Every finding on record at Community Subacute and Transitional Care Center

Based on observation, interview, and record review, the facility failed to ensure each resident's medications regimen must be free from unnecessary medications and the entire medication regimen was monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being (refers to the state of mental, emotional, and social health of an individual) for one of three sampled residents (Resident 1), when Resident 1's target behaviors and indication of use of psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was not accurately monitored and documented.These failures had resulted in Resident 1 to be inaccurately assessed and inappropriately monitored by nursing staff related to Sertraline use and had the potential to inaccurately evaluate the effectiveness of psychotropic medication and to receive inappropriate doses of psychotropic medications leading to ineffective treatment. Findings:During an observation on 8/19/26 with Resident, in the hallway outside of Resident 1's room, Resident 1 was ambulating without assistive device with Certified Nursing Assistant (CNA) 1 following him with a wheelchair.During a concurrent observation and interview on 8/19/26 12:05 p.m. with Resident 1, in Resident 1's room, Resident 1 was awake lying in bed with CNA 1 at bedside. Resident 1 was alert and oriented to his name. Resident 1 stated he was in military. Resident 1 stated he can walk and go anywhere he wanted.During a concurrent interview and record review on 8/19/26 at 3:09 p.m. with the Social Services Supervisor, Resident 1's Psychotropic Meeting dated 8/11/26, was reviewed. The Psychotropic Meeting indicated, .B. Psychotropics 2. Behavior(s) being monitored: depressive behaviors m/b isolating himself from others, monitor episodes of wandering throughout the facility, inappropriate touching of staff physical aggression towards staff; 3. Behavior(s) occurrences: Increased; 4. Total number of behaviors observed in previous month: Depressive episodes July-0, Aug (August)-5 Wandering 7/14/26 -7/27/26:41 episodes, [DATE] inappropriate touching July-116 episodes, [DATE] Physical aggression-July-54 episodes, [DATE] Sleep - [DATE] episodes.7. MD (Doctor of Medicine) and IDT (Interdisciplinary Team) Discussion: [Brand Name] Sertraline (used to treat certain mental/mood disorders such as depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) was increased from 50 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) to 75 mg on 8/5/26, A psychiatric re-eval was completed on 8/11/26, with recommendation to initiate [Brand Name] Quetiapine (used to treat mental health conditions that may involve disruptions in mood, thinking, perception, sleep, and behavior) 25 mg at bedtime for paranoia and to continue [Brand Name] Sertraline. The SSS stated Resident 1's depressive episodes had been stable with zero episodes while other behaviors such as inappropriate touching, physical aggression and inability to sleep have increased and worsened. During a concurrent interview and record review on 8/19/26 at 4:06 p.m. with Registered Nurse (RN) 2, Resident 1's Electronic Medication Administration Record (EMAR - a daily electronic documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/26 to 8/19/26 and care plan for depression dated 3/11/26 were reviewed. The EMAR indicated, Sertraline HCL (Hydrochloride) Oral Tablet 50 mg Give 1 tablet by mouth one time a day for Depression manifested by (m/b) isolating himself from others Start Date: 3/14/26. Sertraline HCL Oral Tablet 25 mg Give 1 tablet by mouth one time a day for Depression manifested by (m/b) isolating himself from others Start Date 8/5/26. Monitor for episodes of depressive behaviors m/b isolating himself from others. Non-drug intervention: NA (Not Applicable) = No intervention needed #1 Offer ice cream #2 Listen to music. Outcome with non-drug interventions: 0: unchanged +: improved -: worsen Date initiated: 3/11/26. Hours: Day, Evening, Night.# (number)=0 (zero) INT (intervention)=NA OUT (outcome)=NA with initial of licensed nurse. The care plan indicated, Monitor for episodes of depressive behaviors m/b isolating himself from others (Sertraline).Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Intervention: Monitor for episodes of depressive behaviors m/b isolating himself from others. RN 2 stated Resident 1 was admitted at the facility with diagnosis of depression and multiple behaviors such as physical and verbal aggression toward staff. RN 2 stated Resident 1's behaviors were monitored by nursing staff every shift and were documented in the EMAR. RN 2 stated Resident 1's EMAR for behavior of isolating himself from others showed check marks from 8/1/26 to 8/19/26 and were initialed by licensed nurses which indicated Resident 1 was monitored for behavior of isolating himself from others and had no episodes of behavior observed every shift from 8/1/26 to 8/19/26. RN 2 stated Resident 1 had never had episodes of isolating himself from others. RN 2 stated Resident 1 was always out of the room socializing with staff and other residents. RN 2 stated Resident 1 had been wandering in the hallway. RN 2 stated Resident 1's behavior of isolating himself from others was not the target behavior for the use of antidepressant medication. RN 2 stated Resident1 was not appropriately assessed by the licensed nurses for the appropriate behavior related to the use of antidepressant medication. RN 2 stated Resident 1's care plan for depression should be updated to reflect the accurate target behavior exhibited by Resident 1. RN 2 stated care plan goal for depression should be objective and measurable by focusing on the target behavior and not on the adverse reactions of the psychotropic medication to appropriately evaluate the effectiveness of psychotropic medication.During a concurrent interview and record review on 8/21/26 at 3:00 p.m. with the Assistant Director of Nursing (ADON), Resident 1's care plan for depression dated 3/11/26 and psychiatry progress note dated 8/11/26 were reviewed. The care plan indicated, Monitor for episodes of depressive behaviors m/b isolating himself from others (Sertraline). Intervention: Monitor for episodes of depressive behaviors m/b isolating himself from others. The psychiatry progress note indicated, .Patient last seen on 8/3/26. He was increased on his [Brand Name] Sertraline from 50 mg to 75 mg daily. Writer asked to follow up with patient due to worsening agitation. He has not been sleeping; last night he was noted to be walking around, shouting to staff, wandering the hall, unable to sleep. Has been having frequent altercations with staff and residents. Makes derogatory statements regarding the 1:1 (one on one) sitter. Diagnosis: Unspecified Depressive Disorder Dementia with behavioral disturbance. Recommendations: .continue [Brand Name] Sertraline 75mg for mood and impulsivity, maintain a consistent daily routine, provide frequent verbal redirection and reassurance, avoid confrontation, minimize environmental overstimulation, promote good sleep hygiene and limited sleep during the day. The ADON stated Resident 1's target behavior for Sertraline use was not the behavior Resident 1 was exhibiting. The ADON stated Resident 1 had no behavior of isolating himself from others. The ADON stated the psychiatrist note indicated Resident 1's Sertraline use was for mood and impulsivity. The ADON diagnosed Resident 1 with Unspecified Depressive Disorder Dementia with behavioral disturbance. The ADON stated Resident 1's physician's order, medical diagnosis, and care plan should be updated to reflect the indication of antidepressant use and to accurately evaluate if the prescribed psychotropic medication was effective for Resident 1's symptoms and diagnosis. The ADON stated Resident 1 should be monitored by the nursing staff for the appropriate behavior to accurately identify the need and indication of psychotropic medication use. During an observation on 8/21/26 at 4:32 p.m., in Resident 1's room, Resident 1 was sitting in his bed and talking to a staff member inside his room, Resident 1 was calling out a staff's attention when passing by his room. During an interview on 8/21/26 at 5:15 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had no behavior of self-isolation. The DON stated it was her expectation for all licensed nurses to appropriately identify residents' targeted behaviors related to psychotropic medication used to appropriately assess whether psychotropic medications were effective. The DON stated it was important to have accuracy and clarity of the documentation of residents' behaviors and indication of use of psychotropic medication to address the behaviors appropriately and manage effectively. The DON stated care plan directs the care of the residents and goals should be objective and measurable.During a review of facility's policy and procedures (P&P) titled, Psychotropic Medication Use, dated 7/29/25, the P&P indicated, I. PURPOSE: To provide guidance to facility staff on assessing and treating Residents with psychotropic medications appropriately based on diagnosis and/or current condition. III. POLICY A. Each Resident's medication regimen is managed and monitored to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being; D. Psychotropic medications are to be used only when a provider determines that the medication(s) is appropriate to treat a Resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the Resident, as demonstrated by monitoring and documentation of the Resident's response to the medication(s). IV. PROCEDURE A. For all Residents receiving a psychotropic medication, facility staff must ensure: 2. The specific condition or diagnosis being treated and the behaviors manifested are identified in the provider's order; 4. Behaviors associated with use of the medication are identified in the Resident centered care plan; K. The facility Psychotropic Committee will review each Resident on psychotropic medications at least quarterly, to determine the effectiveness of the interventions and need to continue the medication (discontinue, increase or decrease) based on the Resident's current needs. V. DOCUMENTATION: D. The Resident-centered care plan will be developed, implemented and updated as necessary to capture the Resident's behavior/need for the medication, goal for use and interventions implemented.During a review of facility's P&P titled, Comprehensive Care Plan, dated 10/15/25, the P&P indicated, I. PURPOSE A. Each Resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the Resident's medical, physical, mental and psychosocial and cultural needs. 1. The care plan must be based upon the Resident Assessment. B. As the Resident's status changes, facility staff, attending provider and the Resident or Resident Representative (if applicable), will review and/or revise care plan goals and treatment choices. III. POLICY A. Through the care planning process, facility staff must work with the Resident and/or Resident Representative, if applicable, to understand and meet the Resident's preferences, choices and goals during their stay at the facility. B. The facility will establish, document and implement the care and services to be provided to each Resident to assist in attaining or maintaining their highest practicable quality of life, including physical, mental and psychosocial well-being. C. Care planning drives the type of care and services that a Resident receives. D. The facility will develop and implement a comprehensive person-centered care plan for each Resident. and includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. 2. The Comprehensive Care Plan must reflect interventions to enable each Resident to meet their objectives.IV. PROCEDURE A. A comprehensive care plan will be: 3. Reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. The care plan will also be reviewed and updated if there is a significant change in the Resident's condition. B. The team will reassess the effectiveness of the interventions and review and revise the Resident's care plan (with input from the Resident or Resident Representative to the extent possible), if necessary to meet the Resident's needs. C. Care Plan Implementation 1. All care team staff must be informed of their responsibilities for implementing the care plan. 2. Care interventions must be provided as documented in the care plan. 3. Direct care staff are aware of and educated about care plan interventions.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan (a detailed approach to care customized to an individual resident's needs) to maintain the resident's highest practicable physical, mental, and psychosocial well-being (refers to the state of mental, emotional, and social health of an individual) for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's care plan was not developed to reflect assessment and interventions to address potential Trauma Triggers of Post Traumatic Stress Disorder (PTSD -a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event).This failure placed Resident 1 at risk for re-traumatization (re-experiences or re-lives their traumatic experience).2. CNA 2 did not use a communication board/ picture to effectively communicate with Resident 2 while providing care.This failure had the potential for Resident 2 not to receive necessary care and services to meet Resident 2's needs.Findings:1.During a concurrent observation and interview on 8/19/26 12:05 p.m. with Resident 1, in Resident 1's room, Resident 1 was awake lying in bed with Certified Nursing Assistant (CNA) 1 at bedside. Resident 1 was alert and oriented to his name. Resident 1 stated he was in military. Resident 1 stated he can walk and go anywhere he wanted.During an interview 8/19/26 12:08 p.m. with CNA 1, CNA 1 stated he was doing one on one for Resident 1 due to behavior of inappropriate touching with female staff. CNA 1 stated Resident 1 was ambulatory without the use of assistive devices and wanders in the hallway. CNA 1 stated Resident 1 was calm during the day.During a concurrent interview and record review on 8/19/26 at 3:30 p.m. with the Social Services Supervisor (SSS), Resident 1's Social Service History/Initial assessment dated [DATE] and care plan report undated were reviewed. The Social Service History/Initial Assessment indicated, A. Patient Information and History 10. Military Service: Veteran 10a. Branch of Military: Army.Trauma/PTSD Screen.Sometimes things happen to people that are unusually or especially frightening, horrible or traumatic. 5. Have you experienced this kind of event? Yes -If yes, in the past month, have you: 5b. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes. Signed dated: 6/24/26. The care plan report does not include a care plan for trauma informed care. The SSS stated Resident 1 was assessed and screen for PTSD and indicated Resident 1 had history of PTSD. The SSS stated Resident 1 was a veteran and was in an army according to the assessment. The SSS stated she was not aware of Resident 1 had history of PTSD. The SSS stated Resident 1 was identified to be at risk for PTSD from admission. The SSS stated it was important to develop and implement a care plan for PTSD based on assessment to address and meet Resident 1's needs.During a concurrent interview and record review on 8/21/26 at 2:24 p.m. with the Assistant Director of Nursing (ADON), Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/21/26, care plan report, undated, and Social Service History/Initial assessment dated [DATE] were reviewed. The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of alcoholic cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), delusional disorder (a mental condition with false beliefs or judgment about external reality), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. The care plan report did not indicate a care plan for PTSD. The Social Service History/Initial Assessment indicated, A. Patient Information and History 10. Military Service: Veteran 10a. Branch of Military: Army.Trauma/PTSD Screen.Sometimes things happen to people that are unusually or especially frightening, horrible or traumatic. 5. Have you experienced this kind of event? Yes -If yes, in the past month, have you: 5b. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes. Signed dated: 6/24/26. The ADON stated Resident 1 was admitted on [DATE] and she cannot locate Resident 1's diagnosis and care plan for PTSD. The ADON stated Resident 1's assessment indicated he had experienced traumatic life events being in an army. The ADON stated care plan should have been created when PTSD was identified based on assessment by social services on admission to minimize possible triggers. The ADON stated care plan should reflect necessary care, treatment and services based on residents' assessment and needs. The ADON stated it was important for Resident 1's care plan for PTSD to be developed and implemented for staff to know the possible triggers which could place Resident 1 at risk for re-triggering his trauma.During an interview on 8/21/26 at 1:00 p.m. with the Dietary Unit Host ([NAME]), the [NAME] stated she was informed by the Administrator (ADM) and dietary supervisor about Resident 1 having PTSD with behavior of inappropriately touching women. The [NAME] stated she learned about PTSD after the incident with Resident 1 on 8/2/26 when ADM and dietary supervisor informed her via phone to look for possible triggers of PTSD, use buddy system, and maintain distance when around him. The [NAME] stated she did not receive formal training about PTSD and would love to have training to know what interventions she needed to implement to avoid possible triggers.During an interview on 8/21/26 at 5:20 p.m. with the Administrator (ADM), the ADM stated Resident 1 was in military and had PTSD.During an interview on 8/21/26 at 5:25 p.m. with the Director of Nursing (DON), the DON stated a care plan for PTSD should be developed when Resident 1 was identified and assessed by social services with history of trauma. The DON stated it was important to develop and implement care plan for PTSD to address Resident 1's needs and implement necessary interventions and services to prevent triggers. During a review of facility's policy and procedures (P&P) titled, Trauma-Informed and Culturally Competent Care, dated 8/19/26, the P&P indicated. I. Purpose: To provide guidance to facility staff on providing care that is culturally competent and to address the needs of residents who have experiences trauma by minimizing triggers and or re-traumatization. II DEFINITION: F. Trauma-Informed Care: An approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. III BACKGROUND: A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in Residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. A. A individual's experience to an event determines whether it is traumatic, and everyone's experience is unique. C. Traumatic events which may affect individuals during their lifetime may include. 1. Physical, sexual and emotional abuse; 3. Interpersonal violence; 12. Violence in the community, war or terrorism; 13. Generational or historical trauma; and/or 14. Any other life-threatening experience. IV. POLICY - In order to provide a trauma-informed approach to care, facility staff need to recognize and understand that Resident's life experiences and preferences have an effect on them and incorporate them in their individual plans of care. V. PROCEDURE - B. Resident screening/assessment for trauma will be completed upon admission, annually, and when appropriate based on Resident needs. 1. Social services or designee will complete the Trauma-Informed Care Assessment-PTSD5-V2 in the Resident's electronic health record (EHR), to determine possible exposure to traumatic events and to evaluate the presence of symptoms, relationship to trauma, as well as identified triggers. a. Signs of trauma may include: i. Intrusive thoughts of the event that may occur out of the blue; iv. Loss of memory and concentration abilities; v. Disorientation; vi. Confusion; vii. Easily startled; viii. Mood swings; and/or ix. Behaviors. C. Resident care planning will be individualized based on each Residents' life experiences and current needs. 1. The facility will develop individualized care plan(s) that address past trauma in collaboration with the Resident and/or Resident Representative/family, as appropriate. a. interventions will include the identification and decreased exposure to triggers that may retraumatize the Resident; and b. The facility will recognize the relationship between past trauma and current health concerns (Substance abuse, eating disorders, anxiety, homelessness, depression, etc.). 2. The facility will develop individualized care plan(s) that incorporate language needs, culture, cultural preferences, norms and values. including, but not limited to:c. Physical contact or provision of care by a person of the opposite sex; . VI. DOCUMENTATION: A. Social Services will complete the Trauma-Informed Care Assessment PTSD5-V2 in the EHR during the admission process, annually and as needed. 1. Based on the Assessment, an individualized care plan will be developed to address the trauma, triggers associated and interventions to ensure Resident safety and overall well-being. VIII. STAFF EDUCATION: A. All staff are provided with in-service training about trauma and trauma-informed care upon hire and annually. B. Nursing staff and the facility interdisciplinary team (IDT) are trained on trauma screening and assessment tools. C. All staff are provided in-service training on culturally competent care upon hire and annually.During a review of facility's P&P titled, Comprehensive Care Plan, dated 10/15/25, the P&P indicated, I. PURPOSE A. Each Resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the Resident's medical, physical, mental and psychosocial and cultural needs. 1. The care plan must be based upon the Resident Assessment. B. As the Resident's status changes, facility staff, attending provider and the Resident or Resident Representative (if applicable), will review and/or revise care plan goals and treatment choices. III. POLICY A. Through the care planning process, facility staff must work with the Resident and/or Resident Representative, if applicable, to understand and meet the Resident's preferences, choices and goals during their stay at the facility. B. The facility will establish, document and implement the care and services to be provided to each Resident to assist in attaining or maintaining their highest practicable quality of life, including physical, mental and psychosocial well-being. C. Care planning drives the type of care and services that a Resident receives. D. The facility will develop and implement a comprehensive person-centered care plan for each Resident. and includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. 1. The Comprehensive Care Plan must describe the following: e. The services provided or arranged by the facility, as outlined by the Comprehensive Care Plan, must be culturally competent and trauma informed. i. interventions for trauma survivors should recognize the interrelation between trauma and symptoms of trauma such as: I. Substance Abuse; II. Eating Disorders; III. Aggression; IV. Depression; V. Anxiety and/or Withdrawal; .2. The Comprehensive Care Plan must reflect interventions to enable each Resident to meet their objectives.IV. PROCEDURE A. A comprehensive care plan will be: 3. Reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. The care plan will also be reviewed and updated if there is a significant change in the Resident's condition. B. The team will reassess the effectiveness of the interventions and review and revise the Resident's care plan (with input from the Resident or Resident Representative to the extent possible), if necessary to meet the Resident's needs. C. Care Plan Implementation 1. All care team staff must be informed of their responsibilities for implementing the care plan. 2. Care interventions must be provided as documented in the care plan. 3. Direct care staff are aware of and educated about care plan interventions. 2. During an interview on 8/19/26 2:13 p.m. with Registered Nurse (RN) 1, RN 1 stated she was the assigned nurse for Resident 2, and she was familiar with his care. RN 1 stated Resident 2 was alert and oriented to names, places, time and situation. RN 1 stated Resident 2 had difficulty speaking and was able to respond to a yes and no question. RN 1 primarily communicates with the use of sign language, gestures, and facial expression. RN 1 stated Resident 2 requires more time in understanding his needs due to communication deficit.During an interview on 8/21/26 at 1:55 p.m. with CNA 2, CNA 2 stated Resident 2 had difficulty speaking due to Stroke (a loss of blood flow to part of the brain). CNA 2 stated Resident 2 mumbles and unable to speak clearly. CNA 2 stated he worked with Resident 2 twice and had experienced difficulty communicating with Resident 2. CNA 2 stated he had a hard time understanding Resident 2, it was a guessing game figuring out what he wanted. CNA 2 stated he needed to ask Resident 2 multiple times to repeat what he said and Resident 2 started to get irritated and frustrated. CNA 2 stated Resident 2 started to aggressively be pointing into an object which indicated Resident 2 was getting frustrated during the conversation. CNA 2 stated Resident 2's frustration was related to language and communication barriers. CNA 2 stated he did not use a communication board to communicate with Resident 2, and he was not aware of the communication board. CNA 2 stated Resident 2 would benefit for the use of communication board to effectively communicate with him and for Resident 2 not to get irritated and frustrated during care.During a concurrent interview and record review on 8/21/26 at 3:00 p.m. with the Assistant Director of Nursing (ADON), Resident 2's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), undated and care plan report, undated, were reviewed. The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebrovascular disease affecting right dominant hand, and aphasia. The care plan indicated, Risk of impaired communication Cerebrovascular Accident (CVA) and diagnosis of Aphasia Date Initiated 11/8/25. Goal: Resident will be able to effectively communicate basic needs through non-verbal tools.Interventions: Observe effectiveness of communication strategies using communication board. The ADON stated Resident 2 had difficulty speaking with diagnosis of aphasia. The ADON stated Resident 2's care plan interventions with the use of communication board should be utilized by the nursing staff to understand and effectively communicate with Resident 2's needs. During a concurrent observation and interview on 8/21/26 at 3:30 p.m. with Resident 2, in Resident 2's room, Resident 2 was opening his bedside bottom dresser and took the file of communication pictures. Resident 2 stated he uses pictures when staff have difficulty understanding him. Resident 2 stated he was taking more time to express what he wanted verbally and he gets frustrated when staff are not patient and in a hurry. During an interview on 8/21/26 at 4:12 p.m. with the Director of Nursing (DON), the DON stated Resident 2's communication board should be at bedside and available for use. The DON stated it was her expectation for nursing staff to utilize the communication board as needed to effectively communicate with Resident 2.During a review of facility's P&P titled, Comprehensive Care Plan, dated 10/15/25, the P&P indicated, I. PURPOSE A. Each Resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the Resident's medical, physical, mental and psychosocial and cultural needs. 1. The care plan must be based upon the Resident Assessment. B. As the Resident's status changes, facility staff, attending provider and the Resident or Resident Representative (if applicable), will review and/or revise care plan goals and treatment choices. III. POLICY A. Through the care planning process, facility staff must work with the Resident and/or Resident Representative, if applicable, to understand and meet the Resident's preferences, choices and goals during their stay at the facility. B. The facility will establish, document and implement the care and services to be provided to each Resident to assist in attaining or maintaining their highest practicable quality of life, including physical, mental and psychosocial well-being. C. Care planning drives the type of care and services that a Resident receives. D. The facility will develop and implement a comprehensive person-centered care plan for each Resident. and includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. 2. The Comprehensive Care Plan must reflect interventions to enable each Resident to meet their objectives.IV. PROCEDURE B. The team will reassess the effectiveness of the interventions and review and revise the Resident's care plan (with input from the Resident or Resident Representative to the extent possible), if necessary to meet the Resident's needs. C. Care Plan Implementation 1. All care team staff must be informed of their responsibilities for implementing the care plan. 2. Care interventions must be provided as documented in the care plan. 3. Direct care staff are aware of and educated about care plan interventions.

Based on observation, interview and record review, the facility failed to follow the policy and procedure (P&P) to ensure the Care Plans were reviewed and revised for one of three sample residents (Resident 3) when Resident 3's care plan for closing her room door at night per Resident 3's request for safety of his roommate and himself was not revised and updated to reflect the current plan of care.This failure had the potential for Resident 3 not to receive the necessary care to meet his needs based on his preferences and needs to keep him safe during his stay at the facility.Findings:During a concurrent observation and interview on 8/19/26 at 11:44 a.m. with Resident 3, in Resident 3's room. Resident 3 was sitting in a wheelchair, awake, alert, and oriented to names, places, time, and situation/events. Resident 3 stated Resident 1 entered his room two days ago around 11:00 p.m. and heard verbal interaction with CNA 3, Resident 1 and Resident 2. Resident 3 stated Resident 1 have behaviors of getting restless and aggressive with staff especially with female staff, saying bad words, cursing the staff, wandering, and trying to leave the facility. Resident 3 stated Resident 1's behavior never changed and uncontrollable which requires hospital's security staff assistance to manage his behavior on multiple occasions. Resident 3 stated Resident 1 requires two to four staff to calm him down when his agitation increases. Resident 3 stated he does not feel safe around him not with him. Resident 3 stated CNAs started closing his door at night to prevent Resident 1 entering the room, so we feel safe. During an interview on 8/19/26 at 11:55 a.m. with the Director of Nursing (DON), the DON stated the facility won't allow residents to keep their door closed at night for their safety.During an interview on 8/21/26 at 3:49 p.m. with CNA 3, CNA 3 stated CNAs had been closing Resident 3's room door at night around bedtime between 9:30 p.m. to 10:00 p.m. because he has an order to keep the door closed. During a concurrent interview and record review on 8/21/26 at 4:00 p.m. with the Assistant Director of Nursing (ADON), Resident 3's care plan report, undated, was reviewed. The ADON indicated Resident 3 had a care plan for closing the door during the daytime when roommate was not present which was initiated on 8/9/26. The ADON stated there was no care plan for closing the door at night for Resident 3. The ADON stated roommate and responsible party should agree to close the door at night. The ADON stated Resident 3's care plan should be updated and revised to reflect current intervention of closing the door at night to prevent another resident (Resident 1) entering the room for his safety.During an interview on 8/21/26 at 5:15 p.m. with the Director of Nursing (DON), the DON stated licensed nurses will be revising Resident 3's care plan to reflect current plan of care of closing his door at night to prevent another resident entering their room. The DON stated it was important for care plan to reflect current plan of care for staff to be aware to ensure the needs of the residents are met. During a review of facility's P&P titled, Comprehensive Care Plan, dated 10/15/25, the P&P indicated, I. PURPOSE A. Each Resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the Resident's medical, physical, mental and psychosocial and cultural needs. 1. The care plan must be based upon the Resident Assessment. B. As the Resident's status changes, facility staff, attending provider and the Resident or Resident Representative (if applicable), will review and/or revise care plan goals and treatment choices. III. POLICY A. Through the care planning process, facility staff must work with the Resident and/or Resident Representative, if applicable, to understand and meet the Resident's preferences, choices and goals during their stay at the facility. B. The facility will establish, document and implement the care and services to be provided to each Resident to assist in attaining or maintaining their highest practicable quality of life, including physical, mental and psychosocial well-being. C. Care planning drives the type of care and services that a Resident receives. D. The facility will develop and implement a comprehensive person-centered care plan for each Resident. and includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. 2. The Comprehensive Care Plan must reflect interventions to enable each Resident to meet their objectives.IV. PROCEDURE A. A comprehensive care plan will be: 3. Reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. The care plan will also be reviewed and updated if there is a significant change in the Resident's condition. B. The team will reassess the effectiveness of the interventions and review and revise the Resident's care plan (with input from the Resident or Resident Representative to the extent possible), if necessary to meet the Resident's needs. C. Care Plan Implementation 1. All care team staff must be informed of their responsibilities for implementing the care plan. 2. Care interventions must be provided as documented in the care plan. 3. Direct care staff are aware of and educated about care plan interventions.

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information and was posted in a prominent readily accessible place to residents and visitors when:1. Daily nurse staffing information was posted behind nursing station 1 and nursing station 2, which was inaccessible to residents and visitors.2. Daily nurse staffing information did not include the actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN)s, and Certified Nursing Assistant (CNA)s.This failure resulted in restricted public access to posted nurse staffing information for 99 out of 99 residents admitted within the facility which had the potential to result in residents not knowing how many total or actual direct care hours were provided.During an observation on 12/19/25 at 11:26 a.m. at nursing station 1, Transitional Care, the facility's posted daily nurse staffing information titled, Report of Nursing Staff Directly Responsible for Resident Care, dated 12/19/25, was observed behind nursing station 1. The document did not include posted actual hours worked by RNs, LVNs, or CNAs. The document stated, .Daily posting of this information is required for nursing homes participating in Medicare and Medicaid. Pursuant to Section 941 of the Medicare, Medicaid & SCHIP Benefits Improvement. Pursuant to Section 941 of the Medicare, Medicaid & SCIP Benefits Improvements and Protection Act of 2000 (BIPA). During an observation on 12/19/25 at 11:28 a.m. at nursing station 2, Sub-Acute Care, the facility's posted daily nurse staffing information titled, Report of Nursing Staff Directly Responsible for Resident Care, dated 12/19/25, was observed behind nursing station 2. The document did not include posted actual hours worked by RNs, LVNs, or CNAs. The document stated, .Daily posting of this information is required for nursing homes participating in Medicare and Medicaid. Pursuant to Section 941 of the Medicare, Medicaid & SCHIP Benefits Improvement. Pursuant to Section 941 of the Medicare, Medicaid & SCIP Benefits Improvements and Protection Act of 2000 (BIPA).During a concurrent interview and record review on 12/19/25 at 2:06 p.m. with the Director of Staff Development (DSD), the facility's posted daily nurse staffing information titled, Report of Nursing Staff Directly Responsible for Resident Care, dated 12/19/25 was reviewed. The DSD stated daily nurse staffing information was posted behind nursing station 1 and nursing station 2. The DSD stated actual hours worked by RNs, LVNs, and CNAs were not included in the posted daily nurse staffing information. The DSD stated only facility staff had access to nursing station 1 and nursing station 2. The DSD stated residents and visitors were not allowed behind the nursing stations. The DSD stated total, or anticipated, nurse staffing information was not posted in a prominent readily accessible place to residents and visitors. The DSD stated actual daily nurse staffing information was not posted in the facility for staff, residents and visitors to view. The DSD stated staff, residents and visitors had a right to know how many total and actual hours of licensed and unlicensed nursing care hours were provided daily to ensure adequate care was scheduled and provided. During a concurrent observation and record review on 12/19/25 at 2:50 p.m. with Administrative Assistant (ADA) 1, posted daily nurse staffing information was observed behind nursing station 1 and nursing station 2. ADA 1 stated night shift licensed nursing staff posted total, or anticipated, daily nurse staffing information behind the nursing stations. ADA 1 stated posted total daily nurse staffing information was not in a prominent readily accessible place to residents and visitors. ADA 1 stated she calculated actual daily nurse staffing information each morning for the previous day. ADA 1 stated actual hours worked by RNs, LVNs, and CNAs were completed the following day to ensure accuracy of all hours worked by licensed and unlicensed nursing staff. ADA 1 stated actual hours worked by RNs, LVNs, and CNAs could be different than total, or anticipated, hours worked if there were call outs, no shows, or assignment changes. ADA 1 stated total, or anticipated, daily nurse staffing information were important to post in a prominent readily accessible place so residents and visitors could ensure the facility scheduled required staff to meet their needs. ADA 1 stated it was important to post actual daily nurse staffing information so residents and visitors could ensure enough care was provided to meet their needs. During an interview on 12/29/25 at 4:09 p.m. with the Director of Nursing (DON), the DON stated total, or anticipated, daily nurse staffing information was posted behind nursing station 1 and nursing station 2. The DON stated nursing stations were not accessible to residents or visitors. The DON stated total, or anticipated, daily nurse staffing information was not posted in a prominent readily accessible place to residents and visitors. The DON stated it was important to post total, or anticipated, daily nurse staffing information in prominent readily accessible locations so residents and visitors could ensure enough licensed and unlicensed staff were scheduled to meet their needs. The DON stated actual daily nurse staffing information was not posted after it was calculated. The DON stated staff, residents, and visitors had a right to ensure licensed and unlicensed staffing hours met their needs. The DON stated she expected the facility to be in compliance at all times with posted daily nurse staffing information. During a review of the Center for Medicaid and State Operations document titled, BIPA 941 Nursing Home Requirement Effective January 1, 2003; Follow-up to S&C-03-03 Memorandum of October 10, 2002, dated 1/9/23, the document indicated, . the required facility nursing staff numbers must be prominently displayed in a public area. this information must include the actual number of licensed and unlicensed nursing staff directly responsible for the care of residents for that particular day on each shift. This may mean that the nursing facility would post each shift staff numbers very close to the beginning of the shift in order to ensure that the posted numbers are the actual staff working the shift.

Based on observation, interview and record review, the facility failed to establish and maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable (contagious) diseases and infections for four of ten sampled residents (residents 107,7, 39, and 42) when:1. A dignity bag was not correctly put on Resident 107's urine catheter bag and the urine catheter bag was touching the floor. This failure placed Resident 107 at risk to develop a Catheter-Associated Urinary Tract Infection (CAUTI -a serious infection occurring when germs enter the urinary system through a urinary catheter).2. A medication tray was not cleaned or disinfected in between use and contact with Resident 42, Resident 7 and Resident 39, whom were on Enhanced Barrier Precautions (EBP-- an infection control intervention designed to reduce transmission of resistant organisms using gown and glove use during high contact resident care activities).This failure placed Resident 42, Resident 7, and Resident 39 at risk for the spread and introduction of Multidrug-Resistant Organism (MDROs germs resistant to antibiotics, making infections difficult to treat) which could result in serious medical condition.1. During a review of Resident 107's admission record (AR), dated 12/18/25, the AR indicated Resident 107 was admitted from an Acute Care Hospital (GACH), on 12/05/25 with the diagnosis of fracture of lumbar (lower back region) vertebrae (the small, individual bones that stack up to form the spinal column [backbone], in humans and other vertebrates, protecting the spinal cord, providing body structure, and allowing for movement), fracture of right pubis (part of the hip bone that joins the two sides at the pubic symphysis [a cartilage joint] and forms part of the pelvis, protecting organs and providing muscle attachment), and benign prostatic hyperplasia without urinary tract infection [UTI]). During an observation on 12/16/25 at 9:38 a.m. in Resident 107's room. Resident 107 had a urinary drainage bag that was not placed in the dignity urine cover bag (cover or holder designed to conceal the urine from view) and was touching the floor. During a concurrent observation and interview on 12/16/25 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 1 in the hall outside of Resident 107's room. LVN 1 stated the dignity bag should be covering the entire urine bag and it should not be touching the ground. The urine bag touching the ground could be a source of infection for the resident. During a concurrent observation and interview on 12/17/25 at 10:30 a.m. with Certified Nursing Assistant (CNA) 2. CNA 2 stated, the catheter bag must be covered so that no urine is seen. The dignity bag is to provide privacy for the resident. The bag should not touch the floor because germs could get onto the bag and infect the resident. During a concurrent observation and interview on 12/18/25 at 11:10 a.m. with the Infection Preventionist (IP), the IP stated the catheter bag was not up to her expectations. The urine drainage bag should have been completely covered by the dignity bag and should never touch the floor. Having the catheter touch the floor could cause the resident to get a CAUTI. During a concurrent observation and interview on 12/19/25 at 4:02 pm with Director of Nurses (DON), the DON stated, it is not her expectation to have catheter bag touching floor it could cause infection. During a review of the facility's policy and procedure titled, Indwelling Urinary Catheter Insertion, Maintenance and Removal dated 9/22/25, indicated, . be sure the catheter tubing and drainage bag are off the floor at all times. cover urinary drainage bags with a modesty bag .). 2. During a record review of Resident 42's Care Plan Report (CP), dated 11/7/25, the CP indicated, .resident is on enhanced barrier precautions [related to] increased risk for MDRO.goal.to prevent the transmission of MDROs to the resident during high-contact activities. During a record review of Resident 39's Care Plan Report (CP), dated 11/7/25, the CP indicated, .resident is on enhanced barrier precautions [related to] increased risk for MDRO.goal.to prevent the transmission of MDROs to the resident during high-contact activities. During a record review of Resident 7's Care Plan Report (CP), dated 11/7/25, the CP indicated, .resident is on enhanced barrier precautions [related to] increased risk for MDRO.goal.to prevent the transmission of MDROs to the resident during high-contact activities. During an observation on 12/17/25 at 2:46 p.m. in Resident 42's room, with LVN 6, LVN 6 was observed entering Resident 42's room carrying a medication tray (MT) with Resident 42's medication. LVN 6 was observed placing the MT on top of Resident 42's bedside table. LVN 6 was observed administering Resident 42's medication through his gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach). LVN 6 was observed touching the MT with her gloved hand after handling Resident 42's gastrostomy tube. LVN 6 was not observed disinfecting the MT after use. LVN 6 was observed placing the MT on Resident 7's bedside table, Resident 42's roommate, while she removed her gown, gloves and washed her hands in the resident restroom. LVN 6 was observed picking up the MT from Resident 7's bedside table, exiting the room and placing the MT on top of the medication cart. LVN 6 was not observed disinfecting the MT after use. LVN 6 was observed placing Resident 39's medication into the MT. LVN 6 was observed entering Resident 39's room carrying the MT with Resident 39's medication. LVN 6 was observed placing the MT on Resident 39's bedside table. LVN 6 was observed administering Resident 39's oral medication. LVN 6 was not observed disinfecting the MT after use. LVN 6 was observed placing the MT on top of the medication cart. LVN 6 was not observed disinfecting the MT. During an interview on 12/18/25 at 3:16 p.m. with LVN 6, LVN 6 stated she could not remember if she cleaned (removes debris and some germs) or disinfected (kills germs with chemicals) the MT after use. LVN 6 stated she typically cleaned the MT with soap and water in the resident restroom before exiting the room. LVN 6 stated it was important to disinfect the MT after use to prevent the spread of infection. During an interview on 12/18/25 at 4:20 p.m. with the IP, the IP stated soap and water could clean the MT and remove visible debris, but would not disinfect the MT. The IP stated soap and water could be used prior to disinfection, but not as a sole practice for disinfection of the MT. The IP stated the facility had designated wipes, which included chemicals, intended for disinfection and required a 2-minute dwell time per manufacture guidelines to ensure reusable equipment was disinfected prior to use with the next resident. The IP stated licensed nursing staff were not meeting infection control standards of practice when reusable medical equipment between resident use was not disinfected. The IP stated licensed nursing staff were not meeting infection control standards of practice using soap and water only to disinfect reusable medical equipment after resident use. The IP stated residents with indwelling medical devices, such as tracheostomies (a tube inserted into the airway) and gastrostomy tubes, were on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms using gown and glove use during high contact resident care activities). The IP stated residents on EBP were at an increased risk for acquiring Multidrug-Resistant Organism (MDROs germs resistant to antibiotics, making infections difficult to treat). The IP stated the MT was a reusable medical equipment device and needed to be disinfected after use or contact with residents and their environment to prevent the introduction and spread of infections to residents. During an interview on 12/19/25 at 4:09 p.m. with the DON, the DON stated she expected all licensed nursing staff to follow infection control standards of practice. The DON stated all reusable medical equipment needed to be disinfected after use. The DON stated the facility had designated wipes, which included chemicals, intended for disinfection and required a 2-minute dwell time per manufacture guidelines to ensure reusable equipment was disinfected prior to use with the next resident. The DON stated facility policy and procedures were not followed when the MT came into contact with Resident 42, Resident 7, and Resident 39 and their environment without being disinfected. The DON stated it was important to disinfect reusable medical equipment after use to prevent the spread and introduction of infection to residents. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Plan-CMC, dated 2/27/25, the P&P indicated, .the goal of the CHS Infection Prevention Program is to minimize the risk of acquiring and transmitting healthcare-associated infections (HAI)/infectious diseases to patients, employees, medical staff, residents, volunteers, contractors, students and visitors. The overall goals of CHS Infection Prevention program include.limiting unprotected exposures to pathogens.limiting the transmission of infections associated with procedures.limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. Standard Precautions are practices to reduce healthcare associated infections used with all patients, regardless of diagnosis or isolation status. Apply to interacting with blood, body fluids, secretions and excretions except sweat, regardless of whether they contain visible blood, non-intact skin and mucous membranes. During a review of the facility's P&P titled, Enhanced Barrier (Standard) Precautions, dated 9/29/25, the P&P indicated, .MDRO .can be transmitted from patient to patient in the absence of effective infection control precautions.passage of an infectious agent.to another person either directly or, more commonly indirectly via.medical equipment that has not been cleaned and disinfected adequately between patients.disinfect shared equipment after use on a Resident and before removal from the room. During a professional reference review retrieved from https://www.cdc.gov/infection-control/hcp/core-practices/index.html titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, the professional reference review from CDC indicated, . Use Standard Precautions to care for all patients in all settings. Standard Precautions include.Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients.When information from manufacturers is limited regarding selection and use of agents for specific microorganisms, environmental surfaces or equipment, facility policies regarding cleaning and disinfecting should be guided by the best available evidence and careful consideration of the risks and benefits of the available options.Clean and reprocess (disinfect or sterilize) reusable medical equipment.prior to use on another patient or when soiled.Maintain separation between clean and soiled equipment to prevent cross contamination .

Based on observation, interview and record review, the facility failed to maintain the dignity and privacy for one of 11 sampled residents (Resident 50) when Resident 50 was observed from the hallway of his room without any clothing on two occasions. This failure violated Resident 50's right to maintain his privacy.Findings:During a concurrent observation and interview on 12/16/25 at 10:20 a.m. in Resident 50's room, Resident 50 was observed in bed covered with a sheet, holding the sheet to his chin with both hands. Resident 50 was asleep but woke up when knocked on the door and introduction made. Resident 50 stated he had been at the facility for three weeks, because he went to Mexico. Resident 50 did not answer any further questions.During a review of Resident 50's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/18/25, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it, not caused by trauma), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), and chronic pain (longstanding pain that persists over three months, or beyond the usual recovery period).During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 9/17/25, the MDS section C indicated Resident 50 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 9 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 50 was moderately impaired.During an observation on 12/16/15 at 12:36 p.m. from the hallway outside Resident 50's room, Resident 50 was observed sitting on the side of his bed without wearing any clothing eating his meal. A staff member was seen leaving Resident 50's room carrying a meal tray cover. Resident 50's door was open, and his curtain was not pulled to protect Resident 50 from being observed from the hallway. During a concurrent observation and interview on 12/18/25 at 3:42 p.m. with Certified Nursing Assistant (CNA) 3, in hallway outside Resident 50's room, Resident 50 was observed in his room without wearing any clothing in his wheelchair in his room. CNA 3 stated Resident 50 did not like wearing gowns and clothes. CNA 3 stated Resident 50 had schizophrenia and preferred laying down naked. CNA 3 stated being naked comforted and calmed Resident 50, it helped Resident 50 sleep. CNA 3 stated staff were not supposed to keep Resident 50's door closed as Resident 50 was a fall risk. CNA 3 stated Resident 50's curtain had to be in a certain position, so no one was able to look in Resident 50's room, but Resident 50 opened his curtain. CNA 3 stated staff had to keep an eye on Resident 50 as he came out of his room naked in his wheelchair. CNA 3 stated Resident 50 needed his curtain to be closed for privacy. CNA 3 stated R50's curtain should have been drawn so no one could see Resident 50 naked in his room. CNA 3 stated it was a risk to Resident 50's dignity and privacy to have his curtain open when he was naked in his room. CNA 3 stated a reasonable person would have wanted the curtain closed so no one could see in their room.During a concurrent interview and record review on 12/18/25 at 4:32 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 50's CP, undated was reviewed. The CP indicated, . Resident prefers to remain unclothed while in bed, which may affect dignity, privacy, safety, and temp regulation. Date initiated: 12/06/25 . resident will maintain dignity, comfort and safety while honoring his preference to remain unclothed . ensure door, privacy curtain is drawn when needed to maintain dignity . date initiated: 12/06/25 . LVN 5 stated Resident 50 was unclothed all the time. LVN 5 stated Resident 50's curtain was often pulled from the door to his bed. LVN 5 stated staff asked Resident 50 to cover himself if he was in his wheelchair uncovered. LVN 5 stated Resident 50's curtain should have been pulled to prevent seeing Resident 50 naked. LVN 5 stated it was a risk for Resident 50 to be exposed, which could have compromised Resident 50's dignity.During an interview on 12/19/25 at 4:00 p.m. with the Director of Nursing (DON), the DON stated it was important to preserve Resident 50's dignity whenever he was naked by ensuring he had his sheet to cover himself, make sure his curtain was pulled, and provide redirection of Resident 50 if needed. The DON stated the facility needed to preserve Resident 50's dignity. The DON stated Resident 50's nakedness was a preference and sometimes Resident 50 wanted to be naked, and sometimes he did not want to be naked. The DON stated if staff discovered a trend with residents, a care plan should have been implemented at that time. The DON stated the purpose of the care plan is for staff to be aware of the residents' plan of care. The DON stated there was a risk to the residents if no care plan was in place due to staff's lack of awareness of each resident's plan of care. The DON stated if a resident had a specific need, it should have been care planned and the care plan should have been followed. The DON stated every resident should have had a care plan specific to their plan of care.During an interview on 12/19/25 at 4:39 p.m. with the Administrator (ADM), the ADM stated care plans were very thorough and reviewed often. The ADM stated staff checked for any residents that had a specific need to make sure they had a care plan for their needs. The ADM stated she expected the resident's care plans to be individualized and person- centered. The ADM stated she expected the residents' needs to be met. The ADM stated some residents did let staff draw their curtains and sat in front of their window naked. The ADM stated she expected staff to check on the residents and remind them to cover themselves. The ADM stated it was important to have the naked resident's curtain drawn to respect the resident's dignity.During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services, dated 10/21/25, the P&P indicated, . Purpose . to ensure all Residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each Resident and are trained in ways to support Residents in distress .the assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the Resident's dignity, autonomy, privacy . and safety .During a review of the facility's P&P titled, Resident Rights, dated 3/3/25 the P&P indicated, . it is the policy of this facility to provide each Resident and their responsible party (if applicable) with a copy of Resident Rights on admission .During a review of the facility document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate care Facilities, dated 5/24, the document Attachment F indicated, . Resident [NAME] of Rights . to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs . a right to dignity, privacy and humane care . Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect .

Based on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 5) received personal privacy and confidentiality of his personal and medical records when Licensed Vocational Nurse (LVN) 4 left Resident 5's Medication Administration Record (MAR) computer screen visible in the hallway while administering medications. This failure resulted in Resident 5's personal and medical records being visible to staff, residents and visitors, which could lead to unauthorized access to confidential personal and medical records. During an observation on 12/17/25 at 12:18 p.m. Medication Cart 3 (MC 3) was observed next to Resident 5's room with the drawers and computer screen facing out toward the facility hallway. Licensed Vocational Nurse (LVN) 4 was observed removing medication from MC 3. LVN 4 was observed donning personal protective equipment (PPE) and entering Resident 5's room. LVN 4 was observed closing Resident 5's room door. MC 3 was observed unattended in the hallway, next to Resident 5's room, with the drawers and computer screen facing out toward the facility hallway. MC 3's computer screen was observed with Resident 5's Medication Administration Record (MAR) profile visible. The MAR profile included Resident 5's name, profile picture, identification number, isolation information, status, location, gender, date of birth , age, physician, allergies, code status, current vital signs, medication orders, enteral feed orders, non-pharmacological ordered interventions for as needed medications, and heel protector orders. During an observation on 12/17/25 at 12:26 p.m. MC 3 was observed next to Resident 5's room with the drawers and computer screen facing out toward the facility hallway. MC 3's computer screen was observed with Resident 5's Medication Administration Record (MAR) profile visible. LVN 4 was observed exiting Resident 5's room and returning to MC 3. During a concurrent interview and record review on 12/17/25 at 3:57 p.m. with LVN 4, a picture of MC 3 dated 12/17/25 at 12:18 p.m., was reviewed. LVN 4 stated he entered Resident 5's room to administer medications and closed the room door. LVN 4 stated MC 3 was left unattended with the drawers and computer screen facing out toward the facility hallway. LVN 4 stated he did not log off or lock MC 3's computer screen. LVN 4 stated Resident 5's MAR profile was visible on MC 3's computer screen while he was in Resident 5's room administering medication. LVN 4 stated the computer screen on MC 3 should have been logged off or locked to protect Resident 5's personal and medical record information from unnecessary view by staff, residents, and visitors. LVN 4 stated Resident 5's personal and medical record information was only to be viewed by staff providing care and Resident 5 had the right to secure and confidential medical records. During a concurrent interview and record review on 12/18/25 at 5:06 p.m. with LVN 5, a picture of MC 3 dated 12/17/25 at 12:18 p.m., was reviewed. LVN 5 stated medication cart computer screens were expected to be logged off or locked when unattended to prevent unauthorized use or view of confidential resident information. LVN 5 stated licensed nursing staff were responsible for protecting resident personal and medical records from being accessed by unnecessary staff, residents, and visitors. LVN 5 stated Resident 5's privacy was violated when MC 3 was unattended and Resident 5's MAR profile was visible on the computer screen from the facility hallway. During an interview on 12/19/25 at 4:09 p.m. with the Director of Nursing (DON), a picture of MC 3 dated 12/17/25 at 12:18 p.m., was reviewed. The DON stated she expected licensed nursing staff to maintain resident privacy and confidentiality during medication administration. The DON stated privacy and confidentiality of resident personal and medical records were maintained by logging off or locking computer screens on medication carts when unattended or not in use. The DON stated facility policy and procedure was not followed when Resident 5's MAR profile was visible from the facility hallway on MC 3 and unattended. The DON stated Resident 5's privacy and confidentiality of personal and medical records was violated when Resident 5's MAR profile was visible from the facility hallway on MC 3 and unattended. The DON stated Resident 5 was at risk for personal and medical records being accessed by unauthorized staff, residents and visitors. During a review of the facility's policy and procedure (P&P) titled, HIPAA Security and Information Security Workstation Use, dated 10/6/22, the P&P indicated, .workforce members shall use workstations in the appropriate manner to properly protect the sensitivity of ePHI [electronic protected health information] and to minimize the possibility of unauthorized access to such information.workstations will be placed in locations so that the information displayed on the workstation may not be viewed by unauthorized persons.workstation users will abide by the following.users sharing a workstation with other users must log off prior to leaving the workstation. Those using a dedicated workstation, or one in which the user is the sole user, should either log off or lock the system when leaving the workstation to prevent the unauthorized use.close files and programs when not in use. During a review of the facility's P&P titled, Medication Administration General Guidelines, dated 1/2023, the P&P indicated, .Resident's health information needs to remain private. The pages of the MAR notebook containing resident health information must remain closed or covered when not in direct use .During a review of the facility's P&P titled, Resident Rights Under Federal Law, undated, the P&P indicated, .the resident has the right to personal privacy and confidentiality of his or her personal and clinical records.

Based on interview, and record review the facility failed to ensure two out of 22 residents (Resident 38 and Resident 87) received a level II Pre-admission Screening and Resident Review (PASRR- evaluation for individuals suspected of having a Serious Mental Illness (SMI) or Intellectual/Developmental Disability (I/DD)/Related Condition (RC), triggered by a positive Level I screen, to determine if they need specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when: 1. Resident 38 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed. 2. Resident 87 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed.These failures resulted in Resident 38 and Resident 87 not receiving the required PASRR level II screening which had the potential to result in missed identification of specialized services needed and put Resident 38 and Resident 87 at risk of delayed treatment.1. During a review of Resident 38's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/18/25, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (blood flow to part of brain gets blocked) and major depressive disorder (mood disorder causing persistent sadness, loss of interest, and impacts daily life). During a concurrent interview and record review on 12/18/25 at 1:47 p.m. with the Minimum Data Set Coordinator Nurse (MDSN), Resident 38's document titled, Pre-admission Screening and Resident Review (PASRR) Level I Screening, dated 11/14/25, and PASRR level II screening notice titled, Notice of Attempted Evaluation, dated 11/18/25, were reviewed. The MDSN stated PASRR level I screenings were completed on all residents who were admitted or had a significant change in condition. The MDSN stated if a PASRR level I screening was positive for SMI a PASRR level II screening was required to be completed by the Department of Health Care Services (DHCS) to determine appropriate nursing facility services and specialized services. The MDSN stated Resident 38 had a PASRR level I screening completed on 11/14/25 which indicated he was positive for SMI and required a PASRR level II screening. The MDSN stated Resident 38 had not received a PASRR level II screening. The MDSN stated the facility received a notice on 11/18/25 titled, Notice of Attempted Evaluation, which indicated DHCS could not reach the facility on two or more attempts to complete Resident 38's PASRR level II screening and the case had been closed. The MDSN stated the facility was responsible for ensuring Resident 38's PASRR level II screening was completed. The MDSN stated the facility had not resubmitted a PASRR level I screening to reopen Resident 38's case. The MDSN stated it was important that PASRR level II screenings were completed to ensure residents received the most appropriate placement in the least restrictive setting, and whether specialized services were needed. The MDSN stated PASSR level II screenings were a screening tool and without it residents could be placed at risk for delayed treatment, identification of care or services. During an interview on 12/18/25 at 2:29 p.m. with Social Worker (SW) 1, SW 1 stated the MDSN was responsible for ensuring positive PASRR level I screenings were followed up with a PASRR level II screening by the designated authority. SW 1 stated residents were at risk for delayed services and care if they had a PASRR level I screening positive for SMI and a PASRR level II screening was not completed. SW 1 stated PASRR level II screenings were required to ensure the facility could meet and provide the care residents needed. During a concurrent interview and record review on 12/19/25 at 4:09 p.m. with the Director of Nursing (DON), Resident 38's PASRR level II screening notice titled, Notice of Attempted Evaluation, dated 11/18/25, was reviewed. The DON stated the document indicated Resident 38's PASRR level II screening had not been completed. The DON stated the document indicated Resident 38's PASRR level II screening was not completed due to facility failure to respond. The DON stated the MDSN was responsible for ensuring PASRR follow-up and completion with the required state-designated authorities. The DON stated it was important PASRR level II screenings were completed to ensure residents received appropriate services and care for their needs. The DON stated if PASRR level II screenings were closed without being completed residents were at risk for not having their care needs met by the facility. During a review of Resident 38's PASRR level II screening notice titled, Notice of Attempted Evaluation, dated 11/18/25, the document indicated, .unable to complete level II evaluation for serious mental illness (SMI).the California Department of Health Care Services (DHCS) administers the PASRR process when the level I screening returns a positive result for possible SMI. In the event of a positive SMI level I screening, a SMI level II Mental Health Evaluation is required to determine if the individual can benefit from specialized services. However, a SMI level II Mental Health Evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening.this case is now closed. To reopen, the facility must resubmit a new level I screening.please note this letter is a courtesy notice for administrative purposes only and does not comprise a completed individualized determination. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), dated 10/15/25, the P&P indicated, .PASRR.its purpose is to identify individuals with serios mental illness (SMI) or intellectual/developmental disabilities (IDD) and ensure they receive appropriate services and placement. all new admissions and readmissions are screened for serious mental disorders (SMI), intellectual disability (ID) /developmental disability (DD), or related conditions (RC), per the Medicaid PASRR process.Level I screening and Level II (if needed), and determination must be completed for any individual regardless of the individual's age or payor source . If the Level I screening is positive for an individual having, or is suspected of having, a PASRR condition, i.e., SMI, ID/DD, or RC, then a Level II Evaluation will be performed by the state-designated authority to help determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed.The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third party contractor. 2. During a review of Resident 87's AR, dated 12/18/25, the AR indicated Resident 87 was admitted on [DATE] with a re-admission on [DATE] from a nursing home with diagnoses of intracerebral hemorrhage (bleeding in the brain caused by a ruptured blood vessel), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), obstructive and reflux uropathy (when urine cannot drain and backs up into the kidney), and chronic pain (longstanding pain that persists over three months, or beyond the usual recovery period). During a review of Resident 87's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/2/25, the MDS section C indicated Resident 87 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 9 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 87 was moderately impaired. During a concurrent interview and record review on 12/18/25 at 1:53 p.m. with the MDSN, Resident 87's DHCS document titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 3/11/25 was reviewed. The PASRR indicated, .Level I – Positive for SMI. The MDSN stated the PASRR screening was completed for new admission, or if residents had a change of condition (COC). The MDSN stated since Resident 87 was positive for a PASRR level I assessment for SMI, she needed to have a PASRR level II assessment. The MDSN stated she was unable to find if a documented PASRR level II assessment was completed for Resident 87. During a concurrent interview and record review on 12/18/25 at 2:00 p.m. with the MDSN, Resident 87's DHCS document titled, Notice of Attempted Evaluation, dated 3/17/25 was reviewed. The document indicated, . facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening.the case is now closed. To reopen, the facility must resubmit a new Level I Screening. The MDSN stated there was no documentation that someone called DHCS to follow up on Resident 87's level II PASRR screening. The MDSN stated Resident 87's PASRR screening was incomplete. The MDSN stated she should have followed up with Resident 87's PASRR Level II assessment. The MDSN stated SMI indicated a serious mental illness, and the PASRR assessment determined if the resident required any treatment or specific needs to be meet and if the facility was able to care for the resident. The MDSN stated the facility could not make a determination of SMI or the specific needs of the resident without completion of the PASRR. The MDSN stated there was a possible risk for the facility to not meet Resident 87's needs if the PASRR Level II assessment was not completed. The MDSN stated per DHCS and federal guidelines, the facility had to complete the PASRR screening for every resident. During an interview on 12/18/25 at 2:30 p.m. with SW 1, SW 1 stated the MDSN was responsible for the completion of PASRRs. SW 1 stated if a level II PASRR assessment was identified on resident admission, the MDSN followed up with DHCS to see if the resident needed a level II assessment. SW 1 stated the Level II assessment results had a determination letter with recommendations for the resident's care. SW 1 stated the SW department was only involved if a Level II was positive and the resident needed referrals for the indicated recommendations for care. SW 1 stated the PASRR was important for positive Level II assessments as it helped identify if resident placement was appropriate for their facility and if additional services were needed so the resident would benefit from the facility's care. SW 1 stated if a resident had a positive Level I assessment and a PASRR level II was not completed, and if the resident had a positive level II PASRR assessment, there was the possibility the resident would receive delayed services and would not receive services the resident could potentially benefit from. During an interview on 12/19/25 at 4:00 p.m. with the DON, the DON stated the PASSR was the preadmission screening tool for mental illness to provide a plan of care for residents. The DON stated the PASRR screening helped determine care plan interventions for residents. The DON stated if the PASRR level II assessment was positive and if interventions were needed, the interventions would have been care planned and carried out by staff. The DON stated her expectation was for level I PASRR assessments to be completed prior to admission for resident clearance, and that positive level II PASRR assessments had been completed to verify the facility was able to accommodate the resident. The DON stated if a level II PASRR assessment was needed, her expectation was for MDS to do a significant change assessment and get the level II PASRR assessment completed. The DON stated if the resident had a positive PASRR level I assessment and the PASRR level II assessment was not completed, the resident could have had different risks for care than other residents and their care would be undetermined because the facility would not have known what the risks were. During an interview on 12/19/25 at 4:39 p.m. with the Administrator (ADM), the ADM stated the PASRR was used to determine the appropriate care for the residents. The ADM stated the DON oversaw the MDSN, and all staff were involved with PASRRs. The ADM stated her expectation was for residents to have a completed level II PASARR for a positive level I PASRR screen. The ADM stated she expected staff to follow up on closed PASRRs. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), dated 10/15/25, the P&P indicated, .PASRR.its purpose is to identify individuals with serios mental illness (SMI) or intellectual/developmental disabilities (IDD) and ensure they receive appropriate services and placement. all new admissions and readmissions are screened for serious mental disorders (SMI), intellectual disability (ID) /developmental disability (DD), or related conditions (RC), per the Medicaid PASRR process.Level I screening and Level II (if needed), and determination must be completed for any individual regardless of the individual's age or payor source . If the Level I screening is positive for an individual having, or is suspected of having, a PASRR condition, i.e., SMI, ID/DD, or RC, then a Level II Evaluation will be performed by the state-designated authority to help determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed.The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third party contractor. During a review of the facility's P&P titled, Behavioral Health Services, dated10/21/25, the P&P indicated, .to ensure all Residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each Resident, which includes non-pharmacological interventions . Procedure . the facility utilizes the comprehensive assessment process for identifying and assessing a Resident's mental and psychosocial status and providing person-centered care . 1. complete PASRR screening.

Based on observation, interview and record review the facility failed to ensure residents had a well-balanced diet that meets their daily nutritional and special dietary needs when the facility's approved therapeutic diet manual:1. Was not based on current standard of practice or nationally recognized diet for residents with diabetes when the facility had a Reduced Concentrated Sweets (RCS) diet order for nutrition care with diabetes for one sampled resident (Resident 107); and 2. Did not contain a small portion diet or menu for one sampled resident (Resident 29) when the physician's diet order was for a small portion diet.These failures had the potential to result in inconsistent nutritional management related to therapeutic diet planning, limiting resident choices and failure to have all the diet choices in the diet manual could result in resident's receiving incorrect portions of food items. 1. During kitchen observation on 12/16/25 at 10:49 a.m. with Dietary Aid (DA) 1, DA 1, was observed preparing Resident 107's lunch tray. DA 1 stated his job was to place condiments, drinks, and plates on the tray for residents as well as checking meal tickets. During observation of the lunch meal service on 12/16/25 at 11:53 a.m. Resident 107's meal ticket dated 12/16/25, indicated diet Reduced Concentrated Sweets (RCS) texture regular .Profile Note.Large portions protein and non-starchy vegetables for weight gain. During a review of Resident 107's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/18/25 , the AR indicated Resident 107 had the following diagnoses but limited to: diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (MDD- a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, and significantly interfering with daily life, involving symptoms like sleep/appetite changes, fatigue, concentration issues, and feelings of worthlessness, not just a bad mood). During a review of Resident 107's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 12/18/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 107 had no cognitive impairment. During a review of Resident 107's Order Summary (OR) dated 12/18/25, the OR indicated, .RCS diet- Regular texture.Large portions protein.) During a review of the facility's Diet Manual and Enteral Nutrition Formulary 2025, revised 9/25, indicated Carbohydrate Modification.incorporated consistent carbohydrate intake. During a review of the facilities document titled Daily Nutrient Summary: Week 1 undated, indicated, a wide variation in total caloric and Carbohydrate intake from meal to meal and day to day. The documentation did not reflect a consistent carbohydrate distribution or standardized caloric range. During an interview on 12/17/25 at 4:06 p.m. with the Registered Dietitian (RD), RD stated a few duties of the RD were to participate in resident assessments, nutrient analysis and menu development. The RD stated the RCS diet was used to make carbohydrate intake as consistent as possible while allowing a more liberalized diet. The RD stated the facility reduced sugar by modifying dessert portions, such as reducing portions by half, rather the eliminating items completely. The RD stated the facility focused on making less certain foods instead of not offering them at all. The RD acknowledged the facility did not follow the standard of practice for the diet for residents with diabetes During an interview on 12/18/25 at 8:37 a.m. with Medical Director (MD), MD stated he signed off on the facility's policies and procedures, including the diet manual, reviewed them as part of his role. The MD stated he had not seen the RCS diet used at other facilities. The MD stated he was not aware the RCS diet was not considered standard of practice. The MD stated he was familiar with concentrated carbohydrate or consistent carbohydrate diets recommended for diabetic residents, and stated residents may prefer items such as ice cream instead of other carbohydrate sources, which he stated made sense to him. During an interview on 12/18/25 at 9:50 a.m. with the RD, she acknowledged in Academy in Nutrition and Dietetics (AND) Nutrition Care Manual stated that the RCS diet was obsolete and they will do Consistent Carbohydrate Diet and update diet manual and menus. During a review of the facility's policy and procedure (P&P) titled, Diet Manual and Enteral Nutrition Formulary Nutrition Care Manual, dated 9/30/25, the P&P indicated, To provide a reference source for use by the medical staff, nursing, and nutrition service staff. and .reflects current research and changing standards of care. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2025, the NCM indicated, Obsolete diets and Diet Terminology; For condition Type 1 Diabetes and Type 2 Diabetes Obsolete Diet Name.No Concentrated Sweets diet, No Sugar Added, Low Sugar, Liberal Diabetic Diet. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2025, the NCM indicated, A consistent carbohydrate diet provides the same amount of total carbohydrate daily, distributed evenly across all meals and snacks. A consistent amount of carbohydrate at each daily meal is the goal. The exact amount and type of carbohydrate served is individualized by the registered dietitian nutritionist (RDN). The name of the diet used in your facility should no longer emphasize the restriction of sugar or sweets but rather emphasize consistent carbohydrates or carbohydrate controlled . During a review of Management of Diabetes in Longterm Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, dated February 2016, the article indicated, No concentrated sweets or no sugar diet orders are ineffective for glycemic [A measure of the increase in the level of blood glucose (a type of sugar) caused by eating a specific carbohydrate (food that contains sugar) compared with eating a standard amount of glucose] management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes . 2. During a concurrent observation and record review on 12/16/25 at 12:40 p.m. in the kitchen, with the Dietary Aid (DA)1, the DA1 checked Resident 29's meal tray ticket and prepared the meal tray for lunch. Resident 29's meal tray ticket indicated three meatballs for small portions. DA1 plated 1.5 meatballs in Resident 29's lunch tray. During a record review of Resident 29's admission Record (AR), dated December 18,2025, the AR indicated, Resident 29's admission date was on 9/20/21. The AR indicated Resident 29's diagnosis included Muscle weakness and Vitamin D Deficiency (not enough vitamin D). The Order Summary Report (OSR), dated 7/27/2, indicated, Regular diet. Regular texture. Small portions for weight loss also per RD recommendations. During an interview on 12/17/25 at 4:06 p.m. with the Registered Dietitian (RD), the RD stated small portion diet is separate and is an extension of the menu. The RD stated small portions is a preference so not listed as a diet in the diet manual. During a concurrent interview and record review on 12/18/25 at 12:12 p.m. with the RD, Resident 29's OSR, dated 12/18/25 was reviewed. The OSR indicated, Resident 29's physician order was small portion. RD acknowledged Resident 29 had a physician diet order dated 7/27/25 for the small portion diet. RD stated, the facility did not have a small portion menu and that it should be in the diet manual but was not. During a review of Resident 29's Meal tray ticket, dated 12/16/25, the meal tray ticket indicated, .Lunch I 2025-12-16 Diets: Regular, Texture: Regular. Fluids: Regular/Thin Liquids. [3 each] Beef Meatballs [2 oz] Marinara Sauce [1(4z spoodle)] Spaghetti Noodles [0.5 cup] Sauteed [NAME] Beans [0.5 cup] Peaches [1 each] Breadstick [4 fl.oz] Apple Juice [4 fl.oz] Cranberry Juice. Daily Note: SPOONS ONLY, SMALL PORTION STARCH AND PROTEIN. Small portions for weight loss also per RD recommendations. During a review of the facility's policy and procedure (P&P) titled, Patient Diet Orders and Menus, dated 07/28/2025, the P&P indicated, .Diet orders will be ordered and produced in accordance with the guidelines referenced in the diet manual.

Based on observations, interviews, and record reviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when two of three kitchen staff (Dietary aid 1 and 2) did not have hair and facial hair fully restrained or covered during meal preparation and service. This failure had the potential to compromise food sanitation and resident safety.During an observation of lunch meal service on 12/16/25 at 12:35 pm, in the kitchen, Dietary Aid (DA)1 was wearing a baseball cap with longer hair in back and hair was not fully covered. DA 1 was not wearing hairnet. DA 1 was calling out trays, checking out meal tickets and meal trays with food, putting cold beverages on meal trays and placing meal trays into food carts.During a concurrent observation and interview on 12/17/25 at 12:32 pm with DA 2 in the kitchen, DA 2 was wearing surgical mask, the side of face had facial hair and was uncovered. DA 2 stated that he was mixing Juven (medical drink mixture with vitamins and minerals), diet cranberry beverages in cups and food preparation for residents. During a concurrent interview and record review on 12/18/25 at 10:04 am with the Certified Dietary Manager (CDM), the facility's policy and procedure (P&P) titled, Uniforms and Personal Hygiene, dated 12/18/25 was reviewed. The P&P indicated, Provided hair covering must be worn at all times within the department. All hair must be restrained by hair covering. [NAME] nets will be worn if any facial hair is evident. The CDM stated, the facility policy is for all hair to be covered or restrained. The CDM stated, that the DA 1 and 2 were not wearing hairnet during food preparation.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. The cook failed to follow the diet order for three of three residents (Residents 56, 69, and 88). 2. The facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. These failures had the potential to result in residents being exposed to contaminated food which could lead to food born illness for all residents who receive food prepared in the kitchen and had the potential for Resident 56, Resident 69 and Resident 88 to have weight gain or loss by diet orders not being followed. Findings: 1. During a concurrent observation and interview on 8/27/24 at 12:20 p.m. with the Dietary Manager (DM), in the facility's kitchen, the [NAME] (DA), did not follow the recipe for three residents with small portion diet orders during the lunch service tray line. The DA used the gray 1/2 cup serving scoop and not the blue 1/4 cup serving scoop as indicated on the resident diet orders. The DM stated, the gray scoop was to be used for regular portions and the blue scoop was to be used for small portions. The DM stated, the DA should have switched scoops for the residents on with small portion diet orders. Not using the correct portions could lead to residents gaining undesired weight. During an interview on 8/27/24 at 2:15 p.m. with the Dietary Director (DD), the DD stated the expectation of the cook is to follow the diet orders exactly as ordered. The DA should have switched to the blue scoop for the small portion diets. During an interview on 8/30/24 at 2:50 p.m. with the Administrator (ADM), the ADM stated, the expectation for the DA is to follow diet orders as written. During a review of the facility's policy and procedure (P&P) titled, Meal Service dated 11/28/22, indicated, . Patient service parameters encourage accuracy of meal service within identified guidelines . During a review of the facility's P&P titled, [NAME] Job Description (undated), indicated, . follows standard recipes . During a review of Residents 56's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Section C assessment dated [DATE], indicated Resident 8's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 56 had no cognitive impairment. During a review of Resident 56's Admission Record (AR), dated 8/29/24, the AR indicated, Resident 56 was admitted on [DATE] with diagnosis of Cardiomegaly (enlarged heart), Systematic Inflammatory Response Syndrome (SIRS - an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, lack of oxygen, or cancer), and Hyperglycemia (high blood sugar). During a review of Resident 56's Physician Order (PO), dated 8/12/24, the PO indicated . ease of chewing and promoting weight loss . small portion starch . During a review of Resident 69's AR dated 8/29/24, the AR indicated, Resident 69 was admitted on [DATE] with diagnosis of Aortic Aneurysm (a bulge or weakening in the aorta, the main artery that carries oxygenated blood from the heart to the body), Pain, and Hyperlipidemia (high levels of fat in the blood). During a review of Resident 69's MDS Section C dated 4/30/24, indicated Resident 69's BIMS score was 09. The BIMS assessment indicated severe cognitive impairment. During a review of Resident 69's PO, dated 5/8/24, the PO indicated . small portion starch . During a review of Resident 88's AR dated 8/29/24, the AR indicated, Resident 89 was admitted on [DATE] with diagnosis of Hypertension (high blood pressure), and Cerebrovascular Accident (CVA - a medical emergency that occurs when the blood flow to the brain is stopped). During a review of Resident 88's MDS Section C dated 6/28/24, indicated Resident 88's BIMS score was 15. The BIMS assessment indicated no cognitive impairment. 2. During an observation on 8/27/24 at 2:30 p.m. in the facility's kitchen, the food preparation sink was observed not having an air gap under the sink. During a concurrent observation and interview on 8/29/24 at 2:50 p.m. with the Building Maintenance Supervisor (BMS), in the facility's kitchen, the BMS stated the facility should have an air gap under the food preparation sink to prevent sewage back up into the sink and exposing food to contaminated water. During an interview on 8/30/24 at 10:10 a.m. with the ADM, the ADM stated the food prep sink should have had an air gap to prevent backup of sewer into food being prepared for residents. During a review of the FDA Food Code Section 5-402.11 Backflow Prevention dated 2022, the FDA Food Code indicated, . 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During a review of the Food and Drug Administration (FDA), Food Code Section 5-203.14 Backflow Prevention Device dated 2022, the FDA Food Code indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, .backflow prevention is required by LAW, by: (A) Providing an air gap .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for three of 11 sampled residents (Resident 37, Resident 43, Resident 69) when: 1. Registered Nurse (RN) 1 administered medication to Resident 37's and did not provide privacy. This failure resulted in Resident 37 not being provided with respect and dignity while taking her medication. 2. RN 1 checked Resident 69's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. This failure resulted in Resident 69 not being provided with respect and dignity while her B/P was checked. 3. Resident 43's privacy curtain was tied in a knot. This failure resulted in Resident 43 not being provided his right for a respectful and dignified existence and denied Resident 43 the right to have an environment that promotes maintenance or enhancement of his quality of life. Findings: 1. During an observation on 8/29/24 at 8:59 a.m. in Transitional Unit, RN 1 prepared Resident 37's medications, walked in Resident 37's room and administered her (Resident 37) medications and did not provide privacy. RN 1 did not close the privacy curtain or closed the door, staff and other residents walking by. During a review of Resident 37's Admission Record, dated 8/30/24, the Admission Record indicated, Resident 37 was admitted to the facility with diagnoses which included heart failure, liver disease and hypertension (high blood pressure). During a review of Resident 37's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 37's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 13 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 37 had no cognitive deficit. During an interview on 8/29/24 at 10:05 a.m. with RN 1, she stated she administered medications to Resident 37 in her room and did not close the privacy curtain or the door. RN 1 stated it was Resident 37's right to have privacy when she took her medications. RN 1 stated she should have closed the privacy curtain and or the door because staff, residents and visitors were walking by. During an interview on 8/29/24 at 11:30a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated it was important to close the privacy curtain to provide privacy to residents when administering their medications because there are residents, staff and visitors walking by and could see what was going on inside resident's room. During an interview on 8/29/24 at 2:25 p.m. with LVN 1, she stated the practice was to always pull the privacy curtain when administering medications to residents in their room and never administer medication in the hallway. LVN 1 stated residents need to have their privacy respected including taking their medications. 2. During an observation on 8/29/24 at 9:18 a.m. in Resident 69's room, Resident 69 was lying in bed dressed appropriately. RN 1 approached Resident 69's bedside and checked Resident 69's blood pressure without closing the privacy curtain or the door. Staff, residents, and visitors walked by. During a review of Resident 69's Admission Record, dated 8/30/24, the Admission Record indicated, Resident 69 was admitted to the facility with diagnoses which included hypertension, hyperlipidemia (high cholesterol) and pain. During a review of Resident 69's Minimum Data Set, assessment dated [DATE], indicated Resident 69's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 9 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 69 had moderate cognitive deficit. During an interview on 8/29/24 at 10:10 a.m. with RN 1, RN 1 stated she checked Resident 69's blood pressure in her room and did not close the privacy curtain or the door. RN 1 stated Resident 69's bed was closest to the door and anyone walking by could see what was going on inside the room. RN 1 stated it was important to respect resident their rights to their privacy, RN 1 stated she did not realize she did not close the privacy curtain or the door. During an interview on 8/29/24 at 11:35 a.m. with LVN 2, she stated residents have rights to their privacy and that includes checking their blood pressure or administering medications. LVN 2 stated the facility practice was to ensure resident rights are respected. During an interview on 8/30/24 at 10:22 a.m. with the Director of Nursing (DON), The DON stated she did not see an issue of privacy when the nurse administered oral medications to Resident 37 and checked Resident 69's blood pressure and did not close privacy curtain. The DON stated she would be more worried if the nurse administered medication through a tube feeding and or checking the blood sugar because resident would have been exposed. DON stated residents have rights and facility staff must give their rights to their privacy. During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 3/20/24, the P&P indicated, . right to a dignified existence . be free of interference, coercion . right to be fully informed . right to personal privacy and confidentiality . During a review of facility's P&P titled, Medication Administration General Guidelines, dated 1/23, the P&P indicated, . Medications are administered in accordance with written orders . Provide for privacy . 48424 3. During an observation on 8/26/24 at 3:29 p.m. in Resident 43's room, Resident 43's privacy curtain was tied in a knot, hanging near the door and out of reach. During an observation on 8/29/24 at 10:08 a.m. in Resident 43's room, Resident 43's privacy curtain was tied in a knot hanging on the left side of the Resident's bed. During a concurrent observation and interview on 8/29/24 at 11:36 a.m. with certified nursing assistant (CNA) 6 outside of Resident 43's room, Resident 43's privacy curtain was tied in a knot. CNA 6 stated Resident 43's curtain should not have been tied in a knot. CNA 6 stated having the curtain tied in a knot did not provide Resident 43 privacy or dignity. CNA 6 stated Resident 43 had the right to have his curtain in its intended condition and appearance. During an interview on 8/29/24 at 1:53 p.m. with licensed vocational nurse (LVN) 4, LVN 4 stated Resident 43's curtain was not supposed to be tied up in a knot. LVN 4 stated having the curtain tied up in a knot did not provide Resident 43 with privacy and dignity. LVN 4 stated every other resident in the facility has their curtains in a normal condition and Resident 43 had the right to have his curtains in the same condition as everybody else. During an interview on 8/29/24 at 2:45 p.m. with the environmental services manager (EVSM), the EVSM stated housekeeping staff would not tie curtains in a knot if they needed to clean the room. The EVSM stated all resident curtains should have been hanging freely towards the ground and not tied in a knot. During an interview on 8/29/24 at 3:11 p.m. with Director of Staff Development (DSD), the DSD stated, nursing staff should have untied the curtain if they saw it tied in a knot. The DSD stated having a proper hanging curtain was important to be able to provide privacy. During an interview on 8/30/24 at 8:41 a.m. with CNA 5, CNA 5 stated he was unsure why a curtain would be tied in a knot and no one else's curtain was like this. CNA 5 stated it was important to not have resident curtains tied in a knot because it helped provide privacy when used properly. During an interview on 8/30/24 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she did not know who would tied Resident's 43's curtain in a knot. LVN 5 stated she doubted the resident would be able to do it himself because he does not have control of his lower extremities. LVN 5 stated it was important to have the curtain untied and hanging down so it was easy to access in order to provide privacy. During an interview on 8/30/24 at 10:53 a.m. with the Director of Nursing (DON), when asked if it is acceptable to have curtain tied in a knot and hanging out of reach of the Resident, the DON stated Resident 43 could have done it himself and he can do more than we think. When asked if the DON's expectation was for curtains to be tied in a knot for any resident, DON stated Resident 43 probably did it himself. During an interview on 8/30/24 at 1:43 p.m. with Administrator (ADM), the ADM stated she expected staff to untie curtains if they saw them tied in a knot. During a review of the facility's Policy and Procedure (P&P) titled, Philosophy, dated 7/02/2024, the P&P indicated, It is the philosophy of CSTCC to provide resident care based on each resident's physical, psychosocial and clinical needs; focusing on each resident's overall well-being . 1. The facility will show respect for each resident's individuality, offering choices . 3. The facility will provide privacy and dignity when care is delivered. 51134

Based on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven sampled residents (Resident 6, Resident 55 and Resident 41) when Resident 6, Resident 41 and Resident 55's copy of Physician Orders for Life-Sustaining Treatment (POLST-a medical document which outlines a patient's preferences for end-of-life care) were incomplete and not readily available as part of Resident 6 and 55's current medical records. These failures had the potential risk for Resident 6, Resident 41 and 55's decision regarding their healthcare treatment options not being honored. Findings: During a review of Resident 6's Admission Record, (AR-document containing resident profiles) dated 8/29/24, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (occurs when the kidneys are no longer able to function properly and filter waste from the blood) and heart failure. During a review of Resident 55's Admission Record, dated 8/29/24, the AR indicated, Resident 55 was readmitted to the facility on [DATE] with diagnoses which included Transient Ischemic Attack (TIA-occurs when there's a brief interruption in blood supply to the brain) and schizophrenia (chronic mental illness that affects a person's thoughts, feelings, and behaviors). During a concurrent interview and record review on 8/27/24 at 11:42 a.m. with Director of Staff Development (DS) Resident 41's Physician Orders for Life Sustaining Treatment (POLST [form is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness]) was reviewed. The POLST did not have the preparation date filled out on the form. DSD validated the date of preparation of the POLST form was missing. DSD stated the POLST must be totally filled out to be considered complete and accurate. During a concurrent interview and record review on 8/28/24 at 8:47 a.m. with Licensed Vocational Nurse (LVN 1), Resident 41's POLST form was reviewed. LVN 1 stated, the POLST form should have been filled out to ensure accuracy. During a concurrent interview and record review on 8/29/24 at 10:17 a.m. with Registered Nurse (RN) 1, Resident 6 and Resident 55's POLST form was reviewed, RN 1 stated the POLST forms of Resident 6 and Resident 55 was incomplete. RN 1 stated Resident 6 and Resident 55's POLST forms did not have dates when forms were prepared and completed. RN 1 stated POLST forms have to be completed, each column filled, signed and dated. During a concurrent interview and record review on 8/29/24 at 11:25 a.m. with LVN 2, LVN 2 stated POLST forms are completed on admission by the admission nurse. Resident 6 and Resident 55's POLST forms was reviewed. LVN 2 stated Resident 6 and Resident 55's POLST forms are incomplete, because there was no date when the POLST forms were prepared and there should have been. During a concurrent interview and record review on 8/30/24 at 10:50 a.m. with the Director of Nursing (DON), the DON reviewed Resident 6 and Resident 55's POLST forms and stated there was no date when POLST forms were prepared. DON stated Resident 6 and Resident 55's POLST forms are incomplete because it was missing the date when the forms were completed. During an interview and record review on 8/29/24 at 2:10 p.m. with the Director of Nursing (DON), Resident 41's POLST was reviewed. The DON stated, the POLST form needs to be filled out because it's part of the form. The DON stated, a complete form should have all areas that need to be filled out be completed. The DON stated, an incomplete form could have created uncertainty about the accuracy or validity of the from. During a review of facility's policy and procedure (P&P) titled, Physician Orders for Life-Sustaining Treatment (POST), dated 2/5/24, the P&P indicated, .Completion of a POLST form should reflect a process of careful decision making by the resident . Once the POLST form is completed, it must be signed by the resident, or . resident's legally recognized healthcare decision maker, and the attending physician . The POLST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference . During a review of the professional standards by the Centers for Medicare and Medicaid Services (CMS) titled, Standing Orders, dated, October 2008, the CMS Professional Standard indicated, .orders should be reviewed .all orders must be dated and authenticated promptly .All patient medical record entries must be .complete, dated .and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided. 48430

Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 6) when Resident 6's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 6's care needs not met. Findings: During a review of Resident 6's Admission Record (document with resident demographic and medical diagnosis information), dated 8/29/24, indicated Resident 6 was admitted in the facility on 8/30/23 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and end stage renal disease (terminal illness that occurs when kidneys can no longer function on their own). During a review of Resident 6's Minimum Data Set, assessment dated [DATE], indicated Resident 6's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 6 had no cognitive deficit. During a review of Resident 6's Order Summary, dated 8/29/24, the Order Summary Report indicated, . OLANZAPINE 10 MG [milligram-unit of measurement] TABLET. Give 1 (one) tablet by mouth at bedtime for UNSPECIFIED PSYCHOSIS . During a concurrent interview and record review on 8/29/24 at 3:39 p.m. Resident 6 annual MDS assessment dated [DATE], section N was reviewed by the Minimum Data Set Coordinator (MDSC). The MDSC stated Resident 6 received antipsychotic medication. MDSC stated Resident 6 use of antipsychotic medication was not coded on the annual MDS assessment. MDSC stated Resident 6 should have been coded as receiving antipsychotic medication. During an interview on 8/30/24 at 10:45 a.m. with the Director of Nursing (DON), the DON stated her expectation was for MDS assessments to be accurate. DON stated MDS nurses are responsible in making sure their assessments are accurate. During an interview on 8/30/24 at 2:20 p.m. with the administrator (ADM), the ADM stated her expectation was accurate documentation from MDS. ADM stated MDS nurse needed to accurately assess residents use of psychotropic medications. During a review of the facility document titled, RN MDS Coord-CSTCC Job Description, reviewed date 10/31/23, the Job Description indicated, . Responsible for accurate and timely completion and transmission of Minimum Data Set (MDS) assessment of all residents in the facility . During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment and Care Planning, dated 4/9/24, the P&P indicated, . The facility will complete resident assessments based on the most current Resident Assessment Instrument (RAI) guidelines .

Based on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy and procedures for one of two medication carts in Transitional Unit when medication cart contained Resident 53's (Fluticasone Propionate brand name- used to relieve allergic and non-allergic nasal symptoms) 50 mcg (microgram-unit of measurement) was found to not have an open date and beyond use date (BUD-the last date you can safely use a medication). This failure had the potential for Resident 53's medication to be administered past the discard date which could result in loss of effectiveness of medication leading to poor management of Resident 53's condition. Findings: During a concurrent observation and interview on [DATE] at 2:06 p.m. at the medication cart in Transitional Unit with Licensed Vocational Nurse (LVN) 1, Resident 53's (Fluticasone propionate brand name) was found with no open date and BUD. LVN 1 stated there was no open date and BUD because the facility followed the expiration date provided by pharmacy. During a review or Resident 53's Admission Record, dated [DATE], the Admission Record indicated, Resident 53 was admitted to the facility with diagnoses which included paraplegia (loss of muscle function in the lower half of the body, including both legs) and Chronic Obstructive Pulmonary Disease (COPD-lung disease causing restricted airflow and breathing problems). During an interview on [DATE] at 2:18 p.m. with LVN 1, LVN 1 stated, . They told me the policy was to label medication [Fluticasone-brand name] with the date it was opened as soon as the box was opened . LVN 1 stated open date should have been placed on the box when it was first opened and the used by date. During a concurrent interview and record review on [DATE] at 10:37 a.m. with the Director of Nursing (DON) the DON stated pharmacy labels the medication (Flonase-brand name). The DON stated the medication was given to Resident 53 daily so it will run out before the expiration date of ,d+[DATE]. The DON reviewed facility policy and procedure titled Medication Administration Medication Guidelines and stated the facility will follow their policy and procedure and pharmacy recommendation. During a review of facility's policy and procedure (P&P) titled, Medications and Medication Labels, dated ,d+[DATE], the P&P indicated, . Multi-dose vials should be labeled to assure product integrity . Nursing staff should document the date opened on multi-dose vials . During a review of facility;s policy and procedure (P&P) titled, Medication Administration General Guidelines dated ,d+[DATE], the P&P indicated, . No expired medication will be administered to a resident . The nurse shall place a 'date opened' sticker on the medication . and enter the date opened . multi-dose vials and ophthalmic drops have shortened end-of-use dating, once opened, to ensure medication purity and potency . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for (Fluticasone propionate/ Salmeterol brand name) indicated, After removing from box and foil pouch, write the Pouch opened and Use by dates on the label on top of the device. The Use by date is 1 (one) month from date of opening the pouch.

Based on observation, interview and record review the facility failed provide one of 11 residents an accessible call system when Resident 43's call light (a device that is used by a resident to call staff for assistance) was out of reach and wrapped around the television arm behind the resident's bed. This failure resulted in Resident 43 being unable to call for assistance and had the potential to delay care during an emergency and cause adverse outcomes. Findings; During a review of Resident 43's Admission Record (AR), dated 8/29/24, the AR indicated Resident 43 had been admitted on [DATE]. Resident 43's admitting diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), chronic obstructive pulmonary disease (COPD- lung disease that causes restricted airflow and makes it difficult to breathe) with acute exacerbation (a sudden worsening of respiratory symptoms), epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and schizophrenia (mental health condition that affects how people think, feel, and behave). During an observation on 8/26/24 at 3:25 p.m. in Resident 43's room, Resident 43's call light was out of reach and wrapped around the television arm behind the resident's bed. During an observation on 8/27/24 at 2:00 p.m. in resident 43's room, Resident 43's call light was was out of reach and wrapped around the television arm behind the resident's bed. During an interview on 8/28/24 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the resident had the ability to call for help. LVN 4 stated sometimes Resident 43 would yell out for help when someone walks by the room. LVN 4 stated Resident 43 would use his call light in the past. During an interview on 8/28/24 at 2:34 p.m. with Certified Nursing Assistant (CNA) 5, CNA5 stated all residents should have had their call light next to them so they could use it if needed. CNA 5 stated there was no instance where it would not be placed by a resident, it must always be within reach. During a concurrent observation and interview on 8/29/24 at 11:34 a.m. with CNA 6 outside of Resident 43's room, Resident 43's call light wire was laying on right side of the bed with call button on the floor. CNA 6 stated, [Resident 43] is very cooperative and aware . I reinforce call light education every time I am in the room. During interview on 8/29/24 at 1:54 p.m. with LVN 4, LVN 4 stated, It is important for [residents] to have a call light to tell us their needs even if unable to use one . No matter what their function is, it's important to have one. LVN 4 stated she was unsure why Resident 43's call light was wrapped around the base of the TV arm connected to the wall behind Resident 43. LVN 4 stated Resident 43 should have had his call light placed next to him. During interview on 8/30/24 at 9:43 a.m. with LVN 5, LVN 5 stated it is important for residents to have call light next to them. LVN 5 stated having a call light was important for safety and in case he needed help. LVN 5 stated every resident needs a call light because it was their right to have one even if they could not use it. During an interview on 8/30/24 at 10:53 a.m. with Director of Nursing (DON), when shown a photo of Resident 43's call light on the television arm connected to the wall behind the Resident's bed, DON stated I did not observe this. When asked if it were an acceptable practice to have call light away from patient, DON stated I did not observe this. DON stated, residents do have call light by them. Call lights should be placed next to residents. Important so call light is accessible. When asked if it were okay for Resident 43 to not have call light near them, DON stated she already answered the question. During an interview on 8/30/24 at 1:42 p.m. with Administrator (ADM), shown a photo of Resident 43's call light on television arm connected to the wall behind the Resident's bed. When asked if this is acceptable, ADM stated, resident will tell you if he needs help and will act based on his behavior. He's not a normal patient. When informed call light was like this all day on Monday and Tuesday, ADM stated Resident 43 may have placed it their himself. ADM stated, usually would like to have call light as close to resident as possible. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Residents, dated 9/2022, the P&P indicated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observations, interviews and record review, the facility failed to ensure residents received proper hydration and health care for eight of 12 residents (Resident 18, Resident 82, Resident 33, Resident 78, Resident 26, Resident 44, Resident 60, and Resident 19) with tracheostomies (tracheostomy or trach, a surgical opening in front of the neck into the windpipe. A tube is placed into the hole to keep it open for breathing) and gastrotomy tubes (GT, a tube inserted through the abdomen to provide that bring nutrition directly to the stomach) when: 1. The Charge Nurses (CN), Registered Dietitian (RD) and Licensed Nurses (LN) failed to assess the appropriate fluid status for Resident 18, whose diagnoses included congestive heart failure (CHF- when the heart does not pump blood as well as it should, which could cause blood to back up and fluid can build up in the lungs causing shortness of breath), experienced an unplanned severe weight gain of 38 lbs. (38.3%) over a 3-month period and no interventions to assess the cause of the weight gain between 9/22/22 and 12/8/22. Resident 18 was administered more free water (free water flushes- additional water provided in the resident's daily regimen [prescribed course of treatment]) than prescribed for 62 of 78 days. The RD, food and nutrition expert assigned to Resident 18 was aware of the unplanned weight gain and did not conduct a nutrition assessment to determine the cause of the weight gain. Instead, the RD documented a new weight goal to maintain the new weight for each period where the weight increased. The physician was not notified of Resident 18's weight changes. These failures resulted in Resident 18 experiencing respiratory distress, high respiratory rate, high heart rate, and oxygen desaturation (a lower-than-normal level of oxygen in the blood), exacerbated (made worse) Resident 18's CHF. Resident 18 was taken by ambulance to an acute care hospital on 12/9/22 for higher level of care, where Resident 18 presented with respiratory dyspnea (shortness of breath) and was diagnosed with pneumonia (an infection inflaming the air sacs in the lungs, where fluid may fill the air sacs), pericardial effusions (buildup of too much fluid in the saclike structure around the heart), and pleural effusions (a buildup of fluid between the layers of tissue lining the lungs and chest cavity). 2. Resident 82's physician's dietary and free water orders were not followed, and Resident 82 was administered an additional 600 ml (milliliters- a unit of measurement for fluid) to 1240 ml of free water from 12/5/22 to 12/8/22 and 950 ml of tube feeding (TF- a way of giving liquid foods [formula] or medication thorough a tube which goes into the stomach, used to provide nutrition to individuals who are unable to swallow safely) on 12/6/22. This failure had the potential to result in fluid overload, weight gain, respiratory distress/failure, or death 3. Resident 33's physician orders for dietary and free water were not followed and Resident 33 was administered an additional 300 ml of free water and 600 ml of TF on 12/8/22. This failure had the potential to result in fluid overload, weight gain, respiratory distress/failure, or death. 4. Resident 78's physician orders for dietary and free water were not followed and Resident 78 was administered an additional 600 ml (milliliters- a measurement of fluid) of free water from 12/5/22 to 12/7/22. This failure had the potential to result in fluid overload, weight gain, respiratory distress/failure, or death. 5. Resident 26 had a diet and free water order that was not followed, Resident 26 had a weight gain of 15 pounds in less than one month and the facility staff failed to notify the registered dietician, responsible party, and the physician for appropriate interventions. This resulted in Resident 26's respiratory failure and being sent to the hospital on 12/7/22 where he passed away. 6. Resident 44's physician orders for dietary and free water were not followed and Resident 44 was administered twice the amount of free water for over 12 hours, This failure had the potential to result in fluid overload, weight gain, respiratory distress/failure, or death. 7. Resident 60's physician orders for dietary and free water were not followed and Resident 60 was administered an additional 550 ml of free water. This failure had the potential to result in fluid overload, weight gain, respiratory distress/failure, or death. 8. Licensed nurses did not accurately administer the prescribed feeding and/or free water flushes via gastrostomy tube for Resident 19 when more fluids than prescribed were administered according to the intake flowsheets (IF). This failure had the potential to result in fluid overload, weight gain, respiratory failure, or death. Because of the serious actual harm of significant and unplanned weight gain for Resident 18, and the serious potential harm related to not accurately documenting the volume of free water administered to Residents 82, 33, 78, 26, 44, 60, and 19, and the facility's lack of a comprehensive nutritional assessment system process to consistently and effectively respond to residents' weight gain, and identify residents at overhydration risk in order to maintain acceptable parameters of hydration, an Immediate Jeopardy (IJ, a condition where the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called on 12/9/22, at 7:40 p.m. under Code of Federal Regulations (CFR) S483.25(g) Nutrition/Hydration Status Maintenance (F692) with Administrator (ADM) 1, ADM 2, the Director of Nursing (DON), The Director of Post Acute Operations (DPAO), Registered Nurse Supervisor (RNS), the Registered Dietician/Food Services Director (RDFSD), and the Quality Manager (QM) in attendance. The Centers for Medicare & Medicaid Services (CMS, a federal agency which administers the nation's major healthcare programs) IJ Template was provided to the facility with an expectation for the facility to submit a written Plan of Removal based on the need for immediate actions as listed on the IJ Template. The facility submitted an acceptable IJ Plan of Removal (POR), Version 3 on 12/11/22, at 5:44 p.m. the Plan of Removal included but was not limited to the following: 1) On 12/9/22, the facility identified 40 residents with gastrostomy tubes in the facility. 2) On 12/9/22, the facility notified the Medical Director and attending physicians or the identified residents at risk for over hydration. 3) On 12/9/22 & 12/10/22, the Registered Dietician (RD) assessed nutrition and hydration status of the residents at risk, reviewed weight trends, made recommendations, and documented in the medical record. 4) On 12/10/22 & 12/11/22, physicians were followed up with and physician orders were carried out. 5) On 12/9/22, the DPAO and the DON reviewed the facility's policy and procedure titled, Weight Variance Monitoring and updated the policy. ADM 1 conducted a final review of the policy with revised verbiage. Changes included: Adding Residents are weighed upon admission and then weekly X 4 (four times) weeks, then monthly thereafter unless specified by a Clinician Removed verbiage surrounding unusual or significant weight variance, to align with both state and federal regulations. 6) On 12/9/22, the DPAO educated the DON and RNS in person on the facility's Weight Variance Policy, following up on RD recommendations, physician orders (specific to tube feeding [a way of giving medications, liquids and liquid foods through a small tube going into the stomach] and free water), documentation in the electronic health record (EMR), and notification of physician when there is a weight variance in accordance with the facility's policy and procedure. 7) On 12/10/22, licensed nurses assessed the sample of 11 residents at risk for changes in condition, such as signs and symptoms of respiratory distress, dehydration (a condition when the body loses too much water and other fluids that the body needs to work normally), fluid overload, edema (swelling caused by excess fluid trapped in the body tissues), fatigue, weight gain or loss of five pounds or more. The physicians for those residents that did exhibit a change of condition were notified. 8) On 12/9/22, the RNS entered an Incident Reporting Intranet System (IRIS, an internal reporting system) to request a Root Cause Analysis (RCA, a collective term to describe a wide range of approaches to uncover the cause of a problem) for Resident 18. The facility's DON, ADM 1, ADM 2, QRN (Quality Registered Nurse), DASO, and RDFSD initiated an RCA for why free water administration documentation, weights, weight variance, and nutrition/hydration had not been addresses for the identified residents. 9) On 12/9/22, the DON and RNS educated the licensed Nurses in person via lecture and question and answer to ensure understanding and comprehension using EMR resident examples on the following: Review of physician orders o Tube feeding type (formula) o Tube feed method (continuous vs. [versus- in contrast to] bolus [intermittent]) o Notes if meal percentages were not met by physician's orders o Bowel rest time [no feedings] o Free water rate if included in therapy o Administration of free water to flush (to rinse with liquid) medications At each shift handoff, the licensed nurses are to round, and validate the tube feeding administered with the physician's order How to document tube feeding in the flowsheet o Once per shift enter the order type o Residual [amount remaining in the stomach] o Administration of free water with medication administration via GT o Create a time column for each hour of the day, to document: Tube feeding volume given Free water given In the comment box, also add Flush water volume (amount of water needed to flush liquid food or medication through the tubing), if applicable Liquid medication volume, if applicable 10) On 12/9/22, Licensed nurses were instructed to the following: Follow the (Academic publishing company) Education for Skills: Feeding Tube: Medication Administration in reference to water flushes for medications o The enteral (involving or passing through the intestine) tubing is flushed with at least 15 mL of water between medication administrations unless otherwise directed by the physician o Enteral tubes are flushed before administering medications and after all medications have been administered with at least 15 mL of water unless otherwise directed by the physician Nursing Assessments: o All residents are assessed every shift with documentation in the EMR o Usual or significant weight variances per facility policy will be reported to physician immediately and physician notifications will be documented in the licensed nurses' progress notes o Assessments of resident condition include, but are not limited to shortness of breath, edema, signs of dehydration, abnormal lab (laboratory) values, over hydration, unusual or significant weight variance o A licensed nurse will notify the resident/Responsible Party (RP) as soon as staff is able (without compromising resident's care) of changes in the resident's condition and steps being taken per facility policy, Change in Resident Condition RD Recommendations o Licensed nurses are to notify the physician of RD recommendations within 24 hours o If significant weight change was noted, a licensed nurse will notify the physician per the RD assessment and document in the resident medical record. The survey team validated out of 62 licensed nurses on staff, 56 were educated by the DON, Director of Staff Development (DSD), or Designee on the above education by 12/11/22 via in person lecture or via zoom (for those unable to attend in person); an attestation of understanding will be collected at the end of the education. The outstanding 6 licensed nurses are currently on leave of absence (LOA) or approved leave and will be educated by the DON, DSD, or designee before the start of their next shift. 11) On 12/9/22, the RDFSD educated the RDs on the Weight Variance Policy, Academy of Nutrition and Dietetics-Methods of Estimating Fluid Requirements, providing recommendations to licensed nurses and following up to ensure recommendations are followed up within 24 hours. If recommendations were not communicated to the physician, the RD will notify the DON or designee for follow up. 12) On 12/10/22, the DON educated the Restorative Nursing Assistants (RNAs) on obtaining resident weights as ordered. RNAs were trained to review the previous weight to the weight collected. If there is a weight variance of 5 lbs. (pounds) or more, the resident will be reweighed immediately per policy, Weight Variance Monitoring. If the weight is valid and accurate, with a variance of 5lbs or more, the RNA will notify the RD, or Nursing Supervisor in the RD's absence prior to documenting the weight in the EMR. The RD or Nursing Supervisor, if RD is not available, will review if significant weight change is identified. If significant weight change is identified, the physician, resident/RP will be notified. An IRIS notification will be generated by the licensed nurse when significant weight change is reported. IRIS reports will be reviewed by the Interdisciplinary Team, (IDT, an approach relying on health professionals from different disciplines, working as a team) in daily standup for immediate investigation and follow up. Starting on 12/9/22, weights were obtained by the clinical staff, with 17 residents weighed. All residents will be reweighed by 12/12/22. 13) On 12/10/22, the DSAO educated ADM 1, the DON, QRN, DSD, RDFSD, and RNS on the facility's Weight Variance policy and the expectations for the weekly weight variance meeting to include reviews of: Most recent weight vs. previous weight Director of Nutrition and Dining/(RD) Recommendations Physician Orders Resident weight history over the past 6 months to identify trends Labs (Albumin [a protein that helps keep fluid from leaking out of blood vessels into other tissues], BNP [a protein made by the heart and blood vessels], etc.) Care plans Physician notification of significant weight gain/loss RP/Resident notification of significant weight gain/loss 14) On 12/10/2022, the DON and QRN will audit every resident with gastrostomy tubes to ensure licensed nurses are following physician's orders (specific to tube feeding and free water) with reconciliation with the flowsheet. Clinical Leadership (the DON, RNS, QRN, Minimum Data Set [MDS, an assessment performed on every resident annually] Nurse, DSD, Infection Preventionist (IP) Nurse and/or designee) will continue to audit daily for the next 30 days. Clinical Leadership will report findings daily (Monday-Friday) during stand up. After day 30, Clinical Leadership will audit 25% weekly to ensure all residents are audited at least once a month for the next 3 months. Findings will be reviewed at monthly Practice & Compliance Meetings for recommendations and additional follow up as needed 15) On 12/10/22, the Administrator and QRN started Performance Improvement Projects (PIPs) on gastrostomy feeding and weight variance. Data from audits conducted via direct observation and clinical record review will be reviewed, analyzed and reported monthly in the Practice & Compliance Meetings for recommendations and additional follow up as needed. 16) On 12/10/22, the IDT met and reviewed all residents with a gastrostomy tube and evaluated fluid needs for these residents after review of RD recommendations 17) On 12/12/22, all licensed nurses will receive training and complete a competency assessment on hydration management. Education will be provided by cardiac educators (teachers providing education relating to the heart). Any licensed nurses not captured in this training and competency assessment due to LOA, or other excused leaves, will receive training and be evaluated for competency before their next scheduled shift. 18) Beginning the week of December 19, 2022, a formal Department Monthly Quality Review will take place which is led by executive leadership. Through observations, interviews, and record review, the survey team was able to validate all action items in the IJ Plan of Removal, onsite. The IJ was removed on 12/14/22, at 10:54 a.m., with the ADM 1, the ADM 2, and the DPAO present. Findings: 1. During a review of Resident 18's Face Sheet (document which provided the resident's name, date of birth, insurance, responsible party, physicians, and diagnoses), dated 12/1/22, the Face Sheet indicated, Resident 18 was admitted [DATE] with a diagnosis of Chronic Respiratory Failure (airways to the lungs become narrow and damaged causing difficulty breathing). During an observation on 12/5/22, at 9:54 a.m., in Resident 18's room, Resident 18 was lying in bed with a trach attached to a ventilator (a medical device used to support or replace breathing for a person) and a feeding tube (a medical device used to provide nutrition to people who cannot take nutrition by mouth). During a review of Resident 18's Diet Tube Feeding Order (Diet Order), dated 11/22/22, the Diet Order indicated Resident 18 was receiving a high-protein and fiber fortified formula continuously via GT at a rate of 50 ml (milliliters, a unit of measure) per (/,every) hour (1200 ml/24 hr, hour) with free water flushes at 25 ml every hour (600 ml /24 hr). During a concurrent interview and record review on 12/7/22, at 2:57 p.m., with RNS 1, RNS 1 reviewed Resident 18's Weight, dated 8/17/22 to 12/1/22. RNS 1 stated Resident 18's Weight indicated, the following weights recorded for Resident 18: On 8/17/22 = 99 pounds (lbs., a unit of measure) 8 Ounces (oz., a unit of measure) On 8/22/22 = 99 lbs. 11.2 oz. On 9/3/22 = 96 lbs. 14.4 oz. On 10/19/22 = 114 lbs. 8 oz. On 11/6/22 = 111 lbs. On 11/27/22 109 lbs. On 12/1/22 = 137 lbs. (42.7% weight gain since 9/3/22) During a review of Resident 18's Nutrition Risk Assessment (NRA), dated 8/18/22, the NRA indicated, . Past Medical History: Diagnosis . legally blind [the central visual acuity, vision that allows a person to see straight ahead, of 20/200 or less in the better eye of correction] . CHF [congestive heart failure] . hypertension [high blood pressure] . Weight . 99lbs 8 oz . NA [sodium- needed for normal muscle and nerve function] . 8/16/22 . 137 . 8/17/22 . 139 . Weight goal: Maintain CBW [current body weight] 99lbs +/- [plus or minus] 3% during admit . During a concurrent observation and interview on 12/7/22, at 3:57 p.m., in Resident 18's room, Resident 18 was lying in bed with eyes closed. Certified Nursing Assistant (CNA) 1 weighed Resident 18 on a scale with a sling (a device used to weigh bed-bound individuals). The scale indicated a weight of 133.6 lbs. CNA 1 stated Resident 18's current weight was 133.6 lbs. CNA 1 stated this was not a routine weighing, but a re-check of the Resident 18's weight. During an interview on 12/8/22, at 1:33 p.m., with the RDFSD, the RDFSD stated she had oversight of the kitchen, the Food Services Manager, and the dietary employees. The RDFSD stated she performed clinical nutrition assessments of the residents. The RDFSD stated she performed admission assessments, monthly until stable and quarterly utilizing an assessment form in the EMR (electronic medical record). RDFSD stated the RDs reviewed the resident's past medical history, type of diet, feeding ability, level of assistance to eat, resistance to care, adaptive devices needed, mouth pain, missing teeth, swallowing difficulty, food-medication interactions, labs, skin, diet education needs, how much they are eating and risk factors for weight loss and physical assessment. The RDFSD stated she made recommendations and weight goals after doing the review. During a concurrent interview and record review on 12/8/22, at 1:33 p.m., with the RDFSD, the RDFSD reviewed Resident 18's NRA by RD 1, dated 6/24/22. The RDFSD stated NRA indicated Resident 18's weight on 6/24/22 was 97 lbs. and BMI (body mass index, a measure of body fat based on height and weight) was 19.62. The RDFSD stated the goal BMI in the NRA was 21. The RDFSD stated Resident 18's goal weight with a BMI of 21 should have been approximately 105 lbs. During a concurrent interview and record review on 12/8/22, at 1:35 p.m., with the RDFSD, the RDFSD reviewed Resident 18's NRA by RD 2, dated 8/18/22. The RDFSD stated the NRA indicated, Resident's weight was listed at 99 lbs. 8 oz. (from 8/17/22) and BMI of 20.14. The RDFSD stated the weight goal was to maintain current body weight of 99 lbs. plus or minus (+/-) 3%. During a review of Resident 18's NRA, dated 8/18/22, the NRA indicated . NA [normal range - 135 to 145 mEq/L, milliequivalents per liter - unit of measure] . 8/16/22 . 137 mEq/L . 8/17/22 . 139 mEq/L . During a concurrent interview and record review on 12/8/22, at 1:38p.m., with the RDFSD, the RDFSD reviewed Resident 18's Monthly 1 RD Assessment (M1RDA) by RD 1, dated 9/20/22. The RDFSD stated the M1RDA indicated, Resident 18's weight was listed as 96.9 lbs. (from 9/3/22) and no weight goal was noted. During a concurrent interview and record review on 12/8/22, at 1:41 p.m., with the RDFSD, the RDFSD reviewed Resident 18's Monthly 2 RD Assessment (M2RDA) by RD 1, dated 10/18/22. The RDFSD stated the M2RDA indicated, Resident 18's weight from 9/3/22 (month of September) was replicated for the October monthly review and no goal weight was noted. During a concurrent interview and record review on 12/8/22, at 1:43 p.m., with the RDFSD, the RDFSD reviewed Resident 18's Quarterly 1 Nutrition Assessment (Q1NA) by RD 1, dated 11/21/22. The RDFSD stated the Q1NA indicated, Resident 18 weight was listed as 111 lbs. (from 11/6/22). The RDFSD stated the Q1NA indicated weight changes of +14.9 lbs. for 1 month (15.5%) and 11.5 lbs. for 3 months (11.6%) and the weight goal was modified to maintain current body weight of 111 lbs. plus or minus 3% (108 to 114 lbs.). During an interview on 12/8/22, at 1:46 p.m., with the RDFSD, the RDFSD stated the facility practice was to weigh the residents located in one fourth of the facility the first week of the month, another fourth of the residents the second week of the month, another fourth of the residents the third week of the month and another fourth of the residents the last week of the month. The RDFSD stated the facility started weighing all residents at the beginning of the month of December. The RDFSD stated she had a paper spreadsheet where the CNAs report the weights to better keep track of residents' weights. During a concurrent interview and record review on 12/8/22, at 1:50 p.m., with the RDFSD, the RDFSD reviewed the RD Spreadsheet, dated 10/2/22. The RDFSD stated the RD Spreadsheet indicated Resident 18's weight was documented by the CNA on the paper sheet as 96.1 lbs. on 10/2/22. The RDFSD stated she could not find the weight (96.1 lbs. on 10/2/22) documented in the EMR. The RDFSD stated the CNAs were required to document in the EMR but not on the spreadsheet. The RDFSD stated Resident 18 weight was not on the RD Spreadsheet for 10/18/22. During a concurrent interview and record review on 12/8/22, at 1:53 p.m., with the RDFSD, the RDFSD reviewed the RD Spreadsheet, dated 12/1/22. The RDFSD stated the RD Spreadsheet indicated, Resident 18's weight for 12/1/22 was 137.7 lbs. The RDFSD stated she had not done her weekly review of residents' weights. The RDFSD stated the nurse usually informed her of any significant weight changes, such as a 28 pounds gain in 4 days. The RDFSD stated it was not normal for a resident's weight to vary that much. The RDFSD stated she was unaware of Resident 18 was weighed again on 12/7/22. The RDFSD reviewed the Weight Summary for Resident 18. The RDFSD stated there was no weight noted for Resident 18 on the RD Spreadsheet. During a review of the facility's policy and procedure (P&P) titled, Weight Variance Monitoring, dated 7/20/22, the P&P indicated, . Unusual or significant weight variance includes the following: . Gain or loss of 5 lbs. or more or 5% of weight (whichever is greater) in one month when resident weighs over 100 lbs. Gain or loss of 3 lbs. or more in one month when the resident weighs 100 lbs. or less . Consistent weight gain or loss over several months or 10% of weight in 6 months . Unusual or significant unplanned weight losses or gains will be reported to the physician . All obtained weights will be recorded in the resident's permanent health record . All physician notifications will be documented in the Licensed Progress notes . Validate weight discrepancies by re-weighing prior to notification of the physician . During an interview on 12/8/22, at 1:55 p.m., with the RDFSD, the RDFSD stated it was important to monitor residents' weight loss for nutritional needs and weight gain. The RDFSD stated if the resident had CHF or liver disease they could have fluid retention from getting too much free water. The RDFSD stated Resident 18 had CHF. The RDFSD stated if a resident with CHF was given too much fluid, they could die from fluid overload. During a concurrent interview and record review on 12/8/22, at 1:58 p.m., with the RDFSD, the RDFSD reviewed the Diet Order, dated 9/13/22 to 9/29/22, for Resident 18. The RDFSD stated the Diet Order, indicated free water 15 ml/hr. for 20 hrs. per day (300 ml/day) and tube feeding 40 ml/hr. for 20 hrs./day (800 ml/day) (Total fluid per day =1100 ml =1.1 L [liters, a unit of measure]). During a concurrent interview and record review on 12/8/22, at 2:00 p.m., with the RDFSD, the RDFSD reviewed the Diet Order, dated 9/29/22 to 11/22/22, for Resident 18. The RDFSD stated the Diet Order, indicated free water 20 ml/hr. for 20 hrs./day (400 ml/day) and tube feeding 45ml/hr. for 20 hrs./day (900 ml/day) (Total fluid per day =1300 ml =1.3 L). During a concurrent interview and record review on 12/8/22, at 2:03 p.m., with the RDFSD, the RDFSD reviewed the Diet Order, dated 11/22/22, for Resident 18. The RDFSD stated the Diet Order, indicated free water of 25 ml/hr. for 20 hrs./day (500 ml/day) and tube feeding of 50ml/hr. for 20 hrs./day (1000 ml/day) with a total fluid of 1500 ml (1.5 L) for the day. The RDFSD stated the purpose for increasing free water for Resident 18 was to make sure Resident 18 receives enough fluids for her baseline needs (calculated to achieve 1.2L to 1.4 L per day). The RDFSD stated if Resident was receiving more protein, the RD would increase the fluids. The RDFSD stated Resident 18 the calculated free water would be more conservative since Resident 18 had CHF. During a concurrent interview and record review on 12/8/22, at 2:05 p.m., with the RDFSD, the RDFSD reviewed Resident 18's lab values. The RDFSD stated when calculating Resident 18's needs the RD assessed for elevated BNP (B-type natriuretic peptide, a protein that was produced when the heart had to work harder to pump blood, thus the higher the BNP levels the more likely heart failure is present and the more severe the heart failure) as well as her sodium level to see if it was low and determined the need to adjust free water. The RDFSD stated Resident 18 did not have a BNP in November 2022 and the last one was done in September 2022 which was 371 pg/mL (normal = 0-100 picograms per milliliter). The RDFSD stated Resident 18's sodium was low at 133 mEq/L on 11/18/22. During a concurrent interview and record review on 12/8/22, at 2:08 p.m., with the RDFSD, the RDFSD reviewed Resident 18's Q1NA, dated 11/21/22. The RDFSD stated the Q1NA indicated a recommendation to increase free water to 25ml/hr. for 20 hrs. The RDFSD stated the Q1NA did not indicate why free water was increased. The RDFSD stated it was important to monitor fluid intake of a resident with CHF such as Resident 18 since the resident could get fluid overloaded and die. The RDFSD stated it was important to have an accurate weight record since a spike (sudden increase) in weight could indicate fluid retention. The RDFSD stated the expectation was for nursing staff to notify the RD of the weight gain. The RDFSD stated the RD should have conducted an assessment and evaluated Resident 18's feeding and free water needs. THE RDFSD stated the RD should have monitored the effects of any adjustments. During a review of the Clinical Dietitian Job Description (CDJD), the CDJD indicated, . Essential Accountabilities . Conducts a nutrition assessment for patients at nutritional risk within required time frames. Obtains timely and appropriate data and analyzes/interprets data based on evidence-based standards . Provides appropriate documentation that summarizes the nutrition care plan in the patient's medical record, including nutrition assessment, diagnosis, plan/goals, implementation, and progress toward goals . works closely with other disciplines . to insure [sic] continuity of care . During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team Duties in Team Conference, dated 7/19/22, the P&P indicated, . Responsible Disciplines and Duties . Nutritional Services/Dietitian . Monitors dietary intake . Monitors labs in conjunction with nursing and pharmacy . During an interview on 12/8/22, at 3:36 p.m., with Registered Nurse (RN) 2, RN 2 stated the nursing staff assessed the resident's lungs by auscultation (listening), assessed blood pressure, medications, side effects, and edema (swelling) for residents with CHF, like Resident 18. RN 2 stated nursing staff completed a full body assessment on every resident on every shift. RN 2 stated nursing documented the assessment on the flowsheet. RN 2 stated the edema assessment on the flowsheet was under the peripheral vascular (the circulation of blood to body parts other than the brain or heart) section of the assessment. RN 2 stated the nurse chose to document different indicators, such as WNL (within normal limits) or exceptions to normal limits, such as generalized edema (general swelling all over the body), sacral (lower back), facial, and each extremity (limb). RN 2 stated pulses were assessed by selecting strength of the pulse on each site. During a concurrent interview and record review on 12/8/22, at 3:39 p.m., with RN 2, RN 2 reviewed Resident 18's peripheral vascular assessment for 12/7/22, at 10:37 p.m. RN 2 stated the nurse documented the peripheral vascular assessment WNL and absent edema in all areas (all four extremities). RN 2 validated Resident 18's peripheral vascular assessment was blank between 10/29/22, at 11:00 p.m. to 12/7/22. At 10:37 p.m., a period of 38 days. RN 2 stated the expectation was for the peripheral vascular assessment to be done every shift. RN 2 stated it was important to assess the peripheral vascular system every shift to assess if the resident was retaining more fluid. RN 2 stated, So we can consult with the dietitian and doctor because they [resident] may need less fluid. RN 2 stated if nursing staff did not assess the peripheral vascular system, they will not know if the resident had edema. During a concurrent interview and record review on 12/8/22, at 3:41 p.m., with RN 2, RN 2 reviewed Resident 18's EMR Weight. RN 2 stated the Weight indicated, Resident 18 weighed 109 lbs. on 11/27/22 and 137 lbs. on 12/1/22. RN stated the last weight of 12/1/22 was taken by CNA 2. RN 2 stated it was not normal for a weight to go from 109 lbs. to 137 lbs. in 4 days. RN 2 stated when a weight was significantly different the CNA must tell the nurse and the nurse needed to follow up with the dietician and doctor. RN 2 stated if nursing staff suspected a resident's weight was not correct, the expectation was to have the CNA re-weigh the resident and document in the re-weigh in the EMR. RN 2 validated there was no documentation of a re-weigh in Resident 18's EMR after the weight of 137 lbs. During a concurrent interview and record review on 12/8/22,

Based on observation, interview, & record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards and facility policy and procedure when: 1. Two boxes of over-the-counter bisacodyl (medication used for constipation) was expired in North 1 medication room and was not segregated from medications currently used by nursing staff. 2. Resident 82's punctured vial of Lantus (insulin medication for diabetes) was opened and did not have a sticker with a resident identifier or an open date on the medication. 3. Resident 45's Fluticasone propion-salmeterol (fluticasone-propionate salmeterol, a combination of drugs used to treat difficulty breathing) was labeled with the wrong expiration date. 4. Resident 8's Hydroxyzine (medication for itching) medication blister card (card used to individually store tablets) did not have a change of direction sticker to reflect current usage directions. 5. Discontinued medications for Residents 56, Resident 67, Resident 66, Resident 94, Resident 100, Resident 34, Resident 29, and Resident 1's were not disposed and was in the medication cart along with active (currently used) medications. These failures demonstrated a system of storing and labeling medications in an unsafe manner and did not follow acceptable professional standards for storing medications, placing the residents at risk for receiving the wrong medications, which could cause medication adverse reactions (harmful, unintended result caused by a medication), and had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications. 6. A medication cart in the transitional care unit was left unlocked and unattended by Licensed Vocation Nurse (LVN) 5. This failure resulted in the availability of medications to unauthorized residents, staff and visitors. Findings: 1. During a concurrent observation and interview on 12/5/22, at 9:31 a.m., at the Station 1 North Medication Room, Register Nurse (RN) 5 opened the stock medication drawer. There were 2 boxes of bisacodyl (a laxative) suppositories (a method of putting a medication in the body) with expiration date of 9/30/22 written on the boxes. One box contained 12 suppositories and the other box, 8 suppositories. RN 5 stated, the suppositories should have been discarded because they were expired. RN 5 stated, if the suppository was used on a resident the medication probably not going to work because it was expired. During an interview on 12/15/22, at 11:04 a.m., with Consultant Pharmacist (CP) 1, CP 1 stated, a medication used beyond the use by date would not be effective anymore. During an interview on 12/16/22, at 1:20 p.m., with the DON, the DON stated if the expired bisacodyl suppositories were given to a resident, the medication would not be effectiveness to the resident. The DON stated night shift nurses were responsible for checking for expired medications. The DON stated the expired medications were not being properly managed and disposed. 2. During a review of Resident 82's Minimum Data Set (MDS, an assessment and screening of residents), dated 12/9/22, the MDS indicated, Resident 82 had diagnoses including diabetes (a chronic condition that causes too much sugar in the blood). During a review of Resident 82's Order Listing Report (Order), dated 9/7/22, the Order indicated, . insulin glargine [a long-acting hormone that assists in moving sugar from the blood to other tissues where energy is needed] . 40 Units . Subcutaneous [injected under the skin] nightly . During a concurrent observation and interview on 12/6/22, at 3:46 p.m., with LVN 1, at South station Medication Cart 1, an insulin glargine pen [a pre-loaded, reusable injector, holding many doses] was not labeled with the date it was opened. LVN 1 stated, verified the pen had already been opened and was not labeled with the opened or discard date. LVN 1 stated, the policy was to label the pen with the date it was taken out of the refrigerator. LVN 1 stated the medication was less effective after 28 days. LVN 1 stated she did not know if it had been opened for 28 days since the medication was not dated. During an interview on 12/15/22, at 11:10 a.m., with CP 1, CP 1 stated if a resident received expired insulin glargine, the resident could have fluctuation in blood sugar, as the medication would not be effective. During an interview on 12/16/22, at 1:15 p.m., with the DON, the DON stated it was important for the insulin pen to be properly labeled with the correct dose. If the resident received the wrong dose, the resident's diabetes would be poorly managed. 3. During a review of Resident 45's Admission Record (AR-a one page summary of important information about a patient), dated 11/9/22, the AR indicated, Resident 45 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that make it hard to breathe and get worst over time). During a review of Resident 45's Order Listing Report (Order), dated 10/21/22, the Order indicated, . fluticasone propion-salmeterol [fluticasone-propionate salmeterol, a combination of drugs used to treat difficulty breathing] . 1 puff .every 12 hours . During a concurrent observation and interview on 12/6/22, at 3:13 p.m., with LVN 3, at North Station, Medication cart 3 Odd, Resident 45's fluticasone-propionate salmeterol inhalation power container found on medication cart. Container's hand-written label indicated, opened on 11/8/22 and discard on 12/11/22. LVN 3 stated, it was important to use the proper expiration date (12/8/22) so the medication will be effective for the resident. During an interview on 12/16/22, at 1:17 p.m., with the DON, the DON stated the facility should have followed the manufacturer's guidelines when the fluticasone-propionate salmeterol container was labeled for discard. The DON stated, if medication was used past expiration date, the resident's condition would not be properly managed. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for [Fluticasone and Salmeterol], the manufacturer for [Fluticasone and Salmeterol] indicated, . After removing from box and foil pouch, write the pouch opened and use by dates on the label on top of the device. The use by date is 1 month from date of opening the pouch. Discard device 1 month after you remove it from the foil pouch or when the dose counter reads '0' (whichever comes first) . 4. During a review of Resident 8's Order Listing Report (Order), dated 11/7/22, the Order indicated, . Hydroxyzine . 50 mg tablet . 3 TIMES DAILY PRN [as needed] for itching . Indication for Use . pruritus [itchy skin] of skin . During a review of Resident 8's Medication Administration Record (MAR), dated 12/3/22, the MAR indicated hydroxyzine had currently been administered to Resident 8. During a concurrent observation and interview on 12/06/22, at 4:30 p.m., with RN 5, at the South Station medication cart 5, medication card [a blister package of doses with prescription instructions] label indicated, hydroxyzine 50 mg tablet three times a day as needed for 14 days for itching medication was issued on 11/6/22. RN 5 stated the order was still active and had been made routine (around the clock) three times a day. RN 5 stated, pharmacy did not send a new medication card if the medication was still available for the resident. RN 5 stated, Usually we put a change of direction (administration directions) sticker on the medication card to prevent mistakes. RN 5 stated there was no change of direction sticker on the medication card. During an interview on 12/15/22, at 11:05 a.m., with CP 1, CP 1 stated, if directions for medication change and still have medication card, nursing should have placed a change of direction sticker on the blister card, if they don't a nurse could commit a medication error (mistake) by giving the wrong dosage or frequency. 5. During a concurrent observation and interview on 12/6/22, at 2:59 p.m., with LVN 2, on South Station at medication cart 3, found Resident 56's medication (med) card for ondansetron (a medication given for nausea) 4 mg 1 tablet by mouth three times a day for 14 days, issued on 7/2/22. LVN 2 stated, she was unable to locate current order in the MAR. LVN 2 stated, it was important to remove from discontinued medications from the med card so it would not be given accidentally. During a concurrent observation and interview on 12/6/22, at 3:13 p.m., with LVN 3, at North Station, med cart 3 odd, found Resident 67's med cards with 22 tablets for ondansetron 1 tablet by mouth three times daily for 10 days before meals, issued on 10/19/22. Found Resident 20's med card with 11 tablets for ondansetron 4 mg tablet by mouth three times daily as needed for up to 7 days for nausea, issued on 11/7/22. LVN 3 stated both orders were discontinued for the 2 residents. LVN 3 stated it was important to remove discontinued meds. LVN 3 stated, Because if we gave the meds when the resident does not have symptoms, the residents could have side effects of medication. During a concurrent observation and interview on 12/6/22, at 3:30 p.m., with LVN 4, on North Station at med cart 4 odd, found Resident 66's med card with ondansetron prescribed 4 mg tablet, give one tablet every eight hours as needed for up to 7 days for nausea/vomiting, issued 8/26/22. LVN 4 stated she did not see an active order in the MAR and the medication was discontinued and should have been put in the medication room for destruction. During a concurrent observation and interview on 12/6/22, at 3:46 p.m., with LVN 1, on South Station at med cart 1, found Resident 94's med card with 27 tablets of lorazepam (a controlled medication that can be easily abused and under strict government control, used for treating seizures) 0.5 mg, prescribed 0.5 tablet (0.25 mg) via G-Tube every 12 hours as needed for anxiety for 14 days, issued on 10/29/22. During a concurrent observation and interview on 12/6/22, at 3:56 p.m., with LVN 1, on South Station at med cart 1, found Resident 100's med card with 30 metoclopramide (a drug given for nausea and vomiting) tablets prescribed for one tablet by mouth every six hours as needed for up to 14 days for nausea/vomiting, issued on 11/16/22. Found Resident 100's med card with 2 tablets of sulfamethoxazole (a medication to treat infections) prescribed one tablet via G-Tube twice daily for 7 days, issued 11/24/22. LVN 1 unable to locate an active order in MAR. During a concurrent observation and interview on 12/6/22, at 4:05 p.m., with LVN 1, on South Station at med cart 1, found Resident 34's med card with four dicyclomine 20 mg tablets, prescribed one tablet by mouth three times a day as needed for 14 days for irritable bowel syndrome, issued 5/22/22. LVN 1 unable to locate an active order in the MAR. During a concurrent observation and interview on 12/6/22, at 4:10 p.m., with LVN 1, on South Station at med cart 1, found Resident 29's med card with 10 tablets of ondansetron 4 mg, prescribed one tablet via G-Tube every eight hours as needed for vomiting for up to 14 days, issued on 8/12/22. LVN 1 unable to locate an active order in the MAR. During a concurrent observation and interview on 12/6/22, at 4:21 p.m., with RN 5, on South Station at med cart 5, found Resident 1's med card with four - half tabs of quetiapine fumarate (medication used to treat mental mood disorders) 25 mg tabs, prescribed 1/2 tab twice a day via G-Tube for 27 doses, issued 9/27/22. Found Resident 1's med card with 11 tablets of ondansetron 4 mg tablets, prescribed one tablet viz G-Tube every 6 hours as needed for nausea/vomiting for up to 14 days, issued 5/31/22. RN 5 stated both medications were discontinued. During an interview on 12/7/22, at 10:59 a.m., with the DON, the DON stated Resident 94's lorazepam order from 10/29/22 was discontinued on 10/29/22. During an interview on 12/15/22, at 11:04 a.m., with CP 1, CP 1 stated, nursing needs to remove discontinued medications for the med carts so they don't make a mistake, if they accidentally give a discontinued medication to a resident, without an order it would be unnecessary and expose the resident to more side effects. During an interview on 12/16/22, at 1:25 p.m., with the DON, the DON stated discontinued medications should be separated from active medications, removed from the cart, and then destroyed, it is important to minimize errors and harmful to resident depending on the medication. During a review of the facility's policy and procedure (P&P) titled, Medications - Orders, Administration, Storage Documentation, dated 8/4/22, the P&P indicated, . Medications will be securely stored at all times and at the appropriate temperature . Nursing personnel shall remove any expired medication in a timely fashion from their med carts and place in the appropriate bin located in each nursing unit medication room. Discontinued medications will be held for 30 days, then destroyed . Controlled medications that are expired or discontinued shall be stored in the medication carts until they are collected by the Director of Nursing (DON) or DON designee for destruction . Obtain the medication from the medication room . refrigerator, as appropriate and verify the medication label matches the MAR or prescriber's [physician] order . Medications for discharged patients or those that are discontinued, will be removed immediately from the medication cart . Controlled substances for discharged residents or those that are discontinued, will be kept in the cart until the next day the DSD [Director of Staff Development] or designee is available to receive and catalog the medication for disposal . 40641 6. During an observation on 12/7//22, at 2:57 p.m., in Transitional Care nursing station, there was an unlocked medication cart by the nursing station, unattended by staff. The unlocked medication cart was easily accessible to residents, staff and visitors. During an interview on 12/7/22, at 3 p.m., with LVN 5, LVN 5 stated another nurse borrowed her medication cart keys to unlocked the medication cart to put medications for a resident that was readmitted in the facility. LVN 5 stated the medication cart keys was returned to her but she did not ask if the medication cart was locked afterwards. LVN 5 stated she did not check if the the medication cart was locked. LVN 5 stated the medication cart should not have been left open and unattended. LVN 5 stated residents, staff and visitors could have accessed the medications inside the medication cart which could lead to self medication and or overuse of medication. During an interview on 12/7/22, at 3:05 p.m., with Registered Nurse (RN) 10, RN 10 stated she borrowed the medication cart keys from LVN 5 to put back the medications for a resident that was readmitted . RN 10 stated she returned the keys to LVN 5 and did not lock the medication cart. RN 10 stated, she should have locked the medication cart as soon as she turned her back. RN 10 stated . Residents, staff or other people could access the cart and take medications without our knowledge . During an interview on 12/15/22, at 2:50 p.m., with the Director of Nursing (DON), DON stated his expectation is for all the medication carts to be locked all the time anytime the nurse turned their back and not within their sight. The DON stated, . There are residents walking by all the time and sometimes visitors and staff may have access to the medications inside the medication cart that may lead to overdose and or allergic reactions . During a review of facility's policy and procedure (P&P) titled, Medications- Orders, Administration, Storage Documentation, dated 8/4/22. The P&P indicated, . D. Medication Storage . 3. Medication storage areas are to be locked when not in use . 4. Only authorized personnel will have access to medication storage areas . 41166

Based on observations, interviews, and record review, the facility failed to ensure residents were free from chemical restraints imposed for convenience for two of three residents (Resident 9, Resident 18, and Resident 42) when: 1. Resident 18 was prescribed quetiapine (a medication to reduce symptoms like hallucinations [see, hear, smell, taste, or feel, things that appear real but only exist in the mind], delusions [a belief that is clearly false and indicates an abnormality in thought], and disordered thinking, and other mental health problems), following behaviors of pulling on medical tubes and scratching herself. Licensed nursed did not attempt resident-centered, non-pharmacologic methods to address the behaviors prior to administering quetiapine. The physician did not consult with mental health professional prior to inaccurately diagnosing bipolar disorder (a mental illness that causes extreme mood swings). These failures placed Resident 18 at risk for unnecessary potential medication interactions, and quetiapine adverse effects that include, but are not limited to drowsiness, high cholesterol, high blood sugars (which increases the risk of diabetes, an illness that affects the ability to remove the sugar from the blood and convert it to energy used elsewhere on the body), weight gain, liver dysfunction, heartburn, dry mouth, and weakness. 2. Resident 42 was prescribed quetiapine, inaccurately diagnosed with schizophrenia (a serious mental disorder in which people interpret reality abnormally and impairs daily functioning), and no resident-centered interventions were attempted prior to the use of quetiapine, after Resident 42 attempted to elope the facility and made erroneous phone calls. Licensed nursed did not attempt resident-centered, non-pharmacologic methods to address the behaviors prior to administering quetiapine. The physician did not consult with mental health professional prior to inaccurately diagnosing. This failure resulted in Resident 42's weight gain and increased A1c level (a blood test for average blood sugar level was over the past two to three months), placed Resident 42 at risk for diabetes (a condition that alters the ability to remove sugar from the blood and use as energy in other parts of the body), as well as risk of liver dysfunction, heartburn, dry mouth, and weakness (adverse effects of quetiapine). Findings: 1. During a review of Resident 18's Minimum Data Set (MDS, an assessment and screening tool for long term care residents) dated 6/29/22, the MDS indicated, Resident 18 was a 74. year old female who was admitted from an acute care hospital on 6/23/22 to the facility, whose diagnoses included heart failure (heart muscle does not pump a well as it should), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), respiratory failure (serious condition the makes it difficult to breath), and unspecified dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without psychiatric or mood disorder or potential indicators of psychosis (when people lose some contact with reality). The MDS indicated, Resident 18 was severely impaired in the ability to make decisions regarding tasks of daily life. During a review of Resident 18's Medication Orders (MO), the MO indicated Resident 18 had an order for quetiapine 12.5 mg (milligrams, a unit of measure) via G-Tube (gastrostomy tube, a tube inserted through the belly, directly to the stomach with which to feed individuals who cannot eat by mouth) daily, initiated on 9/18/22. The MO indicated, Admin [administration] Instructions: agitation, pulling life sustaining tube, scratching skin raw . Indications of use: bipolar disorder [a psychotic mental health condition that causes extreme mood swings] in remission [decreased intensity of a disease] . The MO indicated Resident 18 was prescribed this order through 12/8/22. During a review of Resident 18's Hospital Discharge Summary (HDS), dated 6/23/22, the HDS indicated, Resident 18's diagnoses did not include bipolar disorder, and Resident 18's hospital medication orders did not include an order for quetiapine. During a concurrent interview and record review on 12/7/22, at 2:03 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 18's electronic medical record (EMR) was reviewed. RNS 1 stated, the EMR indicated, Resident 18 was admitted [DATE] from the acute care hospital with diagnoses of respiratory failure, tracheostomy (trach, a hole in the neck and into the windpipe in which a tube was placed to keep the hole open for breathing), ventilator (a machine that provides breathing in and out for a person that cannot breathe on their own) dependent, heart failure, dementia, hypertension (high blood pressure). RNS 1 stated, the EMR indicated the diagnosis of bipolar disorder was added on 9/22/22. RNS 1 stated, Resident 18 last left facility to an acute care hospital on 7/29/22 and was discharge back to the facility on [DATE]. RNS 1 reviewed HDS, dated 8/1/22. RNS 1 stated, the HDS indicated, no antipsychotics were prescribed. During a concurrent interview and record review on 12/7/22, at 2:10 p.m., with RNS 1, RNS 1 reviewed Resident 18's History & Physical (H&P), dated 8/17/22, at 5:12 p.m., RN 1 stated the H&P indicated Resident 18 had no diagnosis of psychosis or bipolar disorder. During a concurrent interview and record review on 12/7/22, at 2:11 p.m., RNS 1 reviewed Physician's Progress Note (PPN), dated 9/21/22. RNS 1 stated, the PPN indicated no diagnosis of bipolar disorder. RNS 1 stated, the PPN indicated no documentation of quetiapine being prescribed. During a concurrent interview and record review on 12/7/22, at 2:14 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 8/21/22, at 6:45 a.m. RNS 1 stated the NN indicated, @ [at] 2330 [11:30 p.m.] assessment noted G Tube was dislodged Resident was holding in Right hand Replaced with G tube size # 16 . MD [medical doctor] 1 informed . During a concurrent interview and record review on 12/7/22, at 2:13 p.m., RNS 1 reviewed Resident 18's Nursing Notes (NN), dated 9/2/22, at 12:34 a.m. RNS 1 stated, the NN indicated, . Noticed resident itching and scratching self. [MD 1] was informed and ordered [hydroxyzine, a medication to treat itching] 25 mg TID [three times a day] as needed for 14 days. Order carried out . During a concurrent interview and record review on 12/7/22, at 2:15 p.m., RNS 1 reviewed Resident 18's Medication Administration Record (MAR), dated 8/1/22 to 10/5/22. RNS 1 stated, the MAR indicated, an original order for hydroxyzine 25 mg BID (twice a day) as needed for 7 day was initiated on 8/21/22. RNS 1 stated, the MAR indicated from 9/2/22 to 10/4/22 the order was changed to 25 mg TID as needed for scratching and given once a day on 9/15, 9/16, 9/19, 9/21, 9/22. 9/27, 9/28, 10/1, and 10/4. RNS 1 stated the MAR indicated order was changed to routine (around the clock) three times a day on 10/5/22. During a concurrent interview and record review on 12/7/22, at 2:17 p.m., RNS 1 reviewed Resident 18's NN, dated 9/18/22, at 1:42 p.m. the RNS 1 stated, the NN indicated, . Resident disconnected her trach from the ventilator at least twice during shift and began to desaturate [decreased saturation of oxygen in the blood] down to 91% prior to reconnecting ventilator. After being reconnected resident returned to 98% oxygen saturation. Resident also repeatedly scratching herself during shift. [MD 1] notified, new order received to start [quetiapine] 12.5 mg via PEG [G-Tube] daily . During a review of Resident 18's Behavioral Monitoring Flowsheet (BMF) dated 6/1/22 to 12/7/22, the BMF indicated, Resident 18 exhibited no behaviors of scratching self, pulling on tubes, or agitation in the month of 6/2022 or 7/2022. The BMF indicated, one episode of scratching in 8/2022; one episode of scratching and 6 other episodes without comments and indicating mood as calm in 9/2022; one episode of scratching and 2 other episodes without comments and indicating mood as calm in 10/2022; 4 episodes of scratching and 2 other episodes without comments and indicating mood as calm in 11/2022; and no episodes of behaviors of scratching, pulling tubes or agitation in 12/2022. During a concurrent interview and record review on 12/7/22, at 4:24 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 18's EMR. The DSD stated, the EMR indicated there were no non-pharmacological interventions scratching, pulling at tubes, or agitation prior to starting Resident 18 on quetiapine. During a concurrent interview and record review on 12/9/22, at 2:09 p.m., with the DSD, The DSD reviewed Resident 18' s' Care Plan (CP). The DSD stated the CP indicated, . Problem: Resident with psychotic disorder . The DSD stated, the first intervention is to administer medications as ordered. The DSD stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD .suicidal ideation, self harming threats . The DSD stated the CP had no non-pharmacological plan for monitoring scratching, pulling tubes, or agitation for a resident with a psychotic disorder. The DSD stated the CP was not specific to the resident. During a concurrent interview and record review on 12/9/22, at 2:15, the DSD and Licensed Vocational Nurse (LVN) 1, reviewed Resident 18's Problem List (PL). The DSD stated, the PL indicated bipolar disorder was added to Resident 18's PL on 9/22/22. The DSD stated Resident 18 did not have a history of delusions. LVN 1 stated she was unaware of Resident 18 had any disorganized speech or hallucinations because the resident was non-verbal. LVN 1 stated Resident 18 did not know what goes on around her. During an interview on 12/9/22, at 4:23 p.m., with the Director of Sub Acute Operations (DSAO), the DSAO stated there was no documentation in the corporation's record for Resident 18's diagnosis of bipolar disorder. During a review of Resident 18's MDS, dated [DATE], The MDS indicated, under potential indicators of psychosis the box was checked for none of the above. The MDS indicate, no physical verbal or other behaviors symptoms were exhibited. During an interview on 12/15/22, at 10:48 a.m., with Consultant Pharmacist (CP) 1, CP 1 stated, when Resident 18 came into the facility in June, the resident was not on quetiapine. CP 1 stated, she asked the facility where the diagnosis of bipolar came from because she had not seen it before being placed on quetiapine. CP 1 stated, the facility stated Resident 18 had a history of bipolar, they were adamant about the history. CP 1 stated, the facility told her the resident kept pulling tubes and I asked about using mittens. CP 1 stated the facility told her they tried mittens, but it didn't work. CP 1 stated, pulling of tubes was not an approved use for quetiapine. CP 1 stated, pulling at tubes was not a sign of bipolar disorder. CP 1 stated, if the resident had not exhibited behaviors, then the MD should have tapered the dose down. CP 1 stated, the 11/2022 was the first month she saw the facility monitoring behaviors. CP 1 stated, if someone had a trach and could not speak or communicate you cannot diagnose them as bipolar. CP 1 stated, Resident 18 cannot communicate, so it is even harder to tell if the resident was having side effects of the medication or if it is working or not. During an interview on 12/15/22, at 11:20 a.m., with Resident 18's daughter (Family Member, FM 2), FM 2 stated, Resident 18 has never been diagnosed with bipolar disorder but was made aware of her mother being place on a medication to help stop her itching and pulling. During an interview on 12/16/22, at 7:43 a.m., with Resident 18's son (Family Member, FM 1), FM 1, stated, the facility did contact him when his mother was started on quetiapine but did not mention anything about her being bipolar. FM 1 stated, Resident 18 is not bipolar but has a history of Parkinson's and some dementia. FM 1 stated, he has lived with his mother his whole life until she went into the hospital. During an interview on 12/16/22, 11:07 a.m., with MD 1, MD 1 stated, he did not recall Resident 18. MD 1 stated . I don't play with psychotropics. I don't walk in and start on [quetiapine] . When asked to define bipolar in remission, MD 1 stated . I can't answer unless I can see the record. I don't have access to the record now . MD 1 stated he would put a resident on quetiapine if they were on it in the emergency room or previously on quetiapine. During a concurrent interview and record review on 12/16/22, at 2:01 p.m., with the Director of Nursing (DON), the DON reviewed Resident 18's EMR. The DON stated the EMR indicated, Resident 18 was on quetiapine 12.5 mg daily, starting on 9/18/22 and the indication for use was pulling on life sustaining tubes and scratching. The DON stated he had never heard the term bipolar in remission. The DON stated, signs and symptoms of bipolar disorder would be hallucinations and delusions, so he does not know how the resident can be diagnosed with bipolar when she could not communicate. The DON acknowledged grabbing at a tube that is not naturally present would be normal. The DON validated there was no hallucination or delusions were noted on the MDS, dated [DATE]. The DON validated the ability to monitor mood and behaviors was limited in July- November of 2022, due to limitations with [the electronic documentation system]. The DON acknowledged Resident 18' s' CP for psychotic disorder was generic and not specific to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Use, dated 7/19/22, indicated, . For all residents receiving antipsychotic or other psychotropic medication the nurse ensures . specific condition or diagnosis being treated, and the behaviors manifested are identified in the physician's order and physician's notes . Behaviors associated with use of the mediation are identified in the care plan . In each scheduled Interdisciplinary Team (IDT) meeting residents use of these type of medications will be evaluated for efficacy in controlling [sic] behavior, the advisability of attempting a gradual dose reduction (GDR) and any adverse drug reactions . Procedure . All residents are assessed upon admission and as needed during their stay for physical or behavioral triggers which may necessitate the use of medication to control resident's behavior . Alternate methods are attempted and documented in the resident's plan of care prior to the implementation of new psychoactive mediation treatment . During a review of the Manufacturer's Package Insert for Quetiapine (MPI), dated 1/1/22, the MPI indicated, . Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect size in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic adverse reaction . hyperglycemia [high blood sugar] . weight gain . changes in cholesterol . drowsiness . heartburn . constipation . dry mouth . 2. During a review of Resident 42's Face Sheet (FS, a one-page document with important information about the resident), dated, 1/31/22, the FS indicated, Resident 42 was a [AGE] year-old male and the reason for Resident 42's admit was a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and a history of a traumatic brain injury (TBI, an injury that affects how the brain works). During a review of Resident 42's History & Physical (H&P), dated 12/17/19, the H&P indicated, diagnoses of TBI, subarachnoid hemorrhage, subdural hematoma (when a blood vessel in the space between the skull and the brain is damaged, blood leaks and forms a clot that places pressure on the brain and damages the brain), prostate mass (non-cancerous nodule), left inguinal hernia (a bulge in the groin area caused by fatty tissue or intestines pushes through a weak spot in the muscles surrounding the abdomen), intraventricular hemorrhage (bleeding into the fluid -filled areas, or ventricle, surrounding the brain), hypertension (HTN, high blood pressure), cardiac arrhythmia( irregular heart beat), dysphagia (difficulty swallowing), and a past history of arthritis (inflammation or swelling in one or more joints) & HTN. The H&P indicated, no history or diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally). During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, the active diagnosis box for schizophrenia was not checked. During a review of Resident 42's Medication Orders (MO), dated 1/30/20 to 1/31/22, the MO indicated, MD 1 prescribed quetiapine 50 mg two times daily from 1/30/20 to 2/15/20 and the indication for use was schizophrenia, manifested by episodes of delusions. The MO indicated, MD 2 altered the quetiapine order to 100 mg three times daily on 2/16/20 (three times the previous daily dose). The MO indicated, MD 1 altered the prescription to 200 mg 2 times a day with the indication for use as schizophrenia, manifested by episodes of delusions manifested by wanting to leave facility to drive his truck or wanting to get to his job. During a review of Resident 42's Nursing Progress Notes (NPN), dated 12/22/19, the NPN indicated, . Pt [patient] is alert and responsive, verbal, able to make needs know [sic], forgets limitations, tolerates meds [medications] well . During a review of Resident 42's NPN, dated 1/23/20, at 6:17 a.m., the NPN indicated, . At approximately 04:45 [4:45 a.m.] patient tried to elope, when he was scheduled for shower, still dressed exited at the door by PT [physical therapy] room, Staff nurse and CNA were with the patient trying to stop from leaving, resident didn't listen, called security and police dept [department] to Incident. , [sic] contacted supervisor by staff nurse, notified RP [responsible party] via phone . Patient was trying to enter property . while being accompanied by staff, security arrived and take [sic] the resident back to the facility. Patient is safe and went back to bed, remained in bed . During a review of Resident 42's NPN, dated 1/29/20, at 6:16 p.m., the NPN indicated, . Resident called 911 to ask for information on a friend who lives in [city name]. He is pacing up and down the hallways and opening the emergency exits. Resident wants to leave to go drive trucks in [nearby state]. RP to be contacted and MD to be informed . During a review of Resident 42's NPN, dated 1/29/20, at 7:17 p.m., the NPN indicated, . Resident called [nearby behavioral facility] 18 times. Resident was asked not to use the lobby phone anymore and to ask staff to dial for him from now on. Resident's sister (RP) was contacted and informed of behaviors of the resident. She asked if we could get him some medications to calm him down. MD contacted. Awaiting response . During a review of Resident 42's NPN, dated 1/29/20, at 7:34 p.m., the NPN indicated, . MD responded with new orders. Give 1mg [lorazepam, a medication to treat anxiety] STAT [immediately] and start him on [quetiapine] 50mg BID [twice daily] . During a review of Resident 42's NPN, dated 1/29/20, at 11:52 p.m., the NPN indicated, . After first administration of [lorazepam] 1mg IM [intramuscularly, a method of injecting medication into the muscle] Resident continued to attempt to run away. He ran out the front door and was brought back by staff he then went out the Emergency exit. Security responded and spoke with resident . He was still obsessing about leaving and wouldn't calm down. [MD 2] contacted and gave orders for additional 1mg [lorazepam] IM STAT. He also gave orders for [lorazepam] 1mg by mouth BID along with the [quetiapine] 50mg BID. [MD 2] stated we need to contact him every few days to increase [quetiapine] until it reaches 900mg. He also said we need to think about other types of psychotropics that work better for TBI patients . During a review of Resident 42's NPN, dated 1/30/21, at 6:38 a.m., the NPN indicated, . Pt. Slept [sic] good during the shift, no attempt to go outside the facility,randomly [sic] check patient, he get up to go bathroom twice and be able to go [sic]back to bed to sleep with no problem . During a review of Resident 42's NPN, dated 1/30/20, at 3:29 p.m., the NPN indicated, . Patient was seen walking out of building passing by at The [sic] activity area by the time we were out [sic] patient was already across the street. Patient ask why he [sic] went outside stated just wanted to go for a walk. Educate patient the danger [sic] of getting lost . During a review of Resident's NPN, dated 2/2/20, at 2:15 p.m., the NPN indicated, . Patient monitor for this shift patient in his room most of the time was on his phone ate in his room no attempt of going outside facility at this time he is in the activity likely to watch football [sic]. Supervisor made aware of night nurse endorsing about medication per supervisor [sic] will TX [text?] MD . During a review of Resident's NPN, dated 2/2/20, at 4:07 p.m., the NPN indicated, . Spoke with [MD 2] patient remained calm and cooperative, no signs of wandering at this time. Patient behaviors are currently controlled with current dose of [quetiapine] and [lorazepam]. Will continue to monitor . During a review of Resident's NPN, dated 2/2/20, at 9:33 p.m., the NPN indicated, . MD faxed back order to change diagnosis of [quetiapine] to schizophrenia M/B [manifested by] episodes of delusions . During a review of Resident's NPN, dated 2/14/20, at 10:34 p.m., the NPN indicated, . Patient eloped from facility at approximately 2145 [9:45 p.m.] this shift. Security, [city] PD [police department], RP and pt friend [name], MD, APS [adult protective services] and facility supervisor all made aware of patient elopement. Patient last seen asking a staff member if they could take him to [another town]. [city] PD said they would have officers out canvassing area . During a review of Resident's NPN, dated 2/15/20, at 1:41 a.m , the NPN indicated, . PD came back to facility and stated they still have not found patient out on the street . PD said . they will hand case to . PD missing persons . During a review of Resident's NPN, dated 2/16/20, at 10:42 p.m., the NPN indicated, . Patient seen pacing around facility and trying to exit the building through all doors. He is telling female staff they're 'his girl and they need to outside to his truck with him.' Multiple staff tried redirecting pt with TV, snacks offered, and that dinner would be in bedroom shortly but continued to say he needs change so he can find a ride to get to his job. Pt was reminded that he does not have work right now and that he lives here at the facility. Patient stated, 'No I don't, I need to get to my truck right now.' .RP called .he doesn't want to talk . call her tomorrow . [MD 2] notified . New MD orders to increase [quetiapine] 100mg TID, reinstate [lorazepam] 1mg by mouth BID, and to give [lorazepam] 1mg IM x1 [once] stat . All orders carried out . During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, verbal behavior directed toward other occurred 1 to 3 days. The MDS indicated, no physical or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, wandering behavior question was unanswered. During a review of Resident 42's MDS, dated [DATE], the MDS indicated, under potential indicators for psychosis, the boxes for hallucinations and delusions were not checked and the box for none of the above was checked. The MDS indicated, no physical, verbal, or other behaviors had not been exhibited. The MDS indicated, no wandering behavior was exhibited. During a concurrent interview and record review on 12/8/22, at 10:47 a.m., with the DON, the DON reviewed the EMR for Resident 42. The DON stated he could not find any documentation of behavior monitoring prior to the administration of quetiapine, because there were no behaviors except for the elopement. During a concurrent interview and record review on 12/8/22, at 10:49 a.m., with the DON, the DON reviewed Resident 42's Physician Progress Notes (PPN), dated 2/28/20 to 12/21/20. The DON stated, the PPN did contain any documentation of a schizophrenia diagnosis or schizophrenia symptoms. During a review of Resident 42's Weights, dated 12/19/19 to 12/1/22, the Weights indicated, .12/19/19 . 216 pounds [lbs., a unit of measure] . 1/19/20 .205.3 lbs. 2/8/20 .210.3 lbs. [no weights between 2/8/20 and 6/13/20] . 6/13/20 . 226.4 lbs. 7/31/20 . 267.7 lbs. [+41.3 lbs. {18.2%} in one month] . 12/12/20 . 272.2 lbs. [+56.2 lbs. {26%} in one year] . 3/13/21 . 280.9 lbs. 6/18/21 . 284.8 lbs. 9/9/21 . 290 lbs. 11/02/22 . 296.3 lbs. During an interview on 12/9/22, at 10:40 p.m., with the RDFSD, the RDFSD reviewed Resident 42's EMR. The RDFSD stated, Resident 42 's diagnoses on admission included, arthritis, hypertension, hyperlipemia. The RDFSD stated, continued weight gain could worsen these diagnoses. The RDFSD stated, Resident 42 has been on a regular diet since at before 3/17/20. During a review of Resident 42's Hemoglobin A1C (HbA1c or A1C lab results, dated 3/6/20 to 10/12/22, The HbA1c indicated, . Ref [reference] Range & Units 4.8 - 5.6% . 3/6/20 . 5.4 . 3/5/21 . 5.7 . 6/18/21 . 6.0 . 12/16/21 . 6.1 . 2/2/22 . 6.3 . 10/12/22 .6.4 . During a review of Resident 42's Hemoglobin A1C results (A1C), dated 10/12/22, at 1:09 p.m., the A1C indicated, it was a fax and the result of 6.4 is circled and signed by [MD 1]. During a review of Resident 42's NPN, dated 10/12/22, at 10:17 p.m., the NPN indicated, . MD faxed back regarding patient's lab results: CBC [complete blood cell count], CMP [complete metabolic panel, electrolytes and minerals], Lipid [fats in the blood] Panel, Vitamin D, and HA1C [A1C]. No new orders at this time . During a concurrent interview and record review on 12/14/22, at 2:16 p.m., with LVN 8, LVN 8 reviewed Resident 42's EMR. LVN 8 stated, she could not locate any non-pharmacological (non-medication) interventions attempted prior to starting quetiapine and no targeted behavior to monitor on the flowsheet. LVN 8 stated, the EMR indicated, non-pharmacological interventions for behaviors documented in the flowsheet on 2/23/22. LVN 8 stated the expectation is to document on planned alternate to psychotropics every shift. LVN 8 stated the planned interventions do not show up in the EMR until the quetiapine is ordered. LVN 8 stated, the planned interventions were general, like noise and lighting reduction. During a concurrent interview and record review on 12/14/22, at 2:17 p.m., with LVN 8, LVN 8 reviewed the Psychotropic Medication Behavior Flowsheet (PMBF), dated 11/1/22 to 12/13/22. LVN 8 stated, the PMBF indicated, no target behaviors were observed. During a concurrent interview and record review on 12/14/22, at 2:18 p.m., with LVN 8, LVN 8 reviewed Resident 42's CP. LVN 8 stated, there was a care plan for quetiapine for history of wanting to leave the facility. LVN 8 stated, the CP indicated, the first intervention is to administer medications as ordered. LVN 8 stated, the CP indicated, . involve in activity program . reassurance and orientation . explain procedures . observe for delusions, hallucinations, disorganized speech, catatonic behavior, disorganized behavior . Psych. [psychiatric] Consult as indicated . Notify MD .suicidal ideation, self harming threats . LVN 8 stated, a lot of the interventions were general, not specific to resident. LVN 8 stated, it was important to have resident-centered non-pharmacological interventions so you can provide better care to the resident. During a concurrent interview and record review on 12/14/22, at 2:20 p.m., with LVN 8, LVN 8 stated she could not find a psychiatric consult nor an order for a psychiatric consult in Resident 42' medical record During a review of Resident 42's Behaviors and Moods (BM), dated 11/8/22 to 12/8/222, The BM indicated, all entries for physical behaviors observe are 'appropriate; all entries for verbal behaviors observed are appropriate; and all entries for emotion moods or behavior observed are calm or cooperative, or both, except one entry on 11/18/22 at 10:30 a.m., which indicated, calm; cooperative; anxious. During an interview on 12/15/22, at 10:10 a.m., with CP 1, CP 1 stated, she remembered Resident 42 because he had eloped and that is how he was started on quetiapine. CP 1 stated, Resident 42 had a TBI and patients with TBI can cause behavior that are impaired, it varies from patient to patient. CP 1 stated, she did not know if the facility documented behaviors prior to starting quetiapine; I review once a month and he was already on quetiapine when I reviewed his record. CP 1 stated, the facility switched to [electronic documentation system] in 2019, and it is not made for long term care. CP 1 stated the facility got access to document behaviors in November of 2022. CP 1 stated, if the facility cannot document behaviors, there would be nothing for the physician to assess about dose reduction. CP 1 stated non-pharmacological interventions were important and needed to be patient-specific because drugs are not the first line of treatment. CP 1 stated if a patient was schizophrenic, they need to see a psychiatrist. During an interview on 12/15/22, at 10:20 a.m., with CP 1, CP 1 stated, Resident 42 gained weight after starting quetiapine. CP 1 stated, I think quetiapine might have cause the gain. CP 1 stated, weight and A1C were important to monitor for this resident because of hypertension, possible diabetes or stroke. CP 1 stated Resident 42 needs to be on the lowest dose possible, but if behaviors are not monitored, h [TRUNCATED]

Based on interview and record review the facility failed to notify the State Long-Term Care (LTC) Ombudsman (OMB) of transfers and discharges for three of eight sampled residents (Resident 78, 82, and 83) when the OMB office was not notified for Resident 78, Resident 82 and Resident 83's hospitalization s. This failure resulted in Resident 78, Resident 82 and Resident 83 not having access to an advocate (the ombudsman) who could inform them their options and rights while being in the hospital. Findings: During a concurrent interview and record review on 12/8/22, at 9:01 a.m., with the Director of Staff Development (DSD), Resident 78's Electronic Health Records (EHR) for admitted [DATE] was reviewed. The DSD stated Resident 78 was sent to the hospital on 9/1/22 for a GI (gastrointestinal - stomach) bleed and again on 10/5/22 for sepsis (a serious infection that could lead to shock and or death). The DSD stated the nursing notes indicated the change in conditions and the responsible party being notified. The DSD stated she did not know where the documentation for Ombudsman notification for hospitalization was noted in the Resident 78's EHR. During a concurrent interview and record review on 12/8/22, at 10:49 a.m., with the DSD, Resident 82's EHR for admitted [DATE] was reviewed. The DSD stated Resident 82 was sent to the hospital on 8/28/22 for continuous fever and pneumonia (PNA - lung infection). The DSD showed the Nursing note that indicated the responsible party was notified of the resident going to the hospital. The DSD stated she did not know where the documentation for Ombudsman notification for hospitalization was noted in the Resident 82's EHR. During an interview on 12/9/22, at 11:22 a.m., with the DSD, the DSD stated, We send a list to the Ombudsman monthly of all the residents that are sent out for the previous month. The DSD provided a document indicating dates to send ombudsman notices. The DSD stated the Administrator (ADM) 1 informed her ombudsman notices were sent out monthly and was done by the social services staff. The DSD stated the facility was not able to send out ombudsman notices timely. During a review of facility documents (binder) titled, TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN (OMB) PROGRAM, indicated there was no transfer forms sent for Resident 78's hospitalization s on 9/1/22 and 10/5/22 and for Resident 82's hospitalization on [DATE]. During an interview on 12/9/22, at 11:44 a.m., with Licensed Clinical Social Worker (LCSW) 2, LCSW 2 stated, Yesterday. I was told to send these forms [TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN PROGRAM] to the Ombudsman, and we have never had to do it before. We [Social Services] are not responsible for this; you would have to speak with [name of ADM 2]. During an interview on 12/9/22, at 11:48 a.m., with ADM)2, ADM 2 stated, The social workers [SW] are working on finding the binder [Transfer/ Discharge Binder]. ADM 2 stated it was the social workers responsibility to ask for the binder for the Ombudsman forms for tracking of discharges and transfers. ADM 2 stated they had a SW quit 2 months ago and she was responsible for the binder and faxing these forms to the OMB. ADM 2 stated the SW currently assigned to fax the transfers and discharges should have sent the notices to the OMB office. During a concurrent interview and record review on 12/15/22, at 4:15 p.m., with the Quality Registered Nurse (QRN), Resident 83's EHR for admitted [DATE] and 10/6/22 were reviewed. The QRN stated Resident 83 was sent to the hospital on 10/4/22 for GI bleed and on 10/6/22. The QRN stated Resident 83 was again sent to the hospital on 10/31/22 for bloody emesis (vomit). During a review of facility documents (binder) titled, TRANSFER OR DISCHARGE FAX COVER SHEET [city name] LONG TEM CARE OMBUDSMAN (OMB) PROGRAM, indicated Resident 83's transfer document for date 10/31/22 was missing the reason for transfer and the facility the resident was being transferred to. There was also no transfer form sent for Resident 83's hospitalization s on 10/4/22. During an interview on 12/9/22, at 12:15 p.m., with ADM 1, ADM 1 stated she was not aware of the issue with the transfer and discharge paperwork for the OMB office until yesterday when the DSD asked her about it. ADM 1 stated the Transfer and Discharge Fax Cover Sheet did not provide the needed information to for the OMB office. ADM 1 stated it did not provide the facility the resident was being transferred to and the reason for the transfer or discharge. ADM stated the transfer forms should have all the needed information. During an interview on 12/16/22, at 3:17 p.m., with the Director of Nursing (DON), the DON stated it was important to let the OMB know when there were transfers and discharges because they were the resident's advocate and could help to ensure the resident came back to the facility. The DON stated if the OMB was not informed of the resident going to the hospital they would not be able follow up on the resident to make sure their issues were being addressed. During a review of a professional reference titled, California Advocates for Nursing Home Reform [CANHR] Long Term Care Justice and Advocacy, dated 7/15/22, indicated, . Transfer and Discharge Rights . Written Notice Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand. 42 CFR 483.15(c)(3)(i). The facility must send a copy of the notice to the long-term care ombudsman program . The notice must contain all of the following information . The reason for the transfer or discharge . The effective date of transfer or discharge . The location to which the resident will be transferred or discharged . Retrieved from: http://www.canhr.org/factsheets/nh_fs/html/fs_transfer.htm

Based on observation, staff and family interviews, and clinical and administrative document review, the facility failed to ensure the residents' right to be free of physical restraints imposed for purposes of convenience, in an effort to control behavior, for 1 of 21 sampled residents (Resident 12) when: 1. Physical restraints were used continuously for six months without documentation that alternative and least restrictive methods had been attempted. 2. A nursing care plan was not developed and implemented to include a method to reduce the use of physical restraints. This failure resulted in psychosocial and physical harm to Resident 12, evidenced by restlessness and behaviors which led to multiple falls to the floor while attempting to free himself of the physical restraints. Findings: 1. On 10/6/15 at 9:15 a.m., during an observation on initial tour, Resident 12 laid in bed, sleeping on his back, with a tracheotomy (trach - an artificial airway consisting of a tube inserted into the neck). Charge Nurse (CN) 1 stated Resident 12 did not speak English. CN 1 stated Resident 12 displayed behaviors which included restlessness and pulling out his tracheotomy (trach) tube. CN 1 stated bilateral (both left and right) wrist restraints were implemented to prevent pulling out the trach. Resident 12's clinical record indicated he was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 12's physician order, dated 2/26/15 at 10:30 a.m., indicated, Bilateral soft wrist restraint at all times to prevent fall and to prevent pulling of life sustaining devices . Resident 12's physician orders, dated 10/2015, indicated the following medical orders: Apply bilateral wrist restraints at all times to prevent pulling tubes. Two medications were ordered for behaviors: [MEDICATION NAME] - an anti-anxiety medication evidenced by unpurposeful movement; and [MEDICATION NAME] - an antipsychotic medication for [DIAGNOSES REDACTED]. On 10/6/15 at 1:10 p.m., during an interview, Registered Nurse (RN) 1 stated Resident 12 had become increasingly agitated since admission, with episodes of pulling out [MEDICAL CONDITION] and G tube, and a recent episode which required multiple staff to control his behavior. RN 1 stated the resident was usually calm and restraints were removed when resident's family visited. On 10/6/15 at 1:20 p.m., during an observation, Resident 12 was observed in bed asleep. Wrist restraints were not removed while Resident 12 was observed sleeping. Resident 12's untitled Plan of Care (POC) dated 3/13/15, indicated under Problems/Strengths, Impaired Physical Mobility; Risks: (At risk for falls/self injury due to spasms, .and/or altered mental status. Under Interventions it indicated, .Restraint use will be evaluated and efforts to reduce use will be attempted on a regular basis. Resident 12's Social Services (SS) notes, dated 3/31/15 at 12:15 p.m., indicated Resident exhibit(s) episodes of hitting staff at times .had episodes of restlessness, rolling on and off bed, pulling out GT and kicking or hitting staff. Resident is alert to self with episodes of confusion and forgetfulness .he currently has bilateral wrist restraint due to pulling at tubes .Staff is encouraged to access for basic needs and environment for possible triggers . The note was signed by Social Work Coordinator 1 (SWC 1). Resident 12's Nursing Notes (NN), dated 5/18/15 at 11 p.m. indicated, Patient found on mat between his bed and bed A .left wrist restraint attached to patient and bed . Resident 12 NN, dated 5/19/15 at 11:30 a.m., indicated, Paged (doctor) for the second time due to pt's attempt to get out of bed, tugging and finally tearing his restraint. He also started to appear tearful . Resident 12's NN, dated 5/28/15 at 7:10 p.m., indicated, pt. attempted to pull hand out of restraint, and upon inspection noted abrasion to wrist . Resident 12's NN, dated 6/2/15 at 10:20 p.m., indicated, Called R/P (responsible party) to get verbal consent to apply mitten to L (left) hand. R/P did not consent. R/P said he feels the pt (patient) will become more agitated he (patient) wants to sit up; R/P suggested staff observe patient closely if pt. is agitated, trying to take restraint off, then take restraint off and have pt. sit up at side of bed for 45 minutes. Resident 12's NN, dated 6/3/15 at 2:30 a.m., indicated, Pt. had multiple attempts of pulling at tubing, pulling on restraint to untie, attempting to get out of bed. Pt. education provided on the importance of not pulling on tubing, trach, restraint, getting out of bed. Pt continued behaviors. Distraction, dim lights were provided and were not effective. R (right) wrist was applied per PRN (as needed) order. Pt. continued to pull at restraints, get out of bed . Resident 12's NN, dated 8/25/15 at 11:40 a.m., indicated, .Pt was received this morning very agitated, pulling, struggling and trying to get out from bed kicking his leg. Pt. attempted by bending his body to grab [MEDICAL CONDITION] off . On 10/7/15 at 9 am, during an interview, the Director of Nursing (DON) stated Resident 12 had a history of [REDACTED]. When asked about Resident 12's assessment, and the interventions attempted to decrease or eliminate the use of his restraints, she stated antipsychotic medication was ordered, and lights were dimmed in his room. When asked about the effectiveness of those interventions in reducing Resident 12's behaviors, she stated, They (behaviors) really didn't change much. She further stated obtaining psychiatric evaluations for residents was difficult, and the resident had not been evaluated by a mental health professional. On 10/7/15 at 2:30 p.m., during an interview, the DON stated she reviewed Resident 12's clinical record. The DON did not provide documentation of a care plan or targeted interventions initiated. On 10/7/15 at 4:15 p.m., during an interview, Registered Nurse (RN) 2 stated she cared for Resident 12 three to four times a week. When asked whether she provided input toward Resident 12's care planning, she stated she was not asked to provide it. She further stated Resident 12's family visited almost daily, and stated, The family told us he doesn't want to be here, he wants to go home .he was crying one day. She stated the family had recently requested a wheelchair to take him outside during their visits. On 10/8/15 at 7:45 a.m., during an interview, Clinical Supervisor 1 (CS 1) stated she attended all IDT meetings for Resident 12, and meetings focused on his behaviors and medication changes. She further stated there had not been improvement in his behaviors. The facility policy and procedure titled, Physical (soft wrist and mitt) Restraints dated 1/5/15, indicated under II. Policy, It is the policy of this facility to utilize padded mittens/soft wrist under the direction of a physician's orders [REDACTED]. 2. On 10/6/15 at 9:15 a.m., during an observation on initial tour, Resident 12 laid in bed, sleeping on his back,with a tracheotomy (trach-an artificial tube inserted into the neck for breathing) in place. Charge Nurse (CN) 1 stated Resident 12 did not speak English, his behaviors included restlessness and decannulation (pulling out his tracheotomy tube), and bilateral wrist restraints were implemented to prevent this behavior. Resident 12's clinical record indicated he was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident 12's physician order [REDACTED]. On 10/6/15 at 1:10 p.m., during an interview, Registered Nurse (RN) 1 stated Resident 12 had become increasingly agitated since admission, with episodes of pulling out [MEDICAL CONDITION] and G tube, and a recent episode which required multiple staff to control his behavior. She stated the resident's restraints were removed when resident's family visited, and he was usually calm during those periods. On 10/6/15 at 3:15 p.m., during an observation, Resident 12 was observed quiet and alert, looking toward his room entrance. A family member was observed entering his room. Upon her entrance, Resident 12's facial expression changed immediately. He made direct eye contact with her, produced a large smile, and attempted to move his body toward the family member. She greeted him in a warm manner. Resident 12's Nurses Notes (NN) dated 3/17/15 at 0030 a.m. indicated, Patient found on mat lying on stomache. Loose BM (bowel movement) noted. No injuries. Assisted back to bed and cleaned x (by) three staff members . Resident 12's NN dated 3/17/15 at 0530 a.m. indicated, Patient found on mat on side of bed lying on stomache. Resident 12's NN dated 4/2/15 at 2pm p.m. indicated, Pt. (patient) found laying on the mattress/floor pad . Resident 12's NN dated 6/2/15 at 8:20 p.m. indicated, Called R/P (responsible party) to get verbal consent to apply mitten to L (left) hand. R/P did not consent. R/P said he feels the pt (patient) will become more agitated he (patient) wants to sit up; R/P suggested staff observe patient closely if pt. is agitated, trying to take restraint off, then take restraint off and have pt. sit up at side of bed for 45 minutes. Resident 12's NN dated 6/3/15 at 2:30 a.m. indicated, Pt. had multiple attempts of pulling at tubing, pulling on restraint to untie, attempting to get out of bed. Pt. education provided on the importance of not pulling on tubing, trach, restraint, getting out of bed. Pt continued behaviors. Distraction, dim lights were provided and were not effective. R (right) wrist was applied per PRN order. Pt. continued to pull at restraints, get out of bed . Resident 12's NN dated 8/25/15 at 11:40 a.m. indicated, .Pt was received this morning very agitated, pulling, struggling and trying to get out from bed kicking his leg. Pt. attempted by bending his body to grab [MEDICAL CONDITION] off . Resident 12's untitled Plan of Care (POC) dated 3/13/15, indicated under Problems/Strengths, Impaired Physical Mobility; Risks: (At risk for falls/self injury due to spasms, .and/or altered mental status. Under Interventions it indicated, .Restraint use will be evaluated and efforts to reduce use will be attempted on a regular basis. Resident 12's untitled POC dated 3/13/15, indicated under Problems/Strengths, [MEDICAL CONDITION] as manifested by (blank space). Under Goals, it stated, Resident will remain free of psychotic symptoms. Review Q (each) month in Team Conference. Under Interventions it stated, .Obtain psychiatric consultation Resident 12's untitled POC dated 3/13/15, indicated under Problems/Strengths, .Inability to meet own social and emotional needs. Under Interventions it indicated, Social service coordinator to provide supportive social visits at least 3 times per month or more often as needed. Resident 12's untitled POC dated 3/13/15 indicated under Problems/Strengths Mood/Behavioral concerns as evidenced by: Episodes noted of resident pulling out tubes, constantly moving in and out out of bed. 3/18/15: Episode of striking staff. Risks: depression, anger, isolation, lack of socialization. Strengths: He has good family support. Under Interventions it indicated, Obtain psychiatric consult as needed. MD to assist as needed. Staff to refer resident to Fresno County Mental Health as needed .SS (Social Services) to provide 1:1 (one to one) visits to resident as needed for psychosocial needs and issues .Staff to assess for possible triggers of behavior and basic needs. On 10/7/15 at 2:30 p.m., during an interview, the DON stated she reviewed Resident 12's clinical record. The DON did not provide documentation of a care plan or targeted interventions initiated.When asked about family involvement toward restraint reduction, the DON did not respond. She stated she did not attend the interdisciplinary (IDT) meetings for Resident 12. On 10/7/15 at 4:15 p.m., during an interview, Registered Nurse (RN) 2 stated she cared for Resident 12 three to four times a week. RN 2 stated, I never go to those meetings (Resident 12's IDT meeting). When asked whether she provided input toward Resident 12's care planning, she stated she was not asked to provide it. She further stated Resident 12's family visited almost daily, and stated, The family told us he doesn't want to be here, he wants to go home .he was crying one day. She stated the family had recently requested a wheelchair to take him outside during their visits. On 10/8/15 at 7:45 a.m., during an interview, Clinical Supervisor 1 (CS 1) stated she attended all IDT meetings for Resident 12, and meetings focused on his behaviors and medication changes. She further stated no input was received from Resident 12's family regarding his behaviors or potential interventions to minimize the use of restraints. She further stated there had not been improvement in his behaviors. On 10/8/15 at 8:15 a.m., during an interview, Medical Director (MD) stated he attended all IDT meetings for Resident 12. He further stated he had no knowledge of targeted restraint reduction interventions, and did not know whether family input was obtained in planning Resident 12's care. On 10/8/15 at 10:05 a.m., during an interview with the Social Work Coordinator (SWC) 1, she stated she had recently seen Resident 12 outside in the garden with family, and stated, (Resident 12) was fine, he was so calm, it was a nice view to see. When asked how her observation was used for planning Resident 12's care, she stated, I don't know. She further stated she wrote Resident 12's untitled POC for Mood/Behavioral concerns dated 3/13/15. When asked if Resident 12 was referred for psychiatric assessment or to county mental health, she stated, No. When asked about her resident 1:1 visits as per his care plan, she stated she had not visited him. When asked how often she observed Resident 12 outside his room with staff, she stated she had never seen it, other than for his shower. On 10/8/15 at 11 a.m., during an interview, Family Member (FM) stated Resident 12 became agitated when he wanted to get out of bed, or be placed back in bed, and his agitation increased when facility staff forced him to do something. FM stated, He is not as agitated with family .occasionally .my mother is able to control him and can calm him down. The FM stated Resident 12 enjoyed doing yard work in his spare time and spent time outdoors. FM stated the family recently requested a wheelchair to take him outside during visits. He stated he had never found Resident 12 outside his room when he visited. On 10/8/15 at 2:50 p.m., during an interview, the Assistant Director of Nursing (ADON) stated the facility did not have a system in place at the current time for residents requiring psychiatric assessment or behavioral health services. The facility policy and procedure titled, Interdisciplinary Team Duties in Team Conference dated 6/23/15, indicated under II. Policy, D. Responsible Disciplines and Duties as follows: .4. Clinical Nurse Supervisor/Charge RN a. Gives the nursing update, states nursing goals and revises nursing care plan as indicated with input from resident/family and the team c. Answers resident/family questions/concerns regarding nursing care 6. Social Services Coordinator .c. Updates resident and/or family on any social issues or concerns .f. Identifies ways to contribute to the team goals. The facility policy and procedure titled, Minimum Data Set (MDS) Assessment and Care Planning dated 1/5/15, indicated under III. Policy, .The assessment information is used to develop a comprehensive resident care plan to allow the resident his/her highest practicable level of physical, mental, and psychosocial functioning The care plan is based on the individual needs of the resident. Resident care planning includes participation from all involved health care disciplines with continual reassessment and updating until resident's discharge. It is an interdisciplinary effort .with the resident and/or family.

Based on observation, interview, clinical record, and administrative document review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) was free from verbal abuse when Licensed Nurse (LN) 1 cursed at Resident 1. This failure resulted in Resident 1 feeling humiliated and disrespected and had the potential to compromise Resident 1's ability to maintain her highest practicable level of physical, mental, and psychosocial well-being. Findings: On 7/29/14 at 10:53 a.m., Health Facilities Evaluator Nurse (HFEN 1) was in the hallway near Resident 1's room, while conducting an abbreviated survey on an unrelated matter, when HFEN 1 heard an unknown person say, "I can't f***ing stand you." The HFEN 1 had seen LN 1 go into Resident 1's room immediately before this was heard. On 7/29/14 at 12:17 p.m., during an interview on an unrelated matter, Resident 1 stated, "Did you hear that nurse (LN 1) wearing a blue shirt, cussed me out when she brought me my meds (medications)? She gave me meds twice, so I asked her if I was supposed to take the second ones and she got all mad and said, 'I can't f***ing stand you', and slammed my meds on the table." Resident 1 was crying and visibly upset when she recalled the incident. Resident 1 stated she was very upset that she was treated so meanly and felt she did not deserve to be humiliated and disrespected. Resident 1 was oriented to person, place, time, and situation during this interview. On 7/29/14 at 12:40 p.m. during an interview, the Director of Nursing (DON) stated Resident 1 had told staff immediately after the incident, that LN 1 had cussed her out. The DON stated she believed Resident 1 was telling the truth because she had checked the Medication Administration Records and it showed LN 1 had provided medication to Resident 1 at the time of the complaint. The DON also stated she had received complaints from other staff members that LN 1 was often rude or "had an attitude" with them, so she was not surprised when she heard about this incident. During an administrative record review, LN 1's employee file indicated she had received abuse training on 5/13/14, and successfully completed the post-test evaluation on the same day. On 8/4/14 at 3:00 p.m., during an interview, the DON stated the facility's investigation was complete and LN 1 was to be terminated 8-7-14. On 8/4/14 at 3:38 p.m., during an interview, Resident 1 was able to recall the incident of LN 1 cursing at her, exactly as previously told. Resident 1 again became visibly upset when she recalled the incident. Resident 1 was oriented to person, place, time, and situation during the interview. During a clinical record review, Resident 1's Minimum Data Set (MDS - an assessment tool used to determine mental and physical ability) assessment dated [DATE], indicated her BIMS score ( Brief Interview for Mental Status - an assessment tool used to determine the cognitive level of residents) was 15 out of 15, which indicated Resident 1 was cognitively intact. The hospital policy and procedure titled, "Abuse Policy - Investigative and Prohibitive Protocol", dated 8/17/2010, indicated, "II. Policy: D. The resident has the right to be free from verbal, ... physical, mental, financial abuse, ... and to attain/maintain physical, mental, psychosocial well-being."