Every finding on record at La Canada Care Center

NOT REVIEWED BY 22 Based on facility documentation, staff interviews, and policy review, the facility failed to ensure that daily staff posting information was accurate for total numbers of direct care staff, actual hours worked by direct care staff, and actual staffing totals worked by licensed and unlicensed direct care nursing staff for 9 out of 9 days reviewed. The census was 92. The deficient practice could result in residents, visitors, and facility staff not being informed of accurate and current staffing information. Findings include: Review of 9 randomly selected days of daily staff postings with corresponding punch details revealed the actual hours worked on the daily staff postings were inaccurate related to the number of actual RN, LPN and CNAs working each shift, the actual number of hours worked each shift, and the total number of actual staff hours worked each day. The daily staff posting dated 10/25/2024, revealed a census of 101 residents with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked:7.28 registered nurse (RN) hours, 97.31 licensed practical nurse/licensed vocational nurse (LPN/LVN) hours, and 194.13 certified nursing assistant (CNA) hours However, review of the punch details requested for that day revealed: 34.82 RN hours, 84.06 LPN/LVN hours, and 196.86 CNA hoursThere was a discrepancy of 27.54 RN hours, 13.25 LPN/LVN hours, and 2.73 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 10/26/2024, revealed a census of 95 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked:8.00 RN hours,97.81 LPN/LVN hours and, 145.00 CNA hours However, review of the punch details requested for that day revealed: 8.00 RN hours88.08 LPN/LVN hours and 156.42 CNA hours There was a discrepancy of 9.73 LPN/LVN hours and 11.42 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 10/27/2024, revealed a census of 94 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked: 8.23 RN hours 95.46 LPN/LVN hours and 160.54 CNA hours However, review of the punch details requested for that day revealed: 8.23 RN hours94.80 LPN/LVN hours and 160.72 CNA hours There was a discrepancy of 0.66 LPN/LVN hours and 0.18 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 8/30/2025, revealed a census of 104 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked:18.63 RN hours 77.77 LPN/LVN hours, and 188.95 CNA hours However, review of the punch details requested for that day revealed 18.41 RN hours, 70.97 LPN/LVN hours, and 167.60 CNA hours There was a discrepancy of 0.22 RN hours, 6.8 LPN/LVN hours, and 21.35 CNA hours , between the daily staff postings and punch details. The daily staff posting dated 8/31/2025, revealed a census of 98 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked:25.69 RN hours,67.99 LPN/LVN hours, and 186.84 CNA hours However, review of the punch details requested for that day revealed: 25.69 RN hours68.99 LPN/LVN hours and 202.52 CNA hours There was a discrepancy of 1.00 LPN/LVN hours and 15.68 CNA hours , between the daily staff postings and punch details. The daily staff posting dated 9/1/2025, revealed a census of 99 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked: 9.15 RN hours, 89.25 LPN/LVN hours, and 188.77 CNA hours However, review of the punch details requested for that day revealed 25.15 RN hours, 97.25 LPN/LVN hours and 181.88 CNA hours There was a discrepancy of 16.00 RN hours, 8 LPN/LVN hours, and 6.89 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 11/28/2025, revealed a census of 98 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked:8.6 RN hours, 84.83 LPN/LVN hours, and 163.76 CNA hours However, review of the punch details requested for that day revealed: 24.60 RN hours, 100.56 LPN/LVN hours, and 167.23 CNA hoursThere was a discrepancy of 16 RN hours, 15.73 LPN/LVN hours, and 3.47 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 11/29/2025, revealed a census of 102 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked: 28.10 RN hours, 59.45 LPN/LVN hours, and 160.88 CNA hours However, Review of the punch details requested for that day revealed:28.10 RN hours, 66.07 LPN/LVN hours, and 144.62 CNA hours There was a discrepancy of 6.62 LPN/LVN hours and 16.26 CNA hours, between the daily staff postings and punch details. The daily staff posting dated 11/30/2025, revealed a census of 102 with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licnesed staff and CNAs each day. The daily staff posting included the following actual hours worked: 24.83 RN hours, 61.02 LPN/LVN hours, and 166.00 CNA hoursHowever, review of the punch details requested for that day revealed: 23.35 RN hours,61.52 LPN/LVN hours, and 187.08 CNA hours There was a discrepancy of 1.48 RN hours, 0.50 LPN/LVN hours, and 21.08 CNA hours, between the daily staff postings and punch details. An interview was conducted on April 24, 2026 at 10:08 a.m. with the Staffing Coordinator (Staff #94). The Staffing Coordinator stated she is responsible for staffing schedules, recruiting, and patient appointments, with human resources assisting in documenting actual hours worked by staff. The Staffing Coordinator stated she completes daily staff postings, including scheduled and actual hours worked, and further stated the daily staff postings reflect hours worked per shift rather and does not include the number of staff members. The Staffing Coordinator stated each shift is generally calculated as 8 hours which is why she does not include the number of staff on the daily postings. Regarding hours per patient day (PPD) and staffing numbers for CNA/LPN/RN staff, the Staffing Coordinator stated she knows how to calculate staffing needs; however, PPD is not listed on the daily staffing sheet. The Staffing Coordinator further stated staffing decisions are based on general guidelines from the Director of Nursing (DON), acuity and census of the building, and resident feedback. The Staffing Coordinator stated facility expectations are for postings to be accurate and completed each morning. The Staffing Coordinator reviewed the sampled daily postings and punch details for the following days; 10/26/2024-10/28/2026, 8/30/2025-9/1/2025, and 11/28/2025-11/30/2025. After reviewing the sampled days the Staffing Coordinator stated the numbers did not match, however, further stated the daily staff postings meet facility expectations. The Staffing Coordinator stated she did not know how to prove the accuracy of the daily staff postings. The Staffing Coordinator stated inaccurate postings could affect reporting of care hours PPD and compliance staffing regulations. An interview was conducted on April 24, 2026 at 10:58 a.m. with the Director of Nursing (DON/Staff #134). The DON stated she oversees staffing operations and monitors daily staffing postings. The DON stated that the Staffing Coordinator is responsible for completing daily staffing postings and documenting actual hours worked by direct care staff. The DON stated that she expected the daily staff postings should be routinely updated; however, staff call-outs and punch-in/punch-out inaccuracies were not always identified until the end of the pay period. The DON stated the facility did not always know staff were not punching in and out correctly until staff turned in punch-in/out correction forms at the end of the pay period. The DON stated corrections to staffing postings after the fact were difficult due to frequent call-outs and delayed identification of attendance discrepancies. The DON stated the purpose of maintaining accurate daily staffing postings was to ensure awareness of staffing coverage levels and assist the facility in determining staffing needs. The DON stated that she expects daily staffing postings to be completed accurately and maintained consistently. The DON stated inaccurate posting of actual hours worked by clinical staff could result in inaccurate staffing schedules and the facility not knowing when additional staff coverage was needed. Review of the Staffing Numbers, Posting policy, last revised October 2025, revealed the facility will post the number of staff working who are directly responsible for resident care and include hours worked by Registered Nurses, Licensed Practical/Vocational Nurses, and Nursing Assistants for each shift.

Based on record review, staff interviews, review of facility documents, and review of policies, the facility failed to ensure that a blood pressure medication order was followed in compliance with a physician order according to accepted standards of clinical practice for one resident (#44). The deficient practice could result in medications being administered without following the physician's order and could place the resident's health at risk for illnesses.Findings include:Resident #44 was admitted to the facility on [DATE] with diagnoses of high blood pressure (hypertension), chronic pain syndrome, and urinary tract infection.A review of the Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident cognition was intact.The Resident's care plan initiated on 10/10/2024, revealed that the Resident had hypertension. The interventions included for the staff to administer antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate.On 04/24/2026, at 8:03 AM, a medication administration observation was conducted with a Licensed Practical Nurse (LPN/Staff #18) for Resident #44. One of the medications that Staff #18 prepared for Resident #44 was an order for Lisinopril oral tablet 2.5 mg (miligram) give 2.5 mg by mouth one time a day for high blood pressure and hold the lisinopril for a systolic blood pressure below 120. At 04/24/2026, at 8:13 AM, the Resident took her lisinopril medication.A review of the physician orders revealed an order dated 11/30/2025, for Lisinopril oral tablet 2.5 mg, give 2.5 mg by mouth one time a day for high blood pressure and hold the lisinopril for a systolic blood pressure below 120.A review of the December 2025, Medication Administration Record (MAR) revealed a transcribed order dated 11/30/2025, for Lisinopril oral tablet 2.5 mg give 2.5 mg by mouth one time a day for hypertension and hold the lisinopril for a systolic blood pressure below 120.The MAR revealed that on 12/3/2025, the blood pressure documented in the MAR was 118/47 and the MAR revealed that the medication was administered outside the parameter order which was to hold if the Resident's systolic blood pressure was below 120. Further, the December MAR revealed that from 12/4/2025, there were no blood pressure documented when Lisinopril medication was administered.A review of the February 2026 MAR revealed a transcribed order dated 11/30/2025, for Lisinopril oral tablet 2.5 mg give 2.5 mg by mouth one time a day for high blood pressure and to hold lisinopril for systolic blood pressure below 120. Further, the MAR revealed no blood pressure was documented during the administration of Lisinopril.A review of the March 2026 MAR revealed a transcribed order dated 11/30/2025, for Lisinopril oral tablet 2.5 mg give 2.5 mg by mouth one time a day for high blood pressure and to hold lisinopril for systolic blood pressure below 120. Further, the MAR revealed no blood pressure was documented during the administration of Lisinopril. Review of the April 2026 MAR revealed a transcribed order dated 11/30/2025, for Lisinopril oral tablet 2.5 mg give 2.5 mg by mouth one time a day for high blood pressure and to hold lisinopril for systolic blood pressure below 120. Further, the MAR revealed no blood pressure was documented during the administration of Lisinopril. On 04/24/2026, at 10:12 AM an interview was conducted with a Licensed Practical Nurse (LPN/Staff #96). She said that some blood pressure medications have parameter orders. For example, a Lisinopril order could have a parameter to hold for systolic blood pressure of 120. She stated that if there was a parameter order, she would have the vital signs taken early in the morning, and if the systolic blood pressure was 115, she would hold the medication because it was less than the ordered parameter. She also said that if she did not follow the ordered blood pressure parameter and administered the blood pressure medication while the systolic blood pressure was less than 120, the blood pressure of the Resident would tank. An interview was conducted on 04/24/2026, at 10:40 AM with the Director of Nursing (DON/Staff #134). The DON stated that medication administration is performed based on the physician's order, right medication, right dose, right frequency, right route, right time, and right resident. Regarding blood pressure medications, the DON stated that a blood pressure medication such as a lisinopril with a hold order for systolic blood pressure less than 120, requires staff to adhere to the physician's order, the right medication, right dose, right frequency, right route, right time, and the right resident. She stated that the risk to the Resident if the blood pressure was administered below 120 was that their blood pressure could be reduced lower than what is expected. The DON stated that she expects the nurse to check the Resident's blood pressure before administering the medication, the Resident's blood pressure would be recorded in the medical record, and in the vital signs section tab in the electronic medical record. She further stated that if the blood pressure was not documented, she would not know if the Resident's blood pressure was checked or not. Regarding Resident #44's lisinopril order, the DON stated that the lisinopril order in the electronic medical record for the Resident was lisinopril 2.5 mg po one time a day and hold for a systolic blood pressure below 120 was ordered on 12/1/2025. Further, the DON looked at the Resident's April 2026 MAR and stated that there was no blood pressure recorded on the MAR. She said that she did not know why there was no blood pressure recorded in the MAR. She also said that she would take the Resident's blood pressure prior to medication administration, and she said that she would not want a vital sign taken hours or using the night shift vital signs before administering a blood pressure medication scheduled in the morning. She said that it does not meet her expectation if the staff used a night shift vital sign.An interview was conducted on 4/24/26, at 10:55 AM with LPN staff (Staff #18). The LPN stated that regarding administering blood pressure medications, she said that if the blood pressure was below the ordered parameter, she would hold the medication. She said that the risk could make the Resident's blood pressure drop lower. She also said that the side effects could include feeling dizzy and lightheaded, and the Resident could become unresponsive if the blood pressure drops too low.A review of the facility policy titled Physician Orders, which was revised on 5/2021, revealed that the drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs, and for the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on record review, staff interviews, review of facility documents, and review of policies, the facility failed to protect the resident right to be free from chemical restraints by not administering pain medication in accordance with the physician's order for one resident (#1). The deficient practice could result in medications being administered without following the physician's order and could place the resident's health at risk for illnesses.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included a fracture of her right thigh with subsequent encounter for closed fracture with routine healing, Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, and epilepsy.The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident was cognitively intact. Further, the assessment revealed that the Resident used opioid medications.A review of the physician's orders revealed an order for Acetaminophen oral tablet to give 650 mg (milligram) by mouth every 4 hours as needed for pain level 1-5 and an order for Oxycodone-Acetaminophen 5-325 mg tablet to give 1 tablet by mouth every 4 hours as needed for pain level of 6-10. A review of the April 2026 Medication Administration Record (MAR) revealed a transcribed order dated 03/31/2026, for Oxycodone-Acetaminophen tablet 5-325 MG give 1 tablet by mouth every 4 hours as needed for pain level of 6-10. Further, the MAR revealed that on: -04/4/2026, at 4:53 PM, the Resident's documented pain level was 4, and Oxycodone-Acetaminophen 5-325 mg tablet to give 1 tablet by mouth every 4 hours as needed for pain level of 6-10 was administered, despite an order to give for pain level of 6-10.- 04/4/2026, at 8:58 PM, the Resident's documented pain level was 4, and Oxycodone-Acetaminophen 5-325 mg tablet to give 1 tablet by mouth every 4 hours as needed for pain level of 6-10 was administered, despite an order to give for pain level of 6-10.- 04/21/2026, at 4:38 PM, the Resident's documented pain level was 5, and Oxycodone-Acetaminophen 5-325 mg tablet to give 1 tablet by mouth every 4 hours as needed for pain level of 6-10 was administered, despite an order to give for pain level of 6-10.- 04/21/2026, at 8:41 PM, the Resident's documented pain level was 5, and Oxycodone-Acetaminophen 5-325 mg tablet to give 1 tablet by mouth every 4 hours as needed for pain level of 6-10 was administered, despite an order to give for pain level of 6-10.The care plan review revealed that on 03/31/2026, the Resident was currently prescribed an Opioid for pain, and had the potential for adverse outcomes from opioid use related to status post right femur fracture and right hip pain. The interventions included to use non-pharmalogical interventions; administer opioids as prescribed; assess the Resident for risk of substance abuse and refer as needed; and monitor, document, and report to the provider as needed signs and symptoms of opioid adverse drug reaction such as drowsiness, sedation, dizziness, nausea and vomiting, constipation, or respiratory depression. An interview was conducted on 04/24/2026, at 10:12 AM with a Licensed Practical Nurse (LPN/Staff #96). The LPN stated that when she is administering a pain medication, and the pain medication has a parameter of pain level 1-10, that she would ask the resident their pain level, and then would administer the medication. She said that if the pain level order parameter was 6-10 for a controlled medication, and the Resident's pain level was 4 or 5, she would not administer the controlled pain medication to the Resident because it is not within the ordered pain level parameter of 6-10. She said that if the pain level was below the ordered pain level parameter, she would administer another pain medication that was ordered for a lower pain level or she would reach out to the Resident's provider or the pain specialist.On 04/24/2026, at 10:40 AM an interview was conducted with the Director of Nursing (DON/Staff #134). The DON stated that medication administration is performed based on the physician's order, right medication, right dose, right frequency, right route, right time, and right resident. She said that regarding administering pain medication, she expects her staff to adhere to the order, the right medication, right dose, right frequency, right route, right time, and right resident. The DON stated that if there was a pain level of 6-10 parameter ordered for a medication such as an oxycodone, and the reported pain of the Resident was within pain level of 6-10, she expects her staff to administer the medication. The DON stated that if the ordered pain medication was given outside the pain level of 6-10 parameter, with Resident's reported pain level was 4 or 5, she said that it does not meet her expectation because her expectation was that the staff adheres to the physician's order. She said that when the staff fail to follow the physician's order, the impact could include that the resident could receive the medication outside the physician's order, and the potential risk for the resident was that the resident could receive more medication than what was ordered for that level of pain. Regarding Resident #1's pain medication order of oxycodone 1 tablet every 4 hours as needed for pain level of 6-10, the DON stated that on 04/4/2026 and 04/21/2026, the pain medication was administered outside the ordered parameter and it did not meet her expectation.An interview was conducted on 4/24/26, at 10:55 AM with LPN staff (Staff #18). The LPN stated that regarding pain medications, that different residents have different pain levels. She stated that she would ask the Resident's pain level before administering the medication. She further stated that if she administers the medication outside the ordered parameter, it could lead to over sedation or it could be ineffective if the resident had a different pain level. A review of the facility policy titled Physician Orders, which was revised on 05/2021, revealed that the drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs, and for the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.A review of the facility policy titled Pain Management, which was reviewed on 10/2025, revealed that the Resident pain is assessed and managed by the interdisciplinary team who work together to achieve the highest practicable outcome. For monitoring, the policy revealed to consult the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures.

Based on observations, interviews, and policy review, the facility failed to provide housekeeping services necessary to maintain a clean and homelike environment for residents in three of four resident rooms and hallways. This deficient practice can increase the risk of infection, and not provide the residents with a safe and clean environment. Findings Include:A complaint received on the online complaint portal system, dated January 2, 2026, revealed that the facility did not seem to have enough staff to keep the facility clean, and that the overall cleanliness of the facility is not good. Additionally, the complainant revealed that staff would not clean up the floor after her meal tray spilled. On March 3, 2026, at approximately 8:42 a.m., an observation of room [ROOM NUMBER] was conducted while both residents in Beds A and B were present. During the observation, trash and crumbs were noted on the floor. Multiple visible dark streaks were also observed in high-traffic areas of the flooring. During the observation, the resident in Bed A stated, It takes a lot to get the rooms cleaned around here. The resident in Bed B, stated that the floor and room has been dirty for quite a while. The resident further stated that cleaning staff do not clean the room on a daily basis, but stated he could not estimate how often they come. On March 3, 2026, at approximately 8:54 a.m., an observational tour of the 100 Hall was conducted with the Business Office Manager (Staff #72). During the tour, the manager identified rooms that did not meet the facility's cleanliness expectations and stated the three identified rooms had visible dirt and streaks on the floor (rooms [ROOM NUMBER]); two of the rooms had multiple pieces of trash on the floor (rooms [ROOM NUMBERS]); and one room had visible food crumbs on the floor along with multiple dark streaks and scuff marks in the flooring surface (room [ROOM NUMBER]).On March 3, 2026, at approximately 9:00 a.m., an observation of room [ROOM NUMBER] was conducted with a Certified Nursing Assistant (CNA/Staff #77). During the observation, small pieces of paper, and small loose debris, were noted on the floor along with a few discarded items near the trash can. The CNA stated that housekeeping typically cleans resident rooms daily; however, housekeeping had not yet arrived on the unit that morning, as the meal cart was still present in the hallway. The CNA also stated that the drink cart located in the 300-hallway had multiple areas of visible spillage on the red cooler, on both metallic drink dispenser surfaces, and on the cart surfaces. The CNA indicated that spills should be cleaned when they occur and stated that the cart was being returned to the kitchen to be properly cleaned.On March 3, 2026, at 9:10 a.m., during medication pass with a Registered Nurse (RN/Staff # 75), the nurse identified and stated that room [ROOM NUMBER], failed to meet facility standards due the buildup of streaked dirt, areas of dried spills on the floor, as well as trash on the floor. The RN stated that the room should have been kept clean, and that the current condition of the room was neither home-like nor appropriate for decreasing the risk for spreading infection. The RN stated that trash, messes and spills should be cleaned up immediately and not be allowed to accumulate. An interview was conducted on March 3, 2026, at approximately 3:00 p.m. with the Housekeeping Supervisor (Staff #8). The Housekeeping Supervisor stated that maintaining a clean and home-like environment includes ensuring floors are swept and mopped, trash is removed regularly, and bathroom fixtures such as mirrors, sinks, and toilets are cleaned. She explained that the goal of housekeeping services is to keep the environment organized and smelling clean in order to support a comfortable atmosphere for residents. The supervisor stated that housekeeping staff are instructed to clean under furniture and routinely clean and disinfect high-touch surfaces. She explained that these practices help create a peaceful and comfortable environment for residents. The supervisor stated that she conducts routine walkthroughs throughout the facility to monitor housekeeping performance and ensure resident rooms receive daily cleaning. During these rounds, she stated that areas needing deep cleaning are identified and rooms are checked to ensure they have the supplies and environmental conditions necessary to support a comfortable living environment. The Housekeeping Supervisor stated that housekeeping staff are assigned to specific halls and begin cleaning at the start of each hallway, addressing resident rooms, hallways, and common areas as they proceed. She stated that a floor technician operates the floor machine each morning to maintain hallway floors. The supervisor stated that she also performs morning rounds to observe environmental conditions and address concerns that are identified. The Housekeeping Supervisor stated that previously one housekeeper was assigned to cover two halls; however, she stated that due to an increase in census, staffing assignments are being reassessed so that each hall will have a dedicated housekeeper. The supervisor stated that the facility is in the process of hiring additional staff and reported that one candidate is pending background clearance. She also stated that the facility recently obtained a new washer and continues to implement system improvements to support environmental cleanliness. The supervisor revealed that housekeeping staff are regularly scheduled from 8:00 a.m. to 4:45 p.m., including the supervisor, floor technician, and housekeeping staff assigned to each hall. She explained that while housekeeping staff perform routine cleaning during scheduled hours, all facility staff share responsibility for maintaining a clean environment by reporting spills or debris so they can be addressed promptly. The Housekeeping Supervisor stated that maintaining a clean and homelike environment is the responsibility of all staff within the facility. She stated that spills are expected to be cleaned immediately once identified or reported in order to prevent accidents and maintain a safe environment. The supervisor stated that spills or debris must be reported to housekeeping staff as soon as they occur because if housekeeping is not notified they may not be aware of the issue. She stated that staff typically communicate spills through radio communication so housekeeping staff can respond quickly. The supervisor also stated that maintaining clean floors and surfaces helps prevent illness and infection and reduces the spread of contamination within the facility. The Housekeeping Supervisor stated that the Director of Nursing informed her, of concerns identified with the surveyor during the survey. The supervisor stated that after being notified of the concerns, she personally responded to address the identified issues. The supervisor stated she was instructed to bring room [ROOM NUMBER], up to facility standards, which included cleaning the feces off the toilet. The supervisor revealed that she was also told to address the tube-feeding residue that accumulated on the floor mat in room [ROOM NUMBER]. Following these incidents, the supervisor stated that she spoke with housekeeping staff and reinforced expectations that bathrooms, floors, and other high-use areas must be carefully checked during routine cleaning and that spills, residue, or debris must be addressed promptly. She stated that some resident rooms require closer monitoring because certain residents may have difficulty maintaining cleanliness within their rooms. The Housekeeping Supervisor stated that the findings reported to her by the Director of Nursing on March 3, 2026 did not meet the facility's expectations for environmental cleanliness. She stated that the department is addressing these concerns by hiring additional housekeeping staff, adjusting hall assignments to ensure adequate coverage, and utilizing the new washer to improve cleaning processes. The supervisor stated that the department will continue monitoring the environment and refining processes to ensure the facility consistently maintains a clean, safe, and comfortable environment for residents.An interview was conducted on March 5, 2026, at approximately 9:48 a.m. with the Assistant Director of Nursing (ADON/Staff #83). The ADON stated that maintaining cleanliness and hygiene is an important professional standard within the facility. The ADON further stated that cleanliness is important for residents who are healing, especially those who may be immunocompromised. In addition, the ADON continued to state that a clean, sanitary, and hygienic environment was imperative to both physical health and mental well-being. The ADON also revealed that an unclean environment could potentially contribute to declines in health and negatively impact residents' comfort. The ADON also stated that spills should be cleaned immediately to prevent slip hazards and that overall presentation of the environment should prioritize resident safety. The ADON indicated that situations involving cleanliness concerns provide opportunities for staff education and reinforcement of facility expectations.A follow-up clarification interview was conducted on March 5, 2026, at approximately 10:50 a.m. with the resident in Bed B of room [ROOM NUMBER] to obtain additional clarification regarding his prior statement. During the interview, the resident stated that he was not joking when the Director of Nursing (DON) and the surveyor were previously in the room. The resident reported that even though his roommate has dementia; neither one of them were joking when the DON and the surveyor was present in the room earlier about the need for housekeeping improvement, and that their room is not cleaned on a daily basis. The facility's Infection Control Program policy, with the reviewed date of August 2025, revealed the goal of the infection control program, it to identify and correct problems relating to infection control practices. The facility's Homelike Environment policy, with the reviewed date of May 2022, revealed that it is the policy of the facility to provide a home like environment.

Based on observations, interviews and facility policy, the facility failed to protect the rights of one of 13 sampled resident's (#600) to be free from abuse by another resident (#525). The deficient practice could result in residents being abused by other residents or staff.Findings include:A facility 5-day incident report, dated April 17, 2023, revealed that on April 9, 2023 at 10:55 p.m. Resident #525 was overheard by a Licensed Practical Nurse (LPN/staff #64) and a Certified Nursing Assistant (CNA/staff #801), using obscenities including the racial profanity nigger towards Resident #600. The facility report included that the abuse was substantiated, resulting in no injury.-Resident #525 (alleged perpetrator):Resident #525 was originally admitted on [DATE] with diagnoses that included malnutrition, hemorrhagic telangiectasia, anxiety disorder, blindness in one eye, and insufficient sleep syndrome. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated normal cognition. The assessment also revealed that no behaviors physical or verbal directed toward others had occurred in 1-6 days during the assessment.A Daily Skilled progress note dated April 9, 2023 revealed that the resident was alert and oriented x 3, with no active symptoms or treatments effecting mood or behavior. However, the note included that Resident #525 yelled obscenities at the roommate (Resident #600), was redirected, and proceeded to call the roommate a nigger.-Resident #600 (alleged victim): Resident #600 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, asthma, and depression.A quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated normal cognition.Review of progress notes revealed no evidence regarding the altercation that occurred on April 9, 2023.An interview was conducted on March 4, 2026 at 2:44 pm with an LPN (staff #64), who witnessed the incident that occurred on April 9, 2023. She stated that verbal abuse included yelling, cursing and racial/prejudice remarks. She further stated that the incident included a racial slur toward Resident #600 by Resident #525, who was prejudice.An interview was conducted on March 5, 2026 at 12:30 pm with the Assistant Director of Nursing (ADON/staff #83), who stated that verbal abuse included yelling, profanities, and racial slurs. She further stated that when verbal abuse occurs the residents are separate and the incident is reported to the Abuse Coordinator. The ADON stated that this incident occurred prior to her employment at the facility.An interview was conducted with the Executive Director (ED)/Abuse Coordinator (staff #19), who stated that he expected abuse allegations to be reported immediately. He further stated that verbal abuse included name calling and racial slurs that could cause distress to residents if the person receiving takes offense. The ED/Abuse Coordinator reviewed the facility 5-day report and stated that Resident #525 used colorful language toward Resident #600 that included racial verbiage. The ED/Abuse Coordinator stated that Resident #525 was moved into another room the next day, and there were no reports of any more incidents. The ED/Abuse Coordinator also stated both residents declined to be interviewed, and neither wanted to talk about the incident. The ED/Abuse Coordinator also stated that the facility investigation substantiated the verbal abuse.A policy titled, Abuse: Prevention of and Prohibition Against, revised/reviewed October 2025, revealed that it is the policy of the facility that each resident has the right to be free from abuse. Nursing home residents have a right to be free from verbal, sexual, physical and mental abuse. The policy included that willful abuse means the individual must have acted deliberately. Verbal abuse includes the use of oral or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of age, ability to comprehend, or disability.A policy titled, Resident Rights, revealed that the resident has the right to be free from verbal abuse.

Based on clinical record review, interviews, review of facility documentation and policy and procedures, the facility failed to ensure 1 of 3 sampled residents (#20) was free from a significant medication error. The deficient practice could result in harm to the resident.Findings include:Resident #20 was admitted [DATE] with diagnoses of metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit and syncope and collapse.The physician order summary report active as of January 16, 2026 included the following medications:Acidophilus (Lactobacillus-probiotics), 1 tablet by mouth one time a day for probioticB-complex w/biotin & folic acid (supplement), 1 tablet by mouth one time a day for supplementClopidogrel bisulfate (antiplatelet) 75 mg (milligrams)1 tablet by mouth one time a day for a history of transient ischemic attackFluconazole (antifungal) 200 mg 1 tablet by mouth one time a day for toe infectionLoratadine (antihistamine) 10 mg 1 tablet by mouth one time a day for allergiesMultivitamin (supplement) 1 tablet by mouth once a day for supplementPolyethylene glycol (laxative)3350 powder 17 grams by mouth daily for bowel regimenPropranolol (beta-blocker) ER (extended release) 120 mg, 1 capsule by mouth one time a day for hypertensionFluticasone propionate (synthetic corticosteroid) nasal suspension, 50 mcg (microgram)/Act (activation) 1 spray in both nostrils every 12 hours for allergiesLamotrigine (anticonvulsant) 100 mg 1 tablet by mouth every 12 hours for seizuresAcetaminophen (analgesic) 1000 mg by mouth every 8 hours for chronic painHeparin (anticoagulant) 5000 unit/ml (milliliter), inject 5000 unit subcutaneously every 8 hours for deep vein thrombosis prophylaxisThese medications were transcribed onto the MAR (medication administration record) for January 2026. Review of the MAR revealed documentation that these medications were administered as ordered.A nursing progress note dated January 16, 2026, at 4:00 p.m. included that the resident's family arrived to visit and found the resident #20 slumped over in her chair. It also included that the nurse assessed the resident and noted that the resident did not respond to verbal cues but did respond to physical stimulation. Per the documentation, the resident was unable to state her birthday, the current year, or her location; and, the only question resident could answer was the name of her family. Further, the documentation included that the resident's eyes rolled back while speaking and that the resident fell asleep immediately afterward. According to the documentation, the resident's BP (blood pressure) was 162/81 and the provider was notified. Further, the note included an instruction to send the resident out due to a change in condition.A nursing progress note dated January 16, 2026 at 10:41 p.m. revealed that the resident's family notified the facility that the resident was being admitted to the hospital for observation related to elevated blood pressure.A review of an undated handwritten document written by the License Practical Nurse (LPN/Staff #7) revealed a list of medications of another resident that was given to Resident #20 included the following:Amiodarone (antiarrhythmic) 200 mg;Aripiprazole (antipsychotic) 5 mg;Aspirin (non-steroidal anti-inflammatory) 325 mg;Citalopram (antidepressant) 40 mg;Apixaban (direct acting anticoagulant) 2.5 mg;Ferrous sulfate (supplement) 325 mg;Folic acid (supplement) 1 mg;Lasix (diuretic) 40 mg;Midodrine (antihypotensive) 10 mg;Multivitamin with minerals (supplement);Potassium (supplement) ER 20 mEq (milliequivalent);Vitamin B12 (supplement) 1000 mcg; and,Vitamin D3 (supplement) 1000 IU (international units).However, review of the clinical record revealed no evidence that Resident #20 had physician orders for the following medications administered to Resident #20 and listed in the handwritten document: amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, Lasix, midodrine, a multivitamin with minerals, potassium ER, vitamin B12, or vitamin D3.Continued review of an undated handwritten document showed a list of morning vital signs documented as prior to event, including a blood pressure of 140/72, pulse of 73, oxygen saturation of 93, respirations of 18, and a temperature of 98 degrees. The documentation indicated that the resident did not understand at all and was alert and oriented x2ish, when she was notified of the error at 12:20 p.m. An undated typewritten facility investigation revealed that on January 16, at approximately 12:10 p.m., the registered nurse (RN/staff #46) and Physical Therapy Assistant (PTA/Staff #57), informed Licensed Practical Nurse (LPN/Staff#7), that Resident #20 was given several medications that were prescribed for a different resident. Per the documentation, the resident reported that she took her medications when she was informed that the nurse gave her additional medications that were not ordered for her. It also included that the resident was leaning to the side and was not responsive to verbal cues, but was responsive to physical stimuli at 4:00 p.m., when the resident's family arrived; and that, vital signs were taken and revealed resident had elevated BP. The documentation included that the provider was notified and orders were received to send Resident #20 to the emergency room; and that, later that evening, the resident's family informed the facility that Resident #20 was admitted for observation for her elevated blood pressure. Further, the documentation included that a follow-up with the hospital on January 21, 2026 confirmed that Resident #20 was still in the hospital; and, had an admitting diagnosis of unintentional use of medication and pneumonia.A phone interview with the family of Resident #20 was conducted on January 21, 2026 at 1:00 p.m. The family stated that on January 16, 2026 at around 1:45. p.m., the resident's nurse called and informed her that another nurse went into the therapy area and asked which therapist was working with another resident. The family said that she was told that the therapist who was working with Resident #20 told the nurse that he had Resident #20; and that, the nurse gave the medications to Resident #20 instead of the other resident. The family said the nurse told her the doctor was onsite and staff were monitoring Resident #20; but, staff did not immediately inform her which medications were given to Resident #20 or that the resident's vital signs were abnormal. She stated that eventually the facility gave her a list of the medications shortly after she arrived at the facility that day. The family stated that when she arrived at the facility, Resident #20 was slumped over in her wheelchair and there were no staff in the room with the resident. The family said that she immediately left the room to call for help and was able to get the LPN (staff #64) to assess and ask the resident questions. She stated that within a minute, the LPN decided to call the ambulance; and the facility sent Resident #20 to the emergency room by 4:00 p.m. Further, the family said that the blood pressure of Resident #20 skyrocketed; and the resident could not lift her head. The family also said that Resident #20 was given medications to treat schizophrenia.A phone interview was conducted on January 21, 2026 at 1:13 p.m. with a LPN (staff#64) who stated that she was scheduled to start the evening shift at 2:00 p.m. on the day of the incident and learned about the incident during shift change. She said that she was told that a nurse from another hall was going to administer medications to another resident who was not in her room, so the nurse went to the therapy room to locate the resident. The LPN stated she did not know how the nurse identified the resident, but the nurse asked Resident #20 if she was the other resident and Resident #20 responded yes. The LPN stated that the therapist later informed the nurse that the medication had been given to the wrong resident. She reported that she asked the CNAs for the vital sign monitoring sheet, and that blood pressure and heart rate checks were initiated. According to the LPN, the resident's blood pressure increased slightly with each hourly check. The LPN stated that at approximately 3:30 p.m., while she was administering medications in another room, the family of Resident #20 arrived and asked why the resident was slumped over in her wheelchair. The LPN reported that she went to the resident's room and saw Resident #20 slumped over in her wheelchair and unable to lift her head. She stated that she reassessed the resident's vital signs and noted that the resident was not coherent, stated her birthday as October 25, 2025, and had eyes rolling back. The LPN stated that she contacted the physician, who ordered the resident to be sent to the hospital due to a change in condition and had a BP reading of 162/81.An interview was conducted with another LPN (Staff #7) on January 21, 2026, at 1:35 p.m. The LPN stated that when administering medications, she verifies the resident's name, date of birth , and photo in the electronic medical record and follows the medication rights, including the right medication, right patient, right time, and right route. She stated that she was Resident #20's nurse and that during the Friday day shift she administered the correct medications to the resident. The LPN reported that later that morning, a nurse from another hall informed her that medications intended for another resident had been administered to Resident #20. She stated that she then contacted the physician who was onsite, reviewed all medications the resident had received with the physician, and obtained the resident's vital signs before notifying the resident, the family, and the Director of Nursing (Staff #27). The LPN stated that the medication error occurred at approximately 12:10 p.m. while the resident was in therapy. She said the nurse who administered the incorrect medications reported verifying the resident's name with both resident #20 and the therapist present in the therapy room. The LPN stated that the physician instructed staff to hold Resident #20's heparin and propranolol the following day so the resident could be monitored.An interview with the Director of Nursing (DON/Staff #7) was conducted on January 21, 2026, at 2:28 p.m. The DON stated that nursing staff were expected to prepare and verify medications according to the physician's orders, confirm the correct resident, and sign the electronic medication administration record (eMAR) after administering medications. She stated that resident identification may be verified by asking the resident their name and date of birth , checking the door tag, and using the resident's photo in the electronic medical record. The DON stated that when medications are administered in error, nurses were expected to immediately observe the resident, notify the provider with a list of the medications given in error, obtain monitoring orders, and notify the resident and the responsible party. She also said that receiving incorrect medications could result in various health outcomes, including hospitalization or the resident receiving medications for conditions they do not have. Regarding Resident #20, the DON stated that the resident received medications prescribed for Resident #61 while participating in a group therapy session. She said that the RN (staff #46) entered the therapy gym looking for the other resident, and the therapist working with Resident #20 told the RN (staff #46) that he had the other resident. The DON stated that Resident #20 also identified herself as the other resident, and the RN (staff #46) administered the medications to Resident #20. The DON said that after the therapy session, the therapist realized the error and informed the RN (staff #46) that he had been working with Resident #20, not the other resident. The DON stated that a nurse then took Resident #20's vital signs, contacted the provider, and notified Resident #20's assigned nurse. She reported that the resident's vital signs were stable for the first few hours; however, later the resident's blood pressure increased, and the resident became slumped over in her chair, requiring staff to support her head to obtain a response. The DON stated that although the blood pressure was not critically high, the decision was made to send Resident #20 to the hospital due to the medication error.A phone interview was conducted on January 21, 2026, at 2:46 p.m. with a registered nurse (RN, Staff #46) who administered medications of another resident to Resident #20. The RN stated that when administering medications, she checks the medications due and verifies the correct medication, dose, time, and resident. She said that she was the nurse for another resident on the day of the incident when the medication error occurred involving Resident #20. The RN stated that she had never worked on the other resident's hall before and had only seen Resident #20 once previously. She reported that she reviewed the other resident's chart, prepared the other resident's medications, and went to administer them, but the other resident was not in her room. The RN stated that she then went to the therapy gym and asked therapists to locate the other resident. According to the RN, a therapist stated that he had the other resident, and Resident #20 also told the RN that she was the other resident. The RN then administered the medications to Resident #20. The RN stated that approximately 20 to 40 minutes later, the therapist informed her that the medications had been given to the wrong resident and apologized, explaining that he was assigned to both Resident #20 and the other resident. The RN stated that she immediately reported the error to the Director of Nursing, the LPN (Staff #7), and the provider (Staff #15). She further stated that she stayed after her shift to complete documentation and heard the ambulance arrive to transport Resident #20 to the hospital. The RN stated that the potential risks of administering medications to the wrong resident range from medication side effects to death.A phone interview was conducted on January 21, 2026, at 2:56 p.m. with a physical therapist assistant (PTA/Staff #57). The PTA stated that he had not met Resident #20 or the other resident prior to the day of the incident. He reported that on the day of the incident, Resident #20 was brought to the therapy gym for scheduled services. The PTA stated that he introduced himself to the resident and reviewed the resident's level of functioning through a chart review. The PTA stated that the RN (Staff #46) entered the therapy gym looking for the other resident, and he told the RN that he had the other resident. He stated that he should have taken more time to verify the resident's identity but believed the resident he was working with was the other resident. The PTA reported that the RN then administered the other resident's medications to Resident #20. The PTA stated that it was not until he was escorting Resident #20 back to her room that he realized the medications had been given to the wrong resident. He reported that he immediately informed the RN (Staff #46) and the Director of Nursing (Staff #7) of the error.Review of a policy titled, Medication Administration - Oral, with a review date of April 2025 revealed that it was their policy to accurately prepare, administer, and document oral medications. Essential points of the policy included that no medication was to be administered without a physician's order, and the resident must be identified before administering any medications.

Based on clinical record review, interviews, review of facility documentation and policy and procedures, the facility failed to ensure medications administered to 1 of 3 sampled residents (#20) had physician orders. The census was 101. The deficient practice resulted in resident hospitalization due to a change in resident's condition.Findings include:Resident #20 was admitted [DATE] with diagnoses of metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit and syncope and collapse.The history & physical note dated January 12, 2026 included the resident was admitted at the facility for inpatient rehabilitation; and that, all medications were reviewed and reconciled. Assessments included history of TIA (transient ischemic attack); muscle weakness and seizure disorder. Medications included Primidone.A care plan initiated on January 13, 2026, revealed a focus on the resident having hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as hypotension and increased heart rate.The eMAR (electronic medication administration record) notes dated January 13, 2026 revealed that prescribed medications for Resident #20 was documented as administered as ordered by a Registered Nurse (RN/Staff #46) on January 13, 2026.The physician order summary report active as of January 16, 2026 included the following medications:Acidophilus (Lactobacillus-probiotics), 1 tablet by mouth one time a day for probioticB-complex w/biotin & folic acid (supplement), 1 tablet by mouth one time a day for supplementClopidogrel bisulfate (antiplatelet) 75 mg (milligrams)1 tablet by mouth one time a day for a history of transient ischemic attackFluconazole (antifungal) 200 mg 1 tablet by mouth one time a day for toe infectionLoratadine (antihistamine) 10 mg 1 tablet by mouth one time a day for allergiesMultivitamin (supplement) 1 tablet by mouth once a day for supplementPolyethylene glycol (laxative)3350 powder 17 grams by mouth daily for bowel regimenPropranolol (beta-blocker) ER (extended release) 120 mg, 1 capsule by mouth one time a day for hypertensionFluticasone propionate (synthetic corticosteroid) nasal suspension, 50 mcg (microgram)/Act (activation) 1 spray in both nostrils every 12 hours for allergiesLamotrigine (anticonvulsant) 100 mg 1 tablet by mouth every 12 hours for seizuresAcetaminophen (analgesic) 1000 mg by mouth every 8 hours for chronic painHeparin (anticoagulant) 5000 unit/ml (milliliter), inject 5000 unit subcutaneously every 8 hours for deep vein thrombosis prophylaxisReview of the clinical record revealed documentation that prescribed medications for Resident #20 were administered as ordered on January 16, 2026A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. Per the assessment, the resident was taking anticoagulants, antiplatelets and anticoagulants with 4 medications being received through injections.A nursing progress note dated January 16, 2026, at 4:00 p.m. included that the resident's family arrived to visit and found the resident #20 slumped over in her chair. It also included that the nurse assessed the resident and noted that the resident did not respond to verbal cues but did respond to physical stimulation. Per the documentation, the resident was unable to state her birthday, the current year, or her location; and, the only question resident could answer was the name of her family. Further, the documentation included that the resident's eyes rolled back while speaking and that the resident fell asleep immediately afterward. According to the documentation, the resident's BP (blood pressure) was 162/81 and the provider was notified. Further, the note included an instruction to send the resident out due to a change in condition.A nursing progress note dated January 16, 2026 at 10:41 p.m. revealed that the resident's family notified the facility that the resident was being admitted to the hospital for observation related to elevated blood pressure.A review of an undated handwritten document written by the License Practical Nurse (LPN/Staff #7) revealed a list of medications of another resident that were given to Resident #20 included the following:-Amiodarone (antiarrhythmic) 200 mg;-Aripiprazole (antipsychotic) 5 mg;-Aspirin (non-steroidal anti-inflammatory) 325 mg;-Citalopram (antidepressant) 40 mg;-Apixaban (direct-acting anticoagulant) 2.5 mg;-Ferrous sulfate (supplement) 325 mg;-Folic acid (supplement) 1 mg;-Lasix (diuretic) 40 mg;-Midodrine (antihypotensive) 10 mg;-Multivitamin with minerals (supplement);-Potassium (supplement) ER 20 mEq (milliequivalent);-Vitamin B12 (supplement) 1000 mcg; and,-Vitamin D3 (supplement) 1000 IU (international units).The clinical record revealed no evidence that Resident #20 had physician orders for medications listed in the handwritten document and documented as administered to her, including amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, Lasix, midodrine, a multivitamin with minerals, potassium ER, vitamin B12, or vitamin D3.Continued review of an undated handwritten document showed a list of morning vital signs documented as prior to event, including a blood pressure of 140/72, pulse of 73, oxygen saturation of 93, respirations of 18, and a temperature of 98 degrees. The documentation indicated that the onsite provider was notified at 12:14 p.m.; the resident, who did not understand at all and was alert and oriented x2ish, was notified at 12:20 p.m.; and, the resident's family, who was described as very angry and requested a list of medications given to Resident #20, was notified at 1:43 p.m. According to the documentation, the physician instructed staff to hold the resident's heparin and propranolol for 24 hours and to monitor vital signs every hour until midnight, then every four hours; and that the monitoring sheet was provided to the CNAs (certified nursing assistants).An undated typewritten facility investigation revealed that on January 16, at approximately 12:10 p.m., the registered nurse (RN/staff #46) and Physical Therapy Assistant (PTA/Staff #57) informed Licensed Practical Nurse (LPN/Staff#7) that Resident #20 was given several medications that were prescribed for a different resident. Per the documentation, the resident reported that she took her medications when she was informed that the nurse had given her additional medications that were not ordered for her. It also included that the resident was leaning to the side and was not responsive to verbal cues, but was responsive to physical stimuli at 4:00 p.m., when the resident's family arrived; and that vital signs were taken and revealed the resident had elevated BP. The documentation included that the provider was notified and orders were received to send Resident #20 to the emergency room; and that, later that evening, the resident's family informed the facility that Resident #20 was admitted for observation for her elevated blood pressure. Further, the documentation included that a follow-up with the hospital on January 21, 2026, confirmed that Resident #20 was still in the hospital and had an admitting diagnosis of unintentional use of medication and pneumonia.A phone interview with the family of Resident #20 was conducted on January 21, 2026, at 1:00 p.m. The family stated that on January 16, 2026, at around 1:45. p.m., the resident's nurse called and informed her that another nurse had gone into the therapy area and asked which therapist was working with another resident. The family said that she was told that the therapist who was working with Resident #20 told the nurse that he had Resident #20, and that the nurse gave the medications to Resident #20 instead of the other resident. The family said the nurse told her the doctor was onsite and staff were monitoring Resident #20, but staff did not immediately inform her which medications were given to Resident #20 or that the resident's vital signs were abnormal. She stated that, eventually, the facility gave her a list of the medications shortly after she arrived at the facility that day. The family stated that when she arrived at the facility, Resident #20 was slumped over in her wheelchair, and there were no staff in the room with the resident. The family said that she immediately left the room to call for help and was able to get the LPN (staff #64) to assess and ask the resident questions. She stated that within a minute, the LPN decided to call the ambulance, and the facility sent Resident #20 to the emergency room by 4:00 p.m. Further, the family said that the blood pressure of Resident #20 skyrocketed, and the resident could not lift her head. The family also said that Resident #20 was given medications to treat schizophrenia.A phone interview was conducted on January 21, 2026, at 1:13 p.m. with an LPN (staff#64) who stated that she was scheduled to start the evening shift at 2:00 p.m. on the day of the incident and learned about the incident during shift change. She said that she was told that a nurse from another hall was going to administer medications to another resident who was not in her room, so the nurse went to the therapy room to locate the resident. The LPN stated she did not know how the nurse identified the resident, but the nurse asked Resident #20 if she was the other resident, and Resident #20 responded yes. The LPN stated that the therapist later informed the nurse that the medication had been given to the wrong resident. She reported that she asked the CNAs for the vital sign monitoring sheet, and that blood pressure and heart rate checks were initiated. According to the LPN, the resident's blood pressure increased slightly with each hourly check. The LPN stated that at approximately 3:30 p.m., while she was administering medications in another room, the family of Resident #20 arrived and asked why the resident was slumped over in her wheelchair. The LPN reported that she went to the resident's room and saw Resident #20 slumped over in her wheelchair and unable to lift her head. She stated that she reassessed the resident's vital signs and noted that the resident was not coherent, stated her birthday as October 25, 2025, and had eyes rolling back. The LPN stated that she contacted the physician, who ordered the resident to be sent to the hospital due to a change in condition and had a BP reading of 162/81.An interview was conducted with another LPN (Staff #7) on January 21, 2026, at 1:35 p.m. The LPN stated that when administering medications, she verifies the resident's name, date of birth , and photo in the electronic medical record and follows the medication rights, including the right medication, right patient, right time, and right route. She stated that she was Resident #20's nurse and that during the Friday day shift, she administered the correct medications to the resident. The LPN reported that later that morning, a nurse from another hall informed her that medications intended for Resident #61 had been administered to Resident #20. She stated that she then contacted the physician who was onsite, reviewed all medications the resident had received with the physician, and obtained the resident's vital signs before notifying the resident, the family, and the Director of Nursing (Staff #27). The LPN stated that the medication error occurred at approximately 12:10 p.m. while the resident was in therapy. She said the nurse who administered the incorrect medications reported verifying the resident's name with both resident #20 and the therapist present in the therapy room. The LPN stated that the physician instructed staff to hold Resident #20's heparin and propranolol the following day so the resident could be monitored.An interview with the Director of Nursing (DON/Staff #7) was conducted on January 21, 2026, at 2:28 p.m. The DON stated that nursing staff were expected to prepare and verify medications according to the physician's orders, confirm the correct resident, and sign the electronic medication administration record (eMAR) after administering medications. She stated that resident identification may be verified by asking the resident their name and date of birth , checking the door tag, and using the resident's photo in the electronic medical record. The DON stated that when medications were administered in error, nurses were expected to immediately observe the resident, notify the provider with a list of the medications given in error, obtain monitoring orders, and notify the resident and the responsible party. She also said that receiving incorrect medications could result in various health outcomes, including hospitalization or the resident receiving medications for conditions they do not have. Regarding Resident #20, the DON stated that the resident received medications prescribed for Resident #61 while participating in a group therapy session. She said that the RN (staff #46) entered the therapy gym looking for the other resident, and the therapist working with Resident #20 told the RN (staff #46) that he had the other resident. The DON stated that Resident #20 also identified herself as the other resident, and the RN (staff #46) administered the medications to Resident #20. The DON said that after the therapy session, the therapist realized the error and informed the RN (staff #46) that he had been working with Resident #20, not the other resident. The DON stated that a nurse then took Resident #20's vital signs, contacted the provider, and notified Resident #20's assigned nurse. She reported that the resident's vital signs were stable for the first few hours; however, later the resident's blood pressure increased, and the resident became slumped over in her chair, requiring staff to support her head to obtain a response. The DON stated that although the blood pressure was not critically high, the decision was made to send Resident #20 to the hospital due to the medication error.A phone interview was conducted on January 21, 2026, at 2:46 p.m. with a registered nurse (RN, Staff #46) who administered medications of another resident to Resident #20. The RN stated that when administering medications, she checks the medications due and verifies the correct medication, dose, time, and resident. She said that she was the nurse for another resident on the day of the incident when the medication error occurred involving Resident #20. The RN stated that she had never worked on the other resident's hall before and had only seen Resident #20 once previously. She reported that she reviewed the other resident's chart, prepared the other resident's medications, and went to administer them, but the other resident was not in her room. The RN stated that she then went to the therapy gym and asked therapists to locate the other resident. According to the RN, a therapist stated that he had the other resident, and Resident #20 also told the RN that she was the other resident. The RN then administered the medications to Resident #20. The RN stated that approximately 20 to 40 minutes later, the therapist informed her that the medications had been given to the wrong resident and apologized, explaining that he was assigned to both Resident #20 and the other resident. The RN stated that she immediately reported the error to the Director of Nursing, the LPN (Staff #7), and the provider (Staff #15). She further stated that she stayed after her shift to complete documentation and heard the ambulance arrive to transport Resident #20 to the hospital. The RN stated that the potential risks of administering medications to the wrong resident range from medication side effects to death.A phone interview was conducted on January 21, 2026, at 2:56 p.m. with a physical therapist assistant (PTA/Staff #57) who stated that he had not met Resident #20 or the other resident prior to the day of the incident. He reported that on the day of the incident, Resident #20 was brought to the therapy gym for scheduled services. The PTA stated that he introduced himself to the resident and reviewed the resident's level of functioning through a chart review. The PTA stated that the RN (Staff #46) entered the therapy gym looking for the other resident, and he told the RN that he had the other resident. He stated that he should have taken more time to verify the resident's identity, but believed the resident he was working with was the other resident. The PTA reported that the RN then administered the other resident's medications to Resident #20. The PTA stated that it was not until he was escorting Resident #20 back to her room that he realized the medications had been given to the wrong resident. He reported that he immediately informed the RN (Staff #46) and the Director of Nursing (Staff #7) of the error.Review of a policy titled, Medication Administration - Oral, with a review date of April 2025, revealed that it was their policy to accurately prepare, administer, and document oral medications. Essential points of the policy included that no medication was to be administered without a physician's order, and the resident must be identified before administering any medications.Review of a policy titled, Quality of Care, with a review date of May 2025, included that it is their policy that residents would be given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.

Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#12). The sample size was 20. Findings include: The resident was admitted on [DATE] with diagnosis including anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance , anxiety, depression, schizophrenia, acute respiratory failure with hypoxia, pleural effusion, other non specific findings of the lung field, pneumonia, chronic obstructive pulmonary disease and a wedge compression fracture. A review of the MDS (minimum data set) dated December 07, 2023 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further noted that the resident was on oxygen therapy. A review of the of the physician's orders dated January 2, 2024 for resident #12 revealed an order for 4 liters of oxygen per minute via nasal cannula. An update to the orders was made on January 30, 2024 at 2:00 PM noting oxygen via nasal cannula for chronic obstructive pulmonary disease and may citrate to keep oxygen saturation (SP02) levels at or above 90% A review of the resident's care plan initiated on December 29, 2019 revealed a focus that resident #12 has emphysema, and chronic obstructive pulmonary disease and the included intervention that oxygen therapy is to be given as ordered by the physician. Furthermore, the care plan revealed that the resident has oxygen therapy and that the oxygen settings were noted to be at 5 liters per minute continuously via nasal cannula; however, oxygen was observed to be above the ordered liters per minute and above the documented care plan rate for resident #12. An observation on January 30, 2024 at 9:52 AM revealed that resident #12 was observed to be on 6 liters of oxygen as observed on the oxygen concentrator setting. An observation on January 30, 2024 at 12:26 PM revealed that resident #12 was still on 6 liters of oxygen. An interview was conducted on January 30, 2024 at 12:26 P.M. with staff #70 LPN (Licensed Practical Nurse). Staff #70 stated that oxygen settings were as ordered by the physician. She further stated that oxygen settings are checked during rounding every 2 hours. She stated that oxygen setting for resident #12 should be at 4 liters per minute. She stated that the risk for settings outside of the parameters that the physician had established could impact the gas exchange and could impede the resident's breathing. An interview was conducted with staff #13, DON (Director of Nursing) on January 30, 2024 at 12:40 PM Staff #13 stated that some patients, depending on the physician's order, may have settings designated on a range to maintain oxygen at a certain level. She stated that the nurse assigned to the resident, is required to sign off on the oxygen order every shift. Staff #13 reviewed the medical record for resident #12 and stated that the orders for this resident are at 4 liters per minute. She stated that the expectation is to ensure that the oxygen orders established by the physician are followed. Staff #13 stated that the risk could be that the resident may not get enough oxygen and that the resident's oxygenation could be impeded. A review of the oxygen administration policy with a review date of May 2023 revealed that oxygen therapy is administered by a licensed nurse as ordered by the physician; however, the oxygen therapy settings observed on 2 separate occasions were not as ordered by the physician and noted to be 2 liters above the ordered setting. It was however observed that the facility did have the order changed on the same day the concern was brought to their attention.

Based on review of facility documentation and staff interview, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the actual hours worked by licensed and unlicensed nursing staff and the resident census. Findings include: An interview was conducted on 2/2/2024 at 12:36 PM with the Staffing Coordinator (staff #18) who said daily staff postings should be accurate. She said that that she gets the numbers from the daily staff tracking form so staff must have left early or late that day. She reviewed the posting for 12/30/2023 and said that it was not accurate. An interview was conducted on 2/2/2024 at 12:56 PM with the Director of Nursing (DON/staff#13) who said that daily staff postings should be accurate. She said that she'd have to assume that their numbers are accurate but she would have to double check. An interview was conducted on 2/2/2024 at 1:31 PM with the Administrator (staff #115) who said that he did not know if there was a policy regarding the accuracy of staff postings and that he would check with the Director of Nursing. A follow up interview conducted on 2/2/2024 at 1:56 PM with the DON included that the facility does not have a policy regarding the accuracy of staff postings.

Based on clinical record, staff interviews, facility records and facility policies, the facility failed to ensure that a resident was supervised to prevent urinating on another resident's room floor. This practice resulted in assault of a residents' dignity, infection control risks and disruptions of a resident's privacy. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses of COVID-19, malignant neoplasm of colon and rectum and need for assistance with personal care. An Admission Minimum Data Set (MDS) dated [DATE] included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was cognitively intact. This document also included that the resident required limited 2 person assistance for transfers and that the resident did not walk in the room or corridor during the lookback period. A review of the resident's clinical record did not find any record of a resident urinating on this residents' floor. -Resident #23 was admitted to the facility on [DATE] with diagnoses of COVID-19, pneumonia, dementia and Alzheimer's disease. A Discharge -return not anticipated MDS dated [DATE] included that this resident makes herself understood and understands others. This document included that a Brief Interview for Mental Status (BIMS) indicated that this resident was moderately cognitively impaired. This document also included that the resident had wandered 4 to 6 days of the 7 day lookback, but less than daily. An initial care plan did not include wandering. A comprehensive care plan included to monitor for effects of psychiatric drugs which included wandering. However, no care plan or intervention were put in place to stop wandering. A Tasks document included behavior monitoring. This document included that the resident had wandered on the 1st and 3rd of January 1, 2023. The clinical record did not include that this resident had urinated in another resident's room. A progress noted dated January 5, 2023 included that the resident was alert, confused per usual, up out of bed at times restless walking into hall looking for the bathroom. This nurse included that she assisted him into the bathroom. An interview was conducted on January 25, 2023 at 12:05 PM with a Nursing Assistant (staff #100) who said that one of the demented residents peed on resident #4's floor. She said that she had worked the next morning and that resident #4 had told her about it. She said that the she and other Nursing Assistants cleaned up the pee. She said that resident #23 was so hard to contain because he had dementia and would wander. She said that once she stopped him from urinating in a trash can in the hall. An interview was conducted on January 26, 2023 at 3:37 PM with a Licensed Practical Nurse (LPN/staff #19) who said that she was not there that night but that she was informed by resident #4 that a man came in urinated on floor and that she put on the call light. She said that she thought he urinated near the resident's doorway. She said resident #23 was the one that was wandering, that he had dementia, and that he was in that end of the hall. She said that it was difficult to keep residents with dementia in the room. She said that resident #23 was a wanderer and that he seemed to stay in that area. She said that this resident was in the second or third room and that she thought he was attracted to the door to look outside and it makes sense that he would go to the room right next to that. She said that resident #4 was in the room next to the door. An interview was conducted on January 26, 2023 at 2:46 PM with a nursing assistant (#103) who said that resident #23 was incontinent and that he was really confused. This nursing assistant said that resident #23 used to walk to the bathroom sometimes and he would have accidents or go over to the roommate and the roommate said, He's right here staring at me. This staff said that he used to drip when he was walking, sometimes he would pee with a brief on but that the resident would stand up and the brief would fall and sometimes the resident would move the brief. An interview was conducted on January 27, 2023 at 11:39 AM with a LPN (staff #99) who said that if a resident wanders, it has to be put in the care plan for the resident's safety. She said that a nurse can update the care plan but usually it is the MDS nurse. An interview was conducted on January 27, 2022 at 12:18 PM with the Director of Nursing (DON/staff #52) who said that it is not abuse to have a resident peeing on another resident's floor if the resident is cognitively impaired. She said that care planning is an interdisciplinary process because it not one person caring for the resident. She said that because the outside doors were key coded and that because a charting area was nearby the room that a direct care plan for wandering was not needed. A Facility Assessment included that this facility may accept residents with Alzheimer's Disease and Non-Alzheimer's dementia and other psychiatric/mood disorders except those residents who are deemed by the facility IDT to be a danger to self or others, or who have severe dementia and are continually exit Seeking. A policy titled Resident Safety revealed that it is the policy of this facility to create a safe environment for the resident. A policy titled Care Planning revealed that It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Care Plan will be revised as needed, and interventions will be implemented.

Based on review of facility logs and staff interview, the facility failed to provide evidence that temperatures for the reach-in refrigerator was consistently monitored. The deficient practice could result in foodborne illness. Findings include: During the initial kitchen observation conducted on October 11, 2022 at 8:12 a.m. the October kitchen log for the freezer and refrigerators were reviewed. The Kitchen Manager (staff #1110) was present during the walk-through and review of the logs conducted on October 11, 2022 at approximately 8:12 a.m. During the review, it was noticed that the reach-in refrigerator did not have a temperature log. The refrigerator had a thermometer inside and it indicated that the temperature was 40 degrees Fahrenheit. The refrigerator had items inside such as individual serving containers of salad and cottage cheese. During an interview with the Kitchen Manager (staff #1110) conducted on October 11, 2022 at 8:21 a.m., he stated that they did not have a temperature log for the reach-in refrigerator. When asked if there were logs from previous months, he stated that they did not. He stated that it had completely slipped his mind since they have had kitchen inspections and none of the inspectors had looked at or asked for the reach-in refrigerator's temperature log. He stated that he would fix it immediately and ensure that a log is placed on the refrigerator so that the temperature could be monitored. A follow-up interview was conducted with staff #1110, on October 12, 2022 at 10:34 a.m. He stated that the reach-in refrigerator is used to store salads, cottage cheese, and salad dressing. He stated that he understands why the refrigerator's temperature had to be monitored. He stated that monitoring the refrigerator temperature helps ensure that the food items stored inside are safe to serve to the residents. During the final interview with the Kitchen Manager (staff #1110) on October 13, 2022 at 12:48 p.m., he stated that there was not a specific policy with regards to temperature monitoring.

Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were completed as required for 3 residents (#57, #34, and #41). The sample size was 3. The deficient practice increases the risk for residents being inappropriately placed into nursing facilities and/or not receiving the services they need. Findings include: -Resident #57 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level 1 PASRR dated 03/06/21 indicated the resident did not have serious mental illness, including [CONDITION(S)]. Review of the clinical record revealed the resident was discharged from the facility on 12/03/21 and subsequently readmitted on [DATE]. The Level I PASRR evaluation dated 12/06/21 revealed the physician had certified before admission to the facility that the resident required 30 days or less of nursing facility services. A behavior care plan dated 08/19/22 related to the potential to demonstrate physical behaviors had a goal to not harm self or others. Interventions stated to remove the resident from the situation and take the resident to an alternate location as needed. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. According to the assessment, the resident demonstrated behavioral symptoms, including: physical behaviors directed towards others, verbal behaviors directed towards others, and other behavioral symptoms not directed towards others (e.g., hitting or scratching self, pacing, or public sexual acts) for 1 to 3 days out of the 7-day lookback period. The assessment indicated that the resident's behaviors significantly interfered with the resident's participation in activities or social interactions, put others at significant risk for injury, and significantly disrupted care or the living environment. According to the assessment, the resident's current behavior status was worse compared to the prior assessment. However, review of the clinical record did not reveal the resident Level 1 PASRR had been updated or that a referral for Level II evaluation and/or services was done. -Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I PASRR screening completed 08/09/19 revealed the physician had certified before admission to the facility that the resident required 30 days or less of nursing facility services. According to the discharge Minimum Data Set (MDS) records, the resident was discharged on [DATE] with return not anticipated. The resident subsequently readmitted to the facility on [DATE]. However, there was no Level I PASRR associated with the readmission identified in the clinical record. Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the discharge MDS assessment, the resident was discharged on [DATE] with return not anticipated. Per the clinical record, the resident subsequently readmitted on [DATE]. However, there was no correlating Level I PASRR identified in the clinical record. Per the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the resident's clinical record did not indicate that the resident had been referred to the state-designated authority for Level II PASRR evaluation and review. The quarterly MDS assessment dated [DATE] revealed the resident scored 12 on the BIMS, indicating moderate cognitive impairment. The resident reported feeling tired or having little energy for 2 to 6 out of the 7-day lookback period. According to the assessment, the active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/22 at 10:06 a.m., an interview was conducted with the Director of Social Services (staff #5) and a Clinical Resource Nurse (staff #115). Staff #5 stated that she did not know when PASRR evaluations were completed. Staff #115 stated that PASRRs were completed before admission or upon admission. She stated that the hospital will typically complete the form. She stated that if the hospital did not complete the form, she thought that admissions would complete it. Staff #115 stated that the interdisciplinary team, case managers, and social services may also review for accuracy. She stated that accuracy and timeliness of assessments were her expectation. An interview was conducted on 10/14/22 at 10:16 a.m. with the Director of Nursing (DON/staff #20). She stated that ideally, a PASRR will be sent from the hospital when the resident admits. The DON stated if not they will be screened at the facility. She stated that because the Director of Social Services was being trained, admissions complete the screening at this time. She stated that if the resident stays in the facility longer than 30 days, she believed another PASRR needed to be done. She stated that her expectation is that the documentation will be accurate and timely. -Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level I PASRR dated 8/29/14 revealed the physician had certified the resident required 30 days or less of nursing facility services. Review of the Level 1 PASRR dated 8/1/18 revealed a referral for Level II was not necessary. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Solution 5mg/ml, inject 5 mg intramuscularly as needed for [CONDITION(S)] activity may repeat one more after 10 minutes. Ordered 8/1/2018. -[MEDICATION(S)] tablet 1 mg, give 1 tablet via G-Tube every 8 hours for anxiety as evidenced by restlessness. Ordered 8/3/2018 A PASRR care plan dated 4/6/2020 revealed focus: has a PASRR level 1 with no recommendations for a PASRR Level II referral. Goal: wishes to continue current activities and medication. Intervention: refer resident for a PASRR Level II if conditions change. Review of the clinical record revealed resident #41 has a diagnosis [CONDITION(S)] Disorder on 5/10/21. However, the resident's clinical record did not reflect that a PASRR Level I was updated or PASRR Level II screening had been completed after resident #41 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] revealed the resident was rarely or never understood. Review of the October 2022 Medication Administration Records revealed [CONDITION(S)] medications were administered in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview conducted on 10/14/22 at 7:59 AM with the social services director (staff #5), she stated she does not do anything with PASRR personally. Staff #5 stated she only sees the PASRR from the hospital that the admission department gives to her. Staff #5 stated she did not know how to rate the levels for PASRR. An interview was conducted with the DON (staff #20) on 10/14/22 at 9:53 AM. The DON stated she is unfamiliar with the process but every resident should have one. The DON stated if PASRR identifies additional services, it has to be requested. The DON stated resident #41 is pulled every year and PASRR was never discussed. Review of the facility's PASRR Policy revised 5/2022 revealed the following: It is the policy of the facility to ensure that each resident is properly screened using the PASRR specified by the state.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for one resident (#24). The sample size was 4. The deficient practice could result in residents being at risk for potential nutritional decline. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on April 14, 2022 included a problem for moderate malnutrition related to acute illness. The care plan goals stated resident #24 will maintain adequate nutritional status as evidenced by maintaining weight with no signs and symptoms of malnutrition. The intervention included the RD (registered dietician) evaluating and making diet changes recommendations as needed; supplement; and weekly weights for 4 weeks and then monthly if stable. Review of the weight summary dated April 14, 2022 at 9:29 p.m. stated the resident weighed 135 pounds. Review of physician's progress notes dated April 19, 2022 at 8:06 p.m. stated the resident was resting comfortably and stated he is still hungry after eating meals. Review of physician's progress notes dated April 24, 2022 at 3:27 p.m. stated the resident was resting comfortably and asking for second portions for the lunch meal. Review of physician's progress notes dated May 4, 2022 at 1:49 p.m. included the resident stating that he is hungry. Review of Speech Therapy notes dated May 4, 2022 stated recommended MBSS (modified [MEDICATION(S)] swallow study) to further assess safest diet, appropriate for PO (by mouth) versus PEG (percutaneous endoscopic gastrostomy) due to continued coughing and difficulty with carryover of safe swallow instructions. The note stated the MBSS was discussed with nursing, and currently waiting scheduling of an appointment. Review of a LN-Nutrition Interdisciplinary Team Update form dated May 9, 2022 revealed SLP (speech language pathologist) reported the resident continues to struggle even with thickened liquids, awaiting [MEDICATION(S)] swallow to determine next steps. Review of speech therapy notes dated June 3, 2022 stated pending scheduling for MBSS to analyze most appropriate diet and possible need for alternate nutrition plan, pending as of April 27, 2022. Continued review of the clinical record revealed no evidence of MBSS follow-up regarding the safest diet for the resident or evidence the resident was offered additional snacks or food items to meet resident #24's complaints. Review of the clinical record did not reveal another weight for the resident until July 20, 2022 at 1:53 p.m. Resident #24 weighed 111 pounds; a weight loss of 17% in 13 weeks. A quarterly MDS (minimum data set) assessment dated [DATE] revealed resident #24 BIMS (brief interview of mental status) score was 14, which indicated intact cognition. The MDS assessment stated the resident needed extensive assistance with eating, and had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight loss regimen. The weight summary revealed that on October 9, 2022 at 10:26 p.m., the resident's weight was 112 pounds, a weight loss of 17% in about 6 months. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A lunch observation was conducted on October 12, 2022 at 12:40 p.m. Resident #24 was in his room seated in the wheelchair, with a lunch tray placed on a bedside table in front of the resident. An SLP was observed assisting resident #24 1:1 with the meal. Resident #24 was observed reaching for the spoon when he wanted the next bites. The SLP (staff #39) stated the resident has a good appetite, but has poor safety awareness. The SLP stated resident #24 takes too much food at once and drinks regular water from the sink at times, that is why the resident has to have assistance with meals. A follow up interview was conducted on October 12, 2022 at 2:24 p.m. with SLP (staff #39), who stated she was familiar with resident #24. Staff #39 stated on October 10, 2022, she evaluated resident #24's BIMS and scored 15/15, which indicated the resident's cognition was intact. Staff #39 stated the resident has no carry through, he does not have recall overtime, very impulsive, and no safety awareness. Staff #39 stated resident #24 was food seeking, but has ataxic dyskinesia, which causes abnormal movement and impacts the resident ability to swallow, making the resident a very high aspiration risk. Staff #39 stated she requested an MBSS April 2022, and also recommended tube feeding during the last admission to the case manager. An interview was conducted on October 14, 2022 at 10:41 a.m. with resident #24. Resident #24 stated he has a good appetite and he can eat just about anything. The resident stated most of the time he is still hungry, and that he has not been offered any snacks or fluids in between meals. The resident stated he asked the staff for snacks or fluids, that sometimes the staff brings it and sometimes the staff would not come back. He stated he is constantly craving for more food. The resident stated he lost a lot of weight and it bothers him. The resident stated no staff in the facility has discussed alternative ways of keeping his weight including tube feeding and that he would not mind it if it will help him gain some weight back. An interview was conducted on October 14, 2022 with the director of nursing (DON/ staff #26), who stated a newly admitted resident is weighed upon admission, then weekly for 4 weeks, then monthly thereafter. Staff #26 stated she did not know why resident #24 was not weighed again until July 2022. The DON stated she does not recall anything about the MBSS, and that she has to access the record. Regarding resident #24 weight loss from April 14, 2022 through July 20, 2022 and no implementation of interventions to address the weight loss, the DON only stated ok. A facility policy, Nutrition, stated it is the policy of the facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Each resident is to be weighed upon admission, weekly weights for four (4) weeks and monthly weight thereafter unless otherwise specified by the attending physician. The weight will be entered into the resident's clinical record. Once the resident has been evaluated for nutrition status, the Registered Dietitian, Dietary Technician and/or designee will determine if there is a significant change in the resident's condition. If so, additional nutritional interventions will be offered to those residents. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, interventions required and need for further recommendations and/or referral.

Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure one resident (#397) signed and was issued a written Notice of Medicare Non-Coverage (NOMNC) when there was an ending of Medicare services. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #397 was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged [DATE]. The admission Minimum Data Set assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. Review of the resident's face sheet revealed the resident was the financially responsible party. A weekly skilled nursing note dated April 20, 2022 indicated the resident was discharge ready and that the NOMNC was to be issued. Discharge was set for April 27, 2022. Review of a weekly skilled review note dated April 27, 2022 revealed the resident's previous NOMNC was rescinded since the provider had not wanted the resident to discharge yet due to changes in range in motion. Review of the resident's clinical record and request for NOMNC documentation did not reveal any completed NOMNC forms. A nursing note dated April 30, 2022 stated the resident was discharged home, condition stable, voiced no issues or concerns. Personal belongings, medications and discharge instructions were given to the resident. Review of Skilled Nursing Facility Beneficiary Protection Notification review forms presented to the facility for completion on October 11, 2022 revealed that the facility did not complete a NOMNC for resident #397. The facility indicated the reason as a clerical error and stated that copies were not found. During an interview with the Social Service Director/Case Management (staff #5) conducted on October 13, 2022 at 10:04 a.m., she stated that she had only taken over the NOMNC process the previous week. Staff #5 stated that she issues NOMNC three days prior to a resident's scheduled discharge i.e. if the resident is discharging October 14, then that resident would have been issued the NOMNC on October 11. She stated that if the resident has Medicare, then the discharge is driven by therapy, determined by weekly skilled notes, and goes by estimated stay driven by therapy. She stated therapy then lets her know if the resident is discharge ready. She stated she would then print out the NOMNC and present it to the resident. She also stated the resident is informed about the appeal process, and if a resident decides to appeal, they cannot discharge the resident without a decision. Staff #5 stated the facility will provide the resident a financial responsibility form to inform them that they might have to pay out of pocket if the decision is not made before their last day of coverage. In regards to this resident, staff #5 stated that she is not sure what happened or if the resident was provided a NOMNC since she is new. She stated she also is not aware of what happens if the NOMNC is not provided. She could not find documentation regarding NOMNC completion for the resident. Staff #5 stated that since she took over the NOMNC process, she documents NOMNC in the resident's progress note. She also stated that she has a binder where she keeps a copy of the NOMNC as well as putting a copy on the drive so that Medical Records can upload into the resident's electronic record. In an interview with the Director of Nursing (DON/staff #20) conducted on October 13, 2022 at 1:12 p.m., she stated that if a resident is not provided a NOMNC, it is an incomplete record or documentation. The DON stated that since it is a time-sensitive action, it is not something that can be corrected. The DON stated case management/social services are the ones that receive information about NOMNC. Review of the facility's NOMNC process implemented on or about April 21, 2022, indicated that once it is determined that a NOMNC needs to be issued, the case manager (CM) determines if the resident can sign for themselves or if a Power of Attorney will need to sign the document. During the presentation of the NOMNC, the CM will explain what the notice entails, go over the last day of coverage, discharge date , and the appeal process. Once signed, a copy is given to the resident and another copy is sent to the Business Office and Medical Records for upload to the resident's record. The original is kept in the Medicare NOMNC binder located in the Social Services Office. The CM then documents this event on a progress note in the resident's record.

Based on observations, resident and staff interviews, clinical record review, review of facility documentation and policy and procedure, the facility failed to ensure that one resident (#191) who was unable to carry out activities of daily living (ADLs) received services to maintain good grooming. The sample size was 10. The deficient practice may result in residents with poor personal hygiene. Findings include: Resident #191 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An ADL self-care performance deficit care plan dated 09/28/22 related to decline with function and mobility had a goal to improve independence with ADL tasks and functional mobility. Interventions included required staff participation with bathing. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The assessment also revealed the resident required extensive assistance for most ADLs, including bathing. On 10/11/22 at 9:38 a.m., an interview with resident #191 was conducted. The resident stated that she had not received any showers since she had been admitted . The resident stated that she usually shaves her whiskers off at home and that she would like them to be shaved off while she was in the facility. During the interview, the resident's hair was observed to appear very greasy and stuck to her head. Another observation of the resident was conducted on 10/12/22 at 12:45 p.m. The resident continued to appear unwashed and disheveled. The resident's eyes, face, and hair had visible white matter attached to it and her hair appeared to be greasy and uncombed. Review of the Certified Nursing Assistants (CNAs) Point of Care documentation dated 09/28/22 through 10/12/22 revealed that the resident had received a total of 3 bed baths. Additional review did not indicate that the resident had refused additional opportunities for bathing/showers. On 10/14/22 at 11:19 a.m., an interview was conducted with a Nursing Assistant (NA/staff #90). She stated that a lot of residents liked to have showers on their scheduled days. She stated that residents will be offered showers, but if they do not feel good, she will offer a bed bath. She stated that resident #191 was fairly new. She stated that yesterday was the resident's shower day, but that the resident wanted to do a bed bath instead. She stated that the CNAs are supposed to document whether or not the resident refused. She stated that she did not know why the resident had only received a couple of bed baths. An interview was conducted with a Licensed Practical Nurse (LPN/staff #65) on 10/14/22 at 11:45 AM. She stated that she should receive shower sheets when the CNA completes the shower. She stated that CNAs complete the Skin Assessment Shower Sheets in addition to completing the Point of Care documentation. The LPN stated if the resident refused, CNAs should mark refused if the resident refuses. The LPN stated that residents should be offered showers or bed baths twice weekly. On 10/14/22 at 11:53 a.m., an interview was conducted with the Director of Nursing (DON/staff #20). She stated the shower schedule assigns the residents two showers weekly. The DON stated that it was within the residents' rights to request a different time or day, according to their preference. She stated the residents will usually tell their CNA, the CNA would tell the nurse, and the nurse would notify administration to modify the schedule. She stated the caregivers will document on a flow sheet on their task assignments. The DON stated that CNAs also are expected to document on a shower sheet and to turn the sheets in to their nurse at the end of the shift. She stated that her expectation is that residents will be offered 2 bathing opportunities per week. The DON stated that outcomes of not receiving twice weekly showers or bed baths may include diminished skin integrity, dignity, and comfort. Review of the facility policy titled ADL, Services to Carry Out, reviewed 08/2022, included it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with the written plan of care. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal and oral hygiene will be provided by qualified staff. Bathing will be offered at least twice weekly, and as-needed per resident request. ADL care provided will be documented in the medical record accordingly.

Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure the posted daily nurse staffing information was accurate. The deficient practice resulted in information not being readily available to residents and visitors. Findings include: During an observation conducted on October 13, 2022 at 2:00 p.m., the nurse staffing information was observed posted on a bulletin board in the hallway. However, the posted staffing information did not include the actual hours worked by the staff. An interview was conducted with the staffing coordinator (staff #22) on October 14, 2022 at 11:12 a.m., who stated she does not know the hours worked until after the shift is over. Immediately following the interview, staffing information that was posted for the last 3 months was requested from staff #22. However, review of the staffing information postings dated August 1, 2022 through October 13, 2022 did not include the actual hours worked by staff. An interview was conducted with the Director of Nursing (staff #26) on October 14, 2022 at 1:39 p.m. Staff #26 stated the actual hours worked were done electronically and reported directly to CMS (Centers for Medicare & Medicaid Services). Staff #26 stated ever since the PBJ (Payroll Based Journal) started, the actual hours worked are sent directly to the CMS for the 5-star ratings. A facility policy regarding the posting of 24 hour licensed and unlicensed direct care staff included the following: It is the policy of this facility to post staffing numbers. The procedures stated to post the number of staff hours working who are directly responsible for resident care, and to comply with the Benefits Improvement and Protection Act of 2000, the facility must include hours worked by Registered Nurses, Licensed Practical/Vocational Nurses, and Nursing Assistants for each shift.

Based on observations, staff interviews, facility documentation, review of policies and procedures, Centers for Disease Control and Prevention (CDC) guidance and Centers for Medicare and Medicaid Services (CMS) guidelines, the facility failed to ensure appropriate signage were posted outside of resident rooms on quarantine/transmission-based precautions (TBP); failed to ensure one staff (#14) who tested positive for COVID-19 followed the recommended guidelines for returning to work; and, failed to ensure two staff (#14 and #12) completed the COVID-19 screening process. The facility census was 89 and had four COVID-19 positive residents. The deficient practices increase the risk for transmission of COVID-19. Findings include: On June 14, 2022 at 8:15 a.m. an interview was conducted with the Director of Nursing (DON/staff #80) who stated newly admitted residents and/or who were on quarantine/TBP were located at skilled unit at the end of the 400 hall. She also stated the four COVID-positive residents were located at the long-term care (LTC) unit at the end of the 300 hall. -Regarding signage: An observation on the skilled unit was conducted on June 14, 2022 at 9:10 a.m. There were two resident rooms at the end of the hall with signs for droplet precaution posted on their doors. The personal protective equipment (PPE) such as gowns, gloves and goggles/eye protection were found on a large table against the wall at the end of the hallway. However, there were no signs posted regarding what PPE to use and instructions on donning/doffing of PPE. An interview was conducted on June 14, 2022 at 9:13 a.m. with a certified nursing assistant (CNA/staff #8) who stated she was concerned because there were no signs posted on multiple quarantine/new admission resident rooms. She stated two rooms in the unit had signs on the door for droplet precaution; however, there were no instructions related to which PPE to use prior to entering these rooms. The CNA also said she did not know who to ask for hampers to place the used/dirty PPE into. She stated this was an infection control issue because she could have entered the rooms without knowing the resident was in quarantine. In an interview with a licensed practical nurse (LPN/staff #12) conducted on June 14, 2022 at 3:55 p.m., the LPN stated it was assumed that if there were no signs on the doors, the residents were not on any TBP. He stated COVID-positive residents are typically on the COVID unit; however, there should be signs indicating whether or not the residents are on any precautions and the type of PPE required to enter the resident room. An interview was conducted with the DON (staff #80) on June 14, 2022 at 4:38 p.m. She stated her expectations were for droplet precaution signs to be posted on the resident room doors and signs for use of PPE posted in the general area. During an interview with the executive director (ED/staff #17) conducted on June 15, 2022 at 7:00 a.m., he said that CDC/CMS guidelines can be used in lieu of facility policy if needed. The CMS QSO-20-39, revised November 12, 2021 included certain core principles and best practices reduce the risk of COVID-19 transmission. The core principles included appropriate staff use of PPE and instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits, routes to designated areas, hand hygiene). Further, it included that these core principles are consistent with CDC guidance for nursing homes, and should be adhered to at all times. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on February 2, 2022 included to establish a process to identify and manage individuals with suspected or confirmed [CONDITION(S)]-CoV-2 infection, including to ensure everyone is aware of recommended Infection Prevention and Control (IPC) practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and strategic places with instructions about current IPC recommendations (e.g. when to use source control and perform hand hygiene). -Regarding staff returning to work after testing positive: The COVID testing record for a nursing assistant (NA/staff #14) revealed that the NA had tested positive for COVID-19 on June 2, 2022. A review of the Employee Time Details from June 1 through 13, 2022 revealed that staff #14 punched in at 1:53 p.m. and punched out at 10:35 p.m. on June 2, 2022. Further review revealed she returned to work on June 5, 2022 (3 days after she tested positive) at 1:53 p.m.; and had worked on June 6, 7, 8, 11, 12 and 13. In an interview conducted on June 14, 2022 at 4:38 p.m. with the DON (staff #80), she stated staff may return to work within 5 days, if they have no symptoms. However, she said that COVID-positive staff may return to work within 3 days during periods of contingency staffing. The DON said she did not know that staff #14 came back to work 3 days after having tested positive. Further, she said her expectation was for COVID-positive staff to wait at least 5 days before returning to work. Review of the CDC Interim Guidance for Managing Healthcare Personnel (HCP) with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2, updated January 21, 2022, the guidance was updated to enhance protection for HCP, residents, and visitors, and to address concerns about the potential impacts on the healthcare system given a surge of [CONDITION(S)]-CoV-2 infections. The recommended work restrictions for HCP with [CONDITION(S)]-CoV-2 infection during contingency staffing was 5 days with/without negative test, if asymptomatic or mild to moderate illness (with improving symptoms). -Regarding staff screening: A review of the Employee Time Details for a nursing assistant (NA/staff #14) from June 1 through 13, 2022 revealed that staff #14 worked her shifts on June 1, 2, 5, 6, 7, 8, 11, 12 and 13, 2022. However, review of the screening sheets revealed no evidence that staff #14 had completed screening for any of her shifts on June 1, 2, 5, 6, 7, 8, 11, 12 and 13, 2022. Review of the Employee Time Details for an LPN (staff #12) from June 1 through 13, 2022 revealed that the LPN worked her shifts on June 1, 2, 3, 7, 8, 9, 10, 11 and 12, 2022. However, review of the screening sheets revealed no evidence that the LPN had completed screening for any of his shifts on June 1, 2, 3, 7, 8, 9, 10, 11 and 12, 2022. An interview was conducted on June 15, 2022 at 8:53 a.m. with the DON (staff #80) who stated that her expectation was that staff will clock in, then proceed to screening. She stated all staff had been educated on screening through meetings and in-service education. The DON further stated that staff skipping the screening process does not meet her expectations. Review of the facility policy titled, COVID-19 Screening: Staff, HCW (healthcare worker) and Any Visitors for Compassionate Care dated March 12, 2020, included that any person entering the facility at any time will be screened for COVID-19 symptoms following current CDC guidelines, Any person not complying with screening requirements will not be permitted to enter unless secondary screening by the Director of Nursing Services/Infection Preventionist reveals it is related to the individual's chronic condition and not a deviation from baseline.

Based on review of facility records, staff interviews, review of policies and procedures, and Centers for Medicare and Medicaid Services (CMS) guidelines, the facility failed to ensure that residents, families and/or representatives were notified/updated regarding the COVID-19 status in the facility. The deficient practice could result in resident's and their representatives not being aware of the COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. Findings include: During the entrance conference conducted on June 14, 2022 at 8:15 a.m., the Director of Nursing (DON/staff #80) stated there were 4 COVID positive residents in the facility. She stated that she and a certified nursing assistant (CNA/staff #7) were responsible for informing resident, families, and/or representatives of the COVID status in the facility. The DON said the mechanism involve a recorded message that could be accessed via a telephone hotline phone number which was provided to residents, families, and/or representatives. She also said that the receptionist also had the phone number printed on slips of paper that could be obtained by anyone who asked for one. On June 14, 2022 at 2:07 p.m. a call was made to the facility's hotline. The recorded message stated there were no patients and no staff that tested positive for COVID-19. An interview was conducted on June 14, 2022 at 2:33 p.m. with the DON (staff #80) who stated the facility's mechanism for informing residents, families and representatives of COVID cases involved the use of a hotline. She also stated residents were also notified verbally by staff. In another interview conducted on June 14, 2022 at 4:38 p.m. with the DON, she stated the expectation was that any COVID infection acquired at the facility will be reported via the hotline. The DON said that when a staff test positive for COVID, the facility will update the hotline for 5 days. However, the DON stated when residents are admitted with active COVID, this will not be reported in the hotline. During an interview with the executive director (ED/staff #17) conducted on June 15, 2022 at 7:15 a.m., the ED stated that he only updates the hotline with COVID positive cases that were acquired by individuals while at the facility. He stated if a resident tested positive for COVID prior to admission and was admitted at the facility, he will not count or include this resident in his hotline message. The facility policy on Notification of Families/Residents of COVID-19 Status, updated May 5, 2020 included a purpose to ensure that all families and residents are updated on COVID-19 updates as they occur. The policy included that the facility will maintain a COVID-19 hotline with COVID-19 updates as they occur. Further, facility will utilize a COVID-19 Hotline specific to the building to notify family and residents of any new positive tests (staff or residents). These updates will be made to the system by 5 p.m. the next day. The CMS Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes, dated May 6, 2020 included that the facility must inform residents, their representatives and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed case of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours of each other. The information must include any cumulative updates for residents, their representatives and families at least weekly by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed COVID-19 infection is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. The Long-Term Care Facility Requirements for Notification of Confirmed and Suspected COVID-19 Cases among Residents and Staff: Frequently Asked Questions dated May 6, 2020 revealed that for dedicated COVID-19 facilities and those with COVID-19 units, the facility must provide any cumulative updates for residents, their representatives and families. Updates must occur at least weekly or by 5 pm the next calendar day following the subsequent occurrence of either: a confirmed infection of COVID-19 is identified (including new admissions), or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in unnecessary use of an indwelling catheter and increase client risk for urinary infection. Findings include: -Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial care plan dated November 26, 2021 revealed the resident had an activities of daily living (ADL) self-care deficit. Interventions included resident required staff participation to use the toilet. The care plan did not indicate any indwelling catheter as a focus of care. A late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation did not include the resident had indwelling catheter. A daily skilled note dated November 27, 2021 included the resident was alert and oriented x 3, and had an indwelling catheter used as a GU ([CONDITION(S)]) appliance. A late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Surgical history included laser lithotripsy (non-invasive procedure involving the physical destruction of stones) with right [CONDITION(S)] stent placement. Assessment included [CONDITION(S)]. The documentation did not include the resident had an indwelling catheter. The daily skilled notes dated November 29, 30, December 1, 2 and 3, 2021 included there was no GU appliance used. However, the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required limited two-person physical assistance with toileting; and had an indwelling catheter. The CAA (care area assessment) summary included urinary incontinence and indwelling catheter triggered and was coded for care planning. Although triggerred for care planning, the comprehensive care plan did not include indwelling catheter as a focus of care with interventions in place. The daily skilled notes dated December 5 and 6, 2021 revealed the resident had an indwelling catheter. A late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed documentation that the resident had an indwelling catheter from December 7 through 15, 2021 except on December 11 and 13, when it was documented that the resident did not have an indwelling catheter. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The daily skilled note dated December 16, 2021 revealed use of an indwelling catheter. Despite documentation that the resident had indwelling catheter, there was no evidence found in the clinical record of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also no evidence found that catheter care was provided to client #4 from November 26 through December 15, 2021. On December 16, 2021, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Indwelling catheter 16 French/ 10 ml to support [CONDITION(S)] AEB (as evidenced by) urinary retention; -Indwelling catheter care every shift; and -Irrigate indwelling catheter with 60 ml (milliliters) of NS (normal saline) as needed for obstruction/occlusion. -Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial admission record dated March 16, 2022 the resident was frequently incontinent with bladder and there was no urinary catheter in place. The initial care plan dated March 17, 2022 revealed the resident had an ADL self-care deficit related to limited range of motion. Interventions included resident required staff participation to use the toilet. The care plan did not indicate any indwelling catheter as a focus of care. The daily skilled notes dated March 17 and 18, 2022 revealed the resident was alert and oriented, had an amber urine and did not have GU appliances used. The daily skilled note dated March 19, 2022 included the resident had a patent indwelling foley catheter. The Bowel and bladder evaluation dated March 19, 2022 included the resident was confused, was incontinent with bowel and had contributing factors of long-term catheter, debilitating disease longer that 6 months. The evaluation did not indicate the resident had an indwelling catheter. The daily skilled notes dated March 20, 21 and 22, 2022 included the resident had no GU appliances used. The daily skilled note dated March 23, 2022 revealed the resident had an indwelling catheter. The admission MDS assessment dated [DATE] included the resident required extensive two-person physical assistance with toileting and had an indwelling catheter. The CAA summary included urinary incontinence and indwelling catheter triggered and was coded for care planning. Despite the inconsistencies in documentation, the clinical record revealed no evidence of any physician notifications or clarifications made regarding the resident's indwelling catheter from March 16 through April 23, 2022. There was no evidence found in the clinical record of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also no evidence found that catheter care was provided to client #6 from March 16 through April 23, 2022. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed the care plan was not revised until May 2, 2022 to include that the resident had an indwelling catheter and an intervention for catheter care every shift and as needed. In an interview conducted on June 7, 2022 at 3:05 p.m. with a Licensed Practical Nurse (LPN/staff# 59), he stated that the certified nursing assistants (CNAs) perform catheter care. During an interview conducted on June 7, 2022 at 3:26 p.m. with a CNA (staff #20), she stated that catheter care is documented under tasks for toilet use. An interview was conducted on June 8, 2022 at 9:13 a.m. with another CNA (staff #83) who stated they always check if the indwelling catheter needs cleaning. She said the CNA cleans the catheter, empties the bag and encourages the resident to drink water. She said assistance with toileting can either be emptying the catheter bag or cleaning the catheter; and, this is done every shift. She said she will clean the indwelling catheter, will document in the clinical record and notify the nurse if something was wrong. The CNA said that there is no separate area for documenting catheter cleaning in the clinical record. In an interview conducted on June 8, 2022 at 11:04 a.m. with a registered nurse (RN/staff #99), she stated that a catheter requires a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on June 8, 2022 at 2:07 p.m. with the Director of Nursing (DON/staff #32) who stated that her expectation was that a foley catheter is maintained in safe manner. She said that most of the resident at the facility with indwelling catheters come from the hospital; and that, if there are no orders from the hospital, she hoped that staff would catch that. The DON further stated there should be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy on Indwelling Catheter care included that it is their policy that each resident with indwelling catheter will receive catheter care daily and as needed for soiling.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure pain medications were administered to one resident (#60) in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice increases the risk for residents to receive unnecessary medications. Findings include: Resident #60 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An opioid care plan dated 02/22/21 related to oxycodone for pain management had a goal to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included to administer opioid as prescribed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 10/07/21 at 10:16 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated that prior to administering oxycodone to a resident for pain, she will ask the resident to identify what their pain level was and where their pain was located. The LPN stated that it would not be appropriate to administer any narcotic outside of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that if a nurse administered oxycodone outside the order parameters they must let the Director of Nursing (DON) know. On 10/07/21 at 10:44 a.m., an interview was conducted with the DON (staff #61). She stated that it did not meet her expectation for nursing to administer oxycodone outside of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy titled Medication Administration - Oral revised May 2021 included that it is the policy of the facility to accurately prepare, administer, and document oral medications. Verify residents' medication cards with medications orders. Any irregularities in pouring or administering must be reported to the physician. An essential point of medication administration included that if there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies the drug dosage.

Based on closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to consistently assess and monitor one resident's (#263) pressure ulcer. Sample size was three. Findings include: Resident #263 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed an initial data collection tool that identified the resident had three open areas on the lower buttocks. There were no measurements or any other descriptive data noted on this form. A non-pressure skin condition record dated October 25, 2013, documented the wound as "MASD" (moisture associated skin damage), measured 2 centimeters (cm) x 3 cm and was described as "denuded and excoriated." According to a Weekly Skin Integrity Data Collection sheet dated October 25, 2013, the resident had three open areas to the buttocks area. Review of an impaired skin integrity care plan dated October 25, 2013, revealed the resident was at risk for breakdown due to fragile, dry skin. A goal included that the residents "disruption of skin surface" will remain free from infection and show evidence of healing. Approaches included to complete weekly skin checks and observe for signs and symptoms of infection or delayed healing, and report to the physician. The care plan did not reflect the open areas to the lower buttocks area that were identified upon admission. A wound note dated October 30, 2013, included "there is an area of excoriation with denuded tissue" on the left posterior fold. There was no other documentation related to this wound. Review of the Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact and was at risk for developing pressure sores. The assessment also noted that the resident did not have any pressure sores. The Weekly Skin Integrity Data Collection sheets for November 1, 8, and 15, 2013, did not include any documentation regarding the open areas. On November 22, 2013, the box for "old open area" was checked, however; there was no descriptive information. Review of the closed clinical record revealed there were no thorough wound assessments completed from the time of admission until November 27, 2013. Per the non pressure skin record dated November 27, there was one wound which measured 1 x 0.5 x 0.1 cm, and had a large amount of drainage. The documentation included that the wound had deteriorated. The wound bed was described as pale yellow, with "new depth." According to the pressure ulcer record dated December 5, 2013, the assessments had now been changed over to the pressure ulcer status record. The pressure ulcer to the left ischial area measured 2.5 x 2.0 x 1.5 cm and was unstageable. The documentation included the wound had slough and necrotic tissue present, with a large amount of drainage. The note further included the physician had debrided the wound. Review of a physician's progress note dated December 5, 2103, revealed the resident had a stage 3-4 decubitus ulcer to the left ischial tuberosity. During an interview conducted on October 17, 2014, a licensed nurse stated that weekly skin checks should identify all of the areas of the resident's non-intact skin, even if that resident has wounds that are being followed by the wound nurse. In an interview on October 17, 2014, the Director of Nursing (DON) stated that the wound nurses documentation should be more comprehensive than the licensed nurse's assessments. Attempts to interview the wound nurse were unsuccessful. A policy related to the documentation of pressure ulcers was requested. Per the corporate nurse, the facility did not have that policy. A policy titled post admission weekly skin assessments included the weekly pressure ulcer status record and the non-pressure skin condition record are used for the weekly assessment of existing wounds.

Based on review of clinical documentation, observations, staff interviews, and review of facility policy, the facility failed to provide care and services for one resident (# 88) to prevent the development of a pressure ulcer. Findings include: Resident #88 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record reflected a Braden scale for pressure ulcer risk dated May 24, 2013, which identified the resident was at moderate risk. An Admission Skin assessment dated [DATE], revealed that the resident did not have a pressure ulcer. A review of the Risk for Skin Breakdown Interim Care Plan dated May 24, included a goal to maintain intact skin with no breakdown. Interventions listed were as follows: complete Braden scale risk assessment; float heels when in bed; complete weekly skin checks; notify nurse of any new areas of skin breakdown or redness; and observe effectiveness of treatments as ordered. The care plan did not address any repositioning needs for the bed/wheelchair. The wound nurse conducted a second skin check on May 25, 2013, which also documented there were no pressure ulcers present. A review of the Pressure Ulcer Status Record dated May 29, 2013, now revealed the presence of a pressure ulcer on the left lateral plantar foot. The wound was described as a deep tissue injury and measured 2.5 centimeters (cm) x 3.2 cm. There were no descriptions of the condition of the wound. The physician was not notified of the pressure ulcer until the following day on May 30. Physician orders [REDACTED]. The physician order [REDACTED]. A review of the clinical record documentation reflected dressing changes were done as prescribed by the physician. According to the Pressure Ulcer Status Record dated May 30, the physician debrided the top layer of the wound and measured 3.5 cm x 3.3 cm x 0.1 cm in depth and was a stage 3. This assessment did not include any description of the wound bed or of the surrounding tissue. The admission Minimum Data Set (MDS) assessment dated [DATE], assessed the resident to require extensive assistance of one to two persons for bed mobility, transfers and a wheelchair for locomotion. The admission MDS assessment identified that the resident had a stage three pressure ulcer and included the following dimensions 3.5 cm x 3.3 cm x 0.1 cm. The assessment stated, "Granulation tissue - pink or red with shiny, moist granular appearance". The following skin/ulcer treatments were marked on the MDS assessment: pressure reducing device for chair and bed; nutrition or hydration intervention to manage skin problems; ulcer care; and application of dressings to feet (with or without topical medications. The pressure ulcer was next assessed again until seven days later on June 6. Per the Pressure Ulcer Status Record the wound was a stage 3, with grey slough in the center, and had necrotic tissue noted. The wound measured 1.5 cm x 1.0 cm. The assessment did not include any description of the surrounding tissue. The pressure ulcer was assessed seven days later on June 13. The documentation on the Pressure Ulcer Status Record reflected the wound was debrided by the physician and measured 1.3 cm x 1.2 cm and the wound center was grey with slough and granular tissue noted. Despite the wound having slough, the pressure ulcer was assessed as a stage 3. Again, there was no description of the surrounding tissue. A review of the Pressure Ulcer Status Record seven days later dated June 20, reflected the wound measured 1.5 cm x 1.2 cm with slough in the middle. Again, there was no documentation of the condition of the surrounding tissue. An observation of the wound was conducted on June 26, 2013, with a licensed nurse present. The wound measured 1.5 cm x 1.2 cm with some slough. The surrounding tissue was pink. An observation was conducted on June 26, 2013 at 11:00 a.m., of the resident sitting in her wheelchair, with the left lateral portion of her left foot resting against the foot rest of her wheelchair and no SAGE boot was in place as ordered. Another observation was conducted on June 26, 2013 at 3:00 p.m., which revealed the resident was sitting in her wheelchair, with the left lateral portion of her left foot resting against the foot rest of her wheelchair and no SAGE boot was in place as ordered. During an interview conducted on June 26, 2013 at 2:50 p.m., the wound nurse stated that she thought the resident's pressure ulcer developed due to the resident slipping down in bed and the lateral plantar portion of her foot resting against the foot board of her bed. Review of the facility's policy titled Pressure Ulcer Care includes "Ideally, prevention is the key to avoiding pressure ulcers."

Based on resident and staff interviews, clinical record reviews, and review of facility documentation and policies, the facility failed to ensure two residents (#s 160 and 9) were free from neglect and mistreatment that resulted in documented emotional distress. The sample size was 28. Findings include: Resident #160 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was assessed to be alert and oriented and able to make her needs known. A current care plan identified that the resident was frequently incontinent of bladder and bowel with the goal of remaining continent during waking hours. The interventions included that the resident would be assisted to the bathroom or commode as needed and to monitor for signs of emotional distress with the incontinence. Per a nursing note entry dated January 30, 2012, the following was documented, "Resident complained to me that she had her call light on seeking assistance to use the bathroom while in her reclining chair and that one of the Certified Nursing Assistants (CNAs) passed by several times without answering the light. I answered the light. The resident had a bowel movement (BM) on her reclining chair. Another CNA who was assigned to the resident came to take care of the resident. Resident in tears. Resident reassured and comforted. I had a conversation with the associate telling her all call lights should be answered promptly without reference to which section. The resident's family member complained to me that two days ago, on Sunday, the same associate had left the resident on a bedpan for a long time and while trying to empty the bedpan she spilled BM all over the chair." The nursing note entry was signed by staff #1. Resident #160 was re-interviewed on April 4, 2012. She stated she remembered a time, probably in January of 2012, when she was sitting in her recliner as usual and needed to use the restroom or use the bedpan. She stated she had seen the CNA pass by her room several times while the call light was on and the CNA did not come to the room to see what she needed. When the CNA finally came to the room the resident asked to use the bedpan and the CNA gave her the bedpan. When she was done using the bedpan the CNA took it but in the process spilled urine or BM all over the recliner that the resident used all the time. The resident also stated the CNA then denied spilling the urine or BM and hurriedly left the room. The resident then stated she cried and cried and was so upset. The resident also stated she is on [MEDICATION NAME] (diuretic) and when she has to go she has to go. An interview was conducted with staff #1 on April 3, 2012. He stated he was the staff member who had written the nursing note entry dated January 30, 2012. He stated he did not identify the incident as neglect and did not contact any administrative staff to report the incident until the following day. On January 31, 2012, staff #1 stated he notified staff #2 of the incident. Although he stated he did not identify the incident as neglect he concluded the interview with, "The resident was crying, it was a mess. The resident said she may have to wait 15-20 minutes for help." An interview was conducted with staff #2 on April 4, 2012. She stated she had received a request from resident #160 to come to her room to discuss a concern. Staff #2 then provided documentation of the conversation she had with resident #160. The documentation revealed the resident had three specific concerns she wanted to address: -A CNA (identified as staff #3) did not answer her call light and has, "Oftentimes walked right by my room when the light was on." -Staff #3 spilled urine on her chair and then did not provide clean protective pads. -Staff #3 did not properly dispose of the commode contents. Continued in the interview staff #2 stated she had not identified or recognized the incident as neglect and therefore did not immediately report the incident. An interview was conducted with staff #3 on April 4, 2012. She denied that she had not answered the call light for resident #160 in a timely manner and denied that she had spilled the contents of the commode on the resident's chair and then failed to provide clean protective pads. She then stated the resident, "had become fidgety and was crying stating no one comes to help me." -Resident #9 was admitted to the facility February 15, 2012, and was discharged from the facility March 5, 2012. Clinical record review revealed an Initial Data Collection Tool/Nursing Service form dated February 15, 2012, that included documentation that resident #9 needed a one person assist for ambulation, transfers, and toileting. An admission Minimum Data Set assessment dated [DATE], assessed the resident to have no cognitive impairments or to exhibit any behaviors. A discharge assessment summary dated March 3, 2012, included that resident #9 had originally been admitted for an [MEDICAL CONDITION] ulcer and associated [MEDICAL CONDITION], and had made positive progress with rehab and had completed her physical and occupational therapy services. During review of facility documentation for resident #81, an undated interview form conducted with resident #9 revealed that when asked if there was anything that resident #9 was concerned about right now that the interviewer could address for her she stated "Put brief on, and I call on call light have wait 1/2 hr to 1 hr and I can't hold it that long and I have an accident." In response to a question regarding her safety and comfort resident #9 stated "yes - safe, don't know about how comfortable." In a telephone interview conducted April 4, 2012, at 4:20 p.m., resident #9 stated that many times she was left in a soaked diaper all night. Resident #9 further stated that her observation was the aids had too many residents, and when she talked to the nurse practitioner about it she (the nurse practitioner) did not understand it because she said back when she was coming up in her training they had a floater person to help them. When asked about her definition of many times, resident #9 stated I can't give you a specific number during the month I was there, but what I did was stuff Kleenex down inside my pad to kind of help with staying a little bit dryer. During multiple interviews conducted on April 4 and 5, 2012, the Administrator stated that when he came to the facility on e month ago he identified a backlog of incidents and concerns he was currently working through with his new Director of Nursing to ensure they had been reported, thoroughly investigated, and preventative and corrective action implemented as required. During the survey, 20 individual resident interviews were completed as well as three family interviews. One allegation of rough treatment was received from a resident but was unable to be substantiated. In addition, the abuse prohibition review was completed which included the review of three recent investigations completed by the current Administrator. Current deficient practice related to neglect or abuse was not identified. According to the facility policy regarding neglect the following statements were included: -Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -Each resident has the right to be free from neglect. -This facility does not condone resident abuse and/or neglect by anyone.