Every finding on record at Cottage Crest Post Acute

Based on interview, and record review, the facility failed to ensure a care plan for one of three sampled residents (Resident 4) was created when Resident 4 refused a skin assessment during admission to the facility (7/3/2026). This deficient practice resulted in no initial assessment of Resident 4's skin until 7/8/2026 (five days after she was admitted to the facility on [DATE]) and had the potential for interventions necessary for the implementation of Resident 4's care to not be addressed and a baseline assessment of Resident 4's skin to be delayed.Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 had diagnoses including osteomyelitis (inflammation of the bone or bone marrow, usually due to an infection) of the left ankle and foot, stricture of the artery (narrowing of the arterial passages, which can lead to increased total resistance within the vessels) and diabetes mellitus [(DM] a disorder characterized by difficulty in the blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2026, the MDS indicated Resident 4 was able to make decisions that were reasonable and consistent and she required a one to two person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing, toileting and repositioning in bed to a person performs daily). During a review of Resident 4's Progress Notes (Clinical admission Report) dated 7/3/2026 and timed at 11:31 p.m., the Clinical admission Report indicated Resident 4 refused examination and detailed assessment of her skin condition. During a review of Care Plan section of Resident 4's Medical Record, the Care Plan section indicated there was no documented evidence that a Care Plan was created after Resident 4's refusal to have her skin assessed (7/3/32026). During a telephone interview on 7/21/2026 at 11:48 a.m., Registered Nurse Supervisor (RNS) 1 stated Resident 4 refused to have her skin assessed when she was admitted to the facility (7/3/2026) and she did not but should created a care plan that addressed Resident 4's refusal of care with interventions aimed toward a resolution. During an interview on 7/21/2026 at 2:58 p.m., the Director of Nursing Services (DON) stated a care plan should have been created following Resident 4's refusal to have her skin assessed to set a goal and interventions to address Resident 4's preferences for care and services. During a review of the facility's Policy and Procedures (P/P) titled, Comprehensive Care Plans revised 12/19/2022, the P/P indicated the facility shall develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the in the resident's assessment and objectives and interventions will be utilized to monitor the resident's progress. The care plan shall include the interventions of informing the resident and their responsible party of alternate treatment and service options in relation to a refusal of treatment and services and documenting such attempts in the clinical record, including discussion with the resident and their family members.

Based on interview, and record review, the facility failed to ensure a follow up attempt was made to assess the skin for one of three sampled residents (Resident 4), when Resident 4 initially refused to have her skin assessed (7/3/2026). They failed to provide an oral and written endorsement to a licensed nurse on the oncoming shift regarding Resident 4's refusal to have her skin assessed, and they failed to assess Resident 4's skin/wounds on 7/4/2026, 7/5/2026, and 7/7/2026. These deficient practices resulted Resident 1's skin not being assessed for five days after Resident 1 was admitted to the facility (7/3/2026) and had the potential for a delay in recognition of wound deterioration and an inaccurate evaluation of necessary treatment to prevent progression and/or healing of Resident 4's wounds.Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 had diagnoses including osteomyelitis (inflammation of the bone or bone marrow, usually due to an infection) of the left ankle and foot, stricture of the artery (narrowing of the arterial passages, which can lead to increased total resistance within the vessels) and diabetes mellitus [(DM] a disorder characterized by difficulty in the blood sugar control and poor wound healing). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2026, the MDS indicated Resident 4 was able to make decisions that were reasonable and consistent and she required a one to two person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing, toileting and repositioning in bed to a person performs daily). During a review of Resident 4's Progress Notes (Clinical admission Record) dated 7/3/2026 and timed at 11:31 p.m., the Clinical admission Record indicated Resident 4 was admitted to the facility with redness above her left elbow, a right inguinal (groin) surgical wound, pressure ulcers ([PU] localized damage to the skin and/or underlying tissue usually over a bony prominence) and/or injuries to the following locations: a. A Stage 4 (a wound that extends into the muscle and can extend as far down as the bone) left dorsum (the back of) first digit hallux (big toe or the first digit of the human foot) to third toes amputation site b. An unstageable (a wound whose extent of injury cannot be determined because it is covered with slough or eschar) left heel pressure injury c. A Stage 3 (a wound that extends through the skin into the deeper tissue and fat but does not reach the muscle, tendon or bone.) pressure injury on the coccyx (tailbone or the last bone at the bottom of the human spine) d. A Stage 3 pressure injury on the intergluteal cleft (the groove between the buttocks to the perineum containing the anus) e. Left elbow skin redness f. A Stage 1 (a wound that has no breaks or tears and appears reddened and does not lose color when pressed and could be painful.) non-blanchable (skin lesions that do not fade when pressed) right heel pressure injury. Continued review of the Clinical admission Record indicated Resident 4 refused examination and detailed assessment of her skin (7/3/2026) During a review of Resident 4's Medical Record, the Medical Record indicated there was no documentation that a skin assessment was conducted on Resident 4 from 7/3/2026 through 7/7/2026. During a review of Resident 4's Multi Wound Chart Details dated 7/8/2026 (five days after Resident 1 was admitted to the facility), the Multi Wound Chart Details, completed by the Wound Doctor, indicated the following: a. An unstageable left heel PU measuring length 6.3 centimeters ([cm] a unit of measurement) x width 6.7 cm, x depth of zero cm, with moderate serous exudate (a clear, thin, and watery fluid that leaks out of the blood vessels into the tissues), 51 to 75 % eschar (a layer of dead tissue that commonly forms over a wound or burn) and 1% to 25% granulation (a type of a new connective tissue on the skin that indicates the wound is actively healing). b. A left second finger calciphylaxis (painful ischemic necrotic [tissue death caused by a blocked or reduced blood supply] skin lesions [any abnormal change or growth on the skin]) measuring length 0.7 cm, x width 0.6 cm, x depth of zero cm. c. A deep tissue pressure injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) right first toe measuring length 0.5 cm, x width 1.2 cm, x depth of zero cm, with 100% ecchymotic (a bruise) epithelium (layers of cells that make up the outer surface of the body) tissue. d. A left medial (towards the middle or the center) third toe calciphylaxis measuring length 0.7 cm, x width 0.7 cm, x depth of zero cm, with 76% to 100% eschar, e. A stage 4 pressure injury to the coccyx measuring length 4.8 cm, x width 4.2 cm, x depth 0.3 cm, with moderate serous exudate, 1 to 25% epithelization (the final stage of wound healing), 26% to 50% granulation and 25% muscle f. A right dorsal (the back or upper surface of the body) first toe calciphylaxis measuring length 0.8 cm, x width 0.8 cm, x depth zero cm, with 76 to 100% eschar. g. A left lateral (side of, or away from, the middle of the body) first toe calciphylaxis measuring length 3.5 cm, x width 2.3 cm, x depth zero cm, with 76% to 100% eschar. h. A left medial second toe calciphylaxis measuring length 0.5 cm, x width 0.8 cm, x depth zero cm, with 76% to 100% eschar. i. A left fourth finger calciphylaxis measuring length 1 cm, x width 0.8 cm, x depth zero cm, with 76% to 100% eschar. j. A right lateral hip calciphylaxis measuring length 0.4 cm, width 0.4 cm, x depth zero cm, with 76% to 100% eschar.During a telephone interview on 7/21/2026 at 11:48 a.m., Registered Nurse Supervisor (RNS) 1 stated Resident 4 refused to have her skin assessed when she was admitted to the facility (7/3/2026) and she (RNS 1) did not endorse her refusal of a skin assessment to the incoming shift (11 p.m. to 7 a.m.). RNS 1 stated she should have verbally endorsed Resident 4's refusal to have her skin assessed to the oncoming shift licensed nurses and completed a written endorsement through the facility's communication board, so another attempt could have been made to assess Resident 4's skin. During a telephone interview on 7/21/2026 at 12:43 p.m., the Treatment Nurse, Licensed Vocational Nurse (LVN) 3 stated on 7/4/2026 he worked during the 7 a.m. to 3 p.m. shift and did not receive a verbal endorsement regarding the status of Resident 4's skin and/or her refusal to have her skin assessed from the prior shift (11 p.m. to 7 a.m ), nor was there written documentation in the facility's communication record that Resident 4's wounds were not assessed during admission [DATE]) because she (Resident 4) refused. LVN 3 stated he did not conduct a skin assessment of Resident 4's skin on 7/4/2026 During an interview on 7/21/2026 at 2:58 p.m., the Director of Nursing (DON) stated Resident 1's skin should have been assessed by a licensed nurse when she was admitted to the facility (7/3/2026). RNS 1 should have endorsed Resident 4's refusal to the incoming nurses, document in Resident 4's progress notes her refusal for care as well as in the facility's communication endorsement area for continuity of care and follow up. The DON stated a skin assessment is conducted to determine the baseline of a resident's skin/wounds and to identify other skin concerns. During a review of the facility's Policy and Procedures (P/P) titled, Skin Assessment revised 12/19/2022, the P/P indicated the facility shall perform a full body skin assessment as part of their systematic approach to pressure injury prevention and skin management as follows but not limited to: a. a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, and weekly thereafter and shall be performed after a change of condition or after a newly identified pressure injury b. a skin assessment shall be documented to include the date and time of the assessment, observation of the residents' skin conditions, the residents' tolerance and response to the skin assessment, type of wounds with specific measurements, color, type of tissue in the wound bed, drainage, odor and pain, residents' refusal of assessment and what reason and other information as indicated or appropriate.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan failed to address for three of 15 sample residents (Resident 64, 66, and 1) by failing to:a. Initiate a care plan for a Peripheral Intravenous line (PIV, short, flexible, small tube inserted into a vein to deliver medications or fluids directly into the bloodstream) monitoring for Resident 64.b. Initiate a fall care plan for Resident 66.c. Implement Resident 1's care interventions to monitor signs and symptoms of hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) episodes. These failures had the potential to negatively affect the delivery of necessary care and services.Findings: a. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] with diagnoses including fracture of left humerus (bone connecting the shoulder and elbow), pubis (front-lower portion of the hip bone), and left acetabulum (cup-shaped socket located on side of hip bone that holds the head of the thigh bone to form the hip joint), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and pulmonary fibrosis (chronic, progressive scarring and thickening of the lung tissue). During a review of Resident 64's History and Physical (H&P), dated 4/28/2026, the H&P indicated Resident 64 had the capacity to understand and make decisions. During a review of Resident 64's Minimum Data Set (MDS – a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 64 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for bathing and upper body dressing, and was dependent for toileting hygiene and lower body dressing. During a concurrent observation and interview on 5/2/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 had a PIV in the right arm. Resident 64 stated the PIV was inserted at the general acute care hospital (GACH). Resident 64 stated the facility has not given any medication through the PIV for Resident 64 in the six days that they (Resident 64) have been in the facility. During a concurrent observation and interview on 5/3/2026 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 64's room, Resident 64 had a PIV in the right arm. LVN 2 stated the PIV was not dated and LVN 2 did not know when it was inserted. LVN 2 stated PIV accesses should be dated, required an order, and should be monitored. During a concurrent interview and record review on 5/3/2026 at 1:21 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 64's care plans were reviewed. The MDSC stated Resident 64 did not have a care plan addressing the PIV access. The MDSC stated the facility should have initiated a care plan to establish goals and monitoring interventions on admission. During an interview on 5/5/2026 at 11:55 a.m. with the Director of Nursing (DON), the DON stated it is important to initiate care plans so that the facility is aware of the plan of care and to evaluate if goals are being met. The DON stated the PIV access baseline care plan should have been initiated within 48 hours of admission. During a review of the facility's policy and procedures (P&P) titled, Baseline Care Plan, dated 12/19/2022, the P&P indicated the admitting, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including:.iii. Any special needs such as for IV therapy, dialysis, or wound car. c. Once established, goals and interventions shall be document4ed in the designated format. b. During a review of Resident 66's admission Record, the admission record indicated the facility admitted Resident 66 on 4/27/2026 with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the brain after an injury happens), type 2 diabetes mellitus (a condition where the body does not use insulin properly, causing too much sugar to stay in the blood), muscle weakness, and hypertension (high blood pressure). During a review of Resident 66's H&P dated 4/28/2026, the H&P indicated had fluctuating capacity to understand and make decisions. During a review of Resident 66's MDS dated [DATE], the MDS indicated Resident 66 had severe cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 66 needed moderate assistance (helper does less than half the effort to complete activity) with upper body dressing, maximal assistance (helper does more than half the effort to complete activity) with showering, and was dependent on staff assistance with eating, oral and toileting hygiene, lower body dressing, and putting on or taking off footwear. During a review of Resident 66's dashboard (the front page of the residents' electronic medical record), the dashboard indicated Resident 66 was a fall risk. During a review of Resident 66's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 66 was disoriented at all times, had one to two falls in the past 3 months. During a review of Resident 66's care plan report, the care plan report did not indicate a care plan for fall risk. During a concurrent interview and record review on 5/5/2026 8:28 a.m. with the Minimum Data Set Nurse (MDSC), Resident 66's care plan was reviewed. The MDSC stated the care plan for fall risk was not initiated. The MDSC stated the importance of initiating a care plan for fall risk was to ensure Resident 66 had a plan of care to follow and implement interventions necessary to prevent Resident 66 from falling. The MDSC stated if Resident 66's care plan for fall risk was not initiated, there would be potential for Resident 66 to fall multiple times and may cause more complicated injuries. During a review of the facility's policy and procedure (P&P) titled Fall Prevention Program revised 4/20/2026, the P&P indicated, 7. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. interventions will be monitored for effectiveness b. the plan of care will be revised as needed. During a review of the facility's P&P titled Baseline Care Plan revised 12/19/2022, the P&P indicated, 1. The baseline care plan will: a. be developed within 48 hours of a resident's admission. During a review of the facility's P&P titled Comprehensive Care Plans revised 12/19/2022, the P&P indicated, 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. c. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar) with hyperglycemia, and foot ulcer, hypertension (high blood pressure), and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1's H&P dated 3/30/2026, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was mildly cognitively impaired. The MDS indicated Resident 1 is dependent on staff for lower body (below waist) dressing, toileting hygiene, roll left to right, sit to lying, lying to sitting on side of bed, required substantial assistance (Helper does more than half the effort) from staff for bathing, upper body (above waist) dressing, and required partial assistance (Helper does less than half the effort) from staff for eating, oral During a review of Resident 1's monitor record dated 3/1/2026 –3/31/2026 and 4/1/2026 –4/30/2026, there were no monitoring for hyperglycemia and hypoglycemia noted. During a review of Resident 1's care plan dated 4/3/2026, titled, the Resident has Diabetes Mellitus. The care plan goals were to have no complications related to diabetes. The care plan interventions were monitor/document/report as needed (PRN) any signs and symptoms (s/s) of hypoglycemia or hyperglycemia. During a review of Resident 1's change in condition (COC), dated 4/12/2026 at 8:22 p.m., the COC indicated Resident 1 had hyperglycemia. Resident 1 was ordered to repeat Lantus (long-acting insulin) 6 units (standardized measurement of the insulin's strength) subcutaneous (layer of fatty tissue acting as a cushion and fat storage for the body) in after 1 hour. During a review of Resident 1's Order Summary Report (physician order) dated 5/5/2026, the order summary report indicated monitor for s/s of hypoglycemia and hyperglycemia with a start date of 5/3/2026. During a concurrent interview and record review on 5/4/2026 at 4:28 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated residents that are diabetic and have insulin are on monitoring for hyper/hypoglycemia and would be in the physician orders. The MDSC stated the monitoring for s/s of hyper/hypoglycemia for the month of April in the monitor record wasot there. The MDSC stated they would want to monitor residents that are diabetic to ensure they do not have any s/s of hyper/hypoglycemia as it can lead to death if the resident was not being monitored. The MDSC stated the purpose of care plans was to show care for the residents during their length of stay and indicated care plans are important. During an interview on 5/5/2026 at 11:52 a.m. with the Director of Nursing (DON), the DON stated when there is a COC, they monitor the residents to ensure they are following up with the residents to see if they are getting better or worse. The DON stated a care plan is a plan of care, to have a goal and identify if the goal has been met or not. The DON stated care plans are initiated upon admission and as needed. The DON stated monitoring for hyperglycemia/hypoglycemia is done every shift. The DON stated if a resident is diabetic, they would have a monitoring for hyper/hypoglycemia and is the standard protocol for all diabetic residents. The DON stated monitoring is documented in the monitoring record. The DON stated residents are monitored to ensure there are no complications and indicated care plans should be implemented as it is the residents' plan of care and if it is not implemented, there is no plan of care. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. During a review of the facility's P&P titled, Nursing Care of the Resident with Diabetes Mellitus, dated 12/19/2022, the P&P indicated the management of individuals with diabetes mellitus should follow relevant protocols and guidelines. Residents whose blood sugar is poorly controlled of those taking insulin may require more frequent monitoring, depending on the situation.

Based on observation, interview, and record review the facility failed to ensure:1. The door was closed for Resident 66 who was on Novel Respiratory Precautions (isolation)2. Facility staff did not wear the same gown from room to room.3. Staff performed hand hygiene prior to giving medications to Resident 47 and Resident 11. 4a./4b. A Peripheral Intravenous line (PIV, short, flexible, small tube inserted into a vein to deliver medications or fluids directly into the bloodstream) for Resident 64 and Resident 67 was discontinued and removed when no longer indicated. These failures had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.Findings: 1. During a review of Resident 66's admission Record, the admission record indicated the facility admitted Resident 66 on 4/27/2026 with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the brain after an injury happens), type 2 diabetes mellitus (a condition where the body does not use insulin properly, causing too much sugar to stay in the blood), muscle weakness, and hypertension (high blood pressure). During a review of Resident 66's history and physical (H&P) dated 4/28/2026, the H&P indicated Resident 66 had diagnosis of positive Covid (a respiratory illness caused by a virus called coronavirus) and had fluctuating capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS – a resident assessment tool) dated 5/2/2026, the MDS indicated Resident 66 had severe cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 66 needed moderate assistance (helper does less than half the effort to complete activity) with upper body dressing, maximal assistance (helper does more than half the effort to complete activity) with showering, and was dependent on staff assistance with eating, oral and toileting hygiene, lower body dressing, and putting on or taking off footwear. During a review of Resident 66's Care Plan Report, the Care Plan Report dated 4/28/2026 indicated Resident 66 tested positive for Covid-19 with interventions including maintain novel respiratory precautions guideline per Los Angeles County Department of Public Health (DPH) which included keeping the door closed as much as possible. During a concurrent observation and interview on 5/2/2026 at 7:38 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 66's door was observed slightly open. LVN 1 stated novel respiratory precaution indicated isolation room should be closed. LVN 1 stated it was important for Resident 66's door to be completely closed because there would be potential for spreading the infection to other residents and staff. During a concurrent interview and record review on 5/5/2026 at 7:56 a.m. with the Infection Prevention Nurse (IPN), the County of Los Angeles Public Health's Novel Respiratory Precautions was reviewed. The IPN stated the facility does not have a policy specific to covid, but the facility follows the County of Los Angeles Public Health's Novel Respiratory Precautions. The IPN stated the Novel Respiratory Precautions indicated, keep door closed as much as possible, including when the residents are out of room. The IPN stated the importance of keeping the door closed was to prevent the spread of Covid throughout the facility. The IPN stated if the door was not closed there would be potential for spread of Covid throughout the facility. During an interview on 5/5/2026 at 12:17 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure the doors were closed for rooms with residents that were on novel respiratory precautions was to prevent the spread of the infection to other residents. During a review of the facility policy and procedure (P&P) titled Transmission-based precautions (a.k.a. Isolation Precautions) revised 7/18/2023, the P&P did not indicate procedures for Covid isolations. 2. During an observation on 5/2/2026 at 10:00 a.m. Treatment Nurse (TXN) 1 was observed wearing gown (personal protective equipment) obtained from room [ROOM NUMBER] then walked across the hallway to perform tasks in room [ROOM NUMBER]. During an interview on 5/2/2026 at 10:10 a.m. with TXN 1, TXN 1 stated he obtained the gown from room [ROOM NUMBER] because there was no gown available in room [ROOM NUMBER]. TXN 1 stated he should not have worn the gown and walked through the hallway with the gown on. TXN 1 stated the importance of not wearing a gown in the hallway was to prevent cross contamination. TXN 1 stated there would be potential for the spread of infection between residents. During an interview on 5/5/2026 at 12:13 p.m. with the Director of Nursing (DON), the DON stated it was important that staff did not wear the gown in the hallway to prevent cross contamination. The DON stated other residents would be exposed to different pathogens. During a review of the facility policy and procedure (P&P) titled Personal Protective Equipment revised 12/19/2022, the P&P indicated, 6. PPE supply management: .c. The charge nurse shall check isolation supply carts twice per shift (such as beginning and halfway point) and replenish as needed. The P&P did not indicate specific procedures for use or wearing of gown in the hallway. 3a. During an observation on 5/2/2026 at 8:47 a.m., Licensed Vocational Nurse (LVN) 1 was observed not performing hand hygiene coming out of Resident 47's room after taking Resident 47's blood pressure, observed going into Resident 47's room after preparing Resident 47's medication with no hand hygiene, observed coming out of Resident 47's room post medication administration without hand hygiene and proceeded to chart in the computer of the medications Resident 47 refused, took the medications that was refused to the medication disposal area, came back, proceeded to wear gloves with no hand hygiene, cleaned the blood pressure cuff, and observed hand washing in Resident 47's bathroom at the end of all tasks completed. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), hypertension (high blood pressure), and abnormalities of gait (walk) and mobility. During a review of Resident 47's H&P dated 9/5/2025, the H&P indicated Resident 47 has the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was cognitively intact. The MDS indicated Resident 47 was dependent for sit to lying, chair/bed-to-chair transfer, lying to sitting on side of bed, shower transfer, lower body dressing, toileting hygiene, required substantial assistance (Helper does more than half the effort) from staff for bathing, roll left to right, required partial assistance (Helper does less than half the effort) from staff for upper body dressing, and required supervision from staff for eating, oral hygiene, and personal hygiene. During an interview on 5/2/2026 at 9:02 a.m. with LVN 1, LVN 1 stated hand hygiene is performed before and after giving medications and indicated she does not do hand hygiene when she does not touch the resident or goes in and out of the residents' room. LVN 1 stated, since she had medications, she needed to dispose of she could not do hand hygiene. LVN 1 stated she would do hand hygiene after coming out of the residents' room; however she continued to indicate since she did not touch anything and had to dispose of medications she did not find the need to perform hand hygiene. LVN 1 stated hand hygiene is performed for infection control, and not doing hand hygiene could cause residents to get an infection. 3b. During an observation on 5/4/2026 at 8:17 a.m., Registered Nurse (RN) 1 was observed not performing hand hygiene prior to putting on personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) and gloves on prior to entering Resident 11's room to administer medications. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), dementia (group of thinking and social symptoms that interfere with daily functioning), and a gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding) During a review of Resident 11's H&P dated 10/6/2025, the H&P indicated Resident 11 is unable to make healthcare decisions due to dementia. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 was severely cognitively impaired. The MDS indicated Resident 11 was dependent on all aspects of activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview on 5/4/2026 at 8:45 a.m. with RN 1, RN 1 stated hand hygiene is performed before entering and leaving the room, before you touch the resident, or when changing gloves. RN 1 stated he did not perform hand hygiene prior to entering Resident 11's room and indicated hand hygiene is performed to prevent infection. 4a. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] with diagnoses including fracture of left humerus (bone connecting the shoulder and elbow), pubis (front-lower portion of the hip bone), and left acetabulum (cup-shaped socket located on side of hip bone that holds the head of the thigh bone to form the hip joint), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and pulmonary fibrosis (chronic, progressive scarring and thickening of the lung tissue). During a review of Resident 64's H&P, dated 4/28/2026, the H&P indicated Resident 64 had the capacity to understand and make decisions. During a review of Resident 64's MDS, dated [DATE], the MDS indicated Resident 64 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for bathing and upper body dressing, and was dependent for toileting hygiene and lower body dressing. During a concurrent observation and interview on 5/2/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 had a PIV in the right arm. Resident 64 stated the PIV was inserted at the general acute care hospital (GACH). Resident 64 stated the facility had not given any medication through the PIV in the six days that they (Resident 64) have been in the facility. During a concurrent observation and interview on 5/3/2026 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 64's room, Resident 64 was observed with a PIV in the right arm. LVN 2 stated the PIV was not dated and LVN 2 did not know when it was inserted. LVN 2 stated PIVs should be dated, required an order, and should be monitored. During a concurrent interview and record review on 5/3/2026 at 1:21 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 64's orders, Monitoring Records April – May 2026, Medication Administration Record (MAR) April – May 2026, and Treatment Administration Record (TAR) April – May 2026 were reviewed. The MDSC stated Resident 64 did not receive any intravenous (IV – given through the PIV into the bloodstream) medication. The MDSC stated the facility should have clarified with the physician to determine if Resident 64 requires the PIV. The MDSC stated if Resident 64 did not require the PIV, the PIV should be discontinued to prevent infection. 4b. During a concurrent observation and interview on 5/2/2026 at 7:25 a.m. with Resident 67, Resident 67 stated he was getting antibiotics and had a PIV on the right forearm. During a concurrent observation and interview on 5/3/2026 at 12:20 p.m. with Resident 67, Resident 67 was observed with the PIV dated 4/30/2026 and Resident 67 stated the PIV was placed at the hospital prior to getting admitted to the facility and the facility has not used it since the admission. During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), hypertension (high blood pressure), and hypothyroidism (thyroid gland does not produce enough thyroid hormones to meet the body's needs). During a review of Resident 67's H&P dated 5/1/2026, the H&P indicated Resident 67 has the capacity to understand and make decisions. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 was mildly cognitively impaired. The MDS indicated Resident 67 was dependent on staff for bathing, required substantial assistance from staff for eating, oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During an interview on 5/3/2026 at 12:52 p.m. with Registered Nurse (RN 2), RN 2 stated PIVs are there upon admission from the hospital as the residents sometimes continue antibiotics. RN 2 stated if a resident has a PIV, they would monitor the dressing and assess every shift for any signs and symptoms (s/s) for infection. During a concurrent observation and interview on 5/3/2026 at 12:55 p.m. with RN 2, Resident 67's was observed with a PIV in his arm. RN 2 stated when they do the admission, they must put the order for the PIV and is always monitor and check the PIV. RN 2 stated it was not shown in their computer system Resident 67 had a PIV and indicated if the resident does not need the PIV, they will ask the doctor to remove it. RN 2 stated leaving in an PIV when not indicated could cause an infection. RN 2 stated Registered Nurses (RNs) are the only ones that monitor and put the orders for PIV and indicated Resident 67 did not need a PIV. During an interview on 5/5/2026 at 11:55 a.m. with the Director of Nursing (DON), the DON stated the licensed nurse should clarify with the physician on admission when the resident arrives at the facility with a PIV. The DON stated if PIVs are not required for antibiotics or hydration, the nurse should get an order to discontinue the PIV. During an interview on 5/5/2026 at 11:58 a.m. with the Director of Nursing (DON), the DON stated upon admission, the RN will document the indication for a PIV and would monitor the PIV. The DON stated the decision made by the doctor on whether the PIV is necessary or not will be documented in the progress notes. The DON stated if there is no indication for antibiotics or hydration the PIV should not be in place. During an interview on 5/5/2026 at 12:28 p.m. with the DON, the DON stated hand hygiene should be performed as much as possible and is done before and after resident care or certain tasks, when exiting the residents' room, or when changing gloves. The DON stated hand hygiene is performed even if you do not touch the resident to prevent cross contamination. During a review of the facility's P&P titled, Hand Hygiene, revised 12/19/2022, the P&P indicated all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. The use of gloves do not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene Table: Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) before applying and after removing personal protective equipment (PPE), including gloves, before preparing or handling medications. During a review of the facility's P&P titled, Intravenous Therapy, revised 12/19/2022, the P&P indicated IV sites are changed every seventy-two (72) hours unless otherwise ordered by the physician, if the site becomes infiltrated, or if the resident exhibits signs and symptoms of phlebitis (inflammation of a vein). In the event an IV is left in place longer than seventy-two (72) hours, IV site care will be done every twenty-four (24) hours. IV sites are checked every four (4) hours or as per facility protocol and as needed (PRN) for signs and symptoms of infection or inflammation. Factors that may affect frequency or assessment include: ability of resident to report symptoms of pain, redness, etc., type of infusion –is it an irritant or vesicant (an agent that induces blistering)? location of IV catheter – is it inserted in an area of flexion; facility policy based on long-term care IV policies and procedures. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medications and will discontinue as per the practitioner's order. During a review of the facility's policy and procedure (P&P), titled Intravenous Therapy, dated 12/19/2022, the P&P indicated IV documentation is recorded in the nurses' notes and/or Medication Administration Record. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medications and will discontinue as per the practitioner's order.

Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation an advance directive ([AD] written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed and written information provided to the resident and/or responsible party ([RP] the person handling a resident's finances and care decisions) in their primary language for one of 15 sampled residents (Resident 4).This deficient practice violated the Resident 4 and the RP right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents' wishes regarding health care.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (group of thinking and social symptoms that interfere with daily functioning), Type II Diabetes Mellitus (DM, (a chronic disease that affects how the body processes sugar) with hyperglycemia (high blood sugar), and a gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding)During a review of Resident 4's history and physical (H&P) dated 6/16/2025, the H&P indicated Resident 4 cannot make his own medical decisions.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 3/12/2026, the MDS indicated Resident 4 was moderately cognitively impaired. The MDS indicated Resident 4 required substantial assistance (Helper does more than half the effort) from staff for chair/bed-to-chair, sit to lying, rolling left and right, required partial assistance (Helper does less than half the effort) from staff for toileting hygiene, bathing, lower body (below waist) dressing, and required supervision from staff for eating, oral hygiene, upper body (above waist) dressing, and personal hygiene.During a record review of Resident 4's Social Service Assessment indicated the following:-6/25/2025 at 11:53 a.m.: Resident 4's primary language is Vietnamese and was unable to formulate an advance Directive due to Resident 4's dementia. Resident 4's family member (FM) 1 is the RP and helps with Resident 4's healthcare decision making.-10/2/2025 at 4:38 p.m.: Unable to formulate an Advance Healthcare Directive. Will continue with current plan of care.-12/19/2025 at 5:39 p.m.: Resident 4 is unable to formulate an Advance Healthcare Directive due to his cognitive impairment. FM 1 helps with healthcare decision making.During a record review of Resident 4's Social Service assessment dated [DATE] at 1:00 p.m., the Social Service Assessment indicated the following: No Advance Healthcare Directive, unable to formulate.During a concurrent interview and record review on 5/3/2026 at 2:19 p.m. with the Social Service Director (SSD), the SSD stated advance directives are offered upon admission, and if the resident does not have the capacity or have dementia, she will ask the RP if the resident has an advance directive or formulate one. The SSD stated an AD is explained when the resident's baseline and assessment is performed. The SSD stated Resident 4's representative was FM 1 and was Vietnamese. The SSD stated FM 1 brings FM 2 when she visits Resident 4 so FM 2 could translate for FM 1. The SSD stated on the Social Service assessment dated [DATE], the Social Service Assessment indicated: No Advance Healthcare Directive, unable to formulate due to his Dementia and FM 1 helps with healthcare decision making. The SSD stated when they had an Interdisciplinary Team (IDT: Resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) over the phone with FM 1, she had explained what an AD was to FM 1 and indicated since FM 1 did not know what an AD was, she provided a website. The SSD stated FM 1 could barely speak English and had a family friend that translates. During an interview on 5/5/2026 at 12:44 p.m. with the Director of Nursing (DON), the DON stated advance directives are offered upon admission and needs to be explained what it is to ensure the resident/RP knows the risk and benefits of having an AD. The DON stated if an AD was not explained, the resident/RP would not know what it was and indicated it was important to explain the advance directive in the resident's preferred language.During a review of the facility's policy and procedures (P&P) titled, Resident Rights, revised 4/6/2026, the P&P indicated the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Information about resident rights will be given to the resident in a language that the resident understands to the extent possible. If a resident's knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented. The resident has the right to be informed of, and participate in, his or her treatment, including: the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, hir or her medical condition.During a review of the facility's P&P titled, Residents' Rights Regarding Treatment and Advance Directive, revised 12/19/2022, the P&P indicated the facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive.

Based on interview and record review, the facility failed to notify the physician that a resident was experiencing new abdominal pain for one of three sampled residents (Resident 64).This deficient practice had the potential to result in Resident 64 delay of treatment and further harm. Findings:During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] with diagnoses including fracture of left humerus (bone connecting the shoulder and elbow), pubis (front-lower portion of the hip bone), and left acetabulum (cup-shaped socket located on side of hip bone that holds the head of the thigh bone to form the hip joint), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and pulmonary fibrosis (chronic, progressive scarring and thickening of the lung tissue).During a review of Resident 64's History and Physical (H&P), dated 4/28/2026, the H&P indicated Resident 64 had the capacity to understand and make decisions.[NAME] a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 64 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for bathing and upper body dressing, and was dependent for toileting hygiene and lower body dressing. During an interview on 5/2/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 complained of having abdominal pain due needing to have a bowel movement. Resident 64 stated the current medication has not been working to relieve the pressure in the abdomen. Resident 64 stated the pain in the abdomen is so bad that they (Resident 64) requested a pain pill to be able to sleep.During an interview on 5/3/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 stated having abdominal pain and pressure and reported to Licensed Vocational Nurse (LVN) 2.During a concurrent interview and record review on 5/4/2026 at 4:50 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 64's change of condition documentation and nursing notes were reviewed. The MDSC stated there is no documentation that the physician was notified that Resident 64 was experiencing new abdominal pain or pressure. The MDSC stated the facility should have documented a change of condition and communicated the abdominal pain to the physician to ensure Resident 64's implemented treatment and condition is being monitored and to prevent further harm.During an interview on 5/5/2026 at 11:50 a.m. with the Director of Nursing (DON), the DON stated it was important a change of condition was initiated and physician was notified to ensure Resident 64 was monitored and to see if the intervention was effective.During a review of the facility's policy and procedure (P&P), titled Notification of Changes, dated 12/19/2022, the P&P indicated the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:.2, Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications; 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on interview and record review, the facility failed to ensure a communication system was in place to translate for one of 15 sample residents (Resident 4) in their primary language.This deficient practice had the potential for Resident 4 not being provided with the appropriate care and treatment needed.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (group of thinking and social symptoms that interfere with daily functioning), Type II Diabetes Mellitus (DM, (a chronic disease that affects how the body processes sugar) with hyperglycemia (high blood sugar), and a gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding).During a review of Resident 4's history and physical (H&P) dated 6/16/2025, the H&P indicated Resident 4 could not make his own medical decisions.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 3/12/2026, the MDS indicated Resident 4 was moderately cognitively impaired. The MDS indicated Resident 4 required substantial assistance (Helper does more than half the effort) from staff for chair/bed-to-chair, sit to lying, rolling left and right, required partial assistance (Helper does less than half the effort) from staff for toileting hygiene, bathing, lower body (below waist) dressing, and required supervision from staff for eating, oral hygiene, upper body (above waist) dressing, and personal hygiene.During an interview on 5/2/2026 at 3:09 p.m. with Family Member (FM) 1, FM 1 stated she did not speak English only Vietnamese.During a concurrent interview and record review on 5/3/2026 at 2:33 p.m. with the Social Service Director (SSD), the SSD stated Resident 4's representative is FM 1 and is Vietnamese. The SSD stated FM 1 brings Family Member (FM) 2 when she visits Resident 4 so FM 2 can translate for Resident 4. The SSD stated FM 1 could barely speak English and would have a family friend or family translate on behalf of FM 1. The SSD stated the facility would try to utilize the resident's family member to translate before contacting the translation line.During a concurrent interview and record review on 5/3/2026 at 2:48 p.m. with the SSD, the SSD stated there is a language barrier and sometimes uses a free online translation service that instantly converts text, speech, and images from one language to another, but most of the time, the family will translate. The SSD stated if the family is not available, they will use a picture board or communication board. The SSD stated the family is the one that translates when they sign in the informed consent.During a concurrent interview and record review on 5/3/2026 at 2:56 p.m. with the SSD, the SSD stated communication is important to keep the family informed of the residents' status, and if there is no communication in the residents preferred language, the resident may feel confused and worried.During an interview on 5/5/2026 at 12:38 p.m. with the Director of Nursing (DON), the DON stated the facility does not have a language line and indicated family members will be used when translation is needed. The DON stated they utilize a free online translation service but could not say it was a reliable source for translation. The DON stated they do not want to use the free online translation service and indicated a family member was needed, however they are not sure if the information being provided is being translated accurately and appropriately to Resident 4 through the family member. The DON stated it was important for the facility to be able to communicate with the residents in their preferred language and would document the family members that were present when translation services were required.During a review of the facility's policy and procedures (P&P) titled, Resident Rights, revised 4/6/2026, the P&P indicated the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Information about resident rights will be given to the resident in a language that the resident understands to the extent possible. If a resident's knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented. The resident has the right to be informed of, and participate in, his or her treatment, including: the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, hir or her medical condition.

Based on observation, interview, and record review, the facility failed to objectively measure the range of motion (ROM, full movement potential of a joint) for one of five sampled residents (Resident 23) in the left hand in the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 2/17/2026. This deficient practice had the potential for Residents 23 to experience further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).Findings:During an observation on 5/2/2026 at 7:52 a.m., Resident 23 was lying in bed there was a slight flexion contraction (stiff or bending of joint) noted in the left hand involving the thumb, index, middle, and ring fingers, while the left little finger presented with hyperextension (joint forced to move beyond its normal anatomical range of motion) at the metacarpophalangeal (MCP, knuckles or area where your fingers and thumb connects to your palm) joint.During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, rheumatoid arthritis (a chronic autoimmune inflammatory disease that affects the joints), and osteoarthritis (loss of protective cartilage that cushions the ends of your bones).During a review of Resident 23's history and physical (H&P) dated 3/14/2026, the H&P indicated Resident 23 has the capacity to understand and make decisions.During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 23 was cognitively intact. The MDS indicated Resident 23 was dependent for toileting hygiene, bathing, lower body (below waist) dressing, sit to lying, lying to sitting on side of bed, shower transfer, required substantial assistance (Helper does more than half the effort) from staff for upper body (above waist) dressing, roll left and right, sit to stand, chair/bed-to-chair transfer, toilet transfer, required supervision from staff for personal hygiene, and required set up for eating and oral hygiene. The MDS indicated Resident 23 had impairments on one side of the upper (arms/shoulders) and lower (hips/legs) extremities and utilized a wheelchair.During a record review of Resident 23's OT evaluation, dated 2/17/2026, the OT Evaluation indicated Resident 23's ROM of the left hand, left thumb, left index finger, left middle finger, left ring finger, and left little finger were impaired.During an interview on 5/4/2026 at 9:53 a.m. with Resident 23, Resident 23 stated her left pinky being hyperextended occurred in the facility and indicated she has been at the facility for two years and it occurred a year and a half ago.During a concurrent interview and record review on 5/4/2026 at 3:58 p.m. with the Director of Rehabilitation (DOR), the DOR stated the OT evaluation dated 2/16/2026 indicates Resident 23's left fingers are impaired. The DOR stated she did not know how Resident 23's fingers have been before, and it was difficult to tell the degree of the impairment. The DOR stated during the evaluation, if there was an impairment, they would measure it and put it on the evaluation. The DOR stated doing measurements would be good to show if there was more limitation or impairment and can check if it is getting worse or better. The DOR stated if there were no measurements, they would not know whether Resident 23 was improving or declining.During an interview on 5/5/2026 at 12:51 p.m. with the Director of Nursing (DON), the DON stated it was important to provide rehabilitation services to prevent decline. The DON stated if the decline was not measured, they do not have a baseline and could not monitor the extent of the status of the resident. The DON stated they would need to know Resident 23's baseline to know if they are getting better or not and indicated it is important for residents to wear splits to prevent them from further complications and decline as they may become contracted.During a review of the facility's policy and procedures (P&P) titled, Purpose and Objectives of Inpatient Rehabilitation Services, revised 12/19/2022, the P&P indicated Inpatient Rehabilitation Services Department consists of physical therapist & physical therapist assistant, occupational therapist, and occupational therapist assistant and speech therapist. It is the objective of the rehabilitation department to provide comprehensive and integrated therapy services to restore patients to their highest level of function. Therapists will develop an individualized plan of care upon evaluation and continuous assessment during treatment plan.During a review of the facility's P&P titled, Occupational Therapist Job Description, revised 3/23/2016, the P&P indicated provides, directs and supervises all aspects of quality patient care, including, but not limited to; screening, evaluation and treatment, treatment planning, goal setting, family education and documentation, in order to assure the best outcome possible for the patient. Essential Functions: Appropriately and effectively completes documentation including evaluations daily notes, progress notes, discharge summaries, or monthly reports as required.

Based on observation, interview, and record review the facility failed to ensure staff provided feeding assistance for one of seven residents (Resident 10) who required one to one (1:1) feeding assistance during meals and was at risk for aspiration as recommended by the speech therapist.This failure had the potential to result in Resident 10's inadequate nutritional intake, weight loss, dehydration, choking and aspiration.Findings:During an observation on 5/4/2026 at 12:45 p.m., in Resident 10's room a lunch tray was delivered by staff and Resident 10 was observed attempting to feed himself by dipping his hand in his food.During a review of Resident 10's admission Record, the admission indicated the facility admitted Resident 10 on 12/18/2025 with diagnosis including spina bifida (a birth defect that affects the spine and spinal cord causing limitation of movement of limbs), dysphagia (difficulty swallowing), and muscle weakness.During a review of Resident 10's History and Physical (H&P) dated 4/1/2026, the H&P indicated Resident 10 was able to make medical decisions.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 10 had the ability to think and make decisions. The MDS indicated Resident 10 needed supervision with eating and oral hygiene, partial assistance (helper does less than half the effort to complete activity) with toileting hygiene, showering, upper body dressing, and personal hygiene, and maximum assistance (helper does more than half the effort to complete activity) with lower body dressing and putting on or talking off footwear.During a review of Resident 10's lunch meal ticket dated 5/4/2026, the meal ticket indicated Resident 10 was 1:1 feeding assist.During a concurrent observation and interview on 5/4/2026 at 12:55 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 10 was observed sitting up in bed with the lunch tray in front of him. LVN 3 stated Resident 10 feeds himself.During a concurrent interview and record review on 5/4/2026 at 12:57 p.m. with LVN 3, Resident 10's physician order was reviewed. LVN 3 stated Resident 10 was a 1:1 feeder and he would assist Resident 10 to eat. LVN 3 stated the importance of making sure Resident 10 was assisted during meals was to ensure Resident 10 did not choke. LVN 3 stated if Resident 10 was not assisted during meals, there would be potential for Resident 10 to choke, aspirate, lose weight, and affect wound healing.During a concurrent interview and record review on 5/5/2026 at 7:39 a.m. with the Director of Rehabilitation (DOR), Resident 10's speech therapy evaluation notes, communication banner and feeder list were reviewed. The DOR stated the speech therapist evaluation notes dated 5/1/2026 indicated Resident 10 was evaluated by the speech therapist recommended to be placed on 1:1 feeding assistance. The DOR stated the communication banner dated 5/1/2026 indicated Resident 10's diet change, 1:1 feeding assistance, and swallow precautions was communicated to nursing. The DOR stated the feeder list, undated, indicated residents who needed 1:1 feeding assistance and the list would be given to nursing.During a concurrent interview and record review on 5/4/2026 at 1:37 p.m. with the Director of Staff Development (DSD) the facility policy and procedure (P&P) titled Restorative Nursing Programs revised 4/20/2026 was reviewed. The DSD stated the P&P did not indicate specific procedures for 1:1 resident feeding.During an interview on 5/5/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated residents who were identified as 1:1 feeders, the communication between rehabilitation department to nursing department would be documented under the special instructions, mentioned during huddles, documented in the communication banner, and assigned to a specific Certified Nursing Assistant (CNA). The DON stated the importance of making sure Resident 10 was assisted by staff during meals was to ensure Resident 10 would meet his caloric needs and ensure Resident 10 was safe during meals. The DON stated if Resident 10 was not assisted by staff during meals there would be potential for Resident 10 to choke or aspirate and Resident 10 would not meet his nutritional needs.During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Program revised 4/20/2026, the P&P did not indicate a specific procedure for communicating residents identified by the rehabilitation department requiring 1:1 feeding assistance to the nursing department to ensure residents were assisted during meals to prevent weight loss, choking and aspiration.

Based on observation, interview and record review, the facility failed to: a. Assess and monitor the urinary catheter (tube inserted into the bladder to drain urine) for one of seven sampled residents (Resident 64). b. Ensure one of seven sampled residents (Resident 7) had a physician order with indication for the urinary catheter. These deficient practices had the potential to result in a urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney). Findings: a. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] with diagnoses including fracture of left humerus (bone connecting the shoulder and elbow), pubis (front-lower portion of the hip bone), and left acetabulum (cup-shaped socket located on side of hip bone that holds the head of the thigh bone to form the hip joint), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and pulmonary fibrosis (chronic, progressive scarring and thickening of the lung tissue). During a review of Resident 64's History and Physical (H&P), dated 4/28/2026, the H&P indicated Resident 64 had the capacity to understand and make decisions. During a review of Resident 64's Minimum Data Set (MDS – a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 64 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for bathing and upper body dressing, and was dependent for toileting hygiene and lower body dressing. During a concurrent observation and interview on 5/2/2026 at 1:19 p.m. in Resident 64's room, Resident 64 had a urinary catheter. Resident 64 stated the urine catheter was inserted at the general acute care hospital (GACH). During a concurrent observation and interview on 5/3/2026 at 12:15 p.m. with Resident 64 and Licensed Vocational Nurse (LVN) 2 in Resident 64's room, Resident 64 had the urinary catheter. Resident 64 asked LVN 2 if the urinary catheter was going to be removed today. During a concurrent interview and record review on 5/5/2026 at 8:19 a.m. with Treatment Nurse (TXN) 2, Resident 64's orders, Monitoring Records April – May 2026, Medication Administration Record (MAR) April – May 2026, and Treatment Administration Record (TAR) April – May 2026 were reviewed. TXN 2 stated Resident 64's urinary catheter was not being monitored from 4/27/2026 to 5/1/2026. TXN 2 stated the facility should have monitored and assessed Resident 64's urinary catheter starting on admission on [DATE]. TXN 2 stated it is important to monitor resident's output, pain levels, urine characteristics, signs and symptoms of infection, and ensure it did not become dislodged. During an interview on 5/5/2026 at 11:55 a.m. with the Director of Nursing (DON), the DON stated urinary catheter's need to be monitored starting on admission. The DON stated if the urinary catheter is not being monitored, there is a risk of infection. During a review of the facility's policy and procedure (P&P), titled Indwelling Catheter Use and Removal, dated 12/19/2022, the P&P indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to:.ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes.residents that admit with an indwelling catheter or subsequently receives one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessary.Additional care practices include: recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems. b. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 3/1/2025 and was readmitted [DATE] with diagnosis including obstructive and reflux uropathy (a medical condition when urine flow is blocked). During a review of Resident 7's H&P dated 4/6/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set, dated [DATE], the MDS indicated Resident 7 had severely impaired ability to think and make decisions. The MDS indicated Resident 7 was dependent on staff with showering and needed moderate assistance (helper does less than half the effort to complete the activity) with eating, oral and toileting hygiene, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. The MDS indicated Resident 7 had a urinary catheter. The MDS indicated Resident 7 had an active diagnosis of obstructive uropathy. During a concurrent interview and record review on 5/4/2026 at 10:56 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 7's physicians order was reviewed. The MDSC stated Resident 7 did not have an order with the indication for his urinary catheter. The MDSC stated the importance of having an order with an indication was to ensure the urinary catheter was medically necessary for Resident 7. The MDSC stated if the urinary catheter was not medically necessary, there would be potential for Resident 7 to have the urinary catheter in place for an extended period which could lead to urinary infections. During an interview on 5/5/2026 at 5/5/2026 at 12:03 p.m. with the DON, the DON stated the importance of making sure there was a urinary catheter order with a diagnosis was to ensure the urinary catheter was medically necessary and indicated with a diagnosis. The DON stated there would be potential for the urinary catheter not being monitored which could lead to urinary complications or infection. During a review of the facility's policy and procedures (P&P) titled Indwelling Catheter Use and Removal revised 12/19/2022, the P&P indicated It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified. 5. Appropriate indications for indwelling catheter use include: a. acute urinary retention or bladder outlet obstruction; b. need for accurate measurement of urinary output; c. assistance in healing of open sacral or perineal wounds in incontinent residents (typically stage 3 or 4); d. residents that require prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic factures); and e. to improve comfort for end of life care, if needed.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 11) received the correct amount of gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula.This deficient practice had the potential to result in weight loss or gain, dehydration and fluid overload.Findings:During an observation on 5/2/2026 at 7:15 a.m., Resident 11 was observed receiving the GT feeding formula Jevity (calorie dense, fiber fortified, and nutrient dese liquid feeding formula) 1.5 infusing at 47 milliliters (mL - unit of measurement)/hour (hr) and the water flush infusing at 30 mL/hr. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), protein-calorie malnutrition (condition when body does not get the right balance of protein and calories), and dysphagia (difficulty swallowing), and gastrostomy (GT) present.During a review of Resident 11's History and Physical (H&P), dated 10/6/2025, the H&P indicated Resident 11 did not have the capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 11 had severed cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, dependent for eating, oral and toileting hygiene, bathing, and dressing. During a concurrent observation and interview on 5/4/2026 at 12:55 p.m. with Licensed Vocational Nurse (LVN) 2 in Resident 11's room, LVN 2 stated Resident 11's GT feeding formula Jevity 1.5 was infusing at 47 mL/hr and water flush was infusing at 30 mL/hr.During a concurrent observation and interview on 5/4/2026 at 12:59 p.m. with LVN 2, Resident 11's orders were reviewed. LVN 2 stated the GT feeding formula rate was incorrect. LVN 2 stated Resident 11's orders indicated the physician ordered Jevity 1.5 infused at 44 mL/hr and water flush infused at 25 mL/hr starting on 5/1/2026.During an interview 5/5/2026 at 12:06 p.m. with the Director of Nursing (DON), the DON stated the enteral feeding requires a physician order because a specific quantity needs to be given to the resident. The DON stated the enteral feeding and water flush administered should match the order. The DON stated if the enteral feeding and/or water flush administered does not match the order, the resident w/ at risk of losing weight or gaining weight.During a review of the facility's policy and procedure (P&P), titled Provision of Physician Ordered Services, revised 5/15/2023, the P&P indicated medication and therapeutic treatments qualified nursing personnel will administer medications as ordered by the physician, physician assistant, nurse practitioner, or clinical nurse specialist. Medications will be administered following the facility protocols dosage guidelines. And documentation procedures. Dietary Modifications Dietary staff will implement and monitor dietary modifications as prescribed by the physician, physician assistant, nurse practitioner, or clinical nurse specialist. Nutritional needs and restrictions will be communicated to the dietary department and documented for proper meal planning.

Based on interview and record review, the facility failed to ensure three out of 10 sampled residents (Resident 64, 1, and 3)'s medication regimens were monitored for side effects and signs/symptoms as ordered by failing to:a. Monitor for side effects of opioid medication for Resident 64.b. Monitor signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) for Resident 1.c. Monitor signs and symptoms of anticoagulant therapy for Resident 3.These deficient practices had the potential to result in adverse drug reactions, unrecognized complications, and ineffective medication management for the affected residents.Findings: a. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] with diagnoses including fracture of left humerus (bone connecting the shoulder and elbow), pubis (front-lower portion of the hip bone), and left acetabulum (cup-shaped socket located on side of hip bone that holds the head of the thigh bone to form the hip joint), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and pulmonary fibrosis (chronic, progressive scarring and thickening of the lung tissue). During a review of Resident 64's History and Physical (H&P), dated 4/28/2026, the H&P indicated Resident 64 had the capacity to understand and make decisions. During a review of Resident 64's Minimum Data Set (MDS – a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 64 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for personal hygiene, required moderate assistance (helper does less than half the effort) for eating and oral hygiene, required maximal assistance (helper does more than half the effort) for bathing and upper body dressing, and was dependent for toileting hygiene and lower body dressing. During an interview on 5/2/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 stated they had abdominal pain due needing to have a bowel movement. Resident 64 stated the current medication had not been working to relieve the pressure in the abdomen. Resident 64 stated sometimes the pain in the abdomen is so bad that they (Resident 64) requested a pain pill to be able to sleep. During an interview on 5/3/2026 at 1:19 p.m. with Resident 64 in Resident 64's room, Resident 64 stated having abdominal pain and pressure and reported it to Licensed Vocational Nurse (LVN) 2. During a concurrent interview and record review on 5/3/2026 at 1:21 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 64's orders, Monitoring Records April – May 2026, and Medication Administration Record (MAR) April – May 2026 were reviewed. The MDSC stated Resident 64 had an order for Oxycodone with (w/) acetaminophen (narcotic pain reliever given for moderate to severe pain) Oral Tablet 5-325 milligrams (MG – unit of measurement) every five hours as needed for moderate to severe pain. The MDSC stated there was no documentation Resident 64 was being monitored for adverse effects or side effects of oxycodone w/ acetaminophen. The MDSC stated the facility should have monitored Resident 64 for adverse or side effects such as constipation or respiratory depression. During an interview on 5/5/2026 at 12:08 p.m. with the Director of Nursing (DON), the DON stated it was important to monitor side effects and adverse effects such as constipation of opioid medication to evaluate if the medication is therapeutic for the resident or if it needs to be discontinued. The DON stated if it was not documented, the monitoring did not happen. During a review of the facility's P&P titled, Pain, dated 12/19/2022, the P&P indicated Facility staff will reassess resident's pain management regularly for effectiveness and/or adverse consequences such as: i. Tolerance, ii. Physical dependence, iii. Increased sensitivity to pain, iv. Constipation, v. Nausea, vomiting, and dry mouth, vi. Sleepiness, dizziness, and/or confusion, vii. Depression, viii. Itching and sweating. During a review of the facility's P&P titled, Medication Monitoring, dated 12/19/2022, the P&P indicated This policy addressed the facility's collaborative, systemic approach to medication management, including the monitoring of medications for efficacy and safety. Licensed nurses, with periodic oversite by nurse managers, shall adhere to facility policies and current standards of practice for administration and monitoring of medications. b. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar) with hyperglycemia (high blood pressure) and foot ulcer, hypertension (high blood pressure), and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1's H&P dated 3/30/2026, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 was mildly cognitively impaired. The MDS indicated Resident 1 is dependent on staff for lower body (below waist) dressing, toileting hygiene, roll left to right, sit to lying, lying to sitting on side of bed, required substantial assistance (Helper does more than half the effort) from staff for bathing, upper body (above waist) dressing, and required partial assistance (Helper does less than half the effort) from staff for eating, oral hygiene, and personal hygiene. During a review of Resident 1's monitor record dated 3/1/2026 –3/31/2026 and 4/1/2026 –4/30/2026, there were no monitoring for hyperglycemia and hypoglycemia noted. During a review of Resident 1's change in condition (COC), dated 4/12/2026 at 8:22 p.m., the COC indicated Resident 1 had hyperglycemia. Resident 1 was noted with hyperglycemia and was ordered to repeat Lantus (long acting insulin) 6 units (standardized measurement of the insulin's strength) subcutaneous (layer of fatty tissue acting as a cushion and fat storage for the body) in after 1 hour. During a review of Resident 1's Order Summary Report (physician order) dated 5/5/2026, the order summary report indicated the following to monitor for s/s of hypoglycemia and hyperglycemia with a start date of 5/3/2026. During an interview on 5/5/2026 at 11:52 a.m. with the Director of Nursing (DON), the DON stated monitoring for s/s of hyper/hypoglycemia is done every shift. The DON stated if a resident is diabetic, they would have a monitoring for hyper/hypoglycemia and is the standard protocol for all diabetic residents. The DON stated monitoring is documented in the monitoring record. The DON stated they would want to monitor the s/s hyper/hypoglycemia every shift as well as for the use of anticoagulants to ensure they will be able to identify any issues if any changes occur. The DON stated if it is not signed and documented, it did not happen. c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate that can cause poor blood flow), hypertension (high blood pressure), and anxiety disorder. During a review of Resident 3's H&P dated 3/10/2026, the H&P indicated Resident 3 has fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was mildly cognitively impaired. The MDS indicated Resident required partial assistance from staff for lower body dressing, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, shower transfer, required supervision for bathing, upper body dressing, personal hygiene, roll left and right, sit to lying, and required setup for eating, oral hygiene, and toileting hygiene During a record review of Resident 3's Order Summary Report (physician order) dated 5/5/2026, the order summary report indicated the following to monitor for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from wounds, large hemorrhagic area, petechiae (tiny spots of bleeding under the skin) with an order date of 4/10/2026. During a record review of Resident 3's monitor record dated 4/1/2026 –4/30/2026, the monitor record indicated on the days of 4/12/2026, 4/18/2026, 4/24/2026, and 4/29/2026 during the 7:00 a.m. to 3:00 p.m. shift (day shift), the following documentation was left blank to monitor for any of the following: blood in the urine, blood in the stool, unusual bleeding after shaving, bleeding from the gums, bleeding from the nose, excessive bleeding from wounds, large hemorrhagic area, petechiae every shift for use of Apixaban (anticoagulant medication). During a concurrent interview and record review on 5/4/2026 at 4:44 p.m. with MDSC, the MDSC stated anticoagulants were monitored every day due to the risk of bleeding. The MDSC stated the monitor record dated 4/1/2026 –4/30/2026 for Resident 3 has days (4/12/2026, 4/18/2026, 4/24/2026, and 4/29/2026) with no documentation during the day shift and indicated the document should be audited and corrected as soon as possible. The MDSC stated if there was no monitoring for the medication, Resident 3 may have unusual signs of blood in their stool and could be harmed. During a review of the facility's policy and procedures (P&P) titled, Nursing Care of the Resident with Diabetes Mellitus, dated 12/19/2022, the P&P indicated the management of individuals with diabetes mellitus should follow relevant protocols and guidelines. Residents whose blood sugar is poorly controlled of those taking insulin may require more frequent monitoring, depending on the situation. During a review of the facility's P&P titled, High Risk Medications-Anticoagulants, dated 12/19/2022, the P&P indicated This facility recognizes that some medications, including anticoagulants, are associated with greater risks, of adverse consequences than other medications. This policy addressed the facility's collaborative, systemic approach to managing anticoagulant therapy for efficacy and safety. Anticoagulant refers to a class of medications that are used to prevent clot extension and formation. They do not dissolve clots. Examples include Eliquis. Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. During a review of the facility's P&P titled, Medication Monitoring, dated 12/19/2022, the P&P indicated This policy addressed the facility's collaborative, systemic approach to medication management, including the monitoring of medications for efficacy and safety. Licensed nurses, with periodic oversite by nurse managers, shall adhere to facility policies and current standards of practice for administration and monitoring of medications.

Based on observation, interview, and record review, the facility failed to ensure fortified diets (diet to increase calories) were identified and communicated during lunch tray line meal service for ten residents who were on fortified diet as recommended by the dietitian and ordered by the physician.This failure had the potential to result in residents not receiving required nutritional fortification (adding extra vitamins and minerals to food), leading to inadequate nutritional intake, and unintended weight loss.Findings:During an observation on 5/3/2026 at 12:05 p.m. during lunch tray line, [NAME] (CK) 1 did not communicate the fortified diet orders written on the meal tickets to CK 2 who was serving the food.During an interview on 5/3/2026 at 12:58 p.m. with CK 1, CK 1 one stated she had forgotten to communicate the fortified diets to CK 2. CK 1 stated the importance of communicating the fortified diet orders was to ensure the residents receive the calories needed. CK 1 stated if the fortified diet orders were not communicated during tray line, there would be potential for residents to lose weight.During an interview on 5/3/2026 at 1:41 p.m. with the Dietary Supervisor (DS), the DS stated CK 1 did not communicate the fortified diets to CK 2 during tray line. The DS stated the importance of communicating fortified diets during tray line was to ensure residents receive the calories needed for the day. The DS stated there would be potential for residents to lose weight.During an interview on 5/5/2026 at 11:05 p.m. with the Registered Dietician (RD), the RD stated the importance of making sure fortified diets were communicated during tray line was to ensure residents with fortified diet orders were receiving meals with fortified items such as cereal, health shake, vegetables, and pudding. The RD stated if fortified diet orders were not communicated during tray line, the facility was not verifying that residents were receiving fortified food items which could potentially lead to residents losing weight.During a review of the facility's policy and procedure (P&P) titled Standardized Recipes revised 8/31/2018, the P&P indicated 3. Standardized recipes will be adjusted for therapeutic and consistency modifications. The P&P did not indicate specific procedures for diet fortification.

Based on interview, and record review, the facility failed to ensure the Responsible Party (RP) for one of four sampled residents (Resident 1), who did not have the capacity to make decisions, was advised of Resident 1's dental needs and a consent was obtained from Resident 1's RP prior to Resident 1's tooth extraction. This deficient practice resulted in the extraction of Resident 1's tooth without the knowledge or consent of Resident 1's RP. This deficient practice had the potential for Resident 1 to be subjected to an unnecessary procedure and/or to suffer complications such as discomfort/pain, bleeding, and infection.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including metabolic encephalopathy (a disease that affects the brain causing confusion) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/15/2026, the MDS indicated Resident 1 was not able to make decisions that were reasonable and consistent. Resident 1 required a one -person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily routine tasks/activities such as bathing, dressing, toilet transfer, repositioning from sitting to standing position and transferring from the bed/chair-to- chair a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P) dated 7/14/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Dental Medical Order form, dated 12/6/2025, the Dental Medical Order form indicated a proposal to extract Resident 1's number 12 tooth (a tooth located on the left side of the upper jaw used for crushing food) and tooth number 29 (a tooth located on the lower part of the mouth used for chewing and grinding food). The Dental Medical Order form indicated Resident 1's Attending Physician signed the form on 2/4/2026 authorizing and/or providing clearance for Resident 1 to undergo the dental procedures with instructions for the dentist to call Resident 1's RP to explain the procedure. During a review of the Dental Procedure Consent dated 3/3/2026, the Dental Procedure Consent indicated Resident 1's signature authorizing the tooth extraction after she read the consent in its entirety, and her questions were answered to her satisfaction. The Dental Procedure Consent indicated Licensed Vocational Nurse (LVN) 1's signature as a witness to Resident 1's consent for the procedure. During a review of Resident 1's Dental Progress Note dated 3/3/2026, the Dental Progress Note indicated the following: a. Resident 1's number 29 tooth had no swelling and no other symptoms, and was not extracted b. Resident 1's number 12 tooth was unrestorable and was extracted with the use of dental forceps (specialized stainless-steel instrument used to grasp and remove teeth from the bone socket). Resident 1 was medicated with two doses of 1:100,000 epinephrine (an anesthetic used to provide numbness and reduce bleeding). During a review of Resident 1's Change of Condition (COC) Evaluation dated 3/3/2026 and timed at 10:50 a.m., the COC Evaluation indicated Resident 1 underwent a tooth extraction of the number 12 tooth. During a review of Resident 1's Social Service Progress Notes dated 3/5/2026 and timed at 6:10 p.m., the Social Service Progress Notes indicated a complaint by Resident 1's RP that Resident 1's tooth extraction on 3/3/3026 was completed without the RP's knowledge or consent. During a telephone interview on 3/13/2026 at 11:45 a.m., Resident 1's RP stated she was not aware of Resident 1's dental concerns, or that Resident 1's tooth needed to be extracted. The RP stated the facility's dentist, or licensed nurses never called her to provide information about Resident 1's dental needs or to obtain a consent prior to extracting Resident 1's tooth. The RP stated Resident 1 was subjected to unsafe conditions and pain and she was disrespected by not being informed regarding Resident 1's dental needs and the extraction of her tooth. During a telephone interview on 3/13/2026 at 1:10 p.m., LVN 1 stated on 3/3/2026 before lunch (exact time unknown), she was called by the facility's dentist to act as a translator between him (dentist) and Resident 1 during the extraction of Resident 1's tooth. LVN 1 stated the dentist informed Resident 1 that her tooth would be removed and had Resident 1 sign a dental consent before extracting Resident 1's tooth. LVN 1 stated she was asked by the dentist to sign the dental consent following the procedure as a witness that Resident 1's consented to the procedure. LVN 1 stated she did not call Resident 1's RP before the procedure to verify the RP's knowledge of the procedure and she did not check Resident 1's medical record to verify if Resident 1 had the capacity to consent for a medical and/or dental procedure because she thought all this had already been done prior to the procedure. During a telephone interview on 3/13/2026 at 1:13 p.m., the Registered Nurse Supervisor (RNS) stated he was informed by the dentist on 3/3/2026 during the 7 a.m. to 3 p.m. shift that Resident 1's tooth had been extracted. The RNS stated the dentist asked him to witness Resident 1's consent after the procedure was completed, but he (RNS) declined because he knew Resident 1 had no capacity to consent and her family was responsible for Resident 1's healthcare decisions. During an interview on 3/13/2026 at 2:23 p.m., the SSD stated she coordinates/arranges the residents' ancillary services but does not call residents' families to explain dental care concerns or to obtain a consent for procedures. The SSD stated she faxed the Dental Medical Order to the dental office after Resident 1's attending physician signed the order and cleared Resident 1 for the procedure on 2/4/2026. The dental office and their dentists were supposed to inform the family of the residents' dental concerns and obtain the family's consent for the procedure. The SSD stated the dental assistant would normally check in with her before seeing the residents but on the day 3/3/2026, the day of Resident 1's procedure, she was not approached by any of the dental staff. The SSD stated on 3/4/2026, the day after the RP filed the grievance, she followed up with the dental office and was informed by the dental staff that the RP was not informed of the dental procedure, and her consent was not obtained. During a telephone interview on 3/16/2026 at 12:01 p.m., the Dentist stated on 3/3/2026 he explained the dental procedure to Resident 1 through LVN 1, who acted as the translator, he then had Resident 1 sign the dental consent to have her tooth extracted because Resident 1 was agreeable to the procedure. The Dentist stated he did not call Resident 1's RP prior to extracting Resident 1's tooth because Resident 1's face sheet did not indicate there was a RP designated and he assumed the dental office, where he was employed, had called Resident 1's family before scheduling Resident 1's tooth extraction. The Dentist stated he did not verify Resident 1's cognition or capacity to make decisions prior to extracting her tooth and he should have done so prior to the procedure as well as verify with Resident 1's RP responsible party. During a telephone interview on 3/16/2026 at 1:10 p.m., Resident 1's Attending Physician stated it was the responsibility of the dentist to ensure any dental concerns were discussed with Resident 1 and/or her RP and to inform them of any recommended procedures and to obtain permission to proceed with those recommended services prior to the procedure. During an interview on 3/16/2026 at 3:07 p.m., the Director of Nursing (DON) stated LVN 1 should have checked Resident 1's medical records (H&P and Face Sheet) then referred this to the RNS and/or the her (DON) so they could determine if Resident 1 could give consent for the procedure. The DON stated they would have contacted Resident 1's RP to determine if the RP agreed to have the procedure done. The DON stated Resident 1 should not have undergone a tooth extraction because the consent was invalid. During an interview on 3/16/2026 at 3:30 p.m., the Administrator (ADM) stated the dentist should have communicated with Resident 1's RP with pertinent medical information and obtained the RP's permission to extract Resident 1's tooth. During a review of the Dental Facilities Services Agreement dated 11/1/2022, the Dental Facilities Services Agreement indicated the dentist shall at all times maintain a legal and binding informed consent for dental care signed by the residents/and or their responsible parties and should coordinate with the licensed nurses of the facility to check on the residents. During a review of the facility's Policy and Procedure (P/P) titled Notification of Changes revised 12/19/2022, the P/P indicated the facility shall inform the residents' representatives for any decisions that have to be made when the residents are incapable of making decisions. During a review of the facility's P/P titled, Informed Consent revised 12/19/2022, the P/P indicated the facility must uphold the right of the residents to participate in the planning and decision-making process concerning their care and treatment. When a complex situation arises; the facility shall verify the informed consent obtained from the residents and/or their representative prior to any medical intervention or treatment is initiated. During a review of the facility's P/P titled, Resident Rights revised 12/19/2022, the P/P indicated the residents' representatives have the right to be informed, in advance, of any changes to the plan of care of the resident. The residents' representatives have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option that he or she prefers. During a review of the facility's P/P titled Dental Services revised 12/19/2022, the P/P indicated the resident and/or resident representative shall be kept informed of all dental arrangements.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was revised after Resident 2 fell on [DATE].This deficient practice had the potential for the nursing staff to be unaware of Resident 2's current fall-risk precautions and interventions, which could delay or negatively impact the delivery of her care and potentially lead to further falls.Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction), dementia (a progressive state of decline in mental abilities), and difficulty walking.During a review of Resident s's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 2 was not able to make decisions that were reasonable and consistent and required partial/moderate assistance (helper does more than half the effort) from staff to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily), such as toilet transfer, repositioning from sitting to standing, position and transferring from the bed/chair-to-chair. The MDS indicated Resident 2 was incontinent of bowel and bladder (involuntary voiding of urine and stool). During a review of Resident 2's Care Plan, dated 8/10/2025, the Care Plan indicated Resident 2 was at risk for falls due to incontinence, psychoactive drug (medications that affect mood, thinking, behavior, or perception), and unawareness of safety needs. The Care Plan's goal was for Resident 2 to be free from falls and minor injuries and will not sustain serious injuries. The Care Plan's interventions included anticipating and meeting Resident 2's needs, ensuring staff respond promptly to Resident 2's calls and requests for assistance, and providing a safe environment by keeping pathways free of spills or clutter, providing adequate lighting, and ensuring personal items including the call light were within reach. During a review of Resident 2's Change of Condition Evaluation (COC) dated 12/25/2025 and timed 12:58 a.m., the COC indicated Resident 2 had a fall and was found sitting on the lobby floor with blood on her face. During a review of Resident 2's Change in Condition Progress Notes dated 12/26/2025 and timed at 1:59 a.m., the Change in Condition Progress Notes indicated Resident 2 was found on the floor by the nursing station with a quarter sized cut on the forehead actively that was actively bleeding. The Change in Condition Progress Notes indicated the paramedics (a group of individuals trained to provide emergency medical care to people who are injured or ill outside the GACH) were called and Resident 2 was transferred to a general acute care hospital (GACH) via 911 for further treatment.During a review of Resident 2's Clinical Records, there was no documentation indicating an Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) of the facility implemented a care conference with Resident 2's emergency contact to discuss recommendations, changes and/or update Resident 2's fall risk Care Plan interventions.During a review of Resident 2's Risk for Fall Care Plan, the Care Plan did not indicate revisions and/or updates of Resident 2's Care Plan to include interventions after she fell on [DATE].During an interview on 2/23/2026 at 12:20 p.m., Resident 2's Emergency Contact (EC) 1 stated the facility staff informed her when Resident 2 had a fall incident few months ago but was not called to attend a meeting to discuss Resident 2's care concerns and interventions after her fall on 12/25/2025. During a telephone interview on 2/24/2026 at 11:51 a.m., Registered Nurse (RN) 1 stated Resident 2 had an unwitnessed fall on 12/25/2025 at the change of shift (between 3 p.m. to 11 p.m. to 7 a.m.) and the paramedics transferred Resident 2 to the GACH for further treatment. RN 1 stated Resident 2 was transferred back to the facility the same day at 11 p.m. to 7 a.m. shift and he informed the Certified Nursing Assistant (CNA unknown) assigned to Resident 2 to perform frequent visual checks to ensure Resident 2's safety. RN 1 stated he was unable to review and revise Resident 2's risk for fall care plan and did not formulate a care plan for an actual fall. RN 1 stated it was the responsibility of the licensed nurses to update and revise the care plan of the residents to prevent another fall.During a concurrent interview and record review on 2/24/2026 at 12:31 p.m. with the Director of Rehab (DOR), Resident 2's Clinical Record was reviewed. The DOR stated Resident 2 had poor safety awareness and required assistance during transfer and walking because she was unsteady. The IDT had a meeting after Resident 2's fall on 12/25/2026 to discuss Resident 2's fall precautions and revision of care plan interventions. The DOR confirmed there was no IDT meeting documented in Resident 2's Clinical Record and Resident 2's risk for falls care plan had not been revised and/or updated. The DOR stated the IDT should have conducted an interdisciplinary meeting with Resident 2's emergency contacts so the emergency contacts could share recommendations and participate in the planning and/or revising of Resident 2's plan of care.During an interview and concurrent record review on 2/24/2026 at 3:03 p.m., the DON stated and confirmed Resident 2's risk for falls care plan was not revised and/or updated after Resident 2 had a fall on 12/25/2025. The DON stated Resident 2's care plans should have been updated and revised by the licensed nurses after Resident 2's fall to reflect the accurate fall precautions and/or interventions to ensure awareness of the nursing staff and to prevent delay of care of Resident 2.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated the facility shall develop, implement and revise a comprehensive person- centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs based in the resident's comprehensive assessment. The residents' comprehensive care plan will be prepared by the facility's interdisciplinary team that includes, but is not limited to:a. The attending physicianb. A registered nursec. A nurse aided. A member of the nutrition servicese. The resident and the resident's representativef. Other staff or professionals involved in care of the residents such as therapists, social workers, activity personnel, family members, administrator, discharge coordinator, mental health professionals and chaplain.During a review of the facility's P&P titled, Fall Prevention Program, revised 12/28/2023, the P&P indicated the facility shall review the residents' care plan and update as indicated.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) was provided with his preferred activities. This failure resulted in Resident 1 feeling sad and frustrated and had the potential to further affect Resident 1's emotional well-being, which may impact his quality of life and mental health. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including depression (a mood disorder that cause feelings of persistent feeling of sadness and loss of interest affecting the way a person feel, think and behave that affects the normal day to day activities). During a review Resident 1's History and Physical (H&P), dated 9/19/ 2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent and required partial/moderate assistance from staff to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 1 did not ambulate and used a manual wheelchair for mobility. During a review of Resident 1's Activity Assessment, dated 11/10/2025 and timed at 5:26 p.m., the Activity Assessment indicated Resident 1's activity interests included outdoor patio activities, outings and shopping.During a review of Resident 1's Activity Assessment, dated 2/10/2026 and timed at 10:23 a.m., the Activity Assessment indicated Resident 1's activity interests included outdoor patio activities, outings and shopping.During a review of Resident 1's Care Plan, dated 2/9/2025 and revised 5/24/2025, the Care Plan indicated Resident 1 had depression. The Care Plan's goal was for Resident 1 to be free from signs and symptoms of distress and not to exhibit indicators of depression such as a sad mood or anxiety (extreme worry). The Care Plan's interventions included assisting Resident 1 in developing and providing him with activities that were meaningful and of interest. During a review of the facility's Activity Calendar dated 11/2025, 12/2025 and 1/2026, there was no activities which included resident outings and shopping. During a telephone interview on 2/22/2026 at 8 p.m., Resident 1 stated there are days when the weather is good and would like to leave the facility to purchase items from a store; however, the facility does not provide outings or shopping activities for residents. Resident 1 stated that remaining inside the facility makes him feel sad and frustrated and would like to do something outside and/or away from the facility so he could feel like a normal human being. During an interview on 2/23/2026 at 1:08 p.m., Restorative Nursing Assistant (RNA) 1 stated she accompanied Resident 1 to a medical appointment a few weeks ago and Resident 1 told her that he would like to go shopping at a store sometimes, but the facility mostly provides indoor activities rather than outings. RNA 1 stated Resident 1 told her that he feels sad sometimes and wished he could spend a few hours away from the facility. During an interview on 2/23/2026 at 1:43 p.m., the Activity Director (AD) stated the facility has not provided a group outing activity for the residents because she needs to apply for a government ride permit for each resident. The AD stated she should have planned and implemented residents' activities of choice to honor their individual preferences and if the residents' families are not available to take the residents out for an outside activity, the facility should be able to provide outings and shopping because these activities are essential to the residents' mental health and wellbeing. During an interview on 2/24/2026 at 3:03 p.m., the Director of Nursing (DON) stated Resident 1's activity interests should have been provided by the facility to promote meaningful experiences.During an interview on 2/24/2026 at 3:49 p.m., the Administrator (ADM) stated the facility should have offered and provided Resident 1 with activities of his choice while he was at the facility to ensure his comfort and quality of life.During a review of the facility's policy and procedure (P&P) titled, Activities, revised 12/19/2023, the P&P indicated the facility shall provide an ongoing program to support the residents in their choice of activities based on their comprehensive assessment, care plan and preferences to encourage independence and interaction within the community. The facility shall sponsor group, individual and independent activities that are designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented vital signs (essential measurements taken by the healthcare team providers to check the body's most basic and life sustaining functions) for one of three sampled residents (Resident 2) when Resident 2 had a change of condition on 12/25/2026 and was transferred to a General Acute Care Hospital via 911 for further evaluation. This deficient practice had the potential for Resident 2's change of condition to be unrecognized, undetermined, or inadequately identified. This deficient practice also had the potential to negatively impact Resident 2's health status, interrupt the continuity of care, and impair timely and accurate communication among facility team members and with emergency personnel. Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction), dementia (a progressive state of decline in mental abilities), and difficulty walking.During a review of Resident s's Minimum Data Set ([MDS] a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 2 was not able to make decisions that were reasonable and consistent and required partial/moderate assistance (helper does more than half the effort) from staff to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily), such as toilet transfer, repositioning from sitting to standing ,position and transferring from the bed/chair-to- chair. The MDS indicated Resident 2 was incontinent of bowel and bladder (involuntary voiding of urine and stool).During a review of Resident 2's Change of Condition Evaluation (COC) dated 12/25/2025 and timed at 12:58 a.m., the COC indicated Resident 2 had a fall and was found sitting on the lobby floor with blood on her face. There was no documentation indicating Resident 2's vital signs were documented during the change of condition.During a review of Resident 2's Change in Condition Progress Notes dated 12/26/2025 and timed at 1:59 a.m., the Change in Condition Progress Notes indicated Resident 2 was found on the floor by the nursing station with a quarter sized cut on the forehead actively that was actively bleeding. The Change in Condition Progress Notes indicated the paramedics (a group of individuals trained to provide emergency medical care to people who are injured or ill outside the GACH) were called and Resident 2 was transferred to a general acute care hospital (GACH) via 911 for further treatment. There was no documentation indicating Resident 2's vital signs were documented during Resident 2's change of condition.During a telephone interview on 2/24/2026 at 11:51 a.m., RN 1 stated Resident 2 had an unwitnessed fall on 12/25/2025 at the change of shift (between 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m.). RN 1 stated he was able to assess and monitor Resident 2 vital signs during her change of condition but did not document Resident 2's vital signs in her clinical record. RN 1 stated he should have documented Resident 2's vital signs in the clinical record to depict Resident 2's accurate well-being after the fall.During an interview on 2/24/2026 at 3:03 p.m., the Director of Nursing (DON) stated RN 1 should have documented Resident 2's assessments and monitoring during the change of condition to include current vital signs to reflect the accurate well-being of Resident 2 after her fall and her condition and/or deterioration was determined. The DON stated it was the responsibility of the nursing staff to ensure the residents' records are complete.During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, revised 12/19/2022, the P&P indicated the following:a. The residents' medical records shall contain a representation of the residents' experiences and should reflect enough information to provide a picture of the residents' progress, andb. The nursing staff shall document all accurate, relevant and complete assessments, observations, and services provided and all documentation must be completed at the time of service.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four out of seventeen sampled residents (Resident 10, Resident 23, Resident 44, and Resident 45) related to: 1. Resident 45's usage of Apixaban (a blood thinner medication). 2. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 10. 3. develop and implement care plans of bowel and bladder retraining and bowel incontinent for Resident 44. 4. develop and implement care plans of hypoglycemia [a condition in which a person's blood sugar (glucose) level is lower than normal] for Resident 23. These deficient practices could result in the Resident's needs not being met, negatively impacting their well-being, and leading to suboptimal patient outcomes. Findings: 1. During a review of Resident 45's admission Record (Face Sheet), the admission Record indicated Resident 45 was admitted to the facility 1/28/2025 with diagnoses of paroxysmal atrial fibrillation (a rapid and irregular heartbeat), coronary artery disease (CAD, a narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), and congestive heart failure (CHF, a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2025, the MDS indicated Resident 45 was cognitively (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and was taking anticoagulant (blood thinning) medication. During a review of Resident 45's Order Summary Report, the Order Summary Report indicated a physician order was placed on 2/14/2025 for Apixaban Oral Tablet 5 milligrams (mg, a unit of measurement), give one tablet by mouth twice a day for CAD. During an interview and concurrent record review of Resident 45's care plans on 5/30/2025 at 11:53 a.m., the Quality Assurance Nurse (QAN) stated Resident 45 was receiving the anticoagulant medication Apixaban but Resident 45's care plan for Apixaban was not comprehensive and person-centered. The QAN stated Resident 45's care plan related to Apixaban was missing information on monitoring for side effects including bleeding. The QAN stated a comprehensive person-centered care plan for blood thinners was important because it informed the nursing staff what to monitor for and to look for any side effects and the interventions needed. 2. During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was initially admitted to the facility on [DATE] and last re-admission was on 5/27/2023 with diagnoses including urinary retention (a condition in which you are unable to empty all the urine from your bladder) and multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 10's History and Physical (H&P) , dated 5/28/2024, the H&P indicated, Resident 10 had the capacity (ability) to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 10 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, dressing, bed mobility, transfer, and setup or clen-up assistance (Helper sets up or cleans up) from one staff for eating. The MDS section H (Bladder and Bowel) indicated, had no trail of a toileting program (scheduled toileting, prompted voiding, or bladder training). During a concurrent interview and record review on 5/29/2025, at 2:27 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 10's Bowel and Bladder Assessment , dated 10/20/2023 was reviewed. The Bowel and Bladder Assessment indicated, Resident 10 was frequently incontinent for bladder and frequently incontinent for bowel (two or more episodes, but with one continent episode per week). The Bowel and Bladder Assessment indicated, Resident's assessment score was 10 and she was a candidate for prompted retraining. RNS 1 stated, Resident 10 should have been placed in bowel and bladder program as the assessment on 10/20/2023 and the care plan should be initiated for retraining. During a concurrent interview and record review on 5/29/2025, at 3:05 p.m., with RNS 1, Resident 10's Care Plan (CP) , dated from 10/2024 to 5/29/2025, there was no care plan for bowel incontinence and bowel and bladder retraining. RNS 1 stated, Care plan is the residents' plan of care and if it is not initiated or updated, it might delay the treatment. stated, staff should have initiated or update Estrada's care plan for bowel incontinence and retraining. 3. During a review of Resident 44's admission Record, the admission Record indicated, Resident 44 was initially admitted to the facility on [DATE] and last re-admission was on 3/31/2025 with diagnoses including Myasthenia Gravis (a rare long-term condition that causes muscle weakness) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 44's H&P, dated 1/10/2025, the H&P indicated, Resident 44 had the capacity (ability) to understand and make decisions. During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44 required dependent assistance (Helper does all of the effort) from two or more staff for toilet hygiene, dressing, bed mobility, transfer, and moderate assistance (Helper dose less than half the effort) from one staff for personal hygiene. During a concurrent interview and record review on 5/29/2025, at 2:37 p.m., with RNS 1, Resident 44's MDS , dated 2/16/2025 and 4/7/2025 were reviewed. The MDS dated on 2/16/2025, indicated, Resident 44 had urine incontinence frequently and bowel incontinence frequently. The MDS dated [DATE] indicated that Resident 44 had not undergone a toileting program trial and was always continent. RNS 1 noted a change in Resident 44's condition from frequent incontinence to constant incontinence. RNS 1 stated, Resident 44 should have received bowel and bladder training before she had further declined. RNS 1 stated, the staff should have initiated and implemented the care plan for bowel and bladder retraining. During a concurrent interview and record review on 5/29/2025, at 3:05 p.m., with RNS 1, Resident 10's Care Plan (CP) , dated from 1/9/2025 to 5/29/2025, there was no care plan for bowel incontinence and bowel and bladder retraining. stated, staff should have initiated or updated Zazueta's care plan for bowel incontinence. RNS 1stated, there was no care plan for bowel incontinence and retraining. stated, any concern with the resident should be care planned. RNS 1 stated, care plan is the resident's care of plan. RNS 1 stated, all care plan interventions should be implemented, and all interventions practiced should be in care plan. RNS 1 stated, care planning was important because the care plan ensure that the resident received the most appropriate and effective care as it planned. 4. During a review of Resident 23's admission Record, the admission Record indicated, Resident 23 was initially admitted to the facility on [DATE] and last re-admission was on 11/2/2024 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 23's History and Physical (H&P) , dated 11/2/2024, the H&P indicated, Resident 23 had the capacity (ability) to understand and make decisions. During a review of Resident 23's Minimum Data Set ([MDS]-a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 23 required dependent assistance (Helper does all of the effort) from two or more staff for bed mobility, transfer, hygiene, dressing, and moderate assistance (Helper does less than half the effort.) from one staff for eating. During a concurrent interview and record review on 5/29/2025, at 2:17 p.m., with RNS 1, Resident 23's Care Plan (CP) and Nurses Progress Notes (NPN) , dated from 10/2024 to 5/2025 (CP) and 10/31/2024 (NPN) were reviewed. Nurses progress Notes, dated 10/31/2024, indicated, Resident 23's blood glucose was 40 milligram per deciliter (mg/dl) on 10/31/2024 at 9:10 p.m. The Nurses Progress Notes indicated, the staff noticed Resident 23 was unresponsive around 8:56 p.m. and checked vital signs for blood pressure, respiration rate, heart rate, oxygen level. The Nurses Progress Notes indicated, Paramedic arrived at 9:03 p.m. and Blood sugar level was 40 mg/dl. The Care Plan dated from 10/2024 to 5/2025, indicated, there was no care plan for hypoglycemia. RNS 1 stated, there was no care plan for hypoglycemia. RNS 1 stated, significant event should be care planned and intervention should be implemented for each specific care plan. During an interview on May 30, 2025, at 4:08 p.m., the Director of Nursing (DON) explained that a resident's care plan is a specific plan of care that should be implemented as stated. The DON mentioned that care plan interventions need to be carried out and reevaluated. The interventions are discussed and decided upon during Interdisciplinary Team {(IDT) meetings, which involve team members from different disciplines collaborating with a common purpose to set goals, make decisions, and share resources and responsibilities}. These interventions aim to prevent recurrent events or issues. During a review of the facility's policy and procedure (P/P) titled Comprehensive Care Plans dated 12/19/2022, the P/P indicated it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 10, Resident 44, and Resident 3) who were incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, were provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible by failing to: A. ensure Resident 10's bowel and bladder assessment was done and follow through quarterly, and Resident 10 received bowel and bladder retraining as the assessment indicated. B. Ensure Resident 44's bowel and bladder assessment was conducted upon admission, and that Resident 44 participated in the bowel and bladder retraining program. C. Ensure Resident 3 was offered a bowel and bladder training to restore as much bladder function as possible. This failure had a potential to result in Resident 10, Resident 44, and Resident 3's inability to regain control of bowel and bladder function and can lead to a loss of dignity. Findings: A. During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with diagnoses including urinary retention (a condition in which you are unable to empty all the urine from your bladder) and multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 10's History and Physical (H&P) , dated [DATE], the H&P indicated, Resident 10 had the capacity (ability) to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 10 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, dressing, bed mobility, transfer, and setup or clen-up assistance (Helper sets up or cleans up) from one staff for eating. The MDS section H (Bladder and Bowel) indicated, had no trail of a toileting program (scheduled toileting, prompted voiding, or bladder training). The MDS section H indicated, Resident 10 had urinary incontinent frequently (seven or more episodes of incontinence, but at least one episode of continent voiding) and bowel incontinent always. During an interview on [DATE], at 11:10 a.m., with Resident 10, in Resident 10's room, Resident 10 stated, she did not want to talk about her incontinence issue because it made her feel embarrassed. During a concurrent interview and record review on [DATE], at 2:27 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 10's Bowel and Bladder Assessment , dated [DATE] and [DATE] were reviewed. The Bowel and Bladder Assessment on [DATE] showed Resident 10 was frequently incontinent for both bladder and bowel, with two or more episodes but at least one continent episode per week. The Bowel and Bladder Assessment, dated [DATE], indicated, Resident's assessment score was 10 and she was a candidate for prompted retraining. The Bowel and Bladder Assessment, dated [DATE], indicated, there was no score or indication of the candidate for retaining or not. RNS 1 stated, the assessment on [DATE] was not completed and there should be the follow up assessment at least yearly. RNS 1 stated, there were no residents in retraining program and did not know why. During a review of Resident 10's Order Summary Report (OSR) , dated [DATE], the Order Summary Report indicated, there was no order for bowel and bladder retraining. During a review of Resident 10's Care Plan (CP) , dated from 10/2024 to [DATE], there was no care plan for bowel and bladder retraining. B. During a review of Resident 44's admission Record, the admission Record indicated, Resident 44 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with diagnoses including Myasthenia Gravis (a rare long-term condition that causes muscle weakness) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 44's H&P, dated [DATE], the H&P indicated, Resident 44 had the capacity (ability) to understand and make decisions. During a review of Resident 44's MDS), dated [DATE], the MDS indicated Resident 44 required dependent assistance (Helper does all of the effort) from two or more staff for toilet hygiene, dressing, bed mobility, transfer, and moderate assistance (Helper dose less than half the effort) from one staff for personal hygiene. During a concurrent interview and record review on [DATE], at 2:37 p.m., with RNS 1, Resident 44's MDS section H , dated [DATE] and [DATE] were reviewed. The MDS section H, dated on [DATE], indicated, Resident 44 had urine incontinence frequently and bowel incontinence frequently. The MDS section H, dated [DATE], indicated, Resident 44 had no trial of a toileting program and Resident 44 had bowel and bladder continence always. RNS 1 stated, there was a change of Resident 44's from frequent incontinence to always incontinence. RNS 1 stated, Resident 44 should have received bowel and bladder training before she had further declined. During a concurrent interview and record review on [DATE], at 2:50 p.m., with RNS 1, Resident 44's Bowel and Bladder Assessment , dated [DATE] was reviewed. The Bowel and Bladder Assessment indicated, there was no bowel and bladder score and no indication of a candidate for retraining or not. RNS 1 stated, there should be a new assessment done after change of condition noted on MDS, dated [DATE]. RNS 1 stated, it was important to provide bowel and bladder retraining program to residents to promote resident's well-being and maintain their function to prevent further decline. During an interview on [DATE], at 4:08 p.m., with Director of Nursing (DON), DON stated, the staff should screen the resident for bowel and bladder function and placed the resident in retraining program if the resident screened as a possible candidate. DON stated, retraining program was important to preserve current level of function, to prevent further decline, and to promote achieving highest functional level. DON stated, the facility currently had no one in retraining program and did not have any policy and procedure. DON stated, the facility should have the system to recognize the candidate and provided standardized retraining program. DON stated the staff were following education material as a policy. During a review of Resident 44's Order Summary Report (OSR) , dated [DATE], the Order Summary Report indicated, there was no order for bowel and bladder retraining. During a review of Resident 44's Care Plan (CP) , dated from [DATE] to [DATE], there was no care plan for bowel and bladder retraining. c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with a diagnosis including chronic kidney disease stage 4 (severe kidney damage), type 2 diabetes mellitus with hyperglycemia (chronic condition where blood sugars are consistently high), and hypertension (high blood pressure). During a review of Resident 3's MDS, dated 5 /4 /2025, the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 was dependent (resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) with toilet hygiene, lower body dressing, putting on and taking off footwear and substantial / maximal assistance ( helper lifts or holds trunk or limbs and provides more than half the effort with upper body dressing). During a record review of Resident 3's Care Plan Report (CPR), the CPR dated [DATE] indicated a focus on bowel incontinence (inability to control bowel movements ) with a goal indicating the resident would be continent (ability to control your bowel and bladder) during daytime through the reviewing date. The intervention was to take resident to toilet at the same time each day the resident usually has a bowel movement. During a record review of Resident 3's B&B assessment form dated [DATE] Resident 3 had a score of 10 indicating she was a candidate for prompt toileting. The bowel and bladders assessments since the one dated [DATE], were incomplete, one dated [DATE] and [DATE] were both incomplete. During an interview and record review on [DATE] at 10:44 a.m., with the Director of staff development (DSD), the DSD stated Resident 3's Bowel and Bladder assessment form indicated the resident was a candidate for the bowel and bladder training program. The DSD stated when a resident is a candidate, they are placed on the DSD's task sheet, and the DSD would notify the Certified Nurse Assistant (CNA) and the Licensed Vocational Nurse (LVN) so there was a B&B program in place. The DSD stated she did not know why Resident 3 was not getting B&B training. The DSD stated because Resident 3 did not get B&B training, the resident could be at risk for skin breakdown which can also lead to a dignity issue. During an interview on [DATE] at 4:09 p.m., with the DON, the DON indicated if there has been an assessment and the resident is a candidate the facility should try B&B training for the resident. The DON stated it as important for facility staff to carry out assessments and implement. During a review of the facility's Policy and Procedure (P&P) titled, Bladder and Bowel Incontinence: A Care Solution , dated 2022, the P&P indicated, Introduction: resident experiencing incontinence may have feelings of shame, embarrassment, a loss of independence and may isolate themselves due to fear of accidents. Restorative Toileting Program: These programs are individualized, resident-centered, and communicated to the staff and resident. They must be care planned and reevaluated at least quarterly and whenever there is a change in the resident's cognition, continence, or activity of daily living (ADL) status. The use of the bladder/bowel assessment, bladder and bowel diary and bladder/bowel tool can aid the restorative nurse in determining the best program for the resident and serve as part of the documentation of the program and its progress .Care and Care Planning: Care planning for bladder and/or bowel incontinence must be resident centered and must incorporate their goals for care and updated accordingly. Care plans must take into account the results of the resident's assessment, interventions for any reversible causes and appropriate interventions for management of incontinence.

Based on observations, interviews, and record reviews, it was determined that the facility did not store food in a sanitary manner, which is necessary to prevent the growth of microorganisms. These microorganisms can cause foodborne illnesses, such as those resulting from contaminated food with pathogenic bacteria, viruses, parasites, or toxins. This issue affected 47 out of the 50 residents at the facility due to the following deficiencies: A. Ensuring food items were dated, labeled, and discarded properly. B. Ensuring [NAME] (CK) 2 performed hand hygiene (washing Hands) and changed gloves between tasks during trayline (Resident's trays are assembled and check for accuracy before food is delivered to them). This failure had the potential to impact residents, resulting in exposure to pathogens and placing them at risk for foodborne illnesses. Symptoms of such illnesses include upset stomach, cramps, nausea, vomiting, diarrhea, and fever, potentially leading to serious medical complications and hospitalization. Findings: A. During a concurrent observation and interview on 5/27/2025, at 8:22 a.m., with Dietary Supervisor (DS) in dry storage, some food items were not properly dated, labeled, sealed, or discarded for the following: a. opened and used sundried tomatoes in a plastic bin with Receiving Date (RD) of 12/16/2024, no Open Date (OD), and Used By (UB) of 12/15/2025. b. fresh vegetable (Yams/sweet potatoes) in a bin with RD of 5/13/2025 and UB 11/13/2025. one of the yams was damaged with cuts and inner part was exposed to air without sealing. c. opened and used gold medal variety muffin mix in a box with RD 6/11/2024, no OD, and no UB. The manufacture recommended UB was 3/25/2025. d. opened and used Alta Dena Low-fat Cultured Buttermilk in a pack with RD of 5/20/2025, OD of 5/22/2025, and UB of 6/4/2025. DS stated, it was all dietary staff (including herself) responsibility to check all food items for labels, dates, properly stored and sealed. DS stated that these practices were necessary to ensure the food items remained in good condition, as they were consumed by the residents. DS stated, once the food items were opened, there should be different shelf life (a time limit on how long a product can be stored before it becomes unsuitable for consumption or use). DS stated, all staff should refer to Dry Storage Chart for shelf life after opening and labeled UB date on food items. DS stated that all food items should be labeled with the receiving date when delivered. Additionally, they must have an open date and a use-by (expiration) date. During a concurrent observation and interview on 5/27/2025, at 8:39 a.m., with DS, in the refrigerator #1, there were food items that were not dated and discarded properly, as follows: a. opened and used pasteurized (a process in which heat is applied to foods and drinks to kill pathogens) eggs in a box with RD of 4/29/2025 and no UB. b. opened and used snap peas in a zip lock bag with RD 5/13/2025, OD 5/18/2025, and no UB DS stated, all food items should be dated, and dietary staff should follow Refrigerated Storage Chart to ensure safety of perishable items that required refrigeration. During a review of the facility's policy and procedure (P&P) titled, Dry Storage Chart, dated 2023, the P&P indicated, opened dried vegetables' shelf life was one year and keep cool airtight container, if possible, refrigerate. The P&P indicated, fresh vegetables (sweet potatoes' shelf life was two to four weeks. The P&P stated, opened muffin mix's shelf life was nine month and store in airtight container. The P&P indicated, the buttermilk should be refrigerated. During a review of the facility's policy and procedure (P&P) titled, Refrigerated Storage Chart, dated 2020, the P&P indicated, opened buttermilk's shelf life was three to five days. The P&P indicated fresh eggs' shelf life was two to three weeks and store in covered containers. The P&P indicated, peas' shelf life was three to five days. During a review of the facility's policy and procedure (P&P) titled, Date Marking for Food Safety, revised 12/19/2022, the P&P indicated, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .Policy explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day b which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall include the date of opening, and the date the item must be consumed or discarded or may refer to the food storage charts posted as the use by dates if manufacturer expiration dates are not present, the food storage charts are the used by dates. 5. The discard date may not exceed the manufacturer's use by date, whichever is earliest. The date of opening counts as day 1. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised 8/29/2023, the P&P indicated, Policy: Any expired or outdated food products should be discarded .Procedure: All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use Use-By dates on all food stored in refrigerators and use dates according to the timetable in the dry, refrigerated, and freezer storage charts. B. During a concurrent observation and interview on 5/27/2025, at 12:28 p.m., with [NAME] (CK) 2 in the kitchen, CK 2 was placing lunch plates in the lunch cart during trayline. When CK 2 completed with placing the lunch plates in the trays with station 1's lunch cart, she touched doorknob to open the door and pushed the cart to outside with gloves on. CK 2 grabbed the doorknob again to close the door. After closing the door, CK 2 did not wash her hands and did not change her gloves and touched the stations 2 resident's tray. CK 2 stated, she should have washed her hands between the tasks and touching different surfaces to prevent spreading infection and cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). CK 2 stated, she should have performed hand hygiene and changed her gloves between the tasks to prevent cross contamination. During an interview on 5/30/2025, at 4:08 p.m., with Director of Nursing (DON), DON stated, all staff should perform hand hygiene between tasks to prevent cross contamination and protect vulnerable residents from infections. During a review of the facility's Policy and Procedure (P&P) titled, Food Safety and Food Storage, revised 11/4/2024, the P&P indicated, Policy Explanation and Compliance Guidelines:6. Staff should wash hands prior to handling clean dishes, and shall handle them by outside surfaces. 7. Staff shall adhere to safe hygienic practices to prevent contamination of food from hands of physical objects. During a review of the facility's Policy and Procedure (P&P) titled, Hand Hygiene, revised 12/19/2022, the P&P indicated, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Policy Explanation and Compliance Guidelines: 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Twenty medication errors out of total 41 opportunities contributed to an overall medication error rate of 48.78 % affecting five of five residents observed for medication administration (Residents 19, 26, 209, 210, and 211.) The medication errors noted were as follows: 1. Omitted administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 75 milligrams ([mg] a unit of measure for weight) to Resident 26. 2. Failure to administer Clonidine (a medication used to treat high blood pressure) 0.1 mg to Resident 26 for systolic blood pressure ([SBP] - the pressure caused by heart while contracting) greater than or equal to 150 millimeters of mercury ([mmHg] - a unit measurement of pressure) parameters set by Resident 26's physician). On 6/4/2024 at 8:47 a.m., during medication pass observation Resident 26's BP was 153/52 and the HR was 72. 3. An attempt to give Resident 209 medication Furosemide (a medication used for heart failure and high blood pressure) 20 mg outside of the physician's prescribed order to hold medication for SBP less than 110 or heart rate (HR) less than 60 beats per minute (BPM). On 6/4/2024 at 9:10 a.m., during medication pass observation Resident 209's BP was 97/41 and HR was 69. 4. An attempt to give Resident 209 medication Metoprolol Succinate extended release ([ER]- a medication has a slow release over time) 25 mg outside of the physician's ordered parameters to hold for SBP less than 110 or HR less than 60 BPM. On 6/4/2024 at 9:10 a.m., during medication pass observation Resident 209's BP was 97/41 and HR was 69. 5. Omitted administration to Resident 209 of Potassium Chloride (a medication used to treat low potassium [a mineral that organs such as the heart need to function properly] level) ER 10 milliequivalent ([mEq] - a unit of measure for mass). 6. Omitted administration to Resident 209 of Eliquis ([Generic name - Apixaban] a medication used to prevent and reduce the risk of blood clots formation) 2.5 mg. 7. Omitted administration to Resident 209 of Lactobacillus (a dietary supplement or probiotic used to promote normal bacterial flora of the intestinal tract). 8. Omitted administration of Amoxicillin (a medication used to treat infection) 500 mg to Resident 211. 9. Omitted application of Lidocaine (a medication used to treat localized pain) 5% cream to Resident 210. 10. Administration of Multivitamins with Minerals (a supplement used to treat vitamin and mineral deficiency) to Resident 19 via gastrostomy tube ([G-tube] a soft tube surgically placed directly into the stomach for administration of medication and nutrition) instead of plain Multivitamins as ordered. 11. Incorrect medication administration technique to Resident 19 via G-tube by pushing [applying pressure to force the medication down the tube into the resident's stomach] on a syringe plunger instead of using gravity [allowing medication to travel down the tube naturally] and without having the five milliliters ([mL] a unit of measure for liquid volume] of water flush between medications per physician order. 12. Incorrect administration technique of Vitamin C 500 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 13. Incorrect administration technique of Aspirin (a medication used to prevent and reduce the risk of blood clots) 81 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 14. Incorrect administration technique of Ferrous Sulfate (a medication used to treat iron deficiency) 220 mg/ mL to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 15. Incorrect administration technique of Metoprolol Tartrate 25 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 16. Incorrect administration technique of Furosemide 40 mg Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 17. Incorrect administration technique of Docusate Sodium (a medication used to treat constipation) 100 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 18. Incorrect administration technique of Oxybutynin (a medication used to treat overactive bladder) 5.0 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 19. Incorrect administration technique of Pantoprazole (a medication used to treat gastroesophageal reflux disease) 40 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. 20. Incorrect administration technique of Zinc Sulfate (a dietary supplement used to treat zinc deficiency and promote wound healing) 50 mg to Resident 19 via G-tube by pushing on a syringe plunger instead of using gravity. These failures to administer medications in accordance with the physician's orders placed Residents 19, 26, 209, 210, and 211 at risk to experience significant medical complications including, progression of infection, pain, high blood pressure, myocardial infarction (heart attack), blood clots development, stroke, G-tube dislodgement (sudden pulling out or displacement of the G tube) hospitalization and possible death. On 6/6/2024 at 4:03 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to overall medication administration error rate of 48.78 % the presence of the Administrator (ADM) and Director of Nursing (DON.) On 6/7/2024 at 4:47 p.m., the facility provided CDPH with an Immediate Jeopardy Removal Plan containing the following immediate corrective actions: 1. A medication reconciliation for active medication orders and medication availability was completed by licensed staff for the residents listed above. Identified medication that was not available was called to the pharmacy for immediate delivery. Metoprolol Tartrate 75 mg one tablet by mouth (Resident 26). Medication was delivered on 6/5/2024. Apixaban 2.5 mg tab (Resident 209). Amoxicillin (Resident 211) was discontinued on 6/4/2024. Lidocaine (Resident 210). Resident 210 was discharged on [DATE]. Medications available based on physician summary orders on 6/6/2024 to 6/7/2024, there were no missing medications. 2. On 6/6/2024 the Regional Nurse Consultant (RNC) provided re-education to the Director of Nursing (DON), the Director of Staff Development (DSD) and the Infection Preventionist (IP) regarding medication administration, documentation, and medication availability. RNC observed the DON, the DSD and the IP perform medication administration. 3. From 6/6/2024 to 6/7/2024, the pharmacy consultant reviewed physician orders and availability of the medications in the medication carts. There were no missing medications identified. 4. Starting on 6/6/2024 all active licensed nurses identified were provided re-education related to medication administration, documentation, and medication availability by the Director of Nurses/Designee to include medication administration competency. Those nurses who did not have medication administration competency skill check will not be allowed to work on the floor. There are 21 licensed nurses who are eligible to administer medications. Medication administration competency was initiated on 6/6/2024 and will continue until the eligible active licensed nurses have completed the course by 6/7/2024. Staff members on Family Medical Leave Act (FMLA) will be prohibited from administering medications until they have completed the competency skills. The DON, DSD, and IP observed licensed nurses conduct medication administration. 5. Resident 26 was assessed, and denied chest pain, weakness, difficulty talking. No sudden vision change was noted. Resident was placed on monitoring for medical complications due to medication administration error. 6. Resident 209 was assessed, and denied lightheadedness, and chest pain. No shortness of breath or nausea was noted. Resident was placed on monitoring for medical complications due to medication administration error. 7. Resident 211 was assessed and denied ear pain or muffled hearing. No ear drainage was noted. Resident was placed on monitoring for medical complications due to medication administration error. Resident did not have any signs / symptoms of ear infection. Medication was discontinued on 6/4/2024. 8. Resident 19 was assessed, and resident denied stomach pain nor discomfort. No bleeding was noted. No signs and symptoms of infection noted, and resident was placed on monitoring for medical complication due to medication administration error. 9. Resident 210 was discharged to home per resident and responsible party (RP) request on 6/5/2024. Resident was assessed before leaving the facility. Resident was in stable condition. No complaint of pain or any discomfort noted upon discharge. 10. Seven residents with g-tube were re-evaluated by licensed staff for medical complications due to potential medication administration error on 6/6/2024. 11. Thirty-seven (37) residents with medications requiring parameters were re-evaluated by licensed staff for medical complications due to medication administration error. None were identified. 12. A medication reconciliation for active medication orders and medication availability were completed by licensed staff. Any identified medications not available were called to the pharmacy for immediate delivery. There were no missing medications identified. 13. On 6/6/2024 the Director of Nurses/Designee initiated re-education related to medication administration, documentation, medication availability, and re-ordering of medications by the Director of Nurses to include medication administration competency. There are 21 Licensed Nurses eligible to administer medications. Starting 6/6/2024, medication administration competency was conducted until active eligible Licensed Nurses completed by 6/7/2024 (2 staff on FMLA will not be allowed to administer meds without completing competency skills.) 14. On 6/6/2024 the Director of Nurses initiated retraining to the night shift staff on how to audit the medication carts, re-order, and track medication. The medication cart audits will be reviewed weekly by the Director of Nursing/Designee for any necessary follow-up for the next 3 months or until substantial compliance is met. 15. Quality Assurance Performance Improvement (QAPI - a facility's data driven approach to resident care quality improvement) Project was implemented on 6/6/2024. The Director of Nursing / Designee will monitor medication administration and medication availability and documentation. Any trends will be discussed on Cottage Crest Post Acute (CCPA) monthly QA meetings on every third (3rd) Wednesday of the month x (times) 3 months. Based on observation, interview, and record review on 6/8/2024 at 7:04 p.m. after verifying the facility's implementation of the immediate corrective actions, CDPH removed the immediate jeopardy in the presence of the ADM, DON and Nurse Consultant. Findings: 1. During observation of Licensed Vocational Nurse (LVN 1) medication administration and concurrent interview on 6/4/2024 at 8:47 a.m., LVN 1 was observed preparing the following medications for Resident 26: a. One tablet of Aspirin 81 mg. b. One tablet of Clopidogrel ([Plavix]a medication used to prevent blood clots, heart attack [a medical condition when the artery sending blood and oxygen to the heart is blocked] and stroke) 75 mg. c. One tablet of Nephro (vitamins to support kidney function) vitamins. d. One unit of insulin Lispro (a medication used to treat and reduce blood sugar levels) 100 units per one milliliter (mL), subcutaneously ([SQ]- under the skin). During concurrent interview LVN 1 stated Resident 26 had to receive one tablet of Metoprolol Tartrate 75 mg every Tuesday, Thursday, Saturday, and Sunday for hypertension, but the facility currently had no available Metoprolol Tartrate. LVN 1 stated the medication should have been ordered on Saturday 5/31/2024. LVN 1 stated she would check again in the medication room. LVN 1 stated she could not find Metoprolol Tartrate in the medication room and would follow up with the pharmacy to obtain the missing medication. During an interview on 6/4/2024 at 8:47 a.m. LVN 1 stated the four medications listed above were the only medications to administer to Resident 26 this morning besides the missing Metoprolol Tartrate 75 mg. During an observation on 6/4/2024 at 9:00 a.m., Resident 26 was observed taking three medications including one tablet of Aspirin 81 mg, one tablet of Clopidogrel 75 mg, and one tablet of Nephro vitamins by mouth with water. LVN 1 was observed injecting SQ one unit of insulin Lispro to Resident 26. During a review of Resident 26's Admission Record dated 6/4/2024, the Admission Record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition where kidneys stop functioning with the need for regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood]), essential (primary) hypertension and atherosclerosis (a disease of the arteries characterized by the deposition of plaque [sticky deposit] of fatty material on their inner walls) of the right leg. During a review of Resident 26's Order Summary Report (a list of a physician's orders ) dated 5/28/2024, the Order Summary Report indicated Resident 26 had a physician's order for the following medication: a. Aspirin chewable 81 mg by mouth one time a day for cerebrovascular accident ([CVA] a medical condition with an interruption in the flow of blood to cells in the brain) prophylaxis (prevention), ordered on 2/21/2024 with the start date 2/22/2024. b. Clonidine Hydrochloride (HCl) 0.1 mg, give one tablet by mouth every 8 hours as needed for hypertension if systolic blood pressure (SBP) is greater than or equal to 150, ordered 9/20/2023, start date 9/20/2023. c. Metoprolol Tartrate 75 mg, give one tablet by mouth every Tuesday, Thursday, Saturday, and Sunday for hypertension, hold for SBP less than 110 or diastolic blood pressure ([DBP] a pressure in the arteries when the heart rests between beats) less than 70 and pulse less than 60 beats per minute (BPM) (administer with food for enhanced absorption), order date 11/8/2023, start date 11/9/2023. d. Clopidogrel one tablet 75 mg, by mouth one time a day for deep venous thrombosis ([DVT] - a medical term to describe blood clot formation in legs deep veins) for prophylaxis, order date 2/25/2022, start date 2/26/2022. e. Renal multivitamin formula tablet (B complex-C-Folic Acid), one tablet by mouth one time a day for supplement, order date 2/25/2022, start date 2/26/2022. f. Insulin Lispro solution 100 units per one milliliter (mL), to administer SQ two times a day for diabetes (a medical condition in which body does not produce enough insulin or when the body cannot effectively use the insulin it produces), per sliding scale (a term used to define the dose based on blood glucose level) ordered on 2/20/2024 as follows: 1. For blood sugar level 150 - 200 = 1 unit 2. For blood sugar level 201 - 250 = 2 units 3. For blood sugar level 251 - 300 = 3 units 4. For blood sugar level 301 - 350 = 4 units 5. For blood sugar level 351 - 400 = 5 units 6. For blood sugar level above 400 = administer 6 units and notify medical doctor (MD). During an interview on 6/4/2024 at 3:19 p.m., LVN 1 stated she did not call Resident 26's physician or the pharmacy to inform about Metoprolol Tartrate was not available. LVN 1 stated she usually orders medication from the pharmacy when there are three or less medication doses remaining. LVN 1 stated she was supposed to administer Clonidine 0.1 mg to Resident 26 for BP 153/52, which is greater than or equal to 150 SBP and she forgot to give that during medication pass. LVN 1 stated by not receiving medications as prescribed, Resident 26 could have a high blood pressure placing the resident at risk for stroke with serious health complications and hospitalization . 2. On 6/4/2024 at 9:10 a.m., before medication pass, LVN 1 was observation checking Resident 209's blood pressure. Concurrently during the observation, LVN 1 stated Resident 209's BP was 97/41 and HR was 69 bpm. During an observation of medication administration on 6/4/2024 at 9:10 a.m. LVN 1 was observed preparing the following medications for Resident 209: a. One tablet of Furosemide 20 mg. b. One tablet of Metoprolol Cuccinate ER (extended release) 25 mg. Concurrently, during an interview on 6/4/2024 at 9:10 a.m. LVN 1 stated Furosemide 20 mg and Metoprolol Cuccinate ER 25 mg were the only medications to administer to Resident 209 this morning. During a concurrent observation and interview on 6/4/2024 at 9:20 a.m. with LVN 1 in Resident 209's room, LVN 1 was stopped by the surveyor before LVN 1 would administer Furosemide 20 mg and Metoprolol Cuccinate ER 25 mg to Resident 209 and advised to discuss the medications with the surveyor in the hallway. LVN 1 stated she got nervous and did not realize Resident 209's BP was 97/41 and HR was 69 bpm. LVN 1 stated she should have held Furosemide 20 mg and Metoprolol Succinate ER 25 mg at this time as Resident 209's SBP was 97 which was less than 110. During a review of Resident 209's Admission Record, dated 6/4/2024, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation (a medical condition characterized with abnormal heart beats), chronic congestive heart failure ([CHF] - a medical condition where heart cannot pump blood well enough to give normal supply throughout body), essential (primary) hypertension, and atherosclerosis of aorta (a medical term used for the large blood vessel of the body.) During a review of Resident 209's Order Summary Report, dated 6/4/2024, the Order Summary Report indicated Resident 209 had the following medications to be administered every day at 9:00 a.m.: a. Apixaban 2.5 mg, one tablet by mouth two times a day for CVA prophylaxis, ordered on 5/25/2024. b. Furosemide 20 mg, one tablet by mouth two times a day for CHF, hold for SBP less than 110 or HR less than 60, ordered on 5/25/2024. c. Lactobacillus (probiotic or a dietary supplement) one capsule by mouth one time a day for supplement, ordered on 5/25/2024. d. Metoprolol Succinate ER 25 mg one tablet by mouth one time a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/25/2024. e. Potassium Chloride ER 10 milliequivalent (mEq), one tablet by mouth two times a day for potassium supplement ordered on 5/25/2024. During a review of Resident 209's Medication Administration Record (MAR) for June 2024, the MAR indicated LVN 1 marked Lactobacillus, Potassium Chloride ER, and Apixaban as administered at 9:00 a.m., on 6/4/2024. During a concurrent interview and record review on 6/4/2024 at 3:30 p.m., with LVN 1, Resident 209's MAR dated 6/4/2024 was reviewed. The MAR indicated Apixaban tablet 2.5 mg, Furosemide tablet 20 mg, and Lactobacillus one capsule were administered to the resident. LVN 1 stated it was a mistake to mark Apixaban, Lactobacillus and Potassium Chloride as administered to Resident 209. LVN 1 stated she thought that she gave these medications, but she did not. LVN 1 stated that not receiving the Potassium Chloride ER could cause Resident 209 low potassium levels leading to heart function complications. LVN 1 stated missing a dose of Apixaban for Resident 209 could increase the resident's risk for a stroke due to the risk for developing blood clots and deep venous thrombosis (DVT). 3. During an observation of medication pass by LVN 1 on 6/4/2024 at 9:45 a.m., LVN 1 was observed preparing the following medications for administration to Resident 211: a. One tablet of Docusate Sodium 100 mg. b. Four capsules of Potassium ER 10 mEq. During concurrent interview on 6/4/2024 at 9:45 a.m., LVN 1 stated Docusate Sodium 100 mg and Potassium ER 10 mEq were the only medications to administer to Resident 211 this morning. During an observation on 6/4/2024 at 10:00 a.m. in Resident 211's room, Resident 211 observed taking Docusate Sodium 100 mg and Potassium ER 10 mEq by mouth with water and Ensure (a supplement given as a nutrition substitute or meal replacement). During a review of Resident 211's Admission Record, dated 6/4/2024, the Admission Record indicated Resident 211 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery (a medical term for blood vessel supplying blood to the heart) with unstable angina pectoris (a medical condition in which heart does not get enough blood flow and oxygen), unspecified atrial fibrillation, edema (a medical term used to describe swelling caused by too much fluid in the body's tissues) unspecified, and encounter for palliative care (a medical term used for special care provided for people living with a serious illness.) During a review of Resident 211's Order Summary Report, dated 6/4/2024, the Order Summary Report indicated Resident 211 had the following medications to be administered at 9:00 a.m.: a. Amoxicillin 500 mg, give one capsule by mouth three times a day for ear infection for 10 days, ordered 5/29/2024, to start on 5/30/2024. b. Docusate Sodium 100 mg, one tablet by mouth two times a day for constipation, hold for loose stools, ordered on 5/29/2024. c. Furosemide 40 mg, one tablet by mouth one time a day for edema/HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/20/2024 to start on 5/30/2024. d. Potassium Chloride ER 10 mEq, four capsules by mouth one time a day for supplement ordered on 5/29/2024. During a concurrent interview and record review on 6/4/2024 at 4:33 p.m. with LVN 1, Resident 211's MAR dated from 5/30/2024 to 6/4/2024 for Amoxicillin and Furosemide administration was reviewed. The MAR for Amoxicillin administration indicated the Amoxicillin was not administered 5/30/2024 to 6/4/2024. LVN 1 stated she did not have Amoxicillin in stock for Resident 211 that was why this medication was not administered to Resident 211. LVN 1 stated Resident 211's infection would not be treated without Amoxicillin. LVN 1 stated she did not have Furosemide in stock for Resident 211 and that was why Furosemide was not administered from 5/30/2024 to 6/4/2024. LVN 1 stated Resident 211 was at an increased risk for edema and high blood pressure due to facility not having Furosemide available when needed. 4. During an observation of LVN 1's medication pass to Resident 210 on 6/4/2024 at 10:04 a.m., LVN 1 was observed preparing the following medications for administration to Resident 210: a. One tablet of Aspirin 81 mg. b. One tablet of Carvedilol (a medication used to treat high blood pressure and heart condition) 6.25 mg. c. One tablet of Ferrous Sulfate (a medication used to treat iron deficiency) 325 mg. d. One tablet of Furosemide 20 mg. e. One tablet of Hydralazine (a medication used to treat high blood pressure) 50 mg. f. One tablet of Enalapril (a medication used to treat high blood pressure) 5 mg. g. One tablet of Hydrocodone with Acetaminophen (a combination of two medications used to relieve pain) 10 mg/ 325 mg. h. One capsule of Pregabalin (a medication used to treat nerve pain) 100 mg. i. One tablet of Mirabegron (a medication used to treat symptoms of overactive bladder) ER 25 mg. j. One capsule of Duloxetine (a medication used to treat fibromyalgia [a medical condition characterized by musculoskeletal pain], depression and nerve pain) 20 mg. k. One tablet of Propranolol (a medication used to treat high blood pressure and heart condition) 20 mg. l. One capsule of Vitamin D (a supplement to treat vitamin D deficiency) 25 micrograms ([mcg] - a unit of measure for mass). During an interview on 6/4/2024 at 10:04 a.m. LVN 1 stated the 12 medications listed above were the only medications to administer to Resident 210 this morning. During medication pass observation on 6/4/2024 at 10:28 a.m., Resident 210 was observed taking all 12 medications listed above by mouth with water. During a review of Resident 210's Admission Record, dated 6/5/2024, the Admission Record indicated, Resident 210 was admitted to the facility on [DATE] with diagnoses including fibromyalgia, lumbar region radiculopathy (a medical condition described by symptoms of pain, tingling, numbness due to pinched nerve along lumbar region of the spine), other symptoms and signs involving the musculoskeletal system, unspecified diastolic (congestive) heart failure, essential (primary) hypertension, and depression. During a review of Resident 210's Order Summary Report, dated 5/30/2024, the Order Summary Report indicated Resident 210 had the following medications to be administered at 9:00 a.m.: a. Aspirin 81 one chewable tablet one time a day for CVA prophylaxis, monitor for bleeding, ordered on 5/30/2024. b. Carvedilol 6.25 mg to give one tablet by mouth two times a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024. c. Duloxetine HCl oral capsule delayed release 20 mg, give one capsule one time a day for depression manifested by verbalization of sadness, ordered on 5/30/2024. d. Enalapril oral tablet 5 mg, give one tablet by mouth one time a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024. e. Ferrous Sulfate oral tablet 325 (65) mg, give one tablet by mouth two times a day for supplement, ordered on 5/30/2024. f. Furosemide oral tablet 20 mg, give one tablet by mouth one time a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024. g. Hydralazine HCl oral tablet 50 mg, give one tablet by mouth three times a day for HTN, for SBP greater than 160 or DBP greater than 110, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024. h. Myrbetriq (Mirabegron) ER tablet 25 mg, give one tablet by mouth one time a day for overactive bladder ordered on 5/30/2024. i. Norco (Hydrocodone with Acetaminophen) oral tablet 10/325 mg, give one tablet by mouth every six hours as needed for severe pain (level 8 -10) not to exceed three grams ([gm] - a unit of measure for mass) of Acetaminophen in 24 hours, ordered on 5/30/2024. j. Pregabalin oral capsule 100 mg, give one capsule by mouth two times a day for neuropathy, ordered on 5/30/2024. k. Propranolol HCl oral tablet 20 mg, give one tablet by mouth two times a day for HTN, hold for SBP less than 110 or HR less than 60, ordered on 5/30/2024. l. Vitamin D3 oral capsule 50 mcg, give one capsule by mouth one time a day for supplement, ordered on 5/30/2024. m. Lidocaine external cream 5%, apply to affected site topically every 12 hours for arthritic pain, ordered on 5/30/2024. During an interview on 6/4/2024 at 4:22 p.m., LVN 1 stated she did not have Lidocaine cream in stock for Resident 210. LVN 1 stated Resident 210 would not receive topical treatment for pain, making her uncomfortable. 4. During an observation of medication pass by LVN 1 and concurrent interview on 6/4/2024 at 10:52 a.m., LVN 1 was observed preparing the following medications for administration to Resident 19: a. One tablet of Vitamin C 500 mg. b. One tablet of Aspirin 81 mg. c. Seven and a half (7.5) mL of Ferrous Sulfate elixir 220 mg/5 mL. d. One tablet of Metoprolol Tartrate 25 mg. e. One tablet of Furosemide 40 mg. f. One tablet of Docusate Sodium 100 mg. g. One tablet of Multivitamins with minerals. h. One tablet of Oxybutynin 5 mg. i. One packet of Pantoprazole 40 mg dissolved in 7.5 mL apple juice. j. One tablet of Zinc 50 mg supplement. LVN 1 stated Resident 19 has a G-tube, and the resident's medications must be crushed or be in liquid form to administer. LVN 1 stated the ten medications listed above were the only medications to administer to Resident 19 this morning. During an observation on 6/4/2024 at 10:52 a.m., LVN 1 was observed placing one of each medication listed above in individual plastic packet and started crushing each medication separately using a crushing device. LVN 1 was observed pouring each powdered (crushed) medication and liquid Ferrous Sulfate into an individual small plastic water cups. LVN 1 was observed adding 15 mL of water to each cup to dissolve medication. During an observation on 6/4/2024 at 11:02 a.m., before administering medications individually, LVN 1 was observed administering 30 mL of water onto the G-tube by pushing on a syringe plunger. LVN 1 was observed placing 60 ml syringe (a tube with a nozzle and piston or bulb, fitted with a hollow needle, used to inject or withdraw fluid in and out, used for cleaning wounds or body cavities) tip in the medicine cup and pulling syringe plunger to withdraw each medication (Vitamin C, Aspirin, Ferrous Sulfate, Metoprolol Tartrate, Furosemide, Docusate Sodium, Multivitamin with Minerals, Oxybutynin, Pantoprazole, and Zinc) individually and administering each medication, one by one, into Resident 19's G-tube by pushing the syringe plunger. Then, after administering above listed medications, LVN 1 was observed administering another 30 mL of water into Resident 19's G-tube by pushing on the syringe plunger. During a review of Resident 19's Admission Record, dated 6/4/2024, the Admission Record indicated, Resident 19 was admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including nonrheumatic mitral (valve) insufficiency (a medical condition where the valve between left heart chambers does not close properly), acute on chronic systolic (congestive) heart failure, atrial fibrillation, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, overactive bladder, and encounter for attention to gastrostomy. During a review of Resident 19's Order Summary Report, dated 6/5/2024, the Order Summary Report indicated Resident 19 had the following physician's orders for medications to be administered at 9:00 a.m. every day: a. Flushing G-tube with 15-30 mL of water before and after medication administration and with five mL of water between each medication every shift ordered on 5/19/2024. b. Vitamin C 500 mg one tablet via G-tube one time a day for supplement, ordered on 5/19/2024. c. Aspirin 81 mg chewable tablet to give one tablet via G-tube one time a day for CVA prophylaxis, ordered on 5/21/2024. d. Docusate Sodium 100 mg to give one tablet via G-tube two times a day for bowel management, hold if loose stools, ordered on 5/19/2024. e. Ferrous Sulfate oral solution 220 mg/5 mL, give seven and a half (7.5) mL via G-tube one time a day for supplement, ordered on 5/19/2024. f. Furosemide 40 mg to give one tablet via G-tube one time a day for HTN, hold if SBP less than 110, HR less than 60, ordered on 5/19/2024. g. Metoprolol Tartrate 25 mg, give one tablet via G-tube two times a day for HTN, hold if SBP less than 110, HR less than 60, ordered on 5/19/2024. h. Multivitamins, give one tablet via G-tube one time a day for supplement, ordered on 5/19/2024. i. Oxybutynin Chloride 5 mg, give one tablet via G-tube two times a day for overactive bladder, ordered on 5/19/2024. j. Pantoprazole oral tablet delayed release 40 mg, give one tablet via G-tube two times a day for gastroesophageal reflux disease ([GERD] - a medical condition in which the stomach contents move up into the esophagus [the part of the alimentary canal that connects the throat to the stomach]), ordered on 5/19/2024. k. Vitamin D3 oral capsule 50 mcg, give one capsule via G-tube one time a day for

A.Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for two of five sampled residents (Resident 22, and Resident 6) by: A1. Failing to ensure one of two sampled residents (Resident 22) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 22. A2. Failing to ensure one of two sampled residents (Resident 6) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 6. This deficient practice had the potential to result in use of unnecessary psychotropic drugs for Residents 22, and Resident 6 which can lead to side effects and adverse consequence such as a decline in quality of life and functional capacity. B. Failing to ensure, the residents did not develop an adverse effect (an undesired effect of a medication or other type of treatment) from receiving antipsychotic (medication used to treat mental health conditions like schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder ( a mental health condition that causes extreme mood swings that include emotional highs and lows), medications Seroquel, Risperdal and Ativan and for two of 18 sampled residents (Resident 25 and Resident 34). These deficient practices resulted in Resident 25 having increased confusion, becoming lethargic (sluggish) and difficult to arouse with low blood pressure of 96/59. Blood pressure reference range is 120/80. On 6/5/2024 at 9:16 a.m., Emergency medical services (EMS) were called and transferred Resident 25 to a general acute care hospital (GACH). Resident 25 was admitted to the GACH from 6/5/2024 to 6/11/2024 for evaluation and treatment. At the GACH's emergency room (ER) the resident was hypoxic (low blood oxygen level) upon arrival with high blood sugar of 209 milligrams per deciliter (mg/dL). Blood sugar reference range is 70 to 99 mg/dL. Findings: A1. During a review of Resident 22's Admission Record, the Admission Record indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 22's History and Physical (H&P), dated 5/10/2024, the H&P indicated, Resident 22 had no capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 22 required dependent assistance (helper does all of the effort) from two or more staff for shower, toileting hygiene, personal hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, moderate assistance (helper does less than half the effort) from one staff for eating, oral hygiene, and independent for rolling left and right. The MDS indicated, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed to chair transfer was not attempted due to medical condition or safety concerns. The MDS Section N (medications) indicated, Resident 22 was taking antipsychotic (a group of drugs that have been used for treating a variety of mental disorders), antianxiety (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress), and opioid (a class of drug used to reduce moderate to severe pain) medications. The MDS section E (Behavior) indicated, Resident 22 had no hallucinations (an experience involving the apparent perception of something not present) or delusions (an unshakable belief in something that's untrue) and no physical, verbal other behavioral symptoms. The MDS section E indicated, Resident 22 had no behavior or rejecting care or wandering. During a review of Resident 22's Preadmission Screening and Resident Review (PASARR), dated on 5/7/2024, the PASARR indicated, Negative level I screening, which indicated a level II mental evaluation was not required. During a review of Resident 22's Care Plan (CP), initiated on 5/11/2024, the CP Focus indicated, Resident 22 received a psychotropic medication (Seroquel-an antipsychotic medication to treat certain mental/mood disorders) related to behavior management. The CP Interventions indicated, administer psychotropic medication as ordered by physician and monitor for side effects. During a review of Resident 22's CP, initiated on 5/11/2024, the CP Focus indicated, Resident 22 received psychotropic medication (Ativan-medication to treat anxiety disorder) related to anxiety. The CP Interventions indicated, administer antianxiety medication as ordered by physician and monitor for side effects. During a review of Resident 22's Order Summary Report (OSR), dated 6/6/2024, the OSR indicated, to monitor for episodes of anxiety manifested by restlessness. Tally by hashmark every shift. Ordered on 6/1/2024. The OSR indicated, Ativan 0.5milligrams (mg - a unit of measure of weight) one tablet by mouth every six hours as needed for anxiety manifested by agitation. Ordered 5/7/2024. The OSR indicated, Quetiapine Fumarate (Seroquel) 25mg by mouth every 24 hours as needed for anxiety manifested by restlessness ordered originally 5/7/2024 and reordered on 5/27/2027. During a review of Resident 22's Medication Administration Record (MAR), dated from 5/7/2024 to 6/4/2024, The MAR indicated, Quetiapine Fumarate (Seroquel) 25 mg, Give one tablet by mouth in the afternoon for anxiety manifested by restlessness. The MAR indicated, there was charting Yes on restless behavior for 6/1/2024 (4:00 p.m.) and 6/3/2024 (4:00 p.m.). The MAR indicated, there was no other behavior charted except 6/1/2024 and 6/4/2024. During a review of Resident 22's MAR, dated 6/5/2024, the MAR indicated, Quetiapine Fumarate (Seroquel) 50 mg, Give one tablet by mouth two times a day for psychosis manifested by aggression and combativeness. The MAR indicated, Resident 22 refused Seroquel on 6/5/2024 (5:00 p.m.) and 6/6/2024 (5:00p.m.) and no behavioral episode were charted on the MAR. During a review of Resident 22's MAR, dated from 5/7/2024 to 6/4/2024, the MAR indicated, Ativan 0.5mg by mouth every six hours as needed was given on 5/7/2024 (8:46 p.m.), 5/15/2024 (3:55 p.m.), 5/16/2024 (7:33 p.m.), 5/25/2024 (6:27 p.m.), 5/26/2024 (4:03p.m.), 5/30/2024 (8:32 p.m.), and 5/31/2024 (9:33 p.m.) and charted as medication was effective. During a review of Resident 22's Hospice (comfort care for residents nearing end of life) RN Visit Note dated 6/4/2024, the Hospice RN Visit Note indicated, Resident 22 had behavioral issues at night per staff and staff reports that Ativan is not effective with calming the resident down. New orders from a doctor for Seroquel 50 mg twice daily for psychosis received. (Dose was increased). During a review of Resident 22's Hospice RN Visit Note, dated 6/7/2024, the Hospice RN Visit Note indicated, Resident 22 had no anxiety, depression, agitation, and other symptoms. The Hospice RN Visit Note indicated that staff reports that Resident 22 is still having a lot of behavioral issues, especially during bathing and diaper changes, not allowing staff to adequately clean her. Resident is also having a lot of agitation at night, attempting to get out for bed and calling out for her family and confusion in Narrative section. During a review of Resident 22's Interdisciplinary Care Conference ([IDT]-different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 5/10/2024 and signed 5/16/2024, the IDT care conference indicated, Gradual dose Reduction ([GDR]- the stepwise tapering of a dose to best diagnose whether a patient's symptoms or risks can be adequately managed through a lower dose or even if the medication can be eliminated) was not documented. The IDT care conference indicated that there were no behaviors noted at this time in the behavior problem/psychotropic medication section. During an interview on 6/6/2024, at 11:15 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, Resident 22 did not have many behavioral episodes and there was no reason to increase the dose for Seroquel. RNS 1 stated, staff should have documented the number of behavioral episodes, instead of yes or no. RNS 1 stated, irritation and aggression could be signs and symptoms of dementia and Alzheimer's disease. During a concurrent interview and record review on 6/6/2024, at 12:02 p.m., with the Medical Records Director (MRD), Resident 22's psychotropic medication informed consent, undated, was reviewed. The informed consent indicated, it was obtained from surrogate (one appointed to act in place of another) for Ativan 0.5 mg and Seroquel 25 mg without date. The MRD stated, the date of the consent obtained should be documented. The MRD stated, she could not find or provide the informed consent for the new order of Seroquel 50 mg. A2. During a review of Resident 6's Admission Record, the Admission Record indicated, Resident 6 was initially admitted to the facility on [DATE] and last admission was 4/3/2024 with diagnoses including recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia and Alzheimer's disease. During a review of Resident 6's H&P, dated 4/12/2024, the H&P indicated, Resident 6 had fluctuating capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 required maximal assistance (Helper does more than half the effort) from one staff for toilet hygiene, shower, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and moderate assistance (Helper does less than half the effort) from one staff for oral hygiene. The MDS indicated, eating was not attempted due to medical condition or safety concerns. The MDS section E(Behavior) indicated, Resident 6 did not have hallucination or delusions. The MDS section E indicated, Resident 6 did not reject the care. During a review of Resident 6's PASARR level I, dated 8/10/2023, the PASARR I indicated, positive level I screening which indicates a level II mental health evaluation was required. During a review of Resident 6's PASARR level II, dated on 8/10/2023, the PASARR II indicated, unable to complete level II evaluation. The individual has no serious mental illness. During a review of Resident 6's CP, initiated on 3/20/2023 and revised on 6/4/2024, the CP Focus indicated, Resident 6 received antianxiety medication (Ativan) related to anxiety manifested by verbalization of feeling anxious. The CP Interventions indicated, administer antianxiety medication as ordered by physician and monitor for side effects. During a review of Resident 6's CP, initiated 3/20/2023 and revised 6/4/2024, the CP Focus indicated, Resident 6 received antidepressant medication (Sertraline-medication to treat mood disorder/depression) related to depression manifested by verbalization of sadness. The CP Interventions indicated, administer antidepressant medication as ordered by physician and monitor for side effects. During a review of Resident 6's OSR, dated 6/6/2024, the OSR indicated, to monitor for depression. Tally episodes every shift for Sertraline use. Ordered 5/2/2024. The OSR indicated, to monitor for anxiety. Tally episodes every shift for Lorazepam (Ativan) use. Ordered on 5/2/2024. During a review of Resident 6's OSR, dated 6/6/2024, the OSR indicated to monitor for episodes of depression manifested by verbalization of feeling depressed. Tally episodes every shift for Sertraline use. Ordered 5/10/2024. The OSR indicated, to monitor for episodes of anxiety manifested by verbalization of feeling anxious. Tally episodes every shift for Lorazepam (Ativan) use. Ordered on 5/10/2024. During a review of Resident 6's MAR, dated 6/2024, The MAR indicated, Lorazepam (Ativan) 0.5mg, give one tablet by mouth every 12 hours as needed for anxiety manifested by verbalization of feeling anxious. During a review of Resident 6's MAR, dated 6/2024, the MAR indicated, Sertraline 50mg, give one tablet at bedtime enterally (in a way that involves putting food substances or medicine into someone's digestive system) for depression manifested by verbalizing feeling depressed. During a concurrent interview and record review on 6/6/2024, at 11:25 a.m., with the RNS 1, Resident 6's MAR, dated from 3/1/2024 to 6/4/2024 was reviewed. The MAR indicated, there was no documentation of anxiety and depression episodes under behavior monitoring sections. The RNS 1 stated, GDR should have been attempted because there was no behavioral episodes documented. During a concurrent interview and record review on 6/6/2024, at 12:07 p.m., with the MRD, Resident 6's Sertraline medication informed consent, undated, was reviewed. The informed consent indicated, there was no documentation about who consented, and it was left blank. The informed consent indicated, there was no date for when the informed consent was obtained. The MRD stated, the consent form was incomplete, and staff should have followed up. During a concurrent interview and record review on 6/6/2024, at 12:09 p.m., with the MRD, Resident 6's Ativan medication informed consent, dated 5/10/2024, was reviewed. The informed consent indicated, there was no documentation about who consented. and it was left blank. The MRD stated, the consent form was incomplete. During a review of Resident 6's IDT, dated 5/15/2024, the IDT Care Conference indicated, GDR was contraindicated at this time because the resident is on optimal dose and is clinically stable. During an interview on 6/7/2024, at 10:36 a.m., with the Director of Nursing (DON), the DON stated, the facility should have attempted GDR for Residents 22 and 6 based on their behavioral episodes. The DON stated, nursing staff should have checked the informed consent for its completion before giving medication. The DON stated, Resident 22 and Resident 6 had dementia and Alzheimer and staff should have considered and ruled out symptoms of those diagnoses before giving psychotropic medication. The DON stated, it could be considered as a chemical restraint if psychotropic medications were given unnecessarily, and its use should be minimized. During an interview on 6/10/2024, 2:30 p.m., with Psychiatry Physician Assistant (PPA) 1, PPA 1 stated, GDR should have been attempted if the resident did not have any behavioral episodes or a reasonable number of episodes such as two or three episodes per month to prevent giving psychotropic medications to the residents excessively. PPA 1 stated, the goal was giving psychotropic medication as little as possible to control the behavior. PPA 1 stated, psychosis behaviors were similar to behaviors of dementia and Alzheimer disease. PPA 1 stated, healthcare practitioners should rule out those diagnoses before giving psychotropic medications to avoid giving unnecessary medications. PPA 1 stated, residents could suffer from adverse reaction and side effects. B. Based on observation, interview, and record review the facility failed to ensure, the residents did not develop an adverse effect (an undesired effect of a medication or other type of treatment) from receiving antipsychotic (medication used to treat mental health conditions like schizophrenia [a serious mental disorder in which people interpret reality abnormal], bipolar disorder [a mental health condition that causes extreme mood swings that include emotional highs and lows]), medications Seroquel, Risperdal and Ativan for two of 18 sampled residents (Resident 25 and Resident 34). The facility failed to: 1. Ensure Resident 25, who had a physician's order to discontinue administration of Seroquel 25 milligrams ([mg]- a unit of measure of weight) dated 5/14/2024, did not receive Seroquel for an additional 20 days, a total of 20 extra doses from 5/14/2024 to 6/4/2024. 2. Ensure the licensed nurses monitored Resident 25 for psychotropic medication adverse effects including Seroquel and Depakote Sprinkles. 3. Ensure licensed staff followed the facility's policy titled Use of Psychotropic Medication, which indicated residents are not given psychotropic medication unless the medication is necessary to treat a specific condition and ensure Resident 25 was not prescribed Seroquel. 4. Ensure Resident 34 did not receive Risperdal and Ativan without indication for use and a obtain consent to receive these medications for one month from 5/9/2024 to 6/11/2024. These deficient practices resulted in Resident 25 having increased confusion, becoming lethargic (sluggish) and difficult to arouse with low blood pressure 96/59. Blood pressure reference range is 120/80. On 6/5/2024 at 9:16 a.m., Emergency medical services (EMS) were called and transferred Resident 25 to a general acute care hospital (GACH). Resident 25 was admitted to the GACH from 6/5/2024 to 6/11/2024 for evaluation and treatment. At the GACH's emergency room (ER) the resident was hypoxic upon arrival with high blood sugar of 209 milligrams per deciliter (mg/dL). Blood sugar reference range is 70 to 99 mg/dL. A review of the article titled Drugs and Supplements-Seroquel from the nationally recognized Mayo Clinic; indicated Seroquel may increase the amount of sugar in the blood. High blood sugar levels associated with Seroquel can, in some cases, be extreme and lead to a precipitous drop in blood pH (chemical balance in the blood that can cause harm if not in balance) levels (ketoacidosis - dangerous imbalance of chemicals in the blood), coma (where a person is unresponsive and cannot be woken), or death. https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/precautions B1.During a review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain caused by issues with the blood vessels that supply it), hemiplegia (severe weakness on one side of the body), hemiparesis (one sided weakness without complete paralysis), dementia (a group of symptoms that affects memory and thinking) without behavioral disturbance (aggression, anxiety) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25 did not exhibit behaviors such as hallucinating (seeing, hearing, touching, or smelling something that is not actually there), delusions, or physical (hitting, biting) and verbal (screaming at others) behaviors. The MDS indicated Resident 25 was moderately depressed. The MDS indicated Resident 25 required maximal assistance from staff for transferring from chair to bed, rolling in bed left and right and required moderate assistance for toileting, bathing, and dressing. During a review of the H&P dated 4/14/2024, the H&P indicated Resident 25 did not have the capacity to make medical decisions. During a review of the psychiatrist's (a medical practitioner that specializes in the diagnosis and treatment of mental illness) note dated 5/14/2024, the psychiatrist's note indicated Resident 25 had a diagnosis of anxiety and treatment for anxiety and psychosis and had episodes of disruptive behaviors or behaviors that interfere with activities of daily living, restlessness and constant attempts to get out of bed, was difficult to redirect, easily frustrated and agitated, constant fidgeting and unable to keep still, inability to relax, frequent shakes and tremors, and had persistent sad facial expressions. The Psychiatrist's note indicated to start Depakote Sprinkles (medication used to treat bipolar disorder) 25 mg twice a day, Lexapro (medication used to treat depression) 10 mg once a day, and to continue Ativan (medication used for anxiety and insomnia) 0.5 mg every six hours as needed for 14 days then re-evaluate. The Psychiatrist's note indicted to discontinue Seroquel on 5/14/2024. During a review of the OSR dated 6/6/2024, the OSR indicated Resident 25 had the following physician's orders: 1. Lexapro oral tablet 10 mg one time a day for depression manifested by (m/b) low interest in activities of daily living (ADL's) ordered on 5/15/24. 2. Monitor for episodes of depression m/b low interest in ADL's, tally by hashmark every shift for Lexapro ordered on 5/21/2024. 3. Depakote Sprinkles delayed release oral capsule 125 mg by mouth two times a day for dementia m/b constantly getting up ordered on 5/14/2024. 4. Seroquel 25 mg by mouth at bedtime for depression m/b verbalization of feeling sad. During a review of Resident 25's MAR for May 2024, the MAR indicated there was an order for Seroquel 25 mg one tablet by mouth at bedtime for depression manifested by verbalization of feelings of sadness to start on 5/2/2024 with a discontinue date of 6/4/2024. The MAR indicated Resident 25 had been receiving Seroquel 25 mg from 5/15/2024 until 6/3/2024, after it was discontinued. During a review of the MAR for the month of June 2024 there was no documentation to indicate Resident 25 was monitored for adverse effect from Seroquel including anticholinergic effects (dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating), akathisia ( feeling of muscle quivering, restlessness, and inability to sit still, sometimes a side effect of antipsychotic or antidepressant medication), parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down) cerebrovascular ([CVA]- stroke) event, neuroleptic malignant syndrome ([NMS] a life-threatening idiosyncratic (having strange or unusual habits, ways of behaving, or features)reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction) tardive dyskinesia (condition affecting the nervous system, often caused by long-term use of some psychiatric drugs) and excessive sedation (a state of calm or sleep). During an observation on 6/4/2024 at 7:41 a.m., Resident 25 was observed sleeping in bed. During an interview on 6/5/2024 at 7:40 a.m. in Resident's 25 room, Licensed Vocational Nurse (LVN7) stated that the resident was always very sleepy and was hard to wake up. During a concurrent observation and interview on 6/5/2024 at 8:10 a.m., Certified Nurse Assistant (CNA 6) stated she was not sure why Resident 25 had been getting very sleepy every day and was not given breakfast because CNA 6 could hardly keep the resident awake. During an interview on 6/6/2024, at 11:15 a.m., Registered Nurse Supervisor (RNS 1) stated that it was the responsibility of the nurses to carry out doctor's orders. During a concurrent interview and record review of the OSR on 6/10/2024 at 9:54 a.m. with RNS 1, RNS 1 stated that was the only order for monitoring the side effects of taking psychotropic medication. RNS 1 stated Resident 25 was supposed to have an order to monitor Resident 34 for adverse effects of Seroquel when the medication was ordered. During an interview on 6/10/2024 at 2:12p.m., PPA 1, PPA 1 stated on 5/14/2024 Resident 25's Seroquel was discontinued, and the resident was started on Depakote, which is a mood stabilizer, for his behaviors. PPA 1 stated he tries to avoid using antipsychotic medications, such as Seroquel, for residents with dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) unless the resident is having psychosis with delusions such as the resident thinking the facility is trying to poison their food and would weigh the risks and benefits, but it would depend on the resident. PPA 1 stated if a medication is not necessary, he would discontinue it. PPA 1 stated antipsychotic medications are not necessary for behaviors such as confusion as it is not a sign and symptoms of psychosis such as delusions and hallucinations. PPA 1 stated if the resident is confused due to dementia, a mood stabilizer such as Depakote is more appropriate. During a concurrent interview and record review on 6/11/2024 at 12:49 p.m., PPA 1 stated the order for Seroquel 25 mg on the May MAR should have been discontinued effective 5/14/2024 but was missed and he (PPA 1) should have placed an order to discontinue this medication. PPA 1 stated for residents with dementia who are trying to get out of bed, Depakote is a better medication to manage the behavior than antipsychotics such as Seroquel. According to the National Institute of Health ([NIH]- the [NAME] medical research agency), use of an antipsychotic medication in residents with dementia is limited, due to its significant adverse effects. The NIH indicated antipsychotics should be used as a last resort. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994396 During a concurrent interview with the DON on 6/11/2024 at 4:45p.m and a record review of the Behavioral Management note (group of staff that meets monthly consisting of Social Service Designee(SSD), MDS nurse, Activities Director, Dietician and Pharmacy Consultant) dated 5/14/2024, the DON stated on that it was documented to discontinue the Seroquel 25 mg in the Behavioral Management note on 5/14/2024, but it was not carried out or followed up on. On 6/11/2024 at 4:48p.m, during a concurrent interview and review of Resident 25's MAR for June 2024 with the DON, the DON stated the physician's order to discontinue Seroquel on 5/14/2024 was not carried over to MAR. During a review of the PPA 1's note dated 5/14/2024, PPA' 1s note indicated Resident 25 was reported to be very sleepy and that it could have been caused by the adverse effects of the Seroquel, which had not been monitored. During a review of the Change of Condition ([COC]- facility's documentation of a resident's sudden change from baseline) form dated 6/5/2024, the COC indicated Resident 25 was observed very difficult to arouse, deep sternal (bone in the middle of the chest) rub (a lifesaving painful technique used to get a response from an unresponsive person) was initiated, but the resident was not responding and appeared very lethargic with low blood pressure 96/59. During a review of Resident 25's GACH emergency record (ER) notes dated 6/5/2024, the record indicated Resident 25 was admitted due to increased confusion, immediately falls back to sleep, obviously weak and lethargic. During a review of the facility's P&P titled, Dementia Care, revised 12/19/2022, the P&P indicated it is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. During a review of the facility's P&P titled, Use of Psychotropic Medication, revised 12/19/2022, the P&P indicated residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The indications for initiating, withdrawing, or withholding medication(s), as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment .identification of underlying causes (when possible). The indications for use of any psychotropic frug will be documented in the medical record .psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed .nonpharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Other medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medications but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication consistent with accepted clinical standards of practice. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to during the pharmacist's monthly medication regimen review .in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan of care. During a review of the facility's P&P titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 12/19/2022, the P&P indicated it is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free form unnecessary drugs. Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Indication for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. B2. During a review of Resident 34's Admission Record, the Admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses including dementia without behavioral disturbances, psychotic disturbances (severe mental disorder that causes abnormal thinking and perceptions), mood disturbances (mood disorders that affect a person's emotional state and quality of life) and anxiety (an intense excessive and persistent worry and fear about everyday situations During a review of Resident 34's Progress Notes, dated 5/8/2024, the Progress Note indicated Resident 34 was admitted to the facility with diagnoses of weakness, hypertension and rule out dementia. The Progress Note indicated Resident 34 was alert and oriented to name, place, and time and was able to make needs known. The Progress Notes indicated Resident 34 was pleasant upon approach, had a pleasant mood, and no unwanted behavior was witnessed. The Progress Notes indicated Resident 3[TRUNCATED]

Based on interview and record review, the facility failed to contact and notify the hospice agency (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) that one of five sampled residents (Resident 1) had missed dialysis treatments (mechanical process of removing waste products and toxins, and excess fluid from the body) on [DATE], [DATE], [DATE] and [DATE] due to issues with transportation from the facility to the dialysis center. This deficient practice resulted in Resident 1 being sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 ultimately expired (died ) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Cross reference F698 Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 milliequivalent per liter (mEq/L, a unit of measure) (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated ,d+[DATE], the Order Summary Report indicated orders were entered on [DATE] for the following: 1. Continue orders for 45 days unless otherwise specified. 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the HSPC for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the hospice agency that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the Hospice Agency Communication log indicated the Hospice Agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated ,d+[DATE], the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB (shortness of breath) due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium (a substance that is needed by all tissues in the body) level of 8.2 mEq/L and a hyperkalemia (high potassium level that can cause life-threatening abnormal heart beats) order set was initiated (Resident 1 received medications to try to lower the potassium level), Resident 1 ' s SOB was likely due to hypervolemia (fluid overload, too much fluid volume in the body), and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively) but lifesaving medications (names of medications not specified) were to be given. Resident 1 received a total of 5 rounds of life saving medications in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge Summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 2. Fluid overload due to missed dialysis 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m., Resident 1 ' s family member (FM1) stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the HSPC administrator (ADM2) stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the HSPC was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the HSPC was informed [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 days later ([DATE]). During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them on what needed to be done. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the HSPC of the transportation issues on her shift [DATE]. During a review of the facility ' s policy and procedure (P/P) titled Notification of Changes revised [DATE], the P/P indicated the facility must promptly inform .the resident ' s physician when there is a change requiring notification. During a review of the facility ' s P/P titled Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received dialysis (process of mechanically removing waste products/ toxins and excess fluid from the body) according to the physician ' s orders and plan of care for dialysis management by failing to: 1. Ensure Resident 1 did not miss three scheduled dialysis treatments ([DATE], [DATE], and [DATE]) and one make-up dialysis treatment ([DATE]). 2. Notify the hospice (health care service that focuses on the care, comfort, and quality of life of a person with serious illness who is approaching the end of life) agency overseeing Resident 1 ' s care while in the facility when Resident 1 missed his first dialysis treatment in the facility ([DATE]). The hospice agency was not being notified of each missed dialysis treatment until [DATE] after Resident 1 had missed three dialysis treatments ([DATE], [DATE], and [DATE]). Resident 1 ' s last dialysis was on [DATE]. These deficient practices resulted in Resident 1 getting sent out via 911 (emergency medical transport) to a general acute care hospital (GACH) for emergency dialysis on [DATE]. Resident 1 was found to have severe hyperkalemia (high potassium [a substance that is needed by all tissues in the body] levels that can cause life-threatening abnormal heart beats) at a level of 8.2 milliequivalent per Liter (mEq/L, a unit of measure. A dialysis patient ' s optimal range of blood potassium levels is 3.5 mEq/L to 5.5 mEq/L), shortness of breath (SOB, trouble breathing), and hypervolemia (fluid overload, too much fluid volume in the body). Resident 1 expired (died ) at 9:32 p.m. (3 hours 23 minutes after arriving to the GACH ' s Emergency Department) on [DATE] after receiving multiple rounds of life saving medications (names of medications not specified). Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted on [DATE] with diagnoses of dependence on renal (kidney) dialysis and hypertensive heart disease (high blood pressure) without heart failure (heart is unable to pump blood around the body properly). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 was cognitively (thinking, reasoning, or remembering) intact. The MDS indicated Resident 1 was receiving dialysis. During a review of Resident 1 ' s last laboratory tests (diagnostic tests from a sample of blood), dated [DATE], Resident 1 ' s potassium level was 5.6 mEq/L, (Normal range 3.5 mEq/L to 5.5 mEq/L). During a review of Resident 1 ' s Discharge Order from the GACH dated [DATE], the Discharge Order indicated Resident 1 was to discharge back to the facility under the hospice agency and to receive antibiotics (medicines that fight bacterial infections) for two weeks during his dialysis treatments. During a review of Resident 1 ' s (readmission) Order Summary Report dated ,d+[DATE], the Order Summary Report indicated orders were entered on [DATE] for the following: 1. Continue orders for 45 days unless otherwise specified. 2. Dialysis: Tuesdays, Thursdays, Saturdays. Chair time 4:45 a.m., transportation pick up time 3:45 a.m. During a review of Resident 1 ' s care plans, an untitled care plan initiated on [DATE] indicated Resident 1 was receiving dialysis every Tuesday, Thursday, and Saturday with a dialysis chair time (appointment time) of 4:45 a.m. and was to be picked up by transportation at 3:45 a.m. The care plan goal indicated Resident 1 ' s clinical condition was to be managed. The care plan interventions included communicating with the dialysis center and the hospice agency as needed and to coordinate transportation as needed with the transportation company and the hospice agency. During a review of Resident 1 ' s Physicians ' Certification for Hospice Benefits dated [DATE], the Physician ' s Certificate indicated Resident 1 was admitted to the facility (on [DATE]) under a hospice agency ' s care and the diagnosis that qualified him for hospice was hypertensive heart disease without heart failure. Resident 1 was admitted to hospice under routine medical care. The Physician ' s Certificate indicated the facility staff were informed and aware to call the hospice agency for any concerns or changes of condition. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Saturday), the progress note indicated Resident 1 ' s scheduled transportation company did not pick him up for his scheduled dialysis treatment and a make-up dialysis treatment was scheduled for [DATE] (Monday). The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE], the progress note indicated Resident 1 again missed his make-up dialysis appointment due to transportation issues. The Nurse Progress Note did not indicate the hospice agency was notified of Resident 1 not receiving his dialysis treatment on [DATE]. During a review of Resident 1 ' s Nurses Progress Notes dated [DATE] (Tuesday), there was no mention in the progress notes that Resident 1 missed his scheduled dialysis appointment again or that the hospice agency was notified. During a review of the Physician ' s Progress Note dated [DATE], the Physician ' s Progress Note indicated Resident 1 wished to continue dialysis treatment while on hospice and staff were to communicate with the hospice agency for dialysis treatment. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE], the Hospice Agency Communication Log indicated the facility informed the hospice agency that Resident 1 had missed dialysis (this is the first communication to the hospice agency regarding missed dialysis) due to transportation issues and Resident 1 had not received dialysis since [DATE] but Resident 1 was currently stable and dialysis was scheduled for the next morning ([DATE], Thursday). During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 1:35 p.m., the Hospice Agency Communication log indicated the facility informed the HSPC that Resident 1 missed dialysis again that morning due to transportation issues. During a review of Resident 1 ' s Hospice Agency Communication log dated [DATE] at 2:24 p.m., the Hospice Agency Communication log indicated the hospice agency reached out to Resident 1 ' s dialysis center to try to schedule an emergency dialysis treatment but the dialysis center informed the hospice agency that Resident 1 did not qualify for dialysis at their center, Resident 1 required emergency dialysis due to missing more than two ([DATE], [DATE], [DATE] and [DATE]) consecutive dialysis appointments. The facility was instructed to call 911 (an emergency service) to send Resident 1 to the GACH. During a review of Resident 1 ' s Hospice Agency Communication Log dated [DATE] at 2:53 p.m., the Hospice Agency Communication Log indicated the hospice agency spoke to the facility again and reiterated the urgency and instructed the facility to call 911. During a review of Resident 1 ' s Change of Condition Evaluation dated [DATE], the Change of Condition Evaluation indicated the hospice agency recommended sending Resident 1 to the GACH for dialysis after Resident 1 missed three consecutive, scheduled dialysis treatments ([DATE], [DATE], and [DATE]). During a review of Resident 1 ' s Order Summary Report dated ,d+[DATE], the Order Summary Report indicated an order dated [DATE] indicating Resident 1 may transfer to the GACH due to missed dialysis ([DATE], [DATE], [DATE] and [DATE]) with a seven-day bed hold (reserve resident ' s bed while receiving care in the hospital). During a review of Resident 1 ' s GACH ED (Emergency Department) Note dated [DATE], the GACH ED Note indicated Resident 1 arrived at the ED at 6:09 p.m. with a chief complaint of missing dialysis for one week and was last dialyzed on [DATE]. The ED Note indicated Resident 1 presented with worsening SOB due to the missed dialysis. The GACH ED Note indicated that Resident 1 informed the ED physician that there was trouble with his transportation to the dialysis center and that was why he had missed dialysis for one week. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 ' s laboratory results came back with a potassium level of 8.2 mEq/L and a hyperkalemia order set was initiated (Resident 1 received medications to try to lower the potassium level); Resident 1 ' s SOB was likely due to hypervolemia; and the plan was to admit Resident 1 to the intensive care unit (ICU a higher level of care for critically ill patients) for emergency dialysis. During a review of Resident 1 ' s GACH ED Noted dated [DATE], the GACH ED Note indicated before getting transferred to the ICU, Resident 1 ' s heart rate began to drop to the 30 ' s (very low heart rate, normal range 60 to 100 beats per minute) and he became unconscious. During a review of Resident 1 ' s GACH ED Note dated [DATE], the GACH ED Note indicated Resident 1 had refused intubation (insertion of a breathing tube) and cardiopulmonary resuscitation (CPR chest compressions done when the heart stops beating or beats ineffectively), but life saving medications were to be given. Resident 1 received a total of 5 rounds of life saving medications (names of medications not specified) in the ED before he finally went asystole (no pulse, resident expired). During a review of Resident 1 ' s GACH Discharge Summary dated [DATE], the Discharge Summary indicated Resident 1 ' s admitting diagnoses were as follows: 1. Severe hyperkalemia secondary to missed dialysis 2. Fluid overload due to missed dialysis 3. Uremia (a condition involving abnormally high levels of waste products in the blood) secondary to missed dialysis 4. Acidosis (buildup of acid in the blood stream) secondary to missed dialysis After multiple rounds of life saving medications (names of medications not specified) in the ED, Resident 1 had asystole and expired at 9:32 p.m. on [DATE]. Reason for death was cardiopulmonary arrest. Discharge diagnoses were as follows: 1. Cardiopulmonary arrest 2. Severe hyperkalemia 3. Missing dialysis During an interview on [DATE] at 11:53 a.m. with Resident 1 ' s family member (FM1), FM1 stated Resident 1 had been released from the GACH on [DATE] on hospice. FM1 stated Resident 1 chose to be on hospice because Resident 1 was getting gangrene (death of body tissue due to a lack of blood flow or serious bacterial infection) infections on his limbs (hands, legs, feet) and did not want to get any more amputations (removal of limbs) but Resident 1 did not want to stop his dialysis treatments while on hospice. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated he was not aware that Resident 1 missed multiple dialysis treatments ([DATE], [DATE], [DATE]) besides the one on [DATE]. FM1 stated he found out when Resident 1 went back to the GACH on [DATE]. FM1 stated the ED physician had called him and informed him that Resident 1 had missed a week of dialysis appointments due to transportation issues and that Resident 1 ' s laboratory results in the ED had come back catastrophic (involving or causing great damage or suffering) and Resident 1 ' s potassium level was twice what it should be. During an interview on [DATE] at 11:53 a.m. with FM1, FM1 stated the next call he received was from the ED physician telling him that Resident 1 had passed away. FM1 stated the hospice agency called FM1 after his death and said it was in the orders that Resident 1 was to continue dialysis at the facility and the hospice agency was not aware that the facility was having issues with transportation or why the resident missed all those dialysis days ([DATE], [DATE], [DATE], [DATE]). During an interview on [DATE] at 12:13 p.m., the hospice agency administrator (ADM2), ADM2 stated Resident 1 ' s wishes were to continue dialysis treatment while on hospice and that was to be respected. ADM2 stated the hospice agency was first alerted on [DATE] that there were issues going on with Resident 1 ' s transportation to the dialysis center and Resident 1 had a dialysis appointment the next day for [DATE]. ADM2 stated the hospice agency was informed on [DATE] that Resident 1 missed his dialysis appointment again that day and the facility was directed to call 911 to send Resident 1 to the GACH for emergency dialysis. During an interview on [DATE] at 12:13 p.m., ADM2 stated the protocol for residents on hospice while residing in a facility was the facility was to inform the hospice agency with any issues, right away so the hospice agency could intervene and be aware. ADM2 stated the hospice agency should have been made aware when Resident 1 missed the first dialysis on [DATE] but they were not notified until 4 days later ([DATE]). During an interview on [DATE] at 1:16 p.m., a registered nurse supervisor (RN1) stated Resident 1 was supposed to attend dialysis appointments on Tuesdays, Thursdays, and Saturdays as ordered by the physician. RN1 stated Resident 1 missed dialysis on [DATE], [DATE] (make up dialysis for [DATE]), [DATE], and [DATE] due to the transportation company not picking up the resident. During an interview on [DATE] at 1:16 p.m. with RN1, RN1 stated when he informed Resident 1 ' s attending physician (MD1) on [DATE] regarding the missed dialysis she told RN1 to contact the hospice agency to manage Resident 1 ' s care. RN1 stated the hospice agency was informed on [DATE] regarding the missed dialysis sessions. RN1 stated when Resident 1 missed dialysis again on [DATE], he reached out to the hospice agency and was told to send Resident 1 to the GACH. During an interview on [DATE] at 11:17 a.m., the social services director (SSD) stated if the facility was having issues with transportation for dialysis and the resident was on hospice, facility staff should inform the hospice company so they could coordinate another transportation company to ensure the resident made it to their dialysis appointments. During an interview on [DATE] at 11:17 a.m., with the SSD, the SSD stated when a resident was on hospice, facility staff have to inform the hospice agency of any issues the resident was encountering right away, and the hospice agency should have been made aware of the first missed dialysis on [DATE] on that same day. During an interview on [DATE], at 11:17 a.m., with the SSD, the SSD stated she was not informed of the number of missed dialysis appointments until [DATE] and if she had been aware prior to that day, she would have helped contact the hospice agency sooner for assistance. The SSD stated it was not okay for a resident to miss their dialysis appointments. The SSD stated dialysis was a very important treatment and the potential consequence of a resident missing dialysis was death. During an interview on [DATE] at 2:36 p.m., with licensed vocational nurse (LVN1), LVN 1 stated when Resident 1 was having problems with transportation on Saturday, [DATE], and missed dialysis, she did not contact the hospice agency. LVN1 stated on Monday, [DATE] when Resident 1 missed his make-up dialysis, she did not inform the hospice agency again. LVN1 stated facility staff must notify the hospice agency right away, if a resident on hospice was having any issues, so they could get orders from them. During an interview on [DATE] at 3:04 p.m., the Minimum Data Set nurse (MDSN), MDS N stated the facility nurses should have informed the hospice agency immediately that Resident 1 had missed a dialysis appointment (on [DATE]). The MDSN stated it was very important that the facility had good communication with the hospice agency, so they could be informed of what was going on with the resident because all orders for hospice patients needed to go through the hospice agency. The MDSN stated the importance of ensuring a resident received their dialysis treatments was a matter of life or death. During an interview on [DATE] at 4:12 p.m., with the Director Of Nursing (DON), the DON stated she was not informed of the issues regarding Resident 1 missing dialysis until [DATE] and she told RN1 (on [DATE]) to communicate with the hospice agency about what was going on. The DON stated when RN1 communicated with the hospice agency on [DATE], the hospice agency made the decision to transfer Resident 1 to the GACH for emergency dialysis. The DON stated she was notified at 2 a.m. (on [DATE]) that Resident 1 had expired in the GACH (on [DATE] at 9:32 p.m.). During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated that all decisions for residents on hospice needed to go through the hospice agency, and the hospice agency should have been informed right away when Resident 1 was not making his dialysis appointments due to transportation issues. During an interview on [DATE] at 4:12 p.m., with the DON, the DON stated the risks of not receiving dialysis treatments were fluid overload, respiratory distress, toxin (a poisonous substance) build up in the body, altered level of consciousness (confusion) and death. The DON stated the facility management should have been notified of transportation issues right away so they could help the nurses make the arrangements to get the residents to their dialysis appointments. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she was assigned to Resident 1 on [DATE] (Resident 1 ' s scheduled dialysis day). LVN2 stated Resident 1 ' s transportation to dialysis was late on [DATE]. LVN2 stated Resident 1 was finally picked up late, at 5:40 a.m. (regular pick-up time was 3:35 a.m.) by the transportation company to go to dialysis. During an interview on [DATE] at 8:36 a.m., with LVN2, LVN2 stated she later learned that the dialysis center had sent Resident 1 back to the facility on [DATE] because he was late and missed his dialysis chair time. LVN2 stated she did not inform the hospice agency of the transportation issues during her shift on [DATE]. During a review of the facility ' s P/P titled, Coordination of Hospice Services dated [DATE], the P/P indicated when a resident chose to receive hospice services, the facility staff was to coordinate and provide care in cooperation with hospice staff to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The P/P indicated the facility was to contact and communicate with hospice staff regarding any significant changes in the resident ' s status, clinical complications, or emergent situations. During a review of the HSPC Contract Agreement with the facility for Resident 1 dated [DATE], the Contract Agreement indicated the HSPC was to be notified if there were clinical complications that suggested a need to alter the resident ' s plan of care and/ or a need to transfer the patient from the facility.

Based on observation, interview and record review, the facility failed to evaluate and supervise one of four residents (Resident 4) when drug paraphernalia (equipment to use drugs) was found in Resident 4's room. The facility failed to: 1. Ensure Resident 4 was prevented from procuring (an effort of getting something) and using illicit (addictive and illegal) drugs while at the facility by monitoring and supervision of Resident 4. 2. Ensure staff assessed, monitored, and educated Resident 4 about adverse interaction and adverse effects of amphetamine (central nervous system stimulant that causes hypertension, increased heart rate with increased feelings of energy) and other illicit drugs. 3. Ensure Resident 4's primary care physician (PCP) was informed of Resident 4's possible use of illicit drugs the day of the incident, 9/18/2023. 4. Failed to implement the facility's Policy and Procedure (P/P) on Resident Possession and Use of Illegal Substances dated 12/19/22, by determining how Resident 4 have gained access to illegal substance brought into the facility, by not contacting the law enforcement, and not providing additional monitoring and supervision including Resident 4's supervised visitation. 5. Failed to report the allegation of use of illicit drugs with paraphernalia in the facility to the California Department of Health (CDPH), and local law enforcement. These failures had the potential to cause serious harm and a causative factor in Resident 4 complaining of headache, left sided chest pain, weakness, high blood pressure of 227/121 millimeters of mercury ([mmHg] high blood pressure is greater than 140/90) and was transferred to General Acute Care Hospital (GACH) via 911 (emergency number) on (9/21/2023). On 10/8/2023 at 4:47 p.m., the Registered Nurse Supervisor (RNS), Licensed Vocational Nurse (LVN) and Administrator (over the phone) were notified of an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility's failure to ensure Resident 4 was prevented from procuring and using illicit drugs while residing on the facility. The facility's RNS, LVN and Administrator were notified of the seriousness of all residents' health and safety being threatened by failing to evaluate and supervise one of four residents (Resident 4) when drug paraphernalia (equipment to use drugs) was found in Resident 4's room. An IJ removal plan (an intervention to immediately correct the deficient practices) was requested. On 10/9/2023 at 5:45 p.m., the facility submitted an acceptable IJ Removal Plan and was informed the plan was approved. After onsite verification if the IJ Removal plan was implemented through observations, interviews, and record reviews, the IJ was removed on 10/9/2023 at 5:45 p.m., in the presence of the Administrator and Resource Nurse Consultant. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. On 10/5/23, a physical assessment and change of condition was completed by licensed nurse for Resident 4. On 10/5/23, Resident 4 physician was notified of the resident's toxicology (test that checks for drugs or other chemicals) results. MD gave order to discontinue out on pass (temporary permission of a resident to leave the facility in a specified time). On 10/6/23, Norwalk Police Department were notified. On 10/6/23, Resident 4 was provided and educated on the facility policy on the Possession and Use of Illegal Substances by the administrator. On 10/5/23, Resident 4 was placed on monitoring for procurement and continued use of illicit drugs. On 10/6/23, a smoking evaluation was completed by licensed nurse and Resident 4 was identified as a supervised smoker. On 10/6/23, an Interdisciplinary Team (IDT) meeting was conducted for Resident 4 and care plan was updated. On 10/6/23, the Social Service obtained and arranged another dialysis (dependent on a machine used filter to clean the blood to remove harmful substances from the body the body) transportation for the resident. On 10/6/23, IDT members (Minimum Data Set Nurse, Activity staff , Dietary staff , Social Service Director (SSD), Administrator and Director of Nursing (DON) met with Resident 4 regarding use of illicit drug. Resident 4 denied the use of the illicit drugs. Education provided on policy and procedure titled Resident Possession and Use of Illegal Substance and risks and benefits provided. 10/9/23 the IDT reviewed assessments for September 2023. There were no identified symptoms related to the use of illegal substance. 10/9/23, Administrator and Resource Nurse interviewed two male residents. Both denied of knowing any resident/s' who use illicit drugs nor any visitor that brings illegal substances to residents in the facility. The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 10/8/2023) On 10/8/2023 the Resource Nurse Consultant provided re-education to licensed staff on the identification and prevention of drug abuse in the facility, resident monitoring, and assessment after out on pass and other medical and or personal outside appointments. On 10/8/23, the Regional [NAME] President of Operations provided re-education to the Administrator and Director of Nurses regarding investigation and reporting of unusual occurrences to the local enforcement, local ombudsman, and state agency. On 10/8/23, the Resource Nurse Consultant conducted an in service to staff on Policy and Procedure on Resident Possession and Use of Illegal Substances and Notification of Changes with emphasis on initiating and completing a documentation of resident's changes and notify attending physician and resident's representative to staff. The Director of Nursing (DON) or designee will audit residents with change of condition daily for signs of illicit drug use. The Administrator/Designee will conduct observation rounds to residents daily for suspicious drug paraphernalia. On 10/8/23, the Administrator completed observation rounds for suspicious drug and/or paraphernalia, none found. The SSD or designee will check current residents when having visitor in the facility to ensure resident is safe. The Licensed Nurse will assess for change in condition upon return from out on pass or therapeutic leave. The Residents and/or Resident representatives will be interviewed and ask for any items such as food, medication/drugs, clothing by DON or designee upon return from out on pass or therapeutic leave for labeling and storage. Any unusual items found will be reported to Administrator, DON immediately for prompt follow-up and intervention. The Administrator, DON and Activity Director will hold a Resident Council ((organized group of residents who meet regularly to discuss and address concerns about their rights, and care in the facility) meeting on 10/9/23 with current residents regarding the policy of Resident Possession and Use of Illegal Drugs and the process to take place when a resident returned from out on pass or therapeutic leave to determine items for storage and labeling. The Psychologist health professional who help people cope with mental health conditions ) will conduct a visit on 10/10/23 for psychological evaluation for Resident 4. A Quality Assurance Performance Improvement (measures compliance against certain necessary standards) has been initiated to report on the above monitoring and auditing procedures. All findings from the Performance Improvement Project will be presented at the monthly Quality Assessment and Assurance meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Findings: During a review of Resident 4's Admission Record (face sheet), the face sheet indicated Resident 4 was admitted on [DATE] the facility with diagnosis that included low back pain, hypertension (blood pressure higher than normal), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids in a permanent basis), dependence on renal dialysis and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest and can interfere with one's day to day activities). During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/7/2023, the MDS indicated Resident 4 had intact cognitive (ability to learn, remember, understand, and make decision) ability for daily decision making, able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 4 requires extensive one-person physical assist to complete his activities of daily living (ADLs) task such as bed mobility, transfer and dressing. During a review of Resident 4's medical record titled Change of Condition (COC) form, dated 9/21/2022 at 4:35 p.m., the COC indicated Resident 4 was transferred to a GACH via 911 due to Resident 4 complaining of headache, left sided chest pain, the pain level was a 5/10 on the pain scale (pain scale with 0 as no pain and 10 as worse possible pain) weakness, and high blood pressure of 227/121 mmHg. Resident 4 received hemodialysis (on 9/20/2023. During a review of GACH discharge summary dated 9/22/2023 for Resident 4, emergency department visit on 9/21/2023 the discharge summary indicated the resident was presented with chest pain, hypertension, and elevated B-type natriuretic peptide (BNP-blood test indicating the heart has to work harder to pump blood, this test is important tool for a physician to diagnose heart failure quickly). The discharge summary indicated that Resident 4 blood pressure upon discharge from GACH was 144/83 mmHg which was still above reference range. During a record review of Resident 4's Lab Results Report collected on 9/28/2023 at 6:30 a.m. and reported on 10/5/2023 at 6:04 pm., the Lab Results Report indicated Resident 4 tested positive for amphetamine through a urine drug screen done in the facility. During an interview on 10/4/2023 at 4:22 p.m., with Resident 4, Resident 4 stated he has been using drugs (crystal meth and amphetamine) for years now. Resident 4 stated the last time he used illicit drugs was two weeks ago (9/18/23). Resident 4 stated it happened inside his room early in the morning. Resident 4 stated he was holding the glass pipe (paraphernalia) and lit it when it suddenly got hot and he dropped the glass pipe on the floor, causing it to break. Resident 4 stated no one saw him when he lit the glass pipe and dropped it on the floor. Resident 4 stated he thought he picked up the broken glass pieces from the floor. Resident 4 stated facility staff did not ask him if his belongings could be checked in his room when he returned from dialysis and when he returned from an out on pass. Resident 4 further stated that no facility staff discussed with him the policy of illicit drug use in the facility. Resident 4 stated that no education has been provided to him about the health and safety risks associated with using illicit drugs in the facility. Resident 4 expressed concerns that this lack of information could potentially compromise the safety and well being of himself, other residents residing in the facility and facility staff. During an interview on 10/4/2023 at 1:54 p.m. with Housekeeper (HK) 1, HK 1 stated that on 9/18/2023 during the 7:00 a.m. to 3:00 p.m. shift, she found some crystal-like particles on the floor of Resident 4's room. These particles looked like thin broken glass and were found in a towel next to Resident 4's bed. HK 1 stated she noticed a broken glass pipe that appeared burnt and had black substance residue on it. HK 1 stated she promptly informed the charge nurse (LVN 3) about her findings. During an interview on 10/4/2023 at 12:16 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated HK 1 informed LVN 3 about the broken pipe wrap in a towel in Resident 4's room on 9/18/23. LVN 2 and LVN 3, had a meeting with the Director of Nursing (DON) and the Administrator (ADM) at the nursing station. LVN 2 stated the DON stated this incident of suspected illicit drug use was not reportable because the facility was just assuming. LVN 2 expressed concern about the potential impact of suspected illicit drug use on the health and safety of Resident 4, other residents, and staff as there was no guidance from the DON and Administrator. LVN 2 stated Resident 4 was not assessed and monitored after the incident. During a telephone interview on 10/4/2023 at 2:52 p.m., with LVN 3, LVN 3 stated on 9/18/2023, HK 1 gave her what she found on Resident 4's room. LVN 3 stated she placed the items (broken glass pipe and broken glass like substances with black residue) inside a zip lock bag and gave it to the DON. LVN 3 stated a change of condition assessment, documenting the incident on the nursing progress notes and initiating a care plan were not done as instructed by the DON. LVN 3 stated Resident 4's physician was not informed of the incident on 9/18/2023. She further stated Administrator told her to just monitor Resident 4. During a review of Resident 4's medical record, the medical record indicated there was no documentation to demonstrate the facility staff neither monitored, assessed for signs and symptoms of amphetamine adverse effect and possible interaction with other medication nor educated Resident 4 of amphetamine adverse effects. During a telephone interview on 10/5/2023 at 11:00 a.m., with Resident 4's primary care physician (PCP), the PCP stated he was aware of Resident 4's suspected use of (amphetamines) crystal meth. PCP stated facility's staff informed him of suspicion that Resident 4 was using illicit drug (cannot remember the exact date). The PCP stated he gave an order for urine drug toxicology (test that checks for drugs or other chemicals in your urine) or blood toxicology (a test that checks for drugs or other chemicals in the blood) as Resident 4 was anuric (does not produce urine). The PCP stated he was concerned of Resident 4's adverse drug interactions (unintended, harmful events attributed to the use of medicines) if he uses illicit drugs in combination with his other medications. Another concern regarding the use of illicit drugs like crystal meth would be for Resident 4, who has a diagnosis of ESRD, could lead to a change in his condition, specially causing severe high blood pressure (hypertensive crisis), this would be detrimental to Resident 4's health and overall wellbeing. During an interview on 10/5/2023 at 4:19 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 4 was transferred to GACH on 9/21/2023 due to complaining of chest pain, rated as a 5 on the pain scale and high blood pressure of 227/121 mm Hg. RNS 2 stated that if there was any suspicion of illicit drug used, she (RNS 2) will gather the evidence and secure it, as it can be used for investigation by law enforcement agencies. RN 2 stated that the use of illicit drugs in the facility poses a health and safety risk to other residents, staff, and visitors. The resident using illicit drugs can change their behavior, potentially affecting the safety of everyone in the facility. RN 2 stated licensed nurses were expected to contact the physician to inform the physician of the resident's condition, to obtain orders, referrals, and other necessary treatments. RNS 2 stated licensed nurses should initiate a change of condition process to ensure continuous assessment and monitoring were provided to Resident 4. Additionally, body checks should have been conducted when Resident 4 returned to the facility from dialysis, out on pass, and other appointments. During an interview on 10/5/2023 at 1:59 pm with the DON, the DON stated there was no investigation conducted by either her or the Administrator after LVN 2 and LVN 3 informed them about what was found in Resident 4's room by HK 1, the glass like particles on the floor and broken glass pipe that appeared burnt and had a black substance residue. The DON stated Resident 4's physician was not notified of the incident and no in-services were done with the licensed nurses regarding the facility's policy on Resident Possession and Use of Illegal Substances. During an interview on 10/6/2023 at 9:44 a.m., with the Social Services Director (SSD), the SSD stated she was not notified of Resident 4's suspected illicit drug use in the facility. SSD stated there was no interdisciplinary care plan meeting (care team gathers to review the plan of care for a resident.), social services reassessment, and psychologist (a person who specializes in the study of mind and behavior) referral for Resident 4. The SSD stated this unusual occurrence was not immediately reported to the local law enforcement, Ombudsman, and the State Agency. The SSD stated this incident (suspicion of illicit drug used) was alarming because the potential actions of a suspected illicit drug user while under the influence of illicit drugs were unknown. This uncertainty raises concerns about the potential impact on the residents and staff within the facility. During an interview on 10/6/2023 at 10:42 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 4 could potentially experience adverse drug interactions if he uses illicit drugs in combination with his other medications. The MDSN stated that illicit drugs are strong stimulants (substances that speed up the body's functions) and can cause multiple side effects (increased blood pressure, irregular heart rate and increased breathing). The MDSN stated that the facility should have investigated the incident to determine if the incident (suspicion of illicit drug use) really occurred or not. MDSN stated it was the responsibility of the facility to prioritize the safety of Resident 4 and other residents by acknowledging the situation and taking appropriate action. During an interview on 10/6/2023 at 11:26 a.m., with the Administrator (ADM), the ADM stated the incident with Resident 4 (found broken glass pipe that appeared burnt and had black substance residue) should have been thoroughly investigated. The ADM stated the facility does not tolerate illicit drug use in the facility. The ADM stated there was no investigation conducted by the facility after LVN 2 and LVN 3 reported the incident to him regarding HK 1 finding a broken glass pipe that appeared burnt and had black substance residue in resident 4's room. During a review of the facility's Policy and Procedure (P/P) titled, Unusual Occurrence revised 12/19/2022, the P/P indicated it is the policy of the facility that an unusual occurrence be reported to the Department of Public Health within 24 hours of occurrence that included but not limited to, occurrences which constitute an interference with facility operations which affect the welfare, safety, or health of patient/ residents, personnel and visitors. During a review of the facility's Policy and Procedure (P/P) titled, Resident Possession and Use of Illegal Substances, revised 12/19/2022, the P/P indicated the possession and use of illegal substances by the residents will not be tolerated. The P/P indicated if the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility must make a referral to the local law enforcement, provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing/ using illegal substances into the facility and the facility staff to have knowledge of signs, symptoms and triggers of possible illegal substance use. During a review of the facility's P/P titled Resident Personal Belongings revised 12/19/2022, the P/P indicated the facility may refuse to allow a resident to retain his or her personal possession if the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source and the facility may choose to provide additional monitoring and supervision determined on a case to case basis. During a review of the United States Department of Justice Drug Enforcement Administration Drug Fact Sheet (DFS) on Methamphetamine, dated 10/2022, https://www.dea.gov/factsheets/methamphetamine the DFS indicated methamphetamine is a Schedule II stimulant (substances, or chemicals are defined as drugs with a high potential for abuse) under the Controlled Substances Act .Methamphetamine comes in a pill or powder form and Crystal Meth resembles glass fragments or shiny blue, white rocks of various sizes and such drug can be swallowed, snorted, injected, or smoked. Chronic meth users can exhibit violent behavior, anxiety, confusion, insomnia (sleeplessness) and psychotic (symptoms that affect the mind, where there is loss of contact with reality) features including paranoia (unjustified suspicion and mistrust), aggression, visual and auditory hallucinations (experience involving the apparent perception of something not present), and delusions (a false belief or judgement about external reality)- such as sensation of insects creeping on or under the skin and such paranoia can result in homicidal (capable of or tending towards murder) or suicidal (likely to have damaging effect on oneself or one's interests) thoughts. Taking small amounts of methamphetamine can result in increased wakefulness, increased physical activity, decreased appetite, rapid breathing and heart rate, irregular heartbeat, increased blood pressure and hyperthermia (a body temperature greater than normal) which can cause convulsions ( a sudden, violent irregular movement of a part of the body or of the body due to the presence of certain toxins/agents/substances in the blood, cardiovascular collapse (collapse, no pulse, no breathing, loss of consciousness), and death. High doses may result in death from stroke, heart attack or multiple organ problems caused by overheating.

A pattern of the facility's failure to ensure each resident's drug regimen was free from unnecessary drugs, in excessive dose (including duplicate therapy) and without adequate monitoring (vitals signs, labs, weight), in which indicated the dose should be reduced or discontinued. The systems failed and resulted in an immediate threat to the health and safety for Resident 1. Resident 1 who had a [DIAGNOSES REDACTED]. obstruction [MEDICAL CONDITION] disease (lung disease that makes it hard to breath ([MEDICAL CONDITION])), and tobacco use. On March 3, 2014, at 3 p.m., an immediate Jeopardy (IJ) was declared and the facility's administrator and director of nurses were notified. The facility submitted a plan of action (POA) on March 3, 2014, however failed to follow the plan and another POA was given on March 4, 2014. The POA included the attending physician (medical director) reducing the narcotic and Klonopin (used to control [MEDICAL CONDITION] in [MEDICAL CONDITION] and for the treatment of [REDACTED]. The IJ was lifted on March 5, 2014 at 8:20 a.m., and the administrator and director of nurses were informed, after the team confirmed that the facility's plan of action was implemented as follows: 1. The attending physician visited the resident and titrated (decrease) the amount of [MEDICATION NAME] and Klonopin was given 2. Ordered and drew blood laboratory work. 3. A neurologist and pain management physician to see the resident. 4. To monitor the resident's vital signs. 5. Pharmacist consultant reviewed all Resident 1's medications after titration and the physician signed the Medication Regimen Review (MRR). Based on observations, interviews, and record review, the facility failed to ensure each resident was free from unnecessary drugs for 1 of 2 residents (Resident 1). Resident 1, who had a [DIAGNOSES REDACTED]. (Refer to F428 F386 for further information). These failures resulted in the resident sleeping all day until the afternoon, not participating in the activities of daily living and exhibiting adverse consequences of the medication, which included drowsiness, body tremors, slurred speech, and the excessive amounts of [MEDICATION NAME] had the potential to lead to respiratory arrest and death. Findings: On March 3, 2014, at 8:20 a.m., during an initial tour of the facility, Resident 1's room door was observed closed with a "Do Not Disturb" sign on the door. Upon knocking and entering after given permission, Resident 1 was observed in bed in a dark room, barely able to hold her head up with a slurred speech. A review of Resident 1's record indicated the resident was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED].(GERD)) and tobacco use. A review of an admission Minimum Data Set (MDS), a standardized assessment and care screening tool, with an assessment reference date of December 19, 2013, indicated the resident had clear speech, able to express ideas and wants and understood verbal content. The MDS functional content (activities of daily living), under Section G, indicated Resident 1 required extensive assistance in bed mobility, transferring, dressing, and required a one-person assist with toilet use. A review of the resident's Medication Administration Record [REDACTED]. According to the Controlled Drug Records, Resident 1 received [MEDICATION NAME] (The Drug Abuse Prevention and Control Act 1970 classifies [MEDICATION NAME] as a schedule II opioid [MEDICATION NAME], which means that any such drug has a high potential for abuse, and that such abuse may lead to severe psychological and/or physical dependence) in the form of IR, ER, and Sublingual Concentration, from December 1, 2013 through March 5, 2014. The Controlled Drug Record indicated: in December 2013, Resident 1 received 107 doses totaling 9,090 mg of [MEDICATION NAME]; in January 2014, Resident 1 received 267 doses totaling 19,940 mg of [MEDICATION NAME]; in February 2014, Resident 1 received 163 doses totaling 13,800 mg of [MEDICATION NAME]; in the first five days of March 2014, Resident 1 received 23 doses totaling 2,220 mg of [MEDICATION NAME]. Resident 1 also received [MEDICATION NAME] administered via a patient-controlled [MEDICATION NAME] (PCA) pump (method of allowing a person in pain to administer their own pain relief) for February 6-14, 2014, however the facility failed to produce the administration records for the PCA. The manufacturing label for the [MEDICATION NAME] at <http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=e0472c35-3f44-42e2-9b75-37b2e9ff65f6> indicated, "Proper dosing and titration are essential and ([MEDICATION NAME]) should only be prescribed by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain ...Respiratory depression is the chief hazard of opioid agonists, including MS Contin. Respiratory depression if not immediately recognized and treated, may lead to respiratory arrest and death." According to "Lexi-Comp ONLINE," a nationally recognized drug information source, indicates that potential drug related concerns associated with the use of [MEDICATION NAME] include an increased risk for central nervous system (CNS) depression, anxiety, coma, [MEDICAL CONDITION], lethargy (abnormal drowsiness), [MEDICAL CONDITION], slurred speech, drowsiness; and for patients with pre-exiting respiratory disease, such as [MEDICAL CONDITION], should be used with caution as critical respiratory depression may occur, even at therapeutic dosages. Use with caution in patients with [MEDICAL CONDITION] disorders; ([MEDICATION NAME]) may cause or exacerbate per-existing [MEDICAL CONDITION]. Some dosage forms may be contraindicated in patients with [MEDICAL CONDITION] disorder. On March 3, 2014, at 9:56 a.m., during an interview with a certified nursing assistant (CNA 1), and a review of CNA 1's declaration she stated, "The resident does not want to get up in the mornings, does not eat breakfast or lunch, tells the staff to do not disrupt, and usually gets up around 1 p.m." CNA 1 stated, " She is always so drowsy, she can barely open her eyes, with slurred speech and it is always dark in her room. She always wants four cups of coffee when she gets up and stays in the patio to smoke all day, sometimes till 5 a.m." During interview and review of another declaration, CNA 2 stated, "The resident sleeps most of the day, does not eat breakfast or lunch, doesn't get up till around 2 p.m., and she likes to smoke. She also puts her cell phone alarm on to wake her up for her medication,so she doesn't forget it. She is always shaking and drowsy." On March 3, 2014 at 10:20 a.m., during an interview, licensed vocational nurse (LVN 1), stated she administered Resident 1's 8 a.m., medication that morning. She stated, " The resident uses her cell phone alarm to wake up for her medication and I still give her medications on time even if she is drowsy, but as a nurse I know I shouldn't." On March 3, 2014 at 10:39 a.m., during an interview, the director of nurses (DON) stated, "She (Resident 1) came to our facility with all those medications on admission. We tried to taper, but she is always refusing. She requested to be on hospice, probably for more medication. I knew it was going to come to this. She is manipulative. She refuses everything. The physician is aware of her refusing her labs, but she is still getting her medication." When asked should the licensed staff administer medications while the resident was drowsy and unable to talk, the DON stated, "If the resident is drowsy and slurring I would not give the medication." On March 3, 2014 at 11:05 a.m., during an interview, the administrator stated, " She wants to be on hospice. We got the hospice to make her feel better and because she requested it. We just give her whatever she wants to make her happy." On March 3, 2014, at 2:29 p.m., during an interview and observation, Resident 1 was observed in the room with CNA 2 sitting in a reclining chair crying with hands trembling. Resident 1 stated, " I don't sleep. I wake up every 10, 15, 20 minutes, I have anxiety and I didn't have that before." During a speaker telephone interview in the presence of the survey team, on March 3, 2014 at 1:21 p.m., Physician 2 (medical director) stated, "The resident is difficult to handle, she is noncompliant, needs to be detox and have psychiatric support. She also needs a conservator." When asked about Resident 1's maximum doses and duplication of narcotic medications, he stated, "She's still alive isn't she?" During a record review, Nursing Progress Notes, through the months of December 2013- March 2014, indicated Resident 1 repeatedly refused to be weighed, have laboratory draws, x-rays, and vital signs to be taken, although the pharmacist consultant requested respiratory rates due to the resident receiving large amounts of narcotics. There was only one vital sign taken and documented in December 2013 since the resident was admitted , in which was the resident's temperature. On March 4, 2014, during a review of a physician's orders [REDACTED]. Another physician order, dated February 7, 2014, indicated an order for [REDACTED]. According to "Lexi-Comp ONLINE," a maintenance PCA dose (when self-administered intermittently) of 0.5- 2 mg, usually not more frequently than every 6 to 12 minutes (totaling 10 mg per hours). However, Resident 1 was receiving through the PCA a total of 26 mg of [MEDICATION NAME] every hour, which is over two and half times the maximum recommended maintenance dose of [MEDICATION NAME]. On March 4, 2014, during a review of the MAR for February 2014, indicated that while the resident was under hospice care from February 6-14, 2014, the resident received 46 doses of [MEDICATION NAME] 20 mg SL PRN for a total of 920 mg of [MEDICATION NAME] being administered in addition to receiving [MEDICATION NAME] PCA pump, until the medical director at the hospice indicated the resident did not meet the criteria for hospice care and was not " at the end of life" and was discharged from the hospice service (February 14, 2014).

A pattern of the facility's failure to ensure that all pharmacist's irregularities were reported to the physician and acted upon to prevent unnecessary drugs, in excessive dose (including duplicate therapy) and without adequate monitoring (vital signs, especially the resident's respiratory rate, labs, and weight), in which indicated the dose should be reduced or discontinued. The systems failed and resulted in an immediate threat to the health and safety for Resident 1, who had a [DIAGNOSES REDACTED]. obstruction pulmonary disease (COPD/lung diseases that block airflow and make breathing difficult) and tobacco use. The latter two [DIAGNOSES REDACTED]. On March 3, 2014, at 3 p.m., an immediate Jeopardy (IJ) was declared and the facility's administrator and director were notified. The facility submitted a plan of action (POA) on March 3, 2014, however failed to follow the plan and another POA was given on March 4, 2014. The POA included the attending physician (medical director) reducing the narcotic and Klonopin, drawing stat laboratory blood work, and Keppra levels, and contacting a neurology /pain management consultant. The IJ was lifted on March 5, 2014 at 8:20 a.m., and the administrator and director of nurses were informed, after the team confirmed that the facility's plan of action was implemented as follows: 1. The attending physician visited the resident and titrated the amount of Morphine and Klonopin was given. 2. Ordered and drew blood laboratory work. 3. A neurologists/ pain management physician to see the resident. 4. To monitor the resident's vital signs. 5. Pharmacist consultant reviewed all Resident 1's medications after titration and the physician signed the Medication Regimen Review (MRR). F428 Based on interview and record review, the facility failed to act upon the Medication Regimen Reviews (MRR) for three months. The report was from the pharmacist consultant regarding the clinically significant risks and existing adverse consequences and irregularities for 1 of 2 residents (Resident 1). Resident 1 was receiving large doses of morphine (narcotic pain reliever) for pain management, which is a respiratory depressant without monitoring of the resident's respiratory rate. (Refer to F329 and F386 for further information). These failures resulted in the resident continued to received high doses of morphine in the presence of adverse consequences, and duplication of medication doses without adequate monitoring. Findings: On March 3, 2014, at 8:20 a.m., during an initial tour of the facility, Resident 1's room door was observed closed with a "Do Not Disturb" sign on the door. Upon knocking and entering, after given permission, Resident 1 was observed in bed, in a dark room, barely able to hold her head up with slurred speech. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED].), chronic obstructive pulmonary disease (COPD/lung diseases that block airflow and make breathing difficult).and tobacco use. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 19, 2013, indicated the resident had clear speech, able to express ideas and wants, and understood verbal content. The MDS functional content (activities of daily living), under Section G, indicated the resident required extensive assistance in bed mobility, transferring, dressing, and only required a one-person physical assist with toileting. During an interview on March 3, 2014, at 11:05 a.m., the administrator was asked why Physician 1 was not responding to the facility's pharmacist consultant's recommendations, he stated, "The doctor got off the case because of too much medication." The administrator also indicated all the resident's medications were not good for her. During an observation on March 3, 2014, at 2:30 p.m., after the resident had been sleeping all day, the resident was up out of bed in a reclining chair in the room. The resident was observed to have body tremors, nervousness, and was agitated. A review of the physician's orders [REDACTED]. A review of the pharmacist consultant's Medication Regimen Review (MRR) for December 1, 2013- December 31, 2013, dated December 11, 2013, indicated the resident was receiving both Morphine sulfate 45 mg and MS contin 120 mg every 6 hours. The pharmacist made a recommendation to consider monitoring for adverse consequences of long-acting opiate therapy (i.e. respiratory depression (drug or other agent that diminishes normal breathing functions such as alcohol and opiates, act by depressing the central nervous system), somnolence ( a state of near- sleep, a strong desire for sleep, or sleeping for unusually long periods ) etc.) by ensuring the respiratory rate was being monitored frequently. There was no indication the resident's physician saw or was informed of the recommendation. The nurse wrote on the MRR Report, "Resident refuses vital signs. There was no further documentation in the clinical record that the resident's respiratory rate was assessed or monitored. On March 3, 2014, at 9:56 a.m., during an interview and review of a declaration, a certified nursing assistant, (CNA 1) stated, "The resident does not want to get up in the mornings, does not eat breakfast or lunch, tells them to do not disrupt, and usually gets up around 1 p.m." CNA 1 also stated, " She is always so drowsy, she can barely open her eyes, with slurred speech and it is always dark in her room. She always wants four cups of coffee when she gets up and stays in the patio to smoke all day, sometimes till 5 a.m." The pharmacist's MRR report for the month of December 2013, indicated the resident was receiving duplication therapy of Klonopin and diazepam for seizure disorder. The pharmacist recommended to re-evaluate the need for both agents. There was a check to decline the recommendation without any explanation why. There was no signature of the physician on the report to indicate the physician read the report. It was documented as T/O (telephone order) to the physician and dated February 2, 2014. The MRR report for December 1-31, 2013, the pharmacist indicated the resident had a [DIAGNOSES REDACTED]. The pharmacist recommended for a re-evaluation of the continued use of Reglan and consider to discontinue, if possible. Under physician's response, the box for "decline" was checked and indicated, " Per resident request to continue with Reglan" without a physician's signature. A review of the Medication Regimen Review (MRR ), for January 1, 2014 to January 31, 2014, the pharmacist recommended to monitor for involuntary movements (tardive dyskinesia/TD) due to the ongoing use of Reglan, but the physician decline recommendation per the resident's refusal. According to the MRR, the pharmacist indicated the rationale for the recommendation was for early detection of TD-like symptoms as one of the best opportunities to avoid irreversible tardive dyskinesia (TD). She also indicated there was no assessment documented in the resident's record in the previous three months. A review of the resident's, history and physical examination [REDACTED]. According to a Monthly Prescribing Reference (MPR), dated January 2014, the adverse reaction of Reglan included restlessness, drowsiness, fatigue, dizziness, and extrapyramidal effects (serious side-effects of antipsychotic and other drugs/ disorders of movement). On March 3, 2014, at 9:47 a.m., during an interview, the director of nurses stated we would call the physician (Physician 1) and give her the pharmacist's recommendation and document for her. She stated the physician never saw the MRRs. When the DON was asked about the resident's vital signs being monitored,especially while receiving large doses of morphine, she stated the resident would refused to have her vital signs taken. Multiple attempts were made to contact Physician 1. On March 3, 2014 at 12:30 p.m., March 4, 2014 at 10:03 a.m., and at 1:15 p.m., to speak with the physician regarding her not acting upon the MRRs. Messages were left for Physician 1 to call back for an interview with no response. During a telephone interview, on March 3, 2014, at 11:31 a.m., the pharmacist consultant indicated that she was aware that the resident was receiving duplication of medications. She stated she had made recommendation to the physician to evaluate and monitor for the long acting pain meds that can cause respiratory depression, but the physician declined the recommendations. A review of the facility's policy with an effective date of December 1, 2012, titled, "Medication Regimen Review" indicated the facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team and resident; the facility should encourage the physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR, for those issues that require a physician/prescriber intervention, the facility should encourage them to either (a) accept and act upon the recommendations contained in the MRR, or (b) reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected. The policy also indicated the facility should provide the medical director with a copy of the MRRs and he or she would do a follow-up. However, neither Physician 1 or 2 acted upon the pharmacist's consultants recommendation of excessive narcotics and pain medications Resident 1 was receiving. During a speaker telephone interview on March 3, 2014, at 1:23 p.m. in the presence of the survey team, Physician 2, who is the medical director of the facility, stated he took over Resident 1's care on February 2, 2014. When the physician was asked about the excessive amounts of narcotics and pain medications the resident was receiving, Physician 2 stated, "I thought she has been on hospice care for years, which is why she's on all that medication." Physician 2 indicated he was not aware of pharmacy consultant reviews not being signed. The resident's physician asked, "She's still alive isn't she?"