Every finding on record at Manchester Healthcare Center

Based on interview and record review, the facility failed to investigate when one of seven sampled residents (Resident 1) found a condom (rubber used for safety during sexual intercourse to prevent pregnancy and sexually transmitted diseases) on her bed.This failure had the potential for the facility to not identify nonconsensual (non-consented) sexual activity in the building, violate Resident 1's right to privacy and placed the resident and other residents at risk for potential non-consensual (non-consented) sexual abuse.Findings: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 sciatica (a pain that happens when a big nerve in lower back gets pinched or irritated) right side, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (health condition where a person feels really worried, scared, or nervous a lot of the time, even when there is no real danger).During a review of Resident 1's History and Physical (H&P), dated 1/27/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability think and process) was moderately impaired. The MDS indicated Resident 1 used a walker and required moderate assistance (helper does less than half the effort) from staff for activities of daily living and mobility.During a concurrent interview and record review on 5/12/2026 at 12:45 p.m. with the Social Service Director (SSD), Resident 1's medical record was reviewed. The SSD stated the Care Plan was not updated, a Change of Condition (COC) was not initiated and there was no documentation by the DON or herself in the progress notes regarding Resident 1 finding the condom on Resident 1's bed.During an interview on 5/12/2026 at 12:15 p.m., with Resident 1, Resident 1 stated when she returned to her room on 5/6/2026 at 8:00 a.m., she found a condom on her bed. Resident 1 stated, on 5/6/2026, she reported the condom to the Social Services Director (SSD). The SSD stated she would inform the DON about Resident 1 finding a condom on her bed. Resident 1 stated the Director of Nursing (DON) asked her to attend a meeting with the DON, SSD, Activities Director (AD), Administrator, and a Licensed Vocational Nurse (LVN). Resident 1 stated the DON asked her if the condom belonged to another resident. Resident 1 stated she felt interrogated during the meeting, left the conference room and went to the restroom. Resident 1 stated she did not return to the meeting.During an interview on 5/12/2026 at 2:18 p.m. with the SSD, the SSD stated, on 5/6/2026 between 9:00 a.m. to 10:00 a.m., Resident 1 approached her in the hallway and reported the condom she found on her (Resident 1) bed. The SSD stated Resident 1 showed her (SSD) the condom Resident 1 was holding. The SSD stated no one was in Resident's 1 room when she (Resident 1) discovered the condom. The SSD stated she then left Resident 1 and attended 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) meeting. After the IDT meeting, the SSD stated she informed the DON about Resident 1's reported condom found on the resident's bed. The SSD stated the DON asked the SSD to escort Resident 1 to the conference room to discuss Resident 1's report. The meeting started around 11:00 a.m. with the presence of the DON, Director of Rehabilitation (DOR), Activities Director (AD), and herself (SSD). The DON informed Resident 1 she would ask staff if they saw anyone near Resident 1's bed. The SSD stated she only interviewed Resident 1 and did not conduct an investigation on why and how the condom was found on Resident 1's bed. The SSD stated she was unaware whether the DON investigated the allegation. During an interview on 5/13/2026 at 12:40 p.m. with the DON, the DON stated, on 5/6/2026, after the SSD reported that Resident 1 found a condom on her bed, she (DON) did not conduct an investigation. The DON stated she did not interview other staff or the male residents near Resident 1's room if they observed anyone left the condom on Resident 1's bed. During an interview on 5/13/2026 at 1:20 p.m., with the Registered Nurse (RN), the RN stated on 5/6/2026, between 8:00 a.m. to 8:30 a.m., Resident 1 exclaimed, Who put this (condom) here! The RN stated she approached Resident 1 and observed the resident holding the condom in a wrapper in her hand. The RN stated she reported the incident (condom on Resident 1's bed) to the DON. The RN stated that she did not investigate the condom found on Resident 1's bed and did not document in Resident 1's progress notes. During an interview on 5/13/2026 at 1:34 p.m., with the DON, the DON stated condoms are used for protection during sexual intercourse (activity). The DON stated Resident 1 did not have signed consent or any documentation in the medical record indicating consent to engage in intercourse. The DON stated if there is no signed consent or documentation for sexual activity in the resident's medical record, the situation could be considered a possible indication of sexual abuse.During a record review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 10/1/2023, the P&P indicated residents had the right to voice grievances and the facility must respond to those grievances in a prompt manner.During a record review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 5/5/2025, the P&P indicated the facility is committed to protecting residents from abuse by anyone and has zero tolerance for abuse and must not permit anyone to engage in sexual abuse. The P&P indicated covered individuals will be trained through on-going training sessions regarding abuse prevention, investigation, reporting and documentation of abuse. Supervisors shall immediately intervene, correct and report identified situations where abuse is at risk of occurring. The facility should promptly and thoroughly investigate reports of resident abuse. The investigator should review all relevant documentation, interview the person making the incident report, interview witnesses, interview facility staff members, resident roommate and prepare an investigation report documenting findings of the investigation.

Based on interview and record review, the facility failed to review and act on the Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) conducted for all facility residents on 12/10/2025. This deficient practice resulted in delays to adjustments to multiple residents' medications and/or plans of care due to lack of physician notification of the facility's consultant pharmacist's recommendationsFindings: During a review of the facility's Medication Regimen Review (MRR), dated 12/20/2025, the MRR indicated the facility's consultant pharmacist made recommendations for 24 of the 44 residents reviewed. During an interview on 3/26/2026 at 9:00 a.m., with the Director of Nursing (DON), the DON stated there was no evidence available to demonstrate that the MRR recommendations dated 12/10/2025 were reviewed and acted upon. The DON stated timely review and intervention was important to ensure the residents' physicians were notified of the pharmacist's recommendations, and to ensure modifications to the plan of care were made timely. The DON stated this ensured the safety of the facility's residents. During a review of the facility's policy and procedure (P&P) titled Drug Regimen Review, dated 10/1/2023, the P&P indicated the facility was to maintain the residents' highest practicable level of well-being, and prevent or minimize adverse consequences related to medication therapy, by providing oversight by a licensed pharmacist, attending physician, medical director, and the DON. The P&P indicated the DON was responsible for following up with the attending physician as indicated, and the attending physician was to respond to any irregularities reported by the pharmacist. The P&P indicated this documentation was to occur within 30 days of issuance of the MRR.

Based on observation, interview, and record review, the facility failed to keep the privacy curtain and window closed during medication administration for one of six sampled residents (Resident 14). This deficient practice had the potential to compromise Resident 14's dignity, privacy, and emotional well-being during the provision of care. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2026, the MDS indicated Resident 14's cognitive skills for daily decision making (the ability to think and process information) was severely impaired. The MDS indicated Resident 14 was dependent (helper does all the effort) 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 14's History and Physical (H&P), dated 3/16/2026, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During an observation on 3/24/2026 at 8:30 a.m., at Resident 14's bedside, Licensed Vocational Nurse (LVN) 2 was observed administering medications to Resident 14 via g-tube. LVN 2 opened the window curtain exposing Resident 14 to outside view. LVN 2 failed to close the privacy curtain to protect Resident 14's privacy. Resident 14 was visibly exposed during the medication administration process. During an interview on 3/24/2026 at 2:50 p.m., with LVN 2, LVN 2 stated the window and privacy curtains should not have been opened during medication administration as it exposed Resident 14 to the outside and others. LVN 2 stated it was important to ensure Resident 14's privacy, dignity, and confidentiality during g-tube medication administration and provision of care. During an interview on 3/26/2026 at 9:30 a.m., with the Director of Nursing (DON), the DON stated staff were expected to protect resident privacy and dignity during all care and treatment, including g-tube medication administration. The DON stated staff were responsible for ensuring the privacy curtain was closed and the window curtain remain closed to protect the resident's privacy and dignity during care. During a review of the facility's policy and procedure (P&P) titled Resident Rights- Quality of Life, dated 10/1/2023, the P&P indicated the facility will ensure that all residents are treated with the level of dignity while residing at the facility. The P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality.

Based on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the administration of Depakote ([psychotropic medication] -a medication that affect the mind, emotions, and behavior) was completed for one of three sampled residents (Resident 2). This deficient practice resulted in the violation of Resident 2's right to make an informed decision regarding the use of psychotropic medication and had the potential for increased risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) leading to impairment or decline in Resident 2's mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 1/11/2026, the MDS indicated Resident 2's cognitive skills for daily decision making (ability to think and process information) was moderately impaired. The MDS indicated Resident 2 required maximum (helper does more 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). The MDS indicated Resident 2 received antipsychotic medication. During a review of Resident 2's physician order, dated 1/6/2026, the physician order indicated to administer Depakote 750 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth, twice a day for bipolar disorder. The physician order indicated informed consent was obtained. During a review of Resident 2's Medication Administration Records (MAR), dated 1/1/2026 through 3/24/2026, the MARs indicated Resident 2 received Depakote 750 mg a total of 153 doses. During a concurrent interview and record review on 3/24/2026 at 2:15 p.m., with the Director of Nursing (DON), Resident 2's informed consent for psychotropic medication (Depakote) dated 1/6/2026, was reviewed. The informed consent did not indicate Resident 2's and/or Resident 2's representative's (RR) signature. The informed consent did not indicate licensed nursing staff verified with the resident and/or RR that the physician obtained informed consent prior to the initiation of Depakote. The DON stated Resident 2's informed consent indicated the name of the RR; however, the date and signature were missing. The DON stated Resident 2's informed consent was incomplete. The DON stated licensed staff should have ensured Resident 2's informed consent was fully completed prior to administration. The DON stated this violated Resident 2's and Resident 2's RR right to make informed decision about the treatment and could result in the resident receiving medication without understanding the reason for the use, risks and alternatives. During a review of the facility's policy and procedure (P&P) titled Informed Consent, revised 4/1/2024, the P&P indicated residents have the right to make informed decision prior to undergo medical therapies and procedures. The P&P indicated:1. The attending physician prior to prescribing a psychotherapeutic drug shall personally examine and obtain the informed written consent of the resident or the resident's representative.2. The facility verifies that informed consent was obtained prior to the administration of a medical intervention.3. The informed consent must be signed by the resident or the resident's representative and the physician who provided the information.4. If the signature of the resident or resident's representative cannot be obtained, a licensed nurse shall sign and date the informed consent.

Based on observation, interview, and record review, the facility failed to ensure the wall next to a residents' bed was maintained in good repair for one of six sampled residents (Resident 10). This deficient practice had the potential to negatively impact Resident 10's comfort and well-being and contributed to an environment that was not consistent with a clean, safe, and home-like setting. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 10's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 10 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 an observation on 3/23/2026 at 11:45 a.m., in Resident 10's room, an area on the wall adjacent to the right side of Resident 10's bed, between the bed and bedside cabinet, was observed with chipped and peeling paint, and cracked and missing plaster exposing the underlying material beneath the painted surface. The area was unrepaired. During a concurrent observation and interview on 3/25/2026 at 9:15 a.m., with Maintenance Supervisor (MS) 1, in Resident 10's room, observed the wall between the right side of Resident 10's bed and the bedside cabinet. MS 1 measured the area of the wall. The area measured 22 inches in length and six (6) inches in width. MS 1 stated the wall was damaged and should have been repaired to maintain the room in good condition. MS 1 stated resident rooms should be maintained in a manner that supports a clean, safe, and home-like environment. During a review of the facility's policy and procedure (P&P) titled Maintenance Services, dated 10/1/2023, the P&P indicated the maintenance department was responsible to maintain all areas of the building and grounds in a safe and operable manner at all times.

Based on interview and record review, the facility failed to ensure three of six sampled residents (Resident 14, Resident 1, and Resident 52) were free from chemical restraints when staff failed to: 1. Ensure Resident 1 and Resident 52's as needed (PRN) psychotropic medications (drugs that affects mental processes) were limited to an administration period of 14 days. 2. Document attempted gradual dose reductions (GDR, the stepwise tapering of a medication dose to determine if symptoms can be managed by a lower dose or if the medication can be discontinued) for Resident 14's fluoxetine (medication to treat depression) and olanzapine (antipsychotic medication). 3. Develop and document non-pharmacological interventions provided to Resident 14 for her behavioral manifestations, from 2/2/2025 to 11/24/2025, for which staff administered fluoxetine and olanzapine. These deficient practices placed Residents 14, 1, and 52 at risk of receiving psychotropic medications without clinical indication.Findings:1a. 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 major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 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 1's physician order, dated 2/18/2026, the physician order indicated Resident 1 was to receive Olanzapine (a psychotropic medication) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one (1) tablet by mouth every eight (8) hours as needed for psychosis (a mental health symptom involving loss of contact with reality). The order did not indicate a stop date. 1b. During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), hypertension (HTN- high blood pressure), and muscle weakness (loss of muscle strength). During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 cognition was intact. The MDS indicated Resident 52 required moderate assistance from staff for ADLs. During a review of Resident 52's physician order, dated 2/19/2026, the physician order indicated Resident 52 was to receive Restoril (a psychotropic medication) 15 mg, 1 capsule by mouth every 24 hours as needed for inability to sleep. The order did not indicate a stop date. During a concurrent interview and record review on 3/25/2026 at 10:25 a.m., with the Director of Nursing (DON), Resident 1's physician order for Olanzapine 10 mg, dated 2/18/2026, Resident 52's physician order for Restoril 15 mg, dated 2/19/2026, and the facility's policy and procedure (P&P) titled Psychotherapeutic Drug Management, revised 1/6/2026, were reviewed. The physician orders did not indicate a stop date for the administration of Olanzapine and Restoril. The P&P indicated the PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician evaluates the resident in person for the appropriateness of that medication. The DON stated the purpose of the 14-day limit was to ensure the continued need for the psychotropic medication was clinically justified to prevent unnecessary use of such medications. 2a. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 14's diagnoses included major depressive disorder, schizophrenia, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had severely impaired cognition. The MDS indicated Resident 14 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 14 required substantial to maximal assistance from staff to roll left and right in bed and was dependent on staff for all other mobility. During a review of Resident 14's discontinued physician orders, dated 1/28/2025, the order indicated to administer Olanzapine from 1/28/2025 to 9/17/2025, for bipolar disorder. During a review of Resident 14's discontinued physician orders, dated 1/28/2025, the order indicated to administer Fluoxetine from 1/28/2025 to 11/24/2025, for depression. During a review of Resident 14's discontinued physician orders, dated 9/18/2025, the order indicated Resident 14 received Olanzapine from 9/18/2025 to 11/24/2025, for auditory hallucinations (hearing things). During an interview on 3/25/2026 at 1:59 p.m., with the DON, the DON stated that non-pharmacologic interventions were to be implemented for residents receiving psychotropics. The DON stated non-pharmacological interventions of less restrictive measures should be implemented for managing behaviors and to assist in identifying causes of the behaviors. During an interview on 3/25/2026 at 2:06 p.m., with the DON, the DON stated Resident 14 did not have non-pharmacological interventions ordered, or documented as provided, from 2/2/2025 to 11/24/2025. During a review of the facility's P&P titled Psychotherapeutic Drug Management, revised 1/6/2026, the P&P indicated the use of non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications. 2b. During a review of Resident 14's discontinued physician orders, dated 11/25/2025 to 3/5/2026, the orders indicated Resident 14 received:1. Fluoxetine 10 mg, once daily, for uncontrollable crying.2. Olanzapine 10 mg, once daily, for yelling and screaming without cause during care. During a review of Resident 14's Medication Administration Record (MAR), dated 1/1/2026 to 1/31/2026, the MAR indicated that on 1/7/2026, Resident 14 exhibited one episode of uncontrollable crying, yelling, and screaming without cause during care. There were no other behaviors documented for 1/2026. During a review of Resident 14's MAR, dated 2/1/2026 to 2/28/2026, the MAR indicated Resident 14 did not exhibit behaviors for which staff administered fluoxetine or olanzapine. During a review of Resident 14's MAR, dated 1/1/2026 to 1/31/2026, the MAR indicated Resident 14 did not exhibit the behaviors for which staff administered fluoxetine or olanzapine. During an interview on 3/25/2026 at 2:03 p.m., with the DON, the DON stated staff were to conduct behavior monitoring on residents receiving psychotropic medications to monitor for effectiveness and identify if there was a continued need for the medication. The DON stated that if the resident was not displaying the behavior the psychotropic was indicated for, the expectation was that a gradual dose reduction (GDR) would be attempted. The DON stated the GDR attempts were to be documented and care planned. During an interview on 3/25/2026 at 2:06 p.m., with the DON, the DON stated there was no documented evidence of a GDR being conducted for Resident 14's administration of fluoxetine and olanzapine since 6/2025. The DON stated that continued use of psychotropic medication, without documented indication of the target behaviors, placed Resident 14 at risk for sustaining adverse effects (undesired, harmful, and unexpected reactions occurring from medical treatment) from the medications. During a review of the facility's P&P titled Psychotherapeutic Drug Management, revised 1/6/2026, the P&P indicated nursing staff were to review the use of psychotropic medication with the Attending Physician/Licensed Healthcare Professional (LHP) and Interdisciplinary Team at least quarterly to determine the continued presence of target behaviors. The P&P indicated that unless clinically contraindicated, the Attending Physician/Licensed Healthcare Professional was to attempt a Gradual Dose Reduction (GDR).

Based on interview and record review, the facility failed to accurately code Section N of the Minimum Data Set (MDS, a resident assessment tool) for one of 12 sampled residents (Resident 14). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS, the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace) regarding Resident 14's health status and increased the potential for Resident 14 to not receive the care and services to address the medications she was receiving.Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 14's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (MDD, a serious mental health condition characterized by persistent 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), and convulsions (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 14's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 14 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 14 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 14 was not receiving antipsychotics (prescription medications used to treat psychosis and severe mood disorders, including schizophrenia), antidepressants (medication used to treat depression), anticonvulsants (medication used to prevent or reduce the severity of convulsions), or hypoglycemic agents (medications that lower blood sugar levels). During a review of Resident 14's Medication Administration Record (MAR), dated 3/1/2026 to 3/31/2026, the MAR indicated Resident 14 received antipsychotics, antidepressants, anticonvulsants, and hypoglycemic agents within the MDS reference date (the dates of the MAR reviewed when the MDS is completed). During an interview on 3/25/2026 at 12:16 p.m., with the MDS Coordinator (MDSC), the MDSC stated Resident 14's MDS dated [DATE] did not accurately identify the medications Resident 14 was receiving. The MDSC stated it was important to identify and record Resident 14's medications accurately because the MDS guided the plan of care. The MDSC stated this would ensure Resident 14's medications were routinely reviewed for effectiveness, and that there was an indication for their continued use. During a review of the facility's policy and procedure (P&P) titled RAI Process, revised 5/19/2025, the P&P indicated that all information recorded within the MDS assessment must reflect the resident's status at the time of the Assessment Reference Date.

Based on interview and record review the facility failed to ensure one of one sampled resident's (Resident 6) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder are placed in facilities that can provide the appropriate care) was filled out to indicate an existing psychiatric condition.This deficient practice had the potential to result in improper placement and unidentified specialized services for Resident 6. Findings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 6 on 7/08/2021 and was re-admitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was cognitively intact. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)During an interview and record review on 3/24/2026 at 1:51 p.m. with Social Worker (SW) 1 Resident 6's admission Record and PASARR and Resident Review Level I Screening, dated 11/12/2025 was reviewed. SW 1 stated Resident 6 had a diagnosis of schizophrenia. The SW 1 stated Resident 6's PASARR Level I Screening diagnosis of schizophrenia should have been checked (as yes). The SW 1 stated completing the PASARR Level 1 screening correctly was important to be able to meet the needs of the resident and identify if the Resident needed a PASSAR II.During an interview on 3/25/2026 at 12:31 p.m. with the Director of Nursing (DON), the DON stated PASARR should be accurate for proper recommendation and appropriate resident placement.During a record review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review, revised 10/01/2023, the P&P indicated the facility conducts Level I PASARR screen for all admissions and readmissions. The P&P indicated All individuals, regardless of payor source, seeking admission to a Medi-Cal-certified Skilled Nursing Facility (SNF) must have a PASRR Determination by the Department of Health Care services (DHCS) or Department of Development Services (DDS) prior to the facility accepting the admission.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review ([PASRR] - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) screening was completed for one of six sampled residents (Resident 1), who had diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), upon admission. This deficient practice had the potential to result in Resident 1 not receiving a required evaluation and identification of the resident's need for specialized mental health services. 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 major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 1 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). The MDS indicated Resident 1 had major depression major depressive disorder and paranoid schizophrenia as active diagnoses. During a concurrent interview and record review on 3/26/2026 at 9:30 a.m., with the Director of Nursing (DON), Resident 1's medical records were reviewed. The medical records did not indicate a PASRR Level I screening had been completed upon admission to determine whether Resident 1 had a mental illness requiring PASRR review. The DON stated a PASRR Level I screening should have been completed for Resident 1 for his diagnoses of depression and schizophrenia. The DON stated the facility failed to ensure a PASRR screening was completed for Resident 1 upon admission due to the resident's mental health diagnoses. The DON stated this failure had the potential to result in the resident's mental health needs and services not being identified and addressed. During a review of the facility's policy and procedure (P&P), titled Pre-admission Screening and Resident Review (PASRR), dated 10/1/2023, the P&P indicated: 1. All residents are screened for mental illness or intellectual disability with state agency coordination. 2. PASRR must be completed prior to admission. 3. The facility performs PASRR Level I screenings for all residents, including those currently residing with mental illness or intellectual disability.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for three of 18 sampled residents (Residents 1, 32, and 5 ), by failing to:Develop and implement care plan interventions for Resident 1's diagnoses of major depression major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a feeling of fear, dread, and uneasiness). Develop and implement care plan interventions for Resident 1's use of Buspirone (an antianxiety medication).Develop and implement care plan interventions for Resident 32's risk for falls and convulsions. Develop and implement care plan interventions for Resident 5's history of post traumatic stress disorder (PTSD - a mental health condition that is triggered by experiencing or witnessing terrifying life-threatening events). These deficient practices had the potential to result in Residents 1, 32, and 5's unmet mental health, psychosocial, safety, and trauma informed care needs, and placed the residents at risk for ineffective care planning, and avoidable harm. Findings: 1. 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 major depressive disorder, paranoid schizophrenia, and anxiety. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required moderate (helper does less than half the effort) assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS did not indicate major depression, paranoid schizophrenia, and anxiety as active diagnoses. During a concurrent interview and record review on 3/26/2026 at 9:02 a.m., with the Director of Nursing (DON), Resident 1's medical records were reviewed. The medical records did not indicate a care plan related to Resident 1's diagnoses of major depression, paranoid schizophrenia, and anxiety. The medical records did not indicate a care plan related to Resident 1's use of Buspirone. The DON stated a care plan should have been developed to address Resident 1's identified mental health diagnoses and medication use, including specific interventions to guide staff with direction for the resident's care and services. The DON stated without a comprehensive person-centered care plan, there was a potential for unmet psychosocial and mental health needs, and ineffective symptom management. 2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE]. Resident 32's diagnoses included epilepsy (a brain condition that causes recurring seizures [convulsions, sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), generalized muscle weakness, and difficulty walking. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 32 required substantial to maximal assistance from staff for personal hygiene and mobility while in and out of bed. During a review of Resident 32's Physician's Progress Notes, dated 2/6/2026, 2/9/2026, and 2/23/2026, the progress notes indicated Resident 32 lacked coordination and was at high risk for repeat falls requiring hospitalization. During an interview on 3/23/2026 at 1:04 p.m., with Resident 32, Resident 32 stated he had a fall a few months ago but could not provide details about how the fall occurred or why. During an interview on 3/24/2026 at 12:29 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 32 was at risk of falls and had a history of convulsions. LVN 2 stated both conditions required a care plan. LVN 2 stated Resident 32 did not have a care plan addressing his risk of falls or history of convulsions. LVN 2 stated the purpose of care planning these conditions was to ensure the resident's safety, and to provide a plan of care that outlined what services and interventions were to be provided. 3. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 2/13/2026 with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and post traumatic stress disorder (PTSD - a mental health condition that is triggered by experiencing or witnessing terrifying life-threatening events). During a review of Resident 5's MDS dated [DATE], the MDS indicated the resident had intact cognition. During a review of Resident 5's H &P dated 2/14/2026, the H&P indicated Resident 5 had the capacity to make medical decisions. During a review of Resident 5's Care Clan, the care plan indicated the resident had a worsening case of depression as evidence by history PTSD. Resident 5's care plans did not address assessments or interventions relating to the resident's history of PTSD. During a concurrent observation and interview on 3/26/2026, at 8:45 a.m. with Resident 5, Resident 5 was observed lying in bed under the blanket. Resident 5 stated that she has PTSD but does not want it in her medical record. Resident 5 stated she has had PTSD for many years. During a interview on 3/26/2026, at 11:43 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 5 sometimes seems depressed. During a concurrent interview and record review on 3/26/2026 at 2:45 p.m. with Social Worker (SW) 1, Resident 5's care plans were reviewed. SW 1 stated there was no documentation indicating the resident had a comprehensive care plan for PTSD. During a concurrent interview and record review on 3/26/2026, at 4:03 p.m. with the DON, the DON stated the importance of having a care plan for residents with PTSD was to have treatment for the resident to be taken care of properly. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 1/2023, the P&P indicated the facility will develop a comprehensive person-centered for each resident based on their individual assessment needs. The P&P indicated the care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. The P&P indicated The facility's Interdisciplinary Team, in coordination with the resident and family or representative must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, physical, mental, and psychosocial needs that are identified. The P&P indicated assessments of residents are ongoing, care plans are reviewed and revised.

Based on observation, interview, and record review, the facility failed to maintain fingernails clean and neat for one of six sampled residents (Resident 18). This deficient practice had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for development of infection.Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses included legal blindness (vision loss), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 18's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 18 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 18's care plan titled The resident has impaired skin integrity, dated 3/12/2026, the care plan indicated to keep Resident 18's fingernails short. During an observation on 3/23/2026 at 11:04 a.m., at Resident 18's bedside, Resident 18's fingernails were observed long and untrimmed with dark brown debris underneath the nail bed. During a concurrent observation and interview on 3/25/2026 at 12:35 p.m., with Resident 18, at Resident 18's bedside, Resident 18 was observed eating lunch using his hands. Resident 18's fingernails were observed long with black substance underneath the nails. Resident 18 stated he was blind and unable to see his fingernails, but could feel they were long. Resident 18 stated he would like staff to cut them. During an interview with the Infection Preventionist (IP) on 3/24/2026 at 1:41 p.m., the IP stated nail care should be assessed daily. The IP stated residents who required assistance with cleaning or trimming their nails should be assisted by the certified nursing assistants (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 Nail Care and revised on 2/24/2026, the P&P indicated that residents' nails are to be maintained in a clean, trimmed, and hygienic condition.

Based on observation, interview, and record review, the facility failed to ensure care and treatment were provided with professional standards of practice for two of three sampled residents (Residents 3 and 14) by failing to ensure:1. Resident 3 and 14's tube feeding bottles were correctly labelled.2., Staff verified Resident 14's gastrostomy tube ([g-tube]- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and patency prior to medication administration. These deficient practices had the potential to place Residents 3 and 14 at risk for unsafe care, improper treatment administration, and avoidable complications and serious medical complications requiring medical intervention and hospitalization.Findings:1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included presence of a gastrostomy tube (g-tube, a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications, or to vent gas/liquids). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making (noticeable decline in memory, language, thinking). The MDS indicated Resident 3 required substantial to maximum assistance for toileting hygiene and was dependent on staff for personal hygiene and rolling left and right in bed. During an observation on 3/23/2026 at 10:00 a.m., at Resident 3's bedside, observed a bottle of enteral feeding (liquid nutrients administered through a g-tube) connected to Resident 3's enteral feeding pump. The enteral feeding bottle was labelled with a different resident's name (Resident 14). During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 14's diagnoses included presence of a g-tube. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 14 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 14's physician order, dated 3/11/2026, the order indicated staff were to label the enteral feeding bottle with the resident's name. During an observation on 3/23/2026 at 10:13 a.m., at Resident 14's bedside, observed a bottle of enteral feeding connected to Resident 14's enteral feeding pump. The enteral feeding bottle was labelled with Resident 3's name. During an interview on 3/24/2026 at 12:42 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated enteral feeding bottles were to be labelled with the resident's name to ensure the enteral feeding type was correct. LVN 2 stated that incorrectly labelled enteral feeding bottles created the potential for nutritional issues. During an interview on 3/24/2026 at 1:04 p.m., with the Director of Staff Development (DSD), the DSD stated staff were to document the resident's name on the enteral feeding bottle. The DSD stated the information documented on the enteral feeding label should match the order and the resident it is being administered to. The DSD stated this was to ensure the resident received the right feeding and nutrition ordered, and to prevent allergic reactions to the formula. During a review of the facility's policy and procedure (P&P) titled Care and Services, dated 2/20/2026, the P&P indicated staff were to provide residents with the necessary care and services to maintain the highest level of practicable functioning in an environment that enhances quality of life in the facility. 2. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included g-tube, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 14 was dependent (helper does all the effort) from staff for ADLs. During a review of Resident 14's History and Physical (H&P), dated 3/16/2026, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's care plan titled G-tube, dated 1/26/2026, the care plan indicated to check g-tube placement before medication administration. During a review of Resident 14's physician order, dated 3/10/2026, the physician order indicated to check for g-tube placement and patency before each medication administration, every shift. During an observation on 3/24/2026 at 8:30 a.m., at Resident 14's bedside, observed LVN 2 administer eight medications to Resident 14 without first verifying g-tube placement and patency. During an interview on 3/24/2026 at 2:45 p.m., with LVN 2, LVN 2 stated she administered Resident 14's medications through the g-tube without checking for placement and patency prior to administration. LVN 2 stated it was important to check g-tube placement and patency prior to medication administration to ensure the g-tube remained properly positioned in the stomach and was free from obstruction before use. LVN 2 stated failure to verify placement and patency could result in medication being administered through a displaced or clogged tube, which could lead to ineffective medication administration, aspiration (choking), blockage, and injury. LVN 2 stated these could place Resident 14 at risk for medical complications requiring hospitalization. During an interview on 3/26/2026 at 9:20 a.m., with the Director of Nursing (DON), the DON stated nursing staff were expected to confirm g-tube placement and patency prior to administering medications through the g-tube in order to ensure safe and appropriate medication delivery. The DON stated administering medications without first verifying g-tube placement and patency was unsafe, inconsistent with facility expectations, and not in accordance with professional standards of nursing practice. The DON stated these had the potential to place Resident 14 at risk for harm. During a review of the facility's P&P titled Feeding Tube- Administration of Medication, revised 2/24/2026, the P&P indicated the facility will ensure medications are administered appropriately and safely when the resident has a feeding tube in place. The P&P indicated:Check tube placement by gently inserting 15 cubic centimeters (cc, unit of measurement) of air into the tube via the piston syringe (medical device used for irrigation, wound cleansing, and flushing feeding tubes or catheters) and auscultating (listening) the resident's abdomen about 3 inches below the sternum (breast bone) with the stethoscope (medical instrument for listening to the action of someone's heart or breathing).After establishing the tube was patent and in the correct position, clamp the enteral tube.Flush the tube with approximately 30 cc of purified water.Administer medication(s).

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, therapeutic support surfaces designed to prevent and treat pressure ulcers [PU, localized damage to the skin and/or underlying tissue usually over a bony prominence]) was set to the correct weight setting for one of two sampled residents (Resident 3). This deficient practice created the potential for Resident 3 to develop a PU.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 3 had moderately impaired cognition (noticeable decline in memory, language, thinking). The MDS indicated Resident 3 required substantial to maximum assistance for toileting hygiene. The MDS indicated Resident 3 was dependent on staff for personal hygiene and rolling left and right in bed. The MDS indicated Resident 3 was at risk for developing pressure ulcers (PUs). During a review of Resident 3's physician order, dated 2/27/2026, the order indicated Resident 3 was to be placed on a low air loss mattress (LALM), with the setting based on his weight. During a review of Resident 3's weight measurement, dated 3/4/2026, the measurement indicated Resident 3 weighed 133 pounds (lbs., a unit of weight measurement). During an observation on 3/23/2026 at 10:00 a.m., at Resident 3's bedside, Resident 3 was observed lying on a LALM. The dial on the LALM machine indicated the setting was for a weight between 150 lbs. and 180 lbs. During an interview on 3/24/2026 at 1:23 p.m., with the Treatment Nurse (TN), the TN stated the purpose of a LALM was to prevent the development of PUs and maintain resident skin integrity. The TN stated the weight settings affected the pressure of the mattress, with lower weight settings being softer, and higher weight settings being firmer. The TN stated that if the weight setting was too high, the LALM mattress would be too firm and increase the risk for the resident to develop a PU. During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines, dated 10/1/2023, the P&P indicated the facility was to provide care and services to promote prevention of pressure ulcer development.

Based on interview and record review, the facility failed to ensure accident hazards were identified and care planned for two of four sampled residents (Resident 14 and Resident 32) when: 1. Staff did not conduct quarterly fall risk evaluations for Resident 14. 2. Staff did not develop care plans for Resident 32's high fall risk and diagnosis of convulsions (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This deficient practice increased the potential for Resident 14 to experience falls and fall-related complications. This deficient practice also increased the likelihood that Resident 32 would not receive the care and services required to prevent falls, and to prevent convulsions and/or complications from convulsions (e.g., falls, injuries). Findings: 1. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 14's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a stroke, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and convulsions. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 14 had severely impaired cognitive skills for daily decision making (significant difficulties with memory, orientation, and attention). The MDS indicated Resident 14 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 14 required substantial to maximal assistance from staff to roll left and right in bed, and was dependent on staff for all other mobility. During an interview on 3/24/2026 at 1:00 p.m., with the Director of Staff Development (DSD), the DSD stated fall risk evaluations were to be conducted upon admission, quarterly, annually, and as needed. The DSD stated any licensed nurse was able to complete the evaluation. The DSD stated the purpose of the evaluation was to identify residents who were at risk for falls, and to prevent falls and possible injuries. The DSD stated Resident 14 had not had a fall risk evaluation since 1/28/2025. The DSD stated Resident 14's fall risk status could have changed since 1/8/2025, and stated she could be at an unidentified risk for falls and injury. 2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE]. Resident 32's diagnoses included epilepsy (a brain condition that causes recurring seizures [convulsions]), generalized muscle weakness, and difficulty walking. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severely impaired cognition. The MDS indicated Resident 32 required substantial to maximal assistance from staff for personal hygiene and mobility while in and out of bed. During a review of Resident 32's Physician's Progress Notes, dated 2/6/2026, 2/9/2026, and 2/23/2026, the progress notes indicated Resident 32 lacked coordination and was at high risk for repeat falls requiring hospitalization. During an interview on 3/23/2026 at 1:04 p.m., with Resident 32, Resident 32 stated he had a fall a few months ago but could not provide details about how the fall occurred or why. During an interview on 3/24/2026 at 12:29 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 32 was at risk of falls and had a history of convulsions. LVN 2 stated both conditions required a care plan. LVN 2 stated Resident 32 did not have care plans for his risk of falls, or his history of convulsions. LVN 2 stated the purpose of care planning these conditions was to ensure the resident's safety, and to provide a plan of care that outlined what services and interventions were to be provided. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 10/1/2023, the P&P indicated a comprehensive care plan was to be developed, and was to include any services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the facility's P&P titled Fall Risk Evaluation, dated 2/24/2026, the P&P indicated that fall risk evaluation was to be completed quarterly. The P&P indicated the information in the fall risk evaluation was used to develop a person-centered care plan. The P&P indicated the fall risk evaluation was to be kept in the patient's record.

Based on interview, and record review, the facility failed to ensure trauma-care evaluation was conducted for one of one sampled resident's (Resident 5) who had a history of trauma (a lasting emotional response to distressing events that overwhelm a person's ability to cope, causing fear, helplessness, and shattered safety). This failure had the potential to result in Resident 5 experiencing re-traumatization.Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated the facility admitted resident on 2/13/2026 with diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and aphagia (a language disorder caused by brain damage that impairs speaking, writing, reading, and understanding).During a review of Resident 5's History and Physical (H&P), dated 2/14/2026, the H&P indicated, Resident 5 was able to make decisions for activities of daily living.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 2/20/2026, the MDS indicated Resident 5 was independent in showering, bed mobility, dressing, transfer, hygiene, and eating.During a interview on 3/26/2026, at 9:44 a.m. with Resident 5, Resident 5 stated she was diagnosed with PTSD as a teenager. Resident 5 stated having nightmares and difficulty sleeping and was startled by loud noises.During a concurrent interview and record review on 3/26/2026, at 10:06 a.m., with the Director of Staff Development (DSD), Resident 5's medical record was reviewed. The DSD stated there was no Trauma Care Evaluation (TCE - assessment form) record found in the resident's record. The DSD stated, he could not get much information regarding trauma and triggers (internal or external stimuli-such as sights, sounds, smells, or specific situations-that remind a survivor of a past traumatic event, triggering intense physical and emotional reactions like flashbacks, panic, or fight or flight responses) from Resident 5. The DSD stated, he should have contacted Resident 5's psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) to obtain information regarding Resident 5's PTSD. The DSD stated trauma related care training for staff was combined with behavior training but does not specifically include trauma-based care strategies. The DSD stated that the resident's triggers were important to be identified to prevent recurring psychological events. During an interview on 3/26/2026, at 4:03 p.m. with the Director of Nurses (DON), the DON stated facility staff should have assessed Resident 5's PTSD. The DON stated possible re-traumatization would harm the resident's psychosocial well-being.During a review of the facility's Policy and Procedure (P&P) dated 2/20/2026 titled, Care and Services, the P&P indicated, Residents are provided with the necessary care and services to maintain the highest level of practicable functioning in an environment that enhances quality of life in the facility.

Based on observation, interview, and record review, the facility failed to ensure signage for enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs]) and personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) were placed outside of the room for one of 12 sampled residents (Residents 3). This deficient practice increased the potential for spread of infection to Resident 3 and other residents.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included presence of a gastrostomy (a feeding tube placed through the abdominal wall directly into the stomach, providing nutrition for people unable to eat normally). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 3 required substantial to maximum assistance for toileting hygiene and was dependent on staff for personal hygiene and rolling left and right in bed. During a review of Resident 3's physician order, dated 6/23/2025, the order indicated staff were to administer enteral feeding (a method of delivering nutrients directly into the stomach or small intestine when a person cannot eat or swallow safely) at 65 milliliters (ml) per hour every shift. During an observation on 3/23/2026 at 9:57 a.m., outside of Resident 3's room, there were no indicators or signage posted indicating EBP precautions were required. There was no PPE available outside of the room. During an interview on 3/24/2026 at 1:40 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated EBP was implemented for all residents with indwelling medical devices, including gastrostomy tubes. The IPN stated EBP protected the residents from contracting MDROs. The IPN stated signage was to be posted outside of the room to alert staff of the need for EBP, and PPE was to be made available outside of the room for use during care activities. The IPN stated that if EBP was not implemented, there was risk for spread of infection. During a review of the facility's policy and procedure (P&P) titled Standard and Enhanced Precautions, dated 4/1/2024, the P&P indicated EBP was indicated for residents with gastrostomy tubes. The P&P indicated EBP was to be implemented for the duration of the resident's stay in the facility.

Based on interview and record review, the facility failed to ensure each resident had 80-square feet (sq. ft., a unit of area measurement) of living space in Rooms: 101, 102, 103, 104, 105, 107, 109, 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 207, 209, 211, 212, 214, 215, and 217. This deficient practice increased the potential for facility residents to be unable to move around freely, and also increased the potential for staff to have difficulty providing high quality care due to a lack of space.Findings: During a interview on 3/23/2026 at 3:14 p.m., with the Administrator (ADM), the ADM stated the facility did not have any active room waivers. The ADM did not provide a room waiver request letter. During a review of the Client Accommodation Analysis, dated 3/23/2026, the analysis indicated the facility's rooms had the following measurements: room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 Square (sq) Feet (ft) per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 215 square feet with 3 beds (74 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) room [ROOM NUMBER] is 215 square feet with 3 beds (74 sq ft per resident) room [ROOM NUMBER] is 155 square feet with 2 beds (77.5 sq ft per resident) During a review of a document titled Room Waiver Request, dated 3/25/2026, the document indicated the facility requested a room waiver for Rooms 101, 102, 103, 104, 105, 107, 109, 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 207, 209, 211, 212, 214, 215, and 217. During observations and interviews conducted from 3/23/2026 to 3/26/2026, there were no concerns observed as a result of the facility not providing residents with at least 80 sq. ft. of living space. Quality of care was not affected, and no complaints or concerns were reported by facility staff or residents.

Based on interview and records review, the facility failed to create an individualized care plan and implement interventions to prevent, one of three sampled residents, Resident 1, who was identified on admission with a significant actual risks for wandering (traveling/ walking from place to place, especially without any clear aim or purpose) and elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision), from leaving the facility unsupervised.This deficient practice without an individualized intervention resulted in Resident 1 leaving the facility on 1/30/2026, between 8:30 pm and 8:45 pm, undetected and was later found at a recovering unit in a general acute care hospital (GACH) after 2 days (2/2/2026).Findings: During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease or malfunction of the brain that alters the structure or function resulting in impaired mental state), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), altered mental status, and high blood pressure.During a review of Resident's 1 Minimum Data Set ([MDS] a resident assessment and care-screening tool) dated 1/6/2026, the MDS indicated Resident 1 can make his needs known, and the ability to understand others. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching assistance/ steadying/ and/or contact guard assist as resident completes activity) with sit to stand, chair/bed-to chair-transfer, toilet transfer and walking 50 feet with 2 turns. Resident 1 required partial/ moderate assistance (Helper does less than half the effort) walking 10 feet. The MDS indicated Resident 1 did not use a wheelchair.During a review of Resident1's Nursing admission assessment dated [DATE], done by Registered Nurse (RN 2), the Wandering and Elopement Assessment section indicated that Resident 1 had recent history of wandering and had a significant Actual Risk for wandering and elopement.During a review of Resident 1's eInteract Change in Condition (COC) Evaluation, dated 1/30/2026 at 3:30 p.m., the COC indicated on 1/30/2026, between 8:30 pm and 8:45 pm, the Director of Nursing (DON) noted during rounds Resident 1 was not in his room. During a review of Resident 1's progress notes dated 1/31/2026 at 8:46 a.m., the progress notes indicated on 1/30/2026 at approximately 8:30 pm and 8:45 pm, staff reported that Resident 1 was not in his room. Staff searched for Resident 1 in rooms, common areas, closets, and restrooms, but could not find him in the facility. Other staff drove along the street and called nearby hospitals but couldn't locate Resident 1. The progress notes indicated on 2/2/2026 at approximately 2:54 pm, Resident 1 was found at a Recovering Unit in a GACH. The Administrator picked up Resident 1 from the GACH and brought back to the facility.During interview on 2/3/2026 at 9:30 a.m., with the DON, the DON stated Resident 1 was not at risk for elopement before this incident. The DON stated it was believed that Resident 1 left the building through the exit door near the rehab room.During a concurrent observation and interview on 2/3/26 at 11: 30 a.m., with Resident 1, Resident 1 was awake on his bed awake; he responded to greetings. Resident 1 was asked how he left the faciity on Friday (1/30/2026). Resident 1 stated that he did not understand and could not answer the question. During interview on 2/3/2026 at 1:40 p.m., with License Vocational Nurse (LVN1), LVN 1 stated that no staff sits and monitors the exit door but will look at the exit door during her rounds and if any resident is getting close to the exit door, that resident will be redirected.During an interview on 2/3/26 at 3:05 p.m., with the RN Supervisor (RN 1), RN 1 stated he saw Resident 1 in his room around 7:30 to 7:45 p.m. during his rounds. Then around 8:00 pm, while he was taking care of a newly admitted resident, he heard the door alarm beside the rehab room went off, he and other staff responded to the alarm. He looked outside the door and into the parking lot and did not see anyone, At the same time a Certified Nurse Assistant (CNA) told him that Resident 1 was not in his room. RN 1 stated staff searched for Resident 1, both inside the facility and outside, but they did not see him. It was dark outside. He then notified the Administrator and the law enforcement about Resident 1 missing. During the interview, the RN 1 confirmed that all the exit doors in the facility were not locked, all doors have alarms, and the alarm would go off if someone tried to leave, but no one can access the doors from outside. RN 1 stated that the exit doors are being monitored by the nursing staff whose assignments are close to the exit doors, they will monitor the doors during their rounds.During an interview on 2/3/2026 at 3:50 p.m., with the Administrator, the Administrator confirmed the doors were not locked because the facility is not a locked facility, the doors can easily be assessed from inside in case of emergency. The Administrator stated that the nurses monitor the exit door near their assigned area.During a concurrent interview and record review on 2/4/2026 at 1:45 p.m., with RN 2, RN 2 stated according to the admission assessment on Resident 1 on 12/30/2025, Resident 1 was identified with significant risks for wandering and elopement, but there was no care plan developed, to prevent Resident 1 from getting out of the facility.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 10/1/2023, the P&P indicated that the purpose of the policy was to ensure that a comprehensive person-centered Care Plan is develop for each resident based on their individual assessed needs. The P&P indicated the facility's Interdisciplinary Team (IDT) should develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with Omnibus Budget Reconciliation Act of 1987, (OBRA, a federal law that established foundational quality of care standards and rights for nursing home residents) and MDS guidelines.During a review of the facility's P&P titled, Wandering and Elopement, dated 10/1/2023, the P&P indicated to enhance the safety of residents of the facility, the facility will identify residents at risk for elopement and minimize any possible injury because of elopement. The P&P indicated the Licensed Nurse will assess residents upon admission and readmission and determine their risk of wandering/elopement. Residents at risk of wandering/elopement, preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission.

Based on observation, interview and record review, the facility failed to provide supervision for 2 of 6 sampled residents (Residents 2 and 3), who were assessed as requiring supervision while smoking. This failure had the potential to cause accidental burns and injuries to Residents 2 and 3. Findings:During a concurrent observation and interview on 12/16/2025 at 11:25 a.m. with the Activity Director (AD), on the patio, Resident 2 was observed smoking a cigarette without staff supervision. The AD stated Resident 2 should be supervised while smoking. The AD stated failure to supervise residents may increase the risk of residents getting burned or having accidents while smoking.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 paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest) and generalized anxiety disorder (GAD- is a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 2 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Activities of Daily Living (ADLs) such as toileting hygiene, dressing and personal hygiene. During a review of Resident 2's Smoking Assessment, dated 12/04/2025, the Assessment indicated Resident 2 was a smoker and required staff supervision while smoking. A review of Resident 2's Care Plan titled, [Resident 2] is a cigarette smoker dated 12/16/2025, the Care Plan goal indicated Resident 2 would not smoke without supervision through the review date. The Care plan nursing interventions included instructing Resident 2 about the facility policy on smoking: locations, times, safety concerns and notifying the charge nurse immediately if it is suspected Resident 2 had violated the facility smoking policy.During a concurrent observation on 12/16/2025 at 1:15 p.m., on the patio, Resident 3 was observed smoking a cigarette without staff supervision. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness, dysphasia (difficulty swallowing) and right hip pain.During a review of Resident 3's MDS, dated [DATE], the MDS Resident 3 required set up or clean up assistance with toileting hygiene, personal hygiene, and upper body dressing.During a review of Resident 3's Smoking Assessment, dated 12/11/2025, the smoking assessment indicated Resident 3 was a smoker and required staff supervision while smoking. A review of Resident 3's Care Plan titled, [Resident 3] is a smoker dated 12/17/2025, the Care Plan goal indicated Resident 3 will not suffer injury from unsafe smoking practices and Resident 3 will not smoke without supervision through the review date. The Care Plan nursing interventions included instructing Resident 3 about the facility policy on smoking: locations, times, safety and concerns, and notifying the charge nurse immediately if it is suspected Resident 3 had violated facility smoking policy.During an interview on 12/16/2025 at 2:10 p.m., with the Director of Nursing (DON), the DON stated Smoking should be supervised by the Activity Department staff or Assistant, and the lack of supervision may increase the risk of injuries or burns.During a review of the facilities policy and procedure (P/P) titled, Smoking, dated 10/1/2023, the P/P indicated the purpose of this policy is to maintain a safe healthy environment for both smokers and non-smokers. The P/P indicated smokers shall be identified at the time of admission, residents will be provided with a copy of this policy during the admission process. The P/P indicated all smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly. All smoking sessions will be supervised by Facility Staff members.

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medications (drugs that alter brain chemistry to manage mental health conditions like depression, anxiety, schizophrenia) prior to administering psychotropic medications to one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for experiencing unexpected and/or unwanted adverse effects or complications from the medications, including increased risk of suicidal thoughts, cognitive impairment, and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body).Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 1's diagnoses included paranoid schizophrenia (a subtype of schizophrenia, a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior), restlessness and agitation, and emotional lability (rapid, intense, and often uncontrollable mood swings). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/7/2025, the MDS indicated Resident 2 had severe cognitive impairment (significant trouble with thinking, memory, learning, concentrating, or decision-making). The MDS indicated Resident 2 required supervision or touch assistance from staff for mobility while in and out of bed. During a review of Resident 2's History and Physical (H&P), dated 10/3/2025, the H&P indicated Resident 2 did not have the capacity to understand or make medical decisions. During a review of Resident 2's record titled Informed Consent for Psychotherapeutic Medications, dated 10/13/2025, the record indicated Resident 2 was to receive Vistaril (a prescription medication with sedative and anti-anxiety properties). The record indicated informed consent for the administration of Vistaril was obtained from Resident 2. During a review of Resident 2's record titled Informed Consent for Psychotherapeutic Medications, dated 10/17/2025, the record indicated Resident 2 was to receive trazodone (an antipsychotic medication). The record indicated informed consent for administration of trazodone was obtained from Resident 2. During an interview on 12/12/2024 at 11:13 a.m., with the Director of Nursing (DON), the DON stated Resident 2 did not have decision making capacity. The DON stated staff should not have obtained informed consent for Vistaril and trazodone from Resident 2. The DON stated that these medications were chemical restraints, and stated it was the right of the resident, or a responsible party, to consent to the administration of the medications. During a review of the facility's policy and procedure (P&P) titled Psychotherapeutic Drug Management, dated 5/2025, the P&P indicated staff were to ensure risks and benefits of psychotropic medications were explained prior to their use.

Based on interview and record review, the facility failed to provide emergency care (the provision of care for conditions that require rapid intervention to avoid death or permanent disability) to the resident, who had an altered mental status (a change in a resident's level of awareness, cognition, often indicating an underlying medical or neurological issue [any condition that affects the nervous system, including the brain, spinal cord, and nerves) and high blood pressure (BP- of 200/109 millimeters of mercury ([mmHg, a unit of measurement], reference range is120/80 or lower) to prevent intracerebral hemorrhage ([ICH] a type of stroke involving bleeding within the brain tissue) for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1 immediately (instantly/ without delay) after Resident 1 had altered mental status on [DATE] at 2:14 p.m. 2. Immediately provide emergency interventions by sending Resident 1 to the general acute care hospital (GACH) without a delay for evaluation and treatment. 3. Implement the facility's policy and procedure (P&P) titled, Emergency Care-General, which indicated to summon help and immediately call 911 (medical emergency phone number) for medical emergency assistance for new onset of unconsciousness or unresponsiveness to verbal or physical stimuli, severe low blood sugar with impaired consciousness, or any seizure activity (a sudden, abnormal surge of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness). As a result of these failures, Resident 1 did not receive the emergency care (the immediate medical attention provided to individuals experiencing serious or life-threatening health conditions) on [DATE], from 2:14 p.m. to 5:47 p.m. (a total of three (3) hours and 33 minutes), when Resident 1 had a change in condition, resulting in Resident 1 suffering an intracerebral hemorrhage as evidenced by GACH 1's Computerized Tomography (CT, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) scan of the brain without contrast (no contrast agent used) dated [DATE], at 7:15 p.m., leading to Resident 1's intubation (when a breathing tube inserted through the mouth or nose, down to the trachea [windpipe], connected to the mechanical ventilator (a form of life support) and death on [DATE] in GACH 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body) affecting right dominant side (resident's preferred side of the body to use), and epilepsy (a neurological disorder characterized by a tendency to have recurrent, unprovoked seizures) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with eating and upper body dressing. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting hygiene, lower body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent (helper does all the effort) on shower/bath and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance with rolling from lying on back, to left and right side, and in returning to lying on back on the bed. The MDS indicated Resident 1 required substantial/maximal assistance with sitting to lying and lying to sitting position on side of the bed. The MDS indicated Resident 1 was dependent on chair/bed-to-chair transfer, and tub/shower transfer. During a review of Resident 1's care plan titled, The resident has altered endocrine (tissue that make and release hormones that travel in the bloodstream and control the actions of other cells or organ) status, diabetes, initiated [DATE], the care plan indicated the goal for Resident 1 was not to experience any complications (problems) from diabetes and receive medications as ordered. The care plan interventions indicated to monitor Resident 1 for reports of changes to the eye (eye condition) and report to the physician as needed. During a review of Resident 1's Physician's Order Summary report dated [DATE], the Physician's Order Summary report indicated the following orders: 1. Finger stick blood sugar (FSBS, to check blood sugar level by pricking the finger and using a small drop of blood from the fingertip) as needed for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). If FSBS is less than 60 (normal blood sugar range-70 to 99 milligrams per deciliter (mg/dL, a unit of measurement) and the resident is alert/ responsive, to give snack and recheck the blood sugar after 15 minutes, hold insulin (medicine for diabetes) and call the physician immediately, every 15 minutes, as needed. 2. Gvoke ([Glucagon] a prescription medicine used to treat very low blood sugar) prefilled syringe (PFS, a disposable syringe that comes with a pre-measured dose of insulin already loaded), 1 milligram ([mg] unit of mass measurement)/0.2 milliliter ([ml] unit of volume measurement), to inject 0.2 ml intramuscularly (injection into the muscles) as needed for hypoglycemia, if FSBS is less than (<) 60 and resident is unresponsive, call medical doctor (MD) immediately and recheck FSBS in 15 minutes. (hold insulin). 3. Insulin Glargine-yfgn (injection medication for diabetes) subcutaneous (SQ, fatty tissue layer just below the skin tissue) solution pen-injector 100 units, inject 15 milliliters (ml, a unit of measurement) SQ at bedtime. 4. Monitor vital signs (physiological measurements that indicate a person's basic bodily functions, includes blood pressure, heart rate, temperature and oxygen saturation (a measure of how much oxygen is in the blood, normal range 95-100%) every shift. 5. Amlodipine Besylate oral tablet 10 mg., one (1) tablet by mouth one time a day (medicine for hypertension [high blood pressure]), hold when systolic blood pressure (SBP- the top number in a BP reading) is <110. 6. Aspirin (medicine for stroke prevention) 81 mg oral tablet, delayed release, daily. 7. Atorvastatin Calcium (medicine to lower cholesterol levels) 40 mg., tablet by mouth at bedtime for hyperlipidemia (high fats or lipids in the blood). 8. Lisinopril (medicine to treat high blood pressure) 20 mg., tablet by mouth, daily. Hold when SBP <110 and heart rate (HR, normal rate between 80-100 beats per minute) <60. 9. Levetiracetam oral solution (a medication primarily used to treat epilepsy by controlling various types of seizures [sudden, temporary episodes of abnormal brain activity that can cause a variety of symptoms, including muscle spasms, loss of consciousness, and altered behavior]) 100 mg/ml, to give 15 ml by mouth two times a day. The Physician's Order Summary report indicated Resident 1 was discharged to GACH 1 via 911 on [DATE] (no reason indicated). During a review of Resident 1's Medication Administration Record (MAR) for [DATE], the MAR indicated Resident 1 was administered Amlodipine and Lisinopril on [DATE] at 9 a.m., however the MAR did not indicate a documented BP reading. The MAR indicated Resident 1 refused the Levetiracetam morning dose on [DATE], [DATE] and [DATE]. During a review of Resident 1's Licensed Nurses Progress Notes dated [DATE] at 2:14 p.m., the Licensed Nurses Progress Notes indicated Resident 1 was transferred to GACH 1 via 911 (notes did not specify date and time of transfer) due to altered mental status. The Licensed Nurses Progress Notes did not indicate documentation regarding Resident 1's condition, any assessment conducted, and interventions provided to Resident 1 after the change in condition was observed on [DATE] at 2:14 p.m. and prior to the arrival of the paramedics on [DATE] at 5:47 p.m. During a review of Resident 1's Los Angeles Fire Department (LAFD) Patient Care Report (report) dated [DATE] at 5:37 p.m., the report indicated paramedics dispatch were notified on [DATE] at 5:37 p.m. and was on scene with Resident 1 at 5:47 p.m. The report indicated Resident 1 was unconscious (unresponsive to all stimuli). The report indicated Resident 1 was hypoglycemic (with low blood sugar level). The report indicated Resident 1 had been confused for one hour in the facility (time not specified). The report indicated at 5:47 p.m. paramedics checked Resident 1's blood sugar and it was 31. The report indicated Resident 1's BP was 140/80 at 5:47 p.m. and 160/80 at 5:58 p.m. The report indicated an intravenous line ([IV] a thin, flexible tube inserted into a vein to administer fluids, medications or blood products directly into the bloodstream) was established and Resident 1 was given Glucagon which raised Resident 1's blood sugar level to 164 mg/dl. The report also indicated Resident 1 was given (administered) IV of Dextrose 10 (D10- 10% [percent]of sugar in water used to provide body with extra water and calories from sugar). During a review of Resident 1's e-interact Change of Condition (COC) Evaluation dated [DATE] at 6:21 p.m., completed by Licensed Vocational Nurse (LVN) 1, the COC indicated Resident 1 had a minor shortness of breath (the feeling of not being able to breathe deeply enough or get enough air) (time not specified). The COC indicated Resident 1 did not have any oxygen in use. The COC indicated the date and time the physician was notified was [DATE] at 2:23 p.m. The COC indicated, per medical order, Resident 1 was to be transferred to GACH due to altered mental status. During a review of Resident 1's GACH 1 record titled, Emergency Department (ED) note, dated [DATE] at 6:52 p.m., the ED notes indicated, Resident 1 had altered mental status one hour prior to the paramedic's arrival at the facility. The ED notes indicated Resident 1 was hypoglycemic and arrived at the ED still altered. The ED notes indicated Resident 1 had left sided gaze deviation (a condition where a person's eyes are deviated or turned towards the left side which can be due to various neurological conditions, including stroke). The ED notes indicated Resident 1's glucose level was 248, potassium (an essential mineral and electrolyte that plays a vital role in nerve and muscle function, including the heart) level of 3 (normal range is 3.5 to 5.2 milliequivalent per liter ([mEq/L] unit of measurement). The GACH 1 CT of the brain without contrast dated [DATE] at 7:15 p.m., indicated Resident 1 had a focal (localized) hematoma (a localized collection of blood outside of the blood vessels) at the left fronto (front of the head, behind the forehead) parietal (the top and back of the head, behind the frontal lobe and above the temporal (second largest lobe that sit behind the ears) and occipital lobe (the visual processing area of the brain) region, measuring 3.7 x 2.6 x 3.9 centimeters ([cm] unit measure of length) for a total ICH volume of 19.5 cubic centimeters ([cc] a unit of measurement of volume] the volume of blood collected within the brain tissue following a stroke). The impression indicated a focal ICH (bleeding that is localized to a specific area within the brain or its surrounding spaces) at the left posterior (back) parietal area. The ED notes indicated Resident 1 was intubated on [DATE] at 8:43 p.m. for airway protection during transport to GACH 2 for a higher level of care with neurosurgery (the medical specialty concerned with the diagnosis and treatment of patients with injury to, or diseases/disorders of the brain, spinal cord and spinal column, and peripheral nerves within all parts of the body). The ED notes indicated Resident 1 was transferred to GACH 2 on [DATE] at 10 p.m. During a review of GACH 2's History and Physical (H&P, the physician's examination of a patient) report, dated [DATE] at 10:27 p.m., the GACH 2's H&P indicated Resident 1 was transferred from GACH 1 for the management of left parieto-occipital (the region or structures situated between the parietal (walls) and occipital lobes of the brain) intracerebral hemorrhage. The H&P report indicated, according to the nursing staff at the facility on [DATE] at around 1 p.m. to 2 p.m., Resident 1 exhibited facial abnormalities, possibly twitching or asymmetry (uneven), with left-sided gaze deviation along with movement of the resident's arms, hands and legs. The H&P indicated that despite the concerning signs, Resident 1 was not immediately sent to the GACH, rather, was transferred between 4:00-5:00 p.m. (2-3 hours after). The H&P indicated Resident 1 was intubated and was connected to a mechanical ventilator (a breathing machine). During a review of GACH 2's Discharge Documentation dated [DATE], the documentation indicated Resident 2 was compassionately extubated (the process of withdrawing mechanical ventilation from a patient at the end of life to allow for a peaceful and comfortable death) and died on [DATE] at 6:54 a.m. During a review of Resident 1's Certificate of Death indicated, Resident 1 died on [DATE]. The Certificate of Death indicated the immediate cause of death was cardiopulmonary arrest (sudden cessation of heart function and breathing) sequentially (in succession) to cerebral edema (brain swelling), non-traumatic intracranial hemorrhage and hypertension (high blood pressure). During a phone interview on [DATE] at 3:22 p.m., with Resident 1's Family Member (FM 1), FM 1 stated when FM 2 visited Resident 1 on [DATE] around 2:30 p.m., while Resident 1 was being cleaned by Certified Nurse Assistant (CNA 1), Resident 1 was not responsive. FM 1 stated Licensed Vocational Nurse (LVN) 1 reported to FM 2 that Resident 1 had a seizure but when LVN 1 checked the BP, it was 220/138 mmHg. FM 1 stated, according to FM 2, it took the staff over one hour to send Resident 1 to GACH 1. FM 1 stated even though Resident 1 had a stroke before, Resident 1 remained alert and aware of her surroundings. FM 1 stated according to FM 2, Resident 1 was not talking or moving on [DATE]. FM 1 stated from GACH 1 Resident 1 was taken to GACH 2 because GACH 1 found a bleed in her brain and GACH 2 confirmed it was a second stroke. During an interview on [DATE] at 12:43 p.m. with CNA 1, CNA 1 stated on [DATE] around 2:30 p.m., she went to Resident 1's room because FM 2 was visiting Resident 1. CNA 1 stated when she entered Resident 1's room Resident 1 was looking blankly towards the left side and was not answering. CNA 1 stated she cleaned the resident and kept calling Resident 1's name while she was cleaning her, but Resident 1 was not answering. CNA 1 stated Resident 1 was usually awake, alert, able to make all her needs known and move all extremities (both upper arms and both lower legs) despite being bedridden. CNA 1 stated she called LVN 1 to check on Resident 1 after she finished cleaning the resident on [DATE] (duration not specified). CNA 1 stated LVN 1 told her Resident 1 had a seizure. CNA 1 stated, when she saw Resident 1, Resident 1's one side of face (side not specified) looked droopy. CNA 1 stated it looked like Resident 1 had a stroke. CNA 1 stated it did not look like a seizure. CNA 1 stated she notified LVN 1 and LVN 1 took Resident 1's vital signs. CNA 1 stated she was not sure what time the LVN 1 took Resident 1's vital signs but after that, she believed LVN 1 called paramedics on [DATE] (time not specified). During a phone interview on [DATE] at 12:53 p.m. with LVN 1, LVN 1 stated he received a report from CNA 1 on [DATE] at around 2:15 p.m. or 2:30 p.m. that Resident 1 did not look like herself (changed) and had altered mentation from her baseline (normal status). LVN 1 stated he initially suspected a seizure because Resident 1 had a history of seizures. LVN 1 stated he checked the blood pressure, and it was 200/109 mmHg. LVN 1 stated he called the physician (MD) immediately (time not specified) and requested to send Resident 1 to GACH 1. LVN 1 stated on [DATE] in the morning (time not specified), Resident 1 was watching television with her roommate and was verbally responsive and was able to make needs known. LVN 1 stated when he went to Resident 1's room on [DATE] at around 2:15 p.m. or 2:30 p.m., Resident 1 was staring blankly and was not responding. LVN 1 stated it was a medical emergency when a resident has a blood pressure of 200. LVN 1 stated Resident 1 should have been sent to the hospital immediately. LVN 1 stated Resident 1 was at a very high risk for heart attack or stroke. LVN 1 stated he should have assessed Resident 1 for signs of stroke or heart attack like chest pain, sweating, numbness (loss of feeling or sensation), confusion, difficulty understanding and talking, vision, poor balance, facial drooping (a condition where the muscles on one side of the face become weak or paralyzed, causing them to droop or sag) or the ability to hold up arms. LVN 1 stated Resident 1 was not assessed because the resident was very stiff and was not following any commands at that time (on [DATE] at around 2:15 p.m. or 2:30 p.m.) LVN 1 stated he called 911 on [DATE] around 4:30 p.m. or 4:35 p.m. and it took the paramedics 15-25 minutes to arrive (time not specified). During an interview on [DATE] at 3:13 p.m. with LVN 1, LVN 1 stated he was not sure why the sequence of events and the time he assessed Resident 1, did not match his documentation in the COC on [DATE] at 6:21 p.m. and the progress notes on [DATE] at 2:14 p.m. LVN 1 stated he did not check Resident 1's blood sugar at all on [DATE]. LVN 1 stated the BS reading of 100 in Resident 1's clinical record on [DATE] at 4:23 p.m., was a typo on his part. LVN 1 stated the only blood sugar reading was from LAFD which indicated 30 and he was not sure if anything was given for it. LVN 1 stated FM 2 was at bedside and FM 3 arrived 10 minutes after LVN 1 had taken the blood pressure (time not specified). LVN 1 stated on [DATE] (times not specified), he checked the BP about four times, and the BP remained high (around 200's). LVN 1 stated he did not document the BP readings taken on [DATE] (times not specified) in the resident's clinical records. The LVN 1 stated he called the Director of Nursing (DON) who was off on that day (Saturday, [DATE]) at 4:30 p.m. and reported the incident (Resident 1's altered mental status) because the Registered Nurse Supervisor (RN) 1 was busy with another resident. During a concurrent phone interview on [DATE] at 1:22 p.m. with FM 1, FM 2 and FM 3, FM 1 stated FM 2 called her (FM 1) at 3:04 p.m. on [DATE] and was told Resident 1 was not talking and something was wrong (unspecified). FM 2 stated he arrived at the facility a little after 2:30 p.m. on [DATE] while CNA 1 was changing Resident 1. FM 2 stated he observed CNA 1 kept calling Resident 1's name, but Resident 1 was not responding. FM 2 stated he observed a LVN (unidentified) entered the room and checked Resident 1's BP. FM 2 stated Resident 1's BP was 220/138 mmHg. FM 2 stated LVN 1 told him Resident 1 had a seizure because of Resident 1's expression on her face. FM 2 stated he observed LVN 1 tried to give Resident 1 a pill (FM 2 was not sure what it was and LVN 1 did not tell him what it was) but the resident was not swallowing it. FM 2 stated LVN 1 crushed the pill, mixed it with Jello or pudding and gave the crushed pill to Resident 1. FM 2 stated he was not sure if Resident 1 swallowed the crushed pill because Resident 1 was not moving. FM 3 stated she spoke to LVN 1 on [DATE] around 3:30 p.m. and was told that Resident 1 had a seizure. FM 3 stated she asked LVN 1 if it was another stroke, FM 3 stated LVN 1 told her it was not a stroke. FM 3 stated LVN 1 told her that Resident 1 had high BP and that LVN 1 was getting in touch with MD. FM 3 stated she did not notice LVN 1 talking to MD but FM 3 noticed LVN 1 was seen talking to another nurse (unidentified). FM 3 stated it was the other nurse who told LVN 1 to call the paramedics. FM 3 stated Resident 1 was staring towards the left and was not talking or tracking. FM 3 stated LVN 1 was saying Resident 1 needed to go to the hospital, but he (LVN 1) did not call the paramedics until he got off the phone. During a phone interview on [DATE] at 2:36 p.m. with DON, the DON stated RN 1, who was on duty that day ([DATE]), did not see Resident 1 because RN 1 was not aware of the incident. The DON stated when she spoke to LVN 1 on [DATE] (time not specified), LVN 1 told her (DON) that RN 1 had already left for the day. During a phone interview on [DATE] at 2:39 p.m. with RN 1, RN 1 stated LVN 1 called him (RN 1) on the phone on [DATE] at around 3 p.m. while he (RN 1) was on his way to another job. RN 1 stated LVN 1 notified him (RN 1) that Resident 1 had a seizure. RN 1 stated he instructed LVN 1 to send Resident 1 to GACH if the seizure will not stop. During a review of the facility's Policy and Procedures (P&P) titled, Acute Condition Changes (a sudden, clinically significant deviation from a resident's normal state)- Clinical Protocol, dated 3/2018, the P&P indicated the nursing staff will contact the physician based on the urgency of the situation. The P&P indicated, before contacting the physician about someone with an acute change of condition, the nursing staff should collect pertinent details to report to the physician. The P&P indicated phone calls to the attending physician should be made by an adequately prepared nurse who had collected and organized pertinent information, including the resident's current symptoms and status. The P&P indicated the nurse shall assess and document/ report the following baseline information: a. Vital signs; b. Neurological status; c. Level of consciousness; d. Cognitive status; e. Onset, duration, severity; f. Recent labs; g. All active diagnosis h. All current medications. The P&P indicated the nursing staff should contact the physician based on the urgency of the situation. The P&P indicated, for emergencies, the nursing staff should call of page the physician and request a prompt response (within approximately one-half hour or less). The P&P indicated the attending physician should respond in a timely manner to the notification of problems or changes in condition and status and the nursing staff should contact the Medical Director for additional guidance and consultation if they did not receive a timely or appropriate response. The P&P indicated the staff will monitor and document the resident's progress and responses to treatment and the physician will help the staff monitor the resident with acute change of condition until the problem or condition has resolved or stabilized. During a review of the facility's P&P titled, Emergency Care-General, dated 10/2022, the P&P indicated emergency treatment should be given to residents who sustained illness while in the facility to preserve the resident's life, to prevent further harm, and promote recovery. The P&P indicated to summon help and immediately call 911 for medical emergency assistance for new onset of unconsciousness or unresponsiveness to verbal or physical stimuli, severe low blood sugar with impaired consciousness that did not respond to emergency or first-time seizure. The P&P indicated to document the resident's vital signs including blood pressure, pulse, respirations and temperature and notify the physician or Medical Director of the specific complaints and vital signs as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Sixty-four medication errors out of 82 total opportunities contributed to an overall medication error rate of 78 % affecting 17 out of 20 residents observed during medication administration (Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99). The medication errors were as follows: 1. Omitted or late administration of Amiloride HCI (medication to treat high blood pressure) 10 milligram ([mg] unit of measurement) for hypertension ([HTN] high blood pressure), of Finasteride (medication to treat overgrowth of prostate) 5.0 mg for benign prostatic hyperplasia ([BPH] a condition when the prostate [male organ] and surrounding tissue expands), Namenda (medication to treat Alzheimer's [a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) 10 mg for Alzheimer's disease to Resident 1. 2. Omitted or late administration of Acetazolamide (medication to treat glaucoma) 500 mg, Benztropine Mesylate (medication to help body fight infections) 0.5 mg for immunodeficiency (failure of the immune system to protect the body adequately from infection), Risperdal (medication used to treat schizophrenia) 2 mg, Propranolol HCI (medication to treat high blood pressure) 20 mg, Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain) to Resident 2 . 3. Omitted or late administration of Metformin (medication to treat high blood sugar) 500 mg to Resident 3. 4. Omitted or late administration of Vascepa (medication to treat high cholesterol) 1.0 gm two capsules for hyperlipidemia, Amantadine HCl (medication to treat involuntary, erratic, twisting movements of the face, arms, legs or trunk) 100 mg for dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk) Lamotrigine (medication used to treat bipolar disorder [a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows] and schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]) 400 mg, Trihexyphenidyl HCL (medication given to treat Extrapyramidal side effects [EPS], commonly referred to as drug-induced movement disorders) 3.0 gm ([gram] unit of measurement) and Flomax (medication to treat overgrowth of prostate [BPH]) 0.4 mg to Resident 4. 5. Omitted or late administration to Resident 6 of Midodrine (for low blood pressure) 5 mg, Keppra ([Levetiracetam] medication to treat seizure [a sudden, uncontrolled burst of electrical activity in the brain] disorder) 5.0 milliliters ([ml] unit of measurement) of 100 mg/ml for seizure disorder, Gabapentin (medication used to treat nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) 300 mg for neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) to Resident 6. 6. Omitted or late administration of Symbicort inhalation aerosol (medication used to treat [{Asthma} a condition when airways in the lungs become narrowed and swollen, making it difficult to breathe]) 160- 4.5 mg one puff, Norvasc (medication used to treat hypertension) 10 mg HTN, Eliquis (medication to treat damaged tissues in the brain due to a loss of oxygen to the area) 5 mg, Metoprolol Tartrate (medication to treat HTN) 25 mg for HTN, and Losartan Potassium (medication to treat HTN) 25 mg for HTN to Resident 8. 7. Omitted or late administration of Zyprexa ([Olanzapine] medication given to treat hallucinations in mental disorder) 7.5 mg tablet for auditory hallucinations (hearing voices or noises that do not exist in reality) related to schizophrenia and Metformin HCL 500 mg tablet for DM to Resident 14. 8. Omitted or late administration to Resident 15 of Cogentin (medication given to treat EPS) 1.0 mg for EPS, Risperdal (medication to treat schizophrenia)1.0 mg, Metformin HCL 850 mg for diabetes mellitus ([DM] a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Lactulose (medication used to treat elevated ammonia levels[high ammonia levels can cause permanent brain damage, coma, and even death]) 15 ml of 10 gm/15 ml for elevated ammonia levels, and Admelog Solution ([Insulin Lispro] medication used to treat elevated blood sugar) 100 units/ml subcutaneously ([SQ] beneath, or under, all the layers of the skin) to Resident 15. 9. Omitted or late administration of Cogentin 1.0 mg for EPS, Amlodipine Besylate (medication used to treat HTN) 10 mg for HTN, Aspirin 81 mg for CVA prophylaxis, Levetiracetam 10 ml of 500 mg/5 ml for epilepsy (a recurrent seizures, which are brief episodes of involuntary movement that may involve a part of the body or the entire body), Topiramate (medication used to treat seizures) 100 mg for seizure, and Haloperidol (a medication to treat schizophrenia) 1.0 mg for schizophrenia to Resident 16. 10. Omitted or late administration of Fluoxetine HCL (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 10 mg and Levetiracetam 5 ml of 100mg/ml for convulsions to Resident 18. 11. Omitted or late administration of Carvedilol (medication used to treat high blood pressure) 6.25 mg for HTN, Duloxetine HCl (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 60 mg for major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Amlodipine Besylate 10 mg for HTN, and Aspirin 81 mg for CVA prophylaxis to Resident 22. 12. Omitted or late administration of Amlodipine Besylate 10 mg for HTN and Benazepril HCl (medication used to treat high blood pressure) 40 mg for HTN to Resident 25. 13. Omitted of late administration of Duloxetine HCl 40 mg low mood and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Baclofen (medication used to treat muscle spasms [an involuntary and abnormal muscular contraction]) 10 mg for muscle spasms, Amlodipine Besylate 5 mg tablet for HTN, Gabapentin 400 mg for neuropathy, and Keppra 500 mg for seizure to Resident 26. 14. Omitted or late administration of Lasix (diuretic) 60 mg for heart failure (condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), Gabapentin 600 mg, Metformin HCl 1000 mg for diabetes mellitus (DM), Carvedilol 6.25 mg for HTN, Benazepril HCL 40 mg HTN, Clonidine (medication used to treat high blood pressure) 0.2 mg for HTN, and Empagliflozin (medication used to treat high blood sugars) 10 mg for DM to Resident 26. 15. Omitted or late administration of Norvasc 5 mg for HTN, Seroquel (medication used for the treatment of schizophrenia) 37.5 mg for bipolar disorder, and Aspirin 81 mg for CVA prophylaxis to Resident 38. 16. Omitted or late administration of Topamax (medication used to treat seizure) 100 mg for seizure, Lacosamide (medication used to treat seizures) 100 mg for seizure, Keppra 750 mg for seizure, Lisinopril (medication used to treat abnormally high blood pressure) 20 mg for HTN, Cymbalta (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) delayed release capsule 30 mg, Sinemet (medication used to treat Parkinson's disease [a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves]) 10 mg of 10-100 mg for Parkinson's disease, Aspirin 81 mg for CVA prophylaxis, Cenobamate (medication given to treat seizures) 50 mg for seizure, and Baclofen 10 mg for muscle spasm to Resident 44. 17. Omitted or late administration of Morphine Sulfate (narcotic medication used to treat pain) 15 mg for pain to Resident 99. 18. Follow their policy and procedure titled Administering Medications, which indicated medications are administered in accordance with prescriber orders, including required time frame within one before or after prescribed/scheduled time. This deficient practice of failing to administer medications in accordance with the physician's orders at the scheduled administration time increased the risk that Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99 may have experienced serious medical complications such as stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) or complications related to poor blood sugar control including hyperglycemia (an excess of sugar in the bloodstream), diabetic coma (a life-threatening disorder that causes unconsciousness), uncontrolled seizure, worsening of depression, anxiety, and schizophrenia with associated complications including death. On 2/3/2024 at 7:01 p.m., an Immediate Jeopardy (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) situation was identified and declared in the presence of Director of Nursing (DON) and Administrator (Admin) due to the facility's failure to ensure that its medication error rate was less than 5%. The medication error rate was 75.86 %. On 2/4/2024 at 7:15 p.m., the facility provided the California Department of Public Health (CDPH) with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized actions: 1. On 2/3/24, the DON immediately initiated incident reports by way of the Risk Management section of the facilities Electronic Medical Records system as well as notifying the attending physician for the 17 residents affected by the deficient practice. Initiated 2/4/24 care plans are being updated with additional monitoring added to resident EMAR's in order to ensure they are not experiencing any adverse reactions that could have been cause by the delay of the medication administration described in the CMS-2567, F759. Also, on 2/4/24 11 alert orientated residents and 6 responsible parties will being notified that they received their medication late by the Director of Nursing to ensure they are fully aware of medication error and risk involved. 2. Effective immediately on 2/4/24, the Medical Records Director initiated a clinical audit facility wide of resident Medication Administration Records to ensure they are accurate, complete, and timely. The results of this audit will be shared with the Director of Nurses and Medical Director for recommendations and/or possible immediate corrective actions. 3. Commencing on 2/3/24 the Director of Nursing Service initiated in-service training of the licensed nursing staff as they are scheduled on the policies of Administering Medications, Documentation of Medication Administration, Adverse Consequences & Medication Errors, Medication Errors, as well as Attendance and Punctuality in order to ensure that all licensed nursing staff I fully aware of these important and required policy and procedure changes to immediately follow. This in-service training will include a quiz on the information provided with a special focus on medication administration timeliness and attendance. Staff who are on vacation or who cannot attend the in-service training will be notified by way of email of the Immediate Jeopardy and the policy changes and standards that must be adhered too. 4. Effective immediately on 2/3/24 the Director of Nursing services will review the attendance and punctuality of the facilities licensed nursing staff with the facility Administrator for possible recommendation for resolution. Also, the licensed nursing staff will be required to contact the facility to notify the charge nurse on duty if they are going to be more than 15 minutes late. If no arrival or contact occurs from oncoming scheduled licensed nurse staff the charge nurse on duty will be required to contact the Director of Nursing immediately. Immediate changes to the facility Attendance and Punctuality Policy now requires all employees to submit vacation and time off request 30 days in advance to ensure that there is ample time to schedule coverage for the time off being requested. Another immediate change in the Attendance and Punctuality Policy is if employees will not be able to report for their assigned shift, they must notify their supervisor and the facility within (2 hours for CNA; 4 hours for Licensed Nurse), of the start of their shift. Failure to follow the Attendance Policy may result in further disciplinary action up to and including possible termination of employment. 5. Effective 2/4/24 the facility will now require a charge nurse back up that will administer medication in the event that the scheduled nurse is late or does not report for their assigned shift. The following licensed nurse positions will substitute for the medication administration pass in the following order: 1. Desk Nurse, 2. Director of Staff Development, 3. Infection Prevention Nurse, 4. Director of Nursing and/or 5. Nursing Registry. 6. Effective 2/4/24 the Director of Nursing will ensure that the Licensed Nurses' schedule will be completed at a minimum 45 days forward by the 15th of each month to ensure that there is a stable staffing plan that is well prepared in advance. Thus, avoiding and/or reducing the likely hood of reoccurrence of a negative outcome with medication administration. 7. Effective 2/4/24 the Director of Nursing will spot check the performance of the license nurses by observing the medication administration to ensure they are efficient and timely without delay. Negative finding will be immediately addressed when they occur and then brought forward to the QA/QAPI committee for review and root cause analysis. On 2/4/2024 at 7:31 p.m., while onsite, after verification through observation, interview, and record review the facility's implementation of the IJ immediate corrective actions, the Immediate Jeopardy was removed, in the presence of the Administrator and DON. Findings: 1. During a review of Resident 1's Face Sheet (admission record), dated 2/4/2024, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Alzheimer's Disease, HTN, and BPH. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/11/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 1 had medically complex conditions and was receiving antipsychotic and antidepressant medications. During a review of Resident 1's physician's order dated 6/30/2023, the physician's order indicated an order for Amiloride HCI 5.0 mg to administer two tablets (10 mg) for hypertension, the order dated 3/19/2019 for Finasteride (medication to treat overgrowth of prostate) 5.0 mg give one tablet daily for BPH, and the order for Namenda 10 mg one tablet daily for Alzheimer's disease. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., the licensed vocational nurse (LVN 2) did not administer to Resident 1 Amiloride HCI 10 mg, Finasteride 5 mg, and Namenda 10 mg at 7:30 a.m., as scheduled. During a review of Resident 1's Medication Administration Record (MAR) dated 2/3/2024, the MAR indicated medication Amiloride HCI 10 mg was administered on the same day 2/3/24 at 12:09 p.m., instead as scheduled at 7:30 a.m., and Finasteride 5 mg and Amenda 10 mg were administered on 2/3/24 at 12:10 a.m., which was approximately 4.0 hours and 40 minutes later than scheduled time. 2. During a review of Resident 2's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interaction), immunodeficiency, glaucomatous flecks (subcapsular [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve]) both eyes, and HTN. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others and his vision was severely impaired. The MDS Section N0415 High-Risk Drug Classes indicated Resident 2 had medically complex conditions and was receiving antipsychotic and antiplatelet medication (a group of medicines that stop blood cells (called platelets) from sticking together and forming a blood clot). During a review of Resident 2's physician's order dated 3/12/2019, the physician's order indicated an order for Acetazolamide 500 mg by mouth twice a day for glaucoma, the order dated 8/4/2021 for Benztropine Mesylate 0.5 mg tablet twice a day for immunodeficiency, the order dated 10/24/2022 for Risperdal 2 mg by mouth in the morning for mood swings related to schizophrenia, the order date 2/4/2021 for Propranolol HCI 20 mg tablet twice a day for HTN, and the order dated 7/31/2023 for Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg tablet by mouth once a day in the morning for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain). During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering to Resident 2 Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets as scheduled at 7:30 a.m. During a review of Resident 2's MAR dated 2/3/2024, the MAR indicated medication Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets were administered on 2/3/24 at 12:03 p.m , which was approximately 4.0 hours and 30 minutes later than scheduled time. 3. During a review of Resident 3's Face Sheet (Admission Record), dated 2/4/2024, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 usually was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 3 had medically complex conditions and was receiving hypoglycemic medication (a medication to lower blood sugar level). range). During a review of Resident 3's physician's order dated 6/30/2023, the physician's order indicated the order for Metformin (medication to treat high blood sugar) 500 mg one tablet twice a day for diabetes. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Metformin 500 mg one tablet to Resident 3 for diabetes as scheduled at 7:30 a.m. During a review of Resident 3's MAR dated 2/3/2024, the MAR indicated medication Metformin 500 mg one tablet was administered on 2/3/24 at 11:11 a.m., which was approximately 3.0 hours and 40 minutes later than scheduled time. 4. During a review of Resident 4's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including hyperlipidemia (abnormally high concentration of fat particles [lipids] in the blood), schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly) and unspecified abnormal involuntary movements (occurs when you move your body in an uncontrollable and unintended way). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was able to understand and usually was understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 4 had medically complex conditions and was receiving antipsychotic medication (used to treat symptoms of psychosis [when a person loses contact with reality including seeing or hearing things that others cannot see or hear (hallucinations) and believing things that are not actually true (delusions)]). During a review of Resident 4's physician's order dated 2/21/2023, the physician's order indicated an order for Vascepa 1.0 gm two capsules by mouth twice a day with food for hyperlipidemia, the order dated 5/26/2015 for Amantadine HCl 100 mg one tablet by mouth daily for dyskinesia related to unspecified abnormal involuntary movements, order dated 9/8/2021 for Lamotrigine 400 mg daily for mood lability (unpredictable, uncontrollable, and rapid shifts in emotions) and psychosis, the order dated 3/21/2023 for Trihexyphenidyl HCL 3.0 gm twice a day for EPS, and the order date 8/22/2023 Flomax 0.4 mg one capsule daily. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Vascepa 1.0 gm two capsules, Amantadine HCl 100 mg one tablet, Lamotrigine 400 mg, Trihexyphenidyl HCL 3.0 gm, and Flomax 0.4 mg one capsule to Resident 4 as scheduled at 7:30 a.m. During a review of Resident 4's MAR dated 2/3/2024, the MAR indicated medication Vascepa 1.0 gm two capsules medication, Amantadine HCl 100 mg one tablet, Lamotrigine 400 mg, Trihexyphenidyl HCL 3.0 gm, and Flomax 0.4 mg one capsule were administered on 2/3/24 at 11:48 a.m., which was approximately 4.0 hours and 30 minutes later than scheduled time. 5. During a review of Resident 6's Face Sheet (Admission record), dated 2/4/2024, the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (brain condition that causes recurring seizures), and orthostatic hypotension (low blood pressure that happens when standing after sitting or lying down.) During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was able to understand and be understood by others. The MDS indicated Resident 6 had debility (state of general weakness that may be a result or an outcome of one or more medical conditions) and cardiorespiratory (related to heart and lungs) condition. The MDS Section N0415 High-Risk Drug Classes indicated Resident 6 was receiving antidepressants (medication for sadness.) During a review of Resident 6's physician's order dated 8/31/2023, the physician's order indicated an order for Midodrine 5 mg one tablet by mouth three times a day, order dated 3/31/2023 for Keppra 100 mg/ml) to administer 5.0 ml by mouth twice a day for seizure disorder, an order for Gabapentin 300 mg by mouth twice a day for neuropathy (weakness, numbness, or pain from nerve damage). During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Midodrine 5 mg tablet, Keppra 500 mg Gabapentin 300 mg to Resident 6 as scheduled at 7:30 a.m. During a review of Resident 6's MAR dated 2/3/2024, the MAR indicated medication Midodrine 5 mg tablet, Keppra 500 mg and Gabapentin 300 mg were administered on 2/3/24 at 11:07 a.m., which was approximately 3.0 hours and 30 minutes later than scheduled time. 6. During a review of Resident 8's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including transient ischemic attack ([TIA] occurs when the blood supply to part of the brain is briefly interrupted), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and HTN. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 8 had a stroke and was receiving antipsychotics and anticoagulant medication. During a review of Resident 8's physician's order dated 8/31/2023, the physician's order indicated the order for Symbicort inhalation aerosol (medication used to treat [{Asthma} a condition when airways in the lungs become narrowed and swollen, making it difficult to breathe]) 160- 4.5 mg one puff to inhale orally twice a day for asthma, the order dated 10/17/2022 for Norvasc 10 mg once a day for HTN, the order date 10/17/2022 for Eliquis 5 mg one tablet by mouth twice a day for cerebral infarction, the order dated 9/24/2023 for Metoprolol Tartrate 25 mg one tablet by mouth twice a day for HTN, and the order dated 12/7/2021 for Losartan Potassium 25 mg by mouth daily for HTN. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Symbicort aerosol 160- 4.5 mg inhaler, Norvasc 10 mg, Eliquis 5 mg, Metoprolol Tartrate 25 mg and Losartan Potassium 25 mg to Resident 8 as scheduled at 7:30 a.m. During a review of Resident 8's MAR dated 2/3/2024, the MAR indicated medications Symbicort inhalation aerosol 160- 4.5 mg, Norvasc 10 mg, Eliquis 5 mg, Metoprolol Tartrate 25 mg and Losartan Potassium 25 mg were administered on 2/3/24 at 11:48 a.m., which was approximately 4.0 hours and 30 minutes later than scheduled time. 7. During a review of Resident 14's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 14 was admitted to the facility on [DATE], with diagnosis including schizophrenia, type 2 diabetes mellitus (DM), and HTN. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had cognitive (thinking, reasoning, or remembering) impairment for daily decision making. The MDS indicated Resident 14 was dependent with toileting hygiene, bathing, and dressing. The MDS Section N0415 High-Risk Drug Classes indicated Resident 14 was taking antipsychotic, antidepressant, and hypoglycemic medication. During a review of Resident 14's physician's order dated 6/11/2020, the physician's order indicated the order for Zyprexa ([Olanzapine] medication given to treat hallucinations in mental disorder) 7.5 mg tablet by mouth in the morning daily for auditory hallucinations (hearing voices or noises that don't exist in reality) related to schizophrenia. During a review of Resident 14's physician's order dated 6/24/2020, the physician's order indicated the order for Metformin HCL 500 mg tablet by mouth two times a day for DM. During a review of Resident 14's MAR, dated 2/3/2024, the MAR indicated Resident 14's Metformin 500 mg and Zyprexa 10 mg, scheduled for administration at 8 a.m., were administered on 2/3/2024 at 10:54 a.m. approximately 3 hours later than scheduled time. 8. During a review of Resident 15's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including encephalopathy (disease of the brain where functioning is affected by a condition or toxins), type 2 diabetes mellitus (DM) and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 15 had a medically complex condition and was receiving hypoglycemic medication. During a review of Resident 15's physician's order dated 1/6/2022, the physician's order indicated the order for Cogentin 1.0 mg tablet by mouth twice a day for EPS due to Risperdal usage related to schizophrenia m/b delusion as evidence by hallucination, the order dated 2/9/2023 for Risperdal 1.0 mg tablet by mouth twice a day for paranoid schizophrenia, the order dated 10/26/2022 for Metformin HCL 850 mg by mouth twice a day for DM, the order dated 7/26/2021 for Lactulose 10 gm/15 ml to give 15 ml by mouth daily for elevated ammonia levels, and the order dated 10/3/2021 for Admelog Solution 100 units/ml inject SQ) before meals and at bedtime for diabetes per sliding scale as follows: a. For blood sugar level 151 to 200 - administer two units. b. For blood sugar level 201 to 250 - administer four units. c. For blood sugar level 251 to 300 - administer six units. d. For blood sugar level 301 to 350 -administer eight units. e. For blood sugar level 351 to 400 - administer 10 units. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administer Cogentin 1.0 mg and Risperdal 1.0 mg, did not administer Insulin Lispro per sliding scale before breakfast as scheduled at 7:30 a.m., did not administer Metformin 850 mg as scheduled at 7:30 a.m., and Lactulose 10 gm to Resident 15 as scheduled at 8 a.m. During a review of Resident 15's MAR dated 2/3/2024, the MAR indicated medication Cogentin 1.0 mg, was administered on 2/3/2024 at 11:24 a.m., Risperdal 1.0 mg was administered at 11:25 a.m., Admelog Solution (Insulin Lispro) per sliding scale was administered at 11:27 a.m., and not before breakfast at 8 a.m., Metformin 850 mg was administered and Lactulose 10 mg were administer at 11:24 a.m., which was approximately 4.0 hours later than medication administration scheduled time. 9. During a review of Resident 16's Face Sheet (Admission record), dated 2/4/2024, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including epilepsy, schizophrenia, and HTN. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 16 had a medically complex condition and was receiving antipsychotic, hypoglycemic, and antiplatelet medication. During a review of Resident 16's physician's order dated 6/28/2021, the physician's order indicated the order for Cogentin 1.0 mg tablet by mouth twice a day for EPS due to Haloperidol (medication used to treat nervous, emotional, and mental disorders) use for schizophrenia, the order dated 6/30/2021 for Amlodipine Besylate 10 mg one tablet by mouth once a day for HTN, the order dated 6/30/2021 for Aspirin 81 mg tablet by mouth once day for CVA prophylaxis, the order dated 10/3/2022 for Levetiracetam (used to treat epilepsy [burst of electrical activity in the brain that temporarily affect how it works]) 500 mg/5 ml to give 10 ml by mouth for epilepsy, the order dated 10/3/2022 for Topiramate 100 mg tablet by mouth twice a day for seizure, and the order dated 3/15/2023 for Haloperidol 1.0 mg tablet by mouth twice a day for schizophrenia. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administer Cogentin 1.0 mg, Amlodipine Besylate 10 mg, Aspirin 81 mg, Levetiracetam 1000 mg, Topiramate, and Haloperidol 1 mg to Resident 16 as scheduled at 7:30 a.m. During a review of Resident 16's MAR dated 2/3/2024, the MAR indicated medication Amlodipine Besylate was administered at 11:20 a.m., Cogentin 1.0 mg, Aspirin 81 mg, Haloperidol 1.0 mg, and Levetiracetam 1000 mg were administered at 11:21 a.m., Topiramate 100 mg was administered at 11:22 a.m., which was approximately 4.0 hours later than medication administration scheduled time. 10. During a review of Resident 18's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and lo

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's POLST was completed upon admission to be a Full Code (all treatment measures used to revive a person when their heart stops beating and/or they stops breathing). Physician 1 changed Resident 1's POLST by writing error, over the POLST, that indicated the resident's wishes not to be a Full Code. The facility failed to adhere to Resident 1's POLST and perform cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain), as per the facility's policy and procedure (P/P) titled, POLST (crossed reference to F678). This failure resulted in a miscommunication of Resident 1's code status and resulted in the staff not performing CPR on Resident 1 when he was found unresponsive, without a heartbeat and not breathing. After the paramedics arrived, the paramedics pronounced Resident 1 deceased . Resident 1's initial POLST indicated the resident was a full code. Findings: During a review of Resident 1's Face Sheet (Admission Record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's history and physical (H/P), dated [DATE], the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident 1 was able to understand and make himself understood. During a review of Resident 1's document titled, POLST, dated [DATE] the initial POLST indicated to attempt resuscitation (the action or process of reviving someone from unconsciousness) in the event Resident 1 did not have a pulse or was not breathing. Then the POLST was marked error, and changed to Do Not Resuscitate (DNR). The POLST form indicated Resident 1 wanted Full Treatment to prolong his life but was changed to comfort measures only without a date and/or a signature of who changed the POLST. According the POLST form, when modifying or making changes, a line should be drawn across with the word VOID in large letters with a signature and a date across the line. Resident 1's POLST did not have a date when the changes were done and by whom. The word VOID was not written on the POLST. During a review of Resident 1's care plan titled, Resident Baseline Care Plan, dated [DATE], the care plan indicated Resident 1's code status was to attempt CPR and FULL treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's Multidisciplinary Care Conference ([MCC] team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the care of residents), dated [DATE] and timed at 11:10 a.m., indicated Resident 1's expectations reviewed where to receive full resuscitation. During a review of Resident 1's Change of Condition (COC) documentation, dated [DATE], the COC documentation indicated Resident 1 had abnormal laboratory results and was a FULL CODE. During a review of Resident 1's Licensed Progress Notes (LPN), dated [DATE] and timed at 6:45 p.m., the LPN indicated on [DATE] at 4 p.m., Resident 1 was found unresponsive with no pulse (the expansion of an artery caused by the ejection of blood into the arterial system by the contractions of the heart [heartbeat]). The LPN indicated no CPR was initiated. During a review of Resident 1's Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE], the report summary indicated a call was received from the facility at 4:11 p.m. The report indicated the paramedics documented Resident 1 was obviously dead at 4:17 p.m., had a blood pressure of 0 ([B/P] ,d+[DATE]-,d+[DATE] normal reference ranges [NRR]), respirations of 0 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 0 percent (%) room air ([NRR] ,d+[DATE]%) with rigor mortis (stiffening of the joints and muscles of a body that usually occurs a few hours after death) and lividity (bluish-purple discoloration of skin after death) to his back. The report indicated Resident 1 was pronounced deceased at 4:20 p.m. and no CPR was attempted by the paramedics. During an interview on [DATE] at 12:51 p.m., LVN 2 stated Resident 1 was a FULL CODE meaning CPR should be initiated if the resident stopped breathing and heart stopped. LVN 2 stated she and LVN 3 found Resident 1 unresponsive but did not initiate CPR because they were busy. During a telephone interview on [DATE] at 11 a.m., Resident 1's family member (FM 1) stated Resident 1 was a full code and wanted to be revived when necessary. FM 1 stated she was not called by the facility's staff and informed that Resident 1 was not feeling well with a change of condition. During a telephone interview on [DATE] at 10:50 a.m., Physician 1 stated the POLST was a legal document that needed to represent with accuracy the wishes of the residents so that appropriate and accurate care can be delivered and avoid confusions. Physician 1 stated when there was a new change to the POLST form, a new POLST form should be completed. During a concurrent interview and review of Resident 1's POLST form on [DATE] at 11:45 a.m., the Social Services Director (SSD) stated every time there was a change in the resident's status, a new POLST form was initiated to address the resident's wishes. The SSD stated Resident 1's POLST form had the word error and she was not aware of who made the changes since it did not have initials or dates of when the changes were made. According to the SSD, a new form should have been initiated to reflect the accuracy Resident 1's code status. During an interview on [DATE] at 2:05 p.m., LVN 3 stated Resident 1 was a full CODE meaning if he was found unresponsive, chest compressions would be initiated. During a concurrent interview and review of Resident 1's LPN and vital signs record, Director of Nursing 2 (DON 2) stated there was no documentation on Resident 1's LPN that CPR was initiated. DON 2 stated she did not understand why the staff did not perform CPR on Resident 1. DON 2 stated she was not aware of who made the changes to Resident 1's POLST form. During a concurrent interview and review of Resident 1's POLST, on [DATE] at 11:10 a.m., Physician 1 stated he will take full responsibility of Resident 1's POLST form being misleading as he wrote error on it. Physician 1 stated he made the changes to the POLST and forgot to get a new form, date it, and initial. Physician 1 stated he was aware of the facility's policy for POLST, CPR and the American Heart Association (AHA) guidelines to provide CPR to an unresponsive resident. Physician 1 stated not having the correct and updated information on the POLST can be misleading and prevent the healthcare providers from providing adequate care to the residents. Physician 1 stated he was the current facility's Medical Director and understood all the problems the facility was having. Physician 1 stated the only thing he could do at this time was to move forward to prevent other occurrences. During a review of the Center for Medicare & Medicaid Services (CMS) All Facility Letter Reference S & C ,d+[DATE]-NH, revised on [DATE], the S&C letter indicated prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. During a review of the facility's P/P titled POLST, dated [DATE], the P/P indicated the purpose of the policy was to provide precise required documentation and orders on one form. The P/P indicated in the absence of a completed form, the resident would remain full treatment (Full Code) and resuscitation would be provided. The P/P indicated to initiate a new form when there were any changes to the original, develop a care plan for instructions from POLST such as comfort measures, etc.

Based on interview and record review, the facility's nursing staff failed to ensure two of three sampled residents (Residents 1 and 2), was provided with cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain) immediately upon confirming the residents had no pulse (heart rate) for as per the facility's policy and procedures (P/P) Cardiopulmonary Resuscitation and the American Heart Association (AHA), by failing to: a) Provide immediate CPR upon finding Residents 1 unresponsive (unable to respond or wake-up) without vital signs (clinical measurement of pulse rate, temperature, respiration rate[breaths per minute], and blood pressure [pressure of circulating blood against the walls of blood vessels]) on [DATE] at 4 p.m., by CPR certified (card received acknowledging a staff completed a hands-on and written exam and its knowledgeable on the guidelines of CPR application) Licensed Vocational Nurses 2 and 3 (LVNs 2 and 3), who did not immediately initiate CPR and call 911 until 4:11 p.m., approximately 11 minutes after Resident 1 was found unresponsive. Resident 1 was pronounced deceased by the paramedics in the facility on [DATE] at 4:20 p.m. (20 minutes after found unresponsive). b) Provide immediate CPR upon finding Residents 2 unresponsive on [DATE] at 5 a.m., without vital signs on [DATE] at 5 a.m., by CPR certified LVN 3 and not calling 911 until at 5:30 a.m., (30 minutes after found unresponsive). The paramedics pronounced Resident 2 deceased in the facility on [DATE] at 5:55 p.m. These deficient practices resulted in a delay in life sustaining measures for Residents 1 and 2, who were FULL CODE (if a resident's heart stopped beating and/or stopped breathing, all resuscitation procedures such as chest compressions, intubation [tube inserted through the throat to deliver air to the lungs] should be performed) status. Findings: a) During a review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review for Resident 1's History and Physical (H/P), dated [DATE], the H/P indicated Resident 1 had have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident 1 was able to understand and make himself understood. During a review of Resident 1's care plan titled, Resident Baseline Care Plan, dated [DATE], the care plan indicated Resident 1's code status was to attempt CPR and FULL treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's Multidisciplinary Care Conference ([MCC] team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the care of residents) dated [DATE] and timed at 11:10 a.m., indicated Resident 1's expectations reviewed where to receive full resuscitation. During a review of Resident 1's Change of Condition (COC), dated [DATE], the COC indicated Resident 1 had abnormal laboratory results and was a FULL CODE. During a review of Resident 1's Licensed Progress Notes (LPN) dated [DATE] and timed at 6:45 p.m., the LPN indicated on [DATE] at 4 p.m., Resident 1 was found unresponsive and with no pulse. The LPN indicated no CPR was initiated. During a review of Resident 1's Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE] indicated a call was received from the facility at 4:11 p.m., The report indicated a providers impression of Resident 1's was obvious death at 4:17 p.m., had a blood pressure of 0 ([B/P] ,d+[DATE]-,d+[DATE] normal reference ranges [NRR]), respirations of 0 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 0 percent (%) room air ([NRR] ,d+[DATE]%) and with rigor mortis (stiffening of the joints and muscles of a body that usually occurs a few hours after death) and lividity (bluish-purple discoloration of skin after death) to his back. The report indicated the paramedics pronounced Resident 1 deceased at 4:20 p.m. and no CPR was attempted by the paramedics. During an interview on [DATE] at 4:44 p.m., Licensed Vocational Nurse 3 (LVN 3) stated on [DATE] at 2:30 p.m., she did not document in the chart after observing Resident 1 was awake with two (2) liters ([L] units of measurement) of oxygen ([O2] amount of oxygen in the blood) via nasal cannula (device consisted of a lightweight tube which one end splits into two prongs and its placed in the nose to deliver supplemental oxygen to a resident in need of respiratory help) with vital signs, and blood pressure [measures the force of the heart exerts on the walls of the arteries each time it beats]) stable. LVN 3 stated she was not aware why Resident 1 was receiving 2L of O2 via nasal cannula. During an interview on [DATE] at 12:51 p.m., LVN 2 stated Resident 1 was a FULL CODE meaning CPR should be initiated. LVN 2 stated she and LVN 3 found Resident 1 unresponsive but did not initiate CPR because they were busy. During a telephone interview on [DATE] at 11 a.m., Resident 1's Family Member 1 (FM 1) stated Resident 1 was a full code and wanted to be revived if he needed. FM 1 stated the facility did not call and inform her (FM 1) that Resident 1 was not feeling well. During an interview on [DATE] at 2:05 p.m., LVN 3 stated Resident 1 was a full CODE meaning if he was to be found unresponsive, chest compressions would be initiated. LVN 3 stated the facility did not have all the resources (staffing) that day on [DATE] because the entire facility became COVID-19 (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) positive. During an interview on [DATE] at 4:05 p.m., Certified Nurse Assistant 1 (CNA 1) stated on [DATE] while feeding Resident 1's roommate, she overheard Resident 1 making sounds, upon looking at Resident 1, she noticed Resident 1 was complaining of shortness of breath (SOB), like he could not breathe and was desperate for air. CNA 3 stated, she adjusted Resident 1's O2 nasal cannula and went to call LVN 3. During a concurrent interview and review of Resident 1's LPN and vital signs, the Director of Nursing 2 (DON 2) stated no documentation was found in Resident 1's LPN that CPR was initiation. DON 2 stated not being aware why the staff did not provide CPR as indicated on the facility's CPR policy. DON 2 stated she was not aware of who made the changes to Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11 a.m., CNA 2 stated on [DATE] Resident 1 was having difficulty breathing in the morning and was unable to speak. CNA 2 stated he was later notified by LVN 2, he needed to clean Resident 1 since he was deceased . CNA 2 stated LVNs 2 and 3 waited to call 911 (emergency services) because DPH was in the facility. During an interview and review of Resident 1's POLST, on [DATE] at 11:10 a.m., Physician 1 stated he took full responsibility of the POLST form having written error on it. Physician 1 stated he made the changes and forgot to get a new form or mark on the form the date and initials. Physician 1 stated being aware of the facility's policy for POLST and CPR and was aware of the American Heart Association (AHA) guidelines to provide CPR to an unresponsive resident. Physician 1 stated not having the correct and updated information on the POLST can be misleading and prevent healthcare providers from providing adequate care to the residents. Physician 1 stated he was the current Medical Director (MD) and understood all the problems the facility was having, but the only thing he could do at this time was to move forward to prevent other occurrences. b) During a review of Resident 2's Face Sheet (Admission Record) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident 2 was able to make himself understood and understand others. The MDS indicated Resident 2 required extensive assistance of a one-person physical assist for bed mobility, transferring and personal hygiene. During a review of Resident 2's POLST dated [DATE], the POLST indicated Resident 2 wanted CPR to be attempted with full treatment to prolong his life by all medically effective means. During a review of Resident 2's care plan titled, Potential for Exacerbation (worsening of a disease or an increase in its symptoms) of [CONDITION(S)], dated [DATE], the care plan indicated Resident 2 would be free of exacerbation. The staffs' intervention included to monitor for increased shortness of breath (SOB), wheezing (high-pitched whistling sound made while breathing), chest discomfort, decreased endurance (resident's ability to continue with exercise until exhausted is reduced in comparison to their normal ability), provide oxygen (O2) and notify physician. During a review of Resident 2's Licensed Progress note (LPN), dated [DATE] and timed at 9:06 a.m., the LPN indicated on [DATE] at 5 a.m., during morning rounds, Resident 2 was found unresponsive to verbal and touch stimuli (sense of touch). The LPN indicated the physician was notified and the paramedics were called at 5:30 a.m., and pronounced Resident 2's deceased at 5:55 a.m. During a review of Resident 2's Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE], the report summary indicated a call was received from the facility at 5:35 a.m. The report indicated Resident 2 was obviously deceased , had a blood pressure of 0 ([B/P] ,d+[DATE]-,d+[DATE] normal reference ranges [NRR]), respirations of 0 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (amount of oxygen in the blood) at 0 percent (%) room air ([NRR] ,d+[DATE]%) and with rigor mortis (stiffening of the joints and muscles of a body that usually occurs a few hours after death). The report indicated Resident 2 was pronounced deceased at 5:55 a.m. and no CPR was attempted by the paramedics. 1. During a review of the Center for Medicare & Medicaid Services (CMS) All Facility Letter Reference S & C ,d+[DATE]-NH, revised on [DATE], the letter indicated that prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or in the absence of advance directives or a DNR order. During a review of the AHA article, dated 2020, the article indicated Cardiopulmonary Resuscitation was an emergency lifesaving procedure performed when the heart stops beating. The AHA article indicated immediate CPR can double or triple chances of survival after [CONDITION(S)] by keeping blood flow active. The article indicated for healthcare providers and those trained to first ask loudly if she/he is ok, if no reaction check breathing If the resident is not breathing or is only gasping, administer CPR. https://cpr.heart.org/en/resources/what-is-cpr During an interview on [DATE] at 10:18 a.m., LVN 4 stated he was notified by a CNA (unable to identify) Resident 2 was found unresponsive. LVN 4 stated Resident 2 was experiencing SOB on [DATE] but did not remember if he did any interventions for Resident 2 for the SOB or the resident's health condition after. During an interview and review of Resident 2's LPNs, on [DATE] at 10:40 a.m., Director of Nursing (DON) stated there was no documentation found indicating CPR was initiated by the facility on [DATE] when Resident 2 was found unresponsive. The DON stated the staff should had followed the facility's P/P for CPR, initiated CPR, and document in the LPN any measures performed. During an interview on [DATE] at 11:10 a.m., the facility's Medical Director (Physician 1) stated he was made aware of Resident 2's death. Physician 1 stated the staff did not initiate CPR for Resident 2 because he was already deceased , and it would have been failed attempts if the staff would have initiated CPR. Physician 1 stated, I am aware of the AHA to initiate CPR upon finding a resident unresponsive to attempt to sustain and prolong life, but I am also aware of the problems occurring in the facility and there was nothing to do, but to move forward to prevent any other occurrences in the facility. During an interview on [DATE] at 10:23 a.m., CNA 3 stated on [DATE], on the night shift, Resident 2 was stable with no problems noted. CNA 3 stated on [DATE] at approximately 5 a.m., while conducting rounds, she found Resident 2 unresponsive and immediately notified LVN 3. CNA 3 stated on the morning of [DATE], the facility had two residents unresponsive and it became difficult to provide CPR two both residents at the same time when the entire facility was positive for COVID-19 (a highly contagious virus that causes severe respiratory illness affecting the lungs and airways) and they (LVN 3 and CNA 3) were trying to assist the residents. During a review of the facility's P/P titled, Cardiopulmonary Resuscitation and Emergency Medical Services [EMS] System last revised on [DATE], the P/P indicated (CPR) and 911 call would be initiated upon finding a resident unresponsive. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. The P/P indicated the staff would check for unresponsiveness, call out for help, call 911, position the resident on a flat surface and start chest compressions.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the Coronavirus ((COVID 19), a severe respiratory illness caused by [MEDICAL CONDITION] that spreads from person to person) in accordance with the facility's infection control policies and the Mitigation Plan ((MP), a plan to reduce loss of life and impact of COVID 19 in the facility) for 8 of 8 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8) by failing to: 1. Screen all staff and visitors entering the facility for COVID 19 signs and symptoms, history of travel, and contact with positive COVID 19 persons upon entering the facility. Visitor 1 was not screened upon entering the facility on 12/28/2020. 2. Separate the red zone (an area for residents who tested positive for COVID 19) from the yellow zone, (an area for residents suspected of having COVID 19 and awaiting COVID results) and cohort (group) residents in the green zone indicated in the facility's MP. Residents 1 and 2 where in the yellow zone and Residents 3, 4, 5, 6 7, and 8 where in the red zone. Residents 1, 2, 3, 4, 5, 6, 7 and 8 were negative for COVID-19. 3. Dedicate a Licensed Vocational Nurse1 (LVN 1) to only care for confirmed COVID 19 residents (Residents 1, 2, 3, 4, 5) and not to provide care for non-confirmed COVID 19 residents (Residents 1, 2, 3, 4, 5, 6, 7 and 8). LVN 1 was COVID 19 positive on 12/26/2020 and cared for COVID 19 negative and positive residents. 4. Ensure there was a certified and fully dedicated Infection Preventionist Nurse (IPN) a licensed nurse in charge of identifying, monitoring and preventing infection in the facility) to monitor, prevent and control the spread of COVID 19 in the facility. 5. Develop and implement infection control and prevention policy and procedures, that includes N95 respirator masks (a respiratory protective device that forms a tight seal around the mouth and nose, to prevent airborne infections) fit testing. 6. Provide 6 of 6 staff (Certified Nursing Assistants ((CNAs) 1, 2, and 3), LVNs 1 and 2, and an Environmental Service Staff 1(ESS) with N95 needed to provide residents' care in a facility with a COVID 19 outbreak. 7. Ensure the facility had a full time Director of Nursing (DON) These deficient practices had the potential to expose and infect Residents 1, 2, 3, 4, 5, 6, 7 and 8 with COVID 19 virus. On 12/30/2020 at 6:17 p.m., 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 identified in the presence of the administrator (ADM) and the Licensed Vocational Nurse 1 (LVN 1). The IJ was called for the facility's staff inability to follow and implement interventions and infection protocols to prevent the spread of COVID 19 that threatened the health and safety of the residents, staff and the community. On 1/6/2021 at 3:23 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action ((POA) interventions to correct the deficient practices). The implementation of the POA interventions were verified and confirmed onsite through observation, interview and record review. The IJ was removed in the presence of the ADM and LVN 1. The POA indicated the following actions: 1. The facility will use a third-party provider to provide fit testing to staff with a scheduled completion date of 01/05/2021 at 9:00 a.m. Employees currently on leave, or vacation will be scheduled for a N95 fit test immediately upon their return to duty, to ensure safe and proper usage. There will be Infection Control In services (teachings) regarding donning (putting on) and doffing (taking off) of PPEs, working in the green, yellow and red zones, avoiding cross contamination between residents, and maintaining social distancing among residents. In services will be scheduled once the IPN received training from a reputable nurse consultant and/or a qualified organization that was able to provide the training. The facility is currently searching for a consultant with a completion date of 1/8/2021. 2. The IPN will make rounds twice daily to ensure staff are following COVID 19 infection control guidelines and/or all infection control practices 5 days a week, for the next 90 days. On the weekends or when the IPN is not present the Charge Nurse (CN) on duty, will be responsible for completing infection control rounds. After the rounds, negative findings will be logged, and the administrator will be notified for recommendations. An Infection Control Round Log will be presented to the facilities Quality Assurance committee ((QA) a way of preventing and managing problems in the facility affecting patient care) for review and further recommendations. 3. The facility has enlisted the services of multiple staffing agencies in order to fill gaps in the nursing schedule. Ongoing contact regarding the facility's staffing needs will be made by the ADM and/or designee. 4. Evidence of IPN training and certification will be made available to the Department by 1/6/21. 5. The current owner, who is a Registered Nurse, will cover for the necessary clinical decisions and guidance temporarily until a permanent Director of Nursing is hired. 6. The facility IPN/and or designee has begun the process of rezoning the facility and the cohorting residents. The facility will use the resident health status to determine the facility zoning and this will be reviewed continuously as changes occur. The facility will follow the Los Angeles County Guidelines for cohorting and Zoning. The facility will continue to re zone as needed going forward to ensure safety of residents and staff. Findings: On 12/28/2020 at 2:24 p.m., during a concurrent observation and interview of a Focused Infection Control (FIC) survey, Visitor 1 was not screened for COVID 19 symptoms, prior to entering the facility. LVN 1 stated the facility was short staffed and had no one at the door to screen everyone prior to entering the facility. LVN 1 stated the DON was on medical leave for a month and staff were expected to assess themselves before entering the facility. LVN 1 also stated there was no certified IPN in the facility to monitor infection prevention practices. On 12/28/2020 at 2:48 p.m., during a concurrent observation on initial tour of the facility and interview, three CNAs (CNA 1, 2, and 3), two LVNs (LVN 1 and 2), and ESS 1 were not wearing face shields in the red zone as indicated in their MP. LVN 1 stated staff was not aware they needed to wear face shields and N 95 masks when in the red zone. On 12/28/2020 at 2:50 p.m., during a concurrent observation in the red zone and interview, ESS 1 was wearing a cloth mask, removed the mask, to blow his nose and cough. ESS 1 then reapplied the mask without performing hand hygiene and proceeded into a resident's room where one resident who was positive for COVID-19. ESS 1 stated he did not know he had to perform hand hygiene because he was wearing gloves. On 12/28/2020 at 2:55 p.m., during an interview, LVN 1 stated it was her first day back to work after being on isolation for testing positive for COVID 19 on 12/23/2020. LVN 1 stated she was unsure of the required quarantine (a period of isolation) time but returned to work because the ADM asked her to return. According to LVN 1, since being back at the facility, she was the only Licensed Nurse taking care of 32 positive COVID residents and three COVID negative residents (Residents 20, 21 and 23). On 12/30/2020 at 2:10 p.m., during a concurrent observation and interview, CNA 1 was wearing an N95, gown, gloves and no face shield while providing care for Resident 9, who was positive for COVID-19. CNA 1 stated she needed to wear a face shield while providing care to residents in the red zone she just didn't want to wear it. On 12/30/2020 at 2:15 p.m., during an observation and interview, CNA 2 was observed wearing a cloth black mask while in the red zone. CNA 1 stated he removed his N95 mask and put on a cloth mask to go to the bathroom. CNA 2 also stated he had not been fit tested for an N95 mask. On 12/30/2020 at 2:45 p.m., during an interview, the IPN stated currently all 34 residents were COVID positive and the staff was aware the needed to be wearing an N95 in the facility and their PPEs while providing care for a COVID-19 confirmed residents. The IPN stated not being aware of the facility's MP for zoning and cohorting of residents. On 12/30/2020 at 3:40 p.m., during an interview, the IPN stated asymptomatic COVID-19 confirmed staff members could work in the red zone with residents. The IPN stated currently LVN 1 was providing care to residents in the red zone and yellow zone. The IPN stated she had not been certified for infection control and the facility had not completed fit testing for all staff members. On 12/30/2020 at 4 p.m., during an observation LVN 1 who, tested positive for COVID 19 on 12/23/20, was administering medications to three COVID negative residents (Residents 1, 2, and 3), 8 days after LVN 1 tested positive. On 12/30/2020 at 2:20 p.m., during a concurrent observation and interview, Residents 1 and 2, non COVID confirmed, were in the same hallway with COVID positive residents designated as yellow and red zones. LVN 1 stated the facility did not have a designated space for a green zone (COVID negative cases) as indicated on the facility's map. LVN 1 stated the ADM was in charge of assigning the various zones for residents in the facility. LVN 1 also stated all resident rooms were considered red zone, even though some rooms had signage indicating they were in the yellow zone. On 12/30/20 at 4:30 p.m., during an interview, the ADM stated he was unable to obtain temporary staff to fulfill the staffing shortage due to the COVID 19 virus. The ADM stated the facility was contracted with four (4) staffing agencies but the agencies were unable to provide nurses. According to the ADM, the agencies did not want to work for smaller facilities like his, because small facilities could not pay agencies a lot of money (sic). The ADM also stated the facility did not have a Director of Nursing (DON) since 12/8/2020 and a certified infection preventionist nurse. On 12/30/20 at 4:37 p.m., during a telephone interview a contracted agency on the list utilized by the ADM for staffing, stated they had CNAs, LVNs, and Registered Nurses (RNs) ready to work all shifts at the facility. The SAIP stated the facility's ADM did not contact them for staffing assignments and that as soon as the agency was contacted, staff would be assigned. A review of the facility's document titled COVID Positive Staff indicated LVN 1 tested positive for COVID 19 on 12/16/2020 and 12/26/2020. A review of the Department of Public Health's recommendations, dated 12/16/20, indicated the facility would prohibit employees who were COVID positive or had symptoms from returning to work until they fulfilled the criteria of isolating for at least 10 days after they had first had symptoms, before returning to work. A review of LVN 1's time clock records, dated 12/28/20, indicated she returned to work on 12/28/2020 (five days after testing positive for COVID 19). A review of the facility's policy titled Director of Nursing Policy and Procedures dated 05/16/2008, indicated the DON would be employed eight (8) hours a day, on the day shift five (5) days a week. The DON was responsible for all nursing services within the facility. A review of the facility's policy titled Infection Control dated 01/01/2013, indicated infection control measures such as respiratory hygiene, cough etiquette, hand washing and the use of alcohol hand rubs would be maintained in the facility. This policy indicated standard precautions; droplet precautions shall be implemented in the facility as needed. A review of the Los Angeles County Department of Public Health's recommendations dated 12/16/2020, indicated due to a COVID 19 outbreak in the facility, the facility would initiate standard, contact and droplet precautions plus eye protection for all suspected or confirmed residents with a fever or respiratory symptoms. It also indicated the facility would establish a separate area for within the facility for residents who tested positive for COVID 19 or who had symptoms associated with [MEDICAL CONDITION]. The recommendations also indicated N95 masks must be worn by staff throughout their shifts when working in the red zone and when working with residents within 6 feet (unit of measurement) in other areas of the facility. According to these recommendations, COVID 19 positive staff or staff with COVID 19 symptoms would follow CDC criteria for Return to Work for Health Care Providers (HCP). A review of the facility's Mitigation Plan, dated 8/18/2020, indicated any resident who was symptomatic and or exposed to COVID 19 would be immediately isolated and housed only with other COVID 19 positive residents. This plan also indicated assigned staff would be required to work with COVID 19 positive residents exclusively. According to this plan, all staff would wear recommended PPE for care of all COVID 19 positive residents. A review of the California Occupational Safety and Health ((Cal/OSHA) body that protects workers from safety hazards) Interim Guidance on COVID 19 for Health Care Facilities: Severe Respirator Supply Shortages dated 8/20 indicated employers must implement work practices to minimize the number of employees exposed to suspected and confirmed COVID 19 residents. The guidelines indicated an initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size of a respirator. According to the guidelines, annual respirator fit testing was required for all facilities. A review of the Center for Disease Control and Prevention (CDC) Respiratory Protection during an Outbreak: Respiratory Versus Surgical Mask guidance dated 4/9/20, indicated respiratory protection could not effectively protect the users if it was not properly and consistently worn. The guidance indicated inconsistent use of PPE was common among healthcare professionals and reduced protection. According to these guidelines, the incorrect and incomplete adherence to respirators or surgical masks could contribute to more unprotected infection exposures.

The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who; (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. A pattern of the facility's failure to ensure controlled medications were periodically reconciled for accuracy, failed to ensure establish and implement systems to ensure security and accurate accountability of all medications, failed to ensure safe, accurate, and timely medication administration, failed to ensure medication carts were securely locked, and failed to ensure medication storage had limited access to authorized personnel medication. On July 27, 2017 at 5:35 p.m., an Immediate Jeopardy was declared and the facility's administrator and director of nurses (DON) were notified of the immediacy. The facility submitted a plan of action (POA) on July 28, 2017 at 7:14 p.m., which was accepted. The IJ was removed on July 28, 2017 at 7:14 p.m., after the team confirmed that the facility's Plan of Action (POA) was implemented as follows: 1. The License Vocational Nurse will be removed from medication pass and a directed inserviced are conducted to address the medication errors and assess the LVN for skill competencies, both written and practical return demonstration. 2. Residents 2, 3, 4, 5, 10, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, and 28 were identified by the deficient narcotic medication administration and discrepancies, and the improper storage of the medications will be corrected and the director of nurses will observe the narcotic counts, during shift changes. 3. The medication storage room will be more efficiently organized and label to distinguish between house supply and current residents medications. 4. Expired and discontinued medications will be properly discarded or destroyed by the pharmacy consultant and the director of nurses. 5. All licensed staff will be inserviced, on all shifts, for securing the medication carts, treatment carts, disposal of medications, and medication reconciliation, handling controlled medications, and medication pass, and any other medication concerns that are identified. 6. All of the above are to be implemented on July 28, 2017 and completed by reviewed by the Quality Assurance committee. Based on observation, interview and record review, the facility failed to establish a system to ensure there were adequate safeguards in place to ensure: 1. Controlled medications were periodically reconciled for accuracy and failed to ensure there would be no discrepancy between the Controlled Drug Inventory Record, the Medication Administration Record [REDACTED]. This included medications prescribed for three of 11 sampled residents (2, 4, 5) and seven of 15 random sampled residents (RSR 17, 18, 20, 21, 22, 23 and 25). 2. Establish and implement a system to ensure security and accurate accountability of all medications in sufficient detail to enable an accurate reconciliation from receipt to disposition or destruction. The facility failed to maintain documentation to account for discontinued, expired, returned to the dispensing pharmacy, or destroyed at the facility for each controlled and non controlled medications. These deficient practices had the potential to cause medication errors or for prescribed medications to be missing. 3. Discontinued, expired and discharged resident's medications were clearly marked and not stored in an unmarked box, in the medication storage room. RSRs 15, 16, 17, 18, 19, 27, and 28 medications were in this box, but the reason was unclear. This deficient practice had the potential for the resident to receive discontinued, expired medications or medications from discharged residents increasing the risk of adverse reactions. 4. Residents individually labeled and prescribed medications were stored separate from the facility's house supply for Residents 4 and 5 and random sampled residents (RSR 15, 19 and 26). 5. Safe, accurate, and timely medication administration for two of 11 sampled residents (Resident 2 and 10), as indicated, in accordance with the physician's orders to meet the needs of residents. 6. Medication storage had limited access to authorized personnel, who administer medications for two of two medication carts (Med Cart), on the East and West stations. The Med Carts contained controlled and non controlled medications for residents throughout the facility. Both Med Carts were unlocked and unattended with one observed in the facility's hallway outside residents' rooms and another located by the nursing station. Findings: a. On July 24, 2017, at 11:20 a.m., during a narcotic count, of East Med Cart with LVN 1, the Narcotic Check Sheet was missing a licensed nurse's second signature for the change of shifts on July 23, 2017, at 11 p.m. and July 24, 2017, at 7 a.m. LVN 1 stated, There should always be two signatures for the shift change narcotic audit sheet. LVN 2 should have signed. During a concurrent interview, LVN 2 stated he did not count the narcotics or sign the Narcotic Check Sheet with LVN 3, who worked the 3 p.m. to 11 p.m. shift, on July 23, 2017. He also stated he did not count or sign the Narcotic Check Sheet with LVN 1, who worked the 7 a.m. to 3 p.m. shift, on July 24, 2017. LVN 2 stated he worked, for 16 hours, from 11 p.m. on July 23, 2017 to 3 p.m. on July 24, 201, but did not count the narcotics. On July 24, 2017, at 11:21 a.m., LVN 1 opened the East Med Cart locked narcotic box and pulled the bubble pack for RSR 21. The bubble pack contained 25 tablets of Hydrocodone with acetaminophen 10 mg/325 mg (Hydrocodone/APAP 10/325, a narcotic, used to treat pain); however the form titled, Controlled Drug Record indicated the remaining quantity was 27 tablets. The documentation indicated RSR 21 last received a Hydrocodone tablet at 8 p.m. on July 23, 2017. LVN 1 stated, I gave him (RSR 21) pill number 26 today (July 24, 2017) at 9:30 a.m. I do not know about pill number 27. (The licensed nurses) should record document) as soon as the medication is given to the patient (resident). LVN 1 continued the Narcotic Audit on both Med Cart East and West. The following narcotic discrepancies between the Controlled Drug Record and the actual medications in the bubble packs. The East Med Cart had the following discrepancies: Resident 5's Lorazepam 0.5 mg (a medication used to treat anxiety) bubble pack contained 14 tablets, but the numbers on the Controlled Drug Record were difficult to read because the numbers were written over. LVN 1 stated there were 14 Lorazepam tablets in the bubble pack but the Controlled Drug Record indicated 13 tablets. LVN 1 stated there was one tablet over and she had not given any Lorazepam that morning (July 24, 2017). The physician's order dated October 25, 2016, indicated to take twice a day, as needed for anxiety. RSR 22's Lorazepam 2 mg bubble pack contained 34 half tablet dosages, but the Controlled Drug Record indicated 33 dosages left. LVN 1 stated, I gave her (RSR 22) one tablet this morning. There should be 33 in the bubble pack not 34 dosages. There is an extra dose. RSR 23's Lorazepam 1 mg bubble pack contained 10 tablets but the Controlled Drug Record indicated nine tablets. LVN 1 stated, There should be nine tablets. We are over on this one too. On July 24, 2017 at 11:35 a.m., LVN 1 stated, I have not signed the West Med Cart narcotic count sheet (Narcotic Check Sheet) yet for today (July 24, 2017). The West Med Cart had the following discrepancies: Resident 4 had two bottles of Morphine Sulfate (30 ml each) to be given as needed for severe pain. The starting quantity was 60 ml and the remaining quantity on the Controlled Drug Record indicated 46 ml. After review of the physician's order, and concurrent interview, LVN 1 stated the total remaining quantity should had been 52 ml not 46 ml of Morphine. The remaining medication was incorrect. Resident 4 had three bubble packs of Lorazepam 2 mg (2 bubble packs of 31 tablets and one bubble pack with 16 tablets) totaling 78 tablets. The two sheet Controlled Drug Record indicated there should be 80 tablets remaining. After reviewing both bubble packs, the Controlled Drug Record indicated there were 76 tablets left. The medication was short by two tablets. RSR 17's Lorazepam 0.5 mg bubble pack contained 19 tablets. A review of the Controlled Drug Record indicated a remaining amount of 20 tablets with the last documented administration, at 8 p.m. on July 20, 2017, four days earlier. LVN 1 could not explain the narcotic discrepancy. RSR 18's Lorazepam 1 mg bubble pack contained 20 tablets. A review of the Controlled Drug Record indicated a remaining amount of 19 tablets with the last documented administration, at 6 a.m. on July 22, 2017, two days earlier. LVN 1 could not explain the narcotic discrepancy. RSR 20's Controlled Drug Record failed to include a licensed nurses signature indicating who administered the Hydrocodone/APAP 5/325, on July 15, 2017 at 2 p.m. LVN 1 could not explain the narcotic discrepancy. Resident 2's Tramadol 50 mg bubble pack contained eight tablets. A review of the Controlled Drug Record indicated a remaining amount of seven tablets with the last documented administration, at nine (a.m. or p.m. was not indicated) on July 21, 2017, three days earlier. LVN 1 could not explain the narcotic discrepancy. On July 24, 2017 at 4:19 p.m., in an interview the director of nursing (DON) stated, Nurses are supposed to reconcile narcotics at the change of every shift. If they find an error, they are suppose to write up an incident report. The outgoing nurse and the incoming nurses are to count and verify the narcotic count before accepting the keys before every shift and key transfer. On July 24, 2017 at 4:40 p.m., in the presence of LVN 3, LVN 1 stated, We are fixing the narcotic count. I did not let anyone know that the narcotic counts were off. LVN 3 initialed the Controlled Drug Record for RSR 25. LVN 3 stated, The ones (medications) I remember, I am signing, but we are supposed to sign right after giving the medication. LVN 3 showed the Controlled Drug Record for RSR 25 for Alprazolam 0.5 mg and stated she had just signed for July 22, 2017 at 9 p.m. However, a different licensed nurse signed the Controlled Drug Record for the same date and time. LVN 3 stated, Let me see that. After reviewing the Controlled Drug Record, LVN 3 stated, Oh, I should have written July 23 (2017). I gave the patient (RSR 25) her medication last night. I did not work July 22 (2017). I was off. LVN 1 stated, Instead of July 22 she (LVN 3) should have written July 23 (2017). A review of the July 2017 MAR for RSR 25 indicated RSR 25 was administered one dose of alprazolam 0.5 mg nightly at bedtime every night from July 1, 2017 through July 23, 2017 and the back of the MAR indicated [REDACTED] A review of the Controlled Drug Record for RSR 25 indicated one dose of Alprazolam 0.5 mg was given on July 11, 12, 13, 14, 15, 18, and 21, 2017 and two doses were given on July 17 and 22, 2017. A review of RSR 25's current physician order, dated May 29, 2017, indicated to give Xanax (Alprazolam a medication used to treat anxiety) 0.5 mg tablet by mouth daily at bedtime for anxiety manifested by inability to sleep. On July 24, 2017 at 5:12 p.m., the DON stated, Anytime there are narcotic count errors there should be an incident report. I do not have any incident report. LVN 1 stated, I have not written an incident report; will discuss with the DON. On July 26, 2017 at 4:19 p.m., during a follow up interview LVN 1 stated, Narcotic discrepancies were straightened out. The DON has not asked me to write an incident report. I do not know if the DON did an incident report on the narcotic discrepancies. Pills were popped out and thrown away to correct the Lorazepam count for (RSR 18). I did not call the pharmacy; only call the pharmacist if the medication count is short. On July 27, 2017 at 9:35 a.m., during an interview, the DON stated, The LVN corrected the narcotic discrepancy counts by pulling and documenting the discrepancies. The person that found the discrepancy should do the incident report and give the report to me. I have not done an incident report and have not called the pharmacy. I do not know how many medications had a discrepancy. I have the names of residents, not the medications. LVN 1 stated she would take care of them. The DON stated she was aware of the medication discrepancies for Residents 2, 4, 5, RSR 18, 21, and 25. However, the DON stated she was unaware of medication discrepancies for RSRs 17, 20, 22, and 23. The DON further stated, discrepancies in the narcotic count should be reported to the DON immediately. The DON and the Administrator should notify the consultant pharmacist immediately if any criminal actions are noted. LVNs should not destroy controlled medications. On July 27, 2017 at 9:59 a.m., in the presence of the DON, LVN 1 stated, The Ativan (Lorazepam) medications that were over by one pill, I took it out and destroyed it with LVN 3. The DON stated, The two LVNs were not supposed to destroy the Ativan (Lorazepam). LVN 1 stated, We should have given the medications that were over to the DON to investigate and destroy. I talked to the 3 p.m. to 11 p.m. shift nurse and a lot of the medication discrepancies are due to her lack of documentation. A review of Resident 2's medical records, in the presence of LVN 1 and the DON indicated a prescription order dated August 31, 2016, for Tramadol 50 mg, (given for pain) take one tablet by mouth every six hours as needed for mild pain. However, Resident 2's July 2017 MAR (front and back) for Tramadol were blank. LVN 1 and the DON stated the licensed nurses did not document giving Resident 2's Tramadol on the July 2017 MAR. The pain monitoring documented on Resident 2's MAR indicated [REDACTED]. LVN 1 stated, We are supposed to document before the medication administration and one hour after noting the resident's response to the pain medication. I did not document. The DON stated, I see the problem and will call the pharmacist consultant today (July 27, 2016) to come in. On July 27, 2017 at 10:56 a.m., during a telephone interview, Pharmacist 1 stated, Just today, I found out about the narcotic discrepancies, about a half hour ago. If the facility called the pharmacy I did not get the message. A review of the facility policy and procedures titled, Preparation and General Guidelines Controlled Medications, dated July 1, 2008 indicated, When a controlled medication is administered, the licensed nurse, administering the medication, immediately enters the following information on the accountability record and the Medication Administration Record [REDACTED] 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered. A review of the facility policy and procedures titled, Medication Storage in the Facility: Controlled Medication Storage, dated July 1, 2008, indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. At each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. If a major discrepancy or a pattern of discrepancies occurs or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. b. On July 27, 2017 at 12:51 p.m., during an interview, the DON stated the last narcotic destruction was on March 21, 2017, with Pharmacist 1. Since March, she only had one narcotic medication for destruction. The medication was stored in the double locked drawer in her office. RSR 26's Librium (chlordiazepoxide a sedative and hypnotic medication) 25 mg contained 29 tablets to be destroyed on Pharmacist 1's next visit. The DON stated she did not regularly have many narcotics to destroy at the facility. On July 28, 2017 at 12 p.m., RSR 28 record review indicated the resident was receiving hospice services and was discharged from the facility on June 30, 2017. In a concurrent interview, the DON stated LVN 1 informed her that RSR 28's hospice nurse took the medications. A review of RSR 27 medical record and concurrent interview with the DON, who stated the resident passed away on June 9, 2017. There were no documentation about the disposal or destruction of his prescription medication, Hydrocodone/APAP 5/325. The DON was unable to locate RSR 27 and RSR 28's controlled medications. On August 1, 2017 at 8:17 a.m., the medical record staff (MR 1) provided the Controlled Drug Records for RSR 28 and 27. MR 1 stated she found the Controlled Drug Record sheets in the medical records office. MR 1 stated she would tell the nurses the Controlled Drug Record sheets are kept in the DON's office. The Controlled Drug Record indicated the following: RSR 28, Morphine Sulfate 20 mg/ml, quantity of 30 tablets, was undated and did not include the name of the pharmacy. RSR 28, Hydrocodone/APAP 5/325, quantity of 30 ml, destroyed on July 28, 2017 RSR 28, Lorazepam 1 mg/1ml, contained 30 ml, but the Controlled Drug Record the form was undated and did not include the name of the pharmacy. RSR 27, Hydrocodone/APAP 5/325, quantity of 30 tablets, destroyed on March 20, 2017. However, RSR 27 clinical record indicated an admitted on May 12, 2017. The resident expired on June 9, 2017. On August 1, 2017 at 9:54 a.m., during an interview, in the presence of the DON, LVN 5 stated, Hospice does not take medications back when residents leave the facility or pass away. I give the medications including narcotics (controlled) medications to the DON. The DON could not explain the whereabouts of RSR 27's narcotic medications, after he passed away or RSR 28's medications, after his discharged to the hospital. On August 1, 2017, at 10:22 a.m., during a teleconference with the hospice nurse (RN 2), regarding RSR 28, RN 2 stated, On June 30, 2017, (RSR 28) was discharged from the facility. (RSR 28) was dispensed a comfort kit that included the pain medications, Morphine, Norco (Hydrocodone/APAP), Tylenol (APAP a pain medication), and Ativan (Lorazepam for anxiety), suppositories for fever or constipation; and received all medications once on June 9, 2017. The facility administered his medications and I do not know if the facility ever gave him Norco. We do not ever pick up medications. We are not allowed to carry controlled medications in our care. We can lose our license. On July 27, 2017 at 10:56 a.m., in a telephone interview Pharmacist 1stated he was last at the facility a couple of weeks ago, this month. The DON stated the pharmacist last visit was on July 14, 2017. Pharmacist 1 stated on his monthly visits to the facility he does review the medication storage room and checks the Narcotic Check Sheet, to see that two licensed nurses are signing off each shift. Pharmacist 1 stated, If narcotic discrepancies are identified the nurses should notify the DON; and if the discrepancies cannot be resolved the DON should notify me. The narcotic count reconciliation is required to be done by two licensed nurses every shift. Three times a day the nurses do a shift change and had three times each day to catch the narcotic discrepancy errors. (The nurses) cannot just throw away a pill. Possibly the medication was not given to the patient; (they) must investigate why the medication count was over. Pharmacist 1 stated he does not recall doing any in service at the facility. On July 28, 2017 at 11:14 a.m., during an interview Pharmacist 2 stated prior to today (July 28, 2017) the last time he was at this facility was about one to one and a half years ago; however Pharmacist 1 reviews residents charts monthly at the facility. Pharmacist 2 stated the facility returns all medications, including the hospice residents, to his pharmacy. Pharmacist 2 stated the facility must retain a copy of all the medications being destroyed or returned for three years. On July 27, 2017 at 11:30 a.m., during an interview, the DON stated, I do not usually go into the Med Cart and review the narcotics. That is my fault. This is not the regular staff. I do not normally check the Med Cart narcotic counts because there has never been a mention of anything being wrong before. I suspect they (licensed nurses) are not counting the narcotics and just transferring the keys, because they have worked together for so long. There are more residents on hospice for non chronic conditions. They (licensed staff) have more narcotics available than they are used to. A review of the facility's Consultant Pharmacist Agreement indicated, The Consultant Pharmacist shall oversee the Pharmacy Services committees of the facility. More specifically, these services shall include: Assisting with the Facility's procedures for control and accountability for all drugs and biologicals throughout the facility and that such drug and biological shall be approved and dispensed in compliance with Federal and State laws and the facility's own policies and procedures. Assist and monitoring the records and receipts and disposition of all controlled drugs and the maintenance of such records in sufficient details to allow an accurate reconciliation. Written reports, at least quarterly, to the pharmaceutical service committee on the status of the Facility's pharmaceutical service and staff performance. A review of the facility's policy and procedures titled, Medication Destruction, dated July 1, 2008 indicated, The medication disposition form is kept on file in the facility for two years. A review of the facility's policy and procedures titled, Controlled Drugs, dated October 1, 2014 indicated, To establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and that an account of all controlled drugs is maintained and periodically reconciled. It is the policy of the Facility to ensure that: Drugs listed in Schedule II, III, IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall not be accessible to other than licensed nursing, pharmacy, and medical personnel designated. Separate records of use shall be maintained on all Schedule II drugs. Drug records shall be maintained for drug listed in Schedules III and IV in such a way that the receipt and disposition of each dose of any such drug may be readily traced. Controlled scheduled drugs shall be reconciled at least every shift by counting the drugs and verifying the count with the number on the Control Drug Record for each drug. The count will be conducted by the licensed nurse, assigned to medication administration, going off duty and the licensed nurse coming on duty, assigned to medication administration. When the count is complete and accurate, both nurses will sign on the 8 Hour Verification of Controlled Substances Count form verifying that the count was complete, accurate and that the keys were exchanged. If the count is not correct, the supervising nurse will be notified, immediately, and the drug must be accounted for before the off going nurse leaves the building. If the drug cannot be accounted for, the off going nurse will write an Incident Report and give to the supervising nurse/Unit Manager. c. On July 24, 2017, at 10:12 a.m., during a medication area inspection and an audit with LVN 2, inside the medication storage room a white box was observed and handwritten on top indicated, Please DO NOT Place Bags on Top of Box Thanks, inside the box were filled with bubble packs of prescription medications labeled for individual residents. During a concurrent interview LVN 2 stated RSR 15 whose medications were observed in the box was a current resident and RSR 16 had been discharged from the facility. LVN 2 stated it would be hard to know which residents medications in the white box were still a resident and which residents had been discharged , or why the medications were there because there were no markings on the individual prescription labels inside the box or on the outside of the box. On July 24, 207, at 10:22 a.m., in the medication storage room in the presence of LVN 2, LVN 1 stated, Anything (Everything) in the white box were to be returned to the pharmacy (facility's dispensing pharmacy) to get full credit; the medication in the box included some residents overflow medications and some medications maybe returned to the pharmacy to be destroyed. During a concurrent record review and interview, LVN 1 stated there were medications in the white box for seven residents (RSR 15, 16, 17, 18, 19, 27, and 28) and included the following residents and their medications for: RSR 15, Megestrol 40 mg/ml oral suspension, medication discontinued by physician on July 17, 2017 RSR 15, Metoprolol 25 mg, total quantity of 46 tablets, A clinical record review in the presence of LVN 1 of RSR 15's July MAR indicated [REDACTED] RSR 16, Metoprolol 25 mg, Potassium Chloride 20 millequivalents (mEq), Plavix 75 mg, Losartan Potassium 25 mg, Dutasteride 0.5mg, Amlodipine 2.5 mg, Famotidine 20 mg, Atorvastatin 10 mg, and Tamsulosin 0.4 mg; LVN 1 stated, Would have to look at the MAR (for RSR 16), all the medications should have been marked discontinued on the MAR, because RSR 16 was sent out to the hospital last week. RSR 17, Hydralazine 50 mg, quantity of 30 tablets; LVN 1 stated Hydralazine was current prescription order for RSR 17 that the facility had received too much of the medication (overflow of medication) and was returning some of the medication back to the dispensing pharmacy for credit. RSR 18, Gabapentin, three bubble packs totally 45 capsules (15 capsules per bubble pack), LVN 1 stated resident's Gabapentin order was changed RSR 19, Trazodone 50 mg, quantity of 16 tablets, A review of RSR 18's discharge and readmission records for RSR 18 indicated, the resident was sent out to the hospital and medication order for Trazodone was not renewed upon RSR 18's return to the facility on [DATE] RSR 27, Megestrol 40 mg/ml oral suspension, A review of RSR 27's discharge record indicated RSR 27 was admitted to the facility on [DATE] and expired at the facility on June 9, 2017. RSR 28, Acetaminophen 500 mg, quantity of 30 tablets, A review of RSR 28's discharge record indicated RSR 28 was admitted to the facility on [DATE] and was discharged from the facility to an acute care hospital on June 30, 2017. A review of RSR 16's physician orders for July 2017 document resident was transferred out to the hospital on July 19, 2017; RSR 16's, July 2017 MAR indicated [REDACTED]. On July 24, 2017, at 10:44 a.m., during an interview LVN 1 stated that she had not made a drug return log sheet yet to itemize the medications in the white box for return to the facility's dispensing pharmacy for credit. On July 24, at 10:58 a.m., during an interview in LVN 1's office, LVN 1 stated, I am the one that does the return to the pharmacy of medications. After a while I shred the drug return log. I have already shredded them. I only keep them (Drug Return Log forms) for 3 (three) months. I do not have any copies of the medications (noncontrolled) returned to the pharmacy. I use the same paper (Drug Return Log forms) to destroy the noncontrolled medications. After 90 days I destroy the papers - shred them up. Not required to keep them longer than 90 days. I asked the pharmacist consultant. The medications in the white box were discontinued medications, (resident) overflow medications, medications for resident sent out to the hospital. Residents out to the hospital medications are kept in the (white) box and the nurses (facility's licensed nurses) know where to look if the patient comes back (from the hospital) and is kept on the same medications. On July 24, 2017 at 4:19 p.m., during an interview with the director of nursing (DON), the DON stated, when resident medications are discontinued (D/C), D/C should be written on the prescription label and the date the medication was D/C should be included on the package; overflow medications could be left in the MedCart and a note to other nurses that there are extra medications in the MedCart; discontinued medications should be stored in a locked cabinet separate from the overflow medications. On July 27, 2017 at 10:56 a.m., during a telephone interview with the facility's consultant pharmacist (Pharmacist