Every finding on record at Crestwood Manor

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with accepted professional standards of practice for seven of seven sampled residents (Residents 7,19,75,76,113,132), when during a medication pass observation, a licensed nurse removed medications from original packaging, placed the medications into unlabeled cups with a removable label with only residents last name and first letter of first name, and stored the cups for later administration. The medication cups were poured for multiple residents at the same time and the pre-poured medication cups were unlabeled with the residents' name, drug, and dose. The pre-poured medication cups were stored in a drawer of a medication cart, with sectioned areas labeled with resident's last name and first initial letter.This failure had the potential to cause medication errors, including administering the wrong medication or wrong dose to the wrong resident, as medications were removed from their original packaging, placed into unlabeled cups with handwritten slips, and stored in the medication cart before administration.Findings:During an observation on 12/4/25 at 11:06 a.m. with Licensed Vocation Nurse (LVN) 7 at station 4, LVN 7 pushed the medication cart to the dining room entrance. LVN 7 placed the cart in the hallway, opened the drawer, removed individual cups of medication, opened the Medication Administration Record (MAR), then closed the MAR and left the medication cart with the MAR and administered the medications to the residents who were all seated at tables for lunch. During a concurrent observation and interview on 12/4/25 at 11:09 a.m. with LVN 7 in station 4 wing during afternoon medication pass, LVN 7 was observed administering medication cups that were stored in the top drawer of the medication cart with removable name tags for the residents. The medications were not administered at the time the medications were poured. LVN 7 stated the facility practice at station 3 was to prepare for medication pass by pre dispensing medications for all the residents due for medication. LVN 7 was observed to sign the MAR when the medication was administered to the residents. LVN 7 stated the medication preparation time and administration time were different. LVN 7 stated there was a potential for giving the wrong pre poured medication cup to the wrong resident. LVN 7 stated, I look at the MAR in the med room, pop all the medications for my residents, put the cup under the names, and then take the cart out to the floor. LVN 7 confirmed the labels used are removable with the residents' last name and the cups were not labeled. During an observation on 12/4/25 at 3:35 p.m. to 4:12 p.m. in station 3 medication room, LVN 8 and LVN 5 were observed each pre-dispensing medications into cups and storing them in their respective medication carts, handling medications for their own assigned residents.During an interview on 12/4/25 at 3:35 p.m. in station 3 medication room, LVN 5 stated pre pouring medication had been the facility's process for medication administration. LVN 5 stated in the past year the facility changed the process to one resident at a time with the resident in front of them before administration of medication but had changed back to preparing medications by pre pouring into med cups in the medication room. LVN 5 stated the facility changed back because it worked out better this way. During an interview on 12/4/25 at 4:12 p.m. in station 3 medication room, with LVN 8, LVN 8 stated pre pouring medication was the facility's process for administration medication. LVN 8 stated not all the medication cups were marked and the cup that was marked had the residents' last name written in (brand name) marker, because it wipes off. LVN 8 proceeded to wipe the name off the cup with her finger and remarked on the cup. During a phone interview on 12/4/25 at 4:30 p.m. with the facility pharmacy consultant (PC), the PC stated quality reviews were completed, and was aware of the staff pre-pouring medications, but did not consider the process 'pre-pouring', rather preparation within the acceptable window. The PC stated the practice was safe for the resident population and in accordance with the facility's medication procedures. During an interview on 12/5/25 at 9:26 a.m. with the Director of Nursing (DON), the DON stated the facility followed policy and followed the guidance of the pharmacy consultant. The DON stated the facility followed Titled 22 regulations and this had been discussed with the pharmacy consultant a lot, because the facility's process of preparing medication was an issue on past surveys. The DON stated she agreed the potential for error of a nurse administering the wrong medication to the wrong resident was a possibility. The DON stated she confirmed the facility had been cited in the past for a nurse administering the wrong medication to a resident. The DON stated the facility did training and stopped pre-pouring of medications but went back to pre-pouring because the nurses could not meet the timeframe of administration of medications to residents. During a review of the facility's policy and procedure (P&P) titled, Med Pass, Medication Administration Essentials, revised 4/9/24, the P&P indicated, .3. Preparation of doses for more than one scheduled administration time shall not be permitted.4. Medication will be prepared and then administered as soon as possible, but no more than two hours after doses are prepared and shall be administered by the same nurse who prepares the doses for administration. Doses are to be administered within one hour of the preparation time unless otherwise indicated by the prescriber.During a review of the facility's document titled, SNF [skilled nursing facility] Mini Quality Review, dated 11/3/25, the review indicated .visit summary identified during review.noncompliance under pharmaceutical services, procedures.met professional standards.labeling and storage of drugs.general findings and comments.Med pass observation.Facility pre-pours per policy.During a review of Omnicare.com Professional Reference titled, Medication Pass Fundamentals Video Series, dated 2025, (found at https://www.omnicare.com/resources/medication-webcasts/#anchor1) the reference indicated, . Prepare name tag displayed, professional appearance Med cart clean, stocked and organized.Medication Cart.you should not pre-poured or preset medication.During a professional reference review from https://ismpcanada.ca/bulletin/pre-pouring-medications-a-risky-approach/ titled, Pre-pouring Medications: A Risky Approach, dated 12/13/23, the reference indicated .Pre-pouring is a type of workaround, described as a delay between preparation and administration of a medication or the preparation of multiple medications for different clients.often involves removal of medication from packaging that identifies the medication and/or the intended recipient.prevents confirmation of the medication/dose to be administered against the medication administration record (MAR) just before the patient receives the medication.may lead to delay and/or inaccurate documentation. During a review of nccmerp.org a Professional Reference titled, Recommendations to Enhance Accuracy of Administration of Medications, dated 3/30/23 (found at https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications) the reference indicated, .Healthcare professionals should only administer medications that are properly labeled, and labels should be read during.administration process: 1. Reaching/Handling for medication 2. Preparing the medication 3. Immediately before administering the medication 4. Discarding the container or replacing unused medication it into it's storage location. During a review of bccnm.ca a Professional Reference titled, What is the difference between preparing and pre-pouring medications? Can I pre-pour medications?, dated 2025, the reference indicated . The medication practice standard outlines nurses' accountabilities and responsibilities when preforming actives involving medication.Preparing medications is part of the medication administration process. Preparation includes selecting, calculating, crushing, breaking, mixing labelling, drawing up.as close as possible to the time you administer them. Pre-pouring medication is not safe medication practice. Pre-pouring medications is preparing medications in advance of administration and storing them until you administer them.it increases the risk of errors and risk to the client.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan with measurable interventions for four of 14 sampled residents (Resident 3, 4, 7, and 10) when: 1. Residents 3, 4, and 7 did not have a specific care plan monitoring for side effects for their prescribed psychotropic (drugs that alter brain function, affecting mood, behavior, thoughts, and perception, used to treat mental health conditions) medications.This failure had the potential to cause staff to be unaware of any side effects brought on by psychotropic medications prescribed to Residents 3, 4, and 7.2. Resident 10 had a foley catheter (a soft flexible tube inserted into the bladder to drain urine) inserted on 9/17/25. The care plan did not include infection-control interventions and monitoring for signs and symptoms of infection as appropriate.These failures to include infection-control strategies in the care plan had the potential to result in inconsistent care and increased risk of catheter-associated urinary tract infections (UTI-an infection that happened when germs got into the urinary system [the bodies built-in water filter and waste removal system] and caused pain or problems with urinating [peeing]) for Resident 10. Findings: 1. During a review of Resident 3's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated, 12/5/25, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking, reasoning, and problem-solving) and bipolar disorder (a mental health condition causing extreme mood swings). During a review of Resident 4's AR, dated 12/5/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included dementia and bipolar disorder. During a review of Resident 7's AR, dated 12/5/25, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included dementia and schizoaffective disorder (a complex mental illness blending symptoms of schizophrenia [psychosis like hallucinations/delusions] with symptoms of a major mood disorder, such as bipolar disorder). During a concurrent interview and record review on 12/5/25 at 9:47 a.m. with Registered Nurse (RN) 1, Resident 3's Nursing Care Plan, dated 12/5/25 was reviewed. RN 1 stated Resident 3's Nursing Care Plan indicated, Resident 3 was on the psychotropic medications, divalproex sodium (medication used to treat bipolar disorder), escitalopram (medication used to treat depression [condition characterized by extreme sadness] and anxiety (condition characterized excessive worry or fear), and buspirone (medication used to treat anxiety disorders) and the interventions listed did not specify which side effects to monitor for each medication. During a concurrent interview and record review on 12/5/25 at 9:57 a.m. with RN 1, Resident 4's Nursing Care Plan, dated 12/5/25 was reviewed. RN 1 stated Resident 4's Nursing Care Plan indicated, Resident 4 was on clonazepam (medication used to treat panic disorders), risperidone (medication used to treat mental health disorders), divalproex sodium, and quetiapine (medication used to treat schizophrenia, bipolar disorder, and depressive disorder). RN 1 stated, The interventions listed did not specify which side effects to monitor for each medication. During a concurrent interview and record review on 12/5/25 at 10:00 a.m. with RN 1, Resident 7's Nursing Care Plan, dated 12/5/25 was reviewed. RN 1 stated Resident 7's Nursing Care Plan indicated Resident 7 was on the psychotropic medication's risperidone and lithium (medication used to treat bipolar disorder). RN 1 stated, The interventions listed did not specify which side effects to monitor for each medication. RN 1 stated the current care plans were vague [not specific] and they needed to be more specific. RN 1 stated Residents 3, 4, and 7 all took psychotropic medications and each of their care plans needed to specify and fully explain what side effects to monitor for and what behaviors could be manifested by the medications. RN 1 stated those medications could all have unique side effects which were not shared among any of the other medications. RN 1 stated resident care plans were guidelines on what to do and why the staff were doing them. RN 1 stated, Any staff member who was not familiar with a particular resident or newer staff can learn a lot from a detailed care plan, the care plan needed to be specific so it could be measurable, the care plan is there to help staff know what to do. During an interview on 12/5/25 at 11:26 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated care plans were made through collaborative effort from the floor nurses and the MDSN's. The MDSN stated the facility did not specify the side effects to monitor for in the care plan because they did not think they needed to be specific. The MDSN stated, Having specific interventions like what side effects to look out for helped the staff members better be able to track goals and outcomes for a resident's care. During an interview on 12/5/25 at 2:36 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the nurses did not specify all the side effects to monitor for in the care plans. During a review of the facility policy and procedure (P&P) titled, Care Planning, dated 6/14/17, the P&P indicated, .10. Care planning consists of three main components: a. Problem Solving: or Nursing diagnosis . b. Goal(s)- which are resident/ client oriented, are time limited, and that are realistic and measurable in order to monitor the resident/client's progress c. Interventions(s)- which are measures and actions put in place to assist the resident/client to reach their goal . During a review of Job Description: Registered Nurse, undated, the job description indicated, General Statement of Position.reviews patient care plans for appropriate patient care goals, problems, approaches and revisions based on daily patient needs. 2. During a review of Resident 10's AR, dated 9/25/24, the AR indicated Resident 10 had a history of urinary retention ( a person's bladder [a hollow organ in the body that held urine until a person was ready to pee] filled with urine [ a liquid waste that left the body when a person peed], but they were not able to empty it completely or at all when they tried to pee). During a review of Resident 10's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive [ability to think, memorize and process information] abilities), the MDS indicated a brief interview for mental status (BIMS- an assessment used to determine the cognitive ability of a resident) score of zero (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 10 had severe cognitive impairment. During an observation on 12/2/25 at 11:09 a.m. in Resident 10's room, Resident 10 was observed lying in bed asleep. The room was noted to be clean, clutter-free and without odors. During the observation, Resident 10 awakened, asked the observers' identity and stated it was not a good time to talk. During an interview on 12/4/25 at 11:00a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated symptoms of a UTI include redness, discharge, pain, and a change in behavior from the resident's normal baseline. CNA 3 stated she was to notify the nurse and supervisor as soon as possible if any concerning symptoms were suspected, emphasizing the importance of timely reporting to prevent potential worsening of infection. CNA 3 also stated care plans helped keep her on track and provided helpful information about each resident. CNA 3 stated if a care plan did not exist for an issue, or if something was not included in the care plan, it would be difficult to know how to handle the situation and she would likely forget to address it. During an interview on 12/5/25 at 11:08 a.m. with Nurse Supervisor (NS) 1, NS 1 stated Resident 10 was someone who generally kept to himself but did participate in group activities. NS 1 stated, Resident 10 was noted to be independent in his personal care and activities of daily living. Resident 10 had a foley catheter in place due to urinary retention, which had been in place for several months. NS 1 stated the care plan for the foley catheter should include interventions for emptying the catheter, monthly changes, management of pain, monitoring for retention symptoms, and identification of signs and symptoms of infection. NS 1 stated any staff receiving new orders should update the care plan accordingly. NS 1 stated care plans were important for providing individualized care and served as a quick reference for essential resident information. During a concurrent interview and record review on 12/5/25 at 11:15 a.m. with NS 1, Resident 10's care plan, undated was reviewed. NS 1 stated the care plan did not include symptoms of an infection. NS 1 stated it was important to prevent UTI as UTI's were common with foley catheter use. NS 1 stated Resident 10 was at increased risk for developing a UTI due to the foley catheter placement. During an interview on 12/5/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 10 was pleasant and noted that he rarely had a bad day. LVN 6 stated Resident 10 had a foley catheter due to urinary retention and staff encouraged him to maintain adequate fluid intake. LVN 6 stated nursing staff created, and updated care plans as needed. LVN 6 stated, A care plan for a foley catheter should include monitoring for signs and symptoms of infection and observing the appearance of the urine. If an infection is suspected, staff are to notify the physician. LVN 6 stated there was concern Resident 10's care plan did not include signs and symptoms of an infection, noting that Resident 10 should be monitored for signs and symptoms of an infection. LVN 6 stated Resident 10 was at increased risk for UTI due to the foley catheter. LVN 6 stated care plans were helpful because they set individualized goals for the residents, allowed staff to monitor each resident's progress and helped ensure care was provided according to the residents' needs. LVN 6 stated symptoms of a UTI could include changes in behavior, elevated temperature, and pain. During an interview on 12/5/25 at 2:33p.m. with the ADON, the ADON stated she expected Resident 10's care plan to include the foley catheter orders, catheter size, flushing schedule, time for catheter changes, intake and output and any medications related to the foley catheter. The ADON stated monitoring the color, odor, and amount of urine should be part of the care plan to address the potential for infection. When asked whether the care plan should specifically include symptoms of an infection, the ADON clarified she intended for the color and odor of the urine to serve as indicators of an infection. During a review of the facility's policy and procedure (P&P) titled, Infection Control Plan, dated 11/2015, the P&P indicated, develop procedures that will help in the control of and the decrease of infections throughout the facility.address prevention of infections common to this level of care. During a review of the facility's P&P titled, Charting Guidelines for Nurses, dated 9/1/13, the P&P indicated, charting includes assessments of the resident/clients' condition, actions or interventions taken to resolve a problem, the progress or lack of progress in meeting the goal of the plan of care, food or fluid intake, lab results, special tests and procedures, physician visits or phone calls, room changes, out on leave events/client behaviors, response to restraints or psychoactive medications ( medications that affected the brain and changed how a person thought, felt, or acted) and all other pertinent information pertaining to the resident/client.care plans are to be updated as needed during the weekly progress note process (add, discontinue or revise care plans as needed). During a review of the facility's document titled, Job Description: Registered Nurse, undated, the document indicated, General Statement of Position.reviews patient care plans for appropriate patient care goals, problems, approaches and revisions based on daily patient needs.

Based on observation, interview, and record review, the facility failed to ensure food storage was stored in accordance with facility policy Sanitation and Infection Control, when four of four sampled water pitchers were not labeled with a filled date or an expiration date. This failure had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, bacteria, viruses or fungi) and put the residents at risk for foodborne illness (any illness resulting from consuming contaminated/spoiled foods), symptoms which could range from nausea, vomiting, diarrhea, abdominal pain, fever, headache, and confusion. Findings:During a concurrent observation and interview on 12/5/25 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 2 and Assistant Director of Nurses (ADON), at the snack refrigerator in Medication Storage Room (MSR) 1, two of two water pitchers did not have a label of when the water was poured into the pitcher or when it expired. LVN 2 stated, all the drink pitchers should be dated and be in the refrigerator for no longer than 24 hours to prevent residents from receiving old water which could have been exposed to germs.During a concurrent observation and interview on 12/5/25 at 9:47 a.m. with LVN 3 and ADON, outside of MSR 4, one of one water pitchers did not have a label of when the water was poured into the pitcher or when it expired. The ADON stated she would not want to drink the water without knowing how long it was in the pitcher. The taste of the water could be comprised as well as the safety of the water.During a concurrent observation and interview on 12/5/25 at 9:53 a.m. with Registered Nurse (RN) 1 and Director of Nurses (DON), inside of MSR 4, one of one water pitchers did not have a label of when the water was poured into the pitcher or when it expired. The RN stated all pitchers of liquids should have a date of expiration and should be replaced every 24 hours to prevent residents from getting a food born illness.During an interview on 12/5/25 at 10:13 a.m. with Dietary Aid (DA) 1 in the facility kitchen, DA 1 stated, the water pitchers should all have had labels with date the pitcher was made and when it is expired. All food for residents requires a label.During an interview on 12/5/25 at 2:00 p.m. with the Afternoon [NAME] (PMC), the PMC stated the staff should have labeled the water pitchers. The water pitchers are to be labeled right after they are made and prior to taking them out to the floor for the residents. If the water pitcher does not have a label, it could be left out for the residents use longer than 24 hours and put the residents at [NAME] for illness.During an interview on 12/5/25 at 2:20 p.m. with Dietary Service Manager (DSM) and Assistant Dietary Service Manager (ADSM), the DSM stated the water pitchers should be replaced every 24 hours. If the water pitcher does not have a label with the date the water pitcher was made the staff will not know when to replace the water pitcher. The water pitchers could cause illness to the residents if not changed frequently.During a review of the facility's policy and procedure titled, Sanitation and Infection Control dated 2023, indicated, . The facility will provide residents with clean and sanitize water pitcher daily . poured beverages . should be labeled and dated . then discarded at the end of the day.

Based on observation, interview, and record review the facility failed to assist one of one sampled resident (Resident 34) in obtaining dental services when Resident 34 did not receive a dental referral after the facility in house dentist recommended dentures from the Veterans Administration (VA insurance) when the resident reported dental pain.This failure did not meet Resident 34's need for dental services and placed Resident 34 at risk for unnecessary pain and suffering and difficulty chewing food. Findings:During a concurrent observation and interview on 12/2/25 at 12:13 p.m. with Resident 34 in the station three hallway, Resident 34 was propelling himself through the hallway of station three on his wheelchair. Resident 34 stated he wanted his uppers, and clarified the facility informed him he would get dentures. Resident 34 stated he did not have any dentures and had been waiting a long time for them.During a review of Resident 34's admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), bipolar disorder (mental illness that can affect your thoughts, mood and behavior) and squamous cell carcinoma (skin cancer, developing in the outer skin's layer).During a review of Residents 34's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 11/20/25, the MDS indicated Resident 34's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 34 was cognitively intact.During an interview on 12/4/25 at 10:10 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 34 did not have teeth and did not have dentures. RN 2 stated if Resident 34 had requested dentures Social Services would make the appointments.During a concurrent interview and record review on 12/5/25 at 11:34 a.m. with Social Services (SS) Designee, Resident 34's Dental Services Note, dated 1/15/25 was reviewed., The SS stated the note indicated, . Resident 34 attended/participated scheduled in-house dental services. Per dentist note he was recommended for VA full dentures . During a review of the facility's document titled, Patient Notes, dated 1/15/25, the note indicated, .resident 34 oral exam completed.oral cancer exam normal.recommend VA for full dentures.During a concurrent interview and record review on 12/5/25 at 11:34 a.m. with the SS in the Social Service office in station 3, Resident 34's Electronic Medical Record (EMR), undated was reviewed. The SS stated the EMR indicated Resident 34 was seen by the in-house dentist on 1/15/25, who recommended dentures for Resident 34. The SS stated the EMR indicated on 11/8/25, Resident 34 also reported jaw pain when eating hot and cold food and he had entered this information into the record but was unsure what follow up occurred. The SS stated he was not the primary social service worker for Resident 34 and believed the worker assigned to Resident 34 should have followed up but did not see any documentation in the chart showing that a VA referral, dental consultation, or dental appointment had been made. The SS stated the EMR indicated there were no notes documenting the facility contacted the VA about dentures or Resident 34's pain. The SS stated dentures were not listed on the Resident 34's care plan and confirmed Resident 34 did not have dentures. The SS stated the EMR indicated on 1/15/25, Resident 34 was recommended for dentures, and the process would involve looking into insurance coverage and VA insurance required a different type of referral process. The SS stated he acknowledged Resident 34 had unmet needs, or unaddressed dental pain could affect the resident's behavior or mood.During a concurrent interview and record review on 12/5/25 at 3:06 p.m. with Nurse Supervisor (NS) 2, Resident 34's Progress notes, undated were reviewed. NS 2 stated the Notes indicated Resident 34 was seen on 1/15/25 by the facility in house dentist and the dentist recommended dentures. NS 2 stated the Notes indicated on 9/17/25 Resident 34 reported gum pain and the charge nurse, treatment nurse and social services had been informed, NS 2 stated the note was entered by social service. NS 2 stated the Notes indicated on 11/8/25 Resident 34 reported oral pain again and appropriate staff were made aware. NS 2 stated Resident 34 had seen a VA doctor before and stated if Resident 34 needed a referral or appointments made it was the responsibility of the facility to do it. NS 2 stated no documentation was completed to indicate a follow up addressed Resident 34's pain or recommendation for dentures. NS 2 stated it was the expectation resident appointments and assessments were completed.During an interview on 12/5/25 at 12:29 p.m. with the Director of Nurses (DON), the DON stated the in-house dentist made recommendations and social services were expected to follow up. The DON stated the social services should have made a referral when dentures were recommended and if the residents complained of pain, nursing staff should have contacted the doctor or documented the actions that were taken. The DON stated if pain was going unaddressed there was potential for the residents to become aggravated and upset about their pain not being addressed. During a review of the facility's policy and procedure (P&P) titled, Dental services, dated 10/28/17, the P&P indicated, Routine and emergency dental services are available to meet the oral and dental health needs of resident/clients.4. Social Services personnel are responsible for assisting the resident/family in making dental appointments and transportation arrangements, and makes a referral with 3 days for repair or replacement of broken or lost dentures.During a review of the facility's document titled Social Services Director Job Description, revised 6/12, the job description indicated, .Job Summary: Responsible for the on-going assessment of each resident's social services needs. Will assist with the development and implementation of a plan of care to meet the identified needs.Duties.6. Coordinates referrals to community agencies and act as a liaison with conservators.12. As a resident advocate, as well as a liaison between the resident and his/her family, the facility, and community agencies.15. Assist with driving to and from medical appointments as needed.18. Check and respond to Social Services referral book daily to assure resident's needs are addressed and met. 22. Assist with phone calls.29. Coordinate vision, dental and hearing evaluations and assure follow-up.

Based on observations, interviews and record reviews, the facility failed to follow their policy and procedure (P&P) titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles when:1. A box of expired [guaifenesin](medication administered to loosen mucus) was found in the over the counter medication bin. 2. The key to medication refrigerator containing the narcotics emergency kit (e-kit - a kit with narcotic medications for residents that need narcotics on an emergent basis) was left unattended and the refrigerator was not locked.These failures placed the residents at risk of receiving medications that did not have the desired result to treat their symptoms and had the potential to not have the required controlled medications available in an emergency if the medications in the e-kit was diverted (when a prescription drug meant for one person gets redirected to someone else, often illegally for misuse, sale, or unintended use). Findings:During a concurrent observation and interview on 12/4/25 at 11:00 a.m. with the Assistant Director of Nurses (ADON) and Licensed Vocational Nurse (LVN) 2, in the Medication Storage Room (MSR) 1, a box of guaifenesin with an expiration date of 11/25 was located with the over the counter (OTC) medications. LVN 2 stated the box of guaifenesin should have been discarded on 12/1/25. LVN 2 stated expired medications do not have the same efficacy (effectiveness),and may not treat the residents' ailments (illnesses or physical disorder), as well as the unexpired medication. The ADON stated having an expired OTC medication in the MSR was not meeting her expectations. ADON stated she expected all nurses to monitor the expiration dates on all medications in the MSR as well as the medication carts to prevent harm to the residents by receiving expired medications.During an interview on 12/4/25 at 11:15 a.m. with LVN 2 and the ADON, the medication refrigerator located inside the MSR was not locked. LVN 2 stated, We always keep it unlocked. I do not have a key for the lock. The ADON moved a sheet of paper that was pinned to a cork board on the wall next to the medication refrigerator exposing a key on a lanyard. The ADON stated two nurses shared the medication room, and the key was placed on the cork board so both nurses had access to the key. The ADON stated the key hanging on the cork board left an opportunity for someone to come into the MSR and remove the e-kit and other medications in the refrigerator. The ADON stated the key hanging on the cork board did not meet her expectations and it put the e-kit at risk to be tampered with or removed. The ADON staed, This puts the residents at risk for not having the medications when needed and prolonged pain and discomfort for the residents.During an interview on 12/4/25 at 3:30 pm with Registered Nurse (RN) 1, in MSR 4, RN 1 stated all narcotics should always be under lock and key to prevent residents from getting access to medications and harming themselves. RN 1 stated, the Licensed Nurse Staff (LN), should be in constant awareness of their medication keys as they were responsible for securing the medications.During an interview on 12/4/25 at 4:00 p.m. with Director of Nurses (DON), the DON stated, the key to the medication refrigerator should have been added to the LN key chain and not left on the cork board. The DON stated, other staff such as maintenance and housekeeping had access to the MSR, and they could get the key and take the Narcotic e-kit. The DON stated only LN should have access to keys for medications to prevent abuse or diversion.During a review of the facility's P&P titled, Storage and Expiration of Medications, Biologicals [a medicine that is a direct result of living cells], Syringes, and Needles, dated 12/07, the P&P indicated, .Facility should ensure that only authorized Facility Staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. should store Schedule 2 controlled substances [a drug with a high potential for abuse] and other medications deemed by the facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device. Facility should ensure that medications and biologicals: . Have not been retained longer than recommended by manufacturers or supplier guidelines.

Based on interview and record review, the facility failed to follow policy and procedure (P&P) and professional standards of practice to ensure residents were free from chemical restraints and not prescribed unnecessary medications to treat resident's medical symptoms for one of seven sampled residents (Resident 138), when Resident 138 was prescribed an anti-psychotic (a medication that affects brain activities associated with mental processes and behavior, used to treat a collection of symptoms that affect the ability to tell what's real and what is not) as needed for over 14 days without physician evaluation for renewal of the prescribed medication.This failure had the potential for Resident 138 to receive an unnecessary anti-psychotic medication and put Resident 138 at risk of adverse (harmful or unfavorable) side effects such as restlessness (inability to rest or relax), unusual behavior, depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), difficulty falling asleep or staying asleep, pain in arms, legs, back, or joints, weakness, and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness) from the use of the medication.Findings:During an observation on 12/2/25 at 4:16 p.m. in Resident 138's room, Resident 138 was observed dressed, lying in bed watching television (T.V.). Resident 138 stated he had been at the facility for about one year for kidney surgery. Resident 138 stated he had only one kidney which was going bad, and he had a high heart rate. Resident 138 stated he received other medications and had no problems with his medications.During a review of Resident 138's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/4/25, the AR indicated Resident 138 was admitted to the facility from an acute care hospital on 5/11/22 with a re-admission on [DATE]. Resident 138 was admitted with diagnoses of chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), acquired absence of kidney (surgical removal of a kidney), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 138's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 9/18/25, the MDS section C indicated, Resident 138 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 138 was cognitively intact.During a review of Resident 138's Consent for Treatment with Second Generation Antipsychotic Medications (Consent), dated 8/13/25, the Consent indicated, . medication: Olanzapine [an antipsychotic medication], dose: 5 mg intramuscular (IM), duration: PRN .During a review of Resident 138's Note to Attending Physician/Prescriber (Note), dated 10/21/25, from the Consultant Pharmacist, the Note indicated . Resident has order for [as needed (PRN)] (brand name) Olanzapine 5 mg IM. PRN antipsychotics can only be ordered for 14 days. Recommend to discontinue (DC) current order and reorder with 14-day intervals as needed . Physician/Prescriber Response . ? Patient has chronic illness. In order not to overmedicate (Resident Name), PRNs are used for exacerbations/episodic psychotic symptoms (Sx) and (secondary) agitation [a condition in which a person is unable to relax and be still]. Re-ordering PRNs every (q) 14 days for a chronic illness suggests ignorance of what is meant by Chronic! .During a review of Resident 138's Behavior Monitoring Record (BMR), dated October and November 2025, the BMR indicated, there were no episodes of refusal of routine psychiatric medications listed on the monitoring sheets.During a concurrent interview and record review on 12/4/25 at 10:50 a.m. with Nursing Supervisor (NS) 1, Resident 138's Order Summary Report (OSR), dated 12/4/25 was reviewed. The OSR indicated, . Olanzapine Intramuscular solution Reconstituted [to add water to a powdered or dehydrated substance to restore it to liquid] . inject 5 milligrams [mg - a unit of measurement] intramuscularly [into the muscle] as needed for give if routine psych meds refused . order status . active . order date 02/17/2023 . start date . 02/17/2023 . with no end date listed. NS 1 stated residents should be on as needed anti-psychotic medications for only 14 days then re-evaluated by the physician to see if the medication was still indicated. NS 1 stated if the anti-psychotic medication was administered to the patient, the physician would have extended the prescription. NS 1 stated Resident 138's Olanzapine injection was a routine medication and was ordered PRN to be given if routine psychiatric medications were refused.During a concurrent interview and record review on 12/4/25 at 10:55 a.m. with Nursing Supervisor (NS) 1, Resident 138's Medication Administration Record (MAR), dated October 2025 and November 2025 were reviewed. The MAR indicated, Resident 138 was not administered Olanzapine for Oct. and Nov. 2025. NS 1 reviewed Resident 138's MAR from previous months and stated Resident 138 had not required the use of his Olanzapine medication in a long time, going back to his admission date. NS 1 stated Resident 138 should not have had Olanzapine prescribed longer than 14 days without being re-evaluated for continued use of the medication.During a concurrent interview and record review on 12/4/25 at 5:25 p.m. with the Director of Nursing (DON), the facility's P&P titled, Psychoactive Medication [substances that when taken in or administered into one's system, affect mental processes e.g. perception, consciousness, cognition or mood and emotions] Management, dated 9/1/13, the P&P indicated, .psychoactive medications are prescribed for a specific medical condition or targeted behavior. The clinical record is to reflect the diagnosis, specific reasons for use (i.e. , medical symptom such as auditory hallucinations, possible functional impairment, or specific behaviors exhibited by the resident), with a care plan put in place to include medication use and non-drug interventions that have been attempted to alleviate the condition when applicable . it is recommended that PRN psychoactive drugs be ordered on a temporary basis (i.e. for two weeks) unless behaviors fail to respond to non-drug interventions or are due to a chronic psychiatric condition. As with routine psychoactive drugs, PRN drugs are to have a clear and specific indication for use documented in the clinical record. The DON stated residents were unpredictable and needed PRN medications to be given. The DON stated both she and the physician were aware of the regulations, but the physician wanted the PRN medications ordered for the resident, and she was not able to discontinue the physician's orders or change his reasoning. The DON stated PRN anti-psychotic medications were to be written for 14 days. The DON stated if Resident 138 refused his routine medications, staff were to give the olanzapine injection as a backup. The DON stated the facility had three psychiatrists who were at the facility weekly and had Program Managers in the facility. The DON stated the physicians were accessible and available by phone if staff needed to reach them for medication administration or changes in behavior. The DON stated the facility was not following the P&P for psychoactive medication management. The DON stated Olanzapine should not be continued as an active PRN medication.During a review of the facility job description titled, Director of Nursing Services (DNS), dated 7/14, the job description indicated, . the director is also responsible for the maintenance of quality improvement activities in compliance with current licensing and accrediting policies and regulations . ensures policy and procedure manuals for the various departments are reviewed and updated according to established facility regulatory agency protocols . maintains a working knowledge of standards and regulations governing mental health services .

Based on observation, interview, and record review the facility failed to follow infection control standards of practice for one of seven sampled residents (Resident 8), when Resident 8's Nasal Cannula (NC- device used to transport oxygen from a machine to the resident) tubing was laying on the floor.This failure had the potential to cross contaminate (the process by which bacteria are transferred from one substance or object to another, with harmful effect.) the NC tubing and cause Resident 8 to receive an infection.Findings: During a review of Resident 8's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 12/5/25, the AR indicated, Resident 8 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD- condition which causes difficulty breathing).During a review of Resident 8's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive [ability to think, memorize and process information] abilities), dated 10/24/25, the MDS indicated a brief interview for mental status (BIMS- an assessment used to determine the cognitive ability of a resident) score of thirteen (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 8 had moderate cognitive impairment.During an observation on 12/2/25 at 11:35 a.m. in Resident 8's room, Resident 8's NC tubing was found laying on the floor.During an interview on 12/2/25 at 3:56 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 8 required assistance transferring in and out of bed. CNA 1 stated the staff member who transferred her to a wheelchair should have removed the NC tubing and placed it in a bag or discarded it. CNA 1 stated it was important to place the NC tubing in a bag because it prevented cross contamination.During an interview on 12/4/25 at 2:35 p.m. with CNA 2, CNA 2 stated staff members should have placed the NC tubing in a secure bag so it did not become cross contaminated by any germs on the floor.During a concurrent interview and record review on 12/4/25 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's admission Record Diagnosis Information, dated 12/4/25 was reviewed. LVN 1 stated Resident 8 had COPD and needed to be on two liters (L- a unit of measurement) of oxygen via a NC. LVN 1 stated Resident 8 only had one leg and relied on staff to safely transfer her out of bed. LVN 1 stated the staff member who transferred Resident 8 out of bed should have removed her NC and placed it in a secure bag so the NC did not become contaminated or discarded it immediately once it fell on the floor.During an interview on 12/5/25 at 10:09 p.m. with Registered Nurse (RN) 1, RN 1 stated staff should have known to place the NC tubing in a storage bag so it did not get on the floor. RN 1 stated staff members often forgot to place the NC tubing in a bag which caused the tubing to become cross contaminated. RN 1 stated Resident 8 had COPD so she used her NC often and if she used a dirty one, she could have become ill.During an interview on 12/5/25 at 10:30 p.m. with the Infection Preventionist (IP), the IP stated the staff needed to place the unused NC tubing in a bag to prevent it from being on the floor. The IP stated the floor was considered a dirty surface and it could have caused the tubing to become contaminated and give the resident an infection. During an interview on 12/5/25 at 2:36 p.m. with the Assistant Director of Nursing (ADON), the ADON stated staff had been in-serviced (trainings done in a facility with relevant staff members) on proper handling of NC tubing. The ADON stated the NC should not have been on the floor.During a review of the professional reference (PR), found on https://masvidahealth.com/oxygen-concentrators/maintenance-guide-how-to-clean-a-nasal-cannula-of-an-oxygen-concentrator/, an article titled, Maintenance Guide: How To Clean A Nasal Cannula Of An Oxygen Concentrator, undated, the PR indicated, .Use a dedicated storage container or bag that is also clean and free from contaminants. Ensure the storage area is well-ventilated; a closed, damp environment can encourage bacterial growth. Keep the cannula away from high traffic areas where dust and dirt are more likely to accumulate .During a review of the professional reference (PR), found on https://www.who.int/publications/m/item/care-cleaning-and-disinfection-of-high-flow-nasal-cannula, the article titled, Care, cleaning and disinfection of high flow nasal cannula, dated 1/27/22, the PR indicated, . Consumables [devices which could be thrown away after one or a few uses] associated with oxygen delivery are generally intended as single use devices, should be treated as infectious material and disposed of accordingly.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be a high risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on [DATE]. Resident 1 was assessed to have an unsteady gait, educated on the need to call for assistance, had falls on [DATE], [DATE], [DATE]and fell on [DATE]. On [DATE], Resident 1 went to the bathroom unassisted, staff became aware of her presence in the bathroom alone, did not assist her with toileting, left her alone in the bathroom and Resident 1 fell and injured her right ankle. These failures resulted in Resident 1 not being provided with the level of assistance and supervision needed to prevent a fall, suffered an ankle injury requiring emergency transport to an acute care hospital for care and services and diagnosed with a fracture to the distal fibula [the lower, outer ankle area] and medial malleolus [the lower, inner ankle area]. Resident 1 was provided with a stabilizing splint, sent back to the Skilled Nursing Facility (SNF) with pain medication, new use of a Hoyer lift (an assistive device used to lift patients to transfer between a bed, chair or similar resting place) for transferring and required surgery on [DATE] in order to provide Resident 1 with the chance to walk again. Findings: During a review of Resident 1 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history), dated [DATE], the AR indicated, Resident 1 had diagnoses which included .SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE [a mental illness which can affect thoughts, mood and behavior] .METABOLIC ENCEPHALOPATHY [a change in how the brain works due to a chemical imbalance in the blood which causes confusion, memory loss and loss of consciousness] .DIFFICULTY IN WALKING .UNSTEADINESS ON FEET .ABNORMAL POSTURE .REPEATED FALLS .VERTIGO OF CENTRAL ORIGIN [spinning sensation or dizziness caused by problems within the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 10 (,d+[DATE] severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), ,d+[DATE] moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), ,d+[DATE] no cognitive impairment), which indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on [DATE] at 10:15 a.m. with Resident 1 in the Administrator ' s (ADM) office, Resident 1 was sitting on top of a Hoyer sling in her wheelchair and had a splint (a rigid material used for supporting a broken bone) with a tan bandage wrapped around her right ankle. Resident 1 stated, she fell in her bathroom alone the other day and broke her ankle badly. Resident 1 stated, she called out in a loud voice for help because she needed assistance using the bathroom. Resident 1 stated, staff did not respond in a prompt manner, so she used her wheelchair to go to the bathroom. Resident 1 stated, she used a wheelchair to ambulate because she is usually unsteady and shakes when walking. Resident 1 stated, there was a pressure alarm to her wheelchair which sounded an alarm noise when she stood up from her wheelchair. Resident 1 stated, she did not remember if the alarm went off when she stood up from her wheelchair to use the bathroom. Resident 1 stated, she slipped, hit a rail in the bathroom with her ankle, screamed in pain and fell down. During an interview on [DATE] at 10:23 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 required one staff member to assist her with Activities of Daily Living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). CNA 1 stated, Resident 1 experienced shakiness which required two staff members to assist Resident 1 with ADLs. CNA 1 stated, Resident 1 had fallen in the facility before and was a known fall risk resident. CNA 1 stated, there were stars next to Resident 1 ' s name tag outside Resident 1 ' s room so staff were aware Resident 1 was a fall risk. CNA 1 stated, Resident 1 had an alarm on her bed and wheelchair to alert staff when she attempted to get up. During an observation on [DATE] at 10:47 a.m. in Resident 1 ' s bathroom, an emergency call button was observed on the wall next to the toilet with the words Push For Help on the button. During an interview on [DATE] at 10:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was alerted by staff Resident 1 was on the floor. LVN 1 stated, Resident 1 told LVN 1 she fell when she was attempting to pull up her pants. LVN 1 stated, Resident 1 screamed her ankle hurt badly. LVN 1 stated, Resident 1 ' s ankle visually looked broken, when assessed by LVN 1. LVN 1 stated, Resident 1 ' s physician was called and a call for an ambulance was made. LVN 1 stated, it was important to provide residents with adequate supervision to prevent accidents because Resident 1 ' s safety was the staff ' s priority, and she should have had access to the help she needed. During an interview on [DATE] at 11:12 a.m. with CNA 2, CNA 2 stated, on [DATE], she heard Resident 1 was found on the floor so she went to Resident 1 ' s bathroom to help. CNA 2 stated, she heard Resident 1 say, Ouch! Ouch! and saw Resident 1 ' s ankle was damaged. CNA 2 stated, prior to the fall, the AM[CE1] (daytime shift) Program Manager (AMPM) had responded to Resident 1 ' s wheelchair alarm ringing. CNA 2 stated, Resident 1 declined help from the AMPM so the AMPM left Resident 1 in the bathroom. CNA 2 stated, the AMPM returned to Resident 1 and found Resident 1 on the floor. CNA 2 stated, the AMPM should have pushed the emergency call light in the bathroom and stayed with Resident 1 until another staff member arrived to help. CNA 2 stated, Resident 1 had fallen in the past. CNA 2 stated, she reminded Resident 1 to use the call light because staff did not want Resident 1 to fall and get hurt causing unnecessary pain. During an interview on [DATE] at 11:40 a.m. with the AMPM, the AMPM stated, on [DATE], she had checked on Resident 1 because she heard Resident 1 ' s wheelchair alarm going off. The AMPM stated, Resident 1 was using the bathroom and declined help from the AMPM. The AMPM stated, she left Resident 1 on the toilet, turned off the wheelchair alarm, and went back to her office. The AMPM stated, she did not notify any other staff member Resident 1 was still on the toilet. The AMPM stated, she heard Resident 1 yell out shortly after, went to check on Resident 1 and found her on the floor. During a concurrent interview and record review on [DATE] at 11:53 a.m. with the Director of Nursing (DON), Resident 1 ' s Care Plan Report (CPR), dated [DATE], and Resident 1 ' s MORSE FALL SCALE [CE2] (MFS- An assessment tool that predicts the likelihood that a resident will fall), dated [DATE] were reviewed. The CPR indicated, .[Resident 1] is a high fall risk [as evidenced by] .Repeated falls .Unsteadiness on feet .Abnormal posture .Difficulty in walking .Psychoactive [affecting the mind] drug use .Vertigo of central origin .age related osteoporosis [weak and brittle bones due to lack of calcium and Vitamin D] .right ankle fracture [DATE] due to fall XXX[DATE] Witnessed fall with [Head Injury Protocol (HIP)- facility protocol in which staff assesses and monitors the resident after a suspected or identified head injury] .Fall with HIP [DATE] .Unwitnessed Fall [DATE] without HIP, [DATE] with no HIP .Interventions XXX[DATE]: intervention will be to educate staff and resident about assisting resident fully when resident is using the restroom and ensure their safety when transferring .Anticipate and meet [Resident 1] ' s needs .Follow facility fall protocol .Interventions is to communicate with [Resident 1], encourage her to ask for assistance when attempting to ambulate, utilize the call lights, and make sure her wheelchair is locked before attempting to sit in or get out of it . The MFS indicated, .Score: 50 .High Risk for Falling .Has the Resident ever fallen before? .Yes . The DON stated, on [DATE], Resident 1 ' s wheelchair alarm was going off so the AMPM went to help Resident 1. The DON stated, Resident 1 declined help from the AMPM, the AMPM left and did not notify patient care staff Resident 1 was in the bathroom. The DON stated, Resident 1 fell after the AMPM had left Resident 1 in the bathroom. The DON stated, Resident 1 was not being actively supervised every time she went to the bathroom. The DON stated, Resident 1 ' s CPR included the intervention to educate staff and Resident 1 about assisting Resident 1 fully when Resident 1 used the restroom and ensured her safety when transferring. The DON stated, Resident 1 ' s MFS indicated she was a high risk for falls with a score of 50. The DON stated, Resident 1 was in the Falling Star Program (a program where staff could identify and intervene for residents who have had a fall within the last 30 days). The DON stated, Resident 1 had stars next to her name tag by her room doorway which alerted staff she was in the Falling Star Program. The DON stated the AMPM knew Resident 1 was a high risk for falls. The DON stated, it was important to provide Resident 1 with adequate supervision to prevent accidents to avoid any risk of falls and injuries. During a concurrent phone interview and record review on [DATE] at 1:37 p.m. with the Assistant Director of Nursing (ADON), Resident 1 ' s MDS Section GG- Functional Status (MDSGG), dated [DATE] was reviewed. The MDSGG indicated, .Self-Care .Coding: .Supervision or touching assistance- Helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently .[Resident 1] .Toileting hygiene: The ability to maintain perineal [area between the genitals and anus] hygiene, adjust clothes before and after voiding or having a bowel movement Signed .on [March] 4, 2025 .Supervision or touching assistance . The ADON stated, according to the MDS Section GG, Resident 1 required supervision or touching assistance with toileting. The ADON stated, this meant Resident 1 required assistance with cleaning or help with anything else while toileting. The ADON stated, a staff member responded to Resident 1 ' s wheelchair alarm ringing and found Resident 1 using the bathroom. The ADON stated the staff member left Resident 1 alone in the bathroom then Resident 1 had an unwitnessed fall. The ADON stated, Resident 1 was sent to the emergency room because her ankle was misaligned and was screaming. The ADON stated, Resident 1 was diagnosed with a right ankle fracture at the emergency department [ED]. The ADON stated the staff member who responded to Resident 1 should have pushed the emergency call button in the bathroom to alert more staff to come to assist the resident instead of leaving Resident 1 unassisted in the bathroom. The ADON stated Resident 1 ' s care plan indicated to educate staff and Resident 1 about calling for staff assistance and to ensure safety when transferring. The ADON stated, Resident 1 needed constant reminders for safety and had a history of falls. The ADON stated, Resident 1 had prior falls on [DATE], [DATE] and [DATE]. The ADON stated, Resident 1 was on the Falling Star program which meant there were stars on the name tag by Resident 1 ' s room door so all staff recognized Resident 1 had a fall within the last 30 days. The ADON stated, it was important to provide Resident 1 with adequate supervision to prevent falls. During a phone interview on [DATE] at 10:45 a.m. with the DON, the DON stated, Resident 1 ' s fall was avoidable. During a phone interview on [DATE] at 2:37 p.m. with the DON, the DON stated, Resident 1 returned from the hospital ED with an oxycodone/acetaminophen (pain medication) prescription to alleviate her pain. The DON stated, Resident 1 had an open reduction internal fixation (ORIF) surgery (surgical procedure used to repair broken bones) of the right ankle on [DATE]. During a review of Resident 1 ' s Progress Notes (PN), dated [DATE], the PN indicated, .At [1:25 p.m.], Staff alerted me that [Resident 1] was on the floor in her bathroom. Upon arrival to resident ' s bathroom, I was informed that this was an unwitnessed fall and that [Resident 1] did not hit her head. [Resident 1] reported having pain in her right foot, and upon assessment, [Resident 1] ankle appeared to be displaced. I asked another nurse to assist with contacting [ambulance company name] to send [Resident 1] to the hospital [Resident 1] claimed that her pain was ,d+[DATE] [a numerical pain scale assessment tool used to quantify the intensity of pain by having an individual rate their pain on a numbered scale, with ,d+[DATE] typically representing mild pain, ,d+[DATE] moderate pain, and ,d+[DATE] severe pain] . [Resident 1] stated that she was trying to pull up her pants and transfer herself back to her wheelchair, but the wheels were not locked, and she fell . Initially, [Resident 1] stated that only her Right Foot/leg area were in pain, but when [ambulance company name] showed up at [1:45 p.m.], She told them that her back was also hurt during the fall. [Ambulance company name] splinted her Right Ankle/Foot with a pillow .Author: [LVN] . During a review of Resident 1 ' s Post Fall Assessment (PFA), dated [DATE], the PFA indicated, .Date and Time of Fall: [DATE] [1:25 p.m.] .Where was the resident when they fell ? Residents ' bathroom .What was the resident doing when they fell ? Transferring from toilet to wheelchair .[wheelchair] brakes were unlocked . [Resident 1] stated that she was trying to pull up her pants and transfer herself back to her wheelchair but the wheels were not locked and she fell .Was this fall observed? No .possible ankle fracture .Sent to acute facility .Date of most recent prior fall XXX[DATE] . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .[7:00 p.m.] [Resident 1] returned from acute [diagnosis] right ankle [fracture] .Right ankle in splint. [Resident] able to move toes on right foot with .complaints of discomfort .Reports pain level ,d+[DATE] [severe pain according to the numerical pain scale assessment tool] to right ankle . During a review of Resident 1 ' s Hospital Patient Education & Visit Summary (PEVS), dated [DATE], the PEVS indicated, .[Resident 1] .[brought in by ambulance] from [Skilled Nursing Facility (SNF) facility] reporting unwitnessed [ground level fall] .right ankle deformity observed upon arrival .Patient Diagnosis .Ankle fracture, right .PATIENT EDUCATION INSTRUCTIONS .After an ankle fracture, you can lose ankle mobility and muscle strength and endurance . During a review of Resident 1 ' s Hospital Orthopedic [pertaining to the bones and muscles] Consultation Note (OCN), dated [DATE], the OCN indicated, REASON FOR CONSULTATION: Right ankle fracture .presents to the emergency department via ambulance from [facility] status post [after] unwitnessed ground-level fall .on the ground after an unwitnessed fall, complained of right ankle pain and was noted to have a deformity of the right ankle .ED workup revealed right ankle fracture and orthopedic surgery was consulted .ground level fall with closed right bimalleolar ankle fracture [type of fracture where both the inner and outer ankle are fractured] .leave splint in place until [follow up (f/u)] .closed reduction [a procedure to realign a fractured bone by manipulating it back into its correct position without surgery] and splinting performed in the ED .Patient is stable for discharge home from an orthopedic standpoint with outpatient follow up .in ,d+[DATE] days .[X-RAY (XR)- a form of medical imaging to take pictures of the inside of the body] Ankle Complete .Right .IMPRESSION .Acute [sudden onset] displaced [to move from the original position] fractures [breaks] of the distal fibula and medial malleolus .Orthopedic surgery consultation recommended . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .I accompanied [Resident 1] to her .[orthopedic] appointment today .After reviewing the notes from her [emergency room (ER)] visit on [DATE] and the x-ray images taken that day, [Orthopedic Surgery Doctor of Medicine (OSMD)] asked [Resident 1] if she ' [wanted] to be able to walk again ' , to which [Resident 1] replied that she want the option to try walking again. [OSMD] then explained that she would need surgery if she wanted the opportunity to walk and that is she did not care to walk again, then nothing needed to be done other than to let her ankle heal naturally. [Resident 1] then stated her desire for surgery and agreed with [OSMD] ' s Plan of Care. [OSMD] then stated that [Resident 1] ' s surgery would be ' next Thursday ' . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .Resident returned from surgery .with Orthopedics. Resident had an Open- Reduction- Internal- Fixation of Right Ankle and a Popliteal Nerve block [a technique used to numb the leg, foot, and ankle for procedures like surgery] . During a review of Resident 1 ' s Hospital Encounter Summary (ES), dated [DATE], the ES indicated, .Diagnoses .RIGHT ANKLE BIMALLEOLAR FRACTURE XXX[DATE] .Surgery .RIGHT ANKLE OPEN REDUCTION INTERNAL FIXATION .Medications at Time of Discharge .HYDROcodone/acetaminophen [pain medication] .10 [milligrams- unit of measurement (mg)]/325mg [tablet (tab)] .Take one Tab by mouth every 6 hours as needed .Indications: Closed displaced bimalleolar fracture of right ankle .HISTORY OF PRESENT ILLNESS: [Resident 1] .presents today with right ankle fracture .She reports sustaining the injury in the bathroom. Reduction was done .on [DATE]. She reports pain and rates the pain at ,d+[DATE] [severe pain according to the numerical pain scale assessment tool] .After discussion, she is interested in proceeding with surgical intervention . During a review of the facility ' s policy and procedure (P&P) titled, FALL PREVENTION & MANAGEMENT, dated [DATE], the P&P indicated, .It is the goal of this facility to prevent or reduce the occurrence of falls and severity of fall-related injuries while improving the quality of life for our residents and clients .Upon admission, each resident is assessed using a Fall Risk Assessment tool to determine possible risk for sustaining a fall .Residents scoring high per the risk assessment process, have strategies implemented to reduce the potential for falls outlined in their plan of care .Resident who have actively sustained a fall, will be placed on the facility ' s heightened awareness program (i.e., Falling Star), designed to alert staff of a resident who has actively fell in the presence of standard fall prevention interventions .Visual identifiers will be used to identify residents on the program. Those identifiers may be placed on the nameplate outside the resident ' s room . During a professional reference review retrieved from https://rn-journal.com/journal-of-nursing/preventing-falls-in-the-elderly-long-term-care-facilities, titled Preventing Falls in the Elderly Long Term Care Facilities, undated, .The elderly long-term care population is at increased risk for falls and fall related injuries. The implementation of a fall prevention program is important for ensuring resident safety. Systematically assessing residents ' risk for falls and implementing appropriate fall prevention interventions can reduce the number of falls in the elderly long-term care residents .Falls can cause serious injuries and accidental death, in older people .The elderly in long-term care facilities are predisposed to falling and may fall for a variety of reasons. Predisposing factors include, unsteady gait [a person ' s manner of walking] and balance, weak muscles .Staff should be educated about predisposing [to give a tendency to beforehand] and precipitating [to bring something on] factors for falls and related prevention strategies and interventions . Staff needs to understand the different interventions available to them, in order to apply them when caring for patients .

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a written consent was obtained for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy. Findings included: An undated facility document titled, Consent for Identification Photograph, specified, [Facility name] may utilize audio or video recording and telecommunication if face-to-face services are not available and/or if the treatment team determines this to be an appropriate form of communication. A facility policy titled, Resident Rights, revised 10/2012, specified, 11. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 1. An Admission Record revealed the facility admitted Resident #103 on 10/12/2017. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and adverse effects of unspecified antipsychotics and neuroleptics. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #103 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident had one fall since admission or the prior assessment. Resident #104's care plan, included a focus revised 08/07/2024, that indicated the resident had a potential for falls and/or injuries related to falls. On 08/12/2024 at 12:35 PM, a monitor was observed outside of Resident #103's room. During an interview on 08/12/2024 at 12:36 PM, Certified Nursing Assistant #10 stated the monitor was for Resident #103. On 08/13/2024 at 10:46 AM, a monitor was observed in use outside of Resident #103's room. 2. An Admission Record revealed the facility admitted Resident #124 on 05/16/2022. According to the Admission Record, the resident had a medical history that included diagnoses of delusional disorders, mild cognitive impairment, and other specified disorders of bone density and structure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #124 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had not had any falls since admission or the prior assessment. Resident #124's care plan included a focus initiated 07/04/2024, that indicated the resident was a moderate risk for falls. On 08/12/2024 at 12:47 PM, a monitor was observed outside Resident #124's room. During an interview on 08/12/2024 at 12:48 PM, Certified Nursing Assistant #11 stated the monitor was for Resident #124 so that staff could watch the resident for falls. On 08/12/2024 at 12:59 PM, the surveyor attempted an interview with Resident #124; however, the resident told the surveyor to leave their room. On 08/13/2024 at 10:46 AM, a monitor was observed in use outside of Resident #124's room. During an interview on 08/13/2024 at 3:16 PM, the Administrator stated the facility did not have a consent for the cameras (monitor). The Administrator stated the cameras were used to prevent falls. During an interview on 08/15/2024 at 12:46 PM with the Director of Nursing and the Administrator, the Administrator stated there needed to be a written consent for the use of the camera for the residents' privacy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions when they performed wound care for 1 (Resident #113) of 1 sampled resident reviewed for pressure ulcer/injury. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 05/21/2024, indicated, 1. Identify residents at high risk for MDRO [multiple-drug resistant organisms] colonization and transmission. Use ESP [Enhanced Standard Precautions], primarily gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission. *Presence of indwelling devices *Wounds or presence of pressure ulcer (unhealed). An Admission Record indicated the facility admitted Resident #113 on 02/25/2020. According to the Admission Record, the resident had a medical history that included diagnoses of urinary incontinence and non-pressure chronic ulcer of the right ankle. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2024, revealed Resident #113 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident had one stage 2 pressure ulcer. Resident #113s care plan included a focus area revised 07/02/2024 that indicated the resident had impaired skin integrity as described as a stage 2 pressure ulcer to their left gluteal cleft. Interventions directed staff to clean the open area to the left gluteal cleft with normal saline, pat dry, then apply hydrogel and cover with a waterproof dressing daily (initiated 07/23/2024). Resident #113's Order Summary Report, with active orders as of 08/15/2024, contained an order dated 08/08/2024 that directed staff to clean the open area to left gluteal cleft with normal saline, apply hydrogel, and cover with waterproof dressing daily for 14 days. During an observation on 08/15/2024 at 10:13 AM, Certified Nursing Assistant (CNA) #6 and Licensed Vocational Nurse (LVN) #1 provided wound care for Resident #113. The CNA and the LVN did not implement enhanced barrier precaution (EBP) and wore only gloves and masks during the provision of wound care. During an interview on 08/15/2024 at 10:30 AM, LVN #1 stated staff were to use a gown, gloves, and a mask as EBP for resident safety and during wound care for any resident who had an opened area. LVN #1 stated Resident #113 had an opened area and that she should have worn a gown when she provided wound care to prevent the spread of infection. During an interview on 08/15/2024 at 12:55 PM, the Infection Preventionist (IP) stated EBPs included the use of a gown and gloves should be worn to provide care for a resident with MDRO, open wounds, or indwelling medical devices. The IP stated EBPs were used to prevent the spread of anything like germs, parasites, or fungus to a resident. The IP stated that based on EBP criteria, CNA #6 and LVN #1 should have worn all personal protective equipment (PPE) to provide wound care to Resident #113. During an interview on 08/15/2024 at 1:11 PM, the Director of Nursing stated she expected for staff to be aware of EBPs, and if it was not understood, they were to receive more training. The DON stated she expected EBP to be utilized for resident safety. The DON stated she expected staff to wear the appropriate PPE if the resident required EBPs. During an interview on 08/15/2024 at 1:18 PM, the Administrator stated the facility would in-service staff on the requirements for EBPs and to use EBP when required.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was implemented for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy. Findings included: A facility policy titled, Care Planning, revised 10/28/2017, specified, Policy A person-centered care plan to meet the individual needs of residents/clients is prepared by an Interdisciplinary Team, which is periodically reviewed and revised after subsequent assessments. 1. An Admission Record revealed the facility admitted Resident #103 on 10/12/2017. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and adverse effects of unspecified antipsychotics and neuroleptics. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #103 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident had one fall since admission or the prior assessment. Resident #104's care plan, included a focus revised 08/07/2024, that indicated the resident had a potential for falls and/or injuries related to falls. There was no documented intervention for the use a camera monitor. On 08/12/2024 at 12:35 PM, a monitor was observed outside of Resident #103's room. During an interview on 08/12/2024 at 12:36 PM, Certified Nursing Assistant #10 stated the monitor was for Resident #103. On 08/13/2024 at 10:46 AM, a monitor was observed in use outside of Resident #103's room. 2. An Admission Record revealed the facility admitted Resident #124 on 05/16/2022. According to the Admission Record, the resident had a medical history that included diagnoses of delusional disorders, mild cognitive impairment, and other specified disorders of bone density and structure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2024, revealed Resident #124 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had not had any falls since admission or the prior assessment. Resident #124's care plan included a focus initiated 07/04/2024, that indicated the resident was a moderate risk for falls. There was no documented intervention for the use a camera monitor. On 08/12/2024 at 12:47 PM, a monitor was observed outside Resident #124's room. During an interview on 08/12/2024 at 12:48 PM, Certified Nursing Assistant #11 stated the monitor was for Resident #124 so that staff could watch the resident for falls. On 08/12/2024 at 12:59 PM, the surveyor attempted an interview with Resident #124; however, the resident told the surveyor to leave their room. On 08/13/2024 at 10:46 AM, a monitor was observed in use outside of Resident #124's room. During an interview on 08/14/2024 at 10:57 AM, the Administrator stated there were no care plans for the use of the cameras for Resident #103 and Resident #124. During an interview on 08/14/2024 at 1:58 PM, the Assistant Director of Nursing (ADON) stated care plans were in place to inform the staff what the resident's plan of care was. The ADON stated there were no care plans for the cameras that monitored Resident #103 and Resident #124. During an interview on 08/14/2024 at 2:10 PM, the Director of Nursing (DON)stated the cameras were put in place to monitor the residents for falls and safety. During an interview on 08/15/2024 at 12:46 PM with the DON and the Administrator, the DON stated there needed to a care plan for the use of the cameras for Resident #103 and Resident #124.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of significant medication errors when Licensed Vocational Nurse (LVN) 1 did not correctly identify Resident 1 and administered Resident 4's psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications to her in error. This failure resulted in Resident 1 experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 726) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady. Resident 1 stated a male nurse had given her another resident's medications and she was sent to the hospital but did not remember the exact day. Resident 1 stated the nurse handed her a medication cup. Resident 1 stated she looked at the medication and told the nurse they were not hers. Resident 1 stated, he was saying nonchalantly [casually] they were my meds. Resident 1 stated she knew the medicine was not hers because they were different shapes and sizes than what she usually took. Resident 1 stated she swallowed the pills and the nurse suddenly realized he had given her the wrong medication. Resident 1 stated she became sleepy and was transferred to the hospital but did not remember anything for the rest of the day. During a review of Resident 1's Admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), rheumatoid arthritis (inflammatory disorder affecting the joints), schizoaffective disorder-bipolar type (mental illness that can affect your thoughts, mood and behavior) and tachycardia (rapid heart rate). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Nurses Note, dated 3/6/24 at 11:54 a.m., by Unit Manager (UM) 1, the nurses note indicated, . During 0800 [8:00 a.m.] med [medication] pass Charge nurse made me aware that [Resident 1] had received peers [Resident 4's] medications in error . [Resident 1] received Carbamazepine [used to treat bipolar disorder] 200 mg [milligram-unit of measurement], [brand name for Divalproex Sodium (used to treat bipolar disorder)] 125 mg, [brand name for haloperidol (antipsychotic medication)] 0.5 mg, [brand name for quetiapine (antipsychotic medication)] 400 mg, Vitamin D [nutritional supplement] 1000 un [units (unit of measurement)], Multi vit [multiple vitamin] and oxybutynin [used to treat an overactive bladder] . During a review of Resident 4's Order Summary Report, (OSR) dated 3/2024, the OSR indicated, . CarBAMazepine Oral [by mouth] Tablet . Give 200 mg by mouth one time a day for anger/mood . [brand name] Oral Tablet Delayed Release (Divalproex Sodium) give 125 mg by mouth one time a day . Haloperidol Oral Tablet . Give 0.5 mg by mouth one time a day . multiple vitamin tablet give 1 tablet by mouth one time a day . oxyBUTYnin Chloride Oral Tablet . Give 5 mg by mouth two times a day . QUEtiapine Fumarate Oral Tablet . Give 400 mg one time a day . vitamin D3 oral tablet . Give 1000 IU [international unit-unit of measurement for vitamins and other medical products] by mouth one time a day . During an interview on 3/11/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked at the facility for approximately one year and was familiar with Resident 1. CNA 1 stated Resident 1's baseline was alert, oriented and ambulatory without assistance. During an interview on 3/11/24 at 12:23 p.m. with CNA 2, CNA 2 stated last Wednesday (3/6/24) LVN 1 had asked for her help identifying residents during the medication pass. CNA 2 stated LVN 1 was new and not familiar with the residents. CNA 2 stated LVN 1 had asked her who Resident 1 was and she replied with Resident 1's first and last name. CNA 2 stated she had repeated Resident 1's first and last name to LVN 1 at least four times while he administered the medication to make sure he had the correct resident. CNA 2 stated LVN 1 administered the medications to Resident 1 and then pulled out an inhaler. CNA 2 stated she notified LVN 1 Resident 1 did not use an inhaler. CNA 2 stated LVN 1 asked her, this isn't [Resident 4's name]? CNA 2 stated LVN 1 walked away and spoke with Unit Manager (UM) 1. CNA 2 stated she was later notified Resident 1 had received Resident 4's medication and Resident 1's vital sign had to be checked every 30 minutes. CNA 2 stated when she took Resident 1 a snack around 10:00 a.m. and Resident 1 was drowsy. CNA 2 stated Resident 1 was sent to the hospital around 11:05 a.m. because she was groggy, and her respirations (action of breathing) were slower than normal. During an interview on 3/11/24 at 12:50 p.m. with Resident 4, Resident 4 stated the staff confused her with Resident 1 sometimes because their last names were similar. During a concurrent interview and record review on 3/11/24 at 1:37 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked at the facility since 10/2023. The DSD stated she met with LVN 1 after the medication error on 3/6/24. The DSD stated LVN 1 reported he had given Resident 1's medication to Resident 4. The DSD stated Resident 1 was transferred to the emergency department (ED) as a result of the medication error. The DSD stated LVN 1's medication pass competency had been performed by one of the DSD Assistants in February 2024. LVN 1's competency titled, Medication Pass Observation Worksheet, dated 2/21/24 was reviewed, the observation indicated, . Medication Administration . Hands washed/sanitized using appropriate technique [No] . Label checked times three (including expiration, description) [No] . MAR [Medication Administration Record] initialed immediately after administration [No] . Number of errors [0] . The DSD stated the facility required 100% on the medication pass observation competency. The DSD stated since LVN 1 did not check the medication label correctly or initial the MAR timely the form should not indicate there were zero errors. The DSD stated she or a DSD Assistant should have followed up on LVN 1's medication pass competency. The DSD stated a repeat observation was not done and there was no documentation of training performed at the time of the observation. The DSD stated the expectation was for the nurses to follow the rights of medication administration, verifying the right person, right medication, right time, right dose and right documentation. During a telephone interview on 3/11/24 at 2:45 p.m. with LVN 1, LVN 1 stated he worked the Station 3 I hallway on 3/6/24. LVN 1 stated he was not familiar with the residents, so he took a CNA to help identify the residents. LVN 1 stated there were two residents with similar last names. LVN 1 stated he asked the CNA who a resident was, and she stated the resident was Resident 1. LVN 1 stated he heard Resident 4's last name in error and gave Resident 4's medication to Resident 1. LVN 1 stated when he took Resident 4's inhaler out of the med cart and handed it to Resident 1, Resident 1 said she did not use an inhaler. LVN 1 stated he asked the CNA if there was another resident with a similar name and the CNA told him Resident 4. LVN 1 stated he realized he gave Resident 4's medication to Resident 1 in error. LVN 1 stated, she [Resident 1] went from being fine to not fine. Her [Resident 1's] respirations dropped from 17 to 13 per minute. LVN 1 stated, she became very sedated [calm or to make drowsy by administering a sedating drug] because she got the wrong meds. LVN 1 stated Resident 1's mental status had changed, and the physician ordered for her to be transferred to the ED. LVN 1 stated he believed the medication error was caused because he was not familiar with the residents and the residents' similar names. During a concurrent interview on 3/11/24 at 4:55 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Administrator (ADM), the ADON stated, I think it [the medication error] was caused by the inexperience of a new nurse not knowing the patients. The ADON stated the medication error caused Resident 1 to have a change in condition including a lowered heart rate and being a little shaky. The ADON stated Resident 1 was transferred to the hospital and they flushed her system due to the amount of medications she had received. The ADON stated the medication error caused Resident 1's change in condition and she was admitted to the hospital from 3/6/24 until 3/8/24. The DON stated Resident 1 was not prescribed Quetiapine and was closely monitored because of potential side effects from the medication. During a concurrent interview and record review on 3/11/24 at 4:55 p.m. with the DON, LVN 1's Medication Pass Observation Worksheet, dated 2/21/24 was reviewed. The Medication Pass Observation Worksheet, indicated LVN 1 failed to check the label three times and initial the MAR immediately after administration. The DON stated it was her understanding the DSD assistant had addressed the medication pass observation issues at the time of the observation but was unable to provide documentation it had occurred. The DON stated it was her expectation the number of errors would not be zero on the observation and there should have been a repeat medication pass observation done. During a telephone interview on 3/12/24 at 9:49 a.m. with LVN Unit Manager (UM) 1, UM 1 stated on 3/6/24 at approximately 8:00 a.m. LVN 1 notified her he had made a medication error. UM 1 stated LVN 1 reported he administered Resident 4's medication to Resident 1. UM 1 stated she had assessed Resident 1 shortly after the medication error and notified the physician. UM 1 stated the physician saw Resident 1 later in the morning and sent her to the ED because she was sedated. UM 1 stated Resident 1 was a little bit tired and had her eyes closed but was able to answer questions. The UM stated the medication error was caused by LVN 1 failing to do his three checks of resident identification during the medication pass. During a telephone interview on 3/12/24 at 11:23 a.m. with the Pharmacy Consultant (PC), the PC stated she had been the facility's consultant since 2022. The PC stated she was at the facility on 3/6/24 for the quarterly medication pass observations. The PC stated LVN 1 was passing medication when she arrived, so she observed him. The PC stated during LVN 1 did not properly identify the residents during the medication pass and continued to rely on the CNAs. The PC stated LVN 1 was new and could have avoided the medication error by asking Resident 1 her name and date of birth instead of relying on a coworker. During a telephone interview on 3/13/24 at 10:40 a.m. with UM 2, UM 2 stated he was doing rounds with Resident 1's physician on the morning of 3/6/24. UM 2 stated Resident 1's physician assessed Resident 1 and she was speaking slowly and not alert. UM 2 stated the physician was later contacted and notified Resident 1's respiratory rate had dropped to 13 per minute and the physician ordered Resident 1's transfer to the ED. During a review of Resident 1's Physician's Progress Note, dated 3/6/24 at 11:58 a.m., written by the physician (PHY), the note indicated, . 77 yo [year old] . presents for monthly visit . seen secondary to pt getting NOTHER [another] Patients meds . carbamazepine 200 [mg] . [brand name for divalproex sodium] 125 [mg] . [brand name for haloperidol] 0.5 [mg] . oxybutynin 5 [mg] . [brand name for quetiapine] 400 [mg] . vit [vitamin] D 1000 IU [international units] pt [patient] barely arousable-follow commands RR [respiratory rate] low 13 [breaths per minute] sent to hospital . During a review of the GACH's document titled, ED Provider Notes, dated 3/6/24, the ED notes indicated, . Patient presents with . Altered mental status [decreased level of consciousness] . Physical Exam . Gen [general]: Very somnolent [state of feeling drowsy, ready to fall asleep] . Neuro [neurological- pertaining to the nervous system (brain, nerves and spinal cord)]: Initial exam: Somnolent, but arousable to voice. Unable to speak full sentences . [Resident 1's name] is a [AGE] year old female . who presents with somnolence, near obtundation (diminished responsiveness to stimuli [anything that can trigger a physical or behavioral change], often due to a state of reduced consciousness) after receiving multiple sedating [drugs that calm] and psychotropic medications [drugs that affect a person's mental state] due to medication error at her SNF [skilled nursing facility] . Poison control [specialized unit that advises on and assists in the prevention and management of poisoning] consulted, the recommend monitoring until somnolence resolved . ED Diagnosis . Accidental overdose . During a review of the GACH's document titled, Hospitalist [physician who cares for hospitalized patients] Discharge Summary, dated 3/8/24, the discharge summary indicated, . admitted [DATE] . discharge date [DATE] . Reason for Admission . Altered mental status (BIBA [brought in by ambulance] from [name of facility] for being lethargic after receiving the wrong medications (carbamazepine 200 mg, [brand name for divalproex sodium] 125 mg, [brand name for haloperidol] 0.5 mg, [brand name for quetiapine] 400 mg) none of which are her routine medications.) . presented with AMS [altered mental status], lethargy [lack of energy], and difficulty ambulating [walking] after being given the wrong medications in error . only [brand name for divalproex sodium] is her normal medication . Poison control recommended cardiac monitoring [records heart rate and rhythm], supportive care and to washout the meds from body systems . In ED, pt became more arousable but still having difficulty ambulating . Patient was admitted for Accidental CNS [central nervous system-brain and spinal cord which controls all of the body's functions] meds overdose , on 3/07/24 . Discharge Diagnoses . Accidental overdose . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/carbamazepine-oral-route/side-effects/drg-20062739 titled, Carbamazepine (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . confusion, agitation, or hostility (especially in elderly) . loss of balance control . tiredness . unusual drowsiness . During a review of a professional reference retrieved fromhttps://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/side-effects/drg-20072886 titled, Divalproex Sodium (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . problems with memory or speech . shakiness in the legs, arms, hands, or feet . sleepiness or unusual drowsiness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/side-effects/drg-20064173 titled, Haloperidol (Oral Route), dated 3/1/2024, the reference indicated . Side Effects . loss of balance . weakness of the arms and legs . dizziness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=1 titled, Quetiapine, dated 3/1/2024, the reference indicated, . Side Effects . confusion . sleepiness or unusual drowsiness . During a review of the facility's policy and procedure (P&P) titled Med Pass, Medication Administration Essentials, dated 9/1/13 and revised on 9/18/23, the P&P indicated, . Medications are administered by a licensed nurse in a safe and dignified manner . Medications and treatments are to be administered as prescribed . The licensed nurse shall check the resident's identity by armband, photo or other means of identification prior to administering medication . Medication Errors . The nurse shall notify the physician immediately after a medication error has been noted . The nurse will assess and monitor the resident closely for any adverse effects from medication error . The nurse shall document in resident's record what medication was administered and observations .The Director of Nursing Service/designee shall complete follow-up for medication errors and take necessary corrective action . During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20crucial%20that%20nurses,do%20so%20in%20clinical%20practice. titled, Nursing Rights of Medication Administration, dated 9/4/2023, the reference indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights' . of medications administration . ' Right Patient' . ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . this is best practiced by nurses directly asking a patient to provide his or her full name aloud . It is advisable not to address patients by first name or surname [last name] alone, in the event, there are two or more patients with identical or similar names in a unit . nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence .

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 administered psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications not prescribed to Resident 1 in error. This failure resulted in Resident 1's transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for decreased mental status and treatment of an accidental overdose (dangerous and excessive dose of a drug). (Cross reference F 726, F 760) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady. Resident 1 stated a male nurse had given her another resident's medications and she was sent to the hospital but did not remember the exact day. Resident 1 stated the nurse handed her a medication cup. Resident 1 stated she looked at the medication and told the nurse they were not hers. Resident 1 stated, he [LVN 1] was saying nonchalantly [casually] they were my meds. Resident 1 stated she knew the medicine was not hers because they were different shapes and sizes than what she usually took. Resident 1 stated she swallowed the pills and the nurse suddenly realized he had given her the wrong medication. Resident 1 stated she became sleepy and was transferred to the hospital but did not remember anything for the rest of the day. During a review of Resident 1's Admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), rheumatoid arthritis (inflammatory disorder affecting the joints), schizoaffective disorder-bipolar type (mental illness that can affect your thoughts, mood and behavior) and tachycardia (rapid heart rate). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Nurses Note, dated 3/6/24 at 11:54 a.m., by Unit Manager (UM) 1, the nurses note indicated, . During 0800 [8:00 a.m.] med [medication] pass Charge nurse made me aware that [Resident 1] had received peers [Resident 4's] medications in error . [Resident 1] received Carbamazepine [used to treat bipolar disorder] 200 mg [milligram-unit of measurement], [brand name for Divalproex Sodium (used to treat bipolar disorder)] 125 mg, [brand name for haloperidol (antipsychotic medication)] 0.5 mg, [brand name for quetiapine (antipsychotic medication)] 400 mg, Vitamin D [nutritional supplement] 1000 un [units (unit of measurement)], Multi vit [multiple vitamin] and oxybutynin [used to treat an overactive bladder] . During a review of Resident 4's Order Summary Report, (OSR) dated 3/2024, the OSR indicated, . CarBAMazepine Oral [by mouth] Tablet . Give 200 mg by mouth one time a day for anger/mood . [brand name] Oral Tablet Delayed Release (Divalproex Sodium) give 125 mg by mouth one time a day . Haloperidol Oral Tablet . Give 0.5 mg by mouth one time a day . multiple vitamin tablet give 1 tablet by mouth one time a day . oxyBUTYnin Chloride Oral Tablet . Give 5 mg by mouth two times a day . QUEtiapine Fumarate Oral Tablet . Give 400 mg one time a day . vitamin D3 oral tablet . Give 1000 IU [international unit-unit of measurement for vitamins and other medical products] by mouth one time a day . During an interview on 3/11/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked at the facility for approximately one year and was familiar with Resident 1. CNA 1 stated Resident 1's baseline was alert, oriented and ambulatory (walking) without assistance. During an interview on 3/11/24 at 12:23 p.m. with CNA 2, CNA 2 stated last Wednesday (3/6/24) LVN 1 had asked for her help identifying residents during the medication pass. CNA 2 stated LVN 1 was new and not familiar with the residents. CNA 2 stated LVN 1 had asked her who Resident 1 was and she replied with Resident 1's first and last name. CNA 2 stated she had repeated Resident 1's first and last name to LVN 1 at least four times while he administered the medication to make sure he had the correct resident. CNA 2 stated LVN 1 administered the medications to Resident 1 and then pulled out an inhaler. CNA 2 stated she notified LVN 1 Resident 1 did not use an inhaler. CNA 2 stated LVN 1 asked her, this isn't [Resident 4's name]? CNA 2 stated LVN 1 walked away and spoke with Unit Manager (UM) 1. CNA 2 stated she was later notified Resident 1 had received Resident 4's medication and Resident 1's vital sign had to be checked every 30 minutes. CNA 2 stated when she took Resident 1 a snack around 10:00 a.m. and Resident 1 was drowsy. CNA 2 stated Resident 1 was sent to the hospital around 11:05 a.m. because she was groggy, and her respirations (action of breathing) were slower than normal. During an interview on 3/11/24 at 12:50 p.m. with Resident 4, Resident 4 stated the staff confused her with Resident 1 sometimes because their last names were similar. During a concurrent interview and record review on 3/11/24 at 1:37 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked at the facility since 10/2023. The DSD stated she met with LVN 1 after the medication error on 3/6/24. The DSD stated LVN 1 reported he had given Resident 1's medication to Resident 4. The DSD stated Resident 1 was transferred to the emergency department (ED) as a result of the medication error. The DSD stated LVN 1's medication pass competency had been performed by one of the DSD Assistants in February 2024. LVN 1's competency titled, Medication Pass Observation Worksheet, dated 2/21/24 was reviewed, the observation indicated, . Medication Administration . Hands washed/sanitized using appropriate technique [No] . Label checked times three (including expiration, description) [No] . MAR [Medication Administration Record] initialed immediately after administration [No] . Number of errors [0] . The DSD stated the facility required 100% on the medication pass observation competency. The DSD stated since LVN 1 did not check the medication label correctly or initial the MAR timely the form should not indicate there were zero errors. The DSD stated she or a DSD Assistant should have followed up on LVN 1's medication pass competency. The DSD stated a repeat observation was not done and there was no documentation of training performed at the time of the observation. The DSD stated the expectation was for the nurses to follow the rights of medication administration, verifying the right person, right medication, right time, right dose and right documentation. During a telephone interview on 3/11/24 at 2:45 p.m. with LVN 1, LVN 1 stated he worked the Station 3 I hallway on 3/6/24. LVN 1 stated he was not familiar with the residents, so he took a CNA to help identify the residents. LVN 1 stated there were two residents with similar last names. LVN 1 stated he asked the CNA who a resident was, and she stated the resident was Resident 1. LVN 1 stated he heard Resident 4's last name in error and gave Resident 4's medication to Resident 1. LVN 1 stated when he took Resident 4's inhaler out of the med cart and handed it to Resident 1, Resident 1 said she did not use an inhaler. LVN 1 stated he asked the CNA if there was another resident with a similar name and the CNA told him Resident 4. LVN 1 stated he realized he gave Resident 4's medication to Resident 1 in error. LVN 1 stated, she [Resident 1] went from being fine to not fine. Her [Resident 1's] respirations dropped from 17 to 13 per minute. LVN 1 stated, she became very sedated [calm or to make drowsy by administering a sedating drug] because she got the wrong meds. LVN 1 stated Resident 1's mental status had changed, and the physician ordered for her to be transferred to the ED. LVN 1 stated he believed the medication error was caused because he was not familiar with the residents and the residents' similar names. During a concurrent interview and record review on 3/11/24 at 4:55 p.m. with the Director of Nursing (DON), LVN 1's Medication Pass Observation Worksheet, dated 2/21/24 was reviewed. The Medication Pass Observation Worksheet, indicated LVN 1 failed to check the label three times and initial the MAR immediately after administration. The DON stated it was her understanding the DSD assistant had addressed the medication pass observation issues at the time of the observation but was unable to provide documentation it had occurred. The DON stated it was her expectation the number of errors would not be zero on the observation and there should have been a repeat medication pass observation done. During a telephone interview on 3/12/24 at 9:49 a.m. with LVN Unit Manager (UM) 1, UM 1 stated on 3/6/24 at approximately 8:00 a.m. LVN 1 notified her he had made a medication error. UM 1 stated LVN 1 reported he administered Resident 4's medication to Resident 1. UM 1 stated she had assessed Resident 1 shortly after the medication error and notified the physician. UM 1 stated the physician saw Resident 1 later in the morning and sent her to the ED because she was sedated. UM 1 stated Resident 1 was a little bit tired and had her eyes closed but was able to answer questions. The UM stated the medication error was caused by LVN 1 failing to do his three checks of resident identification during the medication pass. During a telephone interview on 3/12/24 at 11:23 a.m. with the Pharmacy Consultant (PC), the PC stated she had been the facility's consultant since 2022. The PC stated she was at the facility on 3/6/24 for the quarterly medication pass observations. The PC stated LVN 1 was passing medication when she arrived, so she observed him. The PC stated LVN 1 did not properly identify the residents during the medication pass and continued to rely on the CNAs. The PC stated LVN 1 was new and could have avoided the medication error by asking Resident 1 her name and date of birth instead of relying on a coworker. During a telephone interview on 3/13/24 at 10:40 a.m. with UM 2, UM 2 stated he was doing rounds with Resident 1's physician on the morning of 3/6/24. UM 2 stated Resident 1's physician assessed Resident 1 and she was speaking slowly and not alert. UM 2 stated the physician was later contacted and notified Resident 1's respiratory rate had dropped to 13 per minute and the physician ordered Resident 1's transfer to the ED. During a review of Resident 1's Physician's Progress Note, dated 3/6/24 at 11:58 a.m., written by the physician (PHY), the note indicated, . 77 yo [year old] . presents for monthly visit . seen secondary to pt [patient] getting NOTHER [another] Patients meds . carbamazepine 200 [mg] . [brand name for divalproex sodium] 125 [mg] . [brand name for haloperidol] 0.5 [mg] . oxybutynin 5 [mg] . [brand name for quetiapine] 400 [mg] . vit [vitamin] D 1000 IU [international units] pt barely arousable-follow commands RR [respiratory rate] low 13 [breaths per minute] sent to hospital . During a review of the GACH's document titled, ED Provider Notes, dated 3/6/24, the ED notes indicated, . Patient presents with . Altered mental status [decreased level of consciousness] . Physical Exam . Gen [general]: Very somnolent [state of feeling drowsy, ready to fall asleep] . Neuro [neurological-pertaining to the nervous system (brain, nerves and spinal cord)]: Initial exam: Somnolent, but arousable to voice. Unable to speak full sentences . [Resident 1's name] is a [AGE] year old female . who presents with somnolence, near obtundation (diminished responsiveness to stimuli [anything that can trigger a physical or behavioral change], often due to a state of reduced consciousness) after receiving multiple sedating [drugs that calm] and psychotropic medications [drugs that affect a person's mental state] due to medication error at her SNF [skilled nursing facility] . Poison control [specialized unit that advises on and assists in the prevention and management of poisoning] consulted, the recommend monitoring until somnolence resolved . ED Diagnosis . Accidental overdose . During a review of the GACH's document titled, Hospitalist [physician who cares for hospitalized patients] Discharge Summary, dated 3/8/24, the discharge summary indicated, . admitted [DATE] . discharge date [DATE] . Reason for Admission . Altered mental status (BIBA [brought in by ambulance] from [name of facility] for being lethargic after receiving the wrong medications (carbamazepine 200 mg, [brand name for divalproex sodium] 125 mg, [brand name for haloperidol] 0.5 mg, [brand name for quetiapine] 400 mg) none of which are her routine medications.) . presented with AMS [altered mental status], lethargy [lack of energy], and difficulty ambulating [walking] after being given the wrong medications in error . only [brand name for divalproex sodium] is her normal medication . Poison control recommended cardiac monitoring [records heart rate and rhythm], supportive care and to washout the meds from body systems . In ED, pt became more arousable but still having difficulty ambulating . Patient was admitted for Accidental CNS [central nervous system-brain and spinal cord which controls all of the body's functions] meds overdose , on 3/07/24 . Discharge Diagnoses . Accidental overdose . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/carbamazepine-oral-route/side-effects/drg-20062739 titled, Carbamazepine (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . confusion, agitation, or hostility (especially in elderly) . loss of balance control . tiredness . unusual drowsiness . During a review of a professional reference retrieved fromhttps://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/side-effects/drg-20072886 titled, Divalproex Sodium (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . problems with memory or speech . shakiness in the legs, arms, hands, or feet . sleepiness or unusual drowsiness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/side-effects/drg-20064173 titled, Haloperidol (Oral Route), dated 3/1/2024, the reference indicated . Side Effects . loss of balance . weakness of the arms and legs . dizziness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=1 titled, Quetiapine, dated 3/1/2024, the reference indicated, . Side Effects . confusion . sleepiness or unusual drowsiness . During a review of the facility's policy and procedure (P&P) titled Med Pass, Medication Administration Essentials, dated 9/1/13 and revised on 9/18/23, the P&P indicated, . Medications are administered by a licensed nurse in a safe and dignified manner . Medications and treatments are to be administered as prescribed . The licensed nurse shall check the resident's identity by armband, photo or other means of identification prior to administering medication . Medication Errors . The nurse shall notify the physician immediately after a medication error has been noted . The nurse will assess and monitor the resident closely for any adverse effects from medication error . The nurse shall document in resident's record what medication was administered and observations .The Director of Nursing Service/designee shall complete follow-up for medication errors and take necessary corrective action . During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20crucial%20that%20nurses,do%20so%20in%20clinical%20practice. titled, Nursing Rights of Medication Administration, dated 9/4/2023, the reference indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights' . of medications administration . ' Right Patient' . ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . this is best practiced by nurses directly asking a patient to provide his or her full name aloud . It is advisable not to address patients by first name or surname [last name] alone, in the event, there are two or more patients with identical or similar names in a unit . nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence .

Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to assure residents maintained their highest practicable physical, mental, and psychosocial well-being when one of three Licensed Vocational Nurses (LVN 1) did not correctly identify one of four sampled residents (Resident 1) during medication administration. This failure resulted in Resident 1 receiving Resident 4's medication and experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 760) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady. Resident 1 stated a male nurse had given her another resident's medications and she was sent to the hospital but did not remember the exact day. Resident 1 stated the nurse handed her a medication cup. Resident 1 stated she looked at the medication and told the nurse they were not hers. Resident 1 stated, he was saying nonchalantly [casually]they were my meds. Resident 1 stated she knew the medicine was not hers because they were different shapes and sizes than what she usually took. Resident 1 stated she swallowed the pills and the nurse suddenly realized he had given her the wrong medication. Resident 1 stated she became sleepy and was transferred to the hospital but did not remember anything for the rest of the day. During a review of Resident 1's Admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), rheumatoid arthritis (inflammatory disorder affecting the joints), schizoaffective disorder-bipolar type (mental illness that can affect your thoughts, mood and behavior) and tachycardia (rapid heart rate). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Nurses Note, dated 3/6/24 at 11:54 a.m., by Unit Manager (UM) 1, the nurses note indicated, . During 0800 [8:00 a.m.] med [medication] pass Charge nurse made me aware that [Resident 1] had received peers [Resident 4's] medications in error . [Resident 1] received Carbamazepine [used to treat bipolar disorder] 200 mg [milligram-unit of measurement], [brand name for Divalproex Sodium (used to treat bipolar disorder)] 125 mg, [brand name for haloperidol (antipsychotic medication)] 0.5 mg, [brand name for quetiapine (antipsychotic medication)] 400 mg, Vitamin D [nutritional supplement] 1000 un [units (unit of measurement)], Multi vit [multiple vitamin] and oxybutynin [used to treat an overactive bladder] . During a review of Resident 4's Order Summary Report, (OSR) dated 3/2024, the OSR indicated, . CarBAMazepine Oral [by mouth] Tablet . Give 200 mg by mouth one time a day for anger/mood . [brand name] Oral Tablet Delayed Release (Divalproex Sodium) give 125 mg by mouth one time a day . Haloperidol Oral Tablet . Give 0.5 mg by mouth one time a day . multiple vitamin tablet give 1 tablet by mouth one time a day . oxyBUTYnin Chloride Oral Tablet . Give 5 mg by mouth two times a day . QUEtiapine Fumarate Oral Tablet . Give 400 mg one time a day . vitamin D3 oral tablet . Give 1000 IU by mouth one time a day . During an interview on 3/11/24 at 12:23 p.m. with CNA 2, CNA 2 stated last Wednesday (3/6/24) LVN 1 had asked for her help identifying residents during the medication pass. CNA 2 stated LVN 1 was new and not familiar with the residents. CNA 2 stated LVN 1 had asked her who Resident 1 was and she replied with Resident 1's first and last name. CNA 2 stated she had repeated Resident 1's first and last name to LVN 1 at least four times while he administered the medication to make sure he had the correct resident. CNA 2 stated LVN 1 administered the medications to Resident 1 and then pulled out an inhaler. CNA 2 stated she notified LVN 1 Resident 1 did not use an inhaler. CNA 2 stated LVN 1 asked her, this isn't [Resident 4's name]? CNA 2 stated LVN 1 walked away and spoke with Unit Manager (UM) 1. CNA 2 stated she was later notified Resident 1 had received Resident 4's medication and Resident 1's vital sign had to be checked every 30 minutes. CNA 2 stated when she took Resident 1 a snack around 10:00 a.m . and Resident 1 was drowsy. CNA 2 stated Resident 1 was sent to the hospital around 11:05 a.m. because she was groggy, and her respirations (action of breathing) were slower than normal. During a concurrent interview and record review on 3/11/24 at 1:37 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked at the facility since 10/2023. The DSD stated she met with LVN 1 after the medication error on 3/6/24. The DSD stated LVN 1 reported he had given Resident 1's medication to Resident 4. The DSD stated Resident 1 was transferred to the emergency department (ED) as a result of the medication error. The DSD stated LVN 1's medication pass competency had been performed by one of the DSD Assistants in February 2024. LVN 1's competency titled, Medication Pass Observation Worksheet, dated 2/21/24 was reviewed, the observation indicated, . Medication Administration . Hands washed/sanitized using appropriate technique [No] . Label checked times three (including expiration, description) [No] . MAR [Medication Administration Record] initialed immediately after administration [No] . Number of errors [0] . The DSD stated the facility required 100% on the medication pass observation competency. The DSD stated since LVN 1 did not check the medication label correctly or initial the MAR timely the form should not indicate there were zero errors. The DSD stated she or a DSD Assistant should have followed up on LVN 1's medication pass competency. The DSD stated a repeat observation was not done and there was no documentation of training performed at the time of the observation. The DSD stated the expectation was for the nurses to follow the rights of medication administration, verifying the right person, right medication, right time, right dose and right documentation. During a telephone interview on 3/11/24 at 2:45 p.m. with LVN 1, LVN 1 stated he worked the Station 3 I hallway on 3/6/24. LVN 1 stated he felt overwhelmed when he arrived at work and realized he was scheduled in the I hallway because he trained for the hallway once, in 10/2023. LVN 1 stated, I wish I had trained in that hall more, I think it would have helped this [the medication error] to not happen . LVN 1 stated he was not familiar with the residents in the I hallway, so he took a CNA to help identify the residents. LVN 1 stated there were two residents with similar last names. LVN 1 stated he asked the CNA who a resident was, and she stated the resident was Resident 1. LVN 1 stated he heard Resident 4's last name in error and gave Resident 4's medication to Resident 1. LVN 1 stated when he took Resident 4's inhaler out of the med cart and handed it to Resident 1, Resident 1 said she did not use an inhaler. LVN 1 stated he asked the CNA if there was another resident with a similar name and the CNA told him Resident 4. LVN 1 stated he realized he gave Resident 4's medication to Resident 1 in error. LVN 1 stated, she [Resident 1] went from being fine to not fine. Her [Resident 1's] respirations dropped from 17 to 13 per minute. LVN 1 stated, she became very sedated [calm or to make drowsy by administering a sedating drug] because she got the wrong meds. LVN 1 stated Resident 1's mental status had changed, and the physician ordered for her to be transferred to the ED. LVN 1 stated he believed the medication error was caused because he was not familiar with the residents and the residents' similar names. During a concurrent interview on 3/11/24 at 4:55 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Administrator (ADM), the ADON stated, I think it [the medication error] was caused by the inexperience of a new nurse not knowing the patients. The ADON stated the medication error caused Resident 1 to have a change in condition including a lowered heart rate and being a little shaky. The ADON stated Resident 1 was transferred to the hospital and they flushed her system due to the amount of medications she had received. The ADON stated the medication error caused Resident 1's change in condition and she was admitted to the hospital from 3/6/24 until 3/8/24. The DON stated Resident 1 was not prescribed Quetiapine and was closely monitored because of potential side effects from the medication. During a concurrent interview and record review on 3/11/24 at 4:55 p.m. with the DON, LVN 1's Medication Pass Observation Worksheet, dated 2/21/24 was reviewed. The Medication Pass Observation Worksheet, indicated LVN 1 failed to check the label three times and initial the MAR immediately after administration. The DON stated it was her understanding the DSD assistant had addressed the medication pass observation issues at the time of the observation but was unable to provide documentation it had occurred. The DON stated it was her expectation the number of errors would not be zero on the observation and there should have been a repeat medication pass observation done. During a telephone interview on 3/12/24 at 9:49 a.m. with LVN Unit Manager (UM) 1, UM 1 stated on 3/6/24 at approximately 8:00 a.m. LVN 1 notified her he had made a medication error. UM 1 stated LVN 1 reported he administered Resident 4's medication to Resident 1. UM 1 stated she had assessed Resident 1 shortly after the medication error and notified the physician. UM 1 stated the physician saw Resident 1 later in the morning and sent her to the ED because she was sedated. UM 1 stated Resident 1 was a little bit tired and had her eyes closed but was able to answer questions. The UM stated the medication error was caused by LVN 1 failing to do his three checks of resident identification during the medication pass. During a telephone interview on 3/12/24 at 11:23 a.m. with the Pharmacy Consultant (PC), the PC stated she had been the facility's consultant since 2022. The PC stated she was at the facility on 3/6/24 for the quarterly medication pass observations. The PC stated LVN 1 was passing medication when she arrived, so she observed him. The PC stated during LVN 1 did not properly identify the residents during the medication pass and continued to rely on the CNAs. The PC stated LVN 1 was new and could have avoided the medication error by asking Resident 1 her name and date of birth instead of relying on a coworker. During a review of Resident 1's Physician's Progress Note, dated 3/6/24 at 11:58 a.m., written by the physician (PHY), the note indicated, . 77 yo [year old] . presents for monthly visit . seen secondary to pt getting NOTHER [another] Patients meds . carbamazepine 200 [mg] . [brand name for divalproex sodium] 125 [mg] . [brand name for haloperidol] 0.5 [mg] . oxybutynin 5 [mg] . [brand name for quetiapine] 400 [mg] . vit [vitamin] D 1000 IU [international units] pt barely arousable-follow commands RR [respiratory rate] low 13 [breaths per minute] sent to hospital . During a review of the GACH's document titled, ED Provider Notes, dated 3/6/24, the ED notes indicated, . Patient presents with . Altered mental status [decreased level of consciousness] . Physical Exam . Gen [general]: Very somnolent [state of feeling drowsy, ready to fall asleep] . Neuro [neurological]: Initial exam: Somnolent, but arousable to voice. Unable to speak full sentences . [Resident 1's name] is a [AGE] year old female . who presents with somnolence, near obtundation (diminished responsiveness to stimuli, often due to a state of reduced consciousness)after receiving multiple sedating [drugs that calm] and psychotropic medications [drugs that affect a person's mental state] due to medication error at her SNF [skilled nursing facility] . Poison control [specialized unit that advises on and assists in the prevention and management of poisoning] consulted, the recommend monitoring until somnolence resolved . ED Diagnosis . Accidental overdose . During a review of the GACH's document titled, Hospitalist Discharge Summary, dated 3/8/24, the discharge summary indicated, . admitted [DATE] . discharge date [DATE] . Reason for Admission . Altered mental status (BIBA [brought in by ambulance] from [name of facility] for being lethargic after receiving the wrong medications (carbamazepine 200 mg, [brand name for divalproex sodium] 125 mg, [brand name for haloperidol] 0.5 mg, [brand name for quetiapine] 400 mg) none of which are her routine medications.) . presented with AMS [altered mental status], lethargy [lack of energy], and difficulty ambulating [walking] after being given the wrong medications in error . only [brand name for divalproex sodium] is her normal medication . Poison control recommended cardiac monitoring [records heart rate and rhythm], supportive care and to washout the meds from body systems . In ED, pt became more arousable but still having difficulty ambulating . Patient was admitted for Accidental CNS [central nervous system-brain and spinal cord which controls all of the body's functions] meds overdose , on 3/07/24 . Discharge Diagnoses . Accidental overdose . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/carbamazepine-oral-route/side-effects/drg-20062739titled, Carbamazepine (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . confusion, agitation, or hostility (especially in elderly) . loss of balance control . tiredness . unusual drowsiness . During a review of a professional reference retrieved fromhttps://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/side-effects/drg-20072886titled, Divalproex Sodium (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . problems with memory or speech . shakiness in the legs, arms, hands, or feet . sleepiness or unusual drowsiness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/side-effects/drg-20064173titled, Haloperidol (Oral Route), dated 3/1/2024, the reference indicated . Side Effects . loss of balance . weakness of the arms and legs . dizziness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=1titled, Quetiapine, dated 3/1/2024, the reference indicated, . Side Effects . confusion . sleepiness or unusual drowsiness . During a review of the facility's policy and procedure (P&P) titled Med Pass, Medication Administration Essentials, dated 9/1/13 and revised on 9/18/23, the P&P indicated, . Medications are administered by a licensed nurse in a safe and dignified manner . Medications and treatments are to be administered as prescribed . The licensed nurse shall check the resident's identity by armband, photo or other means of identification prior to administering medication . Medication Errors . The nurse shall notify the physician immediately after a medication error has been noted . The nurse will assess and monitor the resident closely for any adverse effects from medication error . The nurse shall document in resident's record what medication was administered and observations .The Director of Nursing Service/designee shall complete follow-up for medication errors and take necessary corrective action . During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20crucial%20that%20nurses,do%20so%20in%20clinical%20practice. titled, Nursing Rights of Medication Administration, dated 9/4/2023, the reference indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights' . of medications administration . ' Right Patient' . ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . this is best practiced by nurses directly asking a patient to provide his or her full name aloud . It is advisable not to address patients by first name or surname [last name] alone, in the event, there are two or more patients with identical or similar names in a unit . nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence .

Based on interview and record review, the facility failed to report an alleged employee to resident physical abuse per their Policy and Procedure (P&P), Resident Allegations of Abuse by Staff for one of three sampled residents (Resident 1), when: 1. The facility did not notify the local law enforcement within 24 hours of the alleged abuse. 2. The facility did not perform a physical assessment of Resident 1 and did not notify a Physician, nor Psychiatrist of the alleged abuse incident. This failure placed Resident 1's safety at risk. Findings: During a review of Resident 1's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses, BIPOLAR DISORDER (disorder associated with episodes of mood swings), ANXIETY DISORDER (feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities) and VASCULAR DEMENTIA (forgetfulness, limited social skills and thinking that interferes with daily functioning). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 99 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). A score of 99 indicated the resident was unable to complete the interview. The BIMS assessment indicated Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1 ' s Behavior Note (BN), dated 10/14/23 at 4:35 p.m., the BN indicated, . (Resident 1) ' s conservator called regarding something that (Resident 1) ' s sister shared with her. (Resident 1) had told his sister that he had gotten assaulted by a staff member here. He did not specify a day or time, but just told his sister that he was assaulted by a staff member . (Resident 1) said that he was assaulted and the staff member who assaulted him was a ' dirty Mexican ' .asked him when this happened and he said that this happened 5 days ago, during mid-morning shift . He then said that contents of a urine bag were dumped over him and his bed. He then pointed to the window by his room and said that him and the staff member were standing there when (Resident 1) was punched and cussed at . During an interview on 10/26/23, at 12:45 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, she was notified of the abuse allegation on 10/14/23 by staff at the facility. The ADON stated she notified the Facility Administrator and started an investigation into the allegation. The ADON stated for the investigation she reviewed video footage, Resident 1 ' s Electronic Medical Record and interviewed all the parties involved, which included: Resident 1, Resident 1 ' s roommates, nurse responsible for Resident 1's care and the staff member that was alleged to have committed the abuse. The ADON stated she completed the investigation into Resident 1 ' s allegation and it was concluded to be unsubstantiated on 10/17/23. During a concurrent interview and record review on 10/26/23, at 1:05 p.m., with the ADON, Resident 1 ' s Electronic Medical Record (EMR), dated 10/26/23 was reviewed. The EMR indicated there was not a notification to the local police department, a physical assessment for Resident 1 completed, or a notification to the Medical Doctor or Psychiatrist in regard to the abuse allegation. The ADON stated staff should have charted these tasks but they were not completed. During an interview on 10/26/23, at 5 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was notified on 10/14/23, in the afternoon, by Resident 1 ' s Conservator that Resident 1 had allegedly been abused by a staff member. LVN 1 stated she did not document a physical assessment after she was notified of Resident 1 ' s abuse allegation. LVN 1 stated that she could not remember if she notified Resident 1 ' s Physician or Psychiatrist in regard to the alleged abuse. LVN 1 stated she did not document a notification to the Physician or Psychiatrist in Resident 1 ' s EMR. LVN 1 stated she did not document notification of local law enforcement in regard to Resident 1 ' s abuse allegation in the EMR. During a concurrent interview and record review on 10/26/23, at 5:30 p.m., with the ADON, the P&P (Facility Name) Internal Step by Step: Resident Allegations of Abuse by Staff, dated 11/2016, was reviewed. The ADON stated that facility staff did not follow the P&P. The ADON stated that staff were trained annually in regards to abuse and there was a binder on the unit with the P&P and instructions on what to do at the time when the incident was reported. During a concurrent interview and record review on 10/26/23, at 5:40 p.m., with the Administrator (ADM), the P&P (Facility Name) Internal Step by Step: Resident Allegations of Abuse by Staff, dated 11/2016, was reviewed. The ADM stated documentation was not present in the EMR for Physician or Psychiatrist notification, physical assessment and local law enforcement notification, in regard to Resident 1 ' s abuse allegation. The ADM stated the facility did not follow the P&P and steps were missed. The ADM stated the P&P was important because they give staff guidance on what needs to be done for resident safety. The ADM stated the safety of the resident was compromised when staff did not follow the P&P. During a review of the facility ' s P&P titled, (Facility Name) Internal Step by Step: Resident Allegations of Abuse by Staff, dated 11/2016, the P&P indicated, If abuse is reasonably suspected or unable to determine: Complaint Investigation Check List: .Reporting .notify the Local Law Enforcement by telephone .within 24 hours for no serious bodily injury .Immediately notify the Charge nurse for physical assessment of the resident .Notify resident ' s .Physician/Psychiatrist .

Based on observation, interview and record review, the facility failed to allow residents to call for staff assistance through a communication system for one of three sampled residents (Resident 1) when Resident 1 did not have a call bell (a replacement of call light when facility staff removed the call light on 10/5/22 to keep Resident 1 safe) available to her on 12/27/22. This failure did not allow Resident 1 to call out for assistance, and placed Resident 1 at risk for accidents and injuries. Findings: During a review of Resident 1 ' s ADMISSION RECORD, undated, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus (a metabolic disorder in which body has high sugar levels for prolonged periods of time), chronic viral hepatitis C (a viral infection that causes inflammation of liver that leads to liver inflammation), unspecified cataract ( a condition affecting the eye that causes clouding of the lens) and schizoaffective (mental) disorder, bipolar (a mental health condition that causes extreme mood swings that include emotional highs and lows) type. During a review of Resident 1 ' s minimum data set(MDS, a core set of screening, clinical and functional status elements of comprehensive assessment), dated 10/7/22, the MDS indicated, Resident 1 ' s Brief Interview Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly) was 6 out of 15 (6, severe cognitive impact) and Resident 1's functional mobility to use the toilet was limited requiring a one-person physical assistance (requires assistance from staff). During an observation on 12/27/22, at 3:25 p.m., in Resident 1 ' s room, Resident 1 was observed sitting in her wheelchair near the door to the hallway. Resident 1 was observed resting her both elbows on the bedside table. Resident 1 was observed independently getting out of her wheelchair and the wheelchair alarm went off. Resident 1 started walking with her socks towards the bathroom, which was located at the end of the private room. Resident 1 arrived in the bathroom by herself. Certified Nursing Assistant (CNA) 1 arrived to respond to the sound of alarm when Resident 1 was already in the bathroom. During a concurrent observation and interview on 12/27/22, at 3:30 p.m., with Resident 1, Resident 1 was observed awake and alert and did not have any difficulty communicating verbally. Resident 1 was asked if she was told to call staff prior to going to the bathroom after her recent fall on 12/20/22. Resident 1 stated, I don ' t remember what happened. I don ' t remember if staff told me to call for help. I just go bathroom without calling the nurse. I don ' t have a call light. I don ' t know how to use it. I can ' t call anyone. It is hard to use my wheelchair to go to the nurse station each time I need help. I have to yell and sometimes someone comes and sometimes someone does not come. During an observation on 12/27/22, at 3:35 p.m., with Certified Nursing Assistant (CNA) 2, in Resident 1 ' s room, CNA 2 approached the bedside and searched the area but was unable to locate a call light or a call bell. During an interview on 12/27/22, at 3:46 p.m., with Representative Staff (RS) 1, in Resident 1's room, RS 1 stated, She used to have a doorbell/push bell. It ' s not here [Resident 1 ' s room]. During an interview on 12/27/22, at 3:40 p.m., with CNA 1, CNA 1 stated, when she came in for her shift at 2 p.m., she did not ensure Resident 1 had her call bell within her reach. CNA 1 stated, it was her responsibility to ensure Resident 1 had a call bell at the beginning of her shift. CNA 1 stated, it slipped her mind since Resident 1 had a wheelchair alarm and bed alarm. During an interview on 12/27/22, at 3:50 p.m., with the Assistant Director of Staff Development (ADSD), the ADSD stated, her expectation was at the beginning of every shift CNAs are to ensure resident call lights were within reach and call lights are working. The ADSD stated, Resident 1 ' s call light was removed due to being a safety hazard about two months ago and Resident 1 was provided with a call bell. The ADSD stated, the staff could not locate Resident 1 ' s call bell in her room. The ADSD stated, CNA 1 should not rely on Resident 1 ' s chair alarm or bed alarm to respond her needs. The ADSD stated, it was the facility ' s responsibility to provide a functioning call light or call bell to each resident. During an interview on 12/27/22, at 4 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she expected CNA 1 to ensure Resident 1 had a call light within reach and for Resident 1 to use her call bell for assistance before she tried to go to the bathroom by herself. LVN 1 stated, she was not sure why Resident 1 ' s call light was removed. LVN 1 stated, Resident 1 ' s alarms for bed and wheelchair were not a call light or a call bell. LVN 1 stated, a functional call light or call bell was essential for residents. LVN 1 stated, she did not know what happened to Resident 1 ' s call bell. LVN 1 stated it was very important to Resident 1 to have a call bell to let staff know when she had to go to the bathroom. During an interview on 12/27/22, at 4:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 ' s call light was removed due to her suicidal thoughts and to prevent her from wrapping the cord around her neck. The ADON stated, she was not sure exactly when the call light was removed and when Resident 1 was provided a call bell as an alternative. The ADON stated she knew Resident 1 did not have a call light. During a review of Resident 1 ' s care plan titled Focus -suicide watch dated 10/5/22, the listed interventions for suicide watch did not contain removing Resident 1 ' s call light or providing Resident 1 a call bell. During a review of Resident 1 ' s care plan titled Focus-actual fall dated 10/31/22, the listed interventions indicated, .Educated resident to pull call light on for assistance . During a review of the facility ' s policy and procedure (P&P) titled Call Lights, dated 9/1/13, the P&P indicated, .Obtain a specialty call light device (i.e. paddle type, doorbell) or other call system if the resident/client is unable to physically use the standard call light cord/button or has been deem unsafe to have a call light attached to a cord .Place the call light within reach of the resident/client upon leaving the room .

Based on interview and record review, the facility failed to provide adequate supervision for two of two residents (Residents 1 and 2) when on 6/27/20 Residents 1 and Resident 2 were in a verbal altercation and staff did not implement effective interventions to deescalate the verbal altercation and prevent further altercation. This failure resulted in Residents 1 and 2 being left alone unsupervised after the verbal altercation and the incident escalated to physical altercation and the potential for physical injury. Findings: During a review of Resident 1's Face sheet (a document with demographic, personal and medical information) , dated 6/27/20, the Face sheet , indicated, Resident 1 was admitted on [DATE] and had the diagnoses of Paranoid [CONDITION(S)] (mental health condition that can involve delusions and fear). During a review of Resident 2's Face sheet, dated 6/27/20, the Face sheet, indicated, Resident 2 was admitted on [DATE] and had the diagnoses of [CONDITION(S)] disorder (mental health condition including [CONDITION(S)] and mood disorder symptoms). During a review of facility document Notification of Resident to Resident Altercation, dated 6/27/20, the Notification of Resident to Resident Altercation, indicated, . incident date 6/27/20 . Description of the event . [Resident 1] and [Resident 2] were in the TV room when [Resident 1] began cussing at [Resident 2] . [Resident 2] asked for staff to help. Staff intervened then left the room once he felt they were ok. [Resident 1] began cussing again, [Resident 2] told her to stop but [Resident 1] continued. [Resident 2] got up suddenly and began pounding with both fist while on top of [Resident 1], until staff intervened . During a review of Resident 1's Progress Notes, dated 6/27/20, the Progress note indicated, . Per team decision at this time she [Resident 1] will be placed on Q ½ hour [every 30 minutes monitoring ] safety watch d/t [due to] related to the incident and [Resident 1's fear of [Resident 2] During a review of Resident 2's Progress Notes, dated 6/27/20, the Progress note indicated, . Resident 2 was in the TV room with Resident 1. Resident 1 was verbally abusive to Resident 2. Resident 2 asked staff for help. Activity Assistant [AA ] went to room to intervene. [AA] left once he [AA] felt that residents were calm. After he [AA] left peer [Resident 1] began swearing again to [Resident 2]. [Resident 2] told her peer to stop but her peer did not. [Resident 2] began punching her peer with her fists, repeatedly, while on top of [Resident 1] until staff intervened . [Resident 2] has agreed to get staff if [Resident 1] is verbally abusive again . During a review of Resident 2's Care Plan, undated, the Care plan indicated, . The resident has potential to be physically aggressive and act out inappropriately r/t [related to] anger history of harm to others and poor impulse control . when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress During an interview on 3/15/21, at 12:05 p.m., with Assistant Program Director (ADP), ADP stated, AA should have not left the residents in the TV room with no staff member to supervise them after the verbal altercation. ADP stated AA should have asked another staff member to supervise Resident 1 and Resident 2. Then AA could have left the room and informed the charge nurse about the verbal altercation between both residents. ADP stated the physical altercation could have been prevented if Resident 1 and Resident 2 were supervised after the verbal altercation. During an interview on 3/15/21, at 2:18 p.m., with Behavior Specialist (BHS), BHS stated, AA should have watch or separated Resident 1 and Resident 2 after verbal altercation. During an interview on 3/15/21 at 3:25 pm, with AA, AA confirmed he was the staff who was called by Resident 2 about the incident between Resident 1 and Resident 2 on 6/27/20 at 6:15 p.m. AA stated initially Resident 1 initiated the incident by being verbally abusive to Resident 2. AA stated he stayed with Resident 1 and Resident 2 in the TV room for about 5 minutes and then determined both residents were ok. AA stated he left both residents in the TV room with no staff member to supervise them. AA stated he left the room to report the incident. AA stated after he left the TV room the physical altercation happened. AA stated he should not have left both residents unattended or he should have separated residents to prevent the physical altercation. During a review of the facility's policy and procedure (P&P) titled, Elder and Dependent Adult abuse, dated 8/1/13, the P&P indicated, . Policy First and foremost, [facility] believes every person served, client or resident has the right to be free of . Physical abuse . H. person served to person served altercations are considered abuse such, are reportable by mandated abuse reporters under the welfare and institutions code . Appropriate measures to consider: (1) Separate the person served, i.e. room change or specific monitoring. During a review of the facility document titled, [Facility] Internal Step by Step dated 11/16, indicated, . Provide Safety for resident, . Check list for Reporting Peer to Peer altercations . Immediately separate and provide safety to the residents .

Based on interview and record review, the facility failed to ensure residents and their Responsible Party (RP) were informed of [MEDICAL CONDITION] (affecting mental activity, behaviors, and perceptions) medications dosages and frequency in accordance with the facility policy and procedure and professional standards of quality for three of seven sampled residents (Resident 146, Resident 148, and Resident 471) when: 1. Resident 146 and the Responsible Party (RP) were not informed of the dosage amount and frequency duration of Resident 146's three [MEDICAL CONDITION] medications: [REDACTED]. 2. Resident 148 and the RP was not informed of the dosage amounts and frequency duration of [MEDICATION NAME] (a medication used to treat anxiety) (feeling of fear) and [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). 3. Resident 471 and the RP was not informed of the dosage amount and frequency duration of [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). These failures resulted in Resident 146, 148, 471 and their RP not being fully informed of the risks and benefits of the [MEDICAL CONDITION] (affecting mental activity, behaviors, and perceptions) medications being administered. Findings: 1. During a review of Resident 146's Face Sheet (resident profile information) undated, indicated Resident 146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 146's Order Summary Report dated 12/18/19, indicated, (paliperidone) Extended-Release (ER) Give 9 mg (milligrams - unit of measure) by mouth one time a day for psychotic Sxs (symptoms)/hallucinations m/b (manifested by) .Give at (8 am) (Diagnosis) [MEDICAL CONDITION] DISORDER, UNSPECIFIED . start date of 12/17/19. During a review of the clinical record for Resident 146, the [MEDICAL CONDITION] medication consent form, dated 10/17/19 indicated, Paliperidone was signed by Resident 146's RP and the prescribing physician on 10/17/19. Resident 146's informed consent for paliperidone did not indicate dosage amount and frequency of the medication administration. During a review of Resident 146's Physician Orders dated 12/17/19, indicated paliperidone was increased to 9 mg daily and given every morning. During a review of Resident 146's Order Summary dated 12/18/19, indicated, [MEDICATION NAME] ER Give 300 mg by mouth at bedtime for mood stabilization and suicidal ideation related to [MEDICAL CONDITION] DISORDER .Give at (8 pm) . start date 10/18/19. During a review of Resident 146's [MEDICAL CONDITION] medication consent dated 10/17/19, indicated, [MEDICATION NAME] was signed by Resident 146's RP and the prescribing physician on 10/17/19. Resident 146's informed consent for [MEDICATION NAME] did not indicate dosage amount and frequency of medication administration. During a review of Resident 146's Order Summary dated 11/17, indicated, [MEDICATION NAME] tablet Give 30 mg by mouth at bedtime for mood and poor appetite m/b lack of motivation related to [MEDICAL CONDITION] DISORDER, UNSPECIFIED . start date 8/15/19. During a review of Resident 146's [MEDICAL CONDITION] medication informed consent dated 10/17/19, indicated, [MEDICATION NAME] was signed by Resident 146's RP and the prescribing physician. Resident 146's informed consent for [MEDICATION NAME] did not indicate medication dosage amount and frequency of medication administration. During an interview with Unit Manager (UM), on 12/18/19, at 9:42 a.m., she stated Resident 146's informed consents for paliperidone, [MEDICATION NAME], and [MEDICATION NAME] did not indicate dosage amount and frequency duration of the medications. UM stated dosage amount and frequency duration of [MEDICAL CONDITION] medications should have been part of Resident 146's informed consents for Resident 146's RP to be fully and accurately aware of the dosages and frequency of [MEDICAL CONDITION] medications. During an interview with Licensed Vocational Nurse (LVN) 1, on 12/18/19 at 2:33 p.m., he stated Resident 146's informed consents should have contained medication dosages and frequency of [MEDICAL CONDITION] medications administration. LVN 1 stated medication dosages and frequencies were important to be part of informed consents for Resident 146's RP to be made aware of how much and how often Resident 146 was getting. During an interview with Resident 146, on 12/19/19 at 9:14 a.m., Resident 146 stated she did not know the medication dosage amounts or frequency of her medications (paliperidone, [MEDICATION NAME], and [MEDICATION NAME]). She stated, No one (facility staff) informed me of the dosage amounts of my medications. She stated medications dosages and frequencies of her [MEDICAL CONDITION] medications were not discussed in the Inter-Disciplinary meetings (IDT - a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) meetings. Resident 146's stated she was not notified of the dosage increase of paliperidone on 12/17/19. During a review of Resident 146's Minimum Data Set (MDS - a resident assessment tool which indicates physical and cognitive abilities) dated 7/8/18, indicated Resident 146's Brief Interview for Mental Status (an assessment of a resident's cognitive status) scored 15 of 15, which indicated Resident 146 was cognitively intact. During an interview with Director of Social Services (DSS), on 12/19/19 at 9:16 a.m., she stated, Yes, she has to know the dosages of her (Resident 146) medications she was taking . The DSS stated the Licensed Nurse (LN) was the one responsible in notifying the Resident 146 and RP of the [MEDICAL CONDITION] medication dosage and frequencies. During an interview with Director of Nursing (DON), on 12/19/19 at 9:27 a.m., she stated Resident 146 and RP should have been informed of the dosages and frequencies of her [MEDICAL CONDITION] medications and licensed nurses should have made Resident 146 and RP aware of the increased dosage of [MEDICAL CONDITION] medication (paliperidone). 2. During a review of Resident 148'sFace sheet indicated Resident 148 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 148's Order Summary Report dated 12/18/19, indicated, (lorazapem) Tablet 0.5 mg Give 0.25 mg by mouth in the evening for anxiety m/b irritability .Give at (6pm) related to [MEDICAL CONDITION] DISORDER, UNSPECIFIED .start date 11/13/19. During a review of Resident 148's [MEDICAL CONDITION] medication consent form dated 11/6/19, indicated, [MEDICATION NAME] signed by Resident 148's RP and the prescribing physician. Resident 148's informed consent for [MEDICATION NAME] did not indicate dosage amount and frequency duration of the medication. During a review of Resident 148's Order Summary Report dated 12/18/19, indicated, ([MEDICATION NAME]) ER (extended release) Tablet 900 mg by mouth at bedtime for mood m/b Rapid mood swings .Give at (8 pm) related to [MEDICAL CONDITION] DISORDER, UNSPECIFIED . start date 11/15/19. During a review of Resident 148's [MEDICAL CONDITION] medication consent dated 11/6/19, indicated, ([MEDICATION NAME]) was signed by Resident 148's RP and the prescribing physician. Resident 148's informed consent for [MEDICATION NAME] did not indicate dosage amount and frequency duration of the medication. During a review of Resident 148's Order Summary Report dated 12/18/19, indicated, ([MEDICATION NAME]) Tablet Give 20 g by mouth BID (twice a day) (at 12:00 pm and 8 pm) for delusions .related to [MEDICAL CONDITION] DISORDER, UNSPECIFIED . start date 11/15/19. During a review of Resident 148's [MEDICAL CONDITION] medication consent form dated 11/6/19, indicated, [MEDICATION NAME] was signed by Resident 148's RP and the prescribing physician on 11/6/19. Resident 148's informed consent for [MEDICATION NAME] did not indicate dosage amount and frequency duration of the medication. During an interview with Resident 148, on 12/19/19 at 9:18 a.m., Resident 148 stated she did not know the dosages and frequencies of her medication's [MEDICATION NAME], and [MEDICATION NAME]. During a review of Resident 148's MDS dated [DATE], indicated Resident 148's BIMS scored was 13 of 15, which indicated the resident was cognitively intact. 3. During a review of Resident 471's Face sheet indicated Resident 471 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 471's Order Summary Report dated 12/18/19, indicated, ([MEDICATION NAME]) Tablet Give 2 mg by mouth in the evening for hallucinations . related to [MEDICAL CONDITION], UNSPECIFIED start date 12/03/19. During a review of Resident 471's [MEDICAL CONDITION] medication informed consent form dated 11/27/19, indicated, ([MEDICATION NAME]) was signed by Resident 471's RP and the prescribing physician on 11/27/19. Resident 471's informed consent for [MEDICATION NAME] did not indicate dosage amount and frequency duration of the medication. During an interview with Resident 471, on 12/19/19 at 9:24 a.m., Resident 471 stated she felt she has the right and the need to know the medication dosages and frequency durations of her [MEDICAL CONDITION] medications and she did not know. Resident 471 stated the nurse did not inform her. During a review of Resident 471's MDS dated [DATE], indicated Resident 471's BIMS scored 15 of 15, which indicated the resident was cognitively intact. During an interview with the Pharmacy Consultant (PC), on 12/19/19 at 8:53 am, he stated Resident's informed consents for [MEDICAL CONDITION] medications should have clearly indicated dosage amount and frequency duration written on the consent forms. The PC stated residents and resident's RP were not be fully informed when the dosages and frequency of every [MEDICAL CONDITION] medication residents were receiving was left out of the informed consent form. During a concurrent interview and record with DON, on 12/18/19 at 3:20 p.m., she reviewed the facility policy and procedure Informed Consent dated 9/1/13 and indicated, .2. Material information to be disclosed by the physician . b. Nature of the procedures to be used in the treatment including their probable frequency and duration . The DON stated Resident 148, Resident 146, and Resident 471's informed consents for [MEDICAL CONDITION] medications should have contained medication dosages amount and frequency durations written as part of their informed consents and that did not occur. She stated Resident 146, 148, and 471 were actively involved in IDT meetings and should have been made aware of the dosages and frequencies of [MEDICAL CONDITION] medications they were receiving. The DON stated licensed nurses were responsible for notifying Resident 146 on medication dosages and changes in medication dosages and that did not occur. During a review of the facility policy and procedure titled Informed Consent dated 9/1/13, indicated, .2. Material information to be disclosed by the physician . b. Nature of the procedures to be used in the treatment including their probable frequency and duration .4. Informed consent is not required every time a treatment or procedure is administered unless .risks change, or there is an increase in the dosage of an antipsychotic medication.

Based on observation, interview, and record review, the facility failed to ensure the results of the Recertification, Abbreviated surveys and State agency (Department of Public Health Licensing and Certification -CDPHL&C) hotline phone number were located in a place readily accessible to the residents and the public for two of two sampled residents (Resident 16 and Resident 63). This failure denied residents and the public the right to be aware of Recertification, Abbreviated survey investigation results and access to the State agency hotline phone number. Findings: On 12/12/18 at 2:08 p.m., during an interview at the Resident Council meeting, Resident 16 and Resident 63 both stated they were not aware they could contact the State agency (Department of Public Health Licensing and Certification -CDPH L&C) for information, questions, concerns, and to submit complaints. Resident 16 and Resident 63 stated they did not know the hotline number for the State agency and the facility did not have the phone number posted for resident to access. On 12/12/18 at 2:10 p.m., during an interview at the Resident Council meeting, Resident 16 and Resident 63 stated the results of the State agency recertification and abbreviated survey were not made available for residents to review. On 12/12/18 at 2:12 p.m. to 2:20 p.m., during a concurrent observation and interview in the nurses' station one, two, three and four, the Program Manager (PM) looked for the posting of the State agency hotline number, and for postings of the facility's recertification and abbreviated survey results and was unable to find postings. The PM stated the facility had not posted the State agency hotline number and the facility's recertification/abbreviated survey results. On 12/12/18 at 2:30 p.m., during an interview, the Administrator stated the survey results and the State agency hotline should have been posted. The Administrator stated the survey results and the State hotline should have been posted where individuals wishing to examine the survey results and to contact the State agency do not have to ask to see the survey result or to ask for the State number. The facility's policy and procedure titled, Resident's Rights dated 11/15/16, indicated, This policy respects and supports residents' rights as stated under OBRA (The Omnibus Budget Reconciliation Act) per Federal regulation . Resident's Right to Information and Communication ( .Required Posting) . 4. The facility post in a manner accessible and understandable to residents and their representatives a list of names, addresses (mailing and email) and telephone number of: A. State Survey agency, B. State Licensure Office .

Based on interview and record review, the facility failed to ensure a baseline resident-centered care plans were developed and implemented to address residents' preference and safety while smoking for 14 of 14 sampled residents (Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162) when residents' smoking care plans were not developed within 48 hours of admission. This failure had the potential to negatively affect residents quality of care by not addressing the resident's smoking preference and safety while smoking. Findings: On 12/12/18 at 8:12 a.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), Resident 70, Resident 105, Resident 15, Resident 162, Resident 75, Resident 116, Resident 146, and Resident 156 were smoking in the facility patio. The ADON stated smoking was allowed in designated areas and residents were supervised by Certified Nursing Assistants' (CNA). Review of facility residents smoking list dated 12/11/18, indicated Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162 were smokers. The ADON validated the smoking list. On 12/12/18 at 6:16 p.m., during a concurrent interview and record review, the Medical Records Supervisor (MRS) reviewed resident clinical records for Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162 and was unable to find documented evidence a baseline care plan for smoking was developed within 48 hours of admission. The MRS stated smoking was the residents' personal preference and there should be a baseline care plan for smokers on admission to meet the resident's immediate care needs. Review of Minimum Data Set (MDS) assessment (resident assessment tool which indicates physical and cognitive abilities) indicated Resident 22 dated 4/20/18, Resident 70 dated 7/6/18, Resident 75 dated 7/11/18, Resident 90 dated 10/14/18, Resident 100 dated 4/27/18, Resident 105 dated 10/31/18, Resident 116 dated 5/7/18, Resident 127 dated 5/12/18, Resident 146 dated 8/22/18, Resident 150 dated 1/29/17, Resident 151 dated 8/21/18, Resident 156 dated 11/24/18 and Resident 162 dated 8/29/18, Section J: Health Conditions . Section J1300: current Tobacco Use reflected 1 (Yes). On 12/12/18 at 2:45 p.m., during an interview, the Director of Nursing (DON) stated all residents who smoke were identified through visual assessment and care plans that should be developed based on the resident's history of dangerous smoking behaviors. On 12/13/18 at 5:37 p.m., during an interview, the Unit Manager (UM) stated baseline care plans should be completed by licensed nurses on admission to meet residents immediate care needs and to evaluate the residents smoking safety awareness. On 12/13/18 at 5:38 p.m., during an interview, the UM stated smoking was considered a personal preference of the resident and must be included in resident care plans. The UM stated there should be a care plan for all residents who smoke to ensure resident who smoke were safe. On 12/13/18 at 5:49 p.m., during an interview, the Social Service Director (SSD) stated she screened all residents through interview for preference on smoking upon admission. The SSD stated the facility must develop a smoking care plan on admission to ensure residents safety. On 12/13/18 at 6 p.m., during an interview, the Assistant Program Director (APD) stated, There should be an assessment tool to show the staff (licensed nurses and certified nursing assistants) of any changes for smoking preferences and interventions for residents who wished to quit smoking. On 12/14/18 at 9:27 a.m., during a concurrent interview and record review, the Minimum Data Set Coordinator (MDSC) reviewed the 14 residents' clinical record and was unable to find documentation of residents' baseline care plan for smoking. The MDSC stated, The facility did not care plan residents on smoking unless it was a problem. On 12/14/18 at 9:29 a.m., during an interview, the MDSC stated there should be a baseline care plan to identify risk factors that can prevent the residents from smoking hazards. The facility's policy and procedure titled Care Planning dated 10/28/17, indicated, .1. Licensed Nurses and other IDT members will develop a baseline care plan to meet the resident's immediate care needs within 48 hours of admission. The baseline care plan includes .g. personal or cultural preferences of the resident.

Based on resident and staff interviews, clinical record review and administrative document review the facility failed to ensure 1 of 3 residents (Resident 1) was free from verbal, mental and physical abuse when, a Certified Nursing Assistant (CNA) harassed, cursed, yelled at, pinched and slapped Resident 1. This failure prolonged Resident 1's abuse from a CNA 1 for over 2 months. Findings: Resident 1's quarterly Minimum Data Set (MDS) assessment, (a tool used to determine mental and physical ability, etc.), dated 11/06/12, indicated Resident 1 was able to remember staff names and faces. The MDS assessment indicated Resident 1 was totally dependent on staff for transfers from his bed to his wheel chair and required 2 staff physical assist with transfers. On 12/27/12 at 10:30 a.m., during an interview, CNA 2 stated she had seen CNA 1 randomly "mess around with" Resident 1. CNA 2 (clarified) and stated, "She (CNA 1) would walk by or go up to him (Resident 1) and grab and pinch his ears or nose, or tap his head to mess around with him." CNA 2 stated Resident 1 would get upset and yell or cuss when CNA 1 would do this to him. CNA 2 stated she observed CNA 1 do this more than twice. CNA 2 stated she had asked CNA 1 not to treat Resident 1 that way, "because it made him mad and upset." CNA 2 stated CNA 1 put her finger up to her mouth and said "Shh, this is how me and him work." CNA 2 stated she had not reported the incidents she had witnessed because she wanted to try to fix it herself between the two CNAs. On 12/27/12 at 1 p.m., during an interview, Resident 1 stated CNA 1 had mistreated him, "All the time" (unable to state specific times). Resident 1 stated, "She (CNA 1) pinches my face and ears, slaps my hands and the top of my head." Resident 1 stated, "She (CNA 1) moves the call light so I can't reach it." Resident 1 stated, CNA 1 had used foul language when speaking to him but wouldn't specify which words. Resident 1 stated he had told CNA 1 to, "Stop it! Leave me alone. That's called abuse. Don't be abusive!" When asked how CNA 1's treatment had made him feel, Resident 1 yelled, "It hurt. It made me mad. Hell, it pissed me off!" On 12/27/12 at 3 p.m., during an interview, CNA 3 stated from late 10/2012 up to 12/20/12, she had observed on more than one occasion CNA 1 physically and/or verbally abuse Resident 1. CNA 3 stated on one occasion she had heard raised voices and cursing from Resident 1's room. CNA 3 stated she went into the room and had observed Resident 1 take a swing at CNA 1. CNA 1 then slapped Resident 1's hands. CNA 3 stated, "She (CNA 1) wasn't trying to block his swing or push his hands away. She slapped him. Like you would a child's hands if they're doing something wrong." CNA 3 stated Resident 1 yelled, "Stop it. Leave me alone." CNA 3 stated, "I must have had a look of shock on my face, like, what's going on?" CNA 3 stated CNA 1 looked at her and said, "Don't tell anyone. This is the relationship we (Resident 1 and CNA 1) have." CNA 3 stated she had not reported the incidents she had witnessed because she was a new employee and afraid of retaliation from CNA 1. On 12/27/12 at 3:30 p.m., during an interview, CNA 4 stated she had heard and observed CNA 1 use inappropriate language and pinch Resident 1 while caring for him. CNA 4 stated Resident 1 would ask to get up and kept using his call light continuously, so CNA 1 had taken Resident 1's call light away from him. CNA 4 stated Resident 1 asked for his call light back and CNA 1 yelled at him, "No. You can't have the f***ing call light." CNA 4 stated Resident 1 had continued asking to get up and have his call light back. CNA 4 stated, "She (CNA 1) then pinched his (Resident 1) ears and face until he was red." CNA 4 stated, "She (CNA 1) saw the look of concern on my face, and she said, "Shh, don't tell anybody." CNA 4 stated, "She (CNA 1) acted like it was okay to do it (yell, curse and pinch Resident 1)." CNA 4 stated, "She (CNA 1) left the room and never did get Resident 1 out of bed." CNA 4 stated she had not reported the incidents she had witnessed because she was new and afraid she would lose her job. On 12/27/12 at 11 a.m., during an interview, CNA 1 stated, "He (Resident 1) is demanding. He yells and cusses at staff." When asked how she responds to Resident 1's behavior, CNA 1 stated, "I try to calm him down. I rub his back and try to soothe him." CNA 1 denied taking the call light away from Resident 1 and placing it where he could no longer reach it. CNA 1 denied cursing, yelling, pinching, or slapping Resident 1. On 12/27/12 at 11:30 a.m., during an interview, the Director of Nursing (DON) stated all staff had received training on resident/elder abuse when they were hired and had signed a form that they understood the facility abuse policy. The DON stated the training included: mandated reporting, abuse definitions, examples of abuse, watching the Department of Justice's video on elder abuse, the ombudsman program documentation related to abuse and review of the facility's resident abuse policy. When asked how the facility monitored for compliance of the abuse policy, the DON stated there was no specific monitoring or audit for abuse. She further stated that she had not done any random observations of care. Review of the facility's undated training document titled, "Part 1: You are a Mandated Reporter" indicated, "Abuse of an elder or dependent adult is defined as: physical abuse, neglect...deprivation by a custodian (facility staff) of services...that are necessary to avoid...mental suffering. Mental suffering means...agitation...or other forms of serious emotional distress...brought about by...harassment or other forms of intimidating behavior." Further review of the same document indicated, "Part 2: What You Report. Examples of Physical Abuse: ... a resident grabs a CNA's shirt...CNA slaps the resident's hands. Examples of Neglect: ... a resident repeatedly uses a call light to get attention. A CNA unplugs the light so the resident can no longer use it." Review of the facility's policy titled, "ELDER AND ADULT ABUSE REPORTING REQUIREMENTS" dated 9/23/99, indicated, "(Facility) is committed to do all that is within its control to prevent occurrences of abuse through the following: Protection of residents through prevention...and reporting of abuse...Staff...shall be encouraged to report incidents of suspected abuse...without fear of reprisal." Review of the facility's "RESIDENT/ELDER ABUSE" training signature page indicated the following: "I certify that I have viewed the Department of Justice Elder Abuse Video...and understand the attached policy on Resident/Elder Abuse." Review of CNA 1's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 1/12/01. Review of CNA 2's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/12/10. Review of CNA 3's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. Review of CNA 4's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. Review of the facility's undated position description titled, "CERTIFIED NURSING ASSISTANT" indicated, "CHARACTERISTIC DUTIES AND RESPONSIBILITIES - ESSENTIAL FUNCTIONS... 4. Provides services that support the care delivered to the resident, both physically and behaviorally.... 8. Conducts self in a professional manner in compliance with unit and facility policies... GENERAL RESIDENT CARE... 16. Approaches residents in a nurturing manner... C. Provides consistent and continuous care, essential for the ...resident. D. Recognizes and reports patterns or behavior noting escalation and agitation and implements appropriate intervention techniques."

Based on resident/staff interview and administrative document review the facility failed to implement their abuse policy to prohibit abuse for 1 of 3 residents (Resident 1), when 3 Certified Nursing Assistants (CNAs - 2, 3, and 4) failed to immediately report witnessed verbal, physical and mental abuse of Resident 1 by co-worker CNA. This failure prolonged Resident 1's abuse from a CNA 1 for over 2 months. Findings: A review of the facility's policy titled, "ELDER AND ADULT ABUSE REPORTING REQUIREMENTS" dated 9/23/99, indicated, "(Facility) is committed to do all that is within its control to prevent occurrences of abuse through the following: Protection of residents through prevention ... and reporting of abuse...Staff...shall ... report incidents of suspected abuse ... without fear of reprisal ... CONDITIONS UNDER WHICH REPORTING OF ABUSE IS REQUIRED: Any dependent adult care custodian ... who has observed an incident that reasonably appears to be physical abuse ... shall report the known or suspected instance of physical abuse ... immediately ... Care Custodians ... specified to report abuse include the following in the (Facility): ... C.N.A ... RESPONSIBILITY - NEW EMPLOYEE/OLD EMPLOYEE: Reviews dependent adult reporting regulations ... signs the form ... Complies with the reporting requirements ..." The facility's undated job description titled, "CERTIFIED NURSING ASSISTANT" indicated, "ADHERENCE TO FACILITY PROCEDURES ... 4. Reports all...incidents observed on the shift that they occur. 5. Familiarizes self with appropriate policy/procedure manuals ..." On 12/27/12 at 10:30 a.m., during an interview, CNA 2 stated she had seen CNA 1 randomly "mess around with" Resident 1. CNA 2 (clarified) and stated, "She (CNA 1) would walk by or go up to him (Resident 1) and grab and pinch his ears or nose, or tap his head to mess around with him." CNA 2 stated Resident 1 would get upset and yell or cuss when CNA 1 would do this to him. CNA 2 stated she observed CNA 1 do this more than twice. CNA 2 stated she had asked CNA 1 not to treat Resident 1 that way, "because it made him mad and upset." CNA 2 stated CNA 1 put her finger up to her mouth and said "Shh, this is how me and him work." CNA 2 stated she had not reported the incidents she had witnessed because she wanted to try to fix it herself between the two CNAs. Resident 1's quarterly Minimum Data Set (MDS) assessment, (a tool used to determine mental and physical ability, etc.), dated 11/06/12, indicated Resident 1 was able to remember staff names and faces. The MDS assessment indicated Resident 1 was totally dependent on staff for transfers from his bed to his wheel chair and required 2 staff physical assist with transfers. On 12/27/12 at 1 p.m., during an interview, Resident 1 stated CNA 1 had mistreated him, "All the time" (unable to state specific times). Resident 1 stated, "She (CNA 1) pinches my face and ears, slaps my hands and the top of my head." Resident 1 stated, "She (CNA 1) moves the call light so I can't reach it." Resident 1 stated, CNA 1 had used foul language when speaking to him but wouldn't specify which words. Resident 1 stated he had told CNA 1 to, "Stop it! Leave me alone. That's called abuse. Don't be abusive!" When asked how CNA 1's treatment had made him feel, Resident 1 yelled, "It hurt. It made me mad. Hell, it pissed me off!" On 12/27/12 at 3 p.m., during an interview, CNA 3 stated from late 10/2012 up to 12/20/12, she had observed on more than one occasion CNA 1 physically and/or verbally abuse Resident 1. CNA 3 stated on one occasion she had heard raised voices and cursing from Resident 1's room. CNA 3 stated she went into the room and had observed Resident 1 take a swing at CNA 1. CNA 1 then slapped Resident 1's hands. CNA 3 stated, "She (CNA 1) wasn't trying to block his swing or push his hands away. She slapped him. Like you would a child's hands if they're doing something wrong." CNA 3 stated Resident 1 yelled, "Stop it. Leave me alone." CNA 3 stated, "I must have had a look of shock on my face, like, what's going on?" CNA 3 stated CNA 1 looked at her and said, "Don't tell anyone. This is the relationship we (Resident 1 and CNA 1) have." CNA 3 stated she had not reported the incidents she had witnessed because she was a new employee and afraid of retaliation from CNA 1. On 12/27/12 at 3:30 p.m., during an interview, CNA 4 stated she had heard and observed CNA 1 use inappropriate language and pinch Resident 1 while caring for him. CNA 4 stated Resident 1 would ask to get up and kept using his call light continuously, so CNA 1 had taken Resident 1's call light away from him. CNA 4 stated Resident 1 asked for his call light back and CNA 1 yelled at him, "No. You can't have the f***ing call light." CNA 4 stated Resident 1 had continued asking to get up and have his call light back. CNA 4 stated, "She (CNA 1) then pinched his (Resident 1) ears and face until he was red." CNA 4 stated, "She (CNA 1) saw the look of concern on my face, and she said, "Shh, don't tell anybody." CNA 4 stated, "She (CNA 1) acted like it was okay to do it (yell, curse and pinch Resident 1)." CNA 4 stated, "She (CNA 1) left the room and never did get Resident 1 out of bed." CNA 4 stated she had not reported the incidents she had witnessed because she was new and afraid she would lose her job. On 12/27/12 at 11 a.m., during an interview, CNA 1 stated, "He (Resident 1) is demanding. He yells and cusses at staff." When asked how she responds to Resident 1's behavior, CNA 1 stated, "I try to calm him down. I rub his back and try to soothe him." CNA 1 denied taking the call light away from Resident 1 and placing it where he could no longer reach it. CNA 1 denied cursing, yelling, pinching, or slapping Resident 1. Review of the facility's undated training document titled, "Part 1: You are a Mandated Reporter" indicated..."All health practioners and all employees in a long-term health care facility are mandated reporters." "Legal responsibilities of a Mandated Reporter...California's mandated reporting law states: Any mandated reporter who...has observed or has knowledge of an incident that reasonably appears to be physical abuse...shall report...immediately, or as soon as practically possible..." Review of the facility's "RESIDENT/ELDER ABUSE" training signature page indicated the following: "I certify that I have viewed the Department of Justice Elder Abuse Video ... and understand the attached policy on Resident/Elder Abuse." CNA 1's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 1/12/01. CNA 2's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/12/10. CNA 3's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. CNA 4's training record titled, "RESIDENT/ELDER ABUSE" indicated she had been certified on 10/09/12. On 12/27/12 at 11:30 a.m., during an interview, the Director of Nursing (DON) stated all staff had received training on resident/elder abuse when they were hired and had signed a form that they understand the facility abuse policy. The DON stated the training included; mandated reporting, abuse definitions and examples of abuse, watching the Department of Justice's video on elder abuse, the ombudsman program documentation related to abuse and review of the facility's resident abuse policy. When asked how the facility monitored for compliance of the abuse policy, the DON stated there was no specific monitoring process to ensure implementation. She further stated that she had not done any random observations of care.

Based on observation, interview, and clinical record review the facility failed to ensure resident 1 received and was provided the necessary care to maintain the highest practicable physical well-being in accordance with Resident 1's plan of care when, Certified Nursing Assistant (CNA 1) failed to use a two person lift when transferring Resident 1. Resident 1 was was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident 1's quarterly Minimum Data Set (tool used to determine cognitive and physical ability) assessment dated [DATE], indicated Resident 1's cognition was moderately impaired and included disorganized thinking. Resident 1 was totally dependent on staff to provide all of her activities of daily living (mobility, transfers, etc.). Resident 1 required 2 staff physical assistance with all transfers, and movement to her upper and lower extremities was impaired on both sides of her body due to a previous stroke, joint disease and hand contractures. Findings: On 12/14/12 at 10:35 a.m., during an observation and concurrent interview, Resident 1 was sitting in the hallway outside her room in a reclining chair. Resident 1 had an immobilizer present on her right shoulder, and both hands had contractures. When asked what had happened to her shoulder, Resident 1 immediately leaned forward and stated loudly and clearly, "(CNA 1) dropped me. On 3/13/13 at 10:44 a.m., during a telephone interview, CNA 1 stated Resident 1 had been agitated and combative after breakfast on 12/4/12 between 8:30 a.m. and 9 a.m. CNA 1 had decided to take Resident 1 back to her room. CNA 1 stated he knew Resident 1 required 2 staff to assist with transfers. CNA 1 stated, "It was busy and everyone was behind. I just thought I could do it (transfer Resident 1) by myself." CNA 1 stated, when he got Resident 1 up from her chair she was yelling and cussing and started pushing at him, and "She started to go down (to the ground)." CNA 1 stated he grabbed Resident 1 under the arms and got her into bed. CNA 1 stated Resident 1 immediately started complaining of right shoulder pain . On 3/15/13 at 1:50 p.m., during an interview, the Charge Nurse (CN) stated, on 12/4/12 between 11:00 a.m. and 11:15 a.m., CNA 1 had informed her Resident 1 was complaining of right shoulder pain. The CN stated she immediately checked Resident 1, and "Her face and eyes had the look of pain." The CN stated Resident 1 had told her (CNA 1) had dropped her. On 3/15/13 at 2:10 p.m., during an interview, the UM stated at approximately 12 p.m. on 12/4/12 she assessed Resident 1's right shoulder. The right shoulder was swollen and Resident 1 had been unable to move it. The UM stated, "She (Resident 1) was in pain." The UM stated Resident 1 told her CNA 1 had dropped her while trying to put her in bed. The UM stated, "I believe she was being [MEDICATION NAME], because when she's delusional her statements are consistently the same topics. They don't change." On 3/15/13 at 3:15 p.m., during an interview the Director of Nursing (DON) was asked how CNA's are given information regarding which residents need assistance with activities of daily living. The DON stated each resident has a "Locker Note" inside their closet that lists specific pertinent needs for each resident, including how a resident should be transferred. Review of Resident 1's "Locker Note" titled "INDIVIDUAL RESIDENT CARE BY CNA" dated 10/3/12, indicated, Resident 1 was not weight bearing and required 2 person physical assistance for transfers. Review of Resident 1's clinical record indicated an onsite x-ray was done on 12/4/13 at 4:21 p.m. The x-ray report indicated, "Exam: SHOULDER RIGHT...RESULTS:[MEDICAL CONDITION] and neck (refers to the top portion of the bone in the upper arm) with modest displacement of the right shoulder....CONCLUSION: Modestly displaced fracture." On 3/13/13 at 11:55 a.m., during an interview, the Medical Doctor who interpreted the x-ray stated, "It's not likely a fracture of this type would be caused by grabbing someone under the arms. I would expect a dislocation not a fracture." MD 1 stated "The mechanical force required to break the head and neck of the shoulder would more likely be caused by a fall to the floor." Review of Resident 1's hospital imaging report dated 12/4/12 at 8:40 p.m., indicated, "...XR SHOULDER COMPLETE RIGHT...FINDINGS: ...There is a comminuted (bone is crushed, splintered or broken into pieces) [MEDICAL CONDITION] humerus (bone in the upper arm that forms the shoulder bone)." Resident 1's right arm was placed in an immobilizer and she was returned to the facility. On 3/15/13 at 10:30 a.m., during an observation and interview (3 months after Resident 1's right shoulder fracture), Resident 1 was resting in bed with an immobilizer on her right shoulder. She was pleasant and smiling. Resident 1 was asked if she remembered how she broke her arm. Resident 1 stated, "Yes. (CNA 1) dropped me." Resident 1 was tearful, and as she explained the incident she became more tearful. The facilities' failure to implement the plan of care for a two person lift during transfer resulted in an injury(comminuted [MEDICAL CONDITION] humerus (bone in the upper arm that forms the shoulder bone)). This caused Resident 1 immediate pain, swelling and inability to move her right arm.