Every finding on record at Haven Post Acute

Based on interview and record review, the facility failed to ensure a significant change in condition for one of three sampled residents (Resident 1) was immediately reported to the physician. This failure resulted in a delay in necessary medical intervention and subsequent hospitalization for Resident 1.Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), and history and physical (H&P -comprehensive medical evaluation written by a doctor) indicated Resident 1 was admitted on [DATE], with diagnoses that included atrial fibrillation (a heart condition where the heart irregularly and fast), cirrhosis (the liver no longer works well), and morbid obesity (excess fat that poses severe health risks). During a review of Resident 1's Minimum Data Set (MDS- federally mandated facility assessment tool), dated [DATE], under Section C (Cognitive Patterns- evaluates a resident's memory, orientation, attention, and indicators of delirium), it indicated Resident 1 had a Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score of 15 (A BIMS score of 13 to 15 means a person's thinking, memory, and orientation are normal or intact). During a review of Resident 1's Progress Notes, dated [DATE], at 11:34 PM, documented by Licensed Vocational Nurse 2 (LVN 2), it indicated, Note Text: Resident is on monitoring for low O2 [O2 means oxygen, the body does not have enough oxygen in the blood] levels; desaturation [drop in blood oxygen levels below the normal below the normal range of 95% to 100%]. Upon shift change, res [resident]was observed to have an oxygen level of 90% [normal is 95% to 100%]. Res [resident] did not c/o [complained] pain or discomfort at this time and responded to verbal commands. At 4:30 [AM], res was seen not compliant with O2. O2 levels were checked and read at 65% Res was encouraged to comply with NC but stated you will not get it in my nose even if you try. At 6pm, res was seen complying with NC [small prongs that is inserted to the nostrils to deliver oxygen] and O2 read at 86%. No c/o of discomfort or pain at this time. Res [Resident] was given meds [medications] as ordered by MD [Doctor of Medicine] with no ASE (side effects) noted. At 8pm, res was seen to be compliant with NC reading at 89%. Res had one c/o for pain during this time and PRN analgesic was administered with no ASE noted. Vitals read 129/75 [blood pressure, force of blood pushing against the walls of the arteries as heart pumps it around the body, normal range is less than 120 for the top and less than 80 for the bottom], HR 125 [heart rate, the number of times a heart beats in 1 minute, normal is 60 to 100 beats per minute] and O2 at 89%. Upon pain reassessment, pain was successfully lowered and HR lowered to 92. Personal items, call light is within reach, and safety precautions are kept in place. POC [Plan of Care - step by step guide to resident's treatment] to continue and monitoring to continue per shift. During a review of Resident 1's Progress Notes, dated [DATE], through [DATE], it indicated there is no record of Resident 1's physician being notified of these concerns. During a review of Resident 1's Weights and Vitals Summary, with an effective date of [DATE], at 1:37 PM, vital summary results showed the following: 1. Blood Pressure 53/41 (the force of your blood pushing against the walls of your arteries as your heart pumps. Normal blood pressure in adult is 120/80) 2. Oxygen saturation 91% with oxygen mask (a measure of how much oxygen your red blood cells are carrying from your lungs to the rest of your body. Normal is 95% to 100% without oxygen supplement) 3. Pulse rate of 125 bpm (the number of times your heart beats per minute. Normal is 60 to 100 beats per minute) 4. Respiration 22 breaths per minute (number of breaths you take a breath per minute. Normal is 12-20 per minute) 5. Temperature 97.2 F (how hot or cold your body is. Normal is 98.6 Fahrenheit) During a review of Resident 1's hospital document titled, Emergency Documentation, it indicated Resident 1 arrived at the emergency room on [DATE], at 2:11 PM, with a chief complaint of SOB (shortness of breath - trouble or difficulty in breathing). A review of Resident 1's Critical Care Note (notes written by doctors and nurses in the intensive care unit [ICU-a 24-hour constant care to residents with life-threatening illnesses or injuries] to track resident's status and treatment plan), dated [DATE], at 2:34 PM, it indicated Resident 1 was in severe distress and was hypoxic (body does not have enough oxygen to function properly). BIPAP (Bilevel Positive Airway Pressure -medical device that helps a resident to breathe more easily by pushing gentle, air through a mask in the lungs) was attempted however Resident 1 did not tolerate the BIPAP (unsuccessful) and was ultimately intubated (flexible plastic breathing tube inserted in the resident's throat and into the windpipe to help in breathing). During a review of the hospital physician's note dated [DATE], at 2:37 PM, it indicated Resident 1 was placed on Do Not Resuscitate (DNR- it is a legal medical order stating that if the resident's heart stops beating or resident stop breathing, medical staff should not try to restart them.) due to very poor prognosis and eventually pronounced deceased (dead) in the afternoon of [DATE]. During a concurrent telephone interview and record review on [DATE], at 12:53 PM, with LVN 2, LVN 2 confirmed she documented that Resident 1 was experiencing low oxygen levels during her shift on [DATE]. When LVN 2 was asked if she notified Resident 1's physician regarding her change of condition at that time, LVN 2 stated she did not. During a telephone interview on [DATE], at 3:55 PM, with Resident 1's physician, he stated he was not informed about Resident 1's worsening condition on [DATE], during the night shift. The physician also stated he could have ordered Resident 1 to be transferred to the hospital via emergency that same night due to the concerning change in her medical condition. During a concurrent interview and record review on [DATE], at 5:17 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP) the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, with a revision date of [DATE], was reviewed. The P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The ADON stated the policy was not followed.

Based on interview and record review, the facility failed to ensure two nursing staff had the specific competencies necessary to care for one of three sampled residents (Resident 1) when: 1.Licensed Vocational Nurse 2 (LVN 2) did not notify the physician of Resident 1's change in condition in a timely manner. 2.LVN 1 contacted a non emergency transport instead of arranging an appropriate emergency transfer for Resident 1. These failures resulted in a delayed in emergency medical intervention when Resident 1's was transfer to a hospital for treatment of a worsening change of medical condition.Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), and history and physical (H&P -comprehensive medical evaluation written by a doctor), dated [DATE], indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a heart condition where the heart beats irregularly and fast), liver cirrhosis (the liver no longer work well), and morbid obesity (excess fat that poses severe health risks). During a review of Resident 1's Minimum Data Set (MDS- federally mandated facility assessment tool), dated [DATE], under Section C (Cognitive Patterns- evaluates a resident's memory, orientation, attention, and indicators of delirium [sudden temporary state of disorientation]), it indicated Resident 1 had a Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score of 15 (A BIMS score of 13 to 15 means a person's thinking, memory, and orientation are normal or intact). During a review of Resident 1's Progress Notes, dated [DATE], at 11:34 PM, documented by Licensed Vocational Nurse 2 (LVN 2), it indicated, Note Text: Resident is on monitoring for low O2 [O2 means oxygen, the body does not have enough oxygen in the blood] levels; desaturation [drop in blood oxygen levels below the normal below the normal range of 95% to 100%]. Upon shift change, res [resident]was observed to have an oxygen level of 90% [normal is 95% to 100%]. Res [resident] did not c/o [complained] pain or discomfort at this time and responded to verbal commands. At 4:30 [AM on [DATE]], res [Resident 1] was seen not compliant with O2. O2 levels were checked and read at 65% Res was encouraged to comply with NC [small prongs that are inserted into the nostrils to deliver oxygen] but stated you will not get it in my nose even if you try. At 6pm [ [DATE]], res was seen complying with NC and O2 read at 86%. No c/o of discomfort or pain at this time. Res [Resident] was given meds [medications] as ordered by MD [Doctor of Medicine] with no ASE (side effects) noted. At 8pm [[DATE]], res was seen to be compliant with NC reading at 89%.Res had one c/o for pain during this time and PRN [as needed] analgesic[medication to relieve pain] was administered with no ASE [side effects]noted. Vitals read 129/75 [blood pressure, force of blood pushing against the walls of the arteries as heart pumps it around the body, normal range is less than 120 for the top and less than 80 for the bottom], HR 125 [heart rate, the number of times a heart beats in 1 minute, normal is 60 to 100 beats per minute] and O2 at 89%. Upon pain reassessment, pain was successfully lowered and HR lowered to 92. Personal items, call lights are within reach, and safety precautions are kept in place. POC [Plan of Care - step by step guide to resident's treatment.] to continue and monitoring to continue per shift. During a review of Resident 1's Progress Notes, dated [DATE], through [DATE], it indicated there is no record of Resident 1's physician being notified of these concerns. During a concurrent telephone interview and record review on [DATE], at 12:53 PM, with (LVN 2) LVN 2 confirmed she documented that Resident 1 was experiencing low oxygen levels during her shift on [DATE]. When LVN 2 was asked if she notified Resident 1's physician regarding her change of condition at that time, LVN 2 stated she did not. During a telephone interview on [DATE], at 3:55 PM, with Resident 1's physician, he stated he was not informed about Resident 1's desaturation on [DATE], during the night shift. Physician also stated he could have ordered Resident 1 to be transferred to the hospital via emergency that same night due to Resident 1's worsening condition. During a concurrent interview and record review on [DATE], at 5:17 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP) the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, with a revision date of [DATE], was reviewed. The P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The ADON stated the policy was not followed when LVN 1 did not notify Resident 1's physician when she had an episode of desaturation and when LVN 2 did not use an emergency transfer in transporting Resident 1 to the hospital when she was transferred due to an altered level of consciousness and desaturation. 2. During a review of Resident 1's vital signs record dated [DATE], at 1:37 PM, the following data was noted: 1. Blood Pressure (the force of blood pushing against the walls of arteries [muscle that carry oxygen-rich away from the heart to the rest of the body] as the heart pumps) 53/41 mmHg (a dangerously low blood reading requires immediate medical attention. Normal blood pressure in adults is 120/80 mmHg [mmHg-standard unit used to measure pressure]). 2. Oxygen saturation (the amount of oxygen the blood is carrying compared to the maximum amount it can hold normal oxygen saturation is 95% to 100%) 91% with oxygen mask (a plastic or rubber cup that straps over nose and mouth to give extra air) 3. Pulse rate (number of times a heart beats for one-minute, normal heart rate are 60 to 100 beats per minute) of 125 bmp (beats per minute) 4. Respiration 22 breaths per minute 5. Temperature 97.2 F (how much heat a human body makes or releases, normal is 98.6 F) During a review of Resident 1's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form, dated [DATE], at 2:01 PM, the SNF/NF to Hospital form indicated Resident 1 was transferred to the hospital on [DATE], at 2:01 PM via non-emergency ambulance. (24 minutes after Resident 1's last vitals were taken.) During an interview on [DATE], at 10:41 AM, with Certified Nursing Assistant (CNA), CNA stated, when she went to pick up Resident 1's tray after lunch on [DATE], she noticed Resident 1 appeared weak, pale, and was having difficulty breathing, so she notified the charge nurse. During a telephone interview on [DATE], at 2:44 PM, with Resident 1's physician, the physician was asked regarding Resident 1's transfer to the hospital due to altered level of consciousness and desaturation. The physician stated records indicated he received a text message on [DATE], at 1:57 PM, from the facility indicating that Resident 1 was transferred to the hospital but only saw the text message when Resident 1 was already transferred to the hospital. Physician further stated he did not speak directly with the transferring nurse. When asked if emergency transportation could have been ordered instead of non-emergency transport, Physician stated given the resident's condition, an emergency transfer would have been more appropriate. During a telephone interview on [DATE], at 10:14 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 confirmed she called for emergency transfer. When presented documentation form called, SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated [DATE], it indicated LVN 1 called the non-emergency transport. LVN 1 admitted she called for non-emergency and could have called emergency transportation, specifically 911, given Resident 1's condition LVN 1 stated she should have called emergency transportation. During a concurrent interview and record review on [DATE], at 5:10 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Transfer or Discharge, Emergency, with a revision date of [DATE] was reviewed. The P&P indicated, Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). The ADON & the IP was asked if this P&P was followed, the ADON stated the P&P was not followed when LVN 1 did not arranged for emergency transportation when Resident 1 needed to be transported to the hospital via emergency for medical evaluation and treatment due to altered level of consciousness and desaturation. During a review of Resident 1's hospital's document titled, Emergency Documentation, from [DATE] to [DATE], the document indicated Resident 1 arrived at the emergency room on [DATE], at 2:11 PM, with a chief complaint of SOB (shortness of breath - trouble or difficulty in breathing). During a review of Resident 1's Critical Care Note (notes written by doctors and nurses in the intensive care unit [ICU-a 24-hour constant care to residents with life-threatening illnesses or injuries] to track resident's status and treatment plan) dated [DATE], at 2:34 PM, it indicated Resident 1 was in severe distress and hypoxic (body does not have enough oxygen to function properly). A BIPAP (Bilevel Positive Airway Pressure -medical device that helps a resident to breathe more easily by pushing gentle, air through a mask in the lungs) was attempted however Resident 1 did not tolerate (unsuccessful) and was ultimately intubated (flexible plastic breathing tube inserted in the resident's throat and into the windpipe to help in breathing). During a review of the hospital physician's note dated [DATE], at 2:37 PM, it indicated Resident 1 was placed on Do Not Resuscitate (DNR- it is a legal medical order stating that if the resident's heart stops beating or resident stop breathing, medical staff should not try to restart them) due to very poor prognosis and eventually pronounced deceased (dead) in the afternoon of [DATE]. `

Based on interview and record review, the facility failed to provide a written notice of transfer to one of three sampled residents (Resident 2) when Resident 2 was transferred to the hospital. This failure violated Resident 2's rights by not providing information regarding the option to return to the facility following a transfer to the hospital.Findings: During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses that included gangrene (death of body tissue due to loss of blood supply), non-pressure chronic ulcer (open skin sore that fails to heal normally, caused by impaired blood circulation), and lack of coordination (the brain cannot tell the muscles how to move together). During a review of Resident 2's Minimum Data Set (MDS- federally mandated facility assessment tool), dated July 24, 2026, under Section C (Cognitive Patterns- evaluates a resident's memory, orientation, attention, and indicators of delirium), it indicated Resident 2 had a Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score of 11 (A BIMS score of 8 to 12 means a person's thinking, memory, and orientation is moderately impaired). During a review of Resident 2's Notice of Transfer/Discharge, dated August 14, 2026, it indicated the Verification of Receipt of Notice, section of the form was incomplete. The document did not have printed names of Resident 2, her representative, and the facility representative, with their respective signatures. This absence suggests that a copy of the notice was not provided or acknowledged as received. During a concurrent interview and record review on August 19, 2026, at 5:21 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, with a revision date of December 2016, was reviewed. The P&P indicated .1. A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: The ADON stated this policy was not followed. During a telephone interview on August 20, 2026, at 5:05 PM, with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was asked if she had provided Notice of Transfer/Discharge, to Resident 2 or any family member when Resident 2 was transferred to the hospital. LVN 3 stated I don't remember giving transfer notice.

Based on interview, and record review, the facility failed to ensure that a care plan (a summary of a resident's health conditions, specific care needs, and current treatments) for oxygen use was developed for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not receiving care and services appropriate to her specific goalsFindings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), and history and physical (H&P -comprehensive medical evaluation written by a doctor) indicated Resident 1 was admitted on [DATE], with diagnoses that included atrial fibrillation (a heart condition where the heart irregularly and fast), cirrhosis (the liver no longer work well), and morbid obesity (excess fat that poses severe health risks). During a review of Resident 1's Minimum Data Set (MDS- federally mandated facility assessment tool), dated July 7, 2026, under Section C (Cognitive Patterns- evaluates a resident's memory, orientation, attention, and indicators of delirium), it indicated Resident 1 had a Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score of 15 (A BIMS score of 13 to 15 means a person's thinking, memory, and orientation are normal or intact). During a review of Resident 1's Order Summary Report, it indicated the following telephone orders for oxygen use were placed on August 7, 2026: 1.OXYGEN: At 3 Liters/Minute (A setting that delivers moderate 30% to 32% of pure oxygen to an airway) via Nasal Cannula (is a light plastic tube with two prongs that rest in the nose to deliver oxygen) Every Shift. 2.OXYGEN: Change Nasal Cannula/Tubing & Storage Bag every week. 3.OXYGEN: Monitor 02 Saturation (a percentage of blood carrying out oxygen to the body) Every Shift Goal to maintain O2 (oxygen) Saturation Greater Than 90% A review of Resident 1's Care Plan Report, dated June 1, 2026, was conducted on August 19, 2026, at 1:57 PM. There was no documented evidence indicating that a care plan addressing the use of oxygen was developed for Resident 1. During an interview on August 19, 2026, at 2:44 PM, with MDS (Material Data Sheet) Coordinator, the MDS Coordinator stated a care plan should be developed upon admission and updated for any new concerns for a resident. The MDS Coordinator acknowledged that Resident 1's care plan for oxygen use was not developed. During a concurrent interview and record review on August 19, 2026, at 5:20 PM, with ADON and IP, the care plan for Resident 1 was reviewed. ADON acknowledged that there was no care plan created for oxygen use. During a concurrent interview and record review on August 19, 2026, at 5:27 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, dated September 2013 was reviewed. The P&P indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The ADON & the IP was asked if this P&P was followed, the ADON stated it was not followed.

Based on observation, interview, and record review, the facility failed to ensure constipation (having fewer than three bowel movements a week or passing hard, dry stools that are difficult or painful to pass) was identified, assessed, and provided appropriate treatment and services for one of three sampled residents (Resident 2). This failure may have potentially contributed to Resident 2 calling 911 emergency services and being transferred to the hospital due to discomfort caused by not having a bowel movement.Findings: During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses that included gangrene (death of body tissue due to loss of blood supply), non-pressure chronic ulcer (open skin sore that fails to heal normally, caused by impaired blood circulation), and lack of coordination (the brain cannot tell the muscles how to move together). During a review of Resident 2's Minimum Data Set (MDS- federally mandated facility assessment tool), dated July 24, 2026, under Section C (Cognitive Patterns- evaluates a resident's memory, orientation, attention, and indicators of delirium), it indicated Resident 2 had a Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline) score of 11 (A BIMS score of 8 to 12 means a person's thinking, memory, and orientation is moderately impaired). During a review of Resident 2's Progress Notes, dated August 14, 202626, at 12:25 AM, on August 19, 2026, at 1:39 PM, it indicated, Resident reports 10/10 achy mid [middle] abdominal pain with onset a couple of hours ago. Resident states nothing improves the pain since it started and any movement exacerbates [make it worse] the pain.Resident requesting further evaluation in acute setting [hospital], so resident independently called 911. Awaiting arrival of emergency transport at this time. During a review or Resident 2's Progress Notes, dated August 14, 2026, at 1:14 PM, on August 19, 2026, at 1:43 PM, it indicated, readmit: Resident came back from [name of the hospital] at 12:46 PM via gurney with [name of the transportation]. Resident left to hospital with c/o (complaint) abdominal pain. During a concurrent interview and record review on August 19, 2026, at 5:40 PM, with the Assistant Director of Nursing (ADON), and Infection Preventionist (IP) of Resident 2's B&B (bowel and bladder) Bowel Elimination, Resident 2's recorded bowel movement prior to transfer to the hospital on August 14, 2026, was August 10, 2026, at 10:59 PM. There was no bowel movements reported on August 11, August 12, and August 13. The next recorded bowel movement occurred on August 14, 2026, at 10:18 PM, after Resident 2 came back from the hospital at 1:14 PM, on the same day. During a review of Resident 2's acute hospital document titled, Discharge Instructions Document (listed care instructions after hospitalization), dated August 14, 2026, it indicated that the reason for the visit was abdominal pain, with a discharge diagnoses of constipation, abdominal pain, and lower leg pain. During a telephone interview on August 20, 2026, at 5:05 PM, with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was asked if she checked Resident 2's bowel movement record prior to Resident 2 being transferred to the hospital on August 14, 2026. LVN 3 stated she did not check but relied on Resident 2's statement. During a concurrent telephone interview and record review on September 16, 2026, at 1:16 PM, with the Director of Nursing (DON), the DON reviewed and acknowledged the Federal Regulation (official rule made by government agency that explains how to follow and enforce laws), which indicated, Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Based on interviews and record review, the facility failed to ensure safe oxygen administration in accordance with its policy for one of three sampled residents (Resident 2) when Resident 2 was connected to an oxygen concentrator (a machine which delivers oxygen) labeled, broken, on June 2, 2026. This failure had the potential to cause a decline in Resident 2's respiratory status, including decreased oxygen saturation (a measurement of how much oxygen the red blood cells are carrying in the blood), shortness of breath (difficulty breathing) and lung injury, placing Resident 2's health and safety at risk.During a review of Resident 2's admission RECORD (contains medical and demographic information), the admission RECORD indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included heart failure (a when the muscle of the heart is too weak to pump blood well), hypertension (a condition with high blood pressure), diabetes (a condition with a high sugar in the blood), chronic respiratory failure (when the lungs cannot properly push fresh oxygen into your blood) and obesity (a condition with too much body fat). During a review of Resident 2's History and Physical, (H&P), dated, May 8, 2026, the H&P indicated, . MEDICAL PROBLEMS: . Chronic respiratory failure on O2 [oxygen] . During a review of Resident 2's physicians' orders, dated June 2026, the physician's orders indicated, Resident 2 had an order for OXYGEN: At 4 (four) liters per minute via [through] nasal cannula[a tube with two small prongs that rest inside the nostrils, delivers oxygen when connected to an oxygen machine]/mask [worn over the nose and mouth, delivers oxygen delivers oxygen directly to the lungs when connected to an oxygen machine] every shift. OXYGEN: Change nasal Cannula/Tubing and Storage bag every week, every night shifts every seven day(s). OXYGEN: Monitor oxygen every shift. Goal to maintain oxygen saturation greater than 90 percent every shift. During an interview on June 22, 2026, at 11:45 AM, with Resident 2, Resident 2 stated her son visited her at the facility on June 2, 2026, and noticed the oxygen concentrator that she was connected to was labeled, broken therefore her son reported to the nursing staff about her oxygen machine. Resident 2 further stated she was recently transferred to an acute hospital because of low oxygen saturation levels. During an interview on June 22, 2026, at 12:10 PM, with the Infection Preventionist (IP), the IP stated, It is the licensed nurses' responsibility to check residents' oxygen and concentrators at the beginning of each shift and throughout the shift for proper functioning including, the nasal cannula and oxygen mask. The IP further stated, A broken oxygen concentrator is usually labeled as broken and kept in the storage or a designated area for repairs. During an interview on June 22, 2026, at 12:15 PM, with the Director of Nursing (DON), the DON stated, Oxygen care is done throughout the shift, and licensed nurses are responsible for checking to make sure the oxygen concentrators are well connected and oxygen machines are working properly. The DON further stated, Oxygen concentrator with a broken label should not be at the bed side of any resident. During an interview on June 30, 2026, at 5:54 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, on June 2, 2026, at the beginning of his shift (3PM to 11PM shift), he received information from another nurse from the previous shift to change Resident 2's oxygen concentrator. LVN 2 stated he brought a new oxygen concentrator from the storage room into the room and connected to Resident 2, because the old oxygen concentrator was labeled broken on it. During a review of Resident 2's care plan (a daily guide to someone's health) dated, May 11, 2026, the care plan indicated, Focus. Alteration in Respiratory status due to: DX (diagnoses) CHRONIC RESPIRATORY FAILURE Goal: Minimize resident's discomfort. Promote adequate/effective respiration. Interventions/Tasks: Give medication as MD order. Oxygen at 4 liters/minutes (liters per minute) via nasal cannula/mask every shift, keep head of bed elevated as per order. Oxygen: monitor oxygen saturation every shift. Goal to maintain oxygen saturation greater than 90 percent. A review of the facility's policy and procedure titled, Oxygen Administration dated, October 2010, indicated, Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Discard used supplies into designated containers.

Based on interview and record review, the facility failed to maintain complete and accurate medical records by not documenting resident-reported falls for one (1) of three (3) sampled residents (Resident 1).This failure resulted in a medical record that did not reflect Resident 1 reported change of condition.Findings: During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included subsequent encounter for fracture (the patient is in the healing or recovery phase, receiving routine follow-up care) and Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated March 3, 2026, under Section C, it indicated her Brief Interview for Mental Status (BIMS- screening tool to assess resident's cognition) score was 12. (A BIMS score of 8-12 suggests moderate problems with thinking and memory). During a concurrent interview and record review on March 17, 2026, at 3:34 PM, with two License Vocational Nurses (LVNs 1 and 2), LVNs 1 and 2 reviewed Resident 1's clinical records and could not find documentation indicating that Resident 1 reported fall within the facility. During a telephone interview on March 18, 2026, at 2:28 PM, with RN 1, RN 1 stated that on March 3, 2026, she went to Resident 1's room after hearing a scream, and found Resident 1 in bed, who claimed to have fallen. She stated that Resident 1 appeared disoriented and was unable to provide an answer when asked further about her alleged fall. She stated that she conducted a thorough assessment of the resident's body and found no indications of injury. During telephone interview on March 18, 2026, at 3:44 PM, with the Director of Nursing (DON), the DON stated she was unable to locate RN 1's documentation regarding Resident 1's reported fall. She further stated RN 1 should have documented the incident despite Resident 1's history of Alzheimer disease. She further stated that according to the policy a change of conditions must be documented. During telephone interview on March 19, 2026, at 8:14 AM, with RN 1, RN 1 stated, she failed to document Resident 1's reported fall and her assessment, admitting it was her oversight. RN 1 acknowledged that the policy mandates documentation of all incidents. A review of the facility Policy and Procedures (P&P), titled, Charting and Documentation, dated July 2017, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: .c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when buildup of grime and debris were noted on the floor and walls of kitchen's walk-in refrigerator. This failure had the potential to result in accumulation of pathogenic microorganisms (germs or infectious agents that can cause disease) and attraction of insects or rodents, which could place the health and safety of 88 highly vulnerable residents who receives food from the kitchen at risk. Findings: During a concurrent observation and interview with the Dietary Supervisor (DS), on March 3, 2025, at 8:44 AM, in the kitchen, the walk-in refrigerator was inspected. There was buildup of grime and debris on the floors and walls, underneath the shelve racks. The DS acknowledged the finding, and stated it is unacceptable. The DS further stated the walk-in refrigerator should be free of grime and debris. During a concurrent interview and record review on March 5, 2025, at 9:09 AM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Sanitation, revised 2023, was reviewed. The P&P indicated, .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, and chipped areas 16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over stove, which will be cleaned by the maintenance staff. The Admin stated the facility staff did not follow the P&P. The Admin further stated the kitchen should be clean, including the walk-in fridge. During a review of the US FDA (United States Food and Drug Administration) Federal Food Code, dated 2022, section 6-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, it indicated, Equipment food-contact surfaces and utensils shall be clean to sight and touch .The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The FDA Food Code, Section 4-601.11, further indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on interview and record review, the facility failed to ensure their weight change protocol was implemented for one of two residents (Resident 50) reviewed for nutrition when the Registered Dietitian Nutritionist (RDN) recommendations for Resident 50, which included weekly weights monitoring and administration of appetite stimulant (substances that increase hunger and food intake) were not carried out timely. These failures have the potential to place Resident 50 at risk for malnutrition (state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients to meet its physiological needs), increasing the risk of further weight loss, frailty, and weakened immune function, muscle wasting, weakness, reduced mobility, and cognitive and psychological decline, potentially leading to confusion, lethargy, and depression. Findings: During a review of Resident 50's Admission Record (contains demographic and medical information), it indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of acute kidney failure (a condition where kidney suddenly stop working properly, making difficult to eliminate waste), dysphagia (difficulty of swallowing foods, liquids or even saliva) and depression ( a mental health condition that causes persistent sadness, hopelessness and loss of interest.) During a review of Resident 50's Nutritional Initial Screener dated July 28, 2024, at 1:57 PM, it indicated, 1. Admitting Diagnosis: Difficulty in walking, acute kidney failure .2. Diet, NAS diet, (not added salt) Regular texture .,12. Appetite a. Poor (0-49%) ., 22. Most Recent Weight, Weight: 142 lbs. (pounds) . During a review of Resident 50's Care Plan dated, August 14, 2024, indicated, Nutritional risk r/t advancing age, weakness, decrease mobility, decrease strength .Goal, maintain weight acceptable to resident / responsible party and clinically appropriate ., Interventions ., monitor weight and notify MD for any undesirable weight changes ., Other dietary interventions . During a review of Resident 50's IDT (Interdisciplinary Team)Weight Variance (measurement of the spread of data points around their weighted mean, assigning different importance to each data point based on its assigned weight), dated September 4, 2024, at 4:30 PM, it indicated .weight 128 lbs. (which is a equivalent of 14 pounds less from the RD evaluation, 9.86 % in, 38 days), Interventions: 1. Weekly weights x 4 d/t weight loss (weekly weight for four weeks due to weight loss), 2 fortify diet d/t weight loss. During a review of Resident 50's Vital Weights for the month of September 2024, there was no documented evidence to indicate Resident 50's weekly weights were taken on the following weeks: September 9, 2024 - September 15, 2024, September 16, 2024 - September 22, 2024, and September 23, 2024 - September 30, 2024. (Three of four weekly weights was not done.) During a review of Resident 50's IDT weight Variance dated November 5, 2024, at 2:45 PM, it indicated A. Weight, Most Recent Weight, Weight:113 lbs. (from last weight, -15 pounds less; 18.7%) .,6. Interventions: Recommendations: 1. Appetite stimulant d/t weight loss/ poor appetite, weights x 4 d/t weight loss.) . During a review of Resident 50's Vital Weights for the month of November 2024, there was no documented evidence to indicate Resident 50's weekly weights were taken on the following weeks: November 5, 2024 - November 10, 2024, November 11, 2024 - November 17, 2024, and November 18, 2024 - November 24, 2024. (Three of four weekly weights was not done) During a review of Resident 50's clinical records, there was no documented evidence to indicate an appetite stimulant was ordered for Resident 50 for the months, November 2024 and December 2024. During a review of Resident 50's Physician Orders dated January 23, 2025, at 9:00 PM, it indicated Mirtazapine (aka Remeron- anti-depressive medication which can be used to improve appetite) Oral Tablet 15 mggive 1 tablet by mouth at bedtime for depression m/b (manifested by) decrease appetite. Start Date January 23, 2025, at 9:00 PM. During a phone interview and concurrent record review of Resident 50's clinical records, on March 5, 2025, at 11:19 AM, with the RD, the RD stated she recommended weekly weight monitoring and appetite stimulant to Resident 50 on November 5, 2024, due to continued weight loss. The record review indicated the appetite stimulant was not ordered until January 23, 2025 (79 days later, with no documentation explaining the delay). The RD stated she had concerns over the lack of follow - through with her recommendations. She stated weekly weight monitoring was essential for tracking fluctuations and ensuring timely interventions but stated she relies on facility staff to implement her recommendations and does not personally verify follow through. During a concurrent interview and record review on March 6, 2025, at 10:34 AM, with the Director of Nurses (DON), the DON reviewed Resident 50's clinical record stated Resident 50's weekly weights monitoring were not consistently performed as recommended by RD, specifically from September 9, 2024, through September 30, 2024, and November 5, 2024, through November 24, 2024. She further stated the appetite stimulant recommended by the RD on November 5, 2024, was not implemented until January 23, 2025 (resulting in 79 - day delay.) The DON stated these failures to a breakdown in communication and an oversight due to an email miscommunication, which led the Resident 50's name being omitted from the list of residents requiring interventions. She stated that while she typically ensures follow-up on RD recommendations through nursing staff, in this instance, she failed to confirm whether the orders were carried out. During a concurrent interview and record review on March 6, 2025, at 10:58 AM, with the DON, the DON reviewed the facility's policy and procedure (P&P) titled, weight Change Protocol dated 2023, which indicated, Early identification of a weight problem and possible cause (s) can minimize complications Assessment of resident experiencing weight changes should be completed in a timely manner. Residents will be weighed monthly and weekly for those newly admitted and those deemed to be at high risk for weight changes or according to the facility's policies. Variances are calculated from monthly and weekly weights that are obtained by facility staff. Resident who experience significant changes in weight or insidious weight loss will be assessed by the RD. The following criteria significant or insidious weight changes: Slow and progressive weight change trending away from weight goal. This can refer to weekly or monthly weights. 3# weight loss or gain in 1 week or as facility policy states, 5# weight loss or gain in 1 month .,5.0% weight loss or gain in 1 month .7.5% weight loss or gain in 3 months . The DON stated this policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure that medications and treatment supplies were stored in accordance with the facility's policy and procedure when: 1. Two expired Central Line Trays (a kit containing the necessary supplies for maintaining a central venous catheter [long thin tube inserted into a large vein near the heart]) were found in the intravenous cart (IV cart- mobile cart used to store intravenous supplies) and were available for use. 2. Six different types of expired dressings (pads or materials applied directly to wounds to protect them, promote healing, and absorb fluids), in various quantities were found inside the treatment cart and were available for use. 3. A medication treatment cup filled with an unidentified cream was found underneath Resident 5's bed. These failures had the potential for the medical and treatment supplies to loss sterility and adhesive strength, increasing the likelihood of infection and ineffective wound care, placing 88 residents' health at risk. Findings: 1. During a concurrent observation and interview on [DATE], at 9:14 AM, with the Registered Nurse (RN 1), the IV cart was inspected. Two central line trays with an expiration date of [DATE] (Expired for four months) were found inside the IV Cart. RN 1 validated the expiration date and stated they should not be inside the IV cart. During a concurrent interview and record review on [DATE], at 8:00 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised [DATE], was reviewed. The P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .4. Labels for stock medications . c. The expiration date . The DON stated the policy was not followed. 2. During a concurrent observation and interview on [DATE], at 9:30 AM, with the Treatment Licensed Vocational Nurse (Tx LVN), the Treatment Cart was inspected. The following expired dressings were found: a. Six Dermafilm hydrocolloid dressings (dressing that maintain a moist wound environment that remains breathable to moisture vapor) dated [DATE], (Expired for more than 22 months) b. Four Medi honey Hydrogel dressings (flexible dressing with manuka honey and sodium alginate which creates an antibacterial environment for wound protection) dated expired [DATE], (Expired for more than 14 months) c. Two Replicare dressings (dressing designed to create and maintain a moist wound environment by absorbing wound secretions to form a soft gel) dated [DATE], (Expired for more than 13 months) d. Six Cutimed Sorbact dressings (dressing that is used to treat infected wounds; coated with a hydrophobic fatty acid that binds to germs and removes them from the wound) dated [DATE], (Expired for more than 11 months) e. One DynaDerm hydrocolloid dressing (waterproof dressing that creates a protective patch over a wound, acting as a scab) dated [DATE], (Expired for more than months) f. One Mepilex Lite dressing (thin foam dressing designed to manage no- to low-exudate wounds) dated [DATE]. (Expired for more than 2 months) The Tx LVN validated the dressings were expired and stated the dressings should not be inside the treatment cart. During a concurrent interview and record review on [DATE], at 8:00 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Labeling of Medication Containers revised [DATE] was reviewed. The P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .4. Labels for stock medications . c. The expiration date . The DON stated the policy was not followed. 51099 3. During a concurrent observation and interview on [DATE], at 9:45 AM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 5's room, a medication treatment cup filled with an unidentified cream was found on the floor, underneath Resident 5's bed. LVN 2 verified the finding, and stated it was not supposed to be left in a resident's room or be within reach to a resident. LVN 2 further stated medications should be properly stored in either the medication room or one of the medication carts. During an interview on [DATE], at 4:15 PM, with the Director of Nursing (DON), the DON stated the expectation was for medications to be safely stored where it cannot be easily accessed by a resident. The DON further stated the medication treatment cup filled with an unidentified cream should have been disposed of and not left inside Resident 5's room. During a concurrent interview and record review on [DATE], at 4:30 PM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Storage of Medications, revised [DATE], was reviewed. The P&P indicated, .Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. The Admin stated the facility staff should have followed the P&P.

Based on observation, interview, and record review, the facility failed to ensure the Pain Assessment and Management policy was implemented for one of two residents (Resident 214) reviewed for pain, when Resident 214's PRN (pro re nata; as needed) pain medication was not administered as ordered by the physician. This failure had the potential to put Resident 214 in unnecessary prolonged pain and discomfort and had the potential for increased suffering, delayed recovery, and reduced mobility, ultimately affecting the resident's overall well-being. Findings: During a review of Resident 214's Admission Record (contains demographic and medical information), it indicated Resident 214 was admitted to the facility on [DATE], with the diagnoses for displaced intertrochanter fracture of the left femur (broken left hip), hypertension (elevated blood pressure), and type 2 diabetes mellitus (a condition where the body has trouble to regulating blood sugar.) During a review of Resident 214's Physician Orders, dated March 1, 2025, at 9:00 AM, it indicated Resident 214 had an order to receive Pregabalin (used to treat nerve pain) 100 mg (milligrams - unit of weight) give 1 capsule by mouth every morning and bedtime for nerve pain. During a review of Resident 214's Physician Orders dated, March 1, 2025, at 11:15 AM, it indicated Hydrocodone -Acetaminophen (Norco - is a opioid, pain medication use for severe pain) oral tablet 10-325 mg give 1 tablet by mouth every 6 hours PRN as needed for pain 1-10 NTE (not to exceed) more than 3 grams (grams unit on weight) in 24 hrs. (hours) Start Date, March 1, 2025 at 11:15 AM. During an observation on March 4, 2025, at 9:19 AM, inside Resident 214's room, Resident 214 was lying in bed, awake, alert, oriented x 3 and was able to verbalize needs. Resident 214 had a facial grimace and stated she was experiencing pain, with a pain scale (tool used to measure and quantify the intensity of pain; 10 means worst pain possible.) of 7/10 (severe pain) in the left hip when moving. She also stated she had not yet received her morning medications. During further observation on March 4, 2025, at 9:35 AM, License Vocational Nurse (LVN 1) entered Resident 214's room and took Resident 214's vital signs (measurements that indicate basic bodily functions and overall health). Resident 214 reported pain of 8/10 (severe pain) to LVN 1. During further observation on March 4, 2025, at 9:47 AM, LVN 1 administered Pregabalin 100 mg to Resident 214. LVN 1 did not offered or give Norco. During a subsequent interview on March 4, 2025, at 9:52 AM, with LVN 1, LVN 1 acknowledged the Norco should have been given as ordered to Resident 214. During a concurrent interview and record review on March 6, 2025, at 11:26 AM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled Administering Medications, revised April 2019, was reviewed. The P&P indicated, Policy Statement, Medications are administered in a safe and timely manner, and as prescribed ., 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribe time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication The DON stated Norco should have been administered for Resident 214's 8/10 pain as ordered by the physician. The DON stated the facility policy was not followed and further stated there was no physician order requiring Norco and Pregabalin to be given separately or one hour apart.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate (determined by calculating the percentage of medication errors (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications; or accepted professional standards and principles) observed during a medication administration observation) were not 5 percent or greater. There were three medication errors identified out of 33 opportunities for errors, affecting one of 8 residents (Resident 214), resulting in an overall medication error rate of 9.09 % when three of Resident 214's were not administered in accordance with prescriber's order and facility policy on March 4, 2025. This failure had the potential to place Resident 214 at risk for dangerously high blood sugar, increasing the risk of serious health complications including infection (when harmful bacteria, viruses or fungi enter the body and start growing causing illness, delayed wound healing, and sepsis (severe infection that spreads through the blood and can damage organs or be life-threatening).Furthermore, this failure had the potential to put Resident 214 in unnecessary prolonged pain and discomfort and had the potential for increased suffering, delayed recovery, and reduced mobility, ultimately affecting the resident's overall well-being. Findings: During a review of Resident 214's Admission Record (contains demographic and medical information) indicated Resident 214 was admitted to the facility on [DATE], with the diagnoses for displaced intertrochanter fracture of the left femur (broken left hip), hypertension (elevated blood pressure), and type 2 diabetes mellitus ( a condition where the body has trouble regulating blood sugar.) During a review of Resident 214's Physician Orders dated March 1, 2025, at 8:00 AM, it indicated Resident 214 had an order to receive Metformin HCL (used to treat high blood sugar levels) 850 mg (milligram- unit of measurement) Give 1 (one) tablet by mouth two times a day for diabetes with breakfast and evening .Start Date, March 1, 2025, at 8:00 AM, and Glipizide (used to treat high blood sugar levels) ER (Extended Release) tablet, Extended Release 24-hour 5 mg, give 1 tablet by mouth one time a day for diabetes hold if bs (blood sugar) is less than 100. Do not crush Start Date March 1, 2025, at 8:00 AM. During a review of Resident 214's Physician Orders dated, March 1, 2025, at 11:15 AM, it indicated Hydrocodone -Acetaminophen (Norco - opioid, pain medication use for severe pain) oral tablet 10-325 mg give 1 tablet by mouth every 6 hours PRN as needed for pain 1-10 NTE (not to exceed) more than 3 grams (grams unit on weight) in 24 hrs. (hours) Start Date, March 1, 2025 at 11:15 AM. During an observation on March 4, 2025, at 9:19 AM, inside Resident 214's room, Resident 214 was lying in bed, awake, alert, and oriented, able to verbalize need. Resident 214 had a facial grimace and stated she was experiencing pain, with a pain scale (tool used to measure and quantify the intensity of pain; 10 means worst pain possible.) of 7/10 (severe pain) in the left hip when moving. Resident 214 stated she had not yet received her morning medications. During a further observation on March 4, 2025, at 9:35 AM, License Vocational Nurse (LVN 1) entered Residents 214's room and took Resident 214's vital signs (measurements that indicate basic bodily functions and overall health) which included her blood sugar, which was 251mg/dL (milligrams per deciliter, used to measure the amount of sugar in the body.) Resident 214 reported pain of 8/10 (severe pain) to LVN 1. During further observation on March 4, 2025, at 9:42 AM, in Resident 214's room, LVN 1 administered Metformin HCL 850 and Glipizide ER 5 mg to Resident 214. (These medications were scheduled for 8:00 AM. The administration time was noted as being one hour and forty-two minutes after the scheduled time.) During further observation on March 4, 2025, at 9:47 AM, LVN 1 continued to administer Resident 214's medications. LVN 1 did not offered or give Norco. During a subsequent interview with LVN 1, on March 4, 2025, at 9:52 AM, LVN 1 stated the Resident 214's Metformin and Glipizide were administered late. LVN 1 also stated the Norco should have been given as ordered to Resident 214. During a concurrent interview and record review on March 6, 2025, at 11:26 AM with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled Administering Medications Policy dated, revised April 2019, was reviewed. The P&P indicated, Policy Statement Medications are administered in a safe and timely manner, in accordance with prescriber orders, including any required time frame ., 7. Medications are Administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . The DON stated the staff did not follow the policy and that the delay in administering Metformin and Glipizide was not in compliance with the physician's orders. She further stated that Metformin was scheduled to be given with breakfast because it was more effective when taken with food to help regulate blood sugar levels through the day. The DON acknowledged that delaying diabetes medications can increase blood sugar. The DON also stated Norco should have been administered for Resident 214's 8/10 pain as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure one of eight residents (Resident 214) reviewed for medication administration was free of significant medication error (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications (not recommendations); or accepted professional standards and principles, which causes the resident discomfort or jeopardizes his or her health and safety) when three of Resident 214's medications were not administered in accordance with physician's order and facility policy on March 4, 2025. This failure had the potential to place Resident 214 at risk for dangerously high blood sugar, increasing the risk of serious health complications including infection (when harmful bacteria, viruses or fungi enter the body and start growing causing illness, delayed wound healing, and sepsis (severe infection that spreads through the blood and can damage organs or be life-threatening).Furthermore, this failure had the potential to put Resident 214 in unnecessary prolonged pain and discomfort and had the potential for increased suffering, delayed recovery, and reduced mobility, ultimately affecting the resident's overall well-being. Findings: During a review of Resident 214's Admission Record (contains demographic and medical information) indicated Resident 214 was admitted to the facility on [DATE], with the diagnoses for displaced intertrochanter fracture of the left femur (broken left hip), hypertension (elevated blood pressure), and type 2 diabetes mellitus ( a condition where the body has trouble regulating blood sugar.) During a review of Resident 214's Physician Orders dated March 1, 2025, at 8:00 AM, it indicated Resident 214 had an order to receive Metformin Hydrochloride (used to treat high blood sugar levels) 850 mg Give 1 (one) tablet by mouth two times a day for diabetes with breakfast and evening .Start Date, March 1, 2025, at 8:00 AM, and Glipizide (used to treat high blood sugar levels) Extended Release 24-hour 5 mg, give 1 tablet by mouth one time a day for diabetes hold if bs (blood sugar) is less than 100. Do not crush Start Date March 1, 2025, at 8:00 AM. During a review of Resident 214's Physician Orders dated, March 1, 2025, at 11:15 AM, it indicated Hydrocodone -Acetaminophen (Norco - opioid, pain medication use for severe pain) oral tablet 10-325 mg give 1 tablet by mouth every 6 hours PRN as needed for pain 1-10 NTE (not to exceed) more than 3 grams (grams unit on weight) in 24 hrs. (hours) Start Date, March 1, 2025 at 11:15 AM. During an observation on March 4, 2025, at 9:19 AM, inside Resident 214's room, Resident 214 was lying in bed, awake, alert, and oriented, able to verbalize need. Resident 214 had a facial grimace and stated she was experiencing pain, with a pain scale (tool used to measure and quantify the intensity of pain; 10 means worst pain possible.) of 7/10 (severe pain) in the left hip when moving. Resident 214 stated she had not yet received her morning medications. During further observation on March 4, 2025, at 9:35 AM, License Vocational Nurse (LVN 1) entered Residents 214's room and took Resident 214's vital signs (measurements that indicate basic bodily functions and overall health) which included her blood sugar, which was 251mg/dL (milligrams per deciliter, used to measure the amount of sugar in the body.) Resident 214 reported pain of 8/10 (severe pain) to LVN 1. During further observation on March 4, 2025, at 9:42 AM, in Resident 214's room, LVN 1 administered Metformin HCL 850 and Glipizide ER 5 mg to Resident 214. (These medications were scheduled for 8:00 AM. The administration time was noted as being one hour and forty-two minutes after the scheduled time.) During further observation on March 4, 2025, at 9:47 AM, LVN 1 continued to administer Resident 214's medications. LVN 1 did not offered or give Norco. During a subsequent interview with LVN 1, on March 4, 2025, at 9:52 AM, LVN 1 stated the Resident 214's Metformin and Glipizide were administered late. LVN 1 also stated the Norco should have been given as ordered to Resident 214. During a concurrent interview and record review on March 6, 2025, at 11:26 AM with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled Administering Medications Policy dated, revised April 2019, was reviewed. The P&P indicated, Policy Statement Medications are administered in a safe and timely manner, in accordance with prescriber orders, including any required time frame ., 7. Medications are Administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . The DON stated the staff did not follow the policy and that the delay in administering Metformin and Glipizide was not in compliance with the physician's orders. She further stated that Metformin was scheduled to be given with breakfast because it was more effective when taken with food to help regulate blood sugar levels through the day. The DON acknowledged that delaying diabetes medications can increase blood sugar. The DON also stated Norco should have been administered for Resident 214's 8/10 pain as ordered by the physician.

Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included unspecified hyperlipidemia (increase levels of lipids - like cholesterol [waxy substance found in the blood] with high cholesterol increases the chance of heart problem). During interview and observation with Resident 1 on May 30, 2024, at 12:00 PM, Resident 1 expressed dissatisfaction with the night shift response to call lights, noting that occasional wait times extend up to two hours. During the review of Resident 2's admission record, the document indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included sepsis (an infection in the blood). During an interview and observation with Resident 2 on May 30, 2024, at 12:30 PM, Resident 2 expressed concern regarding the response time to call light, indicating that staff members take an extended period, ranging from 15 minutes to 15 hours. This has resulted in instances where Resident 2 has been left unattended and soiled. During the review of Resident 3's admission records the document indicated Resident 3 was admitted to the facility on [DATE], with a diagnosis that included Rhabdomyolysis (a condition that causes muscles to breakdown). During an interview and observation with Resident 3 on May 2, 2024, at 12:30 PM, Resident 3 reported extended wait times over an hour or more for staff to respond to her call lights. There was one instance of a three hour- delay, which required intervention by her husband. Resident 3 mentioned that her husband had to file a grievance before she noticed any improvement any staff response time to her call lights. During the review of Resident 4's admission records the document indicated Resident 4 was admitted on [DATE], with a diagnosis that included end stage renal disease (a medical condition in which a person's kidney stop working). During an interview and observation with Resident 4 on May 2, 2024, at 12:56 PM, Resident 4 stated the staff does not respond to call lights on time. During an interview with Social Worker 1 on May 2, 2024, at 1:04 PM, social worker confirmed receiving a grievance from resident 3, and staff were in service about bedside manner. A review of facility provided document titled Resident Grievance/Complaint Investigation Report indicated that a resident reported a grievance on May 14, 2024, regarding a Certified Nurse Assistance bedside manner. The document also mentioned that the Director of Staff Development (DSD) was informed about the grievance. During a review of the facility's policy titled Call System, Resident. The policy indicated, Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately.

Based on interview, and record review, the facility failed to provide adequate supervision, to a resident identified as having moderate risk of elopement (risk that refers to a situation where a resident, has a moderate likelihood or possibility of leaving the premises without authorization or supervision, wandering away from a controlled environment, which can pose safety risks for the individual) for one of three sampled residents (Resident 1), when Resident 1 ' s elopement and wandering care plan did not address the specific monitoring needs and frequency necessary to minimize the risk or prevent Resident 1 leaving a safe area without the facility ' s awareness on March 6, 2024, and had not been found for more than 72 hours. This failure had the potential to place Resident 1's health and safety at risk and for him to likely experience some serious adverse outcome, due to exposure of the (outdoor) elements, missed antipsychotic medications (drugs used to treat symptoms of psychosis (mental disorder characterized by a disconnection from reality) and without vital resources such as food, water, and shelter. Resident 1 was placed at high risk for accidents, psychotic outburst (which might lead danger to self and/or others), heat exposure, hypothermia (prolonged exposure to the cold can lead to complete failure of your heart and respiratory system and eventually to death), dehydration and/or other medical complications, including severe injury and even death. Findings: A review of Resident 1's clinical record titled, Admission Record (contains medical and demographic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health disorder including schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly] and mood disorder symptoms), altered mental status, and toxic encephalopathy (a degenerative neurological (nerve cell) (condition that can lead to memory loss, impaired or loss of vision, and altered mental status). During a review of Resident 1's clinical record from the hospital, dated November 3, 2023, it indicated .Patient [Resident 1] was confused and not able to hold conversation get distracted and walking around . lacks decision making capacity . brought to ER [emergency room ] for AMS [Altered Mental Status]. Patient stated he is from Chicago and walked to California and took for him 99 months to reach California . During a review of Resident 1's History and Physical (H&P), dated November 17, 2023, it indicated Patient [Resident 1] is not able to make own decision . consider psych eval (also known as Psychiatric diagnostic evaluations; used to determine a patient's mental state and guide recommendations for the best treatment. During a review of Resident 1's psychiatric follow up/progress note, dated February 20, 2024, it indicated . Pt [Resident 1] continue to endorse auditory hallucination [happen when you hear voices or noises that don't exist in reality] . MSE [Mental State Examination] Memory - impaired . Insight [level of understanding] - poor . Judgment [ability to make decisions] - poor . Plan/Recommendation/Intervention. 1) Medication Recommendation: a. Continue Olanzapine [medication used to treat schizophrenia] . schizoaffective/hallucinations. b. Increase Depakote [medication used as mood stabilizer], - schizoaffective/mood lability . 5. Continue to monitor for safety . During a review of Resident 1's Initial Elopement Assessment (a form to complete to determine if an individual requires necessary safety intervention. A score 0-18 used to determine the risk level resident for elopement), completed upon admission, dated November 16, 2023, it indicated Resident 1 had score of 9, which was moderate risk (refers to a situation where a resident, has a moderate likelihood or possibility of leaving the premises without authorization or supervision, wandering away from a controlled environment). A review of Resident 1's Social Service Notes, dated January 4, 2024, at 9:27 AM, indicated .discuss resident [Resident 1] medication and referral to public guardianship per (Public Guardian 1 (PG 1)) . Riverside County, Department of Public Social Services. The resident has no Public Guardian set at this time . During a review of Resident 1's Physician's Order Sheet, dated January 10, 2024, it indicated Resident 1 had an order to receive Zyprexa . 10 MG [milligrams-a unit of measure] (Olanzapine) Give 10 mg by mouth every morning and at bedtime for schizoaffective . A review of Resident 1's Physician's Order Sheet, dated February 20, 2024, it indicated Resident 1 had an order to receive Depakote . Give 500 mg by mouth two times a day for schizophrenia disorder . During a review of Resident 1 ' s Quarterly (completed in 3 months from the last elopement assessment) Elopement Reassessment, dated February 8, 2024, the elopement reassessment indicated Resident 1 had score of 7 (moderate risk). During a review of Resident 1's Minimum Data Set (MDS- part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes), Section GG Functional Abilities and Goals, dated February 12, 2024, the MDS indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient/resident completes activity. Assistance may be provided throughout the activity or intermittently) with mobility. During a review of Resident 1's undated Care plan for Self-care deficit: due to need assistance in ADL [activities of daily living]: Impaired cognitive[mental abilities], physical limitation/disability . it indicated the interventions included, .Provide assistance if needed . During a review of Resident 1's undated Care Plan for At risk for elopement and wandering out the facility, it indicated the interventions included Check resident's whereabout. The care plan did not specify supervision, monitoring and frequency required for Resident 1. A review of Resident 1's Social Service Note, dated March 6, 2024, at 4:46 PM, indicated IDT (Interdisciplinary team- composed of staff from various disciplines) met to discuss . resident [Resident 1] was missing from his room, per staff [License Vocational Nurse (LVN 1)] the resident was last seen at before 10AM . During a concurrent interview and record review on March 8, 2024, at 3:30 PM with the Director of Nursing (DON) of the Facility's Notification Memo, sent to the San [NAME] District Office, dated March 7, 2024, written by the Administrator, indicated I am reporting an unusual occurrence that occurred yesterday, March 6, 2024. Our resident [Resident 1] eloped from the facility. It was reported to me at approximately 1:30PM [on March 6, 2024] that Resident 1 could not be located in the facility . The administrator directed the RN [Registered Nurse] Supervisor to notify the physician, conservator, and San [NAME] Police Department per policy . Additional calls have been placed to the police and local hospitals today. Additional expanded searches were completed today of the neighborhoods, parks, and homeless encampments . The DON stated Resident 1 was last seen by staff [LVN 1] in the facility at 10:00 AM during the morning routine medication administration. Resident 1 was not identified as missing despite Resident 1 not being present during lunch time. (There was three and a half hours without adequate supervision and Resident 1 had been gone from the facility had not been found for more than 72 hours.) During further interview on March 8, 2024, at 3:45 PM, with the DON, the DON stated Certified Nurse Assistant 1 (CNA 1) was assigned to care for Resident 1 but failed to report to Licensed Vocational Nurse (LVN 1) Resident 1 was not present for lunch when it was served between 12:15- 12:30 PM. The DON further stated CNA 1 assumed Resident 1 was in the restroom. The DON stated CNA 1 should have checked Resident 1's restroom to confirm Resident 1's location and should have checked Resident 1 more frequently throughout the shift. During a follow up interview on March 8, 2024, at 3:50 PM, with the DON, the DON stated she was not aware that Resident 1 had a previous hospitalization record of walking long distance, resulting in altered mental status and fracture, before admitted to this facility. During a concurrent interview and record review on March 8, 2024, at 3:55 PM with CNA 1 of the statement written by Director of Staff Development (DSD)'s when interview with CNA 1, dated March 7, 2024, it indicated CNA 1 said at 8:40 AM on 3/6/24 [March 6, 2024] she passed his breakfast tray, and she woke him [Resident 1] to eat. Then at lunch she delivered his lunch at 12:20 PM the bathroom door was shut but the light was on, so she assumed he is here. She knocked and then went out of the room. At 1:00 PM she went back to see if he was finished. She noticed he never ate his food [lunch meal], she searches the room and then asked her charge nurse [name of LVN 1] if she had seen him. After checking around there is no sign of [name of Resident 1] . CNA 1 stated she should have not assumed Resident 1 whereabout. Furthermore CNA 1 stated she should have checked Resident 1 restroom to make sure he is actually inside and should had check him more frequently, not just during mealtimes. During an interview on March 8, 2024, at 4:00 PM, with the Social Services Director (SSD), the SSD stated she did not realize that she has not seen Resident 1 all morning until code yellow was announced [facility's code for missing resident] for Resident 1 and while searching Resident 1's room, she noticed that Resident 1's belonging were not in his room. During an interview on March 8, 2024, at 4:05 PM, with LVN 1, LVN 1 stated the last encounter she had with Resident 1 on March 6, 2024, was when she passed his routine morning medication between 9:45 AM to 10:00 AM. LVN 1 further stated, CNA 1 did not report to her that when CNA 1 did not see Resident 1 visually when CNA 1 left Resident 1 lunch tray in his room. LVN 1 stated she did not check on or look for Resident 1 from after the morning medication was passed from 10:00 AM to 1:30 PM after she received report Resident 1 did not eat his lunch and was nowhere to be found. During a phone interview on March 8, 2024, at 4:15 PM, with Receptionist, the Receptionist stated that on March 6, 2024, that she had not seen him all morning, but later she discovered that Resident 1 went missing after the nurses went out the front door to search for him. During a concurrent interview and record review on March 8, 2024, at 4:35 PM with DON, the DON reviewed an undated facility document titled, Certified Nursing Assistant Job Description which indicated . Report to: Charge Nurse. Position Description: A nursing assistant responsible to providing routine nursing care accordance with establish policy and procedures and as may directed by the Charge Nurse, RN Supervisor, Director of Nurses or Administrator, to assure that the highest degree of quality care can be maintain at all times . General Duties and Responsibility: General . Make resident rounds at the beginning of each shift and every 2 hours thereafter to administer quality nursing care . The DON stated the facility did not follow the policy. During a concurrent interview and record review on March 8, 2024, at 4:40 PM with DON, the DON reviewed an undated facility document titled, Charge Nurse Job Description which indicated .Report to: Director of Nursing Services [DNS also known as Director of Nursing (DON)]. Position Description: The Charge Nurse is responsible for staff assignment and provides overall supervision of resident care activities . General Duties and Responsibility: . Supervision . Make resident's round to review physical, medical an emotional status and to implement required nursing intervention . Assure that nursing personal follow establish nursing procedures . The DON stated the facility did not follow the policy. During an interview on March 8, 2024, at 8:20 PM with the Administrator (ADMIN), the ADMIN stated Resident 1 had diminished mental capacity due to his mental health status. The Admin further stated Resident 1 eloped from the facility on March 6, 2024, left with his belongings, and have not been found since. During a concurrent interview and record review on March 8, 2024, at 8:30 PM with LVN 2 , LVN 2 reviewed Resident 1's undated Care plan for At risk for elopement and wandering out the facility and stated checking resident whereabouts meant checking maybe every 30 minutes to an hour. The LVN 2 remained uncertain with the frequency of checking resident's whereabout for residents with risk of elopement and where to document the findings, as no specific direction/guidance was provided. During a concurrent interview and record review, on March 8, 2024, at 8:45 PM, with DON, the DON reviewed Resident 1's undated Care Plan for At risk for elopement and wandering out the facility, and acknowledged it did not specify the frequency on how often to check on resident's whereabouts. The DON further stated the staff should do it every hour, and it should be documented to ensure the task was completed. The DON was unable to provide documentation to show Resident 1's whereabouts were checked by the staff. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised March 2019, the P&P indicated .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident . Policy interpretation and implementation. 1. If identified as at risk for wandering, elopement, or other safety issue, the resident's care plan will include strategies and intervention to maintain resident's safety . An Immediate Jeopardy (IJ- represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) was called under F689 S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents) on March 8, 2024 at 9:10 PM, after confirming Resident 1 did not receive supervision and monitoring required to keep Resident 1 safe on March 6, 2024 when Resident 1 was found to have eloped from the facility and had not been found for more than 48 hours. An IJ was called on March 8, 2024, at 9:10 PM in the presence of the Director or Nursing (DON), Administrator (ADMIN) and Chief Clinical Officer (CCO). A Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on March 9, 2024, at 2:21 PM and included the following: * On 03/07/2024, The Interdisciplinary Team (IDT) reviewed the other two (2) residents who are at risk of elopement including the measures and care plans in place to prevent future elopement. Added Q hour visual checks to be documented frequent visual check log. Kept at nurse's station. * Providing adequate supervision and a safe environment for residents identified as moderate or high risk for elopement, the facility has implemented every hour monitoring of identified residents. Q [every] hour visual checks to be documented frequent visual check log. Kept in Elopement binder at nurse's station. * Licensed Nurses (LNs) and the IDT will assess residents for any possible risk of elopement upon admission, quarterly, annually, and as needed thereafter to ensure necessary interventions are initiated to meet their needs including the provisions of adequate supervision to prevent elopement. * The Elopement Binder located at the Nursing Station which contains a list of residents identified to be at risk for elopement will be updated as necessary by LNs and the IDT. * LNs will conduct huddles at the beginning of every shift to ensure needed information and instructions are communicated and provided to the CNAs to ensure frequent monitoring and adequate supervisions are provided to all residents at risk of elopement., Maintained in Huddle binder at station 1. * LNs and Certified Nursing Assistants (CNAs) in their respective shifts will continue to monitor the whereabouts of residents who are at risk of elopement using the Monitoring Log. Any residents noted with exit seeking behavior will be reported to the ADM and DNS immediately. * During the change of shift, incoming and outgoing Nurses will conduct rounds to ensure residents who are at risk of elopement are in the facility. Any issues identified will be reported to the ADM and DNS immediately. * Starting on 03/09/2024, at 8AM the Director of Staffing Development (DSD) provided in-services to staff regarding the policies and procedures on Wandering and Elopements and Emergency Procedure-Missing Person. All Staff will be in-serviced prior to their next scheduled shift. * Staff will implement the protocol for a missing resident immediately upon discovering that a resident cannot be located in the facility by following the emergency procedure. Emergency Procedure - Missing Resident Policy Statement Resident elopement resulting in a missing resident is considered a facility emergency. 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. * Additional in-services will be provided by the DNS or designee and/or DSD or designee regarding monitoring log put in place. * Maintenance Director or designee will check alarms of all exit doors on a weekly basis to ensure they are properly functioning and record on log. The doors were checked on 3-6-24 and 3-9-24 and logged in the maintenance log located in the maintenance office. The facility submitted an IJ Removal Plan which was reviewed and accepted on March 9, 2024, at 2:21 PM. After observation, interview, and record review, to confirm implementation of the IJ removal plan, without any remaining non-compliance the IJ was lifted while on site on March 10, at 10:57 AM, in the presence of the ADMIN, the DON, and the Medical Records Director (MRD).

Based on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of four sampled residents (Resident 1). This failure placed Resident 1's health and safety at risk, when he developed a facility acquired sacrum (lower back/spine) pressure injury and right hip stage IV (full-thickness skin and tissue loss). Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain), acute embolism and thrombosis of deep veins of right upper extremity (deep vein thrombosis, clots), hypertension (high blood pressure), hereditary and idiopathic neuropathy (sensory and motor nerves are affected). During a concurrent interview and record review, on August 30, 2023, at 2:02 PM, of Resident 1 ' s Medical Record, with the Director of Nursing (DON), the following were reviewed: 1. Body Assessment, dated October 29, 2022, indicated Resident 1 had a Peg tube (abdominal feeding tube) 20FR (Enteral feeding tube, French tube measurement). Further review indiacted his skin was clear, intact, and warm to touch, with normal coloration and turgor. Further review indicated he had no rashes, or suspicious skin lesions noted. 2. Wound Care Progress Note, dated [DATE], at 6:00 PM, (about three months after his admission) indicated Right lateral foot chronic ulcer (painful injury due to poor circulation) unstageable size 1.5xUTD, 100% eschar (dry, dark scab or falling away dead skin). 3. There was no documented evidence to indicate pressure ulcer prevention was initiated and implemented by the facility for Resident 1 prior to February 9, 2023. 4. Change of Condition (COC), dated June 25, 2023, at 12:28 PM, (about eight months after his admission)indicated during the monthly skin sweep (skin assessment), Resident 1 was noted with new wounds to left heel arterial (painful injury due to poor circulation) wound and sacrum pressure injury. 5. Wound Care Progress Note, dated June 27, 2023, at 12:01 PM, indicated New reopened pressure injury to right hip stage IV (stage four) measures 2.5 x 1.5 x 0.7 cm, 50% granulation (healing process, pink tissue new connective tissue), 50% slough (yellowish material in the wound bed). Wound edges are not attached to base .extensive scarring noted, moderate serosanguineous (contains blood and liquid serum) drainage .LAL (Low Air Loss mattress) mattress needed for wound management . Wound site to Right lateral malleolus plateau (bone on the outside of the ankle joint). Measurement 0.7 x 0.3 x UTD. 100% eschar (dry, dark scab or falling away dead skin). No drainage, wound edges attached to base, pressure ulcer. 6. Wound Care Progress Note, dated August 15, 2023, at 7:17 AM, indicated For weekly wound consult on August 14, 2023, upon assessment, a. Pressure Injury to Right hip stage 4 stable and progressing .measurement 1x1x0.2cm 80% granulation, 20% eschar .gentle debridement (removal of damaged tissue) performed. b. Right lateral foot arterial ulcer measurements 1.4x1.5x2,80% granulation, 20 % eschar debridement performed. c. Right medial foot measures 0.4x0.5x0.2cm 80% granulation, 20% slough, debridement performed. During an interview on August 30, 2023, at 2:20 PM, with the Treatment Nurse, the Treatment Nurse stated, Everything is preventable, but it happened, after the wound developed, we put him [Resident 1] on an air loss mattress. During an interview and record review on August 30, 2023, at 2:02 PM, with the Director of Nurses (DON), the DON stated, Resident 1 had no wounds on admission, only Peg tube (abdominal feeding tube). When asked should a resident develop a pressure injury while in the facility? The DON replied, no they [residents] should not develop, but there are some factors. Of course, some factors are unavoidable, nutrition and lack of mobility, age and moisture. The DON reviewed Resident 1 ' s clinical record and aknowledged Resident 1 acquired sacrum pressure injury and right hip stage IV in the facility. During a review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries Level III, revised April 2020, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Skin assessment .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc. Prevention . 1.Keep the skin clean and hydrated.2.Clean promptly after episodes of incontinence.

Based on interview, and record review, the facility failed to ensure that an allegation of abuse was promptly reported to the Administrator, who is the Abuse Coordinator, and the appropriate agencies in accordance with the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential for an allegation of abuse to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1. Finding: An unannounced visit was made to the facility on [DATE], at 4:05 PM to investigate a complaint alleging that Resident 1 was physically abused by another resident. A review of Resident 1's face sheet (contains demographic information and diagnoses) indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included: difficulty walking, limitation of activities due to disability and a mild cognitive impairment (memory loss.) During an observation of Resident 1 on August 15, 2023, at 4:46 PM, Resident 1 was observed to have bruising to the left eye. The bruise circled Resident 1's eye and was approximately 1 inch in diameter. The circle around the eye was black in color. During an interview with Resident 3 (the room mate of Resident 1) on August 15, 2023, at 4:50 PM, Resident 3 stated, The other day someone was smacking Resident 1 around and I heard it. I don't know the name of the person. It was on day shift. It was about 2 or 3 PM. I heard slapping around. Someone said it's getting red where Resident 1 was hit. After that, they kept checking on Resident 1's eye. Resident 3 stated further, I told LVN 3 what happened, and she said good luck with that story. During an interview and concurrent record review with Licensed Vocational Nurse (LVN 1) on August 15, 2023, at 5:20 PM, LVN 1 stated, Resident 1 had a situation with a roommate (Resident 2). Resident 1 and Resident 2 were arguing. Resident 2 was upset. Resident 1 was swinging a sheet trying to hit Resident 2 because he was mad. Resident 1 took his nightgown off and was trying to hit Resident 2 with it. Initially, Resident 1 was in (another room). We moved Resident 1 out of the room. I did not witness Resident 2 hit Resident 1. Resident 1 went to bed with no problem. There was no bruising or a blackened eye. LVN 1 confirmed Resident 1 did not have a black eye after the Resident to Resident altercation on August 11, 2023. LVN 1 stated further, Their incident was nights ago but let me look. I documented on it. It happened on August 11, 2023. I was told that the bruising happened on August 13, 2023. The bruise to Resident 1's eye, it doesn't look like a sheet did that. It looks funny like someone could have hit him. During an interview with Resident 1 and a certified nursing assistant (CNA1, translated Spanish) on August 15, 2023, at 5:32 PM, Resident 1 stated, LVN 2 hit me. LVN 2 hit me with the ball. During a record review of Resident 1's medical record, the SBAR communication form written by LVN 2, on August 15, 2023, at 5:38 PM indicated, Change in skin color or condition. This started on August 13, 2023. Appearance: Discovered left eye. Discoloration after flailing arms in attempts to strike out on August 11, 2023. LVN 2 wrote a late entry note on August 15, 2023, that indicated LVN 2 discovered Resident 1's blackened or bruised left eye on August 13, 2023. During an interview with the Director of Nursing on August 17, 2023, at 12:35 PM, the DON stated, LVN 1 said that Resident 1 hit himself and that's how he got the black eye but there was no discoloration after Resident 1 hit himself. On Sunday, it was noted that Resident 1 had the discoloration to the left eye. LVN 2 called and informed me of the bruise to Resident 2's left eye. The only time discoloration was noted is when LVN 2 went in to see him on Sunday. LVN 2 did a Change of Condition note late (August 15, 2023). DON confirmed this incident of alleged abuse or mistreatment was not reported to the Administrator or the appropriate authorities. DON stated further, Someone should have reported the allegation of abuse to me. It has to be reported so we can start our investigation. That still should have been reported. It should have been investigated. During an interview with the Administrator in training (AIT) on August 17, 2023, at 1:02 PM, AIT stated, That incident should have been reported because it is an allegation of abuse by a staff member to a resident. We should have been told so that we could do an investigation. We investigate the allegation to see if there is any abuse to the resident by a staff member. The facility did not provide documentation that indicated the allegations of abuse, mistreatment or unusual occurrence to Resident 1 was reported to the appropriate authorities as per their policy. The facility policy and procedure titled Abuse Investigation and Reporting dated July 2017, indicated All reports of resident abuse and or injuries of unknown source (abuse ) shall be promptly reported to local, state, and federal agencies as defined by current regulations and thoroughly investigated by facility management . Reporting 2. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source will be reported by the facility Administrator, or his/her designee, to the following persons: a. The State licensing certification agency responsible for surveying licensing the facility; Ombudsman; Adult protective services, law enforcement officials. An alleged violation of abuse, neglect, exploitation, or mistreatment (including allegations of unknown source of origin) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . The facility policy and procedure titled Unusual Occurrence Reporting dated December 2007 indicated As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors .1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect, and misappropriation of resident property; and h. Other occurrences that .affect the welfare, safety, or health of residents. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and or regulations within twenty-four hours of such incident or as otherwise required by federal and state regulations. The facility policy and procedure titled Abuse Prevention Program dated December 2016, indicated Our residents have the right to be free from abuse .This includes but is not limited to verbal, mental, and physical abuse. As part of the resident abuse prevention, the administrator will .4. Require staff training orientation programs that include such topics as abuse prevention, identification and reporting of abuse, and handling verbally and physically aggressive resident behavior .6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements .

Based on interview and record review, the facility failed to report for one of 5 sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged financial abuse by staff member towards (Resident 1). This failure has the potential to put (Resident 1) health, safety and well-being at risk. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include urinary tract infection (bladder infection), pressure ulcer of sacral region (wound to lower back), osteomyelitis (inflammation of bone). During a review concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Social Worker Note dated May 23, 2023 @1720 . call received to Social Services Department (SSD) and Administrator about a staff taking personal items .family will report to police, the news, Administrator attempt to get more info from family. 2. Social Worker Note dated May 24, 2023 @1645 . SSD and Administrator were visited today regarding staff member taking personal belongings from resident, Resident 1's mother stated she had proof to conduct investigation. 3. Timecard Report for CNA1, CNA1 was off May 25, 2023, and back working May 26, 2023, morning shift. 4. Allegation Investigation done by Administrator and Social Services Department, started May 24, 2023, to June 02, 2023. No documentation of Allegation abuse Reporting to any agency. During an interview with the Social Worker (SW) on June 07, 2023, at 11:06 AM, the (SW) stated, Resident 1's family member came into the facility, she didn't initially did give me a name, or a Police report. She came in 3 times, on the 3rd visit she showed me a screenshot of the person in question, and she told me it was CNA 1, but I could not verify because she showed me the screenshot and quickly took it away. During an interview with the Director of Nursing (DON) on June 07, 2023, the DON stated, Resident 1 first called May 23, 2023, stating we are calling the police, that same person called back again, they alleged a second cell phone that was missing. On May 24, 2023, family alleged they had CNA 1, screen shot on an (app to transfer payments and money) account and stole from a cell phone. We asked for the screen shots. We were trying to get more details, each person from the family gave us different details all, had different stories. We were trying to piece all stories. It was hard to validate the story. I had our social worker go to the acute hospital Resident 1 was transferred to and follow up on this issue. On May 24, 2023, was the day CNA1 was mentioned, and he was off that day, on May 25, 2023, we put on administrative leave and was back to work 26th. We did not report because it was not reliable, we could not validate the allegation and the family was uncooperative. We asked for screenshots. If we feel it's a concrete financial abuse, we will report if we have substantiated cause to do an investigation. During an interview with the Administrator (Admin) on June 07, 2023, the (Admin) stated, We did not report this to the state because I was not able to substantiate the allegation, I have documentation on the investigation we did and cannot substantiate it. We did not have a second cell phone in the inventory. CNA 1 was only assigned to this resident one-day morning shift, readmitted back from acute hospital and all department heads were in and out of her room all day. I can tell you that CNA1 was with her a limited time. We put CNA1 on administrative leave until investigation was completed. During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting revised July 2017, the policy and procedure indicated, Reports of resident abuse, exploitation, and mistreatment and or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and investigated by facility management. Findings of abuse investigations will also be reported. Role of Administrator:4.will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .Reporting 1. Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:. The State licensing/certification agency, B. local/state ombudsman, e. law enforcement .2. An alleged violation .will be reported immediately, but not later than: a. Two (2) hours of the alleged violation involves abuse OR has resulted in serious bodily injury or B. Twenty-four (24) hour if alleged violation does not involve abuse AND has not resulted in serious bodily injury. During a review of the facility's policy and procedure titled, Abuse Prevention Program revised December 2016, the policy and procedure indicated, Our residents have the right to be free from abuse, neglect, and exploitation . 7. Investigate and report any allegations of abuse within timeframe's as required by federal requirements, 8. Protect residents during abuse allegations. During a review of the facility's policy and procedure titled, Resident Rights revised December 2016, the policy and procedure indicated, Employees shall treat all residents with kindness, respect, and dignity. AC. be free from abuse, neglect, misappropriation of property and exploitation.

Based on interview, and record review, the facility failed to accurately document that one of three residents (Resident 1) was discharged with their personal belongings. This failure resulted in misplaced personal property for Resident 1. Findings: An abbreviated survey was conducted on May 17, 2023, at 1:20 PM, to investigate an allegation of Misappropriation of Property. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: right hand deformity, osteoporosis (weakens bones which can easily break) and rheumatoid arthritis (inflammation and swelling to the joints). During a review of the clinical record for Resident 1, the Resident Inventory record, indicated At the time of admission, identify the resident's belongings by including the quantity and identifying the attributes of each item of personal belongings .This form must be updated throughout the resident's stay whenever a new item is brought to the Facility or taken out of the Facility .Resident information: Resident 1, Date of Admission: April 26, 2023. Date of Discharge: May 5, 2023. Initial Inventory: 1 cell phone, 1 charger, 1 pair of glasses Receipt: I certify that the items listed above, that remain at the Facility, have been provided to me upon discharge The receipt section of this document was not signed or dated on Resident 1's day of discharge. The missing signatures and dates indicate the facility did not verify all items were sent with resident 1 upon discharge. During a review of the clinical record for Resident 1 with Social Services Director (SSD), on May 17, 2023, at 4:04 PM, SSD stated, The inventory sheet should have been dated and signed. SSD confirmed the inventory sheet was not signed or dated to indicate Resident 1's personal belongings were received upon discharge. During a concurrent interview and record review of Resident 1's Inventory record with the Director of Nursing (DON) on May 17, 2023, at 5:07 PM, the DON stated, I don't see a signature for May 5, 2023. It should have been signed, the resident inventory sheet. The DON confirmed the inventory sheet was not signed or dated to indicate Resident 1's personal belongings were received upon discharge. The facility policy and procedure titled Release of a Resident's Personal Belongings dated March 2017, indicated Our facility protects the personal belongings of a resident who has been transferred or discharged from our facility. 1. The personal belongings of a resident transferred or discharged from our facility will be released to the resident or authorized resident representative .3. Individuals receiving the resident's personal belongings will be required to sign a release for such items. The facility policy and procedure titled, Personal Property dated September 2012 indicated .The resident's personal belongings and clothing shall be inventoried and documented upon admission .

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) had the call light within easy reach. This failure had the potential for Resident 1 to have her needs not met in a timely manner and deprive this mentally compromised resident of assistance when needed to prevent falls. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Encephalopathy (damage of the brain), osteoporosis (weakens bones which can easily break) and fracture of left femur (broken thigh bone). While completing a brief tour of the facility on March 30, 2023, at 11:25 AM, Resident 1 was observed lying on the left side. Resident 1's call light was attached to the privacy curtain which is positioned in between two residents. The call light was out of Resident 1's reach. In an interview with Certified Nursing Assistant (CNA 1) on March 30, 2023, at 11:42 AM, CNA 1 stated, The call light is hanging from the curtain. It is supposed to be in her reach. CNA 1 stated further, the call light is to be within reach so that if anything happens, Resident 1 can let us know right away. During a review of the clinical record for Resident 1, the care plan, undated, indicated Resident is at risk for falls and/or injuries related to the fall risk assessment which states Resident 1 is a high risk for falls and has a history of falls. Interventions: Encourage/remind resident to ask for help when needed if able. Keep the environment free of hazards, clutter free, and the call light within reach. In an interview with Licensed Vocational Nurse (LVN 1), on March 30, 2023, at 11:47 AM, LVN 1 stated, We are to place the call lights on the bed right next to the resident. The call light is supposed to be next to Resident 1 so that Resident 1 can reach it. So, if they need us, they can call us. During an interview with the Director of Nursing on March 30, 2023, at 1:33 PM, when questioned about the position of Resident 1's call light the DON stated, It should be within reach. As long as the resident can access it. The call light should have been within Resident 1's reach. The facility policy and procedure titled, Answering the Call Light dated October 2010, indicated Purpose. The purpose of this procedure is to respond to the resident's request and needs. General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review, the facility failed to ensure that 12 of 81 residents (residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12), were provided a clean and safe environment when: 1. For Residents 1, 2 and 3 in room A, the ceiling was leaking and had erosion near the fire sprinkler and curtain rod, placing them at risk for infection and falls. 2. For Residents 4 and 5 in Room B, Residents 6 and 7 in Room C, Residents 8 and 9 in Room D and Residents 10, 11 and 12 in Room E, the ceilings were stained, bubbled, chipped, eroded and placing them at risk for ceiling particles to fall onto them and expose them to illness. Findings: During a tour of the facility on March 26, 2021, at 10:25 AM, to investigate an unrelated self-reported incident for Resident 1 in Room A, it was noted that there was fluid dripping from the ceiling above the space between Bed-B and Bed-C at the foot of the bed in Room A. Residents 1, 2, and 3 were residing in the room. The ceiling material was hanging from the ceiling. There were multiple gold brown stains on the ceiling. There was a black hole in one area of the ceiling. The ceiling was eroded around the privacy curtain rod mounted on the ceiling. During an observation and concurrent interview on March 26, 2021, at 11:00 AM, with the Director of Nurse's (DON), in Resident 1's room (Room A), the DON confirmed that the ceiling was leaking fluid, and there was a puddle on the floor at the foot of the beds between bed B and bed C. The DON stated, they had tried to fix it, but when the rain came the previous night, the leak had started. The DON confirmed that this was a safety hazard. During an interview and concurrent record review on March 26, 2021, at 11:18 AM, with the Maintenance Director (MM), the Maintenance Request Log was reviewed. The Maintenance Request Log dated March 11, 2021, showed Room A had a leak from the ceiling which had been reported. The Maintenance Request Log for Room A, indicated on March 23, 2021, the ceiling was replaced. The MM stated, We had some roof leaks. We patched the back-hall ceiling at the entrance to the facility, the dietary area, Room A, Room F, and the Director or Nurses office. It was March 3, 2021 when we noticed the ceiling was bubbling and it was wet. Everything was repaired the following week. With the recent rain, it started leaking again. During a further facility tour on March 26, 2021, at 1:30 PM, it was observed that, a. Room B- The ceiling was bubbled and eroded around the ceiling vent. There were two residents in Room B (Resident's 4 and 5). b. Room C- The ceiling and back wall were stained with patches of uneven ceiling material. There were two residents in Room C (Resident's 6 and 7) c. Room D- The ceiling was bubbled and loosened away from the ceiling. There were two residents in Room D (Resident's 8 and 9) d. Room E- The ceiling was stained, bubbled, and chipped. There were three residents in Room E (Resident's 10, 11, and 12). During an interview on March 26, 2021, at 1:40 PM, with Resident 1, who had been moved to another room, Resident 1 stated, Oh yeah, it's (Room A ceiling) been leaking for a while. They put a bucket on the floor, and it was filling the bucket. I have [CONDITION(S)] (a lung condition where the air sacs in the lungs (alveoli) are damaged, and causes shortness of breath) too, and the mold is killing me. During an interview on March 26, 2021, at 2:09 PM, with Certified Nurse's Aide (CNA 2), CNA 2 stated, I know they have been working on the ceiling. I told CNA 1 to write the problem in the Maintenance Request Log at the Nurses Station, but I don't think she did. I asked her (CNA 1) if she did, and she said, 'No. During an interview on March 26, 2021, at 2:35 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated, When the ceiling in Room A started leaking, we put it in the Maintenance Log. I got a report from the night shift nurse who had seen it was leaking. There was a bucket in the room under the leak. We did not remove the residents from Room A. 1. Room-A with ceiling damage and leaking. 1a.) Resident 1 During a review of Resident 1 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 1 diagnoses included [CONDITION(S)] (a progressive nervous system disorder that affects movement). Resident 1 was moved to another room temporarily. 1b.) Resident 2 During a review of Resident 2 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 2 diagnoses included Obstructive [CONDITION(S)] (a blockage along one or more passages in the brain, causing increase pressure within the skull). Resident 2 was moved to another room temporarily. 1c.) Resident 3 During a review of Resident 3 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 3 diagnoses included Human immunodeficiency virus [HIV] disease (a human immunodeficiency virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). Resident 3 was moved to another room temporarily. 2. Room B, C, D, and E with ceiling damage. 2a.) Resident 4 residing in Room B During a review of Resident 4 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 4 diagnoses included urinary tract infection (an infection in any part of the urinary system). The ceiling in Room B was bubbled and eroded around the ceiling vent. 2b.) Resident 5 residing in Room B During a review of Resident 5 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 5 diagnoses included atherosclerosis (a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls) of CABG (Coronary Artery Bypass Graft, a form of bypass surgery that can create new routes around narrowed and blocked coronary arteries). The ceiling in Room B was bubbled and eroded around the ceiling vent. 2c.) Resident 6 residing in Room C During a review of Resident 6 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 6 diagnoses included [CONDITION(S)] (a condition caused by brain damage that leads to paralysis on one side of the body) following unspecified [CONDITION(S)] disease (a disease that affects the blood flow to the brain). The ceiling in Room C was bubbled. 2d.) Resident 7 residing in Room C During a review of Resident 7 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 7 diagnoses included Diabetes Mellitus (high blood sugar). The ceiling in Room C was bubbled. 2e.) Resident 8 residing in Room D During a review of Resident 8 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 8 diagnoses included [CONDITION(S)] (a potentially serious bacterial skin infection that causes skin swelling and redness). The ceiling in Room D was bubbled and loosened away from the ceiling. 2f.) Resident 9 residing in Room D During a review of Resident 9 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 9 diagnoses included chronic obstructive pulmonary disease (a disease that causes blocked airflow from the lungs). The ceiling in Room D was bubbled and loosened away from the ceiling. 2g.) Resident 10 residing in Room E During a review of Resident 10 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 10 diagnoses included Covid-19 (a highly contagious respiratory disease). The ceiling in Room E was stained, bubbled, and chipped. 2h.) Resident 11 residing in Room E During a review of Resident 11 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 11 diagnoses included facial weakness following cerebral infarction (a stroke, a brain lesion in which a cluster of brain cells die when they don't get enough blood). The ceiling in Room E was stained, bubbled, and chipped. 2i.) Resident 12 residing in Room E During a review of Resident 12 face sheet (a document that gives a summary of a resident's information), undated, indicated an admitted [DATE]. Resident 12 diagnoses included acute respiratory failure with hypercapnia (too much of a gas called [MEDICATION(S)] in the blood and not enough of a gas called oxygen). The ceiling in Room E, was stained, bubbled, and chipped. An Immediate Jeopardy (IJ) (a crisis situation in which the health and safety of individual(s) are at risk) was called under 483.90 Physical Environment under tag F 921 Safe/Functional/Sanitary/Comfortable Environment on March 26, 2021 at 3:05 PM, and the Director of Nurse's (DON) and the Director of Plant Maintenance (MM) were notified verbally, when the ceiling in one of 43 rooms which housed three residents (Residents 1,2 and 3) was leaking water which placed the residents at risk for infection and falls. In addition four additional rooms (Rooms B, C, D, and E) which housed residents (4,5,6,7,8,9,10,11 and 12) had ceilings which were in disrepair placing these residents at risk of pieces of ceiling falling down causing the potential for respiratory illness and injury. The Facility submitted an acceptable Corrective Action Plan (CAP) on March 26, 2021, at 6:55 PM. The Corrective Action Plan included the following: COUNTRY HACIENDA HEALTHCARE ACTION PLAN Date: 3/26/2021 Safety Issue: On 3/26/2021 at 10:30am room 40 was found to have a room leakage and the CNA failed to document on the maintenance log. During room inspection the following rooms were identify for possible leakage are room 4, 2, 16, 40 and 43. ======================================================================= Corrective action: 3 residents were transferred to another room and family was informed. Affected resident were assessed by the License Nurse for any injury. Maintenance Supervisor was informed and room was fixed right away. The Maintenance Supervisor will fix the following room 2 and 16 by 3/27/2021 and until all rooms identified will be fix within two weeks. All staff was in-service by the DSD on the process of reporting work order request on the maintenance log. DON/Designee did room rounds to check for any other leakage. No other room leakage noted. Administration will contact roofing contractor to inspect and evaluate the roof and facility will comply to all recommendation provided to provide safety. How to identify other residents: DON or designee assessed all resident who are affected. No other resident was affected with the same deficiency. Measures/Systemic Changes: DON or Designee in-serviced the nursing staff regarding Policy on reporting work order request on the maintenance log. Maintenance Director/ Designee will check log daily for any work request. Department managers will check the room in resident's room daily during room rounds for signs of leakage. Any finding will be included in the morning stand up. DON will in-service Maintenance Supervisor/designee to check the maintenance log daily. Monitoring: Administrator/designee will audit the maintenance log daily x 2 weeks then weekly x 4. Result of the audit observation will be reviewed by the Quality Improvement Steering committee for 3 months or until 100% compliance is achieved. The QA committee will identify any trends or patterns and make recommendation to update the plan of correction as indicated. The facility's corrective action plan included transferring residents to other room while ceiling repairs were completed in the rooms with ceiling damage. Residents in the room with leakage were assessed for injury. All staff were in-serviced on the process for reporting work order requests in the Maintenance Request Log. Administration contacted the roofing contactor to conduct an inspection and evaluation of the roof, and follow any recommendations provided by the roofing company. During a revisit to the facility on [DATE] at 9:04 AM, Room D was noted to have been patched and painted. Room A was being worked on by maintenance. Room B. Residents from Rooms A, B, C, and D were moved to other rooms temporarily. Room E still housed three residents (Residents 10, 11, and 12) and the ceiling had not been patched. There was no further leaking due to it was not raining on this day. During a revisit to the facility on [DATE] at 11:10 AM, Rooms D and B were noted to have been patched and painted. Room A and C were being worked on by maintenance. Residents from Rooms A, B, C, and D were moved to other rooms temporarily. Room E still housed three residents (Residents 10, 11, and 12) and the ceiling had not been patched. There was no further leaking due to it was not raining on this day. During a revisit to the facility on [DATE] at 2:20 PM, Rooms A, B, C, D, and E were noted to have been patched and painted. Residents from Rooms A, B, C, D, and E were moved to other rooms temporarily. There was no further leaking due to it was not raining on this day. An acceptable CAP was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on March 30, 2021 at 3:02 PM, in the presence of the Administrator, Director of Nursing (DON), and the Director of Plant Maintenance (MM). During a review of a Job Description titled, Director of Plant Maintenance, undated, the Job Description, Director of Plant Maintenance indicated, The Director of Plant Maintenance ensures a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State and Corporate requirements. The condition of the ceiling in Room's A, B, C, D, and E was not safe or sanitary. During a review of the facility's policy and procedure titled, Maintenance-Work Orders, dated revised January 1, 2012, indicated, Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority. The Maintenance Request Log with work orders did not include documented evidence of the ceiling leak in Room A on March 26, 2021. During a review of the facility's policy and procedure titled, Maintenance Service, dated, revised January 1, 2012, indicated, The maintenance department maintains all areas of the building, grounds, and equipment. There was no visible evidence that the ceilings were maintained in Resident Rooms A, B, C, D, and E.

Based on observation, interview, and record review, the facility failed to ensure insulin (a drug used to lower blood sugar) vials were used in accordance with manufacturer's recommendations or the facility pharmacy's direction for storage, use, and disposal for two of 27 residents (Resident 14 and 49) receiving insulin when two insulin vials were available for use past the manufacturer's specified beyond use date (BUD) in one of four medication carts (Station 2's medication cart). This failure had the potential for Residents 14 and 49 to receive insulin with reduced potency which could cause inadequate blood sugar control which may result in the physician increasing insulin doses based on the blood sugar results placing the residents at risk for harm. Findings: During an inspection of the medication cart in Station 2 with a Licensed Vocational Nurse (LVN 2) on (MONTH) 6, (YEAR), at 3:32 PM, it was observed that two vials of opened and used insulin were stored in the cart. One of the vials contained [MEDICATION NAME] R (regular insulin) 10 ml (millimeters- unit of measurement) and was labeled for Resident 14. The [MEDICATION NAME] R vial was labeled by nursing with an open date of ,[DATE] ([DATE]) indicating that the vial was available for use for 71 days. The other vial contained Humalog (a fast acting insulin) 10 ml and was labeled for Resident 49. The Humalog vial was labeled by the nursing department with an open date of [DATE] ([DATE], (YEAR)) indicating that the vial was available for use for 30 days. During a concurrent interview, LVN 2 confirmed that the insulin vials were opened and available for use for the residents' current orders. LVN 2 stated the unused portions of the insulin vials should have been discarded after 28 days. LVN 2 stated Resident 14's insulin vial should have been changed last (MONTH) 24, (YEAR), while Resident 49's insulin vial should have been changed last (MONTH) 4, (YEAR). A review of the medication package insert (a document produced by the manufacturer that provides detailed information on the medication including use, dosage, and storage requirements) for [MEDICATION NAME] R, undated, indicated Throw away the vial 42 days after it is kept out of the refrigerator, even if there is insulin left in the vial. A review of the medication package insert for Humalog, revised (MONTH) 5, (YEAR), indicated, Throw away all opened vials after 28 days, even if there is insulin left in the vial. During an interview with LVN 1, on (MONTH) 6, (YEAR), at 4 PM, LVN 1 stated it is the responsibility of the medication nurse every time they use insulin, to check if it needed to be discarded past the 28 days and re-ordered. LVN 1 stated the facility does not have an exact system on checking for expired insulin. LVN 1 further stated, Usually, it would depend on the assigned nurses of the said cart. For my cart (Station 1 cart), the one who is responsible for double checking are the night shift nurses. During an interview with the Director of Nursing (DON), on (MONTH) 7, (YEAR), at 10:54 AM, the DON stated, The nurse that opens the vial, dates it. The last person that uses it closest to the 28 days is the one responsible for refilling or discarding it. The DON stated, I expect for them (licensed nurses) to check it (insulin) every time they use the vial. The DON stated a nurse consultant from the facility's pharmacy inspects the medication carts for expired and discontinued medications, and stated it was last done on (MONTH) 1, (YEAR). A review of the facility's policy and procedure titled Vials and [MEDICATION NAME] of Injectable Medications, dated (MONTH) 2008, indicated Medication in multi-dose vials may be used until the manufacturer's expiration date or 6 months after opening unless otherwise specified. Refer to Guide for Special Handling of Medications. A review of the facility's policy and procedure titled Guide for Special Handling of Medications, revised (MONTH) 3, 2010, indicated Take special note of the medications below which have varying dates of expiration. Each time a medication is opened, sign and date, then check expiration date each time medication is administered . The form had medications listed with columns titled, Medication Name, Route, and Expiration Date. Number three on the list was, Insulin injection with an expiration date indicated as,28 days. An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health the health and safety of a resident) was called under 483.45, Pharmacy Services Refer to F 761 Label/Store Drugs Biologicals) on (MONTH) 7, (YEAR) at 11:48 AM, in the presence of the Administrator (ADM) and the Director of Nursing (DON). On (MONTH) 8, (YEAR), at 1:50 PM, Immediate Jeopardy was lifted in the presence of the DON, after an acceptable corrective action plan was presented and was verified. The corrective action plan was as follows: 1. The facility will implement the following plan to ensure that there is no insulin vials/or insulin pens past the open day of 28 and or 42 days, on the medication cart and that all insulin vials and or pens are disposed of immediately on or before the 28 day or 42 day open date: * The Director of Staff Development with the Quality Assurance Nurse and the Charge Nurse assigned to the station will immediately triple check all medication and refrigerators for insulin pens and or insulin vials immediately and dispose them if any are found. * The Director of Nursing will call the pharmacy to replace any expired insulin. * Mandatory ln-service for all licensed nurses who are currently actively working in the facility starting today and will have all licensed Nurses in-serviced by end of business day tomorrow [DATE] on the importance of ensuring that insulin is within its time frame to administer and if it is not to remove it from the cart and order a new vial or pen from the pharmacy. * Weekly checks of the medication cart and Refrigerators by the Registered Nursing Supervisor ,[DATE] shift for insulin vials or Pens past the open date label (either 28 or 42 days from the open date) or insulin that will require disposal. 2. The Charge Nurse will make daily spot checks to ensure that all insulin is not past the labeled open date and if the insulin is past the labeled open date it will be removed and a call to the pharmacy will be made by the charge nurse to replace with a new insulin vial or pen. 3. The Pharmacy will be notified to come in and check the carts every 2 weeks for a period of 3 months to ensure compliance of the insulin. The pharmacy nurse consultant will then leave a report of her findings with the DON. 4. The DON will take the pharmacy Nurse Consultant report and follow up on all her findings as soon as practical. 5. The licensed nurses in-service will be conducted effective immediately and all licensed nurses who are actively working will be in-serviced by the end of nosiness day tomorrow, [DATE], anyone that is on vacation or not available will be in-serviced prior to return to work. 6. The Director of Nursing and the Director of Staff Development will have a log of all active licensed nurses and the date and time of the in-service will be documented on the log. 7. A three-way medication audit will be completed will be completed with all weekly summaries and turned into the DON at the end of the Charge Nurse's shift. The charge nurse will be instructed to ensure that there is no open insulin vials or Pens pats the 28 day or 42 day open date belonging to the resident for whom the weekly summary is being completed for a total of 30 days. 8. The medical doctor has been notified of all three residents who had insulin in the med cart past the 28 day and 42 day open date. 9. The residents are now being monitored for any acute changes of conditions, in particular [DIAGNOSES REDACTED], [MEDICAL CONDITION] and ketoacidosis. The Director of Nursing services spoke with the Doctor and he verbalized that there are no new orders at present, just monitor the patients. Orders are noted and carried out. 10. The licensed nurses will place a dot on the insulin vials and or pens with the disposal date.

Based on interview and record review the facility failed to ensure the safety for two of ten residents who were at risk for elopement (leaving the facility) when resident's 1 and 3 eloped from the facility. This failure had the potential to place Resident's 1 and 3 at risk for injury or death by exiting (eloping) from the facility without supervision or a physician's ordered pass. Findings: 1) During a review of the clinical record, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was shown to not have the capacity to make his own decisions and was under a court ordered conservatorship. During a review of the clinical record for Resident 1, there was documented evidence in the nursing notes showed Resident 1 had eloped on May 22, 2017 and returned to the facility on the same day after the police were called. During the elopement on May 22, 2017 the resident returned to the facility intoxicated after ingesting alcohol and after leaving the facility without a pass. There was no documented evidence of a physician's order for the resident to leave the facility or to consume alcohol. Resident 1 eloped a second time on June 1. 2017 and did not return to the facility. During a review of the Nursing care plans for Resident 1, for the elopement for May 22, 2017, the interventions included diversional activities to prevent wandering. During a review on the Nursing notes from May 22, 2017 until June 1, 2017 there was no documented evidence of monitoring the Resident for wandering behavior. There was no documented evidence of providing the resident with diversional activities. During an interview with the Director of Nursing (DON) conducted on June 5, 2017 at 2:02 PM the DON stated, Resident 1 went out the front door on June 1, 2017. The Nurses on the 7-3 shift and the 3-11 shift nurses were making rounds and giving report. The Nurses discovered the resident was missing. A code Yellow was called at 4:00 PM on June 1, 2017. The staff looked for the resident around the facility. The staff asked the receptionist if he left the building and she stated he went outside 30 minutes ago. Resident 1 was not found. The DON further stated, Resident 1 did not have a physician's ordered pass to leave the facility. During a record review of the nursing care plans there was no documented evidence to show there were any interventions to prevent the resident from wandering. There was no documented evidence to show Resident 1 was placed on any watch for elopement after the May 22, 2017 elopement. During an interview with the receptionist conducted on June 5, 2017 at 2:50 PM, the receptionist stated she saw Resident 1 leave the facility at 4:00 PM. She did not notify the staff he left the facility. During an interview with the DON conducted on June 5, 2017 at 4:20 PM the DON stated the staff were not notified that Resident 1 was an elopement risk. The DON further stated, Resident 1 was not on a one to one (watched by one staff at all times) or every 15 minute checks after the elopement of May 22, 2017. The DON stated, Resident 1 should have been on every 15 minute checks. During a Review of the facility policy and procedure titled Wandering and Elopement dated January 11, 2016, the policy indicated under section: VII. If facility staff observes a resident leaving the premises without having followed the proper procedures, he/she may: A. Try to prevent the departure in a courteous manner . 2) During a review of the clinical record for Resident 3 the record showed Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record the clinical record (MDS Form-a Resident Assessment Tool) showed that Resident 3 had the capacity to make her own decisions. The clinical record showed Resident 3 eloped from the facility (left the facility) without a physician's order. During a review of the elopement risk assessment completed on June 4, 2017 the assessment indicated Resident 3 had a history of [REDACTED]. During a review of the Situation Background Assessment Recommendation (SBAR)-information sheet, dated June 2, 2017, the SBAR indicated Resident 3 left the facility without notifying the staff and without having a physician's order to leave the facility on a pass. The Charge Nurse was notified by another Resident that Resident 3 had eloped to a fast food restaurant. During a review of the Interdisciplinary Team Conference (IDT) dated June 5, 2017 there were no interventions formulated to prevent Resident 3 from eloping. During a review of the Nursing care plan for elopement there were no interventions put in place to prevent the Resident from eloping. The care plan indicated to redirect resident's behavior when wandering is observed. There was no documented evidence to show the Resident had been redirected. During an interview with Resident 3 conducted at 5:30 PM on June 5, 2017 Resident 3 stated, I left the building to go to a fast food restaurant to try out my new chair. An immediate Jeopardy Situation was called on June 5, 2017 at 5: 35 PM in the presence of the Administrator, and the DON for a lack of system in place for elopement and prevention of further elopement from the facility. During an interview with the DON conducted on June 5, 2017 at 6:00 PM, the DON stated, Resident 3 was placed on elopement risk on June 2, 2017 after she left the facility to try out her electric wheel chair. The DON further stated, the facility policy was discussed with the Resident. There were no interventions formulated to prevent Resident 3 from eloping. During a Review of the Facility policy and procedure titled Wandering and Elopement dated January 11, 2016, the policy indicated under section: VII. If facility staff observes a resident leaving the premises without having followed the proper procedures, he/she may:A. Try to prevent the departure in a courteous manner . Plan of action was developed by the DON, and the Administrator to include: 1. The Facility will implement an Elopement Binder for each resident at risk for elopement; the binder will include the following: a) Elopement assessment b) Picture of the resident c) Face sheet d) Policy for elopement 2. For every resident that is at risk for elopement they will be immediately placed on every 15 minute monitoring for 72 hours and will be reassessed for proper interventions. 3. The interdisciplinary team will interview each resident that is at risk for elopement and will personalize the plan of care. 4. All staff will be in serviced within the next 72 hours and anyone that is on vacation or not available will be in-serviced prior to their return to work. 5. All Possible Admissions will be screened by the Director of Nursing Services to determine appropriate placement. 6. The door alarms will be checked to ensure that they are properly working once daily by the maintenance director or designee. 7. The residents who are at risk for elopement will be identified by a yellow arm band. If the resident refuses to wear the arm band the refusal will be indicated on their plan of care. 8. During huddle the Charge nurse/ RN supervisor will report all the resident's that are at risk for elopement. The corrective action plan was reviewed and accepted on June 5, 2017 at 9:33 PM in the presence of the Administrator and the DON. During interviews with the staff conducted on June 6, 2017 the staff had been in serviced and the action plan had been initiated by the staff as evidenced by every 15 minute checks for the Residents at risk for elopement, Staff in services were conducted, binders were placed at all Nursing stations containing all information in the corrective action plan, Door alarms were checked on a daily basis by the maintenance supervisor, Yellow arm bands were present on all Residents who were identified at risk for elopement. The IJ (Immediate Jeopardy) situation was lifted at 3:44 PM on June 6, 2017 in the Presence of the Administrator and the DON

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was adequately supervised when certified nursing assistant (CNA) 1 failed to implement the care plan and left the resident in her wheelchair, in her room, unattended. This failure resulted in a fall, neck fracture, and head laceration for Resident 1. Resident 1 died nine days after the fall. Findings: During a review of the clinical record for Resident 1, the face sheet (part of the record that includes identifying information) indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a document titled "Change of Condition Assessment", dated [DATE], noted the following documentation: "Resident up in chair, brought to the room by CNA. Per CNA, she went out for approximately 10 minutes to look for someone to help her get the resident to bed. When CNA came back to the room, she found her on the floor by her bedside lying on her right side and noted blood coming out from residents head. Charge nurse was called to residents room and assessed the resident. Assisted up into the chair and assessed the injury sustained. Sustained a laceration to the right side of the forehead. First aid done and called physician. Received order to transfer to hospital for further evaluation." A review of a minimum data set (MDS-a comprehensive nursing assessment), dated [DATE], indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) to transfer between surfaces including from wheelchair to bed, and required one person for physical assistance. A review of the most recent nursing care plan titled, "potential for injury related to fall risk", dated [DATE], prior to Resident 1's fall, indicated the following fall prevention interventions: a. Keep frequently use personal items within reach (call bell) . b. Answer call light promptly. c. Keep resident in frequently monitored areas./Room close to nursing station. (When resident up in wheelchair, to be in view of staff at all times) During a review of an Interdisciplinary Team (IDT) Conference note, dated [DATE], noted the following documentation: "IDT met to discuss regarding the fall incident that happened on [DATE] at 7:10 PM. Resident was found lying on the floor on her right side facing down, with blood coming from the laceration on her forehead. As per CNA, she was getting ready to put the resident back to bed. The resident was on the wheelchair sitting upright. The CNA went to get help to transfer the resident to bed. When she came back, the resident was already on the floor. CNA informed the charge nurse immediately. Charge nurse went to the resident's room and found the resident on the floor." During a review of the hospitals discharge report, dated [DATE], it indicated Resident 1 was diagnosed with [REDACTED]. During an interview with Administrator 1 on [DATE] at 3:35 PM, she stated on [DATE], Resident 1 was left unattended in her room, in a wheelchair, by CNA 1 and the resident had fallen from the wheelchair and was found on the floor by two CNA's (CNA 1 and 2) with bleeding noted to her head. A review of a document titled, "Clinical Notes Report", dated [DATE] at 7:05 AM, noted the following documentation: "Resident expired (died ) 12:30 AM. Doing room rounds, noticed resident not breathing. No rise and fall of chest. Unable to obtain blood pressure or pulse." During further interview with Administrator 1, on [DATE] at 3:35 PM, she stated, "The fall should have never happened. The resident shouldn't have been left in her room, unattended. All staff knew she had a history of [REDACTED]. The resident should have been in staffs line of sight at all times. I reviewed a video tape from that day during my investigation of the fall and saw it was approximately four minutes before staff returned to the room." During a review of CNA 1's employee record, indicated she had been terminated and was no longer employed at the facility and not available for interview. During an interview with CNA 2 on [DATE], at 3:30 PM, he stated, "(CNA 1's Name) came and asked if I could assist the resident back to bed. I told her I was busy and would help as soon as I could. It was probably ,[DATE] minutes before I went to (Resident 1's Name) room. I saw the resident on the ground, in a kneeling position, with blood around her head. It looked like she may have been there awhile because the blood was thick and partially dried." CNA 2 stated, "The residents wheelchair was positioned far from the bed, she couldn't have reached for the call bell if she had tried. It was upsetting to see. Before the resident had the fall and broke her neck, she was very vocal and had a behavior of yelling out. After the fall, she was out of it. It was sad to see." During a review of the facility policy and procedure titled, "Fall Prevention and Incident Management", revised, [DATE], indicated, "It is the policy of the facility to assess resident for fall and accident risk in order to plan and implement interventions to reduce the risk for incidents and injuries. At a minimum, the IDT will re-assess residents risk for fall/incident according to recommended guidelines on admission, quarterly, annually, and significant change of conditions basis." During a concurrent interview and record review with Medical Records personnel on [DATE] at 4:05 PM, she confirmed there was no fall risk assessment to review and she stated, "We didn't complete fall risk assessments at that time. We are doing them now." During an interview with Administrator 2, on [DATE] at 4:08 PM, he said he had just started as Administrator approximately one week prior, and was not familiar with Resident 1, nor the details of the fall which resulted in a fractured neck. Administrator 2 stated, "We don't have a policy to define 'Line of Sight" but I would expect staff to keep an eye on the resident at all times and not to leave her unattended." During a telephone interview with the Director of Nursing (DON) on [DATE] at 9:32 AM, she stated, "The resident should have been in the"Line of Sight" at all times while in her wheelchair. That would mean she was to be watched or in view of all staff, nursing, cna's and definitely not left alone in her room in her wheelchair. It is an isolated and really unfortunate incident that she fell and had an injury. The resident shouldn't have been left by herself." The DON stated, "I'm not sure why there was no fall risk assessment completed for the resident. They should be done at least quarterly and when needed."

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the residents' highest practicable physical, mental and psychosocial well being for 3 of 6 sampled residents (Resident 3, 5, 6) and 1 of 6 unsampled residents (Resident E) . 1. For Resident 3 and 5, the facility failed to monitor the residents' respiratory status prior to administering the narcotic pain medication as per the physician's order. This failure had the potential for the residents to experience side effects of the narcotic medication that may lead to medical complications. 2. For Resident 6, the facility failed to provide a hand roll to the resident's right hand that was observed to have a contracture (A tightening of muscles that prevents normal movement of the associated limb or other body part). This failure had the potential for Resident 6's hand mobility to further decline. 3. For Resident E, the facility failed to manage the resident's behavior of bumping into other residents. This failure had the potential for Resident E's behavior to become escalated and may cause harm to others. Findings: 1. A review of Resident 5's clinical record conducted on 12/15/11. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's order dated 12/10/11 reflected an order for [REDACTED]. A medication pass observation was conducted on 12/15/11 at 9:20 AM. LVN 1 prepared all of Resident 5's AM medications. LVN 1 was observed to pour several medications into a medication plastic pouch including the [MEDICATION NAME] medication. When asked why the medications were poured into the medication plastic pouch, LVN 1 said, "I am going to crush the medications." When LVN 1 was about to crush the [MEDICATION NAME] together with the other tablet medications, the surveyor had to stop LVN 1. The surveyor asked LVN 1 to re-read the MAR for the [MEDICATION NAME]. Then LVN 1 stated, "I am messed up, I should have taken the resident's respirations before I crushed the [MEDICATION NAME]." During an interview with LVN 1 on 12/15/11 at 9:10 AM, she stated that resident 5 received routine [MEDICATION NAME], three times a day. "I just give it to her as the doctor orders." A review of the MAR for December 2011 revealed that Resident 5's respiratory rate had not been checked prior to administering the [MEDICATION NAME] from 12/10/11 to 12/14/11. LVN 1 confirmed and verified the finding during the record review on 12/15/11. A review of "Drugs.com" revealed that one of the side effects from [MEDICATION NAME] was respiratory depression (difficulty breathing). A review of the facility policy and procedure titled " Oral medication Administration", dated 1/09 revealed "24. Obtain and record any vital signs as necessary prior to medication administration." 2. During the initial tour on 12/14/11 at 8:50 AM, Resident 6 was observed lying on her left side in her bed . Resident 6's hands were observed to be contracted. There was a hand roll intact on the left hand . The hand roll on the right hand was not in place. It was observed outside of her right hand at the tip of her fingers. A review of Resident 6's clinical record revealed that Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 12/14/11 at 2:05 PM, Resident 6 was observed lying on her left side in her bed. Resident 6 was observed to have a hand roll on the left hand and there was no hand roll placed into her right hand. Resident 6's hands were contracted. CNA 2 verified the finding during the time of the observation. During an interview with Restorative Nursing Assistant 1 (RNA 1) on 12/14/11 at 2:25 PM, she stated that the RNA used to be the one that applied the hand rolls to Resident 6's hands "but not anymore, it supposedly is the CNA." A review of the physician's order dated 10/25/11, reflected an order for [REDACTED]. A review of the care plan "Minimize risk for further contracture and joint limitation" dated 7/24/11, showed documentation included the intervention "CNA to apply hand rolls..." During an interview with CNA 3 on 12/14/11 at 2:35 PM, she stated that she was assigned to Resident 6 . CNA 3 was asked if she was the one that applied the hand roll on Resident 6's hands. The CNA 3 stated, "I believe the PT ( physical therapy) was the one to put it on her." CNA 3 stated that she was not aware that the CNA was responsible to apply the hand roll to resident 6's both hands. 3. During the initial tour, Resident E was observed backing up out of his room. Resident E also was observed to run into other resident who was sitting in the wheelchair. A review of Resident E's clinical record on 12/15/11 revealed that he was admitted to the facility on 9/4/09 with [DIAGNOSES REDACTED]. During a group interview on 12/15/11 at 11:00 AM, 1 out of 10 residents (Resident D) stated that Resident E had multiple episodes of bumping into her in the hallway and in the activity room . During an interview with the AA on 12/15/11 at 2:40 PM, she stated that she had witnessed that Resident E was bumping in to Resident D in the activity room on 12/12/11 during Bingo. The AA also stated "It happens a few times during the activity with Resident D and with others too." The AA also stated that she always informed the charge nurse whenever she sees Resident E bump into another resident. Then the AA stated, "He always bumps into others, He does that all the time." A review of Resident E's clinical record reflected there was no documentation by the licensed nurse related to Resident E bumping into Resident D in the activity room on 12/12/11. During an interview with LVN 2 on 12/16/11 at 8:50 AM, she stated that Resident E was able to propel himself in the wheelchair. LVN 2 said that Resident E moved so fast, "He often bumped into others. That's not new." A review of Resident E's care plans showed that there was no documentation that the facility had addressed the issue of Resident E bumping into another resident. The DON verified the finding during the record review on 12/16/11. During an interview with the DON on 12/16/11 at 9:10 AM, she stated, "I don't see it in the care plan." 4. On 12/15/11, Resident 3's clinical record was reviewed. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders, dated 11/6/11, showed an order for [REDACTED]. Hold if respiratory rate less than 12. A review of Resident 3's care plan titled, "Potential for episodes of pain secondary to disease process... [MEDICAL CONDITION], [DIAGNOSES REDACTED]," dated 5/09 and updated 12/8/11, showed approaches (actions or interventions) for staff to follow and included, "Administer pain medication as ordered... Monitor for adverse side effects of pain medication such as: ...lethargy (a state of sluggishness, inactivity or unconsciousness resembling deep sleep), drowsiness... Notify MD of side effects..." A review the medication administration record (MAR) for November 2011 showed that a licensed nurse documented Resident 3's respiratory rate at 6:00 AM on 11/9/11, 11/10/11 and 11/11/11. There was no documented evidence to show that the licensed nurses had obtained and monitored Resident 3's respiratory rate prior to administering 69 doses of MS Contin, from 11/7/11 to 11/30/11, per the physician's order. According to the "Nursing 2010 Drug Handbook," copyright 2010 by Lippincott Williams & Wilkins, [MEDICATION NAME] cause possible adverse reactions including respiratory depression (difficulty breathing). On 12/16/11, at 8:45 AM, during an interview with the Director of Nursing (DON), she reviewed Resident 3's clinical record, including the MAR for November 2011. The DON acknowledged that the licensed nurses did not document Resident 3's respiratory rate with every dose of [MEDICATION NAME] was given, from 11/6/11 to 11/30/11, and Resident 3's respiratory rate should have been documented on the MAR. On 12/16/11, a review of the facility's policy and procedure titled, "Oral Medication Administration," dated 1/09, was conducted. The policy and procedure indicated, "Obtain and record any vital signs (temperature, heart rate, and respiratory rate and blood pressure) as necessary prior to medication administration."

Based on interview and record review, the facility failed to ensure that pharmaceutical services were provided to meet the needs of each resident. The facility failed to implement their policy and procedure and ensure that all residents had their medications administered as ordered by the physician for 3 of 17 sampled residents ( Resident 5, 9, and 15) and 1 unsampled (Resident A) . This failure caused Resident 5, 9, and unsampled Resident A to not receive their medication as ordered by the physician causing ineffective pain management and emotional distress to the residents. For Resident 15, the facility failed to provide medications that had the potential to result in medical complications. Because of the facility's failure to follow facility policy and procedures to ensure that residents' medications were reordered in a timely manner to ensure that the residents received their medications as ordered by the prescriber, Immediate Jeopardy was called on 8/17/11 at 2:48 PM with the Administrator present. Findings: 1. During an interview with Resident 5 on 8/15/11, at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he becomes very upset and will start cussing and throwing things at the staff. He stated he is in an extreme amount of pain when he doesn't get his medications. During further interview Resident 5 stated that he was in a car accident years ago with burns over 70% of his body and that it was very painful then and is still painful now. He stated that he has trouble with medication management and that is why he is at the facility, so they can give him his medications. He stated that he has to be on top of the pain to control the pain. A review of Resident 5's medical record on 8/15/11 indicated that he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the history and physical dated 6/24/11 indicated that the resident has capacity to make and understand health care decisions. Review of the MDS (minimum data set/an assessment of the resident), dated 6/30/11, indicated that the resident is cognitively intact. Further review of the MDS indicated that the resident is on a scheduled pain medication regime. The resident reported that he has had frequent pain over the past 5 days. Review of the physician's orders [REDACTED]. 6/25/11 thru 6/26/11 the resident missed the following doses of Morphine: 6/25/11: 6:00 AM, 2:00 PM, 10:00 PM, 6/26/11: 6:00 AM and 2:00 PM for a total of 5 doses of Morphine 7/11/11 thru 7/12/11 the resident missed the following doses of Dilaudid: 7/11/11 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 7/12/11: 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM, for a total of 9 doses of Dilaudid. 8/12/11 thru 8/13/11 the resident missed the following doses of Dilaudid: 8/12/11 12:00 PM, 4:00 PM, 8:00 PM and 8/13/11: 12:00 AM, for a total of 4 doses of Dilaudid. No other notes were found on the MAR indicated [REDACTED]. Review of Resident 5's record indicated that he had not received his prescribed Morphine for 32 hours from 6/25/11 until 6/26/11, nor did he receive his prescribed Dilaudid for 32 hours from 7/11/11 until 7/12/11, and then 20 hours from 8/12/11 until 8/13/11. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that Resident 5 had run out of his pain medication on several occasions and he has to go without the pain medication, since they do not carry Dilaudid in their E-kit. During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she is aware that there is a problem with the availability of medications causing residents to not receive medications as ordered, however, she had left it to the DON to handle. The administrator was unable to explain how the facility attempted to resolve it, nor had she followed up to ensure resolution had been obtained. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine Vicodin (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of Vicodin pulled but nothing else. He stated that he reviews the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their medications. He further stated that he had spoken to the former DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his Dilaudid on 8/12/11 and he didn't receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor. She confirmed that she had not made any notes in the medical record documenting this. On 8/18/11, a review of the policy and procedure provided by the facility titled "Pharmaceutical Services", dated January 2009, indicated the process for refill orders of medications. It states "Reorder these medications when a three to five-day supply remains in the medication storage." The process for reorder of Federal Schedule II controlled substances, "a. Inform the pharmacy when a five-day supply remains in the medication storage. There is no authorized automatic refill available for scheduled II controlled substances ... c. Therefore it is imperative that the facility reorder these medication at least 5 days ahead of running out." Further interview with the administrator on 8/19/11 at 8:07 AM, she stated that she was unable to find any documentation that the facility nurses had been reordering medications prior to them running out. She confirmed that the problem with getting the residents their medications is that the nurses are not ordering them on time to get them to the facility. An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he was not aware of the missed medications. 2. A record review, conducted on 8/16/11 indicated Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS, a tool used by long-term care facilities to assess and plan care for residents) indicated under Section J0100, A, that Resident 9 was on a scheduled pain medication regimen. Resident 9 had a gastrostomy tube (GT, a tube surgically inserted into the stomach for feeding and medication administration purposes) and was non-verbal and unable to express pain symptoms verbally. Review of the physician's orders [REDACTED]. Review of the medication administration records (MAR's) for Resident 9 indicated Resident 9's pain medication was omitted on 7/31/11 at 6:00 AM. The reason documented for the omission was, "not available" . Review of the MAR's for August, 2011 indicated the pain medication was omitted on 8/1/11 at 6:00 AM and 2:00 PM. The reason documented for omission was, "out of stock/pharmacy notified". Additionally, there were several instances on the July and August 2011 MAR's when Resident 9's pain medication was taken from the "E-kit" ( The E-kit is an emergency drug supply that is kept in the facility to have first time doses available to residents, it is not for routine use supply). During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she is aware that there is a problem with the availability of medications causing residents to not receive medications as ordered, however, she had left it to the DON to handle. The administrator was unable to explain how the facility attempted to resolve it, nor had she followed up to ensure resolution had been obtained. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine Vicodin (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of Vicodin pulled but nothing else. He stated that he reviews the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their medications. He further stated that he had spoken to the former DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he was not aware of the missed medications. On 8/22/11 a review of the undated facility policy titled, "Pharmacy Communications Regarding Out-of-Stock Medications" indicated the following: "Medications will be delivered by the pharmacy under the time constraints elsewhere specified in the policies and procedures manual. Medications may become unavailable due to a number of factors, including but not limited to: drug product recalls, manufacturers' production shortages, or other market conditions (e.g. spikes in consumer demand). Medications that are not available for timely delivery will be communicated to the nurse for evaluation and follow-up to assure that the resident's condition is adequately treated. When necessary, a change of medications will be solicited from the physician to assure continuity of treatment of [REDACTED]. 3. During the resident group interview, conducted on 8/16/11 at 11:00 AM, unsampled Resident A stated that she was having to go without pain medication at times because the facility had run out of her medication. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She stated that if possible they will use the E-kit but have, at times exhausted the E-kit supply and residents have to go without their medications. During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she is aware that there is a problem with the availability of medications causing residents to not receive medications as ordered, however, she had left it to the DON to handle. The administrator was unable to explain how the facility attempted to resolve it, nor had she followed up to ensure resolution had been obtained. An interview was conducted on 8/17/11 at approximately 5:00 PM with unsampled Resident A. Unsampled Resident A stated that the facility often runs out of her Robaxin (a medication used to treat muscle spasms) and Percocet (a pain medication). Unsampled Resident A further stated her pain would reach the maximum level on a pain scale of 0 - 10 and when this happened she was unable to sleep. She stated she was very upset and distressed about this. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine Vicodin (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of Vicodin pulled but nothing else. He stated that he reviews the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their medications. He further stated that he had spoken to the former DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. A record review, conducted on 8/19/11, indicated unsampled Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Methocarbamol (Robaxin) 750 mg (milligram) by mouth for muscle spasms QID (4 times/day) at 2 AM, 6 AM, 10 AM, 6 PM Percocet 5/325 mg by mouth for pain every four hours Percocet 5/325 mg 1 tab (tablet) by mouth TID (3 times/day) as needed for pain scale 1 - 4 Percocet 5/325 mg 2 tabs by mouth TID as needed for pain scale 5 - 10. Review of the medication administration records (MAR's) for unsampled Resident A indicated the following documented omissions: 12/15/10, 10 AM - Percocet 5/325 mg, missing 1/28/11, 10 AM - Robaxin, 750 mg, not available 1/29/11, 10 AM - Robaxin, 750 mg, not available 3/01/11, 2 AM - Percocet 5/325 mg, not available 3/01/11, 6 PM - Percocet 5/325 mg, not available 3/01/11, 10 PM - Percocet 5/325 mg, not available 3/10/11, 6 PM - Percocet 5/325 mg, not available 3/10/11, 10 PM - Percocet 5/325 mg, not available 3/11/11, 2 AM - Percocet, not available 4/27/11, 12 AM - Robaxin, not available 4/27/11, 9 AM - Robaxin, not available 4/28/11, 6 AM - Robaxin, not available 7/07/11, 2 AM - Robaxin, not available 7/07/11, 6 AM - Robaxin, not available 7/18/11, 6 AM - Percocet, not available An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he was not aware of the missed medications. On 8/22/11 a review of the undated facility policy titled, "Pharmacy Communications Regarding Out-of-Stock Medications" indicated the following: "Medications will be delivered by the pharmacy under the time constraints elsewhere specified in the policies and procedures manual. Medications may become unavailable due to a number of factors, including but not limited to: drug product recalls, manufacturers' production shortages, or other market conditions (e.g. spikes in consumer demand). Medications that are not available for timely delivery will be communicated to the nurse for evaluation and follow-up to assure that the resident's condition is adequately treated. When necessary, a change of medications will be solicited from the physician to assure continuity of treatment of [REDACTED]. Review of Resident C's medical record indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident C's physician's orders [REDACTED]. On 8/17/11 at 9:00 AM, review of the E-kit inventory indicated for Resident C, Ativan had been used from the E-kit on 7/30/11, 7/31/11, 8/1/11 and 8/2/11. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She stated that if possible they will use the E-kit but have, at times exhausted the E-kit supply and residents have to go without their medications. During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she is aware that there is a problem with the availability of medications causing residents to not receive medications as ordered, however, she had left it to the DON to handle. The administrator was unable to explain how the facility attempted to resolve it, nor had she followed up to ensure resolution had been obtained. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine Vicodin (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of Vicodin pulled but nothing else. He stated that he reviews the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their medications. He further stated that he had spoken to the former DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he was not aware of the missed medications. 4. During review of Resident 15's medical record on 8/19/11, it indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 15's physician admitting orders dated 7/6/11, indicated an order for [REDACTED]. A review of the MAR (medication administration record) for the month of July, 2011 indicated the following: 7/7/11 6:00 AM Protonix was circled by the nurse indicating that it was not given. 7/8/11 6:00 AM Protonix was circled by the nurse indicating that it was not given. 7/9/11 6:00 AM Protonix was circled by the nurse indicating that it was not given. 7/10/11 6:00 AM Protonix was circled by the nurse indicating that it was not given and on the back of the MAR indicated [REDACTED]." 7/11/11 6:00 AM Protonix was circled by the nurse indicating that it was not given and on the back of the MAR indicated [REDACTED]." There was no indication in the record that the physician was notified of the unavailability of the medication. Resident 15 went without medication for GI bleed prevention for five days. A review of the physician orders [REDACTED]. by mouth daily (a medication that reduces acid production in the GI tract) for GI bleed was ordered. An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he was not aware of the missed medications. In an interview with the administrator on 8/22/11 at 9:50 AM, regarding Resident 15 not receiving her medication for GI bleed for five days, the administrator stated that the nurses should have notified the physician of the unavailability of the resident's medication. On 8/22/11 a review of the undated facility policy titled, "Pharmacy Communications Regarding Out-of-Stock Medications" indicated the following: "Medications will be delivered by the pharmacy under the time constraints elsewhere specified in the policies and procedures manual. Medications may become unavailable due to a number of factors, including but not limited to: drug product recalls, manufacturers' production shortages, or other market conditions (e.g. spikes in consumer demand). Medications that are not available for timely delivery will be communicated to the nurse for evaluation and follow-up to assure that the resident's condition is adequately treated. When necessary, a change of medications will be solicited from the physician to assure continuity of treatment of [REDACTED]. Because of the facility's failure to ensure that pharmaceutical services were provided to meet the needs of each resident so that residents received their prescribed medications, Immediate Jeopardy was called on 8/17/11 at 2:48 PM with the Administrator. On 8/17/11 at 7:05 PM, the Administrator presented a plan of corrective action to the survey team. The plan of correction consisted of the following elements: 1) The facility will review the identified residents Medication Administration and other related record to determine if pain medications were provided according to the physician's orders [REDACTED]. 2) The Social Services Designee conducted resident satisfaction interviews today with the identified interviewable residents and none of them C/O pain. The non-interviewable resident pain status was reassessed by the licensed nurse and no indication of pain noted. 3) The facility will develop a list of residents with Narcotic medications, evaluate and ensure availability of medication supply for 5 days according to the policy and procedure. 4) The Nurse Resource Consultant, Director of Nursing Services and or Director of Staff Development (DSD) will Reeducate licensed nurses regarding the facility's narcotic medication ordering and refill procedures according to the facility's policy and procedures. 5) The facility will implement the 3-Way Med Cart Quality Assurance Review on a weekly basis to ensure residents medication orders, compare to medications present, and medications on the medication Administration Record. Any discrepancies will be addressed immediately by Licensed Nursing staff and reported via the 3 way check form to the Director of Nursing Services. 6) The pharmacy consultant will monitor for compliance during monthly Medication Regimen Review. Findings will be reported to the Administrator and Director of Nursing Services for appropriate corrective action. The Plan of Correction was accepted on 8/17/11 at 7:20 PM. On 8/19/11 at 4:02 PM, the survey team met with the facility administrator, DON, CRN and VPO and informed them that the team abated the Immediate Jeopardy.

Based on interview and record review, the facility failed to ensure that administration was conducted in a manner to ensure that residents reached and maintained their highest practicable well-being. This failure resulted in a breakdown of services provided to the residents which resulted in residents not receiving their medications as prescribed, and caused physical pain and emotional distress for 1 of 17 sampled residents (Resident 5) and 2 unsampled residents (unsampled Residents A and C). Findings: 1. During the initial tour on 8/15/11 at 8:45 AM, unsampled Resident C stated that the facility kept running out of her medications, specifically [MEDICATION NAME] (an antianxiety medication), and that it was very upsetting to her. 2. During an interview with Resident 5 on 8/15/11 at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he gets very upset and will start cussing at the staff. 3. During an interview with unsampled Resident A on 8/17/11 at 5:05 PM, she stated that every month the facility runs out of her [MEDICATION NAME] (muscle relaxant medication) and her [MEDICATION NAME] (a scheduled II controlled narcotic pain medication used for moderate to severe pain control). She stated that she will go without her medications for 2-3 days and that her pain will get to a 12 on a 0-10 scale. She further stated that when this happens she is unable to sleep due to the pain. She finds this all to be very upsetting and distressing. On 8/18/11, a review of the policy and procedure titled, "Pharmaceutical Services," dated January 2009, indicated the process for medication refill orders: "Reorder these medications when a three to five-day supply remains in the medication storage." The process for reorder of Federal Schedule II controlled substances is: "a. Inform the pharmacy when a five-day supply remains in the medication storage. There is no authorized automatic refill available for scheduled II controlled substances ... c. Therefore it is imperative that the facility reorder these medication at least 5 days ahead of running out." On 8/18/11, a review of the policy and procedure titled, "Transmitting Medication Orders," dated January 2009, indicated the process for reordering medications: "Refill medication orders may be transmitted by telephone from a licensed nurse to a registered pharmacist or pharmacy technician. The Nurse shall make note of the date, time, and the name of the pharmacist or pharmacy technician to whom the order was transmitted. Such notation is made in the resident's medical record." During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his [MEDICATION NAME] on 8/12/11 and he didn't receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor. She confirmed that she had not documented any notes in the medical record. On 8/16/11 at 10:30 AM, during a review of the resident council minutes, dated "2/8/11 at 10:30 AM," the minutes indicated that there was a complaint that "Pharmacy delivers their meds 2-3 days after their meds ran out." The resident council minutes, dated "5/17/11 at 10:50 AM," further indicated, "Pharmacy are slow in delivery." During the resident group interview on 8/16/11 at 11:00 AM, 3 of 4 residents present stated that they have had to go as long as 3 days without their pain medication because the facility had run out of their medications. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She confirmed that Resident 5 had run out of his pain medication on several occasions and he had to go without since they did not carry [MEDICATION NAME] in their E-kit. (The E-kit is an emergency drug supply that is kept in the facility to have first time doses available to residents, it is not for routine use). During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she was aware that there was a problem with residents not receiving their medications as prescribed. She stated that she had given the issue to the DON to resolve. The administrator was unable to explain how the facility attempted to resolve the issue, nor had she followed up with the DON to ensure resolution had been obtained. During an interview with the administrator on 8/23/11 at 8:30 AM, she stated that when the resident council informs her of any issues or concerns she hands them over to the department heads to take care of the situation. The administrator did not comment on weather she had followed up with the department heads to ensure that the issues and concerns were addressed and resolved.

Based on interview and record review, the facility's quality assurance committee failed to identify quality issues related to the implementation of the policy and procedure for the reordering of medications. This contributed to the failure of nurses to reorder medications for residents in a timely manner to be given as ordered by the prescriber for 1 of 17 sampled residents (Resident 5) and 2 unsampled residents (unsampled Residents A and C). Findings: 1. During the initial tour on 8/15/11 at 8:45 AM, unsampled Resident C stated that the facility kept running out of her medications, specifically [MEDICATION NAME] (an antianxiety medication), and that it was very upsetting to her. 2. During an interview with Resident 5 on 8/15/11 at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he gets very upset and will start cussing at the staff. 3. During an interview with unsampled Resident A on 8/17/11 at 5:05 PM, she stated that every month the facility runs out of her [MEDICATION NAME] (muscle relaxant medication) and her [MEDICATION NAME] (a scheduled II controlled narcotic pain medication used for moderate to severe pain control). She stated that she will go without her medications for 2-3 days and that her pain will get to a 12 on a 0-10 scale. She further stated that when this happens she is unable to sleep due to the pain. She finds this all to be very upsetting and distressing. On 8/18/11, a review of the policy and procedure titled, "Pharmaceutical Services," dated January 2009, indicated the process for medication refill orders: "Reorder these medications when a three to five-day supply remains in the medication storage." The process for reorder of Federal Schedule II controlled substances is: "a. Inform the pharmacy when a five-day supply remains in the medication storage. There is no authorized automatic refill available for scheduled II controlled substances ... c. Therefore it is imperative that the facility reorder these medication at least 5 days ahead of running out." On 8/18/11, a review of the policy and procedure titled, "Transmitting Medication Orders," dated January 2009, indicated the process for reordering medications: "Refill medication orders may be transmitted by telephone from a licensed nurse to a registered pharmacist or pharmacy technician. The Nurse shall make note of the date, time, and the name of the pharmacist or pharmacy technician to whom the order was transmitted. Such notation is made in the resident's medical record." During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his [MEDICATION NAME] on 8/12/11 and he didn't receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor. She confirmed that she had not documented any notes in the medical record. On 8/16/11 at 10:30 AM, during a review of the resident council minutes, dated "2/8/11 at 10:30 AM," the minutes indicated that there was a complaint that "Pharmacy delivers their meds 2-3 days after their meds ran out." The resident council minutes, dated "5/17/11 at 10:50 AM," further indicated, "Pharmacy are slow in delivery." During the resident group interview on 8/16/11 at 11:00 AM, 3 of 4 residents present stated that they have had to go as long as 3 days without their pain medication because the facility had run out of their medications. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She confirmed that Resident 5 had run out of his pain medication on several occasions and he had to go without since they did not carry [MEDICATION NAME] in their E-kit. (The E-kit is an emergency drug supply that is kept in the facility to have first time doses available to residents; it is not for routine use). During an interview with the administrator (a member of the facility's quality assurance committee), on 8/17/11 at 10:05 AM, she stated that she was aware that there was a problem with residents running out of their narcotic medication. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine [MEDICATION NAME] (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of [MEDICATION NAME] pulled but nothing else. He stated that he reviewed the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their pain medications. He further stated that he had spoken to the DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. On 8/18/11, during a review of the pharmacist's drug regimen review from 8/2010 through the present, there was no documentation to show that the pharmacist had identified that resident's were not receiving their prescribed pain medication. During an interview with the Pharmacist on 8/18/11 at 2:20 PM, he stated that during his DRR (drug regimen review) he reviewed the residents MAR's (medication administration record) orders and E-kit logs. He confirmed that he had not identified during his DRRs, that Resident 5 had run out of his medication in June or July 2011. During an interview with the facility administrator on 8/23/11 at 8:23 AM, the administrator stated that the quality assurance committee had identified and had been working on a plan of action regarding the narcotic counts, but had not identified this particular issue with the medications (facility residents not receiving their medications as ordered by the prescriber).

Based on interview and record review, the facility failed to make prompt and effective efforts to resolve grievances voiced by 1 of 17 sampled residents (Resident 5) and 1 unsampled resident (unsampled Resident C) regarding the availability of of medication which resulted in Residents 5 and C to experience physical pain, anxiety and emotional distress due to missed doses of pain and antianxiety medications. Findings: 1. During an interview with Resident 5 on 8/15/11, at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he becomes very upset and will start cussing and throwing things at the staff. He stated that he experiences an extreme amount of pain when he does not receive his medications. During further interview Resident 5 stated that he was in a car accident years ago and [MEDICAL CONDITION] 70% of his body which is still painful now. He also stated that he has trouble with medication management which is why he is at the facility. He stated that he has to be on top of the pain to control the pain. He stated that he had informed the facility of his medications running out but that he doesn't feel that they care. A review of Resident 5's medical record on 8/15/11 indicated that he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Review of the Resident 5's MAR indicated [REDACTED] 6/25/11 thru 6/26/11 the resident missed the following doses of [MEDICATION NAME]: 6/25/11 6:00 AM, 2:00 PM and 10:00 PM, 6/26/11 6:00 AM and 2:00 PM for a total of 5 doses of [MEDICATION NAME]. 7/11/11 thru 7/12/11 the resident missed the following doses of [MEDICATION NAME]: 7/11/11 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 7/12/11 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM and 4:00 PM, for a total of 9 doses of [MEDICATION NAME]. 8/12/11 thru 8/13/11 the resident missed the following doses of [MEDICATION NAME]: 8/12/11 12:00 PM, 4:00 PM, 8:00 PM and 8/13/11 12:00 AM, for a total of 4 doses of [MEDICATION NAME]. There was no further written documentation found on the MAR indicated [REDACTED]. A review of Resident 5's record indicated that he had not received his prescribed [MEDICATION NAME] for 32 hours from 6/25/11 until 6/26/11, nor did he receive his prescribed [MEDICATION NAME] for 32 hours from 7/11/11 until 7/12/11, and then 20 hours from 8/12/11 until 8/13/11. During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his [MEDICATION NAME] on 8/12/11 and he did not receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor, however, she had not made any notes in the medical record documenting this. LVN 6 stated that Resident 5 was very vocal about his missed medication. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She stated that if possible they will use the E-kit but have, at times exhausted the E-kit supply and residents have to go without their medications. She confirmed that Resident 5 has run out of his pain medication on several occasions and he has to go without since they do not carry [MEDICATION NAME] in their E-kit. 2. During initial tour on 8/15/11 at 8:45 AM, unsampled Resident C stated that the facility kept running out of her medications, specifically [MEDICATION NAME] (an antianxiety medication), and that it was very upsetting to her. She stated she finds it distressing that her medications are not readily available and that she may not receive them when she needs them. Resident C was observed to be very anxious and tearful while talking. A review of Resident C's medical record indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED]. An interview was conducted with LVN 1 on 8/17/11 at 9:50 AM. LVN 1 stated that they just use medications from the E-kits (an emergency drug supply that is kept in the facility to have 1st time doses available to residents, it is not for routine use if the resident's routine medication is not available). When asked what happens if the E-kit does not have the medication needed, LVN 1 stated she would let the Director of Nurses (DON) know. During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she was aware regarding the problem with the availability of medications, which caused residents to not receive medications as ordered by the physician, however she had left it to the DON to handle. The administrator was unable to explain how the facility attempted to resolve it nor had she followed up to ensure resolution had been obtained.

Based on interview and record review, the facility failed to act upon the grievances voiced by the resident council regarding the availability of pain medications. On 8/16/11, 3 of 4 residents present at the group meeting stated that the facility had run out of their pain medications which caused them to miss doses. This failure resulted in the residents to experience emotional distress and had the potential for feelings of dehumanization and humiliation due to the lack of response by facility staff. Findings: During a review of the resident council minutes on 8/16/11 at 10:30 AM, it indicated that there was a complaint on February 8, 2011 at 10:30 AM, that "Pharmacy delivers their meds 2-3 days after their meds ran out." It was further indicated in the May 17, 2011 at 10:50 AM, resident council minutes that, "Pharmacy are slow in delivery". During the resident group interview on 8/16/11 at 11:00 AM, 3 of 4 residents' present stated that they have had to go as long as 3 days without their pain medication because the facility had run out of their medications. During an interview with unsampled Resident A, who is a member of the resident council, on 8/17/11 at 5:05 PM, she stated that every month the facility runs out of her [MEDICATION NAME] (muscle relaxant medication) and her [MEDICATION NAME] (a class 2 narcotic pain medication used for moderate to severe pain control). She stated that she will go without her medications for 2-3 days and that her pain will get to a 12 (on a 0-10 scale with 10 being the worst pain). She further stated that when this happens she is unable to sleep due to the pain which is very upsetting and distressing to her. A record review, conducted on 8/19/11, indicated that unsampled Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 750 mg (milligram) by mouth for muscle spasms QID (4 times/day) at 2 AM, 6 AM, 10 AM, 6 PM [MEDICATION NAME] 5/325 mg by mouth for pain every four hours [MEDICATION NAME] 5/325 mg 1 tab (tablet) by mouth TID (3 times/day) as needed for pain scale 1 - 4 [MEDICATION NAME] 5/325 mg 2 tabs by mouth TID as needed for pain scale 5 - 10. Review of the medication administration records (MAR's) for unsampled Resident A indicated the following documentation by the licensed nurse: 12/15/10, 10 AM - [MEDICATION NAME] 5/325 mg, missing 1/28/11, 10 AM - [MEDICATION NAME], 750 mg, not available 1/29/11, 10 AM - [MEDICATION NAME], 750 mg, not available 3/01/11, 2 AM, 6 PM, 10 PM - [MEDICATION NAME] 5/325 mg, not available 3/10/11, 6 PM, 10 PM - [MEDICATION NAME] 5/325 mg, not available 3/11/11, 2 AM - [MEDICATION NAME], not available 4/27/11, 12 AM, 9 AM - [MEDICATION NAME], not available 4/28/11, 6 AM - [MEDICATION NAME], not available 7/07/11, 2 AM, 6 AM - [MEDICATION NAME], not available 7/18/11, 6 AM - [MEDICATION NAME], not available An interview was conducted with LVN 1 on 8/17/11 at 9:50 AM. LVN 1 stated that they just use medications from the E-kits (an emergency drug supply that is kept in the facility to have 1st time doses available to residents, it is not for routine use if the resident's routine medication is not available). When asked what happens if the E-kit does not have the medication needed, LVN 1 stated she would let the Director of Nurses (DON) know. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other routine medications. She stated that if possible they will use the E-kit but have, at times exhausted the E-kit supply and residents have to go without their medications. During an interview with the administrator on 8/17/11 at 10:05 AM, she stated that she was aware regarding a problem with the availability of medications which caused residents to not receive medications as ordered. She stated that she had given it to the DON to resolve. The administrator was unable to explain how the facility attempted to resolve it nor had she followed up with the DON to ensure resolution had been obtained. During an interview with the administrator on 8/23/11 at 8:30 AM, she stated that when the resident council informs her of any issues or concerns she refers them over to the department heads to take care of the situation. She was aware that the council had made complaints about the availability of medication however she believed that the DON was taking care of it.

Based on interview and record review, the facility's pharmacist failed to identify during the monthly Drug Regimen Reviews that residents were not receiving their medications as prescribed by the physician. This failure caused 1 of 17 sampled residents (Resident 9) to continue to experience missed doses of their medications which caused them increased pain, and distress. Findings: During an interview with Resident 5 on 8/15/11, at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he becomes very upset and will start cussing and throwing things at the staff. He stated he is in an extreme amount of pain when he doesn't get his medications. During further interview Resident 5 stated that he was in a car accident years ago with burns over 70% of his body and that it was very painful then and is still painful now. He stated that he has trouble with medication management and that is why he is at the facility, so they can give him his medications. He stated that he has to be on top of the pain to control the pain. Review of Resident 5's medical record on 8/15/11 indicated that he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 6/25/11 6:00 AM dose of Morphine- not marked as given 6/25/11 2:00 PM dose of Morphine- marked as not given, documented "Morphine Sulfate 45 mg not available. Pharmacy has been called x 3 spoke with..." 6/25/11 10:00 PM dose of Morphine- not marked as given 6/26/11 6:00 AM dose of Morphine- not marked as given 6/26/11 2:00 PM dose of Morphine- not marked as given 7/11/11 8:00 AM dose of Dilaudid- marked as not given, documented, "Dilaudid not available Rx (pharmacy) made aware". 7/11/11 12:00 PM dose of Dilaudid- marked as not given, documented "Dilaudid 5 mg reordered per Rx not available." It further documents "Rx called again x 2 with statements of med to arrive today." 7/11/11 4:00 PM dose of Dilaudid- marked as not given 7/11/11 8:00 PM dose of Dilaudid- marked as not given 7/12/11 12:00 AM dose of Dilaudid- marked as not given 7/12/11 4:00 AM dose of Dilaudid- marked as not given 7/12/11 8:00 AM dose of Dilaudid- marked as not given 7/12/11 12:00 PM dose of Dilaudid- marked as not given 7/12/11 4:00 PM dose of Dilaudid- marked as not given 8/12/11 12:00 PM dose of Dilaudid- not marked as given 8/12/11 12:00 PM dose of Dilaudid- marked as not given 8/13/11 12:00 AM dose of Dilaudid- marked as not given, documented, "Dilaudid 5 mg not available pharmacy aware." Resident 5 did not receive his prescribed Morphine for 32 hours from 6/25/11 until 6/26/11. He did not receive his prescribed Dilaudid for 32 hours from 7/11/11 until 7/12/11 and then 20 hours from 8/12/11 until 8/13/11. During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his Dilaudid on 8/12/11 and he didn't receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor. She confirmed that she had not documented any of this in the medical record. A review of the Minimum Data Set (MDS, a tool used by long term care facilities to assess and plan care for residents) indicated, under Section J0100, A, that Resident 9 was on a scheduled pain medication regimen. Resident 9 had a gastrostomy tube (GT, a tube surgically inserted into the stomach for feeding and medication administration purposes) and was non-verbal and unable to express pain symptoms verbally. A review of the physician's orders [REDACTED]. A review of the medication administration records (MAR's) for Resident 9 indicated that Resident 9's pain medication was omitted on 7/31/11 at 6:00 AM. The reason indicated for the omission was, "not available". Review of the MAR's for August, 2011 indicated the pain medication was omitted on 8/01/11 at 6 AM and at 2:00 PM. The reason indicated for omission was, "out of stock/pharmacy notified". Additionally, there were several instances indicated on the July and August 2011 MAR's when Resident 9's pain medication was taken from the "E-kit" (emergency medication supply). A record review was conducted on 8/19/11 that indicated unsampled A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Methocarbamol (Robaxin) 750 mg (milligram) by mouth for muscle spasms QID (4 times a day) at 2 AM, 6 AM, 10 AM and 6 PM. Percocet 5/325 mg by mouth for pain every four hours Percocet 5/321 mg 1 tab (tablet) by mouth TID (3 times a day) as needed for pain scale 1- 4 Percocet 5/321 mg 2 tabs by mouth TID as needed for pain scale 5 - 10 A review of the medication administration records (MAR's) for unsampled Resident A indicated the following omissions: 12/5/10, 10 AM- Percocet 5/321 mg, missing 1/28/11. 10 AM- Robaxin, 750 mg, not available 1/29/11, 10 AM- Robaxin, 750 mg, not available 3/01/11, 2 AM- Percocet 5/325 mg, not available 3/01/11, 6 PM- Percocet 5/325 mg, not available 3/01/11, 10 PM- Percocet 5/325 mg, not available 3/10/11, 6 PM- Percocet 5/325 mg, not available 3/11/11, 2 AM- Percocet 5/325 mg, not available 4/27/11, 12 AM- Robaxin, not available 4/27/11, 9 AM- Robaxin, not available 4/28/11, 6 AM- Robaxin, not available 7/07/11, 2 AM- Robaxin, not available 7/07/11, 6 AM- Robaxin, not available 7/18/11, 6 AM- Percocet, not available During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other routine medications. She stated that if possible they will use the E-kit but have, at times exhausted the E-kit supply and residents have to go without their medications. She confirmed that Resident 5 has run out of his pain medication on several occasions and he has to go without since they do not carry Dilaudid in their E-kit. During an interview with the pharmacist on 8/18/11 at 9:38 AM, he stated that some residents had gotten their routine Vicodin (controlled narcotic pain medication used for moderate to severe pain control) from the E-kit. He stated that he only noted the amount of Vicodin pulled but nothing else. He stated that he reviews the E-kit logs monthly as well as all the residents' MAR's and physician orders. He further stated to refill routine controlled medications the facility needs reorder the medication 3-5 days prior to running out of the medications. He stated that he was not aware that residents were running out of their pain medications. He further stated that he had spoken to the former DON regarding this issue and he believed it was due to the nurses not ordering the medication in a timely manner. On 8/18/11, during a review of the pharmacist's drug regimen review from 8/2010 thru the present, no documentation was found that the pharmacist had identified that resident's were not getting their prescribed pain medication as ordered by the physician. . During an interview with the Pharmacist on 8/18/11 at 2:20 PM, he stated that during his DRR (drug regimen review) he reviews the residents MAR's (medication administration record) orders and E-kit logs. He confirmed that he had not identified during his DRRs, that Resident 5 had run out of his medication in June or July, of 2011. An interview was conducted with the facility pharmacist on 8/19/11 at 4:20 PM. The pharmacist stated he is only at the facility once a month and that he is not aware of missed doses of medications unless the facility notifies him.

Based on interview and record review, the facility's governing body failed to ensure that the facility policy and procedure for the reorder of medications for residents was followed on a consistent basis. This failure resulted in 1 of 17 sampled residents (Resident 5) and 1 unsampled residents (Resident A) to not receive their prescribed medication and caused them physical pain and emotional distress. Findings: 1. During an interview with Resident 5 on 8/15/11 at 3:20 PM, he stated that the facility kept running out of his pain medication. He stated that the last time he had gone without his medication was 3 days ago. He further stated when that happens, he gets very upset and will start cussing at the staff. During an interview with LVN 6 on 8/18/11 at 2:25 PM, she stated that Resident 5 had run out of his [MEDICATION NAME] on 8/12/11 and he didn't receive the medication. She stated that she reordered the medication when she saw that he had run out and also notified the doctor. She confirmed that she had not documented any notes in the medical record. During an interview with RN 1 on 8/17/11 at 9:17 AM, she confirmed that the facility has had a problem with running out of the resident's pain and other medications. She confirmed that Resident 5 had run out of his pain medication on several occasions and he had to go without since they did not carry [MEDICATION NAME] in their E-kit. (The E-kit is an emergency drug supply that is kept in the facility to have first time doses available to residents; it is not for routine use). 2. During an interview with unsampled Resident A on 8/17/11 at 5:05 PM, she stated that every month the facility runs out of her [MEDICATION NAME] (muscle relaxant medication) and her [MEDICATION NAME] (a scheduled II controlled narcotic pain medication used for moderate to severe pain control). She stated that she will go without her medications for 2-3 days and that her pain will get to a 12 on a 0-10 scale. She further stated that when this happens she is unable to sleep due to the pain. She finds this all to be very upsetting and distressing. On 8/16/11 at 10:30 AM, during a review of the resident council minutes, dated "2/8/11 at 10:30 AM," the minutes indicated that there was a complaint that "Pharmacy delivers their meds 2-3 days after their meds ran out." The resident council minutes, dated "5/17/11 at 10:50 AM," further indicated, "Pharmacy are slow in delivery." During the resident group interview on 8/16/11 at 11:00 AM, 3 of 4 residents present stated that they have had to go as long as 3 days without their pain medication because the facility had run out of their medications. During an interview with the administrator, on 8/17/11 at 10:05 AM, she stated that she was aware that there was a problem with residents running out of their medications. On 8/18/11, a review of the policy and procedure titled, "Transmitting Medication Orders," dated January 2009, indicated the process for reordering medications: "Refill medication orders may be transmitted by telephone from a licensed nurse to a registered pharmacist or pharmacy technician. The Nurse shall make note of the date, time, and the name of the pharmacist or pharmacy technician to whom the order was transmitted. Such notation is made in the resident's medical record." On 8/18/11, a review of the policy and procedure titled, "Pharmaceutical Services," dated January 2009, indicated the process for medication refill orders: "Reorder these medications when a three to five-day supply remains in the medication storage." The process for reorder of Federal Schedule II controlled substances is: "a. Inform the pharmacy when a five-day supply remains in the medication storage. There is no authorized automatic refill available for scheduled II controlled substances ... c. Therefore it is imperative that the facility reorder these medication at least 5 days ahead of running out." During an interview with the administrator on 8/19/11 at 8:07 AM, she stated that she was unable to provide any documentation that the facility nurses had been reordering medications prior to the medications running out. She confirmed that the problem with getting the residents their medications was that the nurses were not ordering them timely.