Every finding on record at Kearny Mesa Convalescent and Nursing Home

Based on interview and record review, the facility failed to provide adequate supervision for one of two residents reviewed for falls (Resident 1).As a result, Resident 1 was left unsupervised, fell and sustained a hip fracture. Findings:According to the undated admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include abnormalities of gait (a person's manner of walking) and mobility (the ability to move freely and easily) and dementia (a progressive state of decline in mental abilities).According to the physician's History and Physical (H&P), dated 6/26/26, Resident 1 had impaired mobility due to multiple hospital stays. The H&P indicated Resident 1 had poor recall, poor memory, and had no capacity to understand her medical condition. The H&P indicated Resident 1 had generalized weakness, needed assistance, and was at the facility for therapy. According to the Minimum Data Set (MDS, an assessment tool) dated 7/2/26, Resident 1 had moderately impaired cognition. According to the Fall Risk Evaluation form, dated 6/25/26, Resident 1 was at high risk for falls due to three or more falls in the last 90 days, age greater than 85 years, three or more medications which contribute to fall risk, intermittent confusion, impaired walking, and impaired gait and/or balance. According to a Change in Condition Evaluation (CIC), dated 6/26/26, Resident 1 had an unwitnessed fall in the facility dining room. The CIC indicated Resident 1 was last seen sitting in a wheelchair. Per the CIC, Resident 1 complained of severe pain to her right hip and right leg. According to a Health Status Note, dated 6/26/26, Resident 1 was admitted to the hospital with a right femoral neck fracture ( hip fracture). An interview was conducted with the Director of Nursing (DON) on 7/22/26 at 11:30 A.M. The DON stated all residents were considered to be at risk for falls. If a resident was at high risk for falls, they would be monitored closely and not left unattended. Per the DON, Resident 1 had an unwitnessed fall in the dining room. An activity had just finished, and the Activity Assistant (AA) who led the activity was taking residents back to their rooms. The DON stated Resident 1 and another resident were the last two remaining in the dining room, and the AA had placed Resident 1 in the hallway outside of the dining room within view of nursing staff. Per the DON, a daily meeting was conducted to brief staff of new admissions, CICs, or other high risk safety concerns. The DON stated the daily meeting was the main way staff communicated about residents. The DON stated reeducation had been done for Activities and nursing staff that residents at high risk for falls should, .always have eyes on them.An interview was conducted with the Activity Director (AD) on 7/22/26 1:30 P.M. Per the AD, she was not present when Resident 1 fell. The AD stated the music activity was being led by the AA. The AD stated the AA was returning residents to their rooms by himself, and normally this would also be done by other staff, like nurses or Certified Nursing Assistants (CNAs). The AD stated all residents are considered to be at risk for falls. Per the AD, she believed the AA had moved Resident 1 into the hallway outside of the dining room when the activity was finished, so nurses would be able to monitor Resident 1. The AD stated although the AA had placed Resident 1 in a high visibility area, he had not informed the nurses of the need to monitor Resident 1 for safety. An interview was conducted with CNA 1 on 7/22/26 at 3:45 P.M. CNA 1 stated a recent staff education session on fall prevention was conducted. CNA 1 stated the inservice reminded staff that new residents or residents with dementia were never to be left alone as they were unaware of their environment. CNA 1 stated the key takeaway message was to communicate with coworkers. A follow up telephone interview was conducted with the DON on 7/28/26 at 2 P.M. The DON stated when a resident had dementia, it was important to do more frequent monitoring, and to keep them in a high visibility area. The DON stated inside the dining room was not considered a high visibility area. A telephone interview was conducted with the AA on 7/28/26 at 2:10 P.M. The AA stated Resident 1 had attended a music activity on 6/26/26. The AA stated when the activity ended, he placed Resident 1 outside of the dining room where the nurses could monitor her. The AA stated he saw a nurse in the hallway but did not inform her Resident 1 needed monitoring. Per the AA, he later heard that Resident 1 had fallen. The AA stated he did not know much about Resident 1 since she was a new admission. The AA stated he was not aware of her dementia diagnosis or that she was at high risk for falls. The AA stated that the AD would brief staff on new admissions, or any special precautions like high fall risk. Per the AA, he did not recall being informed of Resident 1's high fall risk by the AD. The AA stated that after Resident 1 fell, he had received additional training on communication with staff. According to a facility policy, revised March 2018 and titled Falls and Fall Risk, Managing, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling .

Based on interview and record review, the facility failed to accurately code a resident's fall on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of five sampled residents (Resident 2). This deficient practice placed all fall risk residents at risk for inaccurate plan of care triggers necessary for individualized safety precautions, quality measure (QM-grades clinical outcomes and physical well-being provided by the facility) calculations and reimbursement adjustments being reported to CMS.Findings:A review of Resident 1's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of Abnormalities of Gait (walking) and Mobility, and Mild Cognitive (pertaining to memory, judgement and reasoning ability). A record review of Resident 2's Minimum Data Set, dated [DATE] indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of eight points out of 15 possible points which indicated Resident 2 had moderate cognitive deficits. A review of Resident 2's MDS dated [DATE] section J1800 regarding any falls since admission/entry was coded no for falls. A review of Resident 2's clinical chart fall assessment titled NSG: Fall Risk Evaluation, dated 6/7/26, indicated . Moderate Risk Score: 17. A review of Resident 2's fall interdisciplinary team (IDT-a coordinated group of healthcare professionals from different clinical and support disciplines who work together to plan individualized care for residents) dated 6/9/26 indicated, .@1930.Receptionist passed by room and saw resident on the floor trying to get up. Resident said he was trying to get into his wheelchair from his bed.no apparent injury. with Interventions for Resident 2 that included hourly rounds, floor/landing matts to both sides of Resident 2's bed. On 6/25/26 at 1:43 P.M., an interview and record review was conducted with the MDS nurse (MDSN). The MDSN stated that Resident 2 experienced two falls on 6/9/26 and 6/12/26; however, Section J1800 (Any Falls Since Admission/Entry or Reentry or Prior Assessment) on the MDS assessment reference dated (ARD) 6/11/26 had not been coded correctly on the MDS. The MDSN stated that Resident 2's fall should have been coded as yes because the fall on 6/9/26 had been incorrectly captured with the MDS ARD 6/11/26, which had resulted in inaccurate coding. The MDSN stated accurate MDS coding was important because it drove Resident 2's care planning, was submitted to CMS as part of Resident 2's official health record and was used to calculate Quality Measures (QM-5 star rating for a health facility). The MDSN further stated that Resident 2's MDS would need to be modified to ensure Resident 2's assessment was accurately reflected for Resident 2's fall incident and to maintain Resident 2's safety status with care planning. On 6/25/26 at 1:50 P.M., an interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated that the MDS provided important information about each resident's (all facility residents) health status and care needs. The MDSC stated that the MDS was used to develop care plans, calculate QM, determine Medicare payment and reimbursement, and report resident (all facility residents) information to CMS. The MDSC stated Resident 2's 6/9/26 fall had not been captured on the MDS ARD 6/11/26 and stated the MDS would need to be modified and resubmitted to CMS to accurately reflect Resident 2's fall on 6/9/26. The MDSC further stated it was important for the MDS to accurately reflect Resident 2's condition because CMS relied on the information to provide a complete and accurate picture of Resident 2's health status and the care that Resident 2 required. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2025, (Page J-35) .Section J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment. whichever is most recent .

Based on interview and record review, the facility failed to ensure a medication was administered as ordered, and to ensure unattended medications were not accessible to residents for one of five sampled residents (1). As a result, Resident 1 had an increased risk of pain from the missed medication, and residents were at risk of accidental ingestion or exposure to unattended medications left on the floor.Findings: Per the facility's admission Record, resident 1 was admitted to the facility on [DATE] with diagnoses to include anxiety. Per the facility's Progress Notes, there were no notes documented for Resident 1 on 3/11/26. Per the facility's Progress Note dated 3/12/26 at 9:45 A.M., the Director of Nursing (DON) documented, Visited with resident at bedside earlier this morning, regarding medications from last night.Resident handed 2 capsules which pt (patient) states are her [pregabalin] (a pain medication) and gabapentin (a pain medication) Per the facility's Controlled Drug Record for Resident 1, dated 3/19/26, one dose of pregabalin was signed as given from the package on 3/11/26 at 9 P.M. There were no further doses taken from the package that night after the initial 9 P.M. dose. On 3/24/26 at 12:29 P.M., an interview was conducted with Resident 1. Resident 1 stated, one morning she found her medications on the floor and realized she had not taken all of them the previous night. On 4/2/26 at 11:28 A.M., a telephone interview was conducted with Licensed Nurse (LN) 2. LN 2 stated, on 3/11/26 she had prepared the 9 P.M. medications for Resident 1, then dropped the medications on the floor and was not able to find them. LN 2 further stated, that she then reprepared Resident 1's medications, but forgot to include the pregabalin, so that medication was not administered. LN 2 stated, she should have asked for help finding the dropped medications at the time of the incident. On 4/3/26 at 12:38 P.M., a telephone interview was conducted with the DON. The DON stated, LN 2 should have doublechecked the orders before administering Resident 1's medications, and she should have searched for the dropped medications. Per the facility's policy, titled Administering Medications, revised April 2019, Medications are administered in accordance with prescriber orders

Based on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised to accurately reflect the information in the comprehensive assessment, which affected 1 (Resident #61) of 4 residents reviewed for advance directives. Specifically, the facility failed to revise Resident #61's care plan to reflect the resident's code status listed in the comprehensive assessment. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, 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. The policy revealed, 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission). The policy indicated, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #61's Admission Record indicated the facility admitted the resident on 03/29/2025. According to the Admission Record, the resident had a medical history that included a primary diagnosis of acute pyelonephritis (kidney infection). Resident #61's Physician Orders for Live-Sustaining Treatment (POLST), dated 04/01/2025 and signed by the resident, indicated that if the resident had no pulse and was not breathing, the resident's choice was Do Not Attempt Resuscitation/DNR (Allow Natural Death). An admission MDS, with an Assessment Reference Date (ARD) of 04/04/2025, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Per the MDS, the resident's POLST form identified that if the resident had no pulse and was not breathing, the resident's choice was not to be resuscitated. The MDS was signed as completed on 04/07/2025. Resident #61's Care Plan Report included a focus area, initiated 03/29/2025, that indicated the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. In contrast to the resident's POLST form, a care plan intervention identified that the resident's code status was Attempt Resuscitation - Full Code (initiated 03/29/2025). On 05/08/2025 at 8:55 AM, MDS Coordinator #6 stated all staff had the duty to update a resident's care plan based on a change in condition. He stated a resident's care plan should match their POLST. He noted that resident code statuses were reviewed during clinical meetings. MDS Coordinator #6 stated Resident #61's care plan was not updated with their current code status. On 05/08/2025 at 9:27 AM, the Director of Nursing (DON) stated a resident's care plan should reflect a resident's current POLST. On 05/08/2025 at 9:44 AM, the Administrator stated a resident's care plan should reflect their POLST.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain orders for the use of a non-invasive mechanical ventilator (specifically, continuous positive airway pressure; CPAP) timely, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, directed staff under a Preparation section to 2. Review the physician's order to determine the oxygen concentration and flow and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. An Admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS did not indicate the resident used a non-invasive mechanical ventilator. Resident #184's Care Plan Report did not include information on the use of a non-invasive mechanical ventilator. Resident #184's Cardiology Follow-Up Visit progress note from a hospital visit, dated 03/24/2025, indicated Resident #184 should continue the use of CPAP, and a CPAP company was being contacted. Per the hospital records, Resident #184 was discharged from the hospital on 04/19/2025. Resident #184's medication administration records (MARs) and treatment administration records (TARs), for the timeframe from 04/19/2025 (admission) to 05/07/2025, revealed no evidence of an order for the use of a CPAP machine prior to 05/07/2025. An observation on 05/05/2025 at 10:51 AM revealed a CPAP machine on Resident #184's nightstand with tubing attached, with a mask on the bed above a pillow. An observation on 05/07/2025 at 2:07 PM revealed Resident #184's CPAP machine, with tubing and mask attached, had water in the humidifier chamber. During an interview at the time of the observation, Resident #184 stated they had used the CPAP machine for the last [AGE] years. The resident stated they had not used the CPAP machine in the prior three to four days, but was not sure why. Resident #184's Order Summary Report, for active orders as of 05/07/2025, included the following orders, each with an order date of 05/07/2025: -CPAP/APAP (automatic positive airway pressure): setting from 6.0 to 20.0 centimeter of water (cmH20) pressure. Apply at bedtime and remove in the morning upon awakening. -CPAP: replace mask, tubing, accessories, and device upon degradation as needed (PRN). -CPAP: cleanse the reservoir with solution of saline, rinse, and air dry PRN. -CPAP: Empty the reservoir and refill at night with distilled or sterile water at bedtime. -CPAP: Wash mask in warm soapy water, rinse and air dry every day shift. -CPAP: Wash tubing and headgear in warm soapy water, rinse and air dry every day shift on Sunday. During an interview on 05/07/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #2 stated that if a resident had a CPAP machine, she entered the resident's room when they were ready to go to bed and put distilled water in the humidifier chamber and assisted the resident with putting on their mask as needed. She stated that, other than that, she did not do anything else with CPAP machines. She stated Resident #184 wanted to put on their own CPAP mask, and she had not gone in to determine if the resident had been wearing it lately. She stated she was not aware there were no orders for the use of Resident #184's CPAP machine. During an interview on 05/08/2025 at 9:32 AM, the Director of Nursing (DON) stated orders for the use of a CPAP machine were required, noting the orders should include settings and the care of the equipment. She stated Resident #184's CPAP machine was their own machine. She stated that when she found out about the CPAP machine, she had staff contact the physician and they obtained orders for its use. She stated the resident had no orders for the CPAP machine when they were admitted from the hospital. She stated the resident was not having any distress from not using the CPAP machine. During an interview on 05/08/2025 at 9:52 AM, the Administrator stated staff should confirm any orders for respiratory equipment with the attending physician. He stated communication between nursing staff, admissions staff, family members, and medical staff was needed.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment (specifically, continuous positive airway pressure; CPAP equipment) was stored appropriately, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: An Admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #184's Care Plan Report did not include information on the use of a non-invasive mechanical ventilator. Resident #184's Order Summary Report, for active orders as of 05/07/2025, included the following orders, each with an order date of 05/07/2025: -CPAP/APAP (automatic positive airway pressure): setting from 6.0 to 20.0 centimeter of water (cmH20) pressure. Apply at bedtime and remove in the morning upon awakening. -CPAP: replace mask, tubing, accessories, and device upon degradation as needed (PRN). -CPAP: cleanse the reservoir with solution of saline, rinse, and air dry PRN. -CPAP: Empty the reservoir and refill at night with distilled or sterile water at bedtime. -CPAP: Wash mask in warm soapy water, rinse and air dry every day shift. -CPAP: Wash tubing and headgear in warm soapy water, rinse and air dry every day shift on Sunday. An observation on 05/05/2025 at 10:51 AM revealed a CPAP machine on Resident #184's nightstand with tubing attached, with an associated mask on the resident's bed above a pillow. An observation on 05/06/2025 at 8:59 AM revealed a CPAP machine on Resident #184's nightstand with the tubing draped over the head of the bed and the mask hanging down behind the bed. Resident #184 was sitting on the side of the bed, and a certified nurse assistant (CNA) was assisting the resident to get ready for the day. An observation on 05/07/2025 at 2:07 PM revealed the CPAP machine on Resident #184's nightstand with the tubing attached and the mask on the floor at the head of the bed. The humidifier chamber was full of water. During an interview at the time of the observation, Resident #184 stated they had used the CPAP machine for the last [AGE] years. During an observation and interview on 05/07/2025 at 2:26 PM, Licensed Vocational Nurse (LVN) #1 entered Resident #184's room and verified the CPAP mask was hanging off the bed frame under the head of the bed and that there was no bag to store it in. LVN #1 stated the mask should be stored in a bag when not in use. During an interview on 05/07/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #2 stated that, if a resident had a CPAP machine, she entered the resident's room when they were ready to go to bed and put distilled water in the humidifier chamber and assisted the resident with putting on their mask as needed. She stated that, other than that, she did not do anything else with CPAP machines. During an interview on 05/08/2025 at 9:52 AM, the Administrator stated staff should follow the appropriate protocol to clean and store CPAP equipment.

Based on observation, interview and record review, the facility failed to perform abdominal assessment and verify Resident 1 ' s appointment prior to sending to Interventional Radiology (IR) clinic. As a result , Resident 1 was left outside of the clinic in a cold weather close to an hour and not needed to be seen at the clinic. Findings: A review of Resident 1 ' s Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Hydronephrosis with renal and ureteral calculous obstruction( excess fluid in the kidney due to a backup of urine) and Osteomyelitis of the lumbar region (inflammation of the lower back). A review of the hospital record titled, service encounter dated 12/18/24 Hospitalist, History and Physical indicated, in October 2024, Resident 1 had a rising white blood count and had an interloop (to loop together) collection that underwent an IR drainage after which the catheter was removed on November 22, 2024. During an interview on 12/23/24 at 10:26 A.M., with family member ( FM) 1, FM 1 stated Resident 1 had an appointment on 12/11/24 for a drain site check at the IR hospital and did not need to be seen at the clinic anymore. FM 1 stated, Resident 1 was left out in the cold weather close to an hour and that FM 1 had to pay for Resident 1 ' s transport to the clinic. An interview on 12/23/24 at 12 noon with Licensed nurse (LN)1 was conducted. LN 1 stated she knew Resident 1 did not have a drain site anymore but was sent to IR at the hospital without verifying the appointment. An interview on 12/23/24 at 2 P.M., with the Unit clerk (UC) was conducted. The UC stated, the admission LN placed the standing orders that came with the resident from the hospital. The UC stated after the LN verified the orders, schedule the appointment, the UC would arrange the transportation and inform the resident ' s family regarding the appointment including the payment. An interview on 12/24/24 at 2:46 P.M., with LN 2 was conducted. LN 2 stated, when a resident got admitted to the facility, the licensed nurse follows the physician orders including appointments from the hospital after verifying with the resident's physician. LN 2 stated the UC was responsible to follow up resident's appointment, scheduling of appointment, and transportation arrangements. An interview on 12/30/24 at 12:31 P.M., with the Director of Nursing (DON) was conducted. The DON stated the admission nurse review and carry over the appointment and the hospital orders. The DON stated FM 1 was upset because she had to pay the transportation for Resident 1 that did not happen because there was no appointment. An interview on 1/13/25 at 8:12 A.M., with LN 3 was conducted. LN 3 stated her role included, admissions and medication administration to residents, initial admission assessments and verification of orders, and scheduling of appointments. Resident 1 had an appointment to follow up with IR for a drain site check on 12/11/24 at 2 P.M. LN 3 stated she handed a copy of the order to the UC to follow up with the clinic and to arrange transportation. LN 3 stated she did not verify with the IR clinic regarding Resident 1 ' s appointment. An interview on 1/17/25 at 3:59 P.M, with the certified nursing assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was dependent with his activities of daily living that included feeding , dressing, and toileting. CNA 1 stated he was not sure if Resident 1 had a device of any sort. A record review of Resident 1 ' s minimum date set ( MDS- a federally mandated assessment tool) dated 12/1/24 indicated, Resident 1 ' s brief interview for mental status (BIMS) was 10 which meant Resident 1 had moderate cognition impairment. A review of Resident 1 ' s MDS section GG dated, 12/1/24 indicated, Resident 1 was dependent with his activities of daily living and no attempt was made for Resident 1 to do sit to stand , chair to chair transfer due to medical condition and safety concerns. A review of the weekly summary report dated, 12/07/24 indicated, Resident 1 drain removal site to left lower quadrant with 100% scab, dry and was not being treated. A review of the care plan initiated on 12/7/24 indicated, Resident 1 was admitted with actual impairment to skin integrity with a drain removal site to left lower quadrant (LLQ) of abdomen 0.5 cm x 0.7 cm , 100% scab, dry- arrived back to facility resolved on 12/7/24. A review of the Physicians orders, dated 12/7/24, did not indicate an order for monitoring of the drain site. A review of the facility's undated policy titled, Resident Assessments indicated, assessments are completed by the staff members who have the skills and qualification to assess relevant care areas and who are knowlegeable about the resident's health .

Based on interview and record review the facility failed to provide supervision for one of two residents (Resident 1) when Resident 2's wandering (moving from place to place) behavior was not identified which resulted to an altercation with Resident 1. This failure had the potential for Resident 1's safety and wellbeing. Findings: Review of Resident 1's Admission Record indicated, Resident 1 was admitted on [DATE] to the facility with diagnoses that included Chronic Pain Syndrome, and dependent on wheelchair use. A review of Resident 2's Admission Record indicated, Resident 2 was admitted on [DATE] to the facility with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory), and Dementia (a group of thinking and social symptoms that interferes with daily functioning). An interview on 5/28/24 at 10:30 A.M., with Resident 1 was conducted. Resident 1 stated Resident 1 was sitting on her wheelchair in her room when Resident 2 came from behind. Resident 1 stated she told Resident 2 to get out of the room and Resident 2 suddenly hit Resident 1 at the back of her head and felt pain and told staff. Resident 1 stated staff immediately separated her from Resident 2 and notified the licensed nurses. A record review of Resident 1's Minimum Data Set (MDS-assessment tool) indicated a BIMS (brief interview for mental status) score of 14 which indicated Resident 1's cognition was intact. BIMS score of 0-7 indicated severe cognitive impairment, 8-12 indicated moderate cognitive impairment, and a score of 13-15 indicated cognition was intact. A record review of Resident 2's MDS dated [DATE] indicated Resident 2's BIMS score was 8, which indicated Resident 2's cognition was severely impairment. The same MDS assessment section E for behaviors, indicated, Resident 2 had wandering episodes and behaviors such as resistance to care. An interview on 5/28/24 at 10:50 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated resident 2 was ambulatory (able to walk about) and wandered into other resident rooms. LN 1 stated they tried to closely monitor Resident 2 but sometimes it's not feasible. An interview on 5/28/24 at 11:40 A.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated it was the first incident between Resident 1 and Resident 2, although Resident 2 had behavioral encounters with other residents in the facility. A phone interview on 5/28/24 at 1:30 P.M., with the Director of Nursing (DON) was conducted. The DON stated Resident 2 has had behaviors of grabbing cookies from other residents and a behavior care plan was initiated instead. The DON stated the facility did not have a wandering assessment for Resident 2 since Resident 2 was not exhibiting exit seeking behaviors on admission. Review of Resident 2's care plan dated, 5/16/24 indicated, behavioral symptoms/problem, pinched another resident's arm, revised 5/20/24. Review of facility's policy titled, Admission Assessment; Role of the Nurse dated September 2012 .#3 conduct supplemental assessments including .f. behavioral assessments. Review of the Centers for Medicare & Medicaid Service of the rights of a nursing home resident included the basic human rights, the right to be free from verbal, sexual, physical and mental abuse .

Based on interview and record review, the facility failed to provide medication per the physician ' s order for 2 of 2 sampled residents (1,2). As a result, residents may have had increased pain and anxiety Findings: 1a Per the facility ' s Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (weakness on one side of the body). Per the facility ' s Medication Administration Record, dated April 2022, gabapentin (a medication for nerve pain) was ordered to be given at bedtime. Gabapentin was not marked as administered on 4/9/22, 4/11, or 4/12. Per the facility ' s Progress Notes, on 4/13/22 LN 1 noted that gabapentin was not delivered from the pharmacy. 1b Per the facility ' s Medication Administration Record, dated April 2022, levothyroxine (a medication for low thyroid hormone) was ordered to be given every morning. Levothyroxine was not marked as administered on 4/14/22. On review of the facility ' s Progress notes, dated 4/10/22 through 4/16/22 there was not a note to explain why levothyroxine was not administered on 4/14/22. 1c Per the facility ' s Medication Administration Record, dated April 2022, baclofen (a medication for abnormal muscle stiffness) was ordered to be given three times per day. Baclofen was not marked as administered one time on 4/13/22 and one time on 4/14. Per the facility ' s Progress Notes, on 4/13/22 LN 1 noted that baclofen was not delivered from the pharmacy. Per the facility ' s Progress notes, on 4/15/22 LN 1 noted that Resident 1 missed two doses of baclofen on 4/14/22 because the medication was not delivered from the pharmacy. 2 -Per the facility ' s Admission Record, Resident 2 was admitted to the facility on [DATE]. Per the facility ' s Medication Administration Record, dated April 2022, lorazepam (a medication for anxiety) was not marked as administered on 4/24/22. Per the facility ' s Progress Notes, on 4/24/22, LN 2 noted that lorazepam was not available to administer. On 4/27/22 at 10:47 A.M., an interview was conducted with the administrator. The administrator stated, in the beginning of April 2022, the facility ' s pharmacy made a change to their system which caused a delay in medication deliveries. The administrator further stated, the pharmacy did not notify the facility that the change to their system would occur and cause medication delays. The facility ' s policy, titled Medication Ordering and Receiving from Pharmacy, revised June 2018, did not indicate how timely the pharmacy had to deliver ordered medications.

Based on observation, interview, and record review, the facility failed to include a surgical history of mastectomy (surgical breast removal) on the baseline care plan for one of two sampled residents (1). As a result, staff took Resident 1's blood pressure on the affected side, which had the risk of causing lymphedema (swelling). Findings: Per the facility's Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia (a physical and mental decline), and history of breast cancer. Per the facility's Admission/Readmission Evaluation for Resident 1, dated 10/20/22, .Dx (Diagnoses) of .Mastectomy of left breast . The admission note did not indicate if there were any restrictions on taking Resident 1's blood pressure on either arm. Per the facility's Weights and Vitals Summary dated 12/7/22, the facility took Resident 1's blood pressure 216 times between 10/20/22 and 12/7/22. Of the listed blood pressure results, 55 were obtained from Resident 1's left arm. On 12/7/22 at 3:30 P.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated, on 11/9/22, a sign was posted on Resident 1's wall which directed staff not to take her blood pressure on the left arm. LN 2 further state, prior to 11/9/22, that sign was not posted, and there were not any restrictions on which arm they could use to take Resident 1's blood pressure. On 12/9/22 at 3:55 P.M., a telephone interview was conducted with LN 3. LN 3 stated, at the time of admission, she was aware of Resident 1's history of a mastectomy to the left breast. LN 3 further stated, due to Resident 1's history of mastectomy, her blood pressure should not have been taken on the left arm. LN 3 stated, she did not enter Resident 1's mastectomy or left arm blood pressure restriction into an order or care plan. On 12/13/22 at 4:10 P.M., a telephone interview was conducted with the Administrator. The Administrator stated, even though there was not an order or care plan which directed staff not to take Resident 1's blood pressure on her left arm, the staff should have used their critical thinking skills to know that they should not have taken her blood pressure on the left arm because of her history of mastectomy. Per the facility's policy, titled Baseline Care Plan, revised 2/19/18, .The facility develops a baseline care plan within 48 hours of a resident's admission .Each resident's baseline care plan includes the instructions needed to provide effective and person-centered care for the immediate needs of the resident .The baseline care plan includes the minimum healthcare information necessary to properly care for a resident .

Based on observation, interview and record review, the facility failed to decrease the transmission of COVID-19 to residents when: 1. the facility's staff vaccination policy was not in accordance with federal regulation 2. an unvaccinated staff member did not wear the required protective facial covering. These failures had the potential to contribute to the transmission and spread of COVID-19 to residents, staff, and visitors in the facility. Findings: 1. An interview with the facility's ICP was conducted on 3/16/22 at 2:06 P.M. The ICP stated the facility's staff vaccination policy was reviewed and updated as needed according to state and federal guidelines, adhering to the stricter regulation. On 3/16/22, at 3:50 P.M., a concurrent interview and record review of the facility's policy titled, Health Care Worker Vaccine Requirement, revised on 3/1/22, was conducted with the ICP. Per the facility's policy under Exemption .2 .unvaccinated exempt worker must meet the following requirements when entering of working in the facility .b. Wear a surgical mask or higher-level respirator at all times while in the facility. The ICP stated information in the policy was obtained from websites listed on the reference page. Review of the reference page showed web links to the California Department of Public Health and the Centers for Disease Control and Prevention. The ICP stated she and the other staff members involved with the policy also referred to CMS's Quality Safety & Oversight (QSO) memoranda and guidance when updating the policy. The ICP had QSO 22-07, dated 12/28/21, on her clipboard, which addressed the COVID-19 Health Care Staff Vaccination. When asked if the QSO she had was the most current, the ICP stated as far as she was aware, it was. The ICP was asked to verify if the QSO she had was current. On 3/16/22, at 4:12 P.M., the ICP returned and stated there was an updated QSO 22-07 memoranda released in January 2022. The ICP referred to section 483.80(i)(iii), which indicated .staff who are not yet fully vaccinated, or who have a pending or been granted an exemption .adhere to additional precautions that are intended to mitigate the spread of COVID-19 .requiring staff who have not completed their primary vaccination series to use a NIOSH-approved N95 or equivalent .regardless whether they are providing direct care to or otherwise interacting with patients. The ICP stated the facility's policy for staff vaccination was not in accordance with the current federal regulation. 2. On 3/16/22, at 2:06 P.M., an interview was conducted with the ICP. The ICP stated unvaccinated staff are required to wear a N95 respirator in resident care areas. The ICP provided a list of unvaccinated staff members with approved exemptions. On 3/16/22, at 3:32 P.M., the SSD was observed in the dining room speaking with a state surveyor. The SSD was wearing a black mask, secured looped around the ears. The SSD was identified on the list of unvaccinated staff members. On 3/16/22, at 3:38 P.M., an interview was conducted with the SSD. The SSD stated she was unvaccinated and was granted a religious exemption. She stated the facility provided her with a N95 mask that she was fit tested for but preferred to wear her own personal mask from home. She stated she was not fit tested with the mask she was currently wearing and should be wearing the mask she was fit tested for. She further stated no one in the facility has talked to her about wearing her own personal mask. On 3/16/22, at 3:55 P.M., an interview was conducted with the ICP. The ICP stated all unvaccinated staff members were fit tested for a N95 mask and were instructed to only wear the mask they were fit tested for. On 3/17/22, at 2:07 P.M. an interview was conducted with the DON. The DON stated unvaccinated staff member should be wearing a N95 in patient care areas and in the hallway.

Based on observation, interview and record review, the facility failed to ensure the staff provided the services required for the care of one of one resident (Resident 173) on [CONDITION(S)] (a process of cleaning blood) when: 1. The staff did not remove the dressing on the [CONDITION(S)] vascular access per the [CONDITION(S)] center recommendation 2. The staff did not accurately identify the [CONDITION(S)] access' bruit (sound of blood flow) and thrill (vibrations of blood flow) As a result, there was a potential a [CONDITION(S)] access complication would not be identified. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. On 3/16/22, at 10:16 A.M., an observation of Resident 173's left arm was conducted. A gauze dressing was noted on Resident 173's left upper arm. On 3/16/22, at 2:37 P.M., a concurrent interview and record review with LN 6 was conducted. LN 6 stated Resident 173 has a [CONDITION(S)] access on the left upper arm and his [CONDITION(S)] schedule was every Tuesday, Thursday and Saturday. LN 6 stated the [CONDITION(S)] access dressing should be removed three to four hours after [CONDITION(S)] per the [CONDITION(S)] center's recommendation. On 3/16/22 at 3:16 P.M., a joint observation of Resident 173's [CONDITION(S)] access was conducted with LN 6. LN 6 noted there was still a dressing on the access on the left upper arm. LN 6 stated Resident 173 had [CONDITION(S)] treatment yesterday. LN 6 stated when residents come back to the facility after [CONDITION(S)], the staff had to check the [CONDITION(S)] access. On 3/17/22, at 9:41 A.M., a concurrent interview and record review with LN 7 was conducted. The document titled [CONDITION(S)] Communication Record dated 3/15/22 indicated to remove dressing on the left upper arm three to four hours after [CONDITION(S)]. 2. On 3/16/22, at 3:16 P.M., a joint observation of Resident 173's [CONDITION(S)] access was conducted with LN 6. LN 6 noted there was a [CONDITION(S)] access on Resident 173's left upper arm. LN 6 stated when residents come back to the facility after [CONDITION(S)], the staff had to check if the access was still functioning by listening to the thrill and feeling for the bruit. On 3/17/22, at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated when residents came back to the facility from a [CONDITION(S)] treatment, the staff had to check the communication record from the [CONDITION(S)] facility to check for any changes in orders, instructions and to check if the access was working or not. LN 7 stated the correct way was to listen for the bruit via stethoscope and feel for the thrill. Per the facility's policy and procedure titled, [CONDITION(S)] Management, dated 11/17, .1) The facility has an agreement with contracted [CONDITION(S)] Unit(s) which operate in accordance with current standards of practice including communication and collaboration .

Based on observation, interview and record review, the facility failed to revise fall specific preventative measures for one of one resident (Resident 61), after a fall. As a result, Resident 61 suffered another fall six days later after the initial fall. Findings: Resident 61 was admitted to the facility on [DATE] with diagnoses which included abnormalities of gait and mobility and dementia (impaired memory) per the facility's Admission Record. On 3/15/22 at 9:31 A.M., Resident 61 was observed in bed, leaning towards the right side. Resident 61 was grasping the right siderail of the bed with both hands and attempting to pull himself up. His right leg was off to the right side of the bed. He was wearing a brief, which appeared to be wet. On 3/17/22 at 9:28 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 61 had an incontinent of bladder (having no or insufficient voluntary control over urination). CNA 1 stated Resident 61 was a fall risk. CNA 1 further stated she heard Resident 61 fell before but did not know why or when he fell . On 3/17/22 at 1:36 P.M., an interview was conducted with LN 7. LN 7 stated Resident 61 has dementia, confused, and had tried to get out of bed. LN 7 stated Resident 61 had history of falls prior to this admission and had fallen at least once since being admitted . LN 7 stated when a resident fell , the care plan should have been updated with new interventions by either the medication nurse or the charge nurse. LN 7 stated the interventions should have reflected the cause of the fall. A review of the facility's Monthly Falls Tracking Form indicated Resident 61 fell on [DATE], 2/21/22, and 3/1/22. A review of Resident 61's records was conducted. Resident 61's fall care plan initiated on 2/14/22 had indicated the resident was a high risk for fall. The intervention included in this care plan was to, review information on past falls and attempt to determine cause of falls. Record possible root causes . and to anticipate and meet the resident's needs. Resident 61's eINTERACT SBAR Summary Providers (a form to communicate to physicians) progress note, dated 2/15/22, indicated Resident 61 was found on the floor. Resident 61 had claimed he stood up to go to the bathroom and fell . Interventions added on 2/17/22 to Resident 61's fall care plan after his fall were not related to the cause of the fall. Resident 61's eINTERACT SBAR Summary Providers progress note, dated 2/21/22, stated resident was observed on the floor of resident's restroom. Resident was attempting to use restroom and was unable to tell nurse how he got the floor. On 3/17/22 at 2:03 P.M. an interview was conducted with the DON. The DON stated when a resident falls, interventions added to the care plan should have been based on the cause of the fall. Per the facility's policy titled, Fall and Fall Risk, Managing, dated 7/1/20, Policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try and prevent the resident from falling .

Based on observation, interview, and record review, the facility did not ensure a pressure relieving mattress was set up according to the physician's order for one of five sampled residents (320) with pressure ulcers (areas of damaged skin caused by staying in one position for too long). This failure had the potential to cause Resident 320's pressure ulcer to deteriorate. Findings: Resident 320 was admitted to the facility on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Braden Scale for Predicting Pressure Sore Risk , dated 3/10/22, indicated Resident 320 was at risk, slightly limited mobility, makes frequent though slight changes in body independently. During an observation on 3/14/22, at 8:40 A.M., in Residents 320's room, Resident 320 was in bed, on a low air loss mattress (LAL, alternating pressure low air loss mattress; reduces pressure to aid in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 320's March monthly weight indicated Resident 320's weight was at 226.6 pounds. A review of Resident 320's physician's order, dated March 10, 2022, indicated for LAL set mode alternating and setting based on comfort and/or weight of resident. During an observation on 3/15/22, at 9:40 A.M., Resident 320's mattress was set up at 250 pounds. During a concurrent observation and interview with Resident 320 on 3/16/22, at 11:06 A.M., the LAL mattress was noted to be set up at 250 pounds. Resident 320 stated he was more comfortable with this LAL mattress setting. An interview with LN 12 on 3/17/22 at 10:55 A.M., was conducted. LN 12 stated LAL mattress was being monitored by LN's, based on the resident's weight and comfort. LN 12 stated in monitoring resident's LAL, the priority was resident's weight and then comfort. LN 12 agreed that the LAL mattress should had been set up at 250 pounds on 3/14/22, basing on Resident 320's weight of 226.6 pounds, not at 450 pounds. LN 12 added that it was important to follow physician's orders in setting up the LAL mattress to prevent worsening of pressure ulcers. An interview with the DON on 3/17/22 at 1:24 P.M., was conducted. The DON stated Resident 320's LAL mattress should had been set up according to resident's weight and it was important to prevent worsening of pressure ulcers and promote healing. Per the facility's policy, dated 7/1/2020, titled Prevention of Pressure Ulcers/Injuries .The purpose of this procedure is to provide .Support surfaces and pressure redistribution .select appropriate support surfaces based on the resident's body weight .

Based on interview and record review, the facility failed to ensure the staff followed a physician's orders for one of one resident (Resident 173) on [CONDITION(S)] (a process of cleaning blood) when: 1. The staff did not follow the fluid restriction order 2. The staff took blood pressure measurement on the resident's vascular access arm As a result, 1. Resident 173 was given more fluids than what was ordered 2. There was a potential for vascular access complication Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. On 3/16/22, a review of Resident 173's records was conducted. The physician order dated 3/3/22 indicated fluid restriction of 1600 milliliters (ml)/day- dietary 960 ml/day, nursing 640 ml/day and to document amount of fluid consumed. On 3/16/22 at 10:16 A.M., an interview with Resident 173's family member (FM) was conducted. The FM stated the facility staff did not inform her there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The FM stated the staff knew Resident 173's family brought him food and drinks from home but was not told how much Resident 173 can drink. On 3/16/22 at 2:52 P.M., a concurrent interview and review of Resident 173's records with LN 6 was conducted. LN 6 stated Resident 173 had a physician's order for fluid restriction of 1600 ml/day. She stated any food or drink the family brought in for Resident 173 should have been documented and the family educated regarding Resident 173's fluid intake and diet. Resident 173 was given the following total fluid amounts on these dates: 3/4/22: 1440 ml (from fluid intake) plus 240 ml (from nurse fluids), 80 ml more than the physician ordered maximum fluid per day. 3/6/22: 1160 ml plus 720 ml, 280 ml more than the physician ordered maximum fluid per day. 3/7/22: 1760 ml plus 240 ml, 400 ml more than the physician ordered maximum fluid per day. 3/8/22: 1440 ml plus 240 ml, 80 ml more than the physician ordered maximum fluid per day. 3/10/22: 1440 ml plus 800 ml, 640 ml more than the physician ordered maximum fluid per day. 3/11/22: 1080 ml plus 800 ml, 280 ml more than the physician ordered maximum fluid per day. 3/14/22: 1700 ml plus 240 ml, 340 ml more than the physician ordered maximum fluid per day. 3/16/22: 1440 ml plus 840 ml, 680 ml more than the physician ordered maximum fluid per day. On 3/17/22 at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated residents on fluid restriction should have their fluid intake measured and recorded. He stated if the family of Resident 173 brought extra food or drink, it needed to be reported to the LNs and measured. LN 7 stated the family needed to be educated on Resident 173's fluid restriction. Per the facility's policy and procedure titled Intake and Output revised on 7/19, .Fluid intake and output shall be recorded for each patient as follows: 3. Residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. On 3/16/22, a review of Resident 173's records was conducted. A physician order, dated 2/27/22, indicated not to take blood pressure (BP) on the [CONDITION(S)] access site. The vitals sign flow sheet indicated BP was taken by the staff on the left arm access site on the following dates: 3/6/22 9:10 A.M. 3/8/22 6:03 P.M. 3/9/22 5:47 P.M. 3/10/22 3:53 A.M. 3/15/22 10:16 A.M. On 3/17/22 at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated the [CONDITION(S)] access could clot if BP was taken on Resident 173's [CONDITION(S)] access site. Per the policy and procedure titled [CONDITION(S)] Management, dated 11/17, .Procedure .5) The physician provides orders for [CONDITION(S)] treatments .

Based on interview, and record review, the facility failed to develop a care plan for one of one resident (173) on [CONDITION(S)] (a process of cleaning blood) with fluid restriction. As a result Resident 173 had the potential for fluid overload. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22, a review of Resident 173's records was conducted. The physician order, dated 3/3/22, indicated fluid restriction of 1,600 milliliters (ml)/day. There was no documented care plan for Resident 173's dependence on [CONDITION(S)] and the ordered fluid restriction. On 3/16/22 at 2:52 P.M., a concurrent interview and record review of Resident 173's records with LN 6 was conducted. LN 6 stated there should be a care plan for [CONDITION(S)] and fluid restriction for Resident 173. Per the facility's policy and procedure titled Care Plans- Comprehensive and revised 10/17, Policy Statement: An individualized comprehensive care plan that includes .to meet the resident's medical, nursing, .needs is developed for each resident.

Based on observation, interview and record review, the facility failed to ensure the staff followed the physician's order for one of three sampled residents (20) for pain medication. This failure had the potential for Resident 20's pain to be unrelieved. Findings: Resident 20 was admitted to the facility on [DATE], with a diagnoses of [CONDITION(S)] (bacterial skin infection) of bilateral lower limbs and chronic pain syndrome (pain that lasts for over 3 months that can interfere with daily activities), per the facility's Admission Record. During a clinical record review conducted for Resident 20, per the physician's order dated 2/20/22, [MEDICATION(S)] (medication for pain) tablet 5-325 mg ([MEDICATION(S)]-Acetaminophen), give 1 tablet by mouth every 4 hours as needed for moderate (5-7 pain scale), to severe pain (8-10 pain scale) and dated 7/25/21, [MEDICATION(S)] HCL tablet 2 mg (medication for pain) give 1 tablet by mouth every 4 hours as needed for break through pain A concurrent observation and interview with Resident 20 on 3/14/22 at 9:15 A.M., in her room, was conducted. Resident 20 was observed to be in a wheelchair, alert, oriented and comfortable. Resident 20 stated that she was pain free and knows that she can have her pain medications as needed but was not aware what pain medication she was getting. An interview with CNA 12 on 3/15/22, at 3:55 P.M., was conducted. CNA 12 stated that Resident 20 was alert, gentle and had chronic pain in her legs. CNA 12 added that if Resident 20 was in pain, she normally asked for pain medications. On 3/17/22 at 10:30 A.M., Resident 20's MAR was reviewed with LN 11 for the following dates: 2/21/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 8 at 10:18 P.M., last dose of [MEDICATION(S)] 5-325 mg was at 9:15 A.M. 2/22/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 8 at 8:55 P.M., last dose of [MEDICATION(S)] 5-325 mg was at 8:34 A.M. 2/24/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 8 at 9:12 A.M., last dose of [MEDICATION(S)] 5-325 mg was at 4:32 A.M. 2/27/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 7 at 8:10 P. M., no [MEDICATION(S)] 5-325 mg dose was given 2/27/22 2/28/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 7 at 4:05 P.M., last dose of [MEDICATION(S)] 5-325 mg was at 9:22 A.M. 3/2/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 8 at 10:33 P.M., last dose of [MEDICATION(S)] 5-325 mg was at 8:46 A.M. 3/3/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 7 at 8:35 A.M. and at 3:42 P.M. for a pain of 8, no [MEDICATION(S)] 5-325 mg dose was given on this date. 3/8/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 8 at 8:00 P.M., last dose of [MEDICATION(S)] 5-325 mg was at 4:00 P.M. 3/14/22, [MEDICATION(S)] HCL tablet 2 mg was given for a pain of 7 at 6:57 P.M., no [MEDICATION(S)] 5-325 mg dose was given 3/14/22 The MAR indicated on these dates [MEDICATION(S)] HCL tablet 2 mg was given not for break through pain, as the physician had ordered, but was given for pain scale of 7-8, which was the ordered indication for [MEDICATION(S)] 5-325 mg. LN 11 stated that administering [MEDICATION(S)] HCL tablet 2 mg, first, before [MEDICATION(S)] 5-325 mg was not following physician's orders. An interview with LN 12 on 3/17/22 at 10:45 A.M., was conducted. LN 12 stated [MEDICATION(S)] should have been given first for pain relief, then reassessed the resident in 30-45 minutes post administration. If it was not effective then administer [MEDICATION(S)] HCL tablet 2 mg for break through pain per physician's orders. An interview with the DON on 3/17/22 at 1:40 P.M., was conducted. The DON stated it was important to follow physician's orders for pain management. Per the facility's Policy, titled Pain Assessment and Management, dated June 2016, indicated, .6. Implement the medication regimen as ordered .

Based on interview and record review, the facility failed to notify the physician of a resident drinking insufficient fluids for 12 days for one of two sampled residents (1). As a result, Resident 1 was hospitalized . Finding: Per the facility's Admission Record, Resident 1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/29/21 at 1 P.M., a telephone interview was conducted with the Registered Dietician (RD). The RD stated, identified a resident's fluid requirements at the time of admission, which was documented in her initial assessment. The RD further stated, Licensed Nurses (LNs) should have known to monitor a resident's fluid intake compared to the fluid requirements she identified on her initial assessment. The RD stated, if a resident was consistently taking in less fluid than needed, the LN should have called the RD or physician to notify them. On 4/30/21 at 1:50 P.M., a telephone interview was conducted with LN 1. LN 1 stated, LNs were responsible for monitoring resident's hydration. LN 1 further stated, they used the Intake and Output form to determine if a resident was receiving enough fluid, but was not able to indicate if there was a specific fluid requirement the fluid intake should have met, or how they know what amount of fluid on the fluid Intake and Output form would require calling the physician. On 6/3/21 at 3:53 P.M., a telephone interview was conducted with LN 2. LN 2 stated, the certified nursing assistant notified the LN if a resident was not drinking enough fluid. LN 2 was not able to correctly indicate where to find resident fluid requirements. On 7/1/21 at 10:45 A.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, the RD set a daily fluid requirement if a resident was at risk of dehydration. The DON further stated, if a resident was not taking enough fluid to meet the requirement set by the RD, then the LNs should have notified the RD. Per the facility's Diet: Nutrition Comprehensive Assessment, dated 3/2/21, Resident 1's estimated daily fluid requirements were 1827-2135ml, and he was at risk of dehydration. Per the facility's Intake and Output, dated 4/7/21, on the following dates Resident 1's fluid intake was: 2/24/21 600ml 2/25/21 900ml 2/26/21 1320ml 2/27/21 700ml 2/28/21 880ml 3/01/21 980ml 3/02/21 1320ml 3/03/21 1480ml 3/04/21 840ml 3/05/21 1021ml 3/06/21 1320ml 3/07/21 1560ml Per the General Acute Care Hospital's Emergency Department Note dated 3/8/21, .(Resident 1) sent from his nursing facility for evaluation of his altered mental status . he became more confused and obtunded (slowed response to stimulation) . Patient does appear to be extremely dehydrated . Impression: Acute altered mental status, likely secondary to (caused by) acute severe dehydration .

Based on interview and record review, the facility failed to ensure pain management was effective for one of three residents (Resident 1) reviewed for pain, when the pain level reassessments were not completed by licensed nurses (LNs) following pain medication administration. This failure had the potential for staff to be unaware if the pain medication administered was effective, which could result in Resident 1 experiencing prolonged, unnecessary pain. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/1/19, Resident 1's clinical record was reviewed: Resident 1's history and physical examination [REDACTED]. The physician documented Resident 1 had a hematoma (a mass of clotted blood that forms in tissue) on the right thigh, with chronic pain. According to Resident 1's physician's orders [REDACTED].[MEDICATION NAME] HCL ([MEDICATION NAME]- a strong pain medication) . 1 tablet as needed every 8 hours for Severe Pain . The document titled, Pain Data Collection Tool, completed on admissoin, indicated Resident 1 had right leg pain with a pain scale of 8 (Scale 1 to 10, with 1 being the least amount of pain and 10 being the worst pain) and the pain was relieved with pain medication. Resident 1's Plan of Care, titled Pain, listed Goals: Will be relieved from pain within one hour of medication/intervention daily. Resident 1's Medication Administration Record (MAR) was reviewed from 4/19/19 through 4/21/10. Resident 1 was administered pain medication three times on 4/20/19 at 2:41 A.M., 9:51 A.M., and 5:48 P.M. According to the facility's PRN (as needed) Results and Documentation Report for Resident 1, the pain medication was administered for leg pain with a pain scale of 8 out of 10. The Results section for the three medications administered was completed on,4/22/19 at 3:17 P.M., Per resident helped, after the resident had discharged herself Against Medical Advise on 4/21/20. Resident 1's Nursing Progress notes were reviewed for 4/20/19, and there was no documented evidence the resident's pain had been reassessed following pain medication administration. On 11/18/20 at 10:34 A.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated after pain medication was administered she expected LNs to re-assess the resident's pain within 30-60 minutes. The DON stated re-assessment was essential to determine if the medication was effective. The DON reviewed Resident's MAR and PRN Results and Documentation form and stated Resident 1 was never reassessed so no one knows if the resident had relief. The DON stated the medication computer program back in 4/2019 did not flag or highlight pain medications for reassessment after administration and it was the LN's responsibility to reassess the residents within one hour for pain management. On 11/8/20 at 10:59 A.M., an interview was conducted with LN 5. LN 5 stated all residents required reassessment for pain, one hour after being administer pain medication. LN 5 stated reassessing was the only way to determine if the pain medication was effective. LN 5 stated all reassessments needed to be documented as a means of communicating to other staff, to know what was effective and what was not. According to the facility's policy, titled Pain Assessment and Management, dated June 2016, .Monitoring and Modifying Approaches: 1. Re-assess the resident's pain .Documentation: 1. Document the resident's reported level of pain .

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan related to a suprapubic urinary catheter (a device surgically inserted into the bladder to drain urine into a drainage bag), for one of three residents (Resident 1), reviewed for Quality of Care. This failure had the potential for staff not to deliver consistent urinary catheter care related to monitoring, dressing changes, and flushing (putting sterile water or saline into the bladder through the catheter with a syringe, to clear obstructions). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses, which included end stage [MEDICAL CONDITION] (loss of kidney function) and necrosis (irreversible tissue death) to the penis per the facility's Admission Record. Resident 1's clinical records were reviewed on 8/5/20: According to the hospital emergency room Provider Notes, dated 7/13/20 at 9:34 A.M., Resident 1 was admitted with complaints of an inability to urinate and the sensation of bladder fullness. The hospital Discharge Summary notes, dated 7/15/20 at 5:09 A.M., Resident 1 was to be discharged back to the skilled nursing facility after a suprapubic catheter was placed 7/14/20. According to the facility's Nursing Progress Notes, dated 7/15/20 at 2:22 P.M., Resident 1 was readmitted to the facility with a suprapubic catheter. Resident 1's physician's orders [REDACTED]. A plan of care for the suprapubic urinary catheter could not be located. An interview was conducted with Licensed Nurse (LN 3) on 8/6/20 at 1:25 P.M. LN 3 stated she would expect to see a care plan for Resident 1's suprapubic catheter. LN 3 stated care plans were important to ensure staff provided consistent care. An interview was conducted with LN 1 on 8/6/20 at 2:14 P.M. LN 1 stated Resident 1 should have had a care plan for the suprapubic catheter. LN 1 stated care plans were important for staff communication, so resident care was being consistently followed. An interview and record review was conducted with the Director of Nursing (DON) on 8/6/20 at 2:37 P.M. The DON stated she could not locate a care plan for Resident 1's suprapubic catheter. The DON stated she expected a care plan to be developed for all residents that had a change in condition or new treatment plan. The DON stated care plans were important so staff knew how to care for the resident, in order to reach all the residents goals. According to the facility's policy, titled Care Plans-Comprehensive, dated August 2006, .3. Each resident's Comprehensive Care Plan . b. Incorporate risk factors associated with identified problems; . d. Reflect treatment goals and objectives in measurable outcomes; .