of the eMAR revealed that, from [DATE] until her death on [DATE], Random Resident B received an escalating/increasing dose of [MEDICATION NAME] infusion. There was no clinical justification or documented rationale in the clinical record for escalating/increasing the dose of [MEDICATION NAME] infusion in the absence of pain assessments and in the absence of evidence of increasing pain. Similarly, there was no clinical justification for using duplicate therapy, in addition to [MEDICATION NAME] sulfate, Random Resident B was also receiving a [MEDICATION NAME] regularly. 2. B. The facility failed to monitor Random Resident B for side effects associated with pain medication administration. Random Resident B received both pain medications ([MEDICATION NAME] and [MEDICATION NAME] sulfate) around the clock, however, there was no documented evidence of the effectiveness of these medications for controlling pain for this resident. The documentation for the pain rating using the scale on the flow sheet was inaccurate as the key of the pain rating key was ,[DATE], (0 meaning no pain and 4 meaning very severe pain). However, the flow sheet for the [MEDICATION NAME] infusion showed documentation of the pain rating as 5. There was no evidence that the facility staff was actively monitoring, detecting, analyzing, or acting in response to the side effects related to pain medication. Random Resident B was unresponsive according to the physician progress notes [REDACTED]. The increased dose was administered even though it was documented that Random Resident B was unresponsive. In addition, the [MEDICATION NAME] was applied on an "unconscious" Random Resident B and two nurses signed the eMAR. Furthermore, on [DATE] at 9:35 p.m., PA's progress notes in Random Resident B's clinical record included, "Nurses tell me that she is not waking up." and that Random Resident B is "unresponsive to verbal stimuli, sleeping." Regardless of the condition of the resident, nurses continued to administer the [MEDICATION NAME] drip until the death of the resident. 2. C. The facility failed to monitor Resident 5 for side effects of antipsychotic medication administration. On [DATE] review of Resident 5's [DATE] eMAR revealed that Resident 5 received [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 1 milligrams every 12 hours with a physician order [REDACTED]." Another physician order [REDACTED]. Review of the November, 2013 eMAR had an order to "Monitor for side effects related to use of [MEDICAL CONDITION] medications. My initials indicate absence of signs and symptoms of side effects. Every shift." This area had a 'check' on the eMAR each shift in [DATE]. On [DATE] at 12:10 p.m., in an interview with LN 5, she stated that Resident 5 had received her medication, "[MEDICATION NAME] 1 milligram is given every 12 hours and was given this morning. She is comfortable now. I monitor her behavior every shift and am looking for restlessness. She used to yell, grimace, cry, and speak loudly." Further, LN 5 stated that regarding antipsychotics, "Nurses document observed behavior on an every shift basis as needed." On [DATE] at 1 p.m., in an interview with a hospice LN 7 she stated, "She is very good now. Family is providing private pay caregiver." Resident 5 "is now losing weight and came here due to her skin breakdown. Her agitation was up but is down now and she is very calm. Before she was so sleepy, she really liked watching golf on TV when she was awake. She made lots of demands and has a strong constitution." The facility's document dated 2006 from Omnicare, Inc. titled "Drugs with Black Box Warnings" listed "Atypical Antipsychotics-Black Box Warning-Associated with increased mortality (death) in older patients; these agents are not approved for treatment of [REDACTED]." Another facility document, without a date, titled, "Drugs with Black Box Warnings" stated, "Atypical Antipsychotics-Increased mortality in older adult patient with dementia." Review of the plan of care for Resident 5 dated [DATE] documented, "At risk for adverse effects related to, use of antipsychotic and antidepressant medication with interventions listed as, "evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs." There was no documented evidence of evaluation of effectiveness by facility staff regarding Resident 5's antipsychotic medication as described in the plan of care. LN 1 was unable to provide documentation of evaluation of effectiveness by facility staff. 3. Resident 2, an [AGE] year old female, was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident 2 had a physician's orders [REDACTED]. As per the physician's orders [REDACTED]." After finding no documented evidence in the clinical record of behavior monitoring for Resident 2, an interview was conducted with the Assistant Director of Nurses (ADON), on [DATE] at 5:15 p.m. The ADON was asked in general, how the facility monitors for behaviors and side effects when administering antipsychotics. She indicated that monitoring residents for behaviors are not charted daily or on every shift, but documented only when observed. When asked for their policy on monitoring residents with side effects following the use of antipsychotics, the facility failed to produce a policy that clearly defined procedures for monitoring resident behaviors. 4. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] was manifested by verbalized hallucinations, and the [MEDICAL CONDITION] was manifested by hitting and being resistive to care. Review of the clinical record for Resident 3, conducted on [DATE], revealed that the physician wrote orders on [DATE] for [MEDICATION NAME] 5 mg, every 6 hours as needed for [MEDICAL CONDITION] and, 15 mg to be given at bedtime. The physician orders [REDACTED]. Further review of the clinical record revealed no documented evidence that monitoring of side effects was being done. During an interview with the ADON, conducted on [DATE] at 6:15 p.m., the ADON was asked regarding Resident 3, to explain how residents are assessed and how adverse effects are monitored for residents on antipsychotics. She said that if no behaviors are noted throughout the day, no documentation is needed. 5. A. Resident 18 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident 18's clinical record on [DATE] revealed a summary of physician's orders [REDACTED]. Among the medications that Resident 18 was taking were as follows: a) " [MEDICATION NAME] (a tablet 20 (milligram) give 1 tablet by mouth at bedtime for depression (manifested by) verbalization of sadness; b) [MEDICATION NAME] tablet 15 (milligram) give 1 tablet by mouth at bedtime for depression (manifested by) poor appetite; c) [MEDICATION NAME] tablet 50 (milligram) give 1 tablet by mouth every 6 hours as needed for pain." A review of Resident 18's electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the potential adverse effects at Lexi-comp on-line (a medication resource on-line) for the use of [MEDICATION NAME], and [MEDICATION NAME] could increase the risk of a rare but serious condition called the serotoni[DIAGNOSES REDACTED] (a condition that might occur when taking medications that cause high levels of the serotonin, a chemical needed for the nerve cells and brain to function, to accumulate in a person's body, which leading to too much serotonin causes symptoms that can range from mild - shivering and diarrhea - to severe - muscle rigidity, fever and [MEDICAL CONDITION]. Severe serotoni[DIAGNOSES REDACTED] can be fatal if not treated). (Source: http://online.lexi.com/lco/action/doc/retrieve/docid/allergy_f/ 06) During a concurrent interview with DCD 1 on [DATE] at 11 a.m., the nurse's progress notes, from [DATE] to [DATE], were reviewed and did not reveal any documentation from licensed staff members the monitoring for any adverse effects of the [MEDICATION NAME], and [MEDICATION NAME] medications. DCD 1 acknowledged she was not aware of the adverse effects of combining these medications. During an interview with LN 10 on [DATE] at 1:30 p.m., she stated, "In our computer charting on the eMAR, the side effects to the use of [MEDICAL CONDITION] medications are not specified of what we are supposed to observe. Our initials showed that we have monitored the residents with the side effects that we are supposed to monitor." When asked if she was aware of the possible adverse effects of the use of [MEDICATION NAME] with the anti-depressants(s), LN 10 stated, "No, I don't know about it." 5. B. Resident 18 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident 18's clinical record on [DATE] revealed a summary of physician's orders [REDACTED]. Among the medications that Resident 18 were taking were as follows: a) "[MEDICATION NAME] tablet 50 (milligram) give 1 tablet by mouth every 6 hours as needed for pain; b) [MEDICATION NAME] tablet (pain medication containing [MEDICATION NAME] (a narcotic) and [MEDICATION NAME]) ,[DATE] (milligram) give 2 tablets by mouth every 6 hours for pain management; c) [MEDICATION NAME] tablet ,[DATE] (milligram) give 1 tablet by mouth every day shift before working with therapy..." A review of Resident 18's electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with Resident 18 on [DATE] at 12 p.m., she was asked about her pain status. Resident 18 stated, "Before therapy, I get one tablet of pain medication. Sometimes, I feel I need an extra pain medication when the therapy is a bit longer." A review of the nurse's progress notes, from [DATE] to [DATE], did not show a consistent, every shift assessment of Resident 18's pain issue, particularly after the administration of the routine pain medication. On [DATE] at 11 a.m., DCD 1 was interviewed about the monitoring and the response after receiving routine pain medications. DCD 1 stated, "The nurses are prompted only to document the effectiveness of the pain medication when the pain medication is a prn (as needed). Otherwise, the day shift nurse documents the daily assessment on the eMAR." Concurrent review of Resident 18's clinical record was done with DCD 1. She acknowledged the absence of documentation of the efficacy of the routine pain medications that Resident 18 received. When asked when should be the proper way of re-assessing the effectiveness of the pain medication on a resident, DCD 1 stated, "Within an hour a nurse should do an assesment." 6. A review of Resident 15's clinical record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15 was observed three times in her room on [DATE]: - At 2:30 p.m., she was in bed, positioned on her back with her eyes closed. - At 3:15 p.m., she was in bed, positioned on her back with her eyes closed. Resident 15 was loudly called by name three times before she responded by opening her eyes. Her eyes closed immediately. - At 4 p.m., she was in bed, positioned on her back with her eyes closed. Resident 15 did not respond when called loudly by name twice. Resident 15 was observed in her room three times on [DATE]: - At 8:45 a.m., she was in bed, on her back with her eyes closed. - At 12 p.m., she was in bed, positioned on her back with her eyes closed. She responded with unintelligible verbal comments when her name was called but did not open her eyes. - At 12:55 p.m., she was in bed, positioned on her back with her eyes closed. Resident 15 did not respond in any way to four verbal greetings. A review of Resident 15's physician's orders [REDACTED]. - [DATE] (order date): [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME] - pain medication), ,[DATE] mg to be given every 12 hours around the clock. - [DATE]: [MEDICATION NAME] (an antidepressant)10 mg to be given once a day for depression, verbally expressed as sadness. - [DATE]: [MEDICATION NAME] 0.25 mg to be given at bedtime for [MEDICAL CONDITION] (a psychological or physiological condition with symptoms, including [MEDICAL CONDITION] and audio/visual hallucinations) related to dementia (a loss of brain function due to disease or injury) expressed as hallucinations. According to WebMD: http://www.webmd.com/drugs, [MEDICATION NAME] is associated with " ... increased risk o