Every finding on record at Hampton Post Acute

Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing information accurately and completely reflected the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift when the facility's daily nurse staffing posting reflected projected hours inaccurately as the actual hours worked per shift by nursing staff responsible for resident care.This deficient practice had the potential to prevent residents, staff, visitors and the public from having access to complete, accurate, and current nurse staffing information for a facility census of 115 residents.Findings:During an observation of the nursing staffing information posted outside the administrator's office on 8/26/26 at 8:00 AM, the posting was dated 8/26/26 and had a statement indicating ACTUAL NURSING PPD FOR THE DAY = 3.94During a concurrent interview and record review on 8/26/26 at 8:05 AM with the Staffing Coordinator (SC), the SC reviewed the facility's Nurse Staffing Information posting hours. The SC stated that she prepared and posted the staffing information daily. The SC reviewed the facility's posting and stated that it included the actual hours worked and nursing staffing ratio for certified nursing assistants (CNAs) and Licensed Nurses for the whole day. When asked whether the staffing posting reflected the actual hours worked by nursing staff for each shift, the SC stated that the posting only contained the projected hours and confirmed that actual hours worked were not reflected on the daily staffing posting. The SC stated that the form stated actual hours worked but confirmed that it was incorrect. When asked where the actual hours worked were subsequently posted or made available, the SC stated that she did not post the actual hours worked.During a concurrent interview and record review on 8/26/26 at 10:00 AM with the Assistant Director of Nursing (ADON), the ADON reviewed the facility's Nurse Staffing hours posting information. The ADON confirmed that the posting reflected only the projected hours and not the actual hours worked by nursing staff per shift. The ADON stated that there was no way for the residents, family members, visitors, and staff to know the actual facility's daily nursing staffing hours status. The ADON stated that it was important for the facility to post accurate and complete nurse staffing information daily to make available for residents, staff and visitors. A review of the facility's policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers with a revision date of August 2022, indicated .Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in the clear and readable format. The information recorded on the form shall include.The actual time worked during that shift for each category and type of nursing staff. Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the nurse staffing information form. The charge nurse completes the form and posts the staffing information.

Based on observation, interview, and record review, the facility failed to consistently refer and provide podiatry services (a physician specializing in the care of the feet) for three of three sampled residents (Resident 1, Resident 2 and Resident 3) when a tracking system was not in place that tracked which residents needed to be seen and who had already been seen by the podiatrist for a total census of 115 residents.These failures put Resident 1, Resident 2 and Resident 3 at risk for injury, pain, and infection due to a lack of podiatry care as well as other residents in the facility.Findings:A review of Resident 1's health record titled admission RECORD indicated, Resident 1 was admitted to the facility in late 2020 with multiple diagnoses including Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), extrapyramidal and movement disorder (spontaneous movement disorders caused by disruption of the brain's extrapyramidal system) and unspecified dementia (a decline in memory, language, problem-solving, and other thinking skills that interferes with a person's ability to perform daily activities).A review of Resident 2's health record titled admission RECORD indicated, Resident 2 was admitted to the facility in May 2026 with multiple diagnoses including paraplegia (a medical condition involving the loss of movement and sensation in the lower half of the body), type 1 diabetes mellitus (the body's inability to control blood sugar levels) and muscle weakness (a reduced ability to exert force with your muscles, making routine tasks difficult).A review of Resident 3's health record titled admission RECORD indicated, Resident 3 was admitted to the facility in June 2026 with multiple diagnoses including protein calorie malnutrition (a serious nutritional deficit caused by eating too few calories and proteins) and type 2 diabetes mellitus with hyperglycemia (the body's inability to control blood sugar levels).A review of a physician's order, dated 5/4/22, indicated Resident 1 to have a podiatry evaluation and treatment on an as needed basis.A review of a physician's order, dated 5/9/26, indicated Resident 2 to have a podiatry evaluation and treatment on an as needed basis.A review of a physician's order, dated 7/8/26, indicated Resident 3 to have a podiatry consult for an ingrown toenail (happens when the corner or side of a toenail grows into the soft flesh of the toe, causing pain, swelling, and redness).During an interview on 8/25/26, at 3:07 p.m., Resident 2 stated she had not received podiatry services since her admission to the facility even though she requested it multiple times.During an interview on 8/25/26, at 3:32 p.m., Resident 3 stated she wished to be seen by the podiatrist but had not received any podiatry care since her admission to the facility.During an interview with the social services director (SSD) on 8/25/26, at 2:00 p.m., the SSD stated that podiatry care was being provided by an outside vendor, who visited the facility every 3 to 4 months. The SSD stated the podiatrists' last visit to the facility was on 8/17/26 but they did not have a fixed schedule. During a concurrent interview and record review with the SSD on 8/25/26 at 4:25 PM, the records titled PODIATRY VISIT SUMMARY dated 8/17/26, were reviewed. The SSD stated that the podiatrist visited the facility on 8/17/26 and saw multiple residents. The SSD stated that Resident 1, Resident 2 and Resident 3 were not seen during that visit. The SSD further stated that Resident 1 was seen during a previous visit on 7/6/26 but did not know why Resident 2 and Resident 3 were not seen. According to the SSD, Resident 1 had not been examined by the podiatrist for at least seven months prior to 7/6/26, When questioned about how the SSD monitored which residents required podiatry care or who had been seen by podiatry, the SSD replied that there was no system established to track this information. When questioned about the absence of a tracking system, the SSD admitted that it was possible some residents could miss their podiatry care without a system in place. The SSD stated that without such a system there would be no way to determine how many residents missed these services.During an interview with the assistant director of nursing (ADON) on 8/26/26 at 10:00 AM, the ADON acknowledged that Resident 1, Resident 2 and Resident 3 did not receive consistent routine or as needed podiatry care. The ADON stated that it was important for the residents to receive routine podiatry care as ordered.A review of the facility's undated policy and procedure (P&P) titled, Referrals, Social Services, indicated, .Social Services personnel shall coordinate most resident referrals with outside agencies.Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs.A review of the facility's undated P&P titled, Foot Care, indicated, .Residents are provided with foot care and treatment in accordance with professional standards of practice.Residents are assisted in making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc.) as needed.Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals.

Based on interview and record review, the facility failed to maintain accurate and complete records for one of seven sampled residents (Resident 1) when, Resident 1's behavioral health visits progress notes for visit dates of 2/27/26, 3/20/26, and 4/14/26 were not readily available in Resident 1's medical record. This deficient resulted in care and services provided to not be known across all disciplines in order to assist in making medical decisions for Resident 1. Findings:During a review of Resident 1's clinical record titled, Care Plan Report, review date 4/7/26, the report indicated, .The resident is on (Risperidone) (Anti-psychotic Medications) r/t [related to] (Paranoia).Administer medications as ordered.During a review of Resident 1's clinical record titled, Order Summary Report, orders active as of 5/12/26, the report indicated, .Risperidone Tablet 0.25 MG Give 1 tablet by mouth at bedtime for Paranoia.During a review of Resident 1's clinical record titled, Medication Administration Record, dated 3/26 through 5/26, the record indicated Resident 1 received risperidone starting on 3/6/26 at 9 p.m. through 5/10/26 and continuing to present date.During a concurrent interview and record review on 5/8/26, at 5 p.m. with the Assistant Director of Nursing (ADON), Resident 1's electronic file was reviewed. The ADON confirmed there was no documented evidence of justification or rationale for risperidone use. The ADON stated a healthcare professional was at the facility to evaluate Resident 1 for a need for anti-psychotic medication. The ADON stated the healthcare professional's progress notes (a clinical document written after each patient encounter that records the services provided, current status, response to treatment, and plan of care) were not found in Resident 1's electronic file and stated the notes should have been uploaded. The ADON stated she will get a copy of the progress notes.During an interview on 5/12/26, at 2:33 p.m. with the ADON, the ADON stated that a Nurse Practitioner (NP) was the healthcare professional who evaluated Resident 1 and stated she contacted the NP to send her progress notes to be included in Resident 1's electronic file. The ADON stated the NP notes should have been readily accessible to know what the outcome of the visit was, the reason for prescribing the risperidone, and for the staff to have continuity of care. During a concurrent interview and record review on 5/12/26, at 5:30 p.m. with the ADON, Resident 1's NP progress notes titled, CHE Behavioral Health, dated 2/27/26, 3/20/26, and 4/14/26 were reviewed. The ADON confirmed that the NP was in the facility on those dates and confirmed her progress notes were not in Resident 1's electronic file and stated it should have been uploaded for staff to provide continuity of care.

Based on interview and record review, the facility failed to ensure psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) was administered with consent of the resident or authorized representative for one of seven sampled residents (Resident 1) when an informed consent (process in which a patient is educated on the risks, benefits, and alternatives to obtain agreement and permission for care) was not obtained from Resident 1's Responsible Party (Health Care Decision Maker) prior to administration of an anti-psychotic medication (used to treat and manage symptoms for several psychiatric disorders) prescribed on 3/6/26.This failure had the potential for not honoring resident right to be informed about Resident 1's medical treatment including risks, benefits, and other alternatives to treatment.Findings:During a review of Resident 1's clinical record titled, admission RECORD, dated 5/12/26, the record indicated Resident 1 was admitted to the facility in the middle of 2024 with diagnoses including unspecified dementia (a decline in mental abilities such as memory, thinking, and reasoning that could interfere with daily living) with behavioral disturbance and during her stay in the facility a diagnosis of delusional disorder (an illness characterized by at least 1 month of delusions but no other psychotic symptoms) was added early of 2026. During a review of Resident 1's clinical record titled, MDS Section C-Cognitive Patterns (MDS, Minimum Data Set-an assessment tool), dated 3/31/26, the record indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 11 out of 15 suggesting Resident 1 had moderate cognitive impairment (a decline in cognitive abilities that is severe enough to interfere with a person's independence and basic daily activities).During a concurrent interview and record review on 5/8/26, at 2:24 p.m. with Licensed Nurse (LN) 1, Resident 1's electronic file for psychotropic medication use was reviewed. LN 1 confirmed the order summary report of Resident 1's electronic file indicated an anti-psychotic medication was prescribed for Resident 1. LN 1 stated Resident 1 was prescribed risperidone (a prescription medication used to treat several mental health conditions) 0.25 mg (mg, milligram-a unit of measurement) one tablet by mouth at bedtime for paranoia (excessive mistrust or suspicion of people). LN 1 stated the medication was prescribed on 3/6/26 at 9 p.m. LN 1 confirmed the Medication Administration Report (MAR, a document used to track what medication was given, when it was given, and by whom) of Resident 1's electronic file indicated the risperidone was administered starting on 3/6/26 till present. LN 1 also confirmed that the informed consent for risperidone use was not found in Resident 1's electronic file. LN 1 stated that she could not find the informed consent and she went on to say that there should be consent when risperidone was prescribed.During a review of Resident 1's clinical record titled, Order Summary Report, orders active as of 5/12/26, the report indicated, .Risperidone Tablet 0.25 MG Give 1 tablet by mouth at bedtime for Paranoia.During a review of Resident 1's clinical record titled, Care Plan Report, review date 4/7/26, the report indicated, .The resident is on (Risperidone) (Anti-psychotic Medications) r/t [related to] (Paranoia).Administer medications as ordered.During a review of Resident 1's clinical record titled, Medication Administration Record, dated 3/1/26 through 3/21/26, the record indicated Resident 1 received risperidone starting on 3/6/26 at 9 p.m. through 3/31/26. The record also indicated Resident 1 received risperidone from 4/1/26 through 4/30/26 and from 5/1/26 through 5/10/26 and continuing to present date.During a concurrent interview and record review on 5/8/26, at 3:34 p.m. with the Assistant Director of Nursing (ADON), Resident 1's electronic file was reviewed. The ADON stated the informed consent for risperidone use was not found. The ADON stated that the consent might not have been uploaded in Resident 1's electronic file and would inquire into it.During a concurrent interview and record review on 5/12/26, at 4:11 p.m. with the ADON, Resident 1's informed consent form titled, PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE (Anti-Psychotic) was signed by the attending physician dated 5/9/26 and the responsible party gave verbal consent on 5/11/26. The ADON confirmed the consent was obtained after the risperidone was prescribed and was administered for the months of March, April, and in May 2026 without consent. The ADON stated there were no other consent forms obtained prior to 5/11/26. The ADON also stated consent must be obtained when anti-psychotic medication was prescribed and before administration. The ADON explained that without consent the anti-psychotic medication when administered could become a chemical restraint (when a drug or a combination of drugs is used to restrict or sedate a patient to make them easier to manage) and be used as a convenience for the staff. The ADON also explained the importance of obtaining consent for residents was to be informed about the risks and benefits for anti-psychotic medication use and would have the choice to accept or decline the use of the medication.During a review of the facility's undated policy titled, Psychotropic Medication Use, this policy indicated, .Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative's right to accept or decline the treatment.

Based on interview and record review, the facility failed to ensure psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) was administered with adequate clinical indication for one of seven sampled residents (Resident 1) when the healthcare nurse practitioner's (who has advanced clinical education and training and share many of the same duties as doctors) progress notes were not readily accessible in Resident 1's electronic file for an anti-psychotic medication (used to treat and manage symptoms for several psychiatric disorders) prescribed on 3/6/26.This failure had the potential for Resident 1 at risk for unnecessary anti-psychotic medication use.Findings:During a review of Resident 1's clinical record titled, admission RECORD, dated 5/12/26, the record indicated Resident 1 was admitted to the facility in the middle of 2024 with diagnoses including unspecified dementia (a decline in mental abilities such as memory, thinking, and reasoning that could interfere with daily living) with behavioral disturbance and during her stay in the facility a diagnosis of delusional disorder (an illness characterized by at least 1 month of delusions but no other psychotic symptoms) was added early of 2026. During a review of Resident 1's clinical record titled, MDS Section C-Cognitive Patterns (MDS, Minimum Data Set-an assessment tool), dated 3/31/26, the record indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 11 out of 15 suggesting Resident 1 had moderate cognitive impairment (a decline in cognitive abilities that is severe enough to interfere with a person's independence and basic daily activities).During a review of Resident 1's clinical record titled, Order Summary Report, orders active as of 5/12/26, the report indicated, .Risperidone [a prescription medication used to treat several mental health conditions] Tablet 0.25 MG [MG, milligram-a unit of measurement] Give 1 tablet by mouth at bedtime for Paranoia [excessive mistrust or suspicion of people] .During a review of Resident 1's clinical record titled, Care Plan Report, review date 4/7/26, the report indicated, .The resident is on (Risperidone) (Anti-psychotic Medications) r/t [related to] (Paranoia).Administer medications as ordered.During a review of Resident 1's clinical record titled, Medication Administration Record, [MAR, a document used to track what medication was given, when it was given, and by whom] dated 3/1/26 through 3/21/26, the record indicated Resident 1 received risperidone starting on 3/6/26 at 9 p.m. through 3/31/26. The record also indicated Resident 1 received risperidone from 4/1/26 through 4/30/26 and from 5/1/26 through 5/10/26 and continuing to present date.During a concurrent interview and record review on 5/8/26, at 2:24 p.m. with Licensed Nurse (LN) 1, Resident 1's electronic file for psychotropic medication use was reviewed. LN 1 confirmed Resident 1 was prescribed a risperidone, an anti-psychotic medication with an order date of 3/6/26. LN 1 also confirmed the medication was administered starting on 3/6/26 at 9 p.m. through 3/31/26, all of April from 4/1/26 through 4/30/26, and the beginning of May from 5/1/26 through review date. LN 1 stated the indicated diagnosis of paranoia for the risperidone use was not among the list of diagnoses Resident was admitted for . LN 1 also stated the paranoia diagnosis was not added on the list during her stay in the facility. LN 1 further stated she could not locate documentation in Resident 1's electronic file the justification or rationale for risperidone use, who was the healthcare professional who diagnosed paranoia, and an assessment for the need of anti-psychotic medication. LN 1 confirmed the care plan report of Resident 1's electronic file revealed a black box warning for the use of risperidone which indicated that risperidone is not approved for the treatment of patients with dementia-related psychosis due to increased risk of death in elderly patients. LN 1 stated Resident 1 received an anti-psychotic medication without proper or adequate indication of use.During a concurrent interview and record review on 5/8/26, at 5 p.m. with the Assistant Director of Nursing (ADON), Resident 1's electronic file was reviewed. The ADON confirmed there was no documented evidence of justification or rationale for risperidone use. The ADON stated a healthcare professional was at the facility to evaluate Resident 1 for a need for anti-psychotic medication. The ADON stated the healthcare professional's progress notes (a clinical document written after each patient encounter that records the services provided, current status, response to treatment, and plan of care) were not found in Resident 1's electronic file and stated the notes should have been uploaded. The ADON stated she will get a copy of the progress notes. The ADON stated Resident 1 received risperidone without adequate indication for use from 3/6/26 through 5/12/26.During an interview on 5/12/26, at 2:33 p.m. with the ADON, the ADON stated that a Nurse Practitioner (NP) was the healthcare professional who evaluated Resident 1 and stated she contacted the NP to send her progress notes to be included in Resident 1's electronic file. The ADON stated the NP notes should have been readily accessible to know what the outcome of the visit was, the reason for prescribing the risperidone, and for the staff to have continuity of care. During a phone interview on 5/12/26, at 3:08 p.m. with the Pharmacy consultant (PC), the PC stated that paranoia was not a diagnosis but part of psychosis such as symptoms related to a psychiatric diagnosis. The PC also stated that risperidone could be used for other diagnosis such as dementia with behavior as long as it is documented adequately including but not limited to the following: use of non-pharmacologic approaches before administration, must be care planned, must have monitoring of specific behavior, monitoring of side-effects, and must have the reason for use. The PC further stated the diagnosis of paranoia must be clarified and the NP's progress notes must have information regarding the indication for use of risperidone.During a concurrent interview and record review on 5/12/26, at 5:30 p.m. with the ADON, Resident 1's NP progress notes titled, CHE Behavioral Health, dated 2/27/26, 3/20/26, and 4/14/26 were reviewed. The ADON confirmed that the NP was in the facility on those dates and confirmed her progress notes were not in Resident 1's electronic file and stated it should have been uploaded for staff to provide continuity of care.During a review of the facility's undated policy titled, Psychotropic Medication Use, this policy indicated, .Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Psychotropic medication management is an interdisciplinary process that involves the resident, family, and /or the representative and includes: a. determining adequate indications for use.Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

Based on interview and record review, the facility failed to provide written notice at the time of the position change of the Administrator (ADM) and the Director of Nursing (DON) to the State Agency (SA) when:The current DON started the DON position on 4/21/26, and the facility did not report the change of the DON position to the SA.The current ADM started the ADM position in August 2025 and the facility did not report the change of the ADM position to the SA These failures delayed the SA from verifying that the ADM and the DON were qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 109 residents.Findings:1. During an interview on 4/29/26 at 10:22 a.m. with the facility Administrator (ADM), the ADM stated that he did not think that the application to the Centralized Applications Branch (CAB-part of the SA that reviews, analyzes, and evaluates requests for facility licensure and/or certification, as well as processes other license-associated transactions) was completed for the new DON. The ADM stated that the DON was the one responsible for completing the CAB application. During an interview with the DON on 4/29/26 at 3:58 p.m., the DON stated that she started working at the facility eight days ago. The DON confirmed that she had not filed the application with the CAB. The DON stated that the ADM would get the information. The DON stated that she was not informed about the CAB expectations.A review of the SA database revealed no receipt of the DON application was received from the facility.2. During an interview on 4/29/26 at 10:31 a.m. with the ADM, the ADM stated that he had been working at the facility since August 2025. The ADM stated that the change in ADM application should have been completed and sent to the CAB for his new position back in August 2025 by the facility's corporate office.A review of the SA database revealed no receipt of the ADM application was received from the facility.

Based on interviews and record reviews, the facility failed to ensure an environment free of accidents or hazards for one out of three sampled residents (Resident 3) when Resident 3 eloped (when a resident leaves a healthcare facility without notice/authorization) from the facility in a wheelchair and was found at a gas station one quarter mile away from the facility.This failure had the potential to result in injury to Resident 3 during an elopement on 2/18/26.Findings:A review of Resident 3's admission Record, indicated that Resident 3 was admitted to the facility in 2026 with diagnoses which included Closed Fracture Left Radius (broken bone in the forearm near the wrist with no bones poking out of the skin), Closed Fracture Shaft of Left Tibia (a broken bone between the knee and the ankle with no bones poking out of the skin), Basilar Skull Fracture (broken bones around either ear, the eyes, near the spine, and the nasal cavity), and Suicide Attempt (an act in which an individual tries to end their own life but survives).A review of Resident 3's Physician Order Summary, indicated .1:1 staff assistance to enhance safety d/t [due to] suicidal ideation [thoughts or preoccupation with ending one's own life] x 72hrs [hours] one time only for 3 Days.Order Date.01/28/2026.End Date.01/31/2026.A review of Resident 3's Physician Order Summary, indicated, .NOTIFY provider immediately if suicide ideation/attempt recurs. Every shift for suicidal ideation.Order Date.02/04/2026.Start Date.02/04/2026.A review of Resident 3's Medication Administration Record (MAR, a document listing medications and monitoring parameters) February 2026, indicated that facility staff documented Resident 3's behavior each shift daily.A review of Resident 3's Care Plan Report, indicated, .Focus.Risk for leaving the facility without notice related to.suicide attempt.Date Initiated.02/02/2026.Goal.Resident will remain safe within the facility, demonstrate reduced exit-seeking behavior.Interventions.Allow time for expression of feelings.As appropriate redirect Resident if nears exits or doorways.A review of Resident 3's Care Plan Report, indicated, .Focus.Patient [Resident] may smoke with supervision per smoking assessment.Date Initiated.02/04/2026.Goal.Patient will smoke safely x90 days per smoking assessment.Educate Patient.on the facility's smoking policy.Inform and remind Patient of smoking areas and times.Monitor Patient.A review of Resident 3's Progress Notes, indicated .Effective Date.2/18/2026 10:19:00 [10:19 AM].Around 10:19 [AM] patient told staff member that he wanted to sit in the front of the facility in his wheelchair. Nurse was told that the patient was seen going towards the gas station. Nurse walked on foot to get to the patient at the.gas station away from the facility. Nurse accompanied the patient back safely to the facility. Full body assessment completed with no noted injury.Administrator, unit manager, DON [Director of Nursing] and ADON [Assistant Director of Nursing] notified.Educated that patient.Patient stated he was sorry and just wanted donuts from the gas station.A review of Resident 3's Progress Notes, indicated .Effective Date.02/19/2026 11:43 [AM] .Type.Primary Physician.follow up note.Pt [Patient] stated he would like to get a day pass to go out to the store to buy some stuff. Denies any suicidal ideations.Given the patient's history of.prior suicidal ideations, he is not appropriate for an unsupervised day pass at this time due to safety concerns. However, he may be considered for a day pass if accompanied at all times by a responsible adult who is aware of his history and able to provide appropriate supervision and ensure his safety.During an interview on 4/29/26 at 3:58 p.m. with the Director of Nursing (DON), the DON stated that her expectations were that Licensed Nurses (LNs) rounded on the residents at the start of their shift and made sure that the residents were all accounted for. The DON stated that if a resident left the facility, the staff should check the sign out form at the front desk to see if the resident had a day pass. The DON stated that residents had to get permission from their physicians to leave the facility on the day pass. The DON stated that the staff checked for scheduled appointments and checked with family members to see if the resident was with the family. The DON stated that if a resident had a cell phone, the staff would call the resident's cell phone to see if the resident answered. The DON stated that she expected the staff to look for the resident, to alert the supervisor on duty, and their coworkers on duty to search for the missing resident. The DON stated that if the staff could not find the missing resident in the facility, Code [NAME] (agency code indicating a missing resident) was activated to search for the missing resident. The DON stated that the Certified Nursing Assistants (CNAs), charge nurses, and the medication nurses would tell the unit managers when the resident was last seen. The DON stated that the staff were also expected to notify the DON and the Administrator (ADM), then the police were called. The DON stated that the risk of not following the process was that the missing resident could fall, possibly get into traffic and be injured, possibly be hungry and without their medications, possibly suffer confusion, possibly be cold and tired, or worse.During a concurrent interview and record review on 4/29/26 at 4:28 p.m., with the ADM, the facility policy and procedure, Leave of Absence without [sp] Notice, dated January 2026 was reviewed. The ADM stated that his expectation was that the facility staff followed the elopement policy and procedure in place. The ADM stated that he heard about Resident 3 leaving the facility on 2/18/26. The ADM stated that since facility staff knew the direction Resident 3 went when he left the property on 2/18/26, and staff knew where to go to find Resident 3, that was not considered elopement. The ADM stated that Resident 3 was alert. The ADM stated that Resident 3 was not injured and received education when he returned to the facility. The ADM stated that there were no further incidents of Resident 3 leaving the facility after the education was provided. The ADM confirmed that Resident 3 did not have a day pass to leave the facility alone on 2/18/26. The ADM confirmed that Resident 3 did not have an appointment outside of the facility on 2/18/26 at the time that he left the facility. The ADM acknowledged that based on the definition of elopement listed on the facility policy and procedure, Resident 3 eloped from the facility on 2/18/26. The ADM acknowledged that the facility policy was not followed.During an interview by phone with LN 2 on 4/29/26 at 5:35 p.m., LN 2 stated that she remembered Resident 3. LN 2 stated that she was in the process of medication administration at the facility on 2/18/26 and could see the front of the facility through the windows. LN 2 stated that during medication administration she noticed Resident 3 in his wheelchair leaving the facility parking lot. LN 2 stated that a staff member came to her and asked if Resident 3 had a day pass to leave the facility. LN 2 stated that the staff member stated that Resident 3 was headed in the direction of the gas station. LN 2 stated that she knew that Resident 3 did not have a day pass. LN 2 stated that she walked to the gas station and Resident 3 was inside the gas station mini market. LN 2 stated that she asked Resident 3 if he was hurt and he stated that he was not hurt. LN 2 stated that she told Resident 3 that she was concerned about his safety. LN 2 stated that Resident 3 stated that he just wanted to get snacks. LN 2 stated that she walked with Resident 3 back to the facility. LN 2 stated that she called the ADON and the DON on duty at that time and notified them of the incident. LN 2 stated that she did not know all the forms that needed to be completed for the elopement. LN 2 stated that the DON and the ADON that were on duty that day no longer worked at the facility. LN 2 stated that she asked the DON and the ADON which forms to fill out, and the DON stated that she should call Resident 3's physician and complete a progress note. LN 2 stated that she educated Resident 3 on leaving the facility against medical advice. LN 2 stated that Resident 3 understood the education. LN 2 stated that she suggested that Resident 3 asked staff, visitors, or other residents who had day passes to get snacks for him, or have snacks delivered since he did not have a day pass. LN 2 stated that besides the progress note on the elopement, she did not document any assessments (physical/mental) on Resident 3 since the DON and the ADON only said to call Resident 3's physician and write the progress note.During an interview by phone on 4/30/26 at 12:49 p.m. with CNA 3, CNA 3 stated that she remembered Resident 3. CNA 3 stated that she remembered the incident when Resident 3 left the facility and went to the gas station on 2/18/26. CNA 3 confirmed that the incident occurred in the morning on 2/18/26. CNA 3 stated that the staff wondered where Resident 3 was and asked other staff where he was. CNA 3 stated that she thought that one of the CNAs reported the incident to the unit manager. CNA 3 stated that the CNAs and LNs started looking for Resident 3 in the facility, in the smoking area, and in the front patio of the facility, but did not find him. CNA 3 stated that the staff searched for Resident 3 at the facility for about an hour.A review of a facility policy and procedure (P&P) titled, Leave of Absence without [sp] Notice, dated January 2026, the P&P indicated, .Policy.The Interdisciplinary team members (IDT, a team of professional staff or a care team consisting of different disciplines who work together towards the goals of their clients) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice and identify resident-specific measures in a least restrictive environment.Definitions.Elopement occurs when a resident leaves the premises or a safe area without notice/authorization (i.e., an order of discharge or leave of absence) and/or any necessary supervision to do so.Procedural Guidelines.3. A resident deemed at risk for Leave of Absence without [sp] Notice by IDT are to consider the following measures but not limited to.Initiate/Update plan of care.Procedure for Locating Missing Resident.a. Any staff member becoming aware of the missing resident will alert personnel using facility approved protocol (e.g. internal alert code) .b. The designated facility staff will look for the resident.c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department.d. DON or designee shall notify the physician and family member or legal representative.e. Police will be given a description and information about the resident; include any photos.f. All parties will be notified of the outcome once the resident is located.g. Appropriate reporting requirements to the State Survey agency should be conducted.4. Procedure Post Leave of Absence without Notice.a. A nurse will perform a physical assessment, document, and report findings to physician.e. Documentation in the medical record will include findings from nursing.assessments, physician.notification.as applicable.

Based on interview and record review, the facility failed to implement a known resident staffing preference for one of four sampled residents, when Resident 1 was assigned to Certified Nursing Assistant (CNA) 1, despite the family's prior request to not have CNA 1 provide care to Resident 1 due to concerns related to a prior care encounter involving a skin issue.This failure had the potential to affect Resident 1's dignity, psychosocial well-being, and right to receive care per preferences.FINDINGS:Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with multiple diagnoses, including dementia (a decline in brain function that severely affects memory, thinking, and daily activities), anxiety (a feeling of fear, dread, unease, or worry), and depression (a serious mental health condition characterized by persistent, deep sadness, or a loss of interest).During a concurrent interview and record review on 04/22/2026 at 3:46 p.m. with the Licensed Nurse (LN 1), LN 1 stated CNA 1 was not to care for Resident 1 per family's request. Resident 1's records as listed below were reviewed with LN 1.Review of the facility document titled [NAME] [nurses' station] Patient Preferences, updated as of 3/11/26, indicated Resident 1, Prefers CNA 2 when she is here. The document did not indicate that CNA 1 was not to provide care to Resident 1.Review of Resident 1's comprehensive care plan, last reviewed on 4/22/26, did not reflect the family's staffing request and lacked interventions to communicate the preference to direct care staff.Review of the facility's Nursing Staffing Assignment and Sign-in Sheet, dated 4/12/26, indicated CNA 1 was assigned to the [NAME] PM shift and assigned to Rooms 16A through 17B. Resident 1 resided in room [ROOM NUMBER]B.Review of Resident 1's incontinent task documentation, dated 4/12/26, indicated CNA 1 documented incontinent care for Resident 1.During continued interview and record review on 04/22/2026 at 3:46 p.m., LN 1 confirmed CNA 1 was scheduled and worked with Resident 1 on 4/12/26. LN 1 verified Resident 1's care plan did not include the family's request that CNA 1 not to provide care to Resident 1. LN 1 stated failure to honor the staffing preference could affect Resident 1's dignity.During a concurrent interview and record review on 04/22/2026 at 3:49 p.m. with the Director of Staff Development (DSD), Resident 1's care plan, the 4/12/26 staffing assignment sheet, Resident 1's incontinent task documentation, and the facility's [NAME] Patient Preferences list were reviewed. The DSD confirmed Resident 1's family requested via text message in December 2025 that CNA 1 not to provide care to Resident 1. The DSD stated she might have communicated the request to staff but could not confirm. The DSD confirmed the request was not documented in the [NAME] Patient Preferences list or in Resident 1's care plan. The DSD further confirmed that CNA 1 provided care to Resident 1 on 4/12/26.During a concurrent interview and record review on 04/22/2026 at 5:15 p.m. with the Director of Nursing (DON), Resident 1's care plan, the 4/12/26 staffing assignment sheet, Resident 1's incontinent task documentation, and the facility's [NAME] Patient Preferences list were reviewed. The DON confirmed CNA 1 provided care to Resident 1 on 4/12/26. While reviewing the documents, the DON confirmed CNA 1 was not identified on the [NAME] Patient Preferences list as restricted from providing care to Resident 1, and the family's request was not reflected in the resident's care plan. The DON stated resident and family staffing preferences were important and should be honored.Review of the facility policy titled Accommodation of Needs, revised November 2025, indicated, .The resident has the right to reside and receive services in the facility with reasonable accommodations of their needs and preferences. 1. The resident's individual needs and preferences are accommodated to the extent possible by the facility and staff.Review of the facility policy titled Dignity, revised October 2025, indicated, .2. Resident goals, choices, preferences, values, and beliefs are respected and honored to the extent possible.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures (evidence-based practices designed to prevent the spread of infections) for 1 of 3 sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 2 did not properly wear the required personal protective equipment (PPE, equipment such as protective clothing, gloves, masks or other garments used to prevent or minimize exposure to hazards) while providing high-contact care to Resident 1 who was on Enhanced Barrier Precautions (EBP, infection control steps used in a healthcare setting to prevent the transmission of multidrug-resistant organisms (MDRO, are bacteria often called superbugs, that are resistant to germs that are difficult to treat and spread rapidly in healthcare settings) that are passed by direct contact with a patient or their environment). This failure had the potential to increase the risk of cross-contamination and spread infection to staff and other residents in the facility.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including gastrostomy status (the presence of a surgically created opening in the stomach wall, used for a feeding tube to deliver nutrition, hydration, or medication directly to the stomach. The status implies that the patient requires ongoing care to manage the tube, prevent infection, and ensure proper nutritional intake).Review of the facility provided undated care plan for Resident 1, in the section titled, Focus, indicated, . [Resident 1] is at risk for MDRO colonization/infection due to: presence of g-tube. In the section titled, Interventions, indicated, . required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing. changing linens.During an interview on 4/7/26, at 11:43 AM, CNA 1 stated an EBP sign was posted on residents' doorways as a guide to alert staff to wear appropriate PPE when providing direct care. CNA 1 further stated the purpose of the sign was to reduce the risk of infection transmission to other residents within the facility.During an interview on 4/7/26, at 12:58 PM, Licensed Nurse (LN) 1 stated that purpose of EBP signs was to provide directions to staff to ensure the use of appropriate PPE when delivering high-contact care to residents on EBP. LN 1 added the EBP signs outlined proper PPE use, and staff were expected to follow those instructions to reduce the risk of introducing infections to themselves, other staff, and residents. LN 1 further stated that failure to use appropriate PPE increased the risk of infection transmission throughout the facility.During a concurrent observation and interview on 4/7/26, at 2:12 PM in Resident 1's room, an EBP sign was observed posted on the wall at the doorway. CNA 2 was observed inside the room changing Resident 1's bed linens while Resident 1 was in bed. CNA 2 was not wearing a gown, as required by the EBP sign posted outside of Resident 1's room. Upon exiting the room, CNA 2 confirmed she had not worn the appropriate PPE and acknowledged that she should have worn a gown prior to entering the room to change Resident 1's bed linens, as the resident was on EBP. CNA 2 further stated that failure to wear the required PPE while providing direct care placed her at risk of acquiring infection and contributing to the transmission of infection to other residents within the facility. During an interview on 4/7/26, at 2:43 PM, the Director of Staff Development (DSD) stated that when staff were providing direct care to residents under EBP, they were expected to wear appropriate PPE prior to entering the resident's room. The DSD explained that an EBP sign posted near the doorway served as a guide to inform staff of the required PPE. The DSD further stated that during the provision of direct care, staff should ensure they were wearing the proper PPE to prevent the transmission of infection, thereby protecting other residents from potential cross-contamination.During an interview on 4/7/26, at 3:02 PM, the Infection Preventionist (IP) stated Resident 1 was placed on EBP due to having a surgically inserted feeding tube, which increased the risk for MDRO colonization. The IP stated that high-contact care activities, including changing Resident 1's bed linens, required the use of PPE. The IP further stated staff were expected to wear a gown and gloves while changing Resident 1's bed linens to prevent the possibility of the spread of infection within the facility.During a concurrent interview, and record review, on 4/7/26, at 4:23 PM, with the Assistant Director of Nursing (ADON), the facility Policy and Procedure (P&P) titled, Enhanced Standard/Barrier Precautions, revised on 2/21/25, was reviewed. The review indicated, . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include. e. Changing linens. 8. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until. discontinuation of the indwelling medical device that placed them at higher risk. The ADON stated staff were expected to wear appropriate PPE when providing direct and high-contact care, including changing bed linens for Resident 1 while on EBP. The ADON stated Resident 1's condition increased the risk of infection transmission to other residents and staff when proper PPE was not utilized. The ADON further stated failure to wear appropriate PPE could result in the spread of infection throughout the facility and lead to noncompliance with infection prevention requirements. The ADON acknowledged that the facility P&P was not followed, and also confirmed that nursing staff did not meet the expected infection prevention requirements.

Based on interview and record review, the facility failed to report an allegation of potential sexual abuse to the state survey agency within two hours as required by law for one 1 of two 2 sampled residents (Resident 1) when Housekeeper (HK) 1 observed Resident 1 being touched inappropriately by Resident 2 on 2/20/26 in the facility's dining room but did not report the incident to the administration staff until 2/27/26. This failure resulted in a delay of the state survey agency and facility administrative staff from investigating an allegation of potential sexual abuse which had the potential to put Resident 1 and other residents within the facility at risk for ongoing abuse.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in late 2024 with admitting diagnoses including but not limited to Sequelae of Cerebral Infarction (the lasting, long-term physical, cognitive, and psychological impairments occurring after blood to the brain is blocked) and dementia (a progressive, umbrella term for cognitive decline-including memory loss, language difficulties, and poor judgment-that interferes with daily life).Review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated 12/12/25, indicated, Resident 1 scored 7 out of 15 in a Brief Interview for Mental Status which indicated severe cognitive impairment (a significant, often irreversible decline in cognitive functioning, including memory, reasoning, and awareness, that makes independent living impossible).A review of the SOC-341 form (a form used to report abuse in long term care facilities) submitted to the state survey agency by the facility, dated 2/27/26, the document indicated, .On 2/27/26 [ADM] received report from [HK 1] that on 2/20/26 when she was clocking out, she witnessed [Resident 2] sitting next to [Resident 1] while in the dining room reach his right arm into the left sleeve of [Resident 1] shirt and put his hand on her chest . During an interview on 3/10/26, at 1:31 p.m., HK 1 stated on 2/20/26 at around 4 pm, when she was going home for the day, she saw Resident 2 with his right hand inside Resident 1's left arm shirt sleeve, touching near her shoulder and underarm, in the social dining room. HK 1 further stated she went home and did not report the incident to anybody. HK 1 continued, she came back to work the next day and following days after the incident but did not report the incident to anyone until 2/27/26 after she was given regularly scheduled abuse training by the facility. HK 1 further added, she had received abuse trainings by the facility before and knew that she had to report any kind of abuse but she did not realize that she needed to report this incident until the day she received another abuse training on 2/27/26.During an interview on 3/10/26, at 2:05 p.m., the administrator (ADM) stated, the alleged incident between Resident 1 and Resident 2, was reported to him on 2/27/26 in the afternoon around 1 p.m., which he then reported to the state agency, law enforcement, and the ombudsman (a resident advocate) at around 2:30 p.m. The ADM confirmed that HK 1 should have reported the incident right away.During an interview on 3/10/26, at 4:40 p.m., the Director of Nursing (DON) confirmed the incident between Resident 1 and Resident 2 was witnessed by HK 1 on 2/20/26, but HK 1 did not report it to the facility administration until 2/27/26. The DON stated this was not acceptable and should have been reported immediately or within 2 hours. The DON stated this delay put the residents' at risk of experiencing emotional, physical, and psychosocial harm and it was very important to report on time to ensure the safety of the residents.Review of a facility policy and procedure (P&P) titled Abuse prohibition, revised 10/24, the P&P indicated, .Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor.Review of an undated facility P&P titled Abuse Investigation and Reporting, the P&P indicated, .An alleged violation of abuse, neglect, exploitation our mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with reasonable accommodation of needs when Resident 1's call light (system/device used by residents to call staff for assistance) was not answered in a timely manner. This failure resulted in Resident 1's needs not being met and had the potential to affect Resident 1's psychosocial well-being. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including spinal stenosis (narrowing of the open spaces within the spine resulting in pain, numbness, or weakness in the back, neck, arms, or legs), difficulty walking, and generalized muscle weakness.During an observation on 2/27/26, at 11:37 AM, the call light was noted to be already on for Resident 1 and Resident 2's room.During a subsequent observation on 2/27/26, at 11:40 AM, the call light was not answered. Staff were noted at the nurses' station including licensed nurse (LN) 1 who did not respond to the call light for Resident 1 and Resident 2's room.During an observation on 2/7/26, at 11:44 AM, the call light for Resident 1 and Resident 2's room remained unanswered.During a joint concurrent observation and interview on 2/27/26, at 11:46 AM, with Resident 1 and Resident 2, inside their room, the call light for Resident 1 remained unanswered. Resident 2 stated staff did not come to answer the call light. Resident 2 further stated they (Resident 1 and Resident 2) did not get the attention they needed. Resident 2 stated his roommate (Resident 1) wore incontinent briefs (an absorbent undergarment designed for adults to manage moderate to heavy leakage of urine or feces) that would get wet and needed changing. Resident 2 further stated when his roommate (Resident 1) would ask staff to be change him; staff would tell him they would come back but never did. Resident 2 stated staff would only come to their room during shift change. Resident 1 stated he had not been changed since last night. Resident 1 further stated he needed help with changing and would sometimes wait for 30 minutes for his call light to be answered. Resident 2 stated staff had not come to change his roommate's brief since last night. Resident 2 further stated he did not know the name of the certified nursing assistant (CNA) who was assigned to care for him and his roommate. During an observation on 2/27/26, at 11:54 AM, CNA 2 passed by the hallway in front of Resident 1 and Resident 2's room while wheeling a resident on the wheelchair and did not respond to the call light. During an observation on 2/27/26, at 12:01 PM, the Administrator (ADM) responded to the call light in Resident 1 and Resident 2's room. The ADM looked for assistance from staff and called LN 1. During an interview on 2/27/26, at 12:07 PM, with the Director of Staff Development (DSD), the DSD stated she expected call lights to be answered by staff in 2-3 minutes or at least answer within 5 minutes. The DSD further stated anyone could answer the call light. The DSD explained CNAs needed to check if a resident had to be changed every 2 hours and as needed. The DSD stated a 24 minute wait time for the call light response was not acceptable. The DSD further stated if staff were in the hallway they should have answered the call light for Resident 1. The DSD stated that this incident was avoidable. The DSD further stated staff should have answered the call light even if it was not their assigned resident. The DSD stated the risk for not answering the call light would be lack of patient care and patient safety. The DSD further stated Resident 1 was incontinent and he would be at risk for skin breakdown. The DSD explained Resident 1's dignity could also be affected.During an interview on 2/27/26, at 1:46 PM, with LN 1, LN 1 confirmed that she did not answer Resident 1's call light. LN 1 stated she should have answered it or at least asked the CNAs to answer the call light and see what the resident needed.During an interview on 2/27/26, at 2:35 PM, with the Administrator (ADM), the ADM stated his expectation on call lights was for staff to answer as quickly as possible. The ADM further stated the staff needed to prioritize because sometimes multiple call lights would be on at the same time. The ADM explained that staff needed to stop what they were doing and attend to the call light. The ADM stated LN 1 should have answered the call light for Resident 1. The ADM further stated that staff should be doing rounds in the beginning of the shift and be changing or checking on residents every few hours. The ADM stated that failing to answer the call light promptly could delay a resident's needs. A review of Resident 1's Care Plan Report, dated 5/29/25, indicated, .The resident has an ADL [activities of daily living] Self Care Performance Deficit r/t [related to] Impaired balance, Limited Mobility, Musculoskeletal impairment.Interventions.Encourage the resident to use bell to call for assistance.A review of Resident 1's Care Plan Report, dated 5/29/25, indicated, .Resident is at risk for bowel incontinence episodes r/t musculoskeletal changes.Interventions.Assist resident with cleansing after bowel movement.Discuss and plan toileting schedule with resident.Inform resident of next scheduled toileting. Encourage resident to call for assistance if need to defecate before next scheduled time.Respond promptly to the residents request to toilet.A review of Resident 1's Care Plan Report, dated 1/7/26, indicated, .Impaired Urinary Elimination related to urinary tract infection [infection caused by bacteria entering the bladder or kidneys].Interventions.Assist with toileting and maintain proper perineal hygiene.A review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised 10/24/24, indicated, .The purpose of this procedure is to ensure timely response to the resident's requests and needs.Answer the resident call system.If the resident needs assistance, indicate the approximate time it will take for you to respond.If the resident's request requires another staff member, notify the individual.If the resident's request is something you can fulfill, complete the task within five minutes if possible.When answering a visual request for assistance (light above the room door), knock on the room door.A review of an undated facility P&P titled, Dignity, indicated, .Residents are treated with dignity and respect at all times .Each resident is care for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example.promptly responding to a resident's request for toileting assistance.

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for one of three sampled residents (Resident 2) when Resident 2's blood sugar was not monitored before meals and Resident 2's scheduled medications to control blood sugar were not administered in a timely manner. These failures had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 2 and had the potential for Resident 2 to receive unnecessary doses of insulin (injectable medication used to manage blood sugar levels).Findings: A review of Resident 2's admission RECORD, indicated she was admitted to the facility with diagnoses which included type 2 diabetes mellitus (a chronic condition in which the body has trouble controlling blood sugar levels). During an interview on 2/11/26 at 11:34 AM with Resident 2, Resident 2 stated she had to wait a long time to receive her medications. Resident 2 further stated sometimes when she requested a medication the staff and said OKAY and then Resident 2 stated, the thought was wiped from their minds when they left the room. During a review of Resident 2's clinical document titled, Care Plan Report, dated 9/29/25, the report indicated, .Focus.The resident is at risk for hyperglycemia [elevated blood sugar] r/t [related to] Disease process Diabetes Mellitus Type 2 (DM 2).Interventions.Educate regarding medications and importance of compliance.Finger Stick Blood Sugar (FSBS) [test in which a finger is pricked with a small needle to obtain a drop of blood to determine the blood sugar level] as ordered with regular insulin [medication used to regulate and lower blood sugar levels].Follow MD orders with new insulin regimen/sliding scale [insulin dose adjustment based on blood sugar level]. During a concurrent interview and record review on 2/11/26 at 3:16 PM with the Director of Nurses (DON), Resident 1's MAR (Medication Administration Record, a document that contains information of ordered medications and when the medications were given or held) dated 2/1/26 through 2/28/26, was reviewed. The MAR indicated, .Insulin/Lispro [rapid acting insulin] .Inject as per sliding scale.if 70- [through] 249 [range of blood sugar level] = [equals] 0 units [no insulin given]; 250-300 = 2 units; 301-350 = 4 units.The MAR further indicated Resident 1's blood sugar levels and insulin administration were scheduled at 7:30 AM and 5:00 PM daily.The MAR indicated Resident 1 received insulin for elevated blood sugar levels on three dates between 2/1/26 and 2/11/26 as follows:2/5/26 = blood sugar 324; 4 units of insulin were administered at 9:37 AM2/8/26 = blood sugar 280; 2 units of insulin were administered at 9:18 AMThe DON stated it was her expectation that medications would have been administered within one hour before or after they were scheduled. The DON further stated there was the potential for Resident 2 to have experienced hypoglycemia (blood sugar below the standard range, can be life threatening) or hyperglycemia (high blood sugar, can lead to nerve damage, eye and kidney disease) if her insulin was not administered timely. The DON stated breakfast was provided to Resident 2 at 7:30 daily. During a review of the facility's undated policy titled, Insulin Administration Purpose, the policy indicated, .To provide guidelines for the safe administration of insulin.key characteristics of insulin are.Onset of action- how quickly the insulin reaches the blood stream and begins to lower blood glucose.Rapid-acting.Insulin lispro.Onset within 15 minutes. During a review of the facility's policy titled, Administering Medications, revised 4/19, the policy indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include.Enhancing optimal therapeutic effect of the medication.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals) . During a review of an online article from DAILYMED, accessed on 2/12/26 at 12:44 PM titled INSULIN LISPRO - insulin injection, solution, revised 9/2023, the article indicated, . Administration Instructions for the Approved Routes of Administration.Subcutaneous Injection.Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=97d5e596-aae1-42c9-ae89-c3780959c467&type=display

Based on interview and record review the facility failed to ensure they had an effective system in place to investigate and compensate residents for missing items when one of three sampled residents (Resident 1) reported missing items on 12/19/25 and the allegation was not investigated until 2/11/26. This failure caused Resident 1's missing items to not be returned or replaced and had the potential to negatively affect her psychosocial wellbeing.Findings: A review of Resident 1's admission RECORD, indicated she was admitted to the facility with diagnoses which included adjustment disorder with anxiety (a condition that causes a person to feel worried, anxious, and overwhelmed). During a review of Resident 1's clinical progress note titled, Social Service Progress Note, dated 12/19/25 at 10:48 AM, the progress note indicated, .spoke with [Resident 1's] son.who called about missing clothes 5 pairs of sweat [sic] some shirts and blue [NAME] jacket.SSD [social services director] will follow up with Resident 1. During an interview on 2/11/26 at 12:14 AM with Resident 4 in the room shared by Resident 1 and Resident 4, Resident 4 stated Resident 1 had been transferred to the hospital and was not able to be interviewed. Resident 4 further stated Resident 1's clothes were noted lost and the facility could not find them. During an interview on 2/11/26 at 4:15 PM with the Administrator in Training (AIT), the AIT stated when Resident 1's items were reported as missing on 12/19/25, the facility staff should have searched the facility for the items. The AIT further stated if the items were not located, a theft and loss report should have been filed to begin the investigation process. The AIT confirmed the theft and loss process was not initiated for Resident 1's belongings prior to 2/11/26. The AIT stated residents in the facility had a limited number of belongings and it was their right to retain those items. The AIT further stated it was the facility's responsibility to make sure their theft and loss protocol was followed due to the negative effect the loss could have on the psychosocial wellbeing of Resident 1. During an interview on 2/12/26 at 1030 AM with the Dialysis Social Worker (DSW), the DSW stated Resident 1's family member reported that Resident 1 was so upset about her missing clothes that she wanted to call the police. The DSW further stated the facility told the family they would reimburse Resident 1 two hundred dollars ($200), but the facility had not provided the reimbursement. During a review of the facility's policy titled, Investigating Incidents of Theft and Loss, revised 4/17, the policy indicated, .All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated.Residents have the right to be free from theft and loss.When an incident of theft and/or misappropriation of resident property is reported, the administrator will appoint a staff member to investigate the incident. During a review of the facility's undated policy titled, Dignity, the policy indicated, Residents are treated with dignity and respect at all times.Each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.Residents' private space and property are respected at all times.

Based on interview and record review the facility failed to ensure reasonable accommodation of needs were met for one of three sampled residents (Resident 2) when Resident 2's call light (device used to communicate a need for assistance) was tampered with making in nonfunctional. This failure had the potential risk for Resident 2 to have unmet needs and to suffer physical and psychosocial harm due to the inability to call for assistance.Findings: A review of Resident 2's admission RECORD, indicated she was admitted to the facility with diagnoses which included dementia (condition that causes a decline in cognitive abilities such as memory, thinking, reasoning, and problem solving) and blindness (inability to see). During an interview on 2/11/26 at 1:00 PM with Certified Nurse Assistant (CNA) 4, CNA 4 stated when she delivered snacks to Resident 2, during the middle of the PM shift (3:00 PM through 11:00 PM) on 2/4/26, she noticed there was a plastic item between the call light plug and the outlet. CNA 4 stated she notified the licensed nurse (LN) right away. During an interview on 2/11/26 at 1:39 PM with LN 3, LN 3 stated she had noticed Resident 2's call light was not on as much as usual during the PM shift on 2/4/26. LN 3 further stated when she assessed the call light, she noticed there was a plastic tube between the call light plug and the outlet. LN 3 stated she removed the plastic tube and verified Resident 2 was okay. LN 3 stated she plugged the call light into the outlet without the plastic tube and the light worked. LN 3 further stated she reported the call light concern to her supervisor on 2/9/26 when she again saw a plastic tube in Resident 2's room. During an interview on 2/11/26 at 3:38 PM with the Director of Nurses (DON), the DON stated LN 3 reported Resident 2's call light concern on 2/9/26 when she observed another plastic tube on Resident 2's bedside table. The DON stated it was her expectation that staff would report the tampered call light when they noticed it. During a review of the facility policy and procedure titled, Answering the Call light, revised 1/024/24, the policy indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Be sure the call light is plugged in and functioning at all times.Report all defective call lights to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility failed to ensure care plans (a written, personalized document that outlines a resident's health needs, goals, and the specific services or actions required to address them) were developed and implemented when three of four sampled residents (Resident 1, Resident 2, and Resident 3), with diagnosed substance abuse disorder (SUD, a chronic disease characterized by the continued, compulsive use of alcohol or drugs despite experiencing severe, harmful, and negative consequences), did not have care plans in place for SUD.These failures placed Resident 1, Resident 2, and Resident 3 at risk for exit seeking behavior (the purposeful, often repeated, and urgent attempt by a resident to leave the facility) related to the urge to get drugs or alcohol, lack of interventions in place to support the possible withdrawal symptoms, (vomiting, diarrhea, nausea, paranoia) and potentially could have resulted in injury and/or psychosocial harm. a. A review of Resident 1's clinical document titled, admission RECORD, dated 1/15/26, indicated Resident 1 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:20 AM, Resident 1's care plans were reviewed. The DON confirmed Resident 1 did not have a care plan in place for SUD prior to 2/3/26 and there should have been a SUD care plan in place. The DON stated the importance of Resident 1 having a care plan for SUD was to monitor any potential withdrawals (physical and mental symptoms that a person has when they suddenly stop the use of an addictive substance, such as drugs or alcohol) and any drug seeking behavior. The DON explained the risk to Resident 1 of not having the SUD care plan was not having his psychosocial well-being monitored.b. A review of Resident 2's clinical document titled, admission RECORD, dated, 2/14/25, indicated Resident 2 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:35 AM, Resident 2's care plans were reviewed. The DON confirmed Resident 2 did not have a care plan in place for SUD prior to 2/3/26 and there should have been a care plan in place. The DON stated the importance of Resident 2 having a care plan for SUD was to monitor for any potential withdrawals and any drug seeking behavior. The DON explained the risk to Resident 2 not having a SUD care plan was not having his psychosocial well-being monitored.c. A review of Resident 3's clinical document titled, admission RECORD, dated 7/27/23, indicated Resident 3 had diagnoses which included SUD.During a concurrent interview and record review with the DON on 2/5/26 at 11:40 AM, Resident 3's care plans were reviewed. The DON confirmed Resident 3 did not have a care plan in place for SUD prior to 2/3/26 and should have had one in place. The DON stated the importance of Resident 3 having a care plan for SUD was to monitor any potential withdrawals and any drug seeking behavior. The DON explained the risk to Resident 3 not having a SUD care plan in place was not having her psychosocial well-being monitored.During a concurrent phone interview and record review with the DON on 2/6/26 at 11:37 AM, the facility's policies titled, LAWN Evaluation & Management - Leave of Absence without Notice (LAWN), undated; Wandering and Elopements, revised 3/19; and Goals and Objectives, Care Plans, revised 4/09, were reviewed. The LAWN Evaluation & [and] Management - Leave of Absence without Notice (LAWN), policy indicated, . The interdisciplinary team member (IDT - a collaborative group of professionals-including doctors, nurses, social workers, and therapists-who work together to create and implement a unified, holistic care plan for a resident) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice . Elopement occurs when a resident leaves the premises or a safe area without notice/authorization . and/or any necessary supervision to do so . Residents will be evaluated . for possible leave of absence without notice/authorization upon admission . A resident deemed at risk for Leave of Absence without Notice . are to consider the following measures . Initiate/update plan of care . Identify measures necessary to avoid leaving the facility without notice/authorization . The Wandering and Elopements policy indicated, . the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm . If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . The Goals and Objectives, Care Plans policy indicated, . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . Care plan goals and objectives are defined as the desired outcome for a specific resident problem . Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment . Are resident oriented . Are behaviorally stated . Are measurable . The DON confirmed the facility did not follow their, LAWN Evaluation & Management - Leave of Absence without Notice (LAWN), Wandering and Elopements, and Goals and Objectives, Care Plans policies. The DON confirmed Resident 1, Resident 2, and Resident 3 did not have SUD care plans in place. The DON explained the importance of developing and implementing care plans was so specific problem areas and diagnoses were addressed. The DON explained regarding SUD, the risk to the residents was drug seeking behavior and drug withdrawal.

Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) medical record's contained an accurate representation of their progress and/or their decline in health status after a change in condition when:1. Mucus was found in the stool of Resident 1 on 12/20/25 and nursing staff did not assess and document on the progress and/or decline in Resident 1's condition every shift; and, 2. Blood was found in Resident 2's urine (hematuria) on 1/2/26 and nursing staff did not assess and document on the progress and/or decline in Resident 2's condition every shift. These failures risked missing any changes or deterioration in the physical, mental, or psychosocial conditions of Resident 1 and Resident 2 after their change of condition. Findings:1. Review of Resident 1's medical record titled admission RECORD, indicated Resident 1 was admitted to the facility in late 2024 with diagnoses that included mild chronic kidney disease (long term condition when the kidneys are damaged and cannot filter waste and extra fluid from the blood), Parkinson's disease (a movement disorder of the nervous system) and dementia (a progressive state of decline in mental abilities). Review of Resident 1's medical record titled eINTERACT Change in Condition Evaluation - V 5.1, dated 12/20/25 at 1240, indicated .Resident noted with loose mucus like stool. Review of Resident 1's nursing follow-up documentation or monitoring following the change of condition on 12/20/25, indicated the following completed reports: a. 12/20/25 at 2254 - Follow-up Documentation b. 12/21/25 at 2148 - Follow-up Documentation c. 12/22/25 at 1218 - Follow-up Documentation Review of Resident 1's progress notes on monitoring following the change of condition on 12/20/25, indicated one note regarding the change of condition dated 12/21/25 at 0654 .Resident is alert and verbally responsive. On monitoring for mucus in the stool. During a concurrent interview and record review on 1/7/25, at 2:30 p.m., with Licensed Nurse (LN) 1, LN 1 stated a resident should be monitored every shift for 72 hours following a change of condition, and nurses should document on the report called Follow-up documentation. LN 1 reviewed Resident 1's chart and verified a change of condition report was done on 12/20/25 with three Follow-up documentation reports dated 12/20/25 during PM (evening) shift, 12/21/25 during PM shift and 12/22/25 during AM (morning) shift. LN 1 further reviewed Resident 1's chart and verified there were missing monitoring reports for other shifts following the change of condition on 12/20/25 (a total of 6 follow up documentation reports were missing in the 72 hour period). LN 1 stated Resident 1's chart showed a red alert that read the follow-up documentation reports should have been done every 8 hours. LN 1 stated Resident 1's monitoring following a change of condition should have been done every shift for the 72-hour timeframe. LN 1 stated it was important to monitor a resident every shift following a change of condition to be aware of the resident's status and to ensure whether the condition got better or if it had worsened. 2. Review of Resident 2's medical record titled admission RECORD, indicated Resident 2 was admitted to the facility in 2025 with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland).Review of Resident 2's medical record titled eINTERACT Change in Condition Evaluation - V 5.1, dated1/2/26 at 2201, indicated .Resident c/o [complained] that he is not feeling good.CNA [Certified Nurse Assistant] mentioned dark-colored urine on urinal and hematuria [blood in the urine].Review of Resident 2's follow-up documentation or monitoring following the change of condition on 1/2/26 indicated the following completed reports: a. 1/3/26 at 0713 - Follow-up Documentation b. 1/3/26 at 2315 - Follow-up Documentation c. 1/5/26 at 0619- Follow-up Documentation Review of Resident 2's progress notes on monitoring following the change of condition on 1/2/26, indicated one progress note dated 1/4/26 at 0202 .Alert and responsive.Resident unable to provide urine sample. Resident voided with little amount of urine.Monitored closely.During a concurrent interview and record review on 1/8/26, at 1:38 p.m., with LN 3, LN 3 stated Resident 2 had a change of condition on 1/2/26 because he complained he was not feeling good, had foul smelling urine, and had blood in the urine. LN 3 stated the change of condition process included monitoring the resident every shift for the next three days. LN 3 further stated a resident's condition could change quickly, the resident could be fine in the morning and could have a change by the evening shift. LN 3 reviewed Resident 2's change of condition monitoring and confirmed she only saw two shifts documentation done on 1/3/26, no monitoring report on 1/4/26 and only one report for 1/5/26 (a total of 6 missing follow up documentation reports were missing in the 72 hour period). LN 3 confirmed there should have been at least three follow-up documentation reports for each day of the three-day monitoring period. LN 3 further stated the importance of monitoring Resident 2 every shift for the three days following the change of condition was to have known his status and if the staff were following up on it. During a concurrent interview and record review on 1/9/26, at 3:00 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1 and Resident 2's chart and verified the missing documentation for the 72-hour timeframe, every shift, monitoring period following the change of conditions for both Resident 1 and Resident 2. The DON stated it was her expectation for a resident to have the 72-hour monitoring as part of the change of condition process documented. The DON further stated the staff should have documented on a progress note or completed the Follow-up documentation report every shift for the 72-hour timeframe. The DON stated the risk of not completing the resident monitoring every shift for the 72-hour timeframe would be not catching any subtle changes in the resident and the staff might miss something that could potentially lead to worsening of the resident's condition. Review of facility's policy titled Charting and Documentation, revised 7/2017, indicated .Policy Statement.All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding resident's condition and response to care. Policy Interpretation and Implementation. 2. The following information is to be documented in the resident medical record: .d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident.

Based on interview and record review, the facility failed to ensure the timeliness of laboratory services ordered by the physician for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when:1. Resident 1's stool sample testing result was delayed following a change of condition on 12/20/25; and, 2. Resident 2's STAT order (a physician's order that needs to be done immediately) results for a CBC (Complete Blood Count - a common blood test to check for an infection), BMP (Basic Metabolic Panel - a common blood test to measure fluid balance, blood sugar and certain electrolytes in the blood), and urinalysis with C&S (Culture and Sensitivity - urine testing to check for urinary tract infection and which germs are causing the infection) were delayed following a change of condition on 1/2/26; and,3. Resident 3's PT/INR (Prothrombin Time/International Normalized Ratio - a blood test to determine if the blood is clotting normally) ordered blood draws for December 2025 had delays in draw time (when the blood is ordered to be taken for a sample) and processing results; and, 4. Resident 4's PT/INR blood tests ordered in December 2025 had delayed draw times and delayed results. These failures risked delayed treatment and serious health issues for Resident 1, Resident 2, Resident 3, and Resident 4. Findings:1. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in late 2024 with diagnoses that included mild chronic kidney disease (long term condition when the kidneys are damaged and cannot filter waste and extra fluid from the blood), Parkinson's disease (a movement disorder of the nervous system) and dementia (a progressive state of decline in mental abilities). Review of Resident 1's medical record titled, .Change in Condition Evaluation ., dated 12/20/25, indicated .Resident noted with loose mucus like stool.MD ordered for stool sample to be collected. Review of Resident 1's medical record titled, Order Summary Report, indicated the following laboratory orders: a.Collect stool sample to test for C. Diff [Clostridium difficile - a bacteria that causes an infection of the intestine] one time only for mucus like stool.Order Date: 12/22/25.b.Collect stool sample to test for C. Diff one time only for mucus like stool.Order Date: 12/28/25.Review of Resident 1's Progress Notes indicated the following: c. 12/22/25 at 1218 (12:18 p.m.) - .Monitoring resident for mucus in stool.Stool collection pending. Resident has not had a BM at this time. d. 12/26/25 at 2318 (11:18 p.m.) - .Called [LABORATORY COMPANY NAME] to follow up on lab result at 2000 [8:00 p.m.] and 2300 [11:00 p.m.] no answer, left a message to call facility back. e. 12/27/25 at 2309 (11:09 p.m.) - .Lab called back on 12/27 at approx. 2305 [11:05 p.m.] , writer explained to lab rep that stool was picked up on 12/22, sample was picked up that same day. No result as of now. DON [Director of nursing] made aware. f. 12/28/25 at 2324 (11:24 p.m.) - .Per [LABORATORY STAFF NAME 1] with [LABORATORY COMPANY NAME], sample is no longer viable [good]. Writer explained that it was picked up after writer called lab and why facility wasn't notified ahead of time. [LABORATORY STAFF NAME 1] with [LABORATORY COMPANY NAME] is unaware of what is going on. MD [medical doctor] and DON was notified. g. 12/31/25 at 2101 (9:01 p.m.)- .Stool sample to be collected for C. Diff one time only.Spoke with [LABORATORY STAFF NAME 2] regarding specimen pick up for STAT [to be processed emergently/quickly] C. Diff lab order. h. 1/1/26 at 0443 (4:43 a.m.) - .Stool specimen been pick up by phlebotomist to be taken to laboratory for analysis. i. 1/3/26 at 2159 (9:59 p.m.) - .Writer called lab 3x [three times] to check on STAT lab result, no answer, left a message instead. RP made aware. j. 1/5/26 at 0006 (12:06 p.m.) - .Stool for C-diff result dated 1/4/26 was faxed to MD. During an interview on 1/7/26, at 3:20 p.m., with Licensed Nurse (LN) 2, LN 2 stated Resident 1 was reported to have mucus in her stool and was very smelly but did not have any other symptoms, so a change of condition report was completed on 12/20/25. LN 2 further stated Resident 1's doctor ordered a stool sample test as routine since she did not have any other symptoms. LN 2 stated she called the laboratory right away on 12/22/25 and in less than 5 minutes they came to collect the sample. LN 2 further stated there was a delay in getting Resident 1's stool sample result and she had called the laboratory to follow-up. LN 2 explained the delays to the MD and LN 2 received a second order that was STAT on 12/29/25. LN 2 stated there was no alternative laboratory company to send specimens to if there was an issue with the current company. LN 2 further stated the risk of delayed test results would be the potential for Resident 1's roommate to have been exposed if she had an active infection. LN 2 confirmed there was a delay in Resident 1's stool sample results since the change in condition happened on 12/20/25 and the final test result was received on 1/4/26. LN 2 stated the importance of getting laboratory tests done on time was for the resident to receive the care needed and to prevent worsening of a health condition. During a concurrent interview and record review on 1/9/26, at 3 p.m., with the DON, Resident 1's medical record was reviewed. The DON stated stool sample orders were usually a one-time only order or could be STAT due to a resident's change of condition. The DON further stated the stool sample timeframe would depend on when the sample was obtained and the expectation was for the laboratory to collect the sample within 24 hours or less. The DON stated specimen laboratory results for stool samples would usually take 24 to 72 hours. The DON confirmed Resident 1 had a change of condition for the mucus in the stool on 12/20/25 and the stool specimen was picked up on 12/22/25. The DON further confirmed several attempts were made to follow up with Resident 1's stool sample results. The DON stated this was not her expectation from the laboratory company because they should have followed the timeframes. The DON confirmed there was a delay with Resident 1's stool sample testing. The DON stated the risk to Resident 1 due to the delay of the stool sample was worsening of her condition.2. Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in 2025 with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland).Review of Resident 2's medical record titled, .Change in Condition Evaluation ., dated 1/2/26, indicated, .Resident c/o [complained of] that he is not feeling good.CNA [Certified Nurse Assistant] mentioned dark-colored urine on urinal [a portable container designed to collect urine for individuals with limited mobility] and hematuria [blood in the urine].MD made aware via fax .Review of Resident 2's physician orders indicated the following: a. 1/3/26 - .STAT CBC with differential, BMP, UA with C&S .b. 1/3/26 - .Please follow up with the lab if blood draw is not completed yet or call for the STAT result .c. 1/6/26 - .Send to ED [Emergency Department] for further evaluation .Review of Resident 2's Progress Notes indicated the following: a. 1/3/26 at 2344 (11:44 p.m.) - .[HOSPITAL NAME 1] MD order: STAT CBC with differential, BMP, UA & CS.b. 1/3/26 at 2011 (8:11 p.m.) - .Writer called lab on 1/3/26 at 12:01 [no answer] answer. Faxed order instead requesting for STAT order. No one came. Writer called again and spoke with [LABORATORY STAFF NAME 3] requesting for another STAT order.c. 1/3/26 at 2315 (11:15 p.m.) - .Writer called lab to follow up on STAT blood work. Per [LABORATORY STAFF NAME 3], they will send someone in the facility asap [as soon as possible].Writer endorsed to NOC [night shift] nurse about following up STAT lab if no one came to draw blood.d. 1/4/26 at 1509 (3:09 p.m.) - .Urine sample collected and picked up by [LABORATORY COMPANY NAME] phlebotomist [professional who draws blood]. e. 1/5/26 at 0619 (6:19 a.m.) - .Resident wanted to know when he will be put on atb [antibiotic]. Explained MD needs urine and culture results to start him on atb.f. 1/6/26 at 1611 (4:11 p.m.) - .Pending labs [waiting for] UA C&S. g. 1/6/26 at 2309 (11:09 p.m.) - .At approx 1600 [4 p.m.], resident was seen by [MD NAME]. MD asked writer if UA/CS result came back, no STAT UA/CS result as of yet. Upon MD's assessment, pt looks flushed [a sudden temporary reddening of the skin].Due to resident not having UA/CS result yet, MD requested resident to be sent to ED [emergency department].h. 1/7/26 at 0032 (12:32 a.m.) - .Back from ED.Resident was sent to ED due to painful urination.hematuria as per reported by resident to MD.Per ED discharge diagnosis of Urinary Tract Infection with ABT therapy. During an interview on 1/7/25, at 3:20 p.m., with LN 2, LN 2 stated Resident 2 had a change of condition for having UTI symptoms and hematuria on 1/2/26. LN 2 further stated Resident 2's doctor ordered STAT UA with C&S, CBC and BMP and was not drawn until 1/4/26. LN 2 stated Resident 2's urine sample was collected on 1/4/26 and by 1/6/26 the results were still not received from the laboratory. LN 2 further stated on 1/6/26, Resident 2's MD ordered for Resident 2 to be sent out to the ER because of no results still. LN 2 stated Resident 2 came back the same day of going to the ER and it was confirmed he had a UTI at the hospital. LN 2 further stated it was important to receive laboratory results on time to prevent delays for a resident's care and to get the treatment needed right away. LN 2 stated the risk of delayed laboratory results would be septic shock [a serious life-threatening emergency condition], worsening of the resident's condition, and the need to be sent to the hospital. During a concurrent interview and record review on 1/9/26, at 9:55 a.m., with LN 3, LN 3 reviewed Resident 2's chart for his lab orders. LN 3 confirmed Resident 2's STAT labs were ordered on 1/3/26 for CBC, BMP and UA with C&S. LN 3 stated on 1/3/26, the staff could not obtain a urine sample in the morning and evening shift. LN 3 further stated on 1/3/26, the nurse called the laboratory, but no one came for the blood draw and finally on 1/4/26 the urine sample was collected by the laboratory. LN 3 stated on 1/6/26, Resident 2's MD ordered him to be sent out to the ER because there were still no results received from the laboratory. During a concurrent interview and record review on 1/9/26, at 3 p.m., with the DON, the DON stated the expected timeframe for STAT orders to be drawn would be between 4 to 8 hours and results within 24 hours or less. The DON further stated the expected timeframe for STAT UA with C&S would be for the laboratory company to have collected the sample within 24 hours or less and the results should have been received within 24 hours. The DON confirmed Resident 2's STAT order results were delayed because the laboratory company did not send the results timely. The DON further stated if Resident 2's samples were taken on 1/4/26, the results should have been received within 24 hours. The DON stated the laboratory should have sent the results sooner because they were STAT orders and Resident 2 ended up going to the ER on [DATE] because of the delay. 3. Review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility in 2021 with diagnoses that included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy caused by early brain damage that results in weakness on all limbs, trunk and face) and developmental disorder of speech and language. Review of Resident 3's medical record titled, MEDICATION ADMINISTRATION RECORD, indicated the following orders for PT/INR testing for December 2025: a. 11/29/25 - .Warfarin Sodium oral tablet 5 mg [blood thinner medication].NEXT PT/INR on 12/01/2025.b. 12/03/25 - .Warfarin Sodium oral tablet 5 mg.NEXT PT/INR on 12/08/2025.c. 12/12/25 - .Warfarin Sodium oral tablet 5 mg.NEXT PT/INR on 12/16/25.d. 12/18/25 - .Warfarin Sodium oral tablet 5 mg.NEXT PT/INR on 12/24/25.Review of Resident 3's medical record titled, Order Summary Report, indicated the following PT/INR orders for December 2025:a. 11/27/25 - .LAB: PT/INR on 12/01/2025. b. 12/11/25 - .PT/INR STAT for COUMADIN [brand name for Warfarin] DOSING.Start Date: 12/11/25.c. 12/12/25 - .STAT PT/INR on 12/16/2025. Pls call lab for STAT PT/INR.d. 12/28/25 - .STAT: PT/INR one time only for 4 days.Start Date: 12/28/2025.e. 12/29/25 - .STAT: PT/INR STAT.Start Date: 12/29/2025.Review of Resident 3's Progress Notes for the month of December 2025, indicated the following: a. 12/11/25 at 2313 (11:13 p.m.) - .Called [LABORATORY COMPANY NAME] about PT/INR results. Confirmed with [LABORATORY STAFF NAME 4] from [LABORATORY STAFF NAME 5] (lab coordinator) that PT/INR was drawn on 12/8. Awaiting results. MD aware, continue Warfarin 5 mg dose until next PT/INR. Endorsed to oncoming nurse.b. 12/12/25 at 0444 (4:44 a.m.) - .Phlebotomist in to draw stat pt/inr on resident @0330 [3:30 a.m.]. Made phone call to [LABORATORY COMPANY NAME] @ 0445 [4:45 a.m.] to f/u [follow-up] on pt/inr results. No answer at this time. c. 12/12/25 at 0701 (7:01 a.m.) - .Made phone call to [LABORATORY COMPANY NAME] to f/u on 12/2 pt/inr. No answer. Endorsed to next shift to f/u with results. d. 12/12/25 at 2223 (10:23 p.m.) - .MD reviewed lab results and ordered warfarin 10 mg PO at HS [at bedtime] x 2 days [for two days] and then 5 mg PO in the evening thereafter. Next PT/INR on Tuesday 12/16/25. e. 12/16/25 at 0545 (5:45 a.m.) - .Laboratory work: PT/INR, done today.f. 12/19/25 at 0652 (6:52 a.m.) - .Made lab req [request] for pt/inr draw on 12/24/25. Placed in lab binder.g. 12/24/25 at 0452 (4:52 a.m.) - .Phlebotomists unable to obtain sufficient blood for pt/inr draw.h. 12/26/25 at 2324 (11:24 p.m.) - .LN requested for STAT PT/INR per MD. LN called at 2000 [8 p.m.], 2300 [11 p.m.] and 2324 [12:24 p.m.] no answer, faxed requisition instead. i. 12/27/25 at 2338 (11:38 p.m.) - .Lab called back on 1227 [12:27 a.m.] at approx 2305 [11:05 p.m.], writer explained to lab rep [representative] that it's a STAT order and to call [NAME] when the result is available and fax to facility ASAP. NOC nurse made aware. DON notified. j. 12/28/25 at 0657 (6:57 a.m.) - .Called lab at 0700 [7 a.m.] to f/u on pt/inr results. No answer and phone line cut out. No results on portal in system either.k. 12/28/25 at 2347 (11:47 p.m.) - .Called [LABORATORY COMPANY NAME] and per [LABORATORY STAFF NAME 1], no result yet. Another STAT PT/INR was requested d/t [due to] no result coming from the lab. MD and DON made aware.l. 12/29/25 at 0455 (4:55 a.m.) - .Stat PT/INR drawn by phlebotomist @0400 [4 a.m.].m. 12/30/25 at 1027 (10:27 a.m.) - .Faxed to MD to review, awaiting any new orders. Nurse aware. n. 1/2/26 at 0649 (6:49 a.m.) - .PT/INR laboratory work, not done, per phlebotomist, she can't draw and another phlebotomist will come and do it at around 10:00 am today.During a concurrent interview and record review on 1/7/26, at 11:42 a.m., with LN 1, LN 1 reviewed the [NAME] station laboratory binder log form for Resident 3. LN 1 stated UTO meant unable to obtain and Resident 3 was known to be a hard stick (unable to obtain blood sample). LN 1 further stated Resident 3 got his PT/INR testing done weekly because he was on the medication Warfarin. LN 1 stated the laboratory results would be faxed over to the facility from the new laboratory company they were using. LN 1 explained the facility used to receive laboratory results online through the resident's chart with the old company. LN 1 stated the new laboratory company took a bit longer to receive PT/INR test results. During an interview on 1/7/26, at 3:20 p.m., with LN 2, LN 2 stated Resident 3's PT/INR testing was done weekly and the turnaround time for PT/INR results were usually received right away. LN 2 further stated there was a change in the laboratory company, and since then the nurses have had to follow-up and results have been taking a while. LN 2 stated they were told that the laboratory results would be integrated into the resident's electronic chart but had not been integrated yet so the lab company has to manually fax the results. LN 2 further stated the nurses had to follow up a couple of times due to the delays in getting the laboratory results. LN 2 stated she did not know of any back-up or alternative laboratory that the facility used. During a concurrent interview and record review on 1/9/26, at 9:55 a.m., with LN 3, Resident 3's medical chart was reviewed. LN 3 stated it was important for Resident 3's PT/INR to be done to ensure he was getting the right dose of his Warfarin medication because the MD would adjust the dose based on the test result. LN 3 further stated on 11/27/25, the MD reviewed Resident 3's PT/INR results and the next test would be on 12/1/25. LN 3 stated there was no documentation found for 12/1/25 until 12/11/25 when the nurse called the laboratory to follow-up on the result for PT/INR drawn on 12/8/25. LN 3 further stated on 12/12/25 a phlebotomist came to draw STAT order for PT/INR at 3:30 a.m. LN 3 further stated at 4:45 a.m., another nurse followed up on the PT/INR results, but no one answered at the laboratory. LN 3 explained the facility received results during the evening shift. LN 3 stated Resident 3 had a scheduled PT/INR order on 12/24/25 and the phlebotomist came and could not obtain a sufficient blood sample. LN 3 further stated on 12/26/25, a STAT PT/INR was requested, and the nurse made three calls to the laboratory with no answer. LN 3 stated on 12/27/25, the laboratory called back and the nurse explained the STAT PT/INR order was sent and the DON was then notified. LN 3 further stated on 12/28/25, the nurse called the laboratory to follow-up and the phone line cut out. LN 3 explained that the facility still did not receive the results during the evening shift and another STAT PT/INR was requested and both MD and DON were made aware. LN 3 stated the risk of not getting the laboratory tests timely would be the resident receiving the wrong dose and would cause complications such as blood clots (blood clots can lead to risks like deep vein thrombosis (DVT, blood clot in an extremity like the leg), pulmonary embolism (blood clot in the lung), stroke (blood clot in the brain), or severe bleeding.During a concurrent interview and record review on 1/9/26, at 3 p.m., with the DON, Resident 3's medical records were reviewed. The DON stated the expectation for routine PT/INR blood to be drawn would be within 24 hours and if the order was STAT then it should have been drawn between 4 to 8 hours. The DON further stated the results should have been received in 24 hours or less. The DON confirmed Resident 3 had weekly testing of PT/INR and the schedule would depend on the test results. The DON further confirmed Resident 3's orders and progress notes indicated there were delays in getting Resident 3's PT/INR results from the laboratory. The DON stated there had been issues with getting test results from the new laboratory company and the alternative plan would be sending the resident out to the ER. The DON further stated there was no alternative laboratory company at the time. 4. Review of Resident 4's admission RECORD, indicated Resident 4 was admitted to the facility in 2025 with diagnoses that included atrial fibrillation (an irregular heart rhythm condition) and congestive heart failure (a long-term condition when the heart could not pump blood enough). Review of Resident 4's progress notes for the month of December 2025 indicated the following: a. 12/3/25 at 2314 (11:14 p.m.)- .The Change of Condition/s reported on this CIC [change in condition] Evaluation are/were:.Called [HOSPITAL NAME 1] and informed that there is no current doses order for warfarin. Last pt/inr draw was on 12/01/25 .New order carried out to document med error, if coumadin was not put on hold, but coumadin was missed due to med error then give warfarin 2 mg now, rechecked INR @ 6am morning STAT and notify coumadin clinic and SNF [skilled nursing facility] MD and follow coumadin orders.Stat pt/inr blood draw called over to [LABORATORY COMPANY NAME].b. 12/4/25 at 0635 (6:35 a.m) - .On monitoring for med error of missed doses of warfarin.No adverse effects noted.Phlebotomist in @0400 [4 a.m.] to draw stat pt/inr. Pending lab results. Endorsed to AM LN to f/u lab results and send to coumadin clinic once received and f/u with coumadin clinic for next dose.c. 12/4/25 at 2302 (11:02 p.m.) - .Followed up with [LABORATORY COMPANY NAME] 5 x [five times] for the stat pt/inr lab.but per operator [LABORATORY STAFF NAME 3] and [LABORATORY STAFF NAME 2], the result is not out yet. Called [HOSPITAL NAME 1] and also informed what is going on since resident did not [sic] warfarin dose for today x 2. Per RN [registered nurse], she will contact the [HOSPITAL NAME 1] doctor and will fax over whatever the order will be to this facility. Will endorse to oncoming shift to follow up.d. 12/4/25 at 2359 (11:59 p.m.) - .Ordered carried out to continue coumadin 2 mg.report the INR to the coumadin clinic tomorrow 12/05/25, and monitor s/s [signs and symptoms] of bleeding .e. 12/5/25 at 0602 (6:02 a.m.) - .Called [LABORATORY COMPANY NAME] to follow up on the results of the Stat order for PT/INR that was drawn 12/4/2. No results yet at this time,. Will follow up again.f. 12/5/25 at 0632 - .Phlebotomist in @0320 [3:20 a.m.] asking if stat pt/inr was already done. Per report it was done already but unable to locate the stat pt/inr requisition [labroatory slip] for 12/4/25. Phlebotomist called lab center and lab was drawn for cbc, cmp and pt/inr on 12/4/25 but facility requisition only states cbc and cmp. LN made requisition form for pt/inr. Blood work drawn for pt/inr this am.g. 12/5/25 at 2328 (11:28 p.m.) - .Correction: on 12/04/25 new order from [HOSPITAL NAME 1] to administer warfarin 2 mg and given @ 2200 [10 p.m.]. Per emar [electronic medication administration record], medication was administered around 0115 am. DON and MD notified of medication administration time change. New order carried out for warfarin 2 mg to be administered for 12/05/25. Received another result dated for 12/02/25 @2151 [9:51 p.m.].Review of Resident 4's medical records from [HOSPITAL NAME 1] titled, ANTICOAGULATION-SNF COMMUNICATION FORM, indicated, .Was there a.INR test done since the last INR? .INR Result: 1.2.Date/Time: 12/4.Were there any missed doses of warfarin since the last INR? .Provide dates and details of missed warfarin doses: 12/1, 12/2 and 12/4.During a concurrent interview and record review, on 1/9/26. At 11:07 a.m., with LN 4, LN 4 reviewed Resident 4's chart. LN 4 stated Resident 4 got his PT/INR tested weekly. LN 4 further stated the laboratory results have been taking a while, and the nurses had been calling for the results. LN 4 explained they had to wait for the faxed results and then faxed the results over to the coumadin clinic. LN 4 confirmed on 12/3/25, Resident 4 had a change of condition report that stated medication error for a missed Warfarin dose. LN 4 stated the notes indicated only one missed dose on 12/3/25 and a STAT PT/INR was ordered on 1/4/25. LN 4 further stated she was not aware of what happened, but it was a known fact that there were delays in getting Resident 4's PT/INR results. LN 4 stated on 12/4/25, the phlebotomist came in to draw the STAT PT/INR and a new dose of Warfarin was ordered on 12/5/25. LN 4 further stated the facility should have received a STAT order result on the same day or within 24 hours. LN 4 stated it was important to have timely receipt of laboratory results because if the result was abnormal, then the resident's condition might worsen, and could cause delays in care. LN 4 further stated if Resident 4 missed a dose of Warfarin, then he would need to wait for a new test result to get the medication dosing needed from the coumadin clinic. LN 4 explained the risk to Resident 4 with delays in testing results would be worsening of his condition and blood clots. During a concurrent interview and record review on 1/9/26, at 12:05 p.m., with the DON, Resident 4's medical records were reviewed. The DON stated Resident 4 was under the [HOSPITAL NAME 1] and once his laboratory test results were received, it would be faxed over to the coumadin clinic for the medication orders. The DON further stated she was notified by the nurse that Resident 4's change of condition issue on 12/3/25 was due to the missed Warfarin doses on 12/1/25 and 12/2/25 because his PT/INR draw was not done on 12/1/25. The DON stated she had told the nurse to ask for a STAT PT/INR order and the MD was notified. The DON further stated she was told by the MD to wait for the STAT PT/INR results. The DON explained that she was made aware by the LN that she called the laboratory five times to follow-up. The DON stated the facility had no issues with the old laboratory company because it was established and routine, and due to the changes with the new company it had been a struggle. During a follow-up concurrent interview and record review on 1/9/26, at 3 p.m., with the DON, Resident 4's hospital records were reviewed. The DON confirmed Resident 4's hospital record indicated the missed Warfarin doses on 12/1/25, 12/2/25 and 12/4/25. The DON stated Resident 4's missed Warfarin doses were due to the laboratory issue. The DON further stated the laboratory did not complete Resident 4's PT/INR draw for 12/1/25 and there were no current doses due to the pending result at the time. The DON stated the risk of missed medication doses for Resident 4 was the risk of blood clots. During an interview on 1/9/26, at 5:32 p.m., with the Administrator (ADM), the ADM stated it was his expectation for the laboratory company to have followed their contract for the completion of testing results. The ADM further stated if there were delays, the laboratory should have communicated with the facility for any barriers and what their plans were to address the issue. The ADM stated the facility's alternative if the laboratory company could not provide results would be to find a new provider. The ADM further stated it was important to have laboratory results timely so care was not delayed for the residents. During a phone interview on 1/21/26, at 10:05 a.m., with [LABORATORY STAFF NAME 4], [LABORATORY STAFF NAME 4] stated they have a partnered laboratory that caters to the Stockton area facilities. [LABORATORY STAFF NAME 4] stated the facility orders were received from facilities by email or fax. [LABORATORY STAFF NAME 4] stated once an order was received, they would call the facility to confirm the order and would then send a phlebotomist onsite. [LABORATORY STAFF NAME 4] stated the routine PT/INR orders were usually endorsed during the day of the order and the phlebotomist would also go on the same day to the facility to draw blood from the resident. [LABORATORY STAFF NAME 4] explained for STAT orders they had specialized order processing and it would immediately get sent to their manager based on priority. Review of the facility's contract with [LABORATORY COMPANY NAME] titled California Professional Diagnostics Services Agreement, effective date 11/1/25, indicated .2. [LABORATORY COMPANY NAME] Services and Responsibilities.Laboratory send out results will be made available to the facility when received from the reference laboratory and may vary depending on the test ordered.For all STAT orders provided by the physician, [LABORATORY COMPANY NAME] will prioritize and expedite the services and return results to the facility as promptly as possible. The facility will make its best efforts to limit STAT orders for critical conditions, as deemed absolutely necessary by the physician.Review of facility's undated policy titled, Lab and Diagnostic Test Results - Clinical, indicated, .Protocol.Assessment and Recognition.1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Referral of Problems and Concerns About the Process.1. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director.a. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation.

Based on interview and record review, the facility failed to develop a comprehensive care plan for two of four sampled residents (Resident 1 and Resident 2) following a change of condition when: 1. Mucus was found in the stool of Resident 1 on 12/20/25; and, 2. Blood was found in Resident 2's urine (hematuria) on 1/2/26. These failures placed Resident 1 and Resident 2 at risk of not receiving appropriate and individualized care to meet their needs. 1. Review of Resident 1's medical record titled admission RECORD, indicated Resident 1 was admitted to the facility in late 2024 with diagnoses that included mild chronic kidney disease (long term condition when the kidneys are damaged and cannot filter waste and extra fluid from the blood), Parkinson's disease (a movement disorder of the nervous system) and dementia (a progressive state of decline in mental abilities). Review of Resident 1's medical record titled eINTERACT Change in Condition Evaluation - V 5.1, dated 12/20/25, indicated .Resident noted with loose mucus like stool. During a concurrent interview and record review on 1/7/26, at 2:30 p.m., with Licensed Nurse (LN) 1, LN 1 stated if a resident had a change in condition the nurse would need to complete reports which included updating the resident's care plans to include the new issue. LN 1 reviewed Resident 1's care plans and confirmed Resident 1 did not have a care plan initiated following the change of condition for the mucus in her stool on 12/20/25. LN 1 stated there should have been a care plan initiated for Resident 1's change of condition. LN 1 stated it was important to have initiated a care plan in order for the staff to be aware and to follow-up on health issues, and if the issue happened again, then the care plan would be used as a reference on what interventions were needed or if it was resolved. 2. Review of Resident 2's medical record titled admission RECORD, indicated Resident 2 was admitted to the facility in 2025 with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). Review of Resident 2's medical record titled eINTERACT Change in Condition Evaluation - V 5.1, dated1/2/26, indicated .Resident c/o [complained] that he is not feeling good.CNA [Certified Nurse Assistant] mentioned dark-colored urine on urinal [a plastic container designed to collect urine for individuals with limited mobility] and hematuria.During a concurrent interview and record review on 1/8/26, at 1:38 p.m., with LN 3, LN 3 stated Resident 2 had a change of condition on 1/2/26 because he complained he was not feeling good, urine had a foul odor, and had blood in the urine. LN 3 stated if a resident had a change of condition then a care plan should have been created by the nurse. LN 3 reviewed Resident 2's care plans and confirmed there was no care plan created for the change of condition on 1/2/26 for the hematuria. During a concurrent interview and record review on 1/9/26, at 3:00 p.m., with the Director of Nursing (DON), the DON confirmed both Resident 1 and Resident 2 did not have care plans created for their changes in condition. The DON stated it was her expectation for a care plan to have been created for every change of condition for each resident. The DON stated it was important to have created a care plan because it was specific, resident centered, and individualized to the resident's care needed for the change of condition. Review of facility's policy titled Charting and Documentation, revised 7/2017, indicated .Policy Statement.All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation.2. The following information is to be documented in the resident medical record: .d. Changes in the resident's condition; .f. Progress toward or changes in the care plan goals and objectives.

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly calibrated according to their individual weights.This deficient practice had the potential to delay wound healing and place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.Findings:a. Review of an admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including traumatic subdural hemorrhage (a collection of blood between the brain's surface and its outer covering), Alzheimer's disease (a progressive brain disorder that affects thinking, memory, and language, interfering with daily life), unspecified psychosis (a breakdown in reality where thoughts become jumbled, and external voices or messages might seem real), extrapyramidal and movement disorder (a group of conditions that cause abnormal, involuntary movements, can also include a lack of movement), major depression disorder, anxiety disorder.During an observation on 11/19/25 at 2:28 PM Resident 1 was noted lying on her back in bed on a LAL mattress, which was set for a person who weighed 355 pounds (LBS-a unit of measure).During a concurrent observation and interview, on 11/19/25 at 2:35 PM, CNA 1 stated that Resident 1 had skin breakdown on her right buttock with a wound dressing in place. CNA 1 confirmed that Resident 1 was lying on an LAL mattress on her back and further verified that the mattress was set for someone who weighed 355 LBS.During a concurrent observation, interview, and record review, on 11/19/25 at 3:22 PM, LN 1 stated that Resident 1 had one healed shear wound (when skin sticks to a surface, but underlying tissues (like muscle and bone) slide in the opposite direction due to gravity or movement, damaging deep tissue and blood vessels) on the right buttock and one new wound to the right buttock that was identified during AM shift on 11/19/25. A review of Resident 1's medical record with LN 1 revealed Resident 1's most recent weight, dated 11/2/25, was 137.2 LBS. LN 1 verified the weight and confirmed, in Resident 1's room, that the LAL mattress was set for someone who weighed 355 LBS, which did not reflect Resident 1's actual weight. LN 1 stated that it was the nurses' responsibility to ensure the LAL mattress setting was adjusted according to Resident 1's current weight. LN 1 further explained that incorrect settings posed a potential risk for Resident 1's wound to worsen. LN 1 further stated that the purpose of the LAL mattress was to promote healing of existing wounds and provide preventative care, and that failure to set it correctly could lead to deterioration of the wound. Review of the facility provided user manual for [brand name of LAL] , dated 2019 indicated, . [Model #] LOW AIR LOSS MATTRESS with ALTERNATING PRESSURE. Product Function: (1) Pressure Adjust Valve: Adjust the valve to increase or decrease the pressure for a softer or firmer setting between 1-8 range or by patients weight as noted on the panel. b. Review of an admission Record indicated Resident 2 was admitted to the facility with multiple diagnoses including malignant neoplasm (a cancerous tumor that can invade surrounding healthy tissue and spread to other parts of the body), cellulitis (a common infection affecting the skin's deeper layers and tissues)of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region (an area of damaged skin and tissue near the tailbone, also known as a bedsore, caused by prolonged pressure).During an interview on 11/20/25 at 11:32 AM, Resident 2 stated she was admitted to the facility with multiple skin wounds, including pressure ulcers, and was provided with a LAL mattress for wound management.During a concurrent observation and interview on 11/20/25 at 11:39 AM, the Treatment Nurse (Tx Nurse) stated Resident 2 was admitted with multiple wounds and weighed less than 100 LBS. The Tx Nurse confirmed Resident 2's LAL mattress was set for someone who weighed 160 LBS and verified it was not set correctly for Resident 2's actual weight.During a concurrent interview and record review conducted on 11/20/25 at 12:19 PM, Resident 2's medical record titled Weights and Vitals Summary, dated 11/15/25 was reviewed with the Tx Nurse. The review of Resident 2's weight records indicated the most recent weight on 11/15/25 was 93.4 LBS. The Tx Nurse stated that Resident 2 had pressure wounds, and a LAL mattress was provided to support wound healing and relieve pressure. The Tx Nurse stated the LAL mattress should be set according to Resident 2's current weight. The Tx Nurse reported the mattress was set incorrectly. The Tx Nurse explained that nurses were responsible for adjusting the LAL mattress to match Resident 2's current weight. The Tx Nurse further stated that there was a potential risk of the pressure wounds worsening when the mattress was not set correctly according to Resident 2's weight.Review of Resident 2's Order Summary Report indicated an active order, dated 11/17/25, for pressure ulcer precautions, including providing a pressure relieving mattress.Review of Resident 2's Body Check .x - V2, dated 11/17/25, indicated . SAROCOCCYX UNSTAGEAGBLE PRESSURE INJURY Wound. 2. Pressure Ulcer Prevention Measures. a. Pressure reducing mattress.Review of the facility provided document LAL mattress operator's manual for Brand Name, dated 2016 indicated, . GENERAL. Specifically designed to redistribute pressure, these systems offer a solution for the prevention and treatment of pressure ulcers and offers an optimal solution for pressure redistribution and microclimate control. PRODUCT FUNCTIONS. The WEIGHT SETTING Buttons (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight.During a concurrent interview and record review on 11/20/25 at 4: 20 PM of the facility provided LAL mattress user manual for Brand Name and LAL mattress operator's manual for Brand Name were reviewed with the Director of Nursing (DON). The DON stated nurses were responsible for adjusting the settings on LAL mattresses in the facility. The DON explained the importance of relieving pressure from wound sites and stated that correct weight distribution was essential, noting that improper mattress settings could contribute to the worsening of wounds for residents using LAL mattresses. The DON stated that LAL mattresses were intended to improve pressure wound conditions, and improper pressure distribution might lead to wound deterioration and longer healing periods, potentially affecting the health status of the residents. The DON further stated she expected nurses to adjust the LAL mattress settings for Resident 1 and Resident 2 according to their current weights to ensure the settings matched each resident's actual weight. The DON acknowledged that her expectations were not met. The DON also acknowledged that nursing staff did not follow the manufacturer's guidelines for the LAL mattresses for Resident 1 and Resident 2 when the air pressures were not adjusted to the residents' weights. The DON stated that failure to follow the manufacturer's instructions could significantly contribute to the worsening of Resident 1 and Resident 2's wound conditions and potentially affect their overall health status.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager met Federal, California, and facility standards for food service manager. This failure had the potential of leading to food borne illness and malnutrition for the 112 residents eating facility prepared meals.During an interview with the Dietary Manager (DM), on 7/21/25, at 7:54 AM, the DM stated she had not completed the Certified Dietary Manager (CDM) program which had been purchased in January 2025, after starting work as the DM for the facility in December 2024. The DM also stated she was currently working 40 hours a week as the DM. A review of the facility provided job description titled, Certified Dietary Manager, dated October 2020, indicated the following: Education -Must possess, as a minimum, a bachelor's degree in nutrition, dietary management field from an accredited college or university.Specific Requirements-Must be a Certified Dietary Manager (or comparable certification) in the state. During an interview with Registered Dietitian 2 (RD 2) on 7/23/25, at 1:01 pm, RD 2 described her duties at the facility. RD 2 worked primarily with the residents providing clinical nutrition (assessments, reassessments, care planning nutrition issues, etc.). When asked about her involvement in the kitchen, RD 2 stated that she did a monthly inspection of the kitchen, as well as a monthly observation of the meal plating and a monthly taste test of the meal. Review of California Health and Safety Code 1265.4 indicated that licensed health facilities who do not hire a full-time registered dietitian to manage the kitchen, must employ a full-time Dietary Manager. The Code lists seven pathways, such as a bachelor's degree in food and nutrition, dietetics, or food management, or graduation from a dietetic technician, Dietary Services Supervisor, and Certified Dietary Manager program. It also indicated that A graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, must maintain this certification, as well as having received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility .

Based on interview and record review, the facility failed to provide adequate supervision to prevent an avoidable accident for one of three sampled residents (Resident 3) when, Resident 3 exhibited exit seeking behaviors (type of wandering where residents actively try to leave a designated area, often with the intention of going to a familiar place), Resident 3 was not re-evaluated for risk of elopement (when a resident leaves the premises or a safe area without the facility's knowledge and supervision), and interventions to prevent Resident 3's exit seeking behaviors were not created. This failure resulted in Resident 3 falling from a wheelchair on 3/28/25 while exiting the front door and striking her head on the concrete causing a one-and-a-half-inch open wound that required 6 stitches (used to close a wound by sewing the edges of the cut together to help with wound healing), an abrasion (an injury caused by the skin rubbing off) to Resident 3's right elbow and right knee. Findings: A review of Resident 3's ADMISSION RECORD indicated, Resident 3 was admitted to the facility in early 2020 with a diagnosis that included, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). During an interview on 4/8/25 at 4:42 PM, in the [NAME] Station Hallway, Licensed Nurse (LN) 1 confirmed she was working PM shift (evening shift from 3 PM - 11:30 PM) on 3/28/25 when Resident 3 eloped and was injured. LN 1 stated Resident 3 was awake and in a wheelchair following LN 3 around the [NAME] Station. LN 1 explained later in the shift, LN 3 came up to her and asked if she had seen Resident 3. LN 1 further explained she went looking for Resident 3 toward the front lobby because Resident 3 has a history of .always trying to leave . LN 1 stated she found an empty wheelchair inside the lobby near the front door. LN 1 further stated she checked the name on the wheelchair, and it belonged to Resident 3. LN 1 stated she opened the front door and then found Resident 3 outside on the ground. LN 1 explained she observed Resident 3 partially sitting up, holding a napkin to her head, and had blood running down her face. LN 1 stated she quickly assessed Resident 3 and went to get staff to assist Resident 3. LN 1 further stated Resident 3 had known behaviors of stating she wanted to leave the facility in the past and was making statements earlier in the evening on 3/28/25. LN 1 stated on the evening of 3/28/25 prior to Resident 3 falling, Resident 3 was very adamant and stated several times she wanted to go home. During a telephone interview on 4/9/25 at 3:29 PM, LN 3 stated on 3/28/25, during the PM shift, Resident 3 was in a wheelchair and followed LN 3 from room to room in the [NAME] Hallway while medications were being passed to other residents. LN 3 explained just before 9 PM she had to go into a room where she had to put on full personal protective equipment (PPE -clothing and equipment that is worn or used to provide protection against germs) and give a medication through a gastrostomy tube (GT -a surgically placed tube that provides direct access to the stomach for food or medications) which takes more time to prepare and give. LN 3 further explained she came out of the room, documented the medication in the electronic health record (a collection of resident health information stored in a digital format), and then moved to the next room. LN 3 stated she then realized Resident 3 was no longer following her. LN 3 further stated she checked the nurse's station, the resident's room, bathroom, and other resident's rooms while LN 1 went toward the sound of an alarm at the front door. LN 3 stated LN 1 came back and said she found Resident 3 outside the front door and needed assistance getting her back in the wheelchair. LN 3 stated she checked Resident 3 for injuries, called the MD (medical doctor) and received an order to send Resident 3 to the hospital for evaluation and treatment. LN 3 confirmed Resident 3 did not have on a monitoring bracelet (a device used to alert staff of a resident leaving the premises) on the date of the fall (3/28/25). LN 3 explained Resident 3 had a previous incident of being agitated and verbalized she wanted to leave in the recent past. LN 3 stated last week the resident had wandered (move in a leisurely, casual, or aimless way) into another resident's room towards East station and was asking another residents family member to give her a ride home. LN 3 stated she did not complete an elopement risk assessment but documented the behaviors. During an interview on 4/8/25 at 5:35 PM, Certified Nursing Assistant (CNA) 3 confirmed she was working PM shift on 3/28/25 and assisted in helping Resident 3 back into the wheelchair. CNA 3 further stated she heard the front door alarm sounding for about 5-8 minutes before she was asked to help Resident 3 back into the wheelchair after the fall. CNA 3 explained Resident 3 did not have a monitoring bracelet on at the time of the fall. CNA 2 further explained the front door was armed to alert staff when someone came or left the front door after the front desk staff left for the evening. During a concurrent interview and record review on 4/8/25 at 4:52 PM, Resident 3's Elopement Evaluation, dated 7/12/24 and 3/29/25, were reviewed with LN 2. LN 2 stated Resident 3 was assessed for elopement risk on 3/29/25, one day after the fall with injuries. LN 2 further stated Resident 3 was not considered an elopement risk prior to 3/28/25 because she did not meet criteria when assessed for an elopement risk on 7/12/24. LN 2 explained the elopement risk criteria included: Elopement attempts, verbalizing wanting to leave, and exit seeking behaviors. LN 2 further explained when a resident was on elopement risk monitoring, they add additional interventions like the use of a monitoring bracelet, redirecting the resident from known elopement behaviors, and ensuring the residents are more closely watched. During an interview on 4/8/25 at 5:53 PM, the Assistant Director of Nursing (ADON-Interim Director of Nursing) stated her expectation when a new behavior occurs in cognitively impaired (problems with a person's ability to think, learn, remember, use judgement, and make decisions) resident was the staff were required to complete a Change of Condition (COC) form and then they collaborate with their Interdisciplinary Team (IDT - a team of healthcare professionals) to come up with a goal to help the resident. The ADON explained an elopement risk assessment should be completed on admission and when the resident displayed any behaviors that would trigger an assessment. The ADON stated a resident who verbalized they wanted to leave or had exit seeking behaviors would trigger an elopement risk assessment to be done and the resident should be placed on additional monitoring for elopement, including a monitoring bracelet placement. During a concurrent interview and record review on 4/8/25 at 6:15 PM, the ADON reviewed the facility policy titled, Elopements, revised 2/25, and Resident 3's progress notes (a written record of events related to resident care), dated 3/20/25, 3/23/35, and 3/25/25. The ADON stated, per the facility's elopement policy, an elopement risk assessment should be completed on admission, yearly, and when a resident exhibits elopement behaviors of wandering, repetitively verbalizing a desire to go home or leave, and wanders the facility. The ADON reviewed Resident 3's Progress Notes and confirmed Resident 3 had documented exit seeking behaviors on 3/20/25, 3/23/25 and 3/25/25 when Resident 3 went outside stating she wanted to go home and refused to come back inside the facility. The ADON confirmed these three documented events all occurred prior to Resident 3's fall on 3/282/5. The ADON confirmed Resident 3's elopement risk assessment and care plan (a detailed individualized resident document outlining the specific needs, goals and interventions to meet the goals) for elopement risk was not completed until after the elopement and fall. The ADON further stated a monitoring bracelet was placed on Resident 3 however, it was not documented as placed and monitored until 3/31/25, three days after Resident 3 eloped and was injured. The ADON explained the fall possibly could have been prevented if additional interventions had been in place including: a monitoring bracelet, every 15-minute visual checks (resident safety visual checks to verify resident location) when Resident 3 was in the wheelchair, and an update to the resident's care plan with additional interventions related to an elopement risk. The ADON reviewed Resident 3's, Interdisciplinary Care Conference (a meeting where a team made up of different healthcare disciplines meet to discuss resident care and create a plan for interventions) dated 3/31/25, and stated the root cause of the elopement and fall for Resident 3 was due to cognitive impairment and inadequate supervision. A review of Resident 3's clinical record titled, SBAR [Situation Background Assessment Recommendation; a communication tool used to structure conversations] Communication Form dated 3/20/2025, indicated, . [Resident 3] INCREASED CONFUSION .REPEATEDLY SAYING SHE WANTS TO GO HOME .REQUESTING FOR A RIDE, HEADING TO EXITS .THEN BECAME AGGRESSIVE .Primary Care Clinician notified .3/20/2025 Time: 11:00 PM . A review of Resident 3's clinical record titled, Progress Notes *NEW*, dated 3/23/25 at 3:49 PM, indicated, . [Resident 3] got in her wheelchair and stated she was going home .[Resident 3]went to the front .staff continued to redirect .[Resident 3] to stay inside the facility. After multiple attempts, [Resident] agreed to wait inside in the lobby . A review of Resident 3's clinical record titled, Progress Notes *NEW*, dated 3/25/25 at 3:39 PM, indicated, .[Resident 3] was noted to be agitated .repeatedly stating she wanted to go home, requesting a ride .MD [medical doctor] was notified, and orders were received .for agitation .Behavior monitoring initiated . A review of Resident 3's clinical record titled, View Progress Note, dated 3/25/25 at 4:22 PM, indicated, .[Resident 3] brought in by staff to use the restroom. [Resident 3] still demanding to go home, went back outside the facility. Staff present with [Resident 3] in front of the facility . A review of Resident 3's clinical record titled, Progress Notes *NEW*, dated 3/28/25 at 10:54 AM, indicated, .[Resident 3] requested to talk to family member .stating she wants to go home . A review of Resident 3's clinical record titled, View Progress Note, dated 3/28/28 at 10:42 PM, indicated, .Found [Resident 3] laying in partial supine/sitting position by the front door .checked for injuries .MD [medical doctor] notified with order to send [Resident 3] out to [Hospital name] ED [emergency department]. Noted and carried out . A review of Resident 3's clinical record titled, Progress Notes *NEW*, dated 3/39/25 at 2:41 AM, indicated, .Back to the facility .from [hospital name] .head injury, fall .1 1/2 inch laceration to right side of forehead with 6 stitches .slight swelling and bruising and bleeding, abrasion to right elbow, abrasion to right knee . A review of Resident 3's clinical record titled, Care Plan Report, revised 9/20/23, indicated, .The resident is at high risk for falls r/t [related to] Confusion .Alzheimer's Dementia .unsafe independent activities .Resident attempted to get OOB [out of bed], Resident was agitated, anxious and was exit seeking and attempted to ambulate [walk] by herself . A review of Resident 3's clinical record titled, Care Plan Report, revised 3/13/24, indicated, .[Resident 3] is at risk for falls: cognitive loss [a decline in thinking, learning, and remembering abilities], lack of safety awareness [a deficiency in recognizing, understanding, and reacting to potential hazards and risks in various situation], Impaired mobility [limitation in a person's ability to move independently] .Interventions .Assess for changes in medical status .mental status and report MD as indicated .Assist resident getting in and out of bed with assistance .Assist resident with ambulation providing assistance using a front wheel walker . A review of Resident 3's clinical record titled, Care Plan Report, initiated on 3/4/25, indicated, .[Resident 3] has an ADL [Activities of Daily Living - tasks you do on a regular basis to take care of your body and overall well-being ] Self Care Performance Deficit r/t Alzheimer's, impaired balance .Goal .[Resident 3] will remain free of complications related to .fall related injury . A review of Resident 3's clinical record titled, Care Plan Report, initiated 3/29/25, indicated, .Elopement risk R/T [related to] Dementia and verbalization of wanting to go home. 3/28/25 WENT TO THE FRONT UNATTENDED. WILL HAVE NO FURTHER EPISODES OF LEAVING THE FACILITY. MONITOR WHEREABOUTS WHEN UP ON HER WHEELCHAIR .[brand name of monitoring bracelet] device #8732 to Right side of wheelchair. Date initiated 4/11/25 . A review of the facility policy and procedure titled, Elopements, revised 2/21/25, indicated, .residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care .1. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks .Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and annually .further evaluate the unique factors contributing to risk in order to develop a person-centered care plan .effectiveness of interventions will be evaluated, and changes will be made as needed .

Based on interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one out of four sampled residents (Resident 1) when Resident 1 fell forward to the floor while being pushed in a wheelchair that lacked a footrest. This failure resulted in Resident 1 sustaining injuries to the left knee, left side of the forehead and a fracture (break) of her left leg. Findings: A review of Resident 1's ADMISSION RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included type 2 diabetes mellitus (a chronic condition in which the body has trouble controlling blood sugar levels), dysphagia (difficulty swallowing), and bipolar disorder (a mental health disorder which causes dramatic shifts in mood, energy, and activity levels). During a review of Resident 1's Interdisciplinary Team Progress Notes, (IDT- a team of professional staff or a care team consisting of different disciplines working together towards the goals of the residents) dated 10/15/24, the IDT Progress Notes indicated, .Type of IDT Care Conference: Fall Incident .Date and Time of Fall Incident: 10/14/2024 10:49 [a.m.] .Fall Report (brief summary of the incident): Resident was being wheeled in the hallway when her left shoe gripped the floor causing her to fall forward. On initial assessment, resident sustained skin tear [a rip in the skin causing injury] to left knee and below knee including bruising to left side of forehead. Resident was sent out to E[emergency department]. Resident returned to facility with diagnosis of left tibia [the larger of two bones between the knee and the ankle] fracture .Current functional level. Resident requires assistance with .Transfers .Ambulation [walking] .Dressing .Toilet use .Hygiene .Safety Review/Risk Factors .Other: Resident requires 1 person assist with ADLs [activities of daily living (grooming, toileting, dressing)] and transfers [moving from bed to chair]. Resident mostly stays in bed and requires maximum assistance with wheelchair mobility . During a review of Resident 1's [Acute Care] Emergency Documentation, dated 10/14/24, the record indicated, .Diagnostic Radiology [a branch of medicine that uses non-invasive imaging to locate and identify certain conditions and diseases] .Report .Procedure Date: October 14, 2024 .Exam .Knee 3V [view] .LT [left] .IMPRESSION .tibial [tibia] .fracture .joint effusion [swelling of a joint] and soft tissue swelling . During an interview by phone on 1/3/25, at 10:37 a.m., with Resident 1's Responsible Party (RP), RP stated that the Restorative Nursing Assistant (RNA) pushed the wheelchair too fast. The RP further stated the RNA did not put the left leg rest on the wheelchair. The RP stated that she believed Resident 1's left leg got tired, and her leg slipped down, then the wheelchair tipped (on 10/14/24). The RP further stated Resident 1 was afraid to get up on her feet because of pain but felt that [Resident 1] needed to progress with therapy so that she could return home. During an interview on 1/3/25, at 11:35 a.m., with Certified Nursing Assistant (CNA), CNA stated she heard about Resident 1's fall (on 10/14/24). CNA further stated Resident 1 got up out of bed with assistance since she fell . During an interview on 1/3/25, at 11:36 a.m., with Licensed Nurse (LN) 1, LN 1 stated she was in the facility on the day that Resident 1 fell (on 10/14/24) but did not witness the event. LN 1 further stated Resident 1 loved bingo but had not been to bingo very much since she fell . LN 1 stated Resident 1 also liked talking with staff at the nurses' station but had not been up to the nurses' station since she fell . During an interview on 1/3/25, at 11:40 a.m., with Resident 1 in her room, Resident 1 stated that she had not been up in a chair or to bingo for a while. Resident 1 further stated her leg went under the wheelchair then she fell forward. Resident 1 stated that [RNA 1] was pushing the wheelchair when she fell (on 10/14/24). Resident 1 stated she had not been in the wheelchair since she fell and was receiving physical therapy in her room. During an interview by phone on 1/3/25, at 12:16 p.m., with RNA 1, RNA 1 stated that she remembered the incident when Resident 1 fell (on 10/14/24). RNA 1 further stated that she picked Resident 1 up for physical therapy in her room. RNA 1 stated Resident 1 was already up in the wheelchair dressed and ready. RNA 1 further stated that she did not check to see if the left footrest was on the wheelchair but should have checked. RNA 1 stated that she pushed the wheelchair down the hallway and Resident 1's left foot got tangled with her right foot and Resident 1 fell out of the wheelchair. RNA 1 further stated that she got an LN to help get Resident 1 off the floor. RNA 1 stated that the footrests should always be on the wheelchair. RNA 1 further stated that the incident would have been avoided if the left footrest was on the wheelchair. During an interview on 1/3/25, at 12:47 p.m., with LN 2, LN 2 stated the expectation was that before residents were transported by wheelchair, staff would check the arm rests, footrests, cushions if the resident needed a cushion, and checked to make sure the wheelchair was well functioning before residents were transported. LN 2 further stated that if the footrests were not on the wheelchair, the risk was that the resident's foot could get caught on the floor, and the resident could fall forward and sustain an injury. During an interview by phone on 1/3/25, at 2:22 p.m., with RNA 2, RNA 2 stated that she remembered Resident 1. RNA 2 further stated the wheelchair should have both footrests in place before residents were transported. RNA 2 stated that the risk was the resident may fall. During an interview by phone on 1/3/25, at 3:11 p.m., with Resident 1's physician (MD), the MD stated that he remembered the incident. The MD further stated that when Resident 1 fell , it was a shock to the system. The MD stated after a fall, residents sometimes tried to be more careful not to fall, or became less active or depressed. During an interview by phone on 1/16/25, at 9:50 a.m., with the Director of Nursing (DON), the DON stated she was made aware by staff after Resident 1's fall occurred (on 10/14/24). The DON further stated that the left footrest should have been on Resident 1's wheelchair. The DON stated that she felt that the fall interfered with Resident 1's quality of life. The DON further stated that the accident was preventable. During a concurrent interview and record review on 1/16/25, at 10:30 a.m., with the Activities Director (AD), the AD stated that she was in the facility when Resident 1 fell , but did not witness the fall. The AD further stated that she visited Resident 1 in her room after she came back from the hospital. The AD stated Resident 1 had told her that she needed to heal and receive therapy before participating in activities in the Activity Room. During a follow-up concurrent interview and record review on 1/16/25, at 11 a.m., with the AD, Resident 1's Activity Records (documentation of Resident 1's participation in facility activities) for October, November, and December 2024 were reviewed. The AD stated Resident 1 attended activities regularly until she fell . The AD further stated that when Resident 1 returned to the facility after the fall in October 2024, Resident 1's participation in activities decreased. The AD stated that she did one-on-one visits (meeting or intereaction between only two individuals regarding a specific need, concern or interest) with Resident 1 in October 2024 when she returned to the facility to encourage her to participate in activities when she saw a decrease in Resident 1's participation. A review of a facility document titled, Restorative Nursing Assistant, revised October 2020, indicated, .The primary purpose of these positions is to perform restorative nursing procedures [nursing interventions that promote the resident's ability to adapt and adjust to living as independently and as safely as possible] that maximize the resident's existing abilities, emphasize independence instead of dependence and minimize the negative effects of disability .Duties and Responsibilities .Personal Nursing Care Functions .Essential Functions .Observe body alignment of all residents in bed, chairs and wheelchairs .Monitor wheelchair-bound residents to ensure proper use, positioning and fit of leg extenders and footrests .Follow appropriate safety .measures . A review of a facility policy and procedure (P&P) titled, Repositioning, revised May 2013, indicated, .The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-bound or chair-bound residents .Evaluation .Components to evaluate when a resident is in a chair .Does the resident need intervention to maintain postural alignment [refers to how the head, shoulders, spine, hips, knees, and ankles relate and line up with each other] .Does the resident need devices to maintain sitting balance [ability to maintain the seated posture without falling over. To get a balanced sitting position, choose a chair that supports your spine, adjust the chair height so that your feet rest flat on the floor, or use a footrest so that your thighs are parallel to the floor] .

Based on observation, interview, and record review, the facility failed to ensure a safe environment for six of 40 sampled residents (Resident 15, Resident 14, Resident 23, Resident 75, Resident 54, Resident 74), and residents who required bathing in the east hall shower room when: 1. Resident 14 and 15-minute elopement risk (a resident who is incapable of adequately protecting themselves, and who departs the health care facility unsupervised and undetected) monitoring was not done; 2. The East Hall shower room's grab bar was detached from the wall with screws exposed. 3. A fall mat (a soft mat laid on the floor to help prevent injury from a fall) was not in place for Resident 75; 4. Resident 54's morning medications were left at the bedside; 5. Resident 74's personal items were stored on the floor causing clutter; and, 6. Resident 15 had access to, and consumed, dietary restricted food on [DATE] and choked. These failures placed Resident 14 at risk for elopement; Resident 75 at risk for injury when falling from her bed; Residents wandering into Resident 54's room at risk for accidental ingestion of medications not prescribed to them; Residents and staff in 74's room at risk of tripping/falling over the clutter of Resident 74's personal items; Resident 15 at risk for death due to choking and resulted in her hospitalization on [DATE]; and Residents using the East Hall shower room at risk for falling and skin tears and injuries from the exposed screws; with all these risks posing a hazardous environment for residents residing in the facility and negatively affecting their health and well-being. 1. A review of Resident 14's ADMISSION RECORD, indicated he was admitted to the facility with diagnoses which included dementia (a condition characterized by memory disorders, personality changes and impaired reasoning) and schizophrenia (a disorder that affects a person's ability to clearly think, feel and behave). A review of Resident 14's care plan initiated [DATE], indicated, .The resident is an elopement risk/wanderer AEB [as evidenced by] History of attempts to leave facility unattended .Resident wanders aimlessly .Goal .The resident's safety will be maintained .Interventions .Monitor location every shift .WANDERGUARD [a bracelet that triggers an alarm when a resident attempts to leave the facility] (ON LEFT WRIST) and check per facility policy . During a concurrent interview and record review on [DATE], at 8:59 AM, the Director of nurses (DON) stated staff monitored the residents who are at risk for wandering by utilizing the wander guard bracelet which is monitored for placement on the resident every shift. The DON stated the functioning of the bracelet was monitored either by walking the resident to the door to trigger the alarm or with a handheld testing device. The DON further stated the handheld testing device did not always function properly and had been misplaced. The DON stated the facility had instituted 15-minute monitoring for the Residents who were elopement risks. The DON confirmed Resident 14's document for 15-minute monitoring dated [DATE] did not include any documentation after 7 AM. The DON stated if Resident 14 was not monitored every 15 minutes he was at risk for elopement and of unintended safety issues. A review of a facility policy and procedure titled, Elopement of Resident, revised [DATE], indicated, .Purpose .To provide a process for managing residents at risk for elopement .Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury . 2. During an observation in the East Hall shower room on [DATE], at 7:28 AM, Licensed Nurse (LN) 8 confirmed the bottom portion of the grab bar was not secured to the wall and the screws were completely exposed. LN 8 stated there was the potential for a resident to fall or sustain an injury due the bar being unsecured. A review of a facility work order log dated [DATE]- [DATE], indicated, Work order number .2671 .East shower 1 safety pool [sic] is loose/bolts coming out of wall .Priority .critical . Work order number .2929 .THE HANDLEBAR IN THE SHOWER ROOM ON EAST NEEDS TO BE REPLACED .priority .high . During a concurrent observation and interview on [DATE], at 7:16 AM, in the East Hall shower room, the Maintenance Director (MainD) stated repairing the shower bar was a priority due to the risk of resident safety. The MainD stated issues that affected resident safety were top priority. A review of a facility job description titled, Director of Maintenance, revised [DATE], indicated, .Administrative Functions .Ensure the safe and proper functioning of the environment and equipment that are necessary to care for the resident population in the facility .Provide oversight of staff and contractors to ensure projects are completed correctly .Ensure the facility is .maintained to protect the health and safety of residents . 40583 3. A review of Resident 75's Admission Record indicated Resident 75 was admitted to the facility with diagnoses which included osteoporosis (A condition which causes the bones to become weak and break more easily). During an observation, on [DATE], at 6:36 AM, in Resident 75's room, Resident 75's bed was in low position, and there was not a fall mat on the floor. A review of Resident 75's Care Plan indicated fall mats were to be in place. A review of Resident 75's clinical document titled, Progress Notes, dated [DATE] and [DATE], indicated Resident 75 had falls on both dates. The progress note dated [DATE], indicated, .Nursing observations .[Resident 75] was found side lying on her right side on the floor mat [fall mat] beside her bed . During an interview with certified nursing assistant (CNA) 11, on [DATE], at 7:45 AM, CNA 11 stated the fall mat was not in place when he came into the room. During an interview with licensed nurse LN 8, on [DATE], at 7:45 AM, LN 8 stated the importance of the fall mat was in case Resident 75 fell she would not get injured. During an interview with the DON, on [DATE], at 10 AM, the DON stated the care planned interventions should be implemented. 4. A review of Resident 54's Admission Record indicated Resident 54 was admitted to the facility with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), diabetes (problems with blood sugar), and hypertension (high blood pressure). During an observation, on [DATE], at 10:44 AM, in Resident 54's room, Resident 54's bedside table had a medication cup with three medications inside of it. During an interview with licensed nurse LN 7, on [DATE], at 10:49 AM, LN 7 stated he was supposed to make sure Resident 54 took all of her medications and confirmed he had not. LN 7 explained the medications left at Resident 54's bedside were Losartan (a blood pressure medication), Jardiance (medication used to control blood sugar), and Metformin (medication used to control blood sugar). LN 7 further explained the importance of making sure Resident 54 took all of her medications was so that someone else did not take them, which could lead to adverse effects on that person. During an interview with the Assistant Director of Nursing (ADON), on [DATE], at 5:59 PM, the ADON stated it was important to make sure residents took all their medications and were not left at the bedside for the safety of the residents. A review of the facility policy titled, Medication Administration-General Guidelines, effective date ,d+[DATE], indicated, .The resident is always observed after administration to ensure that the dose was completely ingested [swallowed] . 5. Review of Resident 74's ADMISSION RECORD indicated Resident 74 was admitted with diagnoses which included repeated falls and morbid (severe) obesity (individuals' weight is more than 80 to 100 pounds above their ideal body weight). During an observation on [DATE] at 11:07 a.m., it was observed that Resident 74 was not in her room and multiple small containers were on the floor filled with miscellaneous items including hygiene care, shoes, miscellaneous non-food items, and food and drink items were located next to and underneath Resident 74's bed. During a concurrent observation and interview on [DATE] at 11:13 a.m., with CNA 1, CNA 1 stated that Resident 74 does not want the housekeeper to clean her room because she does not want her stuff touched. CNA 1 stated that the risk for having too many items and containers on the floor next to the residents bed was it could cause a tripping hazard to the resident and it would be hard to access the resident in case of emergency. During an interview on [DATE] at 11:18 a.m., with the Housekeeper (HK), the HK stated that she had not cleaned Resident 74's side of the room for three months because Resident 74 does not want her to touch her things. The HK stated that Resident 74 has a lot of items on the floor. The HK stated that she had let staff know that she was not able to clean Resident 74's room and was told to just clean around the items. The HK stated that the risk to the resident would be a possible fire hazard. During an interview on [DATE] at 9:11 a.m., Resident 74 stated that she wants her things more organized and not on the floor. Resident 74 stated that she had asked the maintenance manager about a month ago and several times before that, for a container with drawers to organize her things. Resident 74 stated that the maintenance director told her he would look into it. Resident 74 stated she saw a container with drawers in the dining room and pointed it out to the maintenance assistant who was in the room with her and told him that she needed a similar container to help organize her things in her room. Resident 74 stated the maintenance assistant told her that she could not have one. Resident 74 stated she wanted to organize her things and for over two months she had been asking staff for help. Resident 74 stated it was not easy to find her things because they were not organized, and she must bend over to get her things off the floor. Resident 74 stated a drawer system would help her with organizing and accessing her things. Resident 74 stated that she had so many clothes that she used parts of her neighbor's closet. During a concurrent observation and interview on [DATE] at 9:44 a.m. with the MainD, the MainD stated that he was the interim Director of Maintenance from a sister site facility and stated that he was not very familiar with the residents at this facility. The MainD stated if there were extra items in a residents room, he would refer the resident to social services to see if they could help because a lot of residents like to have a lot of things in their room. The MainD stated that they will try to assess the area and see if the items are used infrequently and can be stored away or if the items were used frequently. MainD stated that this would help him decide in terms of clearing the resident's room. The MainD stated he would clear the floor of the residents' room because it was important for the safety of the residents. The MainD stated that storing items on the floor was not safe because if there was an emergency the items could be in the way and prevent the resident from being provided needed care. The MainD stated that if a resident needed more space for their things than the provided closet and bedside cabinet, then he would do an assessment to see if they could provide more storage. The MainD stated this would go through social services. The MainD stated that his part was to determine if items were safe to be in the room, and if it not safe we would still not let items be on the ground, we would try to accommodate belongings in the space provided. In an interview on [DATE] at 2:33 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that for safety reasons, especially for a resident who was ambulatory (has ability to walk), then it was her expectation that items should be stored in a closet. The ADON stated that items should not be on the floor and staff should be notifying social services or any management so that we could order something (to store the items in) for the resident. In a concurrent interview and record review on [DATE] at 3:40 p.m., with the Social Services Director (SSD) and the Social Services Assistant (SSA), the SSD stated that if we see that a resident has a collection of many items then we meet with resident to see if there are some things that they can take home or if they are open to having a CNA organize it. The SSA stated they also contact the Maintenance Department to check if they have storage devices such as Tupperware drawers. The SSD stated that for Resident 74 she was aware that she was particular and wants her things near her. The SSD verified and confirmed through a record review that Resident 74 did not have care plans developed related to the issue of having too many items. The SSD stated that she liked to put in a care plan for residents such as Resident 74 who had a behavior of collecting, so staff knew how to approach the resident with respect. The SSD stated that a care plan contained a problem, interventions and goals and Resident 74's collecting of things on the floor, could have included interventions such as an additional drawer provided to Resident 74 to help her with organization. The SSD stated she would like to meet with Resident 74 on a quarterly basis to help the resident with parting ways with her items. The SSD stated that this included being mindful of space, creating interventions for safety and potential fire hazards. The SSD stated that Resident 74 was a resident who she would identify as needing a care plan. The SSD verified that no order was placed with maintenance and that an additional storage drawer was not ordered for Resident 74 for the organization of her things. The SSD stated that potential hazards of too many things included being a fall risk, and risk of not being able to access the resident in case of emergency. In an interview on [DATE] at 6:10 p.m. with the Administrator (Admin), the Admin stated her expectation was that resident belongings are off the floor. The Admin stated that the risk to the resident would be that residents could have a fall, and resident care could be delayed in an emergency. 6. A review of Resident 15's Admission Record indicated Resident 15 was admitted to the facility with multiple diagnoses which included, hemiplegia (weakness on one side of the body), and food in the respiratory tract (airway and lungs). A review of Resident 15's Minimum Data Set (MDS- an assessment tool used to guide the care of a resident) section C, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, the ability to think and understand) score of 7 out of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, 13 to 15 points suggests that cognition is intact). A review of Resident 15's care plan initiated on [DATE], indicated, . [Resident 15] is at risk for aspiration [when something that is swallowed gets in the lungs] .Dysphagia [Difficulty in swallowing] .interventions .Resident will be given snacks by staff after ensuring it follows her diet and diet texture [meals or drinks that have been prepared in a special way to create a certain texture or consistency] .RESIDENT WILL BE ON ASPIRATION PRECAUTION .Residents tray and snacks will be checked before giving to patient . A review of Resident 15's nutrition assessment titled, Nutritional Assessment V 1, dated [DATE], the sections Diet Texture and Thickened Liquids indicated, Resident 15 was on a Dysphagia Puree [food with the consistency of mashed potatoes to make swallowing easier] and Nectar like diet [drinks with the consistency of thick syrup]. A review of Resident 15's physician order, dated [DATE], and titled Order Summary Report, indicated .Fortified [Foods that have added vitamins and minerals] NAS [No Added Salt] diet Puree texture, thick liquids-Nectar consistency .** STRICT PRECAUTIONS** related to DYSPHAGIA . A review of Resident 15's nursing progress note, dated [DATE], at 5:50 p.m., indicated, Resident was seen by staff coming to nurses station and taking left over snacks left during AM [Morning shift] not proper for patient diet. Resident on puree diet and took a sandwich and [NAME] crackers, nurse told resident she could not have those snacks and offered pudding or applesauce in substitute, but resident refused A review of Resident 15's Speech Therapy SLP [Speech Language Pathologist (specialist)] Evaluation & Plan of Treatment Certification Period: [DATE]-[DATE] indicated, .Patient .found to have a swallowing disorder .Definite risk for: Aspiration, Delayed or slow swallow reflex . A review of Resident 15's nursing progress note, dated [DATE], indicated, .around 1545 [3:15 p.m.] roommates family member came to get nurse stated there was something wrong with the resident. Nurse went into residents room and found resident in her chair staring at the sky blinking but not talking. Nurse noticed resident had food stuck in her throat. Nurse tried to the dislodge food but could not. Nurse yelled for help. CNA [Certified Nursing Assistant] yelled that resident was choking on [NAME] crackers. At approximately 1550 [3:50 p.m.] UM [Unit Manager] went in to assist with Heimlich maneuver [sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the airway] along with other nurses. Airway was still partially obstructed [blocked] when UM performed Heimlich. Sating [Measurement of oxygen in blood] at 75 to 80% [95%-100% is the normal range] and suction [A process of inserting a small tube into the airway to remove blockages] was given. Some cracker pieces were noted when suctioned. Heimlich, oxygen and suction continued until firefighters arrived at approximately 1555 [3:55 p.m.]. Resident was sent out to [acute care hospital name] approx.[approximately] 1600 [4 p.m.] . A review of Resident 15's hospital discharge summary, dated [DATE], indicated, Patient [Resident 15] was admitted [DATE] with aspiration PNA [Pneumonia- infection of the lungs] after choking on food at [Facility] .Patient .presents to the ED [Emergency Department] after a choking episode and found to be saturating in the 50's on admission resulting in intubation [a tube inserted into the airway used to deliver oxygen to the body] in the ED .Patient was admitted for management and evaluation of acute hypoxic respiratory failure [when the body lacks enough oxygen in the blood] secondary to choking episode resulting in aspiration pneumonia . Patient intubated on arrival and extubated [a process where the inserted tube is removed from the airway] on ,d+[DATE] .Tube Feedings (nutrition delivered to the body through a tube)- Continuous .Route of admin [Administration]: Small Bowel Feeding Tube [a tube that is surgically placed in the gut] . A Review of Resident 15's active physician order, dated [DATE], indicated, .NPO (Nothing by mouth) diet NPO texture, NPO on all fluids . A review of Resident 15's nutrition assessment titled, Nutritional Assessment V 1, dated [DATE], in the section Diet order indicated, Resident 15 was receiving nutrition through a feeding tube. A Review of Resident 15's active physician order, dated [DATE], indicated, .Enteral Feed [nutrition given through a tube] Order five times a day . During an interview on [DATE] at 8:50 a.m., Licensed Nurse (LN) 4 stated, all snacks used to be kept at the nursing station. LN 4 stated they (facility/staff) were no longer keeping any snacks at the nursing station after Resident 15 choked on crackers. LN 4 explained metal gates were installed at the entrances to the nursing stations in the facility for the safety of the residents. During a concurrent interview and record review on [DATE], at 9:22 a.m., with LN 13, Resident 15's physician order dated [DATE] was reviewed. The physician order indicated Resident 15 was on a fortified pureed nectar thickened diet, confirmed by LN 13. LN 13 stated Resident 15's physician order dated [DATE], indicated Resident 15 was now NPO and required a feeding tube. LN 13 further stated Resident 15 could have died from choking and the incident was avoidable. During an interview on [DATE] at 10:35 a.m. with the Director of Staff Development (DSD), the DSD confirmed Resident 15 choked on crackers. The DSD stated this was an unfortunate incident and could have been avoided. The DSD further stated after the incident metal gates were installed on both nursing stations and they should be locked all the times. During a concurrent interview and record review on [DATE], at 1:45 p.m. with the Director of Nursing (DON), Resident 15's [DATE] progress notes were reviewed. The DON confirmed Resident 15 choked on crackers while eating them in her room and was transferred to hospital. The DON stated if Resident 15's behavior of grabbing snacks from the nursing station was identified on [DATE], the choking incident on [DATE] was avoidable. During an interview on [DATE] at 12:43 p.m. with the Medical Director (MD), the MD stated, Resident 15 was on a puree nectar thickened diet when she choked on crackers. The MD also stated this incident was avoidable. The MD further stated, Resident 15 had enteral feeding after the incident, and it had changed Resident 15's quality of life.

Based on observation, interview, and record review, the facility failed to ensure residents received dental services to meet their needs for one of forty sampled residents (Resident 84), when Resident 84 did not receive routine and urgent dental care services which contributed to Resident 84's unintended weight loss of 22.2 pounds over a six month time period (11/2023 - 5/2024). This failure had the potential for muscle loss, loss of resident independence, poor healing, and increased susceptibility to infections for Resident 84. Findings: Review of Resident 84's ADMISSION RECORD indicated Resident 84 was admitted to the facility in November of 2023 with multiple diagnoses including but not limited to acute infarction of the intestine (occurs when there is a narrowing or blockage of one or more of the arteries that supply the small intestine), diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestine), and Crohn's disease (an inflammatory bowel disease that causes chronic inflammation of the digestive tract). During a concurrent observation and interview on 6/3/24, at 9:15 AM, Resident 84 stated she had lost a lot of weight while living in the facility. Resident 84 stated she had teeth only on the upper right side and on the bottom middle front of her mouth. Resident 84 stated she had only one spot to chew where her upper tooth touched the bottom tooth. Resident 84 stated she had been asking the facility staff to see a dentist. Resident 84 further stated the dentist came to see other residents but did not see her. Resident 84 stated she would love to have dentures. Observed Resident 84 had teeth only on the upper right side of her mouth. Resident 84 had teeth on the bottom front of her lower gums and no teeth on the left and right side on the lower gums. On Resident 84's wall was a list created by her son which indicated Resident 84 takes a long time to eat due to her history of stomach surgery and missing teeth. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 8 and Resident 84 on 6/5/24, at 10:43 AM, in Resident 84's room, CNA 8 stated Resident 84 was still eating breakfast. Resident 84 stated, I have nothing to bite. CNA 8 verified Resident 84 had only 4-5 teeth on the right side of the upper gums and the rest of the teeth were missing on the upper gums. CNA 8 further confirmed Resident 84 had 5 teeth in the middle front on the bottom gums and the rest of the teeth were missing on both sides of the lower gums. CNA 8 stated Resident 84 always took two hours to eat her meals. CNA 8 stated if Resident 84 had dentures that would help her. During a concurrent observation and interview with Licensed Nurse (LN) 5 and Resident 84 on 6/5/24, at 10:54 AM, in Resident 84's room, LN 5 stated Resident 84 had issues with weight loss and eating. LN 5 stated she did not know for sure if Resident 84 had issues with chewing food. When LN 5 asked, Resident 84 replied, I only have one area to chew. When LN 5 asked if Resident 84 wanted to see a dentist, Resident 84 replied, Yeah, I have been wanting to see a dentist. He goes to everyone else but not to me. Resident 84 stated she would like to have dentures. Resident 84 further stated she had partial dentures many many years ago. LN 5 told Resident 84 that she would inform Social Services that she would like to see a dentist. Resident 84 was tearful and replied, That would be wonderful. It would improve my life and my eating. LN 5 confirmed Resident 84 had only one spot where she could bite and chew food and had missing teeth on the upper and lower gums. During an interview with the Social Services Director (SSD) and the Social Services Assistant (SSA) on 6/5/24, at 11:12 AM, the SSD stated the dentist came to the facility every six weeks to see residents for routine dental services and as needed for urgent dental services. The SSD stated if a resident upon admission had missing teeth, discomfort, or pain then they arranged for urgent dental services. The SSD stated they kept track of residents' dental visits and services provided in an ancillary services (supplemental or diagnostic services provided in support of, or in addition to, care) binder in their office. The ancillary services binder was reviewed with the SSD. The SSD stated she did not see a dental record in the binder for Resident 84. The SSD stated Resident 84 had not been served by a dentist since admitted to the facility. The SSD stated she could not recall any one mentioning that Resident 84 needed dental services. The SSD stated residents should be seen by the dentist for routine services within the first 60 to 90 days at the latest when transitioned to long term care status (resident will reside in the nursing home without a plan to return to their former home) in December of 2023. The SSD stated the SSA was responsible to add new residents on the dentist list for routine services (includes screenings, check-ups, and resident counseling to prevent illnesses, disease, or other health problem). The SSD stated she did not know how Resident 84 was missed and was not placed on the dentist list. During an interview on 6/5/24, at 2:36 PM, the SSD stated, based on their facility policy residents should be seen by the dentist every three months for routine dental services. The SSD verified Resident 84 had been in the facility for seven months and had not been seen by the dentist yet. The SSD stated it could affect Resident 84 in multiple ways such as; experiencing oral pain and could potentially experience weight loss. The SSD stated the SSA attended residents' weight loss IDT (An interdisciplinary team brings together knowledge from different health care disciplines to help resident receive the care they need) meetings. During an interview on 6/5/24, at 2:40 PM, the SSA stated she attended Resident 84's weight loss IDT meetings and did not recall any issues discussed about her chewing or dental health. During an interview on 6/5/24, at 11:49 AM, the Registered Dietitian (RD) stated Resident 84 was missing a lot of teeth since she had been in the facility. The RD stated he notified the Social Services regarding Resident 84. The RD stated Resident 84 was on the dentist list to see if she could have dentures which the Social Services was in-charge of. The RD stated part of Resident 84's weight loss problem was her missing teeth. The RD further stated Resident 84 was not able to chew a lot of the food that she wanted to eat which was potentially causing weight loss. The RD stated if Resident 84 would get dentures then she would be able to chew and eat the food she wanted which would help with her weight loss problem and would help Resident 84 to gain weight. The RD stated Resident 84's weight goal was 120 pounds to get her back close to what her usual weight was. During a concurrent interview and record review on 6/5/24 at 12:35 p.m. with the Minimum Data Set Nurse 1 (MDS Nurse 1), the MDS Nurse 1 stated that if a resident had missing teeth, broken teeth, or cavities causing difficulty with chewing, staff would code this on the MDS section L (oral health) on both the admission and quarterly reviews. Review of Resident 84's MDS admission assessment was coded that she had no broken or missing natural teeth. The MDS nurse 1 coordinator confirmed that the admission MDS Assessment (dated 11/30/23) was incorrect, and that the Quarterly assessments (dated 3/1/24 and 6/1/24) were also incorrect. The MDS Nurse 1 further stated that Assessments should be accurate because it affects resident nutrition and the potential for weight loss. When a resident is not assessed correctly, a plan of care is not developed to meet their needs. She (Resident 84) needs a dental appointment and follow up with a dentist. Her care got delayed. During an interview on 6/5/24, at 5:13 PM, the Director of Nursing (DON) stated if a resident had an order of dental consult then he expected Social Services to send a referral to their dental providers so the resident could be seen by a dentist. The DON stated residents should receive routine dental services every three months and as needed. The DON stated it was important so that residents could eat appropriately, resident's teeth were healthy, and any oral issues and dental issues were addressed timely. The DON stated he would have expected Resident 84 to be seen sooner by the dentist especially when they were aware of Resident 84's dental and chewing issues. Review of Resident 84's medical record failed to show that Resident 84 was seen by a dentist. Review of Resident 84's record titled [Facility Name] Dietary Profile dated 11/29/23, indicated, .states appetite is good; normally consumes 3 meals per day .prefers softer foods (easy to chew) due to dentition [teeth] .dentition: missing teeth . Review of Resident 84's physician order dated 11/29/23, indicated, .Dental consult & t/X [treatment] as indicated for dental issues . Review of Resident 84's weight record indicated: 11/30/24 - 127 lbs (pounds: unit of measurement) 12/24/23 -116 lbs 1/23/24 - 107 lbs 2/22/24 - 106 lbs 3/24/24 - 108 lbs 4/28/24 - 106.9 lbs 5/26/24 - 104.8 lbs Review of Resident 84's care plan dated 12/18/23, indicated, .Unexpected wt. [weight] loss .Monitor/record the resident's eating habits, and patterns to assist in determining cause of losing wt Review of Resident 84's Nutritional assessment dated [DATE], indicated, .wt loss -11 lbs/-8.7% x [times] 1 month .Recommend: Change diet to Regular, easy to chew, thin liquids D/C [discontinue] SF [sugar free] [brand name] shake Add [brand name, high calorie nutrition supplement] or equivalent BID [twice a day] . Review of Resident 84's Nutritional assessment dated [DATE], indicated, .Rt [Resident] with Hx [history] of chewing issues .Rt .under review r/t[related to] significant weight loss: -6# [lbs] (5.5 % [percent]) weight loss over~ 1 month. Rt. is also triggering for 17.9% weight loss over~ 2 months . Review of Resident 84's care plan revised 2/6/24, indicated, Resident is at nutritional risk r/t: Underweight, Significant weight loss . Mechanically-altered diet. Feb: Significant weight loss: -6#[pounds-unit of measurement] (5.5%) ~1month. CBW [current body weight] (2/4): 104.3#. Weight loss not desired Honor food preferences within meal plan .Encourage resident to chew and swallow each bite . Review of Resident 84's Speech Therapy Evaluation, dated 2/2/24-2/9/24 indicated, .The patient was referred to speech therapy for evaluation of least restrictive diet. The patient currently has a soft and bite sized diet due to reduced dentition [teeth] and significant wt [weight] loss since the start of care at this facility. The son reported that the patient has difficulty with mastication [chewing] due to poor alignment of dentition [teeth] . (Reduced dentition: Top right row of teeth to from k9 [long pointed tooth located in the upper jaw] to molar and 4 lower front teeth, but no overlap so the majority of mastication happens with upper right dentition against her lower gums.) .Swallowing Disorder Phase: The patient presents with moderate oral phase dysphagia [swallowing difficulty] secondary to poor dentition resulting in poor breakdown of solid presentations. The patient was challenged with various solid textures Including puree [food that has been blended to the consistency of a creamy paste or liquid], mechanical soft [foods that were altered in some way so they are easy to chew and swallow], and regular textures . When challenged with regular textures, due to her reduced dentition, she presented poor breakdown of the presentation and prolonged mastication. After an extended period of time she completed was able to swallow the presentation . The patient was educated and was suggested to continue with soft and bite sized texture to ensure she is able to meet her daily nutritional needs. The patient and son reported that they did not wish to continue with soft and bite sized textures, but rather to try advanced diet textures . Review of Resident 84's Nutrition Assessment, dated 3/7/24, indicated, .Feeding ability: Limited assistance often required Meal intake: 50-75%; Hx [history] of chewing issues; trialed soft & bite-sized [textured modified diet] but preferred to return to Easy-to-Chew. Review of Resident 84's Dietary/Nutritional progress note dated 4/19/24, indicated, Rt [Resident] c/o [complain of] texture of food (easy to chew). Rt noted with poor dentition and current issues are r/t chewing. Social services was made aware and Rt. added to dentistry list. Review of a facility policy titled, Dental Services, revised 12/2016, indicated, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .Social services representatives will assist residents with appointments .All dental services provided are recorded in the resident's medical record .

Based on interview, record review and facility policy review, the facility failed to inform 1 of 2 residents/(RP 1 - Resident 1's Responsible Party) of planned treatment and treatment options when: 1. RP 1 was not contacted to verify informed consent for medications including psychotherapeutics (medications used to treat mental disorders), and 2. RP 1 was not informed by the facility of the medication administration errors. These failures deprived Resident 1 of the right to make informed decisions and prevented: 1. RP 1 from being informed about medications administered to Resident 1 and the opportunity to stop the administration of erroneous medications, and 2. RP 1 from making informed and timely decisions that had the potential to minimize or correct the medication administration error that resulted in Resident 1's death from acute [MEDICATION NAME] toxicity. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated [DATE], reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. Review of the faxed document for Patient 1, dated [DATE], titled Physician's Orders/Medication Status - (hospice name) and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated [DATE]-[DATE] and [DATE]-[DATE] reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) [MEDICATION NAME] (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) [MEDICATION NAME] Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) [MEDICATION NAME] Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) ([MEDICATION NAME]) (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) [MEDICATION NAME] (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) ([MEDICATION NAME]) (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) [MEDICATION NAME] 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) [MEDICATION NAME] 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) [MEDICATION NAME], 20 mg tablet, 1 tablet, by mouth, as needed for [MEDICAL CONDITION] 10) [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disease), 5 mg tablet, 1 tablet, by mouth, every day 11) [MEDICATION NAME], 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) ([MEDICATION NAME]), 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) [MEDICATION NAME], 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) [MEDICATION NAME], 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) [MEDICATION NAME], 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) [MEDICATION NAME] extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) [MEDICATION NAME] concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated [DATE], titled Physician Orders Sheet - (hospice name) reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1's facility documents titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated [DATE]-[DATE] and [DATE]-[DATE] and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of [DATE]: 1) ([MEDICATION NAME]) 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - [DATE] GIVEN at 12:01 a.m. 2) [MEDICATION NAME] extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - [DATE] GIVEN at 6 p.m., - [DATE] NOT GIVEN, at 12 a.m. with reason waiting for medication delivery, and 6 a.m. with reason Will call (hospice name) to follow up medication, REFUSED (by Resident) at 12 p.m., GIVEN at 6 p.m., - [DATE] GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - [DATE] GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as Unable to swallow. 3) [MEDICATION NAME] 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - [DATE] GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - [DATE] GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) [MEDICATION NAME] (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - [DATE] GIVEN 9 a.m. 5) [MEDICATION NAME] (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - [DATE] GIVEN at 9 a.m., - [DATE] REFUSED (by Resident) at 9 a.m., - [DATE] GIVEN 9 a.m. 6) [MEDICATION NAME] 10 mg tablet, ,[DATE] tablet, by mouth, three times a day for spasms - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - [DATE] GIVEN 9 a.m. 7) ([MEDICATION NAME]), 40 mg tablet, 1 tablet, by mouth twice a day for stomach - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., and at 5 p.m., - [DATE] REFUSED (by patient) at 9 a.m., GIVEN at 5 p.m., - [DATE] GIVEN 9 a.m. 8) (quetiapine [MEDICATION NAME]) (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - [DATE] NOT GIVEN at 5 p.m. with reason awaiting delivery from pharmacy, - [DATE] GIVEN at 9 a.m., and at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 5 p.m., - [DATE] GIVEN 9 a.m. 10) (quetiapine [MEDICATION NAME]), 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) ([MEDICATION NAME]), 30 mg capsule, 1 capsule, as needed at bedtime for [MEDICAL CONDITION] - [DATE] GIVEN at 12:26 a.m. 12) ([MEDICATION NAME]) (medication used to treat constipation) 8XXX,[DATE] mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) ([MEDICATION NAME]) rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if ([MEDICATION NAME]) ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated [DATE], reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated [DATE]-[DATE] and [DATE]-[DATE] reflected medications prescribed for Patient 1 were not given, and medications prescribed for Patient 2 were administered to Patient 1. Review of Patient 1's facility document titled MARs dated [DATE]-[DATE] and [DATE]-[DATE] reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days ([DATE] - [DATE]). The Order Summary Report additionally indicated the following: - ([MEDICATION NAME]) tablet 1 mg, Give 1 tablet by mouth every 4 hours as needed for ANXIETY M/B (manifested by) SOB (shortness of breath), ICO (informed consent) by MD (medical doctor) from RP. - (quetiapine [MEDICATION NAME]) Tablet 50 mg, Give 1 tablet by mouth two times a day for anxiety M/B verbalization of anxiety, ICO by MD from RP. - (quetiapine [MEDICATION NAME]) Tablet 50 mg, Give 1 tablet by mouth every 4 hours as needed for anxiety M/B verbalization of anxiety, ICO by MD from RP. - [MEDICATION NAME] capsule 30 mg, Give 1 capsule by mouth as for inability to sleep due to [MEDICAL CONDITION], ICO by MD from RP. - Oxygen at 2L/min via NC per concentrator (a device that concentrates oxygen from the air to supply an oxygen-[MEDICATION NAME] flow) as needed for SOB (shortness of breath) 1. Review of the documents titled Facility Verification of Informed Consent, signed and dated [DATE], reflected verification on three separate forms for ([MEDICATION NAME]), [MEDICATION NAME] and (quetiapine [MEDICATION NAME]). All three forms were signed by Resident 1 indicating the resident had received information for the medications and had given consent to receive the medication. The form further revealed Licensed Nurse (LN) 1 was the facility representative executing the verification. Review of the hospice face sheet indicated RP 1 was the PCG (primary care giver), NOK (next of kin), POA (power of attorney), and EC (emergency contact). Review of the facility document titled Notice of Admission/ Re-Admission indicated Resident 1 was not their own Responsible Party. Review of Resident 1's document titled Physician Orders for Life-Sustaining Treatment (POLST - medical orders dictating treatments to be provided based on the patient/ resident's wishes during a medical emergency) dated [DATE] was signed by Resident 1's POA. During a concurrent interview and document review on [DATE] at approximately 2:45 p.m., LN 1 confirmed the hospice face sheet, the facility admission notice and the POLST all indicated Resident 1 was not their own Responsible Party. LN 1 further concurred RP 1 should have been contacted for the Verification of Informed Consent. In a telephone interview on [DATE] at 1:30 p.m., RP 1 confirmed they were not contacted for verification of informed consent and further stated, (Resident 1) was not on those medications ([MEDICATION NAME] or quetiapine [MEDICATION NAME]). Review of the facility policy titled [MEDICAL CONDITION] (medications used to treat mental disorders) Medication Management, revised [DATE], stipulated, It is the policy of this facility that residents in need of psychotherapeutic medications receive appropriate assessment and intervention in order to achieve their highest practicable level of functioning . When psychoactive medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnosis . Informed Consent for the use of a psychoactive (medications used to treat mental disorders) medication must be contained in the medical record (following verbal verification from the physician), a statement from the physician documented in the progress notes or on the physician orders, or a signed consent form from the resident, family, or legal representative .The Director of Nursing or designee, will be responsible for reviewing new psychoactive medication orders for clinical compliance with federal regulations . 2. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:10 a.m., the ADON stated, .the family knew (of the medication error) before (Resident 1's) death . because the hospice nurse told them. The ADON further stated he was unaware of any discussion of [MEDICATION NAME] (medication used to temporarily reverse the effects of opioid medicines) and it would have been a hospice physician decision. During an interview with LN 4 on [DATE] at 3:45 p.m., LN 4 stated no one considered [MEDICATION NAME] and further stated it would not have occurred to him to use [MEDICATION NAME] for a [MEDICATION NAME] error. A record review of Resident 1's document titled Administration Record Report (MAR - Medication Administration Report) revealed the following: - Resident 1's pain assessments (using a pain scale with 0 = no pain, ,[DATE] = mild pain, 4 - 6 = moderate pain, 7 - 9, 10 = worst+) indicated a pain level of 0 on [DATE] at midnight, at 4 a.m., and at 8 a.m. - Resident 1 received on [DATE] [MEDICATION NAME] 100 mg at midnight and [MEDICATION NAME] at 12:26 a.m. for [MEDICAL CONDITION]. - Resident 1 received on [DATE] 2 ml of [MEDICATION NAME] 20 mg/ml (40 mg) at 3:59 a.m. - On [DATE], Resident 1 did not receive the scheduled [MEDICATION NAME] for 6 a.m. with a notation of 9 which indicated other/ see nurse notes. A record review of Resident 1's document titled Progress Notes revealed the following: - On [DATE] at 4:49 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 2 ml by mouth every 2 hours . Pain Scale was: 0. - On [DATE] at 5:14 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] ER Tablet Extended Release 100 MG Give 1 tablet by mouth every 6 hours for PAIN Unable to swallow. - On [DATE] at 6:39 a.m., LN 4 indicated a Medication Administration Note, OXYGEN 2L/MIN (a unit of measure for flow rate) VIA NC (nasal cannula - a means of delivering oxygen into the nose) PER CONCENTRATOR as needed for SOBPRN (shortness of breath as needed) - On [DATE] at 6:59 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] Capsule 30 mg .PRN Administration was: Effective. - On [DATE] at 7:40 a.m., LN 4 indicated a Health Status Note, Resident in bed placed on continuous O2 (oxygen) @ 2L/min. [MEDICATION NAME] solution given as patient now unable to open mouth and swallow pills. (Agency name) hospice notified of change in status. (RP 1) made aware. During an interview and concurrent record review of the above with LN 4 on [DATE] at 3:55 p.m., LN 4 stated he did not consider a change of condition when Resident 1 could not express her pain for the 3:39 a.m. liquid [MEDICATION NAME] and at 5:14 a.m. when Resident 1 could not open their mouth or swallow a pill. LN 4 additionally stated Resident 1's change of condition was reported to the hospice agency around 7:30 a.m. after Certified Nursing Assistant (CNA) 1 and CNA 2 reported Resident 1 was unresponsive. LN 4 stated the hospice agency notified the hospice physician (HMD). During a telephone interview on [DATE] at 1:30 p.m., RP 1 confirmed the facility left a message about 7:30 a.m., on [DATE], that (Resident 1) was not doing well and was on oxygen. RP 1 stated they returned the call to the facility when they heard the message at approximately 10:00 a.m. RP 1 stated there was no mention of a significant medication error when they arrived at the facility at approximately 12:00 p.m. LN 2 from hospice explained the significant medication error at about 12:15 p.m. RP 1 further stated at no time was the family offered the option of treatment, like [MEDICATION NAME], or a transfer to the hospital. RP 1 stated Resident 1 died about 30 minutes after they arrived to the facility at approximately 12:30 p.m. on [DATE]. Review of the facility policy titled Medication Errors, revised (MONTH) (YEAR), stipulated, It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative . Resident and resident representative should be notified and all actions taken to rectify the situation. Review of the facility policy titled Change of Condition, Resident, revised ,[DATE], stipulated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner .in the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and provide possible transport to an acute hospital.

Based on interview, record review and facility policy review, the facility failed to ensure accurate and timely notification of an acute change in condition (C[NAME]) for 1 of 2 residents (Resident 1) when: 1. Resident 1's Responsible Party (RP 1) was not notified of a significant medication administration error, and 2. Resident 1's facility attending physician (FMD) was not notified of a decline in condition, a significant medication administration error, and Resident 1's death. These failures prevented RP 1 and FMD from making informed and timely decisions that had the potential to minimize or correct the medication administration error that resulted in Resident 1's death from acute [MEDICATION NAME] toxicity. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated [DATE], reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. Review of the faxed document for Patient 1, dated [DATE], titled Physician's Orders/Medication Status - (hospice name) and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated [DATE]-[DATE] and [DATE]-[DATE] reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) [MEDICATION NAME] (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) [MEDICATION NAME] Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) [MEDICATION NAME] Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) ([MEDICATION NAME]) (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) [MEDICATION NAME] (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) ([MEDICATION NAME]) (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) [MEDICATION NAME] 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) [MEDICATION NAME] 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) [MEDICATION NAME], 20 mg tablet, 1 tablet, by mouth, as needed for [MEDICAL CONDITION] 10) [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disease), 5 mg tablet, 1 tablet, by mouth, every day 11) [MEDICATION NAME], 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) ([MEDICATION NAME]), 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) [MEDICATION NAME], 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) [MEDICATION NAME], 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) [MEDICATION NAME], 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) [MEDICATION NAME] extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) [MEDICATION NAME] concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated [DATE], titled Physician Orders Sheet - (hospice name) reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1's facility documents titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated [DATE]-[DATE] and [DATE]-[DATE] and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of [DATE]: 1) ([MEDICATION NAME]) 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - [DATE] GIVEN at 12:01 a.m. 2) [MEDICATION NAME] extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - [DATE] GIVEN at 6 p.m., - [DATE] NOT GIVEN, at 12 a.m. with reason waiting for medication delivery, and 6 a.m. with reason Will call (hospice name) to follow up medication, REFUSED (by Resident) at 12 p.m., GIVEN at 6 p.m., - [DATE] GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - [DATE] GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as Unable to swallow. 3) [MEDICATION NAME] 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - [DATE] GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - [DATE] GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) [MEDICATION NAME] (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - [DATE] GIVEN 9 a.m. 5) [MEDICATION NAME] (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - [DATE] GIVEN at 9 a.m., - [DATE] REFUSED (by Resident) at 9 a.m., - [DATE] GIVEN 9 a.m. 6) [MEDICATION NAME] 10 mg tablet, ,[DATE] tablet, by mouth, three times a day for spasms - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - [DATE] GIVEN 9 a.m. 7) ([MEDICATION NAME]), 40 mg tablet, 1 tablet, by mouth twice a day for stomach - [DATE] GIVEN at 5 p.m., - [DATE] GIVEN at 9 a.m., and at 5 p.m., - [DATE] REFUSED (by patient) at 9 a.m., GIVEN at 5 p.m., - [DATE] GIVEN 9 a.m. 8) (quetiapine [MEDICATION NAME]) (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - [DATE] at NOT GIVEN at 5 p.m. with reason awaiting delivery from pharmacy, - [DATE] GIVEN at 9 a.m., and at 5 p.m., - [DATE] REFUSED (by Resident) at 9 a.m., GIVEN at 5 p.m., - [DATE] GIVEN 9 a.m. 10) (quetiapine [MEDICATION NAME]), 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) ([MEDICATION NAME]), 30 mg capsule, 1 capsule, as needed at bedtime for [MEDICAL CONDITION] - [DATE] GIVEN at 12:26 a.m. 12) ([MEDICATION NAME]) (medication used to treat constipation) 8XXX,[DATE] mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) ([MEDICATION NAME]) rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if ([MEDICATION NAME]) ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated [DATE], reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated [DATE]-[DATE] and [DATE]-[DATE] reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days ([DATE] - [DATE]). Review of Patient 1's facility document titled MARs dated [DATE]-[DATE] and [DATE]-[DATE] reflected medications prescribed for Patient 1 were not given, and medications prescribed for Patient 2 were administered to Patient 1. 1. Review of Resident 1's document titled Order Summary Report dated [DATE] 2:09 p.m., reflected the facility entered medication orders into the facility eMR, then faxed a copy of the report to the pharmacy. The pharmacy faxed the same report to the Facility physician (FMD) to be signed for verification. The form was then returned, signed by the FMD, to the pharmacy for distribution. Review of the hospice face sheet, dated [DATE], indicated RP 1 was the PCG (primary care giver), NOK (next of kin), POA (power of attorney), and EC (emergency contact). Review of the facility document titled Notice of Admission/ Re-Admission, dated [DATE], indicated Resident 1 was not their own Responsible Party. Review of Resident 1's document titled Physician Orders for Life-Sustaining Treatment (POLST - medical orders dictating treatments to be provided based on the patient/ resident's wishes during a medical emergency) dated [DATE] was signed by Resident 1's POA. During a concurrent interview and document review on [DATE] at approximately 2:45 p.m., Licensed Nurse (LN) 1 confirmed the hospice face sheet, the facility admission notice and the POLST all indicated Resident 1 was not their own Responsible Party. During a concurrent interview with the Director of Nursing (DON) and the Administrator (ADM) on [DATE] at 8:40 a.m., the DON stated facility Licensed Nurse (LN) 4 notified LN 2 from hospice of Resident 1's change of condition around 7:40 a.m. on [DATE]. The DON stated LN 2 arrived at the facility at approximately 8:45 a.m. and reviewed the orders in Resident 1's paper chart (hard copy medical record) and discovered Resident 2's orders in Resident 1's chart. The ADM stated LN 2 then compared the paper copy of Resident 1's and Resident 2's physician orders to the orders entered by the facility into the eMR and reported the medications errors to LN 4. LN 2 then notified the hospice physician (HMD) and all medications were discontinued by the HMD. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:10 a.m., the ADON stated the family knew of the medication error before (Resident 1's) death . because the hospice nurse told them. During a telephone interview with LN 2 on [DATE] at 9:05 a.m., LN 2 confirmed the call from the facility regarding the Resident 1's C[NAME], arrival time at the facility, and discovery of the medication administration errors. LN 2 notified the HMD. LN 2 stated the family was not present when she left, but the family was there when she returned at 12:15 p.m. after notification of Resident 1's death. LN 2 stated the family was not aware of the specific medication errors and explained the discovery of the order and administration errors. During a telephone interview on [DATE] at 1:30 p.m., RP 1 confirmed the facility left a message about 7:30 a.m., on [DATE], that (Resident 1) was not doing well and was on oxygen. RP 1 stated they returned the call to the facility when they heard the message at approximately 10:00 a.m. RP 1 stated there was no mention of a significant medication error when they arrived at the facility at approximately 12:00 p.m. LN 2 from hospice explained the significant medication error at about 12:15 p.m. RP 1 further stated at no time was the family offered the option of treatment, like [MEDICATION NAME], or a transfer to the hospital. RP 1 stated Resident 1 died about 30 minutes after they arrived to the facility at approximately 12:30 p.m. on [DATE]. 2. During a concurrent interview with the Director of Nursing (DON) and the Administrator (ADM) on [DATE] at 8:40 a.m., the DON stated the FMD is the attending physician for respite residents while they are in the facility. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:10 a.m., the ADON stated the FMD, was notified on [DATE] at 1:00 p.m. of the medication administration errors, 30 minutes after Resident 1 died . Review of Resident 1's eMR facility document titled Progress Notes reflected a late entry by the ADON, dated [DATE] at 5:08 p.m., indicating attending physician was notified at 1:00 p.m. of Resident 1's death and the medication administration errors. A record review of Resident 1's document titled Administration Record Report (MAR - Medication Administration Report) revealed the following: - Resident 1's pain assessments (using a pain scale with 0 = no pain, ,[DATE] = mild pain, 4 - 6 = moderate pain, 7 - 9, 10 = worst+) indicated a pain level of 0 on [DATE] at midnight, at 4 a.m., and at 8 a.m. - Resident 1 received on [DATE] [MEDICATION NAME] 100 mg at midnight and [MEDICATION NAME] at 12:26 a.m. for [MEDICAL CONDITION]. - Resident 1 received on [DATE] 2 ml of [MEDICATION NAME] 20 mg/ml (40 mg) at 3:59 a.m. - On [DATE], Resident 1 did not receive the scheduled [MEDICATION NAME] for 6 a.m. with a notation of 9 which indicated other/ see nurse notes. A record review of Resident 1's document titled Progress Notes revealed the following: - On [DATE] at 4:49 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 2 ml by mouth every 2 hours . Pain Scale was: 0. - On [DATE] at 5:14 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] ER Tablet Extended Release 100 MG Give 1 tablet by mouth every 6 hours for PAIN Unable to swallow. - On [DATE] at 6:39 a.m., LN 4 indicated a Medication Administration Note, OXYGEN 2L/MIN (a unit of measure for flow rate) VIA NC (nasal cannula - a means of delivering oxygen into the nose) PER CONCENTRATOR (a device that concentrates oxygen from the air to supply an oxygen-[MEDICATION NAME] flow) as needed for SOBPRN (shortness of breath as needed). - On [DATE] at 6:59 a.m., LN 4 indicated a Medication Administration Note, [MEDICATION NAME] Capsule 30 mg .PRN Administration was: Effective. - On [DATE] at 7:40 a.m., LN 4 indicated a Health Status Note, Resident in bed placed on continuous O2 (oxygen)@ 2L/min. [MEDICATION NAME] solution given as patient now unable to open mouth and swallow pills. (Agency name) hospice notified of change in status. (RP 1) made aware. During an interview and concurrent record review of the above with LN 4 on [DATE] at 3:55 p.m., LN 4 stated he did not consider a change of condition when Resident 1 could not express her pain for the 3:39 a.m. liquid [MEDICATION NAME] and at 5:14 a.m. when Resident 1 could not open their mouth or swallow a pill. LN 4 additionally stated Resident 1's change of condition was reported to the hospice agency around 7:30 a.m. after Certified Nursing Assistant (CNA) 1 and CNA 2 reported Resident 1 was unresponsive. LN 4 stated the hospice agency notified the HMD. LN 4 confirmed the FMD was not notified until after Resident 1 had died . Review of the facility policy titled Medication Errors, revised (MONTH) (YEAR), stipulated, It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative .When first discovered, the medication error shall immediately be reported to the physician for appropriate actions to be taken . Resident and resident representative should be notified and all actions taken to rectify the situation . Review of the facility policy titled Change of Condition, Resident, revised ,[DATE], stipulated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner .in the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and provide possible transport to an acute hospital. Review of the facility document titled Skilled Nursing Facility Services Agreement dated (MONTH) 16, (YEAR) and signed by representatives from the facility and (Agency Name) Hospice stipulated, Attending Physician means the doctor of medicine .duly licensed . is identified by a hospice patient (or such patient's legal representative) as having the most significant role in the determination and delivery of such Hospice Patient's medical Care Hospice Services .include .physician services to the extent these services are not covered by the attending physician.

Based on interview, record review and facility policy review, the facility failed to administer medications as prescribed by the physician for 1 of 2 residents (Resident 1) when: 1. Resident 1 did not receive medications prescribed by the admitting physician, including medications for blood pressure and heart function, and 2. Resident 1 received medications prescribed for Resident 2 including medications for pain (high dose [MEDICATION NAME]), nerve pain, and psychiatric disorders. These medication administration errors resulted in an acute [MEDICATION NAME] toxicity which resulted in Resident 1's death. Findings: Review of Resident 1's facility face sheet (document containing patient demographics including insurance information, responsible party, and diagnoses) and admission documents (including hospice request for admission, hospice face sheet, hospice progress notes, facility Notice of Admission, facility progress notes and facility orders), reflected Resident 1 was admitted to the facility for respite care (temporary institutional care of a dependent elderly, ill, or handicapped person, providing relief for their usual caregivers) in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Resident 1 was alert and oriented, ambulated with assistance and spoke some English as a second language. Resident 1's hospice (a medical service focusing on comfort instead of a cure so that a better quality of life can be maintained for as long as possible) face sheet, dated 12/14/17, reflected Resident 1's family member (RP 1) was designated as the Responsible Party and had power of attorney to make decisions. During a concurrent interview and record review with the Administrator (ADM) and Director of Nursing (DON) on 1/3/18 at 8:40 a.m., the ADM stated two faxes (one for Resident 1 and one for Resident 2) were received on 12/18/17 from the referring hospice agency one right after the other. The two faxes were bundled together as one packet and processed as one resident. A third fax was received on 12/28/17 for Resident 1. Review of the above faxed documents, presented by the ADM, reflected the following: - Admission request for Resident 1 received on 12/18/17 at 3:32 p.m., with a cover sheet with Resident 1's name on the cover sheet and with the notation Thank you for your review for respite. Supporting documentation for Resident 1 was also included in the fax totaling 21 pages with Resident 1's name on each page. Documentation included the resident's hospice face sheet, medical history, prescriber orders and nursing notes. - admission orders [REDACTED]. Resident 2's prescriber orders were included in the fax totaling 3 pages with Resident 2's name on each page. - admission orders [REDACTED]. Resident 1's prescriber orders were included in the fax totaling 4 pages with Resident 1's name on each page. After review of the faxed documents, the ADM further stated, the hospice agency faxes the request for respite care to the facility; once accepted, the hospice agency sends the final orders to the facility the day before admission. During the same interview on 1/3/18 at 8:40 a.m., the DON explained the admission process as the following: - The admission packet was sent to admissions from the referring agency and was placed in the resident's chart. - The chart was then sent to the nurses' station the day of admission. - The Unit Manager or Admissions Nurse received the chart and reviewed the admissions orders and history, and if needed, would contact the prescriber for any clarification. Orders were then entered in to the electronic medical record (eMR). - The medication orders were transcribed and then entered into the facility eMR, were then printed and signed by the entering nurse attesting the orders entered were from prescriber written orders. This form was then faxed to the facility pharmacy to be dispensed. - Comfort medications (usually medications for pain, anxiety, antipsychotic and bowel care) are usually supplied to the facility by the hospice provider. Medications not covered by the hospice provider are supplied from the facility pharmacy. During an interview on 1/3/18 at 11:45 a.m., Licensed Nurse (LN) 1, who was the Admission Nurse for Resident 1, verified the admission process and confirmed Resident 1's original orders were not faxed to the pharmacy. LN 1 further confirmed no other facility staff double checked the orders entered into the eMR. LN 1 stated comfort medications were usually delivered to the facility by the hospice pharmacy the day of admission, however there was a miscommunication and Resident 1's medications were refused in the morning by the facility and hospice had them resent later in the day. LN 1 further stated when Resident 1 arrived at the facility, the hospice nurse was notified. In a telephone interview on 1/4/18 at 9:05 a.m., LN 2 (hospice nurse) stated hospice was notified by the facility of Resident 1's arrival. LN 2 stated upon arrival to the facility, Resident 1 was assessed. LN 2 stated admission orders [REDACTED]. LN 2 further indicated Resident 1's admission orders [REDACTED]. LN 2 stated further explanation to LN 1 was discussed regarding the medications with an X marked next to them indicated medications not covered by hospice that would need to be either ordered from the facility pharmacy or medications from home would be brought to the facility by the family to be used. During an interview on 1/5/18 at 2:00 p.m., the DON stated I'm not disputing the order mix - up. During a follow up interview with LN 1 on 1/5/18 at approximately 2:45 p.m., LN 1 confirmed the review of medications with LN 2. LN 1 further stated the orders entered in the facility eMR were the hand written orders .because the orders are not usually printed from hospice (eMR), I skipped over them and went to the next page of hand written orders . LN 1 stated he did not see Resident 2's name on the handwritten medication orders he transcribed into the facility eMR. LN 1 confirmed Resident 1 received medications prescribed for Resident 2. Review of the faxed document for Patient 1, dated 12/28/17, titled Physician's Orders/Medication Status - (hospice name) and review of Patient 1's facility document titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected the medications ordered by the prescriber. These medications were not entered into the eMR for Patient 1 on admission, were not listed on the admission MAR and were not administered to Patient 1. 1) [MEDICATION NAME] (a narcotic pain medication with life threatening toxicity that includes compromise to breathing and blood circulation to vital organs) Solution, 20 mg/ ml (milligrams per milliliter, units of measure, a concentration of a liquid) 0.25 ml, by mouth, every 4 hours as needed for mild pain/SOB (shortness of breath), 2) [MEDICATION NAME] Solution, 20 mg/ ml, 0.5 ml, by mouth, every 4 hours as needed for moderate pain/ SOB 3) [MEDICATION NAME] Solution, 20 mg/ ml, 1 ml, by mouth, every 4 hours as needed for severe pain/SOB 4) ([MEDICATION NAME]) (an anti-anxiety medication), 1 mg tablet, by mouth, every 4 hours as needed for anxiety, 5) [MEDICATION NAME] (medication used to treat chest pain in people who have a narrowing of the blood vessels that supply blood to the heart) Sublingual (under the tongue) 0.4 mg tablet, 1 tablet, sublingual, every 5 minutes up to 3 times, as needed for chest pain 6) ([MEDICATION NAME]) (medication used to treat constipation) 8.6 - 50 mg tablet, 2 tablets by mouth every day for constipation 7) [MEDICATION NAME] 30 mg tablet, 1 tablet, by mouth, at bedtime for depression 8) [MEDICATION NAME] 25 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 9) [MEDICATION NAME], 20 mg tablet, 1 tablet, by mouth, as needed for [MEDICAL CONDITION] 10) [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disease), 5 mg tablet, 1 tablet, by mouth, every day 11) [MEDICATION NAME], 100 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 12) ([MEDICATION NAME]), 20 mg capsule, 1 capsule, by mouth, every day for stomach 13) [MEDICATION NAME], 1 gm tablet, 1 tablet, by mouth, twice a day for stomach 14) [MEDICATION NAME], 10 mg tablet, 1 tablet, by mouth, twice a day for high blood pressure 15) [MEDICATION NAME], 0.2 mg tablet, 1 tablet, three times a day for high blood pressure 16) [MEDICATION NAME] extended release, 60 mg tablet, 1 tablet, twice a day for heart 17) aspirin, 81 mg tablet, 1 tablet, by mouth, every day for heart 18) [MEDICATION NAME] concentrate 2 mg/ml, 0.5 - 1 ml, by mouth, as needed for agitation Review of the faxed document for Resident 2, dated 12/18/17, titled Physician Orders Sheet - (hospice name) reflected the following medications ordered by the prescriber for Resident 2, and review of Resident 1 ' s facility documents titled Administration Record Reports Administration Record Report (MAR - Medication Administration Report) dated 12/1/17-12/31/17 and 1/1/18-1/31/18 and Progress Notes with corresponding medication administration documentation reflected the following medications ordered by the prescriber for Resident 2 and administered to Resident 1 with a start date indicated on the MAR of 12/29/17: 1) ([MEDICATION NAME]) 1 mg tablet, 1 tablet, by mouth, every 4 hours as needed, - 12/31/17 GIVEN at 12:01 a.m. 2) [MEDICATION NAME] extended release 100 mg capsule, 1 capsule, by mouth every 6 hours around the clock for pain, - 12/29/17 GIVEN at 6 p.m., - 12/30/17 NOT GIVEN, at 12 a.m. with reason waiting for medication delivery, and 6 a.m. with reason Will call (hospice name) to follow up medication, REFUSED (by Resident) at 12 p.m., GIVEN at 6 p.m., - 12/31/17 GIVEN at 12 a.m., 6 a.m., 12 p.m., and 6 p.m., - 1/1/18 GIVEN at 12 a.m., NOT GIVEN at 6 a.m. with reason at 5:14 a.m. as Unable to swallow. 3) [MEDICATION NAME] 20 mg/ml, 2 ml, by mouth, every two hours as needed for break through pain or shortness of breath, - 12/31/17 GIVEN at 3:40 a.m. for pain rating of 8 (pain scale of 1 to 10 with 10 being the worst pain) with reason at 4:43 a.m. of effective and pain rating of 2, - 1/1/18 GIVEN at 3:59 a.m. for pain rating of 6 with reason at 4:49 a.m. of effective and pain rating of 0 4) [MEDICATION NAME] (medication used to treat nerve pain), 600 mg tablet, 1 tablet, by mouth, three times a day, - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 5) [MEDICATION NAME] (a steroid medication used to treat pain), 4 mg tablet, 2 tablets, by mouth, every day - 12/30/17 GIVEN at 9 a.m., - 12/31/17 REFUSED (by Resident) at 9 a.m., - 1/1/18 GIVEN 9 a.m. 6) [MEDICATION NAME] 10 mg tablet, 1/2 tablet, by mouth, three times a day for spasms - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., REFUSED (by Resident) at 1 p.m., GIVEN at 5 p.m., - 12/31/17 REFUSED (by Resident) at 9 a.m., GIVEN at 1 p.m., and 5 p.m., - 1/1/18 GIVEN 9 a.m. 7) ([MEDICATION NAME]), 40 mg tablet, 1 tablet, by mouth twice a day for stomach - 12/29/17 GIVEN at 5 p.m., - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED (by patient) at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 8) (quetiapine [MEDICATION NAME]) (an antipsychotic medication used to treat mental illness), 50 mg tablet, 1 tablet, by mouth, twice a day - 12/29/17 NOT GIVEN at 5 p.m. with reason awaiting delivery from pharmacy, - 12/30/17 GIVEN at 9 a.m., and at 5 p.m., - 12/31/17 REFUSED (by Resident) at 9 a.m., GIVEN at 5 p.m., - 1/1/18 GIVEN 9 a.m. 10) (quetiapine [MEDICATION NAME]), 50 mg tablet, 1 tablet, by mouth, every 4 hours as needed for anxiety, NOT GIVEN 11) ([MEDICATION NAME]), 30 mg capsule, 1 capsule, as needed at bedtime for [MEDICAL CONDITION] - 1/1/18 GIVEN at 12:26 a.m. 12) ([MEDICATION NAME]) (medication used to treat constipation) 8.6-50 mg tablet, 2 tablets by mouth twice a day for constipation, NOT GIVEN 13) milk of magnesia (MOM) 400 mg/5 ml, 30 ml, by mouth, every day as needed for constipation, NOT GIVEN 14) ([MEDICATION NAME]) rectal suppository 10 mg, 1 suppository, rectally, every day if MOM is ineffective, NOT GIVEN 15) Fleet enema 7 gm - 19 gm/ bottle, 1 bottle, rectally if ([MEDICATION NAME]) ineffective, NOT GIVEN Review of Resident 1's facility document titled Order Summary Report, dated 12/29/17, reflected medications entered in the eMR on admission for Resident 1 matched the medications ordered for Resident 2. Review of Patient 1's facility document titled MARs dated 12/1/17-12/31/17 and 1/1/18-1/31/18 reflected none of the 18 medications prescribed for Patient 1 were given. It further indicated of the 15 medications prescribed for Patient 2 that were erroneously entered/processed for Patient 1, 10 were administered, and some of them were administered multiple times over 4 days (12/29/17 - 1/1/18). In a telephone interview with LN 3, on 1/4/18 at 9:20 a.m., LN 3 stated she had cared for Resident 1 since (MONTH) of (YEAR) for the hospice agency and had last seen the resident on 12/27/17. LN 3 further stated Resident 1 was alert and oriented to person and place, was able to feed self, ate about 50% of meals, and was able to ambulate to the bathroom in the home. LN 3 additionally stated Resident 1 had received 10 mg of [MEDICATION NAME] once after a fall, but did not like the feeling and did not receive any additional narcotics. LN 3 verified Resident 1 was opioid (narcotic) naive (not chronically receiving opioids on a daily basis). Review of the facility policy titled Record Content - Medication and Treatment Administration Record, dated 11/2017, stipulated, Medications and treatments shall be administered as prescribed by the physician . Review of the facility policy titled Medication Errors, dated (MONTH) (YEAR), stipulated, .A medication error is defined as administration to a resident: To the wrong patient, at the wrong time, at the wrong dose, by the incorrect route, which is not prescribed by a physician, omission if (sic) the prescribed medication . During a telephone interview with the county deputy coroner on 5/1/18 at 9:30 a.m., the coroner stated the [MEDICATION NAME] level for Resident 1 was 0.27 mg/liter. He further stated the reference ranges for [MEDICATION NAME] for a narcotic naive person was 0.01 mg/ liter is therapeutic and 0.05 - 0.4 mg/ liter was lethal .the cause of death for (Resident 1) was acute [MEDICATION NAME] toxicity. Review of the toxicology screen, dated 1/5/18 and received from the county coroner's office on 5/8/18, reflected a [MEDICATION NAME] level of 0.27 mg/ liter for Resident 1. Review of the death certificate, amended on 4/28/18, reflected Resident 1's cause of death as Acute [MEDICATION NAME] toxicity.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure 1 of 3 sampled residents (Resident 3) was free from accidents and injuries when: 1. Resident 3 sustained a severe injury and amputation to her left fifth fingertip (little finger) as she opened and closed the door of Shower Room 2, and 2. Randomly selected resident rooms and shower rooms were noted with splinters and rough areas and four out of four linen closets had no locks and had rough edges around the door handles for a census of 108. These failures resulted to Resident 3 severing her left little fingertip and had the potential to cause injury to other residents who may accidentally wander and open the doors. Findings: 1. Resident 3 was admitted to the facility 11/19/15. She had multiple [DIAGNOSES REDACTED]. Resident 3 had a care plan, initiated on 12/15/15, which indicated under focus, The resident is dependent on staff for activities, cognitive stimulation, social interaction, risk for leaving the building, running into others, grabbing them or objects around her (wheelchair) and risking hurting herself or others. Needs close monitoring throughout the day (related to) severe cognitive deficits and motor restlessness. Interventions included: Escort and sit with the resident once in scheduled activities, and (Resident 3) needs to be closely monitored when up in (activity) room (due to) fall risk and wandering. The care plan did not quantify how closely Resident 3 should be monitored. Resident 3 had a care plan, initiated on 12/22/15, which indicated under focus, Resident 3 at risk for elopement (related to) dementia. The care plan indicated under interventions, Monitor resident whereabouts frequently. The care plan did not specify and/or quantify how often Resident 3 should be monitored. Resident 3 had a care plan, initiated on 2/19/16, which indicated under focus, Resident at risk for skin tears and injury related to poor safety awareness and banging herself to objects. A quarterly Minimum Data Set (MDS, an assessment tool), dated 2/25/16, indicated Resident 3 was rarely or never understood and rarely or never understood others. Resident 3 had short-term and long-term memory problems. Her cognitive skills for daily decision making were severely impaired. The MDS also indicated Resident 3 had physical behavioral problems directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing .) and wandering (which occurred 4 to 6 days a week, but less than daily). Resident 3 required extensive assistance of one person with activities of daily living. Resident 3 had a care plan, initiated on 3/6/16, which indicated under focus, Resident having increased motor restlessness as evidenced by continuous elopement attempts. Resident 3's Progress Note, dated 3/12/16, indicated LN 1 saw Resident 3 at 10:25 p.m. at the East Station shower room opening and closing the shower room door. The Note indicated, When charge nurse (LN 1) came to bring her away from the door, (there were) blood streaks noted on the left door frame and blood drops on floor next to her wheelchair. When examined by charge nurse, the very distal tip of the (left) small finger was severed in slanted direction. Wet to dry gauze was (immediately) placed on the finger to control bleeding. (There) was a moderate amount of bleeding .The severed tip of finger was found on the floor in the space (where) the door hinges are. The Progress Note indicated Resident 3 was given Percocet (pain medication) prior to transfer to the emergency room . Resident 3's hospital visit information sheet, dated 3/12/16, indicated, in part, Finger Tip Amputation, Open (Treatment) . suture removal in approximately 7-10 days. Clindamycin (antibiotic) has been prescribed for prophylaxis since there is a concern for possible bony involvement of the amputation .You have cut off the tip of your finger .there is skin missing and the wound cannot be fully covered by sewing the edges together .it will take from 2-6 weeks for the wound to fill in with new skin. Resident 3 had a care plan, initiated on 3/13/16, which indicated under focus, Resident has injury to (left) distal tip of small finger (related to) severing. Resident 3 had a second care plan, initiated on 3/13/16, which indicated under focus, The resident has actual impairment to skin integrity at 5th left finger (related to) amputation secondary to trauma. An interview was conducted with Licensed Nurse (LN) 1 on 3/18/16 at 10:15 a.m. LN 1 said he heard the sound of a door opening and closing back and forth while he was passing medications in a room adjacent to the nursing station on 3/12/15 around 10:30 p.m. LN 1 pushed the medication cart to the nurses' station and saw Resident 3 sitting next to Shower Room 2. He noted Resident 3 was facing the door. Her hands and the wheelchair were in contact with the door. Resident 3's left hand was toward the left where the door handle was located. LN 1 reported there was no staff at the nurses' station or in sight at the time. LN 1 noted blood smears on the door below the handle, on the floor next to the door, and on Resident 3's hands and shirt. LN 1 indicated he cleaned up Resident 3's hands and noted the left fifth fingertip and nail was missing. LN 1 looked around and found the missing portion of the finger on the floor at the right corner of the hinge of Shower Room 2's door. LN 1 said he was not sure if Resident 3 was in pain, but he administered Percocet 1 tablet by mouth. LN 1 notified the physician and sent Resident 3 to the emergency room . LN 1 indicated Resident 3 always wandered about the facility when she was up in her wheelchair, wandered into other resident's rooms at times, was always seeking the exit doors, and attempting to open them. An observation was conducted of Resident 3 on 3/18/16 at 10:40 a.m. Resident 3 was observed in the hallway near the East Nurses' Station sitting up in her wheelchair sleeping. An alarmed self-releasing belt (a seat belt which the resident can release, that alerts the staff if a resident attempts to get up independently) was placed across her lap. Resident 3's left fifth finger (little finger) was wrapped in a dressing. A family member was sitting next to her. An interview was conducted with Resident 3's family member on 3/18/16 at 10:45 a.m. He indicated she had severely injured her finger while trying to open and close the shower room door near the East Station. Her family member reported he had seen the amputated left little fingertip at the local hospital where she was referred to after the incident. Her family member stated, I felt sorry for her. An interview was conducted with Certified Nursing Assistant (CNA) 1 on 3/18/16 at 11:10 a.m. She indicated Resident 3 wandered into other resident's rooms and about the facility and opened doors with one hand as she moved along. CNA 1 indicated staff tried to re-direct her, but it was difficult because she couldn't stay in one area. CNA 1 reported Resident 3 ran into other residents' wheelchairs, walkers, and objects as she wandered. She had no safety awareness. A change of the wound dressing was observed with Registered Nurse (RN) 1 on 3/18/16 at 11:48 a.m., Resident 3 was observed in her room sitting in her wheelchair with the alarmed self-releasing seatbelt placed across her lap. Her family member was at her bedside. The left fifth fingertip was noted amputated and the nail was missing. There were 3 sutures (stitches) to the finger area. RN 1 reported Resident 3 crushed her left fifth finger as she opened and closed the shower room door on 3/12/16 and was taken to the emergency room where the area was sutured. RN 1 indicated the wound dressing was being changed twice daily. RN 1 reported Resident 3 had behaviors of wandering. An interview was conducted with CNA 2 on 3/18/16 at 1:45 p.m. She indicated Resident 3 wandered all over the facility, grabbed onto objects like wheelchairs and walkers, and opened doors in an attempt to exit the facility. An interview was conducted with LN 2 on 3/18/16 at 1:50 p.m. LN 2 was asked what behaviors Resident 3 displayed. LN 2 indicated Resident 3 went into other peers' rooms, attempted to exit the facility, grabbed on wheelchairs, grabbed door handles, and wandered about the facility. An interview was conducted with CNA 3 on 3/22/16 at 4:10 p.m. She indicated she left Resident 3 in front of the East Nurses' Station on 3/12/16 around 10 p.m. after she provided care to her. CNA 3 then went to assist another resident. CNA 3 indicated there were 3 nurses sitting at the East Nursing Station. CNA 3 indicated Resident 3 wandered about the facility and always had bruises from banging into objects. An interview was conducted with LN 3 on 3/23/16 at 7:30 a.m. He indicated Resident 3 was unable to follow safety instructions, tried to go into other peers' rooms, sought exits, bumped into other peers' wheelchairs and the medication cart, attempted to open doors and exits located in the front lobby and therapy room. LN 3 indicated Resident 3 was started on one to one supervision on 3/13/16 after she injured her finger when opening and closing the shower room door on 3/12/16. An interview was conducted with the Director of Nursing (DON) on 3/18/16 at 1 p.m. The DON indicated Resident 3 was at risk of elopement and wandered about the facility. When asked about the supervision provided to Resident 3 to ensure her safety, the DON indicated all staff were aware of her behaviors and were responsible to monitor her closely. The DON indicated the facility had no policy and procedure specific to prevention of accidents and supervision. 2. A tour was conducted to inspect the facility doors. A concurrent interview was conducted with Maintenance Staff (MS) 1 on 3/18/16 starting at 11:05 a.m. Six out of six shower room doors and four out of five randomly selected resident room doors were noted with loose splinters and rough areas around and below the door handles. Four out of four linen closets had no locks and had rough edges around and below the door handles. MS 1 validated the observations and indicated the doors should have been smoothed out or repaired and the linen closets should have lockable doors.