Every finding on record at Highland Palms Healthcare Center

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received continued nutrition services in accordance with their own policy and procedure (P&P) when Registered Dietician (RD) did not monitor Resident 1 for the months of May 2026, June 2026, and July 2026. This failure had the potential to impact the Resident 1's health and nutritional status and place Resident 1 at further risk of weight loss.Findings: During a review of Resident 1's admission Record (general demographics information), the admission Record indicated Resident 1 was admitted to the facility on February19, 2026, with diagnoses which included cerebral infarction (stroke, blocked blood vessel, stops blood and oxygen from reaching brain) hemiplegia ( paralysis to one side of body) and hemiparesis (weakness or reduced control on one side of body), hypertension (high blood pressure), and diabetes mellitus type 2 (disorder characterized by high/low blood sugar). During a review of Resident 1's Weight Summary Note, indicated:* 07/01/2026 15:14 180 Lbs (pounds) Hoyer Lift (a mechanical assistive device used to lift and transfer people with limited mobility and at times used to get the weight)* 06/01/2026 12:59 186 Lbs (Hoyer)* 05/17/2026 14:39 190 Lbs (Hoyer)* 05/04/2026 08:10 189 Lbs (Hoyer)* 05/01/2026 08:10 189 Lbs (Hoyer)* 04/26/2026 14:02 190 Lbs (Hoyer)* 04/24/2026 15:18 190 Lbs (Hoyer) Re-admit* 04/01/2026 13:06 201 Lbs (Hoyer)* 03/14/2026 15:03 196 Lbs (Hoyer)* 03/08/2026 14:44 200 Lbs (Hoyer)* 03/01/2026 13:17 203 Lbs (Mechanical Lift)* 02/22/2026 14:25 204 Lbs (Mechanical Lift)* 02/20/2026 15:14 204 Lbs (Hoyer)(Resident 1 weight trends of a loss of 24 pounds in 5 months (February 20, 2026, through July 1, 2026), with a 11.76% weight loss. A 10% within a 6-month window is classified as severe. Resident 1 surpassed this limit in just 5 months.) During a review of Resident 1's Dietary Interview Screening, dated April 23, 2026, the Dietary Interview Screening indicated: Diet Order, CCHO (consistent carbohydrate) NAS (no added salt) .Soft and bite sized texture.: Thin Consistency, Supplement/Fortified Food Order, regular diet with thin liquids Some assistance with meals and set up Assist.Recommend 30 ml Prostat (nutritional protein drink) BID (twice a day) at medication pass 1. Nutrition Goals/Monitoring and Evaluation Resident is at increased risk for malnutrition.Altered skin integrity upon admission. During a review of Resident 1's Dietary Interview Screening, dated April 28, 2026, the Dietary Interview Screening indicated: Readmission, increased nutrient needs relates to medical condition, weight loss noted upon readmission. Recommend Fortified CCHO.Soft and Bite Sized diet with thin liquids to optimize PO (by mouth) intake. Resident is at increased risk for malnutrition . Presence of therapeutic diet and texture. Weight loss. Weight loss upon readmission while outside of facility. Medical diagnosis likely contributing to weight loss. Resident showing poor PO (by mouth) intake of meals related to increased needs, poor appetite. Recommend Fortified CCHO.Soft and Bite Sized diet with thin liquids to optimize PO intake. Refer to RD PRN (as needed). During a review of Resident 1's medical records, there were no documentary evidence to indicate the RD monitored Resident 1 for the months of May 2026, June 2026, and July 2026. During an interview and concurrent record review, on August 17, 2026, at 11:30 AM, with the Director of Nursing (DON), the DON reviewed Resident 1's medical records and stated, I don't see any RD notes for May, June and July 2026. During a concurrent interview and record review with the DON, on August 17, 2026, at 11:30AM, the DON reviewed the facility's policy and procedure (P&P) titled, Dietician revised November 2022, which indicated, A qualified, competent, and skilled dietitian will help oversee the food and nutrition services in the facility. Policy Interpretation and Implementation. 1.A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents. 8. Our facility's dietitian is responsible for, but not necessarily limited to: a. assessing nutritional needs of residents; developing and evaluating regular and therapeutic diets; c. developing and implementing person centered education programs involving food and nutrition services for all facility staff. The DON acknowledged the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure that call light (a device that allows residents to communicate with nursing staff when they need assistance) was within resident's reach for one (1) of the five (5) sampled residents (Resident 1), when Resident 1's call light was found to be wrapped around the bedrail and out of Resident 1's reach. This failure had the potential to result in Residents 1's needs not being addressed when needed help, placing him at risk of injury.During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (conditions that affect only one side of the body due to damage in the brain or spinal cord) affecting left non-dominant side, muscle wasting, and atrophy (the loss of muscle mass, which causes muscles to shrink and weaken). During a concurrent observation and interview on July 8, 2026, at 10:57 AM, with Resident 1, in his room, Resident 1 was lying in bed, the call light was wrapped around the right bottom of his bed rail, making it inaccessible to reach. Resident 1 stated the staff had not provided him with a call light and he had to, [NAME] for help. During a concurrent observation and interview on July 8, 2026, at 11:03 AM, with Certified Nursing Assistant (CNA 1), in Resident 1's room, CNA 1 confirmed the call light was wrapped around the right side of bed rail, making it inaccessible to the Resident 1 and that was not the appropriate way to position the call light. CNA 1 stated Resident 1's call light should not be positioned out of his reach, as this could prevent Resident 1 from calling for help in case of an emergency or if assistance is needed. During a concurrent observation and interview on July 8, 2026, at 11:09 AM, with the License Vocational Nurse (LVN 1), in Resident 1's room. LVN 1 stated she administered medications to Resident 1 this morning (July 8, 2026), but did not realize the call light was out of reach. LVN 1 stated it was part of her responsibly to ensure the call light is always accessible to the residents. During a concurrent observation and interview on July 8, 2026, with CNA 2, CNA 2 stated she was assigned to Resident 1, she must have forgotten to return the call light to a position within Resident 1's reach after rendering care and that was unacceptable. During a concurrent record review and telephone interview on July 8, 2026, at 12:11 PM, with the Director of Nursing (DON), in the present of the Administrator (Admin), the facility's policy and procedure (P&P) titled, Answering the Call Light, dated September 2022, was reviewed. The P&P indicated, . 4. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 5. Ensure that the call light immediately becomes re-accessible once it's identified that it is no longer accessible due to resident turning, and or repositioning. The DON confirmed and acknowledged that the staff was not adhering to it the facility's P&P. The Admin also confirmed that it was their policy.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen when the walk-in refrigerator had a wet box containing cold cut meat sitting on top of a thawing roast beef inside the container.This failure had the potential to cause food borne illness (illnesses contracted from eating contaminated food or beverages) to 91 of 91 medically compromised residents who received food from the kitchen.During a concurrent observation and interview on April 27, 2026, at 9:08 AM, with the Dietary Supervisor (DS), in the kitchen, the walk-in refrigerator was inspected. There was a wet box thawing inside a plastic container. When DS lifted the wet box, a thawed roast beef under was observed. DS opened the contents of the wet box and stated the box contained cold meat. and it was sitting on top of the thawing roast beef.During a follow up interview with DS on April 27, 2026, at 3:20 PM, DS stated, the box contains individually rapid cold cuts. DS stated, the cold cut should have been taken out of the box and placed on a pan.During a concurrent interview and record review on April 27, 2026, at 4:39 PM, with Administrator (Admin), the facility's policy and procedure (P&P) titled Thawing of Meats, dated 2023, was reviewed. The P&P indicated, . a. Use a drip pan under food being thawed so drippings do not contaminate other food. The Admin stated, the cold cut should have been taken out of the box and placed on a drip pan.

Based on observation, interview, and record review, the facility failed to maintain infection control and prevention practices for two of four sampled residents (Resident 36 and 122) when:1.Resident 122's foley catheter bag (a drainage unit attached to an indwelling catheter to collect urine) was on the floor, while Resident 122 was in the dining room. 2.One Registered Nurse 1 (RN 1) carried pre-prepared Intravenous medication (IV- into the vein) in his scrub pocket before administering it through a peripherally inserted central catheter (PICC line - a very long thin flexible tube inserted into the large vein in the upper arm and threaded to a vessel just above the heart) to one vulnerable resident (Resident 36). These failures had the potential for compromising 91 vulnerable residents' health and safety, placing them at risk for infectious disease which may result in illness and adverse health outcomes. During a review of Resident 122's admission Record (contains demographic and medical information), it indicated Resident 122 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a common infection caused by germs, usually bacteria, getting into any part of your urinary system and multiplying), bacteremia (the presence of bacteria in the bloodstream, often causing fever, chills, rapid heart rate, and fatigue) and chronic kidney disease (the long-term, progressive loss of kidney function). During a concurrent observation and interview on April 27, 2026, at 12:15 PM, with Treatment Nurse (TN), in the dining room area, Resident 122 was awake, sitting on his wheelchair, and his foley catheter bag was visible and touching the floor. The urine color appeared yellow and cloudy. Treatment Nurse (TN) stated the catheter bag was touching the floor, and that it was not supposed to be dragging on the floor. TN further stated the catheter bag had to be securely hanged on the side of the wheelchair because it was an infection control issue. During a concurrent interview and record review on April 28, 2026, at 2:12 PM, with the Director of Nursing (DON) and Administrator, the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, was reviewed. The P&P indicated.Infection Control. 2. b. Be sure the catheter tubing and drainage bag are kept off the floor when identified. Both Administrator and DON stated the P&P was not followed. The Administrator further stated catheter bag should have been off from the floor for infection control. 2.During a review of facility's documents for Resident 36's AR, dated April 23, 2026, the AR indicated, Resident 36 was admitted to the facility with diagnoses of necrotizing fasciitis (a condition in which the fascia [a thin fibrous connective tissue surrounding the muscle] is infected). During a review of Resident 36's OS, dated April 23, 2026, the OS indicated, Resident 36 had an order for Daptomycin sodium chloride (drug name – an antibiotic) 660 mg (milligram- a unit of measurement) every day through PICC line for necrotizing fasciitis. During a concurrent observation and interview on April 29, 2026, at 8:07 AM, with RN 1, Resident 36's IV medication administration was observed. RN 1 used proper PPE (as gown, gloves and face mask) before entering the resident's room and removed the pre- prepared 50 ml (milli liter- a unit of measurement) IV medication bag of Daptomycin sodium chloride 660 mg from his scrub pants pocket and started to prime (to run the fluid through the tube) the IV tubing ( a line through which the medication is delivered to the patient). then connected it to Resident 36's PICC line. RN 1 stated, he usually brings the pre-prepared medication in his pocket to all residents. RN 1 further stated, he brings the IV cart (a movable table with the IV medication supplies) to the front of the resident's room when he prepares the powdered medication form. During a concurrent interview and record review on April 29, 2026, at 1:30 PM, with the DON, the facility's P&P titled Administration set/tubing changes, dated October 2024, was reviewed. The P&P indicated, .Purpose: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment. Preparation: Assemble equipment and supplies as needed. Assess equipment for sterile condition. Do not use if not sterile. General Guidelines : 1. Adhere to Standard-ANTI when connecting, changing and accessing administration set injection ports. The DON acknowledged that RN 1 did not follow the process correctly. DON stated, it is not acceptable to carry a medication in his scrub pants pocket to be administered for a resident, it is a concern for infection. DON further stated, the policy was not followed. During a concurrent interview and record review on April 30,2026, at 12:45 PM, with Admin, the facility's P&P tilted IPCP, dated October 2018 was reviewed. The P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Admin stated, RN should have done that, it is a concern for infection control.

Based on observation, interview, and record review, the facility failed to maintain a complete and accurate clinical records (documentation used to show that ordered treatments and care were provided) for one of eight sampled residents (Resident 10) reviewed for treatment orders when monitoring and care for indwelling urinary catheter (a tube inserted into the bladder to drain urine that requires routine care and monitoring) and APP mattress (a special air mattress used to prevent skin breakdown that requires routine monitoring to ensure proper function) were not documented for multiple days from March 2026 through April, 2026.This failures had the potential to result in unverified treatment orders, lack of continuity for care, and increase for adverse outcomes, including infection, skin breakdown, and decline in residents conditions.During a review of Resident 10's admission Record (contains demographic and medical information), it indicated, Resident 10, was admitted to the facility on [DATE], with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (a condition where the prostate gland is enlarged, which can block or slow the flow of urine), chronic obstructive pulmonary disease, (COPD - a long-term lung disease that make it hard to breathe) and acute respiratory failure with hypoxia (a serious condition where the lungs are not able to provide enough oxygen to the body)During a concurrent observation and interview on April 27, 2026, at 10:38 AM, inside Resident 10's room, Resident 10 was lying in bed awake, alert, with an indwelling urinary catheter in place. During the interview, Resident 10 reported experiencing leakage from his urinary catheter. Resident 10 stated he had previously informed facility staff of this concern; however, the issue had not been resolved.During a review of Resident 10's Physician Orders dated December 12, 2025, the physician orders, indicated, Indwelling Urinary Catheter Size FR # 16 (16 French - a urinary catheter size used) / 10 ML (ten milliliters, a fluid used to keep the catheter securely in place inside the bladder) [NAME] for Urinary Retention Related to Obstructive Uropathy (a condition where the resident is unable to empty the bladder completely due to blockage or obstruction) Check every shift intact/ Functioning. Start date December 15, 2025 at 3:00 PM.During a concurrent interview and record Review on April 30, 2026 at 11:31 AM, with the Treatment Nurse (TN 1), Resident 10's PACS - Treatment Administration Record TAR dated March 1, 2026 - March 31, 2026, was reviewed. The TAR, indicated there was no documented evidence for the indwelling Urinary Catheter monitoring every evening shift for the following dates: March 3, 2026, evening shift March 4, 2026, evening shift March 5, 2026, evening shift March 10, 2026, evening shift March 11, 2026, evening shift March 12, 2026, evening shiftA total of six (6) occurrences of missing, documentation were was identified and confirmed by TN 1. The TN 1 stated the documentation should have been completed. The TN 1 further stated that failure to document catheter care and monitoring could result in serious complications, including urinary tract infection During a review of Resident 10's Physician Orders dated December 13, 2025, the physician orders indicated, Indwelling Urinary Catheter: Cleanse site with Warm Soap & Water & Rinse Then Pat Dry every shift. Start Date December 13, 2025During further review, the TAR indicated a treatment order Indwelling Urinary Catheter: Cleanse site with Warm & Rinse then Pat Dry, every shift. There was no documented evidence that the treatment was completed during evening shift on the following dates: March 3, 2026, evening shiftMarch 4, 2026, evening shift March 5, 2026, evening shift March 10, 2026, evening shiftMarch 11, 2026, evening shift March 12, 2026, evening shift. A total of six (6) additional occurrences of missing documentation were identified and confirmed by TN 1. The TN 1 stated the treatment should have been documented as completed. The TN 1 further stated the failure to perform and document catheter care could place the resident at risk for complications including urinary tract infection.During a review of Resident 10's Physician Orders dated December 12, 2025, it indicated, APP Mattress. Set to Resident's weight. Check to ensure proper Placement and Function. Every shift for Mattress Check.During a concurrent interview and record review on April 30, 2026, at 11:31 AM, with TN 1, Resident 10's PACS - Treatment Administration Record TAR dated March 1, 2026 - March 31, 2026, was reviewed. The TAR, indicated that there was no documented evidence for the APP Mattress. Set to Resident's Weight. was checked for the following dates: March 3, 2026, evening shift March 4, 2026, evening shiftMarch 5, 2026, evening shift March 10, 2026, evening shift March 11, 2026, evening shift March 12, 2026, evening shiftA total of six (6) additional occurrences of missing documentation were identified and confirmed by TN 1. The TN 1 stated the treatment should have been documented as completed. The TN 1 stated the APP mattress was utilized to provide pressure relief and prevent skin breakdown. TN 1 confirmed the APP mattress checks should have been completed and documented every shift.During a concurrent interview and record Review on April 30, 2026, at 11:31 AM, with the Treatment Nurse, TN 1, Resident 10's PACS - Treatment Administration Record TAR dated April 1, 2026 - April 30, 2026 was reviewed. The TAR, indicated that there was no documented evidence the indwelling Urinary Catheter Size FR. was monitored every evening shift, for the following date:i. April 9, 2026, evening shift.A total of one (1) occurrence of missing documentation was identified and confirmed with the TN 1. The TN 1, stated the treatment should have been documented as completed.During further review, the TAR indicated a treatment order Indwelling Urinary Catheter: Cleanse site with Warm & Rinse then Pat Dry, every shift. There was no documented evidence that the treatment was completed during evening shift on the following date: April 9, 2026, evening shift A total of one (1) occurrence of missing documentation was identified and confirmed with the TN 1. The TN 1, stated the treatment should have been documented as completed. During a further review, of the TAR indicated a treatment order for APP Mattress. Set to Resident's weight Check to ensure proper placement and function. Every shift for mattress check. Start date December 13, 2025 at 07:00 AM. There was no documented evidence that the treatment was completed during evening shift on the following date: i. April 9, 2026, evening shiftA total of one (1) occurrence of missing documentation was identified and confirmed with the TN 1. The TN 1, stated the treatment should have been documented as completed. During a concurrent interview and record review on April 30, 2026, at 11:57 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Physician Orders, Accepting, transcribing, and implementing (noting) was reviewed. The P&P indicated, All physician orders are to be complete and clearly defined to ensure accurate implementation. the DON stated the policy was not followed by the staff because care was not recorded as completed in the Treatment Administration Record.

Based on observation, interview, and record review, the facility failed to ensure the Electronic Health Records (EHR- medical records kept on a computer system) was kept secure for one of five sampled residents (Resident 132), when a Licensed Vocational Nurse (LVN 1) left Resident 132's health information on the computer screen unattended and visible to the public in the hallway.This failure had the potential to place Resident 132's confidential information at risk of disclosure to unauthorized individuals.During a concurrent observation and interview on April 29, 2026, at 09:25 AM, with the LVN 2, the LVN 2 logged into the computer on top of the medication cart, checked Resident 132's EHR, and prepared the medication. LVN 2 then proceeded to go inside room [ROOM NUMBER] without logging off the computer, and administered the medications. Resident 132's information was left open and accessible on top of a medication cart. When asked, LVN 2 stated she was not supposed to keep the computer unattended. During a concurrent interview and review of the facility policy and procedure (P&P) titled, Confidentiality Information and Personal Property , dated October 2017, with the Administrator, on April 30, 2026, at 9:57 AM, the P&P indicated .1.The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records and prevent any breaches of their records. The administrator agreed that the policy was not followed.

Based on observation, interview, and record review the facility failed to ensure its policy and procedure (P&P) for Pre-admission Screening and Resident Review (PASARR- a screening assessment to ensure individuals who are identified to have a significant mental illness [SMI] or intellectual/developmental [I/DD] disability are appropriately placed in nursing homes for long term care) was followed for one out of six residents (Resident 51) when Registered Nurse 1 (RN 1) assessed and documented the level 1 PASARR incorrectly.This failure had the potential to result in Resident 51's condition not being identified prior to admission and the needs for treatment and services not being accurately assessed, placing Resident 51 at risk for unmet mental health needs.During a record review on April 28, 2026, at 8 :44 AM, facility's electronic documents titled PASARR, dated December 20, 2025, was reviewed. The PASARR indicated, Resident 51 level 1 screening for serious mental illness (SMI- major mental disorder) and Intellectual disability (a person's cognitive function and adaptive skills are affected), developmental disability, or related conditions (ID/DD/RC) was negative and Resident 51 does not require a level 2 screening for mental health evaluation.During a review of Resident 51's admission Record(AR), the AR indicated, Resident 51 was admitted on [DATE] with diagnoses which included, schizophrenia (a serious mental disorder where individuals interpret reality abnormally which leads to symptoms as disorganized thinking) and bipolar disorder (a mental health condition where intense, alternating mood swings between extreme highs and low).During an interview on April 28, 2026, at 11:30 AM, with RN1, the RN1 stated he was the person responsible in the facility who completes the PASARR for all the admitting residents. RN1 verified and acknowledged that level 1 screening was incorrect as he wrote no for question regarding resident's diagnosis of serious mental illness. RN 1 further stated, incorrect level I screening delays the residents' care and need for level II screening.During a concurrent interview and record review on April 29,2026, at 3:30 PM, with Director of Nursing (DON), the facility's policies and procedures (P&P) titled, admission Criteria PASARR, dated March 2019, was reviewed. The P&P indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for an MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (I) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. The DON verified and acknowledged that PASARR was documented incorrectly. The DON stated that the policy was not followed as RN did not complete the level 1 screening.

Based on observation, interview, and record review, the facility failed to ensure medications were secured to prevent unauthorized access when one of four medication carts (Medication cart 1), was unattended and unlocked in a common area accessible to residents, staff, and visitors.This failure had the potential to result in medications being accessible, diverted, or used inappropriately by unauthorized individuals.During an observation on April 29, 2026 at 5:59 AM, medication cart 1, was observed unattended and unlocked. The cart was parked directly in front of the Nurses' Station I near the main entrance of the building, an area accessible to residents, staff, and visitors. The medication cart contained eight drawers. On the top of the cart, there was a binder labeled Station I Narcotic & Antibiotic Record. The License Vocational Nurse (LVN 1) was observed down the hallway administering medications, leaving the cart unsecured, and unattended.During a concurrent observation and interview on April 29, 2026, at 6:02 AM, with the facility Consultant 1, (C1), C1 walked by Medication cart 1 and noted the lock was found dislodged from its secured position, resulting in the cart being left unsecured and accessible. The C1 manually pushed the lock back to secure the cart. The C1, confirmed the Medication cart 1, had been left unlocked and unattended. C1 stated the Medication cart should not be left unlocked because it can be accessible to anyone, including residents and visitors.During an interview on April 29, 2026, at 6:22 AM, with LVN 1, LVN 1 acknowledged that leaving the Medication cart 1 unattended and unlocked is not a safe practice. LVN 1 further stated the cart may have been left open after medication administration, approximately at 5:25 AM.During a concurrent interview and record review on April 30, 2026, at 10:01 AM, with the Director of Nursing (DON), in his office, the facility's policy and procedure (P&P) titled, Storage of Medications dated Revised April 2007 was reviewed. The P&P indicated, . 7. Compartments containing drugs and biological shall be locked when not in use, and trays or carts sued to transport such items shall not be left unattended if open or otherwise potentially available to others. The DON stated that medication carts are required to remain locked at all times when not in used to avoid unauthorized access.

Based on interview and record review, the facility failed to report an allegation of sexual abuse involving one of four sampled residents (Resident 1).This failure prevented the California Department of Public Health (CDPH) from ensuring the facility was taking appropriate actions to protect residents from abuse, which could jeopardize the safety and well-being of residents within the facility.Findings:A review of Resident 1's admission Record (a document containing clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a sudden, life threatening condition where the lungs cannot provide oxygen to the blood or fail to remove carbon dioxide), diabetes mellitus (a disorder characterized by high blood sugar), and hypertension (high blood pressure).A review of Resident 1's AMA (against medical advice - document used by healthcare providers to document a resident's decision to leave a facility or discontinue treatment against medical advice.) Release Form indicated Resident 1 went home against medical advice on February 17, 2026.During a telephone interview on February 23, 2026, at 8:57 AM, with Resident 1's family member , the family member stated he took Resident 1 for an out on pass (temporary, approved leave, allowing residents to leave for family visits) on Sunday, February 15, 2026, during which she alleged that she was sexually abused by a staff in the facility. Resident 1's family member further stated that he had reported to the sheriffs and police department, and had taken Resident 1 home last Tuesday, February 17, 2026, after discharging AMA.During an interview on February 23, 2026, at 12:52 PM, with the Director of Nursing (DON), the DON stated the police came into the facility in response to Resident 1's allegations of abuse. The DON stated the facility did not initiate an investigation nor report to California Department of Public Health (CDPH) because Resident 1 had already been discharged when the facility was made aware of the alleged abuse.During a concurrent telephone interview and record review on March 9, 2026, at 9:15 AM, the DON reviewed and acknowledged the facility's policy and procedures (P&P) tilted, Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The P&P indicated, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements.

Based on interview and record review, the facility failed to investigate an allegation of sexual abuse involving one of four sampled residents (Resident 1).This failure had the potential for the facility to not identify the concern or any potential harm, allowing ongoing or future abuse to continue which could jeopardize the health and safety of highly vulnerable residents living in the facility.Findings:A review of Resident 1's admission Record (a document containing clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a sudden, life threatening condition where the lungs cannot provide oxygen to the blood or fail to remove carbon dioxide), diabetes mellitus (a disorder characterized by high blood sugar), and hypertension (high blood pressure).A review of Resident 1's AMA (against medical advice - document used by healthcare providers to document a resident's decision to leave a facility or discontinue treatment against medical advice.) Release Form indicated Resident 1 went home against medical advice on February 17, 2026.During a telephone interview on February 23, 2026, at 8:57 AM, with Resident 1's family member, the family member stated he took Resident 1 for an out on pass (temporary, approved leave, allowing residents to leave for family visits) on Sunday, February 15, 2026, during which she alleged that she was sexually abused by a staff in the facility. Resident 1's family member further stated that he had reported to the sheriffs and police department, and had taken Resident 1 home last Tuesday, February 17, 2026, after discharging AMA.During an interview on February 23, 2026, at 12:52 PM, with the Director of Nursing (DON), the DON stated the police came into the facility in response to Resident 1's allegations of abuse. The DON stated the facility did not initiate an investigation nor report to California Department of Public Health (CDPH) because Resident 1 had already been discharged when the facility was made aware of the alleged abuse.During a concurrent telephone interview and record review on March 9, 2026, at 9:15 AM, the DON reviewed and acknowledged the facility's policy and procedures (P&P) tilted, Abuse, Neglect, Exploitation and Misappropriation Prevention Program,. The P&P indicated, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to document a change of condition for one of six sampled residents (Resident 42) when Resident 42 had new physician orders on October 30, 2024, for moisture associated skin damage (MASD-describes a range of skin conditions that occur when the skin is exposed to moisture for a prolonged period of time). This failure had the potential to result in delayed care and treatment for Resident 42 and cause harm. Findings: During an interview on October 28, 2024, at 10:04 AM, with Resident 42, Resident 42 stated he felt discomfort on his genital area due to skin redness. Resident 42 further stated he informed his nurse about redness. During a review of Resident 42's undated Admission Record, the Admission Record indicated Resident 42 was admitted to the facility with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke of the brain affecting weakness to the left side), type 2 diabetes mellitus (chronic condition where the body doesn't use insulin properly), and benign prostatic hyperplasia with lower urinary tract symptoms (condition causing frequent urination, leaking urine, and weak urine stream). During a review of Resident 42's Physician Order dated October 30, 2024, the Physician Order indicated MASD to right buttocks; cleanse with N/S [normal saline - gentle cleaning solution for wounds], pat dry, apply calcium alginate [medication used to treat wounds with drainage] and cover with dry dressing daily x [times] 14 days then re eval [evaluate]. During a concurrent interview and record review on October 30, 2024, at 3:50 PM with the Director of Nursing (DON), the DON reviewed Resident 42's clinical records. The DON was not able to find documented evidence of Resident 42's change in condition for MASD. The DON stated the nurse did not document the change of condition for Resident 42's MASD. The DON further stated it should have been documented. During a concurrent interview and record review on October 31, 2024, at 12:05 PM, with the DON, the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated revised May 2017, was reviewed. The P&P indicated, .1. The nurse will notify . any change in skin integrity such rashes, skin tears, discoloration, etc . 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status and monitor . The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (an individualized plan for the medical care of a resident) for smoking for one of one resident (Resident 70) investigated for smoking. This failure resulted in the facility to not have a plan of care regarding Resident 70's smoking privileges and facility interventions to ensure a safe smoking environment. This had the potential to increase the risk of accidents or injuries associated with fire hazards. Findings: During a review of Resident 70's Admission Record (contains medical and demographic information), the admission record indicated Resident 70 was initially admitted [DATE], with diagnoses which included muscle wasting and atrophy (loss of muscle mass), muscle weakness, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a condition that causes excessive feelings of fear, dread, and worry that persist over time and interfere with daily life), and major depressive disorder (a disorder where the most prominent symptom is a severe and persistent low mood, profound sadness, or a sense of despair.) During a concurrent observation and interview on October 30, 2024, at 6:52 AM, with Resident 70, Resident 70 stated he smoked regularly while living in the facility and stated he smoked approximately every few hours. Resident 70 further stated he kept his own smoking supplies with him and pointed to three boxes of cigarettes on his end table. Resident 70 further stated he also kept his own lighter in his pocket as he pointed to his pocket which was underneath the blanket covering his torso. During a review of Resident 70's medical record, there was no evidence a care plan for smoking had been created for Resident 70. During an interview and concurrent record review on October 30, 2024, at 7:26 AM, with the Director of Nursing (DON), Resident 70's medical record was reviewed. The DON stated Resident 70 should have had a smoking care plan created but stated he was unable to find evidence of one. During a review of the facility's policy and procedure titled, Smoking Policy - Residents, dated 2001, the policy indicated, This facility has established and maintains safe resident smoking practices .7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision .10. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the policy indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .7. The care planning process will: .b. Include an assessment of the resident's strengths and needs; .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to follow physician orders in accordance with the facility's policy and procedure for one of six sampled residents (Resident 44) when Resident 44's enteral feeding (nutrition feeding through a tube into the stomach) was found running at 65 mL/hr (ml-milliliters - a unit of measurement, hr-hour, amount given in an hour) instead of 60 mL/hr, on October 31, 2024 as specified by physician order. This failure had the potential to result in Resident 44 receiving extra calories than ordered by the physician and excessive weight gain. Findings: During an observation on October 28, 2024, at 10:16 AM, in Resident 44's room, Resident 44 was observed to be lying in bed, with the head of the bed elevated, facing the television. Resident 44 was unable to make needs known. During an observation on October 29, 2024, at 4:21 PM, in Resident 44's room, Resident 44's enteral feeding was running at 60ml/hr . During an interview on October 30, 2024, at 2:04 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 44's physician order for enteral feeding was for 60ml/hr for 20 hours. During a review of Resident 44's Physician Order dated July 13, 2024, the Physician Order indicated, Enteral - Glucerna [feeding formula for diabetics] 1.2 [calorie amount] via G-tube [gastrostomy tube-small tube that is inserted into the stomach to provide nutrition and fluids] @ [at] 60 ml/hr x [times] 20 hrs [hours] for a total of 1200ml/ 1440 calories . During a concurrent observation and interview on October 31, 2024, at 9:40 AM, with the Director of Nursing (DON), in Resident 44's room, Resident 44's enteral feeding was running at 65ml/hr. The DON stated the enteral feeding was running at 65ml/hr. The DON stated the physician order indicated Resident 44's order for the enteral formula was at the rate of 60ml/hr. During a concurrent interview and record review on October 31, 2024, at 12:06 PM, with the DON, the facility's undated policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing, and Implementing (Noting) was reviewed. The P&P indicated, Licensed nursing personnel will ensure that . orders will be recorded and implemented. All physician orders are to be complete and clearly defined to ensure accurate implementation. The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 73) investigated for respiratory care, received services as specified by the physician's orders when Resident 73's tracheostomy (a surgically created hole in the windpipe [trachea] that provides an alternative airway for breathing) was not monitored for redness, discharge, and discoloration every shift. This failure had the potential for Resident 73 to experience a delay in the staff identification and subsequent treatment of possible complications with his tracheostomy (such as infection) which would affect the resident's overall health and safety. Findings: During a review of Resident 73's Admission Record (contains medical and demographic information), the admission record indicated Resident 73 was admitted on [DATE], with diagnoses which included muscle wasting and atrophy (loss of muscle mass), Asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways, making it difficult to breathe), dysphagia (difficulty swallowing), immunodeficiency (The decreased ability of the body to fight infections and other diseases) and tracheostomy status (the presence of a tracheostomy). During a review of Resident 73's care plan (an individualized plan for the medical care of a resident) titled, Resident has a Tracheostomy to neck, dated August 20, 2024, the care plan indicated, Interventions .Administer treatments as ordered and monitor for effectiveness . During a review of Resident 73's physician's orders, an order dated August 20, 2024, indicated, Monitor Tracheostomy to neck for redness, discharge, and discoloration every shift. Notify MD (medical doctor) of any changes. During a review of Resident 73's Treatment Administration Record (TAR - a document where staff records monitoring and treatments provided to the resident), dated September 1, 2024, through September 30, 2024, was reviewed. The TAR indicated Resident 73's tracheostomy was documented as being monitored for redness, discharge, and discoloration only one time each day for the entire month of September instead of once every shift (total of three times each day) as specified by the physician's orders. During a review of Resident 73's Treatment Administration Record (TAR - a document where staff records monitoring and treatments provided to the resident), dated October 1, 2024, through October 31, 2024, was reviewed. The TAR indicated Resident 73's tracheostomy was documented as being monitored for redness, discharge, and discoloration only one time each day for the entire month of October instead of once every shift (total of three times each day) as specified by the physician's orders. During a concurrent interview and record review on October 31, 2024, at 11:17 AM, with the Director of Nursing (DON), Resident 73's physician's orders order dated August 20, 2024, was reviewed. The DON stated the physicians order indicated Resident 73's tracheostomy was supposed to be monitored for redness, discharge and discoloration every shift (three times a day). The DON stated it was important to follow physicians orders to monitor Resident 73's tracheostomy to ensure if an infection was present, it (the infection) can be identified and addressed promptly. During a review of the facility's policy and procedure titled, Ostomy Site Care, dated October 2011, the policy indicated, The purposes of this procedure are to promote cleanliness and to protect the ostomy site from irritation, breakdown and infection .Preparation .2. Review the resident's care plan and provide for any special needs of the resident .Steps in the Procedure .7. Assess the stoma site for signs of redness, pain or soreness, swelling, or drainage. Report any of these signs of infection immediately to your supervisor and the resident's physician .

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures for destruction, final disposition, and disposal for medications were followed when six medication tablets were found on top of the medication waste receptacle, available for use on [DATE]. This failure had the potential for the misuse of expired and discarded medications that could harm residents when administered. Findings: During a concurrent observation and interview on [DATE], at 6:50 AM, with Licensed Vocational Nurse 2 (LVN 2) in the facility's medication supply room, six medication tablets were observed on top of the medication waste receptacle, readily available for use. LVN 2 stated the six medication tablets were not narcotics. The LVN 2 further stated the medication tablets were not properly disposed of inside the medication waste receptable and they (the tablets) were not supposed to be on top of the lid. During a concurrent observation and interview on [DATE], at 6:52 AM, with the Registered Nurse 1 (RN 1) in the facility's medication supply room, the RN 1 confirmed that there were six medication tablets on top of the medication waste receptacle. The RN 1 stated the medication tablets were supposed to be properly disposed inside the medication waste receptacle and not on top of the lid. During a concurrent observation and interview on [DATE], at 7:15 AM, with the Director of Nurses (DON), in the facility's medication supply room, the DON stated there were six medication tablets on top of the medication waste receptacle. The DON stated they should have been inside the receptable and not outside where it is available for use. During a concurrent interview and record review on [DATE], at 3:02 PM, with the DON, the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, revised 2019, was reviewed. The P&P indicated, .Non-controlled (drug or chemical whose manufacture, possession, or use is not regulated by law because it is not considered to be dangerous or to cause addiction) and non-hazardous controlled substances (prescription or over-the-counter drug that is not regulated by the Resource Conservation and Recovery Act [RCRA] and not considered hazardous) will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications .Facility must dispose of the controlled substance(s) by depositing in the authorized onsite receptacle .Both controlled and non-controlled substances may be disposed of in the collection receptacle .Document disposal on the medication disposition record. The DON stated the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from one of the two facility's medication supply rooms when one expired intravenous (IV-a method of delivering fluids, nutrients, medications, or blood directly into a vein using a needle or tube) antibiotic (medicine that treats bacterial infections by killing bacteria or preventing them from growing and multiplying) was found in the medication fridge, readily available for use on October 30, 2024. This failure had the potential for the IV antibiotic to have decreased efficacy (ability to produce a desired result) and sub-therapeutic (less than optimal) effects when administered. Findings: During a concurrent observation and interview on October 30, 2024, at 6:57 AM, in the facility's medication supply room, with the Registered Nurse 1 (RN 1), one IV antibiotic medication of Daptomycin (antibiotic to treat a bone infection) was observed to be inside the medication refrigerator where IV medications are stored, readily available for use. The medication had an expiration date of October 29, 2024 (one day expired). The RN 1 stated the antibiotic expiration was on October 29, 2024, and stated expired medications were supposed to be removed from the medication supply room and discarded. During a concurrent observation and interview on October 30, 2024, at 7:15 AM, in the facility's medication supply room, with the Director of Nurses (DON), the DON read the expiration date of the IV Daptomycin and stated it was October 29, 2024. The DON stated it should have been removed from the medication supply room, and further stated it was the responsibility of the nursing staff to ensure expired medications were removed and discarded. During a concurrent interview and record review on October 30, 2024, at 3:02 PM, with the DON, the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, was reviewed. The P&P indicated, .Nursing staff shall be responsible for maintaining storage AND preparation in a clean, safe, and sanitary manner. Facility shall not use discontinued, expired, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The DON stated the policy was not followed. The DON further stated the facility should have followed it to prevent possible misuse of medication that could potentially harm residents.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when Certified Nursing Assistant 1 did not don (put on) a gown upon entering the room of a resident (Resident 391) who was on contact precautions (a set of measures to prevent the spread of infectious agents through direct or indirect contact with a patient or their environment) on October 29, 2024. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 91 medically compromised residents and staff in the facility. Findings: During a review of Resident 391's Admission Record (contains medical and demographic information), the admission record indicated Resident 391 was admitted [DATE], with diagnoses which included sepsis (is an illness in which the body has a severe, inflammatory response to bacteria or other germs), local infection of the skin and subcutaneous tissue (the deepest layer of the skin), and methicillin resistant staphylococcus aureus (MRSA) infection (infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). During a review of Resident 391's physicians orders, an order dated October 16, 2024, indicated, Isolation with: Contact precautions related to MRSA wound infection to BLE [bilateral lower extremities] .every shift until 11/06/2024 [November 6, 2024]. During a review of Resident 391's care plan (an individualized plan for the medical care of a resident) titled, Isolation Precautions: Resident requires contact isolation precautions due to MRSA infection, dated October 16, 2024, the care plan indicated, Interventions .Safe handling of potentially contaminated equipment or surfaces in the resident environment, and respiratory hygiene/cough etiquette .Use of personal protective equipment as recommended for type of infection . During an observation on October 29, 2024, at 4:37 PM, Certified Nursing Assistant 1 (CNA 1), entered Resident 391's room without putting on (donning) a gown. A sign at the entryway of Resident 391's room indicated, STOP - Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also .put on gown (a type of personal protective equipment) before room entry. Discard gown before room exit . CNA 1 then touched Resident 391's phone which was on a charger across the room and provided the phone to the resident. CNA 1 did not put on a gown prior to entering the room or anytime while in the room. CNA 1 then exited Resident 391's room and entered the room of two other residents who had their call light on (and were not on contact precautions). During an interview on October 30, 2024, at 3:54 PM, with the Infection Preventionist (IP), the IP stated staff were supposed to put on gloves and a gown any time they entered a resident's room who was on contact precautions. The IP further stated it would be unacceptable if a staff member entered the room of a resident on contact precautions and touched a phone in the room and handed it to the resident. The IP stated it was important for staff to follow contact precautions to prevent the spread of whatever infectious organism the resident was in isolation for. During an interview on October 31, 2024, at 11:11 AM, with the Director of Nursing (DON), the DON stated staff should be donning gloves and gowns when entering the room of a resident who is on contact precautions. During a review of the facility's policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022, the policy indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Contact Precautions .1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed .

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored in accordance with facility ' s policies and procedures and standards of practice when one of three residents, Resident 3 was observed to have these medications stored at his bedside unlocked: 1. One opened bottle of Genvoya (used to treat infections). 2. An injection pen of Ozempic (used to treat diabetes). This failure had the potential to place Resident 3 ' s health at risk for drug abuse and ingestion of unsanitary drugs. Findings: During a review of Resident 3 ' s Admission Records, the record (contains demographic and medical information), indicated Resident 3 was admitted on [DATE]. With diagnoses that included type 2 diabetes mellitus (a disease of not able to control the blood sugar levels), cirrhosis of liver (a condition of damaged liver) and chronic kidney disease (a condition when the kidneys gradually stop working). During a review of Resident 3 ' s clinical record, History and Physical dated August 7, 2023, indicated, . Assessment: . 7. HIV (human immunodeficiency viruses (a disease that destroys the cells that fight infection in the body) positive Z21 . During an observation and interview on September 11, 2024, at 9:40 AM, with Resident 3, Resident 3 stated, I keep the medicines here with me (Resident 3 reached for a plastic bag lying on his bed took out a bottle of Genvoya and an injection per of Ozempic). He stated, I keep them here (pointing at the bed) with me. During an interview on September 11, 2024, at 9:50 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 was asked if Resident 3 kept his medications by the bedside. The LVN 1 stated, Yes, he keeps the Ozempic and a bottle of Genvoya medications at the bedside, but it is a nurse that administers the medications to him. During an observation and interview on September 11, 2024, at 9:55 AM, with the Director of Nursing (DON), the DON was asked if Resident 3 kept his medications by the bedside. The DON stated, Yes, we let him keep the Ozempic and Genvoya medications at the bedside, so he does not assume the medications are not available. During a review of Resident 3 ' s Order Summary Report included, Genvoya (medication used to treat HIV infection) tablet 150-200-10 milligram . Give 1 tablet by mouth one time a day for retroviral (medication that treats infection). During a review of Resident 3 ' s care plan dated December 23, 2021, indicated, Focus: HIV and AIDS (acquired immunodeficiency syndrome (a disease caused by HIV) at risk for complications manifested by decreased white blood cells count, fatigue, fluid volume deficit, imbalanced . Goal: will have minimal complications related to extent possible . Interventions: Administer medication as ordered . During a review of Resident 3 ' s Order Summary Report included, Ozempic (medication used to treat diabetes mellitus (0.25 or 0.5 milligram/dose [a unit of measurement) subcutaneous solution pen-injector (injection given in the tissue just under skin) 2 milligrams . inject 1 milligram subcutaneously one time a day every Wednesday for diabetes mellitus. During a review of Resident 3 ' s care plan dated September 9, 2024, indicated, Focus: .Resident requires Ozempic medication related to diabetes. Goal: Will exhibit a therapeutic effect related to the use of the medication. Interventions: Administer medication as ordered . During a concurrent interview and record review on September 11, 2024, at 11:25 PM, with the DON, the facility ' s policy and procedure (P&P), titled, Storage of Medications dated, November 2020, was reviewed. The P&P indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . The DON stated, We did not follow the facility policy and procedure, the medications should have been stored in a locked compartment under proper temperature.

Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice. This failure had the potential to delay and promote wound healing for Resident 1 when one staff did not cover the surgical site (a cut in the skin made by a doctor) during surgery) with dry dressing per physician ' s order. Findings: During a review of Resident 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic aftercare (the care and treatment one receives after an injury of the muscles, bones and joints), alcoholic cirrhosis of liver (a condition that causes the liver to become swollen and stiff), left artificial hip joint (left hip replacement surgery) and osteoarthritis (a condition in which the tissues in the joint break down over time). A review of Order Summary Report (physician ' s orders), indicated, .Surgical site to left hip; cleanse with normal saline, pat dry, cover with a dry dressing daily . A review of Resident 1 ' s care plan dated, July 2, 2024, indicated, .Focus: resident has surgical site to left hip. Goal: Will have optimal skin integrity . Interventions: Administer treatments as ordered and monitor for effectiveness . During an interview on August 8, 2024, at 1:20 PM, with Wound Treatment Nurse (WTN 2), the WTN 2 stated, I did not cover the surgical site when I dd the dressing change because the resident (Resident 1) told me she was allergic to the tape. During an interview on August 8, 2024, at 1:55 PM, with the Director of Nurse (DON), the DON stated, Licensed nurses are to verify and follow physician ' s orders for residents care. The DON further stated, I expected the nurse to have covered the resident ' s surgical site with dry dressing as the order indicated. A review of the facility ' s policy and procedure (P&P), titled, Wound Care revised, October 2010, indicated, Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician ' s order for this procedure. Review the resident ' s care plan to assess for any special needs of the resident . Dress wound .

Based on observation, interview, and record review the facility failed to provide a comprehensive person-centered care plan for one of four sample residents (Resident 1) who had used and tested positive for an illicit drug (a drug that is not allowed by the law). This failure had the potential to place Resident 1's overall health and safety at risk. Findings: During a review of Resident 1's Admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, shortness of breath, opioid use (a chronic condition that causes a person to have an uncontrollable urge to use unlawful drug), other acute and chronic respiratory failure (a condition that makes it difficult to breath on your own) and major depressive disorder a condition that affect how a person feels). A review of Resident 1's hospital records, titled, Discharge Summary page 4 of 36 indicated, Ms. [Name of Resident 1] is a [AGE] year with a history of stroke . and methamphetamine abuse who was brought to the Emergency Department from [NAME] Palms Skilled Nursing Facility on 02/24/25 for shortness of breath and altered mental status . On 02/27/2024 .She is to follow up with her primary care provider for management of her medical problems. During an interview on May 5, 2024, at 11:50 AM with the Licensed Vocational Nurse, when asked about Resident 1, the LVN 1 stated, We were not formerly informed about the resident's illicit drug condition. The daughter of the resident told me the mother had tested positive to illicit drug while in the hospital. During an interview on May 5, 2024, at 12:30 PM with the Director of Nursing (DON), the DON stated, We got a call from the acute hospital that the resident was returning to the facility and that she had tested positive for methamphetamine (a drug that is not allowed by the law). When asked if there was a plan of care in place to monitor resident for provide treatment, the DON stated, No we did not have a care plan. During a concurrent interview and record review on May 5, 2024, at 3:00 PM with the DON, the facility's policy and policy and procedure (P&P) titled, Behavioral Health Services dated February 2019 was reviewed. The P&P indicated, Policy Statement 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . 5 . b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs . The DON stated, There should have been a care plan in place to monitor the resident. During a concurrent interview and record review on May 5, 2024, at 3:00 PM with the DON, the facility's policy and P&P titled, Behavioral Assessment, Intervention and Monitoring dated March 2019 was reviewed. The P&P indicated, . Policy Interpretation and Implementation .Assessment 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder . Management 1. The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly . Monitoring .2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . The DON stated, The IDT should have put in place a care plan for assessment, intervention and monitoring of the resident.

Based on observation, interview, and record review, the facility failed to ensure medications were administered per the physician orders [REDACTED]. 1. For Resident 12, [MEDICATION NAME] (a medication used to treat high blood pressure) was not administered a total of 15 times on days that the resident was out of the facility receiving [MEDICAL TREATMENT] treatment. This failure had the potential to place Resident 12 at risk for elevated blood pressure potentially causing serious medical complications [REDACTED]. 2. For Resident 15, [MEDICATION NAME] (a medication used to treat abnormal heart rhythm) was not given a total of 13 times on days that the resident was out of the facility receiving [MEDICAL TREATMENT] treatment. This failure had the potential to place Resident 15 at risk for abnormal heart rhythm causing serious medical complications [REDACTED]. An Immediate Jeopardy (IJ) situation was called on May 13, 2016, at 11:45 AM, in the presence of the facility's Administrator, Assistant Administrator, Director of Nurses (DON), and the Director of Staff Development (DSD), and they were verbally notified. Specific details of the Immediate Jeopardy situation, including the residents who were at risk due to medications not given as ordered by the physician, were provided to the Administrator, Assistant Administrator, Director of Nurses, and the Director of Staff Development. The facility provided a corrective action plan which included: 1. Physician orders [REDACTED]. 2. The Medication Administration Record [REDACTED] 3. The DON conducted an in-service to the licensed staff. 4. Facility included in their policy that nurses are to notify the attending physician if medications are not given to residents before and after returning from [MEDICAL TREATMENT] treatments. On May 13, 2016 at 3:12 PM, after interviews and record reviews were conducted to verify physician orders, the updated facility policy, and the in-services to licensed nurses were completed as per the corrective action plan, the IJ was lifted in the presence of the Administrator, Assistant Administrator, Director of Nurses, and the Director of Staff Development. Findings: 1. During a review of Resident 15's medical record, on May 12, 2016, the Resident Face Sheet indicated the resident was admitted on [DATE], with the following Diagnoses: [REDACTED].{kidney}failure), history of CABG (coronary artery bypass graft; create new routes around narrowed and blocked coronary arteries), Hypertension (high blood pressure), Unspecified [MEDICAL CONDITION] (abnormal and irregular heart rhythm), Heart Failure, unspecified (severe failure of the heart to function properly), and [MEDICAL CONDITION] (is a narrowing of blood vessels that restricts blood flow). A review of Resident 15's Medication Administration Record [REDACTED]. Resident 15 was not given the 9:00 AM dose of [MEDICATION NAME] medication per physician order [REDACTED]. February 13, 18, and 23, 2016 March 12, 24, 29, and 31, 2016 April 5, 12, 23, and 30, 2016 May 5 and 10, 2016 During an interview on May 12, 2016 at 2:05 PM, with Licensed Vocational Nurse (LVN 3), she stated that Resident 15 leaves for [MEDICAL TREATMENT] prior to receiving the 9:00 AM medications. LVN 3 confirmed that the medications are held without a physician order [REDACTED]. LVN 3 stated that she did not call the doctor to notify him that the medications due to be given at 9:00 AM had been held. During an interview on May 12, 2016 at 2:15 PM with the Director of Nurses (DON), he stated that [MEDICAL TREATMENT] patients should have orders to hold medications on [MEDICAL TREATMENT] days. The DON confirmed that the MEDICATION ORDERS FOR [REDACTED]. During a phone interview on May 12, 2016 at 2:30 PM with Resident 15's attending physician, he stated that he was made aware by facility staff that Resident 15 was not receiving the [MEDICATION NAME] at 9:00 AM on [MEDICAL TREATMENT] days as ordered. The attending physician (AP) stated that he told the staff, That's fine, just give it when he comes back. When asked what staff member he had spoken to, the attending physician was unable to recall who he had spoken to. During an interview on May 13, 2016 at 9:02 AM, with the Clinical Manager of the [MEDICAL TREATMENT] center, she stated that the only mediation given to Resident 15 at the [MEDICAL TREATMENT] center is [MEDICATION NAME] (a medication used to prolong the clotting time of blood). The Clinical Manager said that a daily correspondence form is used on every [MEDICAL TREATMENT] day to maintain communication between the facility and the [MEDICAL TREATMENT] center. On May 12, 2016, during a review of the facility's policy titled, [MEDICAL CONDITION], Care of a Resident with, dated 2001 MED-PASS, Inc. (Revised October 2009), under the section titled: Policy Interpretation and Implementation, 2. Education and training of staff includes, specifically: f. Timing and administration of medications, particularly those before and after [MEDICAL TREATMENT]. The policy did not given any additional information on how or what was to been done with medications that were to be given if the resident was at the [MEDICAL TREATMENT] facility. A review of the facility's policy titled, Administering Medications, dated 2001 MED-PASS, Inc. (Revised April 2010), under the section titled: Policy Interpretation and Implementation, 3. Medications must be administered in accordance with the orders, including any required time frame. 2. During a review of Resident 12's medical record on May 12, 2016, the Resident Face Sheet indicated the resident was admitted on [DATE], with the following Diagnoses: [REDACTED]. A review of Resident 12's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Resident 12 was not given the 2:00 PM dose of [MEDICATION NAME] medication per the physician's orders [REDACTED]. March 17, 19, 22, 24, and 26, 2016. April 2, 7, 9, 12, 14, 16, 19, and 20, 2016. May 3 and 7, 2016. A review of Resident 12's progress notes, on the dates that the medication was not given, indicated no documented evidence that the attending physician was called and was informed of the missed medication. During an interview on May 12, 2016 at 2:15 PM with the Director of Nurses (DON), he stated that [MEDICAL TREATMENT] patients should have orders to hold medications on [MEDICAL TREATMENT] days. The DON confirmed that the MEDICATION ORDERS FOR [REDACTED]. During an interview on May 13, 2016 at 9:02 AM, with the manager of the [MEDICAL TREATMENT] center, he stated that the only medications related to [MEDICAL TREATMENT] that his facility provides are IV (intravenous, into a vein) medications. When asked if the facility ever sends medications with Resident 12, the [MEDICAL TREATMENT] center manager stated, No. During an interview on May 13, 2016 at 11:15 AM, LVN 2 stated that sometimes the resident takes the medication scheduled with them to be given while at [MEDICAL TREATMENT]. When asked what resident unavailable means, as reflected on the MAR, LVN 2 stated that it means either he did not take medications or he left without telling me. When asked if she is to call the attending physician with each episode of missed medications, LVN 2 stated, Yes we are supposed to. I forgot to document in the progress notes yesterday. During an observation and interview with Resident 12 on May 13, 2016 at 1:50 PM, he stated, They hold the med and my blood pressure goes up while at the [MEDICAL TREATMENT]. Resident 12 further stated that they do take his blood pressure prior to [MEDICAL TREATMENT] and when he does take his blood pressure medication prior to [MEDICAL TREATMENT] his blood pressure is down. On May 12, 2016, during a review of the facility's policy titled, [MEDICAL CONDITION], Care of a Resident with, dated 2001 MED-PASS, Inc. (Revised October 2009), under the section titled: Policy Interpretation and Implementation, 2. Education and training of staff includes, specifically: f. Timing and administration of medications, particularly those before and after [MEDICAL TREATMENT]. The policy did not give any additional information on how or what was to been done with medications that were to be given if the resident was at the [MEDICAL TREATMENT] facility. A review of the facility's policy titled, Administering Medications, dated 2001 MED-PASS, Inc. (Revised April 2010), under the section titled: Policy Interpretation and Implementation, 3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 sampled residents (Resident 1) by not implementing the care plan to prevent repeat incidents when Resident 1 fell on [DATE]. This failure resulted in Resident 1 being transferred to the hospital for medical treatment. Resident 1 was diagnosed with [REDACTED]. Resident 1 was found on July 27, 2014 in the facility's back parking lot. The facility failed to develop a care plan to prevent repeat elopement for Resident 1 after he was found on July 27, 2014 in the back parking lot. On July 29, 2014, Resident 1 was found by the paramedics approximately a mile away from the facility. This failure resulted in Resident 1 experiencing a significant medical change of condition with an altered mental status (an abnormal change in responsiveness and awareness) and syncope (temporary loss of consciousness caused by a fall in blood pressure), and a transfer to the acute hospital for medical treatment which included IV (intravenous) fluids. Findings: 1. A review of the clinical record for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical report dated July 1, 2014, reflected the physician documented Resident 1 was alert, oriented x 2 (Person and place), and with a history of falls at home. A review of the nurse's progress note dated July 4, 2014, at 9:35 AM, documented; "At around 8:55 AM, found resident lying flat on the floor next to his shower chair...He was still on the shower chair...Resident got up from the shower chair and fell ." Resident 1 complained of 8/10 (pain scale to determine the severity of a residents pain, the higher the number the greater the pain) pain to the back of his head. Resident 1 was transferred to the acute hospital's emergency room (ER). Resident 1 sustained a cervical (neck) sprain as a result of this fall. During an interview with Registered Nurse (RN) 1, on September 10, 2014, at 7:50 AM, she stated Resident 1 was alert with periods of forgetfulness and confusion. RN 1 stated Resident 1 was at a high risk for falls. On July 4, 2014, Certified Nursing Assistant (CNA) 1 wheeled Resident 1 into his room after finishing a shower. CNA 1 then told Resident 1 to wait when she was going to answer another resident's call light, across the hall of Resident 1's room. Resident 1 remained in the shower chair when CNA 1 left the room. During the investigation, CNA 1 informed RN 1 that she left Resident 1 sitting on the shower chair in his room unattended. CNA 1 also informed RN 1 that the call light was not within the resident's reach when she left the resident by himself in the room. When CNA 1 returned to Resident 1's room, CNA 1 found Resident 1 was on the floor. A review of the care plan for "ADL (Activity of Daily Living such as bathing, toileting, etc) functional...", dated June 28, 2014, documented that Resident 1 identified with "Impaired functional mobility, impaired ADL skill, decreased strength and endurance, decreased balanced and coordination, cognitive, perceptual deficit..." A review of the clinical record for Resident 1, reflected a care plan for "at risk for falls" dated June 28, 2014 which showed, "Approach" (interventions); Call light within reach..." During an interview with CNA 1 on September 10, 2014, at 8 AM, she stated on July 4, 2014, she left Resident 1 alone in his room unattended, sitting on the shower chair. CNA 1 stated she had to leave Resident 1 to attend to another resident's call light, which was across the hallway from Resident 1's room. CNA 1 stated Resident 1 was alert with confusion and was forgetful. CNA 1 stated, "I should have not left him sitting on the shower chair in the room by himself." She was asked if the call light was provided to Resident 1 or if the call light was within the resident's reach. CNA 1 responded, "No." She stated the call light should have been placed within Resident 1's reach where the resident can easily use it to call the staff when he needed assistance. CNA 1 acknowledged that Resident 1 was at a high risk for falls. A review of the physician's progress notes dated July 11, July 14 and July 17, 2014, documented that Resident 1 required a fall precaution due to a history of falls. A review of the facility policy and procedure, titled " Falls and Fall Risk, Management", dated December 2007, indicated "...the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." 2. During an observation of Resident 1 on July 31, 2014 at 12 noon, he was observed sitting on the edge of his bed with his family surrounding him. He was alert and verbally responsive. A review of the clinical record for Resident 1 showed an event report dated July 27, 2014 at 7:48 PM, which documented the resident was found at the facility back parking lot trying to elope. A review of the Event Details Elopement, dated July 27, 2014, indicated " Elopement-Occurs when a resident leaves the facility premises or safe area without authorization and/or any necessary supervision to do so...with no order for discharge or leave of absence." A review of the clinical record for Resident 1, reflected a progress note dated July 27, 2014 at 8:23 PM, which documented; "resident was found by the back of the facility trying to elope. Resident said my wife is not picking my call I have to go home. Resident was assist back to the facility ...will continue to monitor for elopement." Review of the nurses progress notes for Resident 1 dated July 27,2014 at 3:24 AM, documented "resident alert with periods of confusion and forgetfulness at times." A review of the Interdisciplinary Team notes for Resident 1, dated July 28, 2014, documented an interview with the resident;"... he stated that his wife is not responding to all of his calls, that's why he wanted to go home ... " Further review of the clinical record for Resident 1, reflected there was no care plan developed to prevent a repeat elopement, after the elopement episode identified on July 27, 2014. The medical record designee (MRD) verified there was no elopment assessment, care plan and monitoring system provided to Resident 1 after the elopement episode identified on July 27, 2014. This finding was verified by the MRD at the time of record review on July 31, 2014 at 12:25 PM. An interview was conducted with the Director of Nursing (DON) on October 27, 2014 at 4:40 PM, she stated that the care plan is updated as needed, quarterly and /or when there is a change in the resident's condition. A review of the nurse's progress notes dated July 29, 2014 at 1 PM, documented that Resident 1 left the facility. A review of the care plan dated July 29, 2014 documented "Resident left facility without signing out." During an interview with the DON on July 31, 2014 at 12:30 PM, the DON was asked if Resident 1 had an authorization to leave the facility on pass on July 29, 2014, the DON responded, "No." When asked if the facility knew where the resident was, the DON stated, "No." The DON stated Resident 1 had eloped from the facility on July 29, 2014. She stated the charge nurse had sent Restorative Nursing Assistant (RNA) 1 to look for Resident 1. The DON stated, Resident 1 was transferred to the acute hospital on July 29, 2014, straight from the location, where the paramedic found Resident 1. During an interview with RN 1 on August 5, 2014 at 4:10 PM, she stated Resident 1 had episodes of forgetfulness and confusion. On July 29, 2014 at approximately 12 PM, Licensed Vocational Nurse (LVN) 1 reported to her that Resident 1 was missing. RN 1 stated she received a phone call from the paramedic around lunch time, informing her that Resident 1 was found, approximately a mile away from the facility. The facility then sent RNA 1 and the maintenance supervisor (MS) to pick Resident 1 up. Review of the nurses progress notes for Resident 1 dated July 29,2014 at 6:22 AM, documented "res (resident)...noted to have episodes of forgetfulness/confusion at times..." During an interview with RNA 1 on July 31, 2014 at 12:40 PM, he stated that on July 29, 2014, he and the MS were asked by the licensed nurse to pick up Resident 1 on the corner of the street, approximately a half to one mile away from the facility. RNA 1 stated when they had arrived on the location, Resident 1 was being treated by the paramedics and was already loaded into the ambulance. RNA 1 further stated the paramedic had already called the facility to let the facility know they had found him. A review of the paramedic report for Resident 1, dated July 29, 2014 at 1:00 PM, showed the following: "AOS (arrived on scene) to find 74 YOM (year old male) in care of ME541 (Paramedics) on street in wheelchair with C/C (change of condition) of ALOC (altered level of consciousness). Per ME541 Captain, Pt. is a resident of (name of facility). ME541 contacted (name of facility) and spoke to staff whom per ME541 Captain would not disclose the time that patient was last seen at their facility. Pt (Patient)'s skin are dry and flushed and hot to touch, oral temperature (measured body temperature using a thermometer in the mouth) 103.3 (Normal body temperature 98.6 degrees Fahrenheit)) ...blood pressure (BP) at 1:30 PM was 94/33 mmHg (Normal BP is 120/80 mmHg ), received oxygen (Oxygen is widely used for emergency medicine) at 15 liters (high flow oxygen is definitively indicated for use in hypoxemia-abnormal low level of oxygen in the blood) per minute (LPM)." Resident 1's pulses; at 1:10 PM pulse was 129, at 1:13 PM pulse was 126, at 1:18 PM pulse was 122, at 1:20 PM pulse was 123. The pulses indicated rapid and abnormal. (Normal pulse for elderly= 60-100/ minute). The report showed, the resident was found one half to one mile away from the facility. Review of the weather forecast for July 29, 2014 around 12 PM, showed the weather temperature for the location where the paramedics found Resident 1 was 95 degrees Fahrenheit (indicated the weather temperature was too hot for an elderly person). During a review of the hospital's ER records dated July 29, 2014; Resident 1 arrived at the ER at 1:50 PM, suffered with altered mental status and syncope. Resident 1 received 3 liters (3 large jugs of soda, 33.81 oz (ounces) per liter-more than 12 glasses of water) of IV (intra venous) fluids (indicating Resident 1 was dehydrated (lack of fluids). Resident 1 was discharged from the ER with [DIAGNOSES REDACTED]. During an interview with Resident 1 and his wife on July 31, 2014 at 12:00 noon, he stated he did remember the incident but could not remember the exact date when the incident occurred. Resident 1 stated he was wheeling his wheelchair on the street and not knowing where to go but he kept "going and going , I was tired and exhausted." Resident 1's wife stated she was called and informed that Resident 1 was in the emergency room (ER). She further stated Resident 1 received at least "2 bags of IV fluids."

Based on observation, interview, and record review, the facility failed to conduct periodically a comprehensive assessment that identifies the patient's current health status as evidenced by failure to conduct a comprehensive pain assessment when there was worsening of existing pain for 1 of 19 sampled residents (Resident 16). This failure resulted in the facility's failure to adequately evaluate the effectiveness of the pain management interventions, notify the physician of increased pain, and to modify the plan of care based on the resident's current pain status. This failure further resulted in the resident's increasing frequency of complaints of pain, two to 4 times a day for 10 consecutive days. Findings: During an observation of Resident 16 on July 24, 2014 at 11:08 AM, Resident 16 was up in a wheelchair in the dining room, alert and oriented to time, place and situation, and able to answer questions verbally and appropriately. Resident 16 had an arteriovenous fistula (AVF- surgical connection of two blood vessels) shunt on the right upper arm used as an access site during [MEDICAL TREATMENT] (process of removing waste from the blood with the use of a machine) treatment; [MEDICAL CONDITION] (BKA) on both legs with leg prosthesis on. Resident 16 was able to propel himself slowly in a wheelchair independently. In a concurrent interview with Resident 16 on July 24, 2014 at 11:08 AM, he stated he had been having frequent and increasing pain of his hands, arms and upper legs even though he received pain medication on a regular basis. Resident 16 explained that he had reported his worsening pain to the medication (med) nurses (LVNs- {licensed vocational nurses}) multiple times, however, they (med nurses) continued to tell Resident 16 he could not have another (dose of) pain medication because, "It's not time yet" (for the next scheduled administration), and that he could not have more than what was ordered. Resident 16 further stated, "So, I just have to endure the pain, I have no other choice but to wait for the next dose (of pain medication)." A review of Resident 16's medical record on July 24, 2014, indicated the resident was [AGE] years of age and had [DIAGNOSES REDACTED]. Resident 16 received [MEDICAL TREATMENT] (process of removing waste from the blood with the use of a machine) treatment three times per week from an outside [MEDICAL TREATMENT] clinic. A review of the physician's orders [REDACTED]. The pain medication regimen included the following: [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and is also used for joint, back or muscle pain) 200 milligrams (mg) tablet (tab), 1 tab by mouth (PO) once daily (QD). [MEDICATION NAME] (medication used for moderate to moderately severe pain) 50 mg tab, 1 tab PO twice a day (BID) for chronic (long standing) pain. [MEDICATION NAME] (a combination of Tylenol and [MEDICATION NAME], a narcotic pain medication) 325/5 mg tab, 1 tab PO every 4 hours (Q 4 hrs) as needed (PRN) for moderate pain. Despite administration of the resident's current pain management regimen, Resident 16's pain had progressed from moderate to severe, and had increased in frequency from occasional to 2 to 4 times per day from July 15, 2014 to present (July 24, 2014). The complaints of pain were reflected by a pain scale of 0-10 (0= no pain; 1-2= least pain; 3-4= mild; 5-6= moderate; 7-8= severe; 9-10= very severe pain) and included the following: July 15, 2014 (7/15/14), at 11 AM- complained of generalized pain; intensity level at 6 out of 10 (6/10 - moderate) 7/15/14, at 8 PM- body pain at 6/10 7/16/14, at 5 AM- generalized body pain at 5/10 7/17/14, at 5 AM - generalized body pain at 5/10 7/17/14, at 8 PM- generalized body pain at 6/10 7/18/14, at 12:30 AM- generalized body pain at 5/10 7/18/14, at 6 AM- generalized body pain at 5/10 7/18/14, at 12:30 PM- generalized body pain at 6/10 7/18/14, at 9 PM- body pain at 6/10 7/19/14, at 5 AM- generalized body pain at 6/10 7/19/14, at 12 PM- generalized body pain at 6/10 7/19/14, at 9:45 PM- body pain at 6/10 7/20/14, at 5 AM- generalized body pain at 6/10 7/20/14, at 9 PM- body pain at 6/10 7/21/14, at 8 AM- generalized body pain at 6/10 7/21/14, at 12 PM- generalized body pain at 6/10 7/21/14, at 6 PM- body pain at 7/10 (severe pain) 7/22/14, at 12 PM, generalized body pain at 6/10 7/22/14, at 10 PM, generalized pain at 7/10 (severe pain) 7/23/14, at 5 AM, generalized body pain at 6/10 7/23/14, at 12 PM, generalized pain at 6/10 7/24/14, at 5 AM, generalized pain at 5/10 7/24/14, at 9 AM, generalized pain at 6/10 A review of the resident comprehensive minimum data set (MDS- a comprehensive resident assessment) dated July 19, 2014, indicated that Resident 16 was readmitted to the facility on [DATE], and had a pain intensity level of moderate occasional pain. The pain management plan of care for pain, dated July 15, 2014, included to administer pain medication as ordered; to observe the effectiveness of medication and to encourage the resident to discuss feelings about pain. There was no documentation that a comprehensive re-assessment of the resident's worsening and increased frequency of pain had been conducted. The comprehensive plan of care that addressed pain management had not been adjusted based on the resident's current assessment results. In an interview with the Registered Nurse MDS Coordinator on July 24, 2014 at 3:05 PM, regarding Resident 16's frequent complaint of moderate to severe pain, the MDS Coordinator was asked if a comprehensive pain assessment had been conducted. The MDS Coordinator reviewed Resident 16's medical record and stated that an assessment of the resident's complaint of abdominal pain had been conducted on July 18, 2014. The MDS Coordinator acknowledged there was no documentation to indicate that a comprehensive pain assessment was conducted to evaluate Resident 16's frequent complaint of pain (of 2-4 times per day) with increasing intensity of moderate to severe pain. In an interview with the Registered Nurse (RN) Supervisor 1 on July 25, 2014 at 8:58 AM, regarding evaluation of Resident 16's pain management regimen, RN Supervisor 1 stated that a reassessment to evaluate the resident's pain had to be conducted when there was a change in the patient's (resident's) condition, such as worsening of the pain, and that the physician would be notified. A review of the policy and procedure provided by the facility titled, "Pain Assessment and Management", with a revised date of April 2009, the policy general guidelines included the following: "Pain management is a multidisciplinary care process that includes ... monitoring the effectiveness of interventions and modifying approaches as necessary ... Conduct a comprehensive pain assessment ...whenever there is significant change in condition, and when there is onset of new pain or worsening of existing pain." The steps in the procedure included the following: "...Review the Medication Administration Record [REDACTED]"

Based on observation, interview, and record review, the facility failed to ensure necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being were provided for 2 of 19 sampled residents (Resident 16 and 19) and 1 of 6 unsampled residents (Resident A) as evidenced by: 1. Failure to re-evaluate the resident's pain management regimen when Resident 16 showed worsening of existing pain manifested by increasing frequency and intensity of pain level. This failure resulted in the facility's failure to effectively monitor the effectiveness of the pain management interventions and to modify the plan of care, which further resulted in the resident's continued suffering of pain. 2. A [MEDICATION NAME] (a blood thinning medication used to avoid blood clots in the deep veins of the legs) injection solution medication ordered on June 9, 2014, for unsampled Resident A, was not administered on June 21, 22, and 23, 2014 as ordered by the physician. This failure had the potential to cause blood clot formation and stroke affecting the overall condition and safety of Resident A. 3. An [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] {low red blood cell count}) injection medication ordered on July 15, 2014, for Resident 19, was not administered on time during a 9:00 AM medication pass observation. This failure had the potential for Resident 19 with a low hemoglobin (iron containing pigment of red blood cells that carries oxygen) of 8.1 to experience an even lower hemoglobin serum level (normal range is 11.5 - 15.5 g/dl {grams per deciliter} a unit of measure) which could have resulted in Resident 19 going to the hospital for a blood transfusion. Findings: 1. During an observation of Resident 16 on July 24, 2014 at 11:08 AM, Resident 16 was up in a wheelchair in the dining room, alert and oriented to time, place and situation, and able to answer questions verbally and appropriately. Resident 16 had an arteriovenous fistula (AVF- surgical connection of two blood vessels) shunt on the right upper arm used as an access site during [MEDICAL TREATMENT] (process of removing waste from the blood with the use of a machine) treatment; [MEDICAL CONDITION] (BKA) on both legs. In a concurrent interview with Resident 16 on July 24, 2014 at 11:08 AM, he stated he had been having frequent and increasing pain on his hands, arms and upper legs area even though he received pain medication on regular basis. Resident 16 explained that he had reported his worsening pain to the medication (med) nurses (LVNs- {licensed vocational nurses}) multiple times, however, they (med nurses) continued to tell Resident 16 he could not have another (dose of) pain medication because "It's not time yet" (for the next scheduled administration), and that he could not have more than what was ordered. Resident 16 further stated, "So, I just have to endure the pain, I have no other choice but to wait for the next dose (of pain medication)." A review of Resident 16's medical record on July 24, 2014, indicated the resident was [AGE] years of age and had [DIAGNOSES REDACTED]. Resident 16 received [MEDICAL TREATMENT] (process of removing waste from the blood with the use of a machine) treatment three times per week from an outside [MEDICAL TREATMENT] clinic. The resident minimum data set (MDS- a comprehensive resident assessment) re-admission assessment, dated July 19, 2014, indicated that Resident 16 was readmitted from the hospital after undergoing a surgical procedure of declotting (removal of blood clot) of the resident's AVF shunt. Resident 16's pain intensity level was documented as "moderate" with frequency of "occasional' pain." The plan of care for pain dated July 15, 2014 included, to administer pain medication as ordered; to observe the effectiveness of medication and to encourage the resident to discuss feelings about pain. A review of the Medication Administration Record [REDACTED]. Resident 16's pain had progressed from moderate to moderate to severe, and had increased in frequency from occasional to 2 to 4 times per day from July 15, 2014 to present (July 24, 2014). The complaints of pain were reflected by pain scale of 0-10 (0= no pain; 1-2= least pain; 3-4= mild; 5-6= moderate; 7-8= severe; 9-10= very severe pain) and included the following: July 15, 2014 (7/15/14), at 11 AM- complained of generalized pain; intensity level at 6 out of 10 (6/10- moderate) 7/15/14, at 8 PM- body pain at 6/10 7/16/14, at 5 AM- generalized body pain at 5/10 7/17/14, at 5 AM - generalized body pain at 5/10 7/17/14, at 8 PM- generalized body pain at 6/10 7/18/14, at 12:30 AM- generalized body pain at 5/10 7/18/14, at 6 AM- generalized body pain at 5/10 7/18/14, at 12:30 PM- generalized body pain at 6/10 7/18/14, at 9 PM- body pain at 6/10 7/19/14, at 5 AM- generalized body pain at 6/10 7/19/14, at 12 PM- generalized body pain at 6/10 7/19/14, at 9:45 PM- body pain at 6/10 7/20/14, at 5 AM- generalized body pain at 6/10 7/20/14, at 9 PM- body pain at 6/10 7/21/14, at 8 AM- generalized body pain at 6/10 7/21/14, at 12 PM- generalized body pain at 6/10 7/21/14, at 6 PM- body pain at 7/10 (severe pain) 7/22/14, at 12 PM, generalized body pain at 6/10 7/22/14, at 10 PM, generalized pain at 7/10 (severe pain) 7/23/14, at 5 AM, generalized body pain at 6/10 7/23/14, at 12 PM, generalized pain at 6/10 7/24/14, at 5 AM, generalized pain at 5/10 7/24/14, at 9 AM, generalized pain at 6/10 In an interview with the Registered Nurse MDS Coordinator on July 24, 2014 at 3:05 PM, regarding Resident 16's frequent complaint of moderate to severe pain, the MDS Coordinator was asked if a comprehensive pain assessment had been conducted. The MDS Coordinator reviewed Resident 16's medical record and stated that an assessment of the resident's complaint of abdominal pain had been conducted on July 18, 2014. The MDS Coordinator acknowledged there was no documentation to indicate that a comprehensive pain assessment was conducted that addressed Resident 16's frequent complaint of pain (of 2-4 times per day) with increasing intensity of moderate to severe pain. There was no documented evidence that the Medication Administration Record [REDACTED]. There was no documentation that the comprehensive plan of care for pain management had been adjusted based on the resident's current pain status. In an interview with the Registered Nurse (RN) Supervisor 1 on July 25, 2014 at 8:58 AM, regarding evaluation of pain management regimen, RN Supervisor 1 stated that a reassessment to evaluate the resident's pain had to be conducted when there was a change in the patient's (resident's) condition, such as worsening of the pain, and that the physician would be notified. A review of the policy and procedure provided by the facility titled, "Pain Assessment and Management" with a revised date of April 2009, the policy general guidelines included the following: "Pain management is a multidisciplinary care process that includes ... monitoring the effectiveness of interventions and modifying approaches as necessary ... Conduct a comprehensive pain assessment ...whenever there is significant change in condition, and when there is onset of new pain or worsening of existing pain." The steps in the procedure included the following: "...Review the Medication Administration Record [REDACTED]" 2. During a review on July 23, 2014 of Resident A's face sheet and the physician orders, records noted that the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].{[MEDICATION NAME] is a blood thinning medication used to avoid blood clots in the deep veins of the legs, most commonly the femoral vein.}) to be given once a day. A review of the Medication Administration Record [REDACTED]. An interview was conducted with a Licensed Vocational Nurse (LVN 5) on July 23, 2014 at 10:35 AM and a concurrent review of the clinical records including the MAR for July 2014. LVN 5 confirmed that the [MEDICATION NAME] medication ordered on July 9, 2014 was not administered on July 21, 22, and 23, 2014 at 9 AM. She stated, "It has been circled as not given on July 21, 22, and {today} July 23, 2014 at 9 AM; the medication is still not available." LVN 5 stated that she called the facility's pharmacy to find out why it was not available and to tell the pharmacy the medication was needed. LVN 5 confirmed that there was no documented evidence that the medication refill order to the facility's pharmacy was processed per the facility's policy, or that the phone call with the pharmacist was documented in the resident's clinical record. During an interview with the DON (Director of Nurses) on July 23, 2014 at 11:40 AM and a concurrent review of the MAR for July 2014, and the physician orders, she confirmed that the medication [MEDICATION NAME] was not administered as ordered by the physician on July 21, 22, and 23, 2014. She stated that the licensed nurses failed to follow the facility's policy and procedure for reordering medications and should have notified the charge nurse for further assistance, to ensure that the medication was available on-hand for Resident A. A review of the facility's policy and procedure titled, "Physicians' Medication Orders", revised April 2014, noted under Policy Interpretation and Implementation," ...9. Drugs and biological's that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available." 3. During a review on July 23, 2014 of Resident 19's face sheet and the physician orders, records noted that the resident was readmitted on [DATE] (following a transfer to the hospital for gastrointestinal {pertains to the entire digestive tract, from the mouth to the anus} bleeding) and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Special instructions: for CKD ([MEDICAL CONDITION]). Until hemoglobin (the iron containing pigment of red blood cells that carries oxygen from the lungs to the tissues) is > (greater) than 11.5. A review of the Medication Administration Record [REDACTED]. During an interview with LVN 5 on July 23, 2014 at 11:00 AM, when asked why the [MEDICATION NAME] was not administered, she stated that the medication was not available when she checked for it. She stated that she looked for it in the medication room [ROOM NUMBER] refrigerator. An observation of the refrigerator with LVN 5 was conducted and when she opened the refrigerator door, she pointed to the shelves directly in front only, but failed to check the refrigerator's door shelf where the medication was actually stored. The [MEDICATION NAME] vial was labeled with Resident 19's name, and was dated July 22, 2014 (Tuesday) for Wednesday's next dose July 23, 2014. LVN 5 stated, "Oh there it is, I didn't see it there, I didn't look there." During an interview with the DON (Director of Nurses) on July 23, 2014 at 11:40 AM, and a concurrent review of the MAR for July 2014, and the physician orders, she confirmed that the [MEDICATION NAME] was stored in the refrigerator and should have been given to Resident 19 at 9 AM, as ordered by the physician. She also stated that the licensed nurses failed to follow the facility's policy and procedure for reordering medications and should have notified the charge nurse for further assistance, to ensure that the medication was available on-hand for Resident 19. A review of the facility's policy and procedure titled, "Physicians' Medication Orders" revised April 2014, it noted under Policy Interpretation and Implementation," ...9. Drugs and biological's that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available."

Based on observation, interview, and record review, the facility failed to follow the physician's order as prescribed. This failure had the potential for 2 out of 5 Sampled Residents (Resident 10 and Resident 11) and 1 out of 4 Unsampled Residents ( Resident G) to not receive necessary care as prescribed by the physician. Findings: 1. A review of the clinical record for Resident 10 on September 3, 2014, indicated that Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician orders indicated an order dated July 11, 2014 for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-a narcotic pain medication used to relieve moderate to severe pain) 325 mg-10 mg (milligrams) one tablet by mouth every 6 hours as needed for pain to the left below-the-knee amputation and back. The order indicated to "hold (medication administration) if RR (respiratory rate) < 12 (below 12 breaths per minute)." This order was discontinued on August 15, 2014.A physician order dated August 15, 2014 indicated an order for [REDACTED].< 12."A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED].A review of the care plan dated March 1, 2014 indicated that Resident 10 was "at risk for adverse effect from [MEDICATION NAME]. A drug with potential to cause serious side effects ... unintended respiratory depression ..."2. During a review of the clinical record for Resident 11 on September 3, 2014, the face sheet and the physician orders indicated that Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED].A physician order dated July 1, 2014 indicated an order for [REDACTED].< 12."A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence that Resident 11's respiratory rate was assessed prior to the administration of the [MEDICATION NAME], for the 186 times.A review of the care plan dated January 17, 2014 indicated that Resident 11 "was at risk for adverse effect from [MEDICATION NAME]/[MEDICATION NAME]. A drug with potential to cause serious side effects...unintended respiratory depression..."During an interview with licensed vocational nurse (LVN 2) on September 3, 2014 at 1:30 PM and a concurrent review of the clinical records for Residents 10 and 11, when asked what the process was when the physician order for [REDACTED]. When asked to show documented evidence of the respiratory rate obtained, she confirmed that the documentation "was not consistent; it's on and off. There is no space (to document it on)." LVN 2 also acknowledged that assessment of the resident's respiratory rate prior to administration of the medications was important because of the risk for adverse side effects such as respiratory depression. She stated, "I see where you're coming from."During an interview with the director of nurses (DON) on September 3, 2014 at 3:15 PM and a concurrent review of the clinical records, she stated that the pharmacy consultant had told her that the parameters and the monitoring of the respiratory rate prior to the administration of these medications would be according to the physician's discretion. A concurrent review with the DON of the physician's orders indicated to "hold (medication administration) if RR < 12." A review of the facility's policy and procedure titled "Administering Medications," revised April 2010, indicated under policy interpretation and implementation, "...3. Medications must be administered in accordance with the orders, including any required time frame...7. The following information must be checked/verified for each resident prior to administering medications: [REDACTED]"Adverse Consequences and Medication-Related Problems," revised April 2007, indicated under policy interpretation and implementation, "1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported ..."3. During observation of a medication pass for Unsampled Resident G, on September 3, 2014 at 9:00 AM, LVN 1 (licensed vocational nurse) was observed preparing the medication Omega 3 fatty acid 500 MG per capsule (supplement to help lower down fat from the blood). LVN 1 read the MAR (medication administration record) and stated "Omega 3 fatty acids 1,000 MG" (milligrams - a unit of measurement), and poured 3 capsules of the Omega 3 fatty acids and handed the bottle to the surveyor. When asked, how many milligrams was the stock dose, LVN 1 stated "500 MG per capsule", she then read the MAR indicated [REDACTED]." During an interview with LVN 1 on September 3, 2014 at 11:05 AM, she stated, "The physician's order was Omega 3 fatty acids 1,000 MG, and I give 2 capsules every day. I should have not poured 3 capsules." She further stated, "Usually when I go to the patient, I go back and check the pills before I give it to the patient." In a concurrent interview with the DON (director of nursing), she stated that the physician's order indicated, to give 1,000 MG of Omega 3 fatty acids. The Omega 3 fatty acids they have on stock was 500 MG per capsule. A review of the policy titled "Administering Medication", indicated, "Policy Interpretation and Implementation, 3. Medications must be administered in accordance with the orders, including any required time frame". A review of the physician's order dated August 22, 2014 indicated, "Omega - 3 fatty acids tablet; 1,000 mg; Amount to administer: 1,000 mg; oral once a day (supplement)."