Every finding on record at Las Colinas Post Acute

Based on interview and record review, the facility failed to ensure their Change in a Resident Condition or Status policy and procedure was implemented for one of three sampled residents (Resident 1) when Resident 1's spouse was not informed of Resident 1s transfer to the hospital.This failure had the potential to place Resident 1 and Resident 1's spouse in emotional distress.Findings:During a review of Resident 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture (broken leg bone) to left femur (upper leg), bone cancer (malignant tumor in bones), diabetes mellitus type 2 (chronic metabolic disorder characterized by high/low blood sugar), and hypertension (high blood pressure).During a review of Resident 1's Situation Background, Assessment, Review and Notify nursing notes, dated April 6, 2026, it indicated Other change in condition: ALOC, Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). Resident noted to be responsive at 06:00AM. Certified Nursing Assistant (CNA) attempted to wake up resident and resident was unable to be aroused at 07:40AM as CNA was bringing meal tray to resident. CNA called out for charge nurse. Charge nurse assessed resident and noted to not be responsive to name and hard to arouse. Charge assessed resident's Vital Signs at 7:45AM Blood pressure 136/81, heart rate140, Blood Sugar 448, Oxygen 80% Room Air. Registered Nurse (RN) assessed resident and mask administered. At 07:50AM Vital Signs: blood pressure140/98, Blood sugar 440 oxygen 97% NRB 4L, pulse 126. Emergency response called.During a concurrent interview and record review, on April 15, 2026, at 12:15 PM, with the Director of Nursing (DON), the DON stated Resident 1's spouse was upset and claimed that she was not informed of Resident 1's transfer to the hospital. The DON reviewed Resident1's face sheet and Physician Orders for Life Sustaining Treatment (POLST), and stated the forms had different phone numbers listed for Resident 1's spouse. The DON further stated the Admissions Coordinator encoded the information on Resident 1's face sheet, which led to Resident 1's spouse not being notified of the transfer.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents medical/mental condition and or status.10. The business office manager or designee will verify the address and telephone number of the resident's family or representative (sponsor) on a quarterly basis. Any noted changes will be reported to the director of nursing services to ensure that such information is changed in the resident's medical record.

Based on interview and record review, the facility failed to ensure their Charting and Documentation, Change in a Resident Condition or Status policy and procedure was implemented for one of three sampled residents (Resident 1) when Resident 1's face sheet listed an incorrect phone number of Resident 1's spouse.This failure resulted in Resident's 1's spouse not being informed of Resident 1's transfer to the hospital. Findings:During a review of Resident 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture (broken bone) to left femur (upper leg), bone cancer (tumor to the bones in body), diabetes mellitus type 2 (chronic metabolic disorder characterized by high/low blood sugar), and hypertension (high blood pressure).During a review of Resident 1's Situation Background, Assessment, Review and Notify nursing notes, dated April 6, 2026, it indicated Other change in condition: ALOC, Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). Resident noted to be responsive at 06:00AM. Certified Nursing Assistant (CNA) attempted to wake up resident and resident was unable to be aroused at 07:40AM as CNA was bringing meal tray to resident. CNA called out for charge nurse. Charge nurse assessed resident and noted to not be responsive to name and hard to arouse. Charge assessed resident's Vital Signs at 7:45AM Blood pressure 136/81, heart rate140, Blood Sugar 448, Oxygen 80% Room Air. Registered Nurse (RN) assessed resident and Non- Re Breather mask administered. At 07:50AM Vital Signs: blood pressure140/98, Blood sugar 440 oxygen 97% NRB 4L, pulse 126. Emergency response called.During a concurrent interview and record review, on April 15, 2026, at 12:15 PM, with the Director of Nursing (DON), the DON stated Resident 1's spouse was upset and claimed that she was not informed of Resident 1's transfer to the hospital. The DON reviewed Resident1's face sheet and Physician Orders for Life Sustaining Treatment (POLST), and stated the forms had different phone numbers listed for Resident 1's spouse. The DON further stated the Admissions Coordinator encoded the information on Resident 1's face sheet, which led to Resident 1's spouse not being notified of the transfer.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation revised on July 2017, the P&P indicated, .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to label the food belonging to one unsampled resident (Resident 121).This deficient practice could potentially raise the risk of foodborne illnesses among residents, due to staff inability to verify the safety and freshness of the food.During an observation in the facility family room and concurrent interview with Kitchen Staff (KS) on 8/27/25 at 6:00 AM., a closed black bag containing noodles and one plastic container of soup without label were found inside the shared residents' refrigerator for food brought in by family and visitors. A posting outside the shared residents' refrigerator stated All food must have resident's name, room number and date. If any information is missing, it will be thrown out.The KS stated that all food stored inside the residents' refrigerator must be labeled with the room number and resident's name. During an interview with the Director of Food and Nutritional Services (DFNS) on 8/27/25 at 8:40 AM, the DFNS confirmed that all food inside the shared residents' refrigerator is supervised by kitchen staff and must be labeled with resident's name and room number.A review of the facility's policy and procedure titled, Food Receiving and Storage dated 1/2024, indicated, .a. The facility has the right to dispose of any food from outside sources that is not labelled and dated accordingly.

Based on observation, interview, and record review, the facility failed to ensure the main entrance door frame was sealed and the door closed properly, creating entry points for pests.This failure had the potential to affect the health and well-being of 207 residents by allowing disease carrying pests an easy entry point into the facility, which could aversely affect residents' health and well-being. During an observation on 8/26/25 at 8:25 AM, at the facility's main entrance, gaps were noted in the door frame.During an interview with Resident 103 on 8/26/25 at 9:05 AM, Resident 103 stated being bitten by a mosquito three days prior and believed the mosquitoes were entering through the main entrance when people came and went.During a review of the Orkin pest control report dated 6/16/25 the Orkin report indicated open gaps in the front exterior door and recommended adding weather stripping.During an interview with Resident 22 on 8/27/25 at 7:49 AM, Resident 22 stated they do not see bugs every day, but do see them occasionally, particularly when food trays were in the room.During an observation on 8/27/25 at 11:59 AM near nursing station three, there was a fly spotted in the air.During a concurrent observation and interview with Receptionist 1 (R1) and Receptionist 2 (R2) on 8/27/25 at 12:31 PM, R2 stated that the door is not fully closed. R1 and R2 both stated the door does not close properly every time, especially when it is not opened fully by the person entering.During a concurrent observation and interview with R1 at the main entrance on 8/28/25 at 8:56 AM, R1 verified the main entrance door was not closed properly.During a concurrent observation and interview with the Maintenance Service Director (MTD) at the main entrance on 8/28/25 at 9:03 AM, the MTD stated they can see the gaps on the sides, middle, and bottom of the door and pests would be able to enter.During a concurrent interview and record review on 8/28/25 at 10:45 AM, with the MTD and Administrator (ADM) the Orkin pest control dated 6/16/25 was reviewed. The Orkin report indicated that there were open gaps in the front exterior door and recommended adding weather stripping. MTD stated a note was written in the maintenance book about weather stripping but could not provide documentation to verify the repair took place.During a concurrent observation and interview on 8/28/25 at 10:55 AM, with the ADM and MTD at the main entrance. The ADM stated that gaps were present in the main entrance door making it easier for pests to enter the facility. The ADM also stated the door does not always close properly. The ADM further stated that this would be an easy fix with weather stripping and the MTD will fix the weather stripping and adjust the door to close the gaps.A review of the facility's Pest Control policy, dated May 2008, indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure two out of three laundry dryers were heating properly as per the manufacturer's recommendations.This failure could prolong the heating cycle of the dryers, consequently delaying the availability of clean clothes and linens for residents.During a tour of the laundry area, on 8/26/25 at 2:23 PM, all three dryers in the laundry were observed to be in use with settings on High. Dryer 1 had towels, Dryer 2 had bed sheets, and Dryer 3 had residents' clothes. The temperatures of the dryers were noted as follows: Dryer 1 at 140 degrees Fahrenheit, Dryer 2 at 230 degrees Fahrenheit, and Dryer 3 at 100 degrees Fahrenheit.A review of the facility's laundry area Dryer Temperature Log for August 2025 revealed that the temperatures for all three dryers were recorded at 180 degrees Fahrenheit from 8/1/25 through 8/26/25.During an interview with the Environmental Services Director (ESD), on 8/26/25, at 2:31 PM, the ESD stated that the temperature issue should be reported to maintenance, as the dryer temperature was required to be at least 180 degrees Fahrenheit.During an interview with the Laundry Staff (LS), on 8/26/25, at 2:34 PM, the LS stated, The reason why it's low is because if it gets to 180 degrees the clothes will burn, and we need to open it every 15 minutes. The linen will have wrinkles if it's too hot and the residents don't like it. The LS added that during the morning, the dryer temperatures were at 180 degrees Fahrenheit, however, the temperatures decreased in the afternoon as the staff needed to open the dryers every 15 minutes to prevent the towels and linens from burning.During an interview with the Maintenance Director (MTD), on 8/26/25, at 2:45 PM, the MTD stated that there might be an issue with the thermostat, which could cause the low temperature. The MTD added, We need to replace it. Will check with my scanner. I did not receive any report with low temperature. The MTD confirmed and verified that the temperature of two dryers was below the normal range.During subsequent interview with the ESD, on 8/26/25 at 2:55 PM, it was stated that dryer temperatures of 100- and 140-degrees Fahrenheit were too low and needed immediate correction. The ESD confirmed and verified that the temperature of two dryers was below the normal range. The ESD added, We don't have policy for the dryers, we just follow the California regulations that dryer temperatures should be at 180 degrees and above.During an interview with the Director of Nursing, on 8/28/25, at 10:51 AM, the DON confirmed and verified that dryer temperatures of 100- and 140-degrees Fahrenheit were low. The DON stated, It's the facility's responsibility to maintain the equipment in good condition.A review of facility's laundry dryer manual titled, 110 Pound Capacity. Installation Operation Maintenance Parts and Service Manual for Drying Tumblers, indicated, Temperature Control Thermostats. Located nearest the front of the dryer is the high heat thermostat calibrated to open at 185 degrees F +/- and close at 170F +/- 5F. This thermostat operates when the times is places in the A cycle for cotton and linens.A review of facility's policies and procedures titled, Laundry and Bedding, Soiled, revised in September 2022, indicated, Policy Statement. Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Storage. 4. Laundry equipment (e.g., washing machines, dryers) is used and maintained according to the manufacturer's IFU (Instructions for Use) to prevent microbial contamination of the system.A review of facility's policies and procedures titled, Maintenance Service, revised in December 2009, indicated, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when:Certified Nursing Assistant (CNA) 1 did not perform handwashing before and after handling nasal cannula (flexible tube to deliver oxygen into the nose) to Resident 186.The incentive spirometer (a handheld device that exercises your lungs and measures how much air you can breathe in) placed at Resident 148's bedside, was unlabeled and not properly stored.The temperature settings for two of three dryers in the laundry area were below the normal range.The glucometer machine (a device used to measure how much sugar is in the blood) used for Residents 131, 93, and 69 was not sanitized. Licensed Vocational Nurse (LVN) 9 did not disinfect the blood pressure (BP) device prior to measuring the BP of Resident 110.These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of 207 medically compromised residents, staff, and visitors.1. During an initial tour observation, outside Resident 186's room, on 8/25/25, at 9:15 AM, Resident 186 was observed in a wheelchair, assisted by CNA 1. Noted CNA 1 pushing Resident 186's wheelchair into the hallway and then applying a nasal cannula to Resident 186's nostrils. Did not observe CNA 1 perform handwashing before and after applying the nasal cannula. During an interview with CNA 1, on 8/25/25, at 9:17 AM, CNA 1 stated that handwashing should be performed before and after applying nasal cannula to a resident to prevent bacterial infection. During an interview with Licensed Vocational Nurse (LVN) 1, on 8/25/25, at 9:18 AM, LVN 1 stated that staff should do handwashing or wear gloves before and after applying nasal cannula to a resident. During an interview with the Infection Preventionist (IP), on 8/27/25, at 9:25 AM, the IP confirmed the importance of handwashing before and after handling nasal cannula to prevent infection. During an interview with the Director of Nursing (DON), on 8/28/25, at 10:51 AM, the DON confirmed that staff must wash their hands during each resident care for infection control and prevention. A review of Resident 186's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Shortness of Breath and Orthostatic Hypotension (a condition where blood pressure drops significantly upon standing or sitting up from a lying position). A review of facility's policies and procedures titled, Handwashing/Hand Hygiene, revised in October 2023, indicated, Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Indications for Hand Hygiene. Hand hygiene is indicated: a. immediately before touching the resident; .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment. 5. The use of gloves does not replace handwashing/hand hygiene. 2. During an initial tour observation, in Resident 148's room, on 8/25/25, at 8:55 AM, Resident 148 was noted asleep in bed. A shelf was observed by Resident 148's bedside, where an incentive spirometer was placed. The incentive spirometer was unlabeled, uncovered, and not stored in a protective bag. During an interview with the Infection Preventionist (IP), on 8/25/25, at 9:06 AM, in Resident 148's room, the IP verified that the incentive spirometer was unlabeled and not stored appropriately. The IP stated that the incentive spirometer should not be left exposed, as it could cause an infection if placed in the resident's mouth. A review of Resident 148's Order Summary Report for August 2025, indicated no order of incentive spirometer. A review of Resident 148's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Essential Hypertension (high blood pressure) and Type 2 Diabetes Mellitus (a long-term condition that causes high blood sugar levels). A review of Resident 148's Care Plan Report, initiated on 7/31/25, indicated, Focus. Respiratory: Resident requires pulmonary hygiene interventions due to an acute complication of the respiratory system. Interventions. Incentive Spirometer as ordered. A review of Resident 148's Order Summary Report for 7/1/25 through 7/31/25, indicated, Initiate Incentive Spirometer TID (three times a day) for 5 to 10 breath cycles or as tolerated for 10 days with volume metric/goal based on resident's Predictive Nomogram (a tool that represents as scoring system) value of 1550ml (milliliters), related to: (diminished lung sounds). May start at 1000ml until Predictive Nomogram goal is achieved. Instructions: Provide 15 minutes to include the time the Respiratory Therapist/Nurse spends with the resident including evaluation/assessment, treatment administration and monitoring, and setup and removal of equipment. With start date of 7/31/25 and end date of 8/10/25. During an interview and concurrent record review with Registered Nurse (RN) 2, on 8/28/25, at 9:46 AM, Resident 148's physician's order and Medication Administration Record (MAR) were reviewed. The records indicated that Resident 148's incentive spirometer order was started on 7/31/25 and completed on 8/10/25. RN 2 stated that once completed, the incentive spirometer should be discarded or, if retained, it must be stored appropriately. During an interview with the Director of Nursing (DON), on 8/28/25, at 10:51 AM, the DON stated that licensed nurses were responsible for assisting residents with the use of the incentive spirometer and discarding it upon completion of the order. The incentive spirometer should be labeled with names and dates and stored properly. The DON verified that Resident 148 could be at risk of developing a respiratory infection if the incentive spirometer was used continuously. A review of facility's policies and procedures titled, Prevention of Infection Respiratory Equipment, revised in November 2011, indicated, Purpose. The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Infection Control Considerations Related to Medication Nebulizers (a medical device that turns liquid medication into a fine, inhalable mist to be delivered deep into the lungs, primarily for treating respiratory conditions) / Continuous Aerosol (a suspension of fine solid particles or liquid droplets in a gas, usually air): .3. Store the circuit in plastic bag, marked with date and resident's name and replace tubing and plastic bag once a week. 3. During a tour of the laundry area, on 8/26/25 at 2:23 PM, all three dryers in the laundry were observed to be in use with settings on High. Dryer 1 had towels, Dryer 2 had bed sheets, and Dryer 3 had residents' clothes. The temperatures of the dryers were noted as follows: Dryer 1 at 140 degrees Fahrenheit, Dryer 2 at 230 degrees Fahrenheit, and Dryer 3 at 100 degrees Fahrenheit. A review of the facility's laundry area Dryer Temperature Log for August 2025 revealed that the temperatures for all three dryers were recorded at 180 degrees Fahrenheit from 8/1/25 through 8/26/25. During an interview with the Environmental Services Director (ESD), on 8/26/25, at 2:31 PM, the ESD stated that the temperature issue should be reported to maintenance, as the dryer temperature was required to be at least 180 degrees Fahrenheit. During an interview with the Laundry Staff (LS), on 8/26/25, at 2:34 PM, the LS stated, The reason why it's low is because if it gets to 180 degrees the clothes will burn, and we need to open it every 15 minutes. The linen will have wrinkles if it's too hot and the residents don't like it. The LS added that during the morning, the dryer temperatures were at 180 degrees Fahrenheit, however, the temperatures decreased in the afternoon as the staff needed to open the dryers every 15 minutes to prevent the towels and linens from burning. During an interview with the Maintenance Director (MTD), on 8/26/25, at 2:45 PM, the MTD stated that there might be an issue with the thermostat, which could cause the low temperature. The MTD added, We need to replace it. Will check with my scanner. I did not receive any report with low temperature. The MTD confirmed and verified that the temperature of two dryers was below the normal range. During subsequent interview with the ESD, on 8/26/25 at 2:55 PM, it was stated that dryer temperatures of 100- and 140-degrees Fahrenheit were too low and needed immediate correction. The ESD confirmed and verified that the temperature of two dryers was below the normal range. The ESD added, We don't have policy for the dryers, we just follow the California regulations that dryer temperatures should be at 180 degrees and above. During an interview with the Infection Preventionist (IP), on 8/27/25, at 9:25 AM, the IP stated, We will have it fixed. With low temperature, there's a risk for the organism not being killed. We have to maintain the temperature to eliminate the organisms. The IP also stated there were no residents infected with scabies or other skin conditions requiring contact precautions. During an interview with the Director of Nursing (DON), on 8/28/25, at 10:51 AM, the DON confirmed and verified that dryer temperatures of 100- and 140-degrees Fahrenheit were low. The DON stated, It's the facility's responsibility to maintain the equipment in good condition. A review of facility's laundry dryer manual titled, 110 Pound Capacity. Installation Operation Maintenance Parts and Service Manual for Drying Tumblers, indicated, Temperature Control Thermostats. Located nearest the front of the dryer is the high heat thermostat calibrated to open at 185 degrees F +/- and close at 170F +/- 5F. This thermostat operates when the times is places in the A cycle for cotton and linens. A review of facility's policies and procedures titled, Laundry and Bedding, Soiled, revised in September 2022, indicated, Policy Statement. Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Storage. 4. Laundry equipment (e.g., washing machines, dryers) is used and maintained according to the manufacturer's IFU (Instructions for Use) to prevent microbial contamination of the system. A review of facility's policies and procedures titled, Departmental (Environmental Services) – Laundry and Linen, revised in January 2014, indicated, Purpose. The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Washing Linen and other Soiled Items. 5. Follow manufacturer's instructions for all laundry processing materials (equipment, detergents, rinses, etc.). A review of facility's policies and procedures titled, Maintenance Service, revised in December 2009, indicated, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 4. During a medication administration observation on 8/27/25 at 6:40 AM, 6:45 AM and 6:54 AM, with LVN 7 for Residents 131, 93, and 69, respectively, LVN 7 was observed using the glucometer to assess the residents' blood sugar level. However, LVN 7 did not disinfect the glucometer before and after use on each resident. During an interview with LVN 7 on 8/27/25 at 7:02 AM, LVN 7 stated the glucometer should be disinfected before and after use on each resident. LVN 7 verified she did not disinfect before or after use of the glucometer when she checked the blood sugars for Resident 131, Resident 93, and Resident 69. During an interview with the Director of Nursing (DON) on 8/29/25 at 10:54 AM, the DON stated the glucometer should have been disinfected before and after use for each resident. The DON acknowledged the finding. A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces revised 6/2009, indicated .environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities. Most non critical items can be decontaminated where they are used. According to the Centers for Disease and Control (CDC)'s article titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 8/7/24, the recommendations for blood glucose monitoring included to .clean and disinfect blood glucose meters after every use. 5. During a concurrent medication administration observation and interview with LVN 9 on 8/27/25 at 9:29 AM, LVN 9 stated Resident 110's BP needs to be checked prior to the administration of medications. LVN 9 proceeded to measure Resident 110's BP. LVN 9 acknowledged not disinfecting the BP device prior to applying it on Resident 110's wrist. LVN 9 further stated the BP device needs to be disinfected before and after measuring a resident's BP. During a concurrent interview and record review with the Infection Preventionist (IP) on 8/29/25 at 10:40 AM, the facility's policy and procedure (P&P) titled Cleaning and Disinfection of Environmental Surfaces with a revised date of June 2009 was reviewed. The P&P indicated, in part, . 1(c). Non-critical items are those that come in contact with intact skin but not mucous membranes. Most non-critical items can be decontaminated where they are used. The IP acknowledges a BP device is considered a non-critical item. The IP stated the device needs to be disinfected before and after measuring a resident's BP. A review of the facility's policy and procedure (P&P) titled Administering Medications revised in April 2019 indicated, in part, . 25. Staff follows established facility infection control procedures for the administration of medications, as applicable.

Based on interview and record review, the facility failed to ensure advance care planning was completed properly for 8 of 18 sampled residents (Residents 8, 10, 13, 15, 76, 96, 141 and 170) when: A Physician Orders for Life Sustaining Treatment (POLST, a medical form that documents a patient's wishes regarding end-of-life care) was not completed for Resident 141.There was no documentation to indicate Resident 170 received written information addressing advance directives (a document that communicates a person's wishes about health care decisions in the event the person becomes incapacitated of making health care decisions).Resident 13 was not reassessed properly for advance directive.There was no documentation to indicate Resident 96 received written information addressing advance directives.There was no documentation to indicate Resident 10 received written information addressing advance directives.There was no documentation to indicate Resident 76 received written information addressing advance directives.There was no documentation to indicate Resident 15 received written information addressing advance directives.There was no documentation to indicate Resident 8 received written information addressing advance directives.These failures could result in residents receiving unnecessary treatment during an emergency situation. 1. A review of Resident 141's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with Hypoxia (a serious medical condition where the lungs cannot provide enough oxygen to the body) and Hypertension (high blood pressure). A review of Resident 141's POLST form revealed that Section A (Cardiopulmonary Resuscitation - CPR, helps save a life when the heart stops beating), Section B (Medical Interventions) and Section C (Artificially Administered Nutrition) were left blank. Section D (Information and Signatures) had the physician's signature dated [DATE], but it did not include the signature of the patient or legal decision-maker. During an interview with Registered Nurse (RN) 3, on [DATE], at 8:44 AM, RN 3 stated the importance of timely signing and completing the POLST was to ensure accurate care for residents. During an interview with RN 4, on [DATE], at 8:49 AM, regarding the importance of timely completion of the POLST, RN 4 stated, In case of an emergency we know what to do. During an interview with the Director of Nursing (DON), on [DATE], at 10:51 AM, the DON stated that licensed nurses were responsible for contacting the physician and resident's family in completing the POLST. The DON added that POLST should be completed within 48 hours of admission. Additionally, it should be reviewed and discussed during the care conference meeting a few days following the admission. The DON mentioned that if the POLST was not completed on time, and full code treatment was provided to a resident while the family preferred Do Not Resuscitate (DNR - not to perform CPR if patient's heart or breathing stops), the facility could potentially face a lawsuit. The DON confirmed that it was essential to complete the POLST form within 48 hours of admission. A review of facility's undated policies and procedures titled, Physicians Orders for Life-Sustaining Treatment (POLST), indicated, Completing POLST. To be valid a POLST form must be signed by (1) physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Any incomplete section of POLST implies full treatment for that section. 2. A review of Resident 170's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 170's History and Physical Examination dated [DATE], indicated the resident had the capacity to understand and make decisions for the resident's care. A review of Resident 170's Physician's Orders for Life-Sustaining Treatment (POLST, a medical document that outlines a patient's wishes regarding end-of-life care) signed by a physician on [DATE] indicated the resident did not have an advance directive. During a concurrent interview and record review with the Social Services Director (SSD) on [DATE] at 4:31 PM, the facility's P&P (policy and procedure) titled Advance Directives with a revised date of [DATE] was reviewed. The policy indicated, in part, .2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. The written information. is provided in a manner that is easily understood by the resident or representative. The SSD acknowledged the facility provides a document to a resident or the resident's representative titled Information Sheet Advance Care Directives, (a written information addressing advance directive) during admission assessment and annually to ensure such directives are still the wishes of the resident. During a concurrent interview and record review with the SSD on [DATE] at 6:35 AM, the SSD further reviewed Resident 170's medical record for a documentation indicating the resident received the written information about Advance Directive provided by the facility. The SSD stated, there was no documentation indicating Resident 170 received the written information for Advance Directive from the facility. The SSD also stated the information sheet is provided to the resident either electronically or physically. The SSD further stated the facility receives a confirmation report if the resident received the written information electronically. The SSD verified there was no documentation indicating that Resident 170 received the written information about Advance Directive electronically or physically. 3. A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 13's History and Physical Examination dated [DATE] indicated the resident did not have the capacity to understand and make decisions. During a concurrent interview and record review with the SSD on [DATE] at 4:31PM, Resident 13's POLST dated [DATE] was reviewed. The SSD stated a check mark on the Advance Directive in the resident's POLST form meant the resident had an advance directive. During a concurrent interview and record review with the SSD on [DATE] at 6:35 AM, Resident 13's IDT Conference Summary dated [DATE] was reviewed. The SSD stated the resident's current wishes and the resident's POLST was reviewed during the quarterly assessment of preferred intensity of care and advance directive. The SSD verified Resident 13 did not have an advance directive. The SSD confirmed that the check mark for the advance directive on the resident's POLST was completed inaccurately. 4. A review of Resident 96's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 96 was admitted to the facility on [DATE]. A review of Resident 96's POLST dated [DATE], indicated Section D (Advance Directive) of the form was incomplete. The boxes indicating who the Advanced Directives were discussed with was left unchecked, and further review of the section showed Resident 96 did not have an Advance Directive. A review of Resident 96's MDS, dated [DATE], indicated Resident 96 had a Brief Interview for Mental Status, (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 12 (moderate cognitive impairment). A review of Resident 96's History and Physical, dated [DATE], indicated Resident 96 was able to make needs known, but could not make medical decisions. During a concurrent interview and record review with the SSD on [DATE] at 9:26 AM, Resident 96's ISO Report Sent Confirmation, dated [DATE] was reviewed. The ISO Report Sent Confirmation indicated Resident 96's sibling received general information of the facility; however, further review verified that the document, did not include written information regarding Advance Directives. The SSD stated that the residents and their families were asked to bring in a copy of their Advance Directive upon admission. If the residents did not have an Advance Directive, written information on how to formulate an Advance Directive would be provided. The SSD verified that the information on how to formulate the advance directive was not in Resident 96's medical record. 5. A review of Resident 10's admission Record (front page of the chart that contains a summary of basic information about the resident), indicated Resident 10 was initially admitted to the facility on [DATE] with original admission of [DATE]. A review of Resident 10's POLST (Physicians Orders for Life Sustaining Treatment) dated [DATE], indicated Section D (Advance Directive) of the form was incomplete. Additionally, the form indicated Advanced Directives were discussed with Resident 10; however further review of the section did not indicate if Resident 10 had an Advance Directive. A review of Resident 10's Minimum Data Sheet (MDS), dated [DATE], indicated Resident 10 had a Brief Interview for Mental Status, (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 12 (moderate cognitive impairment). A review of Resident 10's History and Physical, dated [DATE], indicated Resident 10 had the capacity to understand and make decisions. During a concurrent interview and record review with the SSD on [DATE] at 9:26 AM, Resident 10's ISO Report Sent Confirmation, dated [DATE] was reviewed. The ISO Report Sent Confirmation indicated Resident 10's sister received general information of the facility; however, further review verified that the document, did not include written information regarding Advance Directives. The SSD stated that the residents and their families were asked to bring in a copy of their Advance Directive upon admission. If the residents did not have an Advance Directive, written information on how to formulate an Advance Directive would be provided. The SSD verified that the information on how to formulate the advance directive was not in Resident 10's medical record. During an interview with Resident 10 on [DATE] at 10:38 AM, Resident 10 stated, not being informed about Advance Directive. Resident 10 also confirmed not receiving any written information about how to formulate an Advance Directive. 6. A review of Resident 76's History and Physical (H&P) dated [DATE], indicated Resident has the capacity to make decisions. A review of Resident 76's quarterly MDS (Minimum Data Sheet – a standardized assessment and screening tool) dated [DATE], indicated Resident has a BIM score of 15 (an assessment uses a point system that ranges from 0-15; 0-7 points suggests severe cognitive impairment; 8-12 points suggests moderate cognitive impairment, and 13-15 points suggests that cognition is intact). During a concurrent interview and record review with the Social Services Director (SSD) on [DATE] at 8:12 AM, the SSD con rmed there was no written acknowledgement provided to the resident and/or family member to formulate an advance directive. During a concurrent interview and record review with the Director of Nursing (DON), on [DATE] at 11:21 AM, the DON con rmed there was no written acknowledgement given to the resident and/or family member to formulate an advance directive. 7. A review of Resident 15's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses (identification of disease process) which included altered mental status (change in cognitive function). A review of Resident 15's history and physical notes dated [DATE] indicated Resident 15 had the capacity to make decisions. A review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated [DATE] indicated a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) summary score of 12 out of 15. During an interview with the Director of Nursing (DON) on [DATE] at 10:38 AM, the DON confirmed there was no proof that an advance directive was offered to Resident 15. The DON also stated, it's unfortunate there was none (Advance Directive). During an interview with the Minimum Data Set Director (MDSD) on [DATE] at 2:35 PM, the MDSD confirmed there was no advance directive for Resident 15. A review of Resident 15's Physician's Orders for Life Sustaining Treatment (POLST – a medical form expressing the resident's wishes in the event of medical emergency) dated [DATE], indicated No advance Directive. 8. A review of Resident 8's admission Records dated [DATE], indicated resident was admitted on [DATE]. A review of Resident 8's History and Physical (H&P), dated [DATE], indicated, status post (S/P - is a medical or clinical shorthand that refers to a state after an intervention) Diabetic Ketoacidosis (DKA - a serious complication of diabetes that occurs when the body does not have enough insulin and starts breaking down fat for energy ) and bacteremia (a condition where bacteria enter the bloodstream). A review of Resident 8's quarterly MDS (Minimum Data Sheet – a standardized assessment and screening tool) dated [DATE], indicated Resident 8 has a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 suggesting moderate cognitive impairment. During a concurrent interview and record review with the Director of Nursing (DON), on [DATE] at 12:20 pm, the Advance Directive acknowledgement receipt form was reviewed. The DON stated that upon admission, resident or resident's Representative needs to sign acknowledgement receipt that advance directive was offered. The DON confirmed that Resident 8 or Resident 8's representative did not sign the acknowledgement form. A review of the facility's policy and procedures titled Advance Directives, dated [DATE], indicated .Determining Existence of Advance Directive.2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on interview and record review, the facility failed to ensure two of five residents (Residents 12 and 162) were kept free from unnecessary medications when:1. Resident 162 was not consistently offered non-pharmacological interventions prior to receiving Ativan (a medication used to treat anxiety) as ordered by the physician.2. Resident 12 received Depakote (a medication used as a mood stabilizer) without an accurate diagnosis.These failures put the residents at risk of adverse effects from the medications. 1. A review of Resident 162's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 162 was admitted to the facility on [DATE], with diagnoses including anxiety.During a concurrent interview and record review with LVN 2 on 8/27/25 at 7:24 AM, Resident 162's Order Summary Report was reviewed. The Order Summary Report indicated an order dated 4/13/25, for non-drug intervention prior to administration of prn (as needed) anti-anxiety medication. The Medication Administration Record (MAR) dated August, 2025 was reviewed. The MAR indicated non-pharmacological interventions were not offered prior to Resident 162 receiving Ativan on the following dates and times:o 8/5/25 10:00 AM, 2:42 PMo 8/15/25 7:53 AM, 12:25 PMo 8/16/25 9:37 AM, 1:40 PMo 8/26/25 8:31 AM, 1:00 PMLVN 2 was unable to answer why the non-pharmacological interventions had not been offered, but stated they should have been.During a concurrent interview and record review with the Director of Nursing (DON) on 8/29/25 at 2:44 PM, the Order Summary Report and MAR were reviewed. The DON verified the above findings and stated non-pharmacological interventions should have been offered prior to each administration of Ativan.A review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated 2001, indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest dose if indicated, and support efforts at gradual dose reduction. 2. A review of Resident 12's Face Sheet indicated Resident 12 was readmitted to the facility on [DATE], with diagnoses including dementia.During a concurrent interview and record review with the DON on 8/28/25 at 2:50 PM, Resident 12's admission Record (face sheet) was reviewed. The face sheet indicated a diagnosis of epilepsy was added on 8/22/25. When asked who would diagnose the resident, the DON stated the attending physician. The psychiatric follow-up note dated 8/22/25, was reviewed. The psychiatric follow up note indicated Resident 12 was taking Depakote for seizure disorder, not psychosis. The DON contacted Resident 12's physician via telephone. Resident 12's physician stated the seizure disorder diagnosis was an error, and the indication should be impulse control.A review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated 2001, indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest dose if indicated, and support efforts at gradual dose reduction.

Based on observation, interview, and record review, the facility failed to comprehensively and accurately assess hearing for one of 35 sampled residents (Resident 68).This failure had the potential to result in Resident 68's care needs not being effectively met.During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 AM, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which include hearing loss.A review of Resident 68's Minimum Data Set (MDS - a standardized assessment tool) dated 9/26/23, and 6/28/25, indicated resident hears adequately and does not use hearing aids.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 08/27/2025 at 6:45 AM, indicated Resident 68 had a right and left hearing aid upon admission.A review of Resident 68's Social History assessment dated [DATE], indicated under Adaptive Aids, Resident 68 used hearing aids and glasses.During a concurrent interview and record review with the Director of Nursing (DON) on 08/27/2025 at 9:35 AM, Resident 68's assessment records were reviewed. The DON verified information regarding Resident 68's hearing disability does not appear in the assessment records. The DON confirmed that the facility did not conduct an accurate comprehensive assessment of Resident 68's hearing disability.During a concurrent interview and record review with Minimum Data Set (MDS) Director (MDSD) on 08/27/2025 at 12:46 PM, dated 9/26/23 and 6/28/25 were reviewed. The MDSD explained that section B (hearing, speech and vision) of the MDS is coded as 0 if it is determined that the resident does not have hearing difficulties, indicating hearing is adequate. The MDSD stated that facility does not inquire whether residents have hearing aids. If the MDSD deemed the hearing adequate, hearing aid is coded as 0, meaning No. The MDSD confirmed that section B of the MDS for Resident 68 was not accurately assessed.During an interview on 08/29/2025 at 9:44 AM with Registered Nurse 4 (RN 4), RN 4 stated that assessments must be accurately conducted to identify and properly address the resident's needs.A review of the facility's policy and procedure (P&P) titled admission Assessment, dated September 2012, indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS.A review of the facility's policy and procedure (P&P) titled Comprehensive Assessment, dated October 2023, indicated, 1. The facility conducts comprehensive, accurate, and standardized, reproducible assessments of each residence functional capacity using the resident assessment instrument specified by CMS.

The facility failed to develop and implement a comprehensive care plan needed to address hearing difficulty, for one of 35 sampled residents (Resident 68). This failure had the potential to result in the residents' care needs not being met effectively During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 am, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which includes hearing loss.A review of Resident 68's Minimum Data Set (MDS - a standardized assessment tool) dated 9/26/23, and 6/28/25, indicated resident hears adequately and does not use hearing aids.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 08/27/2025 at 6:45 AM, indicated Resident 68 had a right and left hearing aid upon admission.A review of Resident 68's Social History assessment dated [DATE], indicated under Adaptive Aids Resident 68 used hearing aids and glasses.During a concurrent interview and record review with the Director of Nursing (DON) on 08/27/2025 at 9:35 AM, Resident 68's care plans were reviewed. The DON confirmed Resident 68 does not have a comprehensive care plan for hearing disability.During a concurrent interview and record review with Minimum Data Set (MDS) Director (MDSD) on 08/27/2025 at 12:46 PM, dated 9/26/23 and 6/28/25 were reviewed. The MDSD explained that section B (hearing, speech and vision) of the MDS is coded as 0 if it is determined that the resident does not have hearing difficulties, indicating hearing is adequate. The MDSD stated that facility does not inquire whether residents have hearing aids. If the MDSD deemed the hearing adequate, hearing aid is coded as 0, meaning No. The MDSD confirmed that section B of the MDS for Resident 68 was not accurately assessed.During an interview on 08/29/2025 at 9:44 AM with Registered Nurse 4 (RN 4), RN 4 stated that assessments must be accurately conducted to identify and properly address the resident's needs.A review of the facility's policy and procedure (P&P) titled Comprehensive Assessment, dated October 2023, indicated, .1. The facility conducts comprehensive, accurate, and standardized, reproducible assessments of each residence functional capacity using the resident assessment instrument specified by CMS.A review of the facility's policy and procedure titled Care Plans, Comprehensive Person - Centered, dated December 2016, indicated, . 8. The comprehensive, person-centered care plan will, b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being.

Based on interview and record review, the facility failed to revise the plan of care for two of 35 sampled residents (Residents 12 and 162). This failure put the residents at risk for their care needs to go unmet.1.A review of Resident 12's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 12 was admitted on [DATE].During a concurrent interview and record review with RN 4 on 8/29/25 at 11:53 AM, Resident 12's Order Listing Report was reviewed. The Order Listing Report indicated Resident 12 had a peripheral IV started on 7/15/25, and the order was discontinued on 7/18/25. A review of the plan of care showed a care plan problem dated 7/15/25, for vascular access, resident at risk for complications due to the presence of a peripheral line. RN 4 stated Resident 12 did not have a current peripheral IV access line. RN 4 stated the care plan should have been revised because otherwise they are monitoring for something that is no longer an issue. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated, assessments of residents are ongoing and care plans are revised as information about the residents' condition change.2. During a concurrent interview and record review with LVN 2 on 8/27/25 at 7:24 AM, Resident 162's plan of care was reviewed. The plan of care indicated Resident 162 was placed on enhanced barrier precautions. When asked how staff would know how to care for a resident, LVN 2 stated she would look at the plan of care. LVN 2 stated because the plan of care wasn't updated, she did not know the resident's order for enhanced barrier precautions had been discontinued. During an interview with LVN 3 on 8/27/25 at 7:53 AM, LVN 3 stated the nurse that discontinued the order should revise the plan of care, at least on the same day.During an interview with DON on 8/29/25 and 2:44 PM, the DON stated the care plan should have been updated at the time the order was changed.A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated , Assessments of residents are ongoing and care plans are revised as information about the residents' condition change.

Based on observation, interview, and record review, the facility failed to replace the broken hearing aids for one of 35 sampled residents (Resident 68).This failure had the potential to prevent effective communication, diminished activities of daily living and resident becoming less engaged in their overall care and well-being.During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 am, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, hearing loss.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 08/27/2025 at 6:45 AM, indicated Resident 68 had a right and left hearing aid upon admission.A review of Resident 68's Social History assessment dated [DATE], indicated under Adaptive Aids Resident 68 used hearing aids and glasses.A review of Audiology notes dated 8/6/25 indicated hearing abnormal by observation and Resident 68 also complained of hearing problems.During an interview with Certified Nurse Assistant (CNA 3) on 8/27/25 at 7:55 am, CNA 3 verified that Resident 68 has had hearing difficulties for the last seven months. CNA 3 stated reporting Resident 68's hearing difficulties to the LVN.During a concurrent interview and record review with Minimum Data Set (MDS) Director (MDSD) on 08/27/2025 at 12:46 PM, dated 9/26/23 and 6/28/25 were reviewed. The MDSD confirmed that section B of the MDS for Resident 68 was not accurately assessed.During an interview with the Director of Nursing (DON) on 08/29/2025 at 10:03 am, DON confirmed that Resident 68's needs for hearing aid have not been addressed.During a review of the facility's policy and procedure (P&P) titled Effective Communication, dated February 2018, indicated, . 4. Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices as indicated. 7. J. Evaluate residents' adaptive needs and progress at regular intervals.

Based on observation, interview, and record review, the facility failed to assist in obtaining new hearing aid for one of the 35 sampled residents (Resident 68).This deficient practice has the potential to cause a decline in Resident 68's ability to communicate and participate in social activities.During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 AM, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid.A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE].A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which includes hearing loss.A review of Resident 68's Inventory of Personal Effects Form dated 9/19/23 on 8/27/2025 at 6:45 AM, indicated Resident 68 had a right and left hearing aid upon admission.A review of Resident 68's Social History assessment dated [DATE], indicated, under Adaptive Aids Resident 68 used hearing aids and glasses.A review of Audiology notes dated 8/6/25 indicated, hearing abnormal by observation. Resident 68 also complained of hearing problems.During an interview with Certified Nurse Assistant (CNA 3) on 8/27/25 at 7:55 AM, CNA 3 verified that Resident 68 has had hearing difficulties for the last seven months. CNA 3 stated reporting Resident 68's hearing difficulties to the LVN.During a concurrent interview and record review with Social Services (SS) on 8/27/25 at 10:04 AM, Audiology notes dated 8/6/25 were reviewed. SS stated that Resident 68 was examined by an audiologist, and an audiogram was recommended. SS mentioned they would follow up on the audiology recommendation and the need for hearing aid replacement for Resident 68.During an interview with the Director of Nursing (DON) on 08/29/2025 at 10:03 AM, the DON confirmed Resident 68's needs for hearing aid had not been addressed.A review of the facility's policy and procedure (P&P) titled Effective Communication, dated February 2018, indicated, .4. Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices as indicated. 7. J. Evaluate residents' adaptive needs and progress at regular intervals.

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was administered continuously in accordance with physician's order for one of two sampled residents investigated for oxygen treatment (Resident 141).This failure may cause Resident 141 to have difficulty breathing, potentially leading to respiratory failure.During an observation, on 8/25/25, at 2:47 PM, Resident 141 was in bed, awake, and showed no signs of pain, discomfort, or distress. An oxygen concentrator (a medical device that supplies up to 95% pure oxygen to patients through a mask or nasal tube) was noted by Resident 141's bedside. It was observed that the oxygen concentrator was turned off.During an interview with Licensed Vocational Nurse (LVN) 1, on 8/25/25, at 3:02 PM, LVN 1 stated that Resident 141's oxygen was supposed to be administered continuously. LVN 1 was asked why the oxygen concentrator was off. LVN 1 responded that the order should be reviewed to confirm if the order was continuous.During subsequent interview with LVN 1, on 8/25/25, at 3:21 PM, LVN 1 stated that Resident 141 might have low oxygen levels if the prescribed oxygen treatment was not administered. LVN 1 confirmed that oxygen was not continuously administered to Resident 141 as ordered.A review of Resident 141's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated that resident was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with Hypoxia (a serious medical condition where the lungs cannot provide enough oxygen to the body) and Hypertension (high blood pressure).A review of Resident 141's Order Details, indicated, Continuous: Oxygen to titrate to start at 2 LPM via NC / Mask to keep O2 saturation above 88% every shift for COPD (Chronic Obstructive Pulmonary Disease - a progressive lung disease which blocks air flow making breathing difficult) with order date of 5/28/25. This order was discontinued and changed to PRN (as needed) order, on 8/25/25, at 6:01 PM.A review of Resident 141's Care Plan Report, initiated on 5/28/25, indicated, Focus. Has Oxygen Therapy r/t (related to) Respiratory illness. Interventions. Give medications as ordered by physician. Focus. Oxygen: Resident requires the use of oxygen. Interventions. Educate the resident on the importance of keeping oxygen on and at the prescribed setting.During an interview and concurrent record review with Registered Nurse (RN) 1, on 8/25/25, at 3:13 PM, RN 1 checked Resident 141's current physician order which indicated, Continuous oxygen to titrate to start at 2 LPM (liters per minute) via NC (nasal cannula - flexible tube to deliver oxygen into the nose) / mask to keep O2 (oxygen) saturation above 88%. RN 1 stated that failure to administer oxygen as prescribed could potentially worsen the resident's respiratory condition and lead to an altered level of consciousness. During an interview with the Director of Nursing (DON), on 8/28/25 at 10:51 AM, the DON stated that if there was an order for continuous oxygen administration, oxygen should be kept on, to prevent shortness of breath and potential medical emergencies. The DON confirmed that oxygen was not continuously administered to Resident 141 as ordered. The DON added that Resident 141's physician was contacted, resulting in a modification of the oxygen therapy order from continuous to as needed.A review of facility's policies and procedures titled, Oxygen Administration, dated 2001, indicated, Oxygen Administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.A review of facility's undated policies and procedures titled, Physician Orders, indicated, Policy Interpretation and Implementation. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on observation, interview and record review the facility failed to replace e-Kits (e-Kit , a collection of prescription drugs, and related supplies, intended to provide immediate medical treatment for injuries and illnesses) in a timely manner, and to accurately complete the e-Kit Usage Slip form.This failure had the potential to delay medication administration for residents in need of emergency medical treatment. Findings:During a concurrent e-Kits inspection and interview with Registered Nurse (RN) 5 on 8/27/25 at 12:08 PM, multiple e-Kits secured with black-colored zip ties were noted. RN 5 acknowledged the findings. RN 5 stated the e-Kits that are secured with black-colored zip ties indicates a medication had been signed out and used for a resident. RN 5 explained that after a medication was signed out from an e-Kit, the licensed staff needs to inform the pharmacy about the usage of the kit. In addition, the licensed staff needs to complete an e-Kit Usage Slip form and leave a copy of the form in the e-Kit. RN 5 stated an e-Kit is usually replaced by the pharmacy within 72 hours from the time of use. The RN 5 further stated that the replacement of an e-kit is to ensure the availability of medications when needed by the residents.A review of the e-Kit Usage Slip forms with RN 5 indicated: 1. a lorazepam (anti-anxiety medication) 0.5 mg (milligram) was signed out on 8/13/25 for Resident 171;2. a 1300-30 mg tablet, medication name not listed, was signed out on 8/22/25 for Resident 116;3. a potassium chloride (supplement) 10 mEq (milliequivalent) was signed out on 8/14, no resident name written on the form;4. two tablets of potassium chloride 10 mEq was signed out on 8/14/25 for Resident 71. RN 5 stated that the e-kits that were inspected and reviewed need to be replaced by the pharmacy. RN 5 verified the medication signed out for Resident 116 was for acetaminophen with codeine (a controlled pain medication), and the potassium chloride 10 mEq was signed out for Resident 237. RN 5 acknowledged that the usage slip needs to be completed properly including resident's name and medication name. During an interview with the DON on 8/28/25 at 11:04 AM, the DON stated the e-Kits need to be replaced promptly. The DON verified the e-Kits that had been used from 8/13/25 to 8/22/25 already needed replacement kits from the pharmacy. The facility was unable to provide specific P&P addressing emergency supply replacement for controlled and non-controlled oral medications.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe manner when: 1. Loose medications were found in the medication cart,2. Expired medications were not removed and discarded from one medication room; and3. The bleach wipes were found stored together with the medications. These failures posed the risk for medication errors, cross contamination, and for medications to have lost their integrity and potency and affect the residents' health outcomes. 1. During a medication cart inspection and concurrent interview with Licensed Vocational Nurse (LVN) 5 on 8/27/25 at 12:03 PM, three loose tablets (one round, white tablet; one round pink tablet, and one round, orange tablet) were observed at the bottom of the medication cart drawer. LVN 5 was not able to identify the medications. LVN 5 stated the medications should have been discarded into the appropriate bin, if they were not administered.2. During a medication room inspection and concurrent interview with Registered Nurse (RN) 2 on 8/27/25 at 12:42 PM, a tube of Silvasorb gel (a gel that provides broad-spectrum antimicrobial protection for various types of wounds) with an expiration date of 6/2025 was observed. RN 2 verified the medication should have been removed from the medication room and discarded. 3. During a medication cart inspection and concurrent interview with LVN 5 on 8/27/25 at 12:03 PM , two containers of cleaning products were observed in the same compartment of oral medications. LVN 5 verified the cleaning products were in the same compartment as oral medications and stated it should have been separated. During a treatment cart inspection and concurrent interview with Treatment Nurse (TN) 1 on 8/27/25 at 1:15 PM, a container of cleaning product was observed in the same compartment as topical medications. TN 1 verified the cleaning product were in the same compartment as the topical medication and stated it should have been separated. During an interview with the Director of Nursing (DON) on 8/29/25 at 10:54 AM, the DON stated medications that have expired, have already been popped out from the bubble pack and not given to the resident should have been discarded into the correct receptacle by the charge nurses. The DON added cleaning solutions should have been kept in a separate compartment from the medications. The DON acknowledged the findings. A review of facility's policy and procedure titled, Storage of Medications with a revised date of 11/2020, indicated .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 6. Hazardous drugs are clearly marked and stored separately from other medications.

Based on observation and interview, the facility failed to ensure eight of 11 sampled residents (Residents 196, 83, 116, 34, 11, 146, 92, and 62) knew the location of the survey results binder.This failure had the potential to keep residents, family members, and visitors from easily reviewing the most recent survey results and the facility's plan of corrections, which are essential for making informed decisions about living at the facility. During an interview on 8/25/25 at 1:50 PM, eight of 11 residents polled at the resident council meeting did not know the location of the survey results binder.During a concurrent observation outside the activities/dining room and interview with the Director of Nursing (DON) and the Administrator (ADM) on 8/25/25 at 4:37 PM, the DON and the ADM verified the location of the survey results binder and confirmed there were no signs at the site as well as anywhere else in the facility indicating where to find it.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for five of 77 resident rooms.This failure had the potential to limit the freedom of movement of the residents that occupied these rooms, which may place them at risk for injury.During the entrance conference interview with the Administrator (ADM), on 8/25/25, at 9:23 AM, the ADM stated the facility had resident rooms with less than the required square footage (80 sq. ft. of livable space).During the environmental tour with the Maintenance Services Director (MTD) on 8/28/25, at 2:06 PM, five of the 77 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements were noted as follows:a. room [ROOM NUMBER] (3 beds) measured 223.54 sq. ft. (74.5 sq. ft. per resident).b. room [ROOM NUMBER] (3 beds) measured 223 sq. ft. (74.3 sq. ft. per resident).c. room [ROOM NUMBER] (3 beds) measured 223 sq. ft. (74.3 sq. ft. per resident).d. room [ROOM NUMBER] (3 beds) measured 223 sq. ft. (74.3 sq. ft. per resident).e. room [ROOM NUMBER] (3 beds) measured 223 sq. ft. (74.3 sq. ft. per resident).These rooms were not crowded and did not impose any safety hazards. There were no complaints about space or room issues from the residents occupying these rooms.During an interview with the ADM, on 8/28/25, at 3:42 PM, the ADM confirmed that five out of 77 residents' rooms did not meet the required 80 square feet per resident requirement.The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on interview and record reviews, the facility failed to follow its policy to provide dental assessment to one of three sample residents (Resident 1) within ninety days of admission. This failure had the potential to place Resident 1 ' s overall health and safety at risk when Resident 1 was not provided with a dental assessment to meet the needs of the resident. Findings. During a review of Resident 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included, intervertebral disc degeneration, lumbar region (breakdown of one or more of the discs that separate the bone of the spine causing pain), type 2 diabetes mellitus (high blood sugar), muscle wasting and atrophy (decrease in muscle mass and strength), obstructive and reflux uropathy(problem with flow of urine through urinary tract), acute kidney failure (condition in which the kidneys suddenly can ' t filter waste from the blood) hypertension (high blood pressure). During an interview on April 29, 2025, at 1:00 PM with Resident 1, when asked about Resident 1 ' s dental services at the facility, Resident 1 replied, I have not had any dental services since my admission to the facility. I ' ve been here since January 3, 2025. During an interview on April 29, 2025, at 2:15 PM with the Director of Nursing (DON), the DON stated, Resident 1 has not had any dental services since his admission to the facility. He should have seen by our dental consultant within ninety days from his admitted . During a concurrent interview and record review on April 29, 2025, at 2:45 PM with the DON, the facility policy titled, Dental Consultant dated April 2007 was reviewed. The Policy indicated, Policy Statement 2. A consultant dentist is retained by our facility and is responsible for .b. providing a dental assessment of each resident within ninety (90) days of admission. The DON stated, Resident 1 should have been seen by our dental consultant within ninety days of being admitted to the facility.

Based on interview and record review, the facility failed to report one of four sampled residents (Resident 1) to a state agency when Resident 1 was noticed to have a blanchable redness to left side of face near left eye.This failure has the potential to affect (Resident 1) ' s health, safety and well-being. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a condition where the brain does not function properly). A review of SBAR (document containing information about change of condition) dated 03/12/2025 indicated, . skin evaluation: abrasion . Observation summary: Resident noted to have blanchable redness to left side of face near left eye . During an interview on March 14, 2025, at 11:32 PM, with Licensed Vocational Nurse (LVN 1) the LVN 1 stated she received a report from Resident 1 ' wife that Resident 1 was complaining about water being too hot when Certified Nurse Assistant (CNA 1) gave him a shower. Resident 1 ' s wife also stated that resident 1 ' s face was scrubbed to hard with the hot water. Stated she reported resident 1 wife ' s complaint to Front Desk LVN (LVN 2) and the Registered Nurse (RN 1). During an interview on March 14, 2025, at 12:21 PM with the LVN 2, the LVN 2 stated LVN 1 reported to her that Resident 1 ' wife was complaining about the CNA1. LVN 1 stated there was red mark on resident face from the water being too hot, and when CNA 1 was rubbing resident face, Resident 1 said the water was too hot. LVN 1 further stated that she reported the complaint to the Director of Nursing (DON). During an interview on March 14, 2025, at 12:35 PM, with the RN 1, the RN 1 stated, Resident 1 ' s wife stated her husband reported that CNA 1 was washing Resident 1 ' s face with a brush of some sort the wife can ' t say if it is a washcloth, and her husband was complaining of the water too hot. Stated she did assessment and noted redness on resident 1 cheek but blanchable. During an interview on March 14, 2025, at 12:50 PM, with the Director of Nursing (DON), the DON stated prior to the shower per the CNA 1 resident doesn ' t have redness on the face, and the redness was not there after the shower, what causes the redness to appear cannot be determined. When asked if the facility reported the unknown injury to California Department of Public Health (CDPH), the DON stated, We did not report it, because they don ' t think it was an abuse although the resident and wife reported of water too hot and the scrubbing was hard but the Interdisciplinary Team (IDT) don ' t see it as an abuse because based on their investigation it doesn ' t seem there is an intent to abuse. During a telephone interview on March 14, 2025, at 4:02 PM, with the Administrator (Admin 1), when asked if the facility reported the unknown injury to CDPH, the Admin stated, because family did not say abuse or alleged abuse and he did not see it as alleged abuse he did not report it to CDPH. During concurrent telephone interview and record review on March 21, 2025, at 11:31 with Admin 1, the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated April 2021, was reviewed. The P&P indicated, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Admin 1confirmed the policy and stead the believe the abuse did not occur and that is why it was not reported. During concurrent telephone interview and record view on March 21, 2025, at 12:40 PM, with Admin 1, document titled IDT (Interdisciplinary Team) Review dated March 12, 2025, was reviewed. The IDT Review indicated, IDT reviewed the plan of care for resident [NAME]. Resident expressed to his wife that he felt the water temperature was hot during his shower earlier. The resident ' s wife spoke with the CNA who spoke with her charge nurse to inform of the resident's wife's concern. The charge nurse and RN supervisor were made aware with interviews conducted with all the staff participating in the care. During the interviews with the staff, staff reviewed process for bathing the resident and determined the resident had specific preferences for care during showers. Upon assessment by the RN supervisor, blanchable redness was noted to the left side of his face. It was determined after review with the interdisciplinary team there was no malicious intent or intent to harm the resident. Staff continued to encourage the resident and his wife to express his preferences in care such as preferred water temperatures during his shower. Staff was also reminded to observe the resident's preferences. After review, there is no incident of abuse determined by IDT. When asked were Resident 1 and Resident 1 ' s wife, included in the meeting, Admin 1 responded no they were not included in meeting.

Based on interview and record review, the facility failed to reassess and monitor one of three sampled residents (Resident 1) for signs and symptoms of depression with mood changes after Resident 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Resident 1's mental health and psychosocial (emotional) wellbeing which resulted in Resident 1's death by suicide on October 27, 2023. Findings: A review of Resident 1's clinical record, the Face Sheet contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Parkinson's (brain disorder that causes unintended or uncontrollable movement) and encephalopathy (disturbance in the way the brain functions.) A review of Resident 1's clinical record, the Licensed Nurses Progress Note dated September 18, 2023, indicated, Late entry: Today Care conference was conducted .family member stated her dad was feeling sad and wanted to go home with her. Family member explained that she was unable to provide care for him at home. Order for psychiatric (mental illness) consult was input and sent to [Psychiatrist (specializing in the diagnosis and treatment of mental illness) name]. The Charge nurse (caring for Resident 1) was informed to follow up and to continue to monitor resident. No documentation could be found to show Resident 1 was monitored daily for sadness or mood changes after this note. A review of Resident 1's clinical record, the Physicians Order dated September 18, 2023, indicated May have consult with psychiatrist due to verbalization of feeling sad. A review of Resident 1's, Minimum Data Set (MDS- set of assessments), Section D for Mood, dated September 18, 2023, indicated over the last two weeks Resident 1 had the presence of these symptoms: little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite, or overeating. The frequency of these symptoms averaged between 7 to 14 days. Section D indicated the symptoms happened half or more of these days. Resident 1's Total Severity Score (an indicator of depression) was 11. A score of 11 indicated Resident 1 had signs and symptoms of moderate depression. No documentation could be provided of resident 1's medical records that indicated Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this assessment. A review of Resident 1's Care Plan (outline of what needs to be done to manage the care, needs of a resident) titled Mood dated September 18, 2023, indicated Resident 1 was at risk for decreased psychosocial well-being and adjustments issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social or spiritual wellbeing related to: a. feeling down, depressed, or hopeless, b. Feeling tired or having little energy, little interest, or pleasure in doing things, c. poor appetite or overeating, d. trouble falling, staying asleep or sleeping too much. The interventions listed included: Assess for clinical issues that may be causing or contributing to the mood pattern. No documentation could be found to indicate Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this care plan was initiated. A review of Resident 1's clinical record, Interdisciplinary Team Conference Summary Note (IDT- team members from different disciplines working together to make decisions), effective date September 18, 2023, at 9:37 AM and signed by a Licensed Vocational Nurse on October 27, 2023, indicated New orders for patient to be seen by psychiatrist regarding the resident stating that he is feeling sad. Sent over face sheets and order to (Psychiatrist) for patient to be seen from verbalization from the family member that her father stated he was sad and wanted to go home. Informed [Psychiatrist name] about order so patient can be seen, continuing to monitor. No documentation could be found that indicated Resident 1 was monitored or assessed daily for sadness, mood changes or signs and symptoms of depression after this note. A review of Resident 1's, Physicians Order dated September 27, 2023, indicated Last cover date (end of insurance coverage) was September 29, 2023. Resident 1 became a custodial care resident (receives non-medical care that can be safely given my non-licensed caregivers at home or in a nursing home) of the facility on September 30, 2023. A review of Resident 1's, Physician's Progress Note dated September 25, 2023, indicated Psychiatrist was unable to see Resident 1 because Resident 1 had (name of insurance carrier) and there was no prior authorization to see the Psychiatrist. A further review of the document indicated to refer Resident 1 to the neurologist (specialist in the diagnosis and treatment of disorders of the nervous system). A review of Resident 1's, Neuropsychological (the study of behavior, the mind, and their relationship with the central nervous system) Consultation Summary from [Name of Neurologist] dated October 16, 2023, indicated Parkinson's ., agitated before his evening medications. Resident had an altercation where he was physical with his family member (while in the facility) . No documentation could be found that indicated the facility documented the report of an altercation between Resident 1 and the family member before the neurological consult or after the consultation was completed. A review of Resident 1's clinical record, the Licensed Nurses Progress Note ' dated October 13, 2023, at 1:16 PM, indicated (Resident 1) left out on pass with family member in a wheelchair. The subsequent nurses note was dated October 15, 2023. No documentation could be found that indicated Residents 1's mood or behavior after his return to the facility on [DATE]. A review of Resident 1's Licensed Nurses' Progress Notes dated October 16, 2023, indicated the nurses note was a late entry which was documented on October 27, 2023, at 5:58 PM, the nurses progress note indicated, Received an order for Seroquel (antipsychotic medication used to treat agitation or depression), for agitation from [Neurologist name] during telehealth appointment. Family member was present during telehealth appointment. Consent obtained from family member. Order carried out. No documentation could be provided of incidents or behaviors that indicated Resident 1 was agitated. No documentation could be found in Resident 1's medical records, the nurses' notes, assessments, and the weekly summaries from September 18, 2023, to October 27, 2023, that demonstrated incidents of agitated behaviors that warranted the use of Seroquel. A review of Resident 1's Licensed Nurses' Progress Note dated October 30, 2023, at 11:25 PM, indicated upon cleaning the resident's room, around 11:15 PM, a handwritten note was found on the side table by a Registered Nurse and Unit manager. The Family member was called and made aware of the note. The nurse read the note to the family member. A review of Resident 1's medical records, the nurses' notes, nurses' assessment notes, and the weekly summaries dated September 18, 2023, to October 27, 2023, indicated Resident 1 was not monitored or assessed daily or weekly for signs and symptoms of depression, sadness, or mood changes. A review of Resident 1's History and Physical (H&P) dated September 19, 2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an interview with Licensed Vocational Nurse (LVN 1) on October 30, 2023, at 3:11 PM, LVN 1 stated, On October 27, 2023, I walked into the room to give medication. I called out his name. Resident 1 did not respond. Resident 1 had the blanket over his head. He was on his back looking up and the ceiling. No response. I looked to see if he was breathing. I pulled the blanket back. The patient belongings bag was tied around his neck. The black charger cord was wrapped around his neck three or four times. LVN 1 stated further, Seroquel? We received an order for 25 mg (milligram, unit of measurement) of Seroquel for agitation. Resident 1 was not agitated for me. I got the order for Seroquel from [Neurologist's name]. The family member set the appointment to see the Neurologist. No documentation could be provided that indicated Resident 1 had episodes of agitation or changes in mood. During a phone interview with Resident 1's family member on October 30, 2023, at 3:26 PM, the family member stated (Resident 1) was not happy and wanted to go home. The last week that he was in the facility he was making the adjustment. Doing the activities and making friends. (Resident 1) was saying that he wanted to die at home. (Resident 1) did say it again, that he wanted to die, when he was in the facility, the first week he was there. I asked them for a psychiatric evaluation. That request for a psychiatric evaluation was a month ago. I told the nurse one time. She was in the room with me when (Resident 1) said that he wanted to die and that's when I asked for a psychiatrist to see him. One of them I told was (Registered Nurse 1, RN 1). (RN 1) said, they would put it in the notes that they would have someone go talk to him. A continuation of the phone interview with Resident 1's family member on October 30, 2023, at 3:26 PM, family member stated further, I had gone to see him after my daughter's wedding. He was upset because he did not go to the wedding. On October 13, 2023, I took him out on pass, and he had no intentions of going back there. He wanted to go home. He was trying to walk away, and I grabbed his shirt, and he started punching at me. It was not like him at all. I said you're hurting me. I yelled for help. (Staff members) eventually came out and helped me . (Staff members) told me to drive away because he was trying to resist going inside. He said he wanted to die the next day. Resident 1's family member then stated, on (October 16, 2023), the neurologist wanted to make sure his medications were right with LVN 1, who was there at the time of this visit. I told the Neurologist about the incident on Friday and the neurologist was concerned that it was the first sign of dementia. That's why the Neurologist ordered the Seroquel. During a phone Interview with LVN 2 on October 30, 2023, at 4:35 PM, LVN 2 stated, the day, October 13, 2023, Resident 1 went out on pass with his family member, Resident 1 took a shower early and was excited. When Resident 1 came back from pass, he said he did not want to go back to the facility. Resident 1's family member asked if we could redirect him LVN 2 stated they redirected him with pizza, but Resident 1 did say he wanted to go home with the family member. No documentation could be found that indicated Resident 1 was assessed or monitored for behavior or mood after he returned from his out on pass visit with his family member. During a phone interview with LVN 3 on October 30, 2023, at 4:53 PM, LVN 3 stated on October 13, 2013, I noticed he was with his family member. I noticed that he was mad at the family member. He was hitting the family member when he came back from out on pass. When LVN 3 was asked further about Resident 1 hitting the family member, LVN 3 stated, I don't remember who told me about (Resident 1) hitting the family member I didn't pay much attention. No documentation could be found that indicated Resident 1 was assessed and or monitored for changes in mood, signs and symptoms of depression or sadness when he returned from out on pass on October 13, 2023. During an interview with the Director of Nursing (DON) on October 30, 2023, at 6:01 PM, the DON stated Registered Nurse (RN 1) reported Resident 1 was mad at the family member, because the family member can't take him home. (RN 1) said, I can't, I don't want to be caught in the middle. (RN 1) said the family member looked like help me that day (October 13, 2023.) (Staff members) lured him back inside with pizza and that was it. I didn't know or they did not mention anything about Resident 1 hitting the family member. There was no documentation about that. (RN 1) should have documented that. The DON stated and confirmed the facility has two psychiatrists [NAMES] and they did not see Resident 1 due to insurance. The DON further stated if Resident 1's psychiatrist consultation was not covered by his insurance. Case management was to follow up. During a concurrent interview and record review of Resident 1's medical record with the DON on October 30, 2023, at 6:01 PM, DON stated, Resident 1's Care Plan, (outline of what needs to be done to manage the care needs of a resident) for Mood, dated September 18, 2023, was reviewed. The DON stated, We don't monitor at risk care plans for mood. After speaking with the social services director (SSD) and reviewing the clinical records for Resident 1, the DON then stated, They should have documented about his mood. The DON could not provide documentation that indicated Resident 1 was monitored daily or weekly for sadness, signs and symptoms of depression or mood changes. The DON confirmed there was no documentation to show Resident 1 was monitored and assessed for changes to mood, signs and symptoms of depression or sadness daily or weekly. During an interview and record review on October 31, 2023, at 2:20 PM with the Assistant Director of Nursing (ADON), ADON stated, The first assessment on Minimum Data Set (MDS) dated [DATE], Section D (Mood), based on the PHQ9 (patient health questionnaire, is an instrument used for screening, diagnosing, monitoring, and measuring the severity of depression), the total severity score was 11. All this was based on Resident 1's interview. The ADON, stated the MDS was done for every admission, or significant change in condition. I don't think a new Preadmission Screening and Resident Review (PASRR) was done, because we would only have to do it again if the resident had a Change of condition. The one we have is from [outside hospital]. There was no suicide assessment done because he was negative on his PASRR from the [outside hospital]. The ADON stated, there was no care plan developed for Seroquel. The ADON further stated, for Seroquel medication, monitoring was not documented on Resident 1's Medication Administration Record (MAR). It's not on the MAR. The ADON verified and confirmed that Resident 1's feeling of sadness and monitoring was not documented in the clinical records and the facility was unable to provide any documented evidence. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician when there has been a: accident or incident involving the resident .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly, i. specific instructions to notify the physician of changes in the resident's condition. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents dated July 2017, the P&P indicated Our facility strives to make the environment as free from accident, hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Individualized, Resident-Centered Approach to Safety .4. Implementing interventions to reduce accident risks and hazards shall include the following: d. enduring that interventions are implemented; and documenting interventions. During a review of the facility's P&P titled, Depression dated November 2018, the P&P indicated, .3. The staff will screen residents for depression, using appropriate screening tools, on admission and subsequently, if suggested by changes in mood, function, or behavior. 4. Staff will evaluate residents for possible evidence of mood disorder. A. signs and symptoms may include depressed mood most of the day, almost every day diminished interest or pleasure in most activities, B. Examples of risk factors for depression include a medical diagnosis associated with a high risk of depression, new admission or change in environment, loss of autonomy, privacy, function . The physician will evaluate underlying causes of mood disorder, including depression and contributing factors . The facility to reassess and monitor one of three sampled residents (Resident 1) for signs and symptoms of depression with mood changes after Resident 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Resident 1's mental health and psychosocial (emotional) wellbeing which resulted in Resident 1's death by suicide on October 27, 2023. On November 01, 2023, at 9:57AM, after interviews and record reviews, an immediate jeopardy (IJ-Immediate Jeopardy means a situation in which immediate corrective action is necessary due to provider's noncompliance with requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to an individual receiving care in a facility) was called under F684 in the presence of the Director of Nursing, Assistant Director of Nursing, and facility Consultant. A corrective action plan was requested on November 01, 2023, at 9:57 AM. A corrective action plan was provided and accepted by facility on November 02, 2023, at 3:41 PM included: Social Services provided psychosocial support to both roommates as needed noted on October 28,2023, October 29, 2023, October 31, 2023, and November 01,2023; Social services department to notify psychologist to provide psychosocial support to affected staff. Facility to conduct assessments using PHQ2-9 (an instrument used for screening, diagnosing, monitoring, and measuring the severity of depression) assessment to residents with diagnosis of Parkinson's Disease. Depression and are alert, oriented x 4 to check for signs and symptoms of depression. Any residents identified on assessment conducted with a score of 1 or above will have behavior monitoring in place, care plan and behavioral management with Psychiatrist. If they trigger Section D if 10 or above, they are monitoring and referred on psych eval, social services will notify the Minimum Data Set nurse (MDS). Systemic changes the facility will identify and monitor residents with depression, or a decline in mood to prevent serious injury, serious harm, serious impairment death. In-service November 02, 2023, on Systemic changes with facility psychiatrist on Suicide Prevention recognizing signs and symptoms of depression, changes or decline in mood and or suicidal ideation. A trigger on MDS section D with no anti-depression medications, they are still assessing and documenting what the actual behavior, in Medication Administration Record (MAR) for monitoring. The DON and ADON conducted an all-staff in-service on November 01, 2023, focusing on recognizing, monitoring, and addressing Suicidal ideation and/or warning signs of Depression. DON conducted in-services on October 28, 2023, and October 30, 2023, to staff including recognizing, monitoring, and addressing Suicidal ideation and/or warning signs of Depression. ADON conducted in services to staff on October 29, 2023, to staff including recognizing monitoring and addressing suicidal ideation and/or warning signs of Depression. The facility Social Services Staff will conduct Social Services Assessment of residents upon admission, quarterly, annually, and for significant change in status assessment. They are going off the MDS calendar, for initial assessment, it monitors behavior. MDS nurse and Social Services working on this together. Quality Assurance Nurse (QA)/Assistant Director of Nursing ADON conducted a facility wide audit on November 01, 2023, of all residents with psychological diagnoses and or receiving psychotropic (medications that affect mental function, behavior, and experience) medications, and residents with a PHQ2-9 total severity score of 1 or higher, ensured care plans and behavior monitoring are in place. Facility Social Services staff conducted interview for residents at risk for depression, decline in mood, and potential psycho-social conditions October 28, 2023, October 29, 2023, and October 30, 2023. Observation of the all-facility staff will be in-service today November 02, 2023, by Psychiatrist doctor regarding identifying/recognizing warning signs and suicidal ideation/symptoms of depression, decline in mood, and change in psycho-social condition, and the facility process to provide necessary psychosocial care to the resident. Observation of all facility staff in-service today, November 02, 2023, by the Director of Nursing regarding the systemic changes that the facility made to prevent this event from re-occurring. Upon PHQ2-9 assessment following MDS calendar, if the resident has a total severity score of 1 or higher, the facility will initiate care plan addressing risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and also add an order to monitor signs and symptoms for depression every shift & notify Medical Doctor accordingly. This will be initiated November 01, 2023, and process maintained by facility. Based on the mood interview score, if score 1 or higher they will implement on every shift, behavior monitoring and document based on the questions triggered, social service with refer to psychiatric evaluation for assessment. The Quality Assurance Nurse and ADON will review the residents with orders of psychotropic medications using PCC (electronic medical record system) Dashboard to ensure the orders are with correct indication, behavior monitoring & care plan and will continue review new orders daily. Documents reviewed. Observation of Director of Nursing and Assistant Director of Nursing will conduct follow up in-services to all staff on November 02, 2023, to ensure they are aware of immediate plan of action, and new systemic changes to prevent serious injury, serious harm, serious impairment, or death of a resident in the future. The facility plans to monitor and provide assistance to residents identified with depression, or a decline in mood to prevent serious injury, serious harm, serious impairment death. MDS and social services are working side by side and the QA and the psychiatrist doctor with physician assistant. Facility in process in asking for another doctor to come in and assist facility. In the event the facility identifies a resident with depression, decline in mood, or a change in psycho-social status, the facility will provide assistance by initiating the following: 1. change of condition, notifying primary care physician, initiating 1 on1 supervision or until the resident is stable or evaluated in the Acute Care Setting, referral for psychology (study of the mind and behavior) or psychiatry (treatment of mental illness) services, implementation of interventions for monitoring the residents' depression, decline in mood, or change in psycho-social condition including but not limited to social contact rounds by Social Services staff, Activities staff, Facility chaplain or Spiritual counselor. 2. In-service for staff regarding implementation of plan of care, medication administration, monitoring for manifestations of identified behavior, and monitoring for side effects related to psychotropic medications. 3. Behavior management meetings monthly with QA Nurse, Social Services Staff, IDT, and Psychiatrist with Gradual Dose Reduction (GDR) if indicated/ordered. If not appropriate for GDR, Behavioral IDT will document contraindication in resident's record. 4.The Facility will aid residents with consultation orders for Psychiatry or Psychology that do not have insurance coverage for services that are required. 5. Residents with contracted insurance benefits that are not covered for Psychiatry or Psychology services in the facility will be provided will still be seen at the incurred cost to the facility as indicated/ordered and evaluated by the contracted Psychiatrist/Psychologist. As of November 02, 2023, the facility's psychiatrist will be seeing residents even if no insurance. And the Interdisciplinary team (IDT), social services will continue with documentation on progress notes. 6. QA Nurse will audit weekly for new residents with ordered Psychiatry/Psychology consults. Any findings will be reported to Social Services, Director of Nursing, Assistant Director of Nursing (immediately within 72 hours). 7. SSD will report monthly any resident with reported signs and symptoms of depression as based on the PHq2 MDS triggers via log to report the interventions provided and outcome during the QA Meeting to monitor for trend. Effective November 01, 2023, new form used, the PHQ9-2 log, used if is there is a 1-9 trigger. The resident is on the list for monitoring and actions exhibited behaviors and psych-eval order obtain from primary doctor and referred to psychiatrist. The immediate jeopardy was removed after the Corrective action plan was verified to be implemented through observations, interviews, and record reviews on November 02, 2023, at 3:48 PM in the presence of the Director of Nursing and Social Services.

Based on interview, and record review, the facility failed to notify the physician of abnormal laboratory results for one of three sampled residents (Resident 1) which delayed treatment and resulted in Resident 1 being hospitalized due to a [DIAGNOSES REDACTED]. Findings: During a record review, the face sheet (a form that includes birth date, diagnoses, date of admission, etc.) indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of the physician's orders, dated June 20, 2017, a telephone order dated June 20, 2017 at 1:51 PM, was obtained by the licensed vocational nurse (LVN) for Resident 1 to have stat (immediately) labs to be drawn to include a complete blood count (CBC- used to rule out infections, [MEDICAL CONDITION], and [MEDICAL CONDITION]), and a basic metabolic panel (BMP- used to monitor blood glucose levels and electrolytes which keep body fluids in balance). A second telephone order was obtained dated June 20, 2017 at 2:03 PM, for Resident 1 to be started on intravenous (IV- into the blood stream via a vein) hydration of normal saline at 80 cc (cubic centimeters a unit of measure)/ hour for 2 liters every shift until June 22,2017. During a review of the nurses' notes dated June 20, 2017 at 8:35 PM, the licensed nurse documented Resident 1 had a change of condition (lethargy). During a review of the laboratory results report dated June 20, 2017, the report revealed the blood sample was collected on June 20, 2017 at 6:35 PM. The laboratory results were reported to the facility on [DATE] at 11:43 PM. The laboratory results showed the BMP was abnormal as follows: Glucose 132 mg (milligrams)/dl (deciliter- units of measurement) (high) 65-99 normal range (can indicate diabetes where the body cannot produce or utilize insulin) BUN (Blood Urea Nitrogen-waste product of the liver)148 mg/dl (high) 7-25 normal range (indicates kidney function, dehydration or heart failure) Creatinine (measures kidney functions in the blood) 6.39 mg/dl (high) .70-1.25 normal range (indicates impaired kidney function) Sodium serum (salt in the blood) > (greater than)165 (high) 135-146 normal range ( indicates dehydration, and can increase blood pressure) The CBC (complete blood count) was also abnormal as follows: White blood cells (WBC) 21.5 thousand/unit (high) 3.8-10.8 normal range (indicates infectious process) During a review of the nursing notes for June 20, 2017 and June 21, 2017, there was no documented evidence to show the physician was notified about the abnormal labs for Resident 1. During a review of the nursing care plans for Resident 1, a care plan for being at risk for dehydration dated February 24, 2017, under the interventions, included that staff were to report abnormal labs to the MD (medical doctor). During a review of the nursing notes dated June 21, 2017 at 3:37 PM, the note revealed Resident 1 continued to be lethargic and had an altered level of consciousness, and a desaturation of oxygen levels (the oxygen levels in the blood are low and cannot nourish the body cells causing respiratory distress), at which time Resident 1 was transferred to the acute care hospital via the paramedics ambulance. During a review of the general acute care hospital history and physical form dated June 21, 2017, the history and physical revealed Resident 1 was admitted with a [DIAGNOSES REDACTED]. Resident 1 had to be intubated (breathing tube inserted to maintain his airway) and placed on a respirator (a machine used to breathe for a person) while in the emergency room . During an interview with the Assistant Director of Nursing (ADON), conducted on August 15, 2017 at 10:40 AM, the ADON verified the MD had not been notified of Resident 1's abnormal labs drawn on June 20, 2017. The ADON stated, The documentation wasn't specific to state the MD was notified of abnormal labs. During a telephone interview with the Director of Nursing (DON), conducted on August 23, 2017 at 9:30 AM, the DON stated, The nurses should be documenting in the progress notes or it should be written on the lab results that the MD was notified of abnormal labs. We are not doing a good job on that. During a review of the facility policy and procedure, undated, and titled, Resident Rights: Notification, Physician, the policy indicated: It is the policy of this facility to notify the resident's Physician of changes in the resident's condition and/or status : 1. Licensed Nurses may notify the attending Physician for the following: B. There is a significant change in the resident's physical, mental, or psychosocial status.

An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under 483.45, Pharmacy Services (Refer to F 333 Free of Significant Medication Errors) on April 3, 2017 at 4:24 PM, in the presence of the Administrator and the Director of Nursing. During an inspection of medication cart's, four opened and used insulin pens/vials expired (after the manufacturer's beyond use date) were active and available in the medications cart's and had been used after the beyond use date. Ten insulin vials/pens used at room temperature were not dated with a date opened. Nurses were not aware of the facility policy and procedure regarding the dating of insulin for the date open. Based on observation, interview, and record review, the facility failed to ensure that residents were free of medication errors: 1) Five (5) residents, two (2) sampled (Resident 5 and 9), and three (3) unsampled (Resident H, I, and G) out of a universe of 196 residents received medication that was past the manufacturer's specified beyond use date (BUD). Four residents (Resident 5, 9, H, and I) had received insulin (a medication used to reduce high levels of sugar in the blood) and one resident (Resident G) had received a routine eye drop for [MEDICAL CONDITION] (a disease in which fluid pressure in the eye increases) that were past the BUD. Administering medication that is past the BUD exposes the resident to potentially contaminated medication and increased risk of infection. In addition, medication that is past the BUD may not be as effective as intended by the manufacturer or prescriber which increases the risk for adverse events. Ineffective eye drops for [MEDICAL CONDITION] may lead to loss of vision. Ineffective insulin may lead to [MEDICAL CONDITION] (high blood sugar levels in the blood) and adverse events associated with [MEDICAL CONDITION] (blurred vision, fatigue, falls, and possibly coma). 2) Unsampled Resident U received a medication for blood pressure despite an order from the prescriber that the medication should be held for low blood pressure. Administering medication that can lower blood pressure to a resident who's blood pressure is already low may lead to extremely low blood pressure ([MEDICAL CONDITION]). [MEDICAL CONDITION] increases the risk for significant and severe adverse events such as stroke, [MEDICAL CONDITION], and possibly even death. Findings: During an inspection of the medication cart 1(one) in Station 1 (one) on April 3, 2017, at 10:35 AM, it was observed that 2 (two) vials of opened and used insulin were stored in the cart. One of the vials was [MEDICATION NAME] R (regular human insulin) 10 mL (millileters- unit of measurement) and labeled for Resident 5. The [MEDICATION NAME] R vial was labeled by nursing with an open date of 12/26/16 indicating that the vial had been in use for 99 days. The other vial was [MEDICATION NAME] (a fast acting insulin) 10 mL and labeled for Resident 9. The [MEDICATION NAME] vial was labeled by the nursing department with an open date of 1/20/17 indicating that the vial had been in use for 74 days. Also observed to be stored in the medication cart were 4 (four) insulin medications that were opened or out of the refrigerator. The following 4 (four) insulin medications were not labeled by nursing with an opened date: 1) One opened and used vial of [MEDICATION NAME] (generic name insulin detemir; a long acting insulin) 10 mL, 2) One opened and used vial of [MEDICATION NAME] R 10 mL, 3) One opened and used [MEDICATION NAME] (insulin in a pen-like device for easier administration), and 4) One [MEDICATION NAME] (generic name insulin [MEDICATION NAME]; a long acting insulin in a pen-like device). During a concurrent interview, LVN 2 confirmed that the insulin vials were active and being used for the resident's current orders. During an inspection of the medication cart #2 (two) in Station 1 (one) on April 3, 2017, at 10:45 AM, it was observed that 2 (two) opened and used insulin medications were stored in the cart. One of the insulins was a vial of [MEDICATION NAME] and labeled for Resident H. The [MEDICATION NAME] vial was labeled by nursing with an open date of 3/1/17 indicating that the vial had been in use for 34 days. The other insulin was [MEDICATION NAME] and labeled for Resident I. The [MEDICATION NAME] was labeled by nursing with an open date of 2/13/17 indicating that the insulin had been in use for 50 days. During a concurrent interview, LVN 3 confirmed that the insulin vial and pen were active and being used for the resident's current orders. During an inspection of the medication cart #2 (two) in Station 1 (one) on April 3, 2017, at 4:20 PM, it was observed that a bottle of latanoprost (an eye medication used to treat [MEDICAL CONDITION]) was stored in the cart and labeled for Resident G. The bottle of latanoprost was labeled by nursing with an open date of 2/3/17 indicating that it had been in use for 60 days. During a concurrent interview, LVN 3 confirmed that the latanoprost was active and being used for the resident's current order. During an inspection of medication cart #3 (three) in Station 2 (two) on April 3, 2017, at 10:50 AM, 3 (three) insulin medications were observed to be stored in the cart and were not labeled by nursing with a date opened: 1) One vial of [MEDICATION NAME] R, 2) One vial of [MEDICATION NAME], and 3) One vial of [MEDICATION NAME] R (regular human insulin similar to [MEDICATION NAME] R). During a concurrent interview, LVN 4 confirmed that the insulin vials were active and being used for the resident's current orders. Administration were made aware of all the expired insulin and insulin opened and undated and available for residents' use. During an inspection of medication cart 6 (six) in Station 3 (three) on April 3, 2017, at 11:05 AM, 3 (three) insulin medications were observed to be stored in the cart and were not labeled by nursing with a date opened: 1) One vial of Humalog (a fast acting insulin similar to [MEDICATION NAME]), 2) One vial of [MEDICATION NAME] R, and 3) One [MEDICATION NAME] pen. During a concurrent interview, LVN 5 confirmed that the insulin vials were active and being used for the resident's current orders. A review of the medication package inserts (a document produced by the manufacturer that provides detailed information on the medication including use, dosage, and storage requirements) for each insulin indicated that medication should be discarded once opened or removed from refrigeration after the following number of days: 1) [MEDICATION NAME] R vial - 42 days, 2) [MEDICATION NAME] vial - 28 days, 3) [MEDICATION NAME] vial - 42 days, 4) [MEDICATION NAME] - 42 days, 5) [MEDICATION NAME] - 28 days, 6) [MEDICATION NAME] vial - 28 days, 7) [MEDICATION NAME] R vial - 31 days, and 8) Humalog vial - 28 days. A review of the package insert for latanoprost indicates that the manufacturer states the bottle should be discarded once opened or removed from refrigeration after 6 (six) weeks (42 days). During an interview with LVN 2 & LVN 3 on April 3, 2017, at 10:35 AM, they were both asked when nursing should label insulins with a date opened. LVN 2 stated, We date open on first use. Both LVN 2 and LVN 3 confirmed that they did not know that insulins should be dated once removed from refrigeration, regardless of whether they were opened or not. During an interview with LVN 4 on April 3, 2017, at 10:50 AM, LVN 4 was asked when nursing should label insulins with a date opened. LVN 4 stated that she dates the insulin with an open date when she firsts uses it. LVN 4 confirmed that she did not know that insulins should be dated once removed from refrigeration, regardless of whether they were opened or not. During an interview with LVN 5 on April 3, 2017, at 11:05 AM, LVN 5 was asked when nursing should label insulins with a date opened. LVN 5 stated that she dates the insulin with an open date when she firsts uses it. LVN 5 confirmed that she did not know that insulins should be dated once removed from refrigeration, regardless of whether they were opened or not. A review of the medication administration records for Residents 5, 9, H, I, and G indicated that their respective medications had been administered after the medication's BUD. A review of facility policy & procedure, titled Medication Storage and Labeling, under the section Date Open Procedures, the policy states: 2. Date Open Stickers - Certain products have limited expiration dates after the product has been mixed or opened for the first time. Refer to Appendix D for a list of specific medications and reagents with manufacturers' specifications for short expiration dates. 4. It will be the responsibility of the Nursing Staff to enter the opening date on all manufacturers' labels or blank pharmacy labels. A review of Appendix D indicates that every insulin except [MEDICATION NAME] was listed in the Appendix with a corresponding Expiration After Opening. The corresponding Expiration After Opening number of days matched the manufacturer's BUD for [MEDICATION NAME], Humalog, and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] (appendix does not indicate R) had a corresponding Expiration After Opening BUD as Manufacturer's expiration date, which is incorrect. The BUD for [MEDICATION NAME] is 42 days and for [MEDICATION NAME] is 31 days. [MEDICATION NAME] and it's corresponding BUD was not listed on the Appendix D. A review of facility policy & procedure, titled Facility Auditing & Removal of Expired and Discontinued Medications, under the section Policy, the policy states, The medication nurse will remove expired medications from the drug storage areas so that they are not administered to residents. The facility staff will remove expired medications from the medication storage areas on a regular schedule and when encountered. Under the section Procedure, the policy states, 1. Prior to each use the nurse administering the medication will verify that the medication is not expired. 2. At least once monthly the nurse responsible for the medication cart for each station will inspect the medication cart and medication room for expiring medications. 2) During a review of the Medication Administration Record [REDACTED]. The order included hold medication parameters that stated, Hold if SBP (systolic blood pressure - the first number in a blood pressure result that represents the pressure when the heart contracts) < (less than) 110 or DBP (diastolic blood pressure - the second number in a blood pressure result that represents the pressure between heart beats) < 70 or lower. A review of the MAR for Resident U for January 2017 indicates that the medication was not held despite a low DBP in 9 of 31 days. A review of the MAR for February 2017 indicates the medication was not held despite a low DBP in 14 of 28 days. A review of the MAR for March 2017 indicates the medication was not held despite a low DBP in 18 of 31 days. A review of the MAR for April 2017 indicates the medication was not held despite a low DBP in 4 of 6 days. During an interview with the Assistant Director of Nursing (ADON) on April 6, 2017, at 3:00 PM, the ADON confirmed that the MAR indicated [REDACTED]. On April 4, 2017 at 1:54 PM, Immediate Jeopardy was lifted in the presence of the Administrator and the Director of Nursing, after an acceptable corrective action plan was presented and was verified. The corrective action plan were as follows: Resident Specific: 1. Removed all insulin vials in house from med carts and replaced all insulin pens/vials with accurate and complete date-opened labels. 2. Order facility wide insulin pens and vials. 3. All four residents assessed by RN and found to have no sign or symptoms of complications. 4. Medical Director to come and assess all four residents' to ensure no adverse affects. Global: 1. All medication carts will be checked to ensure no expired med's exist and all necessary med's have opened date labels. a. Reference manufacturer's recommendation. 2. In-service with licensed nurses regarding medication management with pharmacy nurse consultant and Director of Nursing. 3. On-going in-services will be conducted with licensed nurses. Substandard Quality of Care was found under pharmacy services (Refer F333 Free of Significant Medication Error) and the survey was extended.

Based on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs: 1) Unsampled resident O received [MEDICATION NAME] (a potent anticoagulant medication used to prevent blood clots) and [MEDICATION NAME]/[MEDICATION NAME] double strength (brand name Bactrim DS - an antibiotic used to treat infections) concurrently. Administering both medications together increases the effect of [MEDICATION NAME] and can lead to excessive bleeding. Excessive bleeding can potentially lead to significant cardiopulmonary (heart and lung body systems) adverse events such as severe [MEDICAL CONDITION] (extreme low blood pressure), shock, or even death. Resident O received [MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME] DS concurrently for 8 days and then presented to the nursing staff coughing up blood. Resident O was transferred to a hospital emergency room . 2) Unsampled residents' (Resident P and Resident R) received [MEDICATION NAME] (an anticoagulant medication used to prevent blood clots) past the indicated duration of use by the manufacturer which increases the risk for excessive bleeding. Excessive bleeding can potentially lead to significant cardiopulmonary (heart and lung body systems) adverse events such as severe [MEDICAL CONDITION] (extreme low blood pressure), shock, or even death. 3) Unsampled resident S received two medications concurrently that were from the same class and had similar mechanisms of action. Administering duplicate therapy medications from the same class and similar mechanisms of action increases the risk of adverse effects without any significant corresponding improvement in indicated use. 4) Unsampled resident T received [MEDICATION NAME] (brand name [MEDICATION NAME] - an anticoagulant use to prevent stroke and [MEDICAL CONDITION]) and [MEDICATION NAME] (brand name [MEDICATION NAME] - a medication used to reduce acid in the stomach which can lead to ulcers) concurrently. Administering both medications together increases the risk for the [MEDICATION NAME] to be less effective, which increases the risk for stroke and [MEDICAL CONDITION]. 5) Unsampled resident M received [MEDICATION NAME] (a medication used to treat Pseudobulbar Affect - a neurological condition in which a person laughs or cries uncontrollably) for psychiatric behavior control without adequate monitoring of side effects and behavior monitoring. Findings: 1) During a medical record review for Resident O on April 6, 2017, it was noted that the resident had an active order for [MEDICATION NAME] to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] - a condition in which a blood clot may form in large veins of the body such as the legs, pelvis or arms. Clots of blood in the body can lead to blocking blood flow in the lungs or damaging that vein where the clot has formed). On March 17, 2017, an order to give [MEDICATION NAME] 7mg once daily was written. In addition, an INR (International Normalized Ratio - a blood test that determines the length of time for blood to clot; [MEDICATION NAME] is typically dosed to produce an INR of 2.0 - 3.0) was ordered to be done on March 25, 2017. Three days later on March 20, 2017, the [MEDICATION NAME] was increased to 8mg once daily and the INR scheduled for March 25, 2017, was discontinued. Further review of the record indicated that on March 24, 2017, an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. The MAR further indicates the resident was receiving [MEDICATION NAME] 8mg once daily from March 21, 2017, to March 31, 2017. A review of the nursing progress notes for April 1, 2017, documented at 1:31 AM, indicated the following, Resident came to nurse station and c/o (complains of) coughing up blood at 12:30 am on 4/01/17. Resident noted coughing up blood (approximately 30 ML (milliliters) of fresh blood) .MD (Medical Doctor) notified and received order to send resident to (hospital name). A review of the laboratory results indicated that INR labs were done on March 3, March 8, March 10, March 13, and March 17 of 2017. No further INR results were available in the medical record. A review of the manufacturer prescribing information for [MEDICATION NAME]/[MEDICATION NAME] double strength indicates the following: a) The dose for Bactrim DS (the double strength tablet) for [MEDICAL CONDITION] treatment in an adult is 1 tablet every 12 hours for 14 days. b) Under the section Warnings, the manufacturer states, It has been reported that BACTRIM may prolong the [MEDICATION NAME] time (clotting time which is measured by INR) in patients who are receiving the anticoagulant [MEDICATION NAME]. This interaction should be kept in mind when BACTRIM is given to patients already on anticoagulant therapy, and the coagulation (clotting) time should be reassessed. A review of the manufacturer prescribing information for [MEDICATION NAME] ([MEDICATION NAME]) indicates the following, Elevations of the [MEDICATION NAME] time in the setting of concurrent [MEDICATION NAME] and [MEDICATION NAME] use have been associated with episodes of bleeding. [MEDICATION NAME] time, International Normalized Ratio (INR), or other suitable anticoagulation tests should be closely monitored if [MEDICATION NAME] is administered concomitantly with [MEDICATION NAME]. Patients should also be monitored for evidence of bleeding. During an interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on April 7, 2017, at 10:00 AM, the ADON confirmed that the resident was sent to the emergency room (ER) after presenting to the nursing staff on April 1, 2017, coughing up blood. The ADON and DON were asked why INR labs were not ordered to be done for the resident while receiving [MEDICATION NAME] and Bactrim DS concurrently from March 24, 2017, to March 31, 2017. The ADON stated, I don't know. Both the ADON and DON confirmed that no INRs were done for the resident after March 17, 2017 or while the resident was receiving [MEDICATION NAME], Bactrim DS, and [MEDICATION NAME] concurrently. When asked why the resident was ordered to receive Bactrim DS 2 tablets twice daily, instead of a typical dose for [MEDICAL CONDITION] of Bactrim DS 1 tablet twice daily, the ADON and DON were not able to provide a reason. When asked if there was any documentation in the chart to justify the higher dosing of Bactrim DS and the addition of [MEDICATION NAME] which can also increase the risk of bleeding when used in combination with [MEDICATION NAME], both the ADON and DON confirmed there was no justification documentation in the chart. 2) A review of the medical record for Resident P on April 6, 2017, indicated that the resident was started on [MEDICATION NAME] (a potent injectable anticoagulant used to prevent blood clots) on January 22, 2017 for [MEDICAL CONDITION]. A review of the MARs for January, February, March, and April 2017 indicated that the resident continued to receive [MEDICATION NAME] until the current day. A review of the medical record for Resident R on April 6, 2017, indicated that the resident was started on [MEDICATION NAME] (a potent injectable anticoagulant used to prevent blood clots) on January 20, 2017 for [MEDICAL CONDITION]. A review of the MARs for January, February, March, and April 2017 indicated that the resident continued to receive [MEDICATION NAME] until the current day. A review of the manufacturer prescribing information for [MEDICATION NAME] indicates the following when used for [MEDICAL CONDITION], The usual duration of administration is 7 to 10 days; up to 14 days administration has been administered in clinical trials. Further review of the medical record did not produce any documentation from the physician or nursing staff as to why the resident continued on [MEDICATION NAME] for several months despite the manufacturer indicating administration is usually only up to 14 days. During an interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on April 7, 2017, at 10:00 AM, the DON and ADON were asked why the resident continued on [MEDICATION NAME] for [MEDICAL CONDITION] despite typical therapy only [MEDICATION NAME] for up to 14 days. The DON stated that she spoke with the primary care physician earlier in the day and that the physician indicated that orthopedic specialists were following the cases and determining length of therapy. The ADON and DON were asked if there was any documentation from orthopedics or otherwise in the medical record to justify long term use of [MEDICATION NAME] for Resident P and Resident R. The ADON and DON confirmed there was no justification documentation in the chart. 3) A review of the medical record for Resident S on April 6, 2017, indicated that the resident was started on carvedilol (brand name [MEDICATION NAME] - an antihypertensive medication used to treat high blood pressure and is considered a non-selective beta-blocker (a medication that exerts its effect primarily on beta receptors in the heart, lungs, and smooth muscle of blood vessels) on January 21, 2017. A review of the MARs for January, February, March, and April 2017 indicated that the resident continued to receive carvedilol until the current day. Further review of the medical record indicated that the resident was started on [MEDICATION NAME] (brand name [MEDICATION NAME] - a medication used to treat abnormal heart rhythm and is considered a non-selective beta-blocker) on January 21, 2017. A review of the MARs for January, February, March, and April 2017 indicated that the resident continued to receive [MEDICATION NAME] until the current day. A review of the manufacturer's prescribing information for carvedilol indicates the following, carvedilol .nonselective ß-adrenoreceptor (a receptor in the human body typically associated with affecting heart rate and blood pressure) blocking activity is present. A review of the manufacturer's prescribing information for [MEDICATION NAME] indicates the following, The beta-blocking effect of [MEDICATION NAME] is non-cardioselective. During an interview with the facility's consultant pharmacist on April 7, 2017, at 11:00 AM, the consultant pharmacist confirmed that both medications had non-selective beta-blocking activity and could be considered from the same class. During an interview with the ADON on April 7, 2017, at 3:05 PM, the ADON confirmed that there was no documentation from January 21, 2017, to current day in the chart justifying the concurrent use of carvedilol and [MEDICATION NAME] in Resident S's medical record. 4) A review of the medical record for Resident T on April 6, 2017, indicated that the resident was started on [MEDICATION NAME] and [MEDICATION NAME] concurrently on March 18, 2017. A review of the MARs for March and April 2017 indicated the Resident received the medication every day since it was started. A review of the manufacturer's prescribing information for [MEDICATION NAME] indicates the following, Avoid concomitant use of [MEDICATION NAME] with [MEDICATION NAME]. In clinical studies, [MEDICATION NAME] was shown to reduce significantly the antiplatelet (platelet are proteins in the blood that combine to produce a clot) activity of [MEDICATION NAME] when given concomitantly or 12 hours apart. During an interview with the facility's consultant pharmacist on April 7, 2017, at 11:00 AM, the consultant pharmacist confirmed that the manufacturer indicated that [MEDICATION NAME] and [MEDICATION NAME] should not be used together. During an interview with the ADON on April 7, 2017, at 3:05 PM, the ADON confirmed that there was no documentation from March 18, 2017, to current day in the chart, justifying the concurrent use of [MEDICATION NAME] and [MEDICATION NAME] in Resident T's medical record. 5) A review of the medical record for Resident M on April 6, 2017, indicated that the resident was started on [MEDICATION NAME] (generic name [MEDICATION NAME]/[MEDICATION NAME]) for Pseudobulbar Affect (a neurological condition in which the person typically exhibits uncontrolled laughing or crying) on January 21, 2017. A review of the Resident's Care Plan in the medical record states the following, The resident uses [MEDICAL CONDITION] medications [MEDICATION NAME] r/t (related to) mood disorder. Also listed in the CarePlan were interventions that stated, Administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every nursing shift). A review of the progress notes from Resident M's psychiatrist, documented on January 26, 2017, the psychiatrist listed [MEDICATION NAME] among other psychiatric medications the Resident was receiving. No non-psychiatric medications were listed. A review of the MAR for January, February, March, and April 2017, indicated that no behavior monitoring nor side effect monitoring was being done every shift as indicated should be done by the CarePlan. During an interview with the psychiatrist (PSYMD) on April 7, 2017, at 12:30 PM, the PSYMD confirmed that he documented [MEDICATION NAME] in his January 26, 2017 progress note. During an interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on April 7, 2017, at 10:00 AM, both confirmed that nursing staff were not documenting the monitoring of [MEDICATION NAME] despite the Care Plan intervention requirements and the use of the medication as a psychoactive agent being used to control the Resident's behavior.

Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure for Abuse prevention for one of three sampled residents (Resident 1) when: 1. A licensed vocational nurse (LVN 1) failed to report an allegation of a physical abuse by a certified nursing assistant (CNA 1) toward Resident 1 to the Administrator. On June 15, 2016 at 7:00 PM, after observation, interview, and record review, an Immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of a resident) was called and verbally notified in the presence of the facility's Administrator and the Director of Nursing (DON). The facility's LVN 1 failed to report an allegation of a physical abuse of Resident 1 by CNA 1 to the Administrator according to the facility's policy. The corrective action plan provided by the facility included: a. A registered nurse will conduct an assessment on Resident 1. b. The DON will immediately provide an in-service regarding alleged abuse and reporting procedures to LVN 1 and CNA 1. c. The Director of Staff Development (DSD) will provide in-service regarding alleged abuse and reporting procedures to all departments. d. The DSD or designee will complete an audit of all current employee records to identify those without a completed background check. e. Company 1 will complete a background check for each current employee, who has not had a background check completed. f. The DON, Administrator, or designee will monitor the implementation of the corrective action plan and report findings to Quality Assessment and Assurance (QAA). The IJ was removed on June 16, 2016, at 3:09 PM in the presence of the facility's Administrator and the Registered Nurse Supervisor (RN 1), after interviews with the facility's employees from multiple departments, review of records of employees receiving in-service regarding alleged abuse and reporting procedures, and review of random employees' files from multiple departments to verify that background checks and reference verifications were completed. 2. The facility failed to conduct background checks upon hire for LVN 1 and CNA 1 and failed to conduct a reference verification of past employment for CNA 1. 3. The Administrator failed to notify the local ombudsman or other appropriate agencies, such as the State survey and certification agency with a written report of the allegation of the physical abuse by CNA 1 toward Resident 1 and failed to report the result of the investigation of the alleged physical abuse by CNA 1 toward Resident 1 to an appropriate agency. This failure had a potential for Resident 1 and other vulnerable residents residing at the facility to be subject to further abuse by the facility's staff's failure to follow the facility's policy to prevent abuse. Findings: 1. During an observation, on June 2, 2016, at 1:10 PM, Resident 1 was sitting in her wheelchair. Her left forearm had a yellowish discoloration, approximately 1.5 inches by 3 inches, at the area close to her wrist. During a concurrent interview with Resident 1, she stated a staff was rough to her during care; it occurred at night time when the staff was getting her ready for bed. Resident 1 stated the staff had grabbed and twisted her arm; the resident screamed and told the staff to stop. During a review of the clinical record for Resident 1, the Admission Record dated April 6, 2016, indicated the resident was admitted to the facility on [DATE], with diagnoses, which included dementia (a condition associated with some memory loss), major [MEDICAL CONDITION] (a mood disorder associated with depression), and anxiety. During an interview with Resident 2, on June 2, 2016, at 1:15 PM, she stated she was there when the incident occurred; it was around 8:00 PM or 9:00 PM. Resident 2 stated the staff was getting Resident 1 to bed when Resident 1 yelled You are hurting me. Resident 2 stated she heard a sound made by Resident 1 getting into bed by the staff and it was louder than usual as if she was thrown onto the bed. Resident 2 stated Resident 1 was very emotional. During an interview with a licensed vocational nurse (LVN 2), on June 2, 2016, at 3:30 PM, she stated on May 26, 2016, after Resident 1 received a breakfast tray, LVN 2 noted Resident 1 had a bruise on her left arm. When LVN 2 interviewed Resident 2, the resident told LVN 2 she was thrown against the wall three times a few nights ago. During an interview with the Director of Nursing (DON), on June 2, 2016, at 4:05 PM, she stated on May 31, 2016, during the investigation of Resident 1's discoloration on the left arm, LVN 1 heard CNA 1 telling Resident 1 There's nothing wrong with you, stop yelling, during a transfer of Resident 1 from wheelchair to bed by CNA 1. Furthermore the DON stated CNA 1 told LVN 1 that Resident 1 said CNA 1 had hit Resident 1. During an interview with CNA 1, on June 2, 2016, at 4:30 PM, she stated on May 24, 2016, approximately at 9:30 PM, Resident 1 was sitting up in her bed and trying to get up; the resident was in panic and yelling You're hitting me. Why are you abusing me? while CNA 1 was trying to sit Resident 1 down to the bed. CNA 1 stated she reported what had happened and what Resident 1 had told her to LVN 1 on the same date, May 24, 2016, at around 10:20 PM. During an interview with the DON, on June 2, 2016, at 6:05 PM, she confirmed LVN 1 reported the incident involving Resident 1 and CNA 1 to the DON on May 31, 2016 (seven days after the incident had occurred). During an interview with LVN 1, on June 15, 2016, at 3:25 PM, LVN 1 stated on May 24, 2016, she heard a scream coming from Resident 1's room while LVN 1 was in the hallway. She did not recall the exact time but it was at night time. She went into Resident 1's room, stood behind the drawn curtain around Resident 1's bed, and saw CNA 1 transferring Resident 1 from the wheelchair to the bed. Resident 1 was screaming I don't like you. I don't want to go to bed. LVN 1 stated CNA 1 came to LVN 1 later during the shift and told LVN 1 that Resident 1 had claimed CNA 1 had hit Resident 1. LVN 1 stated she did not report the incident to anyone because she did not think it was a physical abuse and there was no urgency to report nor document the incident. Furthermore, LVN 1 stated she should have reported the incident to the DON or the Administrator immediately. LVN 1 stated she did not remove CNA 1 from the residents' area even after the allegation made by Resident 1. During an interview with the DON, on June 15, 2016, at 6:05 PM, she stated CNA 1 was not removed from providing care to residents after the incident had occurred because LVN 1 did not report the incident to the DON until seven days after; she continued working her regular night shift schedule on Tuesday-Wednesday-Thursday. A review of the facility's Policy and Procedure titled Abuse prevention dated December 31, 2015 reflected: - Under Protection, the policy indicated 1. If a resident is reported, discovered or suspected, where the health, welfare or safety of the resident(s) is involved, the (facility) will take steps to provide a safe environment for the resident(s) as indicated by the situation: b. If the suspected perpetrator is an employee: immediately remove the employee from the care or vicinity of the resident. - Under Reporting, the policy indicated 2. Any mandated reporter who .has observed or has knowledge of an incident that reasonably appears to be physical abuse ., or is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse .or reasonably suspects abuse shall report known or suspected abuse. 2. A review of a certified nursing assistant's (CNA 1) Employee File, on June 15, 2016, indicated CNA 1 was employed at the facility on April 21, 2015. A review of a Compliance Verification Report dated June 15, 2016, indicated the facility conducted a background check on November 10, 2015 (seven months after CNA 1 started employment). There was no reference verification with current or past employment available in CNA 1's Employee File. A review of a licensed vocational nurse (LVN 1) Employee File, on June 15, 2016, indicated she was employed at the facility on October 27, 2015. A review of a Compliance Verification Report dated June 15, 2016, indicated the facility conducted a background check on December 10, 2015 (two months after LVN 1 started employment). During an interview with the Director of Nursing (DON), on June 15, 2016, at 6:00 PM, she confirmed the facility did not complete the background checks upon hire for CNA 1 and LVN 1 and did not complete a reference verification with previous employment for CNA 1. She stated the former Direct of Staff Development (DSD) was responsible to run background checks and reference verifications for potential employees upon hire. During an interview with the current DSD, on June 22, 2016, at 10:15 AM, he stated he was responsible to conduct background checks and reference verifications of past employments for all potential employees. He stated background checks and reference verification needed to be completed before potential employees were scheduled for orientation training. The facility's Policy and Procedure titled Abuse prevention dated December 31, 2015, under Screening, indicated 1. All potential employees will have reference verification with current and/or pas employment .2. All certified nursing assistants (CNAs) will be properly screened for criminal background .4. Criminal background check pursuant to Center or State and Federal law. The facility's Policy and Procedure titled Hiring dated April 2008 indicated 10. Where appropriate, background investigations may be conducted on persons making application for employment with this facility and on current employees. 3. During an interview with the Administrator, on June 15, 2016, at 6:50 PM, when asked for documented evidence the facility had reported the incident of the allegation of a physical abuse by Resident 1 in a written report to an appropriate agency, the Administrator stated he reported the incident via telephone to the State survey and certification agency. He said he did not complete and send the SOC 341 form (a form titled Report of suspected dependent adult /elder abuse, used to report details of an alleged abuse) to the local ombudsman (a long-term care advocate for residents of nursing homes) or other agencies, such as the State survey and certification agency. When asked for documented evidence the facility reported the result of the investigation of the allegation of physical abuse to Resident 1 by CNA 1, the Administrator stated he did not report the result of the investigation of the incident to the State survey and certification agency. The facility's Policy and Procedure titled Abuse prevention dated December 31, 2015, under Reporting, indicated: - 8. The Administrator or designee shall investigate all suspected or alleged abuse and report incident to the local ombudsman or the local law enforcement agency by telephone immediately, .and by written report (SOC 341) sent within two working days. - 11. Administrator or designee shall report the results of investigations of incidents of alleged abuse or suspected abuse in accordance with state law within five working days of the incident .

Based on observations, interviews, and record reviews, the facility failed to have a system in place to identify residents who did not have an identification band for one of 29 sampled residents (Resident 1).This resulted in Resident 1, receiving and being fed a pureed (pudding consistency) diet. This failure placed Resident 1, who had a physician's order to receive Nothing by mouth (NPO), at risk for aspiration (inhaling food or fluid into the lungs) pneumonia (an inflammation of the lungs caused by foreign matter such as food entering the lungs). Findings: On May 23, 2016 at 8:40 AM, sampled Resident 1 was observed in his room with a meal tray at the bedside. Resident 1 did not have a name plate on his door, or a wristband to identify him. The meal tray at his bedside had a tray card with unsampled Resident K's name. Resident 1 was observed with a gastrostomy tube (a feeding tube in the stomach used to provide nutrition to patients who cannot obtain nutrition by mouth, and are unable to swallow safely) and a bottle of Glucerna (a brand of formula used for gastrostomy tube feeding) hung at his bedside. The bottle had a label with unsampled Resident L's name on it. During an interview on May 23, 2016 at 9:00 AM, with a Certified Nursing Assistant (CNA 10) she stated,I don't usually work this hall, so I don't know his (Resident 1's) name. I look at the name plate on the door. If it's not there, I look at the wristband. Since he doesn't have either one, I need to talk to the charge nurse. I don't know how to identify him. A review of the facility policy titled, Resident Identification undated, indicated, Upon admission, all residents will have a hospital identification bracelet made and applied to their wrists During an interview on May 23, 2016 at 9:00 AM, with a Licensed Vocational Nurse (LVN 12) she stated, He is (used name of Resident 1). It is the appropriate formula, but it is not his name on it. (Used the name of unsampled Resident L) has his personal supply and it's sent out weekly. I can't speak for who hung it, but we have an ample supply of the formula for (used the name of Resident 1) from our feeding cupboard. The tray belongs to (used the name of unsampled Resident K). I don't know why the tray is here. (Resident 1) is on tube feeding. During an observation on May 24, 2016 at 8:20 AM, CNA 9 was feeding Resident 1 a meal containing a pureed diet (food that is chopped or ground into a thick paste) of apple juice, pureed donut and pureed egg. The tray had a napkin with Resident 1's room number on it. No name was written on the napkin. During a concurrent interview with CNA 9, she stated, I set him (Resident 1) up and asked if he was hungry and began to feed him. Then I left to go get some pepper. His roommate told me he didn't think he was supposed to be fed. I went to go check to see if he should eat. I checked with LVN 11 who told me he was NPO, so I removed the tray. He ate about three bites of the donut, 1 bite of the egg and drank half of the apple juice. I didn't know he was NPO. During an interview on May 24, 2016 at 8:45 AM, LVN 11, stated, CNA 9 approached me about (used Resident 1's name) if he is supposed to get a tray. I checked the MAR (Medication Administration Record) and the diet list and he is NPO. I even checked with LVN 6 and she double checked the MAR and said he was NPO. A record review of Resident 1's Admission Sheet indicated Resident 1 had a history of [REDACTED]. Resident 1's Physician's Order dated March 18, 2016, indicated NPO status. Resident 1's Physician's Order dated April 9, 2016, indicated a gastrostomy tube feeding using Glucerna (a brand of nutritional formula). A review of Resident 1's Speech Therapist Evaluation dated April 8, 2016, indicated Resident 1 was to continue with the NPO status due to aspiration (choking) risk. A record review of Resident 1's chest x-ray dated May 24, 2016, taken after Resident 1 was fed a pureed diet, indicated, Resident 1 had Patchy basilar infiltrates (fluid in the air spaces in the bottom of the lung) felt secondary to pneumonia. A Speech Therapy Evaluation dated May 24, 2016, indicated, Resident 1's Swallowing status is inadequate for oral intake.

Based on interview and record review, the facility failed to protect one sampled resident (Resident A) from verbal abuse by a staff member when a Certified Nurse's Aide (CNA 1) cursed and yelled at Resident A. This had the potential for Resident A to experience emotional distress, and for her roommate (Resident B) to verbalize to staff CNA 1's behavior made her,"...uncomfortable." Findings: During a review of the "Nurses notes" for Patient A, dated October 23, 2014 at 5:00 PM, the nurse documented, " ... report about allegation of resident stating that CNA used inappropriate language to the resident early this morning. When I asked the resident what happened, she stated that," I don't have any problem with the CNA, I know I made a comment that she looks like she was on drugs, and then she came back to me and stated that, "why are you talking s__t about me." Asked the resident if she was okay, she stated that she was fine. After talking to the resident CNA was sent home right away, MD (physician) aware..." A review of the "IDT"(interdisciplinary team) notes dated October 23, 2014, was conducted. The IDT note indicated, "IDT review due to incident that occurred October 23 , 2014, this resident had a problem with her CNA (CNA 1) and reported that her CNA was speaking inappropriately with her. IDT recommendation: CNA was placed on Administrative leave pending further investigation. SOC filed (SOC 341- Report of Suspected Dependent Adult/Elder Abuse form), Police, Ombudsman and DHS(Department of Health Services now called California Department of Public Health-CDPH) on file." During a review of "Social Services Notes" dated October 23,2014, the note indicated, "SSD (Social Service Director) and Activity Director met with this resident's roommate (Resident B), regarding incident that occurred October 23,2014, with this resident (Resident A) and CNA (CNA 1). When the roommate was interviewed she stated, "My memory is not good, I just remember that when the nurse (CNA 1) came in talking she seemed frazzled, she told us that she was not going to be helping us. I don't really remember what she said, I just.. it made me uncomfortable." During an interview conducted with the Director of Nursing (DON) on December 2, 2014 at 11:35 AM, regarding an entity reported incident (ERI) that CNA 1 allegedly cursed at Patient A, the DON was asked what the result of the investigation was. The DON stated, "She was let go (CNA 1), we did not have a written investigation, it was all documented in the nurses notes." The Administration and Director of Staff Development (DSD) decided to let her go because of the incident as well as, on the grounds of performance too because she comes late to work. The DON stated, "But we ensure that the resident was informed that the particular CNA (CNA 1) will never be assigned to her after the incident. The resident said that she did just not like the attitude of the CNA and appreciated the action done on the situation." A review of the facility's final report which included their investigative summary dated October 28, 2014, was conducted. The report indicated Resident A alleged that CNA 1 had spoken to her inappropriately and then CNA 1 accused Resident A of talking negatively about her. The report indicated Resident A's responsible party, her physician, the police and the Ombudsman were notified of the allegation of verbal abuse by CNA 1 to Resident A. CNA 1 was suspended and terminated. The facility continued to monitor Resident A and assist with her needs. During a review of the facility's document titled,"Short Term Problems"for Resident A, the plan of care noted under "Approach/Plan, dated October 23, 2014, listed: "Encourage resident to report further inappropriate statements. Employee placed under administrative leave until further investigation." During an interview with Patient A on April 7, 2015 at 4:40 PM, she was asked if she remembered the incident that happened between her and CNA 1, she stated, "Yes". Patient A said, "I remember, she could have been a good CNA if she was trained better. I think she was just young and must be very tired because she was doing overtime. I remember talking to my roommate about her that she looks like she's on drugs, but she's not, she got back in the room and said, " nobody talks s__t to me like that, and she was shaking her head while talking, we call that rubber head, she was yelling at me. It scared my roommates. If it's only me I could have not reported, but what if I'm not here? She could be more rude, but it did not bother me, although that was not an excuse. I remember asking for ice after that and she told me, "I won't get it." She was angry, so when I checked the ice she gave me, I poured the ice and checked first if there was nothing in there, but just like I said I did not want to report especially if it will cost her job, but I had to for the sake of my roommates." A review of Patient A's Minimum Data Set (MDS- a computerized assessment) was conducted on April 7, 2015. The MDS revealed Patient A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) On MDS dated [DATE], section C0500: Cognitive/Decision making, Patient's cognitive level was 15 (translated as coherent and appropriate).On section E0100 and E0200: Mood /Behavior/Psychosocial: No noted untoward behavior towards others, On section G0100: ADL (activities of daily living), Patient A was noted to need extensive assistance, on section G0400: ROM (range of motion) indicated Patient A was: impaired one side of the upper extremity and impaired on both lower extremities. During a review of CNA 1's employee file, the file indicated that she was hired on August 7, 2014 and had abuse training dated August 7, 2014 that covers the following: 1. Abuse Training, 2. Inappropriate Conduct, 3. Policy & Procedure regarding resident grievances, 4. "Walk Away" Policy and Procedure (Part of the Policy for "Abuse Prevention,Reporting,and Correction of Inappropriate Conduct including Abuse, Neglect andMistreatment of [REDACTED]. "...This policy provides if an employee is frustrated in a situation with a resident, another employee , or visitor, he/she must walk away from the situation and seek assistance from a supervisor,...unless resident is in immediate danger, inwhcih case employee will cll out for immediate help from another employee." 5. Abuse Training: Staff Confidentiality Rights, 6. Duties of mandated reporter, and the 7. Policy & Procedures Regarding Prevention, Reporting, and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. A review of the document titled, "Change in Relationship Notice" in CNA 1's employee file indicated: "last work day: 10/22/2014, date of change: 10/27/2014, type of change: "You were discharged on [DATE]" Under the section titled,"Comments Regarding Change in Relationship was listed: Failed to follow policy and procedure." A review of the facility's Policy and Procedure titled ,"Policies & Procedures regarding Prevention, Reporting and Correction of Inappropriate Conduct including Abuse, Neglect and Mistreatment of [REDACTED]. This facility works to ensure that its residents are not subject to such inappropriate conduct (...) by any employee ... (...). In this regard, the policies of this Facility include the following: Definitions: A) Abuse: As used in these policies and procedures, an abuse is defined according to the terms of state and federal law. Abuse includes... verbal abuse (oral...or gestured...) C) Inappropriate Conduct: Inappropriate conduct includes abuse and all other related misconduct ..."

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) was free of significant medication error when ear drops medication was administered to Resident 2's left eye. This failure resulted in Resident 2 experiencing severe eye discomfort to the left eye, such as burning sensation, tearing, itching and irritation. Finding: On March 24, 2015, at 3:20 PM, Resident 2 was observed in her room, sitting on a wheelchair at her bedside, wearing dark glasses. Resident 2 removed her glasses for a few seconds. Both eyes were noted to have dark discoloration around the eyes. Tearing of the left eye was observed. During a concurrent interview with Resident 2, she stated 2 days ago LVN 1 from the night shift woke her up early in the morning and put ear drops medication in her left eye. Resident 2 stated immediately after the medication was administered to the left eye, it felt like it was on fire and the left eye hurt very bad. Resident 2 said she had a new medication, "but it is for her ear not for the eye." Resident 2 stated the facility called the doctor and they got her an appointment and she went to the eye doctor yesterday. A review of the clinical record on March 24, 2015 , documented Resident 2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the physician's order dated March 20, 2015, indicated Corticosporin otic suspension 2 drops to left ear BID x 7 days (left otitis externa). During an interview with the DON (Director of Nurses) on March 24, 2015 at 3:45 PM, she stated LVN 1 (Licensed Vocational Nurse) told her that on March 22, 2015 the ear drop medication went into Resident 2's left eye. Resident 2's left eye was flushed with water and artificial tears and the doctor was called...the investigation has not been completed. LVN 1 was under suspension pending the result of the investigation. A review of the nurses note dated March 22, 2015 at 7:30 AM , documented that LVN 1 accidentally put a medication to Resident 2's left eye. Resident 2 complained of itching to left eye. LVN 1 was under suspension, not available for interview during the investigations. A review of the nurses notes dated March 23, 2015 at 2:45 PM, reflected, " incident of ear gtt (drop)was put to L (left) eye." Resident 2 complained of itchy, tears, burning, and blurred vision. Appointment was obtained to see the eye doctor at 4:00 PM. During a review of the facility policy and procedure, not dated, entitled, "Medication Administration" Purpose: To assure that residents receive their medication as ordered by the physician. Procedure: Check medication administration sheet...

Based on observations, record reviews and interviews, the facility failed to ensure that potentially hazardous foods (PHF-those items which require time and temperature control to maintain safety) stored in the refrigerators were maintained at or below 41 ?F (Fahrenheit). This failure occurred when observed PHF temperatures were noted to be greater than 41 ?F, which placed food in the danger zone allowing for growth of bacteria which could cause food-borne illnesses. In addition, the facility failed to utilize refrigerator temperature logs to monitor and ensure the safety of food to prevent food-borne illnesses, from February through April 2012. The dietary staff had been recording temperatures greater than 41 ?F daily without investigating the cause of these unsafe temperatures, or taking steps to prevent a reoccurrence. This failure of the facility to follow its own policies and procedures for ensuring that refrigerated foods were maintained at less than 41 degrees Fahrenheit. This placed the residents at risk for food-borne illness. Findings: The facility failed to ensure the refrigerators maintained the temperature of potentially hazardous foods (PHF) at or below 41 ?F and failed to take action when refrigerator logs consistently indicated temperatures greater than 41 ?F for two months (between February and April 2012). These temperatures were taken first thing each morning when the dietary staff entered the kitchen, and after the refrigerators had been left closed for at least 12 hours. On 3/23/12 at 1:45 PM, during an interview with 17 residents, 10 of 17 residents complained that the milk the facility served was "spoiled, had big lumps in it and was curdled." During a tour of the kitchen on 4/13/12 at 10:15 AM, refrigerator #1 was observed to be densely packed with milk and other food items. The thermometer inside registered 46 ?F. (Adequate circulation of air around refrigerated products is essential to maintain the food temperatures in the safe range). The reach-in refrigerator #2 was observed to be densely packed with half gallon cartons of milk. The thermometer inside the refrigerator registered 50 ?F. During a concurrent interview with the DSS, she stated that they had received a dairy delivery that morning. She verified that the refrigerators were densely packed and did not allow for proper air circulation and cooling. During a concurrent interview with Cook 1, she stated that the dairy delivery came at 6:30 AM that same day. She stated that the dairy delivery man put the milk in the refrigerator. On 4/13/12 at 10:20 AM, two pans of cooked roasts were noted in refrigerator #1. One pan was labeled corned beef and was dated 4/12/12. The temperature of the thickest part of the roast registered 53.3 ?F. The second pan was labeled turkey and was dated 4/12/12. The temperature of the thickest part of that roast registered 56.2 ?F. (Poorly cooked and cooled food may promote the growth of pathogens such as e-coli, salmonella and Norovirus. Due to the density of these meats after they are cooked, they are to be cooled from 135 degrees to 70 degrees in 2 hours, and then from 70 degrees to 41 degrees within the next four hours. Both of these meats exceeded the safe temperature and had to be discarded. During a concurrent interview with the DSS she stated that the roasts were cooked and cooled the day before. She stated that they were supposed to be served for dinner that night. At 10:35 AM, the temperature of a glass of milk in refrigerator #2 was taken and it registered 45 ?F. At 10:40 AM, temperatures of two half gallon containers of milk from refrigerator #1 were checked; the temperature of the milk registered 46 ?F and 48 ?F. During a concurrent interview with the DSS (Dietary supervisor), she stated that the dairy delivery man packs the milk in the refrigerator and blocks the fan of the refrigerator from effectively blowing cold air. There was no documented evidence that since she was aware of the problem that she had taken any steps to resolve it. In addition, there was no documented evidence that this problem of over-crowding of refrigerated food items had been discussed with, or identified by the RD or corporate quality control person during their monthly inspection of the kitchen. At 10:50 AM, refrigerator #3 in the cook's area was observed to have an internal thermometer that registered 50 ?F. A container of liquid whole egg product stored inside was checked and the temperature registered 46.1 ?F. The label on the product stipulated the temperature to be kept between 33 and 40 ?F. Bacteria multiply rapidly in a moist environment in the danger zone of greater than 40 degrees Fahrenheit. At 11:00 AM, the inside temperature of refrigerator #2 registered 44.6 ?F. A review of the facility's "Daily Temperature Record - Kitchen" for the month of April 2012 included directions to the staff that read, "Refrigeration of all perishable foods and beverages shall be maintained at or below a temperature of 41 ?F. There was no evidence that the dietary staff had received directives on what to do if the refrigerators were not below the required forty degrees, prior to the inservice which was done after the I.J had been called. The form further indicated that temperatures were recorded daily for all three refrigerators between 5:05 and 5:35 AM daily. These are the lowest temperatures because the doors have not been repeatedly open and closed for at least twelve hours which maintains a consistent temperature. The following documentation showed: For April, out of 39 temperatures recorded, only 3 were at 41 ?F or below. For March, out of 93 temperatures recorded, only 14 were at 41 ?F or below. For February 12 - 29, out of 54 temperatures recorded, only 22 were at 41 ?F or below. During an interview with Cook 1 on 4/13/12 at 11:05 AM, she stated that she recorded the refrigerator temperatures that morning at 44, 47 and 46 ?F for (three out of three refrigerators #1, 2 and 3 respectively). She stated that she just recorded the temperature and didn't do anything if the temperature is greater than 41 ?F. She stated that she usually worked the AM cook shift and recorded the temperatures when she first arrived to work, before anyone had opened the refrigerators for the day. During a concurrent interview with the DSS, she verified that the temperatures were recorded when the refrigerators had been closed throughout the night and should be at the lowest temperature of the day. She stated that she checks the logs when she " has the time. " The DSS could not remember the last time she had checked the logs. During an interview with the Head of Maintenance (HM) for the facility, he stated that he was not informed that the refrigerator temperatures were not acceptable from 2/12/12 until 4/13/12. He stated that at no point during that timeframe had the maintenance department received communication from the dietary department with regard to the refrigerator temperatures. He also stated that he would only check the refrigerators if he was asked to do so by the staff. During an interview with the RD on 4/13/12 at 12:40 PM, she stated that she had not reviewed the refrigerator logs for a while. She could not recall when the last time she checked the logs. She stated that the corporate Quality Assurance Specialist (QAS) conducted sanitation checks in the kitchen on a monthly basis. A review of the monthly reports from the QAS failed to identify any problems with the temperatures of the refrigerators consistently being above the safe level to prevent potential food-borne bacterial growth, or the overcrowding in the refrigerators that prevented air to circulate. During a telephone interview with the QAS on 4/13/12 at 2:40 PM, she stated that she does not check the refrigerator logs when she does her monthly kitchen inspection, however her pre-printed check list included that as one component of her review and it was consistently marked as not being a problem. According to the 2009 Food Code, except during preparation, cooking, or cooling... potentially hazardous food (time/temperature control for safety food) shall be maintained at 135oF or above, or at 41?F or less. As a result of the risk of food-borne illnesses from not maintaining refrigerated products at forty one degrees or less, an immediate jeopardy was called with the administrator and dietary supervisor. All food at risk from the incorrect temperatures in all three refrigerators was discarded. The facility maintenance supervisor ensured that all thre refrigerators were mechanically capable of maintaining the required food safety temperatures. The facility purchased milk for the evening of April 13, 2012 and the morning of April 14, 2012, after the refrigerator temperatures were verified as being maintained at less than forty one degrees. On April 13, 2012 at 4:50 PM, the Immediate Jeopardy was abated after an inspection of the kitchen with the administrator and dietary supervisor.