Every finding on record at El Centro Post-Acute Care

Based on observation, interview, and record review, the facility failed to provide a safe, nonhazardous environment when:1. A bathroom for one of six residents (Resident 122), had a loose toilet seat, that was not tightened down and moved from side to side; and2. Hazards were identified in two of three resident shower rooms (Shower rooms [ROOM NUMBERS] ). These failures had the potential for Resident 122 to become unbalanced and fall while using the bathroom and for residents using Station 1 and Station 2's shower room to cut, puncture, or injure themselves from the shower stall hazards.On 1/06/26 at 3:09 P.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 4 of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]). CNA 4 stated there were orange-colored screws next to the handlebar that were protruding out from the tile, under the faucet, and next to the shower handlebar. CNA 4 stated she did not know why the screws were there. CNA 4 stated if a resident brushed up against a screw it could have caused a resident to get a skin tear, scrape, or be injured. On 1/6/26 at 3:34 P.M., an observation and interview was conducted with the Director of Nursing (DON) of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]). The DON stated there were orange-colored screws sticking out from tiles, next to the handlebar, and under the water knob. The DON stated the white porcelain soap dish was broken and had jagged edges. The DON stated the screws and the broken soap dish were potential safety hazard because someone could have gotten cut or scrape their skin. The DON stated her expectation was that the soap dish and screws would have been removed immediately so no one would have been injured. On 1/6/26 at 3:48 P.M., a joint interview and observation was conducted with the Administrator (ADM) and Maintenance Director (MD) of shower room [ROOM NUMBER]. The MD stated he should have removed the protruding screws because someone could get hurt. The ADM stated they had been aware the showers needed to be worked on and that the screws needed to be removed and it should have been done. On 1/9/26 at 9:15 A.M., a joint interview was conducted with the Director of Nursing (DON) and the Administration (ADM). The DON and ADM stated they were aware that the showers needed repair and the dish soap was broken. The ADM stated there had been a QAPI (Quality Assurance Performance Improvement - a proactive approach to improving quality of care and resident safety) project identified to improve the environment. The DON stated her expectation was that the showers be safe for the residents' use. A review of the facility's policy titled Maintenance Service dated December 2009 indicated Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to .b. Maintaining the building in good repair and free from hazards.i. Providing routinely scheduled maintenance service to all areas.3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. Resident 122 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following an intestinal obstruction (blockage), per the facility's admission Record. An interview was conducted with Resident 122 in his room, during initial tour on 1/6/26 at 8:36 A.M. Resident 122 stated his toilet seat had been loose since he arrived to the facility and he had asked numerous staff that it needed to be fixed. Resident 122 stated he was afraid he would fall every time he used the bathroom. An observation of Resident 122's bathroom was conducted on 1/6/26 at 8:37 A.M. The toilet seat moved from side to side when touch with my shoe and needed to be tightened down. A review of Station 1's maintenance book was conducted on 1/6/26 at 11:05 A.M. at the nursing station. There was no documented evidence in the maintenance book that Resident 122's toilet seat was identified as loose and a repair was requested. On 1/6/25, Resident 122's clinical record as reviewed. According to the Minimum Data Set (MDS - a clinical assessment tool), dated 12/30/25, Resident 122 had a cognitive score of 13, indicating cognition was intact. Resident 122's functional abilities assessment indicated he was independent and could ambulate on his own without any assistive devices. An observation and interview was conducted with certified nursing assistant (CNA 3) of Resident 122's toilet seat on 1/7/26 at 12:16 P.M. CNA 3 observed the loose toilet seat and stated someone could fall when trying to sit down or stand up. CNA 3 stated the toilet seat repair should be put in the maintenance book right away to avoid any injuries. A review of the maintenance book was conducted with CNA 3 on 1/7/26 12:21 P.M. CNA 3 stated the toilet seat for Resident 122 was not listed in the book, so she would log it in now and call the maintenance department. An observation and interview was conducted with Licensed Nurse 2 (LN 2) of Resident 122's bathroom on 1/7/26 at 12:23 P.M. LN 2 observed the loose toilet seat and stated, That's definitely a safety issue. An observation and interview of Resident 122's bathroom was conducted with the Administrator (ADM) on 1/7/26 at 12:30 P.M. The ADM observed the loose toilet seat and stated, That should have been reported and fixed. The ADM stated if Resident 122 told staff about the seat, she expected them to put the repair in the maintenance book so it could be fixed. An interview was conducted Director of Nursing (DON) on 1/8/26 at 11:41 A.M. The DON stated she expected staff to identify potential hazards and place the hazards in the maintenance book, so repairs could be made. According to the facility's policy, titled Falls and Fall Risk, Managing, dated 2001, .Fall Risk Factors: 1. Environmental factors that contribute to the risk of falls.

Based on observation and interview, the facility failed to implement and maintain infection control standards of practice when: Two of three shower rooms were found with black residue on the grout between the tiles. Resident 89's nebulizer tubing and mask were not discarded and changed weekly. These deficient practices had potential risks for residents and staff to contract infections. Findings: On 1/6/26 at 3:09 P.M., a joint observation and interview of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]) was conducted with Licensed Nurse (LN) 3 and LN4. The shower stall had dark, scattered black residue in some of the grout and tiles on the wall and floor. In addition, there was dark, brownish, orange-colored streaks scattered on some of the tiles and next to the handrail. There was hair on the floor. LN3 stated the substance looked like mold and rust. LN3 stated the shower had not been cleaned between residents. LN4 stated the shower was not clean and it was important to be clean to prevent infection. On 1/6/26 at 3:18 P.M., an observation and interview of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]) was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated the black residue between the tiles looked like mold and that the shower stall was not clean. CNA 4 stated this would not be considered clean at her house. CNA 4 stated it was important to be cleaned to prevent infection. CNA 4 stated each CNA was to clean the shower at the end of every shift. CNA 4 stated housekeeping was to deep clean the shower at the end of every shift. CNA 4 stated she was not sure if a CNA or a housekeeper had cleaned shower 1 between residents. CNA 4 stated there was not a log kept of shower cleaning. On 1/6/26 at 3:34 P.M., an observation and interview was conducted with the Director of Nursing (DON) of shower room [ROOM NUMBER] (located by room [ROOM NUMBER]). The shower stall had dark, scattered black residue in some of the grout and tiles on the wall and floor. In addition, there was dark, brownish, orange-colored streaks scattered on some of the tiles and next to the handrail. The DON stated the black colored substance could have been mold and the shower stall was not clean. The DON stated this could have been an infection control problem and it was important for the shower stall to be clean. On 1/6/26 at 3:48 P.M., a joint interview and observation was conducted with the Administrator (ADM) and Maintenance Director (MD) of shower room [ROOM NUMBER]. The MD stated the shower had looked like this for a very long time and did not look clean. The MD stated the black substance looked like mold and stated there was rust on the tiles. The ADM stated they had been aware that the showers had a dark black substance in the grout areas and rust on the tiles. The ADM stated the grout should have been white and should not have had black substance on it because it could have been mold and could have been an infection control issue. On 1/9/26 at 9:15 A.M., an interview was conducted with the ADM and the DON regarding shower rooms [ROOM NUMBERS]. The DON stated the shower stalls should have been wiped down with bleach wipes after each resident's shower for infection control purposes. The ADM and the DON stated shower stalls should be maintained in a cleanly manner at all times. The DON stated her expectation was that the dark, black mold should not have been present in the showers to prevent infection. A review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces revised August 2019 indicated, Policy Statement Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne pathogens standard.10. Environmental surfaces will be disinfected (or cleaned) on a regular basis. A review of the facility's policy titled Shower Policy revised February 2023, indicated .Post Shower .3. Clean and disinfect the shower area 2. Per the admission Record, Resident 89 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness. On 1/7/26 at 9:40 A.M., a concurrent observation and interview was conducted with the Respiratory Therapist (RT) during a nebulizer breathing treatment (a small machine with a compressor, tubing, and medicine cup that creates the mist for breathing medicine). Resident 89's mask was observed labeled with a date of 12/28/25. The RT stated the mask should be changed weekly and that he did not notice the date on Resident 89's mask. The RT stated the mask should have been changed for infection prevention. On 1/9/26 at 9:25 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation and the facility policy that nebulizer tubing and mask were changed weekly for infection control. A review of the facility policy titled Respiratory Therapy - Prevention of Infection, dated 11/2001, indicated staff are to .discard the (nebulizer) administration set up every seven days .)

Based on observations, interviews, and record review, the facility failed to follow professional standards for food service safety regarding storage when expired fish was found in a walk-in refrigerator.This failure had the potential to spread foodborne illness.On 1/6/26, at 8:30 A.M., a concurrent observation and interview was conducted with the Dietary Supervisor (DS) during an inspection of the walk-in refrigerator. A tray of fish covered with plastic was found labeled with an expiration date of 1/5/26. The DS stated this should have been discarded because it was expired. A facility policy titled Food Storage, dated 8/29/23, indicated that .any expired or outdated food products should be discarded .

Based on observation, interview, and record review, the facility failed to maintain and provide a safe, home-like environment when: 1. Resident rooms located on Station 1 were in need of repair for five of 20 rooms (Residents 54,118, 119, 122, and 137); and2. Resident rooms located on Station 2 were in need of repair for four of 20 rooms (Residents 5, 20, 51, and 90). These failures had the potential for residents to feel undervalued and unappreciated.2a. A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (an area of brain tissue death caused by a lack of blood flow and oxygen). On 1/6/26 at 8:19 A.M., an observation and interview was conducted with Resident 20 while inside the resident's room. The wall behind Resident 20's bed had been painted an olive-green color and had numerous areas of white colored streaks on it. On the wall across from Resident 20's bed, there was a power supply cable attached to a hanging cable box. A television monitor screen was hanging from the cable box. The television monitor and cable box had cords hanging down from it. Resident 20 stated the cable box had been like that for a long time. Resident 20 stated she felt like no one cared what her room looked like. 2b. A review of Resident 90's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of Intervertebral disc disorder (the degeneration or breakdown of the spinal discs), muscle weakness and dementia. On 1/6/26 at 8:35 A.M., an observation was conducted in Resident 90's room. Resident 90 was not in her room. The wall behind Resident 90's headboard had been painted an olive-green color. The olive-green paint had been scraped down to the white drywall in various areas behind the headboard. The baseboard next to Resident 90's garbage can had been removed from the wall and drywall was exposed. On 1/6/26 at 8:52 A.M., an observation and interview was conducted with the Maintenance Director (MD) of Resident 20 and 90's rooms. The MD stated the power supply cables, cable boxes and wires had been hanging on the walls in many resident's rooms for a while and he was not sure when the cable boxes would be repaired. The MD stated when baseboards were removed from walls and drywall was exposed; he should have fixed it immediately. The MD stated he would not have exposed drywall at his home. The MD stated the rooms did not create a homelike environment. 2c. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of unspecified dementia (a progressive state of decline in mental abilities), muscle weakness and hemiplegia (a form of paralysis that causes weakness, loss of motor function, or complete paralysis on one side of the body). On 1/6/26 at 10:08 A.M., an observation was conducted of Resident 5's room. Resident 5 was not interviewable. The baseboard in Resident 5's room had been removed from the wall revealing white dry wall. On the wall across from Resident 5's bed were exposed cables hanging from a power supply cable box. An empty black cable box bracket was attached to the wall. Dry mounting tape and 4 drywall anchors were painted over next to the cable box. 2d. A review of Resident 51's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anxiety disorder and dementia. On 1/6/26 at 10:13 A.M., an observation was conducted in Resident 51's room. Resident 51 was not interviewable. The wall behind Resident 51's headboard had been painted an olive-green color. The olive-green paint had been scraped down to the white drywall in various areas behind the headboard. On 1/9/26 at 9:15 A.M., a joint interview was conducted with the Director of Nursing (DON) and the Administration (ADM). The DON and ADM stated they were aware the Resident rooms had baseboards pulled away with sheetrock exposed, cable television boxes hung with no televisions, wires displayed, walls with no paint and white sheet rock exposed. The ADM stated the resident rooms were not a homelike environment. The ADM stated that there had been a QAPI (Quality Assurance and Performance Improvement - a proactive approach combining QA and PI to improve resident care, safety, and quality of life) project identified for homelike environment. The DON stated that her expectation was that the resident rooms be clean and aesthetically pleasing and should be homelike for the residents. A review of the facility's policy titled Maintenance Service dated December 2009 indicated Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to .b. Maintaining the building in good repair and free from hazards.i. Providing routinely scheduled maintenance service to all areas.3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Findings: 1a. Resident 118 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-ineffective gas exchange within the lungs), per the facility's admission Record. According to Resident 118's admission Minimum Data Set (a clinical assessment tool), dated 12/27/25, a cognitive score of 12 was listed, indicting cognition was intact. An observation and interview was conducted during initial tour of Resident 118's room on 1/6/26 at 8:09 A.M. Resident 118 had a plastic trash bag tied to an overhead light metal cord. The trash bag hung to the left side of her upper side rail. Resident 118 stated a nurse tied this on, so I could turn my overhead light off and on. Resident 118 stated it looked tacky and was not homelike, but she needed something that worked. 1b. Resident 119 was admitted to the facility on [DATE], with diagnoses which included sepsis (a serious condition when the body responds improperly to an infection), per the facility's admission Record. According to Resident 119's admission MDS, dated [DATE], a cognitive score of 14 was listed, indicating cognition was intact. An observation and interview was conducted during initial tour of Resident 119's room on 1/6/26 at 8:12 A.M. A large, splintered wooden board was broken and pointing upwards near the head of the bed. Resident 119 stated, it broke 2-3 nights ago and staff looked at it and said they would have it fixed. Resident 119 stated she was unaware if the maintenance department was aware of the broken board. Resident 119 asked if I could turn off her overhead light, because she could not reach it and it was on 24/7. The metal cord only hung two inches from the overhead light, above the bed and was unreachable by the resident.The overhead light was approximately 4 feet above the head of the bed. An observation and interview was conducted with Resident 119's visitor, on 1/7/22 at 12:06 P.M., who identified herself as Resident 119's home caregiver. The visitor stated she saw the broken splintered board yesterday when she came in, and thought , That could cause an injury if Resident 119 fell into it. The visitor stated she was glad to see someone pushed the splintered board back downwards, but it still needed to be repaired correctly. The visitor stated it looked really bad yesterday, and hopefully they would fix it properly once Resident 119 was discharged home. 1c. Resident 122 was admitted to the facility on [DATE], with diagnoses which included surgical aftercare following an intestinal obstruction (blockage), per the facility's admission Record. According to Resident 112's MDS, dated [DATE], a cognitive score of 14 as listed, indicating cognition was intact. An observation and interview was conducted during initial tour of Resident 122's room on 1/6/26 at 8:32 A.M. Two plastic bags were tied together and wrapped around the upper right siderail. The plastic bags were tied to a metal overhead cord, used for turning the overhead light off and on. Resident 122 stated a nurse did that for him, because he could not reach the metal cord himself. Resident 122 stated if you think that's bad, check out the wall on the other side of my bed and also in the bathroom. The wall on the other side of Resident 122's bed had large indentations and needed plaster repair, along with paint. The bathroom wall opposite the toilet had a large plaster area, that was rough and not sanded. Resident 122 stated, the walls looked awful and unkept, like they have no pride in the facility's appearance. Resident 122 stated he was being discharge the following day and he was glad to be going home. 1d. Resident 137 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. An admission MDS assessment had not yet been completed, due to the recent admission. An observation and interview was conducted with family visiting Resident 137, in her room on 1/7/26 at 1:50 P.M. Resident 137 was asleep in the bed and family were sitting in chairs next to the bed. On the wall next to the head of the bed, was wallpaper. The wallpaper was torn and peeling downwards. A visible uncovered phone socket was also on the wall near the head of the bed. The family members stated the room was not in good condition and did not present a homelike environment. 1e. Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. According to Resident 54's quarterly MDS, dated [DATE], Resident 54 had a cognitive score of 5, indicating severe cognitive impairment. An observation was conducted of Resident 54's room on 1/7/264 at 12:15 P.M. The bed was empty and made. On the wall, near the head of the bed was multiple areas of peeling wallpaper. An observation and interview was conducted with certified nursing assistant (CNA 3) on 1/7/26 at 12:16 P.M. of Resident 112 and 54's room. CNA 3 stated if repairs were identified by staff, they were expected to put the repairs needed in the maintenance book, as a means of communication. CNA 3 observed the walls in Resident 137's and 54's room and stated, the walls do not look homelike, and if the resident were confused, they could peel off and ingest the wallpaper without realizing it could be harmful. An observation and interview was conducted with Licensed Nurse 2 (LN 2) on 1/7/26 at 12:23 P.M. of Resident 118, 119, and 122's room. LN 2 stated yes, the plastic bags and broken wood did not appear homelike and it looked tacky. An observation and interview was conducted with the Administrator (ADM) of the resident rooms on 1/7/26 at 12:30 P.M. The ADM stated yes, those were easy fixes and should have been corrected. The ADM stated they were in the process of re-doing resident rooms and had identified repairs were needed. An interview was conducted with the Director of Nursing (DON) on 1/8/26 at 11:41 A.M. The DON stated expected all the resident rooms to be in order and present as homelike. The DON stated she expected staff to identify repairs when needed and to document those repairs in the maintenance repair book. According to the facility's policy, titled Homelike Environment, dated 2021, .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Theses characteristics include: a. clean, sanitary and orderly environment; .

Based on interviews and record review, the facility failed to ensure a medication order was accurately documented for one of ten sampled residents (Resident 72) when a medication taken by mouth was ordered for a patient who receives medication via a gastronomy-tube (G-Tube - tube placed through the belly directly into the stomach to deliver liquid food, medicine, and fluids when someone can't eat enough by mouth).This failure had the potential for Resident 72 to be administered medications via the wrong route.Findings:Per the admission Record, Resident 72 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrotomy (opening made into the stomach) for g-tube. On 1/8/26 at 11:00 A.M., a record review of Resident 72's physician's orders was conducted. On 1/1/26 an order for Cephalexin 200mg tablet - 1 tablet four times a day by mouth for cellulitis (infection that makes the skin red, swollen, warm, and painful) to stoma (surgically created opening in the body) until 1/12/26 was placed and documented in Resident 72's clinical record. On 1/9/26 at 9:00 A.M., an interview was conducted with the administrator (ADM) and the director of nursing (DON). The DON stated Resident 72's medication order should have been documented as via GT and not by mouth. The DON stated it was her expectation that licensed nurses were to accurately document physician orders.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent during a random medication pass observation process for one of four residents (Resident 72). Resident 72 had four medications administered incorrectly. The facility's medication error rate was 13.79 percent. As a result, there was the potential for the four medications to become ineffective when crushed, combined, and administered together. (Cross Reference F-658 and F-842)Resident 72 was admitted to the facility on [DATE], with diagnoses which included hemiplegia following cerebral infarction affecting the right side (stroke with weakness on the right extremities) and dysphagia (difficulty swallowing), per the facility's admission Record. An observation of medication preparation and administration was conducted with Licensed Nurse (LN 3) for Resident 72 on 1/7/26 at 10:12 A.M. LN 3 removed four separate medications and crushed them individually. The four medications included:Tamsulosin 0.4 milligrams (mg) (for enlarged prostate)Finasteride 5 mg (for enlarged prostate)Clopidogrel 75 mg (anticoagulant for thinning the blood)Cephalexin 500 mg (antibiotic for infection)LN 3 was observed combining the four medications into one clear plastic medication cup and added 30 cubic centimeters (cc) of water for dilution. The mixture turned white. An observation of LN 3 administering the four diluted medications was conducted on 1/7/25 at 10:16 A.M. LN 3 aspirated the diluted medication solution from the clear plastic cup, with a large 60 cc syringe. LN 3 attempted to administer the medication via the syringe and had resistance. LN 4 obtained a new 60 cc syringe after 3 attempts with the old syringe, and the medication was administered using the syringe plunger to push the medication in. LN 3 withdrew 30 cc of water from a cup with the syringe and used the plunger to push the water in, flushing the G-tube (a surgically inserted tube going into the stomach to provide nourishment, hydration, and medication when someone is unable to swallow safely on their own). An interview was conducted with LN 3 on 1/7/26 at 10:40 A.M., after completing medication administration. LN 3 stated when she started at the facility three months ago, they did train and orient her on medication administration, but she did not receive any training for G-tube medication administration. LN 3 stated she was trained in nursing school to combine all the medications and then administer it. An interview was conducted with LN 4 on 1/7/26 at 10;46 A.M. LN 4 stated all crushed medication needed to be administered separately via G-tube to prevent any counter interactions, losing the effectiveness for each medication. Resident 72's clinical record was reviewed on 1/7/26 at 11 A.M. According to the physician's order dated 9/4/25, Check placement of G-tube before administering medication. Notify medical doctor if placement is not confirmed. In addition, dated 9/30/25, give Tamsulosin HCL oral capsule 0.4 mg. Open capsule to release contents. Mix with 10 cc of water, administer immediately to prevent beads from clumping. Also, dated 1/4/26, give cephalexin 500 mg, give one tablet by mouth (not G-tube) every four hours for cellulitis (infection in the soft tissue) to stoma (G-tube site). An interview was conducted with the Director of Staff Services (DSD) on 1/7/26 at 11:32 A.M. The DSD stated she trained all licensed nurses upon hire for medication administration. The DSD stated she had LNs first watch a video on medication administration and then she shadowed them during medication administration to ensure they had the skills and training to safely administer medication. The DSD stated her training and observation included administering medication via G-tube. The DSD stated she expected all staff to administer the medications separately. with flushes in between. LN 3's employee file was reviewed on 1/7/26 at 11:40 A.M. According to the facility's New Hire Pharmacy Skills Checklist, dated 8/15/25 was checked for competency. Technique for crushing medications was signed off by the DSD as competent The skills check for Medication Administered via Feeding Tube, was listed as, Not Applicable and signed by the DSD. A follow up interview and record review was conducted with the DSD on 1/7/26 at 11:49 A.M., of LN 3 New Hire Pharmacy Skills Checklist. The DSD stated that was her signature on the Skills Checklist and she checked, Not Applicable on LN 3's skills list, because she did not observe a G-tube medication administration and she now realized she should have. An interview was conducted with the Director of Nursing (DON) on 1/8/26 at 11:41 A.M. The DON stated Resident 72's medications were not administered properly, and they should have been. The DON stated she expected all nurses to follow the nursing standard of practice listed in their policy for G-tube medication administration. According to the facility's policy, titled Administering Medication through an Enteral Tube, dated 2001, . 10. Administer each medication separately.13. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount).

Based on interview and record review, the facility failed to ensure adequate monitoring was provided for one of five sampled residents (Residents 42) receiving anticoagulant (blood thinner) medication. This had the potential to cause harm and compromise Resident 42's health and safety if signs and symptoms went undetected.Findings:A review of Resident 42's admission Record, indicated the resident was admitted to the facility on [DATE] with a diagnosis that included atherosclerotic (hardening of the arteries) heart disease.On 1/7/26 at 3:01 P.M., an interview and record review was conducted with Licensed Nurse (LN) 20. LN 20 reviewed Resident 42's physician's order. The Physician's order indicated, Clopidogrel Bisulfate tablet 75 milligrams (mg) one tablet by mouth daily for Cerebrovascular Accident (CVA-stroke) prevention. LN 20 stated there was no documentation for monitoring the negative side effects of the blood thinner for Resident 42 and there should have been. LN 20 stated it was important to monitor negative side effects for patient safety.On 1/8/26 at 2:20 P.M., a telephone interview was conducted with the Pharmacist (PH). The PH stated general side effects for Clopidogrel Bisulfate was abnormal bleeding, bruising, abdominal pain, bloody stools, nosebleeds. The PH stated monitoring for negative side effects should have been documented. The PH stated during the monthly medication review, the lack of documentation for negative side effects should have been identified.On 1/8/26 at 2:55 P.M., a joint interview was conducted with the Director of Nursing (DON), and the Administrator (ADM), also present was the Nurse Consultant (NC). The DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner.A review of the facility's policy titled Anticoagulant, revised November 2018, indicated .5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated.

Based on observation, interview, and record review, the facility failed to demonstrate a Nursing Standards of Practice during administration of medications via a gastrointestinal tube (G-Tube, a surgically inserted tube going into the stomach to provide nourishment, hydration, and medication when someone is unable to swallow safely on their own) for one of two residents (Resident 72) reviewed for G-Tube feeding. This failure had the potential for harm, when placement of the G-tube was not checked prior to medication administration, administering the crushed medications together, and using a syringe plunger to administer the medication instead of gravity, potentially causing too much pressure in the flexible tube, resulting in an implosion of the internal G-tube.(Cross reference F-759)Findings: Resident 72 was admitted to the facility on [DATE], with diagnoses which included hemiplegia following cerebral infarction affecting the right side (stroke with weakness on the right extremities) and dysphagia (difficulty swallowing), per the facility's admission Record. An observation of medication preparation and administration was conducted with Licensed Nurse 3 (LN 3) for Resident 72, on 1/7/26 at 10:12 A.M. LN 3 removed four separate medications and crushed them individually. The four medications included:Tamsulosin 0.4 milligrams (mg) (for enlarged prostate)Finasteride 5 mg (for enlarged prostate)Clopidogrel 75 mg (anticoagulant for thinning the blood)Cephalexin 500 mg (antibiotic for infection)LN 3 combined the four medications into one clear plastic medication cup and added 30 cubic centimeters (cc) of water for dilution. The mixture solution turned white. An observation of LN 3 administering the four diluted medications was conducted on 1/7/25 at 10:16 A.M. LN 3 did not check the G-Tube for proper placement before starting administration. LN 3 aspirated the diluted medication solution from the clear plastic cup with a large 60 cc syringe. LN 3 attempted to administer the medication via the syringe and had resistance when plunging. LN 4 obtained a new 60 cc syringe after 3 attempts with the old syringe, and the medication was administered using the syringe plunger to push the medication in. LN 3 withdrew 30 cc of water from a plastic cup with the syringe and used the plunger to push the water into the G-tube. An interview was conducted with LN 3 on 1/7/26 at 10:40 A.M., after completing medication administration. LN 3 stated she was taught in school to check for G-tube placement to make sure it was inserted into the stomach. LN 3 stated she should have checked Resident 72 for placement and she did not. LN 3 stated when she started at the facility three months ago, they did train and orient her on medication administration, but she did not receive any training for G-tube medication administration. An interview was conducted with LN 4 on 1/7/26 at 10:46 A.M. LN 4 stated it was important to always check G-tube placement before putting anything in the tube because the tube could have accidentally moved outside the stomach. LN 4 stated all crushed medication needed to be administered separately via G-tube to prevent any counter interactions or losing the effectiveness of each medication. LN 4 stated a syringe plunger should never be used to administer medication because the pressure used could rupture the tube. LN 4 stated medication and flushes should be administered by using gravity, for smooth, non-pressured administration. LN 4 stated all nurses needed to utilize the nursing standard of practice when administering medications via G-tube. Resident 72's clinical record was reviewed on 1/7/26 at 11 A.M. According to the physician's order dated 9/4/25: Check placement of G-tube before administering medication. Notify medical doctor if placement is not confirmed. In addition, dated 9/30/25, give Tamsulosin HCL oral capsule 0.4 mg. Open capsule to release contents. Mix with 10 cc of water, administer immediately to prevent beads from clumping. Also, dated 1/4/26, give cephalexin 500 mg, one tablet by mouth (not G-tube) every four hours for cellulitis (infection in the soft tissue) to stoma (G-tube site). An interview was conducted with the Director of Staff Services (DSD) on 1/7/26 at 11:32 A.M. The DSD stated she trained all licensed nurses upon hire for medication administration. The DSD stated she had LNs first watch a video on medication administration and then she shadowed them during medication administration to ensure they had the skills and training to safely administer medication. The DSD stated her training and observation included administering medication via G-tube. The DSD stated she expected all staff to check placement of G-tube, administer the medications separately, and to use gravity flow. LN 3's employee file was reviewed on 1/7/26 at 10:40 A.M. According to the facility's New Hire Pharmacy Skills Checklist, dated 8/15/25, LN 3 was signed off as competent by the DSD for crushing medications. The skills check for Medication Administered via Feeding Tube, was listed as, Not Applicable and signed by the DSD. A follow up interview and record review was conducted with the DSD on 1/7/26 at 11:49 A.M., of LN 3 New Hire Pharmacy Skills Checklist. The DSD stated that was her signature on the Skills Checklist and she checked, Not Applicable on LN 3's skills list because she did not observe a G-tube medication administration and she now realized she should have. An interview was conducted with the Director of Nursing (DON) on 1/8/26 at 11:41 A.M. The DON stated Resident 72's medications were not administered properly, and they should have been. The DON stated she expected all nurses to follow the nursing standard of practice listed in their policy for G-tube medication administration. According to the facility's policy, titled Administering Medication through an Enteral Tube, dated 2001, . 6. Verify placement of feeding tube.10. Administer each medication separately.12. Administer medication by gravity flow: a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion.13. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount).

Based on interview and record review, the facility failed to implement a care plan related to monitoring an anticoagulant (blood thinner) for one of nine residents (Resident 42) reviewed for care plans.This had the potential to cause negative side effects and compromise Resident 42's health and safety.Findings:A review of Resident 42's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included atherosclerotic (hardening of the arteries) heart disease. On 1/7/26 at 3:01 P.M., an interview and record review was conducted with Licensed Nurse (LN) 20. LN 20 reviewed Resident 42's care plan and physician's order. The physician's order indicated, Clopidogrel Bisulfate tablet 75 milligrams (mg) one tablet by mouth daily for Cerebrovascular Accident (CVA-stroke) prevention. The care plan titled Antiplatelet Care Plan indicated, risk for active bleeding, interventions to observe for signs and symptoms of abnormal bleeding such as bleeding gums, nosebleeds, black/tarry stools. LN 20 stated it was important to monitor and document negative side effects for patient safety. LN 20 stated the care plan should have been followed. On 1/8/26 at 2:55 P.M., a joint interview was conducted with the Director of Nursing (DON), and the Administrator (ADM), also present was the Nurse Consultant (NC). The DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner. The DON stated her expectations were for nursing staff to follow the care plans for residents. A review of the facility's policy titled Care Plan, revised November 2016, indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to promote dignity while assisting with a meal for one of three residents (Resident 70), by standing over the resident reviewed for Resident Rights. This failure had the potential for Resident 70 to feel overpowered, rushed, and undignified. Findings:Resident 70 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain disorder), per the facility's admission Record.An observation was conducted inside Resident 70's room during lunch time on 1/6/26 at 12:38 P.M. A staff member was standing on the right side of the bed, feeding Resident 70 a pureed diet (a modified diet consisting of foods blended or mashed until they are smooth, moist, and pudding-like). The staff member was standing approximately 2 feet over the resident's head. An interview was conducted with the staff member, identified as certified nursing assistant 1 (CNA1), on 1/6/25 at 12:40 P.M., outside Resident 70's room. CNA 1 stated she thought it was alright to stand while feeding residents, that no one had ever told her otherwise. An interview was conducted with CNA 2 on 1/8/26 at 8:48 A.M. CNA 2 stated staff should always be at an eye to eye level while feeding residents. CNA 2 stated sitting eye-to-eye with a resident was important to identify early signs of choking, to show respect, and to encourage socialization.An interview was conducted with Licensed Nurse 1 (LN 1) on 1/8/26 at 8:53 A.M. LN 1 stated staff were expected to sit at an eye-to-eye level when feeding residents. LN 1 stated sitting with the resident during meals, demonstrated respect and encouraged the resident to take their time while eating. An interview was conducted with the Director of Nursing (DON) on 1/8/26 at 11:41 A.M. The DON stated she expected all staff to be at an eye-to-eye level when assisting residents with meals. The DON stated they could raise the bed up to maintain the eye to eye level, or sit next to the resident.According to the facility's policy, titled Assistance with Meals, dated 2017, .3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, example: a. Not standing over the residents while assisting them with meals.

Based on observation, interview, and record review, the facility failed to administer pain medication for the appropriate pain scale as indicated by the physician ' s orders for one of two residents (Resident 1) reviewed for pain management. This deficient practice had the potential to cause Resident 1 further discomfort and pain. Findings: A review of the facility ' s Admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included a fracture of the right humerus (a broken right upper arm bone), lack of coordination, and muscle weakness. A review of the Minimum Data Set (MDS, an assessment tool) dated 9/21/24, indicated Resident 1 was cognitively intact with a BIMS (assessment of cognition) score of 14. A review of the physician ' s orders dated 9/20/24 indicated, Oxycodone HCL Oral Tablet 5mg Give 1 tablet by mouth every 4 hours as needed for moderate pain . and Oxycodone HCl Tablet 10mg Give 1 tablet every 4 hours as needed for Severe Pain Score 7-10 for 7 days . On 9/24/2024 at 12:37 P.M., an observation was conducted in Resident 1 ' s room. Resident 1 was sitting in her wheelchair, and her right arm was placed in a sling. Resident 1 was observed with facial grimacing, quietly moaning, with the left hand placed over the right shoulder. Resident 1 stated she was in pain and wanted pain medication. During a medication pass observation on 9/24/24 at 12:47 P.M., Licensed Nurse (LN 1) asked Resident 1 to rate her pain on a scale of one to ten, with ten being the worst pain. Resident 1 stated she had 8/10 pain to the right arm. LN 1 was observed reviewing Resident 1 ' s Medication Administration Record. LN 1 took a medication out of the narcotic drawer and placed one pill into a medication cup, and administered it to Resident 1. LN 1 stated [Resident 1] can have Oxycodone 5mg for severe pain, but if her pain is less than 7, I give her Tylenol . On 9/24/24 at 1:10 P.M., a concurrent interview and record review was conducted with LN 1. A review of the physician ' s orders dated 9/20/24 indicated, Oxycodone HCL Oral Tablet 5mg Give 1 tablet by mouth every 4 hours as needed for moderate pain . and Oxycodone HCl Tablet 10mg Give 1 tablet every 4 hours as needed for Severe Pain Score 7-10 for 7 days . LN 1 stated .(Resident 1) is allowed to have 10mg for severe pain .but I didn ' t see it . LN 1 stated since Resident 1 reported severe pain, Oxycodone 10mg should have been administered. LN 1 stated it was important to manage pain .to make sure the resident is comfortable, its important for healing also . A review of Resident 1 ' s EMAR (Electronic Medical Administration Record) indicated Resident 1 received Oxycodone 5mg with a severe pain level instead of Oxycodone 10mg, on the following days: -9/21/24 at 3:09 A.M. for a pain level of 9/10 -9/21/24 at 12:24 P.M. for a pain level of 7/10 -9/21/24 at 4:50 P.M. for a pain level of 7/10 -9/22/24 at 5:45 A.M. for a pain level of 9/10 -9/24/24 at 1:13 P.M. for a pain level of 8/10 On 9/24/24 at 2 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was .for the resident to maintain a manageable pain level . The DON stated Resident 1 should have been given Oxycodone 10mg for a pain level of 7 or above, instead of Oxycodone 5mg. The DON stated by not administering the appropriate dose to address Resident 1 ' s pain, Resident 1 was at risk for further discomfort and a delay of healing. A review of the facility policy titled Pain-Clinical Protocol revised 10/22 indicated, .The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity .staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident ' s cognitive level .Staff will provide the elements of .appropriate physical .interventions .

Based on observation, interview, record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff were fit tested for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents, which had the potential to affect all residents that resided in the facility, and failed to use proper hand hygiene during catheter care for 1 (Resident #221) of 1 resident observed for catheter care. Findings included: 1. A facility policy titled, Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak), revised 09/2021, specified, When N95 filtering facepiece respirators (FFR) are available and there is not an anticipated shortage, the facility operates under conventional capacity measures, including: a. using airborne isolation rooms for aerosol-generating procedures performed on residents with suspected or confirmed SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] infection. A facility policy titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, revised 09/2022, specified, 4. When caring for a resident with suspected or confirmed SARs-CoV-2 infection: b. Respirator: (1) An N95 respirator (or equivalent or higher-level respirator) is donned before entry into the resident room or care area. CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 03/18/2024, indicated, HCP [healthcare providers] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use NIOSH [National Institute for Occupational Safety and Health] Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protections. During an interview on 09/11/2024 at 1:15 PM, the Infection Preventionist (IP) stated they were not doing any N95 fit testing. The IP stated she did not know N95 fit testing was required until August (2024). The IP stated they were using KN95 masks. During an interview on 09/11/2024 at 3:03 PM, the Director of Nursing (DON) stated the facility was not doing any N95 fit testing. During an interview on 09/12/2024 at 1:42 PM, the Executive Director stated the facility was not completing N95 fit testing. The Executive Director stated he expected his clinical team to know if they were required to complete N95 fit testing. 40141 2. An Admission Record indicated the facility admitted Resident #221 on 09/06/2024. According to the Admission Record, the resident had medical history that included a diagnosis of urinary tract infection. Resident #221's care plan included an undated focus area that indicated the resident required an indwelling urinary catheter and was at risk for urinary tract infection. Interventions directed staff to provide catheter care and perineal care every shift and as needed. During an observation of indwelling catheter care on 09/11/2024 at 1:45 PM, Certified Nurse Assistant (CNA) #5 performed hand hygiene and donned gloves. CNA #5 provided catheter care for Resident #221, and then, without changing gloves, turned the resident onto their side and started cleansing bowel movement from the resident's buttocks. CNA #5 placed the soiled wipes into the soiled brief, rolled the soiled brief, and removed it. Without changing gloves, CNA #5 obtained and applied a clean brief. CNA #5 then touched the resident's shirt, the package of wipes, the sheet to cover the resident, and used the bed controller to reposition the bed before she removed her gloves. During an interview on 09/11/2024 at 1:55 PM, CNA #5 stated catheter care was provided by going from clean to dirty tasks. CNA #5 stated the resident had been soiled with bowel movement. CNA #5 stated she should have changed her gloves between dirty and clean tasks. CNA #5 confirmed she did not change gloves. CNA #5 stated gloves needed to be changed to stop the spread of infection. During an interview on 09/12/2024 at 9:27 AM, CNA #3 stated gloves should be changed before clean items were obtained because the gloves could soil and contaminate other items. During an interview on 09/12/2024 at 12:09 PM, the Infection Preventionist (IP) stated gloves should be changed when staff needed to touch something else during the provision of care or when contaminated. The IP was informed of CNA #5 not changing gloves after providing incontinence care for Resident #221, and then touching the resident's clean brief. The IP stated the CNA should have changed gloves before touching the clean brief. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) stated the CNA should have changed her gloves before touching the resident's clean brief. The DON stated she expected staff to follow infection control practices and change gloves to prevent infections. During an interview on 09/12/2024 at 1:58 PM, the Executive Director stated it was the facility's practice to follow the regulations, especially hand washing and changing gloves, to mitigate the risk for infection control.

Based on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly, affecting 1 of 2 trash dumpsters and 2 of 2 recycle dumpsters. Specifically, a trash dumpster was missing a lid and the recycle dumpsters were full to the point of being unable to be covered. The deficiency had the potential to affect all residents residing in the facility. Findings included: A facility policy titled, Waste Management, dated 2001, indicated, The facility will maintain the outside dumpster area in a manner that minimizes health hazards, pest infestations, and environmental contamination, ensuring all waste is properly disposed of in accordance with local, state, and federal guidelines. The policy indicated, 1. Dumpster Maintenance: included a. Dumpsters must be kept closed at all times to prevent the attraction of pests and to contain odors. An observation on 09/09/2024 at 8:52 AM revealed two trash dumpsters at the end of the parking lot. The dumpsters were designed to have two lids each. One trash dumpster was completely missing one of its two lids, exposing the contents of the dumpster to open air. Further observation revealed two recycle dumpsters containing cardboard boxes stacked up above the walls of the dumpsters and their lids were open exposing the dumpster contents to open air. During an interview on 09/09/2024 at 8:54 AM, the Certified Dietary Manager (CDM) stated she did not know why the trash dumpster's lid was missing or why the two recycle dumpsters were open and stated that she planned to ask the Director of Maintenance. The CDM further stated the facility would have to call the dumpster company to replace the missing lid. An observation on 09/10/2024 at 8:05 AM revealed two recycle dumpsters containing cardboard boxes stacked up above the walls of the dumpsters, making the lids unable to fully close, exposing the dumpster contents to open air. Further observation revealed the dumpster with the missing lid was no longer present at the end of the parking lot. During an interview on 09/10/2024 at 9:20 AM, the Director of Maintenance stated he called the dumpster company the previous day to replace the lid on the dumpster. Per the Director of Maintenance, maintenance staff moved the dumpster away from the end of the parking lot and put a sign on it for staff to not use until the lid was replaced. During an interview on 09/11/2024 at 9:15 AM, Maintenance Assistant #13 stated he did not know how long the lid to the dumpster had been missing and they pushed that dumpster into a covered garage so staff would not use it. Maintenance Assistant #13 further stated the lid to the dumpster's needed to be shut to prevent the spread of infection and to keep people out of the dumpsters. During an interview on 09/11/2024 at 9:30 AM, the Director of Maintenance stated the lid to the dumpster broke over the weekend and the dumpster company was to replace it that day. The Director of Maintenance further stated the dumpsters should be kept closed to prevent the spread of infection and to reduce odors. During an interview on 09/12/2024 at 12:13 PM, the Director of Nursing (DON) stated she did not know there was a regulation related to the dumpsters but expected trash to be enclosed in the dumpsters with a closed lid. During an interview on 09/12/2024 at 12:18 PM, the Executive Director stated he expected the maintenance department to maintain the dumpster area and stated that the dumpsters should be clean and covered.

Based on interview, record review, and facility policy review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level 1 was accurate for 3 (Resident #37, #91, and #71) of 5 sampled residents reviewed for PASRR. Findings included: A facility policy titled, Admission Criteria, dated 2001, revealed, 9. All new admissions and readmissions for a Medicaid contracted facility are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. 1. An Admission Record revealed the facility admitted Resident #37 on 04/03/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified psychosis (onset date 04/03/2023) and anxiety disorder (onset date 04/03/2023). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #37 had Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of anxiety disorder and psychotic disorder. Resident #37's care plan included an undated focus area that indicated the resident was at risk for a decline in psychosocial well-being due to their overall health condition, signs and symptoms of dementia, signs and symptoms of psychosis, and agitation. The care plan also revealed Resident #37 was known to strike at staff and refuse care. Resident #37's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 04/04/2023, revealed the resident had a diagnosis of anxiety. Further review revealed the resident's diagnosis of psychosis was not listed. During an interview on 09/12/2024 at 12:48 PM, the Admissions Coordinator revealed the PASRRs were completed at the hospital. The Admissions Coordinator stated, after the facility reviewed the PASRR, a new one was always done; if needed, corrections would be made at that time. The Admissions Coordinator stated Resident #37's diagnosis of psychosis should have been on the PASRR, and their current PASRR was not correct. 2. An Admission Record revealed the facility admitted Resident #91 on 05/05/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #91 had Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had a diagnosis of bipolar disorder. Resident #91's care plan included an undated focus area that indicated Resident #91 was at risk for a decline in psychosocial well-being due to their overall health condition, signs and symptoms of bipolar disorder, signs and symptoms of depression and agitation, and hitting. Resident #91's hospital records revealed the resident was admitted to the hospital on 04/25/2023. Further review revealed under Patient Active Problem List the resident had a diagnosis of bipolar disorder with depression. Resident #91's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 05/04/2023, revealed the resident did not have any serious mental illness. During an interview on 09/12/2024 at 12:48 PM, the Admissions Coordinator revealed the PASRRs were completed at the hospital. The Admissions Coordinator stated after the facility reviewed the PASRR a new one was always done; if needed, corrections would be made at that time. The Admissions Coordinator stated Resident #91's diagnosis of bipolar disorder should have been on the PASRR, and their current PASRR was not correct. 3. An Admission Record revealed the facility admitted Resident #71 on 03/12/2022. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar disorder (onset 03/12/2022), major depressive disorder (onset 03/12/2022), and anxiety disorder (onset 03/12/2022). An annual [NAME] Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/2024, revealed Resident #71 had Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses of anxiety disorder, depression, and bipolar disorder. Resident #71's care plan included an undated focus area that indicated the resident was at risk for altered mood and behavior as evidenced by loss of interest in daily activities, mood swings, sudden changes in emotion, yelling, and throwing fluids possibly due to a diagnosis of bipolar disorder. Interventions directed staff to report any changes in the resident's mood patterns or signs or symptoms of depression or anxiety to the physician. An additional undated focus area indicated that Resident #71 was at risk for a decline in psychosocial well-being due to their overall health condition related to bipolar disorder, schizophrenia, and anxiety. Interventions indicated that social services staff would assist the resident as applicable. Resident #71's History & Physical, dated 03/25/2022, revealed Resident #71 was taking medication for the treatment of anxiety and bipolar disorder. Resident #71's History and Physical Examination, dated 04/06/2022, revealed Resident #71 had diagnoses of schizophrenia and bipolar disorder. Resident #71's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/28/2023, revealed Section III- Serious Mental Illness Screen, question #10 was answered Yes and reflected the resident's diagnosis of anxiety, but did not reflect bipolar disorder or schizophrenia. During an interview on 09/12/2024 at 1:00 PM, the MDS Coordinator stated she was notified of new diagnoses many ways but ultimately if a new PASRR needed to be completed, a notification was sent to her to update the PASRR. She stated that Resident #71 should have had a new PASRR completed to reflect their diagnoses. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) revealed she was unfamiliar with the PASRR process but expected them to be accurate. During an interview on 09/12/2024 at 1:58 PM, the Executive Director revealed he expected the regulation to be followed.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) was completed accurately for 2 (Resident #60 and Resident #118) of 24 sampled residents reviewed for accurate assessments. Findings included: A facility policy titled, Comprehensive Assessments, Minimum Data Set (MDS), revised March 2022, revealed, 8. Accuracy of MDS Data: d. All sections of the MDS must be completed with information that accurately reflects the resident's status during the assessment reference period. 1. An Admission Record revealed the facility admitted Resident #60 on 01/06/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of schizophrenia. An annual MDS, with an Assessment Reference Date (ARD) of 01/11/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #60 was not considered by the state Level II PASRR (Pre-Admission Screening and Resident Review) process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the State of California- Health and Human Services Agency Department of Health Care Services, dated 01/24/2023, revealed a Level II evaluation was completed for Resident #60 on 01/23/2023. The attached, Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, indicated Resident #60 required specialized services from a nursing facility due to a medical and/or a mental health condition. The MDS Coordinator was interview on 09/11/2024 at 2:46 PM. The MDS Coordinator stated Resident #60's MDS was not accurate, and the answer for the PASRR Level II section was not correct. The Director of Nursing (DON) was interviewed on 09/12/2024 at 12:13 PM. The DON stated she expected the MDS to be accurate. The Executive Director was interviewed on 09/12/2024 at 12:18 PM. The Executive Director stated he expected the MDS to be accurate. 31524 2. An Admission Record revealed the facility admitted Resident #118 on 05/28/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction, type two diabetes mellitus, and chronic kidney disease. Further review revealed Resident #118 discharged to their home on 06/18/2024. An admission MDS, with an Assessment Reference Date (ARD) of 06/04/2024, revealed Resident #118 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #118's Care Plan, cancelled on 06/19/2024, indicated the resident wished to discharge to their home or another facility after completing skilled nursing and rehabilitation services. Interventions directed staff to arrange post skilled nursing facility support as needed with resources such as home health, therapy, nursing services, pharmacy services, and appointment follow-up services. Resident #118's Order Summary Report, contained an order dated 06/13/2024, that indicated the resident's last covered day (LCD) was 06/17/2024, and the resident was to discharge home on 06/18/2024 with home health. Resident #118's nurse Progress Notes, dated 06/18/2024, revealed Resident #118 left the facility with their responsible party. The note revealed that following discharge, the nurse called Resident #118's responsible party who confirmed the resident was safe at home. Resident #118's Skilled Nursing - Notice of Proposed Transfer/Discharge, dated 06/18/2024, revealed Resident #118 discharged home due to improved health and the resident no longer required the services of the facility. A discharge MDS, with an ARD of 06/18/2024, revealed Resident #118 had a planned discharge with no anticipated return. Further review revealed Resident #118 discharged to a short-term hospital, not to their home. During an interview on 09/11/2024 at 2:46 PM, the MDS Coordinator stated it was important to have an accurate MDS to ensure adequate care and services were provided to the residents. The MDS Coordinator further stated Resident #118's discharge MDS was inaccurate due to indicating the resident was discharged to an acute care hospital when the resident went home instead. During an interview on 09/12/2024 at 12:13 PM, the Director of Nursing (DON) stated MDS accuracy was important for billing purposes and expected each resident's MDS to be accurate. During an interview on 09/12/2024 at 12:18 PM, the Executive Director stated he expected a resident's MDS to be accurate because it was important for providing adequate care.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure an as-needed (PRN, pro re nata) order for psychotropic medication specified the duration of use for 1 (Resident #82) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, specified, a. PRN orders for psychotropic medications are limited to 14 days. An Admission Record indicated the facility admitted Resident #82 on 03/09/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dementia and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received an antianxiety medication during the assessment period. Resident #82's Order Summary Report, dated 09/12/2024, contained an order dated 05/30/2024 for lorazepam 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety/restlessness. The order did not indicate an end date. A Note to Attending Physician/Prescriber for Resident #82 from the Consultant Pharmacist, dated 06/28/2024, specified, This resident has PRN Lorazepam 0.5 mg PO [by mouth] Q6H [every six hours] for anxiety. PRN psychotropic medications are limited to 14 days. The Note to Attending Physician/Prescriber also indicated, Please add a length of therapy. Further review revealed the physician had not signed the document. Another Note to Attending Physician/Prescriber for Resident #82 from the Consultant Pharmacist, dated 07/26/2024, specified, This resident has PRN Lorazepam 0.5 mg PO Q6H for anxiety. PRN psychotropic medications are limited to 14 days. The Note to Attending Physician/Prescriber also indicated, Please add a length of therapy. Further review revealed the physician had not signed the document. During a telephone interview on 09/11/2024 at 2:28 PM, the Consultant Pharmacist stated she reviewed each resident's chart monthly. The Consultant Pharmacist stated PRN psychotropic medications required a 14-day stop date. The Consultant Pharmacist said Resident #82's lorazepam did not have a 14-day stop date. During an interview on 09/12/2024 at 11:40 AM, Licensed Vocational Nurse (LVN) #4 stated Resident #82 was administered PRN lorazepam when they got anxious and agitated. LVN #4 said the lorazepam should have a 14-day stop date. During an interview on 09/12/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated PRN psychotropic medications required a 14-day stop date. The ADON stated Resident #82's PRN lorazepam should have had a 14-day stop date and was unsure why it did not. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) stated PRN psychotropic medications needed a 14-day stop date. The DON said she expected for the 14-day stop date to be on the physician order. During an interview on 09/12/2024 at 1:58 PM, the Executive Director stated he expected for the regulation to be followed.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure pharmacy recommendations were followed up on timely for 1 (Resident #82) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Pharmacy Medication Regimen Review, revised in 10/2018, specified, The consultant pharmacist documents in a separate written report any found irregularities. The policy indicated, e. Otherwise, if an irregularity does not require urgent action, attending physician is to be contacted by nursing using the provided recommendation forms. The policy also indicated, The physician may choose to decline the pharmacist's suggestion either directly on the recommendation form, through a telephone order with a licensed nurse, or within the resident's chart (such as in a progress note); but a response must be noted within 30 days with rationale documented in the resident's medical record. An Admission Record indicated the facility admitted Resident #82 on 03/09/2022. According to the Admission Record, the resident had a medical history that included diagnoses of dementia and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received an antianxiety medication during the assessment period. Resident #82's Order Summary Report, dated 09/12/2024, contained an order dated 05/30/2024 for lorazepam 0.5 milligrams (mg) one tablet by mouth every six hours as needed for anxiety/restlessness. The order did not indicate an end date. A Note to Attending Physician/Prescriber for Resident #82 from the Consultant Pharmacist, dated 06/28/2024, specified, This resident has PRN [pro re nata, as needed] Lorazepam 0.5 mg PO [by mouth] Q6H [every six hours] for anxiety. PRN psychotropic medications are limited to 14 days. The Note to Attending Physician/Prescriber also indicated, Please add a length of therapy. Further review revealed the physician had not signed the document. Another Note to Attending Physician/Prescriber for Resident #82 from the Consultant Pharmacist, dated 07/26/2024, specified, This resident has PRN Lorazepam 0.5 mg PO Q6H for anxiety. PRN psychotropic medications are limited to 14 days. The Note to Attending Physician/Prescriber also indicated, Please add a length of therapy. Further review revealed the physician had not signed the document. Resident #82's September 2024 Medication Administration Record [MAR] contained a transcription of an order for lorazepam 0.5 mg one tablet by mouth every six hours as needed with a start date of 05/30/2024. Documentation indicated the medication had been administered to the resident seven times during the month. During a telephone interview on 09/11/2024 at 2:28 PM, the Consultant Pharmacist stated she reviewed each resident's chart monthly. The Consultant Pharmacist stated on the June and July reviews she had noted there was no stop date for Resident #82's PRN psychotropic medication and advised the facility it needed a stop date. The Consultant Pharmacist said it had not yet been done. During an interview on 09/12/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated he and the Director of Nursing (DON) were both responsible for the completion of the pharmacy recommendations. The ADON stated if there was something the physician needed to review then the recommendation would be sent to him via facsimile. The ADON stated he did not know why Resident #82's pharmacy recommendations for June and July were not addressed. During an interview on 09/12/2024 at 1:25 PM, the DON stated PRN psychotropic medications needed to have a 14-day stop date. The DON said she did not understand her role in the pharmacy recommendations, and she had been placing them in the nurse practitioner's box. During an interview on 09/12/2024 at 1:58 PM, the Executive Director stated he did not know why the pharmacy recommendations for June and July were not followed. The Executive Director said it was facility practice to address the recommendations.

Based on interview, record review, and facility policy review, the facility failed to ensure physician ordered medications were available for 2 (Resident #75 and Resident #171) of 6 residents reviewed for pharmacy services. Findings included: 1. A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber order, including any required time frame. An Admission Record indicated the facility admitted Resident #75 on 08/06/2024. According to the Admission Record, the resident had a medical history that included diagnoses of gastro-esophageal reflux disease (GERD) and an acute peptic ulcer. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2024, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #75's Order Summary Report, dated 09/12/2024, contained an order, dated 08/06/2024, for pantoprazole sodium 40 milligrams (mg) by mouth daily for GERD. Resident #75's Medication Administration Record [MAR], for the timeframe from 09/01/2024 through 09/11/2024, revealed staff documented that Resident #75's pantoprazole sodium was not available for administration from 09/03/2024 through 09/08/2024. During an interview on 09/09/2024 at 10:03 AM, Resident #75 stated they were not getting their stomach medications. During a follow-up interview on 09/11/2024 at 1:38 PM, Resident #75 stated they still had not received their stomach medication. Resident #75 stated they were not sure what the name of the medication was but knew it was for their peptic ulcer. Resident #75 stated they had not received the medication since they had been at the facility. During a telephone interview on 09/11/2024 at 2:28 PM, the Consultant Pharmacist stated a 14-day supply of Resident #75's pantoprazole sodium had been dispensed on 08/06/2024 and 09/07/2024. During an interview on 09/12/2024 at 11:40 AM, Licensed Vocational Nurse (LVN) #4 stated if a medication was not available after checking the medication cart, then the process was to go to the medication dispensing machine to see if it was available there. LVN #4 stated if the medication was not in the medication dispensing machine, staff should call the pharmacy. During an interview on 09/12/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated Resident #75's medication for GERD had been destroyed. The ADON stated he did not know why the medication was destroyed, but staff were looking into it. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) stated, if medication was not available on the medication cart, staff were required to check the medication dispensing system and the emergency kit for the medication, and, if there, it should be given. The DON stated she expected physician-ordered medications to be available for administration. The DON stated Resident #75 should have received the pantoprazole. 2. An Admission Record indicated the facility admitted Resident #171 on 09/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of osteomyelitis and diabetes. Resident #171's Order Summary Report, dated 09/11/2024, contained an order, dated 09/05/2024, for ketotifen fumarate ophthalmic solution 0.035% one drop in both eyes every morning and at bedtime for itchiness. An observation of medication pass on 09/10/2024 at 9:34 AM, with Licensed Vocational Nurse (LVN) #2 revealed she prepared Resident #171's medications. LVN #2 did not administer ketotifen fumarate ophthalmic solution to the resident. During an interview on 09/10/2024 at 11:56 AM, Resident #171 stated they did not receive their eye drops that morning because they had to be ordered. During an interview on 09/10/2024 at 2:11 PM, LVN #2 stated Resident #171's eye drops were not administered because they were not available. LVN #2 said the eye drops had not been administered since the resident admitted to the facility because they were either on back order or the insurance did not cover them. Resident #171's Medication Administration Record [MAR], for the timeframe from 09/01/2024 to 09/10/2024, revealed Resident #171's ketotifen fumarate had not been available for administration from 09/06/2024 through 09/09/2024. During a telephone interview on 09/11/2024 at 2:28 PM, the Consultant Pharmacist indicated the ketotifen fumarate for Resident #171 could have been an over-the-counter medication. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) stated, if medication was not available on the medication cart, staff were required to check the medication dispensing system and the emergency kit for the medication, and, if there, it should be given. The DON stated she expected physician-ordered medications to be available for administration. The DON stated Resident #171 should have received their eye drops. During an interview on 09/12/2024 at 1:58 PM, the Executive Director indicated he expected medications to be available and, if they were not, a way needed to be found to make the medications available.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for treatment of a diabetic ulcer was obtained for 1 (Resident #43) of 2 residents reviewed for skin conditions. Findings included: A facility policy titled, Wound Treatment Management, dated 2001, revealed, 1. Initial Assessment and Documentation a. Wound assessment: Upon identification of a wound, a licensed nurse (RN [Registered Nurse] or LVN [Licensed Vocational Nurse]) will: Conduct an initial wound assessment including location, size, depth, appearance, drainage, any signs of infection. Document the wound's characteristics in the resident's medical record and update the care plan. Notify the attending physician to obtain wound treatment orders. b. Physician orders: The attending physician will provide written orders for wound care, specifying the type of treatment (e.g. [exempli gratia, for example], cleansing solution, dressing type, frequency of dressing changes, etc. [et cetera; and so forth]). Ensure the orders are clear and concise, and document them in the resident's medical record. An Admission Record indicated the facility originally admitted Resident #43 on 06/13/2024 and readmitted the resident on 09/04/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and scar conditions and fibrosis of the skin. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2024, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS also revealed Resident #43 had a diabetic foot ulcer. According to the MDS, skin/ulcer treatment included a turning/repositioning program, nutrition or hydration intervention to manage skin problems, and application of dressings to the feet. Resident #43's care plan included an undated focus area that indicated Resident #43 had a diabetic ulcer to the left dorsum hallux (big toe) and was at risk for worsening of the ulcer and amputation due to the disease process. Interventions directed staff to notify the physician as indicated. Resident #43's Progress Notes, dated 09/02/2024, revealed the resident was admitted to the hospital. Further review revealed Progress Notes dated 09/04/2024 indicated the resident was admitted back to the facility. Resident #43's hospital History and Physical dated 09/02/2024, revealed the resident had chronic infection of the left big toe. Resident #43's Skilled Nursing-Admission Initial Eval [Evaluation] dated 09/04/2024, revealed Registered Nurse (RN) #10 documented the resident had a diabetic wound to the left toe. According to the evaluation, the physician was notified of the resident's admission. Resident #43's Wound Evaluation note dated 09/05/2024, completed by RN #6, who was the treatment nurse, revealed the resident had a diabetic ulcer. The note revealed the ulcer was located on the left foot 1st digit (hallux) and was 1.1 centimeters (cm) in length and 1.09 cm in width. The note revealed the wound bed had eschar (black, dead tissue), evidence of infection that included redness/inflammation, and the surrounding tissue was calloused. The note revealed treatment included povidone iodine, mechanical debridement, and dry gauze. According to the note, additional care included a heel suspension/protection device, a moisture barrier, and moisture control. The note revealed the physician was notified of the treatment and ulcer. Per the note, the ulcer was a Chronic stalled wound that was painted with iodine and left open to air. The note revealed there were no open areas or drainage, and foam heel protectors were applied bilaterally. Resident #43's Order Summary Report, with an order date range of 09/04/2024 to 09/30/2024, revealed no active order for treatment to the resident's toe. Resident #43's September 2024 Treatment Administration Record [TAR], revealed staff documented that the left hallux was painted with iodine every day shift from 09/01/2024 through 09/03/2024. The TAR revealed the treatment was discontinued on 09/03/2024. Per the TAR, there was no documented evidence a treatment was provided to the left hallux from 09/04/2024, when the resident was readmitted to the facility, through 09/09/2024. An observation on 09/09/2024 at 12:02 PM of Resident #43 revealed the resident's left foot big toe had a black, crusty discoloration. During a concurrent interview, Resident #43 stated the facility staff had not provided treatment to the toe since re-admission from the hospital. An interview on 09/11/2024 at 8:58 AM with RN #6, revealed it was the responsibility of the admitting nurse to complete an assessment and document any skin issues. RN #6 stated the admitting nurse must also contact the physician and obtain physician orders for treatment. RN #6 revealed she completed the skin assessment and treatment for Resident #43 on 09/05/2024; however, she was not aware there was not an order for care. RN #6 stated all the previous orders were discontinued on 09/03/2024 after the resident was discharged to the hospital. RN #6 stated when the resident returned, the wound care order was not resumed. RN #6 stated she failed to ensure an order was active for care for Resident #43's toe. RN #6 reviewed Resident #43's medical chart and was unable to locate any evidence wound care had been completed on 09/07/2024, 09/08/2024, or 09/09/2024 (Friday through Sunday). RN #6 stated Licensed Vocational Nurse (LVN) #7 was responsible for completing wound/skin care treatment over the weekend. During a follow-up interview on 09/11/2024 at 9:45 AM, RN #6 stated she had not notified the physician, and failed to get an order for skin care for Resident #43. She stated it was an error on her part for failing to obtain an order. During an interview on 09/11/2024 at 9:26 AM, LVN #7 stated staff must receive skin care orders when a resident is admitted . LVN #7 stated he had not completed skin care for Resident #43 since the resident was readmitted because there was no order. An interview with LVN #8 on 09/11/2024 at 10:28 AM, revealed he was the assigned nurse for Resident #43 for the weekend and had not completed wound/skin care for Resident #43. During an interview on 09/12/2024 at 7:57 AM, Nurse Practitioner (NP) #9 stated when a resident was admitted to the facility, a nurse notified him. He stated that he was aware Resident #43 had discharged and returned to the facility from the hospital. He stated there was a lapse in the resident's treatment of the left big toe; however, the few days the treatment lapsed would not have made a significant difference on the wound. NP #9 stated regardless of the healing, there should not have been any lapse in the resident's treatment. An interview with the Director of Nursing (DON) on 09/12/2024 at 1:07 PM, revealed the staff should have reviewed and resumed the order for Resident #43's skin/wound care treatment. During an interview with the Executive Director on 09/12/2024 at 1:23 PM, he stated he expected the staff to provide quality care. He stated staff should get physician orders and follow the orders.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5 percent (%). The facility had 2 medication errors out of 28 opportunities, affecting 2 (Resident #3 and Resident #171) of 6 residents reviewed during the medication administration task, resulting in a medication error rate of 7.14%. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. An Admission Record indicated the facility admitted Resident #3 on 06/28/2024. According to the Admission Record, the resident had a medical history that included diagnoses of protein-calorie malnutrition and osteoarthritis. An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2024, revealed Resident #3 had modified independence with cognitive skills for daily decision making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated the resident had active diagnoses that included malnutrition and anemia. Resident #3's Order Summary Report, with active orders as of 09/11/2024, revealed an order dated 06/28/2024 for vitamin D3 1000 units one capsule by mouth one time a day for supplement. An observation of medication pass on 09/10/2024 at 8:27 AM, with Licensed Vocational Nurse (LVN) #1, revealed she prepared Resident #3's medications, including vitamin D3 2000 units one tablet and administered the vitamin D3 2000-unit tablet to the resident. During an interview on 09/10/2024 at 11:59 AM, LVN #1 retrieved a bottle of vitamin D3 from the medication cart and stated it was the vitamin D3 that was administered to Resident #3. LVN #1 confirmed Resident #3's physician order was for vitamin D3 1000 units but stated vitamin D3 2000 units was the only vitamin D3 that was available. LVN #1 stated she should contact the physician to notify them that the vitamin D3 1000-unit dose was not available. 2. An Admission Record indicated the facility admitted Resident #171 on 09/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of osteomyelitis and type 2 diabetes mellitus. Resident #171's Order Summary Report, dated 09/11/2024, contained an order dated 09/05/2024 for ketotifen fumarate ophthalmic solution 0.035% one drop in both eyes every morning and at bedtime for itchiness. An observation of medication pass on 09/10/2024 at 9:34 AM, with LVN #2 revealed she prepared Resident #171's medications. LVN #2 did not administer ketotifen fumarate ophthalmic solution to the resident. During an interview on 09/10/2024 at 11:56 AM, Resident #171 stated they did not receive their eye drops that morning because they had to be ordered. During an interview on 09/10/2024 at 2:11 PM, LVN #2 stated Resident #171's eye drops were not administered because they were not available. LVN #2 said the eye drops had not been administered since the resident admitted to the facility because they were either on back order or the insurance did not cover them. During an interview on 09/12/2024 at 1:25 PM, the Director of Nursing (DON) stated her expectation was for the medication error rate to be below the required rate. During an interview on 09/12/2024 at 1:58 PM, the Executive Director stated his expectation was for medications to be available and for staff to follow the regulations.

Based on observation, interviews and record reviews, the facility failed to protect the resident ' s (Resident 1) rights to be free from sexual abuse when Resident 2 ' s wandering behavior was not assessed, and he was found in Resident 1 ' s bed engaging in sexual act. As a result, Resident 1 and Resident 2 engaged in sexual encounter which was not consensual and Resident 1 required hospitalization for evaluation of sexual assault. Findings: On 6/9/22 at 2:24 P.M., an unannounced onsite at the facility was conducted related to a facility reported resident abuse. On 6/9/22, a review of Resident 1 and Resident 2 ' s record was conducted. 1. Resident 1 was admitted to the facility on [DATE], from an acute care hospital (ACH) for skilled nursing (a patient's need for care or treatment that can only be performed by licensed nurse), with diagnoses which included stroke (a loss of blood flow to part of the brain, which damages brain tissue) and generalized muscle weakness, per the facility ' s Admission Record. Resident 1 ' s History and Physical (H&P), dated 3/14/22, the H & P indicated the attending physician (AP 1) documented Resident 1 did not have the capacity to understand and make decisions. Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated 3/16/22, the MDS indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 5, which meant Resident 1's cognition was severely impaired. The MDS section G for activities of daily living (ADLs- activities related to personal care .include .getting in and out of bed .) indicated, Resident 1 needed limited assistance and required a one-person physical assist during bed mobility. Resident 1 ' s Change in Condition (CIC) notes, dated 6/9/22 at 3:09 A.M., completed by a Licensed Nurse (LN) 1, indicated Resident 1 was heard shouting from her room, Certified Nursing Assistant (CNA) 3 checked Resident 1, found Resident 2 in Resident 1 ' s bed without underwear, and his hips propped against Resident 1 ' s lower region. Per the nurses ' notes, Resident 2 was in this position until CNA 3 showed up to witness, then Resident 2 released Resident 1 and pulled up his underwear. Resident 1 ' s acute care hospital (ACH) record, dated 6/9/22 at 2:06 P.M., the Emergency Department Attending Physician (EDAP 1) documented Resident 1 presented to the emergency room for evaluation after sexual assault. Per EDAP 1 notes on 6/9/22 at 8:08 P.M., Resident 1 underwent diagnostic test. While hospitalized , Resident 1 received medications including antibiotics. The same EDAP 1 notes indicated, It was unclear if there was actual penetration or not. Resident 1 ' s discharge instructions from the ACH dated 6/10/22 at 3:28 P.M., the discharge instructions indicated, .Final diagnosis: Sexual Assault . The discharge instructions from ACH indicated Resident 1 had to continue antibiotics at home. 2. Resident 2 was admitted to the facility on [DATE], from a skilled nursing facility (nursing home), with diagnoses which included dementia (the loss of cognitive functioning like thinking, remembering, and reasoning), per the facility ' s Admission Record. Resident 2 ' s H&P, dated 2/7/22, indicated, the attending physician (AP 1) documented Resident 2 did not have the capacity to understand and make decisions. Resident 2 ' s MDS dated [DATE], indicated, Resident 2's BIMS score was 6, which meant Resident 2's cognition was severely impaired. The Behavior section of the MDS dated [DATE] and 5/13/22, indicated Resident 2 did not have a wandering behavior. On 6/9/22 at 2:24 P.M., an observation was conducted. Resident 1's room was located adjacent to Resident 2 ' s room at the end of the hallway in Station 2. Resident 1 resided in a two-bedroom by herself with her bed located by the window. Resident 2 resided in the adjacent two-bedroom room by himself. On 6/9/22 at 3:26 P.M., an observation and an interview of Resident 2 was conducted. Resident 2 was sitting in a chair, holding a cane, and was watching a television show in his room. Resident 2 stated he used to go out of his room and did not know why he now had restrictions. Resident 2 stated he did not recall if he had gone to another residents ' room. Resident 2 stated, Maybe I have to start looking for a girlfriend. I want to hold hands with somebody, it was important to me because I always have a girl in my hand/arms. I used to have somebody with me always. On 6/9/22 at 4 P.M., a follow up observation of Resident 2 in his room was conducted. Resident 2 tried to go out of his room, but the CNA stopped him because he was on a 1:1 monitoring at the time of visit. On 6/9/22 at 3:46 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was confused and was totally dependent to staff. CNA 1 stated Resident 1 was admitted to the hospital after the assault. On 6/9/22 at 3:46 P.M., an interview with CNA 1 was conducted. CNA 1 stated Resident 2 had memory impairment when he forgot things like his name and his room. CNA 1 stated Resident 2 tended to go to another resident ' s room but was easily redirected. CNA 1 stated Resident 2 had wandering behaviors and were reported to the licensed nurses. CNA 1 further stated he witnessed Resident 2 entering other residents ' rooms, and CNA 1 redirected Resident 2 out of the room. On 6/9/22 at 4:09 P.M., an interview with CNA 2 was conducted. CNA 2 stated she provided care to Resident 1 and Resident 2. CNA 2 stated Resident 1 was confused, required two persons assist, got nervous when staff moved her. CNA 2 stated Resident 2 was alert, oriented and could hold a conversation. CNA 2 stated Resident 2 would always ask for his room number. CNA 2 stated the staff had to look for him because he would push wheelchair bound, confused female residents from station 2 hallways to the lobby. CNA 2 stated Resident 2 would get mad when staff separated Resident 2 from the female residents, he became violent and swung his cane up the air. CNA 2 stated other CNAs were aware Resident 2 would go to other residents ' rooms. CNA 2 stated his wandering behaviors were reported to the licensed nurses. CNA 2 stated Resident 2 was not on monitoring during the time of incident. On 7/11/22 at 3:16 P.M., a telephone interview with CNA 3 was conducted. CNA 3 stated she provided care to Resident 1 and Resident 2 during the night shift on 6/8/22. CNA 3 stated Resident 1 was nonverbal, yelled when she was being cleaned or changed. CNA 3 stated Resident 2 was independent, wandered around the station and was usually awake during the night shift. CNA 3 stated Resident 2 was aggressive towards staff and cursed everybody out. CNA 3 stated Resident 2 would sometimes walk naked in the hallway, and the licensed nurses would redirect him. CNA 3 stated on 6/9/22, after midnight, she heard Resident 1 yelling. CNA 3 stated she went into Resident 1 ' s room and found Resident 1 lying on her left side, her pull ups (incontinence brief) was on the floor, her legs were around Resident 2 ' s waist, while Resident 2, whose pull ups were to his knees, was on top of Resident 1 and was thrusting. CNA 3 stated, It was hard to see with their position that his penis was in her vagina. CNA 3 stated she told Resident 2 to get out but Resident 2 refused. CNA 3 stated it took them 10 minutes until Resident 2 went out of Resident 1 ' s room. CNA 3 stated Resident 2 was aggressive and said to CNA 3, She gave me consents and I can do anything to her. CNA 3 stated there was feces on Resident 2 ' s shirt and the police officer took the shirt. On 6/9/22 at 4:27 P.M., an interview and facility record review with LN 2 was conducted. LN 2 stated Resident 1 required staff assistance, she was nonverbal and would scream when staff changed her. LN 2 stated Resident 2 was alert, oriented, would walk up and down the hallway and asked for his room number. LN 2 stated she did not witness Resident 2 going into other residents ' room nor received a report from the CNAs that Resident 2 went into other resident ' s room. LN 2 stated Resident 2 would stop in each resident ' s door and wandered around to find his room by walking up and down the hall. LN 2 stated there was no wandering assessment or care plan in Resident 2 ' s record. LN 2 stated the staff did not consider Resident 2 as wanderer because he did not have an exit seeking behavior (wander or try to leave the facility without companion). LN 2 stated, We could have prevented the incident if we had a sitter and redirected him. On 7/11/22 at 1:16 P.M., a telephone interview with LN 3 was conducted. LN 3 stated Resident 1 was confused, required staff assistance with ADLs. LN 3 stated Resident 2 had an aggressive behavior at times, was rude and yelled at staff. LN 3 stated Resident 2 wandered around, walked down the hallway, would come to the nurse ' s station, asked for his room number, would go back to his room then will come out again. LN 3 stated Resident 2 would do the behavior three to four times during her shift. LN 3 stated she did not do any assessment or care plan related to Resident 2 ' s wandering behavior. LN 3 stated she was not in the facility on the day of the incident. LN 3 stated the incident could have been prevented if staff paid more attention to Resident 2 ' s behavior. On 10/24/22 at 5:12 P.M., a telephone call was placed to the police officer, but no answer to phone call and did not return call. On 12/18/23 at 3:34 P.M., a telephone call was placed to Resident 1 ' s daughter, but no answer to phone call, and a voicemail was left. On 12/26/23 at 11:37 A.M., a telephone interview with the Assistant Director of Nursing (ADON) was conducted. The ADON acknowledged that Resident 1 and every resident should have been free from any form abuse. A review of the facility ' s policy titled, Resident Rights, revised December 2016, the policy indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: .c. be free from abuse . A review of the facility ' s policy, titled, Wandering ., revised March 2019. The policy indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm .1. If identified as at risk for wandering .or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety . A review of the facility ' s policy, titled, Safety and Supervision of Residents, revised July 2017, the policy indicated, .Resident safety and supervision .to prevent accidents are facility-wide priorities .Systems Approach to Safety .2. Resident supervision is a core component of the systems approach to safety .

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) 1 implemented interventions to prevent falls and injury for one of one sampled residents (Resident 1). CNA 1 did not place a fall mat (high-impact foam mat beside the bed to help prevent injury from potential falls) on both sides of Resident 1's bed, nor activate a bed sensor alarm (a device that makes a loud sound when a resident moves to alert staff), in accordance with Resident 1's plan of care for falls, when the CNA assisted Resident 1 to bed for a nap after lunch. As a result, Resident 1 had an unwitnessed fall from her bed, and sustained fractures of her tibia and fibula (broken bones in the lower leg), resulting in amputation (removal of the body part) of the resident's left leg below the knee. Findings: Resident 1, a [AGE] year-old, female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's clinical record was conducted on 9/18/19. According to a review of the document titled, Fall Risk Assessment, dated 6/21/18, Resident 1 had a total score of 14. A total score of 10 or above represented high risk for sustaining a fall. According to a review of the document titled Resident Care Plan, dated 6/26/18, Resident 1 had a potential for falls or to have injury due to dementia, [MEDICAL CONDITION], and poor safety awareness. The goal of the care plan was for Resident 1 to have no falls or injury . The approaches and plan to achieve the goal included, the call light and personal belongings were to be within easy reach, reorient to new surroundings, and out of bed as tolerated if appropriate. According to a review of the document titled, Episodic Care Plan: Post (First) Fall, dated 8/30/18, Resident 1 had a fall from her wheelchair to the floor. The care plan was updated and interventions put into place were: Resident 1 was to have a tab alarm (device that clipped to resident's clothing, that made a loud sound if resident attempted to stand up from the wheelchair or get out of bed), low bed and a fall mat. According to a review of the document titled, Episodic Care Plan: Post (Second) Fall, dated 8/13/19, Resident 1 was found lying on her left side, on the fall mat, beside her bed. There was no apparent injury noted for this fall. The added interventions were: Resident 1 was to have a sensor (bed) alarm, fall mats on both sides of the bed, and Resident 1 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] to be closer to the nursing station for close monitoring. According to a review of the document titled, Licensed Personnel Weekly Progress Notes, dated 8/28/19, Licensed Nurse (LN) 1 documented Resident 1 was found sitting on the floor .and noticed blood and exposure of bone to left ankle area . LN 1 called the emergency response service (EMS) and Resident 1 was transferred to the hospital. According to a review of the document titled, Episodic Care Plan: Post (third) Fall, dated 8/28/19, under Identified Factors Contributing to this Fall, alarm was not in place, fall mat not in place . According to a review of the General Acute Care Hospital (GACH) 1 Record, dated 8/28/19, Resident 1 had an unwitnessed fall with concern for open leg fracture. Resident 1 was transferred to GACH 2 for a higher level of care. According to a review of the GACH 2's Operative Note, dated 8/29/19, prior to Resident 1's surgery, the surgeon explained to the family member the risks and benefits of saving Resident 1's leg versus amputation. For saving Resident 1's leg .would have required prolonged no weight bearing (amount of weight a resident can put on an injured body part) which the patient (Resident 1) may not have been able to comply with and any accidental weight bearing would have placed the implants (an artificial object inserted in a resident's body during a surgery) at risk of failure . The family member expressed understanding of the treatment options and Resident 1 had an extensive surgery of left [MEDICAL CONDITION]. CNA 1 who no longer worked at this facility was unavailable for interview. The facility provided CNA 1's written statement. According to CNA 1's written statement, dated 8/29/19, CNA 1 documented she did not realize Resident 1 had an alarm so she did not activate the alarm. On 9/18/19 at 11:33 [NAME]M., an interview was conducted with LN 2. LN 2 stated after Resident 1's fall on 8/13/19, Resident 1 was moved to room [ROOM NUMBER], to be closer to the nursing station. LN 2 stated to prevent Resident 1 from a fall or injury, the staff were to ensure the fall mats were placed on both side of the bed. LN 2 further stated Resident 1 was to have a tab alarm when in a wheelchair and a sensor alarm when in bed. LN 2 stated Resident 1 needed to be in the wheelchair for close monitoring when the resident was awake, because Resident 1 moved a lot when awake in bed, and was a high risk for falls. LN 2 stated CNAs assisted Resident 1 back to bed after lunch, the staff would change her, if Resident 1 was sleepy the staff would leave her on the bed with all the fall interventions in place, and when she woke up she would try to get out of bed. LN 2 stated when Resident 1 was awake, the staff would put her in the wheelchair. LN 2 stated on 8/28/19 around 3:45 P.M., Resident 1 had a third fall. LN 2 stated she, along with LN 1, responded when CNA 4 yelled for assistance. LN 2 stated when she entered the room she did not hear the alarm sound. LN 2 stated she saw Resident 1 sitting on the floor without a fall mat and the alarm was not activated. LN 2 further stated the box alarm was hanging on the wheelchair, by the window, away from Resident 1. On 9/18/19 at 1:24 P.M., an interview was conducted with CNA 3. CNA 3 stated prior to the last fall, Resident 1 was able to stand and turn with two persons for transfer. CNA 3 further stated after the surgery Resident 1 could no longer stand and the staff used a hoyer lift (a mechanical device used for transferring) to transfer Resident 1. CNA 3 stated prior to the last fall, when Resident 1 was awake and on the bed, the staff would get her up to the wheelchair because Resident 1 did not like staying in bed. On 9/24/19 at 11:18 [NAME]M., an interview was conducted with CNA 4. CNA 4 stated she was the lead CNA on 8/28/19. CNA 4 stated she assisted CNA 1 to transfer Resident 1 from wheelchair to bed around 1:30 P.M. CNA 4 stated she reminded CNA 1 to make sure the alarm and fall mats were in place. CNA 4 stated she did not see Resident 1 again until around 3:45 P.M. CNA 4 stated CNA 2 was the assigned afternoon CNA and CNA 2 was giving a shower to another resident. CNA 4 stated when a resident was at risk for fall and awake in bed, the staff should have all the fall precautions in place or get the resident up in wheelchair and put him/her by the nursing station. CNA 4 stated the LNs and CNA's at the end of their shift provides information about the resident and there were written instructions posted on the bathroom door for every resident on how to care for the resident. On 9/25/19 at 8:30 [NAME]M., an interview was conducted with LN 3. LN 3 stated there were nights when Resident 1's sensor pad would alarm when Resident 1 was trying to get out of bed unassisted. LN 3 stated when Resident 1 awoke, the staff would stay with the resident or the staff would get Resident 1 up to the wheelchair for close monitoring to prevent her from falls. CNA 2 was no longer working at this facility but was available for telephone interview. On 9/25/19 at 11:30 [NAME]M., a joint interview and record review of CNA 2's written statement was conducted with CNA 2. CNA 2 documented, on 8/28/19, I didn't notice she (Resident 1) wasn't wearing her tab alarm or the sensor alarm .and mattress on her right side wasn't (placed). CNA 2 stated after CNA 1 left the unit, she saw Resident 1 in bed, awake but calm. CNA 2 further stated she did not inspect or ensure the alarm was functioning, or if both fall mats were present. CNA 2 stated she proceeded to assist another resident. CNA 2 stated Resident 1 moved a lot when awake in bed and was at risk for falls. CNA 2 also stated Resident 1 should have been up in the wheelchair when she was awake. CNA 2 stated she did not realize Resident 1 would try to get up because Resident 1 looked calm. CNA 2 stated she should have checked all the fall precautions before leaving Resident 1. On 9/26/19 at 11 [NAME]M., an interview was conducted with the Director of Nursing (DON). The DON stated the interventions to prevent Resident 1 from falling should have been followed. The DON stated the sensor alarm should have been applied, so when it sounded, the staff would have heard and attended to Resident 1 right away. The DON stated on 8/28/19, CNA 1 did not apply the fall precautions before leaving Resident 1 and CNA 2 did not ensure the fall precautions were in place at the beginning of her shift. The DON further stated the fall care plan interventions were not followed and it was not acceptable. The DON stated Resident 1 sustained a fracture because of the fall and it could have been prevented or at least minimized the injury. Per the undated facility's policy and procedure, titled Fall Management, .Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls .