Every finding on record at Hi-Desert Medical Center D/P SNF

Based on observation, interview, and record review, the facility did not ensure services to increase range of motion (measurement of how far you can move a body part) or to prevent further decrease in range of motion were provided for three of three sampled residents (Resident 1, 2 and 3), when Resident 1, 2 and 3 were assessed for but not provided the services as ordered for the Functional Maintenance Program (FMP -formally the Restorative Nursing Assistance program or RNA- a program to aim to help residents in the long-term care to maintain the highest level of functioning like bed mobility, transfer walking, dressing etc.) after discharged from Physical Therapy and (PT- a branch of rehabilitative health that uses specially designed exercise to help residents regain or improve their physical abilities) and Occupational Therapy (OT-a branch of rehabilitative health that focuses on improving the patient's ability to perform activities of daily living such as bathing, toileting, eating, personal hygiene, etc.) This failure had the potential to contribute to Resident's 1, 2 and 3's decline in range of motion and could have limited to function independently with comfort and quality of life.1. During a review of Resident 1's admission Records (general demographics information), the admission Records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or total loss of motor an sensory function in all limbs and torso), muscle spasms (sudden involuntary contractions of a muscle that cannot relax), and neurogenic bladder dependent on foley (poor bladder control, inability to empty the bladder and depend on an urinary catheter). During an interview on June 16, 2026, at 11:13 AM, with Resident 1, Resident 1 stated, The RNA program stopped. Functional Maintenance Program (FMP) only helps me put on my shirt and shorts, there is no stretching, there is nothing else, all that other stuff is gone. I addressed this issue at the resident council meeting. Resident 1 further stated the facility responded by State said it was OK and his right knee was turning in, had muscle spasms and felt worse, Resident 1 stated he and other residents were not receiving any RNA or FMP services for some time now and the facility was aware. During a review of Resident 1's medical records indicated as follows: a) Order sheet Restorative Program Active Range of Motion (ROM) (measurement of how far you can move a body part), dated December 30, 2025, no, Leg stretches, hand stretches. b) Rehab Note dated May 06, 2026, 1607 (4:07 PM): FMP (formally RNA program) voiced his concerns of not having RNA within last 4 weeks when he has an order for 3x (tree times) week. He (Resident 1) is aware of the transition to FMP and is not happy about this. He (Resident 1) remains appropriate for the continued manual stretching. ROM of both Upper Extremities and Right Lower Extremities . c) Rehab Note dated May 14, 2026, 1709 (5:09 PM): Therapist visited this patient (Resident 1) in the am (morning) and provided Passive Range of Motion PROM (therapist of technique moves patient joint without any muscular effort) to all 4 (extremities)'s as indicated.Patient (Resident 1) informed the therapist that he has not stretched in weeks since there is no longer an RNA program. Therapist attempted to secure patients Certified Nursing Assistant (CNA) for training, but CNA was unavailable at the time. Patient can benefit from continued ROM and stretching activities with nursing. d) Rehab Discharge to Nursing-Plan of Care (outline medical, supportive and daily living services a patient needs) dated May 19, 2026: FMP, goal Resident will maintain current level of function in arms and legs range stretch, function (eating self) interventions: Both arms are tight, has right leg spasms, left leg postures into internal rotation and abduction, Stretch. Abductor pillow has been recommended to keep hips more open. Transfers Dependent Hoyer (mechanical device that helps transfer individuals between surfaces), Out of Bed (OOB) usually to powerchair (motorized mobility devices, electric wheelchair). Passive ROM to both arms and legs, slow sustained stretches. The facility did not provide a care plan addressing RNA, FMP Therapy, ROM, for Resident 1 and did not provide documented evidence of FMP or ROM services being delivered. 2. During a review of Resident 2's admission Records, the admission Records indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or total loss of motor an sensory function in all limbs and torso), neurogenic bladder dependent on foley (poor bladder control, inability to empty the bladder and depend on an urinary catheter) and hypertension (high blood pressure). During an interview on June 16, 2026, at 11:23 AM, with Resident 2, Resident 2 stated, the doctor wrote a prescription 2 days ago for Therapy and RNA and no one has done anything. Resident 2 stated he had been at the facility for over a year and was supposed to have RNA services but did not receive for a really long time. During a review of Resident 2's medical records indicated as follows: a) Rehab Note dated May 05, 2026, 4:43 PM: FMP (formally RNA program) . He (Resident 2) would benefit from manual ROM via FMP at this time. He (Resident 2) needs to participate when they offer services, or he (Resident 2) will be removed from services. Reassess in 6-12 months. b) Rehab Discharge to Nursing-Plan of Care dated May 19, 2026: FMP, goal Resident (Resident 2) will maintain current level of function in hips, shoulders. Function Total Care, Bilateral feet are in plantar flexion, pelvis rotated to right. Active ROM/PROM: Both hips are tight, arms and knees. The facility did not provide a care plan addressing RNA, FMP Therapy, ROM, for Resident 2 and did not provide documented evidence of FMP or ROM services being delivered. 3. During a review of Resident 3's admission Records, the admission Records indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or total loss of motor an sensory function in all limbs and torso), muscle spasms (sudden involuntary contractions of a muscle that cannot relax) and seizures (disturbance in brain to cause sudden involuntary body movements). During a review of Resident 3's medical records indicated as follows: a) Rehab Note dated May 06, 2026, 2:37 PM: FMP (formally RNA program) Review, Patient (Resident 3) is well known to this therapist.He (Resident 3) remains with spasms.He (Resident 3) is appropriate to continue with FMP to address ROM to both Upper Extremities and Lower extremities, seated forward trunk leans and side to side. b) Rehab Discharge To Nursing-Plan of Care dated May 19, 2026: FMP, goal Resident (Resident 3) will maintain current level of function in leg and arm ROM so he (Resident 3) can use power chair, function (total Care), locomotion, uses power wheelchair.has been assessed by PT (Physical Therapy), transfers Hoyer lift, passive ROM focus on left arm and leg, can stretch both. The facility did not provide a care plan addressing RNA, FMP Therapy, ROM, for Resident 3 and did not provide documented evidence of FMP or ROM services being delivered. During a review of the document titled, Resident Council (meetings for group of residents in a nursing home to share concerns, plan activities and help improve quality of life while in facility) Sign in and Acknowledgement, dated May 12, 2026, and June 09, 2026, indicated, RNA cannot be replaced with FMP and Neither RNA or FMP are currently happening During a review of the document titled, Lesson Plan (plan prepared to teach a lesson), Topic: Range of Motion, dated January 2026, it indicated, Topic: We will identify all residents that are currently on a RNA program and place them on the FMP. All staff CNA, nursing and rehab) will receive an in-service on the FMP. [Facility name] is no longer utilizing RNAs alone, all CNAs are responsible for doing the FMP with their assigned residents. All CNAs will be shown all tasks necessary for the FMP. They will be required to complete a competency checklist. CNAs will be provided with assignment sheets to reflect the specific functional maintenance restorative task required to each shift. Audience RNs, LVNs (staff and travelers). Any staff who are not scheduled for an extended period, on a leave of absence or who have not received the education will be in-serviced upon return to the facility and prior to providing patient care. During a review of the document titled, Functional Maintenance Program Individualized CNA Restorative Care Plan Sheet (fill in sheet), the Plan sheet (Fill in sheet, to be Filled out by CNAs for FMP services being provided) (Facility could Not provide Documentation of Services provided for Residents on FMP list). During an interview on June 16, 2026, at 11:43 AM, with Certified Nursing Assistant (CNA 1), CNA 1 stated, I did not get the training on FMP. I have not done anything to my residents. I watched the RNAs before doing the range of motion for residents. During an interview on June 16, 2026, at 11:50 AM, with Certified Nursing Assistant (CNA 2), CNA 2 stated, I'm not too certain about the difference of RNA and FMP. We did not get training. They just threw this at us. We don't have a list but on the resident's door it has if they have FMP. We do not document the FMP services. Before we had 1 RNA for mornings. For both units. They would pull RNAs just to do that and focus on that service. There is not enough time to do the FMP for the CNAs. We could do ROM. It's supposed to be done daily. But we are running short. During an interview on June 16, 2026, at 11:50 AM, with License Vocational Nurse (LVN), stated, Apparently this was implemented when the CNAs are already overworked. They now have to add FMP to their workload; this is not possible. The residents are not getting what they need with FMP. There were RNAs assigned to do the services, but now they want the CNAs to do this. I will say these residents are not getting FMP services. During an interview and record review on June 16, 2026, at 12:32 PM, with the Administrator (Admin), the Admin stated, previously the RNAs had a list and paper to document on but not anymore. The Admin stated she could not show if the residents have been or are currently getting the services and the facility does not have a signing sheet for the lesson plan or in-services provided. Overseeing the FMP program was the responsibility of both departments of Rehab and the Director of Staff Development (DSD) with Administrator monitoring. The Admin further stated there was no job description for FMP, and it was all taught in the C.N.A. courses to be licensed/certified. During a review of the facility's policy and procedure (P&P) titled, Functional Maintenance Program, dated October 2023, the P&P indicated, To provide a structured program of nursing interventions that prevent or slow the decline of a resident's functional status. This policy ensures that maintenance activities are performed safely, effectively, and in accordance with individualized care plans. -Desert Continuing Care Center; . This policy applies to all CNAs and specialized Restorative. Individualized Plan: Each resident in the program must have a written Functional Maintenance Plan detailing specific goals, techniques, and precautions. Supervision: CNAs performing these tasks must be supervised by a Licensed Nurse, with therapists providing consultation as needed. 4. CNA Responsibilities, Adherence to Plan: Follow the specific exercises or activities (e.g., Range of Motion, ambulation, or AOL support) as outlined in the care plan. Nursing Assistants (RNAs) trained to provide restorative or maintenance services. 5. Documentation requirements Daily Records: CNAs must document every session, including the specific activity performed, the duration (in minutes), and the residents' response or level of participation. Reporting Decline: Any significant change or decline in a resident's ability to perform the program must be reported and charted to justify a reassessment by a licensed professional. 6. Training & Competency Only CNAs who have completed specialized training in restorative techniques may be assigned to lead formal FMP/RNP sessions. Annual competency evaluations will be conducted to ensure staff maintain proper technique and safety standards.

Based on observation, interview, and record review, the facility failed to provide appropriate supervision and implement elopement (when a resident leaves facility without staff's permission) preventions for one of three sampled residents (Resident 1), who was assessed as having a high elopement risk. This failure resulted in Resident 1 leaving the facility unsupervised, fell, and subsequently sustained a left hip fracture (broken).Findings: A review of Resident 1's face sheet (contains demographic and medical information), undated, indicated, Resident 1 was admitted on [DATE], with diagnoses including sepsis (serious body-wide reaction to an infection that can damage organs) and dementia (condition that causes memory loss and trouble thinking, severe enough to affect daily life). A review of Resident 1's Elopement Risk Assessment [a tool to identify individuals likely to leave a facility unsupervised, reducing risk of injury], dated March 3, 2026, indicated, Resident 1 had dementia, wandering behaviors (when an individual moves around without clear purpose and may become lost, confused, or unsafe), and was identified as a high elopement risk. A review of Resident 1's Minimum Data Set [MDS - standardized, comprehensive assessment tool used to evaluate resident functional capabilities, health needs, and quality of life], dated March 12, 2026, indicated Resident 1 had diagnosed cognitive loss (gradual reduction in the brain's ability to function as well as it used to) or dementia (decline in brain function that interferes with daily life, caused by diseases that damage brain cells). During an interview on April 22, 2026, at 12:40 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was informed that Resident 1 eloped from the facility on April 16, 2026, around 9:30 AM. LVN 1 added the facility's staff did not see Resident 1 left. LVN 1 confirmed Resident 1 wandered frequently throughout the facility. During a follow-up concurrent observation and interview on April 22, 2026, at 12:50 PM, with LVN 1, the facility's exit doors were observed. The facility's entrance door was unlocked with no alarm, leading to the parking lot that led to a major street. No staff were present in main lobby while residents were observed walking back and forth. The facility's back door leading to the outdoor smoking patio and extended parking lot, was also unlocked with no alarm, and no staff present. LVN 1 confirmed the facility is not a locked unit and that the front entrance and side door leading to the parking lot are unlocked and unalarmed. During an interview on May 6, 2026, at 10:53 AM, with the Admin Secretary (AS), in the main lobby, the AS stated she last observed Resident 1 on April 16, 2026, between 8:30 AM and 9:00 AM. The AS further stated, Resident 1 was observed sitting in the lobby before the AS stepped away from the front desk, then upon return, Resident 1 was no longer in the main lobby. During an interview on May 6, 2026, at 11:02 AM, with Certified Nurse Assistant 1 (CNA1), CNA1 confirmed that he was assigned to Resident 1 on April 16, 2026, during day shift (7:00 AM to 7:00 PM). CNA1 stated he last observed Resident 1 in her room around 8:30 AM and did not see Resident 1 afterwards. CNA1 confirmed Resident 1 frequently wanders the facility and has dementia. CNA1 further stated it was facility expectation for the staff assigned to the residents to monitor and ensure residents' safety. During an interview on May 6, 2026, at 11:27 AM, with LVN 2, LVN 2 confirmed Resident 1 was one of her residents on April 16, 2026, for day shift. LVN 2 stated she last observed Resident 1 in the hall approximately around 8:00 AM. LVN 2 stated Resident 1 often wanders the facility but has never actually left the building. LVN 2 further stated it was facility expectation for staff to monitor residents every two hours with high elopement risk and dementia. LVN 2 was unsure what interventions were on Resident 1's care plan (individual plan that includes residents' health problems, preferences, and goals) for elopement risk and dementia. During a concurrent interview and record review on May 6, 2026, at 12:05 PM, with the Director of Nursing (DON), Resident 1's Nursing Notes, dated April 4, 2026, through April 16, 2026, were reviewed. The Nursing Notes indicated that Resident 1 would often walk throughout the facility, demonstrating confusion and difficulty with redirection, and escalating behavioral concerns. The DON verified Resident 1 was known to be a wander risk, had dementia, and staff relied primarily on frequent checking and redirection. The DON further stated no staff observed Resident 1 leave the building and there were no staff in the lobby or outside the front entrance, on the date of the incident, April 16, 2026. During a concurrent interview and record review on May 6, 2026, at 12:15 PM, with the DON, Resident 1's LTC [long term care] Elopement Risk IPOC [interdisciplinary plan of care] (IPOC), dated April 17, 2026, was reviewed. The IPOC indicated, Resident 1 had a plan of care for elopement risk, which had an intervention of structure day to monitor activities and safety. The DON confirmed there were no other interventions in the elopement IPOC, and the IPOC was not specific to Resident 1's concerns. The DON stated there was no clear guidance for staff to follow to prevent elopement risk. The DON was unable to provide a plan of care for dementia. During a concurrent interview and record review on May 6, 2026, at 2:15 PM, with the DON, the facility's policy and procedure (P&P) titled, Accident Prevention, dated January 2020, was reviewed. The P&P indicated, .Avoidable Accident: means that an accident occurred because the facility failed to:.A. Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and/or.B. Evaluate/analyze the hazards and risks; and/or.C. Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or.D. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. The DON stated the policy was not followed and it should have been followed to ensure Resident 1's safety. During a phone interview on May 6, 2026, at 3:25 PM, with the Director of Rehabilitation (DOR), the DOR stated, on April 16, 2026, around 10:00 AM, she saw Resident 1 outside the facility, unsupervised by staff, walking down the hill on the street. The DOR also noted that Resident 1 appeared to be confused. The DOR stated that while waiting for backup, the DOR proceeded to follow Resident 1 down the hill. The DOR then observed Resident 1 fall backward. Subsequently, the DOR contacted emergency services and arranged for Resident 1 to be transferred to the affiliated General Acute Care Hospital. A review of Resident 1's admission H&P [History and Physical-an initial physical assessment], dated April 16, 2026, indicated Resident 1 was brought into the Emergency Department (ED) for a fall after Resident 1's eloped from the Continuing Care Center (CCC), resulting in left leg fracture.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff in accordance with its policy when the required number of Certified Nursing Assistant (CNAs) was not met for three consecutive days (April 10, 2026. through April 12, 2026). This failure had the potential to result in unmet resident's needs, such as psychosocial, physical needs, and safety concerns for 78 vulnerable residents. Findings: During an interview on April 13, 2026, at 10:25 AM, with Resident 2, Resident 2 stated, I usually don't call because sometimes it takes a long time for someone to come. During an interview on April 13, 2026, at 10:35 AM, with Certified Nursing Assistant (CNA 1), the CNA 1 stated, We [the facility] usually work with not enough CNAs. During an interview on April 13, 2026, at 10:45 AM, with Certified Nursing Assistant (CNA 2), the CNA 2 stated, We have been working with short CNAs, but it is better today. During a telephone interview on April 13, 2026, at 10:50 AM, with the License Vocational Nurse (LVN 1), LVN 1 stated, We have been working with short nurses lately. During a concurrent interview and record review on April 13, 2026, at 11:20 AM, with the Director of Nursing (DON), the DON reviewed the facility's staffing assignments and nursing hours per patient day (NHPPD) - direct care service hours per patient day (DHPPD) staffing requirements of which a minimum of 2.4 hours per patient day shall be performed by CNAs, from April 10, 2026, through April 12, 2026, were reviewed with the Director of Nursing (DON). The staffing assignment and nursing hours indicated the hours to provide 3.5 nursing hours per patient day were not met on the following dates: April 12, 2026 - actual CNA NHPPD was 2.03 hours (short by 1.47)April 11, 2026 - actual CNA NHPPD was 1.87 hours (short by 1.63)April 10, 2026 - actual CNA NHPPD was 1.79 hours (short by 1.71) The DON acknowledged the facility did not meet the staffing requirements on the above dates and emphasized the necessity of adequate staffing for patient safety. During a concurrent interview and review of the facility 's policy and procedure (P&P) titled, DP SNF [Distinct Part Skilled Nursing Facility] STAFFING GUIDELINES dated, April 2018, the P&P indicated, .PURPOSE: To ensure HDMC D/P SNF [Name of facility] provides the adequate provision of nursing hours required for each resident while in the facility. POLICY: In order to provide both optimal quality and well-coordinated patient care. The DON stated, We do have problem with staffing.

Based on observation, interview, and record review, the facility failed to ensure an effective system wide infection control program for the prevention and control of disease for six of seven sampled residents (Resident 25, 92, 90, 66, 30, and 4) when: 1. For five residents (Resident 25, 92, 90, 66 and 30), the nursing staff did not change the oxygen tubing (a thin, flexible tube that delivers oxygen to a patient) according to the facility's policy and procedure (P&P). 2. For one resident (Resident 4), the isolation precaution (infection control methods that involve wearing appropriate cover to protect staff and residents from spreading germs or infection) sign was not posted in front of resident's room. These failures had the potential to place residents at risk of developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite) and increase in cross-contamination (transfer of harmful bacteria from one person to another), which could negatively affect residents' health and delayed recovering.Findings: 1a. During a review of Resident 25 face sheet (clinical record with demographic information), undated, the face sheet indicated, Resident 25 was admitted on [DATE], with diagnoses that included lactic acidosis (body too acidic, due to low oxygen or severe illness), fever, urinary tract infection (UTI—infection to the bladder, urethra, or kidneys), and sepsis (life-threatening infection to body). During a concurrent observation and interview on March 16, 2026, at 11:49 AM, in Resident 25's room, with Registered Nurse (RN 1), Resident 25 is lying in bed on her side with oxygen (O2) at 2 liters per minute (L/min—unit of flow rate) via nasal cannula (an oxygen tube that contains two open prongs intended to deliver oxygen into the nose). The oxygen tubing was unlabeled and undated to indicate when it was last changed. RN 1 stated he was not aware when the oxygen tubing was changed. RN 1 confirmed the oxygen tubing should have been labeled and changed but unsure of what the policy is when it comes to changing tubing. 1b. During a review of Resident 92 face sheet, undated, the face sheet indicated, Resident 92 was admitted on [DATE], with diagnosis that included bilateral (both) humerus (arm bone) fracture (broken). During an observation on March 16, 2026, at 12:08 PM, in Resident 92's room, Resident 92 is in bed sitting with O2 at 2 L/min via nasal cannula. The oxygen tubing was last changed on February 27, 2026. RN 1 confirmed the oxygen tubing should have been changed but unsure of what the policy is when it comes to changing tubing. 1c. During a review of Resident 90 face sheet, undated, the face sheet indicated, Resident 90 was admitted on [DATE], with diagnosis that included sepsis. During a concurrent observation and interview on March 16, 2026, at 12:20 PM, with RN 1, in Resident 90's room, Resident 90 is sitting on his bed resting, with O2 at 2 L/min via nasal cannula. The oxygen tubing was unlabeled and undated to indicate when it was last changed. RN 1 confirmed the oxygen tubing should have been labeled and changed but unsure of what the policy is when it comes to changing tubing. 1d. During a review of Resident 66 face sheet, undated, the face sheet indicated, Resident 66 was admitted on [DATE], with diagnosis that included chronic renal failure (CRF—irreversible loss of kidney function), and anemia (lacks red blood cells). During a concurrent observation and interview on March 16, 2026, at 12:23 PM, with RN 1, in Resident 66's room, Resident 66 is lying on his bed with O2 at 2 L/min via nasal cannula. The oxygen tubing was unlabeled and undated to indicate when it was last changed. RN 1 confirmed the oxygen tubing should have been labeled and changed but unsure of what the policy is when it comes to changing tubing. 1e. During a review of Resident 30 face sheet, undated, the face sheet indicated, Resident 30 was admitted on [DATE], with diagnosis that included chronic obstructive pulmonary disease (COPD—damage to the lungs). During a concurrent observation and interview on March 16, 2026, at 2:52 PM, with RN 1, in Resident 30's room, Resident 30 is sitting on the edge of his bed resting, with O2 at 2 L/min via nasal cannula. The oxygen tubing was unlabeled and undated to indicate when it was last changed. RN 1 confirmed the oxygen tubing should have been labeled and changed but unsure of what the policy is when it comes to changing tubing. During a concurrent interview and record review on March 17, 2026, at 8:10 AM, with the Director of Nursing (DON), the facility's P&P titled, CHANGING OF DISPOSABLE AND NON DISPOSABLE EQUIPMENT, dated November 1, 2016, was reviewed. The P&P indicated, A. Disposable Equipment. 2. Nasal Cannulas, Trach masks and other masks will be changed every Friday. The DON stated the policy was not followed and that the expectation is to change every Friday night shift (7:00 PM to 7:00 AM) and it should be labelled and dated. 2. During a review of Resident 4 's admission Record (contains patient demographics), undated, the admission Record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a condition where body cannot produce enough insulin) with hyperglycemia (high blood sugar), and osteomyelitis (an infection or inflammation of the bone, usually caused by bacteria or, rarely, fungi, which can lead to bone damage if untreated). During a concurrent observation and interview on March 16, 2026, at 11:59 AM, in Resident 4's room, Resident 4 is lying in bed watching television. Resident 4 stated, he was feeling tired, I am positive for flu. During a record review of Resident 4's physician's orders, dated March 14, 2026, the physician's orders indicated, laboratory influenza A, collection date on March 14, 2026. During a review of Resident 4 's Infection Prevention and Control Surveillance Data Collection Tool, undated, indicated positive for influenza (flu) test on March 14, 2026. During an interview on March 16, 2026, at 12:02 PM, with a certified nurse assistant (CNA 1), CNA 1 stated, Resident 4, is positive for influenza. I am not sure why there is no sign at the door. During an interview on March 16, 2026, at 12:15 PM, with a License Vocational Nurse (LVN 1), in Resident 4's room, LVN 1 stated, Resident 4 tested positive for influenza. LVN 1 further stated, the droplet precautions (infection control measures used in healthcare settings to prevent the spread of diseases transmitted through large respiratory droplets such as coughing, sneezing, or talking) sign should have been posted at the door. During a concurrent interview and record review on March 16, 2026, at 15:45 PM, with the DON, the facility's P&P titled, Infection Control-Transmission-based Precautions, dated May 15, 2023, was reviewed. The P&P indicated, .Procedure Notification of Healthcare Team, If the patient/resident is suspected of or identified as having communicable infectious disease, the nurse shall notify the infection Preventionist and the patient's/resident's attending physician for appropriate transmission-based precautions.Responsibilities in the implementation of precautions, Nursing will place the precaution sign, visitor instructions, and supply door hanger or caddy outside the patient's/residents room. The DON reviewed and acknowledged the P&P. The DON stated, the P&P was not followed.

Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to meet the needs for 20 of 20 residents, who were ordered to receive restorative nursing services (a program to maintain or improve residents' physical function provided by a trained staff member such as a certified nurse assist or CNA) from February 1, 2026, through February 28, 2026. This failure resulted in missed restorative nursing services and had the potential to result in decline in residents' health and functional status.Findings: During an interview on March 17, 2026, at 9:10 AM, with the Wound Care Nurse (WCN), the WCN stated she is the only wound care nurse in the facility. The WCN further stated, due to staffing shortages, she would be reassigned from wound care duties to perform medication administration, limiting her ability to complete her assigned responsibilities. During a concurrent interview and record review on March 18, 2026, at 12:21 PM, with CNA1, the facility's RNA [restorative nurse assistant] Assignment Sheet, dated February 2026, was reviewed. The RNA Assignment Sheet indicated, restorative nursing services were completed as follows: On February 3, 2026On February 4, 2026On February 11, 2026On February 19, 2026On February 25, 2026. CNA1 confirmed restorative nursing services were done only on those dates for 20 residents who were on the list to receive RNA and no other dates in February that RNA were completed. CNA1 further stated restorative nursing services were dependent on staffing levels and were only implemented when sufficient CNA staffing was available. During an interview on March 19, 2026, at 8:26 AM, with the Assistant Director of Nursing (ADON), the ADON stated she assists with staffing coordination while the main staff coordinator is out on leave. The ADON further stated, currently in the facility, there are only two staff, both CNAs, that have RNA certification. If there are not enough CNAs scheduled in a shift, then there will be no RNA conducted for residents. RNA is supposed to be done as ordered. During a record review of the facility's staffing records titled, Day Shift Meal & Rest Break Grid [Skilled], dated from February 7, 2026, through March 8, 2026, the Day Shift Meal & Rest Break Grid [Skilled] indicated multiple dates in which staffing levels fell below the facility's established minimum of 3.5 direct nursing hours per patient day (DHPPD) as follows: On February 7, 2026: DHPPD was 2.85On February 8, 2026: DHPPD was 2.80On March 6, 2026: DHPPD was 2.77On March 7, 2026: DHPPD was 3.10On March 8, 2026: DHPPD was 2.45 These findings indicated the facility did not maintain sufficient staffing levels to meet resident needs. During a concurrent interview and record review on March 19, 2026, at 11:10 AM, with the Director of Nursing (DON), the facility's RNA Assignment Sheet, dated February 2026, was reviewed. The DON confirmed restorative nursing services were completed for February 3, 4, 11, 19, and 25. No other dates were completed in the month of February 2026. The DON further stated that the facility does not have enough CNAs scheduled regularly to implement restorative nursing services as ordered. During an interview on March 19, 2026, on 2:29 PM, with the Administrator (Admin), the Admin stated the facility experiences frequent call-offs and described staffing as spotty. The Admin further stated that the facility should have enough staffing available to provide restorative nursing services as ordered because it's important that residents get the care they need. A review of the facility's job description titled, Job Description: Licensed Nursing Home Administrator, undated, indicated, The Administrator is responsible for overseeing the day-to-day operations of the nursing home, including managing staff, developing and implementing policies and procedures, and ensuring compliance with state and federal regulations.Responsibilities include:.Develop and implement policies and procedures to ensure quality of care.Monitor and evaluate staffing levels and patient care services.

Based on interview and record review, the facility failed to complete the facility assessment (a review of the facility resources that are necessary to care for its residents) annually for 90 of 90 residents who are residing in the facility. This failure had the potential to result in inadequate identification and allocation of resources necessary to meet resident care needs.Findings: During an interview on March 17, 2026, at 9:49 AM, with the Director of Nursing (DON), the DON stated the current Administrator (Admin) for the facility is the [name of facility (hospital)] Chief Executive Officer. During a concurrent interview and record review on March 18, 2026, at 8:53 AM, with the DON, the DON stated she was unable to give the current facility assessment report because it was incomplete. The DON further stated it was the Admin's responsibility to complete the facility assessment, but she assisted with the responsibility for the day-to-day operations of the facility, including administrative responsibilities such as ensuring departments (nursing, dietary, and rehabilitation) are functioning properly; ensuring there is enough staff, equipment, services; and even being an on-call administrator during the months of November 4, 2025, through June 1, 2026. During an interview on March 18, 2026, at 3:32 PM, with the Admin, the Admin stated, she was acting as the facility administrator since March 8, 2026. The Admin further stated it is the facility administrator's responsibility to complete the facility assessment annually, and she was aware it was attempted on October 25, 2025, and was not completed. The Admin was unable to state when the facility assessment was last completed. During a concurrent interview and record review on March 19, 2026, at 3:15 PM, with the Admin, the facility's policy and procedure (P&P) titled, Facility Assessment, dated September 2021, was reviewed. The P&P indicated, .Annually conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies and plans to mitigate the risks identified. The Admin stated, it was the facility administrator's responsibility to complete the facility assessment annually in a timely manner, and it was not done per policy. A review of the facility's job description titled, Job Description: Licensed Nursing Home Administrator, undated, indicated, The Administrator is responsible for overseeing the day-to-day operations of the nursing home, including managing staff, developing and implementing policies and procedures, and ensuring compliance with state and federal regulations.Responsibilities include:.Develop and implement policies and procedures to ensure quality of care.Monitor and evaluate staffing levels and patient care services.

Based on interview and record review, the facility failed to ensure the governing body (GB - a group of people responsible for the overall direction and management of an organization) provided effective oversight of the facility. This failure resulted in lack of oversight of facility operation, leading to unaddressed systemic issues that could negatively affect residents' care.Findings: During a review of the facility documents titled, Governing Board Meeting Minutes, dated January 26, 2026, through March 16, 2026, the Governing Board Meeting Minutes indicated quality care outcomes and identified safety concerns discussed at Quality Assurance and Performance Improvement (QAPI-a data driven program to review and improve facility's performance) meetings. There was no mention of staffing concerns or performance improvement progress with wound care treatment compliance, updated care plan (an individualize plan that is created based on each resident's need), unlabeled oxygen tubing, or follow ups with pharmacy recommendations. During an interview on March 19, 2026, at 2:48 PM, with the GB members: Administrator (Admin), Assistant Chief Nursing Officer (ACNO), and Quality Director (QD), the Admin stated, performance improvement audits, progress and updates regarding the facility is discussed in quarterly QAPI meetings, which then go to a Quality Council (QC) meeting that occurs quarterly (every three months), then will be brought up to the GB in a monthly meeting. During an interview on March 19, 2026, 3:00 PM, with the GB members, the following survey team's findings were discussed: staffing concerns or performance improvement progress with wound care treatment compliance, care plans were not patient-centered or updated regularly, unlabeled oxygen tubing, and pharmacy recommendations were not being followed. The Admin stated the GB is aware of staffing concerns, but not regarding wound care treatment compliance, outdated care plans, unlabeled oxygen tubing, and pharmacy recommendations not being followed. The Admin confirmed there was a lack of transparency between the facility and the GB. The Admin further stated, GB has overall responsibility on the facility and for overall patient safety. A review of the facility's policy and procedure (P&P) titled, Rules and Regulations of the Governing Body of [name of facility], dated July 2015, indicated, .Purpose: The purpose of the Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment and services rendered in the Hospital.

Based on interview and record review, the facility did not ensure administration maintained an effective oversight of facility operations for 90 of 90 residents who are residing in the facility. This failure resulted in inadequate oversight of facility operations, with the potential to negatively affect residents care needs.Findings: During a concurrent interview and record review on March 18, 2026, at 8:53 AM, with the Director of Nursing (DON), the DON stated she was unable to give the current facility assessment report (report that determines what resources are necessary to care for the facility's residents competently and outline an education and competency plan for staff) because it was attempted on October 25, 2025 but was never completed. The DON further stated it was the Administration (Admin)'s responsibility to complete the facility assessment. The DON was unable to state when the facility assessment was due or last completed. During a concurrent interview and record review on March 19, 2026, at 2:29 PM, with the facility's Quality Assurance and Performance Improvement (QAPI-a data driven program to review and improve facility's performance) members: Admin, Assistant Chief Nursing Officer (ACNO), Qualities Director (QD), Assistant Director of Nursing (ADON), and DON, the survey team brought up some of the issues identified during survey as follows: insufficient nursing staff to provide restorative nursing services, unlabeled oxygen tubing, wound care treatment orders not being completed consistently, care plans were not patient-centered or updated regularly, and pharmacy recommendations were not being followed. The Admin stated, the issue with staffing has been an ongoing concern the facility is trying to fix, but was not aware it affected restorative nursing services being implemented. The ACNO further stated, the facility was aware with issues with wound care not being completed in a consistent manner, but not regarding pharmacy recommendations not being followed, care plans not being patient-centered or updated regularly, or unlabeled oxygen tubing. The Admin stated she was not aware of these issues and should have been. The Admin further stated, it was the facility administrator's responsibility to maintain oversight of the facility. A review of the facility's job description titled, Job Description: Licensed Nursing Home Administrator, undated, indicated, .The Administrator is responsible for overseeing the day-to-day operations of the nursing home, including managing staff, developing and implementing policies and procedures, and ensuring compliance with state and federal regulations.Responsibilities include:.Develop and implement policies and procedures to ensure quality of care.Monitor and evaluate staffing levels and patient care services.

Based on observation, interview, and record review, the facility failed to ensure no expired medications were available for patients use for two of six medication carts (Cart 100 and Hallway Cart). This failure has the potential to affect all residents receiving beyond the use date (expired) medications, placing them at risk for ineffective therapy and medication errors, which could negatively affect residents' health and safety.Findings: During a concurrent medication cart inspection and interview on March 18, 2026, at 7:44 AM, with Licensed Vocational Nurse (LVN 1), the medication cart (Cart 100) was observed as follows: Omeprazole (medication that use to reduce stomach acid) 20 milligrams (mg-unit of dosing medication) with the expiration date of January 2026 (expired 46 days). Docusate Sodium (medication to prevent constipation) 5 mg with the expiration date of October 31, 2025 (expired 138 days) LVN 1 stated that she was unaware the medications were expired and reported that carts are checked by pharmacist monthly. LVN 1 further stated that there should be no expired medications in the cart. During a concurrent medication cart inspection and interview on March 18, 2026, at 9:25 AM, with Registered Nurse (RN 2), in front of nurse's station in long term care unit, the medication cart (Hallway Cart) was observed as follows: Two opened bottles of artificial tears (eye drops used to keep moisture to eyes) were observed without any label. RN 2 stated that she thought it had just opened yesterday but could not confirm because there was no label to show an open date. RN 2 further stated that medications should be labeled upon opening to ensure that once it past the date it will be discarded. During a review on March 18, 2026, at 3:44 PM, the Manufacturer's Guidelines for Geri-Care Eye Drops, undated, the Manufacturer's Guidelines for Geri-Care Eye Drops, indicated . Discard After: 30 days once opened, even if the expiration date on the bottle is later. During a concurrent interview and record review on March 18, 2026, at 2:47 PM, with the DON, the facility's policy and procedure (P&P) titled, [Facility Name] RX 9.00 Temperature Log and Medication Storage Requirement.DEFINITIONS:.Beyond -Use- Date (BUD) : The date after which a medications or multi-dose vial must no longer be used to prevent contamination and ensure efficacy. This date is typically determined based on manufacturer guidelines or regulatory standards. The DON stated the policy was not followed, she further stated that expired meds should have been discarded and that eyedrops should have been dated.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 8 and Resident 10) received necessary pressure injury (PI-injury to skin and underlying tissues that develop because of prolonged pressure, shear, or friction) treatment when the facility staff did not provide daily wound treatment. This failure had the potential to contribute to worsening of residents' wound or skin condition that could negatively affect residents' health status from delayed wound healing. Findings: 1. During a record review of Resident 8's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses which included, hypertension (high blood pressure), and cerebral palsy (a group of permanent neurological disorders appearing in infancy or early childhood that affect movement, muscle tone, and posture). During a concurrent observation and interview on March 16, 2026, at 10:40 AM, in Resident 8's room, Resident 8 was alert, lying on bed. Resident 8 stated that he has wounds in his back and pointed to his thigh. Resident 8 further stated, sometimes nurses do treatments but are not done every day. During a record review of Resident 8's Nursing Narrative, dated June 30, 2025, the Nursing Narrative indicated, .right ischium (one of the bones forming the pelvis. It is commonly referred to as the sitting bone because it supports the weight of the body when seated) unstageable [a pressure injury where skin and tissue loss is to the extent of damage and obscured by slough (fat that looks yellow) or eschar (dead tissue that look black) tissue] pressure injury wound. During a record review of Resident 8's physician's orders, dated July 22, 2025, the physician's orders indicated, Wound Care TAR, ischial (ischium), daily, PRN (as needed), cleanse with wound cleanser scrubbing lightly to remove slough, apply skin prep to peri wound skin nickel thick santyl (a prescription medication used in wound care to remove dead tissue from wounds, facilitating the healing process) to wound bed cover with foam followed by border foam dressing. During a concurrent interview and record review on March 17, 2026, at 12:20 PM, with wound treatment Licensed Vocational Nurse (TX), Resident 8's TAR, dated July 2025 and March 2026, were reviewed. There was no documented evidence that indicated wound treatment was completed as follows: On July 3, 2025 On July 9, 2025, through July 11, 2025 On July 16, 2025, through July 18, 2025. On March 4, 2026 On March 6, 2026 On March 17, 2026 TX verified and confirmed the above missing wound treatment documentation. TX stated, she does not know why there were missing treatments. TX further stated, Resident 8 is supposed to have daily wound treatment. During a concurrent interview and record review on March 17, 2026, at 3:08 PM, with the Director of Nursing (DON), Resident 8's TAR dated July 2025, and March 2026, were reviewed. There was no documented evidence that indicated wound treatment was completed for July 3, July 9 through July 11, July 16 through July 18, 2025, and March 4, March 6 and March 17, 2026. During a concurrent interview and record review on March 19, 2026, at 8:15 AM, with the DON, and Chief Executive Officer/Administrator (CEO), the facility's policy and procedure (P&P) titled, Wound Care Management Pressure Wounds, dated January 26, 2026, was reviewed. The P&P indicated, .A. Comprehensive initial assessment of skin and reassessment, both initial and ongoing.Each wound/pressure injury will be addressed in the medical record in the shift assessment each shift.Treatment: 5. Initiate appropriate care plan. The DON acknowledged the policy and stated it had not been followed. The DON stated her expectation is for nurses to follow physician orders for treatments. The CEO stated, it is the nurse's responsibility to update information and to follow the policy. 2. During a review of Resident 10's face sheet (clinical record with demographic information), undated, the face sheet indicated, Resident 10 was admitted on [DATE], with diagnosis that included hypotension (low blood pressure). During a concurrent observation and interview on March 17, 2026, at 9:50 AM, in Resident 10's room, with Wound Care Nurse (WCN), Resident 10 is lying in bed on his left side. Resident 10 had an indwelling catheter (a rubber tube that is inserted into the bladder to drain the urine) and a colostomy (a surgical procedure that creates a new opening for waste (poop) to leave the body) attached to colostomy bag (waterproof, and odor-proof pouch used to collect stool (poop) from the body). Wound is located at left ischium. WCN measured the wound 1.4 cm (centimeter) x 0.8 cm, stage 2. During a review of Resident 10's clinical record titled, Orders, dated January 5, 2026, at 12:46 PM, the Orders indicated, .Pressure ulcer (injuries to the skin and underlying tissue caused by prolonged pressure), Left ischial tuberosity (lower, rounded part of the pelvis that supports body weight when sitting), (injuries to the skin and underlying tissue caused by prolonged pressure) Left, Daily, reoccurring stage 2 (partial-thickness skin loss involving the epidermis and/or dermis) pressure injury cleanse with wound cleanser apply skin prep to peri wound skin [Brand] to wound bed cover with boarder foam dressing daily and PRN . During a concurrent record review and interview on March 18, 2026, at 1:20 PM, with the Assistant DON (ADON), Resident 10's clinical record, Flowsheet Print Request for wound treatment, dated January 1, 2026, through January 31, 2026, and March 1, 2026, through March 17, 2026, were reviewed. The Flowsheet Print Request for wound treatment indicated the treatment was not completed as follows: On January 8, 2026, through January 10, 2026 On January 13, 2026, through January 17, 2026 On January 28, 2026, through January 30, 2026 On March 5, 2026, through March 7, 2026 On March 13, 2026, through March 15, 2026 The ADON verified and confirmed that the wound treatment was not completed daily as ordered. During a concurrent interview and record review on March 19, 2026, at 3:25 PM, with the DON, the facility's P&P titled, Wound Care Management Pressure Wounds, dated September 27, 2019, was reviewed. The P&P indicated .Purpose: C. Effective plan of care for patients with existing skin problems/pressure injuries to ensure optimal healing. Procedure: 7. Patients found to have existing pressure ulcers/wounds will have a treatment implemented. 9. C. Implementing skin integrity program. The DON stated the policy was not followed and that the expectation is to perform wound care daily and as needed per physician's order.

Based on interview and record review, the facility failed to act on recommendations made by the pharmacist for one of two sampled residents. (Resident 2). This failure had the potential for unnecessary medication to cause harm to Resident 2. Findings: During a record review of Resident 2's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure, a chronic condition where the force of blood against artery walls is consistently too high), and dementia ( a general term for a decline in mental ability-such as memory, thinking, or behavior-severe enough to interfere with daily life). During a record review of Resident 2's physician's order, dated on July 17, 2025, the physician's orders indicated, seroquel (medication-treat mood and behavioral disorder) 25 mg (milligram- unit of measurement) = 1 tab (tablet), Oral (by mouth) BID (twice a day), start date July 17, 2025, 21:00 [9:00 PM], stop date August 15, 2026. During a concurrent interview and record review on March 19, 2026, at 11:25 AM, with the Director of Nursing (DON), the facility's document titled, Consultant Pharmacist Medication Regimen Review (MMR), dated November 1, 2025, and November 13, 2025, were reviewed. The MMR indicated .Current CMS [Centers for Medicare and Medicaid Services] guidelines appear to require an attempted dose reduction on psychoactive [prescription drug that can control mood and behavior] medications unless it can be shown that previous reductions have been unsuccessful. This resident is currently receiving Seroquel 25 mg Bid. If the drug is to continue, regulations require the reasoning why a reduction is not appropriate. Would a trial of a dose reduction be appropriate for this resident? If a reduction is not warranted, please document below or in the progress notes why a reduction is not appropriate to keep the center in compliance with regulations. The DON acknowledged the recommendation and stated that the physician did not respond to the recommendation. The DON further stated it is very difficult to have the physicians document a sign to acknowledge to pharmacy recommendation. During a concurrent interview and record review on March 19, 2026, at 3:08 PM, with the DON, the facility's policy and procedures (P&P) titled, Medication Regimen Review, dated November 21, 2017, was reviewed. The P&P indicated, Procedure: C. In the event that no action is taken by the physician it is requested that he or she document his or her rational in the resident's medical record, such as a progress note. The DON stated that the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure that oxygen therapy was administered in accordance with physician's order for three of six residents (Resident 92, Resident 90 and Resident 30) while receiving oxygen. This failure had the potential for placing Resident 30, Resident 92 and Resident 25 at risk for inappropriate treatment and altered oxygen saturation (how well oxygen is being delivered to the body) levels.Findings: 1. During a review of Resident 92 face sheet (clinical record with demographic information), undated, the face sheet indicated, Resident 92 was admitted on [DATE], with diagnosis that included Bilateral (both) Humerus (arm bone) Fracture (broken). During an observation on March 16, 2026, at 12:08 PM, in Resident 92's room, Resident 92 is in bed sitting with oxygen (O2) at 2 liters per minute (L/min-unit of flow rate) via nasal cannula (tube that contains two open prongs intended to deliver oxygen into the nose). During a concurrent interview and record review on March 19, 2026, at 2:33 PM, with the Assistant Director of Nursing (ADON), Resident's 92 History and Physical (document by a physician to evaluate resident's health status), dated February 20, 2026, and current medication orders, undated, were reviewed. There is no indication that oxygen therapy was ordered by the physician. The ADON confirmed and stated that the order was missing and Resident 92 should have order for oxygen therapy before administering. 2. During a review of Resident 90 face sheet, undated, the face sheet indicated, Resident 90 was admitted on [DATE], with diagnosis that included sepsis (life-threatening immune response to infection). During an observation on March 16, 2026, at 12:20 PM, in Resident 90's room, Resident 90 is sitting on his bed resting with O2 at 2 L/min via nasal cannula. During a concurrent interview and record review on March 19, 2026, at 3:48 PM, with the ADON, Resident 90's History and Physical, dated November 2, 2025, and current medication orders, undated, were reviewed. There is no indication that oxygen therapy was ordered by the physician The ADON confirmed and stated that the order was missing and Resident 90 should have an order for oxygen therapy before administering. 3. During a review of Resident 30 face sheet, undated, the face sheet indicated, Resident 30 was admitted on [DATE], with diagnosis that included chronic obstructive pulmonary disease (COPD-damage to the lungs). During an observation on March 16, 2026, at 2:52 PM, in Resident 30's room, Resident 30 is sitting on the edge of his bed resting, with O2 at 2 L/min via nasal cannula. During a concurrent interview and record review on March 19, 2026, at 3:00 PM, with the ADON, Resident's 30 History and Physical, dated January 31, 2026, and current medication orders, undated, were reviewed. There is no indication that oxygen therapy was ordered by the physician. The ADON confirmed and stated that the order was missing and Resident 30 should have an order for oxygen therapy before administering. During a concurrent interview and record review on March 19, 2026, at 3:15 PM, with the ADON, the facility's policy and procedure (P&P) titled, DES SNF [Skilled Nursing Facility] - OXYGEN ADMINISTRATION, dated February 16, 2023, was reviewed. The P&P indicated, III. POLICY: .It is the policy of the SNF to: .A. Administer oxygen in accordance with the physician's orders to assist the patient in maintaining adequate oxygenation. The ADON stated the policy was not followed and that before administering oxygen therapy there should be a physician's order for every resident that needs oxygen.

Based on observation, interview, and record review, the facility did not ensure medications were administered in accordance with physician orders for one of 23 sampled residents (Resident 67), when Resident 67 received an antibiotic (medication that treats bacterial infections) intravenous (IV - administered through the vein) at an incorrect rate. This failure resulted in medication error and had the potential to result in ineffective treatment and adverse clinical outcomes such as antibiotic resistance (a condition that bacteria have evolved and difficult to kill).Findings: During a record review of Resident 67's admission History & [and] Physical (H&P-document by a physician to evaluate resident's health status), dated September 10, 2025, the H&P indicated, Resident 67 was admitted to the facility on [DATE], with diagnoses including heart failure (heart cannot pump well enough to meet the body's needs), quadriplegia (paralysis of all four limbs-both arms and legs), and recurrent urinary tract infection (UTI- infection in the urinary system). During a concurrent observation and interview on March 16, 2026, at 12:29 PM, with Resident 67, in Resident 67's room, an IV antibiotic medication bag was programmed at the infusion pump (medical device that is program to deliver IV to resident) running at 20 milliliters per hours (ml/hr-dosing rate of medication). The antibiotic bag indicated, Vancomycin [strong antibiotic used to treat serious bacterial infections] 1,000 milligram [MG-unit of medication], injection, IV piggyback [way to give medication through an IV line, where a small bag of medicine is connected to a main IV line], Q12H [every 12 hours], indication: bone/joint infection, infuse over 60 min [minutes], run at 175 ml/hr. Resident 67 stated, the bag was hung by a registered nurse (RN) at approximately 9:00 AM, then the Assistant Director of Nursing (ADON) came to reprogram the pump when it alarm at around 10:00 AM. During a concurrent observation and interview on March 16, 2026, at 12:40 PM, with the ADON, in Resident 67's room, the IV infusion pump was observed. The ADON confirmed the current rate was set at 20 ml/hr, but the order on the medication bag label indicated running the medication at 175 ml/hr. The ADON confirmed the medication was not running at the correct rate. During a record review of Resident 67's Orders, dated March 15, 2026, the Orders indicated, Resident 67 was ordered Vancomycin 1,000 MG, injection, IV piggyback, Q12H.indication: bone/joint infection, infuse over 60 mins. A review of Resident 67's Medication Administration Record (MAR) Summary, dated from March 15, 2026, through March 17, 2026, indicated, Vancomycin 1,000MG, injection, IV piggyback, Q12H.indication: bone/joint infection, infuse over 60 mins. was administered on March 16, 2026, at 9:00 AM. This indicate that the medication was left infusing for more than three and a half hours (from 9:00 AM to 12:40 PM). During a concurrent interview and record review on March 19, 2026, at 10:55 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, CCC Medication Administration, dated January 2026, was reviewed. The P&P indicated, .(b) Medications shall be administered as ordered . The DON stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure the facility staff reviewed and updated care plan (an individualize plan that is create based on each resident's need) and interdisciplinary team (IDT-a meeting where different professionals come together to discuss a patient's care need) regarding pressure injury (PI-injury to skin and underlying tissues that develop because of prolonged pressure, shear, or friction) for one of two sampled residents (Resident 8). This failure had the potential to contribute to worsening of Resident 8's wounds or skin condition from not reviewing intervention and evaluating the effectiveness of the treatment plan.Findings: During a record review of Resident 8's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses which included, hypertension (high blood pressure, a chronic condition where the force of blood against artery walls is consistently too high), and cerebral palsy (a group of permanent neurological disorders appearing in infancy or early childhood that affect movement, muscle tone, and posture). During a concurrent observation and interview on March 16, 2026, at 10:40 AM, in Resident 8's room, Resident 8 was alert, lying on bed. Resident 8 stated, he has wounds in his back and pointed to his thigh. Resident 8 further stated, sometimes nurses do treatments but are not done every day. During a record review of Resident 8's Nursing Narrative, dated June 30, 2025, the Nursing Narrative indicated, .right ischium (one of the bones forming the pelvis. It is commonly referred to as the sitting bone because it supports the weight of the body when seated) unstageable [a pressure injury where skin and tissue loss is to the extent of damage and obscured by slough (fat that looks yellow) or eschar (dead tissue that look black) tissue] pressure injury wound. During a record review of Resident 8's physician's orders, dated July 22, 2025, the physician's orders indicated, Wound Care TAR, ischial, daily, PRN (as needed), cleanse with wound cleanser scrubbing lightly to remove slough, apply skin prep to peri wound skin nickel thick santyl (a prescription medication used in wound care to remove dead tissue from wounds, facilitating the healing process) to wound bed cover with foam followed by border foam dressing. During a concurrent interview and record review on March 18, 2026, at 10:00 AM, with the Assistant Director of Nursing (ADON), Resident 8's Comprehensive Care Plan Long Term Care (LTC), undated, was reviewed. There was no documented evidence that the care plan was updated for PI. The ADON verified and confirmed the care plan was not updated. During a concurrent interview and record review on March 18, 2026, at 11:08 AM, with the Director of Nursing (DON), Resident 8's Comprehensive Care Plan LTC, undated, was reviewed. There was no evidence of IDT meeting and care plan. The DON stated the care plan has not been updated and there was no IDT meeting regarding PI. The DON further stated, the nurses should have reassessed the skin and documented. The DON stated, It should have been done. During a concurrent interview and record review on March 19, 2026, at 8:15 AM, with the DON, and Chief Executive Officer/Administrator (CEO) the facility's policy and procedure (P&P) titled, Wound Care Management Pressure Wounds, dated January 26, 2026, was reviewed. The P&P indicated, .A. Comprehensive initial assessment of skin and reassessment, both initial and ongoing.Each wound/pressure injury will be addressed in the medical record in the shift assessment each shift.Treatment: 5. Initiate appropriate care plan. The DON acknowledged the policy and stated it had not been followed. The CEO stated, it is the nurse's responsibility to update information and to follow the policy.

Based on interview and record review, the facility failed to investigate and monitor the use of illegal substances (drug or chemical that the government has made against the law to have, use, or sell) for one of three sampled residents (Resident 1), when Resident 1 tested positive for marijuana (most common name of the cannabis plant, widely used either for its mind-altering effect or for medical purposes). This failure had the potential to pose a safety hazard to Resident 1 and other residents in the facility.Findings: During a review of Resident 1's face sheet (which contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included paraplegia (paralysis of the lower half of the body), and multiple sclerosis (a condition where the body mistakenly attacks the nerves, making it harder for the brain to send messages to the rest of the body). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated January 12, 2026, under Section C, it indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool to assess a resident's cognition) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During a review of Resident 1's Nurse's Note, dated December 22, 2025, it indicated, Resident was acting impaired after coming in from smoking, new order for UA (Urine Analysis tests that looks at the appearance of urine and checks for other substances in it.) from [Name of doctor] for drug screen may straight cath [straight catheter or in-and-out catheter]. During a review of Resident 1's doctor's order, dated December 22, 2025, it indicated, Urinalysis with Microscopic Examination if Indicated (UA with Microscopic if Indicated) Urine, Straight cath, Routine collect, Nurse collect, Collection Date 12/22/2025 (December 22, 2025) . Drug screen [a test to check if someone has drugs in their body]. During a review of Resident 1's laboratory results, dated December 22, 2025, it indicated Resident 1 was positive for cannabis (marijuana). During an interview on March 11, 2026, at 11:10AM, with Resident 1, Resident 1 stated she occasionally uses marijuana, which was not prescribed to her. She stated she used to smoke marijuana in the designated smoking area. She further stated that the facility and the staff were not aware of her use of marijuana. During a concurrent telephone interview and record review on March 16, 2026, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure, titled Corporate Policy, dated June 19, 2023, which indicated, .Ill. Definitions: Illegal Substance: Any illegally possessed controlled substance, drug (e.g., marijuana, cocaine, heroin, etc.), drug paraphernalia or unprescribed drugs for which prescriptions are required.B. Investigation 1. The use of Illegal Substances by patients presents a significant threat to the patients' welfare and places the Facility in a position that may result in potential liability. Therefore, the initial investigation should focus on identifying the person responsible for bringing the suspect item into the Facility and whether a patient used or had access to the item. The DON stated they did not investigate to see if there were any illegal substances in Resident 1's room, and according to policy, an investigation should have been done since the resident's drug test came back positive. She acknowledged that conducting the investigation was important because Resident 1 uses an electric wheelchair and could be a safety hazard to herself and others if she was under the influence.

Based on observation, interview, and record review, the facility failed to protect two of three sampled residents (Resident 1 and 3) from verbal abuse (suing negative words and language that cause harm) from Registered Nurse (RN 1). This failure had the potential to contribute to Resident 1 and 3 distrust in the healthcare team which could negatively affect Resident 1 and 3 participating in their care that could lead to actual harm and worsen their condition.Findings: During a review of Resident 1's History and Physical (H&P), dated July 15, 2025, the H&P indicated that Resident 1 was admitted with a diagnosis of multiple sclerosis (a disease that causes breakdown of the protective covering of nerves which can cause numbness, weakness, pain, trouble walking, weakness, vision changes, fatigue, mood changes and other symptoms). During a review of Resident 1's Brief Interview Mental Status (BIMS - test used in nursing homes and hospitals to measure a person's memory and thinking skills where a score of 13 to 15 is considered normal), dated January 24, 2026, the BIMS indicated that his score was 15. During a review of Resident 3's H&P, dated May 14, 2025, the H&P indicated that Resident 3 was admitted after acute hospitalization for an accident-causing bone fractures with anticipated extended healing process. During a review of Resident 3's BIMS, dated November 21, 2025, the BIMS indicated that his score was 15. During an interview on March 3, 2026, at 2:48 PM, with Resident 2, Resident 2 stated RN 1 was yelling at Resident 1 and RN 1 said she did not have to deal with administering medication to Resident 1 right now and she was already late. Resident 2 stated RN 1 was aggressive and yelled. Resident 2 stated Resident 1 was upset and angry and Resident 2 went to Resident 1's room and calmed him down. During an interview on March 3, 2026, at 2:54 PM, Resident 1 stated when he asked RN 1 about the timeliness of his medications, she [RN 1] started freaking out and yelling. Resident 1 stated he withdrew from the area and I could hear her [RN 1] bad mouthing me or it was toward someone else .I couldn't hear exactly what she [RN 1] was saying in the hall. Resident 1 further stated I blocked it out and put on my headphones, and it made him feel like shit, like I wanted to kill somebody. Resident 1 stated it made him feel crazy and anxious because he needed his mediation for his chronic pain due to trigeminal neuralgia (a chronic pain disorder that involves sudden attacks of severe facial pain affecting the trigeminal nerve). During a concurrent observation and interview on March 3, 2026, at 3:10 PM, with Resident 3, Resident 3 stated he overhead Resident 1 got upset when his medications were not on time and when Resident 1 asked RN 1 about the timing of his medication for his pain, RN 1 then started yelling at Resident 1. Resident 3 stated RN 1 was very unprofessional and disrespectful. Resident 3 stated he could not hear what RN 1 was saying but emphasized that he could hear RN 1 yelling when he is four doors down from Resident 1's room. Resident 3 stated he expressed anxiety about having any potential interactions with RN 1 after she was yelling at Resident 1. Resident 3's room is approximately 40 feet from Resident 1's room. During an interview on March 3, 2026, at 3:25 PM, with Social Services (SS), SS stated she met with Resident 1, 2 and 3 after the incident of alleged verbal abuse. SS stated Resident 1, 2, and 3 reported that RN 1 tone may have been loud toward residents and RN 1 may not have been able to maintain her composer in the stressful situation. SS stated that from the report, RN 1 was inappropriate and failed to maintain her composure by being loud talking and dismissive to Resident 1. During an interview on March 3, 2026, at 3:55 PM, with the Director of Nursing (DON), the DON stated the staff who reported the incident were Certified Nursing Assistants, CNA 1 and CNA 2. The DON stated she felt that this was verbal abuse from the yelling that could be heard down the hallway. During an interview on March 4, 2026, at 9:19 AM, with CNA 1, CNA 1 stated that Resident 3 reported to her that he could hear RN 1 yelling at Resident 1 about medication he asked about. CNA 1 stated, Resident 3 was not happy to hear the yelling from RN1 towards Resident 1. During an interview on March 4, 2026, at 9:36 AM, with CNA 2, CNA 2 stated that Resident 3 reported RN 1 was irritated and was yelling at Resident 1. CNA 2 stated that before the incident, she had heard RN 1 talk a little loud toward others. During a review of the facility's policy and procedure (P&P) titled, Resident abuse, neglect prevention, investigation and reporting, dated October, 18, 2021, the P&P indicated, Definition: Verbal abuse: Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Additionally, this includes making any statement which causes the resident to be degraded, embarrassed or otherwise attacks the resident's right to be treated with dignity including using foul language towards a resident or using a tone of voice towards the resident that causes him/her to be frightened and/or feel threatened. The tone of the voice, not the content of the message, may be considered to be abusive.Behavioral Indicators from the Victim: .Fear.Depression, Helplessness, Resignation.Withdrawal.Anger.Agitation, anxiety.

Based on interview, and record review, the facility failed to report an allegation of abuse within 24 hours for one of three sampled residents (Resident 1). This failure prevented the appropriate state agencies from ensuring that the facility was taking the necessary actions to protect Resident 1 and other residents from actual or potential harm.Findings: During of a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341, in California, it is a confidential form used to report suspected abuse or neglect of seniors or dependent adults. Mandated reporters must submit this form to local authorities within two working days of witnessing or suspecting harm), dated January 21, 2026, the SOC 341 indicated the allegation of Psychological/Mental (mind, emotion, and behavior) abuse toward Resident 1 was identified on January 13, 2026, and was reported to the Ombudsman (a state-certified advocate dedicated to protecting the rights, safety, and quality of life of the residents) and the California Department of Public Health (CDPH) on January 21, 2026 (8 days after the incident). During an interview on January 30, 2026, at 2:30 PM, with the Director of Nursing (DON), the DON stated, I was out of town, and the Dietary Supervisor wrote it [Report] as a Grievance and handed it to [the Social Worker (SW)], who placed it in my mailbox. On (January 21, 2026), I read the Grievance and realized it should have been reported as an allegation of abuse and promptly filed an SOC 341 on (January 21, 2026). The DON further stated, there was a delay in reporting. The DON stated the negative outcome for the delay in reporting may not protect Resident 1 and other residents from the potential harm. The DON further stated that the expectation is that all mandated reporters (All employees of a long-term care facility, including support, security, and maintenance staff, regardless of whether they are paid or unpaid) report any allegation of abuse. During a concurrent interview and record review on January 30, 2026, at 2:30 PM, with the DON, the facility's policy and procedure (P&P) titled, Resident Abuse, Neglect Prevention, Investigation and reporting, dated October 18, 2021, was reviewed. The P&P indicated, PURPOSE: To outline the facility and staff's responsibility to establish and maintain a safe environment for our residents. In pursuant to federal and state law, abuse in all of its forms is prohibited .C. Investigate and Report any such allegation of abuse and reasonable suspicion of crime pursuant to all Federal, State, and local laws to the appropriate authorities S483.12(b)(2) .IN THE EVENT OF AN INCIDENT OR ALLEGATION OF ABUSE: Staff member's responsibility: .E. Reporting is the individual responsible of the mandated reporter. No one may prohibit the filing of a required report .Charge Nurse or Supervisor Responsibility: .F. Notify the Skilled Nursing Facility Director of Nursing immediately. If unable to reach or if after hours, notify the House Supervisor and Hospital Administrator on call .E. All allegations of abuse that result in serious bodily injury are reported immediately, but no later than 2 hours after the allegation is made to the administrator of the facility, the State Survey Agency (COPH) and the ombudsman in accordance with State law through established procedures. F. All allegations of abuse that DO NOT result in serious bodily injury are reported within 24 hours to the administrator of the facility, the State Survey Agency (CDPH) and the Ombudsman in accordance with State law through established procedures. S483.12(c)(1), Sec. 11508. [42 U.S.C. 1320b-25] (b)(2). The DON stated the P&P was not followed because as mandated reporters, the individual must report any observation, knowledge of or reasonably suspected abuse to the Ombudsman and CDPH within 24 hours.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received enteral nutrition (tube feeding - a delivery of liquid nutrition directly into the stomach through a percutaneous endoscopic gastrostomy (PEG - a feeding tube that is place through the stomach used for a person who cannot eat or swallow safely)) according to the physician's order, when Resident 1 did not receive the calculated amount of feeding for approximately two days. This failure had the potential to compromise Resident 1's nutritional status placing him at risk for weight loss, dehydration, and decline in condition.Findings: During a review of Resident 1's Face Sheet (FS- a document containing patient demographics) the FS indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Patient 1's History and Physical (H&P- a document containing demographic information), dated January 15, 2026, at 5:18 PM, the H&P indicated, Patient 1 was admitted to the facility with a tracheostomy (a surgically created opening in the neck where a tube is placed to help a person breathe) and PEG tube for further management and support. Patient 1 had a history of hypertension (high blood pressure), hyperlipidemia (a high amount of fat in the blood), multiple cerebral infarctions (blood flow to part of the brain is blocked, causing brain tissue to die from lack of oxygen). A review of Resident 1's Section B [hearing vision, speech] of the Minimum Data Set (MDS- A detailed checklist nursing facilities use to determine a resident's ability of moving around, memory, and medical problems) indicated, B0100 COMATOSE. Persistent vegetative state/ no discernible consciousness. yes. A review of Resident 1's Orders dated January 19, 2026, indicated, Tube Feeding continuous. [name of tube feeding] .Rate [how much to give] . 60 ml [milliliter-unit of measurement] / hr [hour].route [the way something goes into the body] .PEG tube. During an interview on January 29, 2026, at 1:39 PM, with Registered Nurse (RN 1), RN 1 stated, the Licensed Vocational Nurses or the Registered Nurses in charge of a resident can manage the tube feeding. RN 1 added, the tube feeding should be checked by the nursing staff at the start of the shift to ensure that it is being administered as ordered, during the shut off time (3:00 PM to 5:00 PM for day shift and 3:00 AM to 5:00 AM for night shift), and at the end of the shift, to be able to document the resident intake (amount of feeding the patient received). During an interview on January 29, 2026, at 1:48 PM, with the Clinical Coordinator (CC), the CC stated, tube feedings are monitored across the unit by doing rounds that consist of checking the right tube feeding, ensure it is labeled correctly, and that it is infusing (going into the body). The CC further stated the feeding and water is changed every 24 hours for infection control reasons. The CC stated if an issue is noticed with the pump used to infused the tube feeding, the nursing staff should stop the feeding immediately, label the pump, notify the interdisciplinary team (IDT- a group of health professionals who work together to manage a residents care which includes physician, nursing, social services, dietary), and seek further instruction. During an interview on January 29, 2026, at 2:34 PM, with the Registered Dietician (RD), the RD stated that on January 21, 2026, there was a care plan meeting set with Resident 1's daughter regarding a concern about a full tube feeding bottle was hanging at Resident 1's bedside dated January 19, 2026 and Resident 1 did not received tube feeding as physician's order. The RD verified with Resident 1's daughter and it was changed by the nursing staff. The RD stated an incident report was created at this time. A review of Resident 1's Current weights, dated January 14, 2026, through January 25, 2026, were reviewed as follows:January 14, 2026, Current weight: 87.2 kg [kilogram- unit of measurement]January 18, 2026, Current weight: 87.2 kgJanuary 25, 2026, Current weight: 85.4 kg (loss of 1.8 kg) During an interview on January 29, 2026, at 3:17 PM, with the Director of Nursing (DON), the DON stated, when the incomplete tube feeding was identified, the nurse notified the physician, and the decision was made to continue feeding at the same rate. During a concurrent interview and record review on January 29, 2026, at 4:35 PM, with RN 1, the Nursing narrative [NN], dated January 21, 2026, and January 22, 2026, were reviewed. The NN dated January 21, 2026, indicated .upon reconnecting the patient to their enteral feeding it was noted that only water was running through the system. upon inspecting the pump further it appeared was continually only flushing with water. A new bottle of [name of tube feeding] was hung and the pump was reset completely. The NN dated January 22, 2026, indicated . notified physician that the resident's tube feeding was not administered to resident for 48 hours, that only water was being infused via g-tube [PEG] for 48 hours. RN 1 stated, the nursing staff should have checked on the feeding to ensure that it was being administered. RN 1 stated it is important because nutrition is number 1, it can cause the blood sugar to go down, weight loss, and the residents should receive the nutrition they need. During a concurrent interview and record review on January 29, 2026, at 5:02 PM, with the DON, the facility's policy and procedure (P&P) titled, Guidelines for Management of Enteral and Parenteral Nutrition, dated September 19, 2016, was reviewed. The Guidelines for Management of Enteral and Parenteral Nutrition, dated September 19, 2016, indicated .Guidelines.initiate enteral formula (recommended by nutrition support specialist) at full strength at goal rate if no GI [gastrointestinal- related to the stomach and intestines] compromise. The DON stated that the policy was not followed and should have been because it is important to meet each resident's nutritional needs.

Based on interviews, Record Review and observation, the facility failed to follow policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress.This failure had the potential to compromise the residents' health, safety, psychosocial wellbeing and overall quality of care, when the resident was left soiled, and their activities of daily living were not met in a timely manner. Based on interviews, Record Review and observation, the facility failed to follow its policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress.This failure had the potential to compromise the residents' health, safety, psychosocial wellbeing and overall quality of care, when the resident was left soiled, and their activities of daily living were not met in a timely manner.FINDINGS:During a record review of Resident's 1's admission record (general Demographics), the document indicated the resident was admitted to the facility on [DATE], with a diagnosis to include blunt abdominal trauma (an injury to the abdomen caused by a forceful impact, fall, or attack with a dull object, rather than a sharp object) non-displaced C-5 and C-7 fractures (a nondisplaced C5 and C7 fracture means that there is a break in the fifth and seventh vertebrae of the neck, but the bones have not moved out of their normal position, anxiety (Anxiety is a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat) right upper arm partial thrombus (a blood clot, called a thrombus, that forms in a blood vessel but does not completely block it; instead, it only partially obstructs blood flow), (and tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an airway for breathing). During an interview with the Director of Nursing (DON), she stated the incident regarding Registered Nurse 1 (RN) not helping the resident at the time she needed help. She stated there was no reason why he did not help her or at the very least tell a Certified nursing assistant (CNA) that the resident needed help. During a Record Review of the 5-day F/U (follow up) investigation on September 4, 2025, conducted by the Chief Nursing Officer (CNO) of the Hospital, it indicated Registered Nurse 1, interviewed regarding allegation of abuse. He stated that he remembers the incident, the unit was short staffed. He remembers the patient waving her hand at him and he remembers the call light being on and thinking that it was the patient in the other bed who is not his patient. He said that when he realized it was Resident 1, he asked her what she needed, and she did not speak clearly so he asked her to write it down. Resident 1 did not write it down, so he went on about his business until the Respiratory Therapist told him Resident 1 needed to be changed. It also indicated that on September 5, 2025 Decision to bring Registered Nurse 1(RN) back to work. He did fail to follow up on a patient call light. Leave without pay will stand due to failure to respond in a timely manner to patient needs. Final written warning to be issued. No other issues on file for the staff member. Education regarding expectations for patient responsiveness and call light response given. During a review of the facility's policy and procedure titled, Resident abuse, neglect prevention, investigation and reporting, Revised June 16, 2021, it indicated The resident has the right to, AH). Be provided good personal hygiene and be given care to prevent bedsores, and measures shall be used to prevent and reduce incontinence for each patient. HSC S1599.1(b).

Based on interview, and record review, the facility failed in response to safety concerns with suspected abuse for one of three sampled Residents (Resident 1) when the facility reported the suspected abuse to the California Department of Public Health (CDPH) on August 20, 2025, or five (5) days after the suspected abuse incident. This failure had the potential to result in a delay of an investigation to determine abuse which could continue or become more severe, other vulnerable Residents to be put at risk for abuse, worsen long-term psychological and physical effects, delay timely access to medical, psychological, and other services for healing for Resident 1.Findings: During a review of the facility's SOC 341 (California form used by specific people, called mandated reporters, to report suspected abuse or neglect of elders and dependent adults), dated August 20, 2025, at 1:00 PM, the SOC 341 indicated that Licensed Vocation Nurse (LVN2) reported on Friday (August 15, 2025, at 1:00 PM), (Visitor) friend of Resident 3 entered room [ROOM NUMBER] and was observed touching (Resident 1) . without her consent. (LVN2) instructed (Visitor) ‘not to touch (Resident1), or her meal tray'.(Visitor) was instructed to leave and he refused. CNA1 (Certified Nursing Assistant) reported witnessing him eating food from (Resident 1's) tray. Staff instructed (Visitor) to leave and he refused. Staff concerned for safety. (Visitors) presence in resident rooms interferes with care, disrupts residents and impedes (licensed nursing) ability to perform duties as a nurse. During a review of Resident 1's admission History and Physical (H&P), dated March 25, 2025, the H&P indicated Resident 1 had medical history of diabetes (a chronic condition that affects how the body uses sugar [glucose] which will make the blood sugar levels high), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to perform activities of daily living), chronic obstructive pulmonary disease (COPD - lung and airway diseases that restrict your breathing), and hypertension (HTN - the force of blood flowing through your blood vessels continues to be too high over time). During a review of Resident 1's nursing note, dated August 16, 2025, at 5:28 PM, the nursing note indicated, Resident 3 had a visitor who entered the room and woke up Resident 1.(LVN2) instructed (the visitor) not to touch V or (Resident1) meal tray. (The Visitor) responded by stating that (LVN2) did not know what (LVN2) was talking about and claimed (Resident1) was pretending to be asleep. (LVN2) explained that (Visitor) is not an employee and should not be entering resident rooms or disturbing other residents. I directed (the Visitor) to leave at that time. However.there was limited support, and (the Visitor) did not leave. Another CNA later reported witnessing (Visitor) eating food from (Resident1's) tray. I told (Visitor) he needed to leave that he was not to wake up or disturb other residents. (The Visitor) did not leave and there was a concern for (LVN2's) safety as we do not have security up here. When this visitor is seated in the dining room with (Resident3), there are no issues. However, his presence in resident rooms interferes with care, disrupts residents, and impedes my ability to perform my duties as a nurse. During a review of CNA1's statement, dated August 20, 2025, the CNA1's statement indicated, On 8/15 [August 15] I observed a pts visitor, [Resident 1] shares room with pt, visitor approached while [Resident 1] sitting on her bed, attempting to eat off of [Resident 1] plate, visitor touched [Resident 1] hand, this writer made (LVN2) aware, visitor was asked to leave room. During an interview on August 25, 2025, at 11:32 AM, with the Director of Nursing (DON), the DON stated, the visitor placed his hand on Resident 1's arm and he had been interfering with Resident 1's care. The DON stated from what the nurse told me [the visitor] was touching [Resident 1] by helping [Resident 1] get in and out of bed. feeding [Resident 1] and taking food off [Resident 1's] tray. [Resident 1] is a diabetic and [Resident 1] has Alzheimer's [a form of dementia] and unable to consent. [CNA1] gave a statement where she observed [the visitor] eating off [Resident 1's plate and touching [Resident 1's] hand and [the visitor] was asked to leave the room. The DON stated LVN2 tried to get the visitor to leave Resident 1's room on August 15, 2025, and he refused. The DON stated LVN2 was concerned about Resident 1's safety. The DON stated she was made aware of LVN2's nursing note that informed of the event on August 20, 2025 (five days after the incident). The DON stated that everybody was a mandated reporter and should report right away which did not occur. During an interview on August 25, 2025, at 1:44 PM, with LVN2, LVN2 stated she observed the visitor enter Resident 1's room accompanied by Resident 3 where she had line of sight and I saw [the visitor] lean over [Resident 1]'s bed to try to wake her up. And I don't know 100% if [the visitor] touched [Resident 1]. I said please don't wake her up. Then [the visitor] touched [Resident 1]'s meal tray and said to me he was trying to wake her up and help her eat. I told [the visitor] to please leave the room and he was asking why. I said [Resident 1] can't eat anything until blood sugar is checked and told him she needs to sleep and that's when he started (questioning me). I thought [the visitor] had left but he was back, and he apologized for questioning and the way that he spoke to me. I told my charge nurse that day and what happened, and [RN1] said I did the right thing . We went to [Resident 1] on August 20, 2025, to interview [Resident1]. She didn't remember any occurrence of that. LVN2 stated she was told by the DON on August 20, 2025, that she should have reported the incident and should have known. LVN2 confirmed that CDPH was not notified until August 20, 2025 (five days after the incident). During an interview on August 25, 2025, at 2:02 PM, with the DON, the DON stated, as far as reporting there was a delay of five days. The DON further stated, at the time of the event, RN1 and LVN2 should report the incident to the DON who was the abuse coordinator and reported it to the Administration at the hospital. The DON stated that she helped LVN1 filled out the SOC 341 on August 20, 2025. The DON stated she was notified by the MDS (The Minimum Data Set is a standardized assessment tool that measures health status in nursing home residents) nurse who found LVN2's nursing note, dated August 16, 2025, during record review for Resident 1's plan of care meeting. During concurrent interview and record review on August 29, 2025, at 3:30 PM, with the DON, the facility's policy and procedure (P&P) titled, RESIDENT ABUSE, NEGLECT PREVENTION, INVESTIGATION AND REPORTING, dated November 21, 2017, was reviewed. The P&P indicated, .IN THE EVENT OF AN INCIDENT OR ALLEGATION OF ABUSE: Staff Member's Responsibility: .E. Reporting is the individual responsibility of the mandated reporter. No one may prohibit the filing of a required report .Charge Nurse or Supervisor Responsibility: .F. All allegations of abuse that DO NOT result in serious bodily injury are reported within 24 hours to the administrator of the facility, the State Survey Agency (CDPH) and the ombudsman in accordance with State law through established procedures. The DON stated that this P&P was not followed.

Based on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1) received adequate fluid intake and nutrition, as ordered, to maintain their optimal hydration, nutrition, and well-being. This failure contributed in harm to Resident 1, when he was not provided his tube feeding from July 12 to July 15, 2021, as ordered by the physician upon readmission to the facility. This led to Resident 1's second hospitalization where he was diagnosed with indications of significant dehydration (Loss of over 10% of total body water causes mental and physical deterioration. Death occurs at a loss of 15-25% loss of body water) and electrolyte imbalance (Dehydration in older adults can lead to poorer cognitive performance, worsened course of illness and recovery, and a high number of unplanned hospital admissions and increased mortality). This failure further resulted in Resident 1's harm and the potential for Resident 1's death in the facility. Findings: During a review of the Admission Record (document containing a resident's demographic information) for Resident 1, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on July 26, 2022, at 4:10 PM, with the Clinical Quality Improvement/Risk Management (CQIRM) and the Registered Nurse/MDS Coordinator (MDS), the (CQIRM) and the (MDS) stated, there was no documented evidence of Resident 1 received his tube feedings from July 12, 2021 through July 15, 2021, prior to his admission to the Emergency Department (ED) and his subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and record review, on August 30, 2022, between 4:18 PM and 4:55 PM, with the Clinical Dietician (CD), Resident 1's Nutrition Assessment, dated July 13, 2021, was reviewed. The CD reviewed the documentation and indicated the following: - The CD stated Resident 1's water needs would have been assessed through an estimated needs calculation. The CD reviewed Resident 1's Nutrition Assessment, dated July 13, 2021, and stated Resident 1's calculated water needs were between 1,821 mL/day and 2,125 mL/day (mL - milliliters, a unit of measurement). - The CD stated he was not made aware of the possibility that Resident 1 was not fed, according to his tube feeding orders, for three days. The CD further stated he did review the I & O (Intake and Output - documentation that includes a resident's fluid gain and/or loss) documentation for residents, and when they were newly admitted , he would review this documentation weekly for at least the first four weeks. - The CD stated his update to Resident 1's tube feeding order - increasing the feeding volume from 30 mL/hour to 70 mL/hour - would have been based on his completed calculations for Resident 1's Nutrition Assessment, dated July 13, 2021. - The CD stated, beyond his weekly assessments of the residents, he would not be aware whether indicated residents were receiving their tube feedings or not, unless he was specifically notified, or he specifically sought this information. The CD stated he would recommend these types of notifications be implemented into practice at the facility. - The CD stated, beyond his scheduled assessment opportunities and documentation of a resident, he was not aware of the facility's system for monitoring a resident for dehydration, nor was he directly involved in monitoring residents for dehydration, outside of his scheduled assessments. - The CD stated he was not aware of any issues regarding Resident 1's tube feedings, as his interventions towards the resident's care would have been based upon the information available to him. During a continued interview and concurrent record review, on August 30, 2022, between 4:55 PM and 5:18 PM, with the CD, Resident 1's electronic I & O documentation, dated between July 12, 2021, and July 15, 2021, was reviewed. The CD reviewed the electronic health record (EHR) for Resident 1 and stated, there was no documented evidence of Resident 1 received his ordered tube feedings between July 12, 2021 and July 15, 2021. The CD further stated, if he had become aware of any disruption to Resident 1's tube feedings, he would have reported the disruption to the Director of Nursing. The CD was further asked about the expected outcomes for a resident like Resident 1 not receiving the ordered tube feedings for 3 days. The CD stated, 80 percent of the tube feedings are water, so the concern would be that the resident would become dehydrated, included with the lack of indicated free water flushes. During a review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, Tube Feeding Continuous, Formula: [MEDICATION(S)] 1.2, 30 mL /hr (per hour), Route: Gastronomy (PEG - Percutaneous Endoscopic Gastrostomy is a flexible feeding tube is placed through the abdominal wall and into stomach) tube, Free Water at 30 mL/hr, Continuous. During a review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Nutrition Assessment, dated July 13, 2021, the document indicated, the following for Resident 1: - Resident 1's assessment weight was 60.7 kg (133.8 pounds). - Resident 1 had a daily fluid need between 1,821 mL and 2,125 mL, and a daily energy need between 1,821 kCal and 2,125 kCal. The document further indicated, . Increased Nutrition Needs: Weight gain desired, Other: History of malnutrition related to poor PO (oral) intake and possible nutrient displacement (due to) significant alcohol intake . During a review of Resident 1's Nutrition Services Note, dated July 13, 2021, the document indicated, Dietary Note: Correction to Nutrition Assessment: Resident admitted with NPO (nothing by mouth) diet order . To fully meet estimated nutritional needs, change feeding to [MEDICATION(S)] 1.2 (at) 70 mL/hr and FW (free water) (at) 30 mL/hr continuous with pump via PEG to provide 1680 mL feeding, 2016 kcal, 95 gm protein, and 2076 mL water with feeding and flush . During a review of the ED (Emergency Department) documentation titled, Admission H&P EMR (Final Report) [H&P - History & Physical, EMR - Electronic Medical Records] for Resident 1, dated July 15, 2021, the documentation indicated a Chemistry Comprehensive (lab test used to check fluid and electrolyte balance in the body from a blood sample) laboratory analysis was collected and reported on July 15, 2021, at 11:50 AM. The Chemistry Comprehensive laboratory analysis for Resident 1 included the following: - Sodium Level: 167 mEq/L (mEq/L - milliequivalents per liter, a unit of measurement. Normal range: 135-145 mEq/L . This was indicated as abnormally high . A high sodium level can result from dehydration) - Potassium Level: 3.2 mEq/L (This was indicated as abnormally low. Normal range: 3.6.5.2 mEq/L . A low potassium level can result from dehydration) - Chloride Level: 129 mEq/L (Normal range: 96-106 mEq/L. This was indicated as abnormally high. A high chloride level can result from dehydration) - BUN (Blood Urea Nitrogen - the amount of waste product in the blood) Level: 19 (This was indicated as abnormally high. A high BUN level can result from dehydration) - BUN/Creatinine (Ratio of BUN to creatinine - can reveal conditions that cause a decrease of blood flow to the kidneys, including dehydration): 24 (Normal range between 10:1- 20: 1. 24:1 - this was indicated as abnormally high. A high BUN/Creatinine ratio can result from dehydration). During a further review of the ED documentation titled, Admission H&P EMR (Final Report) for Resident 1, dated July 15, 2021, the document indicated the following: - Resident 1 was brought to the facility's associated Emergency Department (ED) by ambulance, due to ALOC (Altered Level of Consciousness) worsening for two days since pt (patient) arrived back from [General Acute Care Hospital] where he was transferred for GI bleed. - Resident 1's History of Present Illness indicated, Resident 1 . presented to the emergency department with chief complaint of being found down at skilled nursing facility . Patient will be admitted to the intensive care unit for further management. - Resident 1 was unresponsive upon arrival to the ED and required intubation (tube inserted into the patient, to establish and maintain a patent airway for breathing/ventilation). - Resident 1 had a documented blood pressure (BP) measurement of (64/44 mm Hg) (mm Hg - millimeters of mercury - unit of measurement) at 8:18 AM, on the same day of his transfer to the ED. A BP measurement of (64/44 mm Hg) is significantly lower than a normal BP measurement of (120/80 mm Hg). - Resident 1's Assessment/Plan indicated, among other conditions, Resident 1 was experiencing hypovolemia (liquid/water portion of the blood is too low), [CONDITION(S)] (Sodium in the blood is too high) with required IV (Intravenous - administration route entering the veins of the body) fluid resuscitation (rapid replacement of lost body fluids) and had a Free water deficit (the amount of water a person has lost) of 7.1 Liters (a unit of liquid measurement). During a review of the facility's nursing documentation titled, Progress Notes: Admission Summary for Resident 1, dated July 12, 2021, at 7:00 PM, the Progress Notes: Admission Summary indicated, . returned from [Initials of General Acute Care Hospital] with dx (diagnosis) of GI (Gastrointestinal) Bleed . Resident is now NPO (Nothing to be given by mouth) and has new orders for PEG tube (artificial feeding tube in the abdominal wall that connects to stomach) feeding (artificial nutrition provided through the feeding tube). Alert and oriented time 1 with confusion . New PEG tube placed on 07/12/21 . During a review of the nursing documentation titled, Rx (Prescription/Treatment) Clinical Note (Final Report) for Resident 1, dated July 15, 2021, the Rx Clinical Note (Final Report) document indicated, Resident having difficulty breathing using excretory [accessory] muscle (using accessory muscles of respiration is one of the earliest sign of airway obstruction), res (resident) on room air sats (oxygen saturation levels) at 56 (percent of oxygen) pulse 138 (normal 60-100). This RN (Registered Nurse) to put res on O2 (oxygen) via NC (nasal cannula - hosed prongs inserted into nostrils attached to an oxygen source) when paramedics arrived. Res (resident) transferred to [Initials of General Acute Care Hospital] ED (emergency department) . During a review of the facility's documentation titled, Discharge Summary EMR [electronic medical record] for Resident 1, dated July 15, 2021, the Discharge Summary EMR indicated, I was informed by nursing that patient is altered, not following commands. Vitals (vital signs: temperature, pulse, respirations and blood pressure) noted with fever, [CONDITION(S)] (rapid heart rate), and hypoxic (low oxygen levels) saturating 85 to 90% on room air. Ordered to transfer to emergency room . During a review of the facility's policy and procedure (P&P) titled, Admission Policy, dated January 28, 2019, the P&P indicated, Purpose: Obtain baseline information and pertinent history to ensure smooth transition into continuum of care. Policy: Every resident admitted to the Skilled Nursing Facility will be admitted by the following procedure . 5. Notify physician of admission and verify orders . During a review of the facility's P&P titled, Standards of Nursing Services, dated October 2, 2018, the P&P indicated, Purpose: Set and maintain a standard for Nursing Services at the [Partial Name of Facility] . Procedure: . 3. The Department of Nursing develops and implements policies and procedures related to resident care which ensures safe and competent clinical practice . During a review of the peer reviewed journal article titled, Narrative Review of Low-Intake Dehydration in Older Adults, dated September 9, 2021, published in the National Library of Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 93/, the article indicated, Adverse health outcomes associated with low-intake dehydration in older adults include poorer cognitive performance, reduced quality of life, worsened course of illness and recovery, and a higher number of unplanned hospital admissions and increased mortality.

Based on observation, interview, and record review, the facility failed to ensure one of twenty-two sampled residents (Resident 2) was free from verbal/physical/mental abuse. This failure resulted in Resident 2's withdrawal from group activity participation by isolating herself in her room and her avoidance of Employee 1 in the patient care area. Findings: During an initial tour observation on August 3, 2015 at 11:25 AM, Resident 2 sat in her bed watching television. During subsequent observations: From August 3-August 5, 2015, Resident 2 did not attend any group activities or eat in the dining room. During a breakfast meal observation and interview on August 5, 2015 at 7:20 AM, Resident 2 stated, Three weeks ago while playing Bingo, Employee 1 cussed at me, I can't remember the words. A review of Resident 2's clinical record documented Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a family interview with Resident 2's family member (FM), on August 5, 2015 at 12:30 PM, the FM stated, Usually she (Resident 2) goes down to the dining room and plays Bingo but she has not gone to play or eat in the dining room for several weeks and I do not know why. During an interview with Resident 2, on August 5, 2015 at 12:45 PM, Resident 2 stated, Since the thing with (Employee 1), I do not go (to activities). During an interview conducted on August 4, 2015 at 10:00 AM, after the group interview (August 3, 2015), Resident 19 stated he need to talk about his concerns about . and an incident he witnessed a couple of weeks ago. During an interview with sampled Resident 19, on August 5, 2015 at 1:30 PM, Resident 19 stated he heard and observed what Employee 1 said and did to Resident 2 a couple of weeks ago. Resident 19 heard Employee 1 making statements to Resident 2, You should not be saying anything about Keno (a game similar to bingo) .I'm not really interested in your opinion since you never attend functions .You should not be here. You should go back to your room. Resident 19 stated he observed Employee 1 grabbing Resident 2's wheelchair and pulling it back quickly causing Resident 2 to shift forward and backward in the seat of the wheelchair. During further interview Resident 19 stated Employee 1's tone of voice to Resident 2 was very stern and very direct - short spoken like a drill sergeant. Resident 19 stated he saw Employee 1 quickly pushing Resident 2 in her wheelchair down the hallway against Resident 2's objection, not wanting to go back to her room. Resident 19 stated Resident 2 became upset because it was Employee 1's tone of voice and how Employee 1 handled Resident 2 in her wheelchair. Resident 19 stated Employee 2 witnessed the incident and Resident 19 reported the incident to Employee 3 on the same date of the incident. Resident 19 recalled the incident occurred, About two weeks ago on a Wednesday or Thursday at 2:30 PM. During an interview with Employee 1, on August 5, 2015 at 3:23 PM, Employee 1 stated, Resident 2 claimed I was rude to her. Employee 1 stated he was counseled after the incident occurred. During an interview with Employee 2, on August 5, 2015 at 4:02 PM, Employee 2 stated she saw and heard a portion of the incident between Employee 1 and Resident 2. Employee 2 stated Employee 1 and she were standing next to a table and Resident 2 and Resident 19 were present. Resident 2 complained about not having either Keno or Pokeno (a game similar to the poker card game and keno combined) and Employee 1 stated there would be something else later. Resident 2 stated she wanted to stay (in the dining room). During further interview Employee 2 stated she observed Employee 1 grab the back of Resident 2's wheelchair and pull it out abruptly causing Resident 2 to shift forward and backward in the seat of her wheelchair. Employee 2 heard Employee 1 stating to Resident 2, I will take you back to your room. Employee 2 heard Resident 2 stating she did not want to go back to her room several times. Employee 2 stated she then walked away from the situation. Employee 2 stated she reported the incident to Employee 3 on July 16, 2015, the date of the incident. During an interview with Employee 3, on August 5, 2015 at 5:00 PM, Employee 3 stated he received a verbal report from Resident 19 around 4:45 PM on July 16, 2015. Employee 3 stated Resident 19 reported Employee 1 being rude to Resident 2 and Employee 1 made Resident 2 go back to her room even though she wanted to stay in the dining room. Employee 3 acknowledged Resident 2 was upset from the incident. Employee 3 acknowledged Employee 2 reported Employee 1 was very rude to Resident 2. During the same interview on August 5, 2015 at 5:00 PM, Employee 3 stated he did not report the incident to the abuse coordinator until the following Monday, July 20, 2015 (4 days after the incident occurred). Employee 3 confirmed Employee 1 worked on Friday, July 17, 2015. Employee 3 stated he did not speak to Employee 1 regarding the incident. Employee 3 acknowledged Employee 1 was not removed from the resident care area during the pending investigation. During a concurrent interview with the Abuse Coordinator, she stated Employee 3 should have reported to her when he had the knowledge of the incident. She further stated the facility's policy stipulated allegation of abuse must be reported immediately to the abuse coordinator and involved staff would be removed from resident care. During an interview with Employee 2, on August 6, 2015 at 11:00 AM, Employee 2 stated Resident 2's level of participation in group activities had decreased. Resident 2 did not attend activities she enjoyed such as games, buffets, poetry and literature club and special events like she used to. During an interview with Resident 2, on August 6, 2015 at 12:55 PM, Resident 2 stated her feelings about the incident and said, I was wondering if (Employee 1) thought I was a f .b (cuss words) and wondered what I did to be treated like that. During a phone interview with a certified nursing assistant (CNA 3), on August 6, 2015 at 1:45 PM, CNA 3 stated she remembered the incident and Resident 2 said Employee 1 was upset at her. CNA 3 stated Resident 2 told her about not wanting to go back down to the dining room because of the way (Employee 1) is. During a record review on August 6, 2015 at 8:35 AM, the annual Resident Assessment Instrument (RAI) (a comprehensive resident assessment tool) dated December 23, 2014, noted the following activities as being very important to Resident 2: Keeping up with the news, doing things with groups of people, doing her favorite activities, going outside for fresh air during good weather and attending religious services. During a record review on August 6, 2015, Resident 2's activity care plan dated, December 23, 2014, indicated a goal of attending/participating in activities three to five times per week. Specific interventions for the activity care plan included . inviting the resident to scheduled activities . modify daily schedule and treatment plan to accommodate activity participation, resident preferred activities- , (name of game), TV, reading newspapers and family visits. A record review of Resident 2's Activity Readmission Review dated June 16, 2015, indicated preferred activities of TV, music, Bingo, Keno, religious services, desire to participate in group activities, desire to talk 1:1 with staff, engage in independent activities e.g. reading and puzzles. Resident 2's assessment did not indicate any cognitive, communication, or hearing deficits but Resident 2 required staff assistance to attend activities. During a record review on August 6, 2015 at 8:35 AM, Resident 2's Activity Quarterly assessment dated [DATE] indicated: attends two to four times per week with a positive response, enjoys TV, reading, Bingo, Keno, and buffets. A record review of the facility's activity calendars for the month of July and August 2015 indicated on Monday, Wednesday, Thursday, and Saturday each week when games of Bingo or Keno occur for each month. A record review of the facility's Daily Work Sheet -Activities dated from April 1, 2015 until June 30, 2015 indicated Resident 2's participation in activities ranged from 20-27 activities per month, and three to five times per week. During July 1-31, 2015, Resident 2 participated in ten activities for the month and averaging two times per week. Continued review reflects Resident 2 participated in group activities on July 16, 18, 23 and 24. There was no documentation to show Resident 2 participated in group activities after July 24. During the week of August 1-5, 2015, Resident 2's participation was zero for all group activities scheduled on the activity calendar for the week. During an interview with Employee 2, on August 6, 2015 at 11:00 AM, Employee 2 stated Resident 2's level of participation in group activities had decreased since the incident with Employee 1. Resident 2 did not attend activities she enjoyed such as games, buffets, poetry and literature club and special events like she used to. A record review of Employee 1's training records indicated Employee 1 received annual abuse training related to mandated reporting on June 26, 2014. A review of the facilities In-Service Lesson Plan titled, Resident Rights-Abuse, dated July 13, 2015, reflects Employee 1 attended the In-service training. A review of the facility policy and procedure titled, Reporting of Abuse, dated April, 1995 with a revised date of June 2013, reflects under Procedure: 5. Reporting of abuse is required when: b. For Dependent Adult/Elder, i. Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed, suspects or has knowledge of an incident that reasonably appears to be physician abuse shall report the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two working days to the appropriate agency. Under section J. Definitions, Abuse of an elder or a dependent adult means physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering (Welfare and Institutions Code Section .07).

Based on interview and record review, the facility failed to ensure adequate supervision and assistance was provided to one sampled resident (Resident A) to prevent accidents as evidenced by failure to revise and update the resident's plan of care that addressed the level of assistance required with toileting and transfer from bed to bedside commode and vice-versa in a universe of 108 residents. This failure resulted in a fall and injury of Resident A. Resident A sustained a fracture (break) of the right pubic ramus (bone located in the lower inner buttock area) requiring hospitalization for further treatment. Findings: On September 12, 2014, a review of the facility's incident report written and dated August 15, 2014 by the Registered Nurse (RN) charge nurse, indicated Resident A "fell due to non-compliance with call system" (activating the call light when needing help by pressing a call button at bedside) on August 5, 2014. The x-ray results on August 15, 2014 showed Resident A sustained a trauma-fracture of the right pubic ramus. A review of the facility's investigation report summary written and dated August 22, 2014 by the Director of Nursing (DON), indicated "on August 5, 2014 at 9:45 AM, the resident (Resident A) was attempting to transfer from bedside commode back to bed which she had been cleared to do independently by the Physical Therapist (PT). Resident A was hopping on her good right leg but her left leg did not follow causing her to fall to her left side." On September 12, 2014 at 2:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1 regarding Resident A's incident of fall on August 5, 2014. CNA 1 stated he was helping Resident A with toileting when the incident of fall happened. CNA 1 stated Resident A fell inside the resident's room when she (Resident A) attempted to get up from the commode and go back to bed by herself without calling for help. When asked whether Resident A was independent or needed supervision with toileting and transfer with the use of a bedside commode according to the resident's plan of care, CNA 1 did not give an answer. CNA 1 stated, he had to step outside (the resident room) by the door and wait until Resident A was done (toileting) and call the CNA for assistance. CNA 1 explained Resident A did not call CNA 1 for assistance and attempted to get up and transfer self from the commode back to bed by herself and fell . On September 12, 2014, a review of Resident A's medical record was conducted. Resident A was [AGE] years of age, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident A's cognitive status included, alert, oriented to person, time, place and situation, and was able to follow instructions. Resident A had been wearing a left leg brace and was unable to put weight on the left leg. A review of the resident's physical therapy treatment discharge summary, dated and signed July 23, 2014 by the Physical Therapist (PT) 1, showed that Resident A was discharged from physical therapy treatment on July 21, 2014, and had met her (Resident A) functional therapy goals which included the following: "Patient (Resident A) able to transfer Supervised on bed< >bedside commode (bed to bedside commode and vise-versa); moderate assistance (MOD A) to transfer on low surfaces (such as toilet seat and standard chair)." The resident's discharge summary functional outcomes showed Resident A had to be supervised (by facility staff) during toileting with the use of bedside commode, and had not been cleared by PT to transfer self independently from bed to commode. A review of Resident A's comprehensive care plans for "Fall risk/Potential for Injury"; "Self care deficit related to post-left knee surgery" and "Impaired mobility" dated July 23, 2014 and July 31, 2014, respectively, noted the fall prevention interventions included the following: 1. Place call light, bedside table and comfort items in reach while in bed or sitting at bedside. 2. Encourage to use call light system. 3. Answer call light promptly. 4. Assist with wheelchair mobility per resident request. There was no written evidence that the IDT (Interdisciplinary Team, such as the PT and the RN) had revised and updated the plan of care to prevent fall and injury after the resident's discharge from physical therapy (on July 23, 2014). The care plan did not reflect the level of staff assistance needed in order to safely transfer from the bed to the bedside commode, or whether supervision was necessary during toileting to prevent falls. Resident A had been discharged from the facility and was no longer available for interview. During a concurrent interview with the Physical Therapist (PT) and the DON on September 12, 2014 at 3:45 PM, the PT was asked regarding Resident A's current functional status (after being discharged from physical therapy) with toileting and transfer from bed to commode and vise-versa. The PT stated Resident A had met her goals of modified independence (MOD I) with toileting, transfer from bed to commode and vise-versa. When asked what modified independence means, and if Resident A needed supervision during toileting transfers from bed to commode and vice-versa, the PT did not give an answer. On September 12, 2014 at 3:45 PM, during the interview with the PT, the DON stated, "She (Resident A) needed to be supervised (by staff during toileting) and staff had to be there present (with the resident) when using the commode." The DON acknowledged that based on the PT's discharge assessment, Resident A had to be supervised during transfer from bed to commode and vice-versa and should have not been left alone by herself in the room while the resident was using the commode.

Based on interview and record review, the facility failed to provide the necessary care and services to five of 22 sampled residents (Residents 1, 5, 6, 17, and 21) when: 1. Resident 5 did not receive multiple doses (a total of 12 doses) of Trazadone (a medication used to treat depression) as prescribed by the physician for depression (a condition affecting mood), due to unavailability of the medication. This failure resulted in Resident 5 to continue exhibiting multiple episodes of yelling and sleeplessness that were not easily redirected. 2. Resident 21 did not receive multiple doses (a total of 7 consecutive doses) of [MEDICATION NAME] (a medication used to treat nerve and muscle pain) as prescribed by the physician for [MEDICAL CONDITION] (a condition affecting the nerves that often causes pain, numbness and weakness), due to unavailability of the medication from July 8 through July 12, 2014. This failure resulted in Resident 21 experiencing unnecessary, severe pain. 3. Resident 1 did not receive timely assessment, interventions, monitoring and evaluation when Resident 1 had a "bloody loose" tooth to bottom of the right gum on June 9, 2014. This failure had the potential for Resident 1, to experience oral and dental complications such as further bleeding or infection. 4. Resident 6 did not receive [MEDICATION NAME] (a medication used to prevent and treat wheezing, shortness of breath, coughing and chest tightness caused by lung disease) for a total of 21 doses, as prescribed by the physician. This failure had the potential for Resident 6 to develop worsening of congestion with difficulty of breathing. 5. Resident 17 did not have a reassessment of pain level after pain medication administration to evaluate the effectiveness of pain medication which had the potential to result in delayed treatment and intervention. Findings: 1. A review of Resident 5's clinical record on September 10, 2014, indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the licensed nurses progress notes indicated Resident 5 had multiple episodes of yelling and sleeplessness that were not easily redirected, from June 4, 2014 through July 1, 2014. A licensed nurses progress notes dated July 1, 2014 at 5:10 PM, indicated that the doctor was notified of Resident 5's "c/o (complains of) depression." A physician's order dated July 1, 2014 indicated an order to [MEDICATION NAME](a medication used to treat trouble sleeping) and to start Trazadone 50 mg (milligrams) one tablet at bedtime for depression manifested by yelling out. A review of the "MEDICATION RECORD AND PROFILE" (MAR) for July 2014 indicated that the Trazadone medication was not administered to Resident 5 from July 1, 2014 through July 12, 2014, due to "awaiting" for the medications from the pharmacy. The monitoring of the episodes of yelling every shift indicated Resident 5, had 32 episodes of yelling from July 1, 2014 through July 12, 2014. The licensed nurses progress notes dated July 3, 2014 at 6:40 AM, indicated that the facility was awaiting the delivery of the [MEDICATION NAME] medication. There was no documented evidence of a follow up or of a communication between the pharmacy staff and the facility licensed nurses regarding the unavailability of the [MEDICATION NAME] medication, after July 3, 2014. A review of the licensed nurses progress notes from July 1, 2014 through July 12, 2014 indicated Resident 5 continued to have multiple episodes of yelling and sleeplessness that were not easily redirected. A licensed nurses progress notes dated July 4, 2014 at 6 AM, indicated "Awaiting Rx (prescription) Trazadone from pharmacy. Resident had noted difficulty sleeping and staying asleep this shift. c/o awful nightmares...Total hours of sleep approx. (approximately) 4-5 (hours)." An interview with the director of nurses (DON) on September 10, 2014 at 11 AM, and a concurrent review of Resident 5's clinical record was conducted. When asked how the facility ensured the availability of medications for the residents, the DON stated, "The licensed nurses should have followed up with the pharmacy when the ordered medications were not received within 24-48 hours from the pharmacy." The DON confirmed the licensed nurses did not follow up and that they should have called the pharmacy right away. An interview with the DON and a concurrent review of Resident 5's physician orders, licensed nurses progress notes, and the July 2014 MAR was conducted on September 10, 2014 at 5 PM. The DON confirmed there was no documented evidence that the attending physician was notified that Trazadone was not available for administration as ordered, from July 1, 2014 through July 12, 2014 (a total of 12 doses) to Resident 5, who continued to exhibit multiple episodes of yelling and sleeplessness that were not easily redirected. A concurrent review of the July 2014 MAR revealed from July 1, 2014 through July 12, 2014 (the period when the Trazadone medication was not administered), Resident 5 had 32 episodes of yelling as follows: On July 1, 2014, 0 episodes On July 2 ,2014, had 0 episodes On July 3, 2014, had 1 episode On July 4, 2014, had 4 episodes On July 5, 2014, had 6 episodes On July 6, 2014, had 5 episodes On July 7, 2014, had 1 episode On July 8, 2014, had 3 episodes On July 9, 2014, had 2 episodes On July 10, 2014, had 2 episodes On July 11, 2014, had 3 episodes On July 12, 2014, had 5 episodes The MAR revealed that from July 13, 2014 through July 31, 2014 (when Trazadone was administered), Resident 5's yelling decreased to 21 episodes. The licensed nurses progress notes dated July 13, 2014 through July 31, 2014 (the period when the Trazadone was already administered to Resident 5) indicated that episodes of yelling had decreased and that Resident 5 was easily redirected and was cooperative. The notes also revealed that Resident 5 had indicated that he "felt good" and had a "good sleep." A review of the facility's policy and procedures titled, "CHANGE IN RESIDENT CONDITION," revision date July 2012, indicated under procedure, "...2. The licensed nurse will notify the attending physician as soon as possible and/or practical regarding incidences involving the resident, significant changes in resident's physical, mental or emotional state..." 2. During an interview on September 10, 2014 at 1 PM, Resident 21 expressed concerns about ensuring availability of the medications because of a prior incident that occurred months ago, when the medication [MEDICATION NAME] (a medication used to treat nerve and muscle pain) was not administered to Resident 21 for approximately 5 or 7 days (as verbalized by Resident 21) because the medication was unavailable. Resident 21 stated that [MEDICATION NAME] was ordered to be taken twice a day for [MEDICAL CONDITION] (a condition characterized by widespread pain, sleep disturbance, fatigue and often psychological distress). Resident 21 stated when the staff nurses were asked about the availability of the medication, "They kept saying that the medication wasn't in yet." Resident 21 stated that not taking the [MEDICATION NAME] resulted to pain that affected the resident's ability to turn and reposition, and disturbance in Resident 21's sleeping pattern; "I was up all night for 3 to 4 days." Resident 21 described the pain present on the whole body as "way past 10" on the pain scale (a scale used to measure a patient's level or intensity of pain from 0 to 10 based on self-report; a level of 0/10 indicates absence of pain and 10/10 being the worst pain). Resident 21 stated, "I was in so much pain I just wanted to shoot myself." A review of Resident 21's clinical record on September 10, 2014, indicated Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set-an assessment tool) with an assessment reference date of July 3, 2014 indicated a BIMS (Brief Interview for Mental Status-a brief screener that aids in detecting cognitive impairment; a score of 13-15 indicates cognitively intact; 8-12 indicates moderate cognitive impairment and 0-7 indicates severe cognitive impairment) score of 15. The physician order dated January 3, 2013, indicated an order for [REDACTED]. The "MEDICATION RECORD AND PROFILE" (MAR) for July 2014, indicated multiple doses had initials encircled that indicated the medication was not administered because of unavailability of the medication for the following dates and doses: July 8, 2014 for 9 PM dose July 9, 2014 for 9 PM dose July 10, 2014 for 9 AM dose July 10, 2014 for 9 PM dose July 11, 2014 for 9 AM dose July 11, 2014 for 9 PM dose July 12, 2014 for 9 AM dose During an interview with the DON on September 10, 2014 at 1:30 PM, and a concurrent review of Resident 21's clinical record, the DON confirmed a total of 7 doses of the medication [MEDICATION NAME] was not available and was not administered to Resident 21, who experienced severe body pain, sleeplessness and difficulty in turning and repositioning as a result. A concurrent record review with the DON of the "MEDICATION RECORD AND PROFILE" (MAR) for July 8, 2014 at 9 PM through July 12, 2014, indicated Resident 21 received [MEDICATION NAME] (a medication used to treat moderate to severe pain) 50 mg one tablet as needed for pain on July 10, 2014 and July 12, 2014 at 9 AM (total of 2 doses only), and only one dose of [MEDICATION NAME] (a medication involved in regulating sleep and wake cycles) 3 mg two tablets (6 mg) at bedtime as needed for "supplement." During a concurrent interview with the DON, when asked how Resident 21's complaints of severe pain and episodes of sleeplessness were assessed, addressed and provided for, the DON stated, "We didn't meet (Resident 21's) needs." A review of the facility's policy and procedures titled, "CHANGE IN RESIDENT CONDITION," revision date July 2012, indicated under procedure, "...2. The licensed nurse will notify the attending physician as soon as possible and/or practical regarding incidences involving the resident, significant changes in resident's physical, mental or emotional state..." 3. During a review of the clinical record on September 10, 2014 for Resident 1, the face sheet and the physician orders indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set-an assessment tool) with an assessment reference date of June 19, 2014 indicated that Resident 1 had a short and a long term memory problem. The licensed nurses progress notes dated June 9, 2014 at 7 AM, indicated Resident 1 had "bloody loose" tooth to the bottom of the gum had denied any pain to site. Social Service was informed to set up necessary appointment and staff was to continue monitoring of the resident's condition. There was no documented evidence to show the physician was notified of the resident's condition nor was there documented evidence of any further assessment or monitoring of the resident's condition. A review of the "MEDICATION RECORD AND PROFILE" for June 2014 indicated that Resident 1 received Xarelto (a blood thinner medication that could cause bleeding) 15 mg (milligrams) one tablet by mouth daily for [MEDICAL CONDITION]. A review of the dental services notes indicated that the last entry was dated October 28, 2011. A review of the social services notes, dated July 1, 2014, indicated "It was reported to this writer that staff observed some bleeding from (resident) mouth..." An interview with the social services assistant (SSA), the DON and the infection control preventionist, and a concurrent review of the clinical record was conducted on September 11, 2014 at 11:05 AM. The SSA confirmed she actually talked to the resident and the family member on July 1, 2014 (22 days after the condition was identified). The SSA further stated that it must have been the only time she was notified verbally by the nursing department of the Resident 1's condition. A care plan titled dental care, dated June 19, 2014 (10 days after the condition was identified), indicated, "Staff report bleeding tooth. Res (resident) declines to see dentist at this time ...SS notified will address with (family member) at CP (care plan) meeting June 25, 2014." An interdisciplinary care conference (care plan meeting) record, dated June 25, 2014, was signed as attended by the SSA. Resident 1's family member "did not attend." Under referrals/appointments, it indicated that SS will follow up with the family member regarding the "dental" (issue). During a concurrent interview, the SSA, the DON, and the infection control preventionist confirmed Resident 1 did not receive timely assessment, interventions, monitoring and evaluation, since the problem was identified on June 9, 2014. The SSA, the DON, and the infection control preventionist confirmed there was no documented evidence to show the physician was notified of the change in Resident 1's condition, and that the use of Xarelto placed Resident 1 at a higher risk for bleeding. During an interview with registered nurse (RN 1) and a concurrent review of Resident 1's clinical record on September 11, 2014 at 10:05 AM, he confirmed when the "bloody loose tooth" was identified on June 9, 2014, there was no documented evidence of an assessment, 72-hour monitoring, no interventions, nor a resolution of the condition. RN 1 acknowledged the use of Xarelto placed Resident 1 at higher risk for bleeding. A review of the facility's policy and procedures titled, "CHANGE IN RESIDENT CONDITION," revision date July 2012, indicated under procedure, "...2. The licensed nurse will notify the attending physician as soon as possible and/or practical regarding incidences involving the resident, significant changes in resident's physical, mental or emotional state..." A review of the facility's policy and procedure titled "DENTAL SERVICES," revised on August 2012, under procedure, "...4. Licensed nurses are responsible for: ...d. contacting the physician when a dental problem is present..." 4. A review of clinical record on September 9, 2014 at 11:00 AM, indicated Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. A record review of Resident 6's physician order on September 10, 2014 at 10:30 AM, indicated a medication order written on July 22, 2014 at 3:00 PM, "[MEDICATION NAME] (a medication used to prevent and treat wheezing, shortness of breath, coughing and chest tightness caused by lung disease) one vial via hand held nebulizer (a mouthpiece is connected to a machine via plastic tubing to deliver the medication) every 4 hours routinely for 14 days for increased congestion." A review of Resident 6's July 2014 MAR (medication administration record) indicated the resident was receiving [MEDICATION NAME] medication every 6 hours from July 22, 2014 to July 30, 2014, with the medication administration time frequency transcribed as 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM instead of every 4 hour as prescribed by physician. During an interview with licensed vocational nurse (LVN 2) on September 10, 2014 at 11:00 AM, she confirmed the [MEDICATION NAME] medication had been administered every 6 hours instead of every 4 hours from July 22 to July 30, 2014. During an interview with the Director of Staff Development (DSD) on September 10, 2014 at 11:00 AM, she stated the nurse should have administered the medication every 4 hours and confirmed the nurse made a mistake in transcription of the time frequency of medication administration. The DSD confirmed there were missing nurse's initials in the MAR on the following time administration of [MEDICATION NAME] : July 25, 2014 at 6:00 PM July 27, 2014 at 6:00 AM July 30, 2014 at 12:00 AM July 31, 2014 at 12:00 AM and 4:00 AM. A review of the facility policy and procedure, titled "Medication Administration Record Documentation," revised date July 2102, indicated, " Procedure 1. All treatments and medications(internal and external), must be administered as per physician's order, accurate in date, time, dosage, route and procedure. Administration of the procedure or medication must be recorded on the Medication Administration Record(MAR)by placing the administering nurse's initials in the appropriate box of the MAR." 5. A review of Resident 17's clinical record on September 12, 2014 at 8:50 AM, revealed resident 17 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 17's physician order, indicated a medication ordered on February 19, 2013, "[MEDICATION NAME] (a pain reliever medication) 5/325 milligram tablet 1 per oral every 4 hour PRN (as needed) for pain." A review of June 2014 and July 2014 MAR (medication administration record) indicated Resident 17 received [MEDICATION NAME] medication for complaint of pain on the following : June 8, 2014 at 11:30 PM July 22, 2014 at 5:00 PM July 12, 2014 at 9 AM July 17, 2014 at 1 PM July 22, 2014 at 9 PM July 27, 2014 at 1 PM July 30, 2014 at 8:05 PM There was no pain rate assessment documentation after the medication was administered to Resident 17. During an interview with licensed vocational nurse (LVN 1) on September 12, 2014 at 9:20 AM, she confirmed and verified the missing pain rate assessment after [MEDICATION NAME] PRN pain medication were administered to Resident 17. She stated the pain level assessment should have been been after administering medication to determine the effectiveness of the pain medication. When asked if the nurse should have indicated a level of pain reassessment, she stated, "yes." A review of Resident 17's care plan on September 12, 2014, indicated a pain problem with intervention such as, "assess characteristic of pain-location, severity on a scale of 1-10, type, frequency. Administer pain medication as ordered." During Quality Assurance (QA) interview with the Administrator on September 12, 2014 at 12:09 PM, she stated there was no approved policy and procedure for pain assessment.

Based on interview and record review, the facility failed to ensure three of 22 sampled residents (Residents 5, 6, and 21) were free from significant medication errors when: 1. Resident 5 did not receive multiple doses (a total of 12 doses) of Trazadone (a medication used to treat depression) as prescribed by the physician for depression (a condition affecting mood), due to unavailability of the medication. This failure resulted in Resident 5 to continue exhibiting behavioral symptoms. 2. Resident 21 did not receive multiple doses (a total of 7 doses) of [MEDICATION NAME] (a medication used to treat nerve and muscle pain) as prescribed by the physician for [MEDICAL CONDITION] (a condition affecting the nerves that often causes pain, numbness and weakness), due to unavailability of the medication from July 8 through July 12, 2014. This failure resulted in Resident 21 experiencing unnecessary, severe pain. 3. Resident 6 did not receive [MEDICATION NAME] (a medication used to prevent and treat wheezing, shortness of breath, coughing and chest tightness caused by lung disease) at the right time and frequency of administration as prescribed by the physician. This failure had the potential to result in Resident 6 experiencing increased respiratory (the act of breathing) discomfort and a decline in health. Findings: 1. A review of Resident 5's clinical record on September 10, 2014, indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the licensed nurses progress notes indicate Resident 5 had multiple episodes of behavioral symptoms as follows: On June 4, 2014 at 6 AM, "...yelling out multiple times 'help'..." On June 5, 2014 at 6 AM, "...yelled out 30-40 x (times)..." On June 19, 2014 at 6:20 PM, "...Episodes of yelling out this shift..." On June 21, 2014 at 6:35 PM, "...continue with multiple episodes of yelling..." On June 22, 2014 at 7:50 AM, "...many instances of yelling out throughout the night..." On June 22, 2014 at 6:25 PM, "...(continues) with behavior of calling out..." On June 23, 2014 at 6 PM, "...(resident) yelling (continue) multiple times..." On June 24, 2014 at 6 AM, "...(continues) to yell out for help..." On June 25, 2014 at 6:30 AM, "...calling out multiple times for assistance. When redirected Resident states 'I'm not yelling'..." On June 26, 2014 at 6:10 PM, "...One episode of yelling out this shift..." On June 27, 2014 at 7:40 AM, "...episodes of yelling out instead of using call light..." On June 27, 2014 at 6 PM, "...preferred to yell for assistance..." On June 28, 2014 at 6:25 AM, "...yelled out x 3 (times) this shift..." On June 28, 2014 at 6 PM, "...(continued) to call out for assistance..." On June 29, 2014 at 6 AM, "...continues to call out for assistance..." On June 29, 2014 at 6 PM, "...(continued) to call out for help..." On July 1, 2014 at 6 AM, "...yelling out at start of shift..." On July 1, 2014 at 5:10 PM, "Notified Dr (name of doctor) of (resident) c/o (complains of) depression...faxed (name of doctor) for signature." On July 1, 2014 at 6:10 PM, "...continues to yell out at times..." A physician's order dated July 1, 2014, reflected an order to [MEDICATION NAME](a medication used to treat trouble sleeping) and to start Trazadone 50 mg (milligrams) one tablet at bedtime for depression manifested by yelling out. A review of the "MEDICATION RECORD AND PROFILE" for July 2014, indicated the Trazadone medication was not administered to Resident 5 from July 1, 2014 through July 12, 2014, due to "awaiting" for the medications from the pharmacy. The monitoring of the episodes of yelling every shift indicated Resident 5 had 32 episodes of yelling from July 1, 2014 through July 12, 2014. The licensed nurses progress notes dated July 3, 2014 at 6:40 AM, indicated, "...ordered Trazadone on (name of pharmacy) order sheet this morning. Awaiting delivery..." There was no documented evidence of a follow up or of a communication between the pharmacy staff and the facility licensed nurses regarding the unavailability of the [MEDICATION NAME] medication, after July 3, 2014. Further review of the licensed nurses progress notes indicated Resident 5 continued to have episodes of behavior symptoms as follows: On July 3, 2014 at 6 PM, "...had episode of yelling out late in the shift..." On July 4, 2014 at 6 AM, "Awaiting Rx (prescription) Trazadone from pharmacy. Resident had noted difficulty sleeping and staying asleep this shift. c/o "awful nightmares...Total hours of sleep approx. (approximately) 4-5 (hours)." On July 11, 2014 at 3:30 PM, "...yelling for help..." On July 11, 2014 at 6:10 PM, "...continued to yell out at intervals..." On July 12, 2014 at 6:15 AM, "...called out ..." On July 12, 2014 at 6 PM, "...had two episodes of calling out..." An interview with the director of nurses (DON) on September 10, 2014 at 11 AM, and a concurrent review of Resident 5's clinical record was conducted. When asked how the facility ensured the availability of medications for the residents, the DON stated the licensed nurses should have followed up with the pharmacy when the ordered medications were not received within 24-48 hours from the pharmacy. The DON acknowledged the licensed nurses did not follow up and that they should have called the pharmacy right away." During an interview with the DON and a concurrent review of the clinical record in the presence of the infection control preventionist on September 10, 2014 at 12:05 PM, the DON stated the nurse who received the physician order on July 1, 2014 had ordered the medication from the pharmacy. When asked to show documented evidence when the order was placed, she was unable to do so. A concurrent review of a copy of the medication reorder/refill form indicated the medication was requested and faxed to the pharmacy on July 3, 2014. The DON confirmed the medication continued to be unavailable and was not administered to Resident 5 until July 13, 2014. The DON stated the resident (Resident 5) used to be on Trazadone prior to the readmission to the facility on [DATE]. The Trazadone medication was not ordered by the physician until July 1, 2014. During a phone interview with the pharmacist on September 10, 2014 at 4 PM, when asked what the process was in ensuring the availability of Resident 5's medication, the pharmacist stated on June 30, 2014 (a day prior to the Trazadone medication was ordered on July 1, 2014), the pharmacy sent the medication Trazadone out to the facility as part of the "cycle" medications. A "manifesto" (a copy of the list of the residents' medications that were sent out by the pharmacy to the facility) dated June 30, 2014, signed by the facility staff, indicated the Trazadone medication was received by the facility. The pharmacist stated a faxed copy dated July 3, 2014, was received by the pharmacy from the facility which indicated an order for [REDACTED]. He explained since the manifesto had indicated the medication had already been sent out to, and was received by the facility, on June 30, 2014, the pharmacy did not send any additional medication supply to the facility in response to the July 3, 2014 faxed request. He confirmed there was no documented evidence that this information was communicated by the pharmacy to the facility nor was there any other follow up calls or notations to show the facility attempted to follow up on the availability of the medication, until July 13, 2014. During an interview with the DON on September 10, 2014 at 5 PM, she confirmed there was no documented evidence to show the attending physician was notified that Trazadone was not administered to Resident 5 due to the unavailability of the medication during the period of July 1, 2014 through July 12, 2014. She confirmed the physician order was not followed for Resident 5. 2. During an interview on September 10, 2014 at 1 PM, Resident 21 expressed concerns about ensuring availability of the medications because of a prior incident that occurred months ago, when the medication [MEDICATION NAME] was not administered to Resident 21 for approximately 5 or 7 days because the medication was unavailable. Resident 21 stated the medication was ordered to be taken twice a day for "[MEDICAL CONDITION] (a condition characterized by widespread pain, sleep disturbance, fatigue and often psychological distress)." Resident 21 stated when the staff nurses were asked about the availability of the medication, "They kept saying the medication wasn't in yet." When asked how the unavailability of this medication had affected this resident, Resident 21 stated, "I was in so much pain I just wanted to shoot myself." Resident 21 explained that the pain was on the "whole body," and the level of the pain according to the pain scale (a scale used to measure a patient's level or intensity of pain from 0 to 10 based on self-report; a level of 0/10 indicates absence of pain and 10/10 being the worst pain) was "way past 10" and "I could not lay on my back" because of the pain. Resident 21 stated, it "affected my sleep; I was up all night for 3 to 4 days," until the medication finally became available. A review of Resident 21's clinical record on September 10, 2014, indicated Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set-an assessment tool), with an assessment reference date of July 3, 2014, indicated a BIMS score (Brief Interview for Mental Status-a brief screener that aids in detecting cognitive impairment; a score of 13-15 indicates cognitively intact; 8-12 indicates moderate cognitive impairment and 0-7 indicates severe cognitive impairment) of 15. The physician order dated January 3, 2013, indicated an order for [REDACTED]. The "MEDICATION RECORD AND PROFILE" for July 2014, indicated multiple doses had initials encircled which indicated the medication was not administered because of the unavailability of the medication for the following dates and doses: July 8, 2014 for 9 PM dose; "[MEDICATION NAME] not given-awaiting doc (doctor's) signature for refill." July 9, 2014 for 9 PM dose; "[MEDICATION NAME] not delivered from pharm (pharmacy). Will call (pharmacy)..." July 10, 2014 for 9 AM dose; "awaiting MD sig (signature)." July 10, 2014 for 9 PM dose; "[MEDICATION NAME] not delivered from pharmacy-pharm (pharmacy) aware." July 11, 2014 for 9 AM dose; (No notation). July 11, 2014 for 9 PM dose; (No notation). July 12, 2014 for 9 AM dose; "[MEDICATION NAME] unavailable pending pharmacy-to be delivered today 7/12 (July 12, 2014) per pharmacy call." During a review of the licensed nurses progress notes for July 2014, there was no documented evidence to show the attending physician was notified of the unavailability of the medication during the period of July 8, 2014 through July 12, 2014. During an interview with the DON on September 10, 2014 at 1:30 PM, and a concurrent review of Resident 21's clinical record, the DON confirmed a total of 7 doses of the medication [MEDICATION NAME] was not available and was not administered to Resident 21. The DON confirmed there was no documented evidence to show the attending physician was notified of the unavailability of the medication. A concurrent review of the medication reorder and refill form indicated a request faxed to the pharmacy for refill which was dated July 5, 2014. The DON confirmed there was no documented evidence on the clinical record which indicated the licensed nurses followed up with the pharmacy regarding the unavailability of the medication during the period of July 8, 2014 through July 12, 2014. A concurrent review with the DON of the "MEDICATION RECORD AND PROFILE" for July 8, 2014 at 9 PM through July 12, 2014, indicated during this period, Resident 21 received [MEDICATION NAME] (a medication used to treat moderate to severe pain) 50 mg one tablet as needed for pain on July 10, 2014 and July 12, 2014 at 9 AM (total of 2 doses only), and only one dose of [MEDICATION NAME] (a medication involved in regulating sleep and wake cycles) 3 mg two tablets (6 mg) at bedtime as needed for "supplement." During a concurrent interview with the DON, when asked how Resident 21's complaints of pain and episodes of sleeplessness were assessed, addressed and provided for, the DON stated, "We didn't meet her needs." During a phone interview with the pharmacist on September 11, 2014 at 9:15 AM, when asked why the medication was not available for administration from July 8, 2014 through July 12, 2014, he stated the pharmacy received a fax from the facility dated July 5, 2014 requesting a refill of the [MEDICATION NAME], the pharmacy staff faxed to the physician's office a request for the physician's approval for refill on July 6, 2014. The request was sent back by the physician's office to the pharmacy on July 8, 2014 with an approval for a refill, however, since the signature and the MD license number provided on the approval was not recognized by the pharmacy as that of the approving attending physician, another request was sent by the pharmacy staff to the physician's office on July 10, 2014. The signed document with the "correct signature and license number" was finally received from the physician's office by the pharmacy staff on July 12, 2014 (the day the medication was finally made available to the facility). When asked if there was any communication between the pharmacy staff and facility staff of any follow up or updates during the period of July 5, 2014 through July 12, 2014, the pharmacist confirmed there was no documented evidence noted. A review of the facility's policy and procedures titled, "MEDICATION SHORTAGES," dated September 2010, indicated under policy, "...The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs." Under procedures, it indicated, "1. The pharmacy staff shall: a. Call and/or provide written notification to the nursing staff that the physician ordered product(s) is/are unavailable. b. Provide nursing with the date that it is anticipated that the drug(s) will become available. c. Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available, which is covered by the resident's insurance ...2. Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product: a. notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available..." 3. During a review of Resident 6's clinical record on September 9, 2014 at 11:00 AM, it revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's physician orders on September 10, 2014 at 10:30 AM, indicated a medication order was written on July 22, 2014 at 3 PM, which reflected, "[MEDICATION NAME] (a medication used to prevent and treat wheezing, shortness of breath, coughing and chest tightness caused by lung disease) one vial via hand held nebulizer (a mouthpiece is connected to a machine via plastic tubing to deliver the medication) every 4 hours routinely for 14 days for increased congestion." A review of Resident 6's July 2014 MAR (medication administration record) indicated the resident was receiving [MEDICATION NAME] medication every 6 hours from July 22, 2014 to July 30, 2014 with the medication administration time frequency transcribed as 6 AM, 12 PM, 6 PM, and 12 AM. During an interview with licensed vocational nurse (LVN 2) on September 10, 2014 at 11 AM, she confirmed the [MEDICATION NAME] medication was transcribed in the MAR to administer every 6 hours instead of every 4 hours from July 22 to July 30, 2014. She confirmed there was no evidence of documentation that the physician was notified of the error in medication administration. During an interview with the DSD (Director of Staff Development) on September 10, 2014 at 11:00 AM, she stated the nurse should have administered the medication every 4 hours. She confirmed the nurse made a mistake in transcription of the time frequency of medication administration. She confirmed there was missing documentation in the MAR on the following date and time of administration: July 25, 2014 at 6 PM July 27, 2014 at 6 AM July 30, 2014 at 12 AM July 31, 2014 at 12 AM July 31, 2014 at 4 AM A review of the facility policy and procedure, revised dated July 2012, titled "Medication Administration Record Documentation," indicated, " Procedure 1. All treatments and medications (internal and external), must be administered as per physician's order, accurate in date, time, dosage, route and procedure. Administration of the procedure or medication must be recorded on the Medication Administration Record (MAR ) by placing the administering nurse's initials in the appropriate box of the MAR."