Every finding on record at Double Tree Post Acute Care Center

Based on observation, interview and record review, the facility failed to ensure industry standards for food safety were met for a resident population of 102, when: Kitchen walls had chipped paint and damaged dry walls, food shelves were rusty, vents over food production area were rusty, floor tiles were chipped, and linoleum tiles had dark discoloration and rust stains making it difficult to determine if clean and sanitary;Spices were labeled using inconsistent use by dating system and one spice had expired;Plastic containers and lids were stacked and stored while wet in ready-to-use area; A metal colander was observed with dried food inside the openings and along the base, a plastic scoop had food residue inside its bowl, and a knife case had dust and crumbs all along the top near insertion sites. All were found in the clean ready-to-use area; andSix out of eight fry pans were found with chipped and greasy cooking surfaces and were available for use. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 1/20/26 at 9 a.m. in the dry storage room during the initial kitchen tour with the Dietary Manager (DM), the walls in the dry storage area and kitchen were seen with chipped paint and dry wall damage near the floorboards. The floor tiles by the dish machine were worn and chipped. The linoleum in the dry storage area and utility closet had dark discoloration, rust stains and gouges. The bread shelf was noted to be rusted on the bottom two shelves, and the food storage shelves also showed rust development. The DM concurred with these observations, noting that the floors had just been cleaned and buffed. During an observation on 1/21/26 at 10:10 a.m. in the kitchen, two air vents over food production areas were noted with many layers of paint and rust. During an interview on 1/22/26 at 11 a.m., with the Maintenance Director (MD), the MD concurred with these observations and stated that the holes in the walls could allow bugs to live and multiply, and the areas of rust and dirt could cause cross contamination of food. A review of the facility's policy titled, Sanitization, revised 10/08, indicated that the food service area shall be maintained in a clean and sanitary manner. Review of the US Food and Drug Administration's (FDA) 2022 Food Guide section 6-501.11 on Repairing indicated that Physical Facilities shall be maintained in good repair.Poor repair and maintenance compromise the functionality of the physical facilities. This requirement is intended to ensure that the physical facilities are properly maintained in order to serve their intended purpose. 2. During a concurrent observation and interview on 1/20/26 at 10:25 a.m. in the kitchen with the DM, 20 spices were observed with inconsistent use by dates. Several spices had a use by date of 3 months, several had a use by date of 20 days, some spices had only received on dates, some spices had no use by date, and a curry spice that expired on 8/12/25 was found. The DM concurred and agreed that the labeling was inconsistent and could cause confusion, and the curry should have been discarded. A review of the facility's policy titled, Suggested Dry Goods Storage Guidelines, dated 2012, was posted in the dry goods storage room and indicated that dried spices and herbs should have a use-by-date of 6-12 months. A review of the facility's policy titled, Food Receiving and Storage, revised 10/17, indicated that dry foods shall be labeled and dated with a 'use by' date. 3. During a concurrent observation and interview on 1/20/26 at 10:10 a.m. in the kitchen with the DM, 5 large plastic containers, and 20 plastic container lids, were seen stacked with visible moisture between each piece of equipment. All were found in the clean and ready-to-use area. The DM stated this did not meet her expectations and could cause bacterial growth. A review of the facility's policy titled, Dishwashing Machine Use, revised 03/10, indicated after running items through entire cycle, allow to air dry. Review of the US FDA 2022 Food Guide section 4-901.11on Equipment and Utensils, Air-Drying Required indicated that After cleaning and sanitizing, equipment.Shall be air-dried.before contact with food.Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms (tiny living things such a bacteria and viruses) can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. 4. During a concurrent observation and interview on 1/20/26 at 10:10 a.m. in the kitchen with the DM, a metal colander was observed in the ready-to-use area with brown food residue inside the hole openings and around the base. A plastic scoop was observed with brown food residue inside its bowl in a ready to use drawer. A knife holder was observed covered with dust and crumbs near the knife insertion sites. The DM stated it was not acceptable and was unsanitary. A review of the facility's policy titled, Preventing Foodborne Illness-Food Handling, revised 7/14, indicated a critical factor implicated in foodborne illness is contaminated (having been made impure) equipment, and.all food service equipment and utensils will be sanitized according to current guidelines. Review of the US FDA 2022 Food Guide section 4-602.11 on Equipment Food-Contact Surfaces and Utensils indicated in bullet A that Equipment food-contact surfaces and utensils shall be cleaned.Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. 5. During a concurrent observation and interview on 1/20/26 at 10:10 a.m. in the kitchen with the DM, six out of eight fry pans were observed with chipped cooking surfaces and greasy residue covering the pans. The DM stated these should have been thrown away as the chipped particles could leach into food that was prepared in them. A review of the facility's policy titled, Sanitization, revised 10/08, indicated all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning.

Based on observation, interview and record review, the pureed and alternate foods made for lunch on 1/21/26 were not made by methods that conserved nutritive value, flavor and appearance when recipes were not utilized. This failure had the potential to lead to poor intake, weight loss and malnutrition for the 6 residents eating the chicken entree and 10 residents (Residents 2, 14, 16, 24, 42, 52, 63, 71, 90 & 95) receiving the pureed pot roast and pureed peas.Findings: During a return visit to the kitchen on 1/21/2026 at 9:42 a.m., [NAME] 1 (Ck 1) was preparing the lunch meal. The main meal consisted of pot roast and roasted potatoes which had been prepared and were in the oven. The alternative entree was Lemon Almond Chicken. No recipes were seen on the counter.Ck 1 opened a bag of thawed chicken breasts, counted out 6 pieces and placed them into a high sided pan. Ck 1 proceeded to sprinkle the chicken with an unmeasured amount of dry mustard, lemon/pepper seasoning, salt, chicken bouillon and garlic powder. Ck 1 mixed the seasonings with the chicken, moved to a flat pan before placing the chicken in the oven. Review of facility provided Lemon Almond Chicken recipe ([NAME] Corporate Dietitians, undated) included the following steps. The recipe began by creating a marinade by blending specific amounts of the following ingredients: Lemon Juice, Canola Oil, Dijon Mustard, Fresh Whole Garlic Cloves, and Ground Rosemary which was to be poured over the chicken and then marinaded for an hour in the refrigerator. Other ingredients used before cooking the chicken included Cornstarch, Low Sodium Chicken Broth, Margarine, Blanched Almonds, Grated or Zested Lemon, Salt and Pepper. During an observation on 1/21/26 at 10:30 a.m. Ck 1 poured an unmeasured amount of boiling beef juices (fluid from the beef being boiled in water) and an unmeasured amount of beef (approximately 1/3 of the total cooked amount) to the blender. Ck 1 blended 3 times d before deciding it was too thin. Ck 1 then added 1/2 of a plastic scoop filled with thickener into the blender (roughly 2 ounces/oz or approximately 4 tablespoons) and proceeded to blend. Ck 1 was content with the texture and added 1/2 of the mixture to a steam table pan. Ck 1 next added the remaining (unmeasured) boiled pot roast to the blender which still contained 1/2 of the original pureed meat mixture. Ck 1 blended before adding an additional (unmeasured) amount of thickener (approximately 3oz or 6 tablespoons). When finished, Ck 1 added to the same steam table pan holding the previous pureed mixture and mixed them together. Ck 1 was unsatisfied with the amount of pureed meat in the pan. Ck 1 grabbed 2 more slices of pot roast from the oven and placed the meat slices into the blender. Ck 1 then added an unmeasured amount of water and an unmeasured amount of chicken broth base. Ck 1 blended and mixed into the pan containing the previously made pureed pot roast. Review of facility provided recipe for pureed fish/meat/poultry ([NAME] Corporate Dietitians, undated) indicated specific amounts of liquid and food thickener (1 Tablespoon for the 10-portion recipe provided). Instructions indicated in bullet 2 that All liquid may not be required, depending on texture of meat . Amount of thickener will vary slightly. Start with 1 1/2 teaspoon (1/2 tablespoon) and add more gradually until desired texture is achieved. During this same kitchen observation on 1/21/26 at 11:04 a.m., Ck 1 removed a pan of peas from the steamer. Ck 1 moved the peas into the blender and added an unmeasured amount of butter and an unmeasured amount of chicken broth. Ck 1 proceeded to blend the peas but found the mixture too thin. Ck 1 then added approximately 3.5 oz (7 tablespoons) of thickener to correct the texture before moving the pureed peas to a steam table pan for lunch. Review of facility provided recipe for pureed vegetables ([NAME] Corporate Dietitians, undated) indicated the following instructions: 1. Remove portions required from regular prepared recipe; drain and reserve cooking liquid. Place in food processor or blender and process until smooth. If necessary, add a small amount of reserved cooking liquid.If needed, gradually add thickener and process until smooth in consistency.Start with 1 1/2 teaspoon (1/2 tablespoon) and add more gradually until desired texture is achieved. Ingredient list for 10 servings indicated 1 tablespoon of thickener. During an interview on 1/22/26 at 4:10 p.m. with the dietary manager (DM), the DM stated that Cooks should use the minimal amount of fluid, so less thickener is needed. When excessive fluid and thickener are used, it leads to the food having less nutrition and flavor.

Based on observation, interview, and record review, the facility failed to address Resident 46's weight loss of 22 pounds over 6 months. This had the potential of leading to Resident 46's malnutrition, muscle loss and functional decline. Findings:During an observation in the lunch dining room on 1/20/26 at 12:31 p.m., Resident 46 was noted to be slowly feeding himself. Resident 46 was noted to have a tremor (shaking movement in one or more body parts) which increased the time needed for self-feeding.During a subsequent interview with Resident 46 on 1/20/26 at 12:37 p.m., Resident 46 stated he doesn't pay attention to his weight and was unsure if there was a change. Resident 46 stated he has a history of depression and felt that he was being warehoused at the facility. Resident 46 also mentioned being bored with the facility food and felt that he had no choice in what he was served. During an observation on 1/21/26 at 7:57 a.m., Resident 46 was the only resident in the dining room. Resident 46 had finished 90% of the breakfast meal and was still eating. During a review of Resident 46's admission Record (AR) on 1/21/26 at 2:36 p.m., the AR indicated Resident 46 was admitted in 2/2017 with diagnoses which included type 2 diabetes, major depressive disorder, dysphagia, and schizophrenia. During a review of Resident 46's electronic medical record a weight variance note from 11/6/25 included the following weight history: Current weight of 189# (pounds)11/1/25=188# 10/5/25=195#9/1/25=200#8/2/25=202#7/1/25-205#6/1/25=207#5/3/25=210# This weight variance note entered on 11/6/25 indicated that Resident 46 had a weight loss of 7 pounds over 1 month (a 3.6% decrease in body weight), a 17-pound weight loss over 3 months (a 8.3% decrease in body weight), and a 22-pound weight loss over 6 months (a 10.5% decrease in body weight). The weight variance note did not discuss a potential cause for weight loss or add interventions to the care plan. A review of Registered Dietitian (RD) Notes indicated Resident 46 had not been assessed by the RD since 08/21/25. During an interview on 1/21/26 at 4:33 p.m. with the Registered Dietitian (RD), the RD stated that significant weight losses were discussed with the interdisciplinary team (IDT, usually consisting of the RD, nursing, rehabilitation and social services, though may include the Physician and Administrator) at the beginning of the month. The RD further indicated that the purpose of this meeting was to determine the root cause for weight change and to make recommendations to stabilize the weight loss based on the root cause. During this interview on 1/21/26, the RD was asked about the IDT meeting for Resident 46 in November 2025. The RD recalled Resident 46 did not want to get out of bed or talk during that time. When asked the root cause for the weight loss, the RD did not have a cause and stated that depression had not been considered. The RD concurred that no interventions had been initiated. During an interview with the Director of Nursing (DON) on 1/22/26 at 2:32 p.m., the DON discussed how weight changes were handled. The DON stated that the RD would apprise the IDT of those with weight loss. The IDT would then meet to tease out potential causes for weight loss such as diuretic use, poor food intake, or dislike of the facility. The team would then work with the physician to develop and implement a plan to address the weight change. The DON did not give a root cause for Resident 46's weight loss. A review of facility provided policy titled, Weight Assessment and Intervention (Med-Pass, Inc., Revised September 2008) indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. In the weight assessment section, bullet 6 defines significant and severe weight loss as follows: a. 1 month-5% weight loss is significant, greater than 5% is severe.b. 3 months-7.5% weight loss is significant, greater than 7.5% is severe.c. 6 months-10% weight loss is significant, greater than10% is severe. In the analysis section, the weight assessment further indicated Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding .1. c. The relationship between current medical condition or clinical situation and recent fluctuations in weight . The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia (poor appetite), weight loss or increasing the risk of weight loss. In the care planning section, the policy indicated that 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort .2. Individual care plans shall address to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. In the section on interventions the policy indicated that 1. Interventions for undesirable weight loss shall be based on careful considerations of the following: a. Resident choice and preferences. c. Functional factors that may inhibit independent eating. f. Medications that may interfere with appetite, chewing, swallowing, or digestion.

Based on the interview and record review, the facility failed to report an allegation of theft within 24 hours to CDPH (California Department of Public Health) for one of 28 sampled residents (Resident 102). This failure delayed the theft allegation investigation by the department and had the potential to compromise Resident 102's safety and psychosocial well-being.Findings: During a review of Resident 102's admission Record (AR), dated 1/23/26 (print date), the AR indicated Resident 102 was readmitted to the facility in July of 2024 with diagnoses which included intellectual disabilities, substance abuse, and cognitive communication deficit. During a review of Resident 102's nursing note (NN), dated 4/23/25, the NN indicated, Resident came to nursing station at 7:05pm reporting that his money worth $2300 is missing from his fanny pack. Per resident, he took a nap, when he woke up he checked his fanny pack and his money is gone. Reported and referred incident to Social Services. During an interview on 1/22/26 at 12:44 p.m. with Resident 102, Resident 102 stated that months ago facility complained about his truck parked on the parking lot and he had to sell it for $2300, and sometime after the sale he brought his money into the room and placed it into his fanny pack in the room, and then went to sleep and when he woke up the money was gone. Resident 102 stated that he was angry and didn't know who took his money. During an interview on 1/23/26 at 9:33 a.m. with the Social Services Director (SSD), the SSD confirmed that Resident 102 sold his truck and reported to social services that the money was missing. The SSD confirmed that it was a large amount, and it had to be investigated. The SSD stated that she expected this incident to be reported to the department. During an interview on 1/23/26 at 9:50 a.m. with the Administrator (ADM), the ADM confirmed that Resident 102 sold his truck and reported that money from the sale was missing. The ADM confirmed that he expected this incident to be reported to the department, but he was unable to provide evidence that the report was sent. During a review of the facility's policy and procedure (P&P) titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised 4/2017, the P&P indicated, All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: a. State Licensing and Certification Agency.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 74) in a census of 102, received his nasal spray medication properly when Licensed Nurse (LN) did not follow the medication administration instructions. This failure had the potential risk for Resident 74's not getting the full benefits of the nasal spray medication and could worsen the allergy symptoms.Findings: During a review of Resident 74's admission Record (AR), dated 1/11/25, the AR indicated Resident 74 was admitted with diagnoses which included nasal allergy symptoms. During a review of the Resident 74's Order Summary Report (OSR), dated 6/25/25, the OSR indicated, Fluticasone Propionate [an allergy medication] Allergy Relief Nasal Suspension 50 mcg/ACT (microgram per actuation, unit of measurement/) Fluticasone Propionate (Nasal) 1 spray in both nostrils one time a day for allergy symptoms. During a review of Resident 74's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 1/26, the MAR indicated, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 spray in both nostrils one time a day for allergy symptoms at 1700 [5p.m.]During a medication pass observation on 1/22/26 at 4:21 p.m., LN 4 prepared the medications for Resident 74 which included the nasal spray. LN 4 then entered the Resident 74's room and handed the nasal spray to Resident 74, and Resident 74 sprayed the medication to each of his nostrils. LN 4 did not provide instructions on how to administer the medication to Resident 74. During a concurrent observation, interview, and record review on 1/22/26 at 4:21 p.m., Resident 74's fluticasone propionate nasal spray quick start guide was reviewed together with LN 4. LN 4 confirmed she allowed Resident 74 to use the nasal spray to his own nostrils but did not follow medication instructions and would not get the full benefit from the medication and the allergy symptoms could worsen. During a concurrent interview and record review on 1/23/26 at 7:41 a.m. with the Director of Nursing (DON), Resident 74's clinical record was reviewed. The DON stated she expected the LNs to follow the medication specifications during administration to ensure Resident 74 would get the full benefit of the medications and not to worsen the allergy symptoms. During a review of the Fluticasone Propionate Nasal Spray, United States Pharmacopeia (USP) Quick Start Guide, the guide indicated, Fr best results, it is important to get a full dose, here's how, in five easy steps:1. shake: gently shake spray bottle. Remove translucent cap; 2. Prime: do this when starting new bottle, have not used it in a week, just cleaned the nozzle. Aim away from face. Grasp spray bottle, pump until fine mist appear; 3. Blow: blow nose gently to clear nostrils; 4. Aim: Close one nostril and put tip of spray nozzle in other nostril. Put just the tip into the nose. Aim slightly away from center of nose. 5. Breathe and Spray: While sniffing gently, press down on spray nozzle once or twice according to dosing instructions. Breathe out through your mouth. Repeat in other nostril. Wipe spray nozzle with clean tissue and replace cap. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2007, the P&P indicated, 7.1: General Guidelines: Medications are administered as prescribed in accordance with manufacturer's specifications .Medication Administration: Medications are administered in accordance with written orders of the prescriber .

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of 28 sampled residents (Resident 113), when:1. The facility did not obtain Resident 113's hemoglobin A1c (HbA1c-a test that indicates the average level of blood sugar [BS] control, a high or low number is a sign of poor blood sugar control) as ordered by the physician;2. The facility did not provide the required diabetic education for Resident 113; and3. The facility did not provide diabetic training, for licensed staff, year 2025 to current date. These failures had the potential to negatively compromise the necessary quality of care and treatment for Resident 113. A review of Resident 113's admission Record (AR) indicated Resident 113 had diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 113's Order Summary Report (OSR), dated 1/12/26, the OSR indicated, Diabetic: HgA1C [sic HbA1c] Q [every] 3 Months-First to be obtained 01/13/26 one time a day every 3 month(s) starting on the 13th for 1 day(s) for Diabetes. During a review of Resident 113's Care Plan Report (CPR), dated 1/13/26, the CPR indicated a focus for DM, with an intervention, Lab work as ordered and report to MD. the CPR did not identify a focus for malnutrition, or for diabetic education. A review of Resident 113's Laboratory [lab]: 1/13/2026 21:55 CBC [Complete Blood Count - routine blood test that measures the number and type of cells in your blood] Report Information did not show a result for the HbA1c. A review of Resident 113's Weights and Vitals Summary indicated the Blood Sugar Summary showed a BS reading of 49 milligrams per deciliter (mg/dl-a unit of measurement used to determine the concentration of blood sugar in the body) on 1/17/26. During a concurrent observation and interview on 1/21/26 at 10:10 a.m. in Resident 113's room, Resident 113 indicated he was a diabetic and on insulin for eleven years. Resident 113 stated that BS was checked last night. it was high, that BS had not been checked and he had not received medication for BS this morning. Resident 113 acknowledged his boxes of sugary food items at bedside and stated the dietitian told me to stuff one in my mouth when my blood sugar drops. Resident 113 stated had not had diabetic teaching from facility staff and would be interested in the information and resources. During a concurrent interview and record review on 1/21/26 at 12:40 p.m. in the Director of Nursing's (DON) office, the DON acknowledged the facility missed obtaining Resident 113's HbA1c lab order, and that licensed staff did not follow the physician's order on 1/13/26. The DON stated it was important staff followed physician's orders to avoid adverse outcomes for Resident 113. During a concurrent interview and record review on 1/21/26 at 12:43 p.m. in the DON's office, the DON acknowledged Resident 113 had not received admission, or periodic, diabetic teaching from staff. The DON stated it was important Resident 113 had diabetic teaching for overall health and safety. During a concurrent interview and record review on 1/21/26 at 12:45 p.m. in the DON's office, the DON confirmed Resident 113's Medication Administration Record [MAR-a document used to track all medications administered to a patient], the column labeled Diabetic: HgA1C Q3 Months., had a check mark, which indicated the HgA1c was done on 1/13/26, The DON verified the check mark was documented in error by the licensed staff. The DON confirmed licensed staff did not document Resident 113's BS reading of 49 mg/dl on the MAR, column labeled Diabetic: If pt (patient) is responsive and BS <70mg/dl., for date 1/17/26. The DON presented a white notebook, labeled In Service Binder. The DON acknowledged there were no in-services for staff related to diabetes, diabetic medication, or documentation. The DON stated it was important licensed staff were properly trained, and competent, to provide diabetic care and treatment for continuity of care. During a telephone interview on 1/22/26 at 1:30 p.m. with the Registered Dietitian (RD), the RD confirmed Resident 113's clinical history for diabetes and malnutrition. The RD saw Resident 113's personal sugary food items at bedside and stated she did not have a discussion and had not reviewed Resident 113's Blood Sugar Summary. The RD acknowledged did not document the bedside foods in the progress notes, did not provide diabetic education for Resident 113, and did not present diabetic in-services for staff. The RD stated it was important to assess how much Resident 113 knew about diabetes, and that education would minimize negative outcomes. During a review of the facility's policy and procedure (P&P) titled, Diabetes-Clinical Protocol, revised 11/2020, the P&P indicated, Assessment and Recognition.Treatment/Management.Monitoring and Follow-Up.Monitor A1C on admission.The staff will identify and report issues that may affect.a patient's.diabetes management. During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, the P&P indicated, The staff will process test requisitions and arrange for tests. During a review of the facility's P&P titled, Goals and Objectives, Care Plans, revised 4/2009, the P&P indicated, .are entered on the resident's care plan so that all disciplines have access to.information and are able to report whether or not the desired outcomes are being achieved. During a review of the facility's P&P titled, Resident Rights, revised 12/2016, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview, and record review the facility failed to maintain a safe environment for one of 28 sampled residents (Resident 83) when resident 83's call light was not in reach.This failure had the potential to result in injury of Resident 83.Findings:During a review of Resident 83's admission Record (AR), the AR indicated Resident 83 was admitted in the fall of 2021 with diagnoses which included abnormalities of gait and mobility (difficulty walking and moving around), and history of falls.During a review of Resident 83's Care Plan Report (CPR), dated 12/25, the CPR indicated Resident 83 had a fall assessment score of 12, which indicated he was at a high risk for falls, and Resident 83's call light should remain within reach.During a concurrent observation and interview on [DATE] at 9 a.m. with Resident 83, Resident 83 lay in bed with his call light tucked above his head. Resident 83 stated he was unable to reach his call light.During a concurrent observation and interview on [DATE] at 9:05 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 83's room, CNA 1 confirmed call light was not within reach. CNA 1 stated Resident 83's call light should be in reach to avoid falls and to give assistance to the restroom.During a concurrent observation and interview on [DATE] at 2:59 p.m. with CNA 3 in Resident 83's room, CNA 3 confirmed Resident 83's call light was not within reach. CNA 3 stated it was expected for the call light to be clipped on the bed or near the resident, and could be a safety concern if not within reach.During a concurrent observation and interview on [DATE] at 5:26 p.m. with Licensed Nurse (LN) 5 in Resident 83's room, Resident 83's call light was observed on the floor. Resident 83 stated he could not reach the call light. LN 5 stated call light should be close to the resident along with bed positioning to avoid emergencies. LN 5 stated that Resident 83 was a fall risk and needed his call light to remain safe. During a concurrent observation and interview on [DATE] at 7:29 a.m. with LN 1 in Resident 83's room, Resident 83's call light was tucked behind Resident 83's pillow. LN 1 confirmed Resident 83's call light was not within reach and expected call light to be in reach. During a concurrent observation and interview on [DATE] at 9:47 a.m. in Resident 83's room, CNA 2 confirmed Resident 83's call light was on the floor. CNA 2 stated the call light was expected to be on the side of the bed or close to the residents so they could reach it. CNA 2 further stated the call light was expected to be placed so it did not fall in the case of an emergency.During an interview on [DATE] at 10 a.m. with the Director of Nursing (DON), the DON stated it was the expectation that call lights be within reach for assistance and needs.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 2017, the P&P indicated, Individualized, Resident-Centered Approach to Safety: Implementing interventions to reduce accident risks and hazards shall include the following: d. Ensuring that interventions are implemented.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 46) for unnecessary medications, received safe and adequate monitoring of a psychotropic medication (any drug that affects behavior, mood, thoughts or perception), when Resident 46's Lithium (a naturally occurring salt used as a powerful mood stabilizer medication) level had not been ordered or drawn since 12/26/24.This failure had the potential to put Resident 46 at risk for ineffective low Lithium levels and/or levels that were too high which could lead to toxicity (a potentially fatal condition that occurs when too much Lithium builds up in the blood).Findings:A review of Resident 46's admission Record indicated he was admitted in early 2017 with diagnoses which included Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Schizophrenia (a mental illness that is characterized by disturbances in thought).During a concurrent observation and interview on 1/20/26 at 12:10 p.m. in the dining hall with Resident 46, Resident 46 was eating his lunch and his arms and hands were visibly shaking. Resident 46 stated, This place is like a warehouse where they keep us, I am kept here because I get very depressed.A review of Resident 46's Care Plan Report indicated an intervention to monitor Lithium levels every 3 months and was initiated on 5/17/19 and revised to continue 3/4/23.A review of Resident 46's lab (laboratory) results indicated the last Lithium level was drawn on 12/26/24.A review of Resident 46's most recent Psychiatric Provider Note, dated 11/12/25, referenced his last Lithium level of 0.5 drawn on 12/26/24. The note indicated Lithium levels should be monitored regularly and there was a plan to order a new Lithium level. A review of Resident 46's Order Summary Report indicated that there were no current orders for Lithium level lab draws.A review of Resident 46's Lithium prescriptions indicated the medication was last refilled by the Facility Medical Director (FMD) on 11/17/25.A review of the Pharmacy Consultant's (PC), Monthly Medication Reviews from 1/2025-1/2026 indicated Resident 46's medications were reviewed monthly and there were no recommendations from the PC.During an interview on 1/22/26 at 11:02 a.m. at the nurses' station with Licensed Nurse 2 (LN 2), LN 2 stated that Resident 46's Lithium level had last been checked on 12/26/24 and she could not locate a more recent level or current orders to have the level drawn. LN 2 stated that Resident 46 was at risk for Lithium levels being too low or too high which could lead to toxicity.During an interview on 1/22/26 at 2:35 p.m. with the Director of Nursing (DON) in her office, the DON confirmed that Resident 46's Lithium level was last checked 12/26/24 and she could not locate a current order for Lithium lab draws. The DON stated the orders should have been placed and Resident 46's Lithium levels should have been monitored every 6 months. The DON stated a lack of monitoring could put Resident 46 at risk for Lithium levels being too high which could cause symptoms of toxicity. During a telephone interview on 1/23/26 at 11:24 a.m. with the PC, the PC stated if a Resident was stable, the Lithium level should be checked every 6 months and if Resident 46's Care Plan Report indicated levels were to be checked every 3 months this should have been followed. The PC stated he did review labs when he completed his monthly medication reviews but must had missed the Lithium levels.During a telephone interview on 1/23/26 at 11:45 a.m. with the Facility Medical Director (FMD), the FMD stated his expectation was for the psychiatrist to have placed the lab orders but if this was not done and the facility team should have identified this gap in care and provided monitoring.A facility policy and procedure on Lithium monitoring was requested but was not provided.A review of the facility's policy titled, Psychotropic Medications Use, updated 4/22, indicated any psychoactive medication prescribed must have an individualized care plan which includes monitoring of side effects of medication.and pharmacy will review psychotropic medication usage on admission, monthly, and as needed.A review of the NIH (National Library of Medicine) drug information website, updated 7/15/22, indicated, Serum lithium levels in uncomplicated cases receiving maintenance therapy during remission should be monitored at least every two months and.blood samples for serum lithium determinations should be drawn immediately prior to the next dose when lithium concentrations are relatively stable (i.e., 8 to 12 hours after the previous dose). Total reliance must not be placed on serum levels alone. Accurate patient evaluation requires both clinical and laboratory analysis.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided for one of twenty-eight sampled residents (Resident 8), when Resident 8's swallow evaluation (test performed to determine if food or liquid is passing safely to the stomach without entering the lungs) was not rescheduled and completed. This failure had the potential to result in delayed restoration of eating and placed Resident 8 at risk for aspiration (choking).Findings:During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted in spring of 2025 with diagnoses which included dysphagia (difficulty swallowing) and esophagitis with bleeding (pain and swelling to throat).During a review of Resident 8's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/1/25, the MDS indicated Resident 8 had no memory impairment and received more than fifty one percent (51%) of nutrition enteral feeding [tube feeding] (nutrition provided directly to the stomach via a tube).During a review of Resident 8's Care Plan Report (CPR), dated 1/11/26, the CPR indicated Resident 8's diet order was NPO (nothing to eat by mouth) and received tube feeding twenty (20) hours per day due to dysphagia. The CPR indicated Resident 8 was at risk for aspiration.During a review of Resident 8's Progress Notes (PN), dated 10/30/25, the PN indicated Resident 8 had a new order for a swallow screen for diet update.During a review of Resident 8's PN dated 10/30/25, the PN indicated Resident 8's swallow screen ended early due to Resident 8's report of pain. The PN indicated a further swallow evaluation treatment was needed when Resident 8 is feeling her best. and demonstrate the ability to participate.During a review of Resident 8's Nurses Note SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents], dated 1/1/26, the SBAR indicated, Resident was yelling i (sic) am in pain because am hungry.Resident continue to say I want to eat.During a review of Resident 8's PN with a print date 1/22/26, the PN indicated Resident 8 was not scheduled for a follow up swallow evaluation after Resident 8 requested to eat on 11/8/25, 11/18/25, 11/28/25, 1/1/26, and 1/14/25.During a concurrent observation and interview on 1/20/26 at 10:27 a.m. with Resident 8 in his bedroom, Resident 8 was lying in bed and was receiving her tube feeding from a pump (a device that automatically provides nutrition at a programmed rate). Resident 8 stated her swallow evaluation was not completed and that she only received nutrition through tube feeding since admission. Resident 8 further stated she had notified staff she wanted to eat by mouth and had not received a follow up evaluation. During a concurrent interview and record review on 1/22/26 at 10:39 a.m. with LN 1, LN 1 confirmed Resident 8 did not have a completed swallow screen on record since 4/2025. LN 1 stated, I would expect her to have one by now .It is important for clients to eat even if it's a thick diet.During an interview and record review on 1/22/26 at 11:14 a.m. with Resident 8's Speech Therapist (ST), the ST confirmed Resident 8 swallow screen was not completed and stated she expected Resident 8 to be re-evaluated for her swallow screen by now.During a concurrent observation and interview on 1/23/26 at 9:44 a.m. with Resident 8 in his room, Resident 8 was lying in bed and was receiving her tube feeding from a pump. Resident 8 stated she was expecting a follow-up from her incomplete swallow evaluation and stated again she would like to eat by mouth. During an interview on 1/23/26 at 10 a.m. with the Director of Nursing (DON), the DON indicated she expected staff to address patient needs. The DON stated it was the expectation that an incomplete swallow evaluation should be followed up on and completed for Resident 8. During a review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated 2018, the P&P indicated, .6. If the resident has a feeding tube placed prior to admission or returning to the facility, the provider and the interdisciplinary team will review the rationale.and the treatment goals and wishes of the resident.the decision to continue or discontinue the use of the feeding tube is made through collaboration between the interdisciplinary team, the provider and the resident.

Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 119) received his diabetic medications with meals as ordered.This failure could potentially result to Resident 119's blood sugar level to drop in dangerous levels and suffer stomach upset. Findings: During a review of Resident 119's admission Record (AR) dated 1/19/26, the AR indicated, Resident 119 had diagnoses which included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 119's Order Summary Report (OSR), dated 1/19/26, the OSR indicated, Metformin HCl Oral Tablet 1000 MG (Metformin HCl). Give 1 tablet by mouth two times a day for DM. Give with meals. During a review of Resident 119's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/19/26, the MAR indicated, Metformin HCl Oral Tablet 1000 MG Give 1 tablet by mouth two times a day for diabetes. diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Give with meals at 17:00 [5 p.m.]During a medication pass observation on 1/22/26 at 5:05 p.m. with Licensed Nurse 5 (LN 5), LN 5 administered the medication Metformin HCl Oral Tablet 1000 MG (milligram, metric unit of measurement, used for medication dosage and/or amount) to Resident 119 without meals. During a concurrent observation, interview, and record review on 1/22/26 on 5:05 p.m. with LN 5, Resident 119's metformin medication bubble pack was reviewed. LN 5 confirmed the medication instruction clearly indicated give with meals. LN 5 confirmed she administered the medication without meals or food to Resident 119. LN 5 stated Resident 119 blood sugar level could go to a very dangerous level and could have stomach upset because she administered the medication without meals. During an interview on 1/22/26 at 5:08 p.m. with Resident 119 inside his room, Resident 119 confirmed he did not take any snacks prior and his dinner was serve around or after 6 p.m. During an interview and record review on 1/23/26 at 7:41 a.m. with the Director of Nursing (DON), Resident 119's clinical record was reviewed. The DON stated she expected the LN to follow the medication instructions when administering anti-diabetic medications. The DON stated if the medication order indicated give with food, the LN should administer the medication with food to ensure Resident 119 would not experience dangerous low blood sugar level which could result to life threatening complications. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 2007, the P&P indicated, 7.1: General Guidelines: Medications are administered as prescribed in accordance with manufacturer's specifications .Medication Administration: Medications are administered in accordance with written orders of the prescriber .3.b: Medications to be given with meals are to be scheduled for administration at the resident's meal times .

Based on observation, interview, and record review, the facility failed to ensure medications of a discharged resident were removed from the nurse's medication cart and mixed with other residents' active medication supplies. This failure had the potential to result in medication errors when the medications were accidentally given by mistake to other residents. During a facility task observation, two medication carts were inspected on [DATE] at 1:21 p.m. Cart #3 was inspected together with Licensed Nurse 3 (LN 3). Inside med cart #3, the lower medication cart drawer contained oral, liquid, and topical medications of active residents. The same lower drawer also contained one box of lidocaine patch which belonged to a resident who was discharged on [DATE]. During a concurrent observation and interview with LN 3 on [DATE] at 1:21 p.m., LN 3 confirmed the resident's name imprinted on the 1 full box of lidocaine patch was already discharged last [DATE]. LN 3 stated medications of discharged residents should have been removed from the nurse's medication cart and not mixed with the medication supplies of active residents. LN 3 stated LNs were not supposed to keep any medication for residents who were no longer in the facility to ensure LNs will not administer medications in error. LN 3 stated, LNs might give the lidocaine patch by mistake to other residents. LN 3 indicated giving the wrong medication to another resident could have an adverse side effect that could be life threatening. During an interview on [DATE] at 7:41 a.m. with the DON, the DON stated the expectations was for the LNs to remove all medications of the residents once they were discharged . The DON stated when medications were just kept there, it could be expired and could be administered in error to other residents. A review of the facility's policy and procedure (P&P) titled, DISPOSAL OF MEDICATIONS, dated 2007, the P&P indicated, Discontinued medications and/or medications left in the nursing care center after a resident's discharge are identified and removed from current medication supply in a timely manner for disposition.

Based on observation, interview and record review, the facility Registered Dietitian lacked the skill set to assess a non-English speaking resident (Resident 11) when language interpreter services were not utilized though the resident appeared to have lost 22 pounds during her 3 months at the facility. This failure had the potential of leading to further weight and muscle loss as well as malnutrition for Resident 11.Findings: During a concurrent observation and interview of the lunch meal on 1/20/26 at 12:36 p.m., Resident 11 was in bed, awake and alert. Resident 11 nodded to answer questions, but after a couple of questions Resident 11 stated she did not speak English and reported her preferred language. During a review of Resident 11's electronic medical record on 1/20/26 at 2:17 p.m. a weight variance note from 1/15/26 was observed. This note included the following weight history:Current wt (weight)=88# (pounds) 1/3/26=84#12/1/25=89#11/1/25=99.5#10/11/25=106# During a concurrent observation and interview on 1/21/26 at 8:27 a.m. with Resident 11, Certified Nursing Assistant 4 (CNA 4) provided interpretation. Resident 11 had eaten most of the breakfast meal tray leaving only the sausage on the plate and her nutrition supplemental drink. Five additional supplement drinks were observed in her room (3 on the cabinet, 2 on the tray table, plus the one on her breakfast tray). Resident 11 pointed out that she ate differently than what was served at the facility, preferring chicken, rice and vegetables. Resident 11 also stated she ate some beef but not often, and avoided pork, fish, and yogurt. Resident 11 reported that she previously weighed 110 pounds and had a current weight of 89 pounds. Resident 11 stated that in her culture nursing homes weren't used and found it depressing to be in one. During a kitchen visit on 1/21/26 at 9:30 a.m., Resident 11's food preferences of chicken, rice and vegetables were shared with the Registered Dietitian (RD) and Dietary Manager (DM) as well as the dislikes. During the lunch meal plating on 1/21/26 at 12:30 p.m., Resident 11 was served pot roast, peas, and roasted potatoes, though chicken, rice, zucchini and carrots were available. During an interview on 1/21/26 at 4:33 p.m. with the RD, the RD found some snack preferences for Resident 11 in the dietary computer system, but no other preferences were listed. The RD stated that she did not speak Resident 11's language and had communicated with her by pointing to things and using body movement. During an interview on 1/22/26 at 2:32 p.m. with the Director of Nursing (DON), communication with a non-English speaking resident was discussed. The DON stated that social services could set up interpretation services within a few minutes and that the expectation was that staff use these services to communicate and provide care when needed. The DON stated that without the use of an interpreter, the residents could not be thoroughly assessed. During an interview on 1/22/26 at 4:40 p.m. with the Dietary Manager (DM), the DM stated that her position and the RD position were the only staff able to input resident food preferences. Resident 11's dietary preferences were reviewed. The dietary computer system indicated that Resident 11 had only one preference which was for rice. No other likes or dislikes had been entered. Review of facility provided Consultant Dietitian Nutritionist Job Description (Nutrition Therapy Essentials, Inc. Food Service Policy & Procedures Manual 2023) indicated, The RDN (Registered Dietitian Nutritionist) provides consultation to the facility for the purpose of providing nutrition care.which will result in optimal health of the resident. Responsibilities included 1. Evaluates the nutritional needs of residents and documents in the nutritional record.5. Reviews and assists.in interdisciplinary care planning and Department of Food and Nutrition Services care plans.10. Visits residents to monitor food acceptance. Review of facility provided policy on Translation and/or Interpretation of Facility Services (Med-Pass, Inc., Revised November 2020) indicated that This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. In bullet 11, it further indicated, Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting; b. A staff interpreter who is trained and competent in the skill of interpreting; c. Contracted interpreter service; d. Voluntary community interpreters who are trained and competent in the skill of interpreting; and e. Telephone interpretation service.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of seven sampled residents (Resident 1) when Resident 2 hit Resident 1 in the head.This failure resulted in Resident 1 having pain and dizziness and had the potential for Resident 1 to experience physical and/or psychosocial harm.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted [DATE] with diagnosis that included Dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) the MDS, dated [DATE] indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) BIMS score of 7 out of 15 which indicated Resident 1 had severe cognition impairment. During a review of Resident 2's clinical record, Resident 2 was admitted [DATE] with diagnosis that included chronic pain syndrome (pain that lasts longer than three months), psychoactive substance abuse (a pattern of compulsive substance use).During a review of Resident 2's MDS dated [DATE], Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 had intact cognition.During a review of Resident 1's Change of Condition (COC) note, dated 12/13/25, the COC indicated Resident 1 was hit in the head by Resident 2 and Resident 1 complained of pain in the area he was struck and dizziness. The COC indicated Resident 1 was sent to the hospital for evaluation.During an interview on 12/22/25 at 10:35 a.m. with Resident 1, Resident 1 stated another resident hit him behind his ear. Resident 1 stated he has continued pain behind his right ear.During a review of Resident 2's Situation, Background, Appearance, Review and Notify (SBAR) communication form, dated 12/12/25. The SBAR indicated Resident 2 got upset and hit Resident 1 with a closed fist and Resident 1 returned an open-handed hit to Resident 2's chest three times.During an interview on 12/22/25 at 10:47 a.m. with Resident 2, Resident 2 stated Resident 1 hit him in his chest while he was in bed and Resident 2 got up and hit Resident 1 in the head. Resident 2 stated there was no one in the room during the altercation.During an interview on 12/22/25 at 2:25 p.m. with the Director of Nursing (DON), the DON confirmed residents have the right to be free from abuse.During a review of the facility's Policy and Procedure (P&P) titled, Residents Rights revised December 2016, the P&P indicated, . residents' right to be free from abuse.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one (Resident 1) out of a census of 108 when Resident 1 was pushed by a visitor during an altercation.This failure resulted in Resident 1 not free from abuse by a visitor.Findings:During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted [DATE] with diagnosis including Alcohol Induced Psychotic Disorder- Unspecified.During a review of Resident's 1 Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 7/9/25 indicated Resident 1 had intact cognition.During a review of Resident 1's Care Plan (CP), indicated there was no documented evidence of a person-centered care plan, related to the potential risk of aggression. During a review of SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers for changes in residents' conditions) dated 7/1/25, it indicated that Resident 1 exhibited verbal and physical aggression towards a visitor and staff members.During an interview with Licensed Nurse 2 on 7/9/25 at 11:48 a.m., LN 2 reported that she witnessed the visitor pushed Resident 1 during the altercation.During an interview on 7/9/25 at 12:50 p.m. with the Director of Nursing (DON), the DON confirmed that residents at their facility have the right to be free from any form of abuse, by any individual.During a review of the facility's policy and procedure (P&P) titled, Resident Rights and Abuse Prevention Policy and Procedure Manual, revised August 2011, indicated, .resident has the right to be free from abuse.residents must not be subjected to abuse by anyone including, but not limited to.family members, friends, or other individuals.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within 2 hours for one of four sampled residents (Resident 1), when an allegation of abuse was reported to the department the following day.This failure reduced the potential to ensure resident safety.Findings:A review of a facility document titled, SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers for changes in residents' conditions) note dated 7/1/25 indicated, .Writer [Licensed Nurse (LN) 3] was also approached by this Resident [1] and also got in writers face . Resident [1] got agitated, and pushed the visitor. visitor reacted and pushed back [Resident 1] as he was getting in his face as well with yelling and cursing. Primary Care Clinician notified 7/1/25 at 6:30 p.m.A review of Interdisciplinary Team (IDT) Follow up dated 7/2/25 at 9:48 a.m. indicated, . On 7/1/25, pm shift, res [1] was verbally aggressive to staff in the hallway. Staff asked him to calm down. Res [1] got close to charge nurses' face about the CNAs. res [1] got agitated and pushed the visitor. Visitor reacted and pushed back [Resident 1]. Staff intervened and calmed the situation.A review of an initial report from the facility indicated the report was faxed on 7/2/25 at 2:57 p.m. and received by the Department on 7/2/25 at 4:16 p.m. indicated, an allegation of suspected dependent adult/elder altercation had been made related to a visitor against Resident 1. During an interview on 7/9/25 at 11:37 a.m. with LN 1, LN 1 stated, any abuse allegations must be reported to the department within 2 hours.During an interview on 7/9/25 at 11:48 a.m. with LN 2, LN 2 stated, she saw the Visitor pushed the resident.During an interview on 7/9/25 at 12:50 p.m. with Director of Nurses (DON), DON stated, the abuse allegation was submitted 7/2/25 because she did not know it was a reportable incident.During interview via telephone on 7/11/25 at 8:30 a.m., the Director of Nurses (DON) stated that it is the facility's policy to report any allegation of abuse to the department within 2 hours. The DON confirmed that the abuse allegation made on 7/1/25 was not reported to the department within the required 2-hour timeframe.During a review of the facility's policy and procedure titled, Reporting Abuse to State Agencies and Other Entities/Individuals, revised August 2011, indicated, All suspected violations. of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Should a suspected violation. of mistreatment. or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies. of such incident.The State licensing/certification agency responsible for surveying/licensing the facility.A review of Center of Medicare and Medicaid State Operations Manual (SOM- a document that provides guidance for surveyors on long term care facilities) indicated, .S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three sampled residents (Resident 2) when facility staff witnessed Resident 1 hit Resident 2. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to be injured. Findings: Resident 1 was admitted [DATE] with diagnoses which included anxiety disorder and muscle weakness. A review of Minimum Data Set (MDS, an assessment tool), dated 7/30/24, indicated Resident 1 had intact cognition. Resident 2 was admitted [DATE] with diagnoses which included hemiplegia (muscle weakness or partial paralysis on one side of the body) and reduced mobility. A review of the MDS, dated [DATE], indicated Resident 2 had intact cognition. During an interview on 10/24/24, at 11:23 a.m. with the Director of Nursing (DON), the DON stated on the morning of 10/16/24, she was informed by Janitor (JN) that he witnessed Resident 1 and Resident 2 get into a verbal and physical altercation outside on the smoking patio. DON confirmed JN stated he witnessed Resident 1 hit Resident 2. DON stated the expectations were for residents to involve facility staff when there is a disagreement and to not get into physical altercations. During an interview on 10/24/24, at 11:40 a.m. with Social Services Director (SSD), the SSD confirmed she had observed on video Resident 1 approach Resident 2 outside in the smoking area. SSD stated Resident 1 hit Resident 2 and saw Resident 2 attempt to hit Resident 1 but wasn't sure if contact was made. SSD confirmed she educated Resident 1 and Resident 2 on smoking policy, resolving conflict and not fighting. During an interview on 10/24/24, at 11:54 a.m., with Resident 1, Resident 1 confirmed a few days ago he got upset at Resident 2 for taking his cigarettes and had confronted Resident 2 outside. Resident 1 stated he hit Resident 2 in his face and Resident 2 had hit him on his shoulder. Resident 1 stated, Didn't hit him hard and he didn't hit me hard. During an interview on 10/24/24, at 12:05 p.m., with Resident 2, Resident 2 confirmed Resident 1 had approached him outside, told him to not take his cigarettes and then hit him. Resident 2 stated he tried hitting Resident 1 in return. During an interview on 10/24/24 at 12:25 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated expectations were for staff to keep residents safe and to keep their smoking supplies. CNA 1 confirmed residents could potentially be hurt and injured if arguments and fights escalated. During a review of Resident 1's Progress Notes (PN), dated 10/16/24, the PN indicated, Resident involved in an altercation in our facility with resident [Resident 2] .Resident is seen on camera assaulting resident [Resident 2]. During a review of Resident 1's PN, dated 10/21/24, the PN indicated, Late entry for 10/16/24 .so I went after him [Resident 2] to the smoking patio and I swung at him but I didn't hit him the first time, but I did the second time, the only thing is that I just don't remember where I hit him. During a review of Resident 2's PN, dated 10/21/24, the PN indicated, Late entry for 10/16/24. This resident [Resident 2] had an physical altercation with other male resident .He [Resident 1] came after me to the smoking patio and hit me in the head . During a review of Resident 2' s SBAR Communication Form, dated 10/16/24, indicated Resident stated aggressor [Resident 1] took his hat, struck him on his face once and hit him with the walker. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised 8/2011, the P&P indicated, Our facility is committed to protecting our residents from abuse by anyone including .other residents . During a review of the facility's Policy and Procedure (P&P) titled, Residents Rights, revised 12/2023, the P&P indicated, .certain basic rights to all residents of this facility. These rights include the resident ' s right to: .be treated with respect, kindness, and dignity .be free from abuse .

Based on observation, interview and record review, the facility failed to properly manage a resident's Type 2 Diabetes Mellitus (DM2-a disease that results in too much glucose, also called blood sugar in the blood) for one of 28 sampled residents (Resident 31) when the Licensed Nurses (LN) did not follow Physician Orders and the standards of care for diabetes. These failures resulted in Resident 31 having dangerously high levels of glucose throughout the day and suffering from unwanted symptoms of hyperglycemia (high sugar level) which could have led to a diabetic coma, a life-threatening medical emergency requiring immediate medical care or death if left untreated. Findings: An Immediate Jeopardy (IJ) situation was declared at 7:25 p.m. on 9/30/24 with Facility leadership representatives including the Regional Administrator (ADM) and Director of Nursing (DON) due to Resident 31 having dangerously high glucose levels throughout the day and suffering from symptoms of hyperglycemia while the Licensed Nurses (LNs) failed to administer Resident 31's morning insulin (a medication that lowers the glucose level in body), notify the physician, follow up with the physician, follow the physician's new insulin order in the afternoon, and properly document the glucose levels for the physician to properly assess Resident 31's condition. The Immediate Jeopardy status was lifted onsite on 10/1/24 at 4 p.m. after the facility provided an acceptable action plan. During a review of Resident 31's undated, Admission Record (AR), the AR indicated Resident 31 was admitted to the facility in August of 2018 with diagnoses that included type 2 Diabetes Mellitus (DM2) with hyperglycemia (a disease characterized by high blood sugar levels) and DM2 with diabetic neuropathy (nerve pain due to having diabetes), End Stage Renal Disease (kidney failure), Chronic Diastolic Heart Failure (condition that the heart cannot pump blood efficiently), and Hypertensive Chronic Kidney Disease (a condition where high blood pressure damages the kidneys). Resident 31 was insulin dependent (a condition that the body is unable to produce enough insulin and requires regular insulin injections). Review of Resident 31's medical record document titled Order Summary Report dated 8/12/24, indicated the following orders for diabetes: - Insulin Regular (Humulin R, a short acting insulin), 100 u/ml (units per milliliter, concentration of insulin in a measurement of fluid). Amount to inject as per sliding scale (insulin dosage based on pre-defined blood glucose ranges); For Blood Sugar (BS) = 70-130 mg/dl (milligrams per deciliter, unit of measure): Give 0 units If BS is < (less than) 70 mg/dl, Follow facility protocol. For BS = 131-150: Give 1 unit For BS = 151-180: Give 2 units For BS = 181-210: Give 3 units For BS = 211-240: Give 4 units For BS = 241-270: Give 5 units For BS = 271-300: Give 6 units For BS = 301-330: Give 7 units For BS = 331-360: Give 8 units For BS = 361-400: Give 10 units If BS greater than 400 mg/dl, Give 12 units and notify MD (Medical Doctor) -Insulin glargine (a long-acting insulin) KwikPen subcutaneous solution pen-injector (disposable insulin delivery device) 100 unit/ml, inject 10 unit subcutaneously (under the skin) at bedtime for DM2. - Glipizide (an oral medication used to lower blood glucose by stimulating the release of insulin), 5 mg (milligram, a unit of measure), give one table by mouth two times a day for DM2. Take 30 minutes before a meal. During a medication administration observation in Resident 31's room, on 9/30/24 at 9:51 a.m., LN 1 administered 5 units of insulin glargine 100 u/ml and one tablet of glipizide 5 mg to Resident 31 after breakfast while LN 1 did not administer Resident 31's sliding scale Humulin R insulin. During an interview on 9/30/24 at 9:55 am with LN 1, LN 1 stated Humulin R was not given since Resident 31's morning blood sugar level was at 466 mg/dl and the insulin sliding scale order only covered up to 400 mg/dl. LN 1 referred to the Medication Administration Record (MAR) insulin calculator tool showing that based on Resident 31's blood sugar level of 466 mg/dl, the sliding scale indicated that this order did not need to be administered. During a reconciliation (review of medications observed being administered against the physician orders) of the observation of medication administration with Resident 31's active Physician Orders indicated an order for glipizide 5mg, give one tablet by mouth two times a day for Diabetes Mellitus 2. Take 30 minutes before a meal. The Physician Order also included orders for the sliding scale Humulin R Insulin. During an interview on 9/30/24 at 11:25 a.m. with LN 1, LN 1 acknowledged that Resident 31's insulin Humulin R order should have been administered in the morning. LN 1 further stated that she had not re-checked Resident 31's blood glucose and she had not notified the physician. During an interview on 9/30/24 at 11:30 a.m. with LN 1, LN 1 acknowledged the order stated to administer Resident 31's glipizide 5 mg 30 minutes before a meal. LN 1 stated Resident 31's breakfast tray was delivered about thirty minutes before the glipizide 5 mg was given on 9/30/24. A review of the meal schedule posted in the hallway for 9/30/24 indicated, the kitchen started serving breakfast at 7:05 a.m. 9/30/24. During an interview on 9/30/24 at 11:31 a.m. with LN 1, LN 1 stated Resident 31 had a BS of 353 mg/dl before lunch and 15 units of Humulin R insulin were given to the resident. A review of Resident 31's progress notes on 9/30/24 at 11:32 a.m., LN 1 had documented 10 units of Humulin R insulin, and 5 units of glargine were administered to Resident 31. During an interview on 9/30/24 at 12:45 p.m. with LN 1, LN 1 stated the blood sugar was high per the glucometer (a device that measures blood sugar level) at 12:45 p.m. LN 1 did not know what a high level reading meant in regard to Resident 31's blood's glucose level. A review of Resident 31's MAR printed on 9/30/24 at 6:04 p.m. stated Resident 31 had only received 8 units of Humulin R insulin by LN 1, not the 15 units LN 1 reported, or the 10 units LN 1 had documented on the progress notes. A review of the glucometer's manual, dated 10/1/24, indicated, a high reading would be the amount of glucose greater than 600 mg/dl. During a review of an online publication on the computer, obtained from the internet, on the importance of diabetes care by the Mayo Clinic, Mayo Foundation for Medical Education and Research (a nonprofit American academic medical center focused on integrated health care, education, and research), if blood sugar level goes above 600 mg/dL, the condition is called diabetic hyperosmolar syndrome (a life-threatening emergency when blood sugars get too high). When blood sugar is very high, the extra sugar passes from the blood into the urine. That triggers a process that draws a large amount of fluid from the body. If it isn't treated, this can lead to life-threatening dehydration (harmful reduction int the amount of water in the body) and a diabetic coma (unconsciousness). During an interview on 9/30/24 at 2:30 p.m. with LN 1, LN 1 stated Resident 31's blood sugar was still high on the glucometer, however, LN 1 was unable to document high on the MAR. During an interview on 9/30/24 at 2:48 p.m. with LN 1, LN 1 stated, it had been difficult to reach the physician for the past two hours. LN 1 further stated, I was finally able to reach the physician [14:48 (2:48p.m.)] after the third call, a new order was placed [for Resident 31] to administer 10 units of Humulin R insulin and to recheck [Resident 31's] blood sugar level in 20 minutes. During an interview on 9/30/24 at approximately 3:15 p.m. with LN 1, LN 1 stated Resident 31's blood sugar was 577 mg/dl, and 10 units of insulin were given to Resident 31 by LN 2. LN 1 was not able to provide the time of Resident 31's insulin administration and stated that the record had not been completed on the MAR as required. On 9/30/24 at approximately 3:30 p.m., LN 2 stated no insulin had been given to Resident 31 and LN 1 was dealing with Resident 31's insulin. LN 2 also stated Resident 31 was napping and had no issues with high sugar levels. On 9/30/24 at 3:34 p.m. with LN 1, LN 1 stated Resident 31 was doing ok and had no symptoms of hyperglycemia. LN 1 also stated that the ordered dose of insulin was still not administered to Resident 31 regardless of Resident 31's high glucose level. During an interview on 9/30/24 at 3:36 p.m. with Resident 31, Resident 31 complained of headache, dizziness, being thirsty, and not feeling well. Resident 31 stated she did not receive her morning insulin and she had never felt this way before. During an interview on 9/30/24 at 3:45 p.m. with LN 2, LN 2 stated that Resident 31's blood sugar was still high after using two different glucometers to double check the reading. LN 2 also stated, the 10 units of insulin had been administered. A review of Resident 31's MAR dated, 9/30/24, at 3:48 p.m., had no documentation for the dose of insulin that was administered per LN 2 in the 3:45 p.m. interview. The MAR documentation did not include the blood glucose levels including the high readings that were taken at: 12:45 p.m. High (per glucometer manual: High would be greater than 600 mg/dl), 2:30 p.m. High, 3:14 p.m. 577 mg/dl, and, 3:45 p.m. High & High (two different glucometers were used). The MAR indicated for 9/30/24 the 6:30 a.m. BS of 466, 11:30 a.m. BS of 353, and the 4:30 p.m. BS of 517. During an interview on 9/30/24 at 4 p.m. with LN 1, LN 1 stated, the physician was just called around 3:55 p.m. and wanted Resident 31 to be sent to the hospital. During an observation and interview on 9/30/24 at 4:17 p.m. with Resident 31 in Resident 31's room and stated, she still did not feel good. Resident 31 reported being dizzy, had a headache, and was thirsty while holding a cup of ice in hand. During an interview on 9/30/24 at 5:11 p.m. with LN 2, LN 2 stated Resident 31's blood sugar was still elevated at 517 mg/dl and Resident 31 was being sent out to the emergency room . During an interview on 9/30/24 at 5:23 p.m. with the DON, the DON stated, that the computer program for documenting the blood sugar levels would only accept numerical values. It would not accept the words high. The DON further stated, the LNs should have followed the Physician Orders to administer the insulin dose on time, reached out to the provider if the blood glucose level was high, or if insulin was not administered, rechecked the levels, and followed the standards of practice. The DON acknowledged that untreated hyperglycemia could cause serious harm. During an interview on 10/1/24 at approximately 10 a.m. with the Information Technologist (IT), the IT confirmed that the computer program for documenting the blood sugar levels would only accept numerical value and it was impossible for the nurses to enter high to document the high blood sugar levels. During a review of another online publication on the computer, obtained from the internet, on the importance of diabetes care by the Mayo Clinic, it's important to treat hyperglycemia. If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart. During an interview on 10/1/24 at approximately 10 a.m. with the ADM, the ADM stated, it (the missed medications and not calling the doctor) was a hundred percent the nurse's fault [LN 1], and the nurse [LN 1] would not be coming back [to the facility]. During an interview on 10/1/24 at 11:52 a.m. with the DON, the DON stated, Resident 31 was still at the hospital while now dealing with kidney issues as well. During an interview on 10/3/24 at 12:20 p.m. with the DON and the facility's Consultant Nurse (CN), the DON and CN were unable to provide standards of care used within the facility to treat the diabetic residents. During an interview on 10/3/24 at 9:26 a.m. with the Consultant Pharmacist (CP), the CP stated that both the morning nurse [LN1] and the afternoon nurse [LN 2] should have called the pharmacy or the physician right away to ask for a recommendation. He acknowledged; the provided diabetes care was inappropriate for Resident 31. During an attempt to discuss the details of Resident 31's case with the physician, a message was left on 10/2/24 at 12 p.m. for the physician at the facility provided number. The physician did not call back. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, dated September 2014, the P&P indicated, The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure the correspondence with the order on the medication sheet and the Physician's Order. The nurse shall notify the director of nursing services and attending physician of any discrepancies before giving the insulin. During a review of the facility's P&P titled, Change in a Resident's Condition or Status dated May 2017, the P&P indicated The nurse will notify the Resident's Attending Physician or physician on call when there has been a .significant change in the resident's physical/emotional/mental condition; .A significant change of condition is a major decline or improvement in the Resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting).

Based on observation, interview, and record review, the facility failed to verify, document, seal, and replace an opened E-Kit (emergency kit, a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 116 residents. This failure had the potential to have expired pharmaceutical products, contribute to decreased availability of medications in an emergency or increase the risk of drug diversion. Findings: During a concurrent observation and interview on [DATE] at approximately 9:15 a.m. with Licensed Nurse (LN) 3 e-kit # 731 was observed to be kept unsealed in the north station medication storage room. LN 3 stated she did not know when the e-kit # 731 was opened and when the e-kit should have been replaced. LN 3 confirmed the opening of the e-kit # 731 was not logged in the e-kit logbook and the contracted facility pharmacy was never contacted for replacement and both pharmacy white labels were not signed by any pharmacists. During an interview with the Director of Nursing (DON) on [DATE] at approximately 11:52 am, the DON acknowledged that e-kit # 731 should have been properly labeled with the pharmacist signatures, kept sealed all the time, properly documented the use, and replaced by another sealed e-kit box. During an interview with a facility's registered pharmacist (RPh) on [DATE] at approximately 11 a.m., the RPh stated that the e-kit boxes go through a double check process in the pharmacy. Both the top and the bottom white labels on the e-kits need to be signed by two different pharmacists and then the e-kit boxes get sealed and sent to the facility. The RPh was unable to explain why e-kit # 731 did not have any pharmacist signatures on it. During a review of the facility's policy and procedure (P&P) titled, Emergency Pharmacy Service and Emergency Kits, dated 2007, the P&P indicated, Emergency medications and supplies are provided by the pharmacy in compliance with applicable state regulations .Upon removal of any medication or supply item from the kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center .Before reporting off duty, the charge nurse indicates the opened or sealed status of the emergency kit at the shift change report .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of 28 sampled residents (Resident 31 and 103). 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin Insulin medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, a medication given 30 minutes before breakfast to lower blood sugar level, 5 mg (milligram, unit of measure) in accordance with the Physician Order. 3. For Resident 103, LN 1 administered lactobacillus, a probiotic to aid in digestion, without clarifying the Physician Order. These failures exposed the residents to possible adverse reactions and health complications. Findings: 1. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 was observed to prepare and administer Resident 31's morning medications which did not include Humulin R insulin. During a reconciliation (review of medications observed being administered against the physician orders) of the observation of the medication administration with Resident's current Physician Orders indicated an order for Humulin R insulin 100 u/ml (units/milliliter, unit of measure) for Diabetes Mellitus 2, a condition whereby the body ineffectively metabolizes sugar. Furthermore, the order indicated administer insulin based on the resident's blood sugar level before meals according to the following blood sugar levels: 70 - 130 mg/dl (milligram/deciliter, unit of measure) give 0 units; 131 - 150 mg/dl give 1 unit; 151 - 180 mg/dl give 2 units; 181 - 210 mg/dl give 3 units; 211 - 240 mg/dl give 4 units; 241- 270 mg/dl give 5 units; 271 - 300 mg/dl give 6 units; 301 - 330 mg/dl give 7 units; 331 - 360 mg/dl give 8 units; 361- 400 mg/dl give 10 units; If blood sugar is greater than 400 mg/dl, give 12 units and notify MD (Medical Doctor). During an interview on 9/30/24 at 11:25 a.m. with LN 1, LN 1 stated Resident 31 did not receive any insulin per sliding scale (various units of insulin based on blood sugar levels) since the blood sugar level was 466 mg/dl at 6 a.m. LN 1 demonstrated the Medication Administration Record (MAR) insulin dose calculator tool and stated, based on the Blood Sugar Value entered, the sliding scale indicated that the Resident's insulin order did not need to be administered. LN 1 further stated she had not checked the blood sugar level since it was checked at 6 a.m. During continued interview with LN 1 when asked how the dose of insulin for the administration was calculated, LN 1 responded based on Resident 31's blood sugar level of 466 mg/dl, the sliding scale insulin order (various units of insulin based on blood sugar levels) was used to calculate the dose that was not administered. During an interview with the Director of Nurses (DON) on 9/30/24 at 5:23 p.m., the DON admitted LN 1 failed to give the medication as ordered and notify the MD. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame. 2. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 administered Resident 31's Glipizide 5 mg after breakfast when the breakfast trays had been removed from the room. During a reconciliation of the observation of medication administration with Resident 31's current Physician Orders, indicated an order for Glipizide 5mg, give one tablet by mouth two times a day for DM2. Take 30 minutes before a meal. During an interview on 9/30/24 at 11:30 a.m. with LN 1, LN 1 stated Resident 31's breakfast tray was delivered thirty minutes before the medication was given. The LN 1 also acknowledged the order stated the medication should be taken 30 minutes before a meal. During a review of the facility's policy and procedure P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions . 3. During an observation of medication administration on 9/30/24 at 9:54 a.m., LN 1 administered one tablet of lactobacillus to Resident 103. During a reconciliation of the observation of medication administration with Resident 103's Physician Order, the order indicated 1 capsule by mouth one time a day for skin infection. Review of dosing recommendation, serving size, and the strength listed on the label printed on the bottle of lactobacillus, indicated to take two 500,000 million unit capsules as single serving size. During an interview on 9/30/24 at 11:30 a.m. with LN 1, stated she had not noticed that there was no strength on the Physician Order, and she had not paid attention to the label on the lactobacillus that was in the medication cart. During an interview on 9/30/24 at 5:23 p.m. with the DON, the DON acknowledged the nurse should have notified the MD, charge nurse, or the DON. Staff failed to follow standard practice of care to meet resident's needs. During a review of the facility's policy and procedure P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents, Resident 31 was free from significant medication errors when: 1. For Resident 31, Licensed Nurse (LN) 1 did not administer Resident's Humulin R Insulin, medication used to lower blood sugar level, in accordance with the Physician Order. 2. For Resident 31, LN 1 did not administer Resident's glipizide, medication to be given 30 minutes before breakfast used to lower blood sugar level, 5 mg (milligram, unit of measure), according to the physician order. These failures resulted in Resident 31's elevated blood sugar levels and subsequent signs and symptoms of high blood sugar (headache, dizziness, thirsty, and not feeling well), and had the potential to result in a diabetic coma (a life-threatening condition that occurs when someone with diabetes experiences dangerously high or low blood sugar levels, leading to unconsciousness). Findings: 1. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 was observed to prepare and administer Resident 31's morning medications which did not include Humulin R insulin. Reconciliation of the observation of the medication administration with Resident's current Physician Orders indicated an order for Humulin R insulin 100 u/ml (units/milliliter, unit of measure) for Diabetes Mellitus 2, a condition whereby the body ineffectively metabolizes sugar. Furthermore, the order indicated administer insulin based on the resident's blood sugar level before meals according to the following blood sugar levels: 70 - 130 mg/dl (milligram/deciliter, unit of measure) give 0 units; 131 - 150 mg/dl give 1 unit; 151 - 180 mg/dl give 2 units; 181 - 210 mg/dl give 3 units; 211 - 240 mg/dl give 4 units; 241- 270 mg/dl give 5 units; 271 - 300 mg/dl give 6 units; 301 - 330 mg/dl give 7 units; 331 - 360 mg/dl give 8 units; 361- 400 mg/dl give 10 units; If blood sugar is greater than 400 mg/dl, give 12 units and notify MD. During an interview on 9/30/24 at 11:25 a.m. with LN 1, LN 1 stated Resident 31 did not receive any insulin per sliding scale (various units of insulin based on blood sugar levels) since the blood sugar level was 466 mg/dl at 6 a.m. LN 1 demonstrated the Medication Administration Record (MAR) insulin dose calculator tool and stated, based on the Blood Sugar Value entered, the sliding scale indicated that the Resident's insulin order did not need to be administered. LN 1 further stated she had not re-checked the blood sugar level since it was checked at 6 a.m. During an interview on 9/30/24 at 3:36 p.m. with Resident 31, Resident 31 complained of headache, dizziness, being thirsty, and not feeling well. Resident 31 stated she did not receive her morning insulin and she had never felt this way before. During an interview on 9/30/24 at 5:23 p.m. with the Director of Nursing (DON), the DON acknowledged LN 1 failed to administer resident's insulin as ordered and LN 1 failed to notify the Physician when the dose was not given. According to Institute for Safe Medication Practices (ISMP), updated in 2017, insulins, all formulations and strengths are considered to be high-alert medications. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame .The individual administering the medication Checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) before giving the medication. During a review of the facility's P&P titled, Insulin Administration, dated September 2014, the P&P indicated, The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure the correspondence with the order on the medication sheet and the Physician's Order. The nurse shall notify the director of nursing services and attending physician of any discrepancies before giving the insulin. 2. During an observation of medication administration on 9/30/24 at 9:37 a.m., LN 1 administered Resident 31's glipizide 5 mg after breakfast when the breakfast trays had been removed from the room. Reconciliation of the observation of medication administration with Resident 31's current Physician Orders indicated an order for glipizide 5 mg, give one tablet by mouth two times a day for Diabetes Mellitus 2. Take 30 minutes before a meal. During an interview on 9/30/24 at 11:30 a.m. with LN 1, LN 1 stated Resident 31's breakfast tray was delivered about thirty minutes before the medication was given. LN 1 also acknowledged the order stated to administer the medication 30 minutes before a meal. During an interview on 9/30/24 at 5:25 p.m. with the DON, the DON acknowledged LN 1 failed to give resident's glipizide 30 minutes before serving breakfast, as ordered. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions .The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) before giving the medication.

Based on interview and record review, the facility failed to maintain, for Resident 1, a therapeutic: 1. hydration status, and 2. nutritional status, when Resident 1 was admitted to the acute hospital with critical lab values and significant weight loss (unintentional loss of 5% or more of normal body weight) occurring over a 15-day period. This failure resulted in Resident 1 experiencing avoidable physical harm which required transfer to a higher level of care. Findings: Resident 1 was admitted to the facility in early 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool), Section C, Cognitive (knowing, thinking, learning) Patterns, dated 4/29/22, the BIMS indicated Resident 1's score was 11, suggesting mild to moderate cognitive impairment. During a review of Resident 1's ST (Speech Therapist)-Therapist Progress & Discharge Summary, dated 5/9/22, the Prior Level, 4/27/22, Swallowing, and Current Level (5/9/22-day of transfer to hospital) indicated, Needs close supervision for safe PO [by mouth] intake. May need some non-oral (tube) feeding .moderate dysphasia w/ [with] risk of aspiration [inhaling contents of mouth down breathing tube rather than swallowing down tube to the stomach], choking and malnutrition. Additionally, the ST documentation indicated Yes, to the prompt Complaints of difficulty or pain with swallowing, for both Prior and Current levels. During a review of Resident 1's Brief Interview for Mental Status, Section K, Swallowing/Nutritional Status, dated 4/29/22, the BIMS did not indicate the resident had difficulty swallowing. During a review of Resident 1's BIMS, Section L, Oral/Dental Status, dated 4/29/22, the BIMS did not indicate a check mark was placed in the box next to Mouth .pain .difficulty with chewing. During a review of Resident 1's (name of acute facility)'s History and Physical (H&P), the H&P indicated Resident 1 was admitted for dehydration and weight loss. During an interview on 10/18/22, at 8:45 a.m., with the ST, the ST indicated that her documentation that read, Needs close supervision for safe PO [by mouth] intake, meant someone needs to feed him .he's a feeder .he can't be left alone to eat.'' The ST was unclear of the process by which Nursing and the IDT (intra-disciplinary team [many specialties who meet to coordinate care]) were made aware of the evaluation and needs of Resident 1. During an interview The ST further stated, There's no one following up .the patients aren't eating .I don't see the follow through I used to see. 1. During a review of Resident 1's Order Summary Report, the OSR revealed no physician-ordered fluid restriction. During a review of Resident 1's Documentation Survey Report-Intake - Fluids (DSRIF), dated April 2022, the DSRIF revealed Resident 1's twenty-four hour fluid intake during the period 4/23/22 to 5/8/22, ranged from 100 mls to 1300 mls (recommended minimum 1700 mls in twenty-four hours for a [AGE] year-old man not on a fluid restriction [Better Health While Aging at https://betterhealthwhileaging.net/qa-how-to-prevent-diagnose-treat-dehydration-aging-adults/]). During a review of Resident 1's Care Plan, Risk for Dehydration, the Care Plan outlines the goals as 1. Decrease risk of electrolyte imbalance, and 2. Maintain adequate hydration status. Indicated documented interventions included assist with fluid, encourage fluid, monitor for s/s (signs and symptoms) of dehydration, monitor weight, notify MD of s/s, and offer hydration during activities. During a review of Resident 1's (name of acute hospital) Emergency Documentation - MD [doctor], the MD indicated, Lab work was remarkable for [CONDITION(S)], 155 [normal is 135-145]. He was started on LR [IV fluid for electrolyte (minerals with electrical charges that affect body functions) and fluid stabilization] .will admit to the hospital for [CONDITION(S)], acute kidney injury, dehydration. Additionally, all renal (kidney) chemistries that were measured, were documented as H [high], as well as the sodium. Resident 1's creatinine (a waste product in the blood that is elevated with kidney damage) was documented as three times the normal value, and double Resident 1's baseline value of 1.2. During a review of Resident 1's (name of acute hospital) History & Physical [H&P], the MD documented in the H&P, .this patient will require at least 2 midnight stays in the hospital while receiving active inpatient treatment. Resident 1 was further described as having generalized weakness, [CONDITION(S)] (too much sodium in the blood, most often occurring in decreased fluid intake), and AKI (sudden kidney failure that occurs rapidly over a few hours or days, most often due to decreased fluid to the kidneys [dehydration]) on CKD. Additionally, the H&P indicated Resident 1 was suffering from Acute (suddenly, severely) Metabolic (having to do with chemical reactions in the body) [CONDITION(S)] (global [widespread] cerebral [part of the brain] dysfunction), significant weight loss, [CONDITION(S)] (decreased potassium in the blood), transient (not permanent) [CONDITION(S)] (slow heart rate) and heart failure. During an interview on 6/23/22, at 2:20 p.m., with Family Member 1/POA [Power of Attorney, a person who has been designated to make medical or financial decisions for the Resident] (FMPOA), the FMPOA indicated, I asked for three days to have something done. I could tell he was dehydrated and not doing well and needed lab work. They wouldn't do anything til I threatened to call 911. During an interview on 7/8/22, at 12 p.m., with the Director of Staff Development (DSD), the DSD indicated the nurse should report to the doctor if the resident had decreased skin turgor (skin elasticity), was sundowning (increasing confusion as nighttime approaches), or dry mucous membranes (the mouth, for example. The DSD continued that the nurse would have to initiate a Change of Condition (event which triggers a cascade of notifications and processes), assess the resident, call the doctor, and get orders. The DSD indicated the nurse might need to call 911 or an ambulance to transport the resident to the ER (emergency room ). During an interview on 7/8/22, at 3:50 p.m., with Licensed Nurse 6 (LN 6), LN 6, regarding signs and symptoms of dehydration, indicated it can be caused by vomiting and diarrhea, and also something in the mouth or throat preventing the resident from drinking. LN 6 stated signs are decreased skin turgor, sunken eyes, and when the CNA, [Certified Nursing Assistant] gives me vital signs and they are low. LN 6 stated, I talk to the CNA about providing more fluids. If the BP (blood pressure) is low, you need to go see the resident right away. During an interview on 7/8/22, at 4:35 p.m., with LN 5, LN 5 indicated a dehydrated resident could be confused, have elevated heart rate or concentrated urine. LN 5 indicated the CNA should tell the cart nurse, who would notify unit manager. LN 5 indicated that Change of Condition paperwork might need to be done and the doctor called if necessary. LN 5 also stated that increasing fluids and drawing a metabolic panel (blood test) might be needed. During an interview on 10/7/22, at 8:55 a.m., with CNA 3, CNA 3 stated Resident 1 wasn't drinking anything at all, even though I was offering fresh water. CNA 3 indicated not remembering if someone was told about the decreased fluid intake. During an interview on 10/7/22, at 9:15 a.m., with Resident 1, Resident 1 stated, through his POA Representative, that he regularly asked for something to drink but they [staff] ignored him and treated him like he wasn't there .and that he was spitting because it hurt to swallow. During an interview on 10/12/22, at 12:30 p.m., with the Director of Nursing (DON) 2, DON 2 stated, The nurse should be tracking the intake. I'm surprised the CNAs are tracking that . During an interview on 10/12/22 at 2:20 p.m., with the Registered Dietician (RD), the RD stated, A thousand mls of PO [oral, by mouth] intake or less in 24 hours, for two weeks, is not an adequate intake for a resident. Someone needs to be doing something about that. During a review of a facility policy and procedure (P&P), titled, Hydration - Clinical Protocol, dated 09/17, the P&P indicated, The physician will manage significant fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. During a review of a facility P&P, titled Encouraging and Restricting Fluids, dated 10/10, the P&P indicated, The following information should be recorded in the resident's medical record .any changes in the resident's condition .any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin, etc. During a review of an undated AMDA (American Medical Director's Association) CLINICIAL PRACTICE GUIDELINES FOR LONG TERM CARE FACILITIES, Dehydration and Fluid Maintenance in the Long-Term Care Setting, pgs 5-6, the AMDA indicated, Dehydration can have severe consequences .the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .the highest mortality rate (71%) was observed in those with .sodium level higher than 154 .[Resident 1's sodium was 155] .and BUN [a blood test which indicates possible kidney damage] greater than 25 [Resident 1's BUN was 45] . 2. During a review of Resident 1's facility Documentation Survey Report v2 (DSRv), dated April 2022, the DSRv indicated the first recorded weight after admission was 189.4 pounds on 4/25/22. Additionally, the prompt for staff, next to Weight, indicated prn (as needed). There were no additional weights documented for April. During a review of Resident 1's facility Documentation Survey Report v2 (DSRv), dated May 2022, the DSRv indicated there were two refusals between 5/1/22 and 5/9/22, by Resident 1, to be weighed. No additional attempts by staff to weigh Resident 1 were documented. During a review of Resident 1's Order Summary Report (OSR), dated April 2022, the OSR indicated, Weekly Weights. During a review of Resident 1's (name of acute facility)'s History and Physical (H&P), dated 5/9/22, at 8:40 p.m., the H&P revealed Resident 1's weight was 180, indicating a 9.4-pound weight loss in fourteen days which was calculated to be a 5% (significant, unintended weight loss of 5% or more of the total body weight in 1 month or less) weight loss. During a review of Resident 1's Progress Notes (PN), dated 4/22/22-5/9/22, the PN revealed no mention of Resident 1's documented, decreased appetite until alerted by Resident 1's Power of Attorney (POA) on 5/6/22. During a review of Resident 1's Care Plan titled, NUTRITIONAL RISK DUE TO .loss of appetite .weight loss, the Care Plan indicated that the documented goal for this area of focus was Maintain weight acceptable to resident/responsible party, and clinically appropriate. The Interventions/Tasks for the Goal was, Monitor weight and notify MD for any undesirable weight changes. During an interview on 6/27/22, at 12:52 p.m., with LN 2, LN 2 indicated a resident would need to eat at least 50 to 75% consistently to maintain their weight and nutritional status. LN 2 stated, If not, the CNA [Certified Nursing Assistant] needs to report to [the] nurse so weights can be done, and also report to [the] doctor. During an interview on 7/7/22 at 2:30 p.m., with the DSD, the DSD indicated Resident 1's weight, on the first documented weight in the skilled nursing facility on 4/25/22, was 189.4 pounds. The DSD further agreed that with a documented weight of 180 on 5/9/22 at the acute facility, there was a 9.4-pound weight loss in 14 days. During an interview on 7/8/22 at 3:50 p.m., with LN 6, LN 6 indicated residents must consistently eat at least 75% of their meals to prevent weight loss During an interview on 7/8/22, at 4:15 p.m., with LN 3, LN3 indicated residents needed to eat at least 50% to 75% of their meals to not lose weight. LN 3 indicated she relies on the CNA to alert her to signs of problems with residents. During an interview on 7/8/22, at 4:35 p.m., with LN 5, LN 5 indicated that residents are monitored for eating habits based on the dietary recommendations. LN 5 stated, It is everyone's responsibility to monitor the residents' eating and notify the nurse, if necessary, but it starts with the CNA .some residents need feeding assistance and that is the CNAs' responsibility to make sure it gets done. During an interview on 8/22/22, at 2:40 p.m., with LN 7, LN 7 indicated residents should eat at least 75% of their meals on average. LN 7 indicated if a resident is not eating that much, .we have to tell the doctor. LN 7 indicated that CNAs should notify the nurse if residents continue below 50 % meal intake on average. LN 7 continued by stating, There are only two days of weights [for Resident 1]. I don't think it's normal to have no more weights for the amount of time he was here. When informed of the weight loss (9.4 lbs. in 15 days, which is 4.963%, or 5%, body weight lost in 14 days), LN stated, That is not an acceptable weight loss .the resident should be weighed regularly, on the same scale at the same time .5% or greater weight loss is significant .the doctor should be notified. LN 7 ended by stating, Weight loss and appetite should be evaluated at the weekly nurse assessment. The nurse should review I&Os, appetite, percent of meals eaten, and weight. During an interview on 9/10/22, at 10:35 a.m., with CNA 1, CNA 1 indicated Resident 1 was a 1:1 (one CNA to one resident) from the time of admission. CNA 1 indicated a CNA was supposed to be with Resident 1, sitting in the room [ROOM NUMBER] hours a day. CNA 1 indicated she was only with Resident 1 the first day. CNA 1 stated, We put another CNA on that wing so we could do 1:1 with him [Resident 1]. CNA 1 concluded, He [Resident 1] was mostly independent with eating. He would take a couple of bites and then drink the shakes. He didn't eat much, just Ensure. The CNA should notify the nurse if the resident is not eating well. Someone should have told the nurse .a meal intake of 25% or 'Resident Refuses' is too low. We have to tell the nurse . During an interview on 10/7/22, at 9:15 a.m., with Resident 1, through his POA Representative, Resident 1 stated eating made the pain worse, so he didn't eat as much, and that when they [staff] missed giving him his mouth rinse medication, it made the pain worse. During an interview on 10/12/22, at 1:50 p.m., with the DON, the DON stated, There should be a weekly weight regardless is something is or is not happening .no there was no weekly weight as ordered .there should have been a weekly weight .I cannot justify anything about why it wasn't done. During an interview on 10/12/22, at 2:20 p.m., with the RD, the RD stated, A resident eating 25% repeatedly is definitely not okay. Someone needs to know about that. During a review of a facility policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, dated 09/17, the P&P indicated, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time .the staff and physician will .identify .high-risk residents with acute symptoms such as .infection .that may be causing or increasing the risk of .weight loss .The staff will report to the physician significant weight .losses or any abrupt of persistent change from baseline appetite or food intake .fluid deficits can result in rapid weight loss .The physician, with the help of the multidisciplinary team, will identify condition .that may be . increasing the risk of weight loss .The physician will review carefully, and rule out medical causes of, oral or swallowing problems .When medical conditions are causing or contributing to altered nutritional status, the physician and staff will collaborate .

Based on staff interview and closed record review, the facility failed to: 1. Conduct a comprehensive assessment related to the use of a urinary catheter (a tube inserted into the bladder in order to drain urine) for 1 of 23 sampled residents (21). The failure resulted in Resident 21 having a urinary catheter at the time of admission without follow-up for indication and a medical order. 2. Provide ongoing assessment, monitoring and care, including the consideration of potential complications related to the use of a urinary catheter, for 1 of 23 sampled residents (21). The failures resulted in Resident 21 being transferred and admitted to the acute care hospital with acute kidney injury (rapid loss of kidney function) due to [MEDICAL CONDITION] (lack of ability to urinate) from an obstructed urinary catheter (blockage). Findings: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21 was transferred to the acute care hospital on [DATE] due to worsening of her condition. Resident 21 was readmitted to the facility on [DATE] with updated [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 21, the "PATIENT DATA COLLECTION" dated 7/26/12 at 3:55 p.m., indicated Resident 21 had an indwelling foley catheter (urinary catheter) upon admission to the facility. Further review of Resident 21's clinical record revealed no documented evidence of a physician's order for use of a urinary catheter. Review of the Physician Discharge Summary (discharge date of [DATE]) revealed "(Resident 21's) condition got worse. She was transferred to (the hospital) for acute care." Review of Resident 21's clinical record revealed a History and Physical (from the acute care hospital) dated 9/9/12 at 5:40 p.m. The History and Physical included the "HISTORY OF PRESENT ILLNESS," which indicated Resident 21 "presented with an altered level of consciousness which started earlier on the day of admission. Normally, she is able to converse. She is a quadriplegic with an indwelling Foley catheter. The patient presented being altered. She also presented hypotensive (abnormally low blood pressure) with a blood pressure of 60/36 ... Her Foley (catheter) was also noted to be obstructed, with sediment in the catheter. The Foley was replaced in the (emergency room ), and immediately she was able to output about 2.5 L (liters; approximately 2.6 quarts) of urine." The History and Physical included the "PHYSICAL EXAMINATION ... ABDOMEN," which indicated "Abdomen on initial presentation is very distended, firm beneath the umbilicus with what appears to be a palpable mass and suspected bladder distention from [MEDICAL CONDITION]. The bladder did (decompress) after the Foley was replaced." The History and Physical included the "IMPRESSION," which indicated " ... acute altered level of consciousness [MEDICAL CONDITION], most likely secondary to a UTI from [MEDICAL CONDITION] secondary to her [MEDICAL CONDITION] bladder, also causing acute kidney injury ..." The History and Physical also included the "PLAN," which indicated the following: "... 2. Regarding the acute kidney injury, this is most likely secondary to [MEDICAL CONDITION] from her obstructed foley and [MEDICAL CONDITION] bladder. She was immediately able to put out 2.5 L upon replacement of the Foley catheter. 3. Regarding her altered level of consciousness, this is most likely secondary to [MEDICAL CONDITION] and uremia (a serious illness caused by the inability of the kidneys to eliminate waste products of metabolism)." Review of Resident 21's Nurse's Notes dated 9/9/12 (the date of transfer to the acute care hospital), indicated "At (1 p.m. Certified Nursing Assistant) came to this writer... and (requested) my emergency assessment, found (patient) lying on her back (with) both feet (up) on the (Trendelenburg) position (with one Certified Nursing Assistant at) bedside trying to (check blood pressure), (patient's) responsive to name calling by open eyes - quickly closed stating 'I'm dying.' 'Am I gonna die?' repeatedly. Skin (warm and dry), color pink (blood pressure) 64/10 palpated (apical pulse) = 88 (respiratory rate) = 20 Started (oxygen) via vent mask (at) 8 (liters per minute) (oxygen saturation level) 96% instructed staff to call 9-1-1 (Check) Advanced (Directive) She's a 'full code' few (minutes) later Fire (Department) 9-1-1 crews arrived (and) took over (5 p.m.) Placed call to (emergency room ) (Patient's) being admitted . (7:35 p.m.) MD called (and requested medications) list, (History and Physical) and additional info to fax to... (Patient's) now in ICU (with) UTI -[MEDICAL CONDITION] ..." Further review of Resident 21's Nurse's Notes, dated 8/22/12 through 9/9/12 revealed the only entry related to Resident 21's urinary catheter was dated 9/4/12 at 4:30 (a.m. or p.m. was not indicated). The note indicated "urine clear, (no) foul odor." There was no other documented evidence related to the assessment or monitoring of Resident 21's urinary catheter during this time (19 days). Review of Resident 21's Nursing Weekly Summaries, dated 8/4/12, 8/11/12, 8/17/12, 8/24/12, and 8/31/12, under the section titled "Bladder," indicated a checkmark in the box for "Incontinent (involuntary loss of urine)." The box titled "Indwelling Foley Catheter" was left unchecked on all five summaries. This represented five consecutive weeks of nursing summaries reflecting Resident 21's care. Review of Resident 21's "INDWELLING CATHETER CARE PLAN" dated 7/26/12, revealed the following interventions: 1) "Follow protocol for indwelling catheter care." 2) "Observe for adequate urine output." 3) "Observe for (signs and symptoms) of infection such as foul odor, blood in urine, sediments and other (signs and symptoms) of infection and refer to MM." Review of Resident 21's "TOTAL INTAKE AND OUTPUT RECORD" indicated Resident 21's fluid intake and output was monitored beginning 7/26/12 and was discontinued on 8/22/12. There was no documentation related to Resident 21's output from 8/22/12 through 9/9/12. Review of Resident 21's Treatment Administration Records, dated 7/1/12-7/30/12 and 8/1/12-8/30/12 revealed no documented evidence that urinary catheter care was performed. During an interview with the DON on 2/7/13 at 10:30 a.m., she stated catheter care was to be performed every shift and documented on the Treatment Administration Record. She stated catheters were only to be changed as needed (e.g., for leakage). She also stated fluid intake and output was monitored for only 30 days following admission for residents with urinary catheters. During an interview with the Director of Nursing (DON) on 2/7/13 at 12:20 p.m., she acknowledged there was no physician's order for a urinary catheter contained in the clinical record for Resident 21. During an interview with the DON on 2/7/13 at 2 p.m. regarding the lack of a physician's order for Resident 21's urinary catheter, lack of assessment and monitoring of Resident 21's urinary catheter, and the findings upon transfer to the acute care hospital, the DON stated she was unaware Resident 21 had developed [MEDICAL CONDITION] due to an obstructed urinary catheter. The DON stated, "I didn't know that." Review of the facility policy titled "Indwelling Catheter Care" dated 3/2000, included the following: "Purpose: Routine catheter care helps prevent infections and other complications and is usually performed daily ... Maintenance: Inspect the catheter tubing periodically to detect compression or kinking that could obstruct urine flow. Keep the drainage tube and collection bag lower than bladder at all times. Empty the collection bag at least every 8 hours ... Normal Voiding: The resident should normally void (within 24 hours) 300 to 400 ml/cc at a time, depending on fluid intake. If the resident voids small amounts (30 to 100 ml/cc every 30 minutes to 1 hour), notify the physician as resident is not emptying bladder completely. Follow physician's orders ... Monitoring: Assess for incontinence, urgency, dysuria or bladder spasms, fever, chills, or bladder distention ... Documentation: In the treatment record, record date and time catheter care was provided."