Every finding on record at Lynwood Post Acute Care Center

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not administered antipsychotic medication (medication affecting mood, thoughts, feelings, and behavior) without a confirmed clinical diagnosis.This deficient practice had the potential for Seroquel (an antipsychotic medication) to be used unnecessarily and inappropriately to manage Resident 1's combative behavior.Cross Reference F684.Findings:During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 1 did not have physical (hitting, kicking, or pushing) or verbal (threatening, screaming, or cursing at others) behavioral symptoms towards others. The MDS indicated Resident 1 was dependent on staff assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's History and Physical (H&P), dated 3/27/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Change in Condition Evaluation (COC), dated 6/12/2026, the COC indicated, on 6/12/2026, while a certified nursing assistant (CNA) assisted Resident 1 into clean clothing the resident became verbally aggressive and threated physical violence towards the CNA, stating he would 'punch the CNA in the face.' The COC indicated the primary clinician recommended to monitor Resident 1, notify of any changes in condition or behavior, and administer Haldol (an antipsychotic medication which affects mood, thoughts, feelings, and behavior) 5 milligrams (mg, a unit of measurement) one time and Seroquel (an antipsychotic medication) 25mg every 12 hours.During an observation on 6/23/2026 at 10:20 a.m., in Resident 1's room, a CNA was observed assisting Resident 1 with dressing. Resident 1 was observed calm and pleasant towards the CNA.During a phone interview on 6/23/2026 at 11:46 a.m., with Registered Nurse (RN) 2, RN 2 stated, on 6/12/2026, he asked the CNA to change Resident 1's adult brief and overhead Resident 1 raise his voice. RN 2 stated he entered the room to assist the CNA and Resident 1 became agitated and threatened to punch the CNA. RN 2 stated Resident 1 had never been aggressive towards the staff or other residents before. RN 2 stated Resident 1 was redirectable and calmed down after RN 2 gave Resident 1 a snack. RN 2 stated he notified Nurse Practitioner (NP) 1 who ordered Haldol and Seroquel for Resident 1. RN 2 stated he did not recall if NP 1 ordered a psychiatric consult (a medical evaluation by a physician specializing in mental health).During a concurrent interview and record review on 6/23/2026 at 12:25 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 1's Physician Order, dated 6/12/2026, was reviewed. The Physician Order indicated to administer Seroquel 25mg by mouth, twice a day for agitation manifested by combative behavior. LVN 4 stated Resident 1's Seroquel order did not indicate a medical diagnosis which manifested Resident 1's combative behavior. LVN 4 stated Resident 1's Seroquel order should have been clarified to ensure Seroquel was given for the appropriate reason and they exhausted other potential causes such as an infection. LVN 4 stated Resident 1 could be irritable at times, however, she never observed Resident 1 become agitated and aggressive. LVN 4 stated Resident 1 was redirectable when irritated such as providing a quiet environment, rest, and snacks. LVN 4 stated Resident 1's combative behavior was new. LVN 4 stated antipsychotic medications were ordered by the physician or NP to treat a medical diagnosis and manage manifested behaviors. LVN 4 stated ensuring a medical diagnosis was present was essential to know if the medication was effective and to know exactly the cause of the behaviors. During a phone interview on 6/23/2026 at 1:02 p.m., with NP 1, NP 1 stated, on 6/12/2026, she was covering for Resident 1's attending physician when RN 2 notified her at approximately 3 a.m. of Resident 1's threat of punching the CNA. NP 1 stated she informed RN 2 to try and deescalate the situation and received a message at approximately 6 a.m. of Resident 1's recurring behavior. NP 1 stated she was familiar with Resident 1's behavior and the licensed nurses informed her of Resident 1's occasional aggressive behavior towards them. NP 1 stated she ordered Seroquel 25mg every 12 hours to treat Resident 1's aggressive and combative behavior. NP 1 stated Resident 1's attending physician was scheduled to be back on duty on 6/15/2026 and assumed the attending physician would review and make any necessary changes to Resident 1's medications. NP 1 stated she also ordered for a psychiatric evaluation to assess Resident 1's aggressive behavior and oversee Resident 1's medication regimen. NP 1 stated antipsychotic medication should be used to treat a medical diagnosis to provide the necessary and appropriate indication for the medication treatment. NP 1 stated she ordered Seroquel 25mg to treat Resident 1's combative behavior to prevent someone from getting hurt. NP 1 stated Resident 1's medical diagnoses should have been evaluated and clarified to ensure Seroquel 25mg was necessary to treat Resident 1's combative behavior.During an interview on 6/23/2026 at 2:59 p.m., with the Director of Nursing (DON), the DON stated antipsychotic medication required an indication and manifested behavior to ensure the staff knew the reason for the medication. The DON stated the attending physician or NP could order the antipsychotic medication and the psychiatrist would follow up. The DON stated the psychiatrist would assess Resident 1 and determine the resident's diagnosis and whether the medication regimen was appropriate. The DON stated it was important to ensure Resident 1's behavior was caused by a psychiatric diagnosis or something else. The DON stated a urinalysis (evaluation of the urine for signs of infection or kidney issues) and urine culture (test to grow and identify the specific bacteria causing the urine infection) were completed and Resident 1 was concurrently treated for a urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of the facility's Policy and Procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, revised 3/2019, the P&P indicated medications prescribed for behavioral symptoms required documented rationale for use and potential underlying cause of the behavior. During a review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was seen by the psychiatrist after exhibiting combative behavior and prescribed antipsychotic medication (medication affecting mood, thoughts, feelings, and behavior).This deficient practice had the potential for Resident 1's combative behavior to be mismanaged.Cross Reference F605.Findings:During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 1 did not exhibit physical (hitting, kicking, or pushing) or verbal (threatening, screaming, or cursing at others) behavioral symptoms towards others. The MDS indicated Resident 1 was dependent on staff assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's History and Physical (H&P), dated 3/27/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Change in Condition Evaluation (COC), dated 6/12/2026, the COC indicated, on 6/12/2026, a certified nursing assistant (CNA) assisted Resident 1 into clean clothing and Resident 1 became verbally aggressive and threated physical violence towards the CNA, stating he would 'punch the CNA in the face.' The COC indicated the primary clinician recommended to monitor Resident 1, notify of any changes in condition or behavior, and administer Haldol (an antipsychotic medication which affects mood, thoughts, feelings, and behavior) 5 milligrams (mg, a unit of measurement) one time and Seroquel (an antipsychotic medication) 25mg every 12 hours.During a review of Resident 1's Physician Order, dated 6/12/2026, the Physician Order indicated to administer Seroquel 25mg by mouth, twice a day for agitation manifested by combative behavior.During a review of Resident 1's Care Plan titled, The Resident Became Verbally Aggressive, dated 6/12/2026, the care plan indicated for a psychiatric consult (a medical evaluation by a physician specializing in mental health) as indicated.During a review of Resident 1's electronic health record (eHR), dated 6/12/2026 through 6/23/2026, the eHR did not indicate psychiatric notes regarding Resident 1's behaviors.During a phone interview on 6/23/2026 at 11:46 a.m., with Registered Nurse (RN) 2, RN 2 stated, on 6/12/2026, he asked the CNA to change Resident 1's adult brief and overhead Resident 1 raise his voice. RN 2 stated he entered the room to assist the CNA and Resident 1 became agitated and threatened to punch the CNA. RN 2 stated Resident 1 had never been aggressive towards the staff or other residents before. RN 2 stated Resident 1 was redirectable and calmed down after RN 2 gave Resident 1 a snack. RN 2 stated he notified Nurse Practitioner (NP) 1 who ordered Haldol and Seroquel for Resident 1. RN 2 stated he did not recall if NP 1 ordered a psychiatric consult (a medical evaluation by a physician specializing in mental health).During an interview on 6/23/2026 at 12:25 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 1 could be irritable at times, however, she never observed Resident 1 become agitated and aggressive. LVN 4 stated Resident 1 was redirectable when irritated such as providing a quiet environment, rest, and snacks. LVN 4 stated Resident 1's combative behavior was new.During a concurrent interview and record review on 6/23/2026 at 12:41 p.m., with LVN 4, Resident 1's Physician Orders, active on 6/23/2026, was reviewed. The Physician Orders did not indicate a psychiatric consult was to be done. LVN 4 stated a psychiatric consult should have been ordered and carried out because Resident 1 exhibited new combative behavior and was receiving Seroquel. LVN 4 stated a psychiatrist was more knowledgeable about Resident 1's behavior and diagnoses and would be able to assess and manage Resident 1's medications appropriately. LVN 4 stated the psychiatrist would determine whether Resident 1's behavior was caused by a psychiatric diagnosis or something else such as an infection.During a phone interview on 6/23/2026 at 1:02 p.m., with NP 1, NP 1 stated, on 6/12/2026, she was covering for Resident 1's attending physician when RN 2 notified her at approximately 3 a.m. of Resident 1's threat of punching the CNA. NP 1 stated she informed RN 2 to try and deescalate the situation and received a message at approximately 6 a.m. of Resident 1's recurring behavior. NP 1 stated she was familiar with Resident 1's behavior and the licensed nurses informed her of Resident 1's occasional aggressive behavior towards them in the past. NP 1 stated she ordered Seroquel 25mg every 12 hours to treat Resident 1's aggressive and combative behavior. NP 1 stated Resident 1's attending physician was scheduled to be back on duty on 6/15/2026 and assumed the attending physician would review and make any necessary changes to Resident 1's medications. NP 1 stated she also ordered for a psychiatric evaluation to assess Resident 1's aggressive behavior and oversee Resident 1's medication regimen. NP 1 stated she ordered Seroquel 25mg to treat Resident 1's combative behavior and prevent someone from getting hurt. NP 1 stated a psychiatrist should have been consulted to ensure Seroquel was appropriate to manage Resident 1's combative behavior. During an interview on 6/23/2026 at 2:18 p.m., with the Social Services Director (SSD), the SSD stated when a physician or NP ordered a psychiatric consult, the licensed nurse was responsible for informing her to ensure the psychiatrist came to assess the resident. The SSD stated the psychiatrist would determine the cause for Resident 1's combative behavior and manage Resident 1's medications. During a review of the facility's Policy and Procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, revised 3/2019, the P&P indicated, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Care Plans - Baseline, which indicated a baseline care plan to meet the resident's immediate health and safety needs should be developed within 48 hours of admission, for one of three sampled residents (Resident 2) who was identified as a high risk for falls.This failure resulted in Resident 2 without safe nursing interventions (actions) to prevent falls for 14 days since admission [DATE] to 4/20/2026), placing the resident at risk for falls, recurrent falls and severe injuries, including hospitalization.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition) and unspecified chronic (continuing over an extended period of time) bronchitis (inflammation of the lining in the tubes that carry air to and from the lungs).During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 2 rarely/never understood and was not able to be assessed for cognitive patterns (the ability to think, learn, use judgement, and make decisions). Resident 2 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADLs) such as toileting and oral hygiene. Resident 2 required partial/moderate assistance to perform movements such as rolling from left to right and changing positions from sitting to standing.During a review of Resident 2's Fall Risk Assessment, dated 4/6/2026, the Fall Risk Assessment indicated that Resident 2 was at risk for falls.During a review of Resident 2's Care Plan titled, Resident is at risk for falls with injury related to (r/t) limited mobility, confusion, deconditioning (deterioration), gait/balance problems, incontinence, pain, poor communication/comprehension, poor safety awareness, vision/hearing problems, dated 4/20/2026, indicated the care plan was initiated on 4/20/2026, two weeks after Resident 2 was admitted to the facility (4/6/2026).During a concurrent interview and record review on 6/11/2026 at 2:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's care plan titled, Resident is at risk for falls with injury r/t limited mobility, confusion, deconditioning, gait/balance problems, incontinence, pain, poor communication/comprehension, poor safety awareness, vision/hearing problems, dated 4/20/2026, and facility's P&P titled, Care Plans - Baseline, dated 3/2022, were reviewed. LVN 1 stated the care plan should have been created immediately to notify other staff and to communicate interventions to prevent falls. LVN 1 stated the facility did not follow its policy to initiate a baseline care plan within 48 hours after admission per facility's P&P, for residents at risk for falls. LVN 1 stated not having a baseline care plan, placed Resident 2 without safety interventions and at risk of a fall.During a concurrent interview and record review on 6/15/2026 at 2:13 p.m., with the Director of Nursing (DON), Resident 2's Fall Risk Assessment, dated 4/6/2026, and care plan tilted, Resident is at risk for falls with injury r/t limited mobility, confusion, deconditioning, gait/balance problems, incontinence, pain, poor communication/comprehension, poor safety awareness, vision/hearing problems, dated 4/20/2026, were reviewed. The DON stated that baseline care plans should be initiated after admission to identify the residents' needs and provide interventions to minimize the risk of Resident 2 from falling.During a review of facility's P&P titled, Care Plans - Baseline, dated 3/2022, the P&P indicated, a baseline care plan to meet the resident's immediate health and safety needs should be developed for each resident within 48 hours of admission.

Based on interview and record review, the facility failed to ensure that one of three sampled residents' (Resident 1) environment remained as free of accident hazards as is possible and received adequate supervision to prevent accidents. The facility failed to: 1). Ensure the Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) identified causes of Resident 1's multiple falls and identified new interventions to minimize falls.2). Update Resident 1's care plan after each fall with new interventions for safety and to prevent recurrent falls.3). Implement its policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, which indicated to monitor and evaluate the effectiveness of interventions, modify or replace interventions as needed; and evaluate the effectiveness of new or revised interventions.4). Implement its P&P titled, Falls and [NAME] Risk, Managing, dated 3/2018, which indicated, if the resident continues to fall, staff should implement additional or different interventions, re-evaluate the situation whether it was appropriate to continue or change current interventions. These failures resulted in a total of 15 falls (four witnessed falls on 5/17/25, 6/30/2025, 8/18/2025 and 10/16/2025, and 11 unwitnessed falls from 2/7/2025 to 5/4/2026), placing Resident 1 at risk for severe injuries, including hospitalization and death.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included unspecified severe protein-calorie malnutrition (a severe form of undernutrition caused by insufficient intake of both protein and calories, leading to muscle wasting, fat loss, and impaired bodily functions), generalized muscle weakness and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P), dated 11/4/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment, dated 1/28/2025, the fall risk assessment indicated Resident 1 was at risk for falls. During a review of Resident 1's Care Plan Focus (titled), Resident is at risk for falls related to (r/t) aging process, generalized weakness, history (hx) of dementia, and hx of falls, dated 1/28/2025, the care plan goal was for the resident to have no falls through next review period. The care plan interventions included frequent rounds, low bed, call light within reach, and implement facility fall prevention protocol. During a review of Resident 1's Change of Condition (COC) Evaluation documents and Post- Fall Review documents for 2025 and 2026, the COC indicated a total of 11 unwitnessed falls from 2/7/2025 to 5/4/2026 and four witnessed falls on 5/17/25, 6/30/2025, 8/18/2025 and 10/16/2025. During a review of Resident 1's Care Plan titled, The Resident is at risk for unavoidable falls with injury r/t impaired function and mobility, poor safety awareness and on medications which may increase the risk of fall, recurrent falls, dated 2/7/2025, the care plan interventions included to anticipate and meet resident's needs, call light within reach, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (w/c), follow facility fall protocol, monitor side effects from medications, physical therapy (PT) to evaluate and treat as ordered or as needed (PRN), review information on past falls, attempt to determine cause of falls, record possible root causes and alter, remove any potential causes if possible. The care plan additional intervention dated 4/28/2026 included bilateral floor mat for fall precautions. During a review of Resident 1's care plan titled Res (resident) had a fall, initiated 6/30/2025, the care plan goal indicated the risk for falls will reduce daily and will not have adverse complications from fall. The intervention indicated to implement fall precautions, provide a clutter free environment, non-slippery floor, call light within reach and answer promptly, keep frequently used items within reach and monitor side effects from medications. The care plan was revised with actual falls dated 4/4/2025, 4/24/2025, 5/17/2025, 5/29/2025, 6/30/2025, 8/18/2025, 10/4/2025, 10/16/2025, 10/31/2025, 1/17/2026 and 5/14/2026, adding the following interventions:-On 4/5/2025, the care plan additional interventions indicated laboratory works as ordered by the physician (MD) and notify MD of results.-On 4/24/2025 to 4/25/2025, 5/17/2025, 5/29/2025, 8/7/2025, 10/4/2025, 10/16/2025, 10/31/2025, 1/17/2026 and 5/24/2026, the care plan had no additional and updated interventions for Resident 1's safety and to prevent recurrent falls.-On 8/18/2025, the care plan additional interventions indicated to evaluate and remove environmental hazards, frequent visual check every hour and as needed, monitor for changes in level of consciousness (LOC), place patient on fall precautions and use appropriate signage, keep bed in lowest position with brakes locked and provide mobility aids. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 10/22/2025, the MDS indicated Resident 1 had severe (extreme) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). Resident 1 was dependent (helper does all the effort) on staff to perform Activities of Daily Living (ADLs) such as toileting hygiene, upper and lower body dressing, and showering/bathing self. Resident 1 required substantial/maximal assistance (helper does more than half the effort) to perform movements such as rolling left and right, changing positions from lying to sitting on side of bed, and chair/bed-to-chair transfer. During an interview on 6/11/2026 at 11:04 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 was very confused. When residents are confused and staff does not make rounds, residents could fall and hurt themselves. During an interview on 6/11/2026 at 1:35 p.m., with Occupational Therapist (OT) 1, OT 1 stated Resident 1's cognition was impaired and was at risk for falls when sitting in a wheelchair. Resident 1 required supervision, assistance, cuing and redirection, in getting up from bed and when Resident 1 gets up on his own. During a concurrent interview and record review on 6/11/2026 at 3:30 p.m., with LVN 2, Resident 1's Post Fall Review dated 5/24/2026 at 4:55 p.m., was reviewed. The post fall review indicated Resident 1 was found by a CNA, lying on his back, on the floor mat next to the resident's bed. Resident 1 had bleeding from a sustained laceration on the right eyebrow (no measurement indicated). LVN 2 stated Resident 1's majority of his falls were unwitnessed. Resident 1 was confused and would have been moved closer to nurses station to get more supervision. If there were no available rooms, LVN 2 stated the facility should have provided a one to one (1:1-when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) supervision to Resident 1. LVN 2 stated Resident 1 move quickly at times needing more interventions. If staff were not close to Resident 1, supervision was not enough (unspecified) and could put him at risk for fall. LVN 2 stated it was important for the staff to update the resident's care plan with new interventions. LVN 2 stated if staff conducted frequent checks every hour and resident keeps falling, frequent checking was not effective. During a concurrent interview and record review on 6/15/2026 at 2:13 p.m., with the Director of Nursing (DON), the care plans titled, The resident is at risk for unavoidable falls with injury r/t impaired function and mobility, poor safety awareness and on medications which may increase the risk of fall, dated 2/7/2025, 4/4/2025, 4/5/2025, 4/24/2025, 4/25/2025 and 5/17/2025, were reviewed. The DON stated there were no changes to the resident's care plan interventions after the third fall on 4/24/2025. The DON stated other interventions that could have been added was to do frequent checks but was not documented on Resident 1's care plan dated 4/25/2025. There were no new interventions implemented after Resident 1's fall on 5/17/2025. The DON stated frequent checks were done by different staff passing by Resident 1's room but were not documented in Resident 1's clinical records. The DON stated Resident 1 could have benefited from increased supervision due to how quickly Resident 1 moved at times. The DON stated Resident 1's care plans were not resident-specific and were not updated with interventions to ensure falls were minimized. The DON stated Resident 1's Care Plan titled, At risk for unavoidable fall, dated 2/7/2025 was not appropriate. The IDT should have identified new and individualized interventions according to the resident's ambulation (walking) ability, cognition, physical and mental capacity to minimize falls. During a concurrent interview and record review on 6/23/2026 at 3:36 p.m., with the DON, Resident 1's active, discontinued, and completed physician's orders and the P&P titled, Falls and Fall Risk, Managing, dated 3/2018, indicating position-change alarms to assist staff in identifying patterns and routines of the resident, were reviewed. The DON stated position-change alarm are alarms that would go off when a resident changes positions, requiring physician's order. The DON stated the position-change alarm was not used or ordered on Resident 1 because it will not prevent falls. The DON stated the IDT should have identified reasons (causes) why and if the resident had multiple falls and provided the interventions. During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, the 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. The P&P indicated individualized, resident-centered approach to safety address safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated monitoring the effectiveness of interventions should include ensuring the interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. During a review of the facility's P&P titled, Falls and [NAME] Risk, Managing, dated 3/2018, the P&P indicated, staff should identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling basing on the previous evaluations and current data. The P&P indicated, staff with the input of the attending physician, should implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If fall recurs despite initial interventions, staff should implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff should try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The P&P indicated position-change alarms will be used to assist the staff in identifying patterns and routines of the resident, efficacy will be monitored and staff should respond to alarms in a timely manner. If the resident continues to fall, staff should re-evaluate the situation whether it was appropriate to continue or change current interventions. As needed, the attending physician should help the staff reconsider possible causes that may not previously have been identified. During a review of the facility's P&P titled, Dementia - Clinical Protocol, dated 11/2018, the P&P indicated, for individual with confirmed dementia, the IDT should identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. During a review of the facility's P&P titled, Care plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, the IDT reviews and updates the care plan when the desired outcome is not met.

Based on interview and record review, the facility failed to review one of three residents' (Resident 1) quarterly smoking assessment for safety.This failure had the potential not to identify changes in Resident 1's ability to smoke safely, placing the resident at risk for injuriesFindings: During a review of Resident 1 's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a condition that affects how the brain works causing changes in thinking alertness behavior and consciousness), Diabetes Mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)and Chronic obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1' Minimum Data Set (MDS- a resident assessment tool) dated 4/29/2026, the MDS indicated Resident had no cognitive (thinking process) impairment. The MDS indicated Resident 1 required set up assistance (helper sets up or cleans up; resident completes activity) from staff for personal hygiene, upper body dressing, oral hygiene and toileting. During a review of Resident 1's care plan titled, At risk for injury related to Smoking, dated 2/6/2026, the goal indicated Resident 1 would have no injuries through next review. During a review of Resident 1's History and physical (H& P) dated 3/4/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a concurrent interview and record review on 6/2/2026 at 2:00 p.m., with Registered Nurse (RN) 1, Resident 1's MDS dated [DATE] was reviewed. RN 1 stated Resident 1's MDS that was reviewed had no quarterly smoking assessment. During interview on 6/2/2026 at 4:00 p.m., with the Director of Nurses (DON), the DON stated the quarterly smoking assessment for Resident 1 was not completed, per the facility smoking policy and stated the missed assessment could be a risk to resident safety. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy- Residents, dated 10/2023, the P&P indicated, the resident's ability to smoke safely are re-evaluated quarterly.

Based on observation and interview, the facility failed to ensure there were adequate privacy curtains available in 17 of 33 rooms (Rooms 2, 3, 4, 7, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). This deficient practice violated the residents' rights to full visual privacy at any given time.Findings: During an observation, on 4/21/2026 at 2:40 p.m., in room [ROOM NUMBER], observed two privacy curtains observed on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:41 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:42 p.m., in room [ROOM NUMBER], observed one privacy curtain on the horizontal track along the foot of the residents' beds. The privacy curtain provided full visual privacy for one of the room's three occupants. During an observation, on 4/21/2026 at 2:42 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:43 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:44 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:45 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:46 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 2:47 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 3:01 p.m., in room [ROOM NUMBER], observed two privacy curtains observed on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 3:04 p.m., in room [ROOM NUMBER], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 3:07 p.m., in room [ROOM NUMBER], observed one privacy curtain on the horizontal track along the foot of the residents' beds. The privacy curtain provided full visual privacy for two of the room's three occupants. During an observation, on 4/21/2026 at 3:10 p.m., in room [ROOM NUMBER], observed one privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for one of the room's two occupants. During an interview on 4/21/2026 at 3:31 p.m., with Certified Nursing Assistant (CNA) 6, CNA 6 stated that privacy curtains were essential for residents' dignity during care, including dressing, bathing, and treatments. CNA 6 stated the privacy curtains should always be fully functional. During an interview on 4/21/2026 at 3:39 p.m., with the Housekeeping Supervisor (HS), the HS stated privacy curtains protected residents' dignity and comfort. The HS stated that without them, the facility's residents may feel uneasy receiving care, impacting their emotional well-being. During an observation, on 4/22/2026 at 3:30 p.m., in rooms [ROOM NUMBERS], observed two privacy curtains on the horizontal track along the foot of the residents' beds. The privacy curtains provided full visual privacy for two of the room's three occupants. During an observation, on 4/22/2026 at 3:34 p.m., in room [ROOM NUMBER], observed two resident beds along the side of the room. Along the horizontal track, at the foot of Beds A and B (left side of the room), there was one privacy curtain providing full visual privacy to one of the two residents. Along the horizontal track at the foot of Beds C and D (right side of the room), there was one privacy curtain providing full visual privacy to one of the two residents. During an observation, on 4/22/2026 at 3:34 p.m., in room [ROOM NUMBER], observed one privacy curtain on the horizontal track along the foot of the residents' beds. The privacy curtain provided full visual privacy for one of the room's three occupants. During an interview on 4/22/2026 at 1:12 p.m., with the HS, the HS stated the facility was aware there were not enough privacy curtains in place to allow each resident to have full visual privacy. The HS stated the concern was brought up to the facility's Administrator. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2023, the P&P indicated employees were to treat all residents with respect and dignity. The P&P indicated all facility residents were to be guaranteed certain basic rights, including the right to privacy and a dignified existence.

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's refusal of a blood laboratory draw for one of six sampled residents (Resident 13). This deficient practice resulted in Resident 13's physician not being informed of Resident 13's refusal, and placed Resident 13 at risk for delayed assessment, treatment, unmanaged change of condition, and potential complications related to medical conditions requiring laboratory monitoring. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included anemia (blood disorder), dementia (a progressive state of decline in mental abilities), syncope (passing out), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 13's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 13 was dependent (helper does all of the effort) on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 13's physician order, dated 4/13/2026, the physician order indicated to collect a complete blood count (CBC- a blood test that measures the main cells in the blood) laboratory test. During a concurrent interview and record review on 4/22/2026 at 2;00 p.m., with the Director of Nursing (DON), Resident 13's medical record and laboratory requisition form (a form used to request or document a laboratory test order), undated, were reviewed. The laboratory requisition form indicated Resident 13's CBC was scheduled to be collected on 4/13/2026. The laboratory requisition form indicated on 4/20/2026 and 4/21/2026, Resident 13's blood specimen was not collected due to patient refusal. The DON stated Resident 13's medical record did not indicate documented evidence showing the physician was notified of Resident 13's refusals on 4/13/2026, 4/20/2026, and 4/21/2026. The DON stated the physician should have been notified each time Resident 13 refused a physician ordered laboratory test. The DON stated the physician needed to be informed so the physician could determine whether the CBC remained medically necessary, whether the laboratory test should be rescheduled, and whether any additional assessment, monitoring, or treatment was needed. The DON stated failure to notify the physician of Resident 13's repeated refusals delayed the physician's ability to review the resident's condition and make timely treatment decisions. The DON stated this placed Resident 13 at risk for delayed assessment, delayed treatment, and unmanaged change in condition related to the medical reason for the ordered laboratory monitoring. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the staff would promptly notify the resident physician of any changes in the resident's medical or mental condition, including treatment refusal on two or more consecutive times.

Based on observation, interview, and record review, the nursing staff failed to ensure one of six sampled residents (Resident 90) was free from physical restraints, when bed linen, towels, and pillows were used as a barrier to prevent Resident 90 from falling out the bed. This deficient practice had the potential to restrict Resident 90's freedom of movement, restrict the resident's ability to reposition or exit the bed, and placed Resident 90 at risk for decreased mobility, skin breakdown, and injury. Findings: During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE] with diagnoses that included legal blindness (vision loss), muscle weakness (loss of muscle strength), and metabolic encephalopathy (a change in how your brain works due to an underlying condition). During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 90's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 90 was dependent (helper does all of the effort) on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 4/20/2026 at 9:55 a.m., with Resident 90, at Resident 90's bedside, Resident 90 was observed lying in bed. The bed linen was covering and tightly positioned along Resident 90's body. The bed linen was tucked under the mattress. Resident 90 stated staff placed pillows and towels on his bed, which restricted him from moving, turning, repositioning, or getting out of bed without staff assistance. During a concurrent observation and interview on 4/20/2026 at 10:33 a.m., with Certified Nursing Assistant (CNA) 1, at Resident 90's bedside, Resident 90 was observed lying in bed. The bed linen was tucked tightly along the side of the resident's body. CNA 1 stated the bed linen was tucked tightly along side Resident 90's body to keep the resident properly positioned in bed and to prevent the resident from moving toward the edge of the bed. CNA 1 stated the bed linen was placed that way to prevent Resident 90 from falling. During a concurrent observation and interview on 4/22/2026 at 11:24 a.m., with the Director of Nursing (DON), at Resident 90's bedside, Resident 90 was observed lying in bed. Bed linen, towels, and pillows were observed between the mattress and bed frame. The DON stated bed linen, towels, and pillows were positioned in a manner that created a barrier and limited Resident 90's ability to freely move or get out of bed without staff assistance. The DON stated the items were placed in a way that limited Resident 90's voluntary movement and functioned as physical restraint. The DON stated residents have the right to be free from physical restraints unless required to treat medical symptoms. The DON stated the staff should not use linen, towels, or pillows to keep a resident in bed or prevent falls. During a review of the facility's policy and procedure (P&P) titled Use of Restraints, revised 4/2017, the P&P indicated restraints should only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.

Based on interview and record review, the facility failed to ensure an as needed (PRN) order for Ativan (a psychotropic medication- drug that affects mental processes, moods, and behaviors) was not continued beyond 14 days for one of six sampled residents (Resident 14). This deficient practice placed Resident 14 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 14 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use.Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 14's Minimum Data Set ([MDS]- a resident assessment tool), dated 1/22/2026, the MDS indicated Resident 14's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 14 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 4/23/2206 at 8:15 a.m., with the Director of Nursing (DON), Resident 14's physician's order dated 3/25/2026 was reviewed. the order indicated Resident 14 was to receive Ativan 0.5 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount), one (1) tablet by mouth every eight (8) hours as needed (PRN) for anxiety (a feeling of fear, dread, and uneasiness). The order indicated to continue for 30 days with a stop date of 4/24/2026. The DON stated Resident 14's order for Ativan exceeded the 14 days PRN psychotropic requirement. The DON stated the resident should be reevaluated every 14 days, and the clinical justification documented if the medication was to continue beyond 14 days. The DON stated there was no documented evidence that the physician completed a required reevaluation or documented clinical justification for the continued use of PRN Ativan beyond 14 days. The DON stated this had the potential to result in the unnecessary use of Ativan without proper clinical review. The DON stated this placed Resident 14 at risk for chemical restraint, over-sedation, confusion, and decreased functional status. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, dated 7/2022, the P&P indicated PRN orders for psychotropic medications are limited to 14 days. The P&P indicated if the attending physician finds it appropriate to extend PRN orders beyond 14 days, they must document the rational and specify the new duration.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) accurately reflected the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening for one of six sampled residents (Resident 8). This deficient practice resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 8's PASRR and had the potential to negatively affect Resident 8's care plan and delivery of necessary care and services.Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 1/8/2026, the MDS indicated Resident 8's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 8 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 8's PASRR Level I screening, dated 6/15/2022, the PASRR Level I indicated Resident 8 had a serious mental illness and required a Level II mental health evaluation. During a concurrent interview and record review on 4/21/2026 at 1:17 p.m., with the MDS Nurse (MDSN), Resident 8's MDS, dated [DATE], and PASRR Level II determination report, dated 6/27/2022, were reviewed. The MDS, dated [DATE], section A1500 Preadmission Screening and Resident Review (PASRR) was marked 0- No indicating Resident 8 was not identified as having a serious mental illness. The MDSN stated the MDS was incorrectly completed because Resident 8's PASRR Level II determination report, dated 6/27/2022, identified Resident 8 as having a serious mental illness. The MDSN stated Resident 8's MDS did not accurately reflect the resident's PASARR Level II determination or serious mental illness. The MDSN stated an accurate MDS was necessary to ensure Resident 8's assessment reflected the resident's actual clinical status, PASRR status, serious mental health needs, and services required. The MDSN stated an inaccurate MDS could result in an incomplete assessment, inaccurate care planning, and inappropriate or delayed mental health services. During a review of the facility's policies and procedure (P&P) titled Resident Assessment, revised 10/2023, the P&P indicated everyone who completed the MDS assessment must sign and confirm the accuracy of the information.

Based on interview and record review, the facility failed to develop and implement a care plan addressing the use of Apixaban (an oral anticoagulant [blood thinner] used to prevent stroke and blood clots) and risk for pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for two of two sampled residents (Resident 4 and Resident 2).This deficient practice placed Residents 4 and 2 at risk for adverse drug reactions, unmonitored medication use, and the development or worsening of pressure ulcers.Findings: a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, dysphagia (difficulty swallowing), multiple fractures (broken bone) of the ribs, hyperlipidemia (high cholesterol), rhabdomyolysis (is a serious, potentially life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle), and cerebral infarction (tissue death caused by a severe reduction in brain blood flow due to arterial blockage). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 4 cognitive skills for daily decision making was moderately impaired (ability to think and reason). The MDS indicated Resident 4 was dependent on staff for assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 4's physician's order dated, 3/26/2026, the order indicated to administer Apixaban 5 milligrams (mg, unit of measurement) two times a day. During an interview on 4/23/2026 at 3:26 p.m. with the Director of Nursing (DON), the DON stated it was important to develop a care plan for Resident 4 who was receiving Apixaban. The DON stated that Apixaban is an anticoagulant medication that increases a resident's risk for bleeding and requires an individualized care plan, so staff are aware to monitor for signs and symptoms of bleeding, implement fall precautions, and promptly report any changes in the resident's condition. The DON stated that a care plan provides direction to staff to ensure the resident's safety and to reduce the risk of preventable complications related to anticoagulant therapy. The DON stated that it is important to develop a care plan for a resident identified as being at high risk for pressure ulcer development because the care plan communicates the specific interventions staff must follow to prevent skin breakdown. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2 diagnosis included muscle weakness, dysphagia, gastro esophageal reflux disease (GERD- a condition in which stomach acid flows back into esophagus causing heartburn), protein calorie malnutrition, and type 2 diabetes. During a review of Resident 2's History and Physical (H&P), dated 4/17/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 was dependent on staff for assistance with ADLs. During a review of Resident 2's Initial Skin assessment dated [DATE], the assessment indicated Resident 2 had blanchable redness (a red or pink skin discoloration that turns white (blanches) when pressed and quickly returns to red, indicating temporary blood flow interruption) to the coccyx area (a small triangular bone at the very base of the spinal column, located below the sacrum between the buttocks). During a review of Resident 2's Braden Scale for Predicting Pressure Ulcer Risk Evaluation tool (a tool that assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear to determine a patient's risk of developing pressure ulcers) dated 1/7/2026, the Braden Scale indicated a score of 14 (moderate risk) for developing pressure ulcers. During a review of Resident 2's Braden Scale for Predicting Pressure Ulcer Risk Evaluation tool dated, 3/3/2026, the Braden Scale indicated a score of 13 (moderate risk) for developing pressure ulcers. During a review of Resident 2's Braden Scale for Predicting Pressure Ulcer Risk Evaluation tool dated, 4/16/2026, the Braden Scale indicated a score of 12 (high risk) for developing pressure ulcers. During an interview on 4/23/2026 at 3:26 p.m. with the DON, the DON stated that with Resident 2's diagnoses, history, admission skin assessment which identified blanchable redness to the coccyx area, and the resident's Braden Scale scores being 12, 13 and 14, Resident 2 was already at risk for further skin impairment and required interventions such as frequent repositioning, pressure relief measures, skin monitoring, and prompt reporting of any worsening areas to prevent further skin breakdown and pressure ulcers. The DON stated that without an individualized care plan, staff did not consistently implement all the needed preventive interventions, placing Resident 2 at high risk for avoidable skin breakdown and the development of a pressure ulcer. During a review of the facility's policy and procedure (P&P), titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to keep one of six sampled resident's (Resident 90) fingernails trimmed and clean. This deficient practice had the potential to result in a negative impact on Resident 90's quality of life and self-esteem, and had the potential for the development of infection.Findings: During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE]. Resident 90's diagnoses included legal blindness (vision loss), muscle weakness (loss of muscle strength), and metabolic encephalopathy (an altered mental status). During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 90's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 90 was dependent (helper does all of the effort) on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation and interview on 4/20/2026 at 9:55 a.m., at Resident 90's bedside, Resident 90's fingernails were observed. Resident 90's fingernails were long and untrimmed with black debris underneath the nail bed. During a concurrent observation and interview on 4/20/2026 at 10:33 a.m., at Resident 90's bedside, with Certified Nursing Assistant (CNA) 1, Resident 90's fingernails were observed. Resident 90's fingernails were long and untrimmed with black debris underneath the nail bed. CNA 1 stated Resident 90's fingernails were dirty and required cleaning and trimming. CNA 1 stated nail care was one of the CNA's responsibilities which included trimming and cleaning the resident's fingernails when they become long and dirty. CNA 1 stated residents' nails should be checked daily to ensure the nails remained clean and neat. CNA 1 stated residents sometimes scratch their skin, and if they scratch hard enough, they could break the skin and create an open wound. CNA 1 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection. CNA 1 stated having dirty fingernails was unsanitary because the residents use their hands to eat, and any bacteria present could be transferred to their mouth. CNA 1 stated if Resident 90 was to touch shared objects bacteria from under his fingernails could be transferred to those items and potentially to other residents. During an interview on 4/22/2026 at 11:22 a.m., with the Director of Nursing (DON), the DON stated fingernail care was a part of the resident's ADLs routine. The DON stated if a resident had long and dirty fingernails, CNAs were expected to clean and trim them. The DON stated dirty fingernails was not acceptable, as they increased the risk of infection, especially if residents touched food or shared items with others. During an interview with the Infection Preventionist Nurse (IPN) on 4/22/2026 at 4:11 p.m., the IPN stated nail care should be assessed daily. The IPN stated residents who required assistance with cleaning or trimming their nails should be assisted by the CNAs or licensed nurses. The IP stated fingernails were a source of bacteria, and that dirty or untrimmed nails could contribute to the spread of infection, especially among residents who may not be able to maintain their own hygiene. The IP stated routine nail care was an essential part of both personal hygiene and infection control. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails Care, revised 2/2018, the P&P indicated nails care included daily cleaning and regular trimming. The P&P indicated proper nail care aid in prevention of skin problems around the nail bed and to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure there were bilateral floor mats to the left and right side of the bed and ensure two intravenous (IV, into a vein) needles were properly disposed of for two of 12 sampled residents (Residents 13 and 2). These deficient practices placed Resident 13 at risk for injury, and the potential for unsafe handling of blood-contaminated sharps (devices with sharp points or edges designed to puncture or cut skin), with the potential for accidental needlestick injuries, and serious harm to Resident 2.Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included dementia (a progressive state of decline in mental abilities), syncope (passing out), and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 13's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 13 was dependent (helper does all of the effort) on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 13's care plan titled The resident is at risk for falls with injury., dated 2/7/2025, the care plan indicated staff were to follow the facility's fall precaution protocol. During a review of Resident 13's physician order, dated 11/3/2025, the physician order indicated to apply bilateral floor mats for fall precaution. During an observation on 4/20/2026 at 9:30 a.m., and 2:13 p.m., at Resident 13's bedside, Resident 13 was observed lying in bed. A floor mat was observed on the right side of Resident 13's bed. There was no floor mat observed on the left side of Resident 13's bed. During an observation on 4/21/2026 at 12:41 p.m., at Resident 13's bedside, Resident 13 was observed lying in bed. A floor mat was observed on the right side of Resident 13's bed. There was no floor mat observed on the left side of Resident 13's bed. During a concurrent observation and interview on 4/22/2026 at 11:24 a.m., at Resident 13's bed side, with the Director of Nursing (DON), Resident 13 was observed lying in bed. A floor mat was observed on the left side of the bed. The DON stated there was no floor mat to the right side of Resident 13's bed. The DON stated Resident 13 was at risk for falls and required interventions to reduce the risk of injury. The DON stated Resident 13 could sustain injuries, including bruising, skin tears, pain or fracture, if the resident were to fall onto the floor without a floor mat in place. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, managing, revised 2/7/2024, the P&P indicated the nursing staff would identify interventions for each resident's risks to prevent falls and reduce complications. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted on [DATE] and re-admitted on [DATE]. Resident 2 diagnoses included muscle weakness, dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD- a condition in which stomach acid flows back into the esophagus causing heartburn), protein calorie malnutrition, and type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). During a review of Resident 2's History and Physical (H&P), dated 4/17/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 was dependent on staff with ADLs. During a concurrent observation and interview on 4/20/2026 at 9:35 a.m., Resident 2 was observed lying in bed under a blanket. Two used intravenous (IV) starter needles containing visible blood were observed on top of the blanket. Resident 2 stated that a nurse had come in earlier that morning to start an IV. Resident 2 stated she was unaware that the used needles had been left on top of her blanket. Resident 2 stated that the dirty needles should have been thrown away and not left on top of her. During a concurrent observation and interview on 4/20/2026 at 9:38 a.m., inside Resident 2's room, with Registered Nurse (RN) 2, the two IV needles were observed on top of Resident 2. RN 2 stated that under no circumstances, the used needles should not have been left on top of Resident 2. RN 2 stated that it was the responsibility of the licensed nurse performing the procedure to ensure all used sharps were immediately and properly disposed of in an approved sharps container upon completion of the IV insertion. RN 2 stated that the IV was initiated by a contracted IV specialist, and that the specialist left the used needles behind instead of disposing of them appropriately. RN 2 stated that leaving contaminated sharps in the resident's immediate environment was not consistent with infection control practices or facility expectations and presents a potential safety risk, including exposure to bloodborne pathogens and risk of accidental injury to the resident or staff. During an interview on 4/22/2026 at 11:22 a.m., with the Director of Nursing (DON), the DON stated that under no circumstances should used needles be left in a resident's immediate environment. The DON stated that all used sharps must be immediately and safely disposed of in an approved sharps container by the licensed nurse or healthcare professional performing the procedure once completed. The DON stated that the IV was initiated by a contracted IV specialist who reportedly failed to properly dispose of the used needles and left them on top of Resident 2's blanket. The DON indicated that this practice is unacceptable, not consistent with facility infection control protocols, and represents a serious breach in standard precautions. The DON stated that leaving contaminated sharps within a resident's bed area placed the resident at risk for potential exposure to bloodborne pathogens and created an immediate safety hazard for both the resident and staff. The DON stated that the facility's expectations included ensuring all contracted clinical staff followed facility policies regarding infection control and sharps disposal. During a review of the facility's P&P, titled Waste Disposal dated 1/2012, the P&P indicated Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations. Immediately after use, sharps shall be disposed of in closable, puncture resistant, disposable containers that are leak-proof on the sides and bottom and are labeled or color-coded. These containers shall be easily accessible to personnel and located in the immediate area of use. During a review of the facility's P&P, titled Peripheral IV Catheter Insertion dated 2/2022, the P&P indicated Discard stylet and syringes in sharps container.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements, as ordered, to two of three sampled residents (Resident 41). This deficient practice placed Resident 41 at risk of not receiving her required amount of calories, protein, and other nutrients, increasing her risk for weight loss and other complications related to malnutrition.Findings: During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE]. Resident 41's diagnoses included dysphagia (difficulty swallowing), moderate protein-calorie malnutrition, cachexia (a condition that causes significant weight loss and muscle loss), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 41 did not have cognitive impairments (ability to think and reason). The MDS indicated Resident 41 required set-up/clean-up assistance from staff to eat. The MDS indicated Resident 41 sustained weight loss in the last six months. During a review of Resident 41's care plan titled Resident is at risk for potential nutrition problem, created 4/6/2022 and revised 3/5/2026, the care plan indicated Resident 41's goal of care included consumption of 100 percent (%) of her supplements. The care plan indicated staff were to provide and serve Resident 41's supplements as ordered. a. During a review of Resident 41's physician order, dated 1/31/2026, the order indicated that starting on 2/1/2026, staff were to provide Resident 41 with a Magic Cup/Nutritional Treat (a high-calorie, high-protein nutritional supplements with 290 calories, 9 grams of protein, and more than 20 vitamins, designed to fight malnutrition or those with involuntary weight loss) twice a day with lunch and dinner. During an observation on 4/21/2026 at 12:57 p.m., at Resident 41's bedside, Resident 41's lunch tray was observed. There was no Magic Cup or other substitute nutritional supplement observed. During an interview on 4/21/2026 at 1:23 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 41 did not receive her Magic Cup, as ordered, as part of her lunch tray. b. During a review of Resident 41's physician order, dated 3/5/2026, the order indicated staff were to provide Resident 41 with a sugar-free high protein nourishment, three times a day, at 10:00 a.m., 2:00 p.m., and at bedtime. During a concurrent observation and interview on 4/22/2026 at 10:27 a.m., at Resident 41's bedside, Resident 41's bedside was observed. No supplements or snacks were observed on Resident 41's bedside table, in the bed, or on her bedside dresser. Resident 41 stated she did not receive a snack or supplement that morning. During an interview on 4/22/2026 at 10:30 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was responsible for distributing the 10:00 a.m. nourishments. CNA 3 stated she did not provide a 10:00 a.m. nourishment to Resident 41. During an interview on 4/22/2026 at 2:47 p.m., with the Registered Dietician (RD), the RD stated the kitchen was experiencing issues with the software that printed the tray tickets (a printed document, often computerized, that outlines a resident's specific diet order, food preferences, allergies, and adaptive equipment needed for a meal). The RD stated tray tickets were transcribed by hand due to the software issue, which could have resulted in Resident 41's Magic Cup not being included with her lunch tray. The RD stated the kitchen also had a delayed delivery of sugar-free nourishment shakes, which were ordered for Resident 41. The RD stated she approved Resident 41 to receive a regular shake instead, to ensure she received a 10:00 a.m. supplement. The RD stated the Magic Cup and sugar-free nourishment provided Resident 41 with additional protein and calories, and stated the expectation was for Resident 41 to receive her supplements as ordered. The RD stated missed supplements could increase Resident 41's potential for weight loss and/or malnutrition. During a review of the facility's policy and procedure (P&P) titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised 9/2017, the P&P indicated the staff and physician were to identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 demonstrated appropriate medication administration, documentation, and communication with the healthcare team, and failed to ensure licensed nursing staff used warm purified water when flushing (a medical procedure using a sterile sodium chloride [saline, salt and water] solution to clear, maintain, and prevent blockage in intravenous [IV- in a vein] catheters) a gastrostomy (G-tube- medical device inserted through the abdominal wall into the stomach to deliver nutrition, fluids, and medications directly, bypassing the mouth and esophagus) for two of six sampled residents (Resident 57 and Resident 2). This deficient practice did not respect Resident 57's right to be informed of and be involved in the care he was receiving. This deficient practice also had potential to negatively impact Resident 57's care from missed medications and inaccurate medical records and communication amongst his care team. This deficient practice also had the potential to place Resident 2 at risk for adverse outcomes, including inappropriate flushing practices, infection, and compromised G-tube function, and demonstrated a failure to ensure safe and appropriate care in accordance with established protocols.Findings: a. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included depression (mental mood disorder characterized by a persistent feeling of sadness, loss of interest in activities, and low energy), type 2 diabetes mellitus (DM II, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperlipidemia (an excess of fats in the blood that increases risk of heart attack and stroke), benign prostatic hyperplasia (BPH, a non-cancerous, age-related enlargement of the prostate gland), a broken left leg bone, and muscle wasting and atrophy (the wasting, decrease in size, or physiological degeneration of cells, tissues, or organs, often resulting from disease, nerve damage, or lack of physical use). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 57 had moderate cognitive impairment (problems with memory, language or judgment). The MDS indicated Resident 57 did not have disorganized thinking (e.g., unclear or illogical flow of ideas) or an acute change in mental status. The MDS indicated Resident 57 required set-up/clean-up assistance from staff to eat and drink. During an observation on 4/23/2026 at 8:15 a.m., outside of Resident 57's room, Licensed Vocational Nurse (LVN) 2 dispensed the following medications from Medication Cart 1 into a medication cup (a small, 1-ounce-sized container designed for safe, accurate dispensing of liquid or pill medication), totaling 10 tablets and/or capsules: Amlodipine (an anti-HTN medication).Aspirin chewable (a medication to reduce the risk of heart attacks or strokes by preventing blood clots).Docusate sodium (a stool softener).Apixaban (a medication used to reduce the risk of stroke and blood clots).Losartan potassium (an anti-HTN medication).Duloxetine hydrochloride (a medication to treat depression).Metformin (a medication to treat DM II).Finasteride (a medication to treat BPH).Multivitamin with minerals.Vitamin D3 (Cholecalciferol, crucial nutrient that enhances calcium absorption for strong bones and boosts muscle health). During an observation on 4/23/2026 at 8:28 a.m., at Resident 57's bedside, observed LVN 2 use a plastic spoon to collect three tablets from the medication cup, then brought the spoon to Resident 57's mouth. LVN 2 did not inform Resident 57 of what the three tablets were. Resident 57 took the three tablets with water. LVN 2 used the plastic spoon to collect three more tablets from the medication cup and Resident 57 stated he did not want any more medications. LVN 2 told Resident 57, You have to take your medicine, and brought the plastic spoon back to Resident 57's mouth. Resident 57 declined the medication. LVN 2 offered to administer the remaining medication with chocolate pudding, and Resident 57 stated he would like the pudding, but did not want the medication. LVN 2 did not inform Resident 57 what the seven remaining medications were or the risks of refusing to take them. During an observation on 4/23/2026 at 8:34 a.m., LVN 2 exited Resident 57's room with the medication cup containing five (5) tablets and two (2) capsules. During an interview on 4/23/2026 at 8:35 a.m., with LVN 2, LVN 2 stated she did not know which three medications she administered and did not know which seven medications remained in the medication cup. LVN 2 stated she did not inform Resident 57 of the medications she administered, or of the names, risks, and/or benefits of the medications he refused. LVN 2 stated she could not explain the risks and/or benefits of the medications because she could not identify each capsule or tablet by their appearance once placed in the medication cup. LVN 2 stated she would need to compare the remaining five (5) tablets and two (2) capsules to Resident 57's blister packs (organized, sealed pharmacy packaging that sorts pills by day and time), and Medication Cart 1's multi-dose bottles of aspirin, multivitamin with minerals, and vitamin D3, to identify what was refused. During a review of Resident 57's Electronic Medication Administration (EMAR) Medication Administration Notes, dated 4/23/2026 from 8:32 a.m. to 8:52 am., the notes indicated LVN 2 explained the risks and benefits for the seven medications Resident 57 refused. The notes indicated Resident 57 refused the following seven (7) medications: Duloxetine hydrochloride 30 milligrams (mg, a unit of dose measurement).Docusate sodium 100 mg.Metformin 850 mg.Losartan potassium 50 mg.Apixaban 5 mg.Amlodipine 10 mg.Aspirin 81 mg. During an observation on 4/23/2026 at 9:09 a.m., at Nurse's Station 1, LVN 2 was observed calling Nurse Practitioner (NP) 1, the advanced practice provider (APP, healthcare professionals who are not physicians but perform similar duties, such as diagnosing, treating, and prescribing medication) for Resident 57's primary physician. LVN 2 told NP 1 that Resident 57 was educated on the risks and benefits of seven medication the residents refused. During a review of Resident 57's progress note, dated 4/23/2026 at 9:14 a.m., documented by LVN 2, the progress note indicated Resident 57 refused his medication. The progress note indicated LVN 2 offered the medication three times and explained the risks and benefits but Resident 57 continued to refuse. The progress note indicated LVN 2 explained what the medications indicated use were. During an interview on 4/23/2026 at 11:17 a.m., with LVN 2, LVN 2 stated Resident 57 was not informed of the medications during administration. LVN 2 stated Resident 57 was not provided with the opportunity to make an informed decision to accept or refuse the medications. LVN 2 stated that her progress notes and communication with NP 1 did not accurately reflect the care provided. During an interview on 4/23/2026 at 2:17 p.m., with the Director of Nursing (DON), the DON stated LVN 2 was to separate each of Resident 57's medications into a separate medication cup to make them easier to identify during the medication administration process. The DON stated LVN 2 was to identify each medication and explain its indication to Resident 57 prior to administration. The DON stated that if Resident 57 refused the medication, LVN 2 was responsible for explaining the benefits of the medication, and the risks associated with refusal. The DON stated LVN 2's documentation of the medication administration process should reflect the care provided. The DON stated care that was not provided should not be documented as done. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2023, the P&P indicated staff were to ensure residents' rights were guaranteed, including their right to be informed of their care planning and treatment, and be supported by the facility in exercising their rights. During a review of the facility's P&P titled Administering Medications, revised 4/2023, the P&P indicated medications were to be administered in a safe and timely manner, and as prescribed. During a review of the facility's job description for Charge Nurse (LVN), undated, the job description indicated the LVN was required to chart nurse's notes in an informative and descriptive manner that reflects the care provided to the residents, as well as the resident's response to the care. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included muscle weakness, dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD- a condition in which stomach acid flows back into esophagus causing heartburn), protein calorie malnutrition, and type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). During a review of Resident 2's History and Physical (H&P), dated 4/17/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent on staff for assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Physician Order dated 4/16/2026, the order indicated to flush Resident 2's tube feeding with 30 milliliter (ml- a metric unit of volume) before and after medication. During a concurrent observation and interview on 4/20/2026 at 10:28 a.m., with Registered Nurse (RN) 2, in Resident 2's room, observed Resident 2 lying in bed. A saline flush was observed connected to the Lopez valve (a three-way stopcock device attached to the G-tube to manage feeding, medication administration, and gastric decompression securely) of the G-tube. RN 2 stated that the saline flush should not be attached to Resident 2's G-tube. RN 2 stated that using a saline flush to irrigate the G-tube following feedings or medication administration was not in accordance with facility protocol. During an interview on 4/23/2026 at 3:26 p.m., with the DON, the DON stated that facility protocol required staff to flush G-tubes with the appropriate prescribed solution, typically (water), before and after feedings and medication administration to maintain tube patency and reduce the risk of complications. The DON stated that attaching a saline flush to the G-tube and utilizing it for routine flushing was not in accordance with facility policy or accepted standards of nursing practice. The DON stated that nursing staff were expected to follow physician orders and established protocols when performing G-tube care, and that deviation from these practices could place the residents at risk for adverse outcomes, including irritation, infection, and improper tube function. During a review of the facility's P&P, titled Administering Medications through an Enteral Tube dated 11/2018, the P&P indicated Use warm purified water for diluting medications and for flushing.

Based on interview and record review, the facility failed to ensure Hydrocodone-Acetaminophen (a medication used to treat pain) was administered according to the physician ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of six sampled residents (Resident 7). This deficient practice resulted in Resident 7 receiving Hydrocodone-Acetaminophen outside the physician-ordered parameter and had the potential for unnecessary opioid (narcotics, medications prescribed by doctors to treat persistent or severe pain) use, adverse medication effects, oversedation (when a patient receives an excessive amount of sedative agents, resulting in a deeper level of consciousness than intended), respiratory depression (when you breathe too slowly or too shallowly), constipation (occurs when your bowel movements become less frequent and stools become difficult to pass), and medication-related harm. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7 diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), gout (joint pain), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (ESRD- irreversible kidney failure). During a review of Resident 7's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 7's cognition (the ability to think and process information) was intact. The MDS indicated Resident 7 was independent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 7's care plan titled Pain, revised 7/11/2025, the care plan indicated to administer Hydrocodone-Acetaminophen as ordered by the physician. During a review of Resident 7's physician order, dated 3/30/2026, the physician order indicated to administer Hydrocodone-Acetaminophen 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet by mouth every eight (8) hours as needed for severe pain of 7-10 on a pain scale (pain scale 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a concurrent interview and record review on 4/22/2026 at 10:47 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's Medication Administration Record (MAR), dated 4/1/2026 through 4/22/2026, was reviewed. The MAR indicated Resident 7 was administered Hydrocodone-Acetaminophen 5-325 mg for the following pain levels on the following dates:4/2/2026- pain level of 5 out of ten.4/4/2026- pain level of 6 out of ten.4/5/2026- pain level of 6 out of ten.4/6/2026- pain level of 6 out of ten.4/9/2026- pain level of 6 out of ten.4/10/2026- pain level of 6 out of ten. 4/14/2026- pain level of 6 out of ten.4/15/2026- pain level of 5 out of ten.4/16/2026- pain level of 5 out of ten.4/17/2026- pain level of 6 out of ten.4/19/2026- pain level of 5 out of ten.4/18/2026- pain level of 5 out of ten.4/20/2026- pain level of 6 out of ten.4/21/2026- pain level of 5 out of ten.4/22/2026- pain level of 6 out of ten. LVN 1 stated Hydrocodone-Acetaminophen should be administered according to the physician's order and within the ordered parameters. LVN 1 stated Hydrocodone-Acetaminophen was administered when Resident 7's documented pain level did not meet the ordered parameters for severe pain. LVN 1 stated this placed Resident 7 at risk for unnecessary opioid use, overdose, adverse medication effects, and medication related harm. During an interview on 4/22/2026 at 11:22 a.m., with the Director of Nursing (DON), the DON stated Hydrocodone-Acetaminophen was administered when Resident 7's pain level was less than 7-10, which was outside the ordered parameters. The DON stated that administering Hydrocodone-Acetaminophen outside the ordered parameters was not consistent with the physician's order and resulted in unnecessary administration of opioid pain medication. The DON stated this placed Resident 7 at risk for unnecessary opioid exposure, oversedation, confusion, and adverse medication effects. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2023, the P&P indicated medications were to be administered in accordance with the physician's orders.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%) for one of five randomly selected residents. The outcome was ten (10) medication errors out of 29 opportunities for errors, resulting in an observed medication administration error rate of 34.48%.Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included depression (mental mood disorder characterized by a persistent feeling of sadness, loss of interest in activities, and low energy), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperlipidemia (an excess of fats in the blood that increases risk of heart attack and stroke), benign prostatic hyperplasia (BPH, a non-cancerous, age-related enlargement of the prostate gland), a broken left leg bone, and muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 57 had moderate cognitive impairment (problems with memory, language or judgment). The MDS indicated Resident 57 did not have disorganized thinking (e.g., unclear or illogical flow of ideas) or an acute change in mental status. The MDS indicated Resident 57 required set-up/clean-up assistance from staff to eat and drink. During an observation on 4/23/2026 at 8:15 a.m., outside of Resident 57's room, Licensed Vocational Nurse (LVN) 2 dispensed the following medications from Medication Cart 1 into a medication cup (a small, 1-ounce-sized container designed for safe, accurate dispensing of liquid or pill medication), totaling 10 tablets and/or capsules: Amlodipine (an anti-HTN medication).Aspirin chewable (a medication to reduce the risk of heart attacks or strokes by preventing blood clots).Docusate sodium (a stool softener).Apixaban (a medication used to reduce the risk of stroke and blood clots).Losartan potassium (an anti-HTN medication).Duloxetine hydrochloride (a medication to treat depression).Metformin (a medication to treat DM II).Finasteride (a medication to treat BPH).Multivitamin with minerals.Vitamin D3 (Cholecalciferol, crucial nutrient that enhances calcium absorption for strong bones and boosts muscle health). During an observation on 4/23/2026 at 8:28 a.m., at Resident 57's bedside, observed LVN 2 use a plastic spoon to collect three tablets from the medication cup, then brought the spoon to Resident 57's mouth. LVN 2 did not inform Resident 57 of what the three tablets were. Resident 57 took the three tablets with water. LVN 2 used the plastic spoon to collect three more tablets from the medication cup. Resident 57 stated he did not want any more medications. LVN 2 told Resident 57, You have to take your medicine, and brought the plastic spoon back to Resident 57's mouth. Resident 57 declined the medication. LVN 2 offered to administer the remaining medication with chocolate pudding. Resident 57 stated he would like the pudding but did not want the medication. LVN 2 did not inform Resident 57 what the seven remaining medications were or the risks of refusing to take them. During an observation on 4/23/2026 at 8:34 a.m., LVN 2 exited Resident 57's room with the medication cup containing five (5) tablets and two (2) capsules. During an interview on 4/23/2026 at 8:35 a.m., with LVN 2, LVN 2 stated she did not know which three medications she administered to Resident 57 and did not know which seven medications remained in the medication cup. LVN 2 stated she would needed to compare the remaining five (5) tablets and two (2) capsules to Resident 57's blister packs (organized, sealed pharmacy packaging that sorts pills by day and time), and Medication Cart 1's multi-dose bottles of aspirin, multivitamin with minerals, and vitamin D3, to identify which medications Resident 57 refused. LVN 2 stated she did not inform Resident 57 of what medications were administered. LVN 2 stated she did not inform Resident 57 of the names, risks, and/or benefits of the medications he refused. During a review of Resident 57's Electronic Medication Administration (EMAR) Medication Administration Notes, dated 4/23/2026 from 8:32 a.m. to 8:52 am., the notes indicated Resident 57 refused the following seven (7) medications: Duloxetine hydrochloride, 30 milligrams (mg, a unit of dose measurement), for depression.Docusate sodium, 100 mg, for constipation.Metformin, 850 mg, for DM.Losartan potassium, 50 mg, for HTN.Apixaban, 5 mg, for prevention of blood clots.Amlodipine, 10 mg, for HTN.Aspirin, 81 mg, for prevention of cerebrovascular accident ( CVA, loss of blood flow to a part of the brain). The notes indicated LVN 2 explained risks and benefits for all seven medications, and that [Resident 57] still refused. During an interview on 4/23/2026 at 11:17 a.m., with LVN 2, LVN 2 stated staff were to inform the resident of what medications they were receiving when administering medications. LVN 2 stated it was the resident's right to be informed of the medications they were receiving. LVN 2 stated Resident 57 was not adequately informed of the medications she administered, or of the medications he refused. LVN 2 stated Resident 57 was not provided with the opportunity to make an informed decision to accept or refuse the medications. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2023, the P&P indicated staff were to ensure residents' rights were guaranteed, including their right to be informed of their care planning and treatment, and be supported by the facility in exercising their rights. During a review of the facility's P&P titled Administering Medications, revised 4/2023, the P&P indicated medications were to be administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to store food properly in the kitchen when one bag of hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were unlabeled and undated. This deficient practice had the potential to place the residents at risk for foodborne illness (is a sickness caused by eating that has harmful bacteria) or contamination (harmful germs get in food and unsafe to eat). Findings: During an observation on 4/20/2026 at 8:21 a.m. and at 11:53 a.m., in the facility kitchen, observed one bag of hamburger buns and two bags of wheat bread were observed open, unlabeled, and undated. Ground Italian seasoning, plain salt, soy sauce and powdered thickener were observed unlabeled and undated. During a concurrent observation and interview on 4/20/2026 at 12:10 p.m., with Dietary Aide (DA) 1, DA 1 stated the hamburger buns, two bags of wheat bread, ground Italian seasoning, plain salt, soy sauce, and powdered thickener were improperly stored. DA 1 stated that proper labeling and dating were important to prevent foodborne illness among residents. During an interview on 4/21/2026 at 10:22 a.m. with the Registered Dietician (RD), the RD stated unlabeled and undated or poorly stored food may lead to salmonella (a type of bacteria (germ) that causes a common foodborne infection known as salmonellosis) in residents. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/2022, the P&P indicated, the facility dry food storage follows safe handling practices, with all items labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure two large trash containers located in the kitchen were maintained in a closed position. This deficient practice had the potential to contribute to environmental contamination, pest infestation, odors and unsanitary conditions that could negatively impact the health and safety of residents, staff, and visitors.Findings: During an observation on 4/20/2026 at 8:15 a.m. and at 12:02 p.m., in the facility kitchen, observed two large trash containers uncovered. The trash containers were filled to capacity with open fruit cans, empty bottles, soiled paper towels and wet meat bags. During a concurrent observation and interview on 4/20/2026 at 12:06 p.m. with Dietary Aide (DA 1), in the kitchen, two large trash containers were observed uncovered. DA 1 stated kitchen trash containers must remain closed when not in use at all times to prevent pests and to keep the facility safe. During an interview on 4/21/2026 at 10:22 a.m. with the Registered Dietician (RD), the RD stated open trash cans in the kitchen could attract pests, promote bacterial growth, and increase risk of cross contamination that could lead to foodborne illness among residents with low immune systems (is a body defense that fights germs). During an interview on 4/22/2026 at 3:02 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated trash bins must stay closed at all times to prevent pests and germs. During a review of the facility's policy and procedure (P&P) titled Waste Disposal, revised 1/2012, the P&P indicated the facility regulated waste disposal shall be placed in closable leak proof containers to ensure waste was properly disposed. The P&P indicated waste containers should be replaced routinely and not allowed to overfill.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) documentation was maintained and readily available in the resident's medical record for review for two of six sampled residents (Residents 1 and 8). This deficient practice resulted in incomplete medical records for Residents 1 and 8 and limited access to required PASRR documentation. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of worry, nervousness). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/12/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review on 4/21/2026 at 2:00 p.m., in the presence of the MDS Nurse (MDSN), Resident 1's medical record was reviewed. Resident 1's records did not include evidence that the PASAR Level I screening, and Level II determination, was maintained and readily available for review. b. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included depression. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decision making was intact. The MDS indicated Resident 8 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a concurrent interview and record review on 4/21/2026 at 2:20 p.m., with the MDSN, Resident 8's medical record was reviewed. The MDSN stated Resident 8's medical record did not include evidence that PASRR Level I, and Level II determination, was maintained and available for review. During an interview on 4/21/2026 at 2:59 p.m., with the MDSN, the MDSN stated PASRR documentation should be maintained in the resident's record and available upon request. The MDSN stated he was responsible for maintaining complete resident record and ensuring required documents, including PASRR information, was available in the resident's medical record. The MDSN stated the facility failed to ensure Residents 1 and 8's record contained readily available PASRR documentation. The MDSN stated this resulting in an incomplete medical record and limited the facility's ability to readily verify that required PASRR documentation was maintained and available for review. During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, revised 7/2017, the P&P indicated the resident's medical, physical, functional or psychological condition shall be documented in the resident's medical record. The P&P indicated resident's medical record will be complete and accurate.

Based on observation, interview, and record review, the facility failed to supervise and prevent the elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization) of one of two sampled residents (Resident 1) who was cognitively (ability to think and reason) impaired and displayed behaviors of wandering (walking around aimlessly without a fixed plan) in the facility, and had previously attempted to elope on 10/2/2022. On 10/10/2022 the facility ' s security alarm sounded, the facility ' s staff conducted a count for all residents and Resident 1 was identified as missing from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 10/10/2022 at approximately 6:30 p.m. which placed Resident 1 at high risk for exposure to harsh environmental conditions including excessive heat during the day and or cold during the night, at risk for being hit by a car, and medical complications including malnutrition (lack of proper nutrients [molecules in food that are needed for growth and energy]), dehydration (not enough water in the body), stroke (blockage of blood to the brain), heat stroke (body is overheating) and possible death. As of 10/14/2022, Resident 1 was still missing from the facility. On 10/14/2022 at 1:19 p.m., during an unannounced visit, an Immediate Jeopardy ([IJ] a situation in which the facility ' s noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified due to the facility ' s staff failing to develop and implement an elopement care plan that included supervision and to monitor Resident 1 after his first elopement attempt on 10/2/2022. Resident 1 eloped from the facility on 10/10/2022 without staff knowledge, placing Resident 1 at risk for serious injury or death. The IJ was called in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). On 10/17/2022 at 10:38 a.m., the ADMIN submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). The IJ was removed on 10/17/2022 at 11:09 a.m., after observations, interviews, and record reviews were completed to confirm implementation of the IJRP while onsite. The acceptable IJRP included the following, the whereabouts of Resident 1 was unknown, so the IJRP was for residents at risk for elopement still in the facility: a. On 10/10/2022 through 10/15/2022, the ADMIN and the Director of Staff Development (DSD) conducted in-services for all staff regarding the facility ' s elopement policy and procedure, elopement risks, Wander guard system (a resident wears a device, and an alarm is activated when the device was near the wander guard sensors installed in exits), and response time from when the door alarm was activated. b. On 10/14/2022, the DSD and DON conducted elopement drills (a practice of emergency procedures to be used in case of a resident elopement) for staff. c. On 10/15/2022, the DON and Minimum Data Set Nurse (MDSN) identified 12 residents who were ambulatory (able to walk) with or without assistive devices and 27 residents were found to have diagnosis of dementia (residents with impaired ability to think and make decisions) and/or Alzheimer ' s disease (brain disorder). Two (2) of the 12 residents were found to be at high risk for elopement. d. Effective 10/15/2022, a staff member will be assigned 24 hours at the front lobby to monitor the front door until the Wander guard system is installed. e. Effective 10/15/2022, the certified nurse assistants (CNA) will do a head count on their specific residents every two (2) hours and the charge nurse will audit at the end of the shift for sixty (60) days. f. Effective 10/15/2022, Maintenance or designee will check the West, North, and Front doors daily to make sure all alarm systems are working properly. g. Elopement risk assessment will be completed on admission for all residents and at least quarterly, or if change of condition occurs by a licensed staff designee. h. If the resident was identified as high risk for elopement, a Wander guard bracelet device will be used, or resident will be place on one-to-one (continuous staff observation to safeguard resident) monitoring (continuous staff observation to safeguard resident) if Wander guard bracelet was not available. All high risk for elopement residents will not be placed in a room with a sliding door that leads to the outside of the facility. On 10/16/2022, sliding door stoppers were placed in eight (8) rooms with sliding doors leading to the outside of the facility, where a resident or wheelchair cannot pass through. Individualized elopement care plans will be initiated for the high-risk residents. i. All residents identified to be at risk for elopement will be reviewed by the Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident) on the following business day (Monday-Friday), quarterly and as needed. j. Medical records will audit all elopement risks assessments for all residents identified as high risk for elopement weekly for eight weeks to ensure elopement assessments were conducted and a care plan was in place for elopement. k. The IJRP will be presented at the next scheduled Quality Assurance (QA) committee meeting on 10/27/2022. Ongoing findings from audits will be reported to the Quality Assurance Performance Improvement (QAPI, team focuses on facility ' s issues) / QA monthly meetings for at least six months. Findings: During a review of Resident 1 ' s Admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally that impairs daily functioning), type 2 diabetes (body does not regulate glucose [sugar] properly), essential hypertension (high blood pressure), attention to [CONDITION(S)] (surgical opening of the colon [stoma] through the abdomen the opening has a pouch to collect stools), and cataract (a condition in which the lens of the eye becomes cloudy making it difficult to see). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/16/2022, the MDS indicated Resident 1 ' s cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 1 required supervision with eating, bed mobility, transfer, and required one person assistance for dressing, toilet use, and personal hygiene. During a review of Resident 1's Admission and Data Tool, Elopement Risk Assessment, dated 3/14/2022, the tool indicated Resident 1 was at risk for elopement. The tool indicated Resident 1 paced, wandered, tried to leave through the door, and to find family or friend. The tool indicated Resident 1 was independent and mobile. During a record review of Resident 1's care plan titled, Using [CONDITION(S)] (drugs that affect mental state) medication [MEDICATION(S)] and [MEDICATION(S)] (medications for [CONDITION(S)]), initiated on 3/14/2022, the care plan indicated to monitor/record occurrence for target behavior symptoms and specify if pacing and or wandering. During a review of Resident 1's medical records, care plans, the care plans indicated there was no documented evidence a plan of care for elopement was initiated on 3/14/2022, after Resident 1 was noted to have high risk behavior for elopement and as identified on the elopement risk assessment tool completed upon admission (Dated 3/14/22). During a review of Nurses Progress Note dated 8/23/2022 at 6:31 p.m., the note indicated Resident 1 was paranoid (characterized by suspiciousness) throughout the day and was noted with rapid audible tangential (a person constantly digresses to random, irrelevant ideas and topics) speech thinking that his medications were rat poison The note indicated Resident 1 was wandering in and out from the smoking patio telling passersbys that he likes the poison. The note indicated staff stated this was Resident 1's normal behavior. During a review of Resident 1's medical records, care plans, the care plans indicated there was no documented evidence a plan of care for elopement was initiated on 8/23/2022 after Resident 1 was noted to be independently mobile and wandering in and out of the patio with behaviors indicative of a risk for elopement. During a review of Resident 1 ' s Los Angeles County Superior Court Conservatorship Re-evaluation Physician ' s Declaration (when a court appoints someone to manage financial and personal affairs) document, executed on 8/2/2022 and signed by two (2) physicians, the document indicated Resident 1 was evaluated on 7/19/2022 and diagnosed with [CONDITION(S)] (a combination of symptoms of [CONDITION(S)] and mood disorder), [CONDITION(S)] type (mental disorder). The document indicated the following for Resident 1: 1. Presents with a history of delusional (distorted reality) thoughts agitation, disorganized thoughts, mood swings. 2. Poor decision making, and lack of appropriate judgement place him at risk for not meeting his basic needs. 3. Displays a history of challenges with compliance with declining medications or hygienic needs. 4. Does not have the capacity of knowingly and intelligently accepting or refusing prescribed medication. 5. Does not have the capacity to complete an affidavit of voter registration and vote. 6. Does not have the privilege of possessing a license to operate a motor vehicle. 7. Possession of a firearm or other deadly weapon by the resident presents a danger to his/her safety or to another person. During a review of Resident 1's Change of Condition Evaluation dated 10/2/2022 at 5:09 p.m., the evaluation indicated the resident (Resident 1) attempted to leave the facility, open up the door and stood there. During a review of Resident 1's Nurses Progress Note dated 10/2/2022 at 5:34 p.m., the note indicated Resident 1 was alert and oriented to self, mostly sat in the lobby throughout the shift and was back and forth to the patio. The note indicated Resident 1 attempted to leave the facility and when asked by staff why, the resident made a nonsense remark. During a review of Resident 1's Elopement Risk Evaluation dated 10/3/2022 at 11:07 a.m., the elopement risk evaluation indicated Resident 1 was not identified as at risk for elopement. There was no documented evidence a plan of care for elopement was initiated after Resident 1 ' s elopement attempt on 10/2/2022. During a review of Resident 1's Progress Notes dated from 10/5/2022 to 10/10/2022, the progress notes indicated there was no documented evidence Resident 1 was being monitored by staff for elopement and wandering behaviors. During a review of Resident 1's Nurses Progress Note dated 10/10/2022 at 6:31 p.m., the note indicated Resident 1 was observed with some confusion. The note indicated at 5:50 p.m. on 10/10/2022, the front door alarm was heard, and no residents were visualized in the lobby or outside. The note indicated a resident head count was completed and Resident 1 was identified as missing. During a review of Resident 1's physician ' s orders dated 10/10/2022, the orders indicated Resident 1 was receiving the following medications: 1. [MEDICATION(S)] (medication used to decrease lipids [fats] in the blood]) 20 milligrams ([mg] unit of measurement) one tablet by mouth at bedtime for antihyperlipidemic (to decrease lipids [fats] in the blood). 2. [MEDICATION(S)] (medication used to treat [CONDITION(S)] [severe mental disorder when people loose contact with reality]) 0.5 mg one tablet by mouth two times a day. 3. [MEDICATION(S)] tablet (medication used to treat [CONDITION(S)] ([CONDITION(S)] (serious mental disorder in which people interpret reality abnormally that impairs daily functioning) manifested by auditory/visual hallucinations [apparent perception of something not present]) 100 mg one tablet by mouth two times a day. 4. [MEDICATION(S)] tablet (medication used to treat diabetes) 2 mg one (1) tablet by mouth two (2) times a day. 5. [MEDICATION(S)] Tablet (medication used to treat [CONDITION(S)] [when body does not have enough [CONDITION(S)] hormones [hormones that control the way body converts food to energy]) 50 micrograms ([mcg] unit of measurement) one (1) tablet by mouth in the morning. 6. [MEDICATION(S)] Capsule (for behavior management for restlessness and agitation) 300 mg one capsule by mouth two (2) times a day. 7. [MEDICATION(S)] (medication used to manage diabetes) 500 mg one (1) tablet by mouth three times a day. 8. [MEDICATION(S)] Tablet (medication used to treat [CONDITION(S)] manifested by agitation and striking staff) 20 mg one tablet by mouth one (1) time a day. During a concurrent observation and interview with Certified Nurse Assistant (CNA) 1 on 10/13/2022 at 7:16 p.m., during an observation the alarm system in the front lobby was triggered but shut off within five (5) seconds. There were no staff observed in the lobby and adjacent nursing station, the emergency medical services (EMS) personnel and three residents seated on their wheelchairs were observed in the front lobby. At 7:24 p.m. (8 minutes later), CNA 1 entered the lobby area and checked on the residents. CNA 1 stated she did not hear the alarm because she was in a resident room (four rooms down from the lobby and nursing station). CNA 1 stated the staff assignment did not indicate to monitor the lobby area. During an interview with Licensed Vocational Nurse (LVN) 1 on 10/13/ 2022 at 7:30 p.m., LVN 1 stated Resident 1 was last seen on 10/10/2022 at approximately 5:30 p.m. eating dinner in his room. LVN 1 stated from 5:50 p.m. to 6 p.m., she heard the front lobby alarm and immediately went to the front door but did not see anyone inside or outside the facility. LVN 1 stated a headcount was completed and at 6 p.m., Resident 1 was identified as missing. According to LVN 1, the Director of Nursing (DON) was notified, and search parties were formed. LVN 1 stated when staff were unable to locate Resident 1, the police was notified, and a missing person report was filed. During a concurrent interview and record review on 10/13/2022 at 8:43 p.m. with LVN 2, Resident 1's Nurses Progress Notes dated 10/2/2022 at 5:34 p.m. was reviewed. LVN 2 stated on 10/2/2022 at 5:34 p.m., Resident 1 was confused and was pacing to and from the patio and lobby. LVN 2 stated Resident 1 then walked briskly towards the door with an intention to exit but LVN 2 stopped the resident. LVN 2 stated an elopement care plan was not created. During a review of Resident 1's Nurses Progress Note dated 10/2/2022 at 5:34 p.m., the note indicated Resident 1 was alert and oriented to self and the resident mostly sat in the lobby throughout the shift and walked back and forth to the patio. The note indicated Resident 2 attempted to leave the facility and when asked why Resident 1 was trying to leave, the resident made a nonsense remark. During an interview with the Social Services Assistant (SSA) on 10/14/2022 at 9:44 a.m., the SSA stated the front lobby coverage was seven days a week from 8:30 a.m. until 5 p.m. or 6 p.m. (varies). The SSA stated from 5 p.m. to 8:30 a.m., no one was assigned to monitor the front lobby. During a review of the facility's Front desk Coverage October schedule (handwritten by SSA), the schedule indicated there was no coverage for the lobby after 5:00 p.m. and sometimes 6:00 p.m. until 8:30 a.m. daily. During a review of the facility's Staffing Sheet dated 10/10/2022 and 10/13/2022, the sheet indicated there was no specific staff assigned to the front lobby. The assignment sheet did not indicate front lobby monitoring as part of staff duties. During an interview with CNA 2 on 10/14/2022 at 10:35 a.m., CNA 2 stated she was assigned to Resident 1 ' s care. CNA 2 stated Resident 1 was usually in the lobby or walking around without an assistive device, talking to himself, and ' in his own world. CNA 2 stated Resident 1 could not carry a conversation and he was unable to take care of himself. During a concurrent interview and medical record review of the Elopement Risk Assessments dated 3/14/2022, 10/2/2022 and 10/11/2022, with the MDS Nurse (MDSN) on 10/14/2022 at 11 a.m., The MDSN verified Resident 1 was mostly confused, conserved, and was unable to take care of himself. MDSN stated Resident 1 ' s behavior on 10/2/2022 should have been addressed with a care plan and a continuous detailed monitoring plan. The MDSN verified Resident 1 ' s Elopement Risk Assessments completed on 3/14/2022, and 10/3/2022, were incorrect because it should have identified Resident 1 as at risk for elopement based on the criteria indicated on the elopement tool. During a concurrent interview and record review with the DON on 10/14/2022 at 12:45 p.m., Los Angeles County Superior Court Conservatorship dated 8/2/22, indicated Resident 1 was under Conservatorship and had a mental disorder and was not able to care for himself. The DON stated Resident 1 was only monitored for three (3) days (from 10/2/2022 to 10/4/2022) after his elopement attempt on 10/2/2022. The DON stated Resident 1 ' s care plan should have addressed the resident ' s elopement risk with a detailed plan to prevent elopement from the facility. The DON stated Resident 1's Elopement Evaluation Risk Tool dated 10/2/2022 and 10/13/2022 should have indicated Resident 1 was high risk for elopement because of the resident ' s attempt to leave the facility and/or because Resident 1 displayed wandering behavior in the facility. During a record review of the facility ' s undated policy and procedure (P&P) titled, ' Wandering, Unsafe Resident, the P&P indicated staff should identify residents who were at risk for harm because of unsafe wandering (including elopement). The P&P indicated staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement. During a review of the facility ' s P&P, updated August 2018 and titled, Emergency Procedure-Missing Resident, the P&P indicated residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. During a review of facility's undated P&P titled, Missing resident, the P&P indicated it was the facility's policy to protect the safety of residents through early assessment of their risk for exit seeking behaviors. Once identified, the facility will mitigate the risk by preparing an individualized care plan in accordance with policies. Care plan is reinforced with clear communication among staff, residents, families, volunteers, and visitors regarding resident's supervision needs.

Based on interview and record review, the facility failed to ensure one of 11 residents (Resident 1) receiving hemodialysis (HD, removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) treatment was provided by failing to: 1. Carry out the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Notify the physician Resident 1 missed HD treatment on 7/23/2022. 3. Assess and monitor Resident 1 after the missed HD treatment. These deficient practices resulted in Resident 1 experiencing shortness of breath (SOB) requiring a transfer to general acute care hospital (GACH) via 911 (emergency services) and being admitted to the GACH for further evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review Resident 1's Admission Record (Face Sheet), the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 7/25/2022, the MDS indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required limited assistance with bed mobility, transfer, dressing, toilet use and bathing. According to the MDS, Resident 1 used a motorized wheelchair for mobility and was receiving HD treatment. During an interview with the Director of Nurses (DON) on 7/29/2022 at 1:15 p.m., the DON stated Resident 1 missed his Saturday appointment (7/23/2022) for HD due to transportation issues. The DON stated Resident 1 was sent out to the GACH on the following Monday (7/25/2022) at approximately 3:00 p.m., due to shortness of breath (SOB). The DON stated he was not notified by Resident 1's assigned nurse on 7/23/2022 that the resident missed his HD treatment. The DON confirmed the charge nurse assigned to Resident 1's care did not complete a change of condition assessment for Resident 1's missed HD treatment on 7/23/2022 or notify the physician. The DON stated the charge nurse should have notified the physician for the missed HD treatment to receive an order either for laboratory tests or to transfer the resident to a GACH for HD treatment. The DON stated there was no documentation recorded in Resident 1's chart for the missed HD treatment on 7/23/2022. During a telephone interview with Resident 1 on 7/29/2022 at 1:48 p.m., Resident 1 stated he had SOB on 7/25/2022 and was picked up by 911. Resident 1 stated he missed his scheduled HD treatment on 7/23/2022 and the resident was informed by the charge nurse the transportation never arrived. Resident 1 stated he told the nurse that he should not have missed the HD treatment because he needed the treatment. During a concurrent interview with the Social Services Director (SSD) and record review on 7/29/2022 at 2:20 p.m., the SSD stated the transportation company used by the facility to pick up Resident 1 for his scheduled Saturday HD treatment did not arrive on 7/23/2022 because there was no available ambulance per the transportation company. The SSD stated she called a transportation company on 7/22/2022 to schedule a pick-up to [CONDITION(S)] for Resident 1. The SSD stated Resident 1's Saturday trips were scheduled as wheelchair services pick up at 4:45 a.m. with a return trip at 10:00 a.m. The SSD stated Resident 1's Request Transportation form, which was faxed to the vendor on 7/22/2022 at 2:51 p.m., indicated a request for [CONDITION(S)] transportation via a van that could accommodate a gurney or wheelchair. During an interview with the DON on 8/17/2022 at 2:30 p.m., the DON stated missing a HD treatment could result in fluid overload (having too much water in the body), SOB and could lead to death. DON stated the licensed nurse should have notified him timely regarding Resident 1's transportation issue so he could make other transportation arrangements. During concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review on 8/17/2022 at 2:48 p.m., LVN 1 stated Resident 1's scheduled HD appointment on 7/23/2022 should not have been missed. LVN 1 confirmed that there was no assessment and monitoring done for Resident 1 missed HD treatment. LVN 1 stated Resident 1 might end up with fluid overload, difficulty breathing, or even death. LVN 1 stated that Resident 1 had no HD treatment appointment on Monday 7/25/2022. LVN 1 stated Resident 1 was transferred on 7/25/2022 at around 3:30 p.m. via 911 to GACH due shortness of breath, physician made aware that last HD treatment was 7/21/2022. During an interview LVN 2 on 8/17/2022 at 3:10 p.m., LVN 2 stated Resident 1's assigned nurse should have notified the physician for an order to transfer Resident 1 to a GACH for HD treatment. LVN 2 stated Resident 1 missed his HD treatment and could have developed [CONDITION(S)] (life-threatening condition that occurs when the body's response to an infection damages its own tissues), fluid overload, and cardiac tamponade (happens when extra fluid builds up in the space around the heart and puts pressure on the heart and prevents it from pumping well). During a telephone interview with LVN 3 on 8/26/2022 at 12:45 p.m., LVN 3 stated Resident 1's HD appointment on 7/23/2022 was missed due to transportation issues. LVN 3 stated she did not notify Resident 1's physician because the HD treatment facility reschedule Resident 1's appointment to the following Monday (7/25/2022) and thought that was okay. LVN 3 stated she should have notified Resident 1's physician immediately to get a transfer order to a GACH so the resident could receive HD treatment on that day (7/23/2022). LVN 3 stated Resident 1's missed HD treatment could lead to fluid overload and shortness of breath. During a telephone interview with Resident 1's Physician (MD 1) on 8/30/2022 at 2 p.m., MD 1 stated he was notified on 7/25/2022 (Monday) by a nurse Resident 1 had shortness of breath. MD 1 stated the nurse called 911 and transferred the resident to a GACH due to missed HD treatment on 7/23/2022 (Saturday). During a telephone interview with Transport Personnel (TP) 1 on 8/30/2022 at 2:06 p.m. TP 1 stated Resident 1 was scheduled for routine transport services via a gurney on Tuesdays, Thursdays, and Saturdays. TP 1 stated because Resident 1 was a new admit it would take 5-10 business days to process the request, but the transport company could provide a courtesy trip. TP 1 stated the transport company received a call on 7/23/2022 from the facility that Resident 1 needed transport services via a wheelchair and the facility was made aware they would try their best get provide transport services with wheelchair accommodations. TP 1 stated the nurse told them the HD treatment was rescheduled to Monday, 7/25/2022. During a telephone interview with Hemodialysis Registered Nurse (HDRN) 1 on 8/30/2022 at 2:20 p.m., HDRN 1 stated Resident 1 had scheduled HD treatment on Saturday, 7/23/2022 at 5:30 a.m., however, did not come to his appointment. HDRN 1 stated Resident 1 had no appointment on Monday 7/25/2022 for HD treatment. HDRN 1 stated Resident 1's routine HD treatment appointment was Tuesdays, Thursdays and Saturdays. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's care plan titled, The resident needs hemodialysis rule out (r/t) end-stage [CONDITION(S)], dated 7/22/2022, the care plan indicated Resident 1 required [CONDITION(S)] and the goal was for the resident to have no signs and symptoms of complication from [CONDITION(S)]. The staff interventions included to monitor/document/report to the physician as needed for renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys) including changes in level of consciousness, changes in skin turgor, oral mucosa (lining or skin inside of the mouth, including the cheeks and lips), and changes in the heart and lung sounds. During a review of Resident 1's Change of Condition evaluation note, dated 7/25/2022 at 3:30 p.m., the note indicated Resident 1 had SOB and was transferred to GACH via 911. During a review of Resident 1's GACH Emergency Department (ED) notes dated 7/25/2022 at 3:29 p.m., the notes indicated Resident 1 missed his HD treatment. The notes indicated Resident 1 stated he has been having difficulty sleeping due to SOB, coughing, mild facial swelling and abdominal pain. Chest x-ray (produce images of your heart, lungs, blood vessels, airways, and the bones of your chest and spine) findings indicated Resident 1 had central pulmonary [CONDITION(S)] (swelling in the lungs). Resident 1 had volume (fluid) overload needing urgent [CONDITION(S)] markedly hyperkalemic (elevated potassium level in the blood) with electrocardiogram ([EKG] test that measures the electrical activity of the heartbeat) changes. Resident 1 had HD treatment on 7/25/2022 in the GACH. During a review of the facility's undated policy and procedure (P/P) titled, Change of Condition, the P/P indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change of condition in the resident's health status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (not self-limiting) and the need to transfer the resident to hospital/treatment center. During a review of the facility's undated P/P titled, End-Stage [CONDITION(S)], Care of Resident With, the P/P indicated residents with [CONDITION(S)] will be cared according to currently recognized standards of care. Education and training of staff includes, specially: 1. The nature and clinical management of [CONDITION(S)], (including infection prevention and nutritional needs). 2. The type of assessment date that is to be gathered about the resident's condition on a daily or per shift basis. 3. Signs and symptoms of worsening condition and/or complication of [CONDITION(S)]. 4. How to recognize and intervene in medical emergencies such as hemorrhage and septic infections.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was free from unnecessary drugs when the facility failed to: 1. Assess and monitor Resident 1 for side effects and adverse reactions for use of multiple central nervous system (CNS) depressants (medicines that treat [CONDITION(S)] [difficulty sleeping], anxiety [extreme worry], panic attacks [sudden episode of intense fear and triggers severe physical reactions when there is no real danger], seizures [sudden uncontrolled electrical disturbance of the brain]) and opiates (substance used to treat pain have serious side effects and serious risks). These deficient practices resulted in Resident 1's mental, physical and psychosocial decline and becoming unresponsive, lethargic (a condition marked by drowsiness and an unusual lack of energy and mental alertness) and was transferred and admitted for nine days to a general acute care hospital (GACH) for opioid ([narcotic] class of drugs that is primarily used for pain relief) overdose (medical emergency occurs when you take more than the normal or recommended amount of the medication, symptoms may include shallow breathing, confusion, lessened alertness, and loss of consciousness). Findings: During a record review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/14/2022, the MDS indicated Resident 1 had clear speech, and was able understood and/or understand others. The MDS indicated Resident 1 required limited assistance with a one-person physical assist with bed mobility, personal hygiene, transfer, and locomotion on and off the unit, and extensive assistance with dressing, bathing, and toilet use. During a record review of Resident 1's History and Physical (H/P) dated 5/17/2022, the H/P indicated the resident had the capacity to understand and make decisions. During a record review of Resident 1's general acute care hospital (GACH) Emergency department (ED) provider notes dated 5/27/2022 at 9:22 p.m., the ED note indicated Resident 1 was brought in by ambulance from the facility for shortness of breath for an unknown amount of time. Upon arrival, resident oxygen saturation (test to see if breathing is fine) was 77 % on room air (normal range is 95 % to 100%). Resident 1 receives [MEDICATION(S)] (opioid [strong medication that treats moderate to severe pain]) extended release and [MEDICATION(S)] (pain medication that also contains opioid) for a recent lower extremity surgery. Clinical impression indicated final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's GACH Records, the records indicated on 5/27/2022 at 10:41 p.m., Resident 1 received [MEDICATION(S)] (medication used to treat narcotic overdose in an emergency) one milligram ([mg] unit of measurement), woke up and became responsive. Resident 1 was discharged from the GACH on 6/6/2022 at 6:32 p.m. diagnosed with [MEDICATION(S)] (opioid, pain medication) intoxication (receiving too much medication), aspiration pneumonia, and [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). During an interview on 7/20/2022 at 11:37 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated when Resident 1 took pain medication, the license nurses need to perform an assessment pre and post administration of the pain medication. LVN 1 stated he asked Resident 1 where and what was the pain level and documented on the MAR to support why the resident needed pain medicine. LVN 1 stated that he was the one who gave the scheduled pain medicine on 5/27/2022 with a zero out of ten ([0/10] used to describe having no pain (0) to greatest level of pain (10) on a pain scale) pain level since it was scheduled medicine. During an interview on 7/22/2022 at 10:30 a.m. with LVN 5, LVN 5 stated when Resident 1 was admitted to the facility the desk (licensed) nurse, Director of Nursing or MDS nurse completes the resident's admission and verifies the order with the physician. LVN 5 stated she was not aware of the admission process or who verified the medication from the hospital. During a record review of Resident 1's care plan dated 5/5/2022 , the care plan titled, Alteration in comfort secondary to acute/chronic pain related to right tibia/fibula (broken tibia-fibula is a fracture in the lower leg that happens when a fall or blow places more pressure on the bones than they can withstand) status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan further indicated to observe for adverse reactions with every interaction with the resident. During a record review of the Resident 1's pain assessment dated [DATE], the assessment indicated there was no scheduled pain medication ordered. During a record review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] sulfate ER tablet extended release 30 milligrams ([mg] unit of measurement), one (1) tablet by mouth one time a day, hold if respirations (breaths) less than 12. 2. [MEDICATION(S)] (used to treat nerve pain) tablet 600 mg, one tablet by mouth two times a day, hold if respirations less than 12. 3. [MEDICATION(S)] (muscle relaxant used to treat pain muscle spasms) 5 mg, one tablet by mouth two times a day. 4. [MEDICATION(S)]-Acetaminophen ([[MEDICATION(S)]] narcotic used to treat mild to severe pain) tablet 10-325 milligrams, one tablet by mouth, every 6 hours as needed (PRN). During a review of Resident 1's Medication Administration Record, for the month of May 2022, the MAR indicated Resident 1's pain level was assessed for each pain medication as ordered. The MAR indicated there was thirty-three (33) instances where the pain level was a zero (0) which meant no pain and the pain medication was still administered to Resident 1 as follows: 1. [MEDICATION(S)] sulfate ER tablet extended release 30 mg, one (1) tablet once daily administered at 9 a.m. There were six (6) instances that Resident 1 stated she had no pain and medication was still administered from 5/20/2022 to 5/27/2022. 2. [MEDICATION(S)] 5 mg, one tablet, administered twice daily at 9 a.m. and 9 p.m. Pain scale was zero (no pain), fourteen (14) instances and medication were administered from 5/19/2022 to 5/27/2022. 3. [MEDICATION(S)] tablet 600 mg, one tablet by mouth, administered twice daily at 9 a.m. and 9 p.m. There were twelve (12) instances where pain level was zero and the resident was medicated with this pain medication, from 5/20/2022 to 5/27/2022. 4. [MEDICATION(S)]-Acetaminophen tablet 10-325 milligrams, one tablet by mouth. Pain was zero in one (1) instance on 5/25/2022 at 5:50 p.m. and medication was still administered to Resident 1. During a record review of Resident 1's Nursing Progress Notes, the progress notes indicated the following: a. On 5/25/2022, indicated that per endorsement from previous shift charge nurse reported Resident 1 was talking to herself and having episodes of restlessness. Prescribed [MEDICATION(S)] (used to treat anxiety and panic disorders) was given and endorsed. 11-7 a.m. shift nurse entered room and the resident accused the nurse of attempting to crawl into her window and reality orientation provided but ineffective. Resident 1 continues to point to an imaginary window and talking to self. b. On 5/26/2022, indicated that LVN heard screaming and Resident 1 stated that she was dreaming about the time she was in the hospital. c. On 5/26/2022, Nurse Practitioner ([NP] an advanced practice registered nurse) increased dose of [MEDICATION(S)] ([antipsychotic] used to treat mental disorders) 5 mg twice daily and discontinued [MEDICATION(S)] ([antipsychotic] used to treat mental disorders). d. On 5/27/2022, Cough medicine administered as for productive cough. e. On 5/27/2022 at 8:44 p.m., Resident 1 was noted to be lethargic and difficult to arouse. Emergency medical services (EMS) 911 ambulance responded to the scene and transferred Resident 1 to a GACH. During a record review of the black box warning details for Resident 1's ordered [MEDICATION(S)] sulfate extended release, dated 5/12/2022, the warning indicated Risks from concomitant (reaction) use with benzodiazepines or other central nervous system ([CNS] brain and spinal cord, controls most functions of the body and mind) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of [MEDICATION(S)] and benzodiazepines (depressants which slow down the body and brain's functions that produce sedation and hypnosis, used to relieve anxiety and muscle spasms) or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. During a record review of the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) for the month of May 2022, the MRR indicated that muscle relaxants such as [MEDICATION(S)] are not recommended in the elderly due to their anticholinergic (drugs that block involuntary muscle movements and various bodily functions) side effects. The PC recommended that Resident 1, who had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/22/2022 at 10:05 a.m. with the Pharmacy Consultant (PC), PC stated that if there was an interaction with the medication upon admission, the pharmacy who received the order would send a drug review regimen. PC stated that Resident 1 was an elderly with renal failure (loss of kidney function) so the central nervous system depressant can make the resident confused, altered level of consciousness, and agitated. PC stated that it was still up to the physician if they want to discontinue or continue with the medicine. PC stated the pharmacist's main responsibility was to check and recommend medications. PC stated that the physician should have also caught that there was multiple psychiatric and opioid medications which was a strong cocktail medication that could make elderly residents confused or can affect mental behavior. PC stated that even before she visited the facility NP and or MD should have also reviewed the medication list and pharmacological management should have been done. During an interview on 7/22/2022 at 11:28 a.m. with the Pharmacist (Pharm) 1, Pharm 1 stated that upon admission whichever pharmacist that received the medication list would go through the medication and if they (pharmacist) noted any discrepancies, the pharmacy would contact the physician and ask if they want to continue or discontinue the said order. During an interview on 7/22/2022 at 11:25 a.m. with the Director of Nursing (DON), DON stated upon admission when the resident comes with [CONDITION(S)] medicine the licensed nurse would have it referred to the Psychiatrist's Nurse Practitioner (NP) who comes to the facility to review and check if the medications are necessary. The DON stated the NP would review all medicine and if there were side effects from other medicine, it was up to the NP to discontinue or continue the medicine. The DON stated the NP should have caught that Resident 1 was having increased confusion and hallucinations because of opioid side effect instead of just increasing and adding [CONDITION(S)] medication or anti-anxiety medication. DON further stated that there was no black box warning in the system. DON stated that since it was a scheduled pain medicine, even if Resident 1 was not experiencing pain, the nurses could still administer the medicine. DON further stated there was no change of condition reported to Resident 1's physician for increased agitation or increased hallucinations on 5/25/2022. During a record review of the Resident 1's Medication Administration Record (MAR), for the month of May 2022, the MAR indicated a black box warning was attached to the [MEDICATION(S)] Sulfate order on the medication administration record. During a record review of Resident 1's bubble packs for [MEDICATION(S)] 10 mg/ 325 mg, [MEDICATION(S)] Sulfate extended release 30 mg, and [MEDICATION(S)] 0.5.mg, dated 5/19/2022, the bubble packs indicated there was a caution black box warning sticker attached as an alert precaution. During a record review of the Resident 1's care plan dated 5/5/2022, the care plan indicated that opioid analgesic risk evaluation and mitigation strategy (REMS) were to ensure that the benefits of opioid analgesics (medications used for pain relief) outweigh the risks of addiction, abuse and misuse, the Food and Drug Administration ([FDA] federal agency responsible to protecting and promoting public health through the control and supervision of prescription and over the counter medications) has required a Risk Evaluation and Mitigation Strategy ([REMS] a drug safety program required for certain medications with serious safety concerns to help ensure the benefits of the medication outweigh its risks) for these products. Under the requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to health care providers. Health care providers are strongly encouraged to complete a REMS- compliant education program and counsel patients and/ or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products, emphasize to patients and their caregivers the importance of reading the medication guide every time it is provided by their pharmacist and consider other tools to improve patient, household, and community safety. During an interview on 7/22/2022 at 3:24 p.m. with Nurse Practitioner (NP), NP stated that she comes to the facility to evaluate residents and manage their medication to stabilize their behaviors. NP stated residents that were already receiving pain medication when they were admitted was difficult to change or manage their medication because they were drug seekers. NP stated that she browsed Resident 1's medication list, but she never looked at the effect of the [MEDICATION(S)] sulfate for change of behavior. NP stated Resident 1 hallucinated when she was first admitted to the facility. NP stated that she did not manage any pain medicine or review any side effects. NP stated she only focused on the resident's behavioral and psychiatric problems. NP stated that dual [CONDITION(S)] medicine was given to Resident 1 due to cross titration (increasing a dose over time) with the other medicine for behavioral management. During a record review of Resident 1's GACH discharge summary dated 6/6/2022 at 4:16 p.m., the discharge summary indicated Resident 1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of the facility's policy and procedure (P/P) dated 12/2016 and titled, Antipsychotic Medication Use, the P/P indicated that the physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. During a record review of the undated facility's P/P titled, Pain- Clinical Protocol, the P/P indicated that the staff and physician will evaluate how pain is affecting the mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.

Based on observation, interview and record review, the facility failed to follow its policy titled, Abuse Prohibition and Prevention, thoroughly investigate two alleged physical abuse incidents, and place staff on suspension during the investigation for one of three sample residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse 1 (LVN 1) roughly took chips away from his hand and mouth on 7/20/2021 and on 8/11/2021 Certified Nurse Assistant 1 (CNA 1) threw water at Resident 1, and yelled at Resident 1 stating, Shut the F@@@-up and go to sleep. This deficient practice resulted in Resident 1 feeling afraid of LVN 1 and CNA 1 possibly retaliating a third time. On 8/18/2021 at 5:40 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared in the presence of the Director of Nursing (DON). The DON was notified of the immediacy for alleged abuse investigations to be investigated and reported to prevent abuse from reoccurring and remove perpetrators from the care of the residents while an ongoing investigation was conducted. The facility submitted an acceptable Plan of Action (POA) on 8/20/2021 of the IJ which included the following: 1. On 8/19,2021, the Clinical Resource (CR) provided a 1:1 in service training to the DON and reviewed policy and procedure (P/P) on Abuse Investigation and Reporting, Abuse Prevention, Recognizing signs and symptoms of Abuse/Neglect. On 7-28-21, LVN 1 was suspended pending investigation and CNA 1 was suspended on 8-11-21 pending investigation. LVN1 was in-serviced on 8-5-21 and 8-18-21. CNA1 was in-serviced on 8-11-21. 2. The Administrator (ADM) and CR and Quality Assurance Nurse (QAN) designee provided staff in-services and training on 8/19/2021 regarding the P/P on Abuse Prevention Investigation and Reporting, Abuse Prevention, Recognizing signs and symptoms of Abuse / Neglect. In services ongoing to be completed on 8-24-21. 3. Resident 1 continued to be monitored for any sign and symptoms of emotional, psychological distress (state of emotional suffering associated with stressors and demands that are difficult to cope with in daily life) related to alleged abuse. Psychologist (person who studies normal and abnormal mental states, perceptual, cognitive, emotional, and social processes and behavior by experimenting with, and observing, interpreting, and recording how individuals relate to one another and to their environments) came to assess resident 8/19/21 with no negative findings noted. Psychiatry visit pending. 4. The Social Services Director conducted resident interviews 8/19/21 and ongoing. Goal is to complete resident interviews at end of 8/19/21. One resident with concern noted, Administrator investigation and reporting in progress. 5.All residents have the potential to be affected by abuse. All resident interviews ongoing and will be completed end of 8/19/21. Social Services Director responsible. Any negative findings will be followed up promptly according to Policy and Procedure in force. 6. Staff in-services related to Policy and Procedure on Abuse Prevention Investigation and Reporting, recognizing signs and symptoms of Abuse/Neglect with emphases on timeline requirement per regulatory guidance provided by the Clinical Resource, Administrator and Quality Assurance Nurse Designee - Ongoing, completion date: 8/23/2021. In-services will be done monthly and/or as needed. 7. The Payroll / AP/ Staffing Designee currently conducting audit of all new hire employee files from last 30 days including registry personnel for completeness and availability of license, certification verification, abuse training, screening, and job description requirement. Ongoing. Infection control Nurse and/or will complete the process moving forward until the Director of Staff Development is hired. To be completed on 8/26/2021. 8. The Department Managers will be conducting resident interviews and observation during daily rounds to ensure residents with concerns and or allegation of any type will be addressed promptly per policy and procedure. This process is ongoing per facility practice. 9. The Director of Nursing/ Designee, RN Supervisor and Licensed Nurse will conduct routine rounds during the shift to include resident and staff interviews and observation to monitor for any signs and symptoms of abuse, initiate investigation promptly for any allegation of abuse as needed and up to reporting process per Policy and Procedure. 10. The Administrator will discuss and review during the morning meeting any findings, trend/ pattern, follow up completed to ensure Abuse Policy and Procedure being followed accordingly with emphases on timely reporting per regulatory guidance. 11. The RN Supervisor will monitor Abuse Prevention and Management program during weekend. Negative findings and concerns will be communicated to the Administrator and or Director of Nursing for prompt follow up and resolution. 12. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. 13. The Administrator will monitor compliance and report findings and outcome/ progress during the monthly QA&A meeting x 3 months for further action and implementation as needed. On 8/21/2021 at 3:52 p.m., the IJ was removed in the presence of the ADM and Registered Nurse Consultant (RNC) after implementation of the acceptable POA were verified and confirmed on an onsite visit via observation, interview, and record review. Findings: On 7/22/2021, the department received a report of Resident 1 alleging being assaulted by LVN 1 on 7/20/2021 and a second report received on 8/13/2021 indicating CNA 1 threw water at Resident 1 and striking him in the face and upper torso area, while in bed on 8/11/2021. During a review of Resident 1 Admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 4/30/2021, the MDS indicated Resident 1 was usually able to make himself understood and understood others and was impaired in cognitive skills (thought process) for daily decision-making. The MDS indicated there were no behavioral symptoms present and Resident 1 required limited to extensive assistance of a one-person physical assist for transfer, bed mobility and activities of daily living. During a review of Resident 1's History and Physical (H/P) examination, dated 5/24/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's care plan titled, The Resident is at Risk for Impaired Cognitive or impaired Thought Process, dated 1/23/2021 and revised on 5/24/2021, the care plan indicated the staffs' intervention were to identify self at each interaction and provide the resident with necessary cues-stop and return if agitated. During a review of Resident 1's Progress Notes- Health Status Note, dated 8/12/2021 and timed 5 p.m., the progress note indicated Resident 1 complained of an incident that happened on 8/11/2021 at approximately 10:40 p.m., with CNA 1. Resident 1 stated CNA 1 went into his room, turned off the television, and threw water from the water pitcher to the resident soaking Resident 1 and his gown. The note indicated CNA 1 told Resident 1 to Shut the F@@@-up and go to sleep. During a review of Resident 1's Interdisciplinary Team note ([IDT] team members from different disciplines working collaboratively with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 8/15/2021 and timed 12:27 p.m., the IDT note indicated Resident 1 claimed staff threw water at him and he was told to turned off his TV and sleep. Upon investigation, CNA 2 denied the allegation because she was on break and CNA 1 was covering for her. During a concurrent observation and interview with Resident 1 on 8/17/2021 at 2:50 p.m., Resident 1 stated he knew abuse would happen again because nothing was done the first time when LVN 1 roughly grabbed the chips from his hand and mouth. Resident 1 stated the Social Services Director (SSD) walked into the room because she heard LVN 1 raising her voice. Resident 1 stated CNA 1 told him to Shut the F@@@-up and go to sleep, and left the room. Resident 1 stated he began to call a nurse for help, but his assigned nurse (CNA 2) was on break. Resident 1 stated the ADM informed him the nurse had been suspended but he was afraid because it was the second time something like that had happen to him. Resident 1 stated CNA 1 threw water all over him including his face. During an interview with the DON on 8/17/2021 at 3:20 p.m., the DON stated he investigated Resident 1's allegations and unsubstantiated both of the incidents with LVN 1 and CNA 1. The DON stated Resident 1's roommate said he did not hear an argument between Resident 1 and the staff. The DON stated he did not interview any other CNA's working in the area on the night of the alleged incident on 8/11/2021. The DON stated CNA 1 was allowed to continue working with the resident and suspended CNA 2 instead. The DON stated CNA 2 should not have been suspended. During an interview with Registered Nurse 3 (RN 3) on 8/17/2021 at 3:35 p.m., RN 3 stated on 8/12/2021 at 5 p.m., she overheard Resident 1 stating CNA 1 threw water on his face and told him to go to sleep. RN 3 stated Resident 1 was not aware of the CNAs name. During an interview with LVN 1 on 8/17/2021 at 4:50 p.m., LVN 1 stated CNA 1 went to help Resident 1 because his assigned CNA was in break. LVN 1 stated Resident 1 had problems before with CNA 1 and CNA 1 did not want to work with Resident 1. LVN 1 stated a few minutes after CNA 1 went into the room, Resident 1 started screaming for help. LVN 1 stated upon entering the room, Resident 1 and his blanket were observed wet and the television off. LVN 1 stated Resident 1 was yelling and screaming CNA 1 had thrown water at him, but CNA 1 denied it. LVN 1 stated RN 1 went into the room and talked to Resident 1 and RN 1 asked for CNA 1 to not return to Resident 1's since a month ago they had a disagreement. During an interview with Family member 1 (FM1) on 8/18/2021 at 1:20 p.m., FM1 stated Resident 1 told her about the first incident when the nurse knocked food from his hands and the second incident when a nurse threw water on him. FM1 stated she thought the staff was going to do something about the incident and was very concerned about Resident 1's safety because Resident 1 was blind and unable to defend himself. During an interview with CNA 1 on 8/18/2021 at 5:20 p.m., CNA 1 stated Resident 1 would scream if he did not get his way. CNA 1 stated on 8/11/2021 she went to the resident's room to turn off the television because it was very loud and Resident 1's assigned CNA was on break. During the interview CNA 1 was observed defensive raising her voice and stating the resident was rude and always yelling at her. During a review of CNA 1's employee file, the file included an Application for Employment, dated 6/21/2021, for a CNA position. The file did not include a Certified Nurse Assistant certificate, no letter of attendance to program for CNA, school completion or identification. During an interview with the ADM, the RNC and DON on 8/19/2021 at 9 a.m., the RNC stated the facility had no files of CNA 1's school completion of the courses for CNAs, no picture identification in the CNA 1's file. The RNC stated the facility did not conduct proper hiring process and allowed CNA 1 to work without having documentation indicating she had gone to CNA school, certification, or a picture ID. The RNC stated CNA 1 provided a name of the school she attended but was unable to verify the school. The DON stated CNA 1 should had not been allowed to work without employment verification. The ADM stated the facility's policy and process was to ensure all documentation was provided and verified prior to the employee starting their shift. During a review of the facility's policy and procedures (P/P) titled, Abuse Prevention Program revised 12/16, the P/P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. As a part of the resident abuse prevention, the administrator would : Protect their residents from abuse by anyone including but not limited to facility staff, other residents, staff from other agencies. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, had a finding entered into the state nurse aide registry concerning abuse of a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse Develop and implement policies and procedures to aid their facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Require staff training / orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Identify and assess all possible incidents of abuse. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Protect residents during abuse investigations. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. During a review of the facility's P/P titled, Abuse Investigation and Reporting, revised 7/2017, the P/P indicated all reports of resident abuse, neglect and mistreatment shall be promptly reported to local state and federal agencies and thoroughly investigated by facility management. The individual conducting the investigation would, as a minimum interview of the staff members (on all shifts) who had contact with the resident during the period of the alleged incident.

Based on observation, interview and record review, the facility failed to follow its policy titled, Abuse Prohibition and Prevention, and investigate and report an alleged physical abuse incident for one of three sample residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse 1 (LVN 1) roughly took chips away from his hand and mouth on 7/20/2021. On 8/11/2021 Certified Nurse Assistant 1 (CNA 1) threw water at Resident 1, yelled at the resident to, Shut the F@@@-up and go to sleep. This deficient practice resulted in Resident 1's alleged abuse allegation to go uninvestigated and placed Resident 1 at risk for harm and continuous abuse. On 8/18/2021 at 5:40 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared in the presence of the Director of Nursing (DON). The DON was notified of the immediacy for alleged abuse to be investigated and reported to prevent abuse from reoccurring and remove perpetrators from the care of the residents while an ongoing investigation was been conducted. The facility submitted an acceptable Plan of Action (POA) on 8/20/2021 of the IJ which included the following: 1. On 8/19,2021, the Clinical Resource (CR) provided a 1:1 in service training to the DON and reviewed policy and procedure (P/P) on Abuse Investigation and Reporting, Abuse Prevention, Recognizing signs and symptoms of Abuse/Neglect. On 7-28-21, LVN 1 was suspended pending investigation and CNA 1 was suspended on 8-11-21 pending investigation. LVN1 was in-serviced on 8-5-21 and 8-18-21. CNA1 was in-serviced on 8-11-21. 2. The Administrator (ADM) and CR and Quality Assurance Nurse (QAN) designee provided staff in-services and training on 8/19/2021 regarding the P/P on Abuse Prevention Investigation and Reporting, Abuse Prevention, Recognizing signs and symptoms of Abuse / Neglect. In services ongoing to be completed on 8-24-21. 3. Resident 1 continued to be monitored for any sign and symptoms of emotional, psychological distress (state of emotional suffering associated with stressors and demands that are difficult to cope with in daily life) related to alleged abuse. Psychologist (person who studies normal and abnormal mental states, perceptual, cognitive, emotional, and social processes and behavior by experimenting with, and observing, interpreting, and recording how individuals relate to one another and to their environments) came to assess resident 8/19/21 with no negative findings noted. Psychiatry visit pending. 4. The Social Services Director conducted resident interviews 8/19/21 and ongoing. Goal is to complete resident interviews at end of 8/19/21. One resident with concern noted, Administrator investigation and reporting in progress. 5.All residents have the potential to be affected by abuse. All resident interviews ongoing and will be completed end of 8/19/21. Social Services Director responsible. Any negative findings will be followed up promptly according to Policy and Procedure in force. 6. Staff in-services related to Policy and Procedure on Abuse Prevention Investigation and Reporting, recognizing signs and symptoms of Abuse/Neglect with emphases on timeline requirement per regulatory guidance provided by the Clinical Resource, Administrator and Quality Assurance Nurse Designee - Ongoing, completion date: 8/23/2021. In-services will be done monthly and/or as needed. 7. The Payroll / AP/ Staffing Designee currently conducting audit of all new hire employee files from last 30 days including registry personnel for completeness and availability of license, certification verification, abuse training, screening, and job description requirement. Ongoing. Infection control Nurse and/or will complete the process moving forward until the Director of Staff Development is hired. To be completed on 8/26/2021. 8. The Department Managers will be conducting resident interviews and observation during daily rounds to ensure residents with concerns and or allegation of any type will be addressed promptly per policy and procedure. This process is ongoing per facility practice. 9. The Director of Nursing/ Designee, RN Supervisor and Licensed Nurse will conduct routine rounds during the shift to include resident and staff interviews and observation to monitor for any signs and symptoms of abuse, initiate investigation promptly for any allegation of abuse as needed and up to reporting process per Policy and Procedure. 10. The Administrator will discuss and review during the morning meeting any findings, trend/ pattern, follow up completed to ensure Abuse Policy and Procedure being followed accordingly with emphases on timely reporting per regulatory guidance. 11. The RN Supervisor will monitor Abuse Prevention and Management program during weekend. Negative findings and concerns will be communicated to the Administrator and or Director of Nursing for prompt follow up and resolution. 12. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. 13. The Administrator will monitor compliance and report findings and outcome/ progress during the monthly QA&A meeting x 3 months for further action and implementation as needed. On 8/21/2021 at 3:52 p.m., the IJ was removed in the presence of the ADM and Registered Nurse Consultant (RNC) after implementation of the acceptable POA were verified and confirmed on an onsite visit via observation, interview, and record review. During a review of Resident 1 Admission Record (Face sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 4/30/2021, the MDS indicated Resident 1 was usually able to make himself understood and understood others and was impaired in cognitive skills (thought process) for daily decision-making. The MDS indicated there were no behavioral symptoms present and Resident 1 required limited to extensive assistance of a one-person physical assist for transfer, bed mobility and activities of daily living. During a review of Resident 1's History and Physical (H/P) examination, dated 5/24/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a concurrent observation and interview with Resident 1 on 8/17/2021 at 2:50 p.m., Resident 1 stated he knew abuse would happen again because nothing was done the first time when LVN 1 roughly grabbed the chips from his and mouth. Resident 1 stated the Social Services Director (SSD) walked into the room because she heard LVN 1 raising her voice at Resident 1 stated a nurse told him to Shut the F@@@-up and go to sleep, and left the room. Resident 1 stated he began to call a nurse for help, but his assigned nurse (CNA 2) was on break. Resident 1 stated the ADM informed him the nurse had been suspended but he was afraid because it was the second time something like that had happen to him. Resident 1 stated the nurse threw water all over him including his face. During an interview with the DON on 8/17/2021 at 3:20 p.m., the DON stated he investigated Resident 1's allegations and unsubstantiated both of the incidents with LVN 1 and CNA 1. The DON stated Resident 1's roommate said he did not hear an argument between Resident 1 and the staff. The DON stated he did not investigate or report to CDPH the alleged abuse. During an interview with Social Services Designee (SSD) on 7/27/2021 at 4 p.m., SSD Resident 1 was frustrated because LVN 1 did not wanted to take him to the patio and started screaming. During a review of the facility's P/P titled, Abuse Investigation and Reporting, revised 7/2017, the P/P indicated all reports of resident abuse, neglect and mistreatment shall be promptly reported to local state and federal agencies and thoroughly investigated by facility management. The individual conducting the investigation would, as a minimum interview of the staff members (on all shifts) who had contact with the resident during the period of the alleged incident.

Based on observation, interview, and record review the facility failed to maintain four of four sampled resident's rooms (Rooms A, B, C, and D) free of cockroaches (also called roaches, small insects that carry infectious bacteria) and failed to conduct an ongoing monitoring for cockroaches in the resident's rooms (34 rooms) for 88 of 88 residents (Resident 1 to 88). These deficient practices had the potential to result in disease transmission to the residents that could lead to life threatening complications and or death. On 8/23/2021 at 4:20 p.m. an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death of resident or residents) was declared and Administrator 1 was notified of the situation and concerns regarding cockroaches found in four resident's rooms (Rooms A, B, C, and D) and failure of the facility to have an ongoing monitoring to ensure the residence rooms (34 resident rooms) of the 88 residents (Resident 1 to 88) were free from cockroaches. On 08/27/2021 at 11:30 a.m., the Department removed the IJ and notified Administrator 1, after verifying and confirming on-site that the facility had implemented the acceptable written plan of action (POA, a plan to remove the IJ situation) as follows: 1. The technician (not identified) of Pest Control Company 1 treated Rooms A and B, the patios, the outside perimeter of the facility, the laundry area, and the central supply closet on 8/23/2021 (at 10 a.m.) for cockroaches using bait. The treatment, which was scheduled after Surveyor 1 informed the facility on 8/21/2021 (Saturday) of the cockroaches found (areas not specified), was completed before Surveyor 2 arrived on 8/23/2021 at 11:20 a.m. Pest Control Company 1 treated Rooms A and B, the patios, the outside perimeter of the facility, the laundry area, and the central supply closet with 10 grams of Abamectin .0500%, which is a bait gel, that was placed in radios, televisions, and other electronic equipment that if the cockroaches eat the bait gel or Abamectin, they will die. The facility also treated with one (1) ounce (a unit of measurement) of Indoxacarb 0.06% gel, an insecticide, that when the cockroaches eat the gel, they will die or spread the gel to other cockroaches through eating each other's feces and cannibalizing (eat) each other which will also result in death. This Indoxacarb gel is placed in any areas, but not in open areas, such as wheels of beds, and in the base board where there are small openings. 2. The technician (not identified) of Pest Control Company 2 completed the treatment of Resident rooms A, B, C and D on 8/23/2021 in the afternoon (time not specified). The technician of Pest Control Company 2 treated Rooms A, B, C, and D with 1 ounce of Maxforce, which is a gel bait with an (IGR) Insect Growth Regulator that does not allow the cockroach to reproduce once eaten and will not allow the infant cockroaches to reach adulthood. 3. Pest Control Company 1 treated all resident rooms on 8/24/2021 in the morning (time not specified) for ants and cockroaches with 12 ounces of Indoxacarb 0.06% gel and with 15 grams of Abamectin .0500% bait gel that was placed in radios, televisions, and other electronic equipment. 4. The administrator (Administrator 1) conducted an environmental assessment with the Maintenance Supervisor and the technician (not identified) of Pest Control Company 2 on 8/24/2021 in the afternoon (indicate not specified). The technician of Pest Control Company 2 completed a treatment of resident rooms, Room A, B, C, and D, where cockroaches and egg casings were identified by Surveyor 2 on 8/23/2021. 5. Administrator 1 conducted an environmental assessment with the maintenance supervisor and the technician of Pest Control Company 1 on 8/24/2021. The technician has completed treatment of all resident rooms (34 rooms) in the facility on 8/24/2021. No other cockroaches were found in any other areas. 6. All 88 residents (Resident 1 to 88) have the potential to be affected by exposure to cockroaches that could lead to disease transmission. When resident rooms are treated with a spray by the technician from the pest management, the residents will be removed from their rooms prior to treatment and can return to their rooms one hour after treatment. 7. Administrator 1 and the Director of Nursing (DON) gave an in-service to the staff starting on 8/23/2021 and ongoing. Any staff on medical leave or unavailable will be in-serviced upon return prior to start of shift or workday. The in-service included educating staff that if any bugs or pests are observed in the facility, the staff will report to the administrator and or Maintenance Supervisor within an hour. The administrator and or Maintenance Supervisor will call Pest Control Company 1 within an hour to treat for any noticed pest issue. 8. The facility has an updated written pest control agreement with Pest Control Company 1 that indicated the frequency of the pest control treating in the facility. Pest Control Company 1 will be in facility once per week for one month. Pest Control Company 1 will use both spray and bait for treatment of the cockroaches and pests in the facility. The facility has a total of 34 resident rooms and Pest Control Company 1 will treat with bait and spray 15 resident rooms each weekly visit which will require the residents to be out of their rooms during and one hour after the treatment. The first service will include kitchen, employee lounge, shower rooms and 15 resident rooms. The second service will include the outside perimeter and 15 resident rooms. The third service will include 15 resident rooms and the fourth service will include 15 resident rooms. If additional areas need to be treated during these weekly services, Pest Control Company 1 has agreed to treat those identified areas. Pest Control Company 1 believes with this treatment regimen along with staff doing facility rounds to identify any issues with pests, that the cockroaches should be eliminated from the facility. If the cockroaches do move in the facility, the spray insecticide with an (IGR) Insect Growth Regulator that sterilizes the cockroach so the cockroaches cannot reproduce and will also act as a killing agent. Administrator 1 along with Maintenance Supervisor and the technician from Pest Control Company 1 will assess for need to continue weekly, bi-monthly, or monthly pest control treatments depending on any trends of cockroach and pest activity. 9. Administrator 1 in-serviced on 8/24/2021 the Maintenance Supervisor and Housekeeping Supervisor to use only commercially approved insecticides for pest treatment in the facility. The unapproved insecticides (insecticides for household use only) were properly disposed of and are no longer in the facility. From now on, the facility will no longer use unapproved insecticides. The Maintenance Supervisor will monitor weekly for any use of unapproved insecticides and report findings to Administrator 1 within an hour. 10. Administrator 1 will monitor weekly compliance by staff of monitoring and reporting of findings on pest control, and report outcomes and or progress during the monthly Quality Assurance and Performance Improvement (QAPI, a program to improve the quality of life and quality of care and services delivered in nursing homes) meeting for three (3) months for further action and implementation as needed. 11. The facility's Pest Control Policy was updated to clarify the frequency of treatment to monthly. 12. The Wallpaper that was coming away from the wall was glued down in resident room, Room A and the baseboard in Room B was replaced to eliminate any hiding places for cockroaches and or pests. 13. Everything was implemented and completed by 8/26/2021 for this POA. Findings: During an interview on 8/23/2021, at 11:25 a.m., Administrator 1 stated, that the facility just received a pest control service (from Pest Control Company 1) that morning around 10 a.m. Pest Control Company 1 treated Room A and Room B, the patios, the outside perimeter of the facility, the laundry area, and the central supply closet before Surveyor 2 discovered cockroaches in a residents' room (Room A, B, C or D) while conducting a follow-up visit for Surveyor 1's report of finding cockroaches in the facility (areas not specified) on 8/21/2021. During a review on 8/23/2021, at 11:30 a.m., of the pest control service records, the service receipts indicate that last pest control service was conducted on 8/23/2021 (at 10 a.m.). The service is normally conducted twice a month per receipts, but extra treatment was requested due to cockroach activity in the facility. Prior to 8/23/2021 (at 10 a.m.) service, the last date of service was 8/2/2021. During an observation tour with the Maintenance Supervisor in Room B on 8/23/2021 at 11:58 a.m., two (2) dead German cockroaches (a small specie of cockroach) were on the floor in Room B near bed C. The Maintenance Supervisor validated the findings (had the same observation). During an interview on 8/23/2021, at 12:02 p.m. with the Housekeeping Supervisor, she stated that she normally sees the cockroaches in the residents' rooms (did not specify which specific rooms) and that she has not seen any cockroach activity recently. When she noticed the cockroaches, she stated she treated them, with a spray. The Housekeeping Supervisor showed the spray she used for the treatment and it was a can of Raid Ant and Roach spray. The can of Raid is marked for household use only. During an interview on 8/23/2021, at 12:05 p.m. with Resident 1, he stated that he observed cockroaches two nights ago (on 8/21/2021) and his room was not sprayed (with an insecticide spray) that time. He also stated that he sees them (the cockroaches) once in a while (in his room). During a tour with the Maintenance Supervisor of Room C on 8/23/2021 at 12:13 p.m., six (6) live German adult cockroaches, three (3) dead German adult cockroaches, and two (2) egg casings were observed on the floor beneath the oxygen concentrator located near Bed A. The Maintenance Supervisor validated the findings (had the same observation). During an interview on 8/23/2021, at 4:20 p.m. with Administrator 1, he stated that the facility would no longer continue to use household use only insecticides to treat insects in the facility. Administrator 1 stated the facility would contact the pest control service for treatment when needed. During a follow up visit at the facility on 8/25/2021 at 2:45 p.m. one (1) live adult German cockroach was observed with Administrator 1 in Room C behind the nightstand of Bed B. Administrator 1 validated the findings (had the same observation). Administrator 1 stated that further treatment would be conducted in this area. During a review of the facility's pest control policy, dated May 2008, the policy indicated that the facility would maintain a pest control program to ensure the building is kept free of insects and rodents.

Based on interview, and record review, the facility failed to provide quality nursing care (nursing care that results in desirable outcome and are consistent with current professional knowledge and practice) for 21 of 21 residents by failing to: 1. Monitor and document blood sugar (BS) levels on the Medication Administration Record (MAR) from 4/1/21 thru 5/10/21 for 21 of 21 residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322). 2. Administer and document insulin (medication used to regulate BS levels) doses on the MAR from 4/1/21 to 5/10/21 for twenty-one of twenty-one residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322) 3. Monitor HgA1c (a test that measures average BS levels over a three-month period) levels for 17 of 21 residents (Residents 2, 7, 10, 11, 25, 26, 32, 35, 36, 41, 47, 52, 54, 57, 172, 173 and 322) as indicated on the facility's Policy and Procedures, Diabetes-Clinical Protocol. These deficient practices of not monitoring and documenting BS levels, not administering and documenting insulin doses and not monitoring HgA1c levels, compromised the health of all 21 residents and had the potential to compromise the resident's health and increased the risk to experienced serious health complications such [CONDITION(S)] (excess of sugar in the blood), coma (a prolonged period of unconsciousness brought on by illness or injury) and likely resulting in hospitalization or death. On 5/10/2021 at 4:09 p.m., the Administrator (ADMIN) and the Director of Nursing 1 (DON 1), were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to have a system in place for 21 of 21 residents from receiving scheduled and as needed (sliding scale) medications as prescribed by the physician. Monitor BS levels and HgA1C testing. The facility's ADMIN and DON 1 were notified of the potential for serious harm to all 21 residents and seriousness of the residents' health and safety being threatened. On 5/11/2021 at 3:25 p.m., the ADMIN was notified the IJ was lifted after review and on-site validation of the accepted Plan of Action (POA) via observations, interviews, and record review of the following: 1. On 5/10/21, Quality Assurance in-serviced all licensed nurses including registry nurses, regarding insulin administration using the facility's electronic computer record (PCC) to ensure that no insulin order has been omitted and performed accordance with physicians' orders and BS check on PCC as ordered. 2. All identified and affected residents were assessed by RN Supervisor on 5/10/21. No acute change in condition noted. 3. On 5/10/21, all residents with diabetes records were reviewed to ensure HgA1c test result were available. Nine residents were identified to not have HgA1c test since admission, and six residents with HgA1c ([hemoglobin A1c] test that evaluates the average amount of glucose in the blood over three [3] months by measuring the percentage glycated hemoglobin in the blood) test more than three months old. 4. On 5/10/21, licensed nurses contacted the physicians for those residents and obtained orders to perform HgA1c test. Lab test performed, processed, and result received as of 5/11/21. Seven resulted HgA1c reviewed, and the physician notified of recent results. Physicians response and orders will be carried out and resident/Responsible Party (RP) notified for any changes. 5. Affected residents will be monitored for 72 hours for any changes in condition. Care Plan reviewed and interventions updated 5/11/21 and ongoing. 6. On 5/11/21, medical records department conducting audit for all residents with MD order for HgA1c and ongoing. 7. Ongoing licensed nurses including registry nurses in-service being conducted by the DON 2 and Director of Staff Development (DSD) on 5/11/21 on the following topic: review of Policy and Procedure on Diabetes Clinical Protocol, Insulin Administration and Medication Administration documentation, including but not limited to laboratory test order follow up with physician and RP notification. Completion date 5/14/21. 8. Medication Administration Record (MAR) will be audited by the medical records designee daily Monday to Friday to ensure that BS check and insulin administration recorded timely. The Registered Nurse (RN) Supervisor/Designee will check the PCC eMAR (electronic MAR) dashboard daily to ensure compliance. 9. Licensed nurses will check and monitor PCC eMAR during their shift to ensure complete and timely documentation. 10. The medical records department will maintain daily audit of laboratory results, for example, HgA1c Monday to Friday. Findings will be discussed during the daily morning meeting for further follow up and management. 11. The Consulting Pharmacist (Consulting Pharmacist) will maintain the monthly Medication Regimen Review (MRR) with emphases on assessing residents with Insulin order and on diabetic management. Follow up with physician, resident and RP notification for any treatment changes will be carried out by the licensed nurses. 12. Applicable Policy and Procedures reviewed on 05/11/2021, no changes made at this time. 13. The CP will monitor compliance with physicians' orders monthly and present a report to the DON2 and ADMIN. 14. The DON2 or designee will provide a summary trend analysis of findings to the monthly Quality Assurance and Performance Improvement ([QAPI] committee meeting for review and recommendations). If there are no negative findings reported after six months, issue is considered resolved. Findings: a) During a review of Resident 2's Admission Record (Face Sheet), dated 5/10/21, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Medication Administration Record (MAR), for the review periods of 4/2021 through 5/2021, the MAR indicated Resident 2 was prescribed [MEDICATION(S)] 20 units in the morning, hold if BS less than 100, subcutaneously before meals and at bedtime and per sliding scale. Resident 2's MAR indicated that a total of 21 BS levels were not documented, seven (7) doses of [MEDICATION(S)] were not signed as administered, and 18 doses of [MEDICATION(S)] R as per sliding scale were not signed as administered to Resident 2. During a review of Resident 2's undated Care Plan titled, Diabetes Mellitus, dated 3/21/2021, the care plan indicated to give diabetic medications as ordered by the physician, and check fasting serum (blood) BS. b) During a review of Resident 6's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 6's Order Summary Report, dated 5/10/21, the report indicated Resident 6 was prescribed [MEDICATION(S)] R as per sliding scale subcutaneously before meals and at bedtime and [MEDICATION(S)] 15 units subcutaneously two times a day and to hold for BS less than 100. During a review of Resident 6's Blood Glucose Monitoring ([BGM] - where the insulin doses and BS are documented) log between 4/1/21 and 5/10/21 indicated a total of 27 BS levels not documented, 12 doses of [MEDICATION(S)] were not signed as administered, and 15 doses of [MEDICATION(S)] R as per sliding scale were not signed as administered. During a review of Resident 6's undated Care Plan titled, Diabetes Mellitus, the care plan indicated to give diabetes medications and check fasting serum BS as ordered by doctor. c) During a review of Resident 7's Face Sheet, dated 5/10/21, the face sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 7's Order Summary Report, dated 5/10/21, the report indicated on 3/18/21 Resident 7 was prescribed [MEDICATION(S)] 5 units subcutaneously one time a day, to hold if BS less than 100, and Insulin Regular as per sliding scale subcutaneously three times a day AC meals and HS. During a review of Resident 7's BGM dated 4/1/21 to 5/10/21, the BGM indicated a total of 11 BS levels not documented, 3 doses of [MEDICATION(S)] and 8 doses of Insulin Regular sliding scale were not signed as administered to Resident 7. During a review of Resident 7's Care Plan titled, Diabetes Mellitus, dated 1/21/21, the care plan indicated to give diabetic medications as ordered by the doctor. During a review of Resident 7's clinical chart, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d) During a review of Resident 10's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 10's Order Summary Report, dated 5/10/21, the report indicated on 11/23/20 Resident 10 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime and on 1/10/21 [MEDICATION(S)] Kwikpen 20 units in the morning and to hold for BS less than 100 was prescribed. During a review of Resident 10's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 22 BS levels not documented, 8 doses of [MEDICATION(S)] Kwikpen were not signed as administered, and 14 doses of Insulin Regular as per sliding scale were not signed as administered to Resident 10. During a review of Resident 10's Care Plan titled, Diabetes Mellitus, dated 10/24/20, the care plan indicated to give diabetic medications as ordered by the doctor. e) During a review of Resident 11's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 11 was initially admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 11's Order Summary Report, dated 5/10/21, the report indicated on 12/12/20 Resident 11 was prescribed [MEDICATION(S)] Kwikpen 20 units subcutaneously two times a day, [MEDICATION(S)] 20 units subcutaneously two times a day, and insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 11's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 17 BS levels not documented, 1 dose of [MEDICATION(S)] was not signed as administered, 6 doses of [MEDICATION(S)] not signed as administered, and 10 doses of Insulin Regular as per sliding scale were not signed as administered to Resident 11. During a review of Resident 11's Care Plan titled, Diabetes Mellitus, dated 10/10/20, the care plan indicated to give diabetes medications as ordered by the doctor and check fasting serum BS as ordered by the doctor. f) During a review of Resident 25's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 25's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 25 was prescribed [MEDICATION(S)] R as per sliding scale subcutaneously three times a day. During a review of Resident 25's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 7 BS levels not documented, and 7 doses of [MEDICATION(S)] R as per sliding scale not signed as administered to Resident 25. During a review of Resident 25's Care Plan titled, Diabetes Mellitus, dated 11/20/20, the care plan indicated to give diabetes medications as ordered by doctor and check fasting serum BS. g) During a review of Resident 26's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 26's Order Summary Report, dated 5/10/21, the report indicated on 4/7/21 Resident 26 was prescribed [MEDICATION(S)] as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 26's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 9 BS levels not documented, and 9 doses of [MEDICATION(S)] sliding scale not signed as administered to Resident 26. During a review of Resident 26's Care Plan titled, Diabetes Mellitus, dated 4/7/21, the care plan indicated to give diabetes medications as ordered by the doctor and check fasting serum BS. h) During a review of Resident 32's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 32 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 32's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 32 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 32's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 19 BS levels were not documented, and 19 doses of Insulin Regular as per sliding scale not signed as administered to Resident 32. During a review of Resident 32's undated Care Plan titled, Diabetes Mellitus, the care plan indicated to monitor BS by finger stick, administer insulin, give diabetes medications, and check fasting serum BS as ordered by the doctor. i) During a review of Resident 33's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 33's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 33 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 33's BGM between 4/1/21 and 5/10/21, the BGM indicated a total of 14 BS levels not documented, and 14 doses of Insulin Regular as per sliding scale not signed as administered to Resident 33. During a review of Resident 33's Care Plan titled, Diabetes Mellitus, dated 12/28/20, the care plan indicated to give diabetes medications and check fasting serum BS as ordered by the doctor. j) During a review of Resident 35's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 35's Order Summary Report, dated 5/10/21, the report indicated on 10/28/20 Resident 35 was prescribed Insulin Regular as per sliding scale subcutaneously two times a day AC (before) breakfast and HS (bedtime), on 3/14/20 [MEDICATION(S)] 10 units subcutaneously one time a day and to hold if BS less than 100, and on 2/27/21 [MEDICATION(S)] (type of insulin) 10 units subcutaneously at HS and to hold if BS less than 100. During a review of Resident 35's BGM between 4/1/21 and 5/10/21, the BGM indicated a total of 15 BS levels not documented, 9 doses of [MEDICATION(S)] and 6 doses of Insulin Regular sliding scale not signed as administered to Resident 35. During a review of Resident 35's Care Plan, titled, Diabetes Mellitus, dated 3/7/20, the care plan indicated to give diabetes medications as ordered by doctor. k) During a review of Resident 36's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 36 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 36's Order Summary Report, dated 5/10/21, the report indicated on 3/9/21 Resident 36 was prescribed Insulin Regular as per sliding scale. During a review of Resident 36's MAR starting 4/1/21 thru 5/10/21, the MAR indicated 13 doses were not given and BS not checked. l) Review of Resident 41's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 41's Order Summary Report, dated 5/10/21, the report indicated on 9/14/20 Resident 41 was prescribed [MEDICATION(S)] 5 unit subcutaneously two times a day and to hold if BS less than 100. During a review of Resident 41's BGM starting 9/1/20 thru 5/10/21, the BGM indicated a total of 60 BS levels not documented, and 60 [MEDICATION(S)] doses not signed as administered to Resident 41. During a review of Resident 41's care plan titled, Diabetes Mellitus, dated 1/2/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. m) Review of Resident 47's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 47's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 47 was prescribed insulin regular per sliding scale. During a review of Resident 47's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 20 BS levels not documented and not signed as administered to Resident 47. During a review of Resident 47's undated care plan titled, Diabetes Mellitus, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. n) Review of Resident 52's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 52's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 52 was prescribed insulin regular per sliding scale. During a review of Resident 52's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 17 BS levels and insulin was not documented, signed as administered to Resident 52. During a review of Resident 52's care plan titled, Diabetes Mellitus, dated 2/21/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. o) Review of Resident 54's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 54's Order Summary Report, dated 5/10/21, the report indicated on 4/29/21 Resident 54 was prescribed insulin regular per sliding scale. During a review of Resident 54's BGM starting 4/29/21 thru 5/10/21, the BGM indicated a total of five (5) BS levels not documented and not signed as administered to Resident 54. During a review of Resident 54's care plan titled, Diabetes Mellitus, dated 3/19/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. p) Review of Resident 57's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 57's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 57 was prescribed insulin [MEDICATION(S)] 15 units subcutaneously two times a day. During a review of Resident 57's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of nine (9) BS levels not documented, and insulin not signed as administered to Resident 57. During a review of Resident 57's care plan titled, Diabetes Mellitus, dated 7/7/20, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. q) Review of Resident 60's Face Sheet, dated 4/11/21, the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 60's Order Summary Report, dated 5/10/21, the report indicated on 4/13/21 Resident 60 was prescribed regular insulin detemir 15 units two times a day and Regular insulin per sliding scale. During a review of Resident 60's BGM starting 4/13/21 thru 5/10/21, the BGM indicated a total of 13 BS levels and insulin doses not documented and not signed as administered to Resident 60. During a review of Resident 60's care plan titled, Diabetes Mellitus, dated 4/12/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. r) Review of Resident 61's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 61's Order Summary Report, dated 5/10/21, the report indicated on 4/13/21 Resident 61 was prescribed insulin regular as per sliding scale and on 2/8/21 [MEDICATION(S)] KiwiPen 20 units every morning and at bedtime was prescribed. During a review of Resident 61's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of nine 30 BS levels and insulin doses not documented and not signed as administered to Resident 61. During a review of Resident 61's care plan titled, Diabetes Mellitus, dated 4/1/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. s) During a review of Resident 172's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 172 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 172's Order Summary Report, dated 5/10/21, the report indicated on 4/3/21 Resident 172 was prescribed insulin [MEDICATION(S)] 30 units subcutaneous at bedtime. During a review of Resident 172's BGM starting 4/3/21 thru 5/10/21, the BGM indicated a total of 13 BS levels and insulin doses were not documented and signed as administered to Resident 172. During a review of Resident 172's care plan titled, Diabetes Mellitus, dated 4/22/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. t) Review of Resident 173's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 173 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 173's Order Summary Report, dated 5/10/21, the report indicated on 4/22/21 Resident 173 was prescribed insulin regular as per sliding scale. During a review of Resident 173's BGM starting 4/22/21 thru 5/10/21, the BGM indicated a total of eight (8) BS levels and insulin doses not documented and not signed as administered to Resident 173. During a review of Resident 173's care plan titled, Diabetes Mellitus, dated 4/22/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. u) During a review of Resident 322's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 322 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 322's Order Summary Report, dated 5/10/21, the report indicated on 5/5/21 Resident 322 was prescribed insulin [MEDICATION(S)] per sliding scale, on 4/30/30 [MEDICATION(S)] 28 units one time a day and [MEDICATION(S)] 30 units at bedtime. During a review of Resident 322's BGM starting 4/29/21 thru 5/10/21, the BGM indicated a total of 20 BS levels and 15 insulin doses not documented and not signed as administered to Resident 322. During a review of Resident 322's care plans indicated no care plan for diabetes monitoring was created. During a review of Resident 41's clinical chart did not contain a record for HgA1c level physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and review of resident's laboratory results, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coordinator stated after a thorough search for Residents 2, 7, 10, 11, 25, 26, 32, 35, 36, 41, 47, 52, 54, 57, 172, 173 and 322 HgA1c levels, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/11/21 at 9:36 a.m., Licensed Vocational Nurse 6 (LVN 6) stated insulin medication information was documented on the MAR, under Blood Sugar (BS). LVN 6 stated prior to the administration of medication, the staff would verify and check physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 6 stated if the staff did not check the BS tab, they would not know to do the BS level checks. LVN 6 stated if registry staff was not familiar with the eMAR, they could overlook the BS tab and not administer the insulin. LVN 6 stated that nursing staff should provide a reason for missed doses of insulin or BS on the eMAR. LVN 6 stated if BS were not checked, then residents can go into diabetic coma because of BS being high. LVN 6 stated when a resident refuses a BS check or insulin dose, licensed nursing staff should make more attempts, make the physician aware, monitor the resident and document on the eMAR and progress notes. During an interview on 5/11/21 at 10:33 a.m., CP stated she completes Medication Regimen Review ([MRR] -a thorough evaluation of the medication regimen of a resident) for all residents. The CP stated for residents with diabetes she makes sure there are HgA1c level orders, and if not then she makes recommendations to the physician to order the level. The CP stated HgA1c levels should be ordered every three months and when residents are stable then it can be done every six months. The CP stated ordering HgA1c levels every three months was standard of practice, and a diagnostic tool to evaluate the effectiveness of therapy for the resident to determine if changes in medication therapy are necessary. The CP stated HgA1c levels above 8% should be evaluated closely and routinely. The CP stated she had noticed the facility had MAR charting gaps for the BS levels and insulin administration and had addressed this failure with the past DON. The CP stated the MRR for the month of March 2021 addresses this failure in the summary section to the previous DON. The CP stated she may have also communicated this failure to the new DON 1, whom she had only met once. During an interview on 5/11/21 at 11:02 a.m., the MDS Coordinator stated HgA1c should be monitored in the residents' Care Plan (document outlining a detailed approach to care customized to an individual resident's need.) The MDS stated that medical records department had not been tracking to ensure residents have HgA1c orders but will do so going forward. The MDS stated diabetic (persons with diabetes) residents on insulin should have HgA1c levels checked every three months. The MDS stated that HgA1c is important because it shows if the insulin therapy is effective for the resident and if any changes to the medications need to be made based on the level. The MDS stated that it is important to have the right medications for diabetic residents to make sure their BS levels are stabilized so that they do not have complications like coma, get hospitalized or die. The MDS stated all diabetic residents should have a baseline HgA1c when admitted and that lab services did not stop working even during COVID. During an interview on n 5/11/21 at 11:51 a.m., the DON 2 stated carrying out the orders given by physicians are important, especially for diabetic residents. The DON 2 stated documentation is basic nursing function. The DON 2 stated if the MAR had gaps and was not signed, then it was understood the BS orders were not carried out, and the insulin doses were not administered. The DON 2 stated HgA1c should be ordered at admission for diabetic residents and re-ordered every three months to know if the medications are working. The DON 2 stated that the diabetes care plan should include the monitoring for HgA1c. The DON 2 stated if BS levels were not checked and insulin doses not given then the residents could have low or high BS levels, go into coma, get hospitalized , have ketoacidosis (serious diabetes complication where the body produces excess blood acids), and even die. During a phone interview on 5/11/21 at 12:40 p.m., during a phone interview, the Medical Doctor (MD) 1 stated she usually orders HgA1c levels and when she overlooks to order the level, she gets reminded by the CP. The MD1 stated HgA1c should be ordered every three months and for stable residents can be every six months or yearly. The MD1 stated that BS levels are not enough to determine effectiveness of the medications and HgA1c level is needed to determine if changes in the medications are needed. The MD1 stated that not having HgA1c levels for residents is a concern and should be part of their diabetes care plan. The MD1 stated it is harmful for the resident when the BS level is not checked, or insulin orders not administered. During a review of the facility's policy and procedures (P/P) titled, Diabetes-Clinical Protocol, revised 2020, the P/P indicated for residents who meet the criteria for diabetes testing, the physician would order pertinent screening such as A1C. the P/P indicated the staff would monitor blood glucose levels as indicated by the physician. During a review of the facility's P/P titled, Insulin Administration, revised on 9/2014, the facility staff would document the blood glucose results as ordered by the physician and document the dose and concentration of the insulin injection. During a review of the facility's P/P titled, Obtaining a Fingerstick Glucose Level, revised 9/2011, the P/P indicated the staff would document the name of the staff performing the fingerstick, date and time performed, assessment and data obtained during the procedure, refusal and reasons for refusal and interventions taken, blood sugar results and physician notification and signature of the staff.

Based on interview, and record review, the facility failed to administer insulin (medication used to treat and regulate high blood sugar [BS] levels) doses and document on the Medication Administration Record (MAR) for 21 of 21 sampled residents (Residents 2, 6, 7, 10, 11, 25, 26, 32, 33, 35, 36, 41, 47, 52, 54, 57, 60, 61, 172, 173 and 322) through the period starting 4/1/2021 thru 5/10/2021 as followed: 1) Resident 2 did not received seven (7) doses of [MEDICATION(S)] insulin (long-acting medication used to control elevated Blood Sugar [BS]) 20 units ([U] units of measurement), and 18 doses of [MEDICATION(S)] R (type of insulin) subcutaneously (under the skin) as per sliding scale (insulin dose dependent on the BS level). 2) Resident 6 did not receive 12 doses of [MEDICATION(S)] (long-acting insulin) 15 units subcutaneously, and 15 doses of [MEDICATION(S)] R (short-acting insulin) as per sliding scale subcutaneously. 3) Resident 7 did not receive three (3) doses of [MEDICATION(S)] (long-acting insulin used to control BS) 5 units subcutaneously, and eight (8) doses of Insulin Regular (type of insulin) as per sliding scale subcutaneously. 4) Resident 10 did not receive eight (8) doses of [MEDICATION(S)] Kwikpen (long-acting insulin) 20 units, and 14 doses of Insulin Regular as per sliding scale subcutaneously. 5) Resident 11 did not receive six (6) doses of [MEDICATION(S)] Kwikpen 20 units subcutaneously, one (1) dose of [MEDICATION(S)] 20 units subcutaneously, and 10 doses of Insulin Regular as per sliding scale subcutaneously. 6) Resident 25 did not receive seven (7) doses of [MEDICATION(S)] R (immediate-acting insulin used to help with elevated BS) as per sliding scale subcutaneously. 7) Resident 26 did not receive nine (9) doses of [MEDICATION(S)] (fast-acting insulin) as per sliding scale subcutaneously. 8) Resident 32 did not receive 19 doses of Insulin Regular as per sliding scale subcutaneously. 9) Resident 33 did not receive 14 doses of Regular Insulin as per sliding scale subcutaneously. 10) Resident 35 did not receive nine (9) doses of [MEDICATION(S)] 10 units, and six (6) doses of Insulin Regular as per sliding scale subcutaneously. 11) Resident 36 did not receive 13 doses of Insulin Regular as per sliding scale subcutaneously. 12) Resident 41 did not receive 60 doses of [MEDICATION(S)] five (5) units subcutaneously between 9/14/20 through 5/10/21. 13) Resident 47 did not receive 20 doses of Insulin Regular as per sliding scale subcutaneously. 14) Resident 52 did not receive 18 doses of Insulin Regular as per sliding scale subcutaneously. 15) Resident 54 did not receive five (5) doses of [MEDICATION(S)] R as per sliding scale subcutaneously. 16) Resident 57 did not receive seven (7) doses of [MEDICATION(S)] 15 units subcutaneously. 17) Resident 60 did not receive six (6) doses of Detemir (type of insulin) 15 units subcutaneously, and eight (8) doses of Insulin Regular as per sliding scale subcutaneously. 18) Resident 61 did not receive 12 doses of [MEDICATION(S)] N Kwikpen (type of insulin) 20 units subcutaneously, and 17 doses of Insulin Regular as per sliding scale subcutaneously. 19) Resident 172 did not receive four (4) doses of [MEDICATION(S)] 30 units subcutaneously. 20) Resident 173 did not receive eight (8) doses of [MEDICATION(S)] R as per sliding scale subcutaneously. 21) Resident 322 did not receive five (5) doses of [MEDICATION(S)] 28 units subcutaneously, two (2) doses of [MEDICATION(S)] 30 units subcutaneously, and 13 doses of [MEDICATION(S)] (type of insulin) as per sliding scale subcutaneously. This deficient practice of failing to administer insulin doses in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/2021 at 4:09 p.m., the Administrator (ADMIN) and the Director of Nursing 1 (DON 1), were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to have a system in place for 21 of 21 residents from receiving scheduled and as needed (sliding scale) medications as prescribed by the physician. The facility's ADMIN and DON 1 were notified of the potential for serious harm to all 21 residents and seriousness of the residents' health and safety being threatened. On 5/11/2021 at 3:25 p.m., the ADMIN was notified the IJ was lifted after review and on-site validation of the accepted Plan of Action (POA) via observations, interviews, and record review of the following: 1. On 5/10/21, Quality Assurance in-serviced all licensed nurses including registry nurses, regarding insulin administration using the facility's Point Click Care (PCC) to ensure that no insulin order has been omitted and performed accordance with physicians' orders and BS check on PCC as ordered. 2. All identified and affected residents were assessed by RN Supervisor on 5/10/21. No acute change in condition noted. 3. On 5/10/21, all residents with diabetes records were reviewed to ensure HgA1c test result were available. Nine residents were identified to not have HgA1c test since admission, and six residents with HgA1c ([hemoglobin A1c] test that evaluates the average amount of glucose in the blood over three [3] months by measuring the percentage glycated hemoglobin in the blood) test more than three months old. 4. On 5/10/21, licensed nurses contacted the physicians for those residents and obtained orders to perform HgA1c test. Lab test performed, processed, and result received as of 5/11/21. Seven resulted HgA1c reviewed, and physician notified of recent results. Physicians response and orders will be carried out and resident/Responsible Party (RP) notified for any changes. 5. Affected residents will be monitored for 72 hours for any changes in condition. Care Plan reviewed and interventions updated 5/11/21 and ongoing. 6. On 5/11/21, medical records department conducting audit for all residents with MD order for HgA1c and ongoing. 7. Ongoing licensed nurses including registry nurses in-service being conducted by the DON 2 and Director of Staff Development (DSD) on 5/11/21 on the following topic: review of Policy and Procedure on Diabetes Clinical Protocol, Insulin Administration and Medication Administration documentation, including but not limited to laboratory test order follow up with physician and RP notification. Completion date 5/14/21. 8. Medication Administration Record (MAR) will be audited by the medical records designee daily Monday to Friday to ensure that BS check and insulin administration recorded timely. The Registered Nurse (RN) Supervisor/Designee will check the PCC eMAR (electronic MAR) dashboard daily to ensure compliance. 9. Licensed nurses will check and monitor PCC eMAR during their shift to ensure complete and timely documentation. 10. The medical records department will maintain daily audit of laboratory results, for example, HgA1c Monday to Friday. Findings will be discussed during the daily morning meeting for further follow up and management. 11. The Consulting Pharmacist (Consulting Pharmacist) will maintain the monthly Medication Regimen Review (MRR) with emphases on assessing residents with Insulin order and on diabetic management. Follow up with physician, resident and RP notification for any treatment changes will be carried out by the licensed nurses. 12. Applicable Policy and Procedures reviewed on 05/11/2021, no changes made at this time. 13. The CP will monitor compliance with physicians' orders monthly and present a report to the DON2 and ADMIN. 14. The DON2 or designee will provide a summary trend analysis of findings to the monthly Quality Assurance and Performance Improvement ([QAPI] committee meeting for review and recommendations). If there are no negative findings reported after six months, issue is considered resolved. Findings: a) During a review of Resident 2's Admission Record (Face Sheet), dated 5/10/21, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Medication Administration Record (MAR), for the review periods of 4/2021 through 5/2021, the MAR indicated Resident 2 was prescribed [MEDICATION(S)] 20 units in the morning, hold if BS less than 100, subcutaneously before meals and at bedtime and per sliding scale. Resident 2's MAR indicated that a total of 21 BS levels were not documented, seven (7) doses of [MEDICATION(S)] were not signed as administered, and 18 doses of [MEDICATION(S)] R as per sliding scale were not signed as administered to Resident 2. During a review of Resident 2's undated Care Plan titled, Diabetes Mellitus, dated 3/21/2021, the care plan indicated to give diabetic medications as ordered by the physician, and check fasting serum (blood) BS. b) During a review of Resident 6's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 6's Order Summary Report, dated 5/10/21, the report indicated Resident 6 was prescribed [MEDICATION(S)] R as per sliding scale subcutaneously before meals and at bedtime and [MEDICATION(S)] 15 units subcutaneously two times a day and to hold for BS less than 100. During a review of Resident 6's Blood Glucose Monitoring ([BGM] - where the insulin doses and BS are documented) log between 4/1/21 and 5/10/21 indicated a total of 27 BS levels not documented, 12 doses of [MEDICATION(S)] were not signed as administered, and 15 doses of [MEDICATION(S)] R as per sliding scale were not signed as administered. During a review of Resident 6's undated Care Plan titled, Diabetes Mellitus, the care plan indicated to give diabetes medications and check fasting serum BS as ordered by doctor. c) During a review of Resident 7's Face Sheet, dated 5/10/21, the face sheet indicated Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report, dated 5/10/21, the report indicated on 3/18/21 Resident 7 was prescribed [MEDICATION(S)] 5 units subcutaneously one time a day, to hold if BS less than 100, and Insulin Regular as per sliding scale subcutaneously three times a day AC meals and HS. During a review of Resident 7's BGM dated 4/1/21 to 5/10/21, the BGM indicated a total of 11 BS levels not documented, 3 doses of [MEDICATION(S)] and 8 doses of Insulin Regular sliding scale were not signed as administered to Resident 7. During a review of Resident 7's Care Plan titled, Diabetes Mellitus, dated 1/21/21, the care plan indicated to give diabetic medications as ordered by the doctor. During a review of Resident 7's clinical chart, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d) During a review of Resident 10's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 10's Order Summary Report, dated 5/10/21, the report indicated on 11/23/20 Resident 10 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime and on 1/10/21 [MEDICATION(S)] Kwikpen 20 units in the morning and to hold for BS less than 100 was prescribed. During a review of Resident 10's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 22 BS levels not documented, 8 doses of [MEDICATION(S)] Kwikpen were not signed as administered, and 14 doses of Insulin Regular as per sliding scale were not signed as administered to Resident 10. During a review of Resident 10's Care Plan titled, Diabetes Mellitus, dated 10/24/20, the care plan indicated to give diabetic medications as ordered by the doctor. e) During a review of Resident 11's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 11 was initially admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 11's Order Summary Report, dated 5/10/21, the report indicated on 12/12/20 Resident 11 was prescribed [MEDICATION(S)] Kwikpen 20 units subcutaneously two times a day, [MEDICATION(S)] 20 units subcutaneously two times a day, and insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 11's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 17 BS levels not documented, 1 dose of [MEDICATION(S)] was not signed as administered, 6 doses of [MEDICATION(S)] not signed as administered, and 10 doses of Insulin Regular as per sliding scale were not signed as administered to Resident 11. During a review of Resident 11's Care Plan titled, Diabetes Mellitus, dated 10/10/20, the care plan indicated to give diabetes medications as ordered by the doctor and check fasting serum BS as ordered by the doctor. f) During a review of Resident 25's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 25's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 25 was prescribed [MEDICATION(S)] R as per sliding scale subcutaneously three times a day. During a review of Resident 25's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 7 BS levels not documented, and 7 doses of [MEDICATION(S)] R as per sliding scale not signed as administered to Resident 25. During a review of Resident 25's Care Plan titled, Diabetes Mellitus, dated 11/20/20, the care plan indicated to give diabetes medications as ordered by doctor and check fasting serum BS. g) During a review of Resident 26's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 26's Order Summary Report, dated 5/10/21, the report indicated on 4/7/21 Resident 26 was prescribed [MEDICATION(S)] as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 26's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 9 BS levels not documented, and 9 doses of [MEDICATION(S)] sliding scale not signed as administered to Resident 26. During a review of Resident 26's Care Plan titled, Diabetes Mellitus, dated 4/7/21, the care plan indicated to give diabetes medications as ordered by the doctor and check fasting serum BS. h) During a review of Resident 32's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 32 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 32's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 32 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 32's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 19 BS levels were not documented, and 19 doses of Insulin Regular as per sliding scale not signed as administered to Resident 32. During a review of Resident 32's undated Care Plan titled, Diabetes Mellitus, the care plan indicated to monitor BS by finger stick, administer insulin, give diabetes medications, and check fasting serum BS as ordered by the doctor. i) During a review of Resident 33's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 33 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 33's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 33 was prescribed Insulin Regular as per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 33's BGM between 4/1/21 and 5/10/21, the BGM indicated a total of 14 BS levels not documented, and 14 doses of Insulin Regular as per sliding scale not signed as administered to Resident 33. During a review of Resident 33's Care Plan titled, Diabetes Mellitus, dated 12/28/20, the care plan indicated to give diabetes medications and check fasting serum BS as ordered by the doctor. j) During a review of Resident 35's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 35's Order Summary Report, dated 5/10/21, the report indicated on 10/28/20 Resident 35 was prescribed Insulin Regular as per sliding scale subcutaneously two times a day AC (before) breakfast and HS (bedtime), on 3/14/20 [MEDICATION(S)] 10 units subcutaneously one time a day and to hold if BS less than 100, and on 2/27/21 [MEDICATION(S)] (type of insulin) 10 units subcutaneously at HS and to hold if BS less than 100. During a review of Resident 35's BGM between 4/1/21 and 5/10/21, the BGM indicated a total of 15 BS levels not documented, 9 doses of [MEDICATION(S)] and 6 doses of Insulin Regular sliding scale not signed as administered to Resident 35. During a review of Resident 35's Care Plan, titled, Diabetes Mellitus, dated 3/7/20, the care plan indicated to give diabetes medications as ordered by doctor. k) During a review of Resident 36's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 36 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 36's Order Summary Report, dated 5/10/21, the report indicated on 3/9/21 Resident 36 was prescribed Insulin Regular as per sliding scale. During a review of Resident 36's MAR starting 4/1/21 thru 5/10/21, the MAR indicated 13 doses were not given and BS not checked. l) Review of Resident 41's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 41's Order Summary Report, dated 5/10/21, the report indicated on 9/14/20 Resident 41 was prescribed [MEDICATION(S)] 5 unit subcutaneously two times a day and to hold if BS less than 100. During a review of Resident 41's BGM starting 9/1/20 thru 5/10/21, the BGM indicated a total of 60 BS levels not documented, and 60 [MEDICATION(S)] doses not signed as administered to Resident 41. During a review of Resident 41's care plan titled, Diabetes Mellitus, dated 1/2/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. m) Review of Resident 47's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 47's Order Summary Report, dated 5/10/21, the report indicated on 3/2/21 Resident 47 was prescribed insulin regular per sliding scale. During a review of Resident 47's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 20 BS levels not documented and not signed as administered to Resident 47. During a review of Resident 47's undated care plan titled, Diabetes Mellitus, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. n) Review of Resident 52's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 52's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 52 was prescribed insulin regular per sliding scale. During a review of Resident 52's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of 17 BS levels and insulin was not documented, signed as administered to Resident 52. During a review of Resident 52's care plan titled, Diabetes Mellitus, dated 2/21/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. o) Review of Resident 54's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 54's Order Summary Report, dated 5/10/21, the report indicated on 4/29/21 Resident 54 was prescribed insulin regular per sliding scale. During a review of Resident 54's BGM starting 4/29/21 thru 5/10/21, the BGM indicated a total of five (5) BS levels not documented and not signed as administered to Resident 54. During a review of Resident 54's care plan titled, Diabetes Mellitus, dated 3/19/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. p) Review of Resident 57's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 57's Order Summary Report, dated 5/10/21, the report indicated on 1/10/21 Resident 57 was prescribed insulin [MEDICATION(S)] 15 units subcutaneously two times a day. During a review of Resident 57's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of nine (9) BS levels not documented, and insulin not signed as administered to Resident 57. During a review of Resident 57's care plan titled, Diabetes Mellitus, dated 7/7/20, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. q) Review of Resident 60's Face Sheet, dated 4/11/21, the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 60's Order Summary Report, dated 5/10/21, the report indicated on 4/13/21 Resident 60 was prescribed regular insulin detemir 15 units two times a day and Regular insulin per sliding scale. During a review of Resident 60's BGM starting 4/13/21 thru 5/10/21, the BGM indicated a total of 13 BS levels and insulin doses not documented and not signed as administered to Resident 60. During a review of Resident 60's care plan titled, Diabetes Mellitus, dated 4/12/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. r) Review of Resident 61's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 61's Order Summary Report, dated 5/10/21, the report indicated on 4/13/21 Resident 61 was prescribed insulin regular as per sliding scale and on 2/8/21 [MEDICATION(S)] KiwiPen 20 units every morning and at bedtime was prescribed. During a review of Resident 61's BGM starting 4/1/21 thru 5/10/21, the BGM indicated a total of nine 30 BS levels and insulin doses not documented and not signed as administered to Resident 61. During a review of Resident 61's care plan titled, Diabetes Mellitus, dated 4/1/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. s) Review of Resident 172's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 172 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 172's Order Summary Report, dated 5/10/21, the report indicated on 4/3/21 Resident 172 was prescribed insulin [MEDICATION(S)] 30 units subcutaneous at bedtime. During a review of Resident 172's BGM starting 4/3/21 thru 5/10/21, the BGM indicated a total of 13 BS levels and insulin doses were not documented and signed as administered to Resident 172. During a review of Resident 172's care plan titled, Diabetes Mellitus, dated 4/22/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. t) Review of Resident 173's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 173 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 173's Order Summary Report, dated 5/10/21, the report indicated on 4/22/21 Resident 173 was prescribed insulin regular as per sliding scale. During a review of Resident 173's BGM starting 4/22/21 thru 5/10/21, the BGM indicated a total of eight (8) BS levels and insulin doses not documented and not signed as administered to Resident 173. During a review of Resident 173's care plan titled, Diabetes Mellitus, dated 4/22/21, the care plan indicated to monitor BS by finger stick, administer oral medication and/or insulin and notify the physician of significant changes. u) Review of Resident 322's Face Sheet, dated 5/10/21, the Face Sheet indicated Resident 322 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 322's Order Summary Report, dated 5/10/21, the report indicated on 5/5/21 Resident 322 was prescribed insulin [MEDICATION(S)] per sliding scale, on 4/30/30 [MEDICATION(S)] 28 units one time a day and [MEDICATION(S)] 30 units at bedtime. During a review of Resident 322's BGM starting 4/29/21 thru 5/10/21, the BGM indicated a total of 20 BS levels and 15 insulin doses not documented and not signed as administered to Resident 322. During a review of Resident 322's care plans indicated no care plan for diabetes monitoring was created. During an interview on 5/11/21 at 9:36 a.m., Licensed Vocational Nurse 6 (LVN 6) stated insulin medication information was documented on the MAR, under Blood Sugar (BS). LVN 6 stated prior to the administration of medication, the staff would verify and check physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 6 stated if the staff did not check the BS tab, they would not know to do the BS level checks. LVN 6 stated if registry staff was not familiar with the eMAR, they could overlook the BS tab and not administer the insulin. LVN 6 stated that nursing staff should provide a reason for missed doses of insulin or BS on the eMAR. LVN 6 stated if BS were not checked, then residents can go into diabetic coma because of BS being high. LVN 6 stated when a resident refuses a BS check or insulin dose, licensed nursing staff should make more attempts, make the physician aware, monitor the resident and document on the eMAR and progress notes. During an interview on 5/11/21 at 10:33 a.m., CP stated she completes Medication Regimen Review ([MRR] -a thorough evaluation of the medication regimen of a resident) for all residents. The CP stated for residents with diabetes she makes sure there are HgA1c level orders, and if not then she makes recommendations to the physician to order the level. The CP stated HgA1c levels should be ordered every three months and when residents are stable then it can be done every six months. The CP stated ordering HgA1c levels every three months was standard of practice, and a diagnostic tool to evaluate the effectiveness of therapy for the resident to determine if changes in medication therapy are necessary. The CP stated HgA1c levels above 8% should be evaluated closely and routinely. The CP stated she had noticed the facility had MAR charting gaps for the BS levels and insulin administration and had addressed this failure with the past DON. The CP stated the MRR for the month of March 2021 addresses this failure in the summary section to the previous DON. The CP stated she may have also communicated this failure to the new DON 1, whom she had only met once. During an interview on 5/11/21 at 11:02 a.m., the MDS Coordinator stated HgA1c should be monitored in the residents' Care Plan (document outlining a detailed approach to care customized to an individual resident's need.) The MDS stated that medical records department had not been tracking to ensure residents have HgA1c orders but will do so going forward. The MDS stated diabetic (persons with diabetes) residents on insulin should have HgA1c levels checked every three months. The MDS stated that HgA1c is important because it shows if the insulin therapy is effective for the resident and if any changes to the medications need to be made based on the level. The MDS stated that it is important to have the right medications for diabetic residents to make sure their BS levels are stabilized so that they do not have complications like coma, get hospitalized or die. The MDS stated all diabetic residents should have a baseline HgA1c when admitted and that lab services did not stop working even during COVID. During an interview on n 5/11/21 at 11:51 a.m., the DON 2 stated carrying out the orders given by physicians are important, especially for diabetic residents. The DON 2 stated documentation is basic nursing function. The DON 2 stated if the MAR had gaps and was not signed, then it was understood the BS orders were not carried out, and the insulin doses were not administered. The DON 2 stated HgA1c should be ordered at admission for diabetic residents and re-ordered every three months to know if the medications are working. The DON 2 stated that the diabetes care plan should include the monitoring for HgA1c. The DON 2 stated if BS levels were not checked and insulin doses not given then the residents could have low or high BS levels, go into coma, get hospitalized , have ketoacidosis (serious diabetes complication where the body produces excess blood acids), and even die. During a phone interview on 5/11/21 at 12:40 p.m., during a phone interview, the Medical Doctor (MD) 1 stated she usually orders HgA1c levels and when she overlooks to order the level, she gets reminded by the CP. The MD1 stated HgA1c should be ordered every three months and for stable residents can be every six months or yearly. The MD1 stated that BS levels are not enough to determine effectiveness of the medications and HgA1c level is needed to determine if changes in the medications are needed. The MD1 stated that not having HgA1c levels for residents is a concern and should be part of their diabetes care plan. The MD1 stated it is harmful for the resident when the BS level is not checked, or insulin orders not administered. During a review of the facility's policy and procedures (P/P) titled, Diabetes-Clinical Protocol, revised 2020, the P/P indicated for residents who meet the criteria for diabetes testing, the physician would order pertinent screening such as A1C. the P/P indicated the staff would monitor blood glucose levels as indicated by the physician. During a review of the facility's P/P titled, Insulin Administration, revised on 9/2014, the facility staff would document the blood glucose results as ordered by the physician and document the dose and concentration of the insulin injection. During a review of the facility's P/P titled, Obtaining a Fingerstick Glucose Level, revised 9/2011, the P/P indicated the staff would document the name of the staff performing the fingerstick, date and time performed, assessment and data obtained during the procedure, refusal and reasons for refusal and interventions taken, blood sugar results and physician notification and signature of the staff.

Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, who was identified as a high risk for falls, received supervision and physical assistance to prevent falls with injuries by failing to: 1. Provide non-skid socks as indicated in the resident's care plan 2. Provide a two-persons assist with transfers and toileting in accordance with Resident 1's needs. 3. Modify the care plan interventions to prevent future falls and injuries after the first three falls on 4/23/19 and 4/24/19. These deficient practices resulted in Resident 1 having four (4) falls within 24 hours and sustaining an injury on the 4th fall of [MEDICATION NAME] head trauma ((BHT) trauma to the head as a result either by impact, injury or physical attack) resulting in an intracranial bleed ((ICB) bleeding within the skull), a hematoma (a collection of blood outside of blood vessels) on the back of the head and being transferred to a general acute care hospital (GACH). Resident 1 required intubation (insert a tube into especially the trachea (windpipe) for ventilation) upon admission to the GACH and placed on a mechanical ventilator (any device which either helps with or completely replaced a person's need to breath) and was hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. to perform everyday activities). A review of Resident 1's Admission/Re-admission Nursing Data Tool, (an initial assessment record) dated 3/6/19 and timed at 5:55 p.m., indicated Resident 1 was sometimes able to express wants and needs, was incontinent (inability to control) of bladder and bowel functions, had lower extremities weakness, required a one-person physical assistance with bed mobility and transfers. This record indicated Resident 1 was at risk for falls due to limited mobility, incontinence, use of blood pressure medications, dizziness, stroke (a disease that affects the arteries leading to and within the brain) and history of falls. A review of Resident 1's care plan, dated 3/6/19 indicated Resident 1 was at risk for falls related to a history of three falls at home, risk of decreased muscle strength, decline in ambulation and ability to transfer. The staff's interventions included to place Resident 1's call light within reach, ensure Resident 1 wore appropriate footwear, such as leather shoes and non-skid socks, use of a front wheel walker (FWW) or a cane. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/13/19, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required a two-person physical assist moving to and from bed, chair and or wheelchair to a standing position, transferring, dressing, toilet use and personal hygiene. The MDS indicated Resident 1 used a cane or walker for mobility. According to the MDS, Resident 1 had a fall in the last month prior to admission or reentry. A review of Resident 1's History and Physical (H/P) report, dated 3/15/19, indicated Resident 1 could make needs known, but could not make medical decisions. A review of Resident 1's Nursing Progress Note, dated 4/24/19 and timed at 5:35 a.m., indicated on 4/24/19 at 5:35 a.m., Resident 1, who did not have slippers on his feet, slipped and fell when he tried to go to the bathroom. A review of Resident 1's Post-Fall Review, dated 4/24/19 and timed at 10:59 a.m., indicated on 4/24/19 at 9 a.m., Resident 1 had an unwitnessed fall in his room. This review indicated Resident 1 was alert and oriented to person, was wearing non-skid shoes at the time the fall occurred. A review of Resident 1's care plan, dated 4/24/19, indicated Resident 1 was found on the floor inside his room. The staff's interventions included to increase supervision by a certified nursing assistant (CNA), provide a safe environment free of clutter, non-slippery floors and to keep frequently used items within reach. A review of Resident 1's untimed Change in Condition Evaluation report, dated 4/26/19, indicated on 4/23/19 in the afternoon, a resident reported that Resident 1 had an unwitnessed fall beside his bed. A review of Resident 1's IDT (interdisciplinary team ((IDT) a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for a resident) report, dated 4/24/19 and timed at 3:52 p.m., indicated on 4/23/19 at 2:30 p.m., Resident 1 was found by another resident on the floor by his bed (first fall incident). This record also indicated on 4/24/19 at 5:23 a.m., Resident 1 had an unwitnessed fall (second fall incident) when he was reaching for his slippers, to go to the toilet. Resident 1 had a third fall found on the floor on 4/24/19 at 7:30 a.m., as an unwitnessed fall and had a 4th fall on 4/24/19 at 9 a.m. Resident 1 sustained a bump on the back of the head with small amount of bleeding and required a transfer to a GACH. The IDT recommendations indicated Resident 1 would be supervised until the resident was transferred to a GACH. A review of Resident 1's untimed Change in Condition Evaluation report, dated 4/26/19, indicated on 4/24/19 in the morning, Resident 1 had an unwitnessed fall in his room that resulted in a bump on the head that required a transfer to a GACH. A review of a Transfer Form, dated 4/24/19 and timed at 10:20 a.m., indicated Resident 1 had an unwitnessed fall, that lead to a bump on the back of his head with a small amount of bleeding. The transfer form indicated Resident 1 was disoriented (confused and unable to think clearly) but could follow simple instructions and was transferred to a GACH. A review of Resident 1's GACH Trauma History and Physical (H/P), dated 4/24/19 indicated Resident 1 arrived by paramedics to the emergency roiagnom on [DATE] after being found on the floor in a skilled nursing facility (SNF) with altered mental status after falling and sustaining [MEDICATION NAME] head trauma. The H/P indicated Resident 1 had an elevated heart rate of 144 beats per minute (bpm) (normal range is 60-100 bpm) and the resident was intubated and placed on a mechanical ventilation. According to the H/P, a CT Scan ((computerized tomography) use of several X-ray images and computer processing to create cross sectional images) of the head was done and was positive for an acute [MEDICAL CONDITION] (bleeding) in the temporal area (sides and base of the skull). The H/P assessment indicated Resident 1 had an [MEDICAL CONDITION] from a fall and a pelvic fracture (broken bone). The plan included for Resident 1 to be admitted in the ICU (intensive care unit (a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically)). The GACH's discharge summary indicated Resident 1 was discharged to another SNF on 6/5/19. A review of a consultation report from the GACH, dated 4/29/19 timed at 2:53 p.m., indicated Resident 1 did not required any surgical interventions for the pelvic fracture. A review of the facility's Interview Record, dated 4/28/19 and timed at 10 a.m., which included a Certified Nursing Assistant 1 (CNA 1), Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) indicated on 4/24/19 at 8:45 a.m., Resident 1 was found on the floor and assisted back to bed. This report also indicated on the same day (4/24/19) at 9 a.m., Resident 1 was found on the floor close to his bed, with a bump on the head. A review of the facility's interview record, dated 4/28/19 and timed at 11 a.m., indicated a RN stated that on 4/23/19 at 1:40 p.m., Resident 1 was observed sitting on the floor, in his room. A review of a facility's interview record, dated 4/28/19 and timed at 1 p.m., indicated a CNA that on 4/23/19 at 1:40 p.m., Resident 1 was found in a sitting position, on the floor. This record indicated Resident 1 stated that he tried to get up to the bathroom when he slid down the bed. A review of an interview record dated 4/29/19 and timed 1 p.m., indicated on 4/24/19 at 5:35 a.m., an LVN stated that Resident 1 was found in a sitting position, on the floor. It also indicated Resident 1's assigned CNA, could not check on the resident because she had other residents to care for. A review of the facility's floor plan indicated Resident 1's room was three doors away from Nurse Station 2 and Resident 1's room was not visible from the Nurse's Station. A review of facility's report, dated 4/30/19 and titled, Unusual Occurrence indicated on 4/23/19 at 1:30 p.m., on 4/24/19 at 5:35 a.m., and on 4/24/19 at 8 a.m., Resident 1 had four unwitnessed falls. This report indicated the 4/24/19 at 9 a.m. fall resulted in an injury, altered mental status and a GACH transfer. According to the unusual occurrence report, Resident 1 did not follow directions, repeatedly attempted to get up unassisted and cognition (thought process) was impaired. According to this report, the IDT team ((IDT) a group of medical professionals that work together towards a common goal for a resident), concluded Resident 1's fall was due to the resident's decreased safety awareness, inability to notify staff for assistance, not using the call light and a fluctuation in cognitive function. On 5/3/19 at 9:14 a.m., during a concurrent interview and review of Resident 1's nursing progress note, Registered Nurse 1 (RN 1) stated within 24 hours, Resident 1 had four unwitnessed falls. RN 1 stated Resident 1 was confused, impulsive (acting or done without forethought), weak and unable to follow directions. RN 1 stated Resident 1 did not have a sitter after the first, second or third falls, but should have. According to RN 1, Resident 1 did not have an order for [REDACTED]. On 5/3/19 at 10 a.m., during a telephone interview, CNA 1 stated Resident 1 did not have a floor mats and/or a sitter at the time of the fall on 4/24/19. CNA 1 stated that Resident 1 had an unsteady gait (walk) and had at high risk for falls. CNA 1 stated Resident 1 required assistance, close monitoring and that she (CNA 1) could not supervise Resident 1 because she had too many residents to care for. CNA 1 added that she was not assigned to be a sitter for Resident 1. On 5/3/19 at 10:11 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated on 4/23/19, Resident 1 who was bare feet, with no floor mats at the bedside when he had an unwitnessed fall from his bed. LVN 1 stated Resident 1's second fall was on 4/24/19 at 8 a.m. and was witnessed by Resident 2. LVN 1 stated that Resident 1 did not have any fall preventive measures in place, including a floor mat and non-skid socks when the fall occurred. According to LVN 1, there was no order to use a floor mat for Resident 1. LVN 1 also stated that after the second fall, Resident 1 should have had a sitter to monitored and supervised the resident closely. LVN 1 stated within 24 hours, Resident 1 had four falls that could have been avoided if the staff had fall prevention measures in place. On 5/3/19 at 10:44 a.m., during a concurrent interview and record review (nursing progress notes), the facility's Director of Nursing (DON) confirmed that Resident 1 had three falls in 24 hours. The DON stated after Resident 1's first fall on 4/23/19, the staff did not increase supervision for Resident 1 to prevent the second fall. The DON stated after Resident 1's second fall on 4/24/19, the resident should have been placed on a 1:1 monitoring and moved closer to the nurses' station for close supervision, to prevent further falls and injuries. On 5/3/19 at 11:10 a.m., during an interview, the facility's Administrator (ADM) stated he was not aware the staff did not have huddles (a quick staff meeting on issues regarding residents) at the start of every shift to update the staff on what to look out for in certain residents. The ADM stated the facility's expectations were to have huddles for the staff to be aware of residents needing more supervision like Resident 1. The ADM stated after Resident 1's second fall a staff should have been assigned to stay with the resident continuously and Resident 1's room should have been moved closer to the nurses' station. On 11/7/19 at 9:34 a.m., during an interview, Resident 1's family member (FM 1) stated, The facility did not take good care of the resident (Resident 1) because the resident had several falls in one day, spent almost two months in a GACH and has not been able to walk ever since. If the staff had supervised the resident like they were supposed to, he would be walking around today. According to FM 1, Resident 1 was discharged from the GACH to another facility, where his needs could be met. A review of the facility's policy titled, Falls-Clinical Protocol, with a revised date of 3/2018, indicated the facility would identify and document resident's risk factors for falls and establish a resident centered fall preventive plan based on relevant assessment information. A review of the facility's policy titled, Assessing Falls and their Causes, with a revised date of 3/2018, indicated the purpose of the policy was to provide guidelines for assessing residents after a fall and to assist the staff in identifying causes of the fall. This policy indicated that after a fall incident, the staff would assess the resident and develop an appropriate intervention to prevent future falls. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 12/2016, indicated a comprehensive, person-centered care plan with measurable objectives and timetables would be developed for each resident to meet the resident's physical, psychosocial and functional needs.

Based on observation, interview and record review, the facility failed to provide care and services for the prevention and deterioration of pressure ulcers (injury to the skin and underlying tissue from prolonged pressure on the skin), which included initial and ongoing accurate skin assessment; following physician's orders for wound care; and following the registered dietician (RD) recommendations for three of three sampled residents (Residents 1, 2, and 3) who were at risk for developing pressure ulcers. This deficient practice had the potential for Residents 2 and 3's wounds to worsen and resulted in Resident 1's deterioration in redness of the buttocks (Stage I) to an infected unstageable (full thickness tissue loss in which the pressure ulcer is covered by dead tissue) pressure ulcer to the sacrococcyx (pertaining to both the sacrum and coccyx (the tailbone)) over a 34 day stay at the facility, which required and admission to the general acute care hospital (GACH) for surgical debridement (removal of unhealthy tissue from a wound to promote healing) and receiving antibiotics for the pressure ulcer being infected. Findings: a. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 3/25/17, did not indicate the resident had skin conditions and/or pressure injury to the skin upon admission. A review of Resident 1's Admission Nursing Data Tool, dated 3/24/17, indicated the resident's skin was assessed on 3/31/17 (eight days after admission) and the resident had redness (Stage I; a pressure injury characterized by intact skin with a localized area of non-blanchable redness) to the buttocks area. The admission note indicated Resident 1 was at risk for developing a skin / pressure injury. A review of Resident 1's Interdisciplinary Team ((IDT), a group of health care professionals who work together for the care of the resident) Wound Management Update note, dated 3/30/17, did not indicate the status and/or recommendations for Resident 1's skin redness on the buttocks. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/31/17, indicated the resident's cognition (ability to reason and think) was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility (how a resident moves and positions body while in bed). A review of Resident 1's Change of Condition ((C(NAME))/ SBAR ((situation, background, assessment, and recommendation), a communication tool used to communicate resident's change of condition among health care providers), dated 4/2/17, indicated the resident had moisture-associated skin damage (MASD), to the bilateral buttocks. The SBAR note indicated Resident 1 had peeling skin to the buttock area with redness. A review of Resident 1's C(NAME)/SBAR note, dated 4/4/17, indicated the resident's Stage I coccyx pressure ulcer increased to a Stage II pressure sore (pressure injury of a ruptured serum-filled blister, and/or an open pressure wound with a pink or red wound bed) and extending to the left buttock. The SBAR note indicated Resident 1's wound was red and pink with exposed dermis (the layer of the skin that forms the true skin and contains blood vessels, nerve endings, hair follicles and other structures) and peri-wound (surrounding skin) redness. A review of a C(NAME)/SBAR note, dated 4/10/17, indicated Resident 1's a coccyx and left buttock pressure ulcer wound increased in size and stage with a full-thickness wound with 50% slough (yellow non-viable tissue that could be stringy or thick and adherent on the tissue bed with slough on wound that should be surgically debrided to allow for ingrowth of healthy tissue). A review of Resident 1's C(NAME)/SBAR, dated 4/23/17, indicated the resident had a wound on the coccyx with undermining (tunneling or a wider area of the wound that lies beneath the wound opening) with foul odor and scant drainage. A review of Resident 1's Wound Evaluation Flowsheet, with an initiated date of 4/4/17, indicated the resident had a pressure ulcer of the coccyx and left buttock that was documented as deteriorating. The flowsheet (a form used to document and monitor wound skin assessment done at regular intervals) indicated on 4/4/17 Resident 1's pressure ulcer was documented as a Stage II with peri-wound redness and measured eight (8) centimeters (cm) in length and six (6) cm in width. The flowsheet indicated on 4/10/17 Resident 1's pressure ulcer was documented as a Stage III measured 8.7 cm in length and 7.5 cm in width with 50% slough. On 4/12/17 Resident 1's pressure ulcer was documented and was clarified by the physician as a pressure ulcer that was unstageable to the sacro-coccyx measuring 10 cm in length by 10 cm in width. A review of Resident 1's Wound Evaluation Flowsheet indicated the resident had a pressure ulcer of the sacrococcyx. The flowsheet indicated on 4/19/17 Resident 1's pressure ulcer was documented as unstageable with foul odor present, and a size of 10 cm in length and 10 cm in width. The flowsheet indicated on 4/26/17 Resident 1's pressure ulcer was documented as unstageable with foul odor, increased exudates (fluid oozing from a wound), 100% necrotic tissue (dead tissue), and a size of 10 cm in length and 10 cm in width. The flowsheet indicated Resident 1 was sent to the GACH on 4/26/17. A review of Resident 1's Treatment Administration Record (TAR), for the month of April 2017, indicated the resident was not given treatment of [REDACTED]. A review of the physician's order, dated 3/25/17, indicated to apply barrier cream (cream that helps with skin protection and help maintain a barrier between the skin and moisture) to buttocks area every shift for seven days. Another physician's order, dated 4/3/17, indicated to apply the skin barrier cream to both buttocks for the moisture-associated skin damage ((MASD), inflammation of the skin caused by prolonged exposure to a source of moisture) every shift for 14 days. A review of Resident 1's dietary progress note, written by the registered dietician ((RD), an individual specializing in human nutrition and diet) dated 4/18/17, indicated the registered dietician recommended pre-[MEDICATION NAME] (a test that measures the amount of protein in the blood and a low levels indicate a sign of poor diet or malnutrition) levels be drawn. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated 8/28/12, indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ A review of Resident 1's Treatment Administration Record (TAR), for the month of April 2017, indicated the resident was not given treatment of [REDACTED]. The TAR indicated an order on 4/4/17 to cleanse the coccyx (triangular bony area that makes up the bottom portion of the spin and tailbone) Stage II pressure ulcer with normal saline and apply Hydrogel (used to protect the wound from infection and promote wound healing); apply barrier cream to peri-wound (skin surround a wound) cover with dry dressing every day for 21 days. The TAR indicated the treatment was discontinued on 4/19/17. A review of Resident 1's physician order summary indicated the following orders: 1. On 4/10/17, cleanse pressure injury Stage III (full-thickness loss of skin in which fat tissues is visible in the wound) to coccyx, apply Santyl ointment (treatment to help the healing of skin ulcers by breaking up and removing dead skin and tissue to promote wound healing), and cover with dry dressing one time a day for 21 days 2. On 4/11/17, consult with a wound care physician and provide treatment if indicated. 3. On 4/19/17, cleanse sacro-coccyx (the body area at the bottom of the spin and tailbone) unstageable pressure injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by dead tissue or yellow non-viable tissue) with Dakin's solution (treatment used to prevent and treat skin and tissue infections from pressure ulcers) A review of Resident 1's care plan, initiated 3/29/17, and revised on 5/2/17, indicated the resident was at risk for development of skin breakdown and at risk for pressure ulcer onset and the staff's intervention included to implement pressure ulcer protocol program. A review of the GACH's emergency department (ER) note, dated 4/26/17, indicated Resident 1 was evaluated for worsening sacral pressure ulcer with foul odor. The ER note indicated there was an unstageable pressure ulcer to the left and right buttocks with drainage and necrosis (dead tissue). A review of Resident 1's hospital History and Physical, dated 4/26/17, indicated the resident presented with an ongoing fever that she was having at the facility. The H/P indicated Resident 1's wound was smelling bad and was positive for an infection. Resident 1 was diagnosed with [REDACTED]. Resident 1 was started on two antibiotics (medication used to treat bacterial infection). A review of Resident 1's GACH operative report (surgical report), dated 4/28/17 indicated the resident's preoperative and postoperative [DIAGNOSES REDACTED]. The report indicated Resident 1 underwent extensive debridement of necrotic (dead tissue) skin, muscle, fascia (band of tissue beneath the skin that stabilizes muscle and internal organs), and fat tissue of an area size of 17 centimeters (cm) by 18 cm. A review of Resident 1's hospital wound culture and sensitivity results, dated 4/30/17, indicated the resident had bacteria in the wound. On 11/15/17 at 3:05 p.m., during a review of Resident 1's Admission Nursing Tool, dated 3/24/17, and a concurrent telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated the resident's skin was assessed and signed off on 3/31/17 (eight days after admission) and the resident had redness to the buttocks area. LVN 1 stated Resident 1's redness of the buttocks was a pressure ulcer Stage I, because the buttocks was a common area for developing pressure ulcers. LVN 1 stated Resident 1 was at risk for developing pressure ulcers because she would be in bed for a long periods of time. LVN 1 stated a complete skin assessment should be done upon admission and then every seven days for residents. LVN 1 stated there was no admission skin assessment done for Resident 1. LVN 1 stated Resident 1 had a C(NAME) on 4/2/17, that was identified MASD to the bilateral buttocks with peeling skin and redness to the buttock area, but LVN 1 stated he would have identified the change of condition as a Stage II pressure ulcer, not MASD. LVN 1 stated changes in Resident 1's skin condition should have been identified accurately and promptly so that the appropriate care would be provided for the resident. LVN 1 confirmed that Resident 1 did not receive treatment for [REDACTED]. LVN 1 stated the resident's TAR does not indicate the resident was receiving the physician's treatment order of Santyl ointment (treatment to help the healing of skin ulcers by breaking up and removing dead skin and tissue to promote wound healing) from 4/13/17 to 4/19/17. LVN 1 stated on 4/12/17 the resident's coccyx pressure ulcer deteriorated from Stage III to unstageable and there was not a revised treatment for [REDACTED]. LVN 1 stated the resident should have been seen by the wound consult when the pressure ulcer was a Stage II to prevent the wound from worsening. A review of Resident 1's dietary progress note, dated 4/18/17, and a concurrent telephone interview, LVN 1 stated the registered dietician recommend pre-[MEDICATION NAME] levels be drawn for the resident. LVN 1 stated there were no physician's order for pre-[MEDICATION NAME] levels to be drawn for Resident 1 and the resident did not have pre-[MEDICATION NAME] levels drawn during facility stay. LVN 1 stated the registered dietician's recommendations were interventions that would improve Resident 1's condition and to prevent the resident's pressure ulcer from deteriorating. LVN 1 stated if the registered dietician's recommendations were not carried out then the facility was not helping Resident 1 get better. On 11/15/17 at 3:05 p.m., during a record review of Resident 1's dietary progress note dated 4/18/17 and a concurrent telephone interview, LVN 1 stated the registered dietician recommend pre-[MEDICATION NAME] levels be drawn for the resident. LVN 1 stated there were no physician's order for pre-[MEDICATION NAME] levels to be drawn for Resident 1 and the resident did not have pre-[MEDICATION NAME] levels drawn during facility stay. LVN 1 stated the registered dietician's recommendations were interventions that would improve Resident 1's condition and to prevent the resident's pressure ulcer from deteriorating. LVN 1 stated if the registered dietician's recommendations were not carried out then the facility was not helping Resident 1 get better. b. A review of Resident 2's Admission Face Sheet Record indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident had impaired cognition (ability to think and reason). The MDS indicated Resident 2 required extensive assistance of a two-person physical assist for bed mobility. A review of Resident 2's Admission/ Readmission Nursing Data Tool, dated 4/22/17, indicated the resident was at risk for developing a skin/ pressure injury. A review of Resident 2's Wound Evaluation Flowsheet form indicated on 5/10/17 the resident had a left and right heel unstageable pressure ulcer. A review of Resident 2's care plan, initiated 4/24/17, indicated the resident was at risk for impaired skin integrity and infection for non-healing wound. The care plan indicated the staff's interventions included turning and repositioning the resident every two hours and as needed, and to check skin integrity every shift for worsening areas of skin breakdown. On 5/16/17 at 3:15 p.m., during an observation and concurrent interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 2's bilateral heels were not offloaded (no pressure on heels), but should have been offloaded to prevent worsening of the resident's bilateral heel pressure ulcers. LVN 2 stated when there was no offloading of the heels then there would be pressure that could possibly lead to the further skin breakdown. LVN 2 stated Resident 2's right heel had a light colored discoloration and the left heel had a black colored skin discoloration. LVN 2 stated Resident 2 was at risk for skin breakdown and the resident had the potential for further skin breakdown of existing pressure ulcer sites. On 5/16/17 at 4:10 p.m., during an interview and concurrent record review of Resident 2's care plan, LVN 2 stated the resident's care plan did not indicated an intervention to offload the resident's heels. LVN 2 stated Resident 2's care plan should have included the need to offload the resident's bilateral heels. c. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident had impaired cognition and disorganized thinking. The MDS indicated Resident 3 required extensive assistance of a two-person physical assist for bed mobility. A review of Resident 3's Braden Scale for Predicting Pressure Ulcer Risk, dated 1/16/17, indicated the resident was at risk for developing skin/ pressure injury. On 5/16/17 at 3:55 p.m., during an observation and concurrent interview, LVN 2 stated Resident 3's bilateral feet was pressed against the top of the bed's frame. LVN 2 stated Resident 3's feet should not have been pressed on the bed frame because the resident was at risk for skin breakdown. LVN 2 stated, after observing, there were indentations underneath the resident's feet after being pressed on the bed's frame. According to the facility's policy and procedure titled, Pressure Injury Risk Assessment, revised on 7/2016, the facility was responsible for the assessment and identification of residents at risk of developing pressure injuries. The policy indicated the skin would be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated to identify changes. The policy indicated at-risk residents need to be identified and have interventions implemented promptly to attempt to prevent pressure injuries and the admission evaluation helped define those initial care approaches. According to the facility's policy and procedure titled, Prevention of Pressure Injuries/ Skin Breakdown, revised on 10/2017, the facility was responsible for changing position of the residents at least every two hours or more frequently if needed for a person in bed. The policy indicated the care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. The policy indicated the facility was responsible for monitoring laboratory values and to notify the physician when appropriate; encouraging proper dietary and fluid intake; and administering vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations. According to the facility's policy and procedure titled, Care Plans- Preliminary, revised August 2006, the facility would review the Attending Physician's order and implement a nursing care plan to meet the resident's immediate care needs.