Every finding on record at Country Hills Post Acute

Based on interview and record review, the facility failed to upload documents into the medical record in a timely manner for one of two sampled residents (1).As a result, completed records were not immediately available for review. Findings:Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (a disorder of unstable blood sugar), and was discharged on 6/18/26.On 8/17/26 the facility provided an incomplete version of the Inventory List, dated 5/28/26. The section of the form to be signed at the time of discharge was blank and unsigned.On 8/21/26 the facility provided the completed version of the Inventory List, dated 5/28/26, with the discharge section completed by the facility on 6/22/26. The facility provided an additional Inventory List at that time, dated 5/22/26, with the discharge section completed by the facility on 6/22/26.On 8/21/26 at 11:08 A.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, they originally provided the incomplete Inventory List because that was the document that was uploaded to the facility's medical record, but on the morning of 8/21/26 they found the completed document in an office.On 8/21/26 at 12:28 P.M., a telephone interview was conducted with the Social Services Assistant (SSA). The SSA stated, he was assisting medical records in finding Resident 1's completed Inventory List when he found the document in a box of medical records that were waiting to be uploaded.On 8/21/26 at 12:58 P.M., a telephone interview was conducted with the Medical Records Director (MRD). The MRD stated, their department was behind on uploading documents into the Electronic Medical Record (EMR). The MRD further stated, that she expected documents to be uploaded to the EMR within 30 days, and that two months for Resident 1's Inventory List was too long.The facility did not have a policy on uploading documents to the EMR.

Based on observations, interviews, and record review the facility failed to provide urinary catheter (a thin, flexible tube inserted into the bladder to drain and collect urine) care per facility policy for two (Resident 9 and Resident 18) of five sampled residents with urinary catheters when staff it did not:Provide meatal care (cleaning the area where a urinary catheter enters the body [the meatus] daily using mild soap and water to prevent infections) to Resident 9 for six days after readmission from the hospital.Secure Resident 18 's urinary catheter drainage bag to the frame of the bed, allowing drainage bag to rest on her bedroom floor. This failure had the potential for Resident 9 and Resident 18's urinary catheters to be at a higher risk for urinary tract infections and put their overall health at risk. Findings:1. Review of admission Record indicated Resident 9 was re-admitted on [DATE], (originally first admitted on [DATE]) for diagnoses which included: Paraplegia (the partial or complete paralysis of the lower half of the body, including both legs) and Urinary Tract Infection (a bacterial infection in any part of the urinary system).Review of Minimum Data Set (MDS-standardized clinical assessment tool used in nursing homes) Section C Cognitive (thinking) Patterns indicated a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition (thinking processes).Review of MDS Section GG-Functional Abilities indicated Resident 9 was coded as Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete activity for Toileting Hygiene.Review of physician orders order dated 5/15/26 indicated Indwelling urinary catheter: Cleanse catheter insertion site with warm water soap & water rinse every shift and prn as needed. Resident 9 was admitted on [DATE] at 10 P.M. indicating a discrepancy of 6 days without ordered cleansing of insertion site.Review of the TAR Treatment Administration Record (TAR) indicated, Indwelling Urinary Catheter: Cleanse Catheter insertion site with warm water soap & water, & rinse every shift. PRN (as needed) treatment was not started until 5/15/26 at 1900 (7 PM), 7 days since admission day. There was no documentation of nurses cleansing the catheter insertion sight for the dates 5/9/26 to 5/15/26 AM shift.On 5/15/26 at 10:35 A.M., an observation and interview was conducted with Resident 9. Resident 9 was observed in bed with foley catheter with clear yellow urine in the bag. Resident was alert, oriented, and agreed to be interviewed. Resident 9 stated that he has had urinary catheters for 11 years. Resident 9 stated the last time he was sent out to the hospital for his catheter was about 5/4/26 to 5/8/26. Resident 9 stated that the nurses don't check his catheter every shift and they are not very consistent. Resident 9 stated that he was not sure how often they assessed and cleaned the insertion site, and he did not remember how many times this month it was done.On 5/15/26 at 10:50 A.M., an interview was conducted with Licensed Nurse (LN 2). LN 2 stated she was Resident 9's medication nurse that day. LN 2 stated that for urinary catheters she followed the orders for flushing and patency, checked the color of the urine, calculated intake and outputs, and checked for signs and symptoms of infection such as burning or change in urination. LN 2 stated she was not sure who was responsible for assessing resident's meatus or cleaning meatus during catheter care and stated, I think the CNA. LN 2 stated that importance of someone checking and cleaning the meatus was to make sure catheter was working properly and to prevent infections.On 5/28/26 at 10:10 A.M., a follow-up interview with Resident 9 was conducted. Resident 9 was observed in bed. Resident 9 was alert, oriented, and agreeable for an interview. Resident stated that, A few of the nurses were doing the catheter care every shift, but not all nurses. Resident 9 stated that he feared having to have his catheter changed again in the hospital, because he had it changed so many times in the past.On 5/28/26 at 10:20 A.M., an interview with Licensed Nurse (LN) 7 and record review of Resident 9's orders was conducted. LN 7 stated she had taken care of Resident 9 twice and was currently Resident 9's medication nurse. LN 7 stated that LN's responsibility for urinary catheters was to check placement, keep track of input & output of urine, monthly catheter changes, assess catheter for any signs or symptoms of infection. LN 7 was not aware of Resident 9's order to cleanse the catheter insertion sight with warm water once a shift. Concurrent record review with LN 7 of order to cleanse sight was conducted. LN 7 stated she had misread the order and thought the order was for PRN cleansing and not per shift. LN 7 stated that she usually does her med pass and then will do the treatments for the resident after she finished her med passes, but she had not cleansed the insertion sight at time of the investigation. LN 7 stated the expectation for urinary catheters was to make sure that they were assessed and cleaned per order to maintain functionality and prevent infection.On 5/28/26 at 11:20 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that when Resident 9 was readmitted from the hospital, staff forgot to get the order for cleansing resident's meatus every shift, so it was not documented in the Treatment Administration Record (TAR). The DON stated she entered the order the first day of investigation, 5/15/26, when this writer started the investigation. The DON stated that the expectation for LN's is to do urinary catheter care every shift which includes assessing the catheter and cleansing the meatus with warm water and soap every shift, and documenting on the TAR. The DON stated that the meatus should be assessed and cleansed by medication nurse every shift to prevent infections.Review of facility policy and procedure titled Catheter Care, Urinary dated 2001, indicated General Guidelines .4 Ensure that the catheter remains secured with a securement devices to reduce friction and movement of insertion site.Catheter Evaluation.2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter in place.Infection Control.1. Use aseptic technique when handling or manipulating the drainage system. 2. Be sure the catheter tubing and drainage bag are kept off the floor.Routine Perineal Hygiene.12. Assess the urethral meatus. 13 For female resident: a. Use a washcloth with warm water and soap (or clean bathing wip) to cleanse labia. Use one area of washcloth (or wipe) for each downward, cleansing stroke. b. Change the position of washcloth (or wipe) and cleanse around the urethral meatus. Do not allow the washcloth/wipe to drag on the resident's skin or bed linens. C. with clean washcloth (or wipe),rinse using the above technique. 14. For a male resident: a Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus. B. Cleanse the glans using circular strokes from the meatus outward. c. Change the position of washcloth(or wipe) with each cleansing stroke. d. With a clean washcloth (or wipe), rinse using above technique. E. return foreskin to normal position. 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately 4 inches outward. 2. Review of admission Record indicated Resident 18 was re- admitted on [DATE] (originally admitted on [DATE]) for diagnoses which included: Metabolic Encephalopathy (brain dysfunction caused by chemical imbalances or underlying systemic diseases in the body), Sepsis(your body's extreme, life-threatening response to an infection), and Acute Kidney Failure(a sudden decline in kidney function, developing within hours or days).Review of Minimum Data Set (MDS-standardized clinical assessment tool used in nursing homes) Section C Cognitive (thinking) Patterns for Resident 18 indicated a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive (thinking processes) impairment.Review of MDS Section GG-Functional Abilities indicated Resident 18 was coded as Dependent-Helper does ALL of the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete activity for Toileting Hygiene.Review of physician orders dated 2/19/26 indicated Monitor proper placement, no kinking, or compression that could obstruct urine flow to gravity bag during catheter care Q shift every shift.On 5/15/26 at 2:30 P.M., an observation and interview with Resident 18 was conducted. Resident 18 was observed resting in bed watching tv. Resident 18 was alert and oriented and agreeable to interview. Resident 18 stated that she had no problems with her catheter, and that staff cleaned it every shift. Resident 18's catheter bag was observed lying flat on the ground.On 5/15/26 at 2:40 P.M. a concurrent observation of Resident 18's catheter bag and interview with LN 6, (Resident 18's medication nurse) was conducted. Resident 18's catheter bag was observed lying flat on the ground. LN 6 stated the expectation was that the urinary catheter bag should be below resident's bladder, and secured to the bed frame, to prevent bacteria from the floor infecting resident's catheter.On 5/15/26 at 2:45 P.M., a concurrent observation of Resident 18's catheter bag and interview with Certified Nursing Assistant (CNA )5, Resident 18's CNA, was conducted. Resident 18's catheter bag was observed on the ground. CNA 5 stated the expectation was that the urinary catheter bag should be below resident's bladder, and secured to the bed frame, to prevent the bag from getting stepped on and prevent bacteria from the floor infecting resident's catheter.On 5/15/26 at 4:30 P.M., an interview with the Infection Preventionist (IP) and observation of picture of Resident 18's catheter bag was conducted. The IP stated the expectation is catheter bag should be secured to the bed's frame below resident's bladder and above the floor to prevent bacteria on the floor from causing a UTI and complications of UTI, such as sepsis.On 5/28/26 at 11:20 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that catheter bags should be secured to bedside below the bladder and not on the floor to prevent unwanted infections and accidental pulling on the catheter.Review of facility policy and procedure titled Catheter Care, Urinary dated 2001, indicated General Guidelines .4 Ensure that the catheter remains secured with a securement devices to reduce friction and movement of insertion site.Catheter Evaluation.2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter in place.Infection Control.1. Use aseptic technique when handling or manipulating the drainage system. 2. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review the facility failed to accurately code a stage IV (4) pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the Minimum Data Set (MDS-a federally mandated resident assessment tool) after a [NAME] Ulcer (nonhealing skin sore that may form when you're dying ) was reclassified as a Stage IV pressure ulcer, for one of three sampled residents (Resident 1). These deficient practices placed Resident 1 at risk for inaccurate assessment data, inappropriate care planning and misrepresentation of the resident's health status to Centers for Medicare Services (CMS).A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of Pressure Ulcer of Sacral (lower back/tailbone) Region and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/30/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 0 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) impairments. On 5/19/26 at 2:07 P.M., an interview was conducted with the Wound Nurse (WN). The WN stated that pressures typically occur over boney prominences (an area where a bone is close to the surface of your skin and sticks out. e.g. back/tailbone, hip bone, back of your head, shoulder blades, elbows and knees) and may be staged from Stage I through Stage IV based on the extent of tissue involvement. The WN further stated wound assessment includes visual inspection, palpation (touch), evaluation of tissue characteristics, and consultation with the physician and wound care team to determine appropriate wound classification and staging. A record review of Resident 1's progress notes dated 4/24/2026 at 14:27 (2:27 P.M.), titled IDT [intradisciplinary team- groups of healthcare professionals from different specialties]- Skin Management indicated, .Resident re admitted with previous Kennedy ulcer that was re-classified as stage IV pressure injury to sacrum area. A record review of Resident 1's MDS Section J1400 Prognosis (prospect of recovery) dated 4/30/26 indicated, .Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation). was coded no. A record review of Resident 1's MDS Section O0110 K1. Special Treatments, Procedures, and Programs dated 4/30/26 indicated Resident 1 was not in hospice care. On 5/20/26 at 1:28 P.M., an observation, interview and record review was conducted with the WN. The WN stated that Resident 1 had a Stage IV Pressure ulcer to the sacral area that had previously been identified as a [NAME] Ulcer and later reclassified as a Stage IV pressure injury (4/27/26). The WN further confirmed there were no physician orders indicating that Resident 1 had received hospice or end-of-life care services. On 5/20/26 at 1:46 P.M., an observation was conducted with the WN and Certified Nursing Assistant (CNA) 2. CNA 2 repositioned Resident 1 to the left side, provided peri-care, and removed the incontinent brief. The WN cleansed the sacral wound with wound cleaner, applied collagen sprinkles to the wound, followed by calcium alginate, and packed the undermining area with gauze before covering the wound with a foam dressing. Observation of the sacral wound revealed a circular Stage IV pressure ulcer approximately t he size of a golf ball, with noted depth and undermining. The wound be appeared bright red with light drainage and without slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) or eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off). The WN pressed on the surrounding sacral skin and observed no color change (non-blanchable tissue). A review of Resident 1's skin notes titled, SW - Skin Issues dated 4/27/2026 at 14:07 (2:07 P.M.), indicated, .Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure - Kennedy terminal ulcer / End of Life. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. On 5/20/26 at 1:52 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1's MDS 4/30/26, Section M0210, was inaccurately coded and should have reflected a Stage IV pressure ulcer to the sacrum after the wound had been reclassified from a Kennedy terminal ulcer to a Stage IV pressure injury. The ADON stated that Resident 1 was receiving ongoing Stage IV pressure ulcer treatments. The ADON stated accurate MDS coding was required to ensure the facility submitted correct resident (all facility residents)assessment data to Centers for Medicare and Medicaid Services (CMS-a federal agency). The ADON stated Resident 1's MDS required correction and resubmission to CMS. On 5/20/26 at 2:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MDS coordinator did not code Resident 1's stage IV pressure ulcer assessment reference date (ARD) 4/30/26 MDS because the wound had previously been identified as a Kennedy terminal ulcer. The DON stated Resident 1was not receiving hospice or end-of-life services and acknowledged Stage IV pressure ulcer should have been accurately coded on the MDS in accordance with the Resident Assessment Instrument (RAI) Manual. The DON stated accurate MDS coding was necessary to ensure resident assessment information submitted to CMS and Quality Measures (QM) reflected Resident 1's actual clinical status and care needs. The DON further stated Resident 1's MDS required correction and resubmission to CMS. A review of Centers for Medicare and Medicaid Services RAI Manual 3.0 October 2025, (Page M-5) M0210: Unhealed Pressure Ulcers/Injuries .Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days . A review of the facility's policy and procedure titled, Resident Assessments dated October 2023, indicated .Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews .

Based on observation, interview and record review, the facility failed to ensure staff adhered to proper infection control practices for one of four residents sampled residents (Resident 1) when:Resident 1's leaking/overflowing urinary catheter (a tube inserted into the bladder to aide in urine flow) was placed in a fracture pan (a device used to hold urine) and a urine-soaked towel were left on the floor.Certified Nursing Assistant (CNA) 1 did not wear Personal Protective Equipment (PPE- gown, gloves) prior to providing direct patient care.These failures had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors.Findings :1.According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy (a blockage in the body that makes it urinate) and resistance to multiple antibiotics (occurs when antibiotics are no longer effective, making infections difficult to treat).A review of Resident 1's Physician's Orders indicated, SUPRAPUBIC [an area below the abdomen and above the pubic area] CATHETER #FR [French- a unit of measurement] 18 WITH 10CC [Cubic Centimeters- a unit to measure volume] BULB TO GRAVITY DRAINAGE BAG [a device to collect urine].During an observation on 4/23/26 at 10:53 A.M., a bed pan (a device used to collect urine or feces for people who are unable to leave their bed to use the bathroom) was observed on the floor, next to Resident 1's bed. A foley catheter bag (a bag which is attached to a urinary catheter, used to collect urine) was placed inside the bed pan. There was a hand towel observed on the floor, next to the bedpan. The hand towel was soaked with a liquid. There was a strong smell of urine inside the room.During an interview with Resident 1 on 4/23/26 at 10:55 A.M., Resident 1 stated his foley catheter bag had a hole in it and needed to be replaced. Resident 1 stated the urine from the catheter bag had leaked onto the floor, so he tossed a hand towel on the floor to soak the urine. Resident 1 stated his catheter bag had been leaking since the night shift, and he was still waiting for a nurse to replace it.On 4/23/26 at 1:27 P.M., an interview was conducted with the Infection Preventionist (IP) 1. IP 1 stated foley catheter bags should be emptied right away when full, and changed immediately if there was any leakage or holes. IP 1 further stated a foley catheter bag should have been hanged on the bed frame, and should never be placed on the floor. Per IP 1, bacteria could travel to the catheter tube into Resident 1's body and placed Resident 1 at a higher risk for infection.During an interview with the Assistant Director of Nursing (ADON) on 4/23/26 at 1:40 P.M., the ADON stated it was his expectation that a catheter bag be replaced when leaking. The ADON stated a catheter bag and tubing should be kept off the floor to prevent the possibility of introducing microorganisms to Resident 1.During a review of the facility's policy titled Catheter Care, Urinary, revised August 2022, the policy indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Be sure the catheter tubing and drainage bag are kept off the floor.2. During an observation on 4/23/26 at 10:30 A.M., a purple sign which indicated Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of bacteria by wearing gown and gloves during high contact care) was posted on the wall, outside Resident 1's bedroom.During an observation on 4/23/26 at 10:53 A.M., a bed pan (a device used to collect urine or feces for people who are unable to leave their bed to use the bathroom) was observed on the floor, next to Resident 1's bed. A foley catheter bag (a bag which is attached to a urinary catheter, used to collect urine) was placed inside the bed pan. There was a hand towel observed on the floor, next to the bedpan. The hand towel was soaked with a liquid. There was a strong smell of urine inside the room.During an observation on 4/23/26 at 11:09 A.M., Certified Nursing Assistant (CNA) 1 was observed entering Resident 1's bedroom. CNA 1 donned (put on) gloves but did not don a gown. CNA 1 proceeded to empty Resident 1's urinary catheter bag into a urinal (a plastic device used to hold urine). CNA 1 then emptied the urine into the toilet. During an interview with CNA 1 on 4/23/26 at 11:27 A.M., CNA 1 stated the EBP sign posted indicated staff needed to wear gloves and a gown when providing direct care to Resident 1. CNA 1 stated emptying the catheter bag was considered direct care, but she was in a hurry to empty the bag and forgot to wear PPE. CNA 1 stated it was important to follow the EBP sign to protect the resident, and herself from contamination.During an interview with the Infection Preventionist (IP) 1 on 4/23/26 at 1:27 P.M., IP 1 stated it was her expectation that staff wear the appropriate PPE while providing direct care to residents on Enhanced Barrier Precaution. IP 1 stated it was important to prevent infection, especially for Resident 1 since he was more prone to infection.During a review of Resident 1's Care Plan Report, the care plan dated 12/26/25 indicated, Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of.Suprapubic catheter.Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g.device care.). During a review of the facility's policy titled Enhanced Barrier Precautions, revised December 2024, indicated, Enhanced barrier precautions apply when.a resident.has a wound or indwelling medical device.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use.

Based on interview and record review, the facility failed to respond to a resident not having a bowel movement for four days, for one of two sampled residents (1). As a result, Resident 1 was admitted to the hospital with diagnoses to include fecal impaction (hard stool that gets stuck in the body and is difficult to pass).Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include muscle weakness. Per the facility's Weekly Summary, dated 2/22/26, Resident 1's last bowel movement was on 2/22/26. Per the facility's Documentation Survey Report v2 for February 2026, under Bowel Continence, Resident did not have any bowel movements on the 23rd, 24th, 25th, or 26th (Four days without a bowel movement). Per the facility's Medication Administration Record for February 2026, Resident 1 had an order dated 11/10/25 for magnesium hydroxide (a medication to treat constipation), to be given if Resident 1 did not have a bowel movement for three days. The medication was not signed as being given on the 23rd, 24th, 25th, or 26th (Four days without a bowel movement). Per the facility's Progress Notes for Resident 1, dated 3/20/26. There were no notes documented between 2/22/26 and 2/26/26 regarding Resident 1's bowel movements or offering magnesium hydroxide. Per the Nurse's note dated 2/27/26 at 7:02 A.M., a phone call confirmed that Resident 1 had been admitted to a general acute care hospital with the diagnoses of altered mental status (not thinking normally), urinary tract infection, and fecal impaction. On 3/27/26 at 1 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, Resident 1 had a bowel movement on 2/22/26, so the nursing staff should have given her magnesium hydroxide for constipation starting on 2/25/26. The facility did not have a policy on managing constipation.

Based on observation, interview and record review, the facility failed to ensure three of five sampled residents were free from significant medication errors (an error which causes the resident discomfort or jeopardizes his or her health and safety) when: 1. Resident 1 received a fentanyl patch (a potent pain medication) which belonged to another resident (Resident 2) without a physician's order. 2. Resident 2 was not administered a fentanyl patch by nursing staff as ordered by the physician. 3. A fentanyl patch was administered to Resident 2 without verification that the previously administered fentanyl patch was removed. 4. A Licensed Nurse (LN) 3 did not properly identify (establish or indicate who someone is) Resident 3 prior to administering medications. As a result of these failures, Resident 1 was placed at risk for adverse reactions (an undesired effect of a drug) due to receiving a potent opioid (a type of drug used to reduce moderate to severe pain) without a physician's order. In addition, these failures placed Resident 2 at risk for experiencing increased pain and discomfort due to not receiving prescribed medications. Furthermore, Resident 2 was placed at risk for experiencing increased effects of Fentanyl. These failures had the potential to cause serious injury, harm, impairment, or death for Resident 1 and Resident 2.Findings: On 3/13/26 at 4:25 P.M., an unannounced onsite visit was conducted to investigate an anonymous complaint regarding a medication error in which a Fentanyl Transdermal (a route of medication administration in which the drug is delivered through the skin) Patch was administered to the wrong resident.1.Review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a lung disease which makes it difficult to breathe), dependence on renal dialysis (a procedure that removes toxins from the lungs when the kidneys have failed), and Alzheimer's disease (a disease that affects memory, thinking, and behavior).A review of Resident 1's Minimum Data Set (MDS- a standardized assessment tool) dated 3/4/26 indicated Resident 1 was unable to complete a Brief Interview for Mental Status (BIMS- a tool to assess cognition -acquiring knowledge mentally or thinking skills). The MDS indicated Resident 1 had a memory problem and severely impaired cognitive skills.During an interview with the Director of Nursing (DON) on 3/13/26 at 4:35 P.M., the DON stated on 3/4/26 at approximately 7 A.M., Resident 1 had a change in condition and was transferred to an acute care hospital via 911 for difficulty breathing. The DON stated the facility was informed by the hospital that a Fentanyl Transdermal Patch was found on Resident 1. The DON further stated the fentanyl patch was intended for a different resident (Resident 2) and that Resident 1 did not have an order for a fentanyl patch. The DON stated an investigation was initiated, and the facility determined on 3/3/26, Licensed Vocational Nurse (LN) 1 administered the fentanyl patch to Resident 1 without a physician's order.During a telephone interview with Licensed Nurse (LN) 1 on 3/17/26 at 12:08 P.M., LN 1 stated on 3/3/26 he was on duty as the medication nurse for Resident 1 and Resident 2. LN 1 stated while providing care for Resident 1, he placed a Fentanyl Patch on her chest. LN 1 stated on 3/4/26, he received a call from the Director of Nursing (DON) and was informed he administered the fentanyl patch to the wrong resident. LN 1 stated his employment with the facility was terminated on 3/5/26 due to the medication error. During a record review of Resident 1's Electronic Health Record (EHR), a Respiratory Note dated 3/4/26 a 7:10 A.M. indicated, Nurse notified writer to assess pt [patient] due to increase [sic] WOB [Work of Breathing- energy expended by the respiratory muscles to move air in and out of the lungs]. Upon assessment pt was found on 2L [a flow rate of oxygen] NC [nasal cannula- plastic tubing placed in the nostrils used to deliver oxygen] in semi-Fowlers position [a position where an individual is laying on their back, with the head raised at an angle between 30 and 40 degrees], spo2 [a percentage of oxygen] 83% RR [respiratory rate] 40 HR [heart rate] 115. Crackles auscultated bilateral lobes. Oral sx [suction] performed with mod [moderate] amount of white, frothy secretions obtained. Ptnoted [sic] to have weak cough effort.During a record review of Resident 1's EHR, a progress note dated 3/4/26 at 7:15 A.M. titled Nurse's Note indicated, Upon report resident was noted with labored [sic] breathing, desaturating 83%, and diaphoretic [sweating]. RT [Respiratory Therapist] assessed resident placed on non-rebreather [an emergency medical device used to deliver high-concentration oxygen to patients experiencing respiratory distress] , MD [Medical Doctor] notified with orders to have resident sent out via 911 for further evaluation.During a record review, the SBAR [Situation, Background, Assessment, Recommendation] Communication Form dated 3/4/26 at 9 A.M. indicated, This writer received call from [Acute Care Hospital] and was notified the upon admission [Resident 1] had Fentanyl [a potent opioid medication used to treat chronic pain] patch w/o [without] order. PCP (Primary Care Physician), DON (Director of Nursing), ADMINISTRATOR, AND RP NOTIFIED.During a record review, the Progress Note dated 3/12/26 at 10 A.M. indicated, Placed call to [Hospital Name] to obtain status update on patient, Transferred to MICU [Medical Intensive Care Unit- a specialized hospital department providing 24/7 care for critically ill patients].spoke with RN and was notified patient had expired on 03/10/2026 due to respiratory failure.During a concurrent telephone interview and record review with the Pharmacy Consultant (PC) on 3/25/26 at 3:58 P.M., the PC stated Resident 1 had only been prescribed acetaminophen (a non-opioid, over the counter medication pain medication) at the facility. The PC stated Resident 1 was assessed to be opioid naive (an individual who had not used opioid medications regularly, and whose bodies were not accustomed to opioid medications). The PC stated, You don't want to give the fentanyl patch to anyone who hasn't taken any other opioids.it's the last line of medication to give. The PC further stated as an opioid naive individual who was given fentanyl, Resident 1 was placed at higher risk for respiratory depression, sedation, and confusion.During a review of the facility provided drug reference sheet for Fentanyl Transdermal System, the document indicated, Schedule 2 opioid substances which include fentanyl.have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression.Since the peak fentanyl concentrations generally occur between 20 and 72 hours of treatment; prescribers [licensed healthcare professions who are authorized to prescribe medications] should be aware that serious or life threatening hypoventilation [breathing at an abnormally slow rate] may occur, even in opioid-tolerant patients [patients whose bodies have adjusted to receiving opioids on a regular basis] during the initial application period. The drug reference sheet further indicated, [Fentanyl Transdermal Patch] should be used with extreme caution in patients with significant chronic obstructive pulmonary disease.In such patients, even usual therapeutic doses of [Fentanyl Transdermal Patch] may decrease respiratory drive to the point of apnea [temporary cessation of breathing].Chronic Pulmonary Disease.Because potent opioids can cause serious or life-threatening hypoventilation, [Fentanyl Transdermal Patch] should be administered with caution to patients with pre-existing medical conditions predisposing them to hypoventilation. In such patients, normal analgesic [pain relieving] doses of opioids may further decrease respiratory drive to the point of respiratory failure.During a review of the Medication Guide for Fentanyl Transdermal System, revised 2009, provided by the facility, the guide indicated, Fentanyl is a very strong opioid narcotic pain medicine that can cause serious and life threatening breathing problems can happen because of an overdose or if the dose you are using is too high for you.A [Fentanyl Transdermal Patch] must be used only on the skin of the person for whom it was prescribed.During a review of the facility's undated policy titled Administering Medications, the policy indicated, Medications are administered in accordance with prescriber orders.The individual administering mediations verifies the resident's identity before giving the resident his/her medications.The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services.2. During a record review, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included traumatic subarachnoid hemorrhage (a life-threatening emergency bleeding into the space surrounding the brain), and fall.During a record review, the History and Physical dated 5/16/25 indicated Resident 2 had a diagnosis of pain.During a record review, the MDS dated [DATE] indicated Resident 2 had a BIMS of 3, which indicated severe cognitive impairment.During an interview with the Director of Nursing (DON) on 3/13/26 at 4:35 P.M., the DON stated Resident 2 was on hospice services and received Fentanyl for pain management and comfort. The DON stated on 3/3/26 Resident 2 was scheduled to receive a Fentanyl Patch. The DON stated the Fentanyl Patch was mistakenly given to Resident 1.During a telephone interview with Licensed Nurse (LN) 1, on 3/17/26 at 12:08 P.M., LN 1 stated on 3/3/26 he was the medication nurse assigned to Resident 1 and Resident 2. LN 1 stated on 3/3/26 during the morning shift, he was replacing Resident 1's gastrostomy tube (GT- a tube inserted into the stomach to administer food and/or medications) dressing, and he had Resident 2's Fentanyl Patch with him. LN 1 acknowledged he did not administer the Fentanyl Patch to Resident 2 as ordered by the physician.During an interview with LN 2 on 3/18/26 at 12:14 P.M., LN 2 stated on 3/4/26 she was informed that Resident 2 did not receive a Fentanyl Patch on 3/3/26. LN 2 stated a skin check was conducted on Resident 2 to see if she had a Fentanyl Patch on. LN 2 stated on 3/4/26, a Fentanyl Patch could not be located on Resident 2. LN 2 stated, it was a medication omission when [Resident 2] didn't receive the patch. and it was important to ensure Resident 2 received all medications as ordered to manage her pain and keep her comfortable.During a review of the facility's undated policy titled Administering Medications, the policy indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.3. During a medication administration observation on 3/17/26 at 9:42 A.M., Licensed Vocational Nurse (LN) 3 was observed preparing medications for Resident 2. LN 3 stated one of the medications was a Fentanyl Transdermal Patch. LN 3 stated per the Electronic Medication Record (EMAR), the previously applied patch was on Resident 2's right arm. LN 3 stated he needed to remove the previously applied patch prior to administering the new patch.On 3/17/26 at 10:06 A.M., LN 3 was observed administering the Fentanyl Transdermal Patch to the right side of Resident 2's chest. LN 3 stated he could not locate the previously applied patch on Resident 2's right arm. LN 3 was observed lifting Resident 2's left arm, and he stated he did not see a Fentanyl patch on the left arm either. LN 3 made no further attempts, such as a full body/skin check, to locate the previously applied Fentanyl patch.During a record review of Resident 2's Physician's Orders dated 3/5/26, indicated, fentanyl Transdermal Patch 72 Hour 12 MCG/HR Apply 1 patch transdermal every 72 hours for pain/comfort and remove per schedule.On 3/17/26 at 10:25 A.M. an interview was conducted with LN 3. LN 3 stated the purpose of removing the previously applied Fentanyl Transdermal Patch was to ensure Resident 2 did not receive too much of the medication. LN 3 stated if the previously applied patch was still on Resident 2's skin, and a new patch was applied, we don't want her to get too much of it.During an interview with the Director of Nursing (DON) on 3/17/26 at 10:40 A.M., the DON stated there was no system in place to monitor the placement of a transdermal patch every shift. The DON stated her expectation was for the medication nurse to do a thorough body check for the previous patch, prior to applying the new Fentanyl Transdermal Patch. The DON stated it was important to try to locate the previously applied patch to prevent the resident from becoming overmedicated.During a review of the Medication Guide for Fentanyl Transdermal System, provided by the facility, the guide indicated, Do not wear more than one [Fentanyl Transdermal System] at a time, unless your doctor tells you to do so.During a review of the facility's policy titled Administering Medications, the policy did not provide guidance on the removal and/or application of transdermal medications. 4. According to the admission Record, Resident 3 was admitted on [DATE] with diagnoses which included chronic pain and type 2 diabetes.A review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool) dated 2/17/26 indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition) of 15, which indicated intact cognition.On 3/17/26 at 8:50 A.M., a medication administration observation was conducted with Licensed Vocational Nurse (LN) 3 for Resident 3. Resident 3 was observed without an identification band on her arms. LN 3 proceeded to administer eye drops (brimonidine-a medication used to treat glaucoma, an eye disease) to Resident 3. LN 3 then handed Resident 3 a plastic cup of medications. Resident 3 was observed consuming her medications. LN 3 did not confirm Resident 3's identification prior to administering her medications. The following medications were administered to Resident 3:-iron (mineral supplement) 65 mg (milligrams- a unit of measurement) , 1 tablet-baclofen (muscle relaxant) 5mg, 1 tablet-Eliquis (blood thinner) 5mg, 1 tablet-duloxetine (a medication to treat depression and/or nerve pain) 30 mg, 1 capsule-gabapentin (a medication used to treat nerve pain) 100 mg, 1 capsule-multivitamin with minerals, 1 tablet-vitamin b12 1000 mcg (micrograms- a unit of measurement) 1 tablet-lidocaine patch 4% (a medication used to treat pain) 1 patch to each knee-brimonidine (medication primarily used to lower high eye pressure) 1 drop in the right eye-dorzolamide 2% (a medication used to treat glaucoma) 1 drop in both eyes.On 3/17/26 at 9:20 A.M., an interview was conducted with LN 3. LN 3 stated prior to administering medications, he should have identified the resident. LN 3 stated one of the identification methods was to check Resident 3's arm band and birthday, and to compare to the Electronic Health Record. LN 3 stated since Resident 3 did not have an identification band, he should have checked her picture in the Electronic Health Record and offer an ID band to Resident 3. LN 3 stated it was important to identify residents prior to administering medications to avoid any medication errors. LN 3 stated, it's one of the rights of med pass.During an interview with the Director of Nursing on 3/17/26 at 10:40 A.M., the DON stated it was her expectation that licensed nurses identify residents prior to administering medications. The DON stated methods of identification included checking the residents' identification bands for the name and date of birth , then comparing against the electronic health record. The DON stated if the resident did not have an identification band, the licensed nurse should use their picture in the EHR. The DON further stated if the resident did not have a picture in the EHR, two staff members should identify the resident. The DON stated it was important to identify the correct resident prior to administering medications to avoid medication errors.During a review of the facility's policy titled Administering Medications, the policy indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.On 3/17/26 at 3:08 P.M., a meeting was conducted with the Administrator (ADM), the Director of Nursing (DON) and Area Lead (AL). The California Department of Public Health (CDPH) Pharmacy Consultant (PC) was also present. The CDPH District Office Manager and Supervisor were present via telephone. The facility was notified of Immediate Jeopardy (IJ- is the highest-level deficiency citation in healthcare, occurring when a provider's noncompliance causes or is likely to cause serious injury, harm, impairment, or death to a patient. It triggers mandatory, urgent corrective action, with potential Medicare/Medicaid termination within 23 days if not resolved). The (IJ) related to the facility's failure to identify the correct resident prior to administering a Fentanyl Transdermal Patch on 3/3/26, and the facility's failure to verify the location of a previously administered Fentanyl Transdermal Patch prior to applying a new patch on 3/17/26. This resulted in placing Resident 1 at risk for serious effects due to receiving a medication that was not ordered for her. Additionally, this failure placed Resident 2 at risk for becoming overmedicated from a potent opioid medication. The IJ Template was provided to the ADM and DON via email. The facility initiated a plan to remove the IJ. On 3/17/26 at 4:25 P.M., the ADM and DON provided a removal plan. The removal plan was reviewed and was not acceptable.On 3/17/25 at 4:52 P.M., the ADM and DON re-submitted a removal plan. The removal plan was reviewed and was not acceptable.On 3/17/26 at 5:43 P.M., the ADM and DON re-submitted a removal plan. The removal plan was reviewed and was not acceptable.On 3/17/26 at 6:23 P.M., the ADM and DON re-submitted a removal plan. The removal plan was reviewed and accepted. The IJ was removed. 1.Immediate Protective ActionsMedical records did a sweep of all residents who were receiving narcotic pain patches. The Assistant Director of Nursing conducted a visual check to ensure narcotic pain patches were applied as ordered.The Medical Records Department did a facility-wide sweep for residents' identification bands on 3/17/26. Residents who did not have an identification band were provided with one, with the following resident information: Name, date of birth , doctor's name, facility address and phone number. 2. Corrective Measure for the Affected ResidentResident 1 was transferred to an acute care facility on 3/4/26 and had expired on 3/10/26. 3. Facility-Wide Systemic ChangesAn extra check was added for residents who had an order for narcotic pain patches. Licensed nurses are now required to check for the location of the patches every shift to ensure missing patches were identified prior to the next administration date.All licensed nurses were required to attend an in-service prior to administering any medications.

Based on interview and record review, the facility failed to allow one of three residents reviewed for discharges (Resident 1) to return to the facility following a hospitalization for aggressive verbal and physical behavior.This failure had the potential for Resident 1 to not receive continuity of care, violated her right to return to the facility per behold agreement, and extended Resident 1's hospital stay unnecessarily.Findings:According to the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included psychotic disorder (a mental health condition causing a loss of contact with reality) with hallucinations due to known physiological condition (related to the function of the body or parts of the body, such as the brain), and dementia (loss of memory, problem-solving, and other thinking skills).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool), dated 1/29/26, indicated Resident 1 had a Brief Interview For Mental Status (BIMS- a tool to assess cognition of 6, which indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 was dependent on staff for all Activities of Daily Living (ADL's- activities such as eating, dressing, toileting, and bathing) as well as bed mobility (rolling to the left and right side, changing position from sitting to lying and vice versa).During an interview with the Director of Nursing (DON) on 3/13/26 at 4:32 P.M., the DON stated on 2/4/26, during resident care, Resident 1 swung at Certified Nursing Assistant (CNA) 1 and was sent to the hospital for physically aggressive behavior. The DON stated Resident 1 had psychiatric diagnoses, however she was unaware of any other incidents of physically aggressive behavior prior to 2/4/26.During an interview with Certified Nursing Assistant (CNA) 1 on 3/18/26 at 11:54 A.M., CNA 1 stated Resident 1 had been on 1:1 monitoring (one staff assigned to stay with the resident at all times) since admission and required two staff members' assistance with all ADL's. CNA 1 stated on 2/4/26, during toileting assistance, Resident 1 swung her fist at CNA 1 and hit her in the face. CNA 1 stated I was pulling up her brief, and she got me pretty good. She punched me with a closed fist. When I stepped back, she came at me. CNA 1 stated Resident 1 was Coming at us.she was mad saying 'Get out of the room.' CNA 1 stated staff did not leave the room because Resident 1 required 1:1 monitoring for safety. CNA 1 stated she provided 1:1 supervision for Resident 1 multiple times, and stated there were no prior incidences of Resident 1 having assaultive behaviors towards her or any other person.During an interview with the Social Services Director (SSD) on 3/18/26 at 1:22 P.M., the SSD stated Resident 1 was confused due to dementia, and exhibited impulsive behavior, such as yelling at staff and attempting to stand up unassisted. The SSD stated the incident of Resident 1 hitting a staff member on 2/4/26 was Resident 1's first incident of physical assault at the facility. The SSD stated, That was her first time being assaultive. There was no indicator that she was assaultive, but she has exhibited impulsive behavior.During a follow-up interview with the DON on 3/18/26 at 3:33 P.M., the DON stated the last known communication she had with the hospital was on 2/5/26. The DON stated the facility refused to accept Resident 1 back to the facility on 2/5/26, because they did not believe her behaviors had been stabilized at the hospital. The DON stated she gave her cell phone number to the hospital contact and .once she's stable, we will take her back. The DON stated Resident 1 did not return to the facility because, We never received any call [from the acute care hospital]. The DON stated since 2/5/26, she does not know if anyone at the facility attempted to call the hospital for an update on Resident 1's status.During a telephone interview with the Administrator (ADMIN) on 3/27/26 at 2:23 P.M., the ADMIN stated sending Resident 1 to the hospital was a transfer to stabilize the resident, and not considered a discharge. The ADMIN acknowledged the facility did not allow Resident 1 to return to the facility because of the assaultive behavior on 2/4/26, but stated the facility did not have any documented attempts at contacting the hospital to see if Resident 1 had been stabilized and/or was ready to return to the facility. The ADMIN stated his expectation was for the facility to follow its policy regarding transfers and bedholds to ensure residents rights to return to the facility.During a review of the facility's policy titled Bed-Holds and Returns, revised 10/22, the policy indicated, Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.

Based on interview and record review, the facility failed to maintain accurately documented records when Licensed Nurse (LN) 1 documented he removed a fentanyl (a potent medication used to control pain) patch (a medication that is applied to the skin) although Resident 2 did not have a fentanyl patch to be removed at that time.This failure resulted in inaccurate documentation in Resident 2's medical record and had the potential to negatively affect her treatment and assessment.Findings:During an interview with the Director of Nursing (DON) on 3/17/26 at 3:16 P.M., the DON stated that LN 1 documented he removed Resident 2's fentanyl patch on 2/28/26 on Resident 2's February 2026 Medication Administration Record (MAR, an official legal document that has a complete and accurate record of all medications administered to a resident to ensure patient safety). The DON stated there was an order to start the fentanyl patch on 2/25/26, but the medication was not delivered until 2/28/26. The DON stated Resident 2 did not have a patch to be removed on 2/28/26.A review of Resident 2's medical record indicated she had an order for fentanyl transdermal (through the skin) patch 72 hour (left on for 72 hours, or 3 days) 12 mcg (micrograms, unit of measure)/hr (hour, unit of measure for time) - apply 1 patch transdermally every 72 hours for pain/comfort and remove per schedule, initiated 2/25/26. Resident 2's February 2026 MAR indicated 9 on 2/25/26 at 12:24 P.M. for the fentanyl patch. The MAR legend for codes indicated, 9 = Other/ See [sic] Nurses Notes. A progress note dated 2/25/26 at 12:25 by LN 4 indicated, .awaiting delivery. Resident 2's February 2026 MAR also indicated a fentanyl patch was removed on 2/28/26 at 11:56 A.M.During an interview with the DON on 3/18/26 at 3:46 P.M., the DON stated Resident 2 did not receive a fentanyl patch on 2/25/26. DON stated there was nothing to remove on 2/28/26, based on the controlled drug record (CDR, count sheet used to track controlled medications). The DON stated the fentanyl patch was not applied to Resident 2's skin on 2/25/26, which meant there was no patch to remove on 2/28/26. The DON confirmed documentation on Resident 2's February 2026 MAR on 2/28/26 at 11:56 A.M. by LN 1 indicated that the fentanyl patch had been removed. The DON stated the documentation was not accurate.A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, indicated, .3. Documentation in the medical record will be objective.complete, and accurate.

Based on observation, interview, and record review the facility failed to ensure timely reporting of an injury of unknown origin to the California Department of Public Health (CDPH), Ombudsman, and/or law enforcement (LE) in accordance with the facility's abuse reporting policy and procedures, for one of three sampled residents (Resident 1).This deficient practice placed one resident (Resident 1) at risk for uninvestigated abuse, neglect, or mistreatment and delayed protective oversight by the appropriate authorities.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).A record review of Resident 1's MDS (Minimum data set: nursing facility assessment tool) dated 1/27/26 indicated that Resident 1 was rarely or unable to understand others or make self-understood and had severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to make decisions.On 3/2/26 at 9:21 A.M., a telephone interview with the complainant ECPD (El Cajon Police Department) Officer was conducted. The ECPD Officer stated Resident 1, a non-verbal resident, had a bruise on the left eye of unknown origin. The officer confirmed ECPD responded to a call for service at the skilled nursing facility on 1/30/26 and notified CDPH (California Department of Public Health) and the Ombudsman (a patient advocate who investigates and helps to resolve complaints and concerns for long term care facilities) about the incident. The ECPD Officer stated there was suspicious documentation, and staff was unable to explain how the injury occurred.On 3/2/26 at 11:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated they (the facility) had not called the ECPD. The DON verified that the ECPD Officer was at the facility because they (ECPD) had received a report that Resident 1 had an injury of unknown origin. The DON stated the facility had identified Resident 1 with a bruise to the left eye as an injury of unknown origin and had conducted an internal investigation. The DON stated staff believed the bruise may have occurred when Resident 1's head leaned against the bed rail. The DON stated the injury was unwitnessed and of unknown origin, but the facility did not report the incident to the required entities (CDPH, Ombudsman and/or ECPD) and/or submitted a required report because staff believed the ECPD Officer did not identify wrongdoing. The DON further stated the incident should have been reported to all required entities (CDPH, Ombudsman and/or ECPD) .On 3/2/26 at 11:45 A.M., an interview was conducted with the Administrator (ADM), in the DON's office. The ADM stated the facility did not report Resident 1's injury of unknown origin to the required entities because the responding ECPD Officer had indicated there was no evidence of abuse. The ADM stated the facility relied on the officer's conclusion and did not complete the required reporting to all required entities.On 3/2/26 at 4:07 P.M., an observation was conducted in Resident 1's room. Resident 1 had padded bed rails on both sides of her bed. Resident 1 was non-verbal and was unable to be interviewed.On 3/2/26 at 4:10 P.M., an interview and record review were conducted with Licensed Nurse (LN) 1, in the third-floor nursing station. LN 1 stated Resident 1 had a change in skin condition with discoloration to the left eye identified on 1/29/26. LN 1 stated injury was unwitnessed, and it was unknown how Resident 1 was injured. LN 1 stated Resident 1's injury should have been reported to all required entities within 24 hours to initiate an investigation and ensure Resident 1's safety. LN 1 stated she did not see documentation indicating the incident had been reported to the required entities.On 3/3/26 at 3:25 P.M., an interview was conducted with the Social Service Director (SSD), in the ADM's office. The SSD stated staff identified discoloration to Resident 1's face on 1/29/26. The SSD stated nursing staff believed the bruise may have occurred when Resident 1 leaned her head against the bed rail. The SSD stated the injury appeared to be a yellow bruise and Resident 1 was at baseline with no signs of distress when observed. The SSD further stated injuries of unknown origin should be reported to CDPH, law enforcement, and the Ombudsman within 24 hours, or immediately within two hours if serious injuries was sustained to ensure all resident safety and initiate an investigation.On 3/5/26 at 5:30 P.M., an interview was conducted with ECPD Officer, by telephone. ECPD Officer stated he and another officer observed discoloration to Resident 1's left eye (1/30/26) which appeared as a light-yellow bruise that was fading.On 3/5/26 at 5:48 P.M., an exit interview was conducted with the DON, by telephone. The DON stated injuries of unknown origin and suspected abuse should be reported to ensure resident (all facility staff) safety and to allow an investigation to be conducted in accordance with reporting requirements.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated December 2017, indicated .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law

Based on observation, interview and record review the facility failed to ensure thorough investigation and appropriate corrective action of an abuse allegation when staff was not aware of the resident-to-resident altercation between Resident 1 and Resident 6, This failure had the potential for not protecting other residents from Resident 1.Findings: On 1/23/26 at 8:39 A.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercation. Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/21/25, section C0500 indicated Resident 1's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 5, severe problems with thinking and memory. During a review of Resident 1's psychosocial care plan dated 1/5/26, the care plan indicated Resident 1 allegedly grabbed her [roommate's] wrists and hands, squeezed them hard after she [Resident 1] attempted to use roommate's wheelchair. Resident 6 was re-admitted to the facility on [DATE] with diagnoses including abnormality of gait (walking) and mobility according to the facility's admission Record. A review of Resident 6's MDS dated [DATE], section C0500 indicated Resident 6's BIMS score was 14, intact cognition. During an interview on 1/23/26 at 9:04 A.M. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 was transferred to the third floor from the fourth floor due to an altercation with her roommate, Resident 6. An interview on 1/23/26 at 9:19 A.M. with Resident 1's assigned Certified Nurse Assistant (CNA) 1 on the third floor was conducted. CNA 1 stated she did not know why Resident 1 was transferred to third floor. CNA 1 further stated Resident 1 had episodes of being angry and grabbing staff. An interview on 1/23/26 at 9:26 A.M. with Resident 1's assigned Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 was transferred to her floor (third floor) about a week ago. LN 1 stated she did not know why Resident 1 was transferred to the third floor. During an interview on 1/23/26 at 10:02 A.M. with CNA 2, CNA 2 stated the CNA assigned to the resident who had an altercation with another resident should know about the incident. CNA 2 stated the assigned CNA should know to monitor the resident with the behavior and prevent another altercation with other residents. An interview on 1/23/26 at 10:09 A.M. was conducted with the Social Service Assistant (SSA). The SSA stated Resident 6 came to her office and reported her roommate (Resident 1) grabbed her arm while reaching for a wheelchair which was in between their beds. The SSA stated staff should be aware of the incident to be aware of Resident 1's behavior and for safety reasons. During an interview on 2/5/26 AT 2:15 P.M. with the ADON, The ADON stated it was important for staff to be aware of the resident's behavior to monitor the resident and other residents. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2001 was conducted. The P&P indicated, Residents have the right to be free from abuse.The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives.Protect residents from abuse.from anyone including.other residents.

Based on interview and record review, the facility failed to make medical records available for Family Member (FM) 1 to review within 24 hours of the request, for one of two sampled residents (1). As a result, Resident 1 was not aware of the details of his medical record and the facility violated his right to access his medical records.Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include heart failure, deaf (inability to hear) nonspeaking, and parkinsonism (a group of symptoms that include difficulty moving). Per the facility's Authorization Form for the Release of Health Information, dated 11/22/24, Resident 1 authorized the facility to release his medical records to FM 1. Per the facility's Authorization Form for the Release of Health Information, dated 3/18/25, Resident 1 authorized the facility to release his medical records to FM 1. On 7/3/25 at 11:27 A.M., an interview and record review was conducted with the Medical Records Director (MRD). The MRD stated, FM 1 requested copies of Resident 1's medical records but FM 1 did not want to pay for the copies. The MRD further stated, FM 1 then requested to review Resident 1's medical records if he could not obtain copies for free, but the facility told FM1 that they would still charge FM1 to review Resident 1's records. The MRD stated that the facility discussed FM 1's record request with him by email. Per an email thread on 12/5/24, FM 1 notified the facility that he wanted to inspect Resident 1's records in person. The facility Administrator responded to FM1's email stating that FM 1 would still have to pay the facility to review Resident 1's records in person. The MRD stated that FM 1 never reviewed Resident 1's medical records at the facility.Per the facility's policy, titled Release of Information, revised November 2009, 8. The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes.9. A resident may have access to his or her records within ____ hours (excluding weekends or holidays) of the resident's written or oral request. The policy did not specify how many hours the facility had to make the records available for review.

Based on observation, interview, and record review, the facility failed to provide routine bathing hygiene to one of four residents (Resident 2), dependent on staff for Activities of Daily Living, (ADL-bathing, dressing, toileting, and re-positioning), when reviewed for Quality of Care.This failure had the potential for skin issues to develop and for Resident 2 to experience low self-esteem. Findings:An unannounced visit was made to the facility on 7/29/25, regarding a complaint. Resident 2 was admitted to the facility on [DATE], with the diagnosis which included morbid (severe) obesity due to excess calories, per the facility's admission Record.Resident 2's clinical record review was conducted on 7/29/25.According to the Admission, Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 4/25/25, a cognitive score of 12 was listed, indicating moderately impaired cognition. The Functional Abilities assessment indicated Resident 2 required maximum staff assistant with turning and transferring. According to the physician's order, dated 7/18/25, .offer pain pill one hour before shower to aid with showers: infection control.According to the facility's Weights and Vitals, Resident 2's admission weight was 367.9 pounds.According to the facility's Shower book , dated June 2025, Resident 2 had received baths four times out of eight opportunities, Resident 2 received two showers on 6/2/25 and 6/30/25, and two bed baths on 6/1/25 and 6/23/25, with no documented refusals. According to licensed nurse 1 (LN 1) shower book documentation was discontinued at the end of June 2025, and in-services were provided for staff to document resident bathing in the computer, under the Task headline.The computer Task screen was reviewed for Resident 2, for July 1, 2025 through July 29, 2025. Three showers were provided (7/7/25, 7/10/25, 7/21/25), out of eight opportunities, and two refusals (7/17/25, 7/24/25) were documented. According to the facility's care plan, titled At Risk for Skin Breakdown, dated 4/18/25, interventions included, administered medication as orders and observe skin integrity for signs of skin breakdown or excoriation.An observation and interview was conducted with Resident 2 on 7/29/25 at 12:47 A.M. While standing outside Resident 2's room, observing the name plate on the wall, a strong odor was detected that did not resemble urine or feces. When entering the room, the odor grew stronger and was more pungent. Resident 2 was sitting up in bed, eating lunch. Resident 2 had long, greasy looking hair. Resident 2 stated she liked both showers and baths and her last shower was about a week ago. Resident 2 stated yes, she was being medicated before the shower and the pain medication helped her a lot. Resident 2 gave permission for this writer to return after she finished lunch, and to have staff assist me with a skin inspection.A follow up observation and interview was conducted with Resident 2 on 7/29/25 at 1:13 P.M. Staff present to assist with the skin inspection were licensed nurse 1 (LN 1), LN 5, certified nursing assistant 1 (CNA 1), and CNA 3. After the skin inspection, all staff left the room so a private interview could be conducted. Resident 2 stated she only refused to bathe one time, and that was when she first arrived at the facility. Resident 2 stated she was afraid of the Hoyer lift (a machine that staff used to safely lift or transfer patients by the use of a sling). Since then, Resident 2 stated she would agree to a shower only if CNA 1 was working, because she trusted CNA 1 on the Hoyer lift. Resident 2 stated if she refused a shower, it was because of who was working the Hoyer lift and for no other reason. Resident 2 stated if she refused a shower, she would still like to have a bed bath. Resident 2 stated she had received some really good bed baths in the past and she really did not have a preference for showers over a bed bath. Resident 2 stated bathing twice a week was good for her. An interview was conducted with the Director of Staff Development (DSD) on 7/29/25 at 2 P.M. with the Director of Nursing (DON) present. The DSD stated since they stopped using the Shower book for documentation, In-services were provided to CNAs and LNs numerous times throughout the month of July, so everyone knew the changes and expectations. The DSD stated if showers were refused, then bed baths should be offered. If still refused, staff were expected to notify the LNs, and document why the refusals were made. The DSD stated bathing was important for prevention of skin breakdown and a resident's self-image.An interview and record review was conducted with the DON on 7/29/25 at 2 P.M. The DON reviewed Resident 2's June shower sheets and the bathing Task for July. The DON stated she expected all residents to have showers or bed baths at least twice a week and for the bathing to be documented. The DON stated if bathing was repeatedly refused, she expected staff to create a care plan for refusals, so appropriate interventions could be implemented.According to the facility's policy, titled Activities of Daily Living (ADL), Supporting, dated 2001, .5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including support n assistance with: s. Hygiene (bathing, dressing, grooming, and oral care); .

The facility failed to administer pain medication for two of four residents (Resident 1 and Resident 2) per the Nursing Standards of Practice, reviewed for Quality of Care when: 1. Pain medication was administered to Resident 1 without assessing the level of pain before or after administration of a narcotic (a controlled that is regulated by the government due to its potential for abuse and addiction) and, 2. The correct pain medication was not administered to Resident 2 according to the pain scale (1-10: 1 being the least amount of pain and 10 being the worst pain). These failures had the potential for Resident 1 to experience addiction and for Resident 2 to not receive adequate pain relief.Findings:1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25.According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to Resident 1's physician's orders, dated 4/21/25, give Hydrocodone-Acetaminophen, (a regulated pain medication to help with moderate to severe pain), 5-325 milligrams oral tablet. Give one tablet every eight hours as needed for moderate to severe pain. A review of Resident 1's Medication Administration Record (MAR), dated July 1 through July 29, 2025, was conducted. The pain medication Hydrocodone-Acetaminophen was administered 16 times. Four of the 16 times when the pain medication was administered the level of pain was marked 0 by Licensed Nurse 4 (LN 4) as a pain level (Pain scale: 1 indicates minimal amount of pain, 10 worst pain) before administration. The pain assessment after medication administration (one hour later) was marked U for unknown, per the facilities coding. According to the facility's care plan, titled Pain, dated 6/24/19, interventions included position for comfort, medications as ordered, and if pain not relieved, contact the physician.An interview and record review was conducted with LN 4, of Resident 1's July MAR on 7/29/25 at 12:10 P.M. LN 4 stated post (after) pain medication should always be assessed to ensure the pain medication was working. LN 4 stated if the medication was not therapeutic, then he would contact the physician. LN 4 reviewed Resident 1's July MAR and was asked the reason pain medication was administered when the resident had no documented pain. LN 4 stated he administered the hydrocodone, because the resident asked for it. LN 4 stated he did not inquire if there was pain, and he did not follow up afterwards to ensure the pain medication was working. LN 4 stated Resident 1 asked for the pain medication, so I gave it to her. LN 4 stated he understood hydrocodone was controlled medication and addictive. LN 4 stated he should have assessed Resident 1's pain before administering the pain medication, and he did not.An interview was conducted with LN 5 on 7/29/5 at 1:37 P.M. LN 5 stated pain levels should also be assessed and documented before administering pain medication. LN 5 stated the standard of practice was to assess the pain one hour afterwards, to ensure the resident had pain relief with the medication. If not, the physician should be contacted, to change or increase the medication. LN 5 stated she would never administer an as needed pain medication if there was no pain, because pain medication could be addictive and make someone dependent.An interview was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated she expected all residents to be assessed for pain levels before and after administration. The DON stated as needed pain medication should not be administered if a pain level was not documented. According to the facility's policy, titled Administering Pain Medications, dated 2001, .1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice. Steps in the Procedure: .3. Conduct a pain assessment.9. Re-evaluate the resident's level of pain 30-60 minutes after administering.2. Resident 2 was admitted to the facility on [DATE], with the diagnosis which included morbid (severe) obesity due to excess calories, per the facility's admission Record.Resident 2's clinical record review was conducted on 7/29/25. According to Resident 2's Admission, Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 4/25/25, a cognitive score of 12 was listed, indicating moderately impaired. The Functional Abilities assessment indicated Resident 2 required maximum staff assistant with turning and transferring. According to Resident 2's physician's order, dated 4/18/25, Give Acetaminophen tablet (Tylenol) 325 milligrams (mg), two tablets by mouth every four hours as need for mild pain (1-3). An additional physician's order was added for pain on 4/30/25. Tramadol HCL (a strong pain medication for moderate to severe pain), 50mg, give one tablet by mouth every six hours as needed for moderate to severe pain.A review of Resident 2's MAR, dated July 1 through July 29, 2025, was reviewed. Acetaminophen was administered 32 times for pain as needed, of the 32 administrations, 23 administrations were for a pain scale level of 4-8, not 1-3 as ordered by the physician. An interview and record was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated as needed pain medication should be administered according to the physician's order in accordance with the pain scale listed. If Resident 2 was receiving Tylenol for moderate pain, there was the possibility she was not getting sufficient pain relief. The DON stated she expected nurses to follow the physician's order based on the pain scale listed. According to the facility's policy, titled, Administering Pain Medication, dated 2001, .Pain management is defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals.Steps in the Procedure: .3. Conduct a pain assessment.6. Administer pain medications as ordered.

Based on observation, interview, and record review, the facility failed to secure prescription medication when:1. A treatment cart (a cart with prescribed lotions and creams, used to treat wounds and skin conditions) was left unlocked for one of six treatment carts (Station 2 North); and,2. Medication was left on top of a medication cart, unsupervised for one of 11 medication carts (Station 3 North); and,3. Medication was left unsupervised at the bedside for one of four residents (Resident 1) when reviewed for safe medication storage.These failures had the potential for unauthorized people (resident, staff, and visitors) to have access to medications not prescribed to them.Findings: 1. An observation was conducted on 7/29/25 at 10:22 A.M. near the nursing station on 2 north. A treatment cart was unlocked, and no staff were nearby. The treatment cart contained medicated creams and lotions in the first and second drawers. Sitting across from the treatment cart were four residents. One male resident wearing a red outfit, walked past the treatment cart twice. Also observed walking past the unlocked treatment cart were staff and two maintenance staff.An observation and interview was conducted with Licensed Nurse 1 (LN 1) on 7/29/25 at 10:26 A.M. LN 1 was observed looking at the treatment cart which was unlocked. LN 1 stated the cart should always be locked when unattended, because anyone could have access to medications, which could be harmful.2. An observation was conducted on 7/29/25 at 10:39 A.M. of a medication cart in the east hallway of Station 3 north. A medication bottle was located sitting on top of the locked medication cart and no staff were seen in the hallway by the medication cart. The medication bottle was labeled D3 (a dietary supplement) 50 micrograms (mcg). The medication bottle was sealed with a white tab and the label indicated the bottle contained 100 tablets.An observation and interview was conducted with LN 2 on 7/29/25 10:41 A.M. LN 2 looked at the unattended medication bottled on top of the medication cart. LN 2 stated unattended medications could be harmful to unauthorized residents, staff, or visitors if taken and ingested. LN 2 stated she believed the medication nurse for this cart (LN 3) was on a break and LN 2 agreed to take the bottle of medication to the nurse's station for supervision purposes.An interview was conducted with LN 3 on 7/29/25 at 10:44 A.M. LN 3 stated she left the bottle of medication on top of her medication cart, but thought it was okay since the bottle was sealed. LN 3 stated, Yes, I guess anyone could have taken it. I probably should not have left it out. 3. An interview was conducted with Resident 1 on 7/29/25 at 12:21 P.M., in her room. Resident 1 stated she had not received her lidocaine patch (a pain relief medicated patch placed on the skin), that morning.An interview was conducted with LN 4, the medication nurse assigned to Resident 1 on 7/29/25 at 12:32 A.M. LN 4 stated he left the patch in her room. LN 4 stated Resident 1 was approved for self-medication of a cream, but he did not know if she had been approved to apply a pain medicated patch. LN 4 proceeded to Resident 1's room to show where he left the lidocaine patch. LN 4 retrieved a sealed lidocaine patch from the Resident 1's bedside table. LN 4 stated Resident 1 had her own pair of scissors to open up the medicated package, and she liked to put the patch on herself, because she had to lift her dress up to put the patch on her lower back.An interview was conducted with LN 5 on 7/29/25 at 1:27 P.M. LN 5 stated if a resident was not assessed and approved to apply a particular medication, then it should never be left with the resident unsupervised by a nurse.Resident 1's clinical record was reviewed. According to the Self-Medication Assessment, dated 4/28/25, Resident 1 was assessed and approved for the self-medication of Terbinafine cream (a cream used to treat itching caused by fungus) by the interdisciplinary team (IDT-when department heads meet to discuss resident issues). No other medications were approved for self-medication.An interview was conducted with Director of Nursing (DON) on 7/29/25 at 2 P.M. The DON stated she expected all treatment carts, medication carts, and medications to be secured within a cart when not in use by staff. The DON stated medication should never be left at the bedside, unattended, unless the resident was approved for the medication listed on the Self-Medication Assessment. According to the facility's policy, titled Administering Medications, dated 2001, .19.the medication cart is kept closed and locked when out of sight of the medication nurse.27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.'

Based on interview and record review, the facility failed to ensure resident records were accurate and concise for one of four residents (Resident 1) when: 1. A quarterly pain assessment was not conducted for Resident 1, to determine if pain levels had increased or decreased over the past three months; and;2. Routine pain mediation was not charted for Resident 1 after administrated and was charted hours later.These failures provided inaccurate documentation in Resident 1's clinical records and could cause staff confusion.Finding: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25. According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to the facility's last quarter Pain Assessment, dated 3/17/25, Resident 1 had no pain reported. There was no documented evidence a quarterly Pain Assessment was conducted in June 2025, to determine if Resident 1 had a increase or change in pain.According to the facility's care plan, titled Pain, dated 6/24/19, interventions included, position for comfort, medications as ordered, and if pain not relieved, contact physician.An interview and record review was conducted with the Minimum Data Set Nurse 1 (MDSN 1) on 7/29/25 at 1:37 P.M. MDSN 1 stated Pain Assessments needed to be conducted with the resident and completed every three months, to determine if their pain had worsened or improved. MDSN 1 stated when completing Residents' MDS assessments, the MDSNs look at the facility's Pain Assessment, so they could complete the MDS. MDSN 1 reviewed Resident 1's quarterly Pain Assessments and stated her last Pain Assessment was completed in March 2025, and a pain assessment should have been done in June, but it was not. MDSN 1 reviewed Resident 1's Annual MDS, dated [DATE], and stated the MDS pain section was completed in July, by an MDSN 2. MDSN 1 stated she assumed MDSN 2 interviewed Resident 1, but if she had, then the facility's Pain Assessment should have been completed and added to Resident 1's record.An interview and record review was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON reviewed Resident 1's Pain Assessments, and stated the last one was in March 2025, and another one should have been completed in June 2025. The DON stated quarterly Pain Assessments were important to evaluate residents' pain. The DON stated she expected pain evaluations to be completed every three months, as required.According to the facility's policy, titled Administering Pain Medication, dated 2001, .4. Comprehensive pain assessments are conducted upon admission, quarterly, whenever there is a significant change in condition.2. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record. A review of Resident 1's clinical record was conducted on 7/29/25.According to Resident 1's Annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to the physician's order, dated 12/20/24, Lidocaine 5% topical, apply to lower back one time and day and remove at bedtime. According to Resident 1's Medication Administration Record (MAR), dated June 2025, The lidocaine was administered late 15 times out of 30 opportunities, (with a documented range of 2 to 6 hours late). According to the facility's policy titled, Administration of Medication, dated 2001, .23. As required.the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; .According to the facility's care plan, titled Pain, dated 6/24/19, interventions included, position for comfort, medications as ordered, and if pain not relieved, contact physician.An interview and record review was conducted with Licensed Nurse 4 (LN 4) on 7/29/25 at 12:10 P.M. LN 4 stated Resident 1 received a lidocaine patch for back pain. LN 4 stated he administered the patch every morning as ordered. LN 4 reviewed Resident 1's July MAR, and stated the patch was administered as ordered around 9 A.M., but he charted the administration of the patch later, when he had time. LN 4 stated he was aware he should have documented the actual time when the patch was applied, not hours later, because it could be confusing for other staff. An interview was conducted with Resident 1 on 7/29/25 at 12:21 P.M. Resident 1 stated she always received her lidocaine patch in the morning, and it was never late because she would not be able to function for the day.An interview was conducted with LN 5 on 7/29/25 at 1:27 P.M. LN 5 stated lidocaine patches should be applied consistently to provide continuous pain relief. Once any medication was administered, it needed to be documented immediately after being given, so other staff were aware it was administered. LN 5 stated if not documented timely, another nurse might administer the same medication, unaware that it was already given.An interview was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated she expected nurses to document medication was administered, immediately after being given. The DON stated it was not acceptable to document medication was administered later in the day, because it was confusing for the reader and inaccurate.According to the facility's policy, titled Administering Medication, dated 2001, .5. Medication administration times are determined by resident need and benefit, not staff convenience.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required.the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; .

ountry Hills 558-E Accommodation of Needs Based on observation, interview, and record review, the facility failed to provide residents with an alert call system for 20 of 44 Residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 17, 19, 20, 21, 22, and 23) in order for staff to respond to their needs, after their electronic call system stopped working on Station 3 North, when reviewed for Accommodation of Needs. In addition, three of the 21 residents (23, 24, and 25) with manual call bells had their call bells out of reach. This failure had the potential for 26 Residents to not have their needs met in a timely manner. Findings: On 6/10/25, an unannounced visit was conducted in response to a complaint of call lights not working on Station 3 North. An interview was conducted with the Director of Nursing (DON) on 6/10/25 at 11:58 A.M. The DON stated the call light system on Station 3 North stopped working on Wednesday 6/4/25. The DON was unaware if the call light outage was reported to the California Department of Public Health, (CDPH), saying I would need to check with the Administrator. An interview was conducted with the Administrator (ADM). The ADM stated he was unaware of any issues with the call light system. The ADM stated he just returned to the facility on 6/10/2525, since he had been on vacation. The ADM stated he was unaware if the call light failure was reported to CDPH, in his absence. The ADM request time to contact the facility's Director of Maintenance (DM) who was currently home sick. An interview was conducted via telephone on with the DM on 6/10/25 at 12:30 P.M. The DM stated the electronic call light system stopped working last Wednesday on 6/4/25. The DM immediately call the repair company and while waiting, he sent a maintenance aide out to purchase more manual call bells. The DM stated the repair company was at the facility on 6/4/25, 6/5/25, 6/8/25, and 6/9/25, in attempts to fix the call light system. The DM stated the plan now was to replace the entire call light system, since the system was old and parts were limited. Then DM stated the facility was waiting for the quote invoice, so repairs could be made as soon as possible. The DM stated every resident on Station 3 North was provided their own manual bell to use, in the mean time. The ADM provided an internal document of how many manual bells were at the facility on 6/4/25 and how many were purchased, with proof of receipt. According to the documents, 22 manual bells were purchased from Staples, (an office supply store) at 11:23 A.M., and 20 manual bells were obtained from social services department, while 25 manual bells were retrieved from the maintenance department, for a total of 67 bells. Starting on 6/10/25 at 12:13 P.M., room rounds were conducted by the State surveyor. a. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral vascular accident (Stroke), per the facility's admission Record. According to the Minimum Data Set, (MDS-a clinical assessment tool, dated 5/8/25, Resident 1 had a cognitive score of 14, indicating cognition was intact. According to the Functional Abilities assessment, Resident 1 used a wheelchair for mobility and required staff assistance for transfers from bed to chair. An observation was conducted on 6/10/25 at 12:13 P.M. The call light system was not functioning and no manual call bell was observed on or around Resident 1's bed. b. Resident 2 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a progressive disorder that affects the nervous system), per the facility's admission Record. According to the MDS, dated [DATE], Resident 2 had a cognitive score of 6, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 2 used a wheelchair for mobility and required staff assistance for transfers from bed to chair. Resident 2 was coded as having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:13 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 2's bed. Resident 2 had fall mats on both sides of the bed. C. Resident 22 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 22 had a cognitive score of 5, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 22 was able to ambulate on his own with no assistive devices, and required minimal staff assistance. Resident 22 was coded as having a fall in the facility within the last six months. An observation was conducted on 6/10/5 at 12:13 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 3's bed. d. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 3 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 3 was able to ambulate on his own with no assistive devices. Resident 3 was coded of having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 3's bed. e. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Guillan-Barre Syndrome (a rare autoimmune disorder), per the facility's admission Record. According to the MDS, dated [DATE], Resident 4 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 3 was able to ambulate on his own with no assistive devices. An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 4's bed. f. Resident 15 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-poor gas exchange in the lungs), per the facility's admission Record. According to the MDS, dated [DATE], Resident 15 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 15 was able to ambulate on his own with no assistive devices. Resident 15 was coded of having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 15's bed. g. Resident 19 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life threatening infection), per the facility's admission Record. According to the MDS, dated [DATE], Resident 19 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 19 required maximum assistance from Resident 19 was coded of having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:22 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 19's bed. h. Resident 21 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 21 had a cognitive score of 5, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 21 required maximum assistance from staff. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 21's bed. i. Resident 5 was admitted to the facility on [DATE], with diagnoses which included surgical after care, per the facility's admission Record. According to the MDS, dated [DATE], Resident 5 had a cognitive score of 1, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 5 required moderate assistance from staff. Resident 5 was coded for having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 5's bed. j. Resident 13 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain dysfunction), per the facility's admission Record. According to the MDS, dated [DATE], Resident 13 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 13 required a wheelchair for mobility and was dependent on staff for all daily activities. moderate assistance from staff. Resident 13 was coded for having a fall at the facility within the last six months. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 13's bed. k. Resident 14 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease, per the facility's admission Record. According to the MDS, dated [DATE], Resident 14 had a cognitive score of 7, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 14 required maximum staff assistance for all daily activities. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 14's bed. l. Resident 6 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 6 had a cognitive score of 11 indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 6 required a wheelchair for mobility and was dependent on staff for all daily activities. An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 6's bed. m. Resident 7 was admitted to the facility on [DATE], with diagnoses which included dementia, per the facility's admission Record. According to the MDS, dated [DATE], Resident 7 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 7 required a wheelchair for mobility and was moderately dependent on staff for all daily activities. Resident 7 was coded for having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 7's bed. n. Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia, per the facility's admission Record. According to the MDS, dated [DATE], Resident 8 had a cognitive score of 10, indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 8 required set-up assistance by staff for daily functions. An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 8's bed. o. Resident 23 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 23 had a cognitive score of 13, indicating cognition was intact. According to the Functional Abilities assessment, Resident 23 required a wheelchair for mobility and set-up assistance by staff for daily functions. An observation and interview was conducted with Resident 23 on 6/10/25 at 12:26 P.M. The call light system was not functioning. The manual call bell was on a bedside table down past the foot of the bed and out of the resident's reach. Resident 23 stated its was hard for the staff to hear her call bell when rung, because it was so busy and loud in the hallway. Resident 23 stated if staff did not come in a reasonable amount of time, she yells and they eventually come to see what she needs. p. Resident 9 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction, per the facility's admission Record. According to the MDS, dated [DATE], Resident 9 had a cognitive score of 00, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 9 required maximum assistance by staff for daily functions. An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 9's bed. q. Resident 10 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a mental illness), per the facility's admission Record. According to the MDS, dated [DATE], Resident 10 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 10 was independent for all daily activities. An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 10's bed. r. Resident 24 was admitted to the facility on [DATE], with diagnoses which included dementia, per the facility's admission Record. According to the MDS, dated [DATE], Resident 24 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 24 was completely dependent on staff for daily functions. An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and the manual call bell was observed on a bedside dresser behind the Resident 24's head and out of reach. s. Resident 11 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental disorder), per the facility's admission Record. According to the MDS, dated [DATE], Resident 11 had a cognitive score of 9, indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 11 was independent for performing daily activities. An observation was conducted on 6/10/25 at 12:41 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 11's bed. t. Resident 25 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 25 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 25 required a wheelchair for mobility and was dependent on staff for all activities. An observation and interview was conducted on 6/10/25 at 12:41 P.M. The call light system was not functioning, and the manual call bell was observed on Resident 25's bedside table The bedside table was pulled away from the bed and out of the resident's reach. Resident 25 stated the staff do come in when she rings the manual bell. Resident 25 stated when staff move her bedside table, her call bell was out of reach and she yells to get there attention. An interview and record review was conducted with the Director of Staff Development (DSD), on 6/10/25 at 1:23 P.M. The DSD stated when the call light system stopped working they immediately provided each resident with a manual call bell. The DSD stated they tested the call bells in the rooms farthest from the nursing station to ensure staff could hear them. The DSD stated they have no idea what happened to the call bells, since they are no longer in some resident rooms. The DSD stated he also in-serviced staff on all shifts who were assigned to that 3 North, to ensure every 30 minutes residents were being checked within their rooms. The DSD stated he did not discuss staff documenting the 30 minutes resident checks An interview and record review was conducted with the DON on 6/10/25 at 2 P.M. The facility's transfer list was reviewed from 6/4/25 through 6/10/25, to see if any residents sustained any injuries or were sent to the hospital from Station 3 North. No residents from 3 North were injured or transferred out to the hospital. The DON stated all residents should have a means to contact staff if help was needed. The DON stated she has no idea where the missing call bells went to, but residents without a call bell were at risk of injury or of not getting their needs met. According to the facility's policy, titled Call System, Residents, dated 2001, .1. Each resident is provided with a means to call staff directly for assistance .3. The resident call system remains functional at all times . According to the facility's policy, titled Accommodation of Needs, dated March 2021, Our facility's environment .assisting the resident in maintaining and/or achieving self-independent functioning, dignity, and well-being.

Based on interview and record review the facility failed to correctly administer medications for one of six residents reviewed for competent nursing staff. (Resident 1) As a result of this deficient practice, the facility could not ensure medications were accurately and safely provided to residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's Admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's Admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit to the facility was conducted related to a medication error. During an interview on 4/7/25 at 9:05 A.M. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 received her roommate's (Resident 2) medications on 3/23/25. The ADON stated Resident 2 was no longer in the building and she had been discharged from the facility. An interview on 4/7/25 at 2:27 P.M. was conducted with LN 3. LN 3 stated she was the assigned medication nurse for Resident 1 on 3/23/25. LN 3 stated she was orienting LN 4 for medication pass on 3/23/25. LN 3 stated Resident 1 was in room [ROOM NUMBER], bed B and Resident 2 was in bed A. LN 3 stated she prepared medications for Resident 2 and labeled the medication cup with Resident 2's name. LN 3 stated she gave Resident 2's medication cup to LN 4 to give to [NAME] (Resident 2). LN 3 stated when she (LN4) was about to administer Resident 1's medications, LN 4 told LN 3 that she (LN 4) already gave Resident 1's medications. LN 3 stated LN 4 misunderstood her when she instructed LN 4 to give the medications to [NAME]. LN 3 stated LN 4 told her that she (LN 4) had heard to give medications to Bed B (Resident 1). LN 3 stated LN 4 gave Resident 1 the medications that she (LN 3) prepared for Resident 2. LN 3 further stated she should not give the cup of medications that she had prepared for another nurse because the medications could be given to the wrong resident. LN 3 stated she herself usually did not administer medications prepared by other nurses, but she had seen other nurses do it and thought it was the process at the facility. An interview on 4/7/25 at 3:39 P.M. was conducted with LN 4. LN 4 stated she was a new graduate nurse, and the facility assigned her to train for medication pass with a registry nurse (LN3) on 3/23/25. LN 4 stated, It was not really training, it was give this and give that. LN 4 stated, I didn't think of it at the time when she gave me the meds to give. LN 4 stated LN 3 instructed her to take Resident 1's vital signs (temperature, heart rate, blood pressure) and then to give the cup of medications . LN 4 stated, I heard, this is for bed B (Resident 1), and then I administered the medications to Resident 1. LN 4 stated LN 3 then gave her another cup of medications which she (LN 4) thought was for Resident 2. LN 4 stated during the medication pass Resident 2 told her that the medications in the cup were not her (Resident 2) medications, and the pain medication was not in the cup. LN 4 stated LN 3 then told her (LN 4) that she had given the wrong medications to Resident 1. Resident 1's record was reviewed on 4/7/25. Progress notes for Resident 1 was reviewed. A change in condition note dated 3/28/25 at 9:48 A.M. indicated Resident 1 was given her roommate's (Resident 2) medications. The progress notes indicated medications administered to Resident 1 were: Amlodipine [for blood pressure]10mg [milligrams], Carvedilol [for blood pressure] 25mg, Enoxaparin [blood thinner] 40mg, Losartan [for blood pressure]100mg, Levetiracetam [for seizures] 1500mg, Multivitamin, Valproic Acid [for seizures] 250mg, Acetaminophen-Codeine [strong pain medication] 300-30mg, Carvedilol 12.5mg, Lisinopril [for blood pressure] 40mg, Baclofen [muscle relaxant] 5mg, Oxycodone-Acetaminophen [strong and addictive pain medication] 5-325mg, Famotidine [for stomach acid] 40mg, Clopidogrel [blood thinner] 75mg, Pregabalin [for nerve pain and seizures] 75mg, Senna [stool softener]17.2mg, Vitamin D 5000 units . A total of 17 medications were incorrectly administered to Resident 1. Resident 1's care plan dated 3/23/25 indicated Resident 1, .was given medications not prescribed for her . An interview was conducted on 4/9/25 at 9:59 A.M. with LN 6. LN 6 stated she was the supervisor at the facility on 3/23/25. LN 6 stated the charge nurse (LN 5) notified her of the medication error. LN 6 stated LN 3 prepared 12 medications for Resident 2 and gave them to LN 4 to administer. LN 6 stated there were two residents in the room and LN 4 administered the medications to the wrong resident (LN 1). LN 6 stated LN 3's process of passing medications was not correct because LN 3 did not follow the five rights (the right resident, right drug, right dose, right route and right time) of the resident. An interview with the facility's Consultant Pharmacist (CP) was conducted on 4/10/25 at 3:03 P.M. The CP stated the nurse should never prepare a resident's medication then have another nurse administer them. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/11/25 at 3:13 P.M. The ADON stated she expected licensed nurses to check for the right resident, right medication, right time and right dose to ensure accuracy of medication administration. The ADON further stated LNs should not give another nurse medications that he or she prepared because the other nurse would not know what was being given to the resident and it would be a medication error. A review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2019 was conducted. The P&P indicated, .Medications are administered in a safe and timely manner .Medications are administered in accordance with prescriber orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications .The individual administering medications checks the label THREE [3] times to verify the right resident, right medication, right dosage, right time and right method [route] .Medications ordered for a particular resident may not be administered to another resident .

Based on interview, and record review, the facility failed to ensure medications were correctly administered according to the physician's order for one of six residents (Resident 1) reviewed for pharmacy services. As a result of this deficient practice, the facility could not ensure pharmaceutical services were safely provided to its residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's Admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's Admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit at the facility was conducted related to a medication error. During an interview on 4/7/25 at 9:05 A.M. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 received her roommate's (Resident 2) medications on 3/23/25. The ADON stated since then Resident 2 has been discharged from the facility. An interview on 4/7/25 at 10:27 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 stated to ensure medication administration accuracy, he checked the resident's electronic medical record (EMR) for the medication list, dosage and directions. LN 2 stated he then checked the EMR for the correct resident's name, room number and the medication cards. LN 2 stated prior to administering the resident's medications he checked the resident's ID bracelet and/or asked the resident his or her name. An interview on 4/7/25 at 11:05 A.M. was conducted with LN 1, LN 1 stated prior to medication administration, she checked the name of the drug, dosage and scheduled time. LN 1 stated she checked the resident's ID wrist band for resident identification prior to giving medications to the resident. An interview on 4/7/25 at 2:27 P.M. was conducted with LN 3. LN 3 stated she was the assigned medication nurse for Resident 1 on 3/23/25. LN 3 stated she was orienting LN 4 for medication pass on 3/23/25. LN 3 stated Resident 1 was in room [ROOM NUMBER], bed B and Resident 2 was in bed A. LN 3 stated she prepared medications for Resident 2 and labeled the medication cup with Resident 2's name. LN 3 stated she gave Resident 2's medication cup to LN 4 to give to [NAME] (Resident 2). LN 3 stated when she (LN4) was about to administer Resident 1's medications, LN 4 told LN 3 that she (LN 4) already gave Resident 1's medications. LN 3 stated LN 4 misunderstood her when she instructed LN 4 to give the medications to [NAME]. LN 3 stated LN 4 told her that she (LN 4) had heard to give medications to Bed B (Resident 1). LN 3 stated LN 4 gave Resident 1 the medications that she (LN 3) prepared for Resident 2. LN 3 further stated she should not give the cup of medications that she had prepared for another nurse because the medications could be given to the wrong resident. LN 3 stated she herself usually did not administer medications prepared by other nurses, but she had seen other nurses do it and thought it was the process at the facility. An interview on 4/7/25 at 3:39 P.M. was conducted with LN 4. LN 4 stated she was a new graduate nurse, and the facility assigned her to train for medication pass with a registry nurse (LN3) on 3/23/25. LN 4 stated, It was not really training, it was give this and give that. LN 4 stated, I didn't think of it at the time when she gave me the meds to give. LN 4 stated LN 3 instructed her to take Resident 1's vital signs (temperature, heart rate, blood pressure) and then to give the cup of medications . LN 4 stated, I heard, this is for bed B (Resident 1), and then I administered the medications to Resident 1. LN 4 stated LN 3 then gave her another cup of medications which she (LN 4) thought was for Resident 2. LN 4 stated during the medication pass Resident 2 told her that the medications in the cup were not her (Resident 2) medications, and the pain medication was not in the cup. LN 4 stated LN 3 then told her (LN 4) that she had given the wrong medications to Resident 1. Resident 1's record was reviewed on 4/7/25. The progress notes for Resident 1 was reviewed. A change in condition note dated 3/28/25 at 9:48 A.M. indicated Resident 1 was given her roommate's (Resident 2) medications. The progress notes indicated medications administered to Resident 1 were: Amlodipine [for blood pressure]10mg [milligrams], Carvedilol [for blood pressure] 25mg, Enoxaparin [blood thinner] 40mg, Losartan [for blood pressure]100mg, Levetiracetam [for seizures] 1500mg, Multivitamin, Valproic Acid [for seizures] 250mg, Acetaminophen-Codeine [strong pain medication] 300-30mg, Carvedilol 12.5mg, Lisinopril [for blood pressure] 40mg, Baclofen [muscle relaxant] 5mg, Oxycodone-Acetaminophen [strong and addictive pain medication] 5-325mg, Famotidine [for stomach acid] 40mg, Clopidogrel [blood thinner] 75mg, Pregabalin [for nerve pain and seizures] 75mg, Senna [stool softener]17.2mg, Vitamin D 5000 units . A total of 17 medications were incorrectly administered to Resident 1. Resident 1's care plan dated 3/23/25 indicated Resident 1, .was given medications not prescribed for her . An interview was conducted on 4/9/25 at 9:59 A.M. with LN 6. LN 6 stated she was the supervisor at the facility on 3/23/25. LN 6 stated the charge nurse (LN 5) notified her of the medication error. LN 6 stated LN 3 prepared 12 medications for Resident 2 and gave them to LN 4 to administer. LN 6 stated there were two residents in the room and LN 4 administered the medications to the wrong resident (LN 1). LN 6 stated LN 3's process of passing medications was not correct because LN 3 did not follow the five rights (the right resident, right drug, right dose, right route and right time) of the resident. An interview with the facility's Consultant Pharmacist (CP) was conducted on 4/10/25 at 3:03 P.M. The CP stated to ensure medication administration accuracy, the nurse should check the electronic medical record (EMR) against the medication card for the right resident, right medication, right route and the right time. The CP further stated the nurse should never prepare a resident's medication then have another nurse administer them. A review of the facility's pharmacy policy and procedure (P&P) manual dated July 2022 was conducted. The P&P indicated, .MEDICATION ADMINISTRATION . Drug Administration refers to the act in which a single dose of prescribed drug .is given to a resident by an authorized person .The complete act of administration involves removing an individual dose .verifying the dose with the prescriber's orders and promptly giving the dose to the proper resident .

Based on interview and record review the facility failed to correctly administer medications for one of six residents reviewed for medication errors. (Resident 1) This failure has the potential affect Resident 1's health and wellbeing. In addition, this failure has the potential to place other residents at risk for medication errors. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included sequelae (after effect) of cerebral infarction (disrupted blood flow to the brain) and hypertension (high blood pressure) according to the facility's Admission Record. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction according to the facility's Admission Record. On 4/7/25 at 9:05 A.M., an unannounced onsite visit at the facility was conducted related to a medication error. During an interview on 4/7/25 at 9:05 A.M. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 received her roommate's (Resident 2) medications on 3/23/25. The ADON stated Resident 2 had been discharged from the facility since the incident had occured. Resident 1's record was reviewed on 4/7/25. During a review of the MDS (a clinical assessment tool) dated 3/25/25 for Resident 1, the MDS listed a cognitive (thinking, reasoning, or remembering) score of 14, which indicated that Resident 1's cognition was intact. An observation and interview was conducted on 4/7/25 at 9:43 A.M. with Resident 1 in her room. Resident 1 was in bed and stated she was sleepy. Resident 1 stated she was not aware of receiving her roommate's medications. Resident 1 stated her mother was involved in her care and did not inform her about receiving her roommate's medications. Resident 1 stated she had not had any change in her condition in the last two weeks and she was fine. Resident 1 then closed her eyes. An interview on 4/7/25 at 10:27 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 stated to ensure medication administration accuracy, he checked the resident's electronic medical record (EMR) for the medication list, dosage and directions. LN 2 stated he then checked the EMR for the correct resident's name, room number and the medication cards. LN 2 stated prior to administering the resident's medications he checked the resident's ID bracelet and/or asked the resident his or her name. An interview on 4/7/25 at 11:05 A.M. was conducted with LN 1, LN 1 stated prior to medication administration, she checked the name of the drug, dosage and scheduled time. LN 1 stated she checked the resident's ID wrist band for resident identification prior to giving medications to the resident. An interview on 4/7/25 at 2:27 P.M. was conducted with LN 3. LN 3 stated she was the assigned medication nurse for Resident 1 on 3/23/25. LN 3 stated she was orienting LN 4 for medication pass on 3/23/25. LN 3 stated Resident 1 was in room [ROOM NUMBER], bed B and Resident 2 was in bed A. LN 3 stated she prepared medications for Resident 2 and labeled the medication cup with Resident 2's name. LN 3 stated she gave Resident 2's medication cup to LN 4 to give to [NAME] (Resident 2). LN 3 stated when she (LN4) was about to administer Resident 1's medications, LN 4 told LN 3 that she (LN 4) already gave Resident 1's medications. LN 3 stated LN 4 misunderstood her when she instructed LN 4 to give the medications to [NAME]. LN 3 stated LN 4 told her that she (LN 4) had heard to give medications to Bed B (Resident 1). LN 3 stated LN 4 gave Resident 1 the medications that she (LN 3) prepared for Resident 2. LN 3 further stated she should not give the cup of medications that she had prepared for another nurse because the medications could be given to the wrong resident. LN 3 stated she herself usually did not administer medications prepared by other nurses, but she had seen other nurses do it and thought it was the process at the facility. An interview on 4/7/25 at 3:39 P.M. was conducted with LN 4. LN 4 stated she was a new graduate nurse, and the facility assigned her to train for medication pass with a registry nurse (LN3) on 3/23/25. LN 4 stated, It was not really training, it was give this and give that. LN 4 stated, I didn't think of it at the time when she gave me the meds to give. LN 4 stated LN 3 instructed her to take Resident 1's vital signs (temperature, heart rate, blood pressure) and then to give the cup of medications . LN 4 stated, I heard, this is for bed B (Resident 1), and then I administered the medications to Resident 1. LN 4 stated LN 3 then gave her another cup of medications which she (LN 4) thought was for Resident 2. LN 4 stated during the medication pass Resident 2 told her that the medications in the cup were not her (Resident 2) medications, and the pain medication was not in the cup. LN 4 stated LN 3 then told her (LN 4) that she had given the wrong medications to Resident 1. Resident 1's record was reviewed on 4/7/25. Resident 1's progress notes were reviewed. A change in condition note dated 3/28/25 at 9:48 A.M. indicated Resident 1 was given her roommate's (Resident 2) medications. The progress notes indicated medications administered to Resident 1 were: Amlodipine [for blood pressure]10mg [milligrams], Carvedilol [for blood pressure] 25mg, Enoxaparin [blood thinner] 40mg, Losartan [for blood pressure]100mg, Levetiracetam [for seizures] 1500mg, Multivitamin, Valproic Acid [for seizures] 250mg, Acetaminophen-Codeine [strong pain medication] 300-30mg, Carvedilol 12.5mg, Lisinopril [for blood pressure] 40mg, Baclofen [muscle relaxant] 5mg, Oxycodone-Acetaminophen [strong and addictive pain medication] 5-325mg, Famotidine [for stomach acid] 40mg, Clopidogrel [blood thinner] 75mg, Pregabalin [for nerve pain and seizures] 75mg, Senna [stool softener]17.2mg, Vitamin D 5000 units . A total of 17 medications were incorrectly administered to Resident 1. Resident 1's care plan dated 3/23/25 indicated Resident 1, .was given medications not prescribed for her . An interview was conducted on 4/9/25 at 9:59 A.M. with LN 6. LN 6 stated she was the supervisor at the facility on 3/23/25. LN 6 stated the charge nurse (LN 5) notified her of the medication error. LN 6 stated LN 3 prepared 12 medications for Resident 2 and gave them to LN 4 to administer. LN 6 stated there were two residents in the room and LN 4 administered the medications to the wrong resident (LN 1). LN 6 stated LN 3's process of passing medications was not correct because LN 3 did not follow the five rights (the right resident, right drug, right dose, right route and right time) of the resident. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/9/25. The ADON stated LN 3 did not properly communicate to LN 4. The ADON stated to prevent medication errors, the nurse who prepared the medication should administer the medications and not give them to another nurse to administer. An interview with the facility's Consultant Pharmacist (CP) was conducted on 4/10/25 at 3:03 P.M. The CP stated a nurse should never prepare a resident's medication then have another nurse administer them. The CP further stated Resident 1 was at risk for significant low blood pressure and increased sedation which placed the resident at increased risk for falls. A review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2019 was conducted. The P&P indicated, .Medications are administered in a safe and timely manner .Medications are administered in accordance with prescriber orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications .The individual administering medications checks the label THREE [3] times to verify the right resident, right medication, right dosage, right time and right method [route] .Medications ordered for a particular resident may not be administered to another resident .

Based on observation, interview, and record review, the facility failed to ensure kitchen staff maintained sanitary food practices when: 1. Drying racks and a drying cart were not clean; and 2. The hanging sprinkler system (Ansel) heads above the stove were covered in dust; and 3. A beard net was not being worn by a dishwasher; and 4. A dishwasher aide did not wash his hands after removing trash and reentering the kitchen. These failures had the potential for cross contamination and to cause food borne illness. Findings: 1. An observation and interview was conducted with Dietary Manager (DM) of the 3-compartment sink area on 3/12/25 at 8:17 A.M., Large pots and pans were upside down, air drying on 3-rack metal shelves next to the 3-compartment sink area. The 3-racks that the pots and pans were resting on appeared dirty and gritty. A finger sweep was performed on each rack, which left a clear, distinguished line on the rack. The DM stated, Yes, I see what you mean, they are dirty. The DM stated the kitchen was deep cleaned every Wednesday, but he could not provide a check list of items that were deep cleaned with staff initials as being completed. An observation and interview was conducted with the DM on 3/12/25 at 8:21 A.M., of a drying cart next to the 3-compartment sink area. The top of the cart contained wet pots with hole in the rack, so water drained to a lower shelf-catch system. The top shelve where the pots were, had debris which could be removed with the swipe of a finger. The DM stated, Yes, I see it and I will get it cleaned right away. According to the facility's policy titled, Sanitation, dated 2001, .2. All utensils, counters, shelves and equipment are kept clean .3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . 2. An observation and interview was conducted with the DM of the water sprinkler heads above the stove on 3/12/25 at 8:32 A.M. The top of the sprinkler heads were covered in dust. The DM stated, Yes, they are dirty and the dust could fall onto the stove while cooking, which would cause cross contamination. According to the facility's policy titled, Sanitation, dated 2001, .8. When cleaning fixed equipment .a. wash and sanitize and non-removable parts cleaned with detergent and hot water . 3. An observation and interview was conducted with the DM and the dishwasher (DSWH) on 3/12/25 at 8:49 A.M. The DSWH was observed removing clean dishwasher racks from the dishwashing machine and allowing them to airdry. The DSWH had a beard approximately 1 inch long and was not wearing a beard net. The beard net was hanging down, around the DSWH's neck. The DSWH stated he forgot it was around his neck and it should have been over his beard. The DSWH stated hair could fall onto the clean dishes. According to the facility's policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 2001, .Hairnets: 15. Hair nets of caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens . 4. An observation and interview was conducted with the DM and the dishwasher aide (DWA) on 3/12/25 at 8:58 A.M., as the DWA removed trash from the kitchen. The DWA removed his gloves and wheeled the trashcan outside to the trash dumpsters. The DWA washed out the trashcan and returned to the kitchen. The DWA returned inside the kitchen to the dishwashing area and started to handle dishes without performing handwashing. The DWA stated he forgot to wash his hands when he returned to the kitchen, which could cause cross contamination. The DM stated he expected all staff to wash their hands when returning to the kitchen. An interview and record review was conducted with the DM on 03/12/25 at 9 A.M. of kitchen staff training, which included hair/beard nets and handwashing. The DSWH and the DWA completed training in August 2024. According to the facility's policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 2001, .Hand Washing/Hand Hygiene: .c. Whenever entering or re-entering the kitchen; . An interview and record review was conducted with the Registered Dietician (RD) on 3/12/25 at 10:34 A.M. The RD stated he expected all shelves and surfaces to be clean and sterile, to prevent cross contamination. The RD stated dust on fire sprinklers above the stove could fall down and contaminate any food being prepared. The RD stated all staff needed to wear hair and beard covers to prevent hair from falling onto surfaces or into food. The RD stated anyone who entered or re-entered the kitchen, must wash their hands to prevent cross contamination. The RD stated he did a kitchen audit on 3/10/25, and provided a copy. The RD made handwritten notes on the bottom of the 2-page audit sheet. The handwritten notes pertained to undated/labeled food and the thawing of meat. The remaining list had line-by- line areas for inspection, which were blank. The RD stated he did not look at everything in the kitchen when he performed the audit and he should have. An interview was conducted with the Director of Nursing (DON) on 3/12/25 at 10:39 A.M. The DON stated he expected the kitchen to be cleaned daily and maintained in a clean, sanitary condition at all times. The DON stated he expected the kitchen to have a deep cleaning list, so staff knew what was expected to be cleaned. The DON stated all staff should wear hair and beard nets to prevent hair from falling into food. The DON stated he expected everyone to wash their hands whenever entering the kitchen to prevent cross contamination.