Every finding on record at French Park Care Center

Based on interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for two of three sampled residents reviewed for blood sugar level monitoring. * The facility failed to ensure Resident 1's blood sugar level check was done on a timely manner as ordered by the resident's physician. * The facility failed to ensure Resident 2's blood sugar level was checked as ordered by the resident's physician. These failures had the potential for the residents not to receive the necessary care and services to maintain their highest physical well-being.Findings:Review of the facility's P&P titled Blood Glucose Monitoring revised 1/23/24, showed it is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under the Policy Explanation and Compliance Guidelines showed to administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 1. Medical record review for Resident 1 was initiated on 8/11/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 1's Order Summary Report dated 8/11/26, showed a physician's order dated 1/12/26, to administer insulin lispro (medication to lower blood sugar level) solution 100 unit/ml per sliding scale. Inject subcutaneously in the evening for DM with the following medication parameters:- no insulin for the blood glucose level of less than 150 mg/dl;- inject 2 units of insulin for the blood glucose level of 150 to 200 mg/dl;- inject 4 units of insulin for the blood glucose level of 201 to 250 mg/dl;- inject 6 units of insulin for the blood glucose level of 251 to 300 mg/dl;- inject 8 units of insulin for the blood glucose level of 301 to 350 mg/dl;- inject 10 units of insulin for the blood glucose level of 351 to 400 mg/dl; and- inject 12 units of insulin for the blood glucose level above 400 mg/dl, and to call the physician. Review of Resident 1's MAR for July 2026 showed the insulin lispro was scheduled to be administered at 1800 hours. Further review of the MAR for the insulin lispro medication dated 7/28/26 at 1800 hours, showed the resident's blood glucose level was 149 mg/dl and no insulin was required. However, the eMAR showed the insulin lispro medication was documented done on 7/28/26 at 2010 hours. On 8/11/26 at 1118 hours, an interview was conducted with Resident 1. Resident 1 stated the Accu-Chek was not done. Resident 1 further stated the facility staff should check her blood sugar before she eats and should not be late in checking her blood sugar. On 8/12/26 at 1046 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she tried to check Resident 1's blood sugar but the resident was not in her room. LVN 3 verified the blood sugar check was due at 1800 hours on 7/28/26, and was done at around 1945 on 7/28/26. LVN 3 stated she should have tried to get hold of Resident 1 and should have come to her room. On 8/12/26 at 1401 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 acknowledged the blood glucose sliding scale for insulin lispro was scheduled for 1800 on 7/28/26. LVN 2 verified Resident 1's blood sugar level of 149 mg/dl was documented on 7/28/26 at 2010 hours in the eMAR. LVN 2 stated the licensed nurse should have done Resident 1's blood sugar check on time. On 8/12/26 at 1531 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was informed and acknowledged the above findings. The ADON stated the nurse should have endorsed to the other licensed nurse if the nurse was not able to find Resident 1 during the administration of the medication.2. Medical record review for Resident 2 was initiated on 8/11/26. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired. Review of Resident 2's Order Summary Report dated 8/11/26, showed a physician's order dated 7/31/26, to administer insulin regular human (medication to lower blood sugar level) solution 100 unit/ml per sliding scale. Inject subcutaneously before meals and at bedtime for DM with the following medication parameters:- inject 2 units of insulin for the blood glucose level of 151 to 200 mg/dl;- inject 4 units of insulin for the blood glucose level of 201 to 250 mg/dl;- inject 6 units of insulin for the blood glucose level of 251 to 300 mg/dl;- inject 8 units of insulin for the blood glucose level of 301 to 350 mg/dl;- inject 10 units of insulin for the blood glucose level of 351 to 400 mg/dl; and- inject 12 units of insulin for the blood glucose level above 400 mg/dl, and to notify the physician. Review of Resident 2's MAR August 2026 showed for insulin regular human medication dated 8/5/26 at 0630 hours, failed to show documented evidence the resident's blood glucose level was checked. On 8/12/26 at 1453 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 2's blood glucose level for the insulin regular human was not done on 8/5/26 at 0630 hours. LVN 2 stated the licensed nurse should have checked Resident 2's blood sugar level. On 8/12/26 at 1550 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was informed and acknowledged the above findings. The ADON stated the licensed nurse should have documented if the resident refused because they were sleeping or did not want to be bothered. The ADON stated the licensed nurse should always report to the physician of the resident's refusal for blood sugar check. On 8/13/26 at 1653 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 14 sampled residents (Resident 6) and one nonsampled resident (Resident A). * Resident 6 waited for 30 minutes for the staff to assist her to be cleaned which resulted in the resident to be lying in her bowel for a long time and feeling dirty. * Resident A waited for 32 minutes for the staff to assist her to change her wet clothing which resulted in the resident feeling upset. These failures had the potential to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 12/19/22, showed the staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 1. On 7/15/26 at 1451 hours, Room A's call light was observed on. There were no facility staff observed responding to the call light. On 7/15/26 at 1511 hours, Family Member 1 was observed coming out from Room A and went to the nurses' station. The call light outside Room A was still on. On 7/15/26 at 1515 hours, an observation of Resident 6 and concurrent interview Resident 6 and Family Member 1 were conducted. Resident 6 was observed lying on the bed, uncovered with blanket and wearing a diaper. Family Member 1 stated they had been waiting for more than 20 minutes for someone to help Resident 6 to be cleaned because the resident had a bowel movement. Family Member 1 stated she even went to the nurse's station, but she was told by the staff in the nurses' station she was not assigned to Resident 6 and would call the assigned staff. Family Member 1 stated Resident 6 had been sitting in her stool for more than 20 minutes. Family Member 1 stated it was usually like this almost every day, they had to wait for a long time to be assisted even if she went out to the nurse's station and asked for assistance. Family Member 1 stated she was in the facility every day before 0940 hours and would stay until passed 1500 hours. Resident 6 stated it was the same at night time. Resident 6 stated she had to wait for 45 minutes to an hour to get help. Resident 6 stated she had to press the call light 50 times before she could get assistance from the staff. Resident 6 stated she had to watch the white wall clock in front of her and the resident pointed the clock showing to the state surveyor. Resident 6 stated she felt dirty because she had been sitting in her poop. On 7/15/26 at 1521 hours, CNA 3 was observed entering Room A and spoked to Resident 6 and Family Member 1. CNA 3 was informed by Family Member 1 Resident 6 needed to be cleaned. Medical record review for Resident 6 was initiated on 7/15/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 7/14/26, showed Resident 6 had no acute neurological deficit and needed continued skilled nursing assistance with activities of daily living. Review of Resident 6's MDS assessment dated [DATE], showed Resident 6 had moderate cognitive impairment and was dependent on toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, and if managing an ostomy, include wiping the opening but not managing equipment). 2. On 7/15/26 at 1510 hours, Room C's call light was observed on. There were no facility staff observed responding to the call light. On 7/15/26 at 1530 hours, an observation and concurrent interview was conducted for Resident A. Resident A was observed lying in the bed with the call light in the resident's hand. Resident A stated she had been waiting to be helped by the staff since 1400 hours and she was upset. Resident A stated she spilled the white stuff from the plastic cup on her right sleeve, and she wanted to change to a new shirt. On 7/15/26 at 1535 hours, LVN 8 was observed entering Room B which was the room opposite to Room C with another resident. LVN 8 was observed coming out of Room C and headed down the hallway where the medication cart was. On 7/15/26 at 1539 hours, CNA 3 was observed entering Room C and asked who called. CNA 3 was observed going to Resident A's bed. On 7/15/26 at 1542 hours, CNA 3 observed going back to Room C and assisted Resident A. Medical record review for Resident A was initiated on 7/15/26. Resident A was readmitted to the facility on [DATE]. Review of Resident A's H&P examination dated 11/10/25, showed Resident A had the capacity to make decisions. Review of Resident A's MDS assessment dated [DATE], showed Resident A had intact cognition and needed substantial/maximal assistance with upper body dressing (the ability to dress and undress above the waist; including fasteners, if applicable) and dependent with lower body dressing (the ability to dress and undress below the waist, including fasteners; does not include footwear). On 7/15/26 at 1550 hours, an interview was conducted with LVN 8. LVN 8 stated the CNAs would usually answer the call lights. LVN 8 stated she did not notice the call lights were on in Rooms A and C as she was passing the medications. LVN 8 was informed and acknowledged the findings for Residents 6 and A. On 7/15/26 at 1600 hours, an interview was conducted regarding Residents 6 and A with CNA 3. CNA 3 stated no one informed her Residents 6 and A were calling. CNA 3 stated she had been very busy since she started her shift. CNA 3 stated the CNAs were responsible for answering the call lights because the nurses were busy too giving the medications to the residents. CNA 3 stated the call lights were always busy. CNA 3 stated if she needed help from the nurses, she would get them, but she tried to do her work independently because the nurses were busy also passing the medications. CNA 3 further stated the residents should not be left waiting for a long time, especially if they were dirty. CNA 3 was informed and acknowledged the findings for Residents 6 and A. On 7/23/26 at 1500 hours, an interview was conducted with the DON. The DON stated the call light should be answered as soon as possible by the staff to meet the residents needs. The DON stated for the residents to wait for more than 30 minutes was not ok. The DON was informed and acknowledged the findings for Residents 6 and A.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by a resident for one of seven sampled residents (Resident 5) investigated for abuse. * Resident 5 received a verbal altercation from Resident 2 resulting for Resident 5 to feel upset and angry. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 12/19/22, showed the following:- It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property;- Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;- Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;- Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability;- Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators;- Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as aggressive and/or catastrophic reactions of residents, wandering or elopement-type behaviors, resistance to care, outbursts or yelling out, and difficulty in adjusting to new routines or staff;- The facility will have written procedures to assist staff in identifying the different types of abuse -mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services; and- Possible indicators of abuse include, but are not limited to verbal abuse of a resident overheard. Review of the facility's SOC 341 dated 7/17/26, showed a resident-to-resident altercation between Residents 2 and 5. On 7/17/26 at approximately 1545 hours, the Administrator was informed by the state surveyor there was a progress note dated 6/28/26, that showed Resident 2 stated the resident had a verbal altercation with Resident 5, in which Resident 2 used derogatory language towards Resident 5. a. Closed medical record review for Resident 2 was initiated on 7/17/26. Resident 2 was admitted to the facility on [DATE], and discharged on 6/29/26. Review of Resident 2's H&P examination dated 3/7/26, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Nurses Progress Note dated 6/28/26 at 2236 hours, showed LVN 1 documented Resident 2 had been on 1:1 (where one dedicated staff member often called a sitter or companion continuously monitors a single patient) for indecent exposure. Resident 2 was being followed by the CNA who observed him going into Room D. When the CNA approached Resident 2 to let him know he was not allowed to go into any room, Resident 2 responded aggressively by pushing the CNA and started to tell the CNA that he did not want to be followed. The charge nurse (LVN 1) talked to Resident 2 about calming down. Resident 2 responded with, The next time he follows me around I am going to punch him. Resident 2 then was walking back to his room when he got into a verbal altercation with another resident where he told her, I'm not going to go easy on you because you are a girl, you picked the wrong guy, Resident 2 then proceeded to call her many derogatory words and also made fun of the way the resident spoke. On 7/17/26 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified she knew Resident 2 and she was the one who documented in the progress note on 6/28/26, regarding Resident 2 making derogatory words to a female resident. LVN 1 stated the female resident was Resident 5. LVN 1 stated the CNA who was doing the 1:1 observation to Resident 1 was CNA 1. LVN 1 stated the incident happened on her shift on 6/28/26 at the PM shift, in the middle of the hallway. LVN 1 stated Resident 2 was returning to his room near the nursing station and was on 1:1 observation by CNA 1. LVN 1 stated when Resident 2 was approaching the nursing station, Resident 5 was sitting next to the nursing station. LVN 1 stated she was across the nursing station, she heard and saw Resident 2 told Resident 5, stupid bitch, I'm not going to stop myself because you're a girl, and Resident 2 was mocking Resident 5's slurred speech because the resident had a stroke. LVN 1 stated CNA 1 was there and the RN supervisor was in the station and heard it also. LVN 1 stated CNA 1 led Resident 2 to his room. LVN 1 stated the RN supervisor did an incident report. When asked if she reported it to anyone, LVN 1 stated the RN supervisor was there and knew about it. When asked if what she witnessed between Residents 2 and 5 would be considered an abuse, LVN 1 stated she considered Resident 2's derogatory remark to Resident 5 and mocking a verbal abuse. b. Medical record review for Resident 5 was initiated on 7/17/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/20/26, showed Resident 5 had the capacity to make own decisions. Resident 5 had diagnoses including of stroke and expressive aphasia. On 7/22/26 at 1330 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 was observed lying in her bed. Resident 5 had slurred speech. Resident 5 stated she remembered when a male resident cursed her one night when she was in the nurse's station on the night of 6/28/26. Resident 5 stated Resident 2 cursed her with bad words and insulted her because of the way she spoke. Resident 5 stated it made her angry and upset. On 7/22/26 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 verified he was doing the 1:1 observation to Resident 2 on 6/28/26 for the PM shift. CNA 1 stated Resident 2 was able to walk and had the behavior of going to different rooms that was why he was doing 1:1 observation for the resident. CNA 1 stated Resident 5 was in the nurse station sitting in her wheelchair and Resident 2 was in the way of Resident 5 when Resident 5 was trying to return a pen. Resident 5 told Resident 2 to get out of the way. CNA 1 stated Resident 2 was already frustrated and told Resident 5, Shut the fuck up! Just because you're a girl, I will not be going easy on you. Resident 5 was just telling Resident 2 to get out of the way. CNA 1 stated since Resident 5 had slurred speech, she kept repeating the same thing to Resident 2. CNA 1 stated he knew where the incident was leading so he took the pen from Resident 5 and the resident left the station. When asked about the incident between Residents 2 and 5, CNA 1 stated he believed it was verbal abuse and he tried to intervene to prevent it from getting worse. On 7/23/26 at 1347 hours, a telephone interview was conducted with RN 3. RN 3 stated he was familiar with Resident 2. RN 3 verified he worked the PM shift on 6/28/26. RN 3 stated he was in the nurses' station and he heard the verbal interaction between Residents 2 and 5. RN 3 stated Resident 2 told Resident 5 something like, shut up and something like, because you're a girl. RN 3 stated he could not recall the exact words and the incident was only a short time. RN 3 stated he did not consider it a verbal abuse. When asked if the nurses followed up or assess Resident 5 related to the incident, RN 3 stated after several nights he asked Resident 5 if she remembered what happened and the resident said no. RN 3 stated when a resident to resident altercation happened, after separating the residents, the incident should be reported to the Administrator and DON, start the SOC and report to CDPH and Ombudsman within two hours. Review of the facility's 5-Day Summary dated 7/22/26, showed the facility was unable to substantiate the alleged abuse occurred. Further document review, the statements Resident 2 made to Resident 5 were rude, however it was not received in a manner that frightened, intimidated, or threatened Resident 5. The 5-Day Summary showed during the investigation by the Administrator, LVN 1 was interviewed and stated the altercation was caused by Resident 2 being upset with the noise a resident was making. Further review of the 5-Day Summary showed CNA 1 was interviewed and stated the incident occurred around when Resident 5 was wheeling herself to the nurse station to return a pen that she borrowed. Resident 2 was standing in the way and then their verbal disagreement began. Resident 2 started by mimicking Resident 5 and the way she spoke with her dysphagia. Resident 5 tried to respond and Resident 2 said derogatory comments towards her. On 7/23/26 at 1500 hours, an interview and concurrent medical record review for Residents 2 and 5 was conducted with the DON. The DON stated Resident 2 had a behavior of wandering around other resident's room, therefore the resident was put on a 1:1 staff observation. The DON stated it was not right for a resident to say derogatory remarks to another resident or staff. On 7/23/26 at 1645 hours, an interview was conducted with the DON and the Administrator. The DON and the Administrator were informed of the findings.

Based on interview, medical record review, facility record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of an abuse in accordance with section 1150B for one of seven sampled residents (Resident 2). * The facility failed to ensure the abuse allegation was reported timely to the CDPH L&C Program, ombudsman and local law enforcement when Resident 2 used derogatory language towards Resident 5 as documented on 6/28/26. This failure had the potential for the abuse allegation to go unreported and for the resident to not be protected from further abuse. Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/ Exploitation revised 12/19/22, showed the following:- It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes;- The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;- A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property;- The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences;- Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation, and- When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated:a. The Licensed Nurse will respond to the needs of the resident and protect him/her from further incident, remove the accused employee from resident care areas, notify the Administrator or designee, notify the attending physician, resident's family/legal representative, and medical director; andb. The Administrator or designee will notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 (two) hours after discovery or forming the suspicion, follow up with appropriate agencies, during business hours, to confirm the report was received. Closed medical record review for Resident 2 was initiated on 7/17/26. Resident 2 was admitted to the facility on [DATE], and discharged on 6/29/26. Review of Resident 2's Nurses Progress Note dated 6/28/26 at 2236 hours, LVN 1's documentation showed Resident 2 had been on 1:1 (where one dedicated staff member often called a sitter or companion continuously monitors a single patient) for indecent exposure. Resident 2 was being followed by the CNA who observed him going into Room D. When the CNA approached Resident 2 to let him know he was not allowed to go into any room, Resident 2 responded aggressively by pushing the CNA and started to tell the CNA that he did not want to be followed. The charge nurse (LVN 1) talked to Resident 2 about calming down. Resident 2 responded with, The next time he follows me around I am going to punch him. Resident 2 then was walking back to his room when he got into a verbal altercation with another resident where he told her, I'm not going to go easy on you because you are a girl, you picked the wrong guy, Resident 2 then proceeded to call her many derogatory words and also made fun of the way the resident spoke. On 7/17/26 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified she knew Resident 2 and she was the one who documented in the progress note on 6/28/26, regarding Resident 2 making derogatory words to a female resident. LVN 1 stated the female resident was Resident 5. LVN 1 stated the CNA who was doing the 1:1 observation to Resident 1 was CNA 1. LVN 1 stated the incident happened on her shift on 6/28/26 at the PM shift, in the middle of the hallway. LVN 1 stated Resident 2 was returning to his room near the nursing station and was on 1:1 observation by CNA 1. LVN 1 stated when Resident 2 was approaching the nursing station, Resident 5 was sitting next to the nursing station. LVN 1 stated she was across the nursing station, she heard and saw Resident 2 told Resident 5, stupid bitch, I'm not going to stop myself because you're a girl, and Resident 2 was mocking Resident 5's slurred speech because the resident had a stroke. LVN 1 stated CNA 1 was there and the RN supervisor was in the station and heard it also. LVN 1 stated CNA 1 led Resident 2 to his room. LVN 1 stated the RN supervisor did an incident report. When asked if she reported it to anyone, LVN 1 stated the RN supervisor was there and knew about it. When asked if what she witnessed between Residents 2 and 5 would be considered an abuse, LVN 1 stated she considered Resident 2's derogatory remark to Resident 5 and mocking a verbal abuse. On 7/17/26 at 1525 hours, an interview was conducted with the Administrator. The Administrator stated he was not informed of the incident when Resident 2 made derogatory remarks and mocked Resident 5. The Administrator was informed of the documented incident in Resident 2's Progress Note dated 6/28/26. The Administrator stated he was aware of the behavior of Resident 2 like defecating in the garden patio but not of the incident which happened on 6/28/26. Review of the facility's SOC 341 dated 7/17/26, showed a resident-to-resident altercation between Residents 2 and 5. On 7/17/2026 at approximately 1525 hours, the Administrator was informed by the state surveyor that there was a progress note dated 6/28/26, the documentation showed Resident 2 stated the resident had a verbal altercation with Resident 5, in which Resident 2 used derogatory language towards Resident 5. Further review of the facility's SOC 341 showed the abuse allegation happened on 6/28/26. However, the abuse allegation was not reported to CDPH, L&C Department until 7/17/26, 19 days later. On 7/22/26 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 verified he was doing the 1:1 observation to Resident 2 on 6/28/26 for the PM shift. CNA 1 stated Resident 2 was able to walk and had the behavior of going to different rooms that was why he was doing 1:1 observation for the resident. CNA 1 stated Resident 5 was in the nurse station sitting in her wheelchair and Resident 2 was in the way of Resident 5 when Resident 5 was trying to return a pen. Resident 5 told Resident 2 to get out of the way. CNA 1 stated Resident 2 was already frustrated and told Resident 5, Shut the fuck up! Just because you're a girl, I will not be going easy on you. Resident 5 was just telling Resident 2 to get out of the way. CNA 1 stated since Resident 5 had slurred speech, so she kept repeating the same thing to Resident 2. CNA 1 stated he knew where the incident was leading so he took the pen from Resident 5 and the resident left the station. When asked about the incident between Residents 2 and 5, CNA 1 stated he believed it was verbal abuse and he tried to intervene to prevent it from getting worse. On 7/23/26 at 1347 hours, a telephone interview was conducted with RN 3. RN 3 stated he was familiar with Resident 2. RN 3 verified he worked the PM shift on 6/28/26. RN 3 stated he was in the nurses' station and he heard the verbal interaction between Residents 2 and 5. RN 3 stated Resident 2 told Resident 5 something like, shut up and something like, because you're a girl. RN 3 stated he could not recall the exact words and the incident was only a short time. RN 3 stated he did not consider it a verbal abuse. When asked if the nurses followed up or assess Resident 5 related to the incident, RN 3 stated after several nights he asked Resident 5 if she remembered what happened and the resident said no. RN 3 stated when a resident to resident altercation happened, after separating the residents, the incident should be reported to the Administrator and DON, start the SOC and report to CDPH and Ombudsman within two hours. On 7/23/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated all the staff should report to the Administrator or to her if the Administrator was not around any suspected abuse. The DON stated for the resident to resident altercation, once both residents were determined to be safe, the SOC should be started right away and send report to the CDPH and Ombudsman within two hours. The DON stated the law enforcement should be notified as well as soon as possible. The DON further stated the staff were being reminded that anything they witnessed that might be considered an abuse to resident or anyone should be reported right away to her and the Administrator, especially if they were in doubt or not sure if it was an abuse or not, so they could make an investigation to determine if an abuse really happened. The DON verified the alleged verbal altercation of Resident 2 and Resident 5 was not reported in a timely manner. On 7/23/26 at 1535 hours, an interview was conducted with the Administrator. The Administrator was made aware and acknowledged the alleged verbal abuse incident between Residents 2 and 5 was not reported in a timely manner. Cross reference to F600 and F610.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for abuse investigation for one of seven sampled residents (Resident 2). * The facility failed to immediately begin an investigation when Resident 2 used derogatory language towards Resident 5 as documented on 6/28/26. This failure had the potential for the abuse allegation to remain unidentified and put the residents at risk for further abuse.Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/ Exploitation revised 12/19/22 showed the following:- The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;- Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property;- Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below;- Protection: The facility will protect residents from harm during an investigation;- Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences;- Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. a. Medical record review for Resident 2 was initiated on 7/17/26. Resident 2 was admitted to the facility on [DATE] and discharged on 6/29/26. Review of Resident 2's H&P examination dated 3/7/26, showed Resident 2 had the capacity to understand and make decision. Review of Resident 2's Nurses Progress Note dated 6/28/26 at 2236 hours, showed LVN 1 documented Resident 2 had been on 1:1 (where one dedicated staff member often called a sitter or companion continuously monitors a single patient) for indecent exposure. Resident 2 was being followed by the CNA who observed him going into Room D. When the CNA approached Resident 2 to let him know he was not allowed to go into any room, Resident 2 responded aggressively by pushing the CNA and started to tell the CNA that he did not want to be followed. The charge nurse (LVN 1) talked to Resident 2 about calming down. Resident 2 responded with, The next time he follows me around I am going to punch him. Resident 2 then was walking back to his room when he got into a verbal altercation with another resident where he told her, I'm not going to go easy on you because you are a girl, you picked the wrong guy, Resident 2 then proceeded to call her many derogatory words and also made fun of the way the resident spoke. b. Medical record review for Resident 5 was initiated on 7/17/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/20/26, showed Resident 5 had the capacity to make own decisions. Resident 5 had medical history of stroke and expressive aphasia. On 7/17/26 at 1506 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified she knew Resident 2 and she was the one who documented in the progress note on 6/28/26, regarding Resident 2 making derogatory words to a female resident. LVN 1 stated the female resident was Resident 5. LVN 1 stated the CNA who was doing the 1:1 observation to Resident 1 was CNA 1. LVN 1 stated the incident happened on her shift on 6/28/26 at the PM shift, in the middle of the hallway. LVN 1 stated Resident 2 was returning to his room near the nursing station and was on 1:1 observation by CNA 1. LVN 1 stated when Resident 2 was approaching the nursing station, Resident 5 was sitting next to the nursing station. LVN 1 stated she was across the nursing station, she heard and saw Resident 2 told Resident 5, stupid bitch, I'm not going to stop myself because you're a girl, and Resident 2 was mocking Resident 5's slurred speech because the resident had a stroke. LVN 1 stated CNA 1 was there and the RN supervisor was in the station and heard it also. LVN 1 stated CNA 1 led Resident 2 to his room. LVN 1 stated the RN supervisor did an incident report. When asked if she reported it to anyone, LVN 1 stated the RN supervisor was there and knew about it. When asked if what she witnessed between Residents 2 and 5 would be considered an abuse, LVN 1 stated she considered Resident 2's derogatory remark to Resident 5 and mocking a verbal abuse. On 7/17/26 at 1525 hours, an interview was conducted with the Administrator. The Administrator stated he was not informed of the incident when Resident 2 made derogatory remarks and mocked Resident 5. The Administrator was informed of the documented incident in Resident 2's Progress Note dated 6/28/26. The Administrator stated he was aware of the behavior of Resident 2 like defecating in the garden patio but not of the incident which happened on 6/28/26. Review of the facility's SOC 341 dated 7/17/26, showed a resident-to-resident altercation between Residents 2 and 5. On 7/17/2026 at approximately 1525 hours the Administrator was informed by the state surveyor that there was a progress note dated 6/28/26, the documentation showed Resident 2 stated the resident had a verbal altercation with Resident 5, in which Resident 2 used derogatory language towards Resident 5. Further review of the facility's SOC 341 showed the abuse allegation happened on 6/28/26. However, the abuse allegation was not reported to CDPH, L&C Department until 7/17/26, 19 days later. On 7/22/26 at 1330 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 was observed lying in the bed. Resident 5 was observed to have a slurred speech. When asked if she remembered what happened on the night of 6/28/26, Resident 5 stated she remembered when a male resident cursed her one night when she was in the nurse's station. When asked if she remembered the exact words spoken to her by Resident 2, Resident 5 stated Resident 2 cursed her with bad words and insulted her because of the way she spoke. Resident 5 stated it made her angry and upset but after that she did not mind it anymore. On 7/23/26 at 1347 hours, a telephone interview was conducted with RN 3. RN 3 stated he was familiar with Resident 2. RN 3 verified he worked the PM shift on 6/28/26. RN 3 stated he was in the nurses' station and he heard the verbal interaction between Residents 2 and 5. RN 3 stated Resident 2 told Resident 5 something like, shut up and something like, because you're a girl. RN 3 stated he could not recall the exact words and the incident was only a short time. RN 3 stated he did not consider it a verbal abuse. When asked if the nurses followed up or assess Resident 5 related to the incident, RN 3 stated after several nights he asked Resident 5 if she remembered what happened and the resident said no. RN 3 stated when a resident to resident altercation happened, after separating the residents, the incident should be reported to the Administrator and DON, start the SOC and report to CDPH and Ombudsman within two hours. On 7/23/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated all the staff should report to the Administrator or to her if the Administrator was not around any suspected abuse. The DON stated for the resident to resident altercation, once both residents were determined to be safe, the SOC should be started right away and send report to the CDPH and Ombudsman within two hours. The DON stated the law enforcement should be notified as well as soon as possible. The DON further stated the staff were being reminded that anything they witnessed that might be considered an abuse to resident or anyone should be reported right away to her and the Administrator, especially if they were in doubt or not sure if it was an abuse or not, so they could make an investigation to determine if an abuse really happened. The DON verified the alleged verbal altercation of Resident 2 and Resident 5 was not investigated in a timely manner. On 7/23/26 at 1535 hours, an interview was conducted with the Administrator. The Administrator stated he started the investigation right away after he was informed on 7/17/26, of the alleged verbal altercation of Resident 2 and Resident 5 which was documented by LVN 1 in Resident 2's medical record on 6/28/26. The Administrator stated if he was informed of what had happened on 6/28/26, he would have done the investigation. Cross reference to F600 and F609.

Based on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive person-centered care plan for one of 14 sampled residents (Resident 5). * The facility failed to ensure a care plan was developed when Resident 5 was allegedly verbally abused by Resident 2. This failure had the potential for the resident to receive inconsistent, inappropriate, and inadequate care.Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 12/19/22, showed the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 7/17/26, showed a resident-to-resident altercation between Residents 2 and 5. On 7/17/26 at approximately 1545 hours, the Administrator was informed by the state surveyor that there was a progress note dated 6/28/26, in the chart of Resident 2 stating the resident had a verbal altercation with Resident 5, in which Resident 2 used derogatory language towards Resident 5. The surveyor informing the Administrator about this progress note was the first time the Administrator had been made aware of this incident. The alleged aggressor, Resident 2, was transferred out on 6/29/26, for direct admission into the psychiatric unit at the order of the psychiatrist for other unrelated behavioral issues in the facility. Resident 2 had not returned to the facility and all other residents remained safe following his verbal episode with Resident 5. Interviews and in-service training were underway. Medical record review for Resident 5 was initiated on 7/17/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 6/20/26, showed Resident 5 had the capacity to make own decisions. Resident 5 with medical history of stroke and expressive aphasia. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 had no behavioral symptoms exhibited such as physical behavioral symptoms directed toward others (for example-hitting, kicking, pushing, scratching, grabbing, or abusing others sexually) and verbal behavioral symptoms directed toward others (for example-threatening others, screaming at others, or cursing at others). Review of Resident 5's Plan of Care with the initiation dates of 5/8 to 7/21/26, failed to show a care plan problem was initiated when the resident was allegedly verbally abused by Resident 2. On 7/21/26 at 1554 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 2. RN 2 stated a care plan should be initiated or revised if a new problem was identified with the resident. RN 2 stated it was necessary to address any incident or problem identified so they could give the proper assessment and interventions to the resident. RN 2 verified there was no care plan initiated when Resident 5 was allegedly verbally abused by Resident 2. On 7/22/26 at 1330 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 was observed lying in the bed. Resident 5 was observed to have a slurred speech. Resident 5 stated she remembered when a male resident cursed at her one night when she was in the nurse's station. When asked if she remembered what happened on the night of 6/28/26, Resident 5 stated Resident 2 cursed at her with bad words and insulted her because of the way she spoke. When asked if she remembered the exact words spoken to her by Resident 2, Resident 5 stated it made her angry and upset but after that she did not mind it anymore. Resident 5 further stated someone asked her already the same questions. Resident 5 stated she never saw Resident 2 anymore, therefore, she was not bothered anymore. On 7/23/26 at 1500 hours, an interview and concurrent medical record review for Resident 5 was conducted with the DON. The DON stated for any identified new focus or problem, a care plan should be initiated to provide proper interventions to the resident. The DON was informed and acknowledged the above findings. Cross reference to F600.

Based on interview, medical record review, and P&P review, the facility failed to revise the comprehensive care plan for one of 14 sampled residents (Resident 2). * The facility failed to ensure Resident 2's comprehensive care plan was revised after an incident when Resident 2 used derogatory language towards Resident 5. This failure posed the risk of not providing appropriate, consistent, and individualized care for the resident.Findings: Medical record review for Resident 2 was initiated on 7/17/26. Resident 2 was admitted to the facility on [DATE], and discharged on 6/29/26. Review of Resident 2's H&P examination dated 3/7/26, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Nurses Progress Note dated 6/28/26 at 2236 hours, showed LVN 1 documented Resident 2 had been on 1:1 (where one dedicated staff member often called a sitter or companion continuously monitors a single patient) for indecent exposure. Resident 2 was being followed by the CNA who observed him going into Room D. When the CNA approached Resident 2 to let him know he was not allowed to go into any room, Resident 2 responded aggressively by pushing the CNA and started to tell the CNA that he did not want to be followed. The charge nurse (LVN 1) talked to Resident 2 about calming down. Resident 2 responded with, The next time he follows me around I am going to punch him. Resident 2 then was walking back to his room when he got into a verbal altercation with another resident where he told her, I'm not going to go easy on you because you are a girl, you picked the wrong guy, Resident 2 then proceeded to call her many derogatory words and also made fun of the way the resident spoke. Review of Resident 2's plan of care showed a care plan initiated 6/19/26, addressing Resident 2's behavior problem. However, the care plan was not revised to show Resident 2's verbal altercation to another resident on 6/28/26. On 7/21/26 at 1554 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 2. RN 2 stated a care plan should be initiated or revised if a new problem was identified to the resident. RN 2 stated it was necessary to address any incident or problem identified so they could give the proper assessment and interventions to the resident. RN 2 verified the care plan for Resident 2 did not reflect the resident's behavior when Resident 2 used derogatory language towards Resident 5 on 6/28/26. On 7/23/26 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated any identified new focus or problem, a care plan should be revised to provide proper interventions to the resident. The DON was informed and acknowledged the above findings. Cross reference to F600.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the timely and accurate administration of the medications for three of three sampled residents (Resident 1, 3, and 4) reviewed for medication administration, and the facility failed to ensure the controlled drugs were signed off by two licensed nurse witnesses for one of two medication carts (Medication Cart A) reviewed for controlled drugs reconciliation. * Resident 1 was not administered with the prescribed amlodipine (medication to lower blood pressure) on 7/6/26. * The medications due at 0900 hours were administered late to Residents 1, 3, and 4 by LVN 4. * Medication Cart A's controlled drugs record was only signed off by one licensed nurse on 7/14 and 7/15/26, for the 0700-1500 and 1500-2300 shift. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delay in interventions and posed the risk of controlled medications being lost or diverted.Findings: Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the following:- Review the MAR to identify medication to be administered;- Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by Physician; and- Sign the MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. Review of the facility's P&P titled Controlled Substance Administration and Accountability revised 6/5/23, showed the following:- It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure;- Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system; and- Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered. 1. Medical record review for Resident 1 was initiated on 7/15/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 4/29/26, showed Resident 1's blood pressure remained elevated with variability. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had no cognitive impairment. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 12/29/25, to administer ferrous sulfate (a supplement used to prevent and treat iron deficiency anemia) 325 mg one tablet by mouth one time a day for supplement;- dated 12/29/25, to administer Januvia (medication used to lower blood sugar) 100 mg one tablet by mouth one time a day for diabetes mellitus (condition causing high blood sugar);- dated 12/29/25, to administer multivitamin-minerals (dietary supplements) one tablet by mouth one time a day for supplement;- dated 12/29/25, to administer cyanocobalamin (medication used to prevent and treat vitamin deficiencies, anemia and low energy) 100 mcg one tablet by mouth one time a day for supplement;- dated 12/29/25, to administer alprazolam (anti-anxiety medication) 0.25 mg one tablet by mouth every 12 hours for anxiety manifested by restlessness; and- dated 12/29/25, to administer amlodipine besylate 7.5 mg one tablet by mouth one time a day for HTN (hypertension, high blood pressure), hold if SBP <110, HR<60; resident okay to provide BP reading from her cuff. a. Review of Resident 1's MAR for July 2026 showed the box for the amlodipine medication under the date July 6 was blank. Further medical record review for Resident 1 failed to show the reason as to why the amlodipine medication scheduled for 7/6/26 at 0630 hours, was not given to the resident. On 7/17/26 at 0735 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 3. LVN 3 verified she was the assigned charge nurse to Resident 1 on 7/6/25, for the day shift. LVN 3 verified the amlodipine medication on 7/6/26, was not signed off in the MAR. LVN 3 stated the blank box in the MAR for the medication would indicate nothing was done to the medication or it might mean the medication was not given. LVN 3 stated since the medication was due at 0630 hours and it was being covered by the night shift, when she opened the MAR she would not see that it was marked red or overdue already. LVN 3 stated she could only see the due medications for her shift unless she changed the shift to night shift. LVN 3 stated she did not remember if the night shift charge nurse endorsed to her that the amlodipine medication was not given on 7/6/26 at 0630 hours. LVN 3 further stated if the medication was not given, she would indicate the code in the box the reason as to why it was not given. On 7/17/26 at 1105 hours, a telephone interview for Resident 1 was conducted with LVN 5. LVN 5 verified she was the charge nurse for Resident 1 on 7/5/26, during the night shift. LVN 5 verified Resident 1 had a physician's order for the amlodipine medication daily and it was scheduled at 0630 hours. LVN 5 stated the medication due at 0630 hours was given by the night shift. LVN 5 stated Resident 1 did not want to be awakened when she was sleeping, and the resident had to check her own BP using her own BP machine. LVN 5 stated Resident 1 was still sleeping until the end of her shift on 7/6/26 at 0730 hours. LVN 5 further stated she endorsed to the incoming day shift licensed nurse the amlodipine medication was not yet given to Resident 1. b. On 7/15/26 at 1135 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed upset and stated she just had her morning medications and those were too late. Resident 1 stated at around 1020 to 1030 hours, LVN 4 came to give her medications, but she was about to take a shower. Review of Resident 1's PointClickCare-eMAR-Resident Details for 7/15/26, showed under the Administration History, the following:- alprazolam tablet 0.25 mg, scheduled at 0900 hours, documented on 7/15/26 at 1107 hours;- cyanocobalamin oral tablet 100 mcg, scheduled at 0900 hours, documented on 7/15/26 at 1107 hours;- ferrous sulfate tablet 325 mg, scheduled at 0900 hours, documented on 7/15/26 at 1107 hours;- multivitamin-minerals tablet, scheduled at 0900 hours, documented on 7/15/26 at 1107 hours; and- Januvia oral tablet 100 mg, scheduled at 0900 hours, documented on 7/15/26 at 1108 hours. 2. On 7/15/26 at 1030 hours, an observation and concurrent interview was conducted with Resident 3. Resident 3 was observed lying in bed holding a medicine cup with a light orange colored liquid in it. Resident 3 stated it was his pain medication, and he instructed the nurse to leave it. Resident 3 was observed drinking the liquid medication in the medicine cup. Resident 3 stated he wanted to be left alone. Medical record review for Resident 3 was initiated on 7/15/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 10/18/25, showed Resident 3 had the capacity to make own decisions. Review of Resident 3's Order Summary Report showed a physician's order dated 6/15/26, to administer methadone hydrochloride oral concentrate (pain medication for severe chronic pain) 10 mg/ml by mouth one time a day for pain management. Review of Resident 1's PointClickCare-eMAR-Resident Details for 7/15/26, under the Administration History, showed:- methadone hcl oral concentrate 10 mg/ml, scheduled at 0900 hours, documented on 7/15/26 at 1009 hours. 3. On 7/15/26 at 1020 hours, an observation for Resident 4 was conducted. LVN 4 was observed coming out of Resident 4's room. Resident 4 was observed awake and lying in the bed. Resident 4 did not answer when asked with questions but just looked at the surveyor. Resident 4's roommate stated Resident 4 was non-verbal. Medical record review for Resident 4 was initiated on 7/15/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had severe cognitive impairment. Review of Resident 4's Order Summary Report showed the following physician's orders:- dated 8/14/25, to administer calcium (supplement) 600 + D3 600-10 mg-mcg one tablet by mouth two times a day for supplement take with food;- dated 8/14/25, to administer Eliquis (medication used to prevent blood clots) 2.5 mg one tablet by mouth two times a day for DVT (deep vein thrombosis, blood clot formation in the vein) prophylaxis;- dated 8/14/25, to administer famotidine (medication used to treat heartburn or acid reflux) 20 mg one tablet by mouth two times a day for GERD (gastroesophageal reflux disease, a condition where stomach acid frequently flows back up into the tube connecting the mouth and stomach);- dated 10/3/25, to administer Cholecalciferol (supplement) 1000 units two tablets by mouth one time a day for supplement; and- dated 11/7/25, to administer polyethylene glycol (laxative) 3350 oral powder 17 gm/scoop one scoop by mouth one time a day for bowel management mix with 4-8 oz of water or juice. Hold for loose stool. Review of Resident 4's PointClickCare-eMAR-Resident Details for 7/15/26, under the Administration History, showed the following:- calcium 600+D3 oral tablet 600-10 mg-mcg, scheduled at 0900 hours, documented on 7/15/26 at 1015 hours;- Eliquis oral tablet 2.5 mg, scheduled at 0900 hours, documented on 7/15/26 at 1015 hours;- famotidine oral tablet 20 mg, scheduled at 0900 hours, documented on 7/15/26 at 1015 hours;- cholecalciferol tablet 1000 units, scheduled at 0900 hours, amount administered two tablets, documented on 7/15/26 at 1015 hours; and- polyethylene glycol 3350 oral powder 17 gm/scoop, scheduled at 0900 hours, documented on 7/15/26 at 1015 hours. On 7/15/26 at 1148 hours, an interview for Residents 1, 3, and 4 was conducted with LVN 4. LVN 4 stated he and the other charge nurse were splitting Medication Cart A for today, day shift. LVN 4 stated he received Medication Cart A at 1000 hours and he started passing the medications then to the residents. LVN 4 stated he had nine residents to pass medications for Medication Cart A. When asked how many residents he had for Medication Cart A, LVN 4 stated he had a complete set of residents in another medication cart and he was done passing the medications to the residents assigned to that cart. LVN 4 stated he had been very busy this morning because he had to go from one station to another, and he had not even taken his break. LVN 4 stated he went to Resident 1 at around 1020 hours but the resident was about to take a shower and instructed him to come back. LVN 4 stated the medications due at 0900 hours could be given an hour before and an hour after. When asked what was the facility's policy regarding passing of medications and timing, LVN 4 stated giving the medications at 1020 hours was still ok because it was still within the 1000 hours time. When asked if administering the medication at 1020 hours was considered late, LVN 4 asked the state surveyor if it was right. LVN 4 was instructed by the state surveyor to verify it with their supervisor or DON. LVN 4 verified he gave Resident 1's medications passed 1100 hours. LVN 4 verified he had given the medications to Residents 3 and 4 passed 1000 hours but LVN 4 stated he gave it as soon as he received Medication Cart A at 1000 hours. On 7/15/26 at 1500 hours, a follow up interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated when he signed off the medications in the MAR, he could modify the time with the exact time he gave the medications, but if the surveyor and LVN 4 would be looking at the MAR table in the computer, the check mark with his initials would still be seen in the 0900 hours box. LVN 4 stated the check mark indicated the medication was given. 4. On 7/16/26 at 1000 hours, a medication cart observation and concurrent facility document review was conducted with LVN 3. Review of Medication Cart A's Controlled Drugs - Count Record for July 2026 showed the following:- on 7/14/26 for 7-3 shift, no signature of licensed nurse on column Nurse On (7-3) and the CII Ekit Serial # column was blank;- on 7/14/26 for 3-11 shift, no signature of licensed nurse on column Nurse Off (7-3);- on 7/15/26 for 7-3 shift, no signature of licensed nurse on column Nurse On (7-3) and the CII Ekit Serial # column was blank; and- on 7/15/26 for 3-11 shift, no signature of licensed nurse on column Nurse Off (7-3).LVN 3 verified the above findings. LVN 3 stated the incoming nurse would do the controlled drugs count with the outgoing nurse and signed off the controlled drug count record together at the time they did the controlled drug count. LVN 3 stated the charge nurses did this process at the beginning of the shift of the incoming nurse. LVN 3 stated it was important for the two charge nurses to witness the controlled drug count to ensure all the controlled drugs were in the medication cart with the correct count. On 7/21/26 at 1436 hours, an interview and concurrent medical record and facility document review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the medications could be given one hour before and one hour after the ordered time of the medication. For example, a medication due at 0900 hours could be given starting at 0800 hours and anytime between 0900 to 1000 hours. RN 1 stated if the medication was given passed 1000 hours, it was considered late. RN 1 stated the expectation for the nurses when signing off the medications in the MAR was to follow the pull, pass, sign process. RN 1 stated the MAR should never be left blank because if there was no documentation, it could indicate the medication was not given. RN 1 stated there should be proper documentation as to why the licensed nurse was not able to give the due medication to the residents. RN 1 stated there were four medication carts on the second floor and if there was short staffing due to sick leave, one medication cart would be shared by two charge nurses. RN 1 stated the controlled drug count record should be signed together by the incoming and outgoing charge nurses to ensure all the controlled drugs were accounted properly. On 7/23/26 at 1500 hours, an interview and concurrent medical record and facility document review was conducted with the DON. The DON stated the medications could be given an hour before and an hour after the due time. The DON stated the licensed nurses should follow the pour, pass and sign process when administering the medications to the residents. The DON stated if the medication was not given, the charge nurse should not leave the MAR blank, but indicate the reason as to why the medication was not given or document that it was endorsed to the incoming nurse. The DON stated the incoming and outgoing charge nurses should be both present when doing the reconciliation for the controlled drugs count to ensure it was properly accounted for and then both would sign the controlled drugs count record. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 4). * Resident 4's medications were not administered timely. This failure posed the risk to negatively impact Resident 4's medical condition.Findings: Review of the facility's P&P titled Medication Administration dated 12/19/22, showed the facility staff must administer medications within one hour of the scheduled medication administration time. Medical record review for Resident 4 was initiated on 6/4/26. Resident 4 was admitted to the facility on [DATE], with diagnoses including chronic pain syndrome. Review of Resident 4's MAR for June 2026 showed the following orders:- dated 12/29/25, Pregabalin (to treat nerve pain) 50 mg, give one capsule by mouth three times a day for chronic pain. The medication was scheduled to be given at 0400, 1200, and 2000 hours;- dated 12/30/25, Buprenorphine HCl (medication to treat chronic pain) 2 mg, give one tablet sublingually three times a day for pain management. The medication was scheduled to be given at 0400, 1200, and 2000 hours; and - dated 3/2/26, Gabapentin (medication to treat nerve pain) 600 mg, give one tablet by mouth three times a day for neuropathy (damage to the nerves outside the brain and spinal cord), hold if respiratory rate is less than 12. The medication was scheduled to be given at 0400, 1200, and 2000 hours Review of Resident 4's Administration Details for June 2026 showed the Pregabalin, Buprenorphine HCl and Gabapentin medications were administer on 6/12/26, on the following times:- Pregabalin 50 mg was administered to the resident at 0602 hours, instead of the scheduled time at 0400 hours;- Buprenorphine HCl 2 mg was administered to the resident at 0600 hours, instead of the scheduled time at 0400 hours; and- Gabapentin 600 mg was administered to the resident at 0601 hours, instead of the scheduled time at 0400 hours. On 6/17/26 at 1400 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON verified the above findings and confirmed the failure to administer these medications in accordance with the provider's order and facility policy had the potential to negatively impact Resident 4's health outcome.

Based on interview and medical record review, the facility failed to ensure the plan of care was revised to address the residents' specific care needs for one of 10 sampled residents (Resident 7). * The facility failed to ensure Resident 7's care plan was revised to reflect the resident's treatment and management of diabetes. This failure had the potential to negatively impact the resident's health and well-being.Findings: Review of the facility's P&P titled Care Plan Revisions Upon Status Change dated 12/19/22, showed the care plan will be updated with the new or modified interventions. Medical record review for Resident 7 was initiated on 5/6/26. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnosis including diabetes. Review of Resident 7's Nursing Progress Note dated 4/30/26, showed Resident 7 with an order to discontinue all insulin with alternative glucose management in place. Review of Resident 7's plan of care showed a care plan problem dated 10/21/25, addressing the use of Insulin Glargine subcutaneous solution, Insulin Lispro injection solution per sliding scale and Metformin HCl for diabetes management. Resident 7's care plan was not revised to reflect the discontinuation of insulin per physician's order on 4/30/26. On 5/7/26 at 1322 hours, an interview and concurrent medical record review for Resident 7 was conducted with LVN 4. LVN 4 verified the findings and stated that the care plan should be revised to reflect Resident 7's current interventions for the management diabetes. On 5/7/26 at 1710 hours, the DON and Administrator were informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored in a safe manner for one of ten sampled residents (Resident 10). * The facility failed to ensure the medications for Resident 10 were not left unattended on by resident's bedside table. This failure had the potential for the medication to be accessed by unauthorized individuals.Findings: Review of the facility's P&P titled Medication Storage dated 12/19/22, showed it is the policy of this facility to ensure all medications housed on premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Further review of the P&P showed during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 5/6/26 at 1508 hours, an observation and concurrent interview was conducted with Resident 10 in his room. There were two medication cups filled with medicated cream with a tongue depressor labeled for arms and another tongue depressor with labeled for back placed inside of each medication cup. Resident 10 stated that he was waiting for his Treatment Nurse to apply these medicated creams to the affected areas. Medical record review for Resident 10 was initiated on 5/6/26. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 10's Order Summary Report dated 5/6/26 showed the following physician's order: - dated 4/13/26, Nystatin External cream 100000 Unit/gm (Nystatin Topical) to apply to back topically every day shift for tinea corpus for 30 days; and - dated 4/13/26, Triamcinolone Acetonide External Cream 0.1% (Triamcinolone Acetonide (Topical) to apply to arms topically everyday shift for psoriasis for 30 days until finished. On 5/6/26 at 1511 hours, Treatment Nurse 1 was called to verify the findings. Treatment Nurse 1 stated that she was waiting to coordinate with the CNA during brief change to apply the medicated cream. She further stated that resident has order for Nystatin cream for his back for treatment of tinea corpus and Triamcinolone cream for treatment of psoriasis of the arms. Treatment Nurse 1 stated that the medicated creams should not be left unattended. On 5/7/26 at 1710 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedure) review, the facility failed to ensure two of five residents (Residents 74 and 179) reviewed for accidents remained free from accident hazards. * The facility failed to ensure Resident 179 was safely transferred from her bed to her wheelchair. This failure resulted in Resident 179 hitting her leg on a wheelchair and sustained a 10-cm (centimeters) abrasion and large hematoma (a collection of clotted blood outside blood vessels, caused by trauma or injury, leading to swelling, pain, and skin discoloration) on her right anterior (situated at or toward the front of the body) shin. * The facility failed to ensure Resident 74's cigarettes and cigarette lighters were stored safely in accordance with the facility's Resident Smoking P&P. This failure had the potential for the residents who were not safe to independently possess a lighter to injure themselves or cause a fire.Findings: 1. Review of the facility's P&P titled Safe Resident Handling/Transfers dated 12/19/22, showed it is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury. Medical record review for Resident 179 was initiated on 4/20/26. Review of Resident 179 Facesheet (quick access to essential patient information, including demographics, insurance, allergies, current medications, and key medical history) dated 4/22/26, Resident 179 was admitted to the facility on [DATE]. Review of Resident 179's MDS (Minimum Data Set - a standardized assessment tool) dated 1/30/26, showed Resident 179's had a BIMS (Brief Interview of Mental Status - a tool used to assess the resident cognitive (the mental processes involved in gaining knowledge, understanding, and comprehension, including thinking, memory, reasoning, and learning) status) score of 14 (cognitively intact). Review of Resident 179's Care Plan Report showed the care plan focus problem to address the following: - ADL (Activities of Daily Living - basic skills necessary for individuals to independently care for themselves, such as eating, bathing and mobility) self-care performance deficit related to impaired function and mobility, due to spinal stenosis (narrowing of the spinal canal, which compresses the spinal cord and nerves, usually caused by age-related wear and tear), scoliosis (abnormal, sideways curvature of the spine), and osteoporosis (a disease that weakens bones, making them fragile and prone to fractures) initiated on 2/10/26; - at risk for falls related to impaired function and mobility initiated on 1/26/26. The care plan goal was for Resident 179 not to sustain serious injury. The care plan interventions included Resident 179 needed to be supplied with appropriate adaptive equipment (devices designed to enhance independence, functionality, and participation for individuals with physical, cognitive, or sensory disabilities) or devices as needed, revised on 2/10/26; and - potential for skin tear of bilateral upper and lower extremities initiated on 1/26/26. The care plan interventions included use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of Resident 179's Nurses Progress Note dated 4/1/26 at 0812 hours, showed Resident 179 sustained a skin tear to her right shin during transfer to her wheelchair. Review of Resident 179's Skin Check note dated 4/1/26 at 0959 hours, showed Resident 179 sustained a skin tear to her right leg with moderate bleeding and a hematoma noted. A skin flap was placed back and Steri-Strips (sterile, breathable, adhesive skin closures) were applied. Review of Resident 179's Daily Skilled Services note dated 4/1/26 1550 hours, showed earlier in the day Resident 179 reported an injury to her right lower extremity. Nursing was aware and recommended to avoid out of bed activities and to keep right lower extremity elevated to reduce inflammation. Strengthening of the left lower extremity in supine position (lying flat on the back) in all possible ranges of motion, avoiding right lower extremity. Review of Resident 179's Physician Progress Note dated 4/1/26 at 2121 hours, showed while transferring Resident 179 into her wheelchair this morning, Resident 179's leg got stuck/caught in the wheelchair, causing a large 10-cm abrasion and large hematoma on her right anterior shin. Review of Resident 179's Nurses Progress Note dated 4/1/26 at 2141 hours, showed Resident 179 was on monitoring for a skin tear on the front of her right lower leg and Resident 179 complained of pain level of six out of 10 (in a pain scale of 0-10, 0 = no pain and 10 = severe pain) to her lower right leg. Review of Resident 179's Skin Check dated 4/17/26 at 1036 hours, showed a physician examined Resident 179 who ordered to wrap Resident 179's right lower leg with an ace bandage (a stretchable wrap used to provide compression) for one week, with a follow up scheduled for next week for possible incision (to cut into with a sharp instrument) and drainage. On 4/20/26 at 1249 hours, an observation and concurrent interview was conducted with Resident 179. Resident 179 was observed lying in her bed with a bandage wrapped around her right lower leg. Resident 179 was asked if she had sustained an injury to her right leg. Resident 179 stated approximately three weeks ago, she sustained an injury while RNA (Restorative Nursing Assistant) 1 was transferring her from her bed to her wheelchair. Resident 179 stated RNA 1 failed to utilize the gait belt (a durable belt worn around a resident's waist to provide caregivers a secure, safe, and comfortable grip for assisting with walking, standing, or transferring) while transferring her and her leg got caught on a piece of metal on the front side of her wheelchair where the footrest would be attached, as a result her right lower leg was injured. Resident 179 stated after her leg hit the wheelchair she yelled for RNA 1 to stop; however, RNA 1 could not control her momentum, which caused the skin to tear off the front of her leg. Resident 179 stated the trauma from her leg hitting the wheelchair caused her leg to bleed and at the time of the injury she suffered a lot of pain. Resident 179 stated she was upset when the staff failed to transfer her properly and she was injured as a result. Resident 179 stated she had weakness in her lower extremities due to injuries to her back and staff would need to use the gait belt when transferring her from her bed to her wheelchair. Resident 179 stated the use of the gait belt offered her more stability and made her feel safe. Resident 179 stated the facility's rehabilitation staff would always utilize the gait belt when transferring her from her bed to the wheelchair; however, the CNAs (Certified Nursing Assistant) and RNAs assigned to the floor did not always utilize the gait belt when transferring her from her bed to her wheelchair. Resident 179 stated after she sustained the injury the facility staff took a photograph of her injury and reported the incident to her family. Resident 179 stated her leg had yet to heal completely and remained swollen. Resident 179 stated the treatment nurse informed her the physician may incise and drain the swollen area to promote healing. Resident 179 stated her goal was to be discharged home with her family and hopefully her leg would heal soon. On 4/22/26 at 1002 hours, a telephone interview was conducted with RNA 1. RNA 1 stated on 4/1/26, during the morning shift, she was assigned to provide care for Resident 179. RNA 1 stated she had cared for Resident 179 once before on 3/31/26. RNA 1 was asked to describe how Resident 179 sustained the injury to her right lower leg during the transfer from her bed to her wheelchair on 4/1/26. RNA 1 stated Resident 179 had an appointment on the morning of 4/1/26. RNA 1 stated she needed to transfer Resident 179 from her bed to the wheelchair. RNA 1 stated she independently transferred Resident 179 from her bed to her wheelchair. RNA 1 stated while she was transferring Resident 179 from her bed to the wheelchair, Resident 179 had difficulty bending her knees, which made it difficult for her to transfer Resident 179 to her wheelchair. RNA 1 further stated the previous morning Resident 179 was able to bend her knees. RNA 1 stated she believed Resident 179 sustained the injury to her right lower leg when Resident 179's right leg hit the metal on the front of the wheelchair where the footrest would be attached. RNA 1 was asked if she utilized a gait belt during the transfer, to which RNA 1 replied, she had not. RNA 1 stated she was not informed Resident 179 needed a gait belt during transfers from her bed to the wheelchair. RNA 1 further stated she was not familiar with Resident 179, having been assigned to care for Resident 179 only on two occasions. On 4/22/26 at 1420 hours, an interview and concurrent medical record review for Resident 179 was conducted with the Director of Rehabilitation. Review of Resident 179's Physical Therapy Treatment Encounter notes dated 3/23/26, showed for transfers (sit to stand), Resident 179 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). The Director of Rehabilitation stated substantial/maximal assistance meant the staff would provide 75 to 80 percent assistance during the sit-to-stand transfers for Resident 179. The Director of Rehabilitation stated the facility protocol was for the staff to always utilize a gait belt when independently transferring the residents from their beds to their wheelchairs. The Director of Rehabilitation stated the facility RNAs and CNAs (Certified Nursing Assistant) were trained to utilize the gait belts when independently transferring the residents from their beds to their wheelchairs, regardless of the level of assistance the residents would require. On 4/23/26 at 1101 hours, an interview and concurrent facility document review for Resident 179 was conducted with the DON (Director of Nursing). The DON stated the facility conducted a risk management investigation specific to Resident 179's injury sustained on 4/1/26, during the transfer from her bed to her wheelchair. The DON stated interviews with Resident 179 and the facility staff were conducted. The DON stated according to Resident 179, on the morning of 4/1/26, while being transferred from her bed to her wheelchair, she scraped her leg against her wheelchair. The DON stated the facility also interviewed RNA 1 who performed the transfer of Resident 179 from her bed to her wheelchair. The DON stated according to RNA 1, during the transfer, Resident 179 was seated at the edge of the bed and Resident 179 was unable to stand up completely. RNA 1 stated she could not place Resident 179 back into bed due to Resident 179's low air loss mattress (a specialized medical support surface designed to prevent and treat pressure injuries by providing, through a blower, constant airflow to manage moisture and heat). RNA 1 then proceeded to transfer Resident 179 to the wheelchair at which time she sustained an injury to her right lower leg. The DON was asked to describe the facility's investigative conclusion. The DON stated RNA 1 failed to secure Resident 179 during the transfer and RNA 1 should have utilized a gait belt to help stabilize Resident 179 during the transfer. The DON stated the facility practice was to utilize the gait belts when the staff independently transfer the residents from their beds to their wheelchairs, regardless of the level of assistance the residents would require. The DON stated the staff would receive this training upon hire and annually. Cross reference to F684, example #1. 2. Review of the facility's P&P titled Resident Smoking dated 4/20/26, showed it is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. Smoking materials will be stored appropriately. On 4/20/26 at 0750 hours, during the initial tour of the facility, an observation and concurrent interview was conducted at Resident 74's bedside. Resident 74 was observed sitting on bed in fowler's position (a standard patient positioning technique where the head of the bed is elevated). An open package of cigarettes, orange-colored cigarette lighter and black-colored cigarette lighter in a plastic cup were observed on top of the overbed table at Resident 74's bedside. The open package of cigarettes, orange and black-colored cigarette lighters were within Resident 74's reach. On 4/20/26 at 0751 hours, an interview was conducted with CNA 6. CNA 6 was asked if the residents could keep their cigarettes and cigarette lighters at bedside, CNA 6 answered, yes, but they smoke downstairs. Medical record review for Resident 74 was initiated on 4/20/26. Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's H&P (History and Physical) examination dated 1/8/25, showed Resident 74 had the capacity to make decisions. Review of Resident 74's Progress Notes dated 4/17/26, an initial note on smoking showed Resident 74 may smoke with supervision. Review of Resident 74's Smoking assessment dated [DATE], showed a goal for Resident 74 to adhere to the tobacco/smoking policies of the facility, initiated on 4/17/26; however, the assessment did not show the safe and appropriate storage of smoking materials. On 4/20/26 at 1433 hours, a follow-up observation was conducted in Resident 74's room. A black -colored lighter previously observed was still in a plastic cup on top of Resident 74's overbed table. LVN (Licensed Vocational Nurse) 2 was immediately called to the room and verified the presence of the black lighter in a cup on top of Resident 74's overbed table. LVN 2 was observed removing the lighter from Resident 74's overbed table and stated, he is not supposed to keep this. On 4/21/26 at 0811 hours, another follow up observation was conducted in Resident 74's room. An orange-colored cigarette lighter was observed at the end of Resident 74's overbed table on the left side of the bed. On 4/21/26 at 0813 hours, an interview was conducted with CNA 7. CNA 7 observed and verified the orange-colored cigarette lighter on top of the overbed table at Resident 74's bedside. CNA 7 was asked should the cigarette lighter be kept by Resident 74, CNA 7 responded, I have to find out, I don't know. CNA 7 was observed removing the cigarette lighter from Resident 74's overbed table. On 4/21/26 at 0815 hours, an interview was conducted with RN 4. RN 4 was made aware of the observations conducted at Resident 74 bedside on 4/20/26 at 0750 and 1433 hours and 4/21/26 at 0811 hours, where there were open package of cigarette and cigarette lighters at Resident 74's bedside table. RN 4 stated Resident 74 should not have cigarettes and cigarette lighters at bedside. On 4/23/26 at 1600 hours an interview was conducted with the Administrator and the DON. The Administrator and DON were informed of Resident 74 having cigarettes and cigarette lighters at bedside and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary medication therapy/management for three of four residents (Residents 31, 129, and 187) observed for the medication administration which resulted to a medication error rate of 12.5%. * The facility failed to ensure the medications were administered as ordered by the physician for Residents 31 and 129. * The facility failed to ensure the medications via GT were administered as per the facility's P&P and accepted standards of practice for Resident 187. These failures had the potential for the residents to experience GT complications and ineffective medication therapy management by not receiving medications timely.Findings: 1. Review of the facility's P&P titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 1/2022 showed Medications .are received from the dispensing pharmacy on a timely basis .If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy .Reorder medication five days in advance of need to assure an adequate supply is on hand .The refill order is called in, faxed, or otherwise transmitted to the pharmacy . a. On 4/20/26 at 0900 hours, a medication administration observation for Resident 129 and concurrent interview was conducted with LVN 13. LVN 13 prepared five oral medications for Resident 129. LVN 13 stated Resident 129's morning dose of amlodipine (medication for high blood pressure) 7.5 mg was not available and LVN 13 would have to check if the pharmacy had delivered it. LVN 13 was observed to not administer Resident 129's morning dose of amlodipine 7.5 mg. Medical record review for Resident 129 was initiated on 4/20/26. Resident 129 was admitted to the facility on [DATE]. Review of Resident 129's Order Details showed a physician's order dated 4/20/26, to administer amlodipine 7.5 mg by mouth one time a day for high blood pressure. Review of Resident 129's MAR for April 2026 showed Resident 129's amlodipine 7/5 mg medication was scheduled to be administered at 0900 hours. The MAR showed on 4/20/26, the amlodipine medication was documented as not given and had the code 2 (See Progress Notes). The MAR for April 2026 further showed the amlodipine 7.5 mg dose was given to Resident 129 on 4/20/26 at 1846 hours. b. On 4/20/26, at 1020, a medication administration observation for Resident 31 Administrator concurrent interview was conducted with LVN 10. LVN 10 prepared 12 oral medications for Resident 31. LVN 10 stated Resident 31's morning dose of apixaban (a blood thinner to prevent blood clot) 2.5 mg and metoprolol (medication for high blood pressure) 25 mg were not available. LVN 10 was observed to not administer Resident 31's morning doses of apixaban 2.5 mg and metoprolol 25 mg medications. Medical record review for Resident 31 was initiated on 4/20/26. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 31's Order Details showed a physician's order dated 4/7/26, for the following medications:- apixaban 2.5 mg by mouth two times a day for DVT prophylaxis; and- metoprolol 25 mg one-half tablet by mouth every 12 hours for high blood pressure. Review of Resident 31's MAR for April 2026 showed two doses of apixaban 2.5 mg and one morning dose of metoprolol 25 mg were documented as not given with the code 6 (See Progress Notes). Review of Resident 31's Progress Notes dated 4/20/26 at 1446 hours, showed the pharmacy was called and the staff inquired regarding the status of the metoprolol 25 mg and apixaban 2.5 mg medications. The notes showed the pharmacy stated they were already working on the apixaban order and reordered the metoprolol 25 mg due to an error from the last reorder of not going through. On 04/20/26 at 1412 hours, an interview was conducted with LVN 10. When asked about Resident 31's apixaban and metoprolol medications, LVN 10 had not contacted the pharmacy yet regarding the two medications that were not available for Resident 31 and would contact the pharmacy when the mid-day medication administration for the residents were completed. LVN 10 stated Resident 31's apixaban 2.5 mg medication was reordered on 4/19/26, and there was no record of the reordering of the resident's metoprolol 25 mg medication. LVN 10 verified Resident 31's apixaban and metoprolol medications were not available. On 4/23/26 at 0940 hours, an interview was conducted with the DON. The DON was made aware of Resident 31 and 129's missing medications during the medication administration and acknowledged the reordering of the residents' medications was not done timely. The DON stated the nurses needed to order the medications timely and would need to communicate with other staff. The DON also stated the nurses needed to notify the MD if the resident missed any dose of the medications. On 4/23/26 at 1020 hours, an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated there should not be any reason to be out of the medications which could be set for autofill by the dispensing pharmacy. 2. Review of Center for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 13-02-NH titled Nursing Homes - Clarification of Guidance related to Medication Errors and Pharmacy Services posting date 11/2/12, showed for administering medications via tube feeding, the standard of practice is to administer each medication separately and flush the tubing between each medication. An exception would be if there is a physician's order that specifies a different flush schedule for an individual resident, for example because of a fluid restriction. Failure to flush before and in between each medication administration is considered a single medication error and would be included in the calculation for medication errors exceeding 5 percent . American Society for Parenteral and Enteral Nutrition (ASPEN) publication dated 11/4/16, in Journal of Parenteral and Enteral Nutrition, Volume 41, Issue 1, pages 15-103, titled ASPEN Safe Practices for Enteral Nutrition Therapy showed Medication Delivery via Enteral Access Devices .Provide appropriate tube irrigation around the timing of drug administration .Prior to administering medication, stop the feeding and flush the tube with at least 15 mL water .Administer the medication using a clean enteral syringe .Flush the tube again with at least 15 mL water, taking into account the patient's volume status .Repeat with the next medication .Flush the tube one final time with at least 15 mL water . Review of the facility's P&P titled Enteral Tube Medication Administration dated 10/2017 showed to safely and accurately administer oral medications through an enteral tube .Administer medication .Administer each medication separately and flush with at least 15 ml of water or other appropriate liquid between each medication . On 4/20/26 at 1020, a medication administration observation was conducted for Resident 187 with LVN 14. LVN 14 prepared the following medications for Resident 187: - one tablet of finasteride (medication to treat enlarged prostate which aids in fertility) 5 mg and 500 mg of calcium carbonate (supplement) both crushed into powder; - 10 ml of docusate (stool softener) 50 mg per 5 ml oral solution; and - 17 grams of polyethylene glycol 3350 (medication for constipation) powder. LVN 14 was observed adding all four medications in a plastic cup containing approximately four ounces of water and mixed them before administering the medication together into Resident 31's GT. On 4/20/26 at 1425 hours, an interview was conducted with LVN 14. When asked about Resident 187's administered medications via GT, LVN 10 was not aware each medication should be administered via GT one medication at a time and stated Resident 187 preferred taking the medications with as minimal water as possible. LVN 10 stated would look in the resident's medical record to see if there was any documentation in the resident's care plan about giving the medications via GT all together. On 4/20/26 at 1445 hours, an interview was conducted with the DON. The DON acknowledged the medication via GT needed to be administered one medication at a time. On 4/23/26 at 0940 hours, a follow-up interview was conducted with the DON. The DON verified there was no documentation of Resident 187's preference or for all the medications to be administered at the same time with minimal water during medication administration via GT. On 4/23/2 at 1020 hours, an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated the current standards would not support mixing and giving all medications at the same time via GT.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of three final sampled residents (Residents 17 and 20) reviewed for pain management. * The facility failed to accurately document the pain level and administer the oxycodone (narcotic pain medication) according to the physician's orders for Resident 17. * The facility failed to administer the hydrocodone-acetaminophen (narcotic pain medication) according to the physician's orders for Resident 20. These failures had the potential to put Residents 17 and 20 at risk for ineffective pain management and/or adverse effects related to the use of unnecessary pain medications.Findings: Review of the facility's P&P titled Pain Management revised 3/17/25, showed based upon the pain evaluation, the facility in collaboration with the attending physician/prescriber, other health care professional and the resident and/or the resident's representatives will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. 1. On 4/20/26 at 0700 hours, an interview was conducted with Resident 17. Resident 17 stated she had generalized body pain and pain on her back that was usually a 10 out of 10 pain (a pain level from 4 to 10, using a pain scale of 0 to 10 with 0= no pain and 10= worst pain). Medical record review for Resident 17 was initiated on 4/20/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 2/22/26, showed Resident 17 was able to understand and make treatment decisions. Review of Resident 17's Order Summary Report dated 4/22/26, showed the following physician's orders: - dated 4/1/26, to administer oxycodone 5 mg give 0.5 (half) tablet by mouth every four hours as needed for moderate to severe pain (a pain level from 4 to 10), to try the nonpharmacological interventions before providing the medication and to document the following: 1. Repositioning, 2. Dim light/quiet room, 3. Relaxation, 4. Distraction, 5. TV (television)/Music, 6. Other- to indicate in the progress notes and to indicate if the non-pharmacological interventions was ineffective or effective; and - dated 4/13/26, to administer oxycodone 5 mg give one tablet by mouth every four hours as needed for moderate to severe pain, to try the nonpharmacological interventions before providing the medication and to document the following: 1. Repositioning, 2. Dim light/quiet room, 3. Relaxation, 4. Distraction, 5. TV/Music, 6. Other- to indicate in the progress notes and to indicate if the nonpharmacological interventions was ineffective or effective. Review of Resident 17's MAR for April 2026 showed Resident 17 was administered the oxycodone 5 mg medication for on the following dates, times and pain levels: - dated 4/2/26 at 2025 hours, for a pain level of 0; - dated 4/3/26 at 1842 hours, for a pain level of 0; - dated 4/5/26 1430 hours, for a pain level of 3; - dated 4/8/26 1345 hours, for a pain level of 3; - dated 4/8/26 2207 hours, for a pain level of 0; - dated 4/13/26 1238 hours, for a pain level of 0; - dated 4/20/26 1230 hours, for a pain level of 3; and - dated 4/21/26 1302 hours, for a pain level of 3. On 4/22/26 at 1027 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 10. LVN 10 stated Resident 17 usually complained of lower back pain and was administered with the oxycodone pain medication as needed for moderate to severe pain. LVN 10 stated when Resident 17 complained of pain, the pain level was assessed, and the nonpharmacological interventions implemented first. LVN 10 stated if the nonpharmacological interventions were ineffective, then the licensed nurse would administer the PRN pain medication as per the physician's orders and within the ordered parameters. LVN 10 reviewed Resident 17's medical record and verified the oxycodone medications were not administered to Resident 17 as ordered by the physician. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 20 was initiated on 4/20/26. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 20's MDS assessment dated [DATE], showed Resident 20 had a BIMS score of 15, indicating the resident had intact cognitive capacity. Review of Resident 20's Order Summary Report dated 4/22/26, showed a physician's order dated 6/10/25 to administer hydrocodone-acetaminophen 5-325 mg tablet by mouth every four hours as needed for moderate (4-7 scale) to severe pain (8-10 scale), to try the nonpharmacological interventions before providing the medication and to document the following: 1. Repositioning, 2. Dim light/quiet room, 3. Relaxation, 4. Distraction, 5. TV/Music, 6. Other- to indicate in the progress notes and io indicate if the nonpharmacological interventions was ineffective or effective. Review of Resident 17's MAR for April 2026 showed Resident 20 was administered the hydrocodone-acetaminophen 5-325 mg on 4/6/26 at 1655 hours, when Resident 17's pain level was 3 and was not within the pain parameter of 4 to 10 as ordered by the physician. On 4/21/26 at 1252 hours, an interview and concurrent medical record review for Resident 20 was conducted with LVN 19. LVN 19 stated Resident 20 should not have received the hydrocodone-acetaminophen 5-325 mg for complain of pain level of 3. On 4/23/26 at 1442 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate hemodialysis care was provided for four of 35 final sampled residents (Residents 14, 26, 49, and 72) and three nonsampled resident (Residents 39, 41, and 97) who were receiving dialysis services. * The facility failed to ensure a hemodialysis emergency kit was available at the bedside for Residents 14, 26, 39, and 97. * The facility failed to ensure Resident 41's dialysis communication record was complete and the hemodialysis center's recommendation to hold Resident 41's metoprolol (blood pressure medication) on dialysis days was followed and communicated to the physician. In addition, the facility failed to ensure Resident 41's hemodialysis access was monitored as per the care plan. * The facility failed to ensure Resident 49's hemodialysis communication were complete and accurate. In addition, the facility failed to ensure Resident 49's fluid restriction, fluid intake and output related to hemodialysis were consistently followed and monitored. * The facility failed to ensure Resident 72's hemodialysis communication record was complete and accurate. These failures had the potential for the residents to not receive appropriate hemodialysis care and treatment and could negatively affect the residents' well-being. Findings: Review of the facility's P&P titled Hemodialysis revised on 6/5/23, showed the facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. The compliance section showed in part the nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. 1. Review of the facility's P&P titled Hemodialysis revised on 6/5/23, showed this facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. a. On 4/20/26 at 0622 hours, during the initial tour of the facility, Resident 39 was observed awake, lying in the bed with a right upper chest perma-catheter. Resident 39 stated he would go to to the hemodialysis treatment every Tuesdays, Thursdays, and Saturdays. Further observation of Resident 39's room failed to show a hemodialysis emergency kit was available at Resident 39's bedside. Medical record review for Resident 39 was initiated on 4/20/26. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's Order Summary Report showed a physician's order dated 3/6/26, to monitor the dialysis site on the right upper chest perma-catheter every shift for sign and symptom of infection. b. On 4/20/26 at 0715 hours, during the initial tour of the facility, Resident 97 was observed awake, lying in bed, with AV shunt noted on Resident 97's left arm. Resident 97 stated he would go to hemodialysis treatment every Tuesdays, Thursdays and Saturdays. Further observation of Resident 97's room failed to show a dialysis emergency kit was available at Resident 97's bedside. Medical record review for Resident 97 was initiated on 4/20/26. Resident 97 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 97's H&P examination dated 4/4/26, showed Resident 97 had the capacity to understand and make decisions. Review of Resident 97's Order Summary Report showed a physician order dated 3/31/26, to monitor dialysis site on the left upper arm AV shunt for redness, swelling, bleeding, and pain every shift. On 4/20/26 at 1157 hours, an observation and concurrent interview for Residents 39 and 97 was conducted with RN 3. RN 3 verified Residents 39 and 97 did not have a hemodialysis emergency kit at bedside. RN 3 stated the dialysis emergency kit was needed at Residents 39 and 97 bedside and should be available to use when there was bleeding at Resident 39 and 97's dialysis access site. c. On 4/20/26 at 0800 hours, during the initial tour of the facility, Resident 14 was observed awake, lying in the bed. Resident 14 was observed to have a right thigh perma-catheter. Further observation of Resident 14's room failed to show a hemodialysis emergency kit was available at Resident 14's bedside. Medical record review for Resident 14 was initiated on 4/20/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's MDS admission assessment dated [DATE], showed Resident 14's cognitive skills for daily decision making was severely impaired. Review of Resident 14's Order Summary Report showed a physician's order dated 4/19/26, to monitor the hemodialysis access site at the right thigh perma-catheter for sign and symptom of infection every shift. d. On 4/20/26 at 0812 hours, during the initial tour of the facility, Resident 26 was observed awake, lying in bed, and eating breakfast. Resident 26 stated he would go to the hemodialysis treatment every Tuesdays, Thursdays, and Saturdays. Further observation of Resident 26's room failed to show a hemodialysis emergency kit was available at Resident 26's bedside. Medical record review for Resident 26 was initiated on 4/20/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 26's Order Summary Report showed a physician's order dated 9/30/25, to monitor the hemodialysis site on the right upper chest perma-catheter every shift for sign and symptom of infection. Review of Resident 26's H&P examination dated 10/1/25, showed Resident 26 had no capacity to make decisions. Review of Resident 26 Care Plan Report dated 10/17/25, showed a with focus care plan for hemodialysis related to end stage renal disease and the interventions included to monitor, document and report as needed for signs of the following bleeding, hemorrhage bacteremia, septic shock and report to MD if indicated. On 4/20/26 at 1150 hours, an observation and concurrent interview for Resident 14 and 26 was conducted with LVN 2. LVN 2 verified the above findings and stated the hemodialysis emergency kit was needed at Resident 14 and 26's bedside and should be available to use when there was bleeding at Resident 14 and 26 's hemodialysis access site. On 4/23/25 at 1341 hours, an interview was conducted with the DON. The DON stated the residents who had hemodialysis treatment should always be checked for bleeding at the hemodialysis access site. The DON further stated the hemodialysis emergency kit was important to always be available and accessible in the residents' room for any complications observed in the hemodialysis access site. The DON was informed and acknowledged the above findings. On 4/23/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Closed medical record review for Resident 41 was initiated on 4/21/26. Resident 41 was admitted to the facility on [DATE], and transferred to Hospital 2 on 4/16/26. Review of Resident 41's MDS assessment dated [DATE], showed Resident 41 had moderately impaired cognition and was coded for receiving hemodialysis treatments. Review of Resident 41's Order Summary Report dated 4/23/26, showed the following physician's orders: - dated 4/7/26, to hold metoprolol (blood pressure medication) 25 mg and iron (supplement) on hemodialysis days; and - dated 4/9/26, for Resident 41's hemodialysis treatments every Tuesday, Thursday, and Saturdays with Dialysis Center B. The pick-up time was 1230 hours and the chair time was at 1330 hours. a. Review of Resident 41's Dialysis Communication Forms showed the following missing and inaccurate documentation: - dated 3/31/26 , the post-hemodialysis section including the assessment for Resident 41's hemodialysis access location/status, catheter dressing, presences of bleeding, and post-dialysis treatment vital signs (BP (blood pressure), pulse, respirations, temperature, and pain) was blank. - dated 4/2/26, the pre-hemodialysis section failed to show the documentation of Resident 41's hemodialysis access location and status; and the dialysis center section failed to show Resident 41's post- hemodialysis weight; - dated 4/7/26, the dialysis center section failed to show the documentation of Resident 41's hemodialysis access location and status; and - dated 4/11/26, the dialysis center section failed to show Resident 41's post- hemodialysis weight. b. Further review of Resident 41's Dialysis Communication Forms showed the following documentation: - dated 4/2/26, for the dialysis center section, under additional information showed a documentation by the hemodialysis nurse: please do not give any blood pressure medications on the day of the hemodialysis to prevent hypotension (low blood pressure) during treatment; and - dated 4/4/26, Resident 41 received hemodialysis treatment. Under the hemodialysis center section, the documentation showed to hold metoprolol, iron, and ESA (erythropoiesis-stimulating agents, used to treat anemia). Review of Resident 41's MAR for April 2026 showed the documentation on 4/4/26 at 0900 hours, Resident 41 was administered the metoprolol 25 mg medication. Further review of Resident 41's medical records failed to show the documentation if the recommendations from the hemodialysis center on 4/2 and 4/4/26 was communicated to the physician on those days. Review of Resident 41's Progress Notes dated 4/7/26 (three days later) at 1124 hours, showed the licensed nurse documented she called the hemodialysis center to clarify the orders from 4/4/26, and sending the order back for clarification. c. Review of Resident 41's Care Plan Report showed a care plan problem dated 4/8/26, addressing Resident 41's need for hemodialysis treatments related to end stage renal disease. The interventions included to monitor the hemodialysis access site in the right subclavian vein for R= redness, S=swelling, B=bleeding, P=pain; and to monitor the access site for bruit and thrill and notify the physician if bruit and thrill were absent. Further review of the Resident 41's Order Summary Report failed to show a physician's order for the monitoring of Resident 41's hemodialysis catheter. Review of Resident 41's medical record failed to show the licensed nurses documentation for the monitoring of Resident 41's hemodialysis access site. On 4/23/26 at 1101 hours, an interview and concurrent medical record review for Resident 41 was conducted with RN 3. RN 3 stated the hemodialysis communication forms were used as a form of communication between the facility and the hemodialysis center. RN 3 stated all sections of the dialysis communication form should be completed. RN 3 further stated when the resident returned to the facility after the hemodialysis treatment, the licensed nurse was responsible for assessing the residents and checking to ensure the hemodialysis center section was complete and any recommendations were communicated to the physician and documented in the progress notes. RN 3 reviewed Resident 41's medical records and verified there was no documentation of the monitoring of Resident 41's hemodialysis access site and there was no documentation to show the physician was informed on 4/2 and 4/4/26 of the recommendations by the hemodialysis center. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 3. Medical record review for Resident 72 was initiated on 4/20/26. Resident 72 was admitted to the facility on [DATE]. Review of Resident 72's MDS assessment dated [DATE], showed Resident 72 had moderately impaired cognition. Review of Resident 72's Order Summary Report dated 4/21/26, showed the following physician's orders: - dated 4/1/26 , to check Resident 72's left chest perma-catheter every shift for signs and symptoms of complications or adverse reactions.; and - dated 4/6/26, for Resident 72's hemodialysis treatments every Tuesday and Saturdays with Dialysis Center A and the pick-up time was at 1000 hours and the chair time was at 1045 hours. Review of Resident 72's Dialysis Communication Forms showed the following missing and/or inaccurate documentation: - dated 4/7/26 , the post-hemodialysis section showed the licensed nurse documented Resident 72's catheter location was in the left upper chest and the Yes was selected for the presence of bruit and thrill; - dated 4/11/26, the hemodialysis center section failed to show the documentation of the dialysis end time; and the post-hemodialysis section showed the licensed nurse documented Resident 72's catheter location was in the left upper chest and the Yes was selected for the presence of bruit and thrill; - dated 4/14/26, the hemodialysis center section failed to show the documentation of the dialysis end time ; and the post-hemodialysis section showed the licensed nurse documented Resident 72's catheter location was in the left upper chest and the Yes was selected for the presence of thrill; - dated 4/18/26, the hemodialysis center section failed to show the documentation of the hemodialysis end time and the hemodialysis catheter location/status; and - dated 4/21/26, the hemodialysis center section failed to show the documentation of the hemodialysis catheter location/status; and the post-hemodialysis section failed to show the documentation of Resident 72's dialysis catheter location/status. A Yes was marked for the assessment of thrill. On 4/22/26 at 1120 hours, an interview and concurrent medical record review for Resident 72 was conducted with LVN 10. LVN 10 stated Resident 10 had a perma- catheter in the left chest. LVN 10 reviewed Resident 10's hemodialysis communication forms and verified the above findings. LVN 10 stated the dialysis communication forms were inaccurate and should be completed accurately. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Medical record review for Resident 49 was initiated on 4/20/26. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's H&P examination note dated 8/6/25, showed Resident 49 had the capacity to understand and make decision. Resident 49 had ESRD and on hemodialysis. a. Review of Resident 49's Order Summary Report dated 4/22/26, showed a physician's order dated 10/14/25, for hemodialysis treatment every Mondays, Wednesdays and Fridays and the pick-up time was at 0830 hours, and the chair time was at 0930 hours. Review of Resident 49's Care Plan Report showed a care plan problem revised on 1/28/25, addressing Resident 49's need for hemodialysis treatments related to end stage renal disease. The interventions included to monitor vital signs pre-hemodialysis and after hemodialysis and to notify physician of significant abnormalities including signs and symptoms of hypotension. Review of Resident 49's Dialysis Communication Forms showed the following missing and/or inaccurate documentation: - dated 3/20/26, the Pre-Dialysis Information, shunt/ catheter location was marked 0 Zero The Post-Dialysis Information section including the assessment for Resident 41's hemodialysis access location/status, catheter dressing, assessment of bruit and thrill, presence of bleeding, general condition of the resident, vital signs (BP, pulse, respirations, temperature, and pain) and the nurse signature were blank - dated 4/16/26, an inaccurate date supposedly 4/15/26, showed the Post-Dialysis Information section including the assessment for Resident 41's hemodialysis access location/status, catheter dressing, assessment of bruit and thrill, presence of bleeding, general condition of the resident, vital signs (BP, pulse, respirations, temperature, and pain) and the nurse signature were blank - dated 4/17/26, showed the Post-Dialysis Information section including the assessment for Resident 41's hemodialysis access location/status, catheter dressing, assessment of bruit and thrill, presence of bleeding, general condition of the resident, vital signs (BP, pulse, respirations, temperature, and pain) and the nurse signature were blank - dated 4/20/26, the Pre-Dialysis Information, showed medications administered prior to dialysis, meal/ snack sent, additional information and the nurse signature were blank'. The Post-Dialysis Information section including the assessment for Resident 41's hemodialysis access location/status, assessment of bruit and thrill, general condition of the resident, vital signs (BP, pulse, respirations, temperature, and pain) and the nurse signature were blank - dated 4/22/26, showed the Post-Dialysis Information section including the assessment for Resident 41's hemodialysis access location/status, catheter dressing, assessment of bruit and thrill, presences of bleeding, general condition of the resident, vital signs (BP, pulse, respirations, temperature, and pain) and the nurse signature were blank On 4/22/26 at 1330 hours, an observation and a concurrent interview of Resident 49 was conducted in the resident's room. Resident 49 was observed sitting in a wheelchair. Resident 49 stated she had returned from hemodialysis treatment few minutes ago. On 4/22/26 at 1403 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 3. RN 3 stated Resident 49 had just returned from hemodialysis treatment. RN 3 verified the Dialysis Communication Form had missing documentation for the hemodialysis access location/status, catheter dressing, assessment of bruit and thrill, presences of bleeding, general condition of the resident, vital signs and the nurse signature. RN 3 stated the Resident 49 should have been assessed upon arrival from hemodialysis and the Dialysis Communication Form should have been completed to document resident's condition. On 4/23/26 1450 hours, an interview was conducted with the DON and Administrator. The DON and the Administrator was informed and acknowledged the above findings. b. Review of the facility's P&P titled Fluid Restriction revised 12/19/22, showed the fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. Water will not be provided at the bedside unless calculated into the daily total fluid restriction. On 4/20/26 at 0747 hours, during the initial tour of the facility the Resident 49 was observed sitting in her wheelchair. A water pitcher with a straw was observed on the resident's bedside table. The pitcher at Resident 49's beside table had no graduated measurement. On 4/20/26 at 0747 hours, an observation of Resident 49 in the room and concurrent interview was conducted with LVN 18. LVN 18 verified Resident 49 had a water pitcher on the bedside table. LVN 18 stated if the resident was on fluid restriction there should be no water pitcher at the resident's bedside. Review of Resident 49's Order Summary Report dated 4/22/26, showed a physician's order dated 6/5/25 for the following: - fluid restriction of 1500 ml/day: nursing for total of 780 ml (0700 hours to 1500 hours shift = 300 ml, 1500 hours to 2300 hours shift = 300 ml, and 2300 shift to 0700 hours shift = 180 ml) dietary for total of 720 ml (breakfast = 240 ml, lunch = 240 ml, and dinner = 240 ml); and - to record intake &output. Intake to be recorded in ml. Output to be recorded by number of times the resident voided. Review of Resident 49's Documentation Survey Report v2 for April 2026 failed to show the intake and output monitoring by the CNAs. On 4/20/26 at 1137 hours, an interview was conducted with Resident 49. Resident 49 stated she drank the water from the pitcher. Resident 49 further stated she was not able to tell the staff whenever she drinks from her water pitcher. On 4/20/26 at 1030 hours, an observation and concurrent interview was conducted with CNA 15. CNA 15 verified Resident 49 had a non-graduated measuring pitcher at the bedside table. CNA 15 stated she would not know how much fluid Resident 49 would consume from the pitcher. CNA 15 further stated Resident 49 would also drink fluids from the meal tray. CNA 15 stated Resident 49's fluid intake and output was not being measured. On 4/22/26 at 1120 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 3. Review of Resident 49's Monitor Record for April 2026 showed the resident's intake and output was not recorded on 4/12, 4/16, and 4/17/26. RN 3 stated the intake and output documented by the licensed nurses in the Monitor Record should include the fluids consumed by the resident from the meal tray. On 4/23/26 at 1105 hours, an interview was conducted with the DSD. The DSD stated Resident 49 was on fluid restriction and should not have any water pitcher at bedside. The DSD stated the CNAs did not record the intake and output; however, the CNAs should report to the charge nurse verbally the resident's intake and output for the shift. On 4/23/26 1450 hours, an interview was conducted with the DON and Administrator. The DON and the Administrator was informed and acknowledged the findings as above. Cross reference to F842, item #2.

Based on observation, interview, medical record, and facility P&P review, the facility failed to ensure the appropriate respiratory care was provided for five of eight final sampled residents (Residents 2,11, 14, 20, and 72) and one nonsampled resident (Resident 31) reviewed for respiratory care. * The facility failed to ensure Residents 2 and 11's oxygen concentrator filter was free of thick, dust like particles. * The facility failed to ensure Resident 14's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 20 was provided with oxygen as ordered. Additionally, the facility failed to ensure the CPAP tubing and headgear was changed weekly as ordered by the physician and as per the facility policy. * The facility failed to ensure Resident 31's nebulizer breathing mask was changed weekly. * The facility failed to ensure a physician's order was obtained for the administration of continuous oxygen therapy via the nasal canula for Resident 72. In addition, the facility failed to ensure a care plan problem was developed for Resident 72's use of the oxygen via the nasal canula. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: 1. Review of the facility's P&P titled Cleaning and Disinfection of Resident Care Equipment dated 12/19/22, showed resident care equipment can be a source of indirect transmission of pathogens. Direct care staff can clean single resident equipment when visibly soiled and according to routine schedule (where applicable). a. On 4/20/26 at 0855 hours, during the initial tour of the facility, Resident 2 was observed lying in bed, on ventilator administered via tracheostomy in progress. The oxygen concentrator filter at the side of the concentrator unit near the foot part of the bed was observed to be covered with dust like particles. Medical record review for Resident 2 was initiated on 4/20/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 2/10/26, showed Resident 2 had no capacity to make medical decisions. Review of Resident 2's Order Summary Report dated 4/23/26, showed the physician's orders dated 4/15/26, for tracheostomy tube Shiley flex cuff size 7.5 inner cannula to change every day shift for prevention of tissue granulation and infection, and ventilator settings: pressure control mode: AC set RR: 10 set Pressure: 25 cm H20 Set PEEP: 5 cm H2O, Set PS: O cmH2O at: 3L/min, may titrate oxygen L/min to maintain oxygen saturation at greater or equal to 92%, humidication: HME apply ventilator continuous as needed for ventilator settings check. b. On 4/20/26 at 1129 hours, during the initial tour of the facility, Resident 2 was observed lying in bed, with oxygen in progress administered via tracheostomy. The oxygen concentrator at bedside at the right side near the foot of the bed was observed to have a filter covered with dust like particles. Medical record review for Resident 11 was initiated on 4/23/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/14/26, showed Resident 11 had findings of neurologic impairment. Review of Resident 11's Order Summary Report dated 4/23/26, showed the physician's orders dated 1/20/26, for tracheostomy tube: Portex uncuffed size 6 change inner cannula every night shift, and oxygen via T-bar at five liters per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 92% every shift. On 41/20/26 at 1131 hours, an interview was conducted with LVN 5. LVN 5 verified the oxygen concentrator filters of Resident 2 and 11 were covered with dust like particles. LVN 5 stated the RT's change it, the filters are supposed to be clean, that's dirty. On 4/20/26 at 1136 hours, an interview was conducted with RT 1. RT 1 verified the dirty oxygen concentrator filters of Resident 2 and 11. RT 1 stated we have a third-party company who would come and clean these concentrators and changes the filters. When asked about the schedule, RT 1 stated I will find out but I could change these filters now, I just need to get a new one. On 4/23/26 at 1600 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. On 4/20/26 at 0736 hours, an observation was conducted at Resident 31's bedside. Resident 31's nebulizer was observed inside a clear storage bag and the nebulizer mask was labeled with date of 2/16. Medical record review for Resident 31 was initiated on 4/20/26. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 31's Order Summary Report dated 4/22/26, showed a physician's order dated 4/7/26, to administer ipratropium- albuterol inhalation solution (breathing treatment medication) 0.5-2.5 mg/3 ml, inhale orally every six hours as needed for shortness of breath or wheezing. On 4/20/26 at 0738 hours, an interview and concurrent observation of Resident 31 was conducted with LVN 10. LVN 10 stated the nebulizer masks should be changed weekly, every Sundays. LVN 10 verified the above findings and was observed discarding the nebulizer mask and tubing in the trash can. 3. Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident goals and preferences. Oxygen was administered under orders of a physician, except in the case of an emergency. Oxygen warning signs must be placed on the door of the resident room where oxygen is in use. On 4/20/26 at 0728 and 1149 hours, Resident 72 was observed receiving continuous oxygen at a rate of 4 liters per minute via nasal canula. An oxygen warning sign was not observed posted on the door of Resident 72's room. Medical record review for Resident 72 was initiated on 4/20/26. Resident 72 was admitted to the facility on [DATE]. Review of Resident 72's Order Summary Report failed to show a physician's order for the use of continuous oxygen therapy via nasal cannula. Review of Resident 72's Care Plan Report failed to show a care plan problem was developed to address Resident 72's use of continuous oxygen therapy via nasal canula. On 4/20/26 at 1153 hours, an observation, interview and concurrent medical record review for Resident 72 was conducted with LVN 10. LVN 10 verified Resident 72 was currently receiving continuous oxygen at a rate of 4 liters per minute via nasal canula. LVN 10 also verified an oxygen warning sign was not posted on the door of Resident 72's room. LVN 10 reviewed Resident 72's medical record and verified there was no physician's order for Resident 72's use of the continuous oxygen therapy via nasal canula. On 4/22/26 at 1105 hours, a follow-up interview and concurrent medical record review for Resident 72 was conducted with LVN 10. LVN 10 verified a care plan problem was not developed for Resident 72's use of continuous oxygen therapy via nasal canula. On 4/23/26 at 1552 hours, an interview was conducted with the DON. The DON stated for the administration of continuous oxygen therapy, there should be physician's order and a care plan initiated/developed to address the use of continuous oxygen therapy. The DON further stated the oxygen tubing, including the nasal canula and nebulizer mask, should be changed weekly. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Medical record review for Resident 20 was initiated on 4/20/26. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 20's MDS assessment dated [DATE], showed Resident 20 had a BIMS score of 15, indicating resident had intact cognitive capacity. a. Review of Resident 24's Order Summary Report showed the following physician's orders: - dated 10/27/25, to administer oxygen via nasal cannula at 2 liters per minute every shift; and - dated 12/1/25, the RN to titrate the oxygen to five liters per minute to maintain an oxygen saturation greater or equal to 92% and call MD if oxygen saturation is less than 92% at a maximum titration as needed. On 4/20/26 at 0749 hours, during the initial tour of the facility, Resident 20 was observed with oxygen at a rate of 4 liters per minute via nasal cannula. On 4/21/26 at 1059 hours, a follow-up observation of Resident 20 in the room and concurrent interview and record review was conducted with LVN 19. LVN 19 verified Resident 20 had oxygen at a rate of 4 liters per minute via nasal cannula. LVN 19 verified Resident 19 had a physician's order for oxygen via nasal cannula only at a rate of 2 liters per minute every shift. On 4/21/26 at 1104 hours, an observation of Resident 20 in the room and a concurrent interview and record review was conducted with RN 3. RN 3 verified Resident 20's oxygen rate was at 4 liters per minute via nasal cannula. RN 3 verified Resident 20's physician order dated 12/1/25, showed RN to titrate oxygen to five liters per minute to maintain oxygen saturation greater or equal to 92%. RN 3 stated he did not titrate the resident's oxygen rate this morning. RN 3 verified Residents 20's MAR for April 2026 failed to show a documentation the oxygen was titrated as needed. RN 3 verified residents oxygen saturation level at 0910 hours was at 95%. RN 3 stated resident's oxygen rate should have been at 2 liters per minute only since Resident 20's oxygen saturation was greater than 92%. On 4/23/26 at 1442 hours, an interview was conducted with the DON and Administrator. The DON and the Administrator were informed and acknowledged the findings as above. b. Review of the facility's P&P titled CPAP/BiPAP Cleaning revised on 12/19/22, showed weekly cleaning activities to a. wash headgear/straps in warm, soapy water and air dry; and b. Wash tubing with warm, soapy water and air dry. Review of Resident 20's Order Summary Report showed a physician's order dated 12/1/25; to clean CPAP tubing and headgear, submerge and let soak in warm water and soap, rinse thoroughly and let air dry every Monday. On 4/21/26 at 1104 hours, an observation and concurrent interview was conducted with Resident 20. Resident 20 was observed with CPAP machine at bedside. The CPAP tubing and headgear was observed in a plastic bag dated 4/13/26. Resident 20 stated she uses he CPAP machine at night. Resident 20 further stated she did not see a nurse cleaned her CPAP tubing and headgear yesterday. On 4/21/26 at 1116 hours, an observation for Resident 20 and concurrent interview was conducted with RN 3. RN 3 verified Resident' 20s CPAP tubing and headgear was observed in a plastic bag dated 4/13/26. RN 3 stated the tubing and headgear should have been cleaned yesterday and labeled the bag with the date the CPAP tubing and headgear was cleaned. On 4/23/26 at 1442 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the findings as above. 5. Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed to change the nebulizer tubing and delivery devices weekly and as needed, per manufacturers recommendation or per facility policy and if they become soiled or contaminated. Medical record review for Resident 14 was initiated on 4/20/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's MDS admission assessment dated [DATE], showed Resident 14's cognitive skills for daily decision making was severely impaired. Review of Resident 14's Order Summary Report showed the following physician's order: - dated 3/24/26, to administer albuterol (a bronchodilator medication used to relax the muscles around the airways in the lungs, making it easier to breathe) inhalation solution 0.5-2.5 mg/ml 1 vial four times a day for shortness of breath or wheezing; and - dated 3/26/26, to administer acetylcysteine (medication to treat thick mucus in respiratory conditions) 10% inhalation solution, to give 10 ml four times a day for mucous secretion. On 4/20/26 at 0800 hours, during the initial tour of the facility, Resident 14's nebulizer tubing was observed on the resident's nightstand in a plastic bag without a name and date. On 4/20/26 at 0806 hours, a follow-up observation for Resident 14 and concurrent interview was conducted with the IP. The IP verified Resident 14's nebulizer tubing was in the plastic bag with no name and date. The IP stated the night shift licensed nurses were to change the nebulizer tubing every week and would need to label the plastic bag with the resident's name and date when it was changed. On 4/23/26 at 1341 hours, an interview was conducted with the DON. The DON stated she expected the licensed nurses to change the nebulizer tubing every Sunday and to label the plastic bag with the resident's name and date. On 4/23/26 at 1420 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications for four of five medication carts and two of two medication rooms inspected, and two of 35 final sampled residents (Residents 12 and 16) who had medications at bedside. * The facility failed to ensure the residents' medications had appropriate pharmacy labels in accordance with regulations and the facility's policy and procedure. * The facility failed to ensure the expired medications were not mixed with active medications and were properly separated for proper disposal. * The facility failed to ensure the multi-use, multi-dose injectable medication vials and insulin pens were properly labeled with the open dates immediately after being removed from the medication refrigerator. * The facility failed to ensure the oral medication was stored properly for Resident 12 when a container of antacid (over the counter medications used to quickly relive heartburn, acid indigestion and sour stomach by neutralizing stomach acid) was observed on top of Resident 12's overbed table. * The facility failed to ensure a topical antiseptic was stored properly for Resident 16 when a bottle of povidone -iodine (a solution which prevents infection, often used to clean and disinfect the skin after an injury or before a procedure) was observed on top of Resident 16's overbed table. These failures had the potential to negatively impact the residents' health outcomes.Findings: 1. Review of the facility's P&P titled Medication Labels dated 4/2014 showed medications are labeled in accordance with facility requirements and state and federal laws .If a label does not fit directly onto the product .the label may be affixed to an outside container or carton, but the resident's name, at least, must be maintained directly on the actual product container .Each prescription medication label includes .Resident's name .direction for use .date dispensed .quantity of medication .Name, address, and telephone number of dispensing pharmacy, Prescription number .Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name . On 4/21/26 at 1530 hours, an inspection of Medication Cart 3 located at Nursing Station 3 and concurrent interview was conducted with LVN 15. Medication Cart 3 drawer was observed with 22 packets of lidocaine (local numbing medication for pain management) 5% patch, rubber banded together, with no pharmacy label. LVN 15 stated there were two residents who had orders for the lidocaine patch. LVN 15 stated someone must have taken them out of the manufacturer box. LVN 15 verified there was no pharmacy label to indicate which resident(s) the lidocaine packets belonged to. On 4/23/26 at 0940 hours, an interview was conducted with the DON. The DON stated if it was not an over-the-counter medication, there should be a resident label on the medication. On 4/23/26 at 1020 hours, an interview with the Consultant Pharmacist was conducted. The Consultant Pharmacist stated there should have been a box with the pharmacy label. The Consultant Pharmacist stated the labeled box and the lidocaine packets should not have been separated and the lidocaine packets should have been left in the medication cart with the box. 2. Review of the facility's P&P titled Discontinued Medications revised on 1/2025 showed when the medications are expired, discontinued .the medications are marked as discontinued or stored in a separate location and later destroyed .the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose . a. On 4/21/26, at 1315 hours, an inspection of the Nursing Station 2 Medication Room and concurrent interview was conducted with RN 3. The medication room shelf was observed with one manufacturer box containing 100 unit-dosed tablets of ferrous gluconate (iron supplement) 325 mg which had the manufacturer expiration date of 3/2026. RN 3 verified the ferrous gluconate tablets were expired and should not have been left on the medication shelf. b. On 4/21/26 at 1530 hours, an inspection of Medication Cart 3 located at Nursing Station 3 and concurrent interview was conducted with LVN 15. Medication Cart 3 was observed with one blister pack containing cyclobenzaprine (a muscle relaxant) 5 mg with the expiration date of 2/22/26. LVN 15 confirmed the medication was expired and stated it should have been removed and placed in the medication room for destruction. c. On 4/21/2026 at 1605 hours, an inspection of Medication Cart 1 located at Nursing Station 2 and concurrent interview was conducted with LVN 16. Medication Cart 1 was observed with three blister cards each containing clonidine (medication for high blood pressure) 0.5 mg with expiration dates of 9/6/25, and 4/15 and 1/15/26. LVN 16 verified all the three blister packs were expired and needed to be placed with the other expired medications in the medication room for disposal. d. On 4/23/2026, at 1110, an inspection of Medication Cart 3 located at Nursing Station 1 and concurrent interview was conducted with LVN 17. The medication cart was observed with the following medications that were past the beyond use date after it was opened: - one Lantus Solostar (synthetic insulin to regulate blood sugar) 100 units per ml insulin pen with the open date of 3/22/26; and - one Lantus Solostar 100 units per ml insulin pen with the open date of 3/25/26. Review of the pharmacy label on both insulin pens showed to discard unused portion after 28 days. LVN 17 confirmed both pens had been opened and used beyond 28 days and were expired. Review of the manufacturer's prescribing information for Lantus Solostar Insulin pen showed .not in-use (unopened) .room temperature .28 days .In-use (opened) .28 days .room temperature . 3. Review of the facility's P&P titled Vials and Ampules of Injectable Medications dated 4/2008 showed the vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal .The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or an accessory label affixed for that purpose) . a. On 4/21/26, at 1228, an inspection of Nursing Station 3 Medication Room and concurrent interview was conducted with RN 3. The medication room refrigerator was observed with one injectable multi-dose vial of cyanocobalamin (medication to treat vitamin B12 deficiency and anemia) 1 mg/ml visibly low in volume with the plastic protective cap removed. The vial was observed to not have an open date on the vial. RN 2 verified and stated there should be an open date on the vial when the vial was used. b. On 4/21/26, at 1530, an inspection of Medication Cart 3 located at Nursing Station 3 and concurrent interview was conducted with LVN 15. Medication Cart 3 was observed with 3 ml Novolog (synthetic insulin to regulate blood sugar) KwikPen insulin pen with no open date in the cart drawer stored at room temperature. LVN 15 verified there was no open date on the Novolog insulin pen. Review of the manufacturer's prescribing information for Novolog Insulin pen showed .not in-use (unopened) Room Temperature .28 days .In-use (opened) Room Temperature .28 days . c. On 4/23/2026 at 1045 hours, an inspection of Medication Cart 1 located at Nursing Station 1 and concurrent interview was conducted with LVN 10. Medication Cart 1 was observed with one 3ml Lantus Solostar insulin pen and one 3ml Humalog (synthetic insulin to regulate blood sugar) insulin pen with no open date written on the pen. The insulin pens were stored at room temperature in the medication cart drawer. LVN 10 verified and stated the staff needed to enter the open date on both the insulin pens and the pharmacy label. On 4/23/26 at 1020 hours, an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated the clock starts when the insulin pens come out of the medication refrigerator. Review of the manufacturer's prescribing information for Humalog KwikPen Insulin pen showed .not in-use (unopened) Room Temperature .28 days .In-use (opened) .28 days .room temperature . 4. On 4/20/26 at 715 hours, during the initial tour of the facility, a container of Antacid tablets with approximately one third of tablets left in the container was observed on top of Resident 12's overbed table in front of Resident 12. Resident 12 was asked if she was taking them, Resident 12 responded Yes, I don't want to bother them and will take it when I need to. Resident 12 further stated she got the antacid medication from home. Review of Resident 12's medical record was initiated on 4/20/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 5/8/25, the neurological examination, showed Resident 12 followed commands and answers appropriately. Review of Resident 12's MAR April 2026 showed a physician's order for calcium carbonate (antacids) tablet 500 mg chewable tablet as needed and simethicone( medication to relieve painful symptoms of excess gas, such as bloating, pressure, and flatulence) tablet 80 mg oral tablet as needed were administered. However, further review of the MAR showed these medications were not administered to Resident 12. On 4/20/26 at 913 hours, an interview was conducted with LVN 4. LVN 4 verified Resident 12's antacid medication on top of the overbed table. LVN 4 stated this should not be there and asked Resident 12 if she could remove the antacid medication. Resident 12 got upset and threw the antacid container at the foot part of the bed. On 4/21/26 at 0815 hours, an interview was conducted with RN 4. RN 4 acknowledged the antacid medication on top of Resident 12's overbed table, the resident should not have it. 5. On 4/20/25 at 905 hours, during initial tour of the facility, Resident 16 was in bed being shaved by a family member. A plastic bottle of povidone -iodine (topical antiseptic used to prevent infections in minor cuts, scrapes, and burns by killing bacteria, fungi, and viruses) three quarters full on top of Resident 16's overbed table positioned against the wall across Resident 16's bed. Resident 16's family member was asked if anyone needed the povidone- iodine bottle, Resident 16's family member stated, I don't know. Medical record re4view for Resident 16 was initiated on 4/20/26. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's H&P examination dated 2/24/26, showed Resident 16 was unable to make decisions. Review of Resident 16's Order Summary Report dated 4/20/26 showed the following physician's orders: - dated 4/17/26, to cleanse left lateral heel DTI (deep tissue injury) with normal saline pat dry, apply povidone iodine and LOA (leave open to air) every day shift for 21 days and to cleanse right medial heel DTI with normal saline, apply povidone- iodine and LOA every day shift for 21 days. On 4/20/26 at 922 hours, an interview was conducted with RN 6. RN 6 verified the povidone iodine on top of Resident 16's overbed table positioned against the wall across Resident 16's bed. RN 6 stated I did my rounds this morning, this was not there, the family sometimes put it there. RN 6 was asked where the family member would get the povidone iodine from, RN 6 did not respond to the question instead RN 6 stated no medications should be at bedside. On 4/20/26 at 1138 hours, an interview was conducted with LVN 5. LVN 5 acknowledged the povidone iodine observed on Resident 16's overbed table and stated, it is not supposed to be there, we did rounds. On 4/23/26 at 1600 hours an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed. * The facility failed to ensure the residents were served the sour cream sauce with the pork cutlet (as per the menu), instead of the sweet glaze sauce. The food substitution was not communicated in advance to the residents. * Resident 54 was not offered the alternative menu when he refused to eat his breakfast and lunch. These failures had the potential to not meet the residents' nutritional needs and negatively impact the residents' nutritional health.Findings: Review of the facility's document titled Diet Type Report dated 4/20/26, showed 155 of 191 residents in the facility received food prepared in the kitchen. 1. Review of the facility's document titled Diet Spreadsheet (undated) for Tuesday, Week 1, showed the residents on regular diet, regular- easy to chew diet, soft and bite-sized diet, minced and moist diet, pureed diet, CCHO diet, and renal diet were to be served the pork cutlet with sour cream sauce. On 4/21/26 at 1139 hours, during the lunch trayline observation, the [NAME] was observed to have served the pork cutlet with an orange-colored glaze, instead of the sour cream sauce. On 4/21/26 at 1332 hours, an interview was conducted with the Cook. The [NAME] was made aware about the observation of the pork cutlet with an orange-colored glaze during tray line. The [NAME] stated the orange-colored sauce was a sweet glaze. The [NAME] verified the menu showed to serve the pork cutlet with sour cream sauce for the lunch meal. The [NAME] stated he could not find the sour cream when he was preparing the sauce for the pork cutlet so he made the sweet glaze instead. The [NAME] stated he did not inform the DSS. On 4/21/26 at 1510 hours, an interview was conducted with DSS 2. DSS 2 stated the menu should be followed and the residents should be served the items on the menu. DSS 2 stated if the items on the menu were not available, the cook should inform the DSS, who would update the menu and inform the residents of the change. DSS 2 stated she was not informed by the [NAME] that the facility was out of sour cream. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Standardized Menus revised on 12/19/22, showed Alternative menus will be available if the primary menu or immediate selections for particular meal are not to resident's liking. The policy further showed if during meal observations, a resident's dietary intake appears inadequate, the facility will make reasonable efforts to review and/or adjust the menu and/or the individual resident's food plan to meet the nutritional, religious, cultural, and ethnic needs, and preferences of the resident. Medical record review for Resident 54 was initiated on 4/20/26. Resident 54 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 54's H&P examination dated 12/7/25, showed Resident 54 had the capacity to understand and make decisions. Review of Resident 54's Nutrition amount eaten on 4/21/26, showed Resident 54 refused meals for breakfast and lunch. On 4/21/26 at 1238 hours, an observation and concurrent interview was conducted with Resident 54. Resident 54 was observed without a lunch meal and stated he returned the tray because he did not like potatoes and beans. Resident 54 further stated he was not offered an alternative menu. On 4/22/26 at 0818 hours, an interview and concurrent medical record review for Resident 54 was conducted with RN 2. RN 2 stated Resident 54 had refused his breakfast and lunch on 4/21/26. When asked about the facility's process when the residents refuse meals, RN 2 explained a substitution order form should be filled in and provided to the kitchen. When asked to provide documentation of alternative menu for Resident 54, RN 2 stated the substitution order form cannot be found and there was no documentation in Resident 54's medical record. On 4/23/26 at 1029 hours, an interview was conducted with CNA 1. CNA 1 stated she does not remember offering an alternative menu to Resident 54 and does not recall completing the substitution form. On 4/23/26 at 1509 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed as per the facility's P&P for 22 residents who were on the pureed texture diet. * The pureed pork cutlet, pureed green beans, pureed bread, and pureed orzo rice (rice-shaped pasta) were observed to be runny and failed to hold their shape. This failure posed a risk to cause residents' choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) episodes.Findings: Review of the facility's document titled Diet Type Report dated 4/20/26, showed 22 of 155 residents in the facility who received food prepared in the kitchen received a pureed texture diet. Review of the facility's P&P titled Puree Food Preparation on 12/19/22, showed it is the policy of the facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. Puree foods shall be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to mashed potatoes. On 4/21/26 at 1150 hours, during the lunch meal tray line, an observation of Resident 140's lunch tray line was conducted with the RD. Review of Resident 140's lunch meal ticket showed Resident 140 was on a pureed thin liquid diet. An inspection of Resident 140's lunch tray showed a scoop of pureed pork with an orange sauce on top, a scoop of pureed bread, pureed green beans, and pureed orzo rice. The pureed pork, beans, rice, and bread were observed not holding its shaped, runny and touching the surrounding entrees. The RD verified the above findings and stated the pureed entrees should hold their shape and if prepared too watery, it may lead to aspiration. The RD was observed stopping the tray line and asking the cook to make the puree items thicker. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food in the kitchen. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the items in the kitchen was discarded after the use-by date. These failures had the potential for exposure to food-borne illnesses for a medical vulnerable population of 155 residents who received food prepared in the kitchen.Findings: Review of the facility's document titled Diet Type Report dated 4/20/26, showed 155 of 191 residents in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section 3-501.17, Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking (undated), showed date marking requirements apply to containers of processed food that have been opened and to food prepared, if held for more than 24 hours, shall be clearly marked to indicate the date or day by which the food shall be consumed on the premise, sold, or discarded. Review of the facility's P&P titled Food Safety and Food Storage revised on 11/4/24, showed practices to maintain safe refrigerated storage include: iv. labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it us used by its use-by-date, or frozen (where applicable)/discarded. On 4/20/26 at 0615 hours, an initial tour of the kitchen was conducted with DSS 1 and the following were observed:- two ham sandwiches stored inside Refrigerator A were not labeled with the preparation or the use-by date;- two boxes of mighty shakes (nutritional shakes) stored inside Refrigerator B were not labeled with the date the shakes were placed the refrigerator. The label on the shake cartons showed to store frozen, thaw at or below 40 degrees F and to use the thawed product within 14 days; and- an orange juice box connected to the juice dispenser. The juice box was labeled with the received date of 4/14/26, and the best by date of 10/14/26. However, the juice box was not observed with the opened date. DSS 1 verified the above findings and stated the food items should be labeled with the use-by date when placed inside the refrigerator. DSS 1 stated the mighty shakes once placed in the refrigerator should be discarded after 14 days. When asked, DSS 1 stated she did not know when the orange juice was opened. DSS 1 further stated when the juice boxes were first opened and connected to the juice dispenser, the boxes should be labeled with the opened, and use-by dates. 2. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C), nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. According to USDA Food Code 2022, 4-602.13, Non-Food Contact Surfaces (undated) showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility's P&P titled Food Safety and Food Storage revised on 11/4/24, showed all equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. On 4/20/26 at 0615 hours, an initial tour of the kitchen was conducted with DSS 1 and the following were observed:- the metal racks holding the plastic trays inside Refrigerator A had dry yellow residue and multiple dry white particles;- the black blender lid was had dry food particles;- the detachable blender blade had tan colored residue;- the gray blender had dry yellow and brown-colored food residue;- a white brush was wet and had orange-colored residue;- a black plastic serving spoon had white-colored residue;- a slotted portion server had yellow residue on the handle;- a yellow handle scooper was wet and had yellow-colored residue;- the stationary can opener had brownish fuzzy substance; and- two sheet pans had brownish-black colored stains. DSS 1 verified the above findings and stated the food preparation equipment should be clean. 3. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics (undated) showed for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/20/26 at 0615 hours, an initial tour of the kitchen was conducted with DSS 1 and the following were observed:- two chipped spatulas;- one white spatula was stained with brownish discoloration; and- one metal spatula with white handle was observed with melted handle. DSS 1 verified the above findings. 4. On 4/20/26 at 0615 hours, an initial tour of the kitchen was conducted with DSS 1 and the following were observed:- nine 16-oz bags of Splenda (a sweetener) had a use-by date of 10/25/25;- six cans of vanilla pudding (in the emergency food supply) was labeled with the best-by date of 11/10/25; and- one box of iced tea, connected to the juice dispenser was labeled with the best-by date of 2/20/26. DSS 1 verified the above findings. On 4/23/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 34 final sampled residents (Residents 73 and 135). * Resident 73 was incontinent and had no pressure ulcers upon readmission to the facility on [DATE]. Resident 73 developed a Stage 2 pressure ulcer on the sacrococcyx (tailbone) on 5/25/19, which had deteriorated to unstageable on 7/29/19. Resident 73's sacrococcyx pressure ulcer was observed without a dressing and the pressure ulcer was observed covered in a large amount of feces. The facility failed to provide appropriate and necessary nursing services to ensure Resident 73 did not develop a pressure ulcer in the facility and failed to ensure the pressure ulcer did not deteriorate. * Resident 135 was dependent on the staff for bed mobility and had no pressure ulcers upon readmission to the facility. Resident 135 developed a blood-filled blister to the right elbow which had deteriorated to a Stage 4 pressure ulcer while at the facility. The facility failed to develop and implement a care plan problem to address the blood-filled blister when it was discovered and after it had ruptured and deteriorated to a Stage 3 pressure ulcer. The facility failed to provide nursing services to prevent the development and worsening of Resident 135's pressure ulcer. Findings: Review of the facility's P&P titled Pressure Injury Management revised 3/27/17, showed a resident who has pressure injuries (ulcers) will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. A pressure injury is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing factors to the development of pressure injuries. Review of the National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and treatment of [REDACTED]. The recommendations included to keep the skin clean and dry and to develop and implement an individualized continence management plan. Cleanse the skin promptly following episodes of incontinence. Incontinence can lead to prolonged skin exposure to excess moisture and chemical irritants in urine and feces. Repositioning individuals is an important component in the prevention of pressure ulcers. The underlying cause and formation of pressure ulcers is multifaceted; however, by definition, pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia and inevitable tissue damage. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Individuals who cannot reposition themselves will require assistance. The recommendations included to reposition all individuals at risk of developing pressure ulcers or with existing pressure ulcers. Support surfaces are an important element in pressure ulcer treatment because they provide an environment that enhances perfusion of injured tissue. However, support surfaces alone neither prevent nor heal pressure ulcers. The NPUAP defines the pressure ulcer stages as follows: - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). (MONTH) also present as an intact or open/ruptured serum-filled blister. - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. 1. On 11/7/19 at 0715 hours, Resident 73 was observed lying on her right side on a low air loss mattress and had an indwelling urinary catheter in place. Medical record review for Resident 73 was initiated on 11/7/19. Resident 73 was readmitted to the facility on [DATE], and was transferred out of the facility on 8/4/19. Resident 73 was then transferred back to the facility on [DATE]. Review of Resident 73's Resident Admission assessment dated [DATE], showed Resident 73 was totally dependent on the staff for bed mobility and toileting. The admission assessment showed Resident 73 had an old scar on the sacrococcyx, but did not have a pressure ulcer. Review of Resident 73's Skin & Body assessment dated [DATE], showed Resident 73 did not have a pressure ulcer. Review of Resident 73's plan of care showed a care plan problem dated 2/6/19, to address Resident 73's risk for the development of pressure ulcers secondary to decreased mobility, [MEDICAL CONDITION], and incontinence. The care plan problem showed Resident 73 had a history of [REDACTED]. The approaches included to turn and reposition the resident as needed for comfort and pressure relief and to provide good skin care daily. A care plan problem dated 2/6/19, to address Resident 73's risk for skin breakdown and recurrent skin breakdown secondary to impaired mobility, incontinence, and a history of pressure ulcers showed the approaches included to turn and reposition Resident 73 every two hours and as needed. Review of Resident 73's MDSs dated 3/8, 6/7, and 9/6/19, showed Resident 73 was totally dependent on two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed) and toilet use (including how the resident was cleaned after elimination and pad changes). The MDSs also showed Resident 73 was always incontinent of bowel movements. Review of the Nurses Notes for Resident 73 dated 5/25/19, showed the CNA reported a skin issue to the licensed nurse. Resident 73 was noted with a Stage 2 pressure ulcer to the sacrococcyx measuring 3 cm (length) x 2 cm (width) x (depth illegible). The notes showed the staff was educated to reposition Resident 73 every two hours and to keep the resident on her sides as much as possible. Review of Resident 73's plan of care showed a care plan problem dated 5/25/19, to address Resident 73's altered skin integrity related to the Stage 2 sacrococcyx pressure ulcer. The contributing factors for further skin breakdown and slow healing included a history of pressure ulcers and incontinence. The approaches included to turn and reposition Resident 73 every two hours and as needed, provide prompt pericare to maintain dryness and comfort, provide skin care during ADL care, and keep the area clean and dry. The care plan problem was revised on 7/25/19, to show the sacrococcyx pressure ulcer had deteriorated to a Stage 3 and was revised again on 7/29/19, to show the sacrococcyx pressure ulcer was then unstageable. Review of the Nurses Notes dated 7/25/19, showed Resident 73's sacrococcyx pressure ulcer was reassessed and was noted to have deteriorated to a Stage 3 with 80% yellow slough (dead tissue that may have a yellow or white appearance) and 20% granulation (pink or beefy red tissue with a shiny, moist, granular appearance). The wound size increased from 1.5 cm (length) x 1.5 cm (width) x superficial (depth) to 3 cm (length) x 3 cm (width) x 0.2 cm (depth). The physician was notified and ordered a wound consultation. The licensed nurse documented to turn and reposition Resident 73 every two hours and as needed. A nursing entry dated 7/29/19, showed Resident 73 was examined by the physician for a wound consultation regarding the sacrococcyx pressure ulcer and noted the wound appeared to be unstageable due to necrotic (non-viable tissue due to reduced blood supply) tissue. An entry dated 8/4/19, showed Resident 73 was transferred to the general acute care hospital for a GT replacement. Review of the electronic health record's Census tab showed Resident 73 returned to the facility on [DATE]. Review of Resident 73's Weekly Wound assessment dated [DATE], showed Resident 73's sacrococcyx pressure ulcer was a Stage 4, measuring 4.6 cm (length) x 3.5 cm (width) x 0.5 cm (depth). On 11/5/19, the Stage 4 sacrococcyx pressure ulcer measured 1.2 cm (length) x 1.2 cm (width) x 1 cm (depth). Review of Resident 73's plan of care showed a care plan problem dated 8/6/19, to address an existing Stage 4 sacrococcyx pressure ulcer. The approaches included to turn and reposition the resident every two hours and as needed. A care plan problem dated 8/6/19, to address Resident 73's ADL deficits related to cognitive loss [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke), requiring assistance for bed mobility and toilet use showed to assist Resident 73 with ADL care to the extent needed, turn and reposition the resident every two hours, and provide incontinence care. A care plan problem dated 8/13/19, to address Resident 73's incontinence showed the resident was totally incontinent. The approaches included to provide incontinence care after each incontinent episode and observe the skin for any abnormalities during toileting and/or changing. On 11/12/19 at 0513 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0646 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0652 hours, CNA 3 was observed providing care to a resident. CNA 3 was asked the last time he provided care to Resident 73. CNA 3 stated he last cleaned and turned Resident 73 at the beginning of his shift and he had not had time to clean or reposition the resident again because he was the only CNA on duty. On 11/12/19 at 0657 hours, an interview was conducted with Licensed Nurse 11. When asked if he provided incontinence care and turned/repositioned Resident 73 during his shift, Licensed Nurse 11 stated no. Licensed Nurse 11 acknowledged the residents were not being cleaned and turned every two hours. On 11/12/19 at 0722 hours, Resident 73 was observed lying on her right side on a low air loss mattress. On 11/12/19 at 0830 hours, an observation of Resident 73 was conducted with CNA 8. Resident 73 was observed lying on her right side, her position was unchanged from the previous observations (beginning at 0513 hours). CNA 8 turned Resident 73 to check if Resident 73 had a bowel movement. Resident 73 was observed lying in a large amount of soft feces. Resident 73's sacrococcyx pressure ulcer was observed with no dressing in place and the wound was observed covered with feces. CNA 8 verified the finding. Resident 73's sacrococcyx pressure ulcer was approximately the size of a dime and appeared deep. The observation of the area surrounding the wound showed it was red. CNA 8 stated she was going to call the licensed nurse. On 11/12/19 at 0837 hours, an observation of Resident 73 was conducted with Licensed Nurse 12. Licensed Nurse 12 verified there was no dressing on Resident 73's sacrococcyx pressure ulcer and it was covered in feces. Licensed Nurse 12 verified the pressure ulcer was supposed to be kept clean and dry and an intact dressing was supposed to cover the sacrococcyx pressure ulcer. Licensed Nurse 12 verified Resident 73 was supposed to be provided incontinence care every two hours and as needed and was supposed to be turned/repositioned at least every two hours to prevent the pressure ulcer from worsening. Licensed Nurse 12 verified Resident 73's pressure ulcer was facility acquired. When asked how the pressure ulcer could have developed, Licensed Nurse 12 stated it could have developed from pressure and moisture. Review of the Sub-Acute Daily Staffing for (MONTH) 2019 showed the census ranged from 24 to 29 residents. There was only one CNA on duty for the 11 PM to 7 AM shifts on the following dates: 7/3, 7/5, 7/6, 7/8, 7/9, 7/14, 7/15, 7/18, 7/20, 7/21, 7/26, 7/27, and 7/30/19. On 7/7, 7/13, 7/19, and 7/25/19, there were two CNAs scheduled, but the second CNA worked less than 1.45 hours on those days. Resident 73's sacrococcyx pressure ulcer deteriorated to a Stage 3 on 7/25/19. On 7/29/19, Resident 73's sacrococcyx pressure ulcer worsened to unstageable due to the presence of necrotic tissue. On 16 of the (11 PM to 7 AM) shifts prior to Resident 73's sacrococcyx pressure ulcer deteriorating, only one CNA was on duty to turn/reposition and provide incontinence care every two hours and as needed for 24 to 29 residents. Cross reference to F725. 2. On 11/7/19 at 1125 hours, Resident 135 was observed lying on her left side on a low air loss mattress and had a dressing in place to her right elbow. Medical record review for Resident 135 was initiated on 11/7/19. Resident 135 was readmitted to the facility on [DATE]. Review of Resident 135's Resident Admission assessment dated [DATE], showed Resident 135 was totally dependent on the staff for bed mobility and had no pressure ulcers on readmission. Review of Resident 135's plan of care showed a care plan problem dated 10/15/17, to address Resident 135's ADL deficits due to cognitive loss and [MEDICAL CONDITION]/weakness. The approaches included to turn and reposition the resident every two hours. A care plan problem dated 10/15/17, to address Resident 135's risk for skin breakdown showed the approaches included to turn and reposition Resident 135 every two hours and as needed. Review of Resident 135's MDSs dated 7/5/19 and 10/24/19, showed Resident 135 was totally dependent on two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed). Review of the Licensed Nurse Progress Notes dated 8/15/19, showed Resident 135 had a right elbow abrasion which had healed and had no pressure ulcers. Review of the Nurses Notes showed an entry dated 8/16/19, showing Resident 135 was noted with a blood-filled blister measuring 2.1 cm (length) x 2 cm (width) to the right elbow. The nurses' note showed the skin breakdown was most likely caused by friction as the resident had bilateral upper extremity contractures. Review of the Nurses Notes for Resident 135 showed an entry dated 8/28/19, showing the blood-filled blister on Resident 135's right elbow opened and was a Stage 3 pressure ulcer measuring 1.8 cm (length) x 1.5 cm (width) x 0.3 cm (depth). The pressure ulcer was assessed as 80% granulation and 20% slough. Review of Resident 135's plan of care failed to show a care plan problem was developed to address the right elbow blood-filled blister and failed to show a care plan problem was developed to address the Stage 3 pressure ulcer to Resident 135's elbow after the blood-filled blister had ruptured. Review of the Weekly Pressure Ulcer Report dated 9/23/19, showed Resident 135's pressure ulcer to the right elbow was assessed as a Stage 4 measuring 2 cm (length) x 2.1 cm (width) x 0.3 cm (depth). Review of Resident 135's plan of care showed a care plan problem dated 10/31/19, to address Resident 135's Stage 4 pressure ulcer to the right elbow. The approaches included to turn and reposition the resident every two hours and as needed. The care plan problem to address the Stage 4 pressure ulcer to Resident 135's right elbow was not developed until over a month after Resident 135's pressure ulcer deteriorated from a Stage 3 to a Stage 4 pressure ulcer. On 11/12/19 at 0511 and 0646 hours, Resident 135 was observed lying on her left side on a low air loss mattress. On 11/12/19 at 0652 hours, CNA 3 was observed providing care to a resident. CNA 3 was asked when was the last time he provided care to Resident 135. CNA 3 stated he last cleaned and turned Resident 135 at the beginning of his shift and he had not had time to clean or reposition the resident again because he was the only CNA on duty. On 11/12/19 at 0657 hours, an interview was conducted with Licensed Nurse 11. Licensed Nurse 11 stated he only turned/repositioned Resident 135 and one other resident during his shift. Licensed Nurse 11 stated he turned/repositioned Resident 135 at 0400 hours when he suctioned her, but he did not provide incontinence care. On 11/12/19 at 0721 hours, Resident 135 was observed lying on her left side on a low air loss mattress. On 11/12/19 at 0800 hours, an ADL care observation for Resident 135 was conducted with CNA 8 and RNA 2. Resident 135 was observed lying on her left side on a low air loss mattress; her position was unchanged from the previous observations (Resident 135 was lying in the same position for four hours since she was last repositioned/turned by Licensed Nurse 11). A dressing to the resident's right elbow was observed saturated with a small amount of blood. When CNA 8 removed Resident 135's incontinence briefs, a strong urine odor was noted. Resident 135's incontinence briefs was observed heavily saturated with yellow urine and a small amount of feces. CNA 8 verified the observations. CNA 8 stated she was going to reposition Resident 135 slightly onto her back because Resident 135's right elbow (where the pressure ulcer was located) would rest directly on the mattress if she was lying on her right side. CNA 8 and RNA 2 completed ADL care (including incontinence care and turning/repositioning) for Resident 135 at 0822 hours. It took two staff members 22 minutes to provide ADL care to one resident. When asked if one CNA could provide incontinence care and turn/reposition 27 residents every two hours and as needed, CNA 8 stated it was not possible. On 11/12/19 at 1032 hours, an interview and concurrent medical record review for Resident 135 was conducted with Licensed Nurse 12. Licensed Nurse 12 stated the elbow was a bony prominence area and the blister could have developed by any combination of pressure, friction, and shearing. Licensed Nurse 12 verified there was no care plan problem developed to address the blood-filled blister to Resident 135's right elbow after it had developed. Licensed Nurse 12 stated Resident 135 was supposed to be turned/repositioned every two hours and at least two staff members were needed to pull and reposition the resident using sheets to prevent shearing because Resident 135 was heavy and stiff. On 11/12/19 at 1119 hours, an interview and concurrent medical record review was conducted with Licensed Nurse 18. Licensed Nurse 18 verified Resident 135 was noted with a blood-filled blister to the right elbow on 8/16/19, which ruptured and became a Stage 3 pressure ulcer on 8/28/19. Licensed Nurse 18 stated when a blister developed on a bony prominence area it was considered a Stage 2 pressure ulcer and a care plan problem was supposed to be developed to address it. Licensed Nurse 18 verified there were no care plan problems developed to address the right elbow blood-filled blister when it developed or when it had ruptured and became a Stage 3 pressure ulcer. Licensed Nurse 18 stated Resident 135 had bilateral upper extremity contractures, so both of her posterior elbows rested directly on the mattress if she was on her back. Licensed Nurse 18 stated if Resident 135 tensed up, she would press both elbows into the mattress. On 11/12/19 at 1302 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she went through the overflow medical records and found a care plan problem to address Resident 135's right elbow. However, the care plan problem was dated 8/20/18, and addressed a non-pressure ulcer site at the right elbow. The care plan problem was not specific to the blood-filled blister that Resident 135 developed to the right elbow on 8/16/19, which later ruptured and deteriorated into a Stage 3 pressure ulcer on 8/28/19. When asked, the DON stated care plan problems should be developed within 24 hours to address pressure ulcers. The DON also verified a care plan problem was not developed to address Resident 135's pressure ulcer to the right elbow when it deteriorated to Stage 4, until 10/31/19. Review of the Sub-Acute Daily Staffing for (MONTH) 2019 showed the census ranged from 27 to 29 residents (some days had no documentation to show the day's census). There was only one CNA on duty for the 11 PM to 7 AM shifts on the following dates: 8/5, 8/6, 8/7, 8/8, 8/11, 8/13, 8/14, 8/16, 8/17, 8/18, 8/19, 8/22, 8/24, 8/25, 8/28, 8/29, 8/30, and 8/31/19. On 8/1, 8/12, and 8/15, there were two CNAs scheduled, but the second CNA worked less than 1.93 hours on those days. On 8/23/19, there was one CNA on duty until 0400 hours, when the second CNA started their shift. Resident 135 developed a blood-filled blister to the right elbow on 8/16/19, which ruptured and deteriorated to a Stage 3 pressure ulcer on 8/28/19. for the majority of (MONTH) 2019, there was only one CNA on duty on the 11 PM to 7 AM shifts prior to Resident 135 developing the blood-filled blister to the right elbow and before it had ruptured. Resident 135 needed to be turned/repositioned every two hours and as needed and required two or more staff members for bed mobility. Cross reference to F725.

Based on observation, interview, and clinical record review, the facility failed to ensure two of 28 sampled residents (Residents 3 and 4) received adequate supervision and assistive devices to prevent accident hazards. * Resident 3 sustained a fall on 12/19/13, resulting in a right hip fracture. Resident 3 was to have a battery operated pressure pad alarm in bed (the alarm activates if the resident's weight comes off the pad) to alert staff if the resident attempted to get out of bed without assistance. However, on 12/19/13, the alarm did not sound. Interview with staff identified the batteries were not working. The CNA failed to check the pad alarm to ensure it was working just prior to the fall. * Resident 4 pulled out her tracheostomy tube seven times in 10 months. In addition, Resident 4 pulled out her GT 16 times in 11 months. The facility tried various preventative measures such as soft wrist restraints, hand mittens, and an abdominal binder (fabric that covers most of the stomach making it difficult to grab the GT). A wrist restraint was discontinued due to the resident becoming anxious. The physician prescribed an antipsychotic medication in an attempt to eliminate the resident's behavior of pulling out her GT and tracheostomy tube; however, the behavior of pulling out the tubes continued. There was no documentation to show facility staff attempted other inventions such as increased activities to engage the resident and distract her from pulling at her tubes or more time spent sitting up in the wheelchair, which would allow for more direct supervision by the staff. The physician documented Resident 4 had hypergranulation (thick red tissue) around the GT insertion site made worse by the resident pulling out the GT. Resident 4 had 20 x-rays to check GT placement since 10/1/13. The frequent pulling out of the GT had the potential to cause bleeding and pain. The frequent pulling out of the tracheostomy tube had the potential for bleeding, infections, and swelling of the airway tissue which could prevent reinsertion of the tube. Findings: 1. On 10/22/14, at approximately 0810 hours, Resident 3 was observed sitting up in a wheelchair in the hallway. Clinical record review for Resident 3 was initiated on 10/22/14. Review of the MDS dated [DATE], showed Resident 3 was cognitively impaired. Documentation dated 11/23/13, showed Resident 3 sustained a fall. Review of the Fall Incident Assessment form dated 11/23/13, showed the resident's score was 16. A score of 10 or above represented a high risk for falls. Review of a Resident Incident Assessment form dated 11/24/13, showed Resident 3 fell at 0710 hours. Review of the IDT Accident/Incident Review form completed on 11/25/13, showed Resident 3 was confused and disoriented. The resident required extensive assistance for mobility and ADLs. Staff documented Resident 3's bed alarm sounded on 11/23/13. Resident 3 was found sitting on the floor mat next to her bed. Resident 3 sustained no injuries. The IDT recommendations to prevent future falls included to continue the use of the pad alarm in bed, a low bed, and to use floor mats on the side of the bed in case Resident 3 should fall out of bed. Review of the Fall Incident Assessment form dated 12/19/13 at 2145 hours, and the IDT Accident/Incident Review form dated 12/20/13, showed Resident 3 sustained an unwitnessed fall on 12/19/13 at 2145 hours. Documentation showed Resident 3 was found lying on her right side on the floor between the foot of her bed and her roommate's bed. Staff documented the resident's call light and pad alarm were not activated (call light was not on and the alarm did not sound). Resident 3 was assisted back to bed and assessed to have pain and swelling to her right hip area. The physician was notified and ordered Resident 3 to be transferred to the acute care hospital's ED. Resident 3 was admitted to the acute hospital with a [DIAGNOSES REDACTED]. On 10/22/14 at 1100 hours, an interview was conducted with Resident 3's family member. The family member stated he and other family members visited Resident 3 at least four times a week. The family member stated the family had no care concerns. The family member said Resident 3 attended several of the facility's activities. The family member stated he was aware of Resident 3's falls. On 10/23/14 at 0900 hours, Resident 3 was observed in a chair attending a church service. An interview with RN 6 was initiated on 10/27/14 at 1200 hours. The RN was asked about the use of the pressure pad alarms. RN 6 stated the pressure pad alarm was battery operated. If the batteries needed to be changed, the alarm would make a low sound to warn staff the batteries need to be changed. RN 6 stated DSD 2 changed the batteries for all pressure pad alarms throughout the facility every two weeks. An interview with DSD 2 and the DON was conducted on 10/28/14 at 1000 hours. The DSD confirmed Resident 3's pressure pad alarm did not sound at the time of her fall on 12/19/13. The DSD stated the batteries might have been dead. The DSD was asked who was responsible for changing the batteries on the pressure pad alarms. DSD 2 stated it used to be the responsibility of the CNAs to check and change the batteries. However, the procedure was changed after Resident 3 fell ; now the DSD was responsible to change the batteries every other week. On 11/5/14 at 1620 hours, a follow-up interview was conducted with the DON and DSD 2 regarding Resident 3's fall and her pressure pad alarm. The DON stated Resident 3 fell on [DATE], after the CNA ambulated the resident to the bathroom. The DON stated the CNA brought the resident back to bed; however, the CNA failed to check the pad alarm to ensure the pad alarm was on and working. Review of the documented statement from RN 8 was received on 11/17/14. The statement showed on 12/19/13, RN 8 was passing the medications and "saw" Resident 3 was lying on the floor. The resident was assisted back to bed with the help of three other staff. An assessment showed swelling and pain to Resident 3's right hip area. The resident was transferred to the acute hospital's ED and admitted for a right hip fracture. There was no documentation to show the alarm sounded at the time of the resident's fall. 2. On 10/22/14 at 0830 hours, Resident 4 was observed lying in bed. The resident had a tracheostomy and GT in place. Resident 4's bed was further from the door and her room was located at the end of the hallway, far from the nurses' station. The resident could not be seen by the staff at the nurses' station. Resident 4 was observed again in bed on 10/22/14 at 1130, 1345 and at 1500 hours. Resident 4 had the ability to move her left arm with purpose. On 10/23/14, Resident 4 was observed in bed at 0640, 0800, 0915, and at 1100 hours. Resident 4 was observed to scratch her shoulder with her left hand. There were no devices in place to prevent the resident's movement and/or distraction from reaching her GT or tracheostomy tube. Clinical record review for Resident 4 was initiated on 10/22/14. Resident 4 was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the resident's plan of care found multiple care plan problems identifying Resident 4's behaviors of pulling out her GT and tracheostomy tube. Between October 2013 to August 2014, Resident 4 pulled out her tracheostomy tube seven times. On several of the occasions, the resident was assessed with [REDACTED]. Between September 2013 to October 2014, Resident 4 pulled out her GT 16 times. On several of the occasions, the resident was assessed with [REDACTED]. Also on several occasions, the resident had an order to administer IV fluids while the GT feedings could not be administered due to the GT being pulled out. In addition, Resident 4 had 20 x-rays done to check the GT replacement due to the GT being pulled out. Review of the various care plan problems developed between 9/2/13 through 10/7/14, showed multiple interventions were developed to address the resident's behaviors of pulling out the tracheostomy tube and GT including: * A left hand soft wrist restraint to be worn at all times. * An abdominal binder to help prevent the resident from pulling out her GT. * Seroquel (antipsychotic medication) 25 mg daily for uncontrolled movements resulting in removal of tracheostomy tube and GT. Seroquel was discontinued. * Abilify (antipsychotic medication) 2 mg twice a day for mood stabilization due to agitation manifested by pulling out vital tubes. Abilify was discontinued. Review of the Surgical consultation reports dated 8/27 and 10/15/14, showed Resident 4 had hypergranulation tissue surrounding the stoma that remained irritated due to her behavior of constantly pulling out her GT. On 10/22/14 at 1000 hours, an interview was conducted with RN 3. RN 3 was asked about Resident 4's repeated behaviors of pulling out her GT and tracheostomy tube. RN 3 stated Resident 4 was paralyzed on her right side and could only use her left arm and hand. RN 3 stated staff did try using a mitten on Resident 4's left hand in July 2013; however, it was discontinued. RN 3 stated they also tried a soft wrist restraint, but it made Resident 4 more agitated and was discontinued. RN 3 stated Resident 4 currently had an abdominal binder; however, she could still pull out the GT. RN 3 also stated the physician ordered Seroquel, but the medication was discontinued as the resident did not have a mental illness to justify the use. The physician then ordered Abilify which was also discontinued. RN 3 was asked if any other interventions were tried besides the physical restraints and medications. RN 3 stated no. An interview with Resident 4's family member was initiated on 10/23/14 at 1100 hours. The family member confirmed Resident 4 pulled out her GT and tracheostomy tube multiple times. The family member stated each time the resident pulled out her GT, the physician had to come to the facility to replace the GT. The family member stated the facility sometimes had to start the IV line to administer the IV fluids until the physician replaced the GT. It was very hard and was painful to start an IV line on Resident 4. Sometimes Resident 4 woke agitated. The family member said she and another family member usually visited the resident every day at different times of the day and tried to keep the resident occupied. The family member stated Resident 4 had never pulled out her GT or tracheostomy tube when a family member was with her. Resident 4 liked to watch the nurses' work. The family member stated a few times when Resident 4 became agitated it was related to her roommate who kept pulling the privacy curtain preventing Resident 4 from seeing out the door. The family member stated she had observed Resident 4 become agitated and she would hold the resident's hand or try to distract her from pulling on her tubes. The family member stated on the weekends, there were more family members who visited and got Resident 4 up in the chair, which made Resident 4 very happy and content, and she did not try to pull at her tubes. During the interview with Resident 4's family member, Resident 4 was observed to scratch her shoulder. In addition, Resident 4 started coughing and turned red. Resident 4 started to grab at her tracheostomy tube; however, the family member gently took the resident's hand and Resident 4 released her tracheostomy tube and calmed down. On 10/23/14 at 1140 hours, a follow-up interview was conducted with RN 3. RN 3 was asked how often Resident 4 was up in her wheelchair. RN 3 stated Resident 4 was transferred into her wheelchair three times a week for an hour. When asked why the resident was not in her wheelchair more often, RN 3 stated it was difficult for staff. RN 3 was asked if either OT or PT staff were consulted or had assessed Resident 4 in an effort to try to reduce or eliminate her behaviors of pulling out her tubes. RN 3 stated no. RN 3 was asked since Resident 4 enjoyed watching the nurses' work and needed supervision to discourage and distract her pulling out her tubes, why her room was at the far end of the hallway, away from the nurses' station. RN 3 did not provide an answer. On 10/23/14 at 1030 hours and on 10/24/14 at 1005 hours, an interview and concurrent clinical record review was conducted with the COTA. The COTA stated she was the Director of the Rehabilitation Department. The COTA stated she participated in the IDT meetings. The COTA stated when Resident 4's family members visited the resident was calm. The COTA confirmed Resident 4 was not assessed by either OT or PT staff in the last year. The COTA was asked if the therapy staff had ever considered giving Resident 4 something to touch or play with in her left hand. She stated no. An interview with RT 1 was conducted on 10/24/14 at 1040 hours. The RT stated he was responsible for providing respiratory therapy care to all of the residents who were ventilator dependent. The RT stated Resident 4 was calmer when sitting in the chair and when her family visited. The RT added Resident 4 needed a lot of attention. On 10/27/14 at 1030 hours, an interview was conducted with Activities Designee 1. When asked what activities were provided to Resident 4, the Designee stated she turned on the television and occasionally gave Resident 4 a hand message or painted her nails. The Activities Designee was asked if Resident 4 was taken out of her room to attend any activities. The Designee stated no, residents who were ventilator dependent would require the RT to accompany them and there was not enough staff to do so.

Based on clinical record review, observation and interview, the facility failed to ensure one of three sampled residents (Resident 3) was free from a significant medication error. Resident 3 received approximately 20 times over the ordered dose of [MEDICATION NAME] ([MEDICATION NAME], a narcotic/opioid [MEDICATION NAME]). In addition, the medication was given via GT (gastromy tube - tube in stomach to administer feeding formula and medications), instead of SL (sublingual, under the tongue), as ordered by the physician. The medication was ordered in milligrams (mg); however, it was interchanged for milliliters (ml). This error caused Resident 3 to have an acute [MEDICATION NAME] intoxication (overdose), which caused her to experience respiratory depression (decreased respirations) and lethargy. [MEDICATION NAME] (medication to reverse the effects of narcotics) was administered and the resident stabilized. Findings: Review of the facility's P&P titled "Administering Medications" dated ,[DATE], showed medications will be administered as prescribed by the attending physician. Should a medication dosage seem excessive, considering the resident's age and medical condition, the person preparing/administering the medication shall contact the resident's attending physician or the facility's Medical Director for further instructions. The individual administering the medication must ensure the right medication, right dosage, right time and right method of administration are verified before the medication is administered. Lexi-Comp Online (web base resource for health professionals) showed [MEDICATION NAME] ([MEDICATION NAME] (MS) IR) should be used with care when prescribing or administering [MEDICATION NAME] solutions. These products are available in dose of mg not by volume ml. Lexi-Comp also showed the peak effect for [MEDICATION NAME] sulfate is one hour and duration is from five to eight hours. Under Warnings and Precautions Errors: use caution when prescribing, dispensing, and administering to avoid dosing errors due to confusion between different concentrations and between MG and ML, which could result in accidental overdose and death. Respiratory depression is an increased risk in the elderly. On [DATE] at 1300 hours, Resident 3 was observed lying in bed. The resident was unable to verbalize her needs. A family member at her bedside was asked how the resident was doing and if she had any concerns about the care. The family member revealed there had been a recent incident involving Resident 3. She stated if she had not been there to ask for help, the resident could have died . On [DATE] at 1645 hours, an interview was conducted with the DON regarding Resident 3. The DON revealed there had been a medication error involving Resident 3. She stated on [DATE] at 1230 hours, after Resident 3 was administered [MEDICATION NAME] (at 1100 hours), Resident 3's family member asked for staff's help. The resident had become lethargic, and was having trouble breathing. It was identified LVN 1 had administered "too much pain medication." The attending physician was immediately called and notified of the medication error. an order for [REDACTED]. Clincal record review for Resident 3 showed a physician's orders [REDACTED]. Review of Resident 3's MAR for October, 2012 showed the physician's orders [REDACTED]." On [DATE] at 1100 hours, LVN 1 initiated the MAR indicated facial grimacing." Under the area for "results" (where staff are to document how the resident responded) was blank. On [DATE] at 1300 hours, staff documented oxygen was being administered due to respiration distress. At 1400 hours, staff documented (under "results") the resident no longer had respiratory depression. Review of the pharmacy narcotic count sheet showed the following: [MEDICATION NAME] ([MEDICATION NAME]) 100mg/5ml solution "take 5mg (0.25ml) every 4 hours as needed for severe pain." On the top of the page read "0.25 ML per dose." There was a total of 10 ml of [MEDICATION NAME] solution sent the facility (one dose of MS 0.25ml = 5mg) in the bottle. Additional review of the narcotic count sheet showed on [DATE] at 1100 hours, LVN 1 had signed the narcotic count sheet showing she had administered one dose of MS to Resident 3. When the LVN withdrew 0.25ml of MS, there should have been 5.75ml remaining in the bottle. However, on [DATE] at 1500 hours, during the shift narcotic reconciliation, two licensed nurses checked the MS bottle and found the bottle was almost empty. There was approximately 0.25 ml of MS solution remaining. There was approximately 5.75 ml MS unaccounted for. Based on licensed nurses' signatures, this was the first time LVN 1 had administered the PRN dose of liquid MS to Resident 3. On [DATE] at 1700 hours, during an interview with the DON, she stated during the medication error investigation, the family member was shown a 30 ml medication cup, and she pointed to the line (showing approximately 5 ml), and stated it was a "blue liquid." The family member stated soon after the medication was administered, the resident became lethargic, and was showing signs of respiratory distress. Review of the facility's documentation dated [DATE], showed at 12:30 hours Resident 3's family member (who had been at her bedside) noticed the resident was experiencing respiratory distress, holding her breath. She also had become lethargic, and her oxygen saturation was fluctuating between ,[DATE]%. The family member summoned staff for assistance. The family member reported to the Unit Manager that she had witnessed LVN 1 administer pain medication (MS) to Resident 3 at 1100 hours. The family member identified the amount of MS seemed to be "a lot." The attending physician was notified immediately and 911 was called. However, after receiving [MEDICATION NAME], the resident began to stabilize; she was arousal and opened her eyes. The family chose not to have her transferred to the emergency department. On [DATE] at 0845 hours, an interview with the facility's Pharmacist was conducted. The Pharmacist stated the pharmacy dispensed [MEDICATION NAME] 10 ml on [DATE], in a bottle, with an adhesive warning label attached around the bottle. The label included [MEDICATION NAME] included the dose, and the directions of use. However, the Pharmacist stated the oral syringe provided with the original manufacturers' packing (to make sure to the right amount of the medication is measured) was not included.

Based on observation, interview and clinical record review, the facility failed to prevent two of three sampled residents from developing pressure ulcers (Residents 1 and 3). In each case, the residents entered the facility with no pressure ulcers and developed them while at the facility. Resident 1 was assessed as a high risk for developing pressure ulcers. The resident had problems with intermittent severe swelling ([MEDICAL CONDITION]) of the lower extremities while at the facility, which puts him at higher risk for developing pressure ulcers on the heels. The facility did not implement any preventive measures until after Resident 1 developed pressure ulcers. Upon admission to the hospital, Resident 1 was identified to have one Stage III (full thickness tissue loss. Subcutaneous fat may be visible) pressure ulcer on his coccyx and sacrum area (upper buttocks) an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough or dead tissue) pressure ulcer to the left heel and right shin, and a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer on the right heel and left shin. Resident 3 was identified with a callous on her right malleolus (ankle bone). An observation of the wound showed it is a Stage II pressure ulcer. The resident was supposed to have her ankles resting on pillows while in bed to keep pressure off the ankle. Resident 3 was observed in bed twice with no pillows to relieve pressure as ordered. Findings: 1. Clinical record review for Resident 1 was initiated on 4/9/12. Review of the Nurses' Admission Record showed Resident 1 was admitted to the facility on [DATE]. Resident 1 was assessed with [REDACTED]. The upper extremities were assessed with [REDACTED]. Review of the care plan problem dated 1/31/12, to address the Activities of Daily Living Deficit showed Resident 1 needed extensive assistance for bed mobility and total assistance with dressing, eating, toilet use and hygiene. Review of the Braden Scale - For Predicting Pressure ulcer Risk dated 1/31/12, showed Resident 1 was assessed as a high risk for developing pressure ulcers. Review of the care plan problem dated 1/31/12, to address the risk of skin breakdown showed the goal to maintain skin integrity and to prevent development of skin breakdown. The approaches were to reposition the resident every two hours, provide a nutritional assessment and use a draw sheet to reduce shearing of the skin (a mechanical force contributing to pressure ulcer formation). The nurse's note dated 2/1/12, showed Resident 1's swelling was gone. Review of the Nurses Weekly Progress Note dated 2/6/12, showed the resident's skin discolorations and bruising had resolved. According to the nurse's note dated 2/23/12, Resident 1 developed an excoriated coccyx. The resident was assessed as having 4+ [MEDICAL CONDITION] (a scale from 0 to 4 to rate swelling, 4 is the most severe) to the left lower extremity, 3+ [MEDICAL CONDITION] of the right lower extremity and 2+ [MEDICAL CONDITION] of the upper extremities. On 2/28/12, the nurse's note showed Resident 1 had redness to the left and right heels measuring 2 cm by 2 cm. The resident had a nine pound weight loss in one week (a significant weight loss) and continued to have 3+ [MEDICAL CONDITION] to both lower extremities. Review of the short term care plan problem dated 2/28/12, to address alteration in the skin showed Resident 1 was assessed as having new Stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure ulcers on the left and right heels. The approaches were to provide pressure relieving devices for the bed and chair, turn and reposition the resident, provide a nutritional assessment, and provide treatment as ordered by the physician. The Medication Sheet dated 2/28/12, showed Resident 1 was started on bilateral heel protectors while in the wheelchair. A multivitamin supplement and a 500 mg vitamin C supplement were ordered. There was no documentation to show a pressure relieving device was provided for the bed or chair, as specified in the care plan. Review of the Resident Transfer Record dated 3/2/12, showed at 2300 hours, Resident 1 was transferred to the hospital for [MEDICAL CONDITION]. Further review of the same form showed the resident had an indwelling urinary catheter (a tube inside the bladder to drain urine) and [MEDICAL CONDITION] feeding tube, but did not show any pressure ulcers or deep tissue injuries (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Review of the Physician's Progress Note from the hospital dated 3/3/12, showed Resident 1 had a left heel deep tissue injury measuring 2 cm by 3 cm, with black maroon discoloration. The right heel was described as a Stage II pressure ulcer, 2 cm by 1.5 cm. The left shin had a Stage II fluid filled blister measuring 5.5 cm by 0.4 cm. The sacrum/coccyx area had a Stage III pressure ulcer measuring 1.3 cm by 1.3 cm. The right shin was assessed as having a wound, but no measurements were documented. The Wound Assessment And Progress Record from the hospital dated 3/3/12, showed the sacrum/coccyx wound measured 1 cm by 2 cm by 0.1 cm. The left shin wound measured 6 cm by 1.5 cm, and was classified as a deep tissue injury. The left heel wound measured 2 cm by 3 cm, and was classified as an unstageable wound. The right heel measured 4 cm by 4 cm, and was classified as an unstageable wound. An interview was initiated with LVN 1 on 4/12/12 at 0850 hours. LVN 1 stated Resident 1 was admitted to the facility with intermittent problems with swelling. The LVN stated the family liked the resident to stay up in the wheelchair for four hours a day. The LVN was asked if any plan was implemented or any pressure relieving device was provided while the resident was in the wheelchair for four hours. He stated, no. LVN 1 stated, after the resident developed the pressure ulcers on his heels, heel protectors were ordered. LVN 1 could not recall if any pressure relieving devices were implemented for the bed or wheelchair as specified in the care plan. An interview with the DON was initiated on 4/12/12 at 1000 hours. The DON was asked to provide documentation of any pressure relieving devices implemented for the bed or wheelchair. No documentation was provided. 2. Clinical record review for Resident 3 was initiated on 4/10/12. Review of the Face Sheet showed Resident 3 was admitted to the facility on [DATE]. Review of the care plan problem dated 2/17/12, to address a calloused right malleolus showed Resident 3 was started on skin treatments for the callous wound on 2/17/12. Review of a physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the care plan problem updated 3/14/12, to address the risk of skin breakdown showed Resident 3 should have a pressure relieving mattress on the bed. Observation on 4/10/12 at 1400 hours, showed Resident 3 in bed. Resident 3 was not wearing her AFO. The resident had her legs slightly apart with her ankles resting on the mattress. There were no pillows supporting her lower legs. Resident 3 did not have an alternating air mattress in place. RN 1 was asked to show the resident's calloused area. The wound area did not have a dressing on it. The wound area was measured and had a brown outer area measuring 2 cm by 2 cm. The inner part of the wound was pink and measured 0.5 cm by 0.75 cm. with a shallow open ulceration in the center. On 4/12/12 at 0900 hours, the resident was observed in bed. The resident did not have any pillows under her lower legs, she was not wearing her AFO, and the wound was resting on the mattress. LVN 1 confirmed the resident was not using any pressure relieving mattress and no pillows were being used. At 0925 hours, LVN 2 was asked to remove the old dressing. The DON was also present. LVN 2 removed the old dressing and stated the callous area had changed, and was now open. The physician needed to be contacted to determine if new wound care orders were needed. An interview with the DON was initiated at 1100 hours. The DON stated she was not sure if the wound was a callous or a Stage II pressure ulcer, but while cleaning the skin, a top layer of the pink tissue came off. The DON stated she felt this showed the wound was a callous, not a pressure ulcer.

Based on observation, interview, and clinical record review, the facility failed to ensure the facility had sufficient staff to provide to meet the needs and provided services for residents on the Subacute Unit. This affected 7 of 14 sampled residents (Residents 1, 2, 3, 6, 9, 11, and 12). Residents 1, 3, 6 and 12 were not promptly changed after being incontinent resulting in UTIs (cross reference F 315). Residents 1, 2, 9, 11 and 12 were not repositioned every two hours or kept clean and dry to prevent the potential for skin breakdown and/or promote healing of existing pressure ulcers (cross reference F309 and F314). Oral care was not provided as often as needed for Residents 1 and 12, resulting in oral thrush (cross reference F 312). In addition, 10 direct care staff interviewed stated they did not have enough time during their shifts to meet the needs of the residents they were assigned to. Statements made by direct care staff included, "forced to do a Mickey mouse job. I go home knowing I cannot give good care. I don't have time to do everything, I have failed to take dinner and/or breaks at times because I am so busy." Findings: 1. On 9/7/10 at 1630 hours, an interview was conducted with the family member of Resident 2. The family member stated he does not understand why staff is sent home in the middle of the shift when residents still need care. The family member stated he has seen licensed nurses stick there head in the door when a CNA is providing care to Resident 2 and tell the CNA to hurry up, other residents needed the CNA. The family member stated he visited the facility frequently and has only seen two licensed nurses helping out the CNAs with direct patient care. The family member stated for the most part the CNAs are very good, there just was not enough of them. The family member further stated he was concerned Resident 2 was only being changed (incontinent care) twice a night and is not provided oral care at times. The family member also stated, "I feel blessed to just receive the bare minimum for her, but we are not even getting that." a. Review of Resident 2's clinical record, showed Resident 2 was treated for [REDACTED]. b. Resident 2 and had eight incidents of denuded skin, rashes and skin irritation of the perianal and buttocks areas. A Non-Pressure Skin Problem form identified a perineal excoriation on 9/8/09; perianal rashes and redness, identified 9/27/09; bilateral groin area skin irritation, identified on 10/13/09; left gluteal area skin irritation, identified 11/3/09; perianal denudation, identified 11/3/09; perineal denudation with scattered open areas, identified 12/2/09; perineal denudation, identified 3/25/10; perianal denudation, identified 6/2/10 On 9/8/10 beginning at 0540 hours, an interview was conducted with CNA 1. CNA 1 stated because of the amount of residents the CNA was assigned to care for during the shift, the CNA was not always able to get to everyone as often as needed. The CNA stated he only had time to check and change residents' incontinence briefs and reposition them twice during the eight shift, and would do oral care if time allowed but admitted he did not always have time to provide oral care. CNA 1 stated he was usually assigned to 13 to 15 dependent residents for shift and was currently assigned to care for 15 dependent residents. 2. On 9/8/10 at 0620 hours, CNA 1 was observed to enter Resident 12's room, to change the resident's incontinence pad and reposition the resident. Resident 12 was observed lying in bed on his back. The resident had a disposable incontinence pad underneath him. The disposable pad was soiled with bowel. A brown colored ring was observed encircling the resident's hip area like a halo. CNA 1 stated Resident 12 was having loose stools. When CNA 1 turned Resident 12 onto his side, the resident had fecal matter from his mid back to mid thighs. As CNA 1 wiped Resident 12's buttocks, specks of fresh blood were observed on the cloth. A closer observation revealed the resident had an open area in his skin between his buttocks. In addition, the resident's perianal and buttocks were red and excoriated. Clinical record review for Resident 12 was initiated on 9/8/10, with further record review conducted on 9/22/10. Resident 12 tested positive for UTI on 8/18/10 with >100,000 alpha streptococcus bacteria and was treated with antibiotics. On 9/8/10 with >100,000 [MEDICATION NAME] resisistant [MEDICATION NAME]. [MEDICATION NAME] is bacteria found in the feces of humans. Resident 12 had been transferred to the acute care hospital on [DATE]. Review of the acute care hospital H&P dated 9/11/10, showed Resident 12 was septic and in acute [MEDICAL CONDITION], had an acute UTI. Resident 12 returned to the facility from the acute care hospital on [DATE]. On 9/22/10 at 0640 hours, an observation of Resident 12 was conducted with LVN 6 and CNA 1. Resident 12 was found lying in liquid stool. The resident's indwelling urinary drainage catheter tubing was lying in the feces. CNA 1 was observed to clean the feces from the catheter with pre-moistened wipes. LVN 6 was observed to obtain a 6 oz bottle of normal saline, retract the resident's genitalia and pour a third of the bottle over the catheter where it entered the urethral meatus. LVN 6 did not utilize any soap or other disincentives agent to provide catheter care even though the tubing was contaminated with feces. 3. Observations of Resident 11 on 9/8/10 at 0730 hours, at c0815 hours, at 1000 hours, at 1015 hours, found the resident positioned on his back in bed. On 9/8/10 at 0930 hours, CNA 9 stated she currently had 7 residents, including Resident 11, assigned to her. She revealed she was also assigned RNA duties for residents. In addition, she was also scheduled to go home at 1200 hours. A follow-up interview conducted on 9/8/10 at 1150 hours, CNA 9 stated she had not had time to provide care for Resident 11 since the start of the shift at 0700 hours. Clinical record review was initiated for Resident 11 on 9/8/10. Resident 11 was readmitted to the facility on [DATE], with two Stage II pressure ulcers, one on each buttock. 4. Review of an CMS form 670, completed by the facility for only the Subacute Unit showed the following: * 25 of the 28 residents were totally dependent on staff for toileting; * 25 of 28 residents were totally dependent on staff for dressing; * 23 of 28 residents were totally dependent on staff for transferring; * 26 of 28 residents were totally dependent on staff for bathing. * None of the 28 residents were able to bathe, dress, transfer, or toilet independently, requiring assistance from one or two staff. On 9/8/10, the most recent MDSs of 28 resident on the Subacute Unit were reviewed; 15 of the 28 residents required two or more staff assistance with bed mobility with all 28 residents requiring extensive to total assistance from staff for bed mobility. Review of Staffing documentation, provided by the administration, from 8/30/10 to 9/7/10, showed the following: a. On the night shift (11pm-7am) two CNAs were were assigned for a census of 27-29 residents. Therefore, each CNA was assigned to provide care for 13 to 15 residents each (Each shift is 8 hours minus one half hour break, plus two 10 minute breaks, for a total of approximately 7 hr 10 min of care provision.); 14 to 15 residents divided by 7hr 10min equals approximately 30 minutes allotted per resident during the eight hours night shift to check/change his/her assigned residents every two hours, reposition every two hours, provide oral care as needed, obtain vital signs, and complete charting. b. On the evening shift (3pm-11pm) three CNA were assigned for a census of 27 to 29. On eight of the nine days of staffing reviewed, a CNA was sent home after four hours, or taken off the floor for 1:1 duties which left the remaining CNA to take this CNA's residents. The above staffing showed the majority of the time, two CNAs were on the floor caring for 27 to 29 mostly dependent residents from approximately 7pm to 7am. c. On the day shift (7am to 3pm) three CNAs and one RNA were assigned for a census of 27 to 29. On seven of the nine days reviewed, a CNA was sent home after four hours and the RNA took over that CNA's residents or after four hours the RNA was reassigned to 1:1 duties. On 9/7/10 at 1545 hours and on 9/8/10 at 1000 hours, interviews were conducted with the Subacute Director. When asked how she ensured there was sufficient staff to meet the needs of each resident residing on the Subacute Unit, the director stated they followed "the matrix" and ensured they were meeting the number of hours per patient per day required by the state, which is 2.0 hours per patient per day for CNAs and 3.8 hours per patient per day for licensed nurses. An observation of this matrix form showed it to be a grid for quick calculation of patient per hours per day for CNA and LVNs. 5. On 9/9/10 at 1155 hours, an interview was conducted with a nondirect care staff member who wished to remain anonymous. The staff member stated all the staff were very good and worked hard, but a lot of the time the unit was understaffed. The staff member stated in particular there was not enough CNAs. The staff member stated the CNAs, "are getting dumped on." The staff member stated the care in the unit would be better if there was more staff providing direct patient care. 6. On 9/1/10 at 1207 hours, an interview was conducted with Resident 1's family. The family member stated she attended a care conference regarding Resident 1's care about a few weeks ago and had informed staff her concerns of find Resident 1 dirty and needing his "diaper" changed. She stated she has found Resident 1 in the mornings "full of poop in his diaper" with it coming out between his legs. She stated she has spoken with the DON "ad nauseam" about staffing concerns and was told they are staffed with the maximum staffing. The family member stated she has observed all of the licensed staff go on break at the same time and no one is at the desk. She stated she has attempted to go through all the proper channels to effect positive change for Resident 1 but nothing has improved. Clinical record review was initiated for Resident 1 on 9/3/10. Review of Resident 1's care plan problem for skin breakdown and ADL deficits dated 5/1/10, showed Resident 1 was to be turned and repositioned every two hours as well as provided incontinent care. Review of Resident 1's MDSs dated 5/10/10 and 8/11/10, showed Resident 1 needed extensive assistance for bed mobility and hygiene needs. On 9/8/10 at 0600 hours, observation and concurrent interview was conducted with CNA 7 while in Resident 1's room. The CNA was preparing to provided incontinent care to Resident 1. Resident 1 had been incontinent of bowel and was observed to have dried and fresh feces around his buttocks. Resident 1 was noted to have a deep indentations into his buttocks measuring approximately 1/2 inch wide. The CNA stated the indentations were from incontinence brief gatherings around the leg openings. 7. On 9/3/10 at 0840 hours, an interview with CNA 2 was conducted. The CNA stated there are three CNAs but one CNA is sent home at 11:00am or 12:00 noon. He states it is scheduled which CNA goes home and every CNA take turns going home early. The CNA stated when the CNA goes home, then the RNA staff member has to pick up that CNA's resident assignment and stops doing the RNA duties. The CNA stated the facility pushes him to go home on time and sometimes he is not able to complete his documentation until the next day. CNA 2 stated he heels forced to do a "Mickey Mouse" job. 8. Clinical record review was initiated for Resident 6 on 9/3/10. Review of Resident 6's care plan problem for ADL deficits dated 6/9/10, showed Resident 6 was to be turned and/or repositioned every two hours. The care plan problem for risk for skin breakdown dated 6/9/10, showed Resident 6 was to be turned and/or repositioned every two hours as well as provided incontinent care. A physician's orders [REDACTED]. On 9/3/10 at 1105 hours, during an interview with Resident 6's family member, the family member stated she visits everyday, stating "No way in hell am I going to take a day off from coming to see" Resident 6. I'd be afraid he'd be laying in poop all shift and I am concerned that's happening to other patients that don't have family members." On 9/23/10 at 0830 hours, during an interview with LVN 3 regarding Resident 6, the LVN stated Resident 6's fecal bag is usually changed twice a shift, most often because it has become dislodged. She stated Resident 6 often has stool in his perineal area. On 9/23/10 at 0840 hours, an interview with LVN 4 was conducted. She stated Resident 6's fecal bag is changed a maximum of three to four times a shift, often due to it being too full, leaking or from it being dislodged and not making a good seal to retain the feces. The LVN stated Resident 6 has been found with stool in his perineal area due to the bag leaking or from having a loose seal. She added that Resident 6 has loose stools constantly. 9. On 9/3/10 at 1220 hours, an interview was conducted with CNA 3. The CNA stated her shift is 7.5 hours. The CNA stated often times there is not enough time to give report to the oncoming shift. She stated all of the residents need to be turned, but she's only able to turn her patients every 3 to 4 hours. CNA 3 stated sometimes she goes home and not everything has been done. The CNA further stated there are times when she is not able to complete her documentation until the following day. CNA 3 stated she likes her job but knows she cannot always give good care, stating she does not have time to finish everything. She stated "Some residents have laid in poop and pee longer than I would like." 10. On 9/3/10 at 1430 hours, an interview with CNA 4 was conducted. The CNA stated all of her residents need to be turned and there are some residents who require two people to turn them. She stated all of her residents are incontinent and all require her to provide oral care. She stated often the family members help to turn their loved one if they are at the bedside. She further stated the residents who have family members are turned more often (three or four times a day), but resident's without family at the bedside may only get turned once or twice a shift. CNA 4 stated she was not always able to finish her documentation before leaving at the end of the shift. She stated if she was five minutes late in clocking out and going home she was told to just clock out and not work any extra time. 11. On 9/3/10 at 1555 hours, an interview was conducted with CNA 5. The CNA stated all of his residents are dependent and need to be turned. He stated most of them require two-person to turns them, but he often has to turns them by himself. The CNA stated the families who visit residents often get better care. 12. On 9/3/10 at 1615 hours, an interview with CNA 6 was conducted. The CNA stated all of his residents are incontinent (except one) and all are dependent or require extensive assistance in being turned or repositioned. He stated residents' families ask for their loved ones to be turned and will help staff turning them. The CNA stated having only two CNAs on the floor was not realistic. There was no enough time to do everything that needed to be done which included turn the resident's every 2 hours. He stated the residents were turned every 3 hours. He added that he felt guilty when he has to go home knowing he was not able to provide some residents' oral care. CNA 6 further stated, "Truthfully, the patients with families do tend to get better care. I have failed to take dinner and breaks at times because I am so busy." 13. Clinical record review was initiated on 9/3/10 for Resident 8 which showed a care plan problem dated 10/4/06, for ADL deficits and for skin breakdown with an approach to turn and repositioned Resident 8 every two hours and provide incontinent care. The MDSs dated 12/2/09 and 9/1/10, showed Resident 8 required extensive assistance with her ADLs and was in incontinent if bowel and bladder. On 9/7/10 at 1448 hours, during an interview with Resident 8, she was able to communicate using hand gestures and by typing on her laptop computer. Resident 8 stated, "I just wanted to say it seems like there is adequate staffing at the beginning of the shift then bare bones each shift." When asked how that affected her, she stated, she lays in soaked (soiled) sheets. She stated she used to get mad, but knows the CNAs work very hard. Resident 8 shared that she is often not transferred into her wheelchair timely and therefore misses seeing her father. She stated her dad will leave if she's late in meeting him and she feels terrible because he's getting old. 14. On 9/8/10 at 0645 hours, during an interview with CNA 7, he stated all of his residents need turning and he turns them all by himself except for the very heaviest ones. He stated all of his residents are turned twice on his shift except for three of them, which were turned three times on his shift. There was no enough staff to assist turning the residents who required two people to turn them. 15. On 9/8/10 at 0630 hours, during an observation and concurrent interview with CNA 7 while in Resident A's room was conducted. The CNA was observed to turn Resident A who was noticed to have deep wrinkles on his left lateral thigh as well as a deep wrinkle along his right lateral malleolus (ankle bone) which was approximately one inch wide and six inches long. CNA 7 stated this was only the second time during this shift that Resident A had been turned. 16. On 9/8/10 at 0645 hours, CNA 7 was observed to turn Resident B. Resident B was observed to have deep wrinkles covering his upper back, his buttocks, and his upper posterior thighs. CNA 7 stated that this was only the second time Resident B has been turned during his shift. 17. On 9/8/10 at 0705 hours, CNA 7 was observed to turn Resident 7. Resident 7 was observed to have deep wrinkles over his entire back, from his shoulders to the lower calves. CNA 7 stated this was the second in turning of Resident 7 for the night. 18. During an interview with CNA 10 on 9/3/10 at 1540 hours, she stated that initially she starts out with nine residents to provide care for but after 7 pm or 8 pm, one CNA is sent home. Then the remaining two CNAs are assigned additional residents. She stated she then has 14 residents to care for. When asked if she is able to provide care for all 14 residents who are dependent on staff for all care needs including turning and repositioning and incontinence care. She stated she tries and I often does not take her breaks so she can attend to her residents. 19. on 9/3/10 at 1555 hours, during an interview with Resident 5's family member, she stated she has to wait for an hour after asking for a CNA to provide care. She stated Resident 5's roommate (Resident 11) has to wait for five hours before care can be provided because he does not have a family member at the bedside. Resident 5 said she cannot tolerate the strong smell of urine and feces so she calls the CNA to provide care for Resident 11. 20. On 9/7/10 at 1430 hours, an interview with Resident 9's family member was conducted. The family member stated the CNAs provide care once every shift but after that she has to go to the nurse station to inform them that Resident 9 needs to be changed. 21. On 9/8/10 at 0920 hours, during an interview with CNA 9, CNA 9 stated she currently has seven residents to provide care to; however, she is also assigned to provide RNA services to all seven residents as well. She stated CNAs are also expected to wheel the residents to the activity room which is located on the first floor and it takes time to do this. The CNA added that she felt there was not enough time during her shift to finish all her assigned duties. On 9/8/10 at 1150 hours, a follow-up interview was conducted with CNA 9. The CNA stated she had not provided any care to three of her residents and she was supposed to go home at 1200 hours, stating "I have not touched those three residents at all." 22. On 9/9/10 at 0832 hours, an interview was conducted with CNA 2. The CNA stated he has nine residents assigned to him and he cannot turn and attend to their incontinent care every two hours. He stated if the resident has family member at the bedside, they usually call him to provide care but for those who do not have a family member visiting he checks on them and will provide care when he can. 23. On 9/9/10 at 0950 hours, an interview with CNA 4 was conducted. The CNA stated she was instructed to check on Resident 3 every 10 minutes but it is impossible because she has nine residents to care for. 24. Clinical record review showed Resident 7's bowel and bladder training program was ordered. On 9/9/10 at 1032 hours, CNA 3 was asked if Resident 7 had been offered a urinal. She replied, "no," because there no time to do so. 25. During an interview with Resident 5's family member on 9/3/10 at 1555 hours, she stated she has to wait for an hour for the CNA to come and provide care. Clinical record review was initiated for Resident 5 on 9/7/10, showed Resident 5 is dependent on staff for toileting, hygiene, dressing and bathing. Resident 5 is incontinent of bowel and bladder. On 9/8/10 at 0620 hours, Resident 5 was observed in bed, face turned towards the window but positioned on his back. Resident 5 was asleep. On 9/8/10 at 0635 hours, CNA 1 he stated he changed Resident 5 at 0530 hours. On 9/8/10 at 0715 hours and 0830 hours, Resident 5 was observed in the same position at 0620 hours. On 9/8/10 at 0910 hours, CNA 9 was observed going in Resident 5's room. When the CNA 9 took off the covers, a towel soaked with urine was observed on top of Resident 5's penis. The linens and the pad underneath Resident 5 were soaked with urine. 26. On 9/3/10 at 1200 hours, during an interview with Resident 3's family member, he stated he hired a 24-hour private caregiver for Resident 3 because Resident was attempting to pull her [MEDICAL CONDITION] at a previous facility. He stated the care at night is so "loose" that the CNA "peeps in" the door to check if the private caregiver is at the bedside and then leaves without providing any care. He stated his private caregivers ends up providing the care themselves because the CNAs have too many residents to provide care to. When asked if he would provide a private caregiver if Resident 3 did not attempt to pull out her [MEDICAL CONDITION], he replied, "Yes." He added that he would worried Resident 3 would not be provided with adequate care otherwise. Clinical record review was initiated for Resident 3 on 9/7/10. The MDS dated [DATE] showed Resident 3 is dependent on staff for toileting. A care plan problem dated 1/4/10, to address bowel and bladder incontinence, showed an approach to provide pericare after each incontinent episode and to check for incontinence every two hours or as needed. On 9/8/10 at 0535 hours, an interview was conducted with Resident 3's private caregiver. He stated the CNAs at night "slacks off" until he voiced concerns two weeks ago. He stated that the CNA had agreed on a schedule to change Resident 3 at 2400 hours, 0300 hours and 0500 hours. On 9/8/10 at 0610 hours, Resident 3 was observed in bed, asleep. There was no private caregiver at the bedside. On 9/8/10 at 0725 hours, a private caregiver was observed at the bedside. She was asked if Resident 3 had been changed. She replied, "No." On 9/8/10 at 0830 hours, a private caregiver was observed at the bedside. She was asked if any CNA had provided care for Resident 3. She stated CNA 8 came in to check Resident 3's vital signs but did not any provide care. On 9/8/10 at 0900 hours, CNA 8 was observed providing bed bath to Resident 3 with the private caregiver assisting him. On 9/9/10 at 0820 hours, Resident 3's private caregiver was observed providing Resident 3 a bed bath. The caregiver was asked why was she providing the bed bath and not facility staff. She stated she had informed the CNA that Resident 3 was wet and restless but the CNA was busy. The caregiver said she couldn't wait any longer and decided to give the care.

Based on observation, interview, clinical record review and facility record review, the facility failed to ensure services and care were provided to prevent the formation of pressure ulcers and/or promote wound healing of existing pressure ulcers for four of 14 sampled residents (Residents 4, 9, 11 and 12) Resident 12 was not kept clean and dry or repositioned every two hours, resulting in an open break in the skin which was not promptly identified and treated. Resident 9 developed a Stage II pressure ulcer while in the facility and was not identified until it was a Stage II. Residents 11 and 12, were not repositioned every two hours as care planned, which had potential to result in pressure ulcer formation and/or further skin breakdown. Resident 4 has a Stage I pressure ulcer but was not repositioned to promote healing. Findings: Review of the facility's P&P entitled Prevention of Pressure Ulcers, Revised July, 2005 showed that a complete body inspection should be done during the resident's weekly progress note is written by the licensed nurse. For a resident in bed, change position at least every two hours; use pillows or wedges to keep bony prominences such as knees or ankles from touching each other and when in bed, every attempt should be made to keep heels off the bed. For a resident in a chair, change position at least every two hours and use foam, gel or air cushion as indicated to relieve pressure. 1. On 9/8/10 beginning at 0540 hours, an interview was conducted with CNA 1. CNA 1 stated because of the number of residents the CNA was assigned to care for during the shift, he only had time to change residents' incontinence brief and reposition them twice on the eight hour night shift. CNA 1 stated he was assigned to 13-15 totally dependent residents. The CNA explained the usual course of his shift: First the CNA took vital signs for his assigned residents, then started a "first run" of changing and repositioning residents. After the first run, the CNA started over with a "second run" of changing and repositioning his assigned residents and by then the shift is over. The CNA stated they also have to chart on each assigned resident during their shift. CNA 1 further stated he had already provided care for some of the residents for the "second run" of the shift. From 0540 hours to 0700 hours, CNA 1 was observed as he providing care for the remainder of the residents on his "second run." On 9/8/10 at 0620 hours, CNA 1 was observed to enter Resident 12's room, to change the resident's incontinence pad and reposition the resident. Resident 12 was observed lying in bed on his back, and was lying on a disposable incontinence pad. On the disposable pad, it was noted the resident had been incontinent of bowel. A brown colored ring was observed encircling the resident's hip area like a halo. CNA 1 stated Resident 12 was having loose stools. When CNA 1 turned Resident 12 onto his side, the resident's buttocks, back of the thighs and up his lower-back area was observed to be covered in liquid feces. The liquid feces had spread from his mid lower back down to just above the back of the resident's knees. As CNA 1 wiped Resident 12's buttocks specks of fresh blood were observed on the cloth the CNA was using. Closer observation revealed the resident had an open area with defined borders on the resident's coccyx area. The open area was vertical (head to toe) and measured approximately 3cm long (1 inch) x 1cm wide. The Resident's perianal area and buttocks were red and excoriated. CNA 1 stated the open area was new and they were going to inform the licensed nurse to look at it. On 9/8/10 at 0640 hours, a licensed nurse entered the room, looked very briefly at the resident's buttocks and wiped Baza cream (an antifungal cream) on the resident's buttocks. The licensed nurse did not fully assess the resident's buttocks area, and did not appear to see the skin was broken and open. (The open area was located in between the buttocks, approximately 2-3 inches above the anus, in the tailbone (coccyx) area). Clinical record review was initiated for Resident 12 on 9/8/10. Resident 12 was admitted to the facility on [DATE]. Resident 12 had a history of [REDACTED]. Resident 12 was currently being treated for [REDACTED].) Review of Resident 12's comprehensive plan of care found a care plan problem dated 7/30/10, for at risk for skin breakdown, further skin breakdown and recurrent skin breakdown, secondary to impaired mobility, incontinence, decreased activity, acute illness/infection, and history of pressure ulcers. Approaches included to reposition the resident every two hours and "incontinence care." On 9/8/10 at 0715 hours, Resident 12 was observed to be positioned on his right side. At 0945 hours, 1015 hours, and 1145 hours, Resident 12 was observed lying in the same position on his right side. On 9/8/10 at 1430 hours, additional record review found no documented evidence of a treatment order to treat the resident's open skin area observed on 9/8/10 at 0630 hours. However, a physician's orders [REDACTED]. An interview was conducted with the treatment nurse, (LVN 1), on 9/8/10 at 1435 hours. LVN 1 stated Resident 12 had a history of [REDACTED]. LVN 1 stated currently Resident 12 was being treated for [REDACTED]. On 9/8/10 at 1437 hours, a concern regarding Resident 12 having an opened area in his skin which was not identified by the licensed nurse, (after the CNA asked the licensed nurse to look at the area), and which remained without treatment orders was shared with the Subacute Director. Record review on 9/9/10, showed a physician's orders [REDACTED]. The wound was to be treated with hydrogel and [MEDICATION NAME] powder every day. Record review on 9/9/10, of a weekly wound assessment form, showed documentation dated 9/8/10, identifying Resident 12 to have a Stage II pressure ulcer measuring 3.5 by 3.0 cm with partial thickness tissue involvement, and scant serosanguineous exudate. Further documentation showed, "Resident with denuded perianal area secondary to loose stools and open area to coccyx right above denuded perianal area." The National Pressure Ulcer Advisory Panel defines a Stage II pressure ulcer as: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Review of a copy of the Wound Care Consult report dated 9/9/10, provided by the facility on 9/17/10, showed Resident 12's wound care physician documented the wound description was a coccyx Stage II measuring 3.5 x 3 x 0.1 cm with 20% [MEDICATION NAME] exudate and 80% granulation tissue. The physician documented, "the wound, although over coccygeal area is not due to pressure - due to excoriations from copious amounts of watery diarrhea." Treatment with hydrogel and [MEDICATION NAME] powder every day was to be continued. Review of the September 2010, Nursing Assistant Daily Flow Sheet for the day, evening, and night shifts for Resident 12, showed the resident was having zero to three diarrhea stools per shift. Resident 12 was transferred to the acute care hospital on [DATE]. Review of documents from the acute care hospital showed Resident 12 arrived in the ER on 9/11/10 at 1503 hours. ER documentation showed Resident 12 had a Stage II sacrococcyx pressure sore on admission to the ER. Review of a color photograph of Resident 12's coccyx, showed the wound was nearly twice the size as observed on 9/8/10. Review of the acute care hospital H&P dated 9/11/10, showed the physician's documented physical assessment of the residents back area was, "Stage 2 or 3 wounds of the coccygeal area." 2. Observations of Resident 11 on 9/8/10 at 0730 hours, 0815 hours, 1000 hours, 1015 hours, found Resident 11 positioned lying on his back in bed. During an interview on 9/8/10 at 1150 hours, CNA 9 stated she had not provided any care for Resident 11 yet. The CNA started the shift at 0700 hours. During an earlier interview on 9/8/10 at 0930 hours, CNA 9 stated she currently had 7 residents assigned to her, additionally the CNA needed to provide RNA services for residents and was scheduled to go home at 1200 hours. Clinical record review was initiated for Resident 11 on 9/8/10. Resident 11 was readmitted to the facility on [DATE], with two Stage II pressure ulcers, one on each buttock. Review of Resident 11's comprehensive plan of care found a care plan problem dated 9/6/10, for an existing pressure ulcer. Approaches included to reposition the resident every two hours. Resident 11 had two Stage II pressure ulcers on his buttocks. According to his plan of care he was to be turned or repositioned every two hours. However, based on observation staff were not turning the resident which placed him at risk for additional skin breakdown or poor healing of his existing pressure ulcers. 3. On 9/7/10 at 1430 hours, during an interview with Resident 9's family, the family stated the CNA comes once every shift to provide care to Resident 9. The family stated she is at the resident's bedside almost the whole day and informs the nurses when Resident 9 is soiled (incontinent) and needs to be changed. On 9/8/10 at 0530 hours, Resident 9 was observed in bed, lying on his back with his face turned towards the window. His eyes were closed. On 9/8/10 at 0620 hours, Resident 9 was observed to be in the same position. On 9/8/10 at 0630 hours, CNA 1 stated he had changed Resident 9 at 0530 hours. On 9/8/10 at 0720 hours and at 0800 hours, Resident 9 was observed to remained in the same position as he was at 0530 hours. On 9/8/10 at 0825 hours, CNA 8 was observed to enter Resident 9's room to provide a bed bath. When CNA 8 took off the resident's covers, Resident 9 was observed to have a pillow underneath his legs; however, his right heel was resting directly on the mattress. The resident's left foot was externally rotated to the left and his his ankle and malleolus (bony prominence) was resting directly on the mattress. LVN 1 removed a dressing and a Stage II pressure ulcer(partial thickness loss of dermis, inner layer of the skin) was a shallow open ulcer was observed on the left lateral malleolus. Clinical record review for Resident 9 was initiated on 9/8/10. The MDS dated [DATE] showed Resident 9 is totally dependent on staff for bed mobility. The Braden Scale - For Predicting Pressure Sore Risk assessment dated [DATE], showed Resident 9 is at High Risk for developing pressure ulcer. A care plan problem dated 12/31/09, was developed to address the risk for skin breakdown. Some of the interventions included to provide a low air loss mattress and a cushion in the wheelchair. However, there was no intervention to address pressure prevention to the heels or his foot pressure ulcer. Review of the Nurses Weekly Progress Note dated 8/14/10, showed documentation Resident 9 was on low air loss mattress and the resident's skin was kept well lubricated. However, there was no documentation of an assessment of the resident's skin. In addition, there was no documented evidence in the nurses' notes from 8/13/10 at 0800 hours to 8/19/10 at 0800 hours, of an assessment on the resident's skin. The nurse's note dated 8/19/10 at 1430 hours, showed documentation of a pressure ulcer on the resident's left lateral malleolus. The Weekly Wound assessment dated [DATE], showed a Stage II pressure ulcer on the resident's left lateral malleolus measuring 1 cm x 1 cm with no drainage. On 9/19/10 at 0920 hours, an interview was conducted with CNA 8. CNA 8 was asked how he relieved pressure on Resident 9's feet. CNA 8 stated he elevates the resident's feet using a pillow. He stated when Resident 9 is in gerichair, he also used a pillow. The CNA added that Resident 9 is gotten up in a gerichair in the morning and returned to bed around 1230 hours daily. 4. Clinical record review was initiated for Resident 4 on 9/7/10. The MDS dated [DATE] showed Resident 4 requires extensive assistance with bed mobility. The Weekly Wound Assessment form dated 8/4/10 showed Resident 4 was admitted with a Stage I pressure ulcer on the sacrococcyx area, measuring 5 cm x 5 cm. A care plan problem dated 8/4/10, to address at risk for further skin breakdown showed an approach to reposition the resident every two hours. On 9/8/10 at 0630 hours, Resident 4 was observed in bed, asleep and positioned on her back. CNA 1 who was present stated Resident 4 had refused to be changed. On 9/8/10 at 0730 hours, at this time RT was observed to suction Resident 4. At this time CNA 2 was observed to take Resident 4's vital signs. Resident 4 continue to be lying on her back. There was no attempt by either CNA 2 or RT to reposition Resident 4. In addition, there was no evidence the resident refuse to be turned. On 9/8/10 at 0820 hours, 0900 hours and again at 0930 hours, Resident 4 was observed in lying in the same position. The resident was observed to be positioned on her back for three hours. On 9/8/10 at 0950 hours, a CNA was observed to provided care to Resident 4 and transferred her to the wheelchair.

Based on observation, interview, and clinical record review, the facility failed to ensure seven of 14 sampled residents (Residents 1, 3, 5, 6, 8, 11, and 14) were provided with appropriate care and services to prevent urinary tract infection and failed to provide necessary services to one of 14 sampled resident (Resident 7) to restore or improve normal bladder as the bowel and bladder program was not implemented as ordered. In addition, the facility failed to promptly change/clean Resident 1 who was incontinent of bowel and/or bladder. Findings: 1. Clinical record review for Resident 6 was initiated on 9/3/10. Review of a physician's orders [REDACTED]. Review of the Assessment form for Incontinence Program dated 6/9/10, showed a history of recurrent UTIs and ESBL (germs normally found in the bowel, easily transmitted to the urinary tract, and are a common cause of urinary tract infections). Review of Resident 6's care plan problem for ADL deficits dated 6/9/10, showed Resident 6 was to be turned and repositioned every two hours. A care plan problem for risk for skin breakdown dated 6/9/10, showed Resident 6 was to be turned every two hours, repositioned, and have incontinent care. Review of Resident 6's lab tests showed: Urinalysis completed 6/3/10 - ESBL positive and >100,000 colonies/ml of E. coli Urinalysis completed 7/6/10 - ESBL positive and >10,000 colonies/ml of E. coli Urinalysis completed 7/27/10 - ESBL positive and >100,000 colonies/ml of E. coli Review of an Infectious Diseases Consultation (from the acute hospital) dated 6/6/10, showed Resident 6 was admitted to the acute hospital on [DATE], with [MEDICAL CONDITION] (low blood pressure) and a urinary tract infection. Resident 6 had an altered level of consciousness likely secondary to urosepsis (a syndrome characterized by fever, chills, [MEDICAL CONDITION], and occasionally an altered mental status, resulting from invasion from the urinary tract to the bloodstream by microorganisms or their products). On 9/3/10 at 1105 hours, during an interview with a family member of Resident 6, she voiced concerns about Resident 6 not being changed often enough. The family member stated, "No way in hell am I going to take a day off from coming to see Resident 6. I'd be afraid he's be laying in poop all shift. I am concerned that's happening to other patients that don't have family members." Review of a physician's orders [REDACTED]. On 9/23/10 at 0830 hours, an interview with LVN 3 was conducted. The LVN stated Resident 6's fecal bag is usually changed twice a shift, and it usually due to becoming dislodged. The LVN stated Resident 6 often has stool in his perineal area due to being incontinent. During an interview with LVN 4 on 9/23/10 at 0840 hours, she stated Resident 6's fecal bag is changed up to three or four times a shift due to being full or leaking, She stated Resident 6 often has stool in his perineal area due to the bag leaking or from the bag not sealing well, The LVN also stated Resident 6 ' s stool is loose, not formed. On 9/12/10, Resident 6 was transferred to the acute care hospital. Review of the emergency department record dated 9/12/10, showed Resident 6 was admitted at 0837 hours. At 0900 hours, Resident 6 was assessed to have a distended bladder. His indwelling urinary drainage catheter was irrigated and found to have a pus clot. Resident 6's [DIAGNOSES REDACTED]. 2. Clinical record review for Resident 1 was initiated on 9/3/10. Review of Resident 1's MDSs dated 5/10/10 and 8/11/10, showed Resident 1 was incontinent of both urine and stool. Review of the Assessment for Incontinence Program for Resident 1 dated 5/14/10, showed he was incontinent of urine. It showed Resident 1 had a history of [REDACTED]. Review of the Bowel Assessment record for Resident 1 dated 5/1/10, showed he had a history of [REDACTED]. Review of Resident 1's Resident care plan for skin breakdown dated 5/1/10, showed the plan to prevent skin breakdown was to reposition Resident 1 every 2 hours and to do incontinent care. During an interview with the Subacute Director on 9/9/10 at 1215 hours, she stated incontinent care is defined as someone who is unable to do anything for themselves and are totally dependant on the staff for their care. She stated the staff needs to provide care for the residents when they are incontinent. The Subacute Director stated incontinent care means to turn and change the resident (if they are incontinent) every two hours and as often as needed. Review of Resident 1's comprehensive care plan for ADL (activities of daily living) deficits plan dated 5/1/10, showed he was to be turned and repositioned every 2 hours. Review of the physician's orders [REDACTED]. Review of Resident 1's urine culture dated 7/12/10, showed greater than 100,000 colonies of Proteus mirabilis. In addition, a urine culture dated 8/29/10, showed greater than 100,000 colonies of Proteus mirabilis. On 9/1/10 at 1207 hours, during an interview with Resident 1's family member, she stated when she comes to visit Resident 1 in the morning, he is often wet and dirty and his incontinence brief had not been changed. She stated she attended a care conference approximately a week and a half ago and had no other complaints except for finding him dirty and needing his diaper changed. She stated Resident 1's physician had told them Resident would not die from his progressive disease, but would die from either pneumonia or a urinary tract infection. She stated when she has come in the morning, she has found Resident 1 "full of poop in his diaper which came up between his legs." The family member stated Resident 1 got a urinary tract infection from not being changed timely. During an interview with CNA 3 conducted on 9/3/10 at 1220 hours, she stated she her shift is 7.5 hours and she does not have time to give report to the oncoming staff. She stated her residents are dependent and are supposed to be turned and/or repositioned every two hours but she's only able to turn them every 3 to 4 hours. CNA 3 stated sometimes she goes home knowing she was not able to do everything that she is supposed. CNA 3 added "I like my job, but I go home knowing I can not always give good care. I don't have time to do everything. Some residents have laid in poop and pee longer than I would like." During an interview with CNA 6 on 9/3/10 at 1615 hours, he stated all of his residents are incontinent (except one) and all need to be turned. CNA 6 further stated with having only 2 CNAs on the floor, it was not realistic to turn the residents every 2 hours. He stated they were turned every 3 hours. CNA 6 further stated, "Truthfully, the patients with families do tend to get better care. I have failed to take dinner and breaks at times because I am so busy." On 9/8/10 at 0600 hours, observation and concurrent interview was conducted with CNA 7 while in Resident 1's room. The CNA was preparing to provided incontinent care to Resident 1. Resident 1 had been incontinent of bowel and was observed to have dried and fresh feces around his buttocks. Resident 1 was noted to have a deep indentations into his buttocks measuring approximately 1/2 inch wide. The CNA stated the indentations were from incontinence brief gatherings around the leg openings. 3. During an interview with Resident 8 on 9/7/10 at 1448 hours. She was able to communicate via hand gestures and by typing on her laptop computer. She stated, "I just wanted to say it seems like there is adequate staffing at the beginning of the shift then bare bones" later in the shifts. When asked how that affected her, she stated, she lays in soaked (soiled) sheets. She stated she used to get mad, but is no longer gets mad because she knows most of the CNAs work really hard. 4. On 9/8/10 beginning at 0540 hours, an interview was conducted with CNA 1. CNA 1 stated because of the number of residents the CNA was assigned to care for during the shift, he only had time to change residents' incontinence brief and reposition them twice during the eight hour shift. CNA 1 stated he is usually assigned 13 to 15 totally dependent residents; he was currently assigned 15 residents. The CNA explained the usual course of his shift: First the CNA took vital signs for his assigned residents, then started a "first run" of changing and repositioning residents. After the first run, the CNA started over with a "second run" of changing and repositioning his assigned residents and by then the shift is over. The CNA stated they also have to chart on each assigned resident during their shift. CNA 1 further stated he had already provided care for some of the residents for the "second run" of the shift. From 0540 hours to 0700 hours, CNA 1 was observed as he providing care for the remainder of the residents on his "second run." On 9/8/10 at 0620 hours, CNA 1 was observed to enter Resident 12's room, to change the resident's incontinence pad and reposition the resident. Resident 12 was observed lying in bed on his back, and was lying on a disposable incontinence pad. On the disposable pad, it was noted the resident had been incontinent of bowel. A brown colored ring was observed encircling the resident's hip area like a halo. CNA 1 stated the resident was having loose stools. When CNA 1 turned Resident 12 onto his side, the resident's buttocks, back of the thighs and up his lower- back area was observed to be covered in liquid feces. The liquid feces had spread down to several inches above the resident's knees and up to the resident's lower back area. Clinical record review was initiated for Resident 12 on 9/8/10. Resident 12 was admitted to the facility on [DATE]. Review of the Resident's MDS dated [DATE], showed Resident 12 was totally dependent on staff for all ADL and had an indwelling urinary catheter. Review of the Vital Signs Record form showed th resident on 8/18/10 at 0715 hours had a fever of 101.5 and at 0800 hours was 101.0. On 8/19/10 at 0550 hours, Resident 12 had a fever of 101.1. A lab results form dated 8/18/10, showed a urinalysis was done. The urinalyses results showed the appearance of the urine tested was cloudy; many bacteria were seen; white blood cells, leukocyte esterase, red blood cells and occult blood were also found in the urine. Review of the urine culture results dated 8/18/10, showed >100,000 colonies/ml of Alpha Streptococcus (bacteria) in the resident urine was found. Review of the September 2010 Nursing Assistant Daily Flow Sheet for the day, evening, and night shift for Resident 12, showed the resident was having zero to three diarrhea stools per shift. On 9/22/10 at 0545 hours, an observation of Resident 12 was made. The resident was lying in bed. The smell of feces was noted while standing next to Resident 12's bed. On 9/22/10 at 0640 hours, CNA 1 entered the room of Resident 12 to change the resident with assistance from LVN 6. Brown stains were observed seeping through Resident 12's hospital gown, near the crotch area and the same smell of feces was noted. CNA 1 pulled a pillow from under the resident's hip which had brown color liquid on it. Between the resident's legs was liquid feces. The resident's indwelling urinary catheter was lying in the liquid feces. When CNA 1 turned Resident 12 onto his side a balled up towel covered with liquid feces was pulled from near the resident's buttocks area. CNA 1 wiped the feces from the catheter with pre-moistened wipes. LVN 6 was observed to obtain a 6 oz bottle of normal saline (salt water), retract the resident's genitalia and and pour a third of the bottle over the catheter where it entered the urethral meatus. LVN 6 did not utilize any soap to provide catheter care. Review of the facilities P&P titled, Urinary Catheter Care, showed for the male resident with a catheter: "Use washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Further clinical record review was initiated on 9/22/10. Review of physician's orders [REDACTED]. Review of the Vital Signs Record form showed documentation dated 9/8/10 at 0800 and 9/9/10 at 0800 hours, Resident 12 had a fever of 100.7 and heart rate of 100 bpm. Further review of the vital signs record showed Resident 12's usual heart rate was in the 70s and 80s and usual temperature was usually 98 degrees. A lab results form dated 9/8/10, showed a urinalysis was done. The urinalyses results showed the appearance of the urine tested was orange and turbid; greater than 31 white blood cells were seen (more than minimal white blood cells indicates pyuria (pus)) and leukocyte esterase were +3 (indicates significant pyuria). Many bacteria and more than normal amounts of red blood cells were found in the urine. The urine culture completed 9/11/10, showed the resident had [MEDICATION NAME] Resistant [MEDICATION NAME] >100,000 colonies in the urine. ([MEDICATION NAME] is a bacteria normally found in the feces of humans and animals) Resident 12 was admitted to the hospital on [DATE]. Review of the acute care hospital H&P dated 9/11/10, showed Resident 12 to be septic and in acute [MEDICAL CONDITION]. The H&P further showed Resident 12 had [DIAGNOSES REDACTED]icile (Resident 12 tested positive for [DIAGNOSES REDACTED]icile and started on the antibiotic, [MEDICATION NAME] on 9/9/10 while still in the facility) and an acute UTI with [MEDICATION NAME] Resistant [MEDICATION NAME], and had no clinical signs of pneumonia. Resident 12 returned to the facility from the acute care hospital on [DATE]. 5. On 9/3/10 at 1115 hours, an interview was conducted with a family member of Resident 5. The family member stated Resident 5's neighbor (Resident 11) was not changed for five hours sometimes. The family member stated they would end up having to call the staff to change Resident 11, because they could not stand the smell of strong urine and feces. Clinical record review was initiated for Resident 11 on 9/8/10. Resident 11 had [DIAGNOSES REDACTED]. Resident 11 had no family identified. Review of Resident 11's MDS dated [DATE], showed Resident 11 was totally dependent on staff for all ADLs. During an interview on 9/8/10 at 1150 hours, CNA 9 stated she had not provided any care for Resident 11 yet. The CNA started the shift at 0700 hours. During an earlier interview on 9/8/10 at 0930 hours, CNA 9 stated she currently had 7 residents assigned to her, additionally the CNA needed to provide RNA services for residents and was scheduled to go home at 1200 hours. 6. On 9/3/10 at 1200 hours, during an interview with Resident 3's family member, he stated he has 24-hour private caregiver for Resident 3 because Resident was attempting to pull her [MEDICAL CONDITION] at a previous facility. He stated the facility instructed him that his private caregivers can not provide nursing care such as changing him or providing any ADL care and they should just call for help from facility staff. He stated the care at night is so "loose" that the CNA "peeps in" the door to check if the private caregiver is at the bedside and then leaves without providing any care. He stated his private caregivers ends up providing the care themselves because the CNAs have too many residents to provide care to. When asked if he would provide a private caregiver if Resident 3 did not attempt to pull out her [MEDICAL CONDITION], he replied, "Yes." He added that he would worried Resident 3 would not be provided with adequate care otherwise. Clinical record review was initiated for Resident 3 on 9/7/10. The MDS dated [DATE] showed Resident 3 is dependent on staff for toileting. A care plan problem dated 1/4/10, to address bowel and bladder incontinence, showed an approach to provide pericare after each incontinent episode and to check for incontinence every two hours or as needed. A urinalysis report dated 5/17/10, showed Resident 3's urine was cloudy and had many bacteria, white blood cells and [MEDICATION NAME] cells. The culture and sensitivity test of the urine dated 5/17/10, showed the resident was positive for Citrobacter Koseri, a bacteria found in the gut. A physician's orders [REDACTED]. A urinalysis report dated 6/5/10 showed the urine was cloudy, had many bacteria, white blood cells and [MEDICATION NAME] cells. The culture and sensitivity test of the urine dated 6/5/10 showed positive for ESBL, a multi-drug resistant bacteria and [DIAGNOSES REDACTED] pneumoniae, a bacteria found in the skin or gut. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A urinalysis dated 7/7/10, showed urine was cloudy, had many bacteria, white blood cells and [MEDICATION NAME] cells. The culture and sensitivity test of the urine dated 7/8/10 showed positive result for E. coli, a bacteria found in the gut and [DIAGNOSES REDACTED] pneumoniae. A physician's orders [REDACTED]. A urinalysis dated 7/14/10, showed urine was cloudy and had many bacteria, white blood cells and [MEDICATION NAME] cells. The culture and sensitivity test of the urine dated 7/14/10, showed positive for ESBL and E. Coli. A physician's orders [REDACTED]. An interview was conducted with Resident 3's private caregiver was conducted on 9/8/10 at 0535 hours. He stated the CNAs at night "slacks off" until he voiced his concerns two weeks ago. He stated that the CNA had agreed on a schedule to change Resident 3 at 2400 hours, 0300 hours and 0500 hours. He stated the CNA had just changed Resident 3 few minutes ago. On 9/8/10 at 0610 hours, Resident 3 was observed in bed, asleep. There was no private caregiver at the bedside. On 9/8/10 at 0725 hours, a private caregiver was observed at the bedside. She was asked if Resident 3 had been changed. She replied, "No." On 9/8/10 at 0830 hours, a private caregiver was observed at the bedside. She was asked if any CNA had provided care for Resident 3. She stated CNA 8 came in to check Resident 3's vital signs but did not any provide care. On 9/8/10 at 0900 hours, CNA 8 was observed providing bed bath to Resident 3 with the private caregiver assisting him. On 9/9/10 at 0820 hours, Resident 3's private caregiver was observed providing Resident 3 a bed bath. The caregiver was asked why was she providing the bed bath and not facility staff. She stated she had informed the CNA that Resident 3 was wet and restless but the CNA was busy. The caregiver said she couldn't wait any longer and decided to give the care. On 9/9/10 at 1320 hours, Resident 3's family member was observed at the bedside. Resident 3's family member was asked if he was aware that Resident 3 had multiple UTIs, he replied, yes, probably because Resident 3 was not changed timely and was not cleaned well so the UTIs were recurring. According to the facility's Private Duty Handbook (undated), it is the facility's policy that private duty personnel (caregivers) only provide companionship for their resident. Nursing care needs, including but not limited to bathing, transferring, ambulating, medication administration, changing, feeding, toileting, etc. must be completed by facility employees (such as RNs, LVNs or CNAs). The private duty personnel must not attempt any nursing care needs on their own, but should utilize the call light system or call for help. Once help has arrived, the private duty personnel may assist the facility staff member to provide the needed care. 7. Clinical record review was initiated for Resident 14 on 9/22/10. The MDS dated [DATE], showed Resident 14 has memory problems and severe cognitive impairment. A physician's orders [REDACTED]. Indwelling catheter care was to be done every shift with soap and water and to irrigate catheter with 100 ml of normal saline every shift. The care plan problem dated 8/21/10, to address antibiotic resistant microorganism infection ( ESBL urine) showed an approach to provide contact isolation and monitor for signs and symptoms of infection. However, there was no care plan problem to address prevention of urinary tract infection. A urinalysis dated 7/7/10, showed the urine was cloudy and had white blood cells, red blood cells and [MEDICATION NAME] cells. The culture and sensitivity test of the urine dated 7/7/10, showed the resident was positive for [MEDICATION NAME] Faecalis, a bacteria found in the gut. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. On 7/14/10, the physician ordered [MEDICATION NAME], an antibiotic 500 mg every six hours for seven days for urinary tract infection. A culture and sensitivity test of the urine dated 8/19/10, showed the resident was positive result of E. Coli and ESBL. A physician's orders [REDACTED]. On 9/22/10 at 1355 hours, an interview with LVN 1 was conducted. The LVN stated licensed nurses provide catheter care. . Review of the treatment record for the month of July, 2010, showed no evidence the catheter was irrigated and catheter care was provided on 7/22/10 during the 7pm - 7am shift; on 7/26/10 7pm - 7am shift and 7/30/10 7pm - 7am. In addition, review of the treatment record form for the month of August, 2010, showed no evidence the Resident 14's catheter was irrigated and catheter care was provided on 8/28/10 7pm - 7am. Review of the Emergency Department Record from the acute care hospital dated 9/14/10, showed Resident 41 was admitted to the hospital with [REDACTED]. 8. On 9/8/10 at 0555 hours, Resident 7 was observed in bed, awake and with mittens on both hand. Clinical record was initiated for Resident 7 on 9/8/10. The MDS assessment dated [DATE], showed Resident 7 is dependent on staff for his toileting and he is incontinent of bowel and bladder. The Assessment for Incontinence Program form dated 8/25/10, showed Resident 7 is not a candidate for toileting program. On 9/8/10 at 1140 hours, Resident 7's family member was observed at the bedside. She was asked if Resident 7 was able to use a urinal. The family member stated if Resident 7 is assisted, he can use a urinal. On 9/8/10 at 1415 hours, Resident 7 was observed on a gerichair which had been placed close to the nurse's station. Resident 7 was observed pointing to his stomach. When asked if he needed help, he replied, yes to the bathroom. RN 3 was observed assist Resident 7. On 9/9/10 at 1015 hours, an interview was conducted with RN 3. The RN was asked if there was any toileting schedule for Resident 7. She stated they initiated a bowel and bladder training program. The RN retrieved the resident's clinical record and showed a physician's orders [REDACTED]. The RN showed a Bowel and Bladder Retraining Program sheet dated 8/30/10 to 9/5/10. The RN was asked how often they offer the resident a urinal or toileting, she stated every two hours. However, review of the documentation found it was not consistently done every two hours on 8/30, 8/31/10, 9/1 and 9/3/10. In addition, there was no documentation of any toileting on 9/2, 9/4 and on 9/5/10. Also, there was no documented evidence that staff implemented the "toileting program" for the 14 days. The RN was asked what was the result of the retraining program. She called RN 1 to join the interview. RN 1 stated after the retraining program, an evaluation is documented on the back of the Bowel and Bladder Retraining Program form. When RN 1 reviewed the form and stated apparently it was not done. An interview was conducted with CNA 3 on 9/9/10 at 1032 hours. When CNA 3 was asked if Resident 7 had been offered a urinal, she replied, "No." She was asked why not. CNA 3 stated there no time to do it.