Every finding on record at Fountain Valley Post Acute

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors. * Resident 1 received more than the recommended dose of insulin (medication to lower blood sugar levels) as order by the physician. This failure posed the risk for hypoglycemia (a condition characterized by abnormally low blood sugar) and other health complications for Resident 1.Findings: Review of the facility's P&P titled Insulin Administration revised 3/2025 showed the type of insulin, dosage requirements, strength, and method of administration are verified with the order on the medication sheet and the physician's order before administration. Medical record review for Resident 1 was initiated on 5/14/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 4/14/26, for HumaLog injection solution 100 unit/ml (Insulin Lispro-a prescribed insulin medication used to control high blood sugar for those with diabetes mellittus) to give subcutaneously before meals for DM. Inject as per sliding scale as follows: If BS <70, call the doctor; 70-150 give no insulin; 151-200 = 2 units;201-250 = 4 units;251- 300 = 6 units;301-350 = 8 units;351- 400 = 10 units;BS > 400 = 12 units and call MD. Review of Resident 1's Medication Administration Record for April 2026 showed a documentation of a blood glucose result of 155 and 2 units of insulin Lispro was administered at 1130 hours on 4/23/26. Review of Resident 1's eINTERACT Change in Condition Report dated 4/23/26, showed documentation Resident 1 received the insulin medication over the amount as ordered by the physician. Further review of the nursing addendum showed Resident 1 received four units of insulin Lispro, instead of two units per sliding scale order at 1154 hours on 4/23/26. On 5/14/26 at 1320 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 stated a medication error was made with Resident 1 on 4/23/26. Resident 1 had a blood sugar level of 155 obtained at 1154 hours. Per the sliding scale order, Resident 1 wass to receive two units of Insulin Lispro but instead he received four units. RN 2 stated the resident's physician was made aware immediately and ordered to monitor the resident's blood glucose level every 30 minutes for four hours after the incident. RN 2 further stated she was not able to document the four units administered in the system as it was defaulted to the sliding scale order. When asked what could happen if resident received too much insulin, RN 2 stated it could affect the resident's health and place him at risk for hypoglycemia. On 5/20/26 at 1235 hours, the Administrator and ADON were informed of the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate respiratory care. * The facility failed to ensure Resident 1's oxygen tubing was changed accordingly. This failure had the potential to lead to respiratory infection and affect the overall health status of Resident 1.Findings: Review of the facility's P&P titled Oxygen Administration (undated) showed the oxygen is administered under orders of the physician. The oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. On 5/14/26 at 1152 hours, Resident 1 was observed wearing a nasal cannula attached to a portable oxygen tank with a setting of three liter per minute. The oxygen tubing was observed with a label dated 4/23/26. Medical record review for Resident 1 was initiated on 5/14/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 5/14/26, showed a physician's order dated 5/12/26, to administer oxygen at three liters per minute via nasal cannula every shift for CHF. On 5/14/26 at 1208 hours, RN 1 was called and verified the findings. When RN 1 was asked how often the oxygen tubing was changed, RN 1 stated the facility had an order for the oxygen tubing to be changed every Thursday and as needed. On 5/20/26 at 1235 hours, the Administrator and ADON were informed of the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's baseline care plan showed treatment and interventions related to mycotic nails. This failure had the potential for Resident 1 not to receive the necessary treatment and services to meet the individualized care needs. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered (undated) showed 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. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being, including:1) services that would otherwise be provided for the above, but are not provided due to theresident exercising his or her rights, including the right to refuse treatment;2) any specialized services to be provided as a result of PASARR recommendations; and3) which professional services are responsible for each element of care;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. Closed medical record review for Resident 1 was initiated on 4/23/26. Resident 1 was admitted to the facility on [DATE], and discharged on 4/20/26. Review of Resident 1's admission assessment dated [DATE], showed Resident 1 had mycotic toenails and bilateral upper extremities skin discoloration. Review of Resident 1's H&P examination dated 3/25/26, showed Resident 1 had no capacity to understand and make medical decisions. Review of Resident 1's Order Summary Report showed a physician's order dated 3/26/26, for Kerasal (a topical ointment prescribed to treat fungal infection of the nails) fungal nail renewal solution, to apply to bilateral toenails for mycotic nails daily for 14 days and reassess. Further review of Resident 1's medical record failed to show the baseline care plan included the treatment and interventions related to the mycotic nails. On 4/24/26 at 1440 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 verified Resident 1's baseline care plan did not address the treatment and interventions related to the resident's mycotic nails. RN 1 further stated Resident 1's care plan should be individualized and include all the current problems and interventions. On 4/24/26 at 1705 hours, the DON was informed and acknowledged the findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety guidelines were followed for the protection of 130 residents who received food prepared in the kitchen. 1. Cleaning cloths were not stored properly in the sanitizing solution. 2. The thawing process for meat was not followed. 3. Hair restraints were not worn properly. 4. The manual dishwashing procedure was not followed. 5. Frozen food was not stored properly. 6. Dry food was stored properly. 7. Two of two ice/water dispensers did not have an air gap. These failures posed the risk for food borne illnesses in 130 residents who received food prepared in the kitchen. Findings: Review of the facility's document titled Diet Order Tally Report dated 1/6/26, showed 130 residents received food prepared in the kitchen. 1. According to the USDA Food Code 2022 Section 3-304.14 Wiping Cloths, Use Limitation (B) (1) showed, Cloths in-use for wiping counter and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer. On 1/5/26 at 0830 hours, during the initial kitchen tour with the DSS, an observation of the sanitizing solution used to store the cleaning cloths was conducted. One of the cleaning cloths stored inside the sanitizing bucket was not fully submerged in the sanitizing solution. The DSS verified the cleaning cloths should be fully submerged in the sanitizing solution. On 1/6/26 at 1144 hours, an additional observation was conducted of the sanitizing bucket containing cleaning cloths. One of the cleaning cloths were not fully submerged in the sanitizing solution. 2. Review of the facility's P&P titled Thawing of Meats dated 2023 showed defrosting meats must be dated when removed from the freezer. On 1/5/26 at 0815 hours, during the initial kitchen tour with the DSS, an observation of the walk-in refrigerator was conducted. Four, ten-pound portions of partially thawed ground beef were observed in a black plastic bin. The ground beef did not have a date when it was removed from the freezer to start the thawing process. In addition, four, five-pound ham [NAME] were observed in a black plastic bin. The ham did not have a date when it was removed from the freezer to start the thawing process. The DSS verified the meats should be dated when removed from the freezer. 3. Review of the facility's P&P titled Dress Code dated 2023 showed if applicable, beards and mustaches (any facial hair) must be covered with a beard restraint. On 1/5/26 at 0910 hours, an observation of the dish room and concurrent interview was conducted with the DSS. Dietary Aide 1 was observed with facial hair wearing a face mask. Dietary Aide 1's facial hair was not covered by the face mask. The DSS was asked if the kitchen staff were allowed to wear a face mask in placed of a beard restraint. The DSS stated they had beard restraints, but it was the employees' choice to wear either a beard restraint or a face mask. On 1/5/26 at 0925 hours, an observation of the kitchen food preparation area and concurrent interview was conducted with the DSS. Dietary Aide 2 was observed with uncovered facial hair. The DSS confirmed Dietary Aide 2 should wear a beard restraint. On 1/7/26 at 1345 hours, an additional observation of the kitchen was conducted. Dietary Aide 1 was observed with facial hair wearing a face mask. Dietary Aide 1's facial hair was not covered by the face mask. 4. Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed the first compartment of the sink is meant for washing, and it should be filled with detergent and hot water. The second compartment is for rinsing and should be filled with clean, clear hot water. The third compartment is for sanitizing and should be filled clean hot water, and sanitizer. On 1/5/26 at 0855 hours, during the initial kitchen tour with the DSS, an observation of manual ware washing was conducted. During the observation there were soiled pans in the rinse and wash sink compartments with no water. In addition, the third sink compartment had dishes not fully submerged in the dish sanitizing solution. Dietary Aide 3 was asked what the process was for washing dishes manually, Dietary Aide 3 stated he was using soap with a scrubbing sponge and then rinses the dishes. When Dietary Aide 3 was asked what the sticker on the outside of the sink labeled water line meant, he stated it was where the water should be. Dietary Aide 3 stated he had drained the water in both the wash and rinse compartments when he started washing the dishes. The DSS confirmed the manual ware washing sink wash and rinse compartments should be filled with water to the indicator line on the outside of the sink. The DSS also stated the dishes in the sanitizing solution in the third compartment of the ware washing sink should be fully submerged in the sanitizing solution for one minute. 5. Review of facility's P&P titled Freezer Storage dated 2023 showed the frozen foods should be stored in an airtight moisture resistant wrapping such as a plastic bag or freezer paper to prevent freezer burn. On 1/5/26 at 0820 hours, during the initial kitchen tour with the DSS, an observation of the walk-in freezer was conducted. One box of Simply wheat dough rolls was left open, and the plastic bag was not sealed. In addition, one box of ground beef hamburger patties was left open, and the plastic bag was not sealed. The DSS confirmed the food items in the freezer should be sealed. 6. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the dry food items which have been opened will be tightly closed, labeled and dated. On 1/5/26 at 0905 hours, an observation of the kitchen preparation area and concurrent interview was conducted with the DSS. A small bin of instant mashed potatoes was observed on a food preparation table with no label, or date when it was placed in the bin. The DSS confirmed the bin of instant mashed potatoes should have been labeled and dated. 7. According to the USDA Food Code 2022 Section 5-202.13 Backflow Prevention, Air Gap showed, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 1/5/26 at 1115 hours, an observation of the ice/water dispensers located in the resident's nourishment room located on the second and third floors and concurrent interview was conducted with the Maintenance Director. The ice/water dispensers had no air gap between the ice machine drain and the flood line of the floor sink. The Maintenance Director verified the two ice/water dispensers did not have an air gap.

Based on interview, medical record review, and facility P&P review the facility failed to timely notify and accurately sent the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when two of three sampled residents (Residents 156 and 158) reviewed for closed records. * The facility failed to ensure notification of proposed transfer was sent to the Ombudsman timely for Resident 156. * The facility failed to ensure the Notice of Proposed Transfer was accurately sent to the Ombudsman for Resident 158. These failures had the potential for the Ombudsman not to be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge.Findings: Review of facility's P&P titled Transfer or Discharge Notices revised 3/2025 showed the residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long -Term Care Ombudsman. A copy of the notice is sent to the Office of the State Long Term- Care Ombudsman at the same time the notice of transfer or discharge is provided to the residents and representatives. 1. Closed medical record review for Resident 156 was initiated on 1/5/26. Resident 156 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of Resident 156's physician order dated 10/29/25, showed transfer the resident to the acute care hospital. Bed hold for seven days. Review of Resident 156's Notification of Proposed Transfer/discharge date d 12/15/25, showed it was faxed to the Ombudsman on 12/15/25. On 1/12/26 at 0906 hours, an interview and concurrent medical record review for Resident 156 was conducted with SSA 1. SSA 1 verified the Notification of Proposed Transfer/Discharge was not sent in a timely manner to the Ombudsman when Resident 156 was discharged on 10/29/25. SSA 1 further stated they missed sending the Notification of Proposed Transfer/Discharge the day Resident 156 was transferred to the acute care hospital. On 1/13/26 at 1415 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Closed medical record review for Resident 158 was initiated on 1/12/26. Resident 158 was admitted to the facility 10/26/25, and discharged [DATE] to lower level of care. Review of Resident 158's physician order dated 11/5/25, showed to transfer Resident 158 to acute rehabilitation per the resident's family request. Review of Resident 158's Notice of Proposed Transfer/discharge date d 11/5/25, showed the Ombudsman was notified. However, the email address of the assigned Ombudsman to the facility was different from the email address the facility sent for the notification of transfer of Resident 158. On 1/12/26 at 0920 hours, an interview and concurrent medical record review for Resident 158 was conducted with the SSD. The SSD was informed and verified the findings. On 1/12/26 at 1351 hours, an interview was conducted for Resident 158 with the DON. The DON was informed and verified the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 17) reviewed for physical restraint was informed of the use of the restraint. * The facility failed to ensure the informed consent was obtained prior to the use of the bed and chair alarms for Resident 17. This failure had the potential for Resident 17 not to be informed of the potential risks and benefits of the restraints.Findings: Review of the facility's P&P titled Use of Restraints revised 1/2025 showed under the Policy Interpretation and Implementation section, restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: the specific reason for the restraint (as it relates to the resident's medical symptom), how the restraint will be used to benefit the resident's medical symptom, and the type of restraint, and period of time for the use of the restraint. Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. On 1/5/26 at 1119 hours, during the initial tour of the facility, Resident 17 was observed in the activity room, up on his wheelchair and working with the activity staff. There was a chair alarm machine at the back of Resident 17's wheelchair and attached to the resident. The activity staff stated Resident 17 had episodes of getting up from the wheelchair unassisted. Medical record review for Resident 17 was initiated on 1/16/26. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/24/25, showed Resident 17 could make needs known but had no capacity to make medical decisions. Review of Resident 17's MDS assessment dated [DATE], showed Resident 17 was dependent with mobility. Review of Resident 17's Order Summary Report showed a physician's order dated 12/29/25, for the use of the bed pressure pad alarm and wheelchair alarm to alert the staff of the resident's attempts to rise unassisted. However, further review of Resident 17's medical record failed to show an informed consent with the risks and benefits of the use of the bed and wheelchair alarm was provided to the resident or responsible party. On 1/7/26 at 0815 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 was awake and sitting in the wheelchair with the red chair alarm attached to the resident. Resident 17 just smiled when asked with questions but did not respond. On 1/7/26 at 1016 hours, an observation of Resident 17 and concurrent interview was conducted with CNA 2. CNA 2 was observed with Resident 17. Resident 17 was observed awake and sitting in the wheelchair with the chair alarm attached to the resident. CNA 2 stated Resident 17 could express simple needs in English language like water or help. CNA 2 stated Resident 17 used the bed and chair alarm because the resident would try to get out of the bed or wheelchair and the resident was unsteady and high risk for fall. On 1/7/26 at 1049 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated prior to the use of the physical restraints, after obtaining the order from the physician, an informed consent explaining the risks and benefits of the restraint should be provided to the resident or responsible party. RN 1 stated the facility used the bed pressure pad alarm and chair alarm for those residents who were impulsive, with poor safety awareness, who tried to get out of the bed or chair without calling for assistance and for those who had multiple history of falls. RN 1 further stated they did not consider the bed or chair alarm as physical restraint, but it was only a safety device. RN 1 verified there was no informed consent for the bed and chair alarm prior to its used. On 1/7/26 at 1140 hours, an interview and concurrent medical record review was conducted with the DON. The DON showed the Nursing - Safety Device Observation/assessment dated [DATE], under Section J. Acknowledgement/Consent, the boxes yes for Acknowledgement and Consent were highlighted, however, the SA (State Agency) informed the DON even if the nurse electronically signed the document, there was no name of the resident/family/resident representative, signature and date. The DON acknowledged it was left blank. Cross reference to F604.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 130) was assessed to self-administer medications. * Resident 130 had medications on the resident's bedside table. Resident 130 was not assessed to self-administer the medications. This failure had the potential to negatively impact on the resident physiological well-being and could administer the medication inaccurately.Findings: Review of the facility's P&P titled Self-Administration of Medications revised February 2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy also showed that any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On 1/5/26 at 0927 hours, Resident 130 was observed with an Albuterol Sulfate inhaler (bronchodilator medication) on top of the bedside table. There was a bag containing multiple medication boxes and container inside the bag with the resident's name on it. Resident 130 stated it was his medication and took it by himself. Resident 130 stated the medications in the bag were his medications and his daughter brought them from home. Medical record review for Resident 130 was initiated on 1/5/26. Resident 130 was admitted to the facility on [DATE]. Review of Resident 130's H&P examination dated 12/11/25, showed Resident 130 had the capacity to make medical decisions. Further review of Resident 130's medical record failed to show documented evidence a physician's order was obtained for the resident to self-administer the Albuterol Sulfate inhaler and store it at the resident's bedside. In addition, there was no care plan initiated or developed to address the resident's self-administration of the Albuterol Sulfate inhaler medication. On 1/5/25 at 0937 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 verified Resident 130 had the Albuterol Sulfate inhaler at the bedside. LVN 5 stated Resident 130 could not have the medication at bedside. On 1/7/26 at 0939 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified Resident 130 did not have a physician's order for self-administration of the Albuterol Sulfate inhaler and did not have a care plan problem addressing the resident's self-administration of Albuterol Sulfate inhaler medication. On 1/12/26 at 1351 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 17) reviewed for physical restraint was free from unnecessary restraints. * The facility failed to assess the need for the use of the wheelchair alarm, determine least restrictive interventions before physical restraints were utilized, and develop and implement interventions to prevent and address any risks related to the use of the restraints for Resident 17. These failures had the potential for increased risk of physical harm and negative potential outcome to the resident. Findings: Review of the facility's P&P titled Use of Restraints revised and reviewed 1/2025 showed:- Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully;- Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; and- When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. The Policy Interpretation and Implementation section showed: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body;- The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint; and- Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. On 1/5/26 at 1119 hours, during the initial tour of the facility, Resident 17 was observed in the activity room, up on his wheelchair and working with the Activity Staff. There was a chair alarm at the back of Resident 17's wheelchair and attached to the resident. The Activity Staff stated Resident 17 had episodes of getting up from the wheelchair unassisted. Medical record review for Resident 17 was initiated on 1/16/26. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's care plan for risk for fall dated 9/23/25, showed interventions included the use of the bed pressure pad alarm and wheelchair alarm to alert the staff of the resident's attempts to rise unassisted. Review of Resident 17's H&P examination dated 9/24/25, showed Resident 17 could make needs known but had no capacity to make medical decisions. Review of Resident 17's Nursing - Safety Device Observation/assessment dated [DATE], showed resident's weakness and balance deficit contributed to the resident's need to use safety device. The recommended type of safety device was bed sensor pad. Review of Resident 17's MDS assessment dated [DATE], showed Resident 17 was dependent with mobility. Review of Resident 17's Order Summary Report showed a physician's order dated 12/29/25, for the use of bed pressure pad alarm and wheelchair alarm to alert staff of the resident's attempts to rise unassisted. Further review of Resident 17's medical record failed to show an assessment for the use of the wheelchair alarm was completed prior to use, least restrictive interventions were implemented before physical restraints were utilized, and interventions to prevent and address any risks related to the use of the restraints were developed and implemented. On 1/7/26 at 0815 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 was awake and sitting in the wheelchair with the red chair alarm attached to the resident. Resident 17 just smiled when asked with questions but did not respond. On 1/7/26 at 1016 hours, an observation and concurrent interview for Resident 17 was conducted with CNA 2. CNA 2 was with Resident 17 in the room. Resident 17 was awake and sitting in the wheelchair with the chair alarm attached to the resident. CNA 2 stated Resident 17 could express simple needs in English language like water or help. CNA 2 stated Resident 17 used the bed and chair alarm because the resident would try to get out of the bed or wheelchair and the resident was unsteady and high risk for fall. On 1/7/26 at 1029 hours, an interview was conducted for Resident 17 with LVN 7. LVN 7 verified they used the bed and wheelchair alarm for Resident 17 to prevent the resident from fall, and it alerted the staff when the resident tried to get out of the bed or wheelchair. LVN 7 stated Resident 17 needed maximum assistance with mobility, but he would try to get out of the bed or wheelchair. On 1/7/26 at 1049 hours, an interview and concurrent medical record review for Resident 17 was conducted with RN 1. RN 1 stated prior to the use of physical restraints, the licensed nurse should conduct an assessment for the device to be used which included assessing the medical symptoms why the use of device being considered and cognitive function, the least restrictive interventions should be implemented prior to the use of the restraint and it should be documented, inform the physician and obtain the consent from the resident or resident's representative, explained to them the risks and benefits, and monitor the resident every shift. RN 1 stated the facility used bed pressure pad alarm and chair alarm for those residents who were impulsive, with poor safety awareness, who tried to get out of bed or chair without calling for assistance and for those who had multiple history of falls. RN 1 further stated they did not consider the bed or chair alarm as physical restraint, but it was only a safety device. RN 1 verified an assessment for the use of wheelchair alarm was not completed prior to use, least restrictive interventions were not implemented before the bed and wheelchair alarms were utilized, and interventions to prevent and address any risks related to the use of the restraints were developed and implemented for Resident 17. On 1/7/26 at 1140 hours, an interview and concurrent medical record review for Resident 17 was conducted with the DON. The DON was informed and acknowledged the findings for Resident 17. Cross reference to F552.

Based on interview, medical record review, and facility P&P review, the facility failed to provide information regarding the rights to formulate the advance directives to three of five final sampled residents (Residents 13, 83, and 130) reviewed for the advance directives. * The facility failed to ensure the advanced directive copy of Resident 13 was available in the resident's medical records. * The facility failed to ensure the formulation of the advance directive for Resident 83 was followed up. * The facility failed to ensure the advance directive copy for Resident 130 was available in the medical records. These failures had the potential for the residents' wishes related to the provision of medical treatment and services to not be followed if the residents were unable to make medical decisions for themselves.Findings: Review of the facility's P&P titled Advance Directives revised September 2022 showed prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/ or his or her legal representative, about the existence of any written directives. The resident or representative is provided a written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. The interdisciplinary team conducts ongoing review of the residents decision-making capacity. Changes are documented in the care plan and medical record. 1. Medical record review for Resident 83 was initiated on 1/6/26. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's IDT Conference Summary dated 12/11/25, showed under the progress note section, Resident 83 stated he has an advanced directive in place, but would like to redo his advance directive, blank copy will be provided to resident to fill out. The SSA was made him aware. Review of Resident 83's Social History Review dated 12/10/25, showed under other notes, no AHCD (Advance Health Care Directive) completed. The SSA offered to complete AHCD, but the resident had declined. Per the resident, I don't like to talk about those things. Further review of Resident 83's medical record failed to show documented evidence a copy of the advance directive was placed. On 1/7/26 at 1013 hours, an interview and concurrent medical record review for Resident 83 was conducted with SSA 1. SSA 1 stated the resident was provided with a blank copy of the advance directive. SSA 1 verified there was no copy of advance directive in the resident's medical record. SSA 1 verified she followed up but did not document the resident's advance directive was completed. 2. Medical record review for Resident 130 was initiated on 1/6/26. Resident 130 was admitted to the facility on [DATE]. Review of Resident 130's Admission/readmission Summary Note dated 12/10/25, showed Resident 130 provided information he did have an advance directive and he would ask his daughter to bring a copy. Review of Resident 130's H&P examination dated 12/11/25, showed Resident 130 had the capacity to make medical decisions. Review of Resident 130's IDT Conference Summary dated 12/12/25, showed under the progress notes social services section, no AHCD completed. The SSA offered to complete AHCD, but the resident had declined. On 1/7/26 at 0912 hours, an interview was conducted with Resident 130. Resident 130 stated he had an advance directive at home. Resident 130 stated the facility asked him about the advance directive, however he was not asked to bring a copy of it when he was admitted to the facility. On 1/7/26 at 1004 hours, an interview and concurrent medical record review for Resident 130 was conducted with SSA 2. SSA 2 verified Resident 130's advance directive was offered but the resident declined. SSA 2 verified she interviewed the resident about an advance directive. SSA 2 reviewed the admission summary note showing the resident had an advance directive and the facility would ask the resident's daughter to bring a copy, and conflicting information on the social services progress note showing Resident 130 did not have AHCD. SSA 2 could not answer the discrepancy. SSA 2 stated when she interviewed Resident 130, she also discussed the POLST and the resident was a full code. SSA 2 was unable to provide a copy of the POLST. On 1/12/26 at 1351 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 3. On 1/6/26 at 1004 hours, an observation and concurrent interview was conducted with Resident 13. Resident 13 was awake and lying in bed. Resident 13 stated his brother would assist him with any legal documents he needed. Medical record review for Resident 13 was initiated on 1/6/26. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's IDT Conference Summary dated 10/23/25, showed under section IV. Notes, Resident 13 had advanced directive and would have the family member bring the copy. Review of Resident 13's H&P examination dated 10/25/25, showed Resident 13 had the capacity to understand and make decisions. Review of Resident 13's medical record failed to show a copy of the advanced directive and documented evidence the facility staff followed up with the resident's family member. On 1/8/26 at 1042 hours, an interview and concurrent medical record review for Resident 13 was conducted with the SSD. The SSD stated the social services department was responsible for the advanced directive- explaining to the resident/responsible party what it was, the benefits of having one, how to formulate one, and following up with the responsible party to bring the advanced directive of the resident if there was already one established. The SSD stated she would give the responsible parties her email address for them to send the copy during her meeting with the resident and responsible parties, would do a follow up telephone call or even via text message to remind them of the need of the advanced directive copy. The SSD further stated she would document each follow-up conversation and once the copy was available, it would be uploaded in the resident's medical records. The SSD verified she was not able to give Resident 13's brother her email address and did not follow up with the brother to give the facility a copy of the resident's advanced directive. On 1/13/26 at 1415 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings.

Based on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 83) reviewed for psychotropic medication use was free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 83's monthly behavior summary was accurately monitored and recorded for the use of mirtazapine (antidepressant) medication. This failure had the potential to place the residents at risk of receiving unnecessary medications and increased risk of serious medication adverse reactions.Findings: Medical record review for Resident 83 was initiated on 1/6/26. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's Order Summary Report dated 1/7/26, showed the following physician's order:- dated 5/30/25, to administer mirtazapine tablet 7.5 mg, one tablet by mouth at bedtime for depression manifested by poor oral intake less than 50%.- dated 9/26/25, to monitor behavior episodes of depression (for the use of mirtazapine medication)manifested by poor oral intake less than 50%. Review of Resident 83's Amount Eaten for 30 days, from 12/10/25 to 1/8/26, showed Resident 83 was consuming less than 50% of his meals for a total of 65 episodes. Review of the Resident Psychotherapeutic Drug Summary Sheet for December 2025 showed under the behavior data, Resident 83 consumed less than 50% of his meals for a total of 41 episodes. On 1/8/26 at 1355 hours, an interview and concurrent medical record review for Resident 83 was conducted with the ADON. The ADON verified the meal percentage monitoring for the use of the mirtazapine medication for Resident 83 was not accurate when compared to the summary of the behavior record. On 1/12/2026 at 1351 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 28 final sampled resident (Resident 11). * The facility failed to provide Resident 11 with a plate guard as per the physician's order. This failure had the potential for Resident 11 not being able to consume his food and drinks without the necessary assistive device.Findings: Review of the facility's P&P titled Adaptive Equipment Policy dated January 2025 showed the provision of the supplies and equipment to support self-care of the residents. Restorative and supportive care includes the assessment of self-feeding skills, providing adaptive devices, and retraining program based on resident needs and capabilities. On 1/5/26 at 1238 hours, an observation of Resident 11 and concurrent interview was conducted with LVN 5 at the bedside. Resident 11 was observed in bed eating his food from the food tray using his right hand. Resident 11's right extremity was observed weak. LVN 5 was asked if Resident 11 had an adaptive equipment to use for eating. LVN 5 was not aware and verified there was no plate guard on Resident 11's food plate. On 1/6/26 at 0847 hours, a follow-up observation was conducted with Resident 11. Resident 11 was observed without an adaptive equipment in the resident's plate. Medical record review for Resident 11 was initiated on 1/6/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report dated 1/6/26, showed a physician's order dated 1/4/26, for Resident 11's use of a plate guard during all meals to facilitate independence with self-feeding three times a day. Review of Resident 11's plan of care showed a care plan problem initiated on 8/22/25, addressing Resident 11's ADL/Mobility. The intervention initiated on 1/4/26, was for the use of the Adaptive Feeding Equipment: plate guard to be provided during all meals to facilitate independence with self-feeding. On 1/7/26 at 0927hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 1. RN 1 verified there was a physician's order for a plate guard as an assistive device for Resident 11 during meals. RN 1 was informed and acknowledged the findings. RN 1 stated the adaptive equipment for eating should have been with the food tray for Resident 11 to use. On 1/12/26 at 1351 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Base on observation, interview, and facility document review, the facility failed to ensure the proper food texture was followed for 12 of 12 residents on an IDDSI Level 6 diet (Soft and Bite-Sized diet, for people who can chew but need food that's soft, tender, moist, and cut into small pieces (about 1.5cm x 1.5cm for adults) that mash easily with a fork, requiring chewing before swallowing). * The facility failed to ensure the meat, vegetables, and bread were properly prepared for the 12 residents on IDDSI Level 6 diet. This failure posed the risk for the 12 residents with swallowing and/or chewing difficulties on mechanically altered diets to not receive the diet texture as ordered by the physician.Findings: Review of the professional reference International Dysphagia Diet Standardization Initiative (IDDSI) a level 6 diet, Soft and Bite-Sized diet should have 'bite-sized' pieces no larger than 1.5 cm equivalent to half an inch. The food must be soft, tender and moist throughout but with no separate thin liquid. According to the IDDSI Audit Tool for the Soft and Bite-Sized diet, the critical tests include Appearance and Fork/Spoon Pressure Test. The appearance test involves measuring food piece size and making sure the food has no separate liquid. The fork/spoon pressure test includes pushing down on a 15 mm by 15 mm (.5 inch) sample with a dinner fork or teaspoon, with enough pressure that the thumb nail turns white, the food can be squashed and will not return to original shape making sure the food has no separate liquid. https://www.iddsi.org/ Review of the facility's document titled General Preparation Recipe: IDDSI Level 6/Soft and Bite Size dated 2025 showed the following:1. Complete regular recipe, measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for the IDDSI Level 6/Soft and Bite Size diets,2. Chop into pieces 1.5 cm x 1.5 cm in size. May moisten food item with sauce or gravy if desired, served at the appropriate thickness, and3. Utilize critical tests and IDDSI audit to confirm texture level 6 specifications. On 1/5/26 at 1223 hours, during the dining observation, Resident 100 was observed in the Dining Room. Resident 100's lunch meal consisted of meat with gravy, vegetables, mashed potatoes with gravy, and a roll. The meat and vegetables were minced or finely chopped consistency. The roll was partially moistened, and the top half of the roll appeared dry in texture. On 1/6/26 at 1000 hours, a meal preparation observation for IDDSI Level 6/Soft and Bite-Sized diets and concurrent interview was conducted with the DSS and [NAME] 1. [NAME] 1 stated he was preparing 12 soft and bite-sized portions of pork. [NAME] 1 measured 12 three-ounce portions of cooked pork. [NAME] 1 put the pork in the Robot Coupe (a food processor). [NAME] 1 blended the pork in the Robot Coupe to obtain a shredded consistency. [NAME] 1 then added seven ounces of gravy and stated he added the gravy so the pork would not be dry. The texture of the pork appeared shredded in consistency. [NAME] 1 then added 12 portions of cooked canned green beans to the Robot Coupe and blended the product. The canned green beans appeared minced in texture. [NAME] 1 added 12 portions of cooked broccoli and one ounce of butter to the Robot Coupe and blended the product. The broccoli appeared minced in texture. The DSS was asked how the employees were trained on IDDSI food textures. The DSS stated she trained the cooks. The DSS added she learned IDDSI food textures from watching the training videos. When asked if an IDDSI audit tool was used to test the different IDDSI food textures for accuracy, the DSS stated no testing was currently being performed on the IDDSI food textures. On 1/7/2026 at 1024 hours, an interview was conducted with the RD. The RD stated she was involved in training the kitchen staff on the IDDSI menus. The RD stated she checked the texture of the IDDSI diets during meal tray line and had no concerns. The RD was made aware the soft/bite-sized pork and broccoli served on 1/6/26 were not the correct texture for IDDSI Level 6/Soft and Bite-Sized diet. The RD acknowledged and stated all diets must be the correct texture in accordance with the physician's order. On 1/7/2026 at 1124 hours, an interview was conducted with the ST. The ST stated she was involved in training the kitchen staff on the IDDSI diet textures. The ST stated she monitored the residents' meal trays to check food textures. The ST was made aware and acknowledged the soft/bite-sized pork and broccoli served on 1/6/26, were not the appropriate texture. The ST added all food textures should be in accordance with the physician's diet order. The ST was made aware of the roll serve to Resident 100 on 1/5/26, and acknowledged the roll was not completely soaked and the meat and vegetables were not soft/bite-sized texture.

Based on observation, interview, and facility document review, the facility failed to ensure a vegetarian meal substitute was served for two nonsampled residents (Residents 94 and 163) who were on vegetarian preference diet. * The facility failed to ensure Residents 94 and 163 received a vegetarian meal substitute equivalent in nutritive value to the main entree served. This failure posed the risk for the residents' nutritional needs, specifically protein needs to not be met.Findings: Review of the facility's document titled Cooks Spreadsheet dated 1/6/26, showed Regular diets were to receive three ounces of pork with pear sauce. Review of the nutritional information provided by the facility for the pork during lunch on 1/6/26, showed the three ounces would provide 15.75 grams of protein. Review of the nutritional information provided by the facility for the tofu during lunch on 1/6/26, for the vegetarian lunch meal alternate, showed the three ounces would provide nine grams of protein. On 1/6/26 at 1000 hours, an interview was conducted with the DSS. The DSS stated the residents who had vegetarian meal preference were to receive stir fried tofu with zucchini for their lunch meal. When asked about the vegetarian meal preference menu, the DSS stated the facility had no menu for the vegetarian diets. The DSS added she spoke with the RD who approved the vegetarian meal substitutions. On 1/6/26 at 1218 hours, a tray line observation was conducted. Resident 94 and 163's lunch tray in the meal cart was observed to have tofu with zucchini in placed of the three ounces of pork with pear sauce for the residents on the regular diets. On 1/7/26 at 0908 hours, an interview was conducted with [NAME] 1 and the DSS. When asked how [NAME] 1 determined what vegetarian meal substitution to serve for the day, the DSS stated there were several vegetarian options to choose from and the cook was responsible to decide which vegetarian meal substitution to serve for the meal. [NAME] 1 stated the vegetarian meal substitutions did not have recipes to follow. When asked how he determined the portion size of the vegetarian meal substitution, [NAME] 1 stated he used the same portion size as the regular diet on the menu spreadsheet. On 1/7/26 at 1024 hours, an interview was conducted with the RD. The RD stated the vegetarian meal preference was an alternate to the regular diet. The RD verified the vegetarian meal preference did not have a menu, recipes or cook spreadsheet for the cook to follow to ensure the vegetarian meal preference was equivalent in nutritive value to the regular menu entree served.

Based on observation, interview, and facility document review, the facility failed to ensure the menu and recipes were followed. * The facility failed to ensure 75 of 75 residents on regular diets were served the correct portion size for the entree of the lunch meal. * The facility failed to ensure the puree broccoli recipe was followed for 19 of 19 residents on the puree diet. These failures posed the risk for 75 residents on regular diets and 19 residents on puree diets to not meet their nutritional needs.Findings: 1. Review of facility's document titled Cooks Spreadsheet dated 1/5/26, showed the regular diet would serve four ounces of the Southern style patty for the regular sized portions and three ounces for small sized portions. On 1/5/26 at 0930 hours, during the initial tour of the kitchen with the DSS, a lunch preparation observation and concurrent interview was conducted with [NAME] 1. [NAME] 1 was observed portioning the ground beef for the Southern style patty. [NAME] 1 stated he was using a two-ounce scoop to form the patties. [NAME] 1 stated the portion sizes for the Southern style patty were to be two to three ounces. On 1/7/25 at 1024 hours, an interview was conducted with the RD. The RD was made aware and acknowledged all recipes should be followed. 2. Review of the facility's document titled Recipe: Pureed (IDDSI Level #4) Vegetables dated 2025 showed to measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets, and puree on a low speed to a paste consistency before adding any liquid. The document further showed to gradually add warm liquid if needed. On 1/6/26 at 1000 hours, an observation of the puree preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing twenty-four servings of broccoli for the puree diets. [NAME] 1 was observed adding broccoli and unmeasured amount of vegetable broth to a blender to be pureed. [NAME] 1 blended the broccoli mixture. After blending the broccoli mixture, the broccoli mixture was observed at a liquid consistency. [NAME] 1 stated he will add thickener as he goes to get the correct texture. On 1/7/25 at 1024 hours, an interview was conducted with the RD. The RD was made aware and acknowledged all recipes should be followed.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 20 kitchen staff (Dietary Aide 3) was competent in preforming the task in the food and nutrition department. * The facility failed to ensure Dietary Aide 3 was competent in the manual dishwashing procedure. This failure posed the risk for the dishes, pots, and pans used to cook the residents' food to not be cleaned and sanitized properly. Findings: Review of the facility's document titled Dietary Aide Competency Checklist signed by Dietary Aide 3 and the DSS on 10/9/25, showed Dietary Aide 3 was competent in washing and cleaning the utensils as directed and performed dishwashing/cleaning procedures. Review of the facility's document titled Dietary In-Service, Topic: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans dated 11/10/25, showed Dietary Aide 3 was in attendance. Review of the facility's P&P titled 3-Compartment Procedure for Manual Dishwashing dated 2023 showed the following:Step 2: Rinse, scrape, or soak all items before washing. Use a brush, cloth, or nylon scrubber,Step 3: The first compartment of the sink is meant for washing. Fill the first compartment with detergent per manufactures instructions and hot water, Step 4: The second compartment is for rinsing. Fill the second compartment with clean hot water. Immerse washed items and rinse thoroughly, making sure detergent is removed, andStep 5: The third compartment is for sanitizing. Fill the third compartment with clean, clear water to the fill line and sanitizer to meet the required concentration on the test strip container. Immerse all washed items per sanitizer manufacturer guidelines. On 1/5/26 at 0855 hours, during the initial tour of the kitchen with the DSS, an observation of manual warewashing and concurrent interview was conducted. During the observation there were soiled pans in the wash and rinse sink compartments with no water. In addition, the third sink compartment had dishes not fully submerged in the sanitizing solution. Dietary Aide 3 was asked to demonstrate the manual dish washing procedure. Dietary Aide 3 stated he would use the soap with a scrubbing sponge and then would rinse the dishes. When Dietary Aide 3 was asked what did the water line labeled on the outside of the wash and rinse sinks meant, Dietary Aide 3 stated it was where the water should be filled up to. Dietary Aide 3 stated he had drained the water in both the wash and rinse compartments when he started washing the dishes. The DSS confirmed the manual warewashing sink's wash and rinse compartments should be filled with water to the indicator line on the outside of the sink. The DSS also stated the dishes in the sanitizing solution in the third compartment of the warewashing sink should be fully submerged in the sanitizing solution for one minute. Cross reference to F812, example #4.

Based on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the recommendation from Dialysis Center and fluid restriction were followed for two of three final sampled residents (Residents 10 and 113) reviewed for dialysis. * The facility failed to ensure the physician's order for 1500 ml of fluid restriction was followed and carried out accordingly for Resident 10. * The facility failed to follow up on a dialysis recommendation to check Resident 113 for C-diff (a harmful bacterium causing diarrhea and colitis often triggered by antibiotic use that disrupts gut bacteria). These failures had the potential of not identifying potential negative outcomes for the residents on dialysis.Findings: Review of the facility's P&P titled Care of Residents on Hemodialysis, Coordination of Care, Evaluation and Communication, revised 1/2025 showed the Dialysis Center, by telephone or in writing, will notify the facility of the following: - any medication given during dialysis care; and - the Dialysis Center and the facility shall communicate via telephone or use of Dialysis Communication papers, matters of difficulty with transportation, emergent changes in the resident's condition or other significant findings. 1. Medical record review for Resident 113 was initiated on 1/5/26. Resident 113 was admitted to the facility on [DATE]. Review of Residents 113's MDS admission assessment dated [DATE], showed a BIMS score of 13, meaning cognitively intact. Review of the Dialysis Center Hemodialysis Communication Observation/assessment dated [DATE], showed a recommendation from Dialysis Center to check Resident 113 for possible C-diff and loperamide (antidiarrheal medication) 4 mg was given at the Dialysis Center. Review of Resident 113's Order Summary Report showed a physician's order dated 12/31/25, for loperamide 2 mg give two tablets by mouth one time a day every Monday, Wednesday and Friday, to administer prior to dialysis transportation pick up for loose stool. On 1/7/26 at 1114 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the recommendation from the Dialysis Center dated 12/29/25, to check for Resident 113 for possible C-diff was not communicated to the facility MD. On 1/13/26 at 1415 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 10 was initiated on 1/7/26. Resident 10 was admitted to the facility on [DATE], with a diagnosis of ESRD. Review of Resident 10's H&P examination dated 11/26/25, showed Resident 10 had no capacity to understand and make decisions. Review of Resident 10's Order Summary Report showed a physician's order dated 11/26/25, for fluid restriction of 1500 ml/24 hours as follows: * Dietary to provide 840 ml of fluid: - 280 ml at breakfast - 280 ml at lunch - 280 ml at dinner * Nursing to provide 660 ml of fluid: - 120 ml for the 11-7 shift - 270 ml for the 7-3 shift - 270 ml for the 3-11 shift Review of Resident 10's MAR for December 2025 showed the fluid restriction record for nursing to provide 660 ml of fluids for 24 hours. However, further review of Resident 10's medical record failed to show documented evidence of the fluid intake from the dietary to provide 840 ml for 24 hours. On 1/8/26 at 0959 hours, an interview for Resident 10 was conducted with CNA 4. CNA 4 verified Resident 10 had dialysis and a fluid restriction order. CNA 4 stated she reported to the nurse on how much fluids Resident 10 consumed for each meal but did not record the amount of fluids, only the meal percentage. On 1/8/26 at 1003 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 1. RN 1 verified Resident 10 was a dialysis resident and on fluid restriction of 1500 ml per day as per physician order. RN 1 stated the licensed nurses documented in the MAR for the fluids given by nursing. RN 1 was asked about the documentation of fluid intake coming from the dietary. RN 1 verified and acknowledged there was no fluid intake was recorded from the dietary. On 1/12/26 at 1334 hours, an interview for Resident 10 was conducted with the DON. The DON was informed and verified the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate GT care and services were provided for one of two final sampled residents (Resident 101) reviewed for GT. * The facility failed to ensure Resident 101's enteral formula bottle was labeled with the correct name of the resident. This failure had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Enteral Nutrition dated January 2025 showed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurses confirm the physician's order for enteral nutrition is complete before administration. During the initial tour on 1/5/26 at 1027 hours, Resident 101 was observed in bed with the GT feeding. The feeding was Glucerna 1.5 cal (enteral feeding formula) and it was infusing via GT feeding machine at 45 ml per hour. The enteral formula bottle was labeled with different name of a resident. LVN 6 was summoned to Resident 101's bedside and verified the findings. LVN 6 verified and acknowledged the GT feeding bottle of Resident 101 had an incorrect name. Medical record review for Resident 101 was initiated on 1/6/26. Resident 101 was admitted to the facility on [DATE]. Review of Resident 101's H&P examination dated 7/30/25, showed Resident 101 could not make medical decisions by himself. Review of Resident 101's Order Summary Report showed a physician's order dated 1/6/26, to administer enteral feeding Glucerna 1.5 at 45 ml per hour via GT for a total of 900 ml. On 1/7/26 at 0947 hours, an interview and concurrent medical record review for Resident 101 was conducted with RN 1. RN 1 verified Resident 101 was on enteral feeding. RN 1 stated the licensed nurses must make sure the physician order, correct formula, and correct resident was verified before administration on enteral feeding. RN 1 was informed of the findings and verified the findings. RN 1 stated the enteral feeding bottle name of the resident label should have been corrected. On 1/12/26 at 1351 hours, an interview for Resident 101 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 20) nephrostomy tube (a small tube inserted through the back into the kidney to drain urine when the normal urinary pathway is blocked). * The facility failed to ensure a physician's order was obtained for the care and monitoring of nephrostomy tube for Resident 20. This failure had the potential for the risk of infection and affected the well-being of the residents. Findings: On 1/5/26 at 1025 hours, during the initial tour of the facility, an observation and concurrent interview for Resident 20 was conducted. Resident 20 was sitting in bed and observed with a leg drainage bag attached to both thighs. Resident 20 stated the drainage was from his kidneys. Resident 20 further stated his drainage bag sometimes had blood. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 11/19/25, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's Order Summary Report dated 1/6/26, showed a physician's order dated 12/29/25, to cleanse the right and left nephrostomy tube with saline, pat dry, and cover with dry dressing. However, further review of the order summary report failed to show a physician's order for the care and monitoring of the nephrostomy tubes. On 1/8/26 at 0951 hours, an interview for Resident 20 was conducted with CNA 4. CNA 4 verified Resident 20 had two drainage bags for his urine. CNA 4 stated she emptied the drainage bags at the end of her shift and as needed. CNA 4 stated she measured the urine output and reported it to the nurse. On 1/8/26 at 1012 hours, an interview and concurrent medical record review for Resident 20 was conducted with RN 1. RN 1 verified Resident 20 had a nephrostomy tube on both right and left kidney. RN 1 was able to show a physician's order for the treatment on the incision site, verified and acknowledged there was no physician's order for the care and monitoring of the nephrostomy tube. On 1/12/26 at 1334 hours, an interview for Resident 20 was conducted with the DON. The DON was informed and verified the findings. Cross Reference to F656.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 28 final sampled residents (Residents 9 and 31). * The facility failed to initiate a change of condition, notify the physician and resident representative when Resident 9 was involved in an allegation of abuse. * The facility failed to ensure Resident 31 was continuously monitored when the resident had dysuria (painful or difficult urination) and antibiotic use. These failures had the potential for the residents not to receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments.Findings: 1. Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 1/2025 showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: - The resident's representative; and - The resident's attending physician. Review of the facility's P&P titled Charting and Documentation revised 1/2025 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Medical record review for Resident 9 was initiated on 1/5/26. Resident 9 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 9/26/25, showed Resident 9 had capacity to make medical decisions. Review of the facility's SOC 341 form dated 12/30/25, showed a resident had reported an allegation of physical abuse by Resident 9. Review of Resident 9's plan of care showed a care plan problem dated 12/30/25, addressing Resident Psychosocial- Emotional/Trauma: At risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to alleged/suspected abuse from roommate. The interventions included contacting resident representative/friend for comfort and support. Review of Resident 9's medical record failed to show a change of condition assessment was initiated when Resident 9 was involved in the allegation of abuse on 12/30/25. Further review failed to show the physician and resident representative were notified on the allegation of abuse. On 1/8/26 at 0937 hours, an interview and concurrent medical record review for Resident 9 was conducted with MDS 2. MDS 2 stated for the allegation of abuse, the licensed nurse was responsible for completing the incident report, the change in condition assessment, developing a care plan, and notification of physician and resident representative. MDS 2 reviewed and verified Resident 9's medical record failed to show a change of condition was initiated and the physician and resident representative were notified. On 1/8/26 at 1315 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON stated for abuse allegations, a change of condition should be completed for the perpetrator and victim. The DON further stated the facility's protocol was to assess the resident and inform the physician and resident's responsible party. The DON reviewed and verified Resident 9's medical record failed to show a change of condition was initiated, notification of the resident's physician and resident representative. 2. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 1/2025 under the Policy Interpretation and Implementation section, showed the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. On 1/6/26 at 0830 hours, an observation and concurrent interview was conducted with Resident 31. Resident 31 stated at times she had pain when urinating. Resident 31 stated she reported it to the nurses. Resident 31 stated she was getting antibiotics through her vein every day. Medical record review for Resident 31 was initiated on 1/6/26. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's H&P examination dated 12/11/25, showed Resident 31 had the capacity to understand and make decisions. Review of Resident 31's eINTERACT Change in Condition Evaluation dated 12/30/25 at 1300 hours, showed Resident 31 complained of pain with urination which started this morning. The attending physician was notified and ordered urinalysis and culture. Review of Resident 31's Order Summary Report showed a physician's order dated 1/3/26, to administer ceftriaxone sodium (antibiotic medication use to treat bacterial infection in many different parts of the body) one gram intravenously every 24 hours for UTI for seven days. Further review of Resident 31's medical record failed to show documented evidence the facility staff continued to monitor the resident when the resident had changed in condition of dysuria and used of antibiotics. On 1/12/26 at 1001 hours, an interview and concurrent medical record review for Resident 31 was conducted with RN 1. RN 1 stated having dysuria, UTI, and use of antibiotics were considered changes in the resident's condition. RN 1 stated when there was a change in condition, the licensed nurses should continuously monitor the resident specific to the changed in condition every shift for at least three days and as needed. RN 1 stated when the resident was receiving antibiotics whether it was administered orally or intravenously, the licensed nurses should continuously monitor the resident throughout the course of antibiotics and another three days after the completion days of the antibiotics to further observe for any adverse reactions from the medication. RN 1 verified Resident 31 was not continuously monitored every shift when the resident experienced dysuria and when receiving antibiotics for the UTI. RN 1 further stated when the resident had a change in condition, it was important for the nurses to monitor or assess the resident on each shift to observe if there were worsening signs and symptoms of the condition or adverse reactions from the medication, and they could notify the physician to further assess the resident, change the treatment if needed and modify the plan of care specific to the change in condition. On 1/13/26 at 1415 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings for Resident 31.

Based on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of 28 final sampled residents (Resident 20). * The facility failed to develop a care plan problem to address Resident 20's nephrostomy tubes (a thin catheter inserted through the back into the kidney to drain urine directly into a bag, bypassing a blockage or leak in the urinary tract). This failure posed the risk of not providing appropriate, consistent, and individualized care to this resident. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, Development, Implementation & Revision revised January 2025 showed the comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the residents' strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. Medical record review for Resident 20 was initiated on 1/8/26. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 11/19/25, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's Order Summary Report showed a physician's order dated 12/29/25, to cleanse the right and left nephrostomy tube with saline, pat dry and cover with dry dressing. Review of Resident 20's comprehensive care plans failed to show an individualized care plan problem was developed to address Resident 20's nephrostomy tubes. On 1/8/26 at 1012 hours, an interview and concurrent medical record review for Resident 20 was conducted with RN 1. RN 1 verified Resident 20 had a nephrostomy tube on both right and left kidney. RN 1 verified there was no specific care plan for the care and monitoring of signs and symptoms of infection for Resident 20's nephrostomy tubes. RN 1 verified the findings. On 1/12/26 at 1334 hours, an interview for Resident 20 was conducted with the DON. The DON was informed and verified the findings. Cross Reference to F690.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 fell to the floor while being transferred to bed by one CNA using a mechanical lift. The facility failed to follow their P&P on requiring two-person assistance with transfers when using a mechanical lift. This failure resulted in Resident 1 being transferred to the acute care hospital due to occipital hematoma (collection of blood) and a left subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Resident 1 required 13 staples to close the skin cut on her scalp. Findings: Review of the facility's P&P titled Mechanical Lift revised 4/2019 showed to verify transfer assistance is needed per Kardex (a way to communicate to the CNAs important information regarding the residents) and obtain additional assistance and needed equipment as indicated. The use of a mechanical lift requires a second caregiver. Review of the facility's P&P titled Lifts and Injury Reducing Devices Manual dated 10/2017 showed the Patient-Care Employees section showing new employees are to be trained on the Lifts and Injury-Reducing Devices Program as part of job-specific orientation and are not to use the lift equipment until they have completed all necessary training and associated skills check-off sheets. Employees will complete and document training during job specific orientation, annually and as required to correct improper use/understanding of safe patient handling movement. Further review of the P&P showed the section for Use of Lifts and Friction Reducing Device showing a subsection Number of Employees Required When Operating a Lift. The P&P showed although one person can operate most models of hydraulic lifts, it is advisable to have two staff members present to stabilize and support the patient. As such, a two-person lift is required when using the lift equipment. Under special circumstances and with proper assessment of the patient, a one-person lift may be acceptable. The location's Interdisciplinary or Care Plan Team must determine and approve the procedure for less than a two-person lift. Medical record review for Resident 1 was initiated on 5/27/21. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively impaired and required two-person physical assistance with transfers. Review of the Therapy Discharge Communication (undated), under the section for Transfers, showed Resident 1 required two-person physical assistance for transfers from bed to wheelchair using a Hoyer Lift (mechanical lift). Review of the Visual/Bedside Kardex Report, under the section for ADLs/Restorative care, showed to transfer Resident 1 with two-person assistance using a Maxi-move lift (mechanical lift) and a large sling to the shower gurney for shower/bath as needed. Review of Resident 1's plan of care showed a care plan problem dated 1/9/17, addressing Resident 1's risk for falls related to medical history of CVA (cerebrovascular accident or stroke) with [CONDITION(S)] (paralysis on one side of the body), dementia (memory loss and confusion), and dysphagia (difficulty with swallowing). Another care plan dated 3/23/15, was created addressing Resident 1's ADL self-care deficits. The interventions in both care plan problems included to transfer Resident 1 with two persons using the Maxi-move lift with a green or large sling. Review of the Progress Notes dated 5/12/21 at 1653 hours, showed LVN 1 was called by CNA 1 at around 1610 hours because Resident 1 fell . The documentation showed LVN 1 found Resident 1 on the floor lying on her back by the right side of the bed. LVN 1 noted some blood on the right side of Resident 1's head. The documentation showed CNA 1 was trying to put the resident back to bed after giving her a shower using the mechanical lift. CNA 1 was lowering the resident down and the resident's buttocks were already resting in the bed when the mechanical lift got stuck. CNA 1 tried to reposition the mechanical lift, when the sling came off, and Resident 1 slid off to the floor. The documentation showed the physician was informed and ordered to transfer the resident to the acute care hospital emergency department via paramedics. Review of the acute care hospital's report of the Computed Tomography of the head dated 5/12/21, showed small focus of high left frontal lobe subarachnoid hemorrhage. Review of the acute care hospital's History and Physical examination dated 5/12/21, showed Resident 1 was admitted to the acute care hospital after a fall from the bed about three feet with occipital hematoma and some bleeding. Review of the Progress Note dated 5/15/21 at 2204 hours, showed Resident 1's posterior scalp was observed to have two separated incision sites. Each site was approximately 3 cm with a total of 13 staples. The surrounding skin was observed to be red and boggy from the hematoma. On 5/27/21 at 1020 hours, an interview was conducted with CNA 2. CNA 2 stated she cared for Resident 1 and transferred her sometimes using the mechanical lift. CNA 2 stated the bed needed to be clear, so when she moved the resident with the mechanical lift, the resident's legs would not get caught with the linen on the bed. CNA 2 stated she always needed two persons to transfer the resident: one person controlled the machine and the other person observed to make sure the resident did not get hit on the pole of the mechanical lift. On 5/27/21 at 1027 hours, an interview was conducted with RNA Director about the incident. The RNA Director stated Resident 1 was nonverbal with contractures to the bilateral upper and lower extremities. Resident 1 required two-person assistance with bed mobility, cleaning, and transfers. On 6/3/21 at 1437 hours, a telephone interview was conducted with CNA 1. CNA 1 was asked about the incident. CNA 1 stated the incident happened on 5/12/21, at around 1600 hours after she gave a shower to Resident 1. CNA 1 stated she placed Resident 1 on the sling connected to the mechanical lift by herself, moved Resident 1 to the shower room, put Resident 1 on the shower chair, removed the mechanical lift from the sling under Resident 1, and gave Resident 1 a shower. After the shower, CNA 1 stated she connected the sling back to the mechanical lift with Resident 1 sitting on the sling. CNA 1 brought Resident 1 back to the resident's room by herself. CNA 1 stated while she pushed the mechanical lift to place Resident 1 on her bed, the stand of the mechanical lift got stuck with the black cord under the bed. CNA 1 moved the black cord away, and continued to push the mechanical lift. CNA 1 stated at this point, the mechanical lift was jerking. Resident 1 was barely on the bed with her bottoms at the edge of the bed. Resident 1 slipped off from the mechanical lift to the floor, hitting the right side of her head. CNA 1 was asked if she had given Resident 1 a shower before, and if she called for help when transferring the resident using the mechanical lift. CNA 1 stated it was her first time giving Resident 1 a shower, and she did not call for help because everyone was busy. On 6/7/21 at 1707 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was informed Resident 1 fell . When she came to the resident's room, Resident 1 was lying on her right side and her head was bleeding. LVN 1 stated Resident 1 was transferred back from the shower using the mechanical lift by CNA 1. Resident 1 was sitting on the edge of the bed with part of her body on the bed. When CNA 1 pushed the mechanical lift, the mechanical lift got stuck. CNA 1 tried to push, the sling came off from the mechanical lift, and Resident 1 fell on the floor. LVN 1 stated she gave Resident 1 a shower before. LVN 1 stated Resident 1's upper and lower extremities were very contracted, and the resident needed two persons assistance using the mechanical lift. One person helped guide the mechanical lift and another person used the mechanical lift control. LVN 1 was asked if she was trained to use the mechanical lift. LVN 1 stated she could not remember if she was trained before the incident, she knew how to use the mechanical lift because she used to work as a CNA. On 6/21/21 at 1231 hours, a telephone interview was conducted with the DON. The DON was asked how the patient care employees (nursing staff) were trained to use the mechanical lift. The DON stated the patient care employees were trained on using the mechanical lift as part of their job orientation. The DON stated the patient care employees had not been trained annually as per their P&P.

Based on interview and clinical record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was as free from accident hazards as possible. Resident 16 has a history of four falls, all unwitnessed by the facility staff. Documentation showed Resident 16 was having episodes of getting up unassisted and trying to walk by herself. In December 2012, Resident 16 had two falls while up in the wheelchair. The facility did not provide any additional safety interventions to protect the resident while in the wheelchair or to address the resident's episodes of getting up unassisted. On 2/10/13, Resident 16 had a fifth fall, this time from the wheelchair. The resident fractured her hip as a result of the fall. Findings: 1. Clinical record review for Resident 16 was initiated on 9/26/13. Review of the Medication Review Report dated 6/28/12, showed Resident 16 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan problem to address high fall risk dated 6/28/12, showed Resident 16 was assessed as being a high risk for falls due to a history of falls, poor coordination, impaired balance, unsteady gait, seizure disorder, confusion, and episodes of sleep cycle reversal (sleeps during the day, up all night). The goal for the problem is to minimize the risk of injury and falls. The interventions are to administer medications as ordered, place the bed in the low position and keep commonly used items within reach, encourage the resident to transfer and change positions slowly and provide assistance to transfer and ambulate. The care plan problem to address ADL care dated 6/28/12, showed Resident 16 needs one person's extensive assistance for transferring and ambulation. Review of the Progress Notes dated 8/21/12, showed Resident 16 had an unwitnessed fall at 2315 hours on 8/20/12. The CNA found the resident on the floor in her room. Review of the care plan problem to address the resident's high fall risk showed floor mats were added to address the unwitnessed fall. The resident was transferred to a different floor in the facility. According to the Progress Notes dated 9/13/12, Resident 16 was getting up out of the wheelchair unassisted several times. No new interventions were implemented on the care plan. A Progress Notes 9/23/12, showed a CNA found Resident 16 sitting on the bedside landing mats in her room. No new interventions were documented on the care plan addressing the high fall risk. Review of the Progress Notes dated 9/24/12 and 9/25/12, showed Resident 16 was having episodes of trying to get out of the wheelchair unassisted. No new interventions were documented on the care plan addressing the high fall risk. Review of the Progress Notes dated 10/15/12, showed Resident 16 continued to have episodes of being awake at night and frequently trying to get up and walk. No new interventions were documented on the care plan addressing the high fall risk. Review of the physician's orders [REDACTED]. Review of the Situation Background Assessment Resolution (SBAR) dated 12/2/12, showed Resident 16 fell out of the wheelchair on 12/2/12. According to the facility's investigation, the resident was in her room and reached down to pick up an item off the floor. Although the facility staff did not witness the fall, a visitor of the resident's roommate observed the resident fall out of the wheelchair. Review of the care plan problem to address the high fall risk showed there were no further updates to the care plan. Review of the SBAR dated 12/9/12, showed Resident 16 had another fall while in the wheelchair. The facility staff did not witness the fall. The IDT investigation into the fall showed the resident was found in the hall sitting on the floor in front of the wheelchair. Review of the MDS (an assessment tool) dated 1/20/13, showed Resident 16 needs extensive assistance from one person to transfer and ambulate. Further review showed the resident has severe cognitive impairment and is always incontinent of bladder and bowel. Review of the Incident Report - Patient Involved dated 2/10/13, showed at 2330 hours, Resident 16 was seated in the wheelchair in front of the nurses' station. According to the investigation, two nurses were at the nurses' station counting medications, but did not observe the resident. CNA 9 was passing by the nurses' station getting linens for another resident and saw Resident 16 get up and fall to the floor. The investigation further showed Resident 16 had received trazodone at 2100 hours for insomnia and Resident 16 was refusing to go back to bed at 2200 hours. When assisted back to bed after the fall, the resident was found to be incontinent of stool and having pain in her left hip. Review of the Progress Notes date 2/11/13 showed at 1115 hours, Resident 16 was transferred to the hospital. Review of the x-ray report dated 2/11/13, showed Resident 16 had a fracture of the left hip requiring surgical repair. An interview with ADON 2 was initiated on 9/26/13 at 1100 hours. ADON 2 stated Resident 16 does not sleep well at night and was placed in the wheelchair in front of the nurses' station late at night. ADON 2 stated Resident 16 is given sleeping medication on a routine basis to try and get her to sleep. An interview with the DON was initiated on 9/26/13 at 1130 hours. The DON was asked about the updates to the resident's care plan addressing the resident's increased fall risk after the first fall. The DON produced an updated care plan; however, no new interventions were documented on the revised care plan since 8/21/12. The updated care plan documented the interventions that had been discontinued. The DON confirmed no other interventions were implemented to reduce the resident's risk for falls. An interview with Resident 16's family member was initiated on 9/26/13 at 1300 hours. The family member stated Resident 16 could no longer understand simple instructions and was at a high risk of falling at home. The resident was admitted to the facility last year due to this problem. The family member was asked about the resident's hip fracture and stated he was told the resident was being assisted back to bed and slipped.

Based on observation, interview, and clinical record review, the facility failed to provide the necessary care to maintain the highest practicable physical, mental, and psychosocial well-being for four of 24 sampled residents (Residents 5, 6, 7, and 4). *The facility failed to manage or prevent Resident 6's pain consistent with the plan of care and failed to assess her implanted medical device and ability to use the call light. This resulted in Resident 6 experiencing severe pain and discomfort. *The facility failed to follow the manufacturer's guidelines when applying the rivastigmine (medication to treat [MEDICAL CONDITION]) patch on Resident 7. This has the potential for the resident to experience skin irritation. *The facility failed to follow the manufacturer's specification for [MEDICATION NAME] extended-release bi-layer tablets "do not crush" for Resident 5. This poses the potential for ineffective therapeutic value of the medication. *The facility failed to follow the physician's orders [REDACTED]. This poses the potential for the resident to develop complications related to their medical conditions. Findings: 1. During initial tour with ADON 3 on 9/24/13 at 0815 hours, the ADON stated Resident 6 is on comfort care (care focused on relieving pain and suffering). a. Review of Resident 6's clinical record was initiated on 9/24/13. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's progress note dated 9/19/13, shows Resident 6 was complaining of pain and the resident's bilateral lower extremities are tender to touch. Resident 6 has unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by dead tissue making it difficult to determine how deep the ulcer is) to both heels, the left buttock, and her coccyx (tailbone). The resident also has a vascular wound and gangrene (death of body tissue due to a lack of blood supply) to her left lower extremity and gangrene on her left great toe. Resident 6 also has an abrasion on her right shin and an open wound on the top of her left foot. Review of the MDS (an assessment tool) dated 9/4/13, shows Resident 6 requires extensive assistance with bed mobility and transfers. Review of the care plan problem dated 8/31/13, to address pain shows interventions to administer pain medication per the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. (a method of delivery of medicine through a special gel-like matrix that is applied to the skin); apply one patch every 72 hours. On 9/24/13 at 1100 hours, RN 1 was observed providing wound care to Resident 6's multiple wounds and unstageable pressure ulcers. Resident 6 was observed with facial grimacing and muscular rigidity (non-verbal signs of pain). Resident 6 winced and moaned throughout the treatment. Resident 6 was observed reaching back and guarding the pressure ulcers on her buttock and coccyx when the dressings were removed. When Resident 6 was turned and repositioned during the wound care, she yelled out. RN 1 stated Resident 6 is in pain every time she is touched, turned, or repositioned. RN 1 stated Resident 6 was pre-medicated with her pain medication 30 minutes prior to the wound care. RN 1 instructed Resident 6 on the process of the treatment and continued with the wound treatment without addressing Resident 6's pain. Resident 6 remained nonverbal throughout the treatment and continued to moan and attempt to guard the areas being treated on her left buttock and coccyx. This procedure lasted 45 minutes. During an interview with RN 1 on 9/24/13 at 1145 hours, RN 1 stated she was not going to perform indwelling urinary catheter care (a process of providing hygiene for the catheter tubing and genitalia) at this time because the resident refused. Review of the MAR for September 2013 showed Resident 6 received one dose of PRN [MEDICATION NAME] 2 mg on 9/24/13 at 1022 hours. The documentation shows an "E" indicating the medication was effective. Review of the Progress Notes dated 9/24/13 at 1236 hours, showed the PRN administration was effective. According to Lexi-Comp Online, a professional resource, [MEDICATION NAME] has a peak effect in 30-60 minutes and is effective for 3-4 hours. Further review of the clinical record showed the physician was notified on 9/24/13 at 1255 hours, regarding lab results and increased discoloration of Resident 6's left lower extremity. Documentation to show the physician was notified of Resident 6's increased pain during wound treatment was not found. During a concurrent interview and clinical record review with ADON 3 on 9/25/13 at 1030 hours, the ADON verified Resident 6 is in pain every time she is turned and repositioned. The ADON verified Resident 6 is turned and repositioned every two hours and, therefore, is in pain every two hours. When the ADON was asked why Resident 6 only received pain medication once on 9/24/13, she stated, maybe the resident was sleeping or not in pain when the nurse checked on her. There was no documentation in Resident 6's clinical record showing Resident 6 was given pain medication to minimize the anticipated pain from turning and repositioning. During a concurrent interview and clinical record review with LVN 1 on 9/25/13 at 1040 hours, LVN 1 was asked how often Resident 6 is monitored for pain. LVN 1 stated Resident 6 is monitored for pain once daily. During a concurrent observation and interview with Resident 6's family member on 9/25/13 at 1045 hours, the family member stated he does not feel like Resident 6's pain is being controlled by the facility. The family member stated the facility should just give the resident her pain medication without having to ask because she won't ask for it and, if the resident is asked if she is in pain, she would say, "I don't know." The family member stated, every time the staff move Resident 6, she screams. During this interview, Resident 6 was observed fidgeting and restless with facial grimacing and muscular rigidity. During an interview with CNA 2 on 9/25/13 at 1510 hours, CNA 2 stated she turns and repositions Resident 6 every 2 hours. The CNA stated Resident 6 always screams when the CNAs touch her and reposition her. The CNA stated the resident does not ask for pain medication, the resident only screams. The CNA stated she notifies the charge nurse every two hours that the resident was screaming, grimacing, and saying, "I hurt" when repositioned. During an interview with LVN 1 on 9/25/13 at 1550 hours, the LVN verified the CNAs notify her when Resident 6 grimaces and screams while being repositioned. LVN 1 stated she assesses the resident and administers the pain medication. Review of documentation provided by the facility on 9/27/13, shows Resident 6 received the following pain medication: *[MEDICATION NAME] 2 mg once on 9/21/13 at 0830 hours, and [MEDICATION NAME] 1 mg once on 9/21/13 at 1757 hours. There was no documentation provided to show the resident received any other pain medication, (other than the [MEDICATION NAME]) on 9/21/13. *On 9/22/13, Resident 6 received [MEDICATION NAME] 2 mg at 0244 hours, 0838 hours and 2119 hours. No other pain medication was documented as being administered to Resident 6 on 9/22/13. *On 9/23/13, Resident 6 received [MEDICATION NAME] 2 mg at 0218 hours, 0935 hours and 2346 hours. There was no documented evidence Resident 6 received any other pain medication. *On 9/24/13, Resident 6 received [MEDICATION NAME] 2 mg at 1022 hours. No other pain medication was administered to Resident 6 on 9/24/13. *On 9/25/13, Resident 6 received [MEDICATION NAME] 2 mg at 0626 hours and 1036 hours. New physician's orders [REDACTED]. On 9/26/13 at 1135 hours, an observation and interview was conducted with the family member. Resident 6 was resting quietly in bed. The family member stated he has never seen the resident so calm, relaxed, and free from pain. The family member stated he feels the resident's pain is controlled now. b. During initial tour with ADON 3 on 9/24/13 at 0815 hours, the ADON stated Resident 6 has a "pain pump" (an implantable device used to administer pain medication) and is receiving medication through the pump to address Resident 6's pain. Description of the "pain pump" location was not provided by the ADON. Review of Resident 6's clinical record showed no documentation Resident 6 has a "pain pump." On 9/24/13 at 1100 hours, RN 1 was observed providing wound care to Resident 6. RN 1 stated Resident 6 has a "pain pump" implanted in her left buttock. RN 1 was unable to verbalize what medication the "pain pump" contains. A lump was observed on Resident 6's left buttock underneath an unstageable pressure ulcer. During an interview with LVN 3 on 9/25/13 at 0920 hours, the LVN stated Resident 6 has a "pain pump" implanted in her left buttock. During an interview and clinical record review with ADON 3 on 9/25/13 at 0930 hours, the ADON was unable to locate documentation showing the type of "pain pump," what medication was being administered and the frequency, when the medication in the pump is to be refilled, when and how frequently follow-up appointments are to be made with the physician managing the pump, or contact information for the physician who manages the pump. The ADON was unable to provide documentation showing an assessment regarding the "pain pump," its care, and treatment. Review of the care plan failed to show a care plan problem to address the care and use of a "pain pump." The ADON verified the findings and stated she knows there is a "pain pump," but is unaware of any details. During an interview with Resident 6's family member on 9/25/13 at 1045 hours, the family member was asked about the "pain pump" implanted in Resident 6's left buttock. The family member stated Resident 6 does not have a pain pump, she has a nerve stimulator (an implantable device which delivers electrical pulses and blocks pain signals from reaching the brain) implanted in her left buttock for her back pain; however, it is not charged and is no longer functional. c. During an interview with Resident 6's family member on 9/25/13 at 1045 hours, the family member stated Resident 6 can not utilize the call light to call the nurse and can not ask for pain medication herself. During an interview with Resident 6's family member on 9/25/13 at 1135 hours, the family member stated he informed the nurses on at least one or two occasions in the past, the resident will not press the call light or ask for pain medication. On 9/26/13 at 1140 hours, an interview was conducted with ADON 3. The ADON verified there has been no evaluation completed for Resident 6's ability to use the call light. 2. Review of Resident 7's clinical record was initiated on 9/24/13. Resident 7 was admitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. According to the manufacturer of rivastigmine, to avoid skin irritation, rivastigmine patches should not be applied to the same spot of skin for 14 days. On 9/25/13 at 1120 hours, a concurrent interview and clinical record review was conducted with LVN 1. LVN 1 was asked to provide documentation showing where the rivastigmine patches are applied each day. Review of the electronic MAR for September 2013 showed rivastigmine 9.5 mg patches were applied daily to the following locations on Resident 7's body: 9/17/13, chest 9/18/13, chest 9/19/13, right arm 9/20/13, left arm 9/21/13, chest 9/22/13, left arm 9/23/13, right arm 9/24/13, chest When LVN 1 was asked if she is knowledgeable about the manufacturer's guidelines to not apply the rivastigmine patches to the same spot of skin for 14 days, she said she was not. LVN 1 was asked to provide documentation showing the rivastigmine patches were applied to different areas on the chest and arms each day, the LVN stated she could not verify where the patches were placed on the chest and arms with the data contained in the computer. LVN 1 produced a blank application site diagram which was provided by the pharmacy. The form shows a diagram of a body with 44 application sites to document the site the patch was applied to each day. When the LVN was asked why the form provided by the pharmacy is not used by the facility, the LVN stated they don't use it. 3. During an observation on 9/25/13 at 0820 hours, LVN 1 was observed preparing and administering a [MEDICATION NAME] 600 mg extended-release bi-layer tablet to Resident 5 through a GT (a tube surgically inserted through the abdominal wall into the stomach to provide nutrition and medication). LVN 1 crushed the the tablet prior to pouring the dose into the medication cup. According to the manufacturer's specifications, the [MEDICATION NAME] extended-release bi-layer tablet should not be crushed, chewed, or broken. An interview was conducted with LVN 1 on 9/25/13 at 0900 hours. LVN 1 verified the above findings. She stated she should not crush the medication. 4. Review of Resident 4's clinical record was initiated on 9/24/13 at 1115 hours. Resident 4 was initially admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Another order dated 9/3/13, showed to get the resident out of bed into a wheelchair daily using a mechanical lift. During an interview and clinical record review with LVN 3 on 9/24/13 at 1145 hours, LVN 3 was asked the last time Resident 4 got up and sat in the wheelchair. LVN 3 stated Resident 4 has not gotten up into a wheelchair yet. During an interview with RN 1 on 9/25/13 at 1000 hours, RN 1 verified the above findings. She stated the reason why Resident 4 has not sit in the wheelchair is because of the insurance, and they do not want to compromise the healing process of the wound on the buttock. When RN 1 was asked about the gel cushion to offload the buttock, she stated Resident 4 does not have a gel cushion because of her insurance. RN 1 verified the gel cushion was ordered on [DATE]. During an interview with Resident 4 on 9/25/13 at 1035 hours, Resident 4 was asked the last time the CNA used the mechanical lift to get her up. Resident 4 stated she has been in her bed for long time and the CNAs have not used the lifting device on her. Resident 4 was asked about the gel cushion she needs to use if she wants to sit in the wheelchair. Resident 4 stated she has not seen a gel cushion in her room. During an interview with CNA 3 on 9/25/13 at 1045 hours, CNA 3 was asked the last time Resident 4 got up and sat in the wheelchair. CNA 3 stated, she never gets up. CNA 3 was asked about the gel cushion. He verified there is no gel cushion in Resident 4's room. CNA 3 verified Resident 4 should be out of bed in a wheelchair.

Based on observation, interview and clinical record review, the facility failed to evaluate medication regimen and monitor the potassium level for one of 24 sampled residents (Resident 4). Resident 4 was receiving [MEDICATION NAME] (a potassium-sparing diuretic) and potassium chloride (potassium replacement medication) when a blood potassium level was 5.1 (normal range is 3.5 - 5.1). The resident continued to receive IV hydration of [MEDICATION NAME] 5% and 0.45% normal saline with 20 mEq of potassium chloride. The resident's potassium level was not assessed between 6/28/11 through 7/5/11. On 7/6/11, Resident 4's potassium level was 8.0. This resulted in the resident being transferred to the emergency department of the acute hospital and subsequently admitted . Review of the Lexi-Comp Online for [MEDICATION NAME], showed a high blood potassium level is a serious side effect of [MEDICATION NAME] and to discontinue or interrupt the therapy if the potassium level is greater than 5. According to Lexi-Comp Online, potassium chloride is used to treat or prevent hypokalemia (low blood potassium level). The potassium level needs to be monitored closely to avoid high blood potassium levels. Severe high blood potassium levels may lead to muscle weakness, paralysis, heart block, abnormal heart rhythm, and death. The treatment and prevention of [MEDICAL CONDITION] (high blood potassium level), the most serious manifestations of high blood potassium levels are muscle weakness, abnormal heart rhythm, [MEDICAL CONDITION] or death. The manifestations usually occur when the serum potassium level is greater or equal to 7 with chronic [MEDICAL CONDITION], or possible at lower levels with an acute rise in blood potassium. Review of the Lexi-Comp Online Interaction Monograph showed the potassium salts (potassium chloride) may enhance the hyperkalemic effect of potassium-sparing diuretic ([MEDICATION NAME]). The severity of the interaction of these two medications is major; the effect may result in death, hospitalization or permanent injury. Further review showed the concomitant use of a potassium-sparing diuretic (such as [MEDICATION NAME]) and a potassium salt (such as potassium chloride) should be avoided except in cases of significant hypokalemia (low potassium level), and only if the serum potassium concentration can be "closely monitored." Findings: On 7/5/11 at 0840 hours, during initial tour rounds accompanied by RN 3, Resident 4 was observed to be asleep in bed. The resident was receiving IV fluids containing [MEDICATION NAME] 5% and 0.45% normal saline with 20 mEq of potassium chloride infusing at the rate of 75 ml per hour. On 7/5/11 at 1015 hours, 1200 hours and 1500 hours, the resident continued to be receiving IV fluids as noted above. On 7/6/11 at 0700 hours, Resident 4 was observed sleeping on her bed and receiving IV fluids as noted above. On 7/5/11, Resident 4's clinical record review was initiated. Resident 4 was an elderly female admitted to the facility on [DATE]. Review of a physician's consultation report dated 5/20/11, showed the resident's potassium level was 2.9. On 6/15/11, the resident's potassium level was 3.2. Review of the blood test collected and reported on 6/26/11, showed the resident's potassium level was 5.1. Review of the admission orders [REDACTED]. Review of a Physician order [REDACTED]. A physician's orders [REDACTED]. Review of the MAR for the month of June and July, 2011, showed [MEDICATION NAME] 25 mg and the potassium chloride 30 mEq were administered twice a day since 6/29/11. According to the physician's orders [REDACTED]. Review of the resident's plan of care found no documented evidence staff had developed a care plan problem to address the risk of high potassium levels even though the resident was receiving the [MEDICATION NAME] and potassium chloride. During an observation and interview with RN 2 on 7/6/11 at 0815 hours, RN 2 stated Resident 4 was mostly independent with turning herself in bed. However, RN 2 was observed to turn the resident onto her left side and instructed the resident to stay on her left side so the nurse could perform skin treatment. But Resident 4 was observed to be unable to hold herself on her left side and fell back onto her back. After attempting four times, the RN stated the resident was unable to turn or hold herself today. On 7/6/11 at 0900 hours, during clinical record review and interview with the DON, the DON acknowledged Resident 4's potassium level was 5.1 on 6/26/11. The DON also confirmed the resident was receiving [MEDICATION NAME] 25 mg and potassium chloride 30 mEq twice a day by mouth since admission; and was receiving IV potassium chloride as well. The DON was asked if the resident's potassium level had been assessed between 6/28/11 and 7/5/11, or if the level was checked prior to starting the IV potassium chloride. The DON stated the blood test was not obtained until 7/5/11, and drawn again today (7/6/11). The DON was asked to review the pharmacy consultant report for Resident 4. Review of the pharmacy consultation report dated 6/29/11 showed the pharmacist recommended Resident 4 have her potassium level checked and to "reduce [MEDICATION NAME]/potassium" and recheck a basic metabolic profile (a blood test to check sodium, potassium, and blood sugar levels and kidney function). Further review showed if this therapy is to continue at the current medication dose, it is recommend that the facility's IDT ensures ongoing monitoring for effectiveness and potential adverse consequences. On 7/7/11 at 1100 hours, an interview with the pharmacy consultant was conducted. The pharmacy consultant was asked when she gave her recommendation to the facility regarding Resident 4's medication. She stated she had provided her recommendations to the facility on ,[DATE] or 6/30/11. Additional review of Resident 4's clinical record showed a physician's orders [REDACTED]. However, there was no order to reduce the [MEDICATION NAME] or the potassium chloride. On 7/6/11 at 0910 hours, during an interview with Resident 4, she stated she felt weak. The resident was observed lying in bed and receiving IV fluids containing [MEDICATION NAME] 5% and 0.45% normal saline with 20 mEq of potassium chloride infusing at the rate of 75 ml per hour. On 7/6/11 at 1050 hours, Resident 4 was observed lying on a gurney and transferred by ambulance out of the facility. On 7/6/11 at 1125 hours, RN 3 was asked about Resident 4. The RN stated the resident was transferred to the acute hospital emergency department because her potassium level was elevated. The RN was asked to review the laboratory report. Review of the blood test results collected and reported on 7/6/11, showed Resident 4's potassium level was 8.0. Additional review of Resident 4's clinical record showed on 7/6/11, Resident 4 had a decrease level of consciousness and was lethargic and her potassium level was 8.0. On 7/18/11, Resident 4's acute hospital laboratory reports were received. The laboratory reports showed the resident's blood was collected on 7/6/11 at 1150 hours, and her potassium level was 7.7. In addition, the acute hospital's emergency department physician's documentation was received on 7/18/11. The physician documentation dated 7/6/11, showed Resident 4 arrived at the emergency department due to a high blood potassium level; the resident was administered insulin via IV, [MEDICATION NAME] 50% water via IV, sodium [MEDICATION NAME] via IV, [MEDICATION NAME] (orally) and calcium [MEDICATION NAME] (IV) to treat the high potassium level. Further review showed the resident was admitted to the hospital with [REDACTED].